American Diabetes Association's new care standards focus on increasing individualized care

The American Diabetes Association is recommending increasing amounts of individualized care in diabetes treatment in its revised Standards of Medical Care, published in a special supplement to the January issue of Diabetes Care.

The Standards of Medical Care are updated annually to provide the best possible guidance to health care professionals for diagnosing and treating adults and children with all forms of diabetes. The Standards are based upon the most current scientific evidence, which is rigorously reviewed by the association's multi-disciplinary Professional Practice Committee, the American Diabetes Association said.

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The revised recommendations include encouraging doctors to explore a variety of options when prescribing medication to treat neuropathy, considering two types of screening for gestational diabetes, and encouraging people with diabetes to work with a nutritionist or dietitian to identify an eating pattern that best fits their individual needs.

"Individualized care is becoming more important in the treatment of diabetes," said Richard Grant, MD, MPH, chair of the Professional Practice Committee and research scientist with the Kaiser Permanente Division of Research. "As the evidence base evolves, we are learning more about how to apply this data to our patients, and we're finding that the evidence often supports looking at individual patient needs rather than a one-size-fits-all approach."

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Treating diabetic neuropathy
For example, Grant said, treating neuropathy, or nerve damage that is often very painful, can be frustrating for both patients and doctors because it has no cure and no one drug affects all patients the same. The new standards encourage doctors to try a variety of medications when treating people with diabetes for this condition, and to carefully monitor how the patient responds to the drugs to ensure maximum relief.

"We need to include the patient more in choosing the best treatment options," Grant said, "to be sure we are getting the right dosage and minimizing use of drugs that cause adverse side effects."

Nutrition and diabetes
The new standards also call for individualized attention for all people with diabetes in choosing an appropriate eating pattern, said Patti Urbanski, Med, RD, LD, CDE, Diabetes Educator at Fond du Lac Human Services and a member of the Professional Practice Committee, as well as a member of the Association's Nutrition Position Statement Writing Committee.

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Urbanski said a review of the scientific evidence showed that no one eating pattern—such as a low-carb diet, or a high-carb, low-fat diet—was any better than another in the treatment of diabetes. However, the evidence did support greater use of dietitians and nutritionists in helping patients to lower their A1C levels. She said research found that those who received comprehensive, group diabetes education that included nutrition therapy were able to lower their A1C levels by up to 1 percentage point for people with type 1 diabetes and up to 2 percentage points for people with type 2 diabetes.

"Receiving Medical Nutrition Therapy and working with a dietitian is very important for people with diabetes," she said. "The evidence is stronger than ever."

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Gestational diabetes screening
Another change in this year's standards is the recommendation for which screening method to use to detect gestational diabetes. Previously, the standards recommended a one-step screening method endorsed by the International Association of the Diabetes and Pregnancy Study Groups (IADPGS). However, this past year another expert panel convened by the National Institutes of Health recommended a two-step process, in which a non-fasting test is given first, followed by a glucose tolerance test only for a subset of women whose glucose levels reach a certain threshold. Both panels reviewed the same data to reach their differing recommendations. Grant said the ADA committee reviewed the evidence supporting both recommendations and determined there was insufficient evidence at this time to recommend one over the other.

The new standards also:

Maintain support of the previous recommendation that people with diabetes limit their intake of sodium to 2,300 mg per day, the same amount recommended for people without diabetes. The Association recommends that people who have both diabetes and high blood pressure try to lower their intake further on an individualized basis.
Clarify that the A1C test, a non-fasting test that measures average blood glucose levels over a three-month period, is one of three appropriate methods for diagnosing diabetes.
Discourage the sole use of sliding scale insulin in the inpatient hospital setting.

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