The American Diabetes Association released new standards of care on Monday to reflect changes in technology, improved medications and a better understanding of the social factors that contribute to disease and diabetes control.
The standards are updated every year, but this year includes nearly 100 new or revised recommendations for all types of diabetes.
The guidelines are available to doctors via an app as well as online. Last year, they were viewed more than 4 million times around the world, said Dr Robert Gabbay, scientific director and doctor of the diabetes association.
“The focus of our guidelines is really to reduce the burden of disease on people with diabetes,” said Dr. Nuha El Sayed, chair of the association’s professional practice committee, which developed the revisions. “It’s at the heart of what we do.”
In addition to changes to standards for weight control, blood pressure and cholesterol management, the revisions also aim to address racial disparities in care, El Sayed said.
Racial differences in diabetes have no biological basis, she said, and the guidelines are designed to “help people open their eyes to the huge disparities in care and outcomes.”
New tools, especially more effective weight-loss drugs that are coming onto the market, should allow patients with diabetes to better control their weight, Gabbay said.
Losing 15% of body weight, as opposed to the previously recommended 5%, should have more health benefits, he said.
“We now have better tools to achieve these goals, which makes them realistic,” Gabbay said.
The guidelines remain the same regarding diet and exercise, including eating a well-balanced diet and reducing processed foods and added sugar. “The lifestyle recommendations haven’t changed and they’re still very important,” he said.
Prevent cardiovascular and kidney diseases
Diabetes is the leading cause of heart disease, and heart disease is the leading cause of death for people with diabetes, Gabbay said.
According to the American College of Cardiology, the new guidelines include a lower target for blood pressure of less than 130 over 80. For LDL cholesterol, the wrong type, the new guideline calls for a measurement of 70 for people without heart disease. (down from 100) and 55 instead of 70 for those with established heart disease.
Gabbay noted that statins are extremely effective at lowering cholesterol levels and that other drugs can effectively lower blood pressure to achieve these goals.
“There are a number of studies showing that even lower goals lead to better outcomes for people with diabetes,” he said.
The guidelines also call for more aggressive treatment to prevent the progression of chronic kidney disease. “Diabetes continues to be the leading cause of end-stage kidney disease,” Gabbay said.
“There is both a societal need and, fortunately, scientific evidence to support the right treatments” for these conditions, he said.
Black Americans with diabetes are three to four times more likely to have an amputated limb than a white person with the same condition, Gabbay said, and the rate of amputations is getting worse, not better.
The new guidelines call for more careful screening for foot ulcers and peripheral arterial disease, both of which can lead to amputations.
Sleep is crucial
The quality and timing of sleep are important, Gabbay said. “Not too much and not too little,” he said. “Both are associated with poorer diabetes outcomes.”
Doctors should counsel their diabetic patients on good sleep habits and identify people who have sleep problems, according to new guidelines.
Many people with diabetes are prone to sleep apnea, a potentially dangerous condition in which a person briefly stops breathing while sleeping. Treating diabetes, especially with weight loss, can improve sleep apnea, and improving sleep apnea can help control diabetes, Gabbay said.
Addressing Social Factors
Everyone with diabetes should be screened for issues that may interfere with good diabetes management, such as food insecurity, living in a food desert with few options, or a “swamp food,” where only processed foods are readily available, he said.
“Educating people to eat healthy when they don’t have access to healthy foods is only going to create frustration,” Gabbay said.
“We want the whole diabetes healthcare team to be involved by asking people about food, but also about other things,” El Sayed added. “Have they lost their jobs? Do they live in a safe neighborhood – before they are told to exercise.
Studies have demonstrated the value of community health workers, especially for underserved and disadvantaged populations, in helping them adhere to medications and lifestyle changes, Gabbay said.
Improve access to technology
Doctors often assume older people aren’t comfortable with technology, so they don’t recommend high-tech treatments, such as automated insulin delivery devices and glucose pumps, Gabbay said. .
The new guidelines recommend instead that everyone be offered the latest technology, including older patients.
Black Americans and other people of color often have less access to advanced technologies than their white counterparts, he said, so the diabetes association has created a technology access program to strengthen the racial equity.
“Everyone should have access to technologies that can help them thrive with their diabetes,” Gabbay said.
When people receive technologies such as continuous blood glucose monitors, they often describe them as “transformative” and “game changers,” Gabbay said. “People of all ages – children, adults, older people with type 1, type 2, or any insulin dependency – should be offered continuous blood glucose monitors.”
Are the changes sufficient?
While the guideline changes are important and necessary, they are too little too late to adequately treat diabetes in black Americans, said Leon Rock, co-founder of the African American Diabetes Association.
Historically, the American Diabetes Association has been guilty of “despicable neglect” of black people with diabetes, he said. The association now pays lip service to their needs, but still does not provide sufficient financial support for their problems or for diabetes researchers at historically black colleges and universities, according to Rock.
“As the money goes in and out of the ADA, it continues to go to institutions like Yale, Harvard, Boston University and Boston College,” not historically black schools. The association is also not doing enough to tackle diabetes in public housing, he said.
“It’s a start,” Rock said, “but the bottom line is: getting started and actually doing are two different things.”
Contact Karen Weintraub at firstname.lastname@example.org.
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