Revisions and Additions to the ‘Standards of Medical Care in Diabetes’
By Janice H. Dada, MPH, RD, CSSD, CDE, CHES
Every year, the American Diabetes Association (ADA) publishes revisions to the “Standards of Medical Care in Diabetes” in one or more of its journals to help health professionals maintain best practices. This year the association made several revisions to the practice recommendations. The following highlights some of the major changes relevant to RDs.
The 2010 version includes a section on cystic fibrosis (CF)-related diabetes in “Diabetes Care in Specific Populations.” Diabetes is the most common comorbidity in patients with CF, occurring in 20% of adolescents and 40% to 50% of adults. The additional diagnosis of diabetes in this population is associated with poor nutritional status, increased severity of lung disease, and greater mortality. In addition, for reasons not well understood, women with CF-related diabetes are particularly vulnerable to excess morbidity and mortality. Insulin deficiency related to destruction of the islet cell mass is the primary defect in CF-related diabetes.
New data suggest that early detection and aggressive insulin therapy have narrowed the gap in mortality between CF patients with and without diabetes and have eliminated the gender difference in mortality. Recommendations for the management of this condition will be published in a consensus report later this year.
Diagnosis of Diabetes
Major changes to the criteria for diagnosing diabetes have been made this year. Most notably, clinicians can now use hemoglobin A1C to diagnose diabetes, with a cut point of greater than or equal to 6.5%. To make a diagnosis using A1C, the test should be performed in a laboratory using a method certified by the National Glycohemoglobin Standardization Program and standardized to the Diabetes Control and Complications Trial assay.
The section of the standards previously titled “Diagnosis of pre-diabetes” has been renamed “Categories of increased risk for diabetes.” An A1C range of 5.7% to 6.4% has been included as a category of increased risk of future diabetes.
Detection and Diagnosis of Gestational Diabetes Mellitus
The standards have been revised to discuss potential changes in the diagnosis of gestational diabetes mellitus (GDM) based on international consensus.
Currently, about 7% of all pregnancies are complicated by GDM. Recommendations call for GDM screening using risk-factor analysis and, if appropriate, the 100-g oral glucose tolerance test (OGTT). Women with GDM should be screened for diabetes six to 12 weeks postpartum and should be followed up with subsequent screening for the development of diabetes or prediabetes.
The International Association of Diabetes and Pregnancy Study Groups (IADPSG) has recommended that high-risk women found to have diabetes at their initial prenatal visit using standard criteria receive a diagnosis of overt, not gestational, diabetes. In addition, the association has recommended that all women not known to have prior diabetes undergo a 75-g OGTT at 24 to 28 weeks of gestation. The group developed new diagnostic cut points for fasting, one-hour, and two-hour plasma glucose measurements.
The ADA is planning to work with U.S. obstetrical organizations to consider adopting the IADPSG’s diagnostic criteria and to discuss the implications of this change. While it is expected to significantly increase the prevalence of GDM, there is increasing evidence that treating even mild GDM will reduce morbidity for both mother and baby.
The standards have revised antiplatelet recommendations to reflect the findings of recent trials questioning the benefit of aspirin for the primary prevention of cardiovascular disease (CVD) in low- or moderate-risk patients. The new recommendation is to consider aspirin therapy at 75 to 162 mg per day as a primary prevention strategy in those with diabetes who are at increased cardiovascular risk (10-year risk greater than 10%). This includes men aged 50 and older and women aged 60 and older with at least one additional major risk factor (eg, family history of CVD, hypertension, smoking, dyslipidemia, albuminuria).
Diabetes Self-Management Education
The standards have revised this section to reflect new evidence. The overall recommendation is that people with diabetes receive diabetes self-management education according to national standards when diagnosed and as needed thereafter. In addition, the standards recommend that diabetes self-management education address psychosocial issues and that self-management effectiveness and quality-of-life outcomes be measured and monitored as part of diabetes care. Diabetes self-management education has been found to reduce medical costs and improve outcomes and thus should be reimbursed by third-party payers.
Strategies for Improving Diabetes Care
The implementation of the standards of care for diabetes has been suboptimal in most clinical settings. Only about 12% of people with diabetes meet treatment goals for glucose, blood pressure, and lipids.
Practices that address more of the chronic care model elements demonstrate lower A1C levels and lower cardiovascular scores. The chronic care model includes five core elements for the provision of optimal care for patients with chronic diseases: delivery system design, self-management support, decision support, clinical information systems, and community resources and policies. Redefining a clinic staff’s role and promoting patient self-management are fundamental to successful chronic care model implementation.
The National Diabetes Education Program maintains an online resource (www.betterdiabetescare.nih.gov) that healthcare professionals should utilize to design and implement more effective healthcare delivery systems.
Diabetes Care in the Hospital
The standards suggest that insulin therapy should be initiated for treatment of persistent hyperglycemia in patients who are critically ill beginning at a threshold of 180 mg/dL. Once insulin therapy is initiated, a glucose range of 140 to 180 mg/dL is recommended for the majority of patients who are critically ill. These patients require an insulin protocol with demonstrated safety and effectiveness in achieving the desired glucose range without increasing risk for severe hypoglycemia.
— Janice H. Dada, MPH, RD, CSSD, CDE, CHES, is a dietitian in private practice, college nutrition instructor, and freelance writer based in southern California.