If you’re living with diabetes, you’re better off if you regularly communicate with your doctor not only about your A1C, but also about things like your mental health and your blood pressure. That’s one of the most significant takeaways from new guidelines released by the American Diabetes Association (ADA), experts say. The ADA’s Standards of Medical Care in Diabetes—2019, which were published in the January 2019 edition of Diabetes Care, include several guidelines aimed at bringing you into the conversation with your doctor in an effort to improve your health and quality of life. “This is really a paradigm shift in that we want the patient to participate," says William T. Cefalu, MD, chief scientific, medical and mission officer at the ADA. “We want an educated patient. We want dialogue between the provider and the patient.” RELATED: 10 People Who Can Help You Manage Type 2 Diabetes
What Are the ADA Standards of Care and Why Should You Care?
The ADA issues its Standards of Care report each year to reflect scientific advances in treating diabetes. The recommendations emerge from evidence-based research on the diagnosis and treatment of children and adults with type 1 diabetes, type 2 diabetes, or gestational diabetes. The report also includes strategies to prevent or delay type 2 diabetes, and therapeutic approaches for reducing type 2 diabetes-related complications and helping improve health outcomes. A committee of 15 leading U.S. experts in the field of diabetes care wrote the documents. That team includes physicians, certified diabetes educators, registered dietitians, and other professionals in the fields of adult and pediatric endocrinology, epidemiology, public health, lipid research, hypertension, preconception planning, and pregnancy care. This year, two representatives from the American College of Cardiology (ACC) reviewed, provided feedback, and endorsed the recommendations for heart disease and risk management on behalf of the ACC. An online version of the Standards of Care, called the Living Standards of Care, will continue to be updated in real time throughout 2019 if new evidence or regulatory changes merit immediate incorporation. “In 1989, the entire Standards of Care was about four pages. This year, it’s about 200 pages,” Dr. Cefalu says. “The evidence is coming in so quickly, you can’t wait a year to update it. Instead of waiting a whole year, we’ve gone to a system where we can constantly update with new information.”
An Overview of the Main Tenets of the 2019 ADA Standards of Care
Here are some of the major changes and takeaways from the new report:
An Emphasis on Protecting Heart Health in People With Diabetes
The 2019 Standards of Care considers the multiple health and lifestyle factors of each person living with diabetes. For the first time, the ADA collaborated with the American College of Cardiology to ensure that the ADA’s recommendations are in sync with heart health guidelines. The Standards of Care also supports the ADA’s new Know Diabetes by Heart initiative, a collaboration with the American Heart Association. These efforts are meant to reduce deaths from cardiovascular disease, which is the leading cause of death for people living with diabetes, according to the ADA. According to the Centers for Disease Control and Prevention (CDC), people with type 2 diabetes are twice as likely to die of heart disease as people without the disease. For patients, this guideline means talking to their endocrinologist, certified diabetes educator, and others involved in diabetes care about heart health, too. “We are in a partnership with American Heart Association to educate the patient on cardiovascular disease,” Cefalu says. “We want the patient to be educated and discuss this with their physicians.” RELATED: How Diabetes and Heart Disease Are Connected The guidelines update the recommendations on which drugs most benefit people who have both diabetes and cardiovascular disease. This includes sodium-glucose cotransporter 2 (SGLT-2) inhibitors, such as Farxiga (dapagliflozin), and glucagon-like peptide 1 (GLP-1) receptor agonists, such as Ozempic (semaglutide). “The drug treatment approach really differs on whether someone has cardiovascular disease or not,” says Robert A. Gabbay, MD, PhD, chief medical officer of the Joslin Diabetes Center in Boston. “There are now drugs for people with cardiovascular disease that not only reduce blood sugar but reduce death from cardiovascular disease. The ADA has said: The first thing you need to know is whether the patient has cardiovascular disease or not.”
More Personalized Diabetes Care
The new guidelines recommend that people living with diabetes have ongoing assessments and work with their doctors to make choices about their care. The document contains a Goals of Care chart that shows the range of topics you can discuss with your doctor, depending on your needs. “We’re putting the patient at the center of treatment,” Cefalu says. “Instead of just managing complications, we’ve put in, for the first time, quality of life. We look at things like motivation and depression and put things in a socioeconomic context. If a patient can’t afford the most expensive medication, why prescribe it? There is shared decision making with the patient.” Studies show that patients adhere better to treatment plans if they participate in selecting treatments and strategies, Dr. Gabbay says. “Diabetes is not simple,” he says. “Because of that, there are a lot of decisions that have to be made. The question is: How does one do that? It has to be patient-centered, meaning there is a shared decision-making process.” It’s important for healthcare professionals to use language that patients can understand, Cefalu adds. “The first thing is to provide awareness that the provider and patient need to be speaking the same language.” The updated guidelines also include a section on nutrition and physical activity for people ages 65 and older. The document also includes information to help simplify medication in older adults. Likewise, the guidelines include recommendations for children and adolescents with type 2 diabetes that incorporate the ADA’s guidance on youth statement, which was published in December 2018 in Diabetes Care. These recommendations now include a comprehensive plan for children and adolescents regarding screening, diagnosis, lifestyle management, treatment, heart health, obesity, and psychosocial factors affecting youths with the disorder. RELATED: A Complete Guide to Eating a Diabetes-Friendly Diet
A Focus on Developing Personalized Diabetes Diets
No single style of eating is “right” for every person with diabetes, according to the new guidelines. A variety of eating patterns can be used to manage diabetes, and the new guidelines suggest that people with diabetes be referred to a registered dietitian for assistance in creating a personalized nutrition plan. “The Standards of Care includes the latest on nutrition,” Cefalu says. “There is not one diet for all individuals with diabetes. It’s an individualized approach.” Research suggests that there isn’t much difference between some of the medically acceptable diets, Gabby says. What matters more is whether a person with diabetes can stay on the diet and make long-term lifestyle changes. “What we have come to realize, in terms of lifestyle changes, is that one size doesn’t fit all,” he says. “In my practice, I ask patients, ‘What have you been successful at in the past?’ That’s probably as good an indicator as anything else.” The new guidelines also stress the benefits of drinking more water and cutting back on sweetened beverages, including drinks containing noncaloric sweeteners. RELATED: Going Low-Carb for Type 2 Diabetes Management: Is Keto, Paleo, or Atkins Best?
Recognizing the Role of Technology in Diabetes Management
Technological innovations are shaping the way people manage diabetes, experts say. The 2019 guidelines provide expanded information on a variety of new syringes, pens, insulin pumps, blood glucose meters, continuous glucose monitors, and automated insulin delivery devices to guide patients who are interested in these products. “This is probably the most rapidly advancing area,” Cefalu says. “Continuous glucose monitoring, especially for type 1 diabetes, has really revolutionized care.” RELATED: The Best Blood Sugar Monitors to Help You Manage Diabetes
How People Living With Diabetes Can Take Advantage of the New ADA Guidelines
Although healthcare professionals use the guidelines to manage care, the updates are meant to benefit those managing diabetes, and these people should be aware of the changes, Cefalu says. An abridged Standards of Care is available to the public on the ADA website. People with diabetes can also receive information about the guidelines in diabetes classes and support groups, he says. “We have many consumer programs. Our Standards of Care is the backbone of what we do. This information is disseminated in many, if not most, of our patient information groups,” including the free Living With Type 2 Diabetes Program. Above all, the guidelines encourage people with diabetes to ask questions and feel comfortable discussing a range of issues with their healthcare providers, including problems adhering to diabetes treatment, depression, and the costs of care. “They should advocate for themselves,” Gabbay says. “One of the simplest ways is asking a lot of questions. If a doctor says, we should start you on this drug, the patient can ask ‘What are the advantages of this drug and are there other drugs?’” RELATED: The Top Diabetes Treatment Options for Better Blood Sugar Control People managing diabetes can stay engaged in their care in other ways, he says, such as keeping track of annual screenings, like eye exams or foot exams. They should educate themselves about diabetes, Gabbay adds. “One of the most powerful things for people with diabetes is to be knowledgeable about diabetes and how to best manage their disease,” says Gabbay. “It is a fundamentally a disease that is self-managed. Talk with your provider about strategies.” RELATED: An Essential Guide to Talking to Your Doctor About Basal Insulin
