Dietary Knowledge, Attitude and Practice (KAP) Among the Family Members of Patients with Type 2 Diabetes Mellitus (T2DM) and Its Influence on the KAP of T2DM Patients

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Abstract

Purpose

To investigate the dietary knowledge, attitude and practice (KAP) among the family members (FMs) of Chinese type 2 diabetes mellitus (T2DM) patients and its influence on the KAP of T2DM patients.

Patients and Methods

Two hundred thirty-six pairs of hospitalized T2DM patients and their FMs (472 in total) in our hospital were enrolled. A pair of self-designed questionnaires on dietary KAP (Cronbach’s α ≥ 0.763, I-CVI ≥ 0.857, S-CVI = 0.964, 0.958) were used to collect data and assess the KAP towards diabetes diets.

Results

The mean score for dietary KAP of T2DM patients was 2.33 ± 0.60, 3.03 ± 0.44 and 2.77 ± 0.38, whereas that of their FMs was 2.37 ± 0.55, 3.08 ± 0.48 and 2.82 ± 0.61, respectively. Pearson’s correlation analysis showed that the glycosylated hemoglobin (HbA1c) of T2DM patients was negatively correlated to their dietary practice ( r = −0.218, P < 0.01). There was a positive correlation between T2DM patients and their FMs for dietary KAP ( r = 0.306, P < 0.05). The dietary practice of T2DM patients was positively correlated with the dietary KAP of their FMs ( r = 0.305, 0.252 and 0.136, respectively, P < 0.01). Logistic regression analysis revealed that the score for dietary knowledge and attitude, occupation, residence, family history, complications of the T2DM patient, and the sex and dietary knowledge score of the FM were significantly associated with dietary practice for T2DM patients.

Conclusion

The dietary attitude of FMs was moderate but dietary knowledge and practice were poor. Dietary KAP was positively correlated with T2DM patients and their FMs.

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Most cited references 37

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WITHDRAWN: Global and regional diabetes prevalence estimates for 2019 and projections for 2030 and 2045: results from the International Diabetes Federation Diabetes Atlas, 9th edition

Pouya Saeedi, Inga Petersohn, Paraskevi Salpea … (2019)

To provide global estimates of diabetes prevalence for 2019 and projections for 2030 and 2045.

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Nutrition Therapy for Adults With Diabetes or Prediabetes: A Consensus Report

Alison B Evert, Michelle Dennison, Christopher Gardner … (2019)

This Consensus Report is intended to provide clinical professionals with evidence-based guidance about individualizing nutrition therapy for adults with diabetes or prediabetes. Strong evidence supports the efficacy and cost-effectiveness of nutrition therapy as a component of quality diabetes care, including its integration into the medical management of diabetes; therefore, it is important that all members of the health care team know and champion the benefits of nutrition therapy and key nutrition messages. Nutrition counseling that works toward improving or maintaining glycemic targets, achieving weight management goals, and improving cardiovascular risk factors (e.g., blood pressure, lipids, etc.) within individualized treatment goals is recommended for all adults with diabetes and prediabetes. Though it might simplify messaging, a “one-size-fits-all” eating plan is not evident for the prevention or management of diabetes, and it is an unrealistic expectation given the broad spectrum of people affected by diabetes and prediabetes, their cultural backgrounds, personal preferences, co-occurring conditions (often referred to as comorbidities), and socioeconomic settings in which they live. Research provides clarity on many food choices and eating patterns that can help people achieve health goals and quality of life. The American Diabetes Association (ADA) emphasizes that medical nutrition therapy (MNT) is fundamental in the overall diabetes management plan, and the need for MNT should be reassessed frequently by health care providers in collaboration with people with diabetes across the life span, with special attention during times of changing health status and life stages (1–3). This Consensus Report now includes information on prediabetes, and previous ADA nutrition position statements, the last of which was published in 2014 (4), did not. Unless otherwise noted, the research reviewed was limited to those studies conducted in adults diagnosed with prediabetes, type 1 diabetes, and/or type 2 diabetes. Nutrition therapy for children with diabetes or women with gestational diabetes mellitus is not addressed in this review but is covered in other ADA publications, specifically Standards of Medical Care in Diabetes (5,6). Data Sources, Searches, and Study Selection The authors of this report were chosen following a national call for experts to ensure diversity of the members both in professional interest and cultural background, including a person living with diabetes who served as a patient advocate. An outside market research company was used to conduct the literature search and was paid using ADA funds. The authors convened in person for one group meeting and actively participated in monthly teleconference calls between February and November 2018. Focused teleconference calls, email, and web-based collaboration were also used to reach consensus on final recommendations between November 2018 and January 2019. The 2014 position statement (4) was used as a starting point, and a search was conducted on PubMed for studies published in English between 1 January 2014 and 28 February 2018 to provide the updated evidence of nutrition therapy interventions in nonhospitalized adults with prediabetes and type 1 and type 2 diabetes. Details on the keywords and the search strategy are reported in the Supplementary Data, emphasizing randomized controlled trials (RCTs), systematic reviews, and meta-analyses of RCTs. An exception was made to the inclusion criteria for the use of meal studies for the insulin dosing section. In addition to the search results, in select cases the authors identified relevant research to include in reaching consensus. The consensus report was peer reviewed (see acknowledgments) and suggestions incorporated as deemed appropriate by the authors. Though evidence-based, the recommendations presented are the informed, expert opinions of the authors after consensus was reached through presentation and discussion of the evidence. EFFECTIVENESS OF DIABETES NUTRITION THERAPY Consensus recommendations Refer adults living with type 1 or type 2 diabetes to individualized, diabetes-focused MNT at diagnosis and as needed throughout the life span and during times of changing health status to achieve treatment goals. Coordinate and align the MNT plan with the overall management strategy, including use of medications, physical activity, etc., on an ongoing basis. Refer adults with diabetes to comprehensive diabetes self-management education and support (DSMES) services according to national standards. Diabetes-focused MNT is provided by a registered dietitian nutritionist/registered dietitian (RDN), preferably one who has comprehensive knowledge and experience in diabetes care. Refer people with prediabetes and overweight/obesity to an intensive lifestyle intervention program that includes individualized goal-setting components, such as the Diabetes Prevention Program (DPP) and/or to individualized MNT. Diabetes MNT is a covered Medicare benefit and should be adequately reimbursed by insurance and other payers or bundled in evolving value-based care and payment models. DPP-modeled intensive lifestyle interventions and individualized MNT for prediabetes should be covered by third-party payers or bundled in evolving value-based care and payment models. How is diabetes nutrition therapy defined and provided? The National Academy of Medicine (formerly the Institute of Medicine) broadly defines nutrition therapy as the treatment of a disease or condition through the modification of nutrient or whole-food intake (7). To complement diabetes nutrition therapy, members of the health care team can and should provide evidence-based guidance that allows people with diabetes to make healthy food choices that meet their individual needs and optimize their overall health. The Dietary Guidelines for Americans (DGA) 2015–2020 provide a basis for healthy eating for all Americans and recommend that people consume a healthy eating pattern that accounts for all foods and beverages within an appropriate calorie level (8). For people with diabetes, recommendations that differ from the DGA are highlighted in this report. MNT is an evidence-based application of the nutrition care process provided by an RDN and is the legal definition of nutrition counseling by an RDN in the U.S. (9–12). Essential components of MNT are assessment, nutrition diagnosis, interventions (e.g., education and counseling), and monitoring with ongoing follow-up to support long-term lifestyle changes, evaluate outcomes, and modify interventions as needed (9,10). The goals of nutrition therapy are described in Table 1. Table 1 Goals of nutrition therapy • To promote and support healthful eating patterns, emphasizing a variety of nutrient-dense foods in appropriate portion sizes, in order to improve overall health and specifically to: ○ Improve A1C, blood pressure, and cholesterol levels (goals differ for individuals based on age, duration of diabetes, health history, and other present health conditions. Further recommendations for individualization of goals can be found in the ADA Standards of Medical Care in Diabetes [345]) ○ Achieve and maintain body weight goals ○ Delay or prevent complications of diabetes • To address individual nutrition needs based on personal and cultural preferences, health literacy and numeracy, access to healthful food choices, willingness and ability to make behavioral changes, as well as barriers to change • To maintain the pleasure of eating by providing positive messages about food choices, while limiting food choices only when indicated by scientific evidence • To provide the individual with diabetes with practical tools for day-to-day meal planning The unique academic preparation, training, skills, and expertise make the RDN the preferred member of the health care team to provide diabetes MNT and leadership in interprofessional team-based nutrition and diabetes care (1,9,13–18). Although certification (such as Certified Diabetes Educator, Board Certified-Advanced Diabetes Management) is not required, ideally the RDN will have comprehensive knowledge and experience in diabetes care and prevention (9,17). Detailed guidance for the RDN to obtain the expert knowledge and experience can be found in the Academy of Nutrition and Dietetics Standards of Practice and Standards of Professional Performance (12). Health care professionals can use the education algorithm suggested by ADA, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics (1) that defines and describes the four critical times to assess, provide, and adjust care. The algorithm is intended for use by the RDN and the interprofessional team for determining how and when to deliver diabetes education and nutrition services. The number of encounters the person with diabetes might have with the RDN is described in Table 2 (9). Table 2 Academy of Nutrition and Dietetics evidence-based nutrition practice guidelines–recommended structure for the implementation of MNT for adults with diabetes (9) Initial series of MNT encounters: The RDN should implement three to six MNT encounters during the first 6 months following diagnosis and determine if additional MNT encounters are needed based on an individualized assessment. MNT follow-up encounters: The RDN should implement a minimum of one annual MNT follow-up encounter. In addition to diabetes MNT, DSMES is important for people with diabetes to improve cardiometabolic and microvascular outcomes in a disease that is largely self-managed (1,19–23). DSMES includes the ongoing process that facilitates the knowledge, skills, and abilities necessary for diabetes self-care throughout the life span, with nutrition as one of the core curriculum topics taught in comprehensive programs (21). Is MNT effective in improving outcomes? Reported hemoglobin A1c (A1C) reductions from MNT can be similar to or greater than what would be expected with treatment using currently available medication for type 2 diabetes (9). Strong evidence supports the effectiveness of MNT interventions provided by RDNs for improving A1C, with absolute decreases up to 2.0% (in type 2 diabetes) and up to 1.9% (in type 1 diabetes) at 3–6 months. Ongoing MNT support is helpful in maintaining glycemic improvements (9). Cost-effectiveness of lifestyle interventions and MNT for the prevention and management of diabetes has been documented in multiple studies (12,17,24,25). The National Academy of Medicine recommends individualized MNT, provided by an RDN upon physician referral, as part of the multidisciplinary approach to diabetes care (7). Diabetes MNT is a covered Medicare benefit and should also be adequately reimbursed by insurance and other payers, or bundled in evolving value-based care and payment models, because it can result in improved outcomes such as reduced A1C and cost savings (12,17,25). What nutrition therapy interventions best help people with prediabetes prevent or delay the development of type 2 diabetes? The strongest evidence for type 2 diabetes prevention comes from several studies, including the DPP (26–28). The DPP demonstrated that an intensive lifestyle intervention resulting in weight loss could reduce the incidence of type 2 diabetes for adults with overweight/obesity and impaired glucose tolerance by 58% over 3 years (26). Follow-up of three large studies of lifestyle intervention for diabetes prevention has shown sustained reduction in the rate of conversion to type 2 diabetes: 43% reduction at 20 years in the Da Qing Diabetes Prevention Study (29); 43% reduction at 7 years in the Finnish Diabetes Prevention Study (DPS) (30); and 34% reduction at 10 years (28) and 27% reduction at 15 years extended follow-up of the DPP (31) in the U.S. Diabetes Prevention Program Outcomes Study (DPPOS). The follow-up of the Da Qing study also demonstrated a reduction in cardiovascular and all-cause mortality (32). Substantial evidence indicates that individuals with prediabetes should be referred to an intensive behavioral lifestyle intervention program modeled on the DPP and/or to individualized MNT typically provided by an RDN with the goals of improving eating habits, increasing moderate-intensity physical activity to at least 150 min per week, and achieving and maintaining 7–10% loss of initial body weight if needed (14,17,33,34). More intensive intervention programs are the most effective in decreasing diabetes incidence and improving cardiovascular disease (CVD) risk factors (35). Both DPP-modeled intensive lifestyle interventions and individualized MNT for prediabetes have demonstrated cost-effectiveness (17,36) and therefore should be covered by third-party payers or bundled in evolving value-based care and payment models (25). To make diabetes prevention programs more accessible, digital health tools are an area of increasing interest in the public and private sectors. Preliminary research studies support that the delivery of diabetes prevention lifestyle interventions through technology-enabled platforms and digital health tools can result in weight loss, improved glycemia, and reduced risk for diabetes and CVD, although more rigorous studies are needed (37–44). MACRONUTRIENTS Consensus recommendations Evidence suggests that there is not an ideal percentage of calories from carbohydrate, protein, and fat for all people with or at risk for diabetes; therefore, macronutrient distribution should be based on individualized assessment of current eating patterns, preferences, and metabolic goals. When counseling people with diabetes, a key strategy to achieve glycemic targets should include an assessment of current dietary intake followed by individualized guidance on self-monitoring carbohydrate intake to optimize meal timing and food choices and to guide medication and physical activity recommendations. People with diabetes and those at risk for diabetes are encouraged to consume at least the amount of dietary fiber recommended for the general public; increasing fiber intake, preferably through food (vegetables, pulses [beans, peas, and lentils], fruits, and whole intact grains) or through dietary supplement, may help in modestly lowering A1C. Do macronutrient needs differ for people with diabetes compared with the general population? Although numerous studies have attempted to identify the optimal mix of macronutrients for the eating plans of people with diabetes, a systematic review (45) found that there is no ideal mix that applies broadly and that macronutrient proportions should be individualized. It has been observed that people with diabetes, on average, eat about the same proportions of macronutrients as the general public: ∼45% of their calories from carbohydrate (see Table 3), ∼36–40% of calories from fat, and the remainder (∼16–18%) from protein (46–48). Regardless of the macronutrient mix, total energy intake should be appropriate to attain weight management goals. Further, individualization of the macronutrient composition will depend on the status of the individual, including metabolic goals (glycemia, lipid profile, etc.), physical activity, food preferences, and availability. Table 3 Eating patterns reviewed for this report Type of eating pattern Description Potential benefits reported* USDA Dietary Guidelines For Americans (DGA) (8) Emphasizes a variety of vegetables from all of the subgroups; fruits, especially whole fruits; grains, at least half of which are whole intact grains; lower-fat dairy; a variety of protein foods; and oils. This eating pattern limits saturated fats and trans fats, added sugars, and sodium. DGA added to the table for reference; not reviewed as part of this Consensus Report Mediterranean-style (69,76,85–91) Emphasizes plant-based food (vegetables, beans, nuts and seeds, fruits, and whole intact grains); fish and other seafood; olive oil as the principal source of dietary fat; dairy products (mainly yogurt and cheese) in low to moderate amounts; typically fewer than 4 eggs/week; red meat in low frequency and amounts; wine in low to moderate amounts; and concentrated sugars or honey rarely. • Reduced risk of diabetes • A1C reduction • Lowered triglycerides • Reduced risk of major cardiovascular events Vegetarian or vegan (77–80,92–99) The two most common approaches found in the literature emphasize plant-based vegetarian eating devoid of all flesh foods but including egg (ovo) and/or dairy (lacto) products, or vegan eating devoid of all flesh foods and animal-derived products. • Reduced risk of diabetes • A1C reduction • Weight loss • Lowered LDL-C and non–HDL-C Low-fat (26,45,80,83,100–106) Emphasizes vegetables, fruits, starches (e.g., breads/crackers, pasta, whole intact grains, starchy vegetables), lean protein sources (including beans), and low-fat dairy products. In this review, defined as total fat intake ≤30% of total calories and saturated fat intake ≤10%. • Reduced risk of diabetes • Weight loss Very low-fat (107–109) Emphasizes fiber-rich vegetables, beans, fruits, whole intact grains, nonfat dairy, fish, and egg whites and comprises 70–77% carbohydrate (including 30–60 g fiber), 10% fat, 13–20% protein. • Weight loss • Lowered blood pressure Low-carbohydrate (110–112) Emphasizes vegetables low in carbohydrate (such as salad greens, broccoli, cauliflower, cucumber, cabbage, and others); fat from animal foods, oils, butter, and avocado; and protein in the form of meat, poultry, fish, shellfish, eggs, cheese, nuts, and seeds. Some plans include fruit (e.g., berries) and a greater array of nonstarchy vegetables. Avoids starchy and sugary foods such as pasta, rice, potatoes, bread, and sweets. There is no consistent definition of “low” carbohydrate. In this review, a low-carbohydrate eating pattern is defined as reducing carbohydrates to 26–45% of total calories. • A1C reduction • Weight loss • Lowered blood pressure • Increased HDL-C and lowered triglycerides Very low-carbohydrate (VLC) (110–112) Similar to low-carbohydrate pattern but further limits carbohydrate-containing foods, and meals typically derive more than half of calories from fat. Often has a goal of 20–50 g of nonfiber carbohydrate per day to induce nutritional ketosis. In this review a VLC eating pattern is defined as reducing carbohydrate to 50%. Overall, few long-term (2 years or longer) randomized trials have been conducted of any of the dietary patterns in any of the conditions examined. What is the evidence for specific eating patterns to manage prediabetes and prevent type 2 diabetes? The most robust research available related to eating patterns for prediabetes or type 2 diabetes prevention are Mediterranean-style, low-fat, or low-carbohydrate eating plans (26,69,74,75). The PREDIMED trial, a large RCT, compared a Mediterranean-style to a low-fat eating pattern for prevention of type 2 diabetes onset, with the Mediterranean-style eating pattern resulting in a 30% lower relative risk (69). Epidemiologic studies correlate Mediterranean-style (76), vegetarian (77–80), and Dietary Approaches to Stop Hypertension (DASH) (76,81) eating patterns with a lower risk of developing type 2 diabetes, with no effect for low-carbohydrate eating patterns (82). Several large type 2 diabetes prevention RCTs (26,74,83,84) used low-fat eating plans to achieve weight loss and improve glucose tolerance, and some demonstrated decreased incidence of diabetes (26,74,83). Given the limited evidence, it is unclear which of the eating patterns are optimal. What is the evidence for specific eating patterns to manage type 2 diabetes? Mediterranean-Style Eating Pattern The Mediterranean-style pattern has demonstrated a mixed effect on A1C, weight, and lipids in a number of RCTs (85–90). In the Dietary Intervention Randomized Controlled Trial (DIRECT), obese adults with type 2 diabetes were randomized to a calorie-restricted Mediterranean-style, a calorie-restricted lower-fat, or a low-carbohydrate eating pattern (28% of calories from carbohydrate) without emphasis on calorie restriction. A1C was lowest in the low-carbohydrate group after 2 years, whereas fasting plasma glucose was lower in the Mediterranean-style group than in the lower-fat group (90). One of the largest and longest RCTs, the PREDIMED trial, compared a Mediterranean-style eating pattern with a low-fat eating pattern. After 4 years, glycemic management improved and the need for glucose-lowering medications was lower in the Mediterranean eating pattern group (89). In addition, the PREDIMED trial showed that a Mediterranean-style eating pattern intervention enriched with olive oil or nuts significantly reduced CVD incidence in both people with and without diabetes (91). Vegetarian or Vegan Eating Patterns Studies of vegetarian or vegan eating plans ranged in duration from 12 to 74 weeks and showed mixed results on glycemia and CVD risk factors. These eating plans often resulted in weight loss (92–97). Two meta-analyses of controlled trials (98,99) concluded that vegetarian and vegan eating plans can reduce A1C by an average of 0.3–0.4% in people with type 2 diabetes, and the larger meta-analysis (99) also reported that plant-based eating patterns reduced weight (weight reduction of 2 kg), waist circumference, LDL cholesterol (LDL-C), and non–HDL-C with no significant effect on fasting insulin, HDL-C, triglycerides, and blood pressure. Low-Fat Eating Pattern In the Look AHEAD (Action for Health in Diabetes) trial (100), individuals following a calorie-restricted low-fat eating pattern, in the context of a structured weight loss program using meal replacements, achieved moderate success compared with the control condition eating plan (101). However, lowering total fat intake did not consistently improve glycemia or CVD risk factors in people with type 2 diabetes based on a systematic review (45), several studies (102–105), and a meta-analysis (106). Benefit from a low-fat eating pattern appears to be mostly related to weight loss as opposed to the eating pattern itself (100,101). Additionally, low-fat eating patterns have commonly been used as the “control” intervention compared with other eating patterns. Very Low-Fat: Ornish or Pritikin Eating Patterns The Ornish and Pritikin lifestyle programs are two of the best known multicomponent very low-fat eating patterns. The Ornish program emphasizes a very low-fat, whole-foods, plant-based eating plan (about 70% of calories from carbohydrate, 10% from fat, 20% from protein, and 60 g of fiber), predominantly from vegetables, beans, fruits, grains, nonfat dairy, and egg whites. The Pritikin intervention advises that people consume 77% of calories from carbohydrate, about 10% from fat, 13% from protein, and 30–40 g of fiber per 1,000 calories, with no calorie restriction during a 26-day stay in an in-patient treatment center. Three nonrandomized single-arm studies with 69 to 652 participants lasting between 3 weeks and 2–3 years show that these multicomponent lifestyle intervention programs may improve glucose levels, weight, blood pressure, and HDL-C, with a mixed effect on triglycerides (107–109). Low-Carbohydrate or Very Low-Carbohydrate Eating Patterns Low-carbohydrate eating patterns, especially very low-carbohydrate (VLC) eating patterns, have been shown to reduce A1C and the need for antihyperglycemic medications. These eating patterns are among the most studied eating patterns for type 2 diabetes. One meta-analysis of RCTs that compared low-carbohydrate eating patterns (defined as ≤45% of calories from carbohydrate) to high-carbohydrate eating patterns (defined as >45% of calories from carbohydrate) found that A1C benefits were more pronounced in the VLC interventions (where 3 drinks per day or 21 drinks per week for men and >2 drinks per day or 14 drinks per week for women) consumed on a consistent basis may contribute to hyperglycemia (222). Starting with one drink per day, risk for reduced adherence to self-care and healthy lifestyle behaviors has been reported with increasing alcohol consumption (223). What are the effects of alcohol consumption on hypoglycemia risk in people with diabetes? Despite the potential glycemic and cardiovascular benefits of moderate alcohol consumption, alcohol intake may place people with diabetes at increased risk for delayed hypoglycemia (221,224–226). This effect may be a result of inhibition of gluconeogenesis, reduced hypoglycemia awareness due to the cerebral effects of alcohol, and/or impaired counterregulatory responses to hypoglycemia (227). This is particularly relevant for those using insulin or insulin secretagogues who can experience delayed nocturnal or fasting hypoglycemia after evening alcohol consumption. Consuming alcohol with food can minimize the risk of nocturnal hypoglycemia (227,228). It is essential that people with diabetes receive education regarding the recognition and management of delayed hypoglycemia and the potential need for more frequent glucose monitoring after consuming alcohol (227,229). How does alcohol consumption impact risk of developing type 2 diabetes? Comprehensive reviews and meta-analyses suggest a protective effect of moderate alcohol intake on the risk of developing type 2 diabetes, with a higher rate of diabetes in alcohol abstainers and heavy consumers (222,230–232). Moderate alcohol intake ranging from 6–48 g/day (0.5–3.4 drinks) was associated with a 30–56% lower incidence of type 2 diabetes (9,222,230–232). Knott et al. (232) reported reduced risk of type 2 diabetes at all levels of alcohol intake 3,500 mg daily (308), should be reduced (8,309–312) to prevent and manage hypertension. While reducing sodium to the general recommendation of 7 g/day were both associated with increased mortality in people with type 2 diabetes (315), leading to continued controversy over the potential benefits versus harms of lowering sodium intake below the general recommendation. In the absence of clear scientific evidence for benefit in people with combined diabetes and hypertension (313,314), sodium intake goals that are significantly lower than 2,300 mg/day should be considered only on an individual basis. When individualizing sodium intake recommendations, careful consideration must be given to issues such as food preference, palatability, availability, and additional cost of fresh or specialty low-sodium products (316). Diabetic Kidney Disease Consensus recommendation In individuals with diabetes and non–dialysis-dependent diabetic kidney disease (DKD), reducing the amount of dietary protein below the recommended daily allowance (0.8 g/kg body weight/day) does not meaningfully alter glycemic measures, cardiovascular risk measures, or the course of glomerular filtration rate decline and may increase risk for malnutrition. Are protein needs different for people with diabetes and kidney disease? Historically, low-protein eating plans were advised to reduce albuminuria and progression of chronic kidney disease in people with DKD, typically with improvements in albuminuria but no clear effect on estimated glomerular filtration rate. In addition, there is some indication that a low-protein eating plan may lead to malnutrition in individuals with DKD (317–321). The average daily level of protein intake for people with diabetes without kidney disease is typically 1–1.5 g/kg body weight/day or 15–20% of total calories (45,146). Evidence does not suggest that people with DKD need to restrict protein intake to less than the average protein intake. For people with DKD and macroalbuminuria, changing to a more soy-based source of protein may improve CVD risk factors but does not appear to alter proteinuria (322,323). Gastroparesis Consensus recommendations Selection of small-particle-size foods may improve symptoms of diabetes-related gastroparesis. Correcting hyperglycemia is one strategy for the management of gastroparesis, as acute hyperglycemia delays gastric emptying. Use of CGM and/or insulin pump therapy may aid the dosing and timing of insulin administration in people with type 1 or type 2 diabetes with gastroparesis. How is diabetic gastroparesis best managed? Consultation by an RDN knowledgeable in the management of gastroparesis is helpful in setting and maintaining treatment goals (324). Treatment goals include managing and reducing symptoms; correcting fluid, electrolyte, and nutritional deficiencies and glycemic imbalances; and addressing the precipitating cause(s) with appropriate drug therapy (227). Correcting hyperglycemia is one strategy for the management of gastroparesis, as acute hyperglycemia delays gastric emptying (325,326). Modification of food and beverage intake is the primary management strategy, especially among individuals with mild symptoms. People with gastroparesis may find it helpful to eat small, frequent meals. Replacing solid food with a greater proportion of liquid calories to meet individualized nutrition requirements may be helpful because consuming solid food in large volumes is associated with longer gastric emptying times (327,328). Large meals can also decrease the lower esophageal sphincter pressure, which may cause gastric reflux, providing further aggravation (327). Results from an RCT demonstrated eating plans that emphasize small-particle-size (<2 mm) foods may reduce severity of gastrointestinal symptoms (329). Small-particle-size food is defined as “food easy to mash with a fork into small particle size.” High-fiber foods, such as whole intact grains and foods with seeds, husks, stringy fibers, and membranes, should be excluded from the eating plan. Many of the foods typically recommended for people with diabetes, such as leafy green salads, raw vegetables, beans, and fresh fruits, and other food like fatty or tough meat, can be some of the most difficult foods for the gastroparetic stomach to grind and empty (324,329). Notably, the majority of nutrition therapy interventions for gastroparesis are based on the knowledge of the pathophysiology and clinical judgment rather than empirical research (227). The use of an insulin pump is another option for individuals with type 1 diabetes and insulin-requiring type 2 diabetes with gastroparesis (330). A small but positive 12-month trial reported a 1.8% reduction in A1C and decreased hospitalizations with insulin pump use (331). An insulin pump can be used to provide consistent basal insulin infusion, as well as the ability to modify mealtime insulin delivery doses as needed. The variable bolus feature allows the user to administer a portion of the meal bolus in an extended fashion over a longer period of time (227). Use of this feature may help to decrease the risk of postprandial hyperglycemia as well as hypoglycemia. How is the risk of malnutrition in diabetic gastroparesis managed? When an individual with gastroparesis falls below target weight, nutrition support in the form of oral (for acute exacerbation of symptoms), enteral, or parenteral nutrition should be considered (327). A 5% unintentional loss of usual body weight over 3 months or 10% loss over 6 months is indicative of severe malnutrition. Other nutritional risk parameters include weight <80% of ideal weight, BMI <20 kg/m2, or a loss of 5 lb or 2.5% of baseline weight in 1 month. PERSONALIZED NUTRITION Consensus recommendation Studies using personalized nutrition approaches to examine genetic, metabolomic, and microbiome variations have not yet identified specific factors that consistently improve outcomes in type 1 diabetes, type 2 diabetes, or prediabetes. Do genetic, metabolomic, or microbiome variants, or other types of personalized nutrition prescriptions, influence glycemic or other diabetes-related outcomes? Currently, use of nutrition counseling approaches aimed at personalizing guidance based on genetic, metabolomic, and microbiome information is an area of intense research. Testing has become available commercially, with direct-to-consumer advertising. Some intriguing research has shown, for example, the wide interpersonal variability in blood glucose response to standardized meals that could be predicted by clinical and microbiome profiles (332). At this point, however, no clear conclusions can be drawn regarding their utility owing to wide variations in the markers used for predicting outcomes, in the populations and nutrients studied, and in the associations found. Further, overall findings tend to support evidence from existing clinical trials and observational studies showing that people with markers indicating higher risk for diabetes, prediabetes, or insulin resistance have lower risk when they reduce calorie, carbohydrate, or saturated fat intake and/or increase fiber or protein intake compared with their peers (333–337). Conclusions Ideally, an eating plan should be developed in collaboration with the person with prediabetes or diabetes and an RDN through participation in diabetes self-management education when the diagnosis of prediabetes or diabetes is made. Nutrition therapy recommendations need to be adjusted regularly based on changes in an individual’s life circumstances, preferences, and disease course (1). Regular follow-up with a diabetes health care provider is also critical to adjust other aspects of the treatment plan as indicated. One of the most commonly asked questions upon receiving a diagnosis of diabetes is “What can I eat?” Despite widespread interest in evidence-based diabetes nutrition therapy interventions, large, well-conducted nutrition trials continue to lag far behind other areas of diabetes research. Unfortunately, national data indicate that most people with diabetes do not receive any nutrition therapy or formal diabetes education (4,9,16,20). Strategies to improve access, clinical outcomes, and cost effectiveness include the following reducing barriers to referrals and allowing self-referrals to MNT and DSMES; providing in-person or technology-enabled diabetes nutrition therapy and education integrated with medical management (9,12,13,15,16,19,22,291–293,338–342); engineering solutions that include two-way communication between the individual and his or her health care team to provide individualized feedback and tailored education based on the analyzed patient-generated health data (38,264,343); increasing the use of community health workers and peer coaches to provide culturally appropriate, ongoing support and clinically linked care coordination and improve the reach of MNT and DSMES (15,19,23,38,343,344). Evaluating nutrition evidence is complex given that multiple dietary factors influence glycemic management and CVD risk factors, and the influence of a combination of factors can be substantial. Based on a review of the evidence, it is clear that knowledge gaps continue to exist and further research on nutrition and eating patterns is needed in individuals with type 1 diabetes, type 2 diabetes, and prediabetes. Future studies should address the impact of different eating patterns compared with one another, controlling for supplementary advice (such as stress reduction, physical activity, or smoking cessation); the impact of weight loss on other outcomes (which eating plans are beneficial only with weight loss, which can show benefit regardless of weight loss); how cultural or personal preferences, psychological supports, co-occurring conditions, socioeconomic status, food insecurity, and other factors impact being consistent with an eating plan and its effectiveness; the need for increased length and size of studies, to better understand long-term impacts on clinically relevant outcomes; tailoring MNT and DSMES to different racial/ethnic groups and socioeconomic groups; comparisons of different delivery methods aided by technology (e.g., mobile technology, apps, social media, technology-enabled and internet-based tools); and ongoing cost-effectiveness studies that will further support coverage by third-party payers or bundling services into evolving value-based care and payment models. 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Standards of Medical Care in Diabetes—2020 Abridged for Primary Care Providers

(2020)

The American Diabetes Association’s (ADA’s) Standards of Medical Care in Diabetes is updated and published annually in a supplement to the January issue of Diabetes Care. The Standards are developed by the ADA’s multidisciplinary Professional Practice Committee, which comprises physicians, diabetes educators, and other expert diabetes health care professionals. The Standards include the most current evidence-based recommendations for diagnosing and treating adults and children with all forms of diabetes. ADA’s grading system uses A, B, C, or E to show the evidence level that supports each recommendation. A—Clear evidence from well-conducted, generalizable randomized controlled trials that are adequately powered B—Supportive evidence from well-conducted cohort studies C—Supportive evidence from poorly controlled or uncontrolled studies E—Expert consensus or clinical experience This is an abridged version of the current Standards containing the evidence-based recommendations most pertinent to primary care. The recommendations, tables, and figures included here retain the same numbering used in the complete 2020 Standards and so are not numbered sequentially in this abridged version. All of the recommendations included here are substantively the same as in the complete Standards. The abridged version does not include references. The complete 2020 Standards of Care, including all supporting references, is available at professional.diabetes.org/standards. 1. IMPROVING CARE AND PROMOTING HEALTH IN POPULATIONS Diabetes and Population Health Population health is defined as “the health outcomes of a group of individuals, including the distribution of health outcomes within the group”; these outcomes can be measured in terms of health outcomes (mortality, morbidity, health, and functional status), disease burden (incidence and prevalence), and behavioral and metabolic factors (exercise, diet, A1C, etc.). Recommendations 1.1 Ensure treatment decisions are timely, rely on evidence-based guidelines, and are made collaboratively with patients based on individual preferences, prognoses, and comorbidities. B 1.2 Align approaches to diabetes management with the Chronic Care Model (CCM). This model emphasizes person-centered team care, integrated long-term treatment approaches to diabetes and comorbidities, and ongoing collaborative communication and goal setting between all team members. A 1.3 Care systems should facilitate team-based care and utilization of patient registries, decision support tools, and community involvement to meet patient needs. B 1.4 Assess diabetes health care maintenance using reliable and relevant data metrics to improve processes of care and health outcomes, with simultaneous emphasis on care costs. B Six Core Elements The CCM includes six core elements to optimize the care of patients with chronic disease: 1. Delivery system design (moving from a reactive to a proactive care delivery system where planned visits are coordinated through a team-based approach) 2. Self-management support 3. Decision support (basing care on evidence-based, effective care guidelines) 4. Clinical information systems (using registries that can provide patient-specific and population-based support to the care team) 5. Community resources and policies (identifying or developing resources to support healthy lifestyles) 6. Health systems (to create a quality-oriented culture) A 5-year effectiveness study of the CCM in 53,436 primary care patients with type 2 diabetes suggested that the use of this model of care delivery reduced the cumulative incidence of diabetes-related complications and all-cause mortality. Patients who were enrolled in the CCM experienced a reduction in cardiovascular disease (CVD) risk by 56.6%, microvascular complications by 11.9%, and mortality by 66.1%. The same study suggested that health care utilization was lower in the CCM group, resulting in health care savings of $7,294 per individual over the study period. Strategies for System-Level Improvement 1. Care teams 2. Telemedicine 3. Behaviors and well-being 4. Cost considerations 5. Access to care and quality improvement Tailoring Treatment for Social Context Recommendations 1.5 Providers should assess social context, including potential food insecurity, housing stability, and financial barriers, and apply that information to treatment decisions. A 1.6 Refer patients to local community resources when available. B 1.7 Provide patients with self-management support from lay health coaches, navigators, or community health workers when available. A Health inequities related to diabetes and its complications are well documented and are heavily influenced by social determinants of health (SDoH). SDoH are defined as the economic, environmental, political, and social conditions in which people live and are responsible for a major part of health inequality worldwide. The ADA recognizes the association between social and environmental factors and the prevention and treatment of diabetes and has issued a call for research that seeks to better understand how these SDoH influence behaviors and how the relationships between these variables might be modified for the prevention and management of diabetes. The complete 2020 Standards of Care include a discussion of assessment and treatment considerations in the context of food insecurity, homelessness, seasonal agricultural work, and language barriers. 2. CLASSIFICATION AND DIAGNOSIS OF DIABETES Classification Diabetes can be classified into the following general categories: 1. Type 1 diabetes (due to autoimmune β-cell destruction, usually leading to absolute insulin deficiency) 2. Type 2 diabetes (due to a progressive loss of β-cell insulin secretion frequently on the background of insulin resistance) 3. Gestational diabetes mellitus (GDM; diabetes diagnosed in the second or third trimester of pregnancy that was not clearly overt diabetes prior to gestation) 4. Specific types of diabetes due to other causes, e.g., monogenic diabetes syndromes (such as neonatal diabetes and maturity-onset diabetes of the young), diseases of the exocrine pancreas (such as cystic fibrosis and pancreatitis), and drug- or chemical-induced diabetes (such as with glucocorticoid use, in the treatment of HIV/AIDS, or after organ transplantation) It is important for providers to realize that classification of diabetes type is not always straightforward at presentation, and misdiagnosis may occur. The diagnosis may become more obvious over time and should be reevaluated if there is concern. Screening and Diagnostic Tests for Prediabetes and Type 2 Diabetes The diagnostic criteria for diabetes and prediabetes are shown in Table 2.2/2.5. TABLE 2.2/2.5 Criteria for the screening and diagnosis of prediabetes and diabetes Prediabetes Diabetes A1C 5.7–6.4% (39–47 mmol/mol)* ≥6.5% (48 mmol/mol)† Fasting plasma glucose 100–125 mg/dL (5.6–6.9 mmol/L)* ≥126 mg/dL (7.0 mmol/L)† Oral glucose tolerance test 140–199 mg/dL (7.8–11.0 mmol/L)* ≥200 mg/dL (11.1 mmol/L)† Random plasma glucose ≥200 mg/dL (11.1 mmol/L)‡ Adapted from Tables 2.2 and 2.5 in the complete Standards of Care. *For all three tests, risk is continuous, extending below the lower limit of the range and becoming disproportionately greater at the higher end of the range. †In the absence of unequivocal hyperglycemia, diagnosis requires two abnormal test results from the same sample or in two separate samples. ‡Only diagnostic in a patient with classic symptoms of hyperglycemia or hyperglycemic crisis. Recommendations 2.6 Screening for prediabetes and type 2 diabetes with an informal assessment of risk factors or validated tools should be considered in asymptomatic adults. B 2.7 Testing for prediabetes and/or type 2 diabetes in asymptomatic people should be considered in adults of any age with overweight or obesity (BMI ≥25 kg/m2 or ≥23 kg/m2 in Asian Americans) and who have one or more additional risk factors for diabetes (Table 2.3). B 2.8 Testing for prediabetes and/or type 2 diabetes should be considered in women planning pregnancy with overweight or obesity and/or who have one or more additional risk factor for diabetes (Table 2.3). C 2.9 For all people, testing should begin at age 45 years. B 2.10 If tests are normal, repeat testing carried out at a minimum of 3-year intervals is reasonable. C 2.12 In patients with prediabetes and type 2 diabetes, identify and treat other CVD risk factors. B 2.13 Risk-based screening for prediabetes and/or type 2 diabetes should be considered after the onset of puberty or after 10 years of age, whichever occurs earlier, in children and adolescents with overweight (BMI ≥85th percentile) or obesity (BMI ≥95th percentile) and who have additional risk factors for diabetes. (See Table 2.4 for evidence grading of risk factors.) TABLE 2.3 Criteria for testing for diabetes or prediabetes in asymptomatic adults 1. Testing should be considered in adults with overweight or obesity (BMI ≥25 kg/m2 or ≥23 kg/m2 in Asian Americans) who have one or more of the following risk factors: • First-degree relative with diabetes • High-risk race/ethnicity (e.g., African American, Latino, Native American, Asian American, Pacific Islander) • History of CVD • Hypertension (≥140/90 mmHg or on therapy for hypertension) • HDL cholesterol level 250 mg/dL (2.82 mmol/L) • Women with polycystic ovary syndrome • Physical inactivity • Other clinical conditions associated with insulin resistance (e.g., severe obesity, acanthosis nigricans) 2. Patients with prediabetes (A1C ≥5.7% [39 mmol/mol], impaired glucose tolerance, or impaired fasting glucose) should be tested yearly. 3. Women who were diagnosed with GDM should have lifelong testing at least every 3 years. 4. For all other patients, testing should begin at age 45 years. 5. If results are normal, testing should be repeated at a minimum of 3-year intervals, with consideration of more frequent testing depending on initial results and risk status. TABLE 2.4 Risk-based screening for type 2 diabetes or prediabetes in asymptomatic children and adolescents in a clinical setting Testing should be considered in youth* with overweight (≥85th percentile) or obesity (≥95th percentile) A who have one or more additional risk factors based on the strength of their association with diabetes: • Maternal history of diabetes or GDM during the child’s gestation A • Family history of type 2 diabetes in first- or second-degree relative A • Race/ethnicity (Native American, African American, Latino, Asian American, Pacific Islander) A • Signs of insulin resistance or conditions associated with insulin resistance (acanthosis nigricans, hypertension, dyslipidemia, polycystic ovary syndrome, or small-for-gestational-age birth weight) B * After the onset of puberty or after 10 years of age, whichever occurs earlier. If tests are normal, repeat testing at a minimum of 3-year intervals, or more frequently if BMI is increasing, is recommended. Reports of type 2 diabetes before age 10 years exist, and this can be considered with numerous risk factors. Marked discrepancies between measured A1C and plasma glucose levels should prompt consideration that the A1C assay may not be reliable for that individual, and one should consider using an assay without interference or plasma blood glucose criteria for diagnosis. (See “6. Glycemic Targets” in the complete 2020 Standards of Care for conditions causing discrepancies.) Unless there is a clear clinical diagnosis based on overt signs of hyperglycemia, diagnosis requires two abnormal test results from the same sample or in two separate test samples. If using two separate test samples, it is recommended that the second test, which may either be a repeat of the initial test or a different test, be performed without delay. If the patient has a test result near the margins of the diagnostic threshold, the provider should follow the patient closely and repeat the test in 3–6 months. 3. PREVENTION OR DELAY OF TYPE 2 DIABETES Recommendation 3.1 At least annual monitoring for the development of type 2 diabetes in those with prediabetes is suggested. E Screening for prediabetes and type 2 diabetes risk through an informal assessment of risk factors (Table 2.3) or with an assessment tool such as the ADA risk test (diabetes.org/socrisktest) is recommended to guide providers on whether performing a diagnostic test for prediabetes and previously undiagnosed type 2 diabetes (Table 2.2/2.5) is appropriate. Those who are determined to be at high risk for type 2 diabetes, including people with an A1C of 5.7–6.4% (39–47 mmol/mol), impaired glucose tolerance, or impaired fasting glucose, are ideal candidates for diabetes prevention efforts. Lifestyle Interventions Recommendations 3.2 Refer patients with prediabetes to an intensive behavioral lifestyle intervention program modeled on the Diabetes Prevention Program (DPP) to achieve and maintain 7% loss of initial body weight and increase moderate-intensity physical activity (such as brisk walking) to at least 150 min/week. A 3.3 A variety of eating patterns are acceptable for persons with prediabetes. B 3.4 Based on patient preference, technology-assisted diabetes prevention interventions may be effective in preventing type 2 diabetes and should be considered. B 3.5 Given the cost-effectiveness of diabetes prevention, such intervention programs should be covered by third-party payers. B The DPP trial demonstrated that an intensive lifestyle intervention could reduce the incidence of type 2 diabetes by 58% over 3 years. Follow-up of three large studies of lifestyle intervention for diabetes prevention has shown sustained reduction in the rate of conversion to type 2 diabetes: 39% reduction at 30 years in the Da Qing Diabetes Prevention Study, 43% reduction at 7 years in the Finnish Diabetes Prevention Study, and 34% reduction at 10 years and 27% reduction at 15 years in the U.S. Diabetes Prevention Program Outcomes Study. Pharmacologic Interventions Recommendation 3.6 Metformin therapy for prevention of type 2 diabetes should be considered in those with prediabetes, especially for those with BMI ≥35 kg/m2, those aged 180 mg/dL [10.0 mmol/L]) are useful parameters for reevaluation of the treatment regimen. E Glucose monitoring is key for the achievement of glycemic targets for many people with diabetes. SMBG is an integral component of effective therapy for patients taking insulin. CGM has emerged as a complementary method for the assessment of glucose levels. The patient’s specific needs and goals should dictate SMBG frequency and timing or the consideration of CGM use. Glucose Assessment Using CGM CGM has evolved rapidly in both accuracy and affordability. To make CGM metrics more actionable, standardized reports with visual cues such as the AGP (Figure 6.1) are recommended and may help patients and providers interpret the data and use it to guide treatment decisions. FIGURE 6.1 Sample AGP report. Adapted from Battelino T, Danne T, Bergenstal RM, et al. Diabetes Care 2019;42:1593–1603. A1C Goals Recommendations 6.6 An A1C goal for many nonpregnant adults of 5%, short-term (3-month) interventions that use very low-calorie diets (≤800 kcal/day) and meal replacements may be prescribed for carefully selected patients by trained practitioners in medical care settings with close medical monitoring. To maintain weight loss, such programs must incorporate long-term comprehensive weight-maintenance counseling. B Pharmacotherapy Recommendations 8.11 When choosing glucose-lowering medications for patients with type 2 diabetes and overweight or obesity, consider a medication’s effect on weight. B 8.12 Whenever possible, minimize medications for comorbid conditions that are associated with weight gain. E 8.13 Weight-loss medications are effective as adjuncts to diet, physical activity, and behavioral counseling for selected patients with type 2 diabetes and BMI ≥27 kg/m2. Potential benefits must be weighed against potential risks of medications. A 8.14 If a patient’s response to weight-loss medications is 10% [86 mmol/mol]) or blood glucose levels (≥300 mg/dL [16.7 mmol/L]) are very high. E 9.8 A patient-centered approach should be used to guide the choice of pharmacologic agents. Considerations include CV comorbidities, hypoglycemia risk, impact on weight, cost, risk for side effects, and patient preferences (Figure 9.1). E 9.9 Among patients with type 2 diabetes who have established ASCVD or indicators of high-risk, established kidney disease, or HF, a sodium–glucose cotransporter 2 (SGLT2) inhibitor or glucagon-like peptide 1 (GLP-1) receptor agonist with demonstrated CVD benefit (Table 9.1) is recommended as part of the glucose-lowering regimen independent of A1C and in consideration of patient-specific factors (Figure 9.1). A 9.10 In patients with type 2 diabetes who need greater glucose lowering than can be obtained with oral agents, GLP-1 receptor agonists are preferred to insulin when possible. B 9.11 Intensification of treatment for patients with type 2 diabetes not meeting treatment goals should not be delayed. B 9.12 The medication regimen and medication-taking behavior should be reevaluated at regular intervals (every 3–6 months) and adjusted as needed to incorporate specific factors that impact choice of treatment (Figure 4.1 and Table 9.1). E CV Outcomes Trials See “10. CVD and Risk Management” below for details. 10. CVD AND RISK MANAGEMENT This section has received endorsement from the American College of Cardiology. ASCVD—defined as coronary heart disease, cerebrovascular disease, or peripheral arterial disease (PAD) presumed to be of atherosclerotic origin—is the leading cause of morbidity and mortality for individuals with diabetes. HF is another major cause of morbidity and mortality from CVD. For prevention and management of both ASCVD and HF, CV risk factors should be systematically assessed at least annually in all patients with diabetes. These risk factors include obesity/overweight, hypertension, dyslipidemia, smoking, a family history of premature coronary disease, chronic kidney disease (CKD), and the presence of albuminuria. The Risk Calculator The American College of Cardiology/American Heart Association ASCVD risk calculator (Risk Estimator Plus) is a useful tool to estimate 10-year ASCVD risk (http://tools.acc.org/ASCVD-Risk-Estimator-Plus). This calculator includes diabetes as a risk factor because diabetes itself confers increased risk for ASCVD. It should be acknowledged that this risk calculator does not account for duration of diabetes or the presence of diabetes complications such as albuminuria. Hypertension/Blood Pressure Control Screening and Diagnosis Recommendations 10.1 Blood pressure should be measured at every routine clinical visit. Patients found to have elevated blood pressure (≥140/90 mmHg) should have blood pressure confirmed using multiple readings, including measurements on a separate day, to diagnose hypertension. B 10.2 All hypertensive patients with diabetes should monitor their blood pressure at home. B Treatment Goals Recommendations 10.3 For patients with diabetes and hypertension, blood pressure targets should be individualized through a shared decision-making process that addresses CV risk, potential adverse effects of antihypertensive medications, and patient preferences. C 10.4 For individuals with diabetes and hypertension at higher CV risk (existing ASCVD or 10-year ASCVD risk ≥15%), a blood pressure target of 120/80 mmHg, lifestyle intervention consists of weight loss if they have overweight or obesity, a Dietary Approaches to Stop Hypertension (DASH)-style eating pattern including reducing sodium and increasing potassium intake, moderation of alcohol intake, and increased physical activity. A Pharmacologic Interventions Recommendations 10.8 Patients with confirmed office-based blood pressure ≥140/90 mmHg should, in addition to lifestyle therapy, have prompt initiation and timely titration of pharmacologic therapy to achieve blood pressure goals. A 10.9 Patients with confirmed office-based blood pressure ≥160/100 mmHg should, in addition to lifestyle therapy, have prompt initiation and timely titration of two drugs or a single-pill combination of drugs demonstrated to reduce CV events in patients with diabetes. A 10.10 Treatment for hypertension should include drug classes demonstrated to reduce CV events in patients with diabetes (ACE inhibitors, angiotensin receptor blockers [ARBs], thiazide-like diuretics, or dihydropyridine calcium channel blockers [CCBs]). A 10.11 Multiple-drug therapy is generally required to achieve blood pressure targets. However, combinations of ACE inhibitors and ARBs and combinations of ACE inhibitors or ARBs with direct renin inhibitors should not be used. A 10.12 An ACE inhibitor or ARB, at the maximum tolerated dose indicated for blood pressure treatment, is the recommended first-line treatment for hypertension in patients with diabetes and urinary albumin-to-creatinine ratio (UACR) ≥300 mg/g creatinine (Cr) A or 30–299 mg/g Cr. B If one class is not tolerated, the other should be substituted. B 10.13 For patients treated with an ACE inhibitor, ARB, or diuretic, serum Cr/estimated glomerular filtration rate (eGFR) and serum potassium levels should be monitored at least annually. B Resistant Hypertension Recommendation 10.14 Patients with hypertension who are not meeting blood pressure targets on three classes of antihypertensive medications (including a diuretic) should be considered for mineralocorticoid receptor antagonist therapy. B Prior to diagnosing resistant hypertension, a number of other conditions should be excluded, including medication nonadherence, white coat hypertension, and secondary hypertension. Mineralocorticoid receptor antagonists are effective for management of resistant hypertension in patients with type 2 diabetes when added to existing treatment with an ACE inhibitor or ARB, thiazide-like diuretic, or dihydropyridine CCB. Lipid Management Lifestyle Intervention Recommendations 10.15 Lifestyle modification focusing on weight loss (if indicated); application of a Mediterranean-style or DASH eating pattern; reduction of saturated fat and trans fat; increase of dietary n-3 fatty acids, viscous fiber, and plant stanols/sterols intake; and increased physical activity should be recommended to improve the lipid profile and reduce the risk of developing ASCVD in patients with diabetes. A 10.16 Intensify lifestyle therapy and optimize glycemic control for patients with elevated triglyceride levels (≥150 mg/dL [1.7 mmol/L]) and/or low HDL cholesterol ( 75 years already on statin therapy, it is reasonable to continue statin treatment. B 10.27 In adults with diabetes aged >75 years, it may be reasonable to initiate statin therapy after discussion of potential benefits and risks. C 10.28 Statin therapy is contraindicated in pregnancy. B Treatment of Other Lipoprotein Fractions or Targets Recommendations 10.29 For patients with fasting triglyceride levels ≥500 mg/dL, evaluate for secondary causes of hypertriglyceridemia and consider medical therapy to reduce the risk of pancreatitis. C 10.30 In adults with moderate hypertriglyceridemia (fasting or nonfasting triglycerides 175–499 mg/dL), clinicians should address and treat lifestyle factors (obesity and metabolic syndrome), secondary factors (diabetes, chronic liver or kidney disease and/or nephrotic syndrome, hypothyroidism), and medications that raise triglycerides. C 10.31 In patients with ASCVD or other CV risk factors on a statin with controlled LDL cholesterol but elevated triglycerides (135–499 mg/dL), the addition of icosapent ethyl can be considered to reduce CV risk. A Other Combination Therapy Recommendations 10.32 Statin plus fibrate combination therapy has not been shown to improve ASCVD outcomes and is generally not recommended. A 10.33 Statin plus niacin combination therapy has not been shown to provide additional CV benefit above statin therapy alone, may increase the risk of stroke with additional side effects, and is generally not recommended. A Diabetes Risk With Statin Use Several studies have reported a modestly increased risk of incident diabetes with statin use, which may be limited to those with diabetes risk factors. A meta-analysis of 13 randomized statin trials showed an odds ratio of 1.09 for a new diagnosis of diabetes, so that (on average) treatment of 255 patients with statins for 4 years resulted in one additional case of diabetes while simultaneously preventing 5.4 vascular events among those 255 patients. Lipid-Lowering Agents and Cognitive Function A concern that statins or other lipid-lowering agents might cause cognitive dysfunction or dementia is not currently supported by evidence and should not deter their use in individuals with diabetes at high risk for ASCVD. Antiplatelet Agents Recommendations 10.34 Use aspirin therapy (75–162 mg/day) as a secondary prevention strategy in those with diabetes and a history of ASCVD. A 10.35 For patients with ASCVD and documented aspirin allergy, clopidogrel (75 mg/day) should be used. B 10.36 Dual antiplatelet therapy (with low-dose aspirin and a P2Y12 inhibitor) is reasonable for a year after an acute coronary syndrome A and may have benefits beyond this period. B 10.37 Aspirin therapy (75–162 mg/day) may be considered as a primary prevention strategy in those with diabetes who are at increased CV risk, after a comprehensive discussion with the patient on the benefits versus the comparable increased risk of bleeding. A Risk Reduction Aspirin has been shown to be effective in reducing CV morbidity and mortality in high-risk patients with previous myocardial infarction or stroke (secondary prevention) and is strongly recommended. In primary prevention, however, among patients with no previous CV events, its net benefit is more controversial. Recommendations for using aspirin as primary prevention include both men and women aged ≥50 years with diabetes and at least one additional major risk factor (family history of premature ASCVD, hypertension, dyslipidemia, smoking, or CKD/albuminuria) who are not at increased risk of bleeding (e.g., older age, anemia, renal disease). The main adverse effect is an increased risk of gastrointestinal bleeding. CVD Recommendations Screening 10.38 In asymptomatic patients, routine screening for coronary artery disease is not recommended as it does not improve outcomes as long as ASCVD risk factors are treated. A 10.39 Consider investigations for coronary artery disease in the presence of any of the following: atypical cardiac symptoms (e.g., unexplained dyspnea, chest discomfort); signs or symptoms of associated vascular disease including carotid bruits, transient ischemic attack, stroke, claudication, or PAD; or electrocardiogram abnormalities (e.g., Q waves). E Treatment 10.40 In patients with known ASCVD, consider ACE inhibitor or ARB therapy to reduce the risk of CV events. B 10.41 In patients with prior myocardial infarction, β-blockers should be continued for at least 2 years after the event. B 10.42 In patients with type 2 diabetes with stable HF, metformin may be continued for glucose lowering if eGFR remains >30 mL/min but should be avoided in unstable or hospitalized patients with HF. B 10.43 Among patients with type 2 diabetes who have established ASCVD or established kidney disease, an SGLT2 inhibitor or GLP-1 receptor agonist with demonstrated CVD benefit is recommended as part of the glucose-lowering regimen. A 10.43a In patients with type 2 diabetes and established ASCVD, multiple ASCVD risk factors, or DKD, an SGLT2 inhibitor with demonstrated CV benefit is recommended to reduce the risk of major adverse CV events and HF hospitalization. A 10.43b In patients with type 2 diabetes and established ASCVD or multiple risk factors for ASCVD, a GLP-1 receptor agonist with demonstrated CV benefit is recommended to reduce the risk of major adverse CV events. A 10.43c In patients with type 2 diabetes and established HF, an SGLT2 inhibitor may be considered to reduce risk of HF hospitalization. C Numerous large, randomized controlled trials have reported statistically significant reductions in CV events for three of the FDA-approved SGLT2 inhibitors (empagliflozin, canagliflozin, and dapagliflozin) and four FDA-approved GLP-1 receptor agonists (liraglutide, albiglutide [although that agent was removed from the market for business reasons], semaglutide [lower risk of CV events in a moderate-sized clinical trial but one not powered as a CV outcomes trial], and dulaglutide). SGLT2 inhibitors also appear to reduce risk of HF hospitalization and progression of kidney disease in patients with established ASCVD, multiple risk factors for ASCVD, or DKD. 11. MICROVASCULAR COMPLICATIONS AND FOOT CARE CKD Recommendations Screening 11.1 At least once a year, assess urinary albumin (e.g., spot UACR) and eGFR in patients with type 1 diabetes with duration of ≥5 years and in all patients with type 2 diabetes regardless of treatment. B Patients with urinary albumin >30 mg/g Cr and/or an eGFR 30 mg/g Cr, particularly in those with urinary albumin >300 mg/g Cr, to reduce risk of CKD progression, CV events, or both. A In patients with CKD who are at increased risk for CV events, use of a GLP-1 receptor agonist may reduce risk of progression of albuminuria, CV events, or both (Table 9.1). C 11.4 Optimize blood pressure control to reduce the risk or slow the progression of CKD. A 11.5 Do not discontinue renin-angiotensin system blockade for minor increases in serum Cr ( 65 years of age is growing. This population has unique challenges and requires distinct treatment considerations. DSME and ongoing support are vital components of diabetes care for older adults and their caregivers. Older adults with diabetes are likely to benefit from control of other CV risk factors, with treatment of hypertension to individualized target levels indicated in most. There is less evidence for lipid-lowering and aspirin therapy, although the benefits of these interventions are likely to apply to older adults whose life expectancies equal or exceed the time frames of clinical prevention trials. Lifestyle Management Recommendation 12.10 Optimal nutrition and protein intake is recommended for older adults; regular exercise, including aerobic activity and resistance training, should be encouraged in all older adults who can safely engage in such activities. B Pharmacologic Therapy Recommendations 12.11 In older adults with type 2 diabetes at increased risk of hypoglycemia, medication classes with low risk of hypoglycemia are preferred. B 12.12 Overtreatment of diabetes is common in older adults and should be avoided. B 12.13 Deintensification (or simplification) of complex regimens is recommended to reduce the risk of hypoglycemia and polypharmacy, if it can be achieved within the individualized A1C target. B 12.14 Consider costs of care and insurance coverage rules when developing treatment plans in order to reduce risk of cost-related nonadherence. B Special care is required in prescribing and monitoring pharmacologic therapies in older adults. See Figure 9.1 for general recommendations regarding glucose-lowering treatment for adults with type 2 diabetes and Table 9.1 for patient- and drug-specific factors to consider when selecting glucose-lowering agents. Metformin is the first-line agent for older adults with type 2 diabetes. Tight glycemic control in older adults with multiple medical conditions is considered overtreatment and is associated with an increased risk of hypoglycemia; unfortunately, overtreatment is common in clinical practice. Deintensification of regimens in patients taking noninsulin glucose-lowering medications can be achieved by either lowering the dose or discontinuing some medications, so long as the individualized glycemic target is maintained. Simplification of insulin regimens may also be appropriate. The needs of older adults with diabetes and their caregivers should be evaluated to construct a tailored care plan. Treatment in Skilled Nursing Facilities and Nursing Homes Recommendations 12.15 Consider diabetes education for the staff of long-term care (LTC) and rehabilitation facilities to improve the management of older adults with diabetes. E 12.16 Patients with diabetes residing in long-term care facilities need careful assessment to establish individualized glycemic goals and to make appropriate choices of glucose-lowering agents based on their clinical and functional status. E Management of diabetes is unique in the LTC setting. Practical guidance is needed for medical providers as well as LTC staff and caregivers. Treatments for each patient should be individualized. Special management considerations include the need to avoid both hypoglycemia and the complications of hyperglycemia. The ADA position statement “Management of Diabetes in Long-term Care and Skilled Nursing Facilities” provide more information on this topic. End-of-Life Care Recommendations 12.17 When palliative care is needed in older adults with diabetes, providers should initiate conversations regarding the goals and intensity of care. Strict glucose and blood pressure control may not be necessary E, and reduction of therapy may be appropriate. Similarly, the intensity of lipid management can be relaxed, and withdrawal of lipid-lowering therapy may be appropriate. A Overall, palliative medicine promotes comfort, symptom control and prevention (pain, hypoglycemia, hyperglycemia, and dehydration), and preservation of dignity and quality of life in patients with limited life expectancy. Different patient categories have been proposed for diabetes management in those with advanced disease. These include stable patients, patients with organ failure, and dying patients. 13. CHILDREN AND ADOLESCENTS The management of diabetes in children and adolescents cannot simply be derived from care routinely provided to adults with diabetes. The epidemiology, pathophysiology, developmental considerations, and response to therapy in pediatric-onset diabetes are different from adult diabetes. Type 1 Diabetes Type 1 diabetes is the most common form of diabetes in youth. A multidisciplinary team of specialists trained in pediatric diabetes management and sensitive to the challenges of children and adolescents with type 1 diabetes and their families should provide care for this population. See “13. Children and Adolescents” in the complete 2020 Standards of Care for specific recommendations. The ADA position statements “Type 1 Diabetes in Children and Adolescents” and “Evaluation and Management of Youth-Onset Type 2 Diabetes” offer additional information. Type 2 Diabetes Management Recommendations Glycemic Targets 13.59 A reasonable A1C target for most children and adolescents with type 2 diabetes treated with oral agents alone is 135/85 mmHg should be treated in the interest of optimizing long-term maternal health. Blood pressure targets should range no lower than 120/80 mmHg, as lower blood pressure targets may impair fetal growth. C 14.20 Potentially harmful medications in pregnancy (i.e., ACE inhibitors, ARBs, statins) should be stopped at conception and avoided in sexually active women of childbearing age who are not using reliable contraception. B Postpartum Care Recommendations 14.21 Insulin resistance decreases dramatically immediately postpartum, and insulin requirements need to be evaluated and adjusted as they are often roughly half the prepregnancy requirements for the initial few days postpartum. C 14.22 A contraceptive plan should be discussed and implemented with all women with diabetes of reproductive potential. C 14.23 Screen women with a recent history of GDM at 4–12 weeks postpartum, using the 75-g oral glucose tolerance test and clinically appropriate nonpregnancy diagnostic criteria. B 14.24 Women with a history of GDM found to have prediabetes should receive intensive lifestyle interventions and/or metformin to prevent diabetes. A 14.25 Women with a history of GDM should have lifelong screening for the development of type 2 diabetes or prediabetes at least every 3 years. B 14.26 Women with a history of GDM should seek preconception screening for diabetes and preconception care to identify and treat hyperglycemia and prevent congenital malformations. E 14.27 Postpartum care should include psychosocial assessment and support for self-care. E 15. DIABETES CARE IN THE HOSPITAL Among hospitalized patients, both hyperglycemia and hypoglycemia are associated with adverse outcomes, including death. Therefore, careful management of inpatients with diabetes has direct and immediate benefits. When caring for hospitalized patients with diabetes, consult with a specialized diabetes or glucose management team when possible. Hospital Care Delivery Standards Recommendations 15.1 Perform an A1C on all patients with diabetes or hyperglycemia (blood glucose >140 mg/dL [7.8 mmol/L]) admitted to the hospital if not performed in the prior 3 months. B 15.2 Insulin should be administered using validated written or computerized protocols that allow for predefined adjustments in the insulin dosage based on glycemic fluctuations. C Considerations on Admission Initial orders should state the type of diabetes. Because inpatient treatment and discharge planning are more effective if based on preadmission glycemia, an A1C should be measured on all patients with diabetes or hyperglycemia. Glycemic Targets in Hospitalized Patients Recommendations 15.4 Insulin therapy should be initiated for treatment of persistent hyperglycemia starting at a threshold ≥ 180 mg/dL (10.0 mmol/L). Once insulin therapy is started, a target glucose range of 140–180 mg/dL (7.8–10.0 mmol/L) is recommended for the majority of critically ill patients and noncritically ill patients. A 15.5 More stringent goals, such as 110–140 mg/dL (6.1–7.8 mmol/L), may be appropriate for selected patients if they can be achieved without significant hypoglycemia. C Hyperglycemia in hospitalized patients is defined as blood glucose levels >140 mg/dL (7.8 mmol/L). An admission A1C value ≥6.5% (48 mmol/mol) suggests that diabetes preceded hospitalization. Hypoglycemia in the hospital is classified the same as in any setting. (See “6. Glycemic Targets” above.) Bedside Blood Glucose Monitoring In patients who are eating, glucose monitoring should be performed before meals; in those not eating, glucose monitoring is advised every 4–6 h. Testing every 30 min to every 2 h is required for intravenous insulin infusion. Several inpatient studies have shown that CGM use did not improve glucose control but detected a greater number of hypoglycemic events than point-of-care glucose testing. However, there are insufficient data on clinical outcomes, safety, and cost-effectiveness to recommend using CGM in hospitalized patients. Glucose-Lowering Treatment in Hospitalized Patients Recommendations 15.6 Basal insulin or a basal plus bolus correction insulin regimen is the preferred treatment for noncritically ill hospitalized patients with poor oral intake or those who are taking nothing by mouth. A An insulin regimen with basal, prandial, and correction components is the preferred treatment for noncritically ill hospitalized patients with good nutritional intake. A 15.7 Use of only a sliding scale insulin regimen in the inpatient hospital setting is strongly discouraged. A In most instances in the hospital setting, insulin is the preferred treatment for glycemic control. In certain circumstances, it may be appropriate to continue home regimens including oral glucose-lowering medications. If oral medications are held in the hospital, there should be a protocol for resuming them 1–2 days before discharge. Insulin Therapy In the critical care setting, continuous intravenous insulin infusion is the best method for achieving glycemic targets. Outside of critical care units, scheduled insulin regimens as described above are recommended. For patients who are eating, insulin injections should align with meals. In such instances, point-of-care glucose testing should be performed immediately before meals. An insulin regimen with basal and correction components is necessary for all hospitalized patients with type 1 diabetes, with the addition of prandial insulin if patients are eating. A transition protocol from insulin infusion to subcutaneous insulin is recommended. Noninsulin Therapies The safety and efficacy of noninsulin glucose-lowering therapies in the hospital setting is an area of active research. See “15. Diabetes Care in the Hospital” in the complete 2020 Standards of Care for a comprehensive review of the inpatient use of these medications. Hypoglycemia Recommendations 15.8 A hypoglycemia management protocol should be adopted and implemented by each hospital or hospital system. A plan for preventing and treating hypoglycemia should be established for each patient. Episodes of hypoglycemia in the hospital should be documented in the medical record and tracked. E 15.9 The treatment regimen should be reviewed and changed as necessary to prevent further hypoglycemia when a blood glucose value of <70 mg/dL (3.9 mmol/L) is documented. C Patients with or without diabetes may experience hypoglycemia in the hospital setting. While hypoglycemia is associated with increased mortality, it may be a marker of underlying disease rather than the cause of fatality. Recently, several groups have developed algorithms to predict episodes of hypoglycemia among inpatients. Models such as these are potentially important and, once validated for general use, could provide a valuable tool to reduce rates of hypoglycemia in hospitalized patients. MNT in the Hospital The goals of MNT in the hospital are to provide adequate calories to meet metabolic demands, optimize glycemic control, and address personal food preferences, and facilitate creation of a discharge plan. The ADA does not endorse any single meal plan. When nutritional issues in the hospital are complex, the involvement of an RD/RDN can contribute to patient care. Self-Management in the Hospital Diabetes self-management in the hospital may be appropriate for selected patients. Sufficient cognitive and physical skills, adequate oral intake, proficiency in carbohydrate estimation, and knowledge of sick-day management are some of the requirements. Self-administered insulin with a stable MDI regimen or insulin pump therapy may be considered. A protocol should exist for these situations. Standards for Special Situations See “15. Diabetes Care in the Hospital” in the complete 2020 Standards of Care for guidance on enteral/parenteral feedings, glucocorticoid therapy, perioperative care, and diabetic ketoacidosis and hyperosmolar hyperglycemic state. Transition From the Acute Care Setting Recommendation 15.10 There should be a structured discharge plan tailored to the individual patient with diabetes. B Transition from the acute care setting presents risk for all patients. A structured discharge plan may reduce length of hospital stay and readmission rates and increase patient satisfaction. Medication Reconciliation The patient’s medications must be cross-checked to ensure that no chronic medications were stopped and to ensure the safety of new prescriptions. Prescriptions for new or changed medication should be filled and reviewed with the patient and family at or before discharge. Discharge planning should begin at admission and be updated as patient needs change. An outpatient follow-up visit 1 month after discharge is recommended. An earlier appointment (in 1–2 weeks) is preferred, and frequent contact may be needed. 16. DIABETES ADVOCACY For a list of ADA advocacy position statements, including “Diabetes and Driving” and “Diabetes and Employment,” see “16. Diabetes Advocacy” in the complete 2020 Standards of Care.

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Journal

Journal ID (nlm-ta): Diabetes Metab Syndr Obes

Journal ID (iso-abbrev): Diabetes Metab Syndr Obes

Journal ID (publisher-id): dmso

Journal ID (pmc): dmso

Title: Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy

Publisher: Dove

ISSN (Electronic): 1178-7007

Publication date (Electronic): 15 January 2021

Publication date Collection: 2021

Volume: 14

Pages: 205-213

Affiliations

[1 ]Department of Medicine, The Third Affiliated Hospital of Sun Yat-Sen University , Guangzhou, People’s Republic of China

[2 ]Department of Endocrinology and Metabolism, The Third Affiliated Hospital of Sun Yat-Sen University , Guangzhou, People’s Republic of China

[3 ]School of Nursing, Sun Yat-Sen University , Guangzhou, People’s Republic of China

Author notes

Correspondence: Mengyin Cai Department of Endocrinology and Metabolism, The Third Affiliated Hospital of Sun Yat-Sen University , No. 600 Tianhe Road, Guangzhou, Guangdong510630, People’s Republic of ChinaTel +86 13922131451 Email my.sabrina.c@163.com

Lingling Gao School of Nursing, Sun Yat-Sen University , No. 74, Zhongshan Er Road, Guangzhou, Guangdong510085, People’s Republic of ChinaTel +86 13539965693 Email gaoll@mail.sysu.edu.cn

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Xiling Hu http://orcid.org/0000-0001-7888-2267

Article

Publisher ID: 290639

DOI: 10.2147/DMSO.S290639

PMC ID: 7815068

PubMed ID: 33488108

SO-VID: d1f8ef76-9391-45c8-9957-deb9120dc956

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This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms ( https://www.dovepress.com/terms.php).

History

Date received : 05 November 2020

Date accepted : 30 December 2020

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Figures: 0, Tables: 8, References: 37, Pages: 9

Funding

Funded by: Chinese Nursing Association;

This research has been supported by Chinese Nursing Association (ZHKY202023).

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