diabetes recommendations 2015

the American Diabetes Association just updated their clinical care recommendations, as they do annually. (see dm diabetes care summary 2015 in dropbox, or go to http://professional.diabetes.org/admin/UserFiles/0%20-%20Sean/Documents/January%20Supplement%20Combined_Final.pdf​ ). I will highlight the significant changes over last year, though i did repeat a few items of importance which did not change.

--they lowered the BMI cutpoint for overweight in Asian Americans from 25 to 23 kg/m², reflecting the observation that there is an increased incidence of diabetes at lower BMIs in Asians. They continue to recommend checking for diabetes in all overweight/obese patients (with the above change for Asian Americans) who have one additional risk factor at any age, and to begin at age 45 otherwise [my comment: there are many, many studies over the years showing that central or visceral obesity is a much stronger cardiovascular risk factor than BMI.  BMI assesses overall weight, which includes the not-so-clinically-significant non-visceral adipose tissue, muscle weight, and maybe even heavier bones...  i am really at a loss that the focus of overweight is with the less consequential BMI --  visceral fat is much more metabolically active, is associated with increased inflammatory markers as well as insulin resistance/metabolic syndrome/diabetes, and is an independent cardiovascular risk factor -- much more so than BMI (which in many studies is not even an independent risk factor). and, it turns out that there is a relatively accurate and simple measure of visceral obesity -- waist circumference. the US criteria for metabolic syndrome include a waist circumference (not BMI...) for men of >40 inches and women of >35 inches.  the International Diabetes Federation had a consensus statement in 4/4/2005 using ethnicity-specific waist circumference (again, not BMI) in their definition of metabolic syndrome (ie, acknowledging 10 years ago that there are important ethnic differences), with the following variations:

        --European (which they call "europoids"): men 94 cm or 37 inches, women 80 cm or 31.5 inches

        --South Asian, Japanese, and Chinese: men 90 cm or 35.4 inches, women 80 cm or 31.5 inches

I should add that there is an increasingly strong correlation between BMI and visceral fat as the BMI gets increasingly elevated, but i have certainly seen some people with dramatic obesity by BMI but normal waist circumference...  so, why not use waist circumference as an easy measurement and which is a better marker from both biological and epidemiological perspectives??

​

--they note that African-Americans may have higher A1c levels than non-Hispanic whites despite similar fasting and post-glucose-load glucose levels, citing a recent study finding that African Americans, both with and without diabetes, had higher A1c's when matching for fasting glucose levels (and also higher fructosamine and glycated albumen, suggesting an actual higher glycemic burden... ???significance of this, especially given my recent blogs showing that even A1c in the high 5's seems to be associated with increased cardiac risk)

--for goal A1c: (no change from prior recs) -- try to get to A1c to 7 or less to reduce microvascular complications. consider lower goal (6.5) if can be achieved easily and without adverse effects. less stringent goals (eg <8%) may be appropriate if limited life expectancy/advanced diabetic complications, or difficult to attain lower A1c because of history of hypoglycemia or just too difficult to attain (brings up past blog on flogging the patient with more and more meds, as in the ACCORD trial, leading to worse clinical outcomes)

--they comment that electronic cigarettes (e-cigarettes) are "not supported as an alternative to smoking or to facilitate smoking cessation". [my comment, as per prior blogs, i continue to have very real concerns about e-cigarettes as in some ways normalizing smoking after so many years of successfully popularizing the bad health effects, being a potential gate-way to real smoking especially for teens, and in fact including potentially dangerous additives. that being said, i have had several patients completely stop smoking by briefly using e-cigarettes as a tool.]

--they have changed the blood glucose targets to a premeal of 80-130 mg/dL (it was 70-130), better reflecting new data correlating actual average glucose levels with A1c levels.

--they have included more guidance on continuous glucose monitoring (CGM), including patient readiness and providing ongoing support. Note, CGM is only suggested for patients with type 1 diabetes (they are not totally explicit on this, but all of their references are from type 1 diabetes patients).

--they have added the new drugs to their therapeutic options (eg SGLT2 inhibitors). they confirm that metformin should be given first if possible, but if the A1c target is not reached within 3 months, then they give equal weight to sulfonylurea, thiazolidinedione, DPP-4 inhibitors, SGLT2 inhibitors, GLP-1 receptor agonists and basal insulin, depending on patient preferences, disease and drug characteristics. [note: remember that all of the newer agents do well at lowering A1c levels but do not have data showing decreases in diabetic clinical outcomes]

--blood pressure: they have incorporated the new JNC-8 recommendations for blood pressure goal (systolic <140, diastolic <90), though comment that lower systolic (<130) and diastolic (<80) may be appropriate for certain people, eg younger patients, if achieved without "undue treatment burden".

lipids: they also totally support the 2013 ACC/AHA lipid treatment guidelines, focusing on when to initiate statins and the dose, looking at risk status and not LDL levels [i have sent out several blogs in the past year critiquing these lipid guidelines -- happy to send out again if you want]. however, they note that since diabetes is a risk factor, these recommendations translate to:

        -- age < 40 and no other risk factors (LDL>100, high blood pressure, smoking, overweight) -- no med

                            and other CAD risk factor -- moderate or high dose statin

                            and overt CAD  -- high dose statin

        --age 40-75 and no other risk factor -- moderate dose statin

                            ​and other CAD risk factor or overt CAD -- high dose statin

        --age >75 and no other risk factor -- moderate dose statin

                            and other CAD risk factor -- moderate or high dose

                            and overt CAD -- high dose

--aspirin: for primary prevention, "consider" low dose aspirin in men >50 yo and women >60 yo with at least one additional major risk factor [note: this recommendation had been more forceful until a few years ago, but then some negative studies came out with aspirin in diabetics, as the POPADAD study -- see dm aspirin POPADAD in dropbox, or  BMJ 2008; 337:a1840)]. they support the use of aspirin for secondary prevention (diabetes and history of CAD), or clopidogrel if aspirin intolerant [no change from prior recs, i just wanted to reiterate it]. ​

--coronary artery disease (CAD): do not do routine screening for CAD in asymptomatic patients (no improvement in outcomes by this. just treat the risk factors).  [this is also not a new recommendation; i just wanted to reiterate it as well]

--immunizations: they have also incorporated the new immunization guidelines for PCV13 in those over 65 years old [though these recommendations apply whether diabetic or not]

--they stress that all diabetics with decreased sensation in their feet, foot deformities, or a history of foot ulcers have their feet examined at every visit

--they have raised the target A1c for children and adolescents to <7.5%, also noting that individualization of the target is still encouraged

--a new section on diabetes in pregnancy, including preconception counseling (stressing importance of trying to achieve A1c<7%), though during pregnancy there are increases in red cell turnover which lowers the normal A1c level, so the  A1c target is <6% if no significant hypoglycemia; medications (esp insulin, metformin, glyburide are the best studied, though the oral agents do cross the placenta); recommendations for blood glucose targets; and monitoring.

--there are sections on the hospital care of diabetics (including discharge planning) as well as a list of some of the ADA's advocacy positions (care of young children with diabetes, diabetes and driving, diabetes and employment, diabetes care in school/daycare, diabetes in correctional institutions)