What to Know About the 2021 Standards of Care for Type 2 Diabetes
What are the Standards of Care?
The ADA Standards of Care provides comprehensive, evidence-based recommendations for the diagnosis and treatment of people with type 1 diabetes (T1D), type 2 diabetes (T2D) and gestational diabetes. The full summary of revisions can be found here.
As a person with type 2 diabetes, it’s important for you to know how the chronic illness is treated and how health professionals determine when to introduce certain medications as type 2 progresses. Also, as the number one person on your healthcare team, we hope this summary of the latest Standards of Care inspires you to stay informed about type 2 diabetes and make your healthcare visits more productive.
What kind of information can you find in the Standards of Care?
The Standards of Care provides information on topics such as:
- The classification and diagnosis of diabetes
- Recommendations on the prevention or delay of type 2 diabetes
- Recommendations on diabetes management and other health-related risks such as cardiovascular disease and kidney disease
- Recommendations on facilitating behavior change and well-being to improve overall health outcomes
- Approaches to treating diabetes with medication
- Diabetes technology and glycemic targets
- Diabetes and pregnancy
- Obesity and diabetes
- Diabetes care in the hospital
- Diabetes advocacy
- Diabetes in older adults, adolescents and children
For the purposes of this guide, we’ll summarize the latest updates to the recommendations for people with type 2 diabetes, as well as prediabetes. To read the full report by the American Diabetes Association (ADA), you can find it here. Please contact your doctor to discuss any changes to your diabetes management plan.
What’s new for people with type 2 diabetes in the Standards of Care?
Improving Health Outcomes by Assessing Socioeconomic Conditions
How a person with type 2 diabetes is able to manage their condition can depend on their access to resources and care. In the new set of guidelines, the ADA recommends providers taking factors like food insecurity, housing security and homelessness, social support and other financial barriers when developing treatment plans for patients. Health inequities are related to the incidences of diabetes and its complications.
Classification and Diagnosis of Diabetes
ADA Recommends Screenings for Prediabetes and Diabetes for People with HIV
Patients with HIV should be screened for diabetes and prediabetes with a fasting blood glucose test before starting antiretroviral therapy, switching antiretrotherapy, or three to six months after starting or switching to it. If the results are normal, fasting blood glucose should be checked annually.
Prevention and Delay of Type 2 Diabetes
A new section called “Delivery and Dissemination of Lifestyle Behavior change” was added to the Standards of Care to provide further evidence for the need for national diabetes prevention programs, as well as using technology to deliver diabetes prevention lifestyle programs through smartphones, telehealth-based programs and web-based applications. Using these methods may be helpful to people in low-income or rural areas.
Treatment for Chronic Kidney Disease and Cardiovascular Disease
One of the key updates to the 2021 Standards of Care is the approach to address the risks of cardiovascular disease (CVD) and chronic kidney disease (CKD) for people with type 2 diabetes. While metformin is still the first recommended line of treatment for T2D, providers are encouraged to treat patients who are at risk or have a history of CVD or CKD with an SGLT-2 or GLP-1 RA, regardless if they’re on metformin or A1C goals.
Previously, the ADA Standards of Care had a subsection called “A1C,” but now this section has been renamed “Glycemic Assessments” to account for other measurements aside from A1C such as time-in-range from continuous glucose monitoring (CGM).
To learn more about CGM and type 2 diabetes, click here.
New recommendations include real-time, professional CGM technology useful for people with diabetes who are on multiple daily injections (MDI) or are using an insulin pump, regardless of age or type of diabetes. Professional CGM allows for patients to wear a CGM device, but the provider receives the data and can make changes to treatment plans based on it and communicate those changes to the patient. This remains a powerful tool to reduce the incidences of hypoglycemia (low blood sugar) while reaching one’s A1C goals, as well as correcting patterns of hyperglycemia (high blood sugar). There are also new guidelines to address issues related to skin reactions due to the adhesives on CGMs. Providers should assess and discuss potential skin issues with patients.
Insulin Pumps for Type 2 Diabetes
Insulin pumps can be considered for patients with T2D who are on MDI. Insulin pumps may help improve satisfaction for patients and simplify their diabetes management regimen.
Obesity and Type 2 Diabetes
The ADA is focusing on a patient-centered approach that encourages the use of nonjudgmental language regarding obesity. Obesity is a subject typically used to stigmatize individuals with type 2 diabetes. First-person language such as “person with obesity” instead of “obese person” to avoid defining patients by their condition. Other ways the ADA is focusing on improving discussions surrounding obesity is by reminding providers to be mindful of past stigmatizing experiences of patients. Providers should ensure that weight measurements are reported without judgment and ensure privacy during weighing for patients who display high levels of weight-related distress.
Older Adults and Diabetes
A reasonable A1C goal for older adults with diabetes who are healthy and have few other chronic illnesses is now <7.0-7.5 percent (53-58 mmol/mol). Those with multiple chronic illnesses, cognitive impairment should have less stringent goals such as an A1C <8.0-8.5 percent (64-69 mmol/mol). The care of older adults with diabetes is complex due because they have higher rates of premature death and other illnesses than those without diabetes. Healthcare professionals also have to take into account other health conditions that come with age such as cognitive impairment (i.e. memory loss), the need for multiple medications, depression, bone health and decreased bladder function.
Children/Adolescents and Type 2 Diabetes
Recent estimates suggest about 5,000 new cases of T2D in youth in the United States. The Centers for Disease Control and Prevention (CDC) projects the prevalence of diabetes in people under the age of 20 will quadruple over the next 40 years.
Type 2 diabetes in children is also more progressive than in adults due to a more rapid decline in beta-cell function and acceleration in complications. Children of color are disproportionately impacted due to socioeconomic reasons. New changes from the ADA to address prediabetes and T2D in youth are recommending 60 minutes of exercise daily, with bone and muscle strength training at least three days per week.
- The ADA’s Standards of Care provides guidelines for healthcare professionals on how to treat patients with diabetes.
- New updates to the 2021 report include:
- Acknowledgments that there are other important ways to track glycemic progress other than A1c.
- People with type 2 diabetes who are at-risk for CVD and CKD should be treated with an SGLT-2 or GLP-1, regardless of A1c or metformin use.
- Professional CGM is beneficial for any person with diabetes on insulin.
- Nonjudgmental language is encouraged to prevent stigmatize people with obesity.
- New evidence shows the importance of diabetes prevention programs.
- In older adults, A1C goals are less stringent for older adults with multiple health conditions compared to older adults without.
- In youth, exercise requirements are more defined for daily physical activity.