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The patient with diabetes

Revised standards of care

By Scott Benson, MD

From Minnesota Healthcare News

Diabetes remains a complex medical condition, potentially impacting a patient’s physical and mental well-being. One of the best ways for physicians to help patients with diabetes reduce the risk of long-term complications and maximize their quality of life is by keeping up with standards of care.

In 2015, the Professional Practice Committee of the American Diabetes Association (ADA) revised several of the ADA standards of medical care for patients with diabetes. This committee consists of physicians, educators, dietitians, and experts in the areas of endocrinology, epidemiology, public health, lipid research, hypertension, preconception, and pregnancy care. Following is a short overview of some of these new standards.

BMI guidelines for Asian-Americans
Studies have found that people of Asian American heritage are at an increased risk of diabetes at lower body mass index (BMI) levels than the general population. As a result, the guideline for screening overweight Asian Americans for prediabetes and type 2 diabetes was lowered from 25 kg/m2 to 23 kg/m2. Physicians should test all of their overweight patients for diabetes starting when a patient is 45, even if the patient is without symptoms. Testing should be done sooner if the patient has one or more additional risk factor for diabetes, such as family history, high blood pressure, or abnormal cholesterol and triglyceride levels. Children
and adolescents who are overweight and have two or more additional risk factors should also be tested.

Sedentary time
It is not news that exercise is good for us. The ADA recommends, however, that patients with diabetes should limit their sedentary time to fewer than 90 minutes at once. Encourage your patients to take frequent breaks from sitting and walk around or engage in exercise of some kind. In addition, adults with diabetes should make it a habit to exercise at least 150 minutes every week. Exercise is important for children with diabetes, too. Encourage them to perform 60 minutes of physical activity every day.

e-cigarettes
We all agree that smoking is harmful to our patients, whether or not they have diabetes. There are many self-help products on the market, but the ADA does not recommend the use of e-cigarettes to help people with diabetes quit smoking, as there is no evidence that they present a healthier alternative. More study is needed to determine the safety and efficacy of e-cigarettes.

Immunizations
The ADA recommends that physicians follow immunization guidelines regarding PCV13 and PPSV23 vaccinations from the Centers for Disease Control and Prevention (CDC) for their patients with diabetes. The CDC recommends that children under five and adults 65 years and older receive the pneumococcal conjugate vaccine (PCV13). Individuals over the age of six with certain risk factors should also receive this vaccine. All adults 65 years and older, as well as those from two to 64 who are at high risk of pneumonia, should also receive the pneumococcal polysaccharide vaccine (PPSV23).

Blood glucose targets
The ADA recommends a blood glucose target level of 80–130 mg/dL before meals. This is a change from the 70–130 mg/dL previously recommended, based on new data. Physicians should perform an A1C test twice a year or more in patients meeting their goals and quarterly in those who are not.

Continuous glucose monitoring
New recommendations were released regarding continuous glucose monitoring (CGM), including additional guidance on how to assess a patient’s readiness for CGM and how to provide ongoing support to patients on CGM. Several products are on the market today to help patients with continuous glucose monitoring, including a product in development by Medtronic to enable people with diabetes under intensive insulin therapy to view their glucose levels in real time on their smart phones.

Approaches to glycemic treatment
With the revised Standards of Care, the type 2 diabetes management algorithm was updated to include the latest therapies for diabetes management. The ADA recommends letting the patient guide the choice of medications, taking into account efficacy, cost, potential side effects, weight, comorbidities, hypoglycemia risk, and individual preferences.

Blood pressure goals
Based on the results of clinical trials, the diastolic blood pressure recommended goal was changed from 80 mmHg to 90 mmHg for most people with diabetes and hypertension. Some patients may still benefit from lower blood pressure targets, however, so physicians need to consider other factors involved in a patient’s medical condition.

Statins
The guidelines for treating patients with statins also was recently updated by the American College of Cardiology and the American Heart Association. The initiation of treatment is now based on risk status instead of LDL cholesterol level. Patients should be screened when diabetes is diagnosed or at the age of 40 and periodically after that.

Foot care
Because diabetes can cause complications involving the feet, physicians should examine a patient’s feet, including the assessment of foot pulses, at every visit if the patient has a history of foot ulcers, foot deformities, or other foot issues. Patients with a positive ankle brachial index should be referred to a vascular specialist for further treatment.

Kidney disease
The ADA recommends that glucose and blood pressure be controlled to reduce the risk or slow the progression of diabetic kidney disease, which occurs in up to 40 percent of patients with diabetes. It is the leading cause of end-stage renal disease. Follow glucose and blood pressure targets to minimize this condition.

Targets for children
The A1C guideline for children is now

Pregnancy guidelines
Gestational diabetes can develop in any pregnant woman, but higher-risk individuals are those older than 25, overweight, with a family history of diabetes, or of African-American, Hispanic, American Indian, or Asian descent. Women with a history of gestational diabetes should be screened throughout their lifetime for the development of diabetes or prediabetes. A new section was added to the “Standards of Medical Care in Diabetes 2015” to address issues such as preconception counseling, medications, blood glucose targets, and monitoring.

Other considerations
Treating patients with diabetes requires a broad understanding of the complications and comorbidities that often accompany the disease. A multidisciplinary care team, including physicians, nurses, dietitians, pharmacists, and mental health providers, can provide the most comprehensive care to these patients.

Some elements of diabetes management have not changed but bear repeating. In addition to serious cardiovascular issues, other common comorbid conditions in patients with diabetes of any kind include sleep disorders, arthritis, liver disease, cancer, hip fractures, low testosterone in men, periodontal disease, and hearing decline. In addition, people with diabetes are more likely to develop depression, anxiety, eating disorders, and cognitive decline than those without the disease, and these conditions often lead to worse outcomes for the patient. As a result, physicians should routinely screen for mental health issues in their patients with diabetes.

As diabetes care improves, patients with diabetes are living longer and experiencing more of these comorbidities. It is more critical, therefore, to put together a comprehensive plan to help patients lower their blood pressure, control their cholesterol, stop smoking, lose weight, and exercise.

Although the Standards of Care are valuable, common sense and professional judgment still need to prevail. The Standards of Care put forth by the ADA need to be used in conjunction with a physician’s expert opinion and personal knowledge of each patient. As Diabetes Care cited in its January 2015 issue, “The Standards of Care recommendations are not intended to preclude clinical judgment and must be applied in the context of excellent clinical care, with adjustments for individual preferences, comorbidities, and other patient factors.”

For more information on the new Standards of Care, visit American Diabetes “Standards of Medical Care in Diabetes – 2015” at http://care.diabetesjournals.org

Scott Benson, MD, is a board-certified family medicine physician at the Apple Valley Medical Center. He has a special interest in non-operative orthopedics, sports medicine, and chronic disease management.

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