Critical Changes to the 2021 ADA Standards of Care

ADA standards of care 2021 changes include enhanced emphasis on the role of social and financial determinants in diabetes patient health. 

At the beginning of this year, the American Diabetes Association (ADA) announced changes in their guidelines for standard of care. The 2021 ADA standards of care define essential factors for patients who have diabetes, their treatment goals, and quality of care. In the guidelines, there are a total of 16 sections. However, we will focus on just a few sections, 1 through 5, that were changed compared to the 2020 guidelines, and what the significant recommendation changes are. 

Section 1 explains improving care and promoting health in populations. The recommendation in the 2021 guidelines states that providers should assess social context. This means finding out the patient’s permanency of housing, any financial barriers, and maintaining the proper food for treatment plans. In the new guidelines, one more was added: social capital and social community support. The ADA mentioned a link between social and environmental factors in treatment and prevention for patients who have diabetes. This helps develop a better understanding in how to adjust the treatment plan for each patient. Housing circumstances, for example, can create difficulties for patients in maintaining proper storage of their insulins and diabetic testing supplies. Providers and social workers should be aware of all the resources to help find housing for their patients. Depending on where patients live, it could be hard for someone to access their medications and appropriate food. The guidelines also note how financial factors can impact medication adherence.  

Section 2 explains the classification and diagnosis of diabetes, including more extensive discussion of LADA (latent autoimmune diabetes in adults). One new thing that was added to this section in 2021 was section 2.14. This section stated that patients who have HIV should be screened for diabetes and prediabetes, before starting new antiretroviral therapy, switching therapy, and 3 to 6 months after starting or changing treatment. If you think about it, patients with HIV are at higher risk of developing diabetes. Certain HIV drugs, protease inhibitors, and nucleoside reverse transcriptase inhibitors can increase the risk of diabetes.  

Section 3 explains the prevention or delay of type 2 diabetes. A section in the 2020 guidelines, section 3.9, explained diabetes self-management education and support but has now been removed. A new subsection has been added to describe evidence for broader dissemination of lifestyle behavior change programs to prevent diabetes. There should be reliable resources to help patients understand and to delay type 2 diabetes. 

Section 4 explains medical evaluation and assessment of comorbidities. The only change here is the new update in 2021 about COVID-19 vaccinations. Both guidelines still recommend patients have their influenza vaccine yearly. Patients who are over the age of 65 should benefit from receiving the higher dose inactivated flu vaccine. The new guidelines recommend adults receive one dose of the PPSV23 and another dose at age 65 or older. PCV13 is not recommended anymore; due to strains and the decline rate of pneumonia, patients over 65 should not get this vaccine. Both guidelines still recommend patients get the hepatitis B vaccine. The new guidelines recommend patients get the COVID-19 vaccine. Although the vaccine is relatively new, because people with diabetes are considered high risk, we recommend that patients get the vaccine when it becomes available to them. 

Lastly, section 5 explains facilitating behavior change and wellbeing to improve health outcomes. A new section has been added for evaluating physical activity and idle time. These types of exercises include walking, yoga, housework, gardening, swimming, and dancing. Physical activity is significant; exercising improves blood glucose control, reduces the risk of cardiovascular disease, helps you lose weight, and improves your wellbeing. The new guidelines state physical activity and exercise should be recommended to all patients with diabetes. This will help manage their glycemic and overall health. Another new section added to the guideline is smoking cessation. We need to address smoking cessation in diabetes education. We should educate our patients on proper diet and exercise and help them quit smoking, so ask each time you have a meeting. 

Practice Pearls: 

• The revised ADA guidelines stress the importance of considering how social context, such as housing stability, can impact patients’ diabetes management. 
• It is recommended that diabetes patients get vaccinated for the flu, pneumonia, hepatitis b, and covid-19.  
• Always inform patients about the importance of a proper diet and exercise to improve their overall health and A1C level. 

“American Diabetes Association Standards of Medical Care in Diabetes 2021.“ Diabetes Care, American Diabetes Association, January 1, 2021, care.diabetesjournals.org/content/44/Supplement_1. 

“American Diabetes Association Standards of Medical Care in Diabetes 2020.“ Diabetes Care, American Diabetes Association, January 1, 2020, care.diabetesjournals.org/content/43/Supplement_1. 

Anina Pham, PharmD. Candidate, Lake Erie College of Osteopathic Medicine, College of Pharmacy