Diabetes care: More aggressive approach to weight loss, cholesterol recommended

The American Diabetes Association has released new standards of care to reflect changes in technology, improved medications and a deeper understanding of social factors that contribute to disease and diabetes control.

The standards are updated annually but this year includes nearly 100 new or revised recommendations affecting all types of diabetes.

The guidelines are available to doctors via an app and online. Last year, they were accessed more than four million times across the globe, said Dr. Robert Gabbay, chief science and medical officer for the diabetes association.

In addition to changes in standards for weight control, blood pressure and cholesterol management, the revisions are also intended to address racial disparities in care, said Dr. Nuha El Sayed, who chairs the association’s Professional Practice Committee, which crafted the revisions, and is a physician at the Joslin Diabetes Center in Boston and an instructor at Harvard Medical School.

Racial differences in diabetes don’t have a biological basis, she said, and the guidelines are designed to “help people open their eyes to the huge disparities in care and outcome.”

Weight management

New tools, particularly more effective weight-loss medications, should allow diabetes patients more control over their weight, Gabbay said. Losing 15% of body weight, as opposed to the previously recommended 5% should yield more health benefits, he said.

“We have better tools now to achieve those goals, making them realistic,” Gabbay said. 

Guidelines remain the same regarding diet and exercise, including eating a well-balanced diet and reducing processed foods and added sugar.

Preventing heart, kidney disease

Diabetes is the leading cause of heart disease, and heart disease is the leading cause of death for people with diabetes, Gabbay said. 

In line with the American College of Cardiology, the new guidelines include a lower target for blood pressure of less than 130 over 80. For LDL cholesterol, the bad kind, the new guideline calls for a measurement of 70 for people without heart disease, down from 100, and 55 instead of 70 for those with established heart disease.

Gabbay noted that statins are extremely good at cutting cholesterol levels and that other medications can effectively reduce blood pressure to meet these targets.

”There are a number of studies demonstrating that even lower goals result in better outcomes for people with diabetes,” he said.

The guidelines also call for more aggressive treatment to prevent the progression of chronic kidney disease.

“Diabetes continues to be the leading cause of end-stage renal disease,” Gabbay said. “There’s both a societal need and fortunately the scientific evidence to support the right treatments.”

Preventing amputations

Black Americans with diabetes are three to four times more likely to have a limb amputated than a white person with the same condition, Gabbay said, and the rate of amputations is getting worse, not better.

The new guidelines call for more careful screening for foot ulcers and peripheral arterial disease, which can lead to amputations.

Sleep crucial

The quality and timing of sleep matters, Gabbay said. “Not too much and not too little,” he said. “Both are associated with poorer outcomes when it comes to diabetes.”

Doctors should be counseling peole with diabetes about proper sleep habits and identifying those who have sleep issues, according to the new guidelines.

Many people with diabetes are prone to sleep apnea, a potentially dangerous condition in which someone stops breathing briefly during sleep. The treatment of diabetes, particularly with weight loss, can improve sleep apnea, and that can help control diabetes, Gabbay said.

Social factors

Everyone with diabetes should be screened for problems that are likely to get in the way of good diabetes management, such as food insecurity, living in a food desert with few options or a “food swamp,” where only processed foods are readily available, he said.

“Educating people about eating healthy when they don’t have access to healthy food is only going to lead to frustration,” Gabbay said.

“We want the entire diabetes health care team to participate in asking people about food but also other things,” El Sayed said. “Did they lose their job? Do they live in a safe neighborhood — before we tell them to exercise.”

Studies have demonstrated the value of community health workers, particularly for underserved and disadvantaged populations, to help them stick with medication and lifestyle changes, Gabbay said.

Improving access to technology

Doctors often assume older adults aren’t comfortable with technology, so they fail to recommend high-tech treatments, such as automated insulin delivery devices and glucose pumps, Gabbay said.

The new guidelines instead recommend that everyone be offered the latest technologies, including older patients.

Black Americans and other people of color are often given less access to advanced technologies than their white counterparts, he said, so the diabetes association has created a technology access program to boost racial equity.

“Everybody should have access to the technologies that can help them thrive with their diabetes,” Gabbay said.

When people are given technologies like continuous glucose monitors, they often describe them as “transformative” and “game changers,” Gabbay said. “People of all ages — children, adults, older adults with Type 1, Type 2 or any insulin dependence — should be offered continuous glucose monitors.”

Are the changes enough?

While the guideline changes are important and necessary, they are too little too late to adequately address diabetes among Black Americans, said Leon Rock, co-founder of the African American Diabetes Association. 

Historically, the American Diabetes Association has been guilty of “woeful neglect” of Black people with diabetes, he said. The association is now paying lip service to their needs but still not providing enough financial support to their issues or to diabetes researchers at historically Black colleges and universities, Rock said.

“As money comes into the ADA and goes out, it continues to go to institutions such as Yale, Harvard, Boston University and Boston College,” not historically Black schools. The association is not doing enough to address diabetes in public housing, either, he said. 

“It’s a start,” Rock said, “but the bottom line is: Starting and actually doing is two different things.”

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