Every year the American Diabetes Association (ADA) puts out an updated Standards of Medical Care approved by their board of directors which is their official position and provides all of their current clinical practice recommendations.
In this year’s Standards they state that “To update the Standards of Care, the ADA’s Professional Practice Committee (PPC) performs an extensive clinical diabetes literature search, supplemented with input from ADA staff and the medical community at large.” they update it each year or as needed online based on incoming evidence or regulatory changes.
It should be noted that most current Standards supersedes all previous ADA position statements.
Citing the way the field of diabetes moves quickly, the 2018 Standards of Care reveals the following major revisions:
Limits of A1c and Diagnostic Recommendations
Since recent evidence shows limits to A1c measurements because of hemoglobin variants among individuals, conditions that affect red blood cell turnover, and assay interference, recommendations have been “added to clarify the appropriate use of the A1C test generally and in the diagnosis of diabetes in these special cases,” states the ADA.
The ADA now recommends pre-diabetes and type 2 diabetes screening in children and teens who are overweight or obese and have one or more additional risk factors.
Comprehensive Medical Evaluation and Comorbidities
Components of a comprehensive medical evaluation now includes “information about the recommended frequency of the components of care at both initial and follow-up visits.”
The ADA added information about “the importance of language choice in patient-centered communication.”
They also now recommend healthcare providers consider checking serum testosterone levels in men with diabetes who have signs/symptoms of hypogonadism.
Dietary Clarification
The ADA stresses a clarification regarding nutrition: the ADA states that “there is no universal ideal macronutrient distribution and that eating plans should be individualized.” They have also included text to “address the role of low-carbohydrate diets in people with diabetes.”
On this point the Standards state, “The role of low-carbohydrate diets in patients with diabetes remains unclear,” They write that some of this confusion is due to different definitions of low-carb diets. “While benefits to low-carbohydrate diets have been described, improvements tend to be in the short term and, over time, these effects are not maintained,”
They concede that some studies show “modest benefits of low-carbohydrate or ketogenic diets” which entail under 50 grams of carbohydrate per day and say that ” this approach may only be appropriate for short-term implementation (up to 3–4 months) if desired by the patient, as there is little long-term research citing benefits or harm.”
The ADA does recommend children and adults with diabetes to reduce their intake of refined carbohydrates and added sugars and to get carbohydrates from vegetables, legumes, fruits, dairy, and whole gains. They write that the “consumption of sugar-sweetened beverages and processed “low-fat” or “nonfat” food products with high amounts of refined grains and added sugars is strongly discouraged,”
CGM Recommendation
Considering the latest data, the ADA now recommends the use of CGM (continuous glucose monitoring) in adults with type 1 diabetes to all adults ages 18 and up who are not meeting their glycemic targets (recommendation was previously for age 25 and up).
Drug Recommendations for Blood Sugar Treatment
Recommendations have been added due to data from the recent cardiovascular outcomes trial (CVOT) which shows that people with atherosclerotic cardiovascular disease should start with lifestyle management treatments plus metformin and “subsequently incorporate an agent proven to reduce major adverse cardiovascular events and/or cardiovascular mortality after considering drug-specific and patient factors.”
Managing Blood Pressure from Home
All patients with high blood pressure are now recommended to monitor their blood pressure at home to find out if they have “masked or white coat hypertension” and to help motivate patients to take their hypertension medication via awareness of elevated blood pressure.
Caution in Older Adults
New recommendations have been added to indicate how important individualized drug therapy is in older adults in order to lower the risk of low blood sugar episodes and to avoid over-treatment, as well as simplifying complicated regimens if at all possible while keeping the A1c target.
Pregnancy and Diabetes
A new recommendation emphasizes that insulin is “the preferred agent for the management of type 1 and type 2 diabetes in pregnancy.”
Citing new evidence, the ADA now recommends that pregnant women with type 1 and type 2 diabetes take a low-dose aspirin beginning at the end of the first trimester for the purpose of lowering the risk of developing preeclampsia.
Diabetes Care in Hospital
Insulin degludec (Tresiba) has been added to the insulin dosing for enteral/parenteral feedings.
For all the revisions visit the Summary of Revisions. For the pdf of the 2018 Standards of Care go here.
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