By Eileen B. Wyner, NP
Bulfinch Medical Group

The American Diabetes Association (ADA) publishes guidelines each January to educate professionals about the best clinical practice for people with diabetes. They were formally called Clinical Practice Recommendations but are now referred to as Standards of Medical Care in Diabetes. I would like to acknowledge that Dr. Deborah Wexler from the Diabetes Center at MGH is a member of the Professional Practice Group of the ADA, Glycemic Group Subchair. This group edits the Standards of Care and reviews ADA Position Statements.

These standards are meant to provide general treatment goals for patients with diabetes. They are not meant to replace clinical judgment. I am going to briefly review some of the changes this year; visit the American Diabetes Association website for a more detailed explanation of the standards. Please remember, that these are in no way meant to replace the individual care that you are participating in with your health care team.

The ADA determined that the following themes were to be considered by clinicians, policymakers, and patient advocates at all times:

1. Patient-Centeredness – These recommendations are a guide to care and must be adapted to each patient’s individual needs. There is no “one size fits all” in the care of diabetes.
2. Diabetes Across the Life Span – People with Type 1 and Type 2 Diabetes are not only increasing in number, but are also living longer. There are few clinical trials that address the needs of this population, so it’s important that all health care team members communicate well to be sure the best care is provided.
3. Advocacy for People with Diabetes – Living with diabetes is challenging. It’s important for all of us in this field to act as educators for our patients and the community. This is the best way to avoid issues of discrimination. The ADA has published position papers on diabetes and employment, diabetes and driving, and diabetes and correctional institutions, to name a few.

Standards Review of Changes

S2: Classification and Diagnosis of Diabetes – Screening of overweight Asian adults with another risk factor should be considered at a BMI of 23 or greater. All other overweight patients with another risk factor should be screened at a BMI of 25 or greater.

S4: Foundations of Care/Education – The ADA supports diabetes self-management education (DSME) for all patients with pre-diabetes and diabetes. This model has better health outcomes as well as possibly resulting in cost savings.

S4: Foundations of Care/Physical Activity – It’s important to be as active as possible. Sitting for more than 90 minutes at a time should be avoided.

S4: Foundations of Care/Smoking Cessation – E-cigarettes are not supported by evidence based research as a good alternative to tobacco products.

S4: Foundation of Care/Immunizations – All patients with diabetes need to be vaccinated annually for influenza. Hepatitis B immunizations should be provided for people ages 19-59 and there is consideration of this being done across the lifespan. Pneumococcal vaccination is also important. These recommendations are based upon the Centers of Disease Control (CDC) recommendations:

• People over the age of 2 should receive the PPSV23 vaccine.
• Adults who are 65 or older and HAVE NOT been vaccinated should receive the PCV13 vaccine and the PPSV23 vaccine 6-12 months after the initial vaccine.
• Adults who are 65 or older and HAVE received PPSV23 should receive a follow up within 12 months of the PCV13 vaccine.

S6: Glycemic Targets – Pre-meal targets have been changed from 70-130 mg/dL to 80-130 mg/dL to better avoid episodes of hypoglycemia.

S7: Approaches to Glycemic Treatment – The algorithm for medication management of diabetes has been updated to include the newest medications available for the treatment of diabetes. Lifestyle changes including healthy eating, weight control, activity, and education are still extremely important in all management strategies for diabetes.

S8: Cardiovascular Disease and Risk Management – The goal for patients with hypertension is now <140/<90. It is also perfectly acceptable for this goal to be changed to meet individual needs. The goals for lipid management have also been changed to focus more on each person’s individual risk and to keep the LDL <100. Again, this goal may be altered to meet the need of each individual.

S9: Microvascular Complications and Foot Care – Feet should be examined at each office visit if there is a history of deformity, ulcer, or decreased sensation.

S11: Children and Adolescents – An A1c level of 7.5% or lower are acceptable.

S12: Management of Diabetes in Pregnancy – This is a new chapter that provides guidance for the care during pregnancy from pre-conception across the lifespan.

It is important to remember that these standards are not the final say in how to care for people with diabetes. Always talk with your health care team about what is the best treatment for YOU.

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