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ADA, others provide important takeaways from 2019 diabetes guidelines
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Among the changes in the 2019 American Diabetes Association’s Standard of Care guidelines are a greater focus on patient-centered care, a new way to assess CV risk, and an extended section on technological options for patients with diabetes and their clinicians, experts told Healio Family Medicine.
These are critically important areas for the primary care physician to be versed in, according to the American Diabetes Association.
“A majority of people with diabetes are treated at the primary care level, so it is very important for these professionals to have the latest research on diabetes,” William T. Cefalu, MD, the ADA’s chief scientific and medical officer, said in an interview.
Healio Family Medicine recently asked Cefalu, Arch G. Mainous III, PhD, department chair of health services research, management and policy at the University of Florida, and Betul Hatipoglu, MD, an endocrinologist in Cleveland Clinic’s Endocrinology and Metabolism Institute, to discuss the important takeaways for PCPs from the guidelines.
Patient - centered care
Whereas past guidelines have focused more on medication recommendations and treatment regimens, this year’s clinical practice recommendations take a more comprehensive view of diabetes management, with a focus on the patient’s experience at each step.
“This is a paradigm change for management of diabetes. We want PCPs and patients to have an open, two-way conversation about prevention, diagnosis, treatment — every aspect of diabetes care-and have the patient be an integral part of the decision,” he said in an interview.
“We recommend thorough discussions between doctor and patient about lifestyle, exercise, nutrition and other well-established measures to prevent and manage diabetes. These patient-centered conversations should continue when discussing medication use and other issues regarding co-existing disease states such as heart disease, etc.”
“There should be discussions regarding compliance or issues related to adherence to medication. These two-way conversations must continue onto treatments with extensive two-way discussions regarding adverse events and cost. These treatment-related conversations should occur at least once annually, or more frequently if there have been any changes in the patient’s health status,” Cefalu continued.
Greater focus on strength training
While healthy weight has been a medical tenet towards preventing diabetes for some time, the consensus of what level of exercise can help achieve that healthy weight is changing, Mainous told Healio Family Medicine.
“For a long time, people have concluded that exercise and being non-sedentary is just walking,” he explained. “But there is a growing amount of data that suggest lean muscle mass from resistance training, resistance exercise, is just as important in patients with diabetes. These 2019 guidelines give this revelation the attention it deserves.”
The guidelines state that:
- All adults, particularly those with type 2 diabetes, should decrease the amount of time spent in daily sedentary behavior. Prolonged sitting should be interrupted every 30 minutes for blood glucose benefits, particularly in adults with type 2 diabetes. (‘B’ level recommendation in all patients; ‘C’ level recommendation in type 2 patients).
- Children and teenagers with type 1 or type 2 diabetes or prediabetes should participate in moderate- or vigorous-intensity aerobic activity at least 60 minutes per day and participate in vigorous muscle-strengthening and bone-strengthening activities at least 3 days per week (‘C’ level recommendation).
- Most adults with type 1 and type 2 diabetes should participate in at least 150 minutes or more of moderate-to-vigorous intensity aerobic activity each week spread over at least 3 days per week and go no more than 2 consecutive days without activity. Younger and more physically fit patients may find durations of 75 minutes per week of vigorous intensity or interval training sufficient (‘C level recommendation in type 1 patients; ‘B’ level recommendation in type 2 patients).
- Adults with type 1 and type 2 diabetes should participate in two to three sessions per week of resistance exercise on nonconsecutive days. (‘C level recommendation in type 1 patients; ‘B’ level recommendation in type 2 patients).
- Older adults with diabetes should participate in flexibility training and balance training two to three times per week. Tai chi and yoga may be included based on the patient’s preferences to increase balance, muscular strength and flexibility. (‘C’ level recommendation)
Glucose levels not the only consideration
According to Hatipoglu, past guidelines categorized all patients solely by their A1C level, with little consideration for individual patients’ unique circumstances.
However, the 2019 guidelines look beyond those levels, she said.
“As a practicing clinician, I knew that some levels would be impossible for patients to reach, no matter how hard they tried. Yet, patients and their physicians would still be chided if the recommended levels could not be reached,” Hatipoglu continued. “These new guidelines are a breath of fresh air in that they acknowledge that a patient’s diabetic status is more than just a number.”
New CV assessment tool
According to the ADA, atherosclerotic cardiovascular disease is the leading cause of morbidity and mortality in patients with diabetes and results in an estimated $37.3 billion in CV-related spending per year. Cefalu said these statistics underscore the importance of knowing who is at risk for atherosclerotic cardiovascular disease.
“The ADA now endorses using ASCVD Risk Estimator Plus — the American College of Cardiology’s atherosclerotic cardiovascular disease risk calculator,” Cefalu said. “With CVD emerging as a major complication from diabetes, it is more important than ever that PCPs assess this risk in their patients.”
Endorsements such as these can avoid confusion among PCPs who previously had to weigh multiple societies’ statements when assessing atherosclerotic cardiovascular disease risk, Hatipoglu noted.
“Sometimes, multiple societies provide different recommendations on the same topic,” she said.
“This caused inadvertent misunderstandings among PCPs, who must be versed in many areas of care. If similar conflicts occur, a PCP should use the guidelines from the group that aligns closest to their area of expertise when societies are inconsistent,” Hatipoglu added.
Treatment recommendations
The guidelines provide a ‘C’ level recommendation regarding the use of SGLT-2 inhibitors or GLP-1 receptor agonists in patients with type 2 diabetes and chronic kidney disease to reduce their risk for chronic kidney disease progression and/or cardiovascular events. This is the first time any type of recommendation for this patient population has been offered, according to the ADA.
The guidelines also provide these treatment updates:
- SGLT-2 inhibitors or GLP-1 receptor agonists should be prescribed to patients with type 2 diabetes with established atherosclerotic cardiovascular disease as part of the antihyperglycemic regimen (‘A’ level recommendation).
- SGLT-2 inhibitors should be prescribed to patients with atherosclerotic cardiovascular disease at high risk for heart failure or in whom heart failure coexists (‘C’ level recommendation).
In addition, the guidelines provide an algorithm to steer treatment decisions involving older patients, whether the patient uses long- or intermediate-acting insulin, mixed insulin, or short or rapid-acting mealtime insulin.
More details on technological treatment options
The guidelines’ new section on technology provides recommendations on insulin delivery, blood glucose meters, continuous glucose monitors and automated insulin delivery devices and also discusses remote delivery of health-related services and clinical information via telemedicine, according to Cefalu.
“We used to put the information on related technologies as part of each corresponding chapter,” he explained. “However, technology is evolving at such a rapid rate that we want to give it special attention and thus created an entire section on it. New technologies will be emphasized in this way moving forward.”
Hatipoglu welcomed the attention paid to telemedicine, adding that it helps with the American Diabetes Association goal of making patients the center of care.
“Patients cannot be passive when it comes to preventing, diagnosing or treating diabetes, or any other medical condition. They must be educated and involved. Some patients may be hundreds of miles away from their clinician or diabetes educator, so the technology can fill that void,” she said.
Mainous expressed concerns that the guidelines do not address what he deemed “important” questions about telemedicine.
“From a patient perspective, how will you help those who don’t want anything that’s not a face-to-face visit? From a reimbursement perspective, who’s going to pay for this?” – by Janel Miller
For more information:
American Diabetes Association. “Standards of medical care.” http://care.diabetesjournals.org/content/42/Supplement_1
American Diabetes Association. “Standards of medical care: Abridged for primary care physicians.” http://clinical.diabetesjournals.org/content/early/2018/12/16/cd18-0105.
Disclosures: Hatipoglu reports being a speaker for Merck and a consultant for Novo. Mainous reports no relevant financial disclosures. Healio Family Medicine was unable to confirm Cefalu’s relevant financial disclosures prior to publication.