A New Emphasis on Individualized Treatment for Diabetes
The American Diabetes Association 2022 Standards of Care include new screening protocols, individualized care and the increasing use of technologies
Maybe you've been living with diabetes for years, or perhaps you were recently diagnosed. Or maybe you're one of the 8.5 million (23%) of U.S. adults, according to Centers for Disease Control (CDC) estimates, who have diabetes and are undiagnosed. The CDC also estimates that 96 million people age 18 and over have prediabetes, with the majority not knowing it. If pandemic fears have kept you from regular medical visits and an annual check-up, get that appointment scheduled now.
Wherever you fit on this continuum, the American Diabetes Association 2022 Standards of Care has copious amounts of information for providers, patients and family members.
The CDC also estimates that 96 million people age 18 and over have prediabetes, with the majority not knowing it.
According to Dr. Robert Gabbay, chief medical and scientific officer of the American Diabetes Association, this year's guidelines focus on four key areas, which include:
1. New screening protocols. The ADA now recommends universal screening starting at age 35, and age 18 for young adults with risk factors such as obesity. New guidelines were added for pregnant women and for those planning a pregnancy.
2. The importance of individualizing care, including how you and your health care providers collaborate to decide on your most appropriate goals and treatments.
3. An expanded view of comorbidities (other medical conditions) and how those are factored into treatment strategies.
4. New emphasis on the increasing use of technologies.
Individualized Care for Diabetes
The 2022 National Standards identifies the importance of providing person-centered services which embrace cultural differences, social determinants of health, and health equity to reduce health disparities.
The choice of devices for diabetes management should be based on patient circumstances, desires and needs as well as financial and insurance concerns. Diabetes self management and support is an important component of individualizing care, giving people the knowledge and skills to make informed decisions, and to cope with the emotions and life stresses — known as diabetes distress.
Gabbay states that Certified Diabetes Care and Education Specialists (CDCES), whose services are covered by Medicare, are an extremely underutilized resource, used by only about 5% of people with diabetes. These specialists can help with everything from understanding how to use devices and using the information garnered from them to recognize patterns, to developing strategies to improve blood glucose control and identifying cost-savings programs.
Comorbidities and How They Affect Treatment Decisions
This year, there is a new recommendation for managing blood glucose levels for people newly diagnosed with type 2 diabetes who have comorbidities (coexisting medical conditions).
Metformin, usually taken with meals one to three times a day, has long been the first-line therapy for managing diabetes. It is still extremely useful since it helps to lower blood glucose levels, decreases the amount of glucose absorbed from your food and reduces the amount of glucose made by your liver. It also increases your body's response to insulin and has been shown to reduce mortality.
But for anyone who currently has, or is at risk for, chronic kidney disease, atherosclerotic cardiovascular disease or heart failure, there are benefits to taking an SGLT2 inhibitor and/or GLP-1 receptor agonist.
These are two classes of drugs that are part of the glucose-lowering regimen and comprehensive cardiovascular risk reduction; examples are Ozempic (Semaglutide) and Trulicity (Dulaglutide). These drugs can be used along with, or in place of, Metformin. The new guidelines also include additional recommendations for managing high cholesterol and hypertension.
The Use of Diabetes Technology
Diabetes technology includes the hardware, devices, and software used to help manage the condition. This includes insulin delivery technology such as insulin pumps and connected insulin pens, glucose monitoring via continuous glucose monitors (CGMs) or glucose meters, and hybrid devices that both monitor glucose and deliver insulin.
Continuous glucose monitors are now the standard of care and experts agree that every insulin user should have access to one. While they used to be recommended primarily for people who were type 1 diabetics and/or who take insulin, they also are particularly helpful for people with hypoglycemia unawareness, and have shown benefits for those who manage their diabetes without insulin.
The new standards represent a four-pillar approach to diabetes management to reduce the risk of developing complications such as chronic kidney disease, obesity and diabetic retinopathy.
Interestingly, says Gabby, "Most people don't realize that, as well as people with type one diabetes, one quarter of people with type two diabetes take insulin." This number increases as people get older, since diabetes is a progressive disease and the ability to make insulin lessens over time.
Although hemoglobin A1C (a three-month average of blood glucose levels) has long been the standard test for monitoring diabetes, the new guidelines recommend use of a 14-day assessment from a CGM, along with Time in Range (TIR) and other metrics to monitor glucose variability. Time in range is the percentage of time that a person spends with their glucose level in the target range, typically 70-180 mg.
For patients who don't use a CGM, their health care provider can provide a professional one to be used during a two-week period.
Other Considerations for People with Diabetes
Besides the above four areas, the ADA is recommending that all adults and eligible children with diabetes receive COVID-19 vaccines, since diabetes is a risk factor for serious COVID complications.
The new standards represent a four-pillar approach to diabetes management to reduce the risk of developing complications such as chronic kidney disease, obesity and diabetic retinopathy. These include maintaining healthy glucose, blood pressure, and lipid levels and the use of glucose-lowering medications that have been shown to prevent or improve heart or kidney benefits.
To treat obesity in those with type 2 diabetes, drugs such as semaglutide 2.4 mg (Wegovy) should be used to promote weight loss, along with nutrition therapy emphasizing the fact that healthy eating for glycemic control is more than just carbohydrate counting.
According to the Diatribe Foundation, a non-profit organization dedicated to advocacy and improving the life of people with diabetes, "This is all atop a foundation of lifestyle modification and diabetes self-management education and support. This marks a key transition to a more comprehensive approach to diabetes management."
Apps, online coaching, clinically validated digital technologies known as digiceuticals (which gather information and provide real-time guidance to improve patient outcomes) and remote monitoring of patient clinical data also provide diabetes self-management support.
Finally, the new standards recommend that in older adults with diabetes, assessment of their ability to manage their illness must take into consideration factors such as cognitive functioning, polypharmacy, arthritis and other physical limitations, and visual impairments.
The ability or willingness to follow a stringent plan to keep their glucose under control needs to be determined by shared decision making with health care providers. Gylcemic goals may need to be altered if individual capacities to follow the regimen decline over time or if there are new medical problems.
Managing a chronic illness is a challenge for anyone, but with the help of new and expanded guidelines and technologies, living with diabetes is much less onerous than it was years ago.
