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S4 Diabetes Care Volume 40, Supplement 1, January 2017

SUMMARY OF REVISIONS

Standards of Medical Care in Diabetesd2017:


Summary of Revisions
Diabetes Care 2017;40(Suppl. 1):S4S5 | DOI: 10.2337/dc17-S003

GENERAL CHANGES approaches were described, and Fig. 2.1 medical evaluation based on emerging ev-
In light of the American Diabetes Associa- was included to provide an example of a idence suggesting a relationship between
tions (ADAs) new position statement on validated tool to screen for prediabetes and sleep quality and glycemic control.
psychosocial care in the treatment of di- previously undiagnosed type 2 diabetes. An expanded list of diabetes comorbid-
abetes, the Standards of Medical Care in Due to recent data, delivering a baby ities now includes autoimmune diseases,
Diabetes, referred to as the Standards of weighing 9 lb or more is no longer listed HIV, anxiety disorders, depression, disor-
Care, has been updated to address psy- as an independent risk factor for the dered eating behavior, and serious mental
chosocial issues in all aspects of care in- development of prediabetes and type 2 illness.
cluding self-management, mental health, diabetes. Section 4. Lifestyle Management
communication, complications, comorbid- A section was added that discusses This section, previously entitled Foun-
ities, and life-stage considerations. recent evidence on screening for diabe- dations of Care and Comprehensive
Although levels of evidence for several tes in dental practices. Medical Evaluation, was refocused on
recommendations have been updated, The recommendation to test women lifestyle management.
these changes are not addressed below with gestational diabetes mellitus for The recommendation for nutrition
as the clinical recommendations have re- persistent diabetes was changed from therapy in people prescribed exible in-
mained the same. Changes in evidence 612 weeks postpartum to 412 weeks sulin therapy was updated to include fat
level from, for example, E to C are not postpartum to allow the test to be sched- and protein counting in addition to car-
noted below. The 2017 Standards of uled just before the standard 6-week post- bohydrate counting for some patients to
Care contains, in addition to many minor partum obstetrical checkup so that the reect evidence that these dietary fac-
changes that clarify recommendations or results can be discussed with the patient tors inuence insulin dosing and blood
reect new evidence, the following more at that time of the visit or to allow the test glucose levels.
substantive revisions. to be rescheduled at the visit if the patient Based on new evidence of glycemic
did not get the test. benets, the Standards of Care now
SECTION CHANGES Additional detail was added to the recommends that prolonged sitting be
Section 1. Promoting Health and section on monogenic diabetes syn- interrupted every 30 min with short
Reducing Disparities in Populations dromes, and a new table was added (Ta- bouts of physical activity.
This section was renamed and now fo- ble 2.7) describing the most common A recommendation was added to
cuses on improving outcomes and re- forms of monogenic diabetes. highlight the importance of balance
ducing disparities in populations with A new section was added on post- and exibility training in older adults.
diabetes. transplantation diabetes mellitus. A new section and table provide infor-
Recommendations were added to as- mation on situations that might warrant
Section 3. Comprehensive Medical
sess patients social context as well as referral to a mental health provider.
Evaluation and Assessment of
refer to local community resources and
Comorbidities Section 5. Prevention or Delay of
provide self-management support.
This new section, including components Type 2 Diabetes
Section 2. Classication and Diagnosis of the 2016 section Foundations of To help providers identify those patients
of Diabetes Care and Comprehensive Medical Eval- who would benet from prevention ef-
The section was updated to include a uation, highlights the importance of forts, new text was added emphasizing
new consensus on the staging of type 1 assessing comorbidities in the context the importance of screening for prediabe-
diabetes (Table 2.1) and a discussion of a of a patient-centered comprehensive tes using an assessment tool or informal
proposed unifying diabetes classication medical evaluation. assessment of risk factors and performing
scheme that focuses on b-cell dysfunc- A new discussion of the goals of provider- a diagnostic test when appropriate.
tion and disease stage as indicated by patient communication is included. To reect new evidence showing an
glucose status. The Standards of Care now recom- association between B12 deciency and
Language was added to clarify screen- mends the assessment of sleep pattern long-term metformin use, a recommen-
ing and testing for diabetes. Screening and duration as part of the comprehensive dation was added to consider periodic

2017 by the American Diabetes Association. Readers may use this article as long as the work is properly cited, the use is educational and not for prot,
and the work is not altered. More information is available at http://www.diabetesjournals.org/content/license.
care.diabetesjournals.org Summary of Revisions S5

measurement of B12 levels and supple- The algorithm for the use of combina- footwear for patients at high risk for
mentation as needed. tion injectable therapy in patients with foot problems.
type 2 diabetes (Fig. 8.2) has been changed
Section 6. Glycemic Targets Section 12. Children and Adolescents
to reect studies demonstrating the non-
Based on recommendations from the In- Additional recommendations highlight
inferiority of basal insulin plus glucagon-
ternational Hypoglycaemia Study Group, the importance of assessment and re-
like peptide 1 receptor agonist versus basal
serious, clinically signicant hypoglycemia ferral for psychosocial issues in youth.
is now dened as glucose ,54 mg/dL insulin plus rapid-acting insulin versus two
daily injections of premixed insulin, as well Due to the risk of malformations asso-
(3.0 mmol/L), while the glucose alert value ciated with unplanned pregnancies and
is dened as #70 mg/dL (3.9 mmol/L) (Ta- as studies demonstrating the noninferior-
ity of multiple dose premixed insulin regi- poor metabolic control, a new recom-
ble 6.3). Clinical implications are discussed. mendation was added encouraging pre-
mens versus basal-bolus therapy.
Section 7. Obesity Management for Due to concerns about the affordability conception counseling starting at puberty
the Treatment of Type 2 Diabetes of antihyperglycemic agents, new tables for all girls of childbearing potential.
To be consistent with other ADA position were added showing the median costs of To address diagnostic challenges asso-
statements and to reinforce the role of noninsulin agents (Table 8.2) and insulins ciated with the current obesity epidemic,
surgery in the treatment of type 2 diabe- a discussion was added about distinguish-
(Table 8.3).
tes, bariatric surgery is now referred to as ing between type 1 and type 2 diabetes in
metabolic surgery. youth.
Section 9. Cardiovascular Disease and
To reect the results of an international A section was added describing recent
Risk Management
workgroup report endorsed by the ADA To better align with existing data, the hy- nonrandomized studies of metabolic sur-
and many other organizations, recommen- pertension treatment recommendation gery for the treatment of obese adoles-
dations regarding metabolic surgery for diabetes now suggests that, for pa- cents with type 2 diabetes.
have been substantially changed, in- tients without albuminuria, any of the
cluding those related to BMI thresholds Section 13. Management of Diabetes
four classes of blood pressure medications
for surgical candidacy (Table 7.1), men- in Pregnancy
(ACE inhibitors, angiotensin receptor Insulin was emphasized as the treatment
tal health assessment, and appropriate blockers, thiazide-like diuretics, or dihy-
surgical venues. of choice in pregnancy based on concerns
dropyridine calcium channel blockers) about the concentration of metformin on
Section 8. Pharmacologic Approaches that have shown benecial cardiovascular the fetal side of the placenta and glyburide
to Glycemic Treatment outcomes may be used. levels in cord blood.
The title of this section was changed from To optimize maternal health without Based on available data, preprandial
Approaches to Glycemic Treatment to risking fetal harm, the recommendation self-monitoring of blood glucose was
Pharmacologic Approaches to Glycemic for the treatment of pregnant patients deemphasized in the management of
Treatment to reinforce that the section with diabetes and chronic hypertension diabetes in pregnancy.
focuses on pharmacologic therapy alone. was changed to suggest a blood pressure In the interest of simplicity, fasting and
Lifestyle management and obesity manage- target of 120160/80105 mmHg. postprandial targets for pregnant women
ment are discussed in separate chapters. A section was added describing the cardio- with gestational diabetes mellitus and
To reect new evidence showing an as- vascular outcome trials that demonstrated preexisting diabetes were unied.
sociation between B12 deciency and long- benets of empagliozin and liraglutide in
term metformin use, a recommendation certain high-risk patients with diabetes. Section 14. Diabetes Care in the
was added to consider periodic measure- Hospital
ment of B12 levels and supplementation Section 10. Microvascular This section was reorganized for clarity.
as needed. Complications and Foot Care A treatment recommendation was up-
A section was added describing the A recommendation was added to high- dated to clarify that either basal insulin or
role of newly available biosimilar insu- light the importance of provider commu- basal plus bolus correctional insulin
lins in diabetes care. nication regarding the increased risk of may be used in the treatment of non-
Based on the results of two large clin- retinopathy in women with preexisting critically ill patients with diabetes in a
ical trials, a recommendation was added type 1 or type 2 diabetes who are plan- hospital setting, but not sliding scale
to consider empagliozin or liraglutide in ning pregnancy or who are pregnant. alone.
patients with established cardiovascular The section now includes specic rec- The recommendations for insulin dos-
disease to reduce the risk of mortality. ommendations for the treatment of ing for enteral/parenteral feedings were
Figure 8.1, antihyperglycemic ther- neuropathic pain. expanded to provide greater detail on in-
apy in type 2 diabetes, was updated to A new recommendation highlights sulin type, timing, dosage, correctional, and
acknowledge the high cost of insulin. the benets of specialized therapeutic nutritional considerations.

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