Exploring the New 2017 Diabetes Standards of Care

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Our correspondent Wil Dubois takes a close look at the newest Standards of Care guidelines, released each year by the American Diabetes Association, on how medical professionals should be treating PWDs (people with diabetes) in the coming year.

You might think that something known as the annual "Standards of Care" would be a boring read, but it contains some juicy points that impact people with diabetes and how their medical professionals are telling them to manage their illness.

Just some of the newest aspects of this year"s guidance released recently by the American Diabetes Association touch on the psychosocial aspects of life with diabetes, CGM access, high insulin prices, better screening to diagnose diabetes early, and even insurance coverage of diabetes shoes.

Welcome to 2017 in diabetes, everyone.

As it does every year, the ADA has updated its recommendations on how to properly care for people of all ages with diabetes: type1, type 2, gestational, and pre-diabetes. This year’s Standards of Medical Care in Diabetes run full 135 pages, aimed at informing both specialists and primary care providers on the latest in treating diabetes.

Continuing the trend of the last few years, this year’s standards are flexible and recognize (as the patient community has for years) that Your Diabetes May Vary (YDMV). New this year, however, is a whole new -- and long overdue -- emphasis on the patient and the patient’s circumstances.

The science and art of medicine come together when the clinician is faced with making treatment recommendations for a patient who may not meet the eligibility criteria used in the studies on which guidelines are based. Recognizing that one size does not fit all, the standards presented here provide guidance for when and how to adapt recommendations for an individual. Standards of Medical Care in Diabetes 2017

Standards Setters

ADA Report Cards Unlike some orgs, the ADA goes to considerable effort to ensure that their guidelines are evidence-based. They even assign “grades” to the strength of evidence behind each guideline, from A to... E?

• A = “clear evidence from well-conducted, generalizable randomized controlled trials”
• B = “supportive evidence from well-conducted cohort studies"
• C = “supportive evidence from poorly controlled or uncontrolled studies”
• E = the hotly contended “expert consensus,” which sometimes proves correct over time, but not always

This grading system is highly useful to docs and patients alike. And just like in school, the grades can change to keep up with evolving science and knowledge in diabetes care.

We’ll take a look at the changes this year, but first, who are the men and women who set the standards that dictate how we should be cared for?

The standards are assembled by the ADA’s Professional Practice Committee, admittedly not a group widely renowned for wild parties. But still, it’s not just a bunch of white-haired endos. The committee is heavy on MDs, but also includes diabetes educators and registered dietitians.

But no patient voices.

Still, while this is high science, attention to real life got a surprising shot in the arm from the experts this year.

So What’s New?

The biggest change, despite the apparent lack of patient voices in the process, is a new focus on the fact that people with diabetes are… well… people. Last year the ADA released a position statement on what it calls the “psychosocial” aspects of diabetes care, and this year’s Standards have been updated to match. The Standards instruct medical providers to address psychosocial issues in “all aspects of care including self-management, mental health, communication, complications, comorbidities, and life-stage considerations."

Specifically, providers are urged to access:

• Food insecurity (a nice way of saying people might not be able to afford to eat well)
• Housing stability
• Financial barriers

The Standards state that, “Treatment decisions should be timely, rely on evidence-based guidelines, and be made collaboratively with patients based on individual preferences, prognoses, and comorbidities.” It further states that patient-centered care (all the rage nowadays) be “defined as care that is respectful of and responsive to individual patient preferences, needs, and values.” Providers are also advised to “consider the burden of treatment” when designing therapies.

But there’s more. Docs are instructed to use community resources and provide self-management support from lay health coaches, navigators, or community health workers when available.

Medical Specifics

This year’s Standards introduces a new staging scheme for T1, breaking the disease down into three stages of development, which we explained in detail here at DiabetesMine in early January.

Other changes include recommendations to:

• Add education on fat and protein counting in addition to carb counting for PWDs using fast-acting insulin.
• Access sleep patterns as part of medical exams because of emerging evidence showing a link between sleep quality and diabetes control.
• Periodically screen metformin users for Vitamin B12, as expanding evidence is showing a relationship between metformin use and B12 deficiency.
• Screen for diabetes in dental practices.
• Screen for full-blown diabetes in women who had gestational diabetes earlier to better coincide better with the typical postpartum obstetrical check up.
• Establish a new blood pressure target of 120-160 over 80-105 for pregnant women to balance “maternal health” without “risking fetal harm.”

As to diabetes medications, the new Standards:

• Give a blessing for basal insulin + GLP1 as being as good as MDI (multiple daily injections) for type 2s
• Expand acceptable classes of high blood pressure meds for cardiovascular disease.
• Add autoimmune diseases, HIV, anxiety disorders, depression, disorder eating behavior, and serious mental illness to the official list of comorbidities of diabetes.
• Redefine “clinically significant hypoglycemia” as below 54 mg/dL, so if you happen to tow the line on the low side, take note of that hypo threshold.
• Recommend that patients avoid prolonged sitting and get bursts of physical activity every 30 minutes.
• Rep-brand bariatric surgery has as metabolic surgery (to emphasize metabolic control over simple weight-loss goals).

Advocacy Through Standards

And finally, sometimes the ADA seeks to right injustice through their Standards, and this year is no exception.

Insulin Prices: No doubt, high insulin prices have been a hot topic this past year. The ‘Mine has had a bunch of news coverage on that affordability issue, and the ADA has taken steps to bump up its advocacy efforts on this front -- including its new MakeInsulinAffordable.org advocacy hub online. The org also makes mention of this priority in its new Standards.

The ADA modified all its treatment algorithms to “acknowledge the high cost of insulin.” The Standard document states, “There have been substantial increases in the price of insulin over the past decade and the cost-effectiveness of different antihyperglycemic agents is an important consideration when selecting therapies.”

In fact, the Standards include charts showing the estimated average monthly cost of therapy for virtually all diabetes meds. It’s great to see the ADA recognizing how much cost is a factor when it comes to diabetes care, and emphaizing that it"s something medical professionals must be aware of.

CGM Access: The ADA Standards also discuss the importance of CGM, stating, “As people with type 1 or type 2 diabetes are living longer, healthier lives, individuals who have been successfully using CGM should have continued access to these devices after they turn 65 years of age.” Remarkably, that"s now actually happening within just a month following the release of these new ADA guidelines, as the Centers for Medicare and Medicaid Services (CMS) issued a case-by-case policy decision that the agency can start covering CGMs for PWDs on Medicare. It"s not all finalized how exactly that coverage will work, but it is a huge step in the right direction to getting more widespread coverage!

Diabetes Shoes: And in a similar way, the new Standards take a stand on diabetic shoes (so to speak), adding a new section highlighting the benefits of diabetic shoes for PWDs at risk of foot problems—likely in response to declining insurance coverage for diabetic footwear over the last few years.

These recommendations remind me of 2013, when the ADA struck back at payors who limited test strips based on loose wording of the old Standards, and spelled out that many patients “require testing 6-8 times daily.” At the time I had hoped that would change the common insurance limit of three strips per day, but it didn’t happen

Will the new 2017 Standards change how insurance companies act when it comes to CGMs and shoes? I doubt it, but at least you’ll have the ADA, and the Standards of Care, in your corner when you’re appealing an insurance denial.

What do you think, Diabetes Community, about these new ADA Standards?

Disclaimer: Content created by the Diabetes Mine team. For more details click here.

Disclaimer

This content is created for Diabetes Mine, a consumer health blog focused on the diabetes community. The content is not medically reviewed and doesn"t adhere to Healthline"s editorial guidelines. For more information about Healthline"s partnership with Diabetes Mine, please click here.

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