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ADA Issues New Standards of Medical Care for Diabetes

Changes include a new blood sugar standard for children and adolescents; a lower BMI screening threshold for Asian Americans; and new recommendations on statin use based on risk status…

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Researchers reviewed the Standards of Medical Care in Diabetes for 2015, focusing on revisions to clinical practice recommendations.

The researchers note that all individuals, including those with diabetes, should be encouraged to limit the amount of sedentary time by breaking up extended amounts of time (more than 90 minutes) spent sitting. The committee also recommends people with diabetes do resistance training at least twice a week, unless they can’t for other medical reasons.

Premeal blood glucose targets were revised to reflect new data with a new target of 80–130 mg/dL.

With respect to cardiovascular disease and risk management, the recommended goal for diastolic blood pressure was changed from 80 to 90 mm Hg for most people with diabetes and hypertension.

Recommendations for statin treatment and lipid monitoring were changed; initiation of treatment and initial statin dose are now recommended primarily based on risk status. These new standards bring the association in line with the American College of Cardiology and American Heart Association, which also recommend giving low- or high-dose statins to all people at risk for heart disease, including people with diabetes.
Based on the new recommendations, lipid monitoring guidelines suggest a screening lipid profile at diabetes diagnosis, at an initial medical evaluation, and/or at age 40 years, and periodically thereafter.

Richard W. Grant, M.D., M.P.H., a research scientist in the Kaiser Permanente Division of Research and chair of the ADA’s Professional Practice Committee, said in a statement, “The big change here is to recommend starting either moderate- or high-intensity statins based on the patient’s risk profile rather than on low-density lipoprotein level.” “It turns out that patients with diabetes have the same risk as people with heart disease, so all of our patients need to be on statins,” he said. However, Grant said some people with diabetes may not need statins. These include younger, healthier patients and very old patients who have other medical conditions that shorten their life expectancy.

Heart disease is the No. 1 killer of people with diabetes, Grant said. People with diabetes are two to four times more likely to have a heart attack or stroke than people without diabetes, he said.

The increased risk of heart disease in people with diabetes is what was behind the rationale for this year’s recommendations on statins, blood pressure and exercise, according to Grant.

“In the old days, all we thought about was sugar, and nowadays we recognize that the leading killer in diabetes is heart disease,” he said. “You have to be aggressive in controlling risks.”

The guidelines for people with diabetes also include:

  • A new blood sugar standard for children and adolescents — a hemoglobin A1C of <7.5 or less.
  • A statement that e-cigarettes are not an alternative to smoking or a way to help smokers quit.
  • A recommendation that people 65 or older get the pneumonia vaccine in two separate shots — PCV13 (Prevnar), followed 12 months later by PPSV23 (Pneumovax).
  • Lowering the BMI threshold to 23 for screening Asian-Americans for diabetes. A BMI of 25 is what’s usually considered overweight, according to the U.S. Centers for Disease Control and Prevention but Asians have an increased risk for diabetes at a lower BMI, according to the ADA.
  • Patients with insensate feet, foot deformities, or a history of foot ulcers have their feet examined at every visit.

Practice Pearls:

  • The recommended goal for diastolic blood pressure was changed from 80 to 90 mm Hg for most people with diabetes and hypertension.
  • The ADA now recommends a premeal blood glucose target of 80–130 mg/dL, rather than 70–130 mg/dL, to better reflect new data comparing actual average glucose levels with A1C targets.
  • Treatment initiation (and initial statin dose) is now driven primarily by risk status rather than LDL cholesterol level.

Standards of Medical Care in Diabetes—2015: Summary of Revisions.