Lifestyle Management Uplifted in 2017 ADA Diabetes Care Standards

Move every 30 minutes during prolonged periods of sitting. Give older adults balance and flexibility training. Pay more attention to sleep patterns, given their known effect on blood sugar levels.

These recommendations and others occupy an entire section of the 2017 Standards of Medical Care in Diabetes devoted to lifestyle management.¹ Together with language on prevention and management of psychosocial stressors, the annual update from the American Diabetes Association (ADA) promotes a more holistic approach, to coordinate care for factors that contribute to the onset and progression of the disease.

ADA’s recommendations come as CMS is moving forward with payment models that fit this approach. CMS has taken the first steps toward paying for the National Diabetes Prevention Program in Medicare starting in January 2018. Starting next month, Medicare will allow billing for collaborative care, which puts behavioral health and primary care services under one roof, a model that been shown especially effective for treatment of persons with diabetes.

Cost of Care. The ADA also took a step to help providers navigate costs: the 2017 standards feature 2 tables that estimate average monthly costs for insulin and non-insulin therapies. Last month, the ADA publicly called on Congress to investigate the rising cost of insulin, which patients with type 1 disease (T1D) need to survive, and which might benefit more patients with type 2 disease (T2D) if priced affordably. The 2017 standards include a new treatment algorithm for managing T2D with insulin, if patients have been unable to achieve glycemic goals.

Key scientific news in the ADA Standards is the report, “Differentiation of Diabetes by Pathophysiology, Natural History, and Prognosis,” which was published in ADA’s journal, Diabetes.² The report was produced at a symposium of the ADA, the JDRF, European Association for the Study of Diabetes, and the American Association of Endocrinologists. According to a statement from ADA, it focuses on beta cell dysfunction and disease staging for T1D and T2D, and seeks to better define the subtypes to achieve more personalized care.

“The expert consensus is that unifying characteristics of the vast majority of diabetes is hyperglycemia, resulting from β-cell destruction of dysfunction,” Robert E. Ratner, MD, FACP, FACE, chief scientific officer for ADA, said in the statement. “With a better understanding of how various factors affect the number and function of β-cells, we may be able to classify subtypes of the diseases, predict the rate of progression and identify where and how interventions can be targeted to prevent or delay disease progression and complications.”

Lifestyle Management. Changes here are so substantial that the section was renamed from, “Foundations of Care and Comprehensive Medical Evaluation.” An important change comes in the opening section on Diabetes Self-Management Education and Support (DSMES), which states that, “There is growing evidence for the role of community health workers, as well as peer and lay leaders, in providing ongoing support.”

The need for diabetes education to continue as the disease changes, not a “once and done” approach, is the subject of the current special issue of Evidence-Based Diabetes Management, produced in partnership with the American Association of Diabetes Educators.

In recent years, multiple studies have taken aim at the harms of sitting for extended periods, the most recent one coming just this month in Diabetologia, which found that short “bursts” of activity throughout the day may be more beneficial (and practical) than trying to schedule extended periods of structured exercise.

With the new recommendations, ADA has endorsed this approach. The 2017 standards say that “all individuals, including those with diabetes, should be encouraged to reduce the amount of time spent being sedentary (e.g., working at a computer, watching TV), by breaking up bouts of sedentary activity (>30 minutes) by briefly standing, walking, or performing at other light physical activities.” Doing so could help prevent T2D in those at risk or improve glycemic control in those already diagnosed, the statement says.

How this recommendation is received in workplaces remains to be seen, but ADA has given payers who work with employers a new tool in designing work stations or policies that confront chronic disease.

The 2017 standards include ADA’s recent call to integrate psychosocial care into an overall diabetes management plan. The recommendations outline when a patient should be referred for mental health care. The standards call on providers to “assess patients’ sleep patterns as part of overall diabetes care, because sleep quality may be associated with blood glucose management.”

Studies have found that working at night, and changing shifts in particular, can increase the risk of diabetes, obesity, hypertension, insomnia, workplace injuries, and tobacco use. The problem is significant enough that some experts say employers who are adding large numbers of workers on overnight shifts must consider the long-term healthcare costs.

Treatment Updates. The 2017 Standards reflect recommendations in the June 2016 issue of Diabetes Care for metabolic surgery, which is now recommended for patients with uncontrolled T2D and a body mass index (BMI) of 30 kg/m² or a BMI of 27.5 kg/m² in patients of Asian ethnicity.

ADA formally recommends 2 therapies for control of diabetes and cardiovascular (CV) disease, which includes those who have suffered a stroke or heart attack, acute coronary syndrome, angina, or peripheral artery disease. Empagliflozin, the sodium-glucose co-transporter-2 inhibitor sold as Jardiance, and liraglutide, the glucagon-like peptide-1 sold as Victoza, have both been shown in clinical trials to have CV benefits. However, ADA is not ready to extend this recommendation to other drugs in the GLP-1 or SGLT2 classes without more research.

Empagliflozin just received a new FDA indication that the drug can reduce the risk of CV death in patients with T2D. This was the first therapy for diabetes to receive this indication.

References

1. American Diabetes Association. Standards of Medical Care in Diabetes--2017. [published online December 15, 2016]. Diabetes Care. 2017; 40(suppl1). S1-S135.

2. Skyler JS, Bakris GL, Bonifacio E, et al. Differentiation of diabetes by pathophysiology, natural history and prognosis [published online December 15, 2016]. Diabetes. https://doi.org/10.2337/db16-0806