Diabetes care gets major update: More aggressive approach to weight loss, cholesterol, disparities recommended


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

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

The guidelines are available to doctors via an app as well as online. Last year, they were accessed more than 4 million times across the globe, said Dr. Robert Gabbay, chief science and medical officer for the diabetes association.

“The emphasis of our guidelines is really to reduce the burden of the disease on people with diabetes,” said Dr. Nuha El Sayed, chair of the association’s Professional Practice Committee, which crafted the revisions. “That is at the heart of what we’re doing.”

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 El Sayed, also a staff physician at the Joslin Diabetes Center and an instructor at Harvard Medical School, both in Boston.

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 coming to market, 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 around diet and exercise, including eating a well-balanced diet and reducing processed foods and added sugar. “Recommendations around lifestyle haven’t changed and they’re still very important,” he said.

Preventing cardiovascular, 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 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” for these conditions, he said.

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, both of which can lead to amputations.

Sleep is crucial

Both the quality and the 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 their patients with diabetes about proper sleep habits and identifying people 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 improving sleep apnea can help control diabetes, Gabbay said.

Addressing 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 added. “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 that 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 is still not providing enough financial support to their issues or to diabetes researchers at historically Black colleges and universities, according to Rock.

“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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