In its new 2022 guidelines, the American Diabetes Association (ADA) now recommends that asymptomatic adults be screened for prediabetes and type 2 diabetes (T2D) beginning at age 35. Other changes include new screening recommendations for pregnant women and those planning a pregnancy. Patients at risk for diabetes who are planning to become pregnant should be screened before conception or, if not screened before conception, before they are 15 weeks pregnant. The standards also urge healthcare professionals to consider screening all those who are currently pregnant or planning to become pregnant regardless of diabetes risk.
Changes on four fronts
The guidelines take a four-prong approach toward more comprehensive diabetes care: glucose management, blood pressure management, lipid management, and using glucose-lowering medications that have been shown to have heart or kidney benefits, all undergirded with a foundation of lifestyle modification and diabetes self-management education and support. For the first time, the revised ADA guidelines also recommend COVID-19 vaccines for all adults with diabetes.
Additional key update areas include expanded recommendations evaluating glucose management using a 14-day assessment from continuous glucose monitoring (CGM), Time in Range, and Glucose Management Indicator (GMI) as complementary measures to A1C as a diabetic metric. The new document highlights the importance of evaluating a patient’s risk of hypoglycemia and also characterizes low blood sugar, if it occurs, as an urgent issue.
Further, CGM is now recommended for all adults who take insulin, including long-acting insulin; recommendations are expanded for diabetes technology such as automated insulin delivery (AID) and CGM to all children who use rapid-acting insulin; and in-hospital technology use is discussed for all patients who are able to safely utilize their devices such as insulin pumps, CGMs, and AID systems in the hospital setting.
In the dark about diabetes
The CDC estimates that 88 million people in the US have prediabetes, the majority of whom do not know it and have not been made aware of it by their healthcare providers. Prediabetes increases the risk of T2D, heart disease, and stroke. Of the estimated 34 million US adults with diabetes in 2018, about 1 in 5 (21%) were undiagnosed.
How you can help
Informing your patients about the benefits of even the most modest lifestyle changes may be among your most powerful patient motivators. Studies show that weight loss of 5% to 7% achieved via calorie reduction and increasing physical activity to at least 150 minutes per week resulted in a full 58% lower incidence of T2D. For your patients 60 and older, that change reduced the incidence of T2D by 71%.
Behavioral specialists advise breaking the most insurmountable-seeming tasks down into manageable “bites.” That 150 minutes of activity per week amounts to roughly 21 minutes per day and a 5% weight loss in a 200-lb patient comes to ~10 pounds. “Translating” these two goals into micro-steps for your patients may boost their perception of them from daunting to doable.
Cost-free support for your patients
The above incidence-reduction data is derived from the results of a CDC-led National Diabetes Prevention Program which has been proven to help prevent or delay T2D.
Your patients may be eligible for the program, which provides a trained lifestyle coach, a CDC-approved curriculum, group support, and a full year of in-person or online meetings. Your patients will learn how to make realistic and achievable lifestyle changes including learning about and eating healthy, incorporating physical activity into their daily routine, managing stress, and recognizing and overcoming barriers that get in the way of healthy changes. To be eligible, patients must be 18 or more years of age and overweight, and either diagnosed with diabetes or previously diagnosed with gestational diabetes.
Note these medication updates
Beyond lifestyle changes, the new guidance makes critical changes to previous diabetes treatment regimens. For instance, the updated guidelines now recommend SGLT-2 inhibitors to treat heart failure and note that these can be started at the time of diagnosis. These therapies had previously been recommended only to treat heart failure with reduced ejection fraction.
In addition, the new guidelines now suggest that certain individuals with stage 4 chronic kidney disease (CKD) take SGLT-2 inhibitors to preserve kidney function. In the past, ADA recommended that, after progressing to stage 4 CKD, patients should stop SGLT-2 therapy as the risk for additional kidney damage actually increased at advanced stages. The new document changes this threshold, suggesting that more people in advanced stages of CKD can now safely use an SLGT-2 inhibitor. For those patients who may not respond well to treatment with these agents, finerenone (Kerendia), a recently approved non-steroidal mineralocorticoid-receptor antagonist (MRA), can alternatively be used to improve both kidney and heart outcomes.
The ADA now also recommends that patients with T2D who take insulin combine insulin with a GLP-1 receptor agonist (such as Rybelsus, Ozempic, Bydureon, Trulicity, Victoza, etc.) if additional glucose lowering is needed, as opposed to only increasing insulin dosing. Past ADA guidelines recommended using an SGLT-2 inhibitor or a GLP-1 receptor agonist for heart or kidney disease. This year, however, recommendations suggest that a combination of both should be considered to lower risk even further. Additionally, instead of adding the drugs one by one, the guidelines indicate that it may be best to begin with a combination of the two depending upon the individual patient’s circumstances.
The new guidelines also now recommend semaglutide 2.4mg (Wegovy) as an effective therapy for weight management for patients with T2D. However, for those patients with T2D who take insulin, using semaglutide at the same time may increase the risk for hypoglycemia. The drug can still be an effective means to achieve some weight loss the update notes, but patients should be educated regarding the signs, symptoms, and risk of hypoglycemia before beginning this medication.
From medicine cabinet to kitchen cabinet
The guidelines also advise managing glucose through more than just carbohydrate-counting. Regardless of the amount of carbohydrate in the meal plan, patients should focus on eating nutrient-dense, high-quality carbohydrate sources high in fiber. Both adults and children should limit the amount of refined or processed carbs consumed — particularly those with added sugars, fat, and salt — and focus instead on getting their carbs from vegetables, legumes, fruits, dairy (milk and yogurt), and whole grains.
Familiarizing yourself with these critical guideline changes will equip you to provide more informed care for this growing patient population in championing their commitment to better lifestyle choices and improved health.
Learn more from CDC and find an approved lifestyle-change program at www.cdc.gov/diabetes/prevention.
Find the full ADA guideline “Standards of Medical Care in Diabetes—2022” at https://doi.org/10.2337/dc22-S001
The contents of this feature are not provided or reviewed by NPWH.