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Wish I were here

I just reviewed the new American Diabetes Association treatment guidelines and wanted to share some of my notes with you. You can read the original document free online. It has 620 references!

PERIODIC TESTS, TREATMENTS, AND GOALS

The American Diabetes Association (ADA) recommends the following items be done yearly (except as noted) in non-pregnant adults with diabetes. (Incidentally, I don’t necessarily agree with all ADA guidelines.)

• Lipid profile (every two years if results are fine and stable)
• Comprehensive foot exam
• Screening test for distal symmetric polyneuropathy: pinprick, vibration, monofilament pressure sense, ankle reflexes
• Serum creatinine and estimate of glomerular filtration rate
• Test for albumin in the urine, such as measurement of albumin-to-creatinine ratio in a random spot urine specimen
• Comprehensive eye exam by an ophthalmologist (if exam is normal, every two years is acceptable)
• Hemoglobin A1c at least twice a year, but every three months if therapy has changed or glucose control is not at goal
• Flu shots

Additionally, the 2014 ADA guidelines recommend:

• Pneumococcal vaccination. Additionally, “A one time re-vaccination is recommended for individuals over 65 years of age who have been immunized over five years ago. previously immunized when they were <65 years of age if the vaccine was administered >5 years ago.” Also repeat the vaccination after five years for patients with nephrotic syndrome, chronic kidney disease, other immunocompromised states (poor ability to fight infection), or transplantation.
• Hepatitis B vaccine for unvaccinated adults who are 19-59 years of age.
• Weight loss for all overweight type 2 diabetic adults. How? By reducing energy intake (calories) while eating healthfully. “Evidence suggests that there is not an ideal percentage of calories from carbohydrate, protein, and fat for all people with diabetes; therefore, macronutrient distribution should be based on individualized assessment of current eating patterns.”
• “Monitoring carbohydrate intake, whether by carbohydrate counting or experience-based estimation, remains a key strategy in achieving glycemic control.”
• Limit alcohol to one (women) or two (men) drinks a day.
• “In people with type 2 diabetes, a Mediterranean-style, MUFA-rich eating pattern may benefit glycemic control and cardiovascular disease risk factors and can therefore be recommended as an effective alternative to a lower-fat, higher-carbohydrate eating pattern.”
• “As recommended for the general public, an increase in foods containing long-chain omega-3 fatty acids (from fatty fish) and omega-3 linolenic acid (ALA) is recommended for individuals with diabetes because of their beneficial effects on lipoproteins, prevention of heart disease, and associations with positive health outcomes in observational studies.”
• “A variety of eating patterns (combinations of different  foods or food groups) are acceptable for the management of diabetes. Personal preference (e.g., tradition, culture, religion, health beliefs and goals, economics) and metabolic goals should be considered when recommending one eating pattern over another.”
• During initial diabetic exam, screen for peripheral arterial disease (poor circulation). Strongly consider calculation of the ankle-brachial index for those over 50 years of age; consider it for younger patients if they have risk factors for poor circulation.
• Restriction of dietary protein is no longer routinely recommended in people with diabetic kidney disease (nephropathy with albuminuria). Instead, the focus is on control of blood pressure and blood sugar to prevent progression.
• Those at risk for diabetes, including prediabetics, should aim for a) moderate weight loss if overweight (about seven percent of body weight), b) exercise: 150 minutes per week of moderate-intensity aerobic activity.
• “A variety of eating patterns have been shown to be effective in managing diabetes, including Mediterranean-style Dietary Approaches to Stop Hypertension (DASH)-style, plant-based (vegan or vegetarian), lower-fat, and lower-carbohydrate patterns.”

This monitor looks like an antique

Some of my dietary recommendations conflict with ADA guidelines. For instance, I think carbohydrate restriction is very important. I expect the experts assembled by the ADA to compose the guidelines were well-intentioned, intelligent, and hard-working. They’re are supported by 620 scientific journal references. I appreciate the expert panel’s work. We’ve simply reached some different conclusions. By the same token, I’m sure the expert panel didn’t have unanimous agreement on all the final recommendations. I invite you to review the dietary guidelines yourself, discuss with your personal physician, then decide where you stand.

GENERAL TREATMENT GOALS

The ADA in 2014 suggests general therapeutic goals for adult non-pregnant diabetics:

• Fasting blood glucoses: 70 to 130 mg/dl (3.9 to 7.2 mmol/l)
• Peak glucoses one to two hours after start of meals: under 180 mg/dl (10 mmol/l)
• Hemoglobin A1C: under 7%
• Blood pressure: under 140 mmHg systolic and under 80 mmHg diastolic
• LDL cholesterol: under 100 mg/dl (2.6 mmol/l). (In established cardiovascular dis-ease: <70 mg/dl or 1.8 mmol/l.)
• HDL cholesterol: over 40 mg/dl (1.0 mmol/l) for men and over 50 mg/dl (1.3 mmol/l) for women
• Triglycerides: under 150 mg/dl (1.7 mmol/l)

The 2013 guidelines of the American Association of Clinical Endocrinologists focus on hemoglobin A1c rather than blood sugars:

• Hemoglobin A1c: 6.5% or less for otherwise healthy people who are also at low risk for hypoglycemia.
• For those with one or more significant illnesses and at risk for hypoglycemia, hemoglobin A1c over 6.5% is fine.

In other words, the target is individualized. Hemoglobin A1c of 6.5% equates to blood sugars that average 140 mg/dl (7.8 mmol/l)—that’s fasting, after meals, whatever. Back in 2011, the AACE recommended blood sugar goals:

• Fasting Blood Sugar: under110 mg/dl (6.11 mmol/l)
• Two Hours After a Meal: under140 mg/dl (7.78 mmol/l)

The ADA reminds clinicians, and I’m sure the AACE guys agree, that diabetes control goals should be individualized, based on age and life expectancy of the patient, duration of diabetes, other diseases that are present, individual patient preferences, and whether the patient is able to easily recognize and deal with hypoglycemia. I agree completely. For instance, there’s not much reason to aim for blood sugars of 100 mg/dl (5.56 mmol/l) in a 79-year-old expected to die of lung cancer in four months. The goal is comfort and symptom relief, even if sugars are 220 mg/dl (12.2 mmol/l).

Steve Parker, M.D.