New recommendation based on results from two large clinical trials for patients with diabetes and CVD.
The standards, produced annually by the ADA focus on screening, diagnosis and treatment to provide better health outcomes for children, adults and older people with type 1, type 2 or gestational diabetes, and to improve the prevention and delay of type 2 diabetes. The following is a breakdown by sections in the new supplement.
One of the major changes, which will have a great benefit for those with type 2 diabetes, includes the new recommendation based on results from two large clinical trials for patients with diabetes and CVD. The guideline recommends clinicians consider two specific glucose-lowering medications — the GLP-1 receptor agonist liraglutide and the SGLT-2 inhibitor empagliflozin — in this high-risk population to lower the risk for death. More research is needed to confirm whether the heart benefits are a class effect or if the benefits persist in patients without established CVD.
Part 1: (Sections 1-5)
Section 1. Promoting Health and Reducing Disparities in Populations
This section was renamed and now focuses on improving outcomes and reducing disparities in populations with diabetes.
Recommendations were added to assess patients’ social context as well as refer to local community resources and provide self-management support.
Section 2. Classification and Diagnosis of Diabetes
The section was updated to include a new consensus on the staging of type 1 diabetes (Table 2.1) and a discussion of a proposed unifying diabetes classification scheme that focuses on β-cell dysfunction and disease stage as indicated by glucose status.
Language was added to clarify screening and testing for diabetes. Screening approaches were described, and Fig. 2.1 was included to provide an example of a validated tool to screen for prediabetes and previously undiagnosed type 2 diabetes.
Due to recent data, delivering a baby weighing 9 lb or more is no longer listed as an independent risk factor for the development of prediabetes and type 2 diabetes.
A section was added that discusses recent evidence on screening for diabetes in dental practices.
The recommendation to test women with gestational diabetes mellitus for persistent diabetes was changed from 6–12 weeks’ postpartum to 4–12 weeks’ postpartum to allow the test to be scheduled just before the standard 6-week postpartum obstetrical checkup so that the results can be discussed with the patient at that time of the visit or to allow the test to be rescheduled at the visit if the patient did not get the test.
Additional detail was added to the section on monogenic diabetes syndromes, and a new table was added (Table 2.7) describing the most common forms of monogenic diabetes.
A new section was added on posttransplantation diabetes mellitus.
Section 3. Comprehensive Medical Evaluation and Assessment of Comorbidities
This new section, including components of the 2016 section “Foundations of Care and Comprehensive Medical Evaluation,” highlights the importance of assessing comorbidities in the context of a patient-centered comprehensive medical evaluation.
A new discussion of the goals of provider-patient communication is included.
The Standards of Care now recommends the assessment of sleep pattern and duration as part of the comprehensive medical evaluation based on emerging evidence suggesting a relationship between sleep quality and glycemic control.
An expanded list of diabetes comorbidities now includes autoimmune diseases, HIV, anxiety disorders, depression, disordered eating behavior, and serious mental illness.
Section 4. Lifestyle Management
This section, previously entitled “Foundations of Care and Comprehensive Medical Evaluation,” was refocused on lifestyle management.
The recommendation for nutrition therapy in people prescribed flexible insulin therapy was updated to include fat and protein counting in addition to carbohydrate counting for some patients to reflect evidence that these dietary factors influence insulin dosing and blood glucose levels.
Based on new evidence of glycemic benefits, the Standards of Care now recommends that prolonged sitting be interrupted every 30 min with short bouts of physical activity.
A recommendation was added to highlight the importance of balance and flexibility training in older adults.
A new section and table provide information on situations that might warrant referral to a mental health provider.
Section 5. Prevention or Delay of Type 2 Diabetes
To help providers identify those patients who would benefit from prevention efforts, new text was added emphasizing the importance of screening for prediabetes using an assessment tool or informal assessment of risk factors and performing a diagnostic test when appropriate.
To reflect new evidence showing an association between B12 deficiency and long-term metformin use, a recommendation was added to consider periodic measurement of B12 levels and supplementation as needed.