Saturday , October 16 2021

New Guide to Diabetes (ADA) 2019 – Review

The American Diabetes Association has published its annual update: "Diabetes Medical Care Standards"

The paper, published in Diabetes Care, includes all of the group's current clinical practice recommendations related to the treatment and treatment of diabetes.

General changes

The field of diabetes treatment is changing rapidly as new research, technologies and treatments that can improve the health and well-being of people with diabetes continue to emerge. With annual updates since 1989, the American Diabetes Association (ADA) has been a leader in producing guidelines that capture the most current state of the field.

To this end, the "Diabetes Care Standards" (Care Standards) now include a section dedicated to diabetes technology, which contains pre-existing material previously found in other sections that have been consolidated, as well as new recommendations.

Although the levels of evidence for several recommendations have been updated, these changes are not addressed below because the clinical recommendations remained the same. Changes in the level of evidence from, for example, E to C are not indicated below. The 2019 Standards of Care contain, in addition to many minor changes that clarify recommendations or reflect new evidence, the following more substantial revisions.

Among the changes since last year's recommendations:

  • For patients with type 2 diabetes who require an injectable drug, a glucagon-like peptide 1 receptor agonist is preferable to insulin.
  • For patients with type 2 diabetes who do not use insulin, routine self-monitoring with glucose has a limited additional benefit.
  • The risk of atherosclerotic disease over 10 years (ASCVD) should be part of the overall risk assessment of the patient.
  • Emphasis should be given to water intake and consumption of sugary and non-sweetened beverages should be discouraged.

Section 1. Improve care and promote health in populations.

Additional information has been included about the financial costs of diabetes for individuals and society.

Because telemedicine is a growing field that can increase access to care for patients with diabetes, a discussion of its use has been added to facilitate remote provision of health-related services and clinical information.

Section 2. Classification and diagnosis of diabetes.

Based on the new data, the criteria for the diagnosis of diabetes were altered to include two abnormal test results from the same sample (ie, fasting plasma glucose and A1C from the same sample).

Additional conditions have been identified that may affect the accuracy of the A1C test, including the postpartum period.


Diabetes can be classified into the following general categories:

  • Type 1 Diabetes (due to the autoimmune destruction of β-cells, which generally leads to an absolute insulin deficiency).
  • Type 2 diabetes (due to the progressive loss of insulin secretion by β-cells often on the background of insulin resistance).
  • Gestational diabetes mellitus (GDM) diabetes diagnosed in the second or third trimester of pregnancy that was not clearly evident in diabetes before pregnancy.
  • Specific types of diabetes due to other causes, for example, monogenic diabetes syndromes (such as neonatal diabetes and diabetes at maturity) [MODY]), exocrine pancreatic diseases (such as cystic fibrosis and pancreatitis), and chemical-induced diabetes (such as glucocorticoids, HIV / AIDS treatment, or after an organ transplant).

Section 3. Preventing or delaying type 2 diabetes

The nutrition section has been updated to highlight the importance of weight loss for people at high risk of developing type 2 diabetes with overweight or obesity.

Because smoke may increase the risk of type 2 diabetes, a section on the use and cessation of smoking was added.


  • Structured behavioral weight loss therapy, which includes a meal plan reduced in calories and physical activity is of utmost importance for people at high risk of developing type 2 diabetes with overweight or obesity.
  • As weight loss through lifestyle changes can only be difficult to maintain in the long run, people receiving treatment with weight loss therapy should have access to ongoing support and additional therapeutic options (such as pharmacotherapy). Yes, it's necessary.
  • According to the intervention trials, eating patterns that may be helpful for people with pre-diabetes include a meal plan Mediterraneanor is a food plan low in calories and low in fat.
  • Additional research is needed to determine if a feed plan low in carbohydrates It is beneficial for people with pre-diabetes.
  • In addition, the evidence suggests that the quality foods (as measured by the Alternative Healthy Eating Index), with emphasis on whole grains, legumes, nuts, fruits and vegetables, and a minimum of processed and refined foodsIt's also important.
  • Although healthy and low-calorie dietary patterns should be encouraged in general, there is also some evidence that certain dietary components affect the risk of diabetes in observational studies.
  • Increased consumption of nuts, berries, yogurt, coffee and tea is associated with a reduced risk of diabetes. In contrast, red meat and sugary drinks are associated with an increased risk of type 2 diabetes.

Section 4. Comprehensive medical assessment and evaluation of comorbidities.

Based on a new consensus report on diabetes and language, new text has been added to guide the use of language by health professionals to communicate diabetes about people with diabetes and professional audiences in an informative, empowering, and educational style.

A new figure was added to the consensus report of the European Association for the Study of Diabetes (EASD) on decision cycle of diabetes care to emphasize the need for continuous assessment and shared decision-making to achieve health care goals and avoid clinical inertia.

A new recommendation was added to explicitly highlight importance of the service team of diabetes and list the professionals who make up the team.

A new table with the factors that increase the risk of hypoglycaemia associated with treatment.

Factors that increase the risk of treatment-associated hypoglycaemia

• Use of insulin or insulin secretagogues (sulfonylureas, meglitinides).

Impaired renal or hepatic function.

• Longer duration of diabetes.

• Fragility and advanced age.

• cognitive impairment.

• Response contrary to regulation, ignorance of hypoglycaemia.

• Physical or intellectual disability that may affect the behavioral response to hypoglycaemia.

• Alcohol use.

• Polypharmacy (especially ACE inhibitors, angiotensin receptor blockers, nonselective beta-blockers).

A recommendation has been added to include the risk of atherosclerotic cardiovascular disease (ASCVD) for 10 years as part of the overall risk assessment.

The section on fatty liver has been revised to include updated text and a new recommendation on when to perform a liver disease test.

The decision cycle for glycemic treatment focused the patient on type 2 diabetes. Adapted from Davies et al. (119).

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  • Provide the routinely recommended vaccines for children and adults with diabetes for age.
  • Annual vaccination against the flu for all people ≥ 6 months of age, especially people with diabetes.
  • Vaccination against pneumococcal disease, including pneumococcal pneumonia, with the 13-valent pneumococcal conjugate vaccine (PCV13) for children before 2 years of age. People with diabetes between 2 and 64 years of age should also receive the 23-valent pneumococcal polysaccharide vaccine (PPSV23). At age ≥65 years, regardless of the history of vaccination, additional vaccination with PPSV23 is required.
  • Administer a series of 2 or 3 doses of vaccine against Hepatitis B, depending on the vaccine, for unvaccinated adults with diabetes between 18 and 59 years.
  • Consider administering a series of 3 doses of Hepatitis B for unvaccinated adults with diabetes aged ≥60 years.
  • Children and adults with diabetes should receive the vaccines according to recommendations appropriate for their age.
  • People with diabetes are at higher risk for hepatitis B infection and are more likely to develop complications from influenza and pneumococcal disease. The Immunization Practices Advisory Committee (ACIP) of the Centers for Disease Control and Prevention (CDC) recommends vaccination against influenza, pneumococcus and hepatitis B specifically for people with diabetes.
  • Vaccines against tetanus, diphtheria, pertussis, measles, mumps and rubella, human papilloma virus and herpes are also important for adults with diabetes, as well as for the general population.


Studies examining the optimal amount of carbohydrate intake for people with diabetes they are not conclusive, although the control of carbohydrate intake and considering the response of blood glucose to carbohydrates in the diet is fundamental to improve postprandial glycemic control.

The bibliography on glycemic index and glycemic load in individuals with diabetes is complex, since they often produce mixed results, although in some studies the reduction in the glycemic load of carbohydrates consumed has shown reductions of 0.2% to 0.5% in A1C (84,85).

Studies of more than 12 weeks do not report a significant influence of glycemic index or glycemic load, regardless of weight loss in A1C; however, mixed results have been reported for fasting glucose levels and endogenous levels of insulin.

For people with type 2 diabetes or pre-diabetes, meal plans low in carbohydrates show a potential to improve glycemic and blood lipid results for up to 1 year.

Part of the challenge in interpreting low carbohydrate research is due to the wide range of definitions for a low carbohydrate intake plan. Because research studies on low carbohydrate intake plans often indicate challenges with long-term sustainability, it is important to re-evaluate and individualize meal plan guidelines regularly for those interested in this approach.

Health professionals should maintain consistent medical supervision and recognize that certain groups are not appropriate for low-carbohydrate eating plans, including pregnant or lactating women, children and people with kidney disease or disordered eating behavior. and these plans should be used with caution for those taking SGLT2 inhibitors because of the potential risk of ketoacidosis. There is inadequate research on dietary patterns for type 1 diabetes to support one eating plan over another at this time.

Most people with diabetes report moderate carbohydrate intake (44-46% of total calories). Efforts to change habitual eating patterns often are not successful in the long run; People usually return to their usual macronutrient distribution.

Therefore, the recommended approach is to individualize meal plans to achieve caloric goals with a macronutrient distribution more consistent with the individual's usual intake to increase the likelihood of long-term maintenance.

For all people in developed countries, it is recommended that children and adults with diabetes minimize the intake of refined carbohydrates and added sugars and instead focus on vegetable, vegetable, fruit, dairy (milk and yogurt) carbohydrates and whole grains.

Consumption of sugary beverages (including fruit juices) and "low fat" or "fat free" processed food products with large amounts of refined grains and added sugars is strongly discouraged.

For people with type 1 or type 2 diabetes who receive insulin At meal time, intensive and continuing education should be given on the need to combine insulin administration with carbohydrate intake.

For people whose consumption of meals or carbohydrates is variable, regular counseling is important to help them understand the complex relationship between carbohydrate intake and insulin needs.

In addition, education about using the insulin-carbohydrate relationship in meal planning can help them effectively modify the insulin dose from one meal to another and improve glycemic control.

People who consume foods that contain more protein and fat than normal should also adjust their mealtime insulin dose to compensate for the delay in postprandial glycemic excursions. For people with a fixed daily insulin schedule, meal planning should emphasize a relatively fixed carbohydrate consumption pattern with respect to time and quantity.

Section 5. Lifestyle Management

Evidence continues to suggest that there is no ideal percentage of carbohydrate, protein, and fat calories for all people with diabetes.

Therefore, more discussions were added on the importance of distribution of macronutrients based on an individualized assessment of current feeding patterns, preferences, and metabolic goals.

Additional considerations have been added to the sections on eating patterns, macronutrient distribution, and meal planning to better identify meal plan candidates, specifically for low-carbohydrate consumption patterns, and for pregnant or lactating women who are at or at risk of eat disorderly, have kidney disease and are taking sodium-glucose cotransporter inhibitors 2.

There is no single food standard for people with diabetes, and meal planning should be individualized.

A recommendation has been modified to encourage people with diabetes to decrease the consumption of sugary and sugar-free drinksand use other alternatives, with an emphasis on water consumption.

The consumption recommendation of sodium has been modified to eliminate the additional potentially indicated restriction for people with diabetes and hypertension.

An additional discussion was added to the section on physical activity include the benefit of a variety of physical leisure activities and flexibility and balance exercises.

The discussion on Electronic Cigarettes was expanded to include more about public perception and how its use to help quit smoking was no more effective than "usual care."

Objectives of nutritional therapy for adult diabetics

Promote and support healthy eating patterns by emphasizing a variety of nutrient-rich foods in appropriate portions to improve overall health and:

  • Reach and maintain body weight goals.
  • Achieving glycemic goals, blood pressure and individualized lipids
  • Delay or avoid the complications of diabetes.
  • Addressing individual nutrition needs based on personal and cultural preferences, health knowledge and arithmetic, access to healthy food, willingness and ability to make behavioral changes, and barriers to change.
  • To maintain the pleasure to eat, providing unbiased messages about food choice.
  • Provide a person with diabetes with the practical tools to develop healthy eating patterns, instead of focusing on macronutrients, micronutrients or individual foods.

Section 6. Glycemic Objectives

This section now begins with a discussion of the A1C tests to highlight the centrality of A1C tests in glycemic management.

To emphasize that the risks and benefits of glycemic goals may change as diabetes progresses and patients age, a recommendation has been added to reassess glycemic targets over time.

The section has been modified to align with the living standards updates made in April 2018 regarding the consensual definition of hypoglycaemia.

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  • Perform the A1C test at least twice a year in patients who meet treatment goals (and who have stable glycemic control).
  • Perform the A1C test quarterly on patients whose therapy has been altered or who do not reach glycemic targets.
  • On-site tests for A1C provide the opportunity for more timely treatment changes.

Objectives of Hb A1C

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  • A reasonable A1C target for many non-pregnant adults is <7% (53 mmol / mol).
  • Providers can reasonably suggest A1C targets more rigorous (such as <6.5% [48 mmol / mol]) for selected individual patients, if this can be achieved without significant hypoglycaemia or other adverse effects of treatment (eg, polypharmacy). Appropriate patients may include those with short-term diabetes, type 2 diabetes treated only with lifestyle or metformin, long-term life or no significant cardiovascular disease.
  • The goals of A1C less rigorous (such as <8% [64 mmol / mol]) may be appropriate for patients with a history of hypoglycemia severe or limited life expectancy, advanced microvascular or macrovascular complications, extensive comorbid conditions, or long-term diabetes in which the goal is difficult to achieve despite education for self-management of diabetes, adequate glycemic control, and effective doses of multiple glucose-lowering agents , including insulin.

The patient and disease factors used to determine the ideal A1C targets are shown. The characteristics and problems on the left justify stricter efforts to reduce A1C; those on the right suggest less rigorous efforts. A1C 7% = 53 mmol / mol. Adapted with permission of Inzucchi et al.

Section 7. Diabetes Technology.

This new section includes new recommendations, self-monitoring of the blood glucose section that was previously included in Section 6 "Glycemic Goals" and a description of insulin delivery devices (syringes, pens and insulin pumps), blood glucose meters in blood, continuous glucose monitors (real time and intermittent scanning) [“flash”]) and automated insulin delivery devices.

The recommendation to use self-monitoring of blood glucose in people who they do not use insulin has been changed to recognize that routine glucose monitoring has Limited additional clinical benefit in this population.

Section 8. Management of obesity for the treatment of type 2 diabetes

A recommendation has been modified to recognize the benefits of weight control, activity, etc., in the context of obtaining and maintaining a healthy weight.

Added a short section on medical devices for weight loss, which currently they are not recommended due to limited data in people with diabetes.

The recommendations for metabolic surgery were modified to align with recent guidelines, citing the importance of considering comorbidities beyond diabetes when considering the adequacy of metabolic surgery for a given patient.

Section 9. Pharmacological approaches for glycemic treatment

The section on pharmacological treatment of type 2 diabetes was significantly modified for alignment according to living standards updated in October 2018 with the ADA-EASD consensus report on this subject, summarized in the new ones.

This includes considerations about the key factors of the patient:

a) Important comorbidities, such as ASCVD, chronic kidney disease and heart failure

b) Risk of hypoglycaemia

c) Effects on body weight

d) side effects

e) Costs

f) Patient preferences.

To align with the ADA-EASD consensus report, the approach to injecting drug therapy was reviewed.

A recommendation that, for most patients who need the most effectiveness of an injectable drug, Glucagon-like peptide 1 receptor agonist It should be the first choice, before insulin.

A new section on the technique of insulin injection was added, emphasizing the importance of the technique for the adequate dosage of insulin and avoiding complications (lipodystrophy, etc.).

The section on non-insulin drug treatments for type 1 diabetes was shortened, they are not recommended.

Initial therapy (metformin)

O metformin should be started at the time type 2 diabetes is diagnosed, unless there are contraindications.

For most patients, this will be monotherapy in combination with lifestyle modifications. Metformin is effective and safe, it is inexpensive and can reduce the risk of cardiovascular events and death. Metformin is available as an immediate release form for dosing twice daily or as a sustained release form which may be administered once daily.

Compared to sulfonylureas, metformin as first-line treatment has beneficial effects on A1C, cardiovascular weight and mortality. There are few systematic data available for other oral agents as initial treatment for type 2 diabetes.

The main secundary effects of metformin are gastrointestinal intolerance due to bloating, abdominal discomfort and diarrhea.

The drug is eliminated by renal filtration and very high levels of circulation (eg as a result of overdose or acute renal failure) have been associated with lactic acidosis. However, it is now known that the onset of this complication is very rare, and metformin can be used safely in patients with low glomerular filtration rates (eTFG); The FDA reviewed the label of metformin to reflect its safety in patients withGFR ≥30 ml / min / 1.73 m2.

A recent randomized trial has confirmed previous observations that the use of metformin is associated with vitamin B12 deficiency and worsening of neuropathy symptoms. This is consistent with a recent report from the Diabetes Prevention Program Outcomes Study (DPPOS) suggesting periodic vitamin B12 testing.

In patients with contraindications or intolerance metformin, initial therapy should be based on patient factors; consider a drug of another type.

When A1C is ≥1.5% (12.5 mmol / mole) above the glycemic target, many patients will require dual combination therapy to achieve their target A1C level.


O insulin It has the advantage of being effective when other agents are not and should be considered as part of any combination regimen when hyperglycemia is severe, especially if catabolic characteristics are present (weight loss, hypertriglyceridemia, ketosis).

Consider starting treatment with insulin when glycemia is ≥300 mg / dL (16.7 mmol / L) or A1C is ≥10% (86 mmol / mol) or if the patient exhibits symptoms of hyperglycemia (ie polyuria or polydipsia), even at the time of diagnosis. or at the start of treatment. As glucose toxicity is resolved, it is often possible to simplify the regimen and / or switch to oral agents.

Section 10. Cardiovascular Diseases and Risk Management.

For the first time, this section is endorsed by the American College of Cardiology. Added additional text to recognize the cardiac insufficiency as an important type of cardiovascular disease in people with diabetes to take into account when determining optimal care for diabetes.

The recommendations of blood pressure they were modified to emphasize the importance of individualizing goals according to cardiovascular risk.

A discussion on the appropriate use of the ASCVD risk calculator has been included and the recommendations have been modified to include the 10-year risk assessment of ASCVD as part of the overall risk assessment and to determine the optimal treatment approaches.

The recommendation and text on the use of aspirin in primary prevention, they were updated with new data.

To align with the ADA-EASD consensus report, two recommendations were added for the use of drugs that showed a cardiovascular benefit in people with ASCVD, with and without heart failure.

Section 11. Microvascular complications and foot care.

To align with the ADA-EASD consensus report, a recommendation has been added for people with type 2 diabetes and chronic kidney disease to consider agents with proven benefits regarding renal outcomes.

The recommendation on the use of telemedicine in retinal screening has been modified to recognize the usefulness of this approach, provided that appropriate references are made for a complete eye examination.

O gabapentin has been added to the list of agents to be considered for the treatment of neuropathic pain in people with diabetes based on data on the efficacy and potential of cost reduction.

The gastroparesis includes a discussion of some additional modalities of treatment.

The recommendation for patients with diabetes to inspect their feet at each visit was modified to include only those with high risk of ulceration. Annual exams are still recommended for everyone.

Section 12. Older Adults

A new section and a recommendation on the management of Lifestyle to meet the unique needs and considerations of physical and nutritional activity for the elderly.

In the discussion of drug therapy, the intensification of insulin regimens to help simplify the insulin regimen to match the individual's self-control capabilities.

A new figure has been added to provide a path for simplification. A new table has also been added to help service providers consider simplifying the drug regimen and lacking numbness / depression in elderly people with diabetes.

Section 13. Children and adolescents

The introductory language was added at the beginning of this section to remind the reader that the epidemiology, pathophysiology, development considerations and response to treatment in pediatric diabetes are different from adult diabetes, and that there are also differences in the recommended care for children and adolescents. with type 1 as opposed to type 2 diabetes.

A recommendation has been added to emphasize the need to perform screening tests Eating disorders in young people with type 1 diabetes from 10 to 12 years of age.

On the basis of new evidence, a recommendation was added which discourage the use of electronic cigarettes in young people.

The discussion on type 2 diabetes in children and adolescents, has expanded significantly with new recommendations in a number of areas including screening and diagnostic testing, lifestyle management, pharmacological management, and transition care for adult providers.

New sections and / or recommendations for type 2 diabetes were added in children and adolescents for glycemic goals, metabolic surgery, nephropathy, neuropathy, retinopathy, non-alcoholic fatty liver, obstructive sleep apnea, polycystic ovarian syndrome, cardiovascular disease, dyslipidemia, tests of cardiac function, and psychosocial factors.

Section 14. Management of diabetes in pregnancy

Women with pre-existing diabetes are now advised to have their care delivered at a multidisciplinary clinic to improve diabetes and pregnancy outcomes.

Emphasis has been placed on the use of insulin as the preferred drug for treating hyperglycemia in gestational diabetes mellitus, since does not cross the placenta to a measurable extent and the way in which metformin and glyburide should not be used as first-line agents, as they cross the placenta and reach the fetus.

Section 15. Diabetes Care in the Hospital

Because of its ability to improve hospital readmission rates and the cost of care, a new recommendation was added for providers to consider consulting a team specializing in diabetes or diabetes management when possible to hospitalized patients with diabetes.

Section 16. Diabetes advocacy

Added to this section were the ADA statement "Working Group on Access and Affordability to Insulin: Conclusions and Recommendations". Published in 2018, this statement compiled public information and convened a series of stakeholder meetings throughout the insulin supply chain to learn how each entity affects the cost of insulin for the consumer, an important issue for the ADA and people living with diabetes.

* Complete guide in English language

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