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Guidelines

The American Diabetes Association (ADA) 2020 Guideline revisions  are available.  The new revisions include changes for screening, nutrition and assessing blood glucose management and more. Since 1989, the ADA has produced diabetes guidelines which reflect best practices of the field, although many global regions criticise the guidelines for being too Western-centric for all people with diabetes across the globe.

Below are five of the most substantial revisions for this year.

1. The reasons are clear

Section 1. Improving care and promoting health in populations

First time information is included on the financial burden of diabetes to individuals and society.  However, ADA missed an advocacy opportunity by not spelling out one of the biggest reasons why the price of insulin has risen. Recorded pricing over the years shows clearly how manufacturers, without regulation in the USA, increased their list prices for analog insulins (jointly) by 600% since 2006.  Specifically, ADA says,

“The cost of diabetes medications, particularly insulin, is an ongoing barrier to achieving glycemic goals. Up to 25% of patients who are prescribed insulin report cost-related insulin underuse. The cost of insulin has continued to increase in recent years for reasons that are not entirely clear.”

2. Goodbye LADA, plus screening for prediabetes recommended

Section 2. Classification and diagnosis of diabetes

The debate as to whether slowly progressive autoimmune diabetes with an adult onset should be termed latent autoimmune diabetes in adults (LADA) is now acknowledged. Goodbye LADA.

“There is debate as to whether slowly progressive autoimmune diabetes with an adult onset should be termed latent autoimmune diabetes in adults (LADA) or whether the clinical priority is awareness that slow autoimmune β-cell destruction means there may be long duration of marginal insulin secretory capacity. For the purpose of this classification, all forms of diabetes mediated by autoimmune β-cell destruction are included under the rubric of type 1 diabetes.”

In addition, a new recommendation to mitigate a delay in diabetes diagnosis for high-risk women now recommends testing for prediabetes and/or type 2 diabetes for overweight or obesity and/or those who have one or more additional risk factors for diabetes who are planning a pregnancy.

All forms of diabetes mediated by autoimmune β-cell destruction are included under the rubric of type 1 diabetes.

3. Variety of foods allowed for prediabetes

Section 3. Prevention or delay of type 2 diabetes

On the basis of the report, “Nutrition Therapy for Adults With Diabetes or Prediabetes: A Consensus Report”, published in April 2019, Nutrition guidelines have been updated and a new recommendation was added to recognize that a variety of eating patterns are acceptable for people with prediabetes.  Key factors to emphasize for a variety of eating patterns: emphasize nonstarchy vegetables; minimize added sugars and refined grains: choose whole foods over highly processed foods to the extent possible.

4. Screening for autoimmune thyroid disease and celiac

Section 4. Comprehensive medical evaluation and assessment of comorbidities

The ADA’s autoimmune diseases recommendation was modified, and a new recommendation was added with autoimmune thyroid disease and celiac disease screening guidance differentiated.

5. “Time in Range” is OK

Section 6. Glycemic targets

Although ADA continues to use the word “control” to describe blood glucose management for people with diabetes – seen by many as judgmental in the language of diabetes –  this new recommendation is a welcome addition as it supports time in range (TIR) for assessment of glycemic management (vs HbA1c).  Of course, until more people with diabetes are given equal access to continuing glucose monitoring technology, this recommendation has a small effect.

“Time in range (TIR) is associated with the risk of microvascular complications and should be an acceptable end point for clinical trials and can be used for assessment of glycemic control. Additionally, time below target (<70 and <54 mg/dL [3.9 and 3.0 mmol/L]) and time above target (>180 mg/dL [10.0 mmol/L]) are useful parameters for reevaluation of the treatment regimen.”

For more information and to see all 2020 revisions, please see:

Summary of Revisions: Standards of Medical Care in Diabetes—2020, Diabetes Care 2020 Jan; 43(Supplement 1): S4-S6.

 

Elizabeth Snouffer is Editor of Diabetes Voice.


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