The American Diabetes Association (ADA) has released the 2023 Standards of Care in Diabetes, a set of guidelines that are updated annually after a thorough review of new research.
This year’s updates are focused on how to more aggressively treat diabetes and reduce diabetes complications, with changes to recommendations on weight loss, high blood pressure, cholesterol, and more.
“The world of diabetes is moving quite quickly. There are lots of new studies, and we want to make sure clinicians have the most up-to-date information to guide them in how to care for people with diabetes,” says Robert A. Gabbay, MD, PhD, who serves as the chief scientific and medical officer of the ADA.
This document, released on December 12, is considered the gold standard of care, and it’s one that providers consult daily or even multiple times a day. Last year, the guidelines were accessed an estimated four million times, according to Dr. Gabbay.
New Standards Support Higher Weight Loss Goals, Up to 15 Percent of Body Weight
This year’s document emphasizes higher weight loss goals — up to 15 percent — provided the person has access to newer medications and responds to them.
“The shift in thinking is to not just consider glucose control, which is what diabetes has always been about. But for people with obesity, which is the majority of people with type 2 diabetes, one needs to think about weight management,” says Gabbay.
It’s been established that mild weight loss is effective in reducing type 2 diabetes burden, with previous recommendations setting a 5 percent goal. But greater weight loss does more to reduce illness and death, Gabbay says: “And we now have some potent agents that can help people achieve their weight loss goals.”
“The newer medications, specifically GLP-1 receptor agonists [such as Ozempic and Wegovy] and SGLT2 inhibitors [like Jardiance and Farxiga], have made a profound impact on both glycemic and weight management in individuals with T2D,” says Donald McClain, MD, PhD, a professor of endocrinology and metabolism at Wake Forest University School of Medicine in Winston-Salem, North Carolina. Dr. McClain, who also serves as the director of the Center on Diabetes, Obesity, and Metabolism at Atrium Health Wake Forest Baptist, was not involved in updating the standards of care.
In general, the medications alone are associated with significant weight loss, close to 25 pounds or even more, he says.
Lower Is Better: New Goals for Blood Pressure and LDL Cholesterol
One new and important update concerns blood pressure, says Gabbay. “The goal has been lowered to less than 130 over 80, a change that was prompted by the evidence showing that people have significantly better outcomes when blood pressure is managed below that level,” he says.
This goal aligns with the current recommendation by the American Heart Association and the American College of Cardiology.
The recommended goals for LDL cholesterol (sometimes called “bad” cholesterol because a high level can lead to a buildup of cholesterol in the arteries and increase the risk of heart disease) has also been lowered for people with diabetes and cardiovascular risk factors to less than 70. It used to be 100, says Gabbay. “For people with diabetes with established heart disease — for example, if a person has had a heart attack — the new goal for LDL is 55 or lower instead of 70,” he says.
In both cases, medications for lowering blood pressure and cholesterol may be necessary to achieve those numbers, adds Gabbay.
Screening for Sleep Issues in People With T2D Is Recommended
“The updated standards recognize the importance of sleep: duration of sleep, because we know that too much or too little can negatively impact health; the quality of sleep; and also the timing of sleep. All of these things can impact blood glucose levels as well as obesity risk,” says Gabbay.
“We know that metabolism has a circadian (day/night) rhythm,” says McClain. Research has shown that working against that rhythm can be sufficient to cause diabetes. For example, night-shift work is associated with higher rates of diabetes, he says.
“We also know interrupted sleep causes abnormalities in glucose handling and insulin production,” says McClain. This is partially why people with sleep apnea can have abnormal glucose and insulin regulation. Elevations in stress hormones and decreased oxygen levels add to the picture, he says.
The document recommends screening for sleep issues and highlights the need for providers to talk with their patients about the relationship between diabetes and sleep. “If there are sleep disturbances, it may be necessary to see a specialist,” says Gabbay.
Exercise Is Especially Important for People With Diabetes
The recommendations for physical activity aren’t so different from those for the general population, but there’s an emphasis on it: Exercise becomes even more important for people with diabetes, not only for weight management, but for its benefits to the heart as well, says Gabbay.
“Most studies show benefits both of low-intensity and high-intensity exercise, and of aerobic and resistance exercise, and in most studies, there is a dose-response relationship such that more is better,” says McClain.
RELATED: Quick Bursts of Intense Physical Activity May Help You Live Longer
The recommendation in adults of 150 minutes a week, spread out over at least three sessions, is a compromise aimed at providing a goal that most people should be able to achieve, he says. “But even modest increases in activity — taking a short stand-up-and-walk every 30 minutes from the computer, for example — are beneficial,” says McClain.
Social Determinants of Health Are a ‘Huge Factor in Diabetes Risk’
Not everyone has equal access to the tools and strategies that reduce the risk of diabetes or the medications and care to treat it. A first step in correcting that is identifying at-risk patients by screening for food and housing insecurity and financial barriers, according to the document.
“If you do not have access to healthcare or the means to pay for it, you are likely not going to be able to afford the best medications or preventive care that might be provided,” says McClain.
And there are lifestyle factors that play an important role as well, he says. “Do you live in a ‘food desert’ where the most accessible food is not necessarily the healthiest food? Do you live in a neighborhood where it is safe to go for a walk, and if not, can you afford membership to a facility where you can go to exercise? And the stress associated with living in an unsafe neighborhood can, in and of itself, contribute to abnormal glucose regulation,” says McClain.
Ask Your Provider About Updated Diabetes Standards of Care
The new standards of care outline changes related to technology, kidney disease prevention, and preventing amputations as well. The complete revised document can be found in the January 2023 issue of Diabetes Care.
People with diabetes should talk with their healthcare professional about the new standards and ask questions, suggests Gabbay. “This could be a helpful prompt to a busy provider. Ask, ‘Is my blood pressure at goal? Are my cholesterol values where they need to be based on these new guidelines?’ Essentially, advocate for themselves and their health,” he says.
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