Diabetes Standards of Care Updated for Preventing or Delaying Type 2 Diabetes
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The American Diabetes Association’s Standards of Medical Care for Diabetes is “all of ADA’s current clinical practice recommendations and is intended to provide clinicians, patients, researchers, payers, and others with the components of diabetes care, general treatment goals, and tools to evaluate the quality of care.”
Presentation: Prevention or Delay of Type 2 Diabetes and Associated Comorbidities
Speakers at this ADA Scientific Sessions presentation included: Florence M. Brown, MD (Joslin Diabetes Center), Vanita R. Aroda, MD (Brigham and Women’s Hospital), Gretchen Benson, RDN, CDCES (Minneapolis Heart Institute Foundation) Jane Reusch, MD (University of Colorado Anschutz Medical Campus).
How are the standards of care (SOC) updated?
At the beginning of the session, Dr. Florence Brown gave an overview of the process of updating the SOC. The process is carried out by the SOC professional practice committee, a multidisciplinary team of diabetes. Updates to the SOC are published every January and are made in response to newly available treatments and new research evidence that supports new recommendations.
The Three Key Elements of the SOC Development include:
- Evidence: Members search through the scientific diabetes research literature and create recommendation revisions per any new evidence.
- Process: All members agree on proposed revisions and submit them to the ADA’s Board of Directors for approval.
- Funding: SOC development is funded by ADA, with no industry support.
Who are the updates for?
When discussing the updates to the SOC, Dr. Vanita R. Aroda raised the very important question of “in whom are we aiming to prevent or delay type 2 diabetes?”
Many clinical trials studying the progression of type 2 diabetes from prediabetes did not include diverse age and ethnic groups, explained Aroda. In the initial Diabetes Prevention Program (DPP) study, the participants met the following eligibility criteria:
- Over age 25
- High-risk: impaired glucose tolerance based on two-hour post-glucose testing
- Fasting glucose between 95 to 125 mg/dL (American Indians below 125 mg/dL)
- Body mass index greater than 24 kg/m (Asians greater than 22 kg/m)
This study showed that incident rates of diabetes were decreased in patients on metformin or who underwent intensive lifestyle changes.
From this study, the SOC was updated to focus on individualized care that is based on the individual risk/benefit assessment with the goals of:
- Weight loss or prevention of weight gain
- Minimizing progression of hyperglycemia
- Attention to cardiovascular risk and associated comorbidities
What do these updates look like in practice?
The DPP study showed that intensive lifestyle changes did help prevent type 2 diabetes development, but Gretchen Benson, RDN, CDCES, stated that action plans to achieve these behavioral changes should be based on patient preferences.
One way of incorporating patient preferences includes updating the SOC to include other types of programs like certified tech-assisted diabetes prevention programs. Diabetes prevention programs can be in-person, online, or a combination of both—and can be found on the CDC website.
Personalized Nutrition
While there is no recommended one-size-fits-all approach to nutrition, the following guidelines should be considered for each individual:
- Eating habits
- Personal preference
- Metabolic goals
- Eating patterns recommended (Mediterranean diet, low carb, veg, DASH)
The types of eating patterns should be used as a conversation starter for healthcare providers and the patient to make the decision together.
Mediterranean-style: Plant-based foods, including vegetables, beans, nuts, seeds, fruits, whole grains, fish, olive oil, dairy and eggs.
- Reduced risk of diabetes
- Reduced A1c
- Lowered triglycerides
- Reduced risk of major cardiovascular events
Vegetarian or vegan: Plant-based vegetarian eating devoid of all flesh foods but including egg and/or dairy products; or vegan eating devoid of all animal-derived products.
- Reduced risk of diabetes
- Reduced A1c
- Promoted weight loss
- Lowered LDL & HDL cholesterol
Low-fat: Emphasized vegetables, fruits, starches, grains, starchy vegetables, lean protein and low-fat dairy; total fat < 30% and saturated fat <10% of calories.
- Reduced risk of diabetes
- Promoted weight loss
Low-carbohydrate: Emphasizes animal/plant proteins, vegetables low in carbohydrates, and fat from animal foods, oils and avocado; avoids starchy and sugary foods; total carb 26-45% of calories.
- Reduced A1c
- Promoted weight loss
- Lowered blood pressure
- Increased HDL cholesterol
- Lowered triglycerides
Very-low carbohydrate: Similar to a low-carbohydrate pattern but further limits carbohydrate-containing foods to 20-50 grams per day.
- Reduced A1c
- Promoted weight loss
- Lowered blood pressure
- Increased HDL cholesterol
- Lowered triglycerides
DASH (dietary approaches to stop hypertension): Emphasizes fruits, vegetables, whole grains and lower-fat dairy; limits saturated fat, added sugars and sodium.
- Reduced risk of diabetes
- Promoted weight loss
- Lowered blood pressure
Benson also emphasized that the quality of food is key for prevention. Foods that are whole, fresh, minimally processed, low in added sugar and non-starchy veggies were best. Additionally, replacing sugary beverages with water and considering portion sizes and calories for each individual was also helpful.
The overall goals of nutrition therapy are:
- Emphasize high-quality whole foods
- Optimize nutrition to reach weight, blood pressure and cholesterol goals
- Maintain pleasure of eating (don’t remove food groups just to remove)
- Provide practical tools (plate method, reading nutrition labels, etc.)
Other SOC nutritional recommendations included having providers refer patients to see a registered dietitian for further support.
Physical Activity Recommendations
DPP study results showed that any physical activity, regardless of whether the patient lost weight or not, still helped prevent or delay type 2 diabetes (T2D). Therefore, the updated SOC physical activity recommendations include:
- 150 minutes per week at moderate intensity
- Resistance training may add benefit
- Breaking up prolonged sedentary time
Current prevention methods aren’t working
Although the SOC updated recommendations focus on helping patients achieve certain health goals in order to prevent or delay T2D, Dr. Jane Reusch stated that past attempts at prevention are failing.
“The bigger picture in prevention is that we’re not preventing diabetes” Reusch stated.
The diabetes epidemic in the United States has still increased over the past six years—from 30.3 million to 37.3 million people diagnosed.
Reusch emphasized that the earlier a person is diagnosed with diabetes, their risk of developing complications is greatly increased.
Having these goals is important for helping patients prevent or delay the onset of T2D, but Reusch claimed that providers need to be realistic about the individual. The SOC needs to be updated to consider the context of the patient and meeting them where they are.
Providers need to determine social determinants of health for each individual when deciding on management plans.
Including:
- Economic stability
- Social and community context
- Adequate health care
- Education
- Neighborhood and environment
“Without equitable care, we will not slow the diabetes epidemic,” Reusch said.
Reusch also stated that it is important for providers to identify people at risk for limitations in their social determinants of health that are going to interfere with their ability to prevent and/or delay the onset of diabetes and its associated complications.
