C, Combination therapy (statin/fibrate) has not been shown to improve ASCVD outcomes and is generally not recommended. See “15. Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered. For patients with complications and reduced functionality, it is reasonable to set less intensive glycemic goals. E, Consider initiating dual therapy in patients with newly diagnosed type 2 diabetes who have A1C ≥1.5% (12.5 mmol/mol) above their glycemic target. A, For patients with diabetes aged <40 years with additional ASCVD risk factors, the patient and provider should consider using moderate-intensity statin in addition to lifestyle therapy. Blood pressure should be measured at every routine clinical visit. r or t diabetes.org T Food for Thought T fro ’ utrto ou ort | American Diabetes Association ® Food for Thought Key Takeaways from ADA’s Nutrition Consensus Report Weight loss works. Starting at puberty and continuing in all women with reproductive potential, preconception counseling should be incorporated into routine diabetes care. Physiologic insulin secretion varies with glycemia, meal size, and tissue demands for glucose. The majority of children and adolescents with type 1 diabetes should be treated with intensive insulin regimens, either via multiple daily injections or continuous subcutaneous insulin infusion. Older adults are at higher risk of hypoglycemia for many reasons, including insulin deficiency necessitating insulin therapy and progressive renal insufficiency. Neuropathic pain can be severe and can impact quality of life, limit mobility, and contribute to depression and social dysfunction. B, Due to increased red blood cell turnover, A1C is slightly lower in normal pregnancy than in normal nonpregnant women. It is important to prevent hypoglycemia to reduce the risk of cognitive decline and other major adverse outcomes. People with bony deformities (e.g., hammertoes, prominent metatarsal heads, bunions) may need extra wide or deep shoes, and some will require custom-molded shoes. They also have higher incidences of all-cause dementia, Alzheimer’s disease, and vascular dementia than people with normal glucose tolerance. Yoga and tai chi may be included based on individual preferences to increase flexibility, muscular strength, and balance. FI is associated with increased risk for type 2 diabetes, suboptimal glycemic control, psychosocial conditions, and low treatment adherence. See “13. The American Diabetes Association and the European Association for the Study of Diabetes have briefly updated their 2018 recommendations on management of hyperglycemia, based on important research findings from large cardiovascular outcomes trials published in 2019. Toward the end of the third trimester, it is common for there to be a greater need for prandial insulin (>50%) than for basal insulin (<50%). Diabetes is an important health condition for the aging population, as approximately one-quarter of people over the age of 65 years have diabetes and one-half of older adults have prediabetes. Abridged for Primary Care Providers. The American Diabetes Association (ADA) recommends initiation of basal insulin at 10 units/day or 0.1–0.2 units/kg/day, adjusted by 10–15% or 2–4 units once or twice weekly to reach a target fasting plasma glucose (FPG) in patients whose A1C remains uncontrolled after >3 months … More stringent A1C targets (such as <6.5%) may be appropriate for selected individual patients if this can be achieved without significant hypoglycemia or other adverse effects of treatment. Level 2 hypoglycemia (defined as a blood glucose concentration <54 mg/dL [3.0 mmol/L]) is the threshold at which neuroglycopenic symptoms begin to occur and requires immediate action to resolve the hypoglycemic event. Several major randomized controlled trials, including the Diabetes Prevention Program (DPP), have demonstrated that an intensive lifestyle intervention can reduce the incidence of type 2 diabetes. Children and adults with diabetes should receive vaccinations according to age-specific recommendations. B. A, All patients should be assessed for diabetic peripheral neuropathy starting at diagnosis of type 2 diabetes and 5 years after the diagnosis of type 1 diabetes and at least annually thereafter. CGM has emerged as a complementary method for the assessment of glucose levels. E, Optimize glucose control to prevent or delay the development of neuropathy in patients with type 1 diabetes A and to slow the progression of neuropathy in patients with type 2 diabetes. People with neuropathy or evidence of increased plantar pressures (e.g., erythema, warmth, or calluses) may be adequately managed with well-fitted walking shoes or athletic shoes that cushion the feet and redistribute pressure. A Ezetimibe may be preferred due to lower cost. Cost-effectiveness of Community-Based Depression Interventions for Rural and Urban Adults With Type 2 Diabetes: Projections From Program ACTIVE (Adults Coming Together to Increase Vital Exercise) II, Association of Objectively Measured Timing of Physical Activity Bouts With Cardiovascular Health in Type 2 Diabetes, Improved Glycemic Outcomes With Medtronic MiniMed Advanced Hybrid Closed-Loop Delivery: Results From a Randomized Crossover Trial Comparing Automated Insulin Delivery With Predictive Low Glucose Suspend in People With Type 1 Diabetes, Institutional Subscriptions and Site Licenses, Special Podcast Series: Therapeutic Inertia, Special Podcast Series: Influenza Podcasts, http://www.diabetesjournals.org/content/license. B, Women with preexisting type 1 or type 2 diabetes who are planning pregnancy or who are pregnant should be counseled on the risk of development and/or progression of diabetic retinopathy. Further secondary end points were whether patients achieved HbA 1c levels below 7.0% (American Diabetes Association target) and at or below 6.5%; weight loss of at least 5% and at least 10%; composites of (1) HbA 1c below 7.0% without hypoglycemia (severe or whole-blood glucose–confirmed symptomatic … Approved by the American Diabetes Association, the Endocrine Society and JDRF - August 2018 1 • These recommendations are intended to be used only in disaster response situations when patients are not on their usual schedule, may have limited monitoring capabilities, or don’t have access to their prescribed insulins. Clinicians are encouraged to review ADA screening recommendations in “11. B. Diabetes is associated with increased risk of cancers of the liver, pancreas, endometrium, colon/rectum, breast, and bladder. E, Pregabalin, duloxetine, or gabapentin are recommended as initial pharmacologic treatments for neuropathic pain in diabetes. Diabetes Care 2018;42(Suppl. 1):S1–S194. The complete Standards of Medical Care in Diabetes—2019 was developed by the ADA’s Professional Practice Committee: Joshua J. Neumiller, PharmD, CDE, FASCP (Chair); Christopher Cannon, MD; Ian de Boer, MD, MS; Jill Crandall, MD; David D’Alessio, MD; Mary de Groot, PhD; Judith Fradkin, MD; Kathryn Kreider, DNP, APRN, FNP-BC, BC-ADM; David Maahs, MD, PhD; Nisa Maruthur, MD, MHS; Melinda Maryniuk, MEd, RD, CDE; Medha N. Munshi, MD; Maria Jose Rdondo, MD, PhD, MPH; Guillermo E. Umpierrez, MD, CDE; and Jennifer Wyckoff, MD. The risk of atherosclerotic CVD (ASCVD) and heart failure, chronic kidney disease (CKD) staging, and treatment-associated hypoglycemia should be used to individualize targets for glycemia, blood pressure, and lipids and to select specific glucose-lowering medication, antihypertension medication, or statin treatment intensity. E. For patients with diabetes and ASCVD, if LDL cholesterol is ≥70 mg/dL on maximally tolerated statin dose, consider adding additional LDL-lowering therapy (such as ezetimibe or PCSK9 inhibitor). High levels of DD significantly impact medication-taking behaviors and are linked to higher A1C, lower self-efficacy, and poorer dietary and exercise behaviors. B. (See Sec. A Consensus Report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD), Sign In to Email Alerts with your Email Address. E. Generally, insulin requirements can be estimated based on weight, with typical doses ranging from 0.4 to 1.0 units/kg/day. Figure 2 depicts factors used to determine A1C targets for individual patients. Recommendations for prandial insulin dose administration should therefore be individualized. Institutional Subscriptions and Site Licenses, Special Podcast Series: Therapeutic Inertia, Special Podcast Series: Influenza Podcasts, Standards of Medical Care in Diabetes—2019 Abridged for Primary Care Providers, 1. Perform a comprehensive foot evaluation at least annually to identify risk factors for ulcers and amputations. B, Children and adolescents with overweight/obesity in whom the diagnosis of type 2 diabetes is being considered should have a panel of pancreatic autoantibodies tested to exclude the possibility of autoimmune type 1 diabetes. B, Reassess glycemic targets over time based on the criteria in Figure 2 or, in older adults, Table 12.1 [in the complete Standards of Care]. Risks associated with alcohol consumption include hypoglycemia (particularly for those using insulin or insulin secretagogue therapies), weight gain, and hyperglycemia (for those consuming excessive amounts). Diabetes Care 2018;41:2669–2701. A. B, Optimize glucose control to reduce the risk or slow the progression of CKD. After adjusting for inflation, economic costs of diabetes increased by 26% from 2012 to 2017. See “4. Metabolic surgery should be recommended as an option to treat type 2 diabetes in appropriate surgical candidates with BMI ≥40 kg/m2 (BMI ≥37.5 kg/m2 in Asian Americans) and in adults with BMI 35.0–39.9 kg/m2 (32.5–37.4 kg/m2 in Asian Americans) who do not achieve durable weight loss and improvement in comorbidities (including hyperglycemia) with reasonable nonsurgical methods. B, The early introduction of insulin should be considered if there is evidence of ongoing catabolism (weight loss), if symptoms of hyperglycemia are present, or when A1C levels (>10% [86 mmol/mol]) or blood glucose levels (≥300 mg/dL [16.7 mmol/L]) are very high. Diabetic neuropathy is a diagnosis of exclusion. Metformin is the preferred initial pharmacologic agent for the treatment of type 2 diabetes. Adapted from Davies MJ, D’Alessio DA, Fradkin J, et al. Diabetes and prediabetes may be screened based on plasma glucose criteria, either the fasting plasma glucose (FPG) or the 2-h plasma glucose (2-h PG) value during a 75-g oral glucose tolerance test (OGTT), or A1C criteria (Table 3). Providers should assess each patient’s readiness to achieve weight loss and jointly determine weight-loss goals and intervention strategies. Metformin therapy for prevention of type 2 diabetes should be considered in those with prediabetes, especially for those with BMI ≥35 kg/m2, those aged <60 years, and women with prior GDM. The American Diabetes Association’s (ADA’s) Standards of Medical Care in Diabetes is updated and published annually in a supplement to the January issue of Diabetes Care. C, Glucose (15–20 g) is the preferred treatment for the conscious individual with blood glucose <70 mg/dL (3.9 mmol/L), although any form of carbohydrate that contains glucose may be used. B, If tests are normal, repeat testing carried out at a minimum of 3-year intervals is reasonable. Comprehensive Medical Evaluation and Assessment of Comorbidities” in the complete 2019 Standards of Care for discussion on these topics. The Mediterranean, Dietary Approaches to Stop Hypertension (DASH), and plant-based eating plans are examples of healthful eating patterns that have shown positive results in research. Glucose-lowering medication in type 2 diabetes: overall approach. Redefining the roles of the health care delivery team and empowering patient self-management are fundamental to the successful implementation of the CCM. B, A follow-up visit should include most components of the initial comprehensive medical evaluation including: interval medical history, assessment of medication-taking behavior and intolerance/side effects, physical examination, laboratory evaluation as appropriate to assess attainment of A1C and metabolic targets, and assessment of risk for complications, diabetes self-management behaviors, nutrition, psychosocial health, and the need for referrals, immunizations, or other routine health maintenance screening. The early recognition and appropriate management of neuropathy in the patient with diabetes is important. This is an abridged version of the 2019 Standards containing the evidence-based recommendations most pertinent to primary care. Indications for referral to a mental health specialist familiar with diabetes management may include positive screening for overall stress related to work-life balance, DD, diabetes management difficulties, depression, anxiety, disordered eating, and cognitive dysfunction, among other issues. E, For patients of all ages with diabetes and ASCVD or 10-year ASCVD risk >20%, high-intensity statin therapy should be added to lifestyle therapy. A. Diabetic neuropathies are a heterogeneous group of disorders with diverse clinical manifestations. Some women with preexisting diabetes should also test blood glucose preprandially. B. The ADA’s Professional Practice Committee, which includes physicians, diabetes educators, registered dietitians (RDs), and public health experts, develops the Standards. A patient-centered communication style that uses person-centered and strength-based language and active listening, elicits patient preferences and beliefs, and assesses literacy, numeracy, and potential barriers to care should be used to optimize patient health outcomes and health-related quality of life. A simple approach to glycemia and weight management emphasizing portion control and healthy food choices, such as the diabetes plate method, should be considered for those with type 2 diabetes who are not taking insulin, who have limited health literacy or numeracy, or who are older and prone to hypoglycemia. Because GDM may represent preexisting undiagnosed type 2 or even type 1 diabetes, women with GDM should be tested for persistent diabetes or prediabetes at 4–12 weeks postpartum with a 75-g OGTT using nonpregnancy criteria (Table 3). Children and Adolescents” in the complete 2019 Standards of Care regarding the use of insulin pumps, blood glucose monitoring, and CGM in pediatric patients with type 1 diabetes. See Sec. A, For patients with ASCVD and documented aspirin allergy, clopidogrel (75 mg/day) should be used. SMBG is an integral component of effective therapy of patients taking insulin. C. Patients with or without diabetes may experience hypoglycemia in the hospital setting. Nearly all FDA-approved medications for weight loss have been shown to improve glycemic control in patients with type 2 diabetes and delay progression to type 2 diabetes in patients at risk. For patients in the LTC setting, special attention should be given to nutritional considerations, end-of-life care, and changes in diabetes management with respect to advanced disease. E, In patients with known ASCVD, consider ACE inhibitor or ARB therapy to reduce the risk of cardiovascular events. For women, no more than one drink per day, and two for men, is recommended. Patients with diabetes should be encouraged to undergo recommended age- and sex-appropriate cancer screenings and to reduce their modifiable cancer risk factors (obesity, physical inactivity, and smoking). Diabetes self-management support is additionally recommended to assist with implementing and sustaining skills and behaviors needed for ongoing self-management. E, Whenever possible, minimize medications for comorbid conditions that are associated with weight gain. A, In pregnant patients with diabetes and chronic hypertension, blood pressure targets of 120–160/80–105 mmHg are suggested in the interest of optimizing long-term maternal health and minimizing impaired fetal growth. Adapted from Davies MJ, D’Alessio DA, Fradkin J, et al. Diabetes Care 2018;41:2669–2701. “Diabetes technology” is the term used to describe the hardware, devices, and software that people with diabetes use to help manage blood glucose levels, stave off diabetes complications, reduce the burden of living with diabetes, and improve quality of life. For prevention and management of both ASCVD and heart failure, cardiovascular risk factors should be systematically assessed at least annually in all patients with diabetes. The Standards include the most current evidence-based recommendations for diagnosing and treating adults and children with all forms of diabetes. Shorter durations (minimum 75 min/week) of vigorous intensity or interval training may be sufficient for younger and more physically fit individuals. Adapted from Davies MJ, D’Alessio DA, Fradkin J, et al. B, ◦ Evaluate for diabetes complications and potential comorbid conditions. ASCVD—defined as coronary heart disease, cerebrovascular disease, or peripheral arterial disease (PAD) presumed to be of atherosclerotic origin—is the leading cause of morbidity and mortality for individuals with diabetes.
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