In the past, the Standards of Medical Care in Diabetes (SMC) was updated once per year by the American Diabetes Association (ADA), and was published each January. Starting in 2019, ADA now updates these standards in real time, so there is no more waiting for “new” standards. This is an important feature, because now any updates can be put to use right away! This blog is a tribute, of sorts, to the yearly published updates; even though we have ready access to them throughout the year, I think now is a great time to review the most current version to ensure we’re ready for 2020.
To back up a bit, let me describe the SMC. This document is provided to help clinicians, patients, researchers, payers, and others affected by diabetes understand the many components of diabetes care, including evidenced-based general treatment goals and tools to help evaluate outcomes. In short, it is a resource providing recommendations to assist (not replace) clinical and professional judgment for individualized care using what is currently known about diabetes.
The SMC is available electronically, free of charge, from the ADA’s website https://doi.org/10.2337/dc20-Sint . Printed versions are available for a fee. There are also numerous webinars available each year (usually at end of January); in fact, the Association of Diabetes Care and Education Specialists (ADCES, formerly American Association of Diabetes Educators or AADE) is hosting such a webinar on January 30th, 2020 for $40 for members/$55 for non-members, with group rates also available. For more information, visit https://www.diabeteseducator.org/event/WEBI200130
There are 16 sections of the SMC, each focusing on a component of diabetes care. Below are the section topics, with the most recent updates summarized. For more complete information, please review the SMC in its entirety.
Now, without further ado, here’s what’s new!
Section 1: Improving Care and Promoting Health in Populations provides information on population health and the current care delivery systems of our healthcare system in order to achieve this goal. This year it makes note of the challenges associated with the high cost of insulin. Also new is a section addressing diabetes management in migrant and seasonal agricultural workers.
Section 2: Classification and Diagnosis of Diabetes categorizes the various diabetes diagnoses: type 1, type 2, gestational, or other causes (ex: monogenic causes, diseases of the exocrine pancreas, drug- or chemical-induced). This section also discusses screening criteria and treatment goals for these populations. For 2020, there is a new recommendation on screening for prediabetes/diabetes in women with at least 1 risk factor PLUS overweight/obesity who are planning pregnancy. Also, a new topic has been added to this section titled, “Pancreatic Diabetes or Diabetes in the Context of the Exocrine Pancreas.” Lastly, look for revisions to the “Gestational Diabetes Mellitus (GDM)” topic.
Section 3: Prevention or Delay of Type 2 Diabetes focuses on the various ways to help keep prediabetes from progressing to diabetes. Updated recommendations were added to the “Nutrition” paragraph based on a new consensus report which states there are a number of acceptable dietary patterns for this population, with the Mediterranean and DASH diets specifically mentioned. Additional comments have been added based on outcomes from the National and Medicare Diabetes Prevention Programs as well as resources such as the Diabetes Prevention Impact Toolkit from the Centers for Disease Control.
Section 4: Comprehensive Medical Evaluation and Assessment of Comorbidities emphasizes the goal of patient-centered collaborative care and offers a “Decision Cycle” graphic to help guide the implementation of necessary components. There is also a checklist with evaluation and assessment questions and whether they should be asked at initial, annual, or every patient visit in order to create a comprehensive treatment plan. New this year: a discussion addressing the association between hepatitis C and an increased incidence of type 2 diabetes; a more encompassing paragraph on “Sensory Impairment”; updated evidence for “Periodontal Disease”; differentiated recommendations for screening for autoimmune diseases (specifically thyroid and celiac disease, but pernicious anemia is also mentioned); and the “Psychosocial/Emotional Disorders” paragraphs have been removed from this section and are now found under Section 5: “Facilitating Behavior Change and Well-Being to Improve health Outcomes.”
Section 5: Facilitating Behavior Change and Well-Being to Improve Health Outcomes replaces the previous title, “Section 5: Lifestyle Management.” This section focuses on what the ADA believes to be the foundation of care when setting treatment goals and focuses on Medical Nutrition Therapy, physical activity, smoking cessation when applicable, and psychosocial care. The “Nutrition Therapy” paragraph has been updated for 2020, and information on e-cigarettes (discouraging their use) is included, based on emerging evidence. The “Psychosocial/Emotional Disorders” paragraphs from section 4 are now found under this section.
Section 6: Glycemic Targets reviews common methods of assessing patients to see if they are meeting blood glucose goals (by using labs such as A1c, self-monitoring of blood glucose (SMBG), using continuous glucose monitors (CGMs), etc.) as well as the strengths and limitations of these methods. This year highlights new recommendations for using the ambulatory glucose profile report and time in range when assessing glycemic targets and provides a simplified estimated average blood glucose table. While this section includes both hyper- and hypoglycemia considerations in regards to glycemic targets, a new recommendation for use when screening patients who are taking medications with hypoglycemia as a side effect is provided, as well as information on current modes of delivery for glucagon medications and the use of CGMs in hypoglycemia prevention. Additionally, this section discusses the correlation between glycemic targets to the macro- and microvascular complications of diabetes and includes a discussion on including SGLT-2 inhibitors or GLP-1 receptor agonists as medications that offer cardiovascular benefit.
Section 7: Diabetes Technology, as the name implies, spans the (now) wide-array of devices used to manage blood glucose in people with diabetes. In general, this section covers how insulin is administered along with how blood glucose is monitored. As this field is expanding rapidly due to technological advances, Section 7 has been reorganized into 3 categories (“Self-Monitoring of Blood Glucose,” “Continuous Glucose Monitors,” and “Insulin Delivery”) and includes revised recommendations and current supporting evidence. It emphasizes the need for patient-centered care, reminding us that there is no “one size fits all” approach, especially when it comes to technology.
Section 8: Obesity Management for the Treatment of Type 2 Diabetes addresses various modes of management for persons with BMI >30, which include diet, physical activity, behavioral therapy, pharmacotherapy, medical devices and metabolic surgery. There are several new recommendations such as BMI screening once per year (vs. every patient visit) and how to improve patient comfort and engagement during this encounter. [Minimal] comments about food availability, cultural preferences and patient motivation are included in this section under “Lifestyle Interventions” paragraph.
Section 9: Pharmacologic Approaches to Glycemic Treatment reviews medication recommendations for people with type 1 and type 2 diabetes. There is also a topic within this section addressing surgical treatment options for people with type 1 (pancreas and islet transplantation). Discussions and new recommendations on early combination therapy for people with type 2 and the use of SGLT-2 inhibitors and GLP-1 receptor agonists in patients with cardiovascular disease, chronic kidney disease, and/or heart failure independent of the patient’s A1c are in this section, along with an easier-to-read medication intensification guide (figure 9.2).
Section 10: Cardiovascular Disease and Risk Management is of utmost importance as it is the leading cause of morbidity and mortality for patients with diabetes (both type 1 and type 2). Look for updated blood pressure and cholesterol considerations and recommendations, and be prepared to again revisit the need for individualized, patient-centered care when considering treatment options.
Section 11: Microvascular Complications and Foot Care reviews diabetes care and treatment plans within the context of chronic kidney disease (it also addresses acute kidney injury), retinopathy, neuropathy (peripheral and autonomic), and peripheral arterial disease. Revisions include several new screening recommendations for chronic kidney disease and diabetic retinopathy, and much more information and evidence is provided regarding medication considerations and how to screen/address progressions of these diseases.
Section 12: Older Adults has added a new recommendation within the pharmacologic therapy segment which discusses therapies such as GLP-1 receptor antagonists and SGLT-2 inhibitors. It also asks providers to consider cost of care and insurance coverage when developing treatment plans as these can pose barriers to medication adherence. Also in this section, more information on the importance of assessing for patient cognitive decline and impairment, particularly as it relates to their diabetes self-management ability. In addition, be sure to review the new segment, “Special Considerations for Older Adults with Type 1 Diabetes”.
Section 13: Children and Adolescents discusses the treatment differences between type 1 and type 2 diabetes in this young population. Additionally, the ADA recognizes that youth require separate and distinctly different treatment recommendations from adults with type 1 or type 2 diabetes. Revisions for 2020 were made under the “Glycemic Control” (regarding need for individualized targets), “Management of Cardiovascular Risk Factors” (specifically for hypertension, dyslipidemia and retinopathy) and “Pharmacologic Management” (recent FDA approval of liraglutide in children 10+ yrs and the recommendations for pharmacologic treatment of hypertension).
Section 14: Management of Diabetes in Pregnancy covers pre-existing type 1 and 2 diabetes as well as the development of gestational diabetes as a complication of pregnancy. Changes to this section focus on the importance of preconception care as well as post-partum management for women with pre-existing diabetes. There is also an expanded discussion on what type of medication (oral or insulin) may be the most appropriate treatment in this varied population. Included in this section is new evidence that found the use of continuous glucose monitors in pregnancy with pre-existing type 1 diabetes shows improved blood glucose control (vs. A1c or other glucose management calculators) with fewer instances of hypoglycemia AND adverse effects for the baby.
Section 15: Diabetes Care in the Hospital covers new evidence that addresses preventing admissions/readmissions. Also new in this section is a discussion of new research supporting the use of closed-loop insulin delivery systems with linked pump/sensor devises for people with type 1 diabetes (see “Transitioning Intravenous to Subcutaneous Insulin”).
Section 16: Diabetes Advocacy has no changes this year.