Diabetes care involves a patient-centered approach
Healthcare providers caring for patients with diabetes need to tailor their approach to the individual patient, according to the American Diabetes Association.
Each year, the association provides clinical practice recommendations for diabetes care in its “Standards of Medical Care in Diabetes,” based on the latest evidence supporting such recommendations. “The common motif of the 2015 Standards is the continued emphasis of individualizing therapeutic decisions based on factors that include ethnicity, overall risk for [atherosclerotic cardiovascular disease], life expectancy, comorbid conditions, the patient’s preferences and goals, and his or her ability to adhere to treatment regimens,” wrote the ADA in a recent commentary in Annals of Internal Medicine, a publication of the American College of Physicians. “Once more, the patient takes the center stage.”
This year’s Standards include 14 sections, but the Annals commentary focused on three:
- Ethnic differences in diabetes risk
- Glycemic controls
- Blood pressure and cardiovascular risk
Ethnic differences
The ADA endorsed a new body mass index (BMI) cut point for prediabetes and Type 2 diabetes screening in Asian Americans, decreasing it from 25 to 23 kg/m2. It has long been recognized that many Asian patients with Type 2 diabetes do not meet “standard” criteria for obesity (BMI >30 kg/m2) or overweight (BMI >25 kg/m2), suggesting that the relationship between BMI and risk for Type 2 diabetes, if any, is shifted toward lower BMI values in this population, according to the association.
“Current BMI criteria for overweight and obesity have been derived from studies in the general population and do not illustrate the unique adipose tissue distribution among ethnic groups. In particular, at every BMI level, Asian Americans tend to have a greater percentage of visceral fat, which more closely correlates with insulin resistance and risk for Type 2 diabetes when compared with peripheral subcutaneous fat depots.”
Glycemic control
Reflecting updated position statements of the ADA and the European Association for the Study of Diabetes, the Standards emphasize the principle that the definition of any patient’s target hemoglobin A1c level and choice of treatment strategy should be individualized, accounting for such factors as age, comorbid conditions, life expectancy, and the patient’s motivation and preferences.
The lack of head-to-head studies evaluating the efficacy, tolerability, safety (including cardiovascular outcomes) and durability of drugs to treat diabetes – including metformin (which ADA calls the preferred initial treatment choice) – have prevented the development of a “more nuanced, evidence-based algorithm,” according to the ADA. “In the absence of robust comparative effectiveness data, the Standards advocate tailoring combination drug choice based on such factors as risk for hypoglycemia, effects on weight, side effects and cost.”
Blood pressure and cardiovascular risk
Both type 1 diabetes and Type 2 diabetes markedly increase the risk for atherosclerotic cardiovascular disease, which is significantly reduced by statin treatment, notes the ADA. The 2015 Standards set forth revised recommendations for initiating, intensifying, and monitoring adherence to statin treatment and, in effect, adopt the 2013 American College of Cardiology/American Heart Association cholesterol treatment guidelines.
Those guidelines recommended revised systolic and diastolic blood pressure goals for patients with diabetes to 140 and 90 mm Hg, respectively. “However, more stringent goals (that is, <130/80 mm Hg) are recommended in patients with other significant cardiovascular risk factors or for those who can achieve them without ‘undue treatment burden.’”
Editor’s note: The commentary referred to in this article was published online first at www.annals.org on March 24, 2015.
Stop diabetes before it starts
With more than 86 million Americans living with prediabetes and nearly 90 percent of them unaware of it, the American Medical Association and the Centers for Disease Control and Prevention announced that they have joined forces to take urgent action to prevent diabetes.
Prevent Diabetes STAT: Screen, Test, Act – Today™ is a multi-year initiative that expands on the work each organization has already begun to reach more Americans with prediabetes and stop the progression to Type 2 diabetes.
“It’s time that the nation comes together to take immediate action to help prevent diabetes before it starts,” AMA President Robert M. Wah, M.D., was quoted as saying. “Type 2 diabetes is one of our nation’s leading causes of suffering and death – with one out of three people at risk of developing the disease in their lifetime. To address and reverse this alarming national trend, America needs frontline physicians and other healthcare professionals as well as key stakeholders, such as employers, insurers, and community organizations, to mobilize and create stronger linkages between the care delivery system, our communities, and the patients we serve.”
People with prediabetes have higher-than-normal blood glucose levels but not high enough yet to be considered Type 2 diabetes, according to AMA and CDC. Research shows that 15 percent to 30 percent of overweight people with prediabetes will develop type 2 diabetes within five years unless they lose weight through healthy eating and increased physical activity.
As an immediate result of their partnership, the AMA and CDC have co-developed a toolkit to serve as a guide for physicians and other healthcare providers on the best methods to screen and refer high-risk patients to diabetes prevention programs in their communities. The toolkit, along with additional information on how physicians and other key stakeholders can Prevent Diabetes STAT, is available online at http://www.ama-assn.org/sub/prevent-diabetes-stat/for-health-care-professionals.html?utm_source=Press_Release&utm_medium=media&utm_term=031215&utm_content=prediabetes_stat&utm_campaign=partnership.