434 - Diabetes Standards of Care 2022 (Part 1), Let’s Stop Pretending

From the Guidelines and the American Diabetes Association (ADA)

1)  ADA Diabetes Standards of Care 2022 Highlights – Part 1

According to the VA Department of health, 1 in 11 Virginians have T2D, and more than 1 in 3 have prediabetes. This trend is similar for other states as well. Given this prevalence, it is essential that we who are providing primary health care become “experts” in the management and prevention of T2D. To that end, this week’s (and next week’s) Take 3 will highlight the ADA 2022 Diabetes Standards of Care.

The ADA evidence-grading system includes levels, A, B, C, and E, with “A” having the strongest evidence and “E” being based on expert opinion. Some recommendations are underlined to provide additional emphasis.

Screening: Recommendations

·         Testing for T2D in asymptomatic people should be considered in adults of any age who are overweight or obese (BMI ≥25 or ≥23 in Asian Americans) and who have one or more additional risk factors. B

·         For all people, screening should begin at age 45 years. B

·         If tests are normal, repeating at a minimum of 3-year intervals is reasonable. C

·         To screen for T2D, fasting plasma glucose, 2-h plasma glucose after 75-g oral glucose tolerance test, and A1C are equally appropriate. B

·         At least annual monitoring in those with prediabetes. E

Diagnosis: Recommendations:

·         A1C: Prediabetes: 5.7-6.4%     Diabetes: > 6.5%

·         Fasting Plasma Glucose (FPG)

Prediabetes: 100-125 mg/dl     Diabetes: > 126 ng/dl

·         Random Plasma Glucose: Diabetes: > 200 mg/dl

Lifestyle Interventions for Weight Loss in T2D: Recommendations

·         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 bodyweight and increase moderate-intensity physical activity (such as brisk walking) to at least 150 min/week. A

·         A variety of eating patterns are acceptable for persons with prediabetes.

·         Based on patient preference, technology-assisted diabetes prevention interventions may be effective in preventing T2D and should be considered. B

Glycemic Monitoring: Recommendations

·         Assess glycemic status (A1C or other glycemic measurement such as time in range [TIR] or glucose management indicator [GMI]) at least two times a year in patients who are meeting treatment goals (and who have stable glycemic control). E

·         Assess glycemic status at least quarterly and as needed in patients whose therapy has recently changed and/or who are not meeting glycemic goals. E

·         A reasonable A1C goal for many nonpregnant adults is <7%. A

·         Less stringent A1C goals (such as < 8%) may be appropriate with a history of severe hypoglycemia, limited life expectancy, advanced microvascular or macrovascular complications, extensive comorbid conditions, or long-standing T2D in whom the goal is difficult to achieve. B

·         If using Ambulator Glucose Profile (AGP)/GMI) to assess glycemia, a parallel goal for many nonpregnant adults is TIR of >70% with time below range <4% and time

<54 mg/dL <1% B

Pharmacologic Interventions for Prediabetes: Recommendations

·         Metformin for prevention of T2D should be considered in those with prediabetes, especially for those with BMI ≥35, those aged <60 years, women with prior gestational DM, and/or those with rising A1C despite lifestyle intervention. A

·         Periodic measurement of vitamin B12 levels should be considered in metformin- treated patients, especially in those with anemia or peripheral neuropathy. B

Blood Glucose Monitoring (BGM): Recommendations

·         People who are on insulin using BGM should be encouraged to check when appropriate based on their insulin regimen. This may include checking when fasting, prior to meals and snacks, at bedtime, prior to exercise, when low blood glucose is suspected, after treating low blood glucose levels until they are normoglycemic, and prior to and while performing critical tasks such as driving. B

·         When prescribed as part of a Diabetes Self-Management Education and Support (DSMES) program, SMBG may help to guide treatment decisions and/or self- management for patients taking less-frequent insulin injections. B

·         Although BGM in patients on noninsulin therapies has not shown clinically significant reductions in A1C, it may be helpful when altering diet, physical activity, and/or medications (particularly medications that can cause hypoglycemia) in conjunction with a treatment adjustment program. E

Obesity Management: Recommendations

·         Diet, physical activity, and behavioral therapy designed to achieve and maintain

>5% weight loss is recommended for patients with T2D who have overweight or obesity and are ready to achieve weight loss. B

Hypertension/Blood Pressure Control and CVD Risk in T2D: Recommendations

·         The ACC/AHA ASCVD risk calculator (Risk Estimator Plus) is a useful tool to estimate 10-year ASCVD risk. Link

·         For individuals with diabetes and hypertension at higher cardiovascular risk (existing atherosclerotic cardiovascular disease [ASCVD] or 10-year ASCVD risk

≥15%), a blood pressure target of <130/80 mmHg may be appropriate, if it can be safely attained. B

·         For individuals with T2D and HTN at lower risk for CVD (10-year risk <15%), treat to a BP target of <140/90. A

·         An ACE inhibitor or ARB, at the maximum tolerated dose indicated for blood pressure treatment, is the recommended first-line treatment for HTN in patients with diabetes and urinary microalbumin-to-creatinine ratio (MACR) >300 and/or eGFR

<60 (A) or MACR between 30–299. (B)

·         If one class is not tolerated, the other should be substituted. B

·         For patients treated with an ACE-I, ARB, or diuretic, serum Cr, estimated glomerular filtration rate (eGFR) and potassium levels should be monitored at least annually. B

Diabetic Kidney Disease: Recommendations

·         At least once a year, assess urinary albumin (e.g. spot MACR) and eGFR in all patients with T2D regardless of treatment. B

·         Patients with diabetes and urinary albumin ≥300 mg/g creatinine and/or an estimated glomerular filtration rate of30–60 mL/min/1.73 m2 should be monitored twice annually to guide therapy. B

·         For people with non-dialysis-dependent CKD, dietary protein intake should be approximately 0.8 g/kg body weight per day (the recommended daily allowance). A

·         An ACE inhibitor or an ARB is not recommended for the primary prevention of diabetic kidney disease in patients with diabetes who have normal blood pressure, normal urinary albumin–to–creatinine ratio (<30), and normal e-GFR. B

Diabetic Retinopathy: Recommendations

·         Patients with T2D should have an initial dilated and comprehensive eye examination by an ophthalmologist or optometrist at the time of the diabetes diagnosis. B

·         If there is no evidence of retinopathy for one or more annual eye exams and glycemia is well-controlled, then screening every 1–2 years may be considered. E

Foot Care:

·         Perform a comprehensive foot evaluation at least annually. B

·         Assessment for distal symmetric polyneuropathy should include a careful history and assessment of either temperature or pinprick sensation (small fiber function) and vibration sensation using a 128-Hz tuning fork (for large-fiber function). All patients should have annual 10-g monofilament testing to identify feet at risk for ulceration and amputation. B

·         Patients with evidence of sensory loss or prior ulceration or amputation should have their feet inspected at every visit. B

Mark’s Comments:

I have selectively chosen recommendations from the much longer document. The abridged document referenced below may be one worth investing the time in reading the entire document. It’s packed full of information and some helpful tables. It is important to note how many of the recommendations are based on expert opinion.

Remember, expert opinion is not necessarily wrong or bad, but it means there is greater uncertainty and more opportunity for bias.

Next week we will highlight the medication recommendations from the ADA Standards.

References:

·         ADA Standards of Medical Care in Diabetes—2022 Abridged for Primary Care Providers. Clin Diabetes January 2022;40(1):10–38. Link

·         DM Standards of care 2022. Diabetes Care January 2022;45(Supplement 1). Link

From PeerRxMed ( www.PeerRxMed.org )

2)    It’s Time to Stop Pretending

“Toxic positivity is positivity given in the wrong way, in the wrong dose, at the wrong time.”  David Kessler, author of “Finding Meaning: The Sixth Stage of Grief.”

“We just need to be more positive!” These words from a healthcare executive in the midst of a discussion about the sobering results of a physician well-being survey still haunt me. In this case, it felt much more like a disingenuous denial of reality rather than a misguided attempt at encouragement. The impact was a “poisoning” of the conversation and shutting down of any meaningful dialogue. In other words, it felt toxic.

Toxic positivity is the belief that one should have a positive mindset and express only positive emotions and thoughts at all times, particularly when things are difficult.                  It often comes disguised as a simplistic attempt to circumvent a challenging circumstance, using phrases such as “No worries,” “It’s all good,” or “It could be worse.” Although perhaps well-intentioned, it has the effect of discounting, dismissing, or even denying emotions that are not positive. The resulting damage can be quite real, including the erosion of trust, emotional harm by devaluing a cry for help, and the suppression of vital dialogue or glossing over adverse circumstances that need to be addressed.

Since I am a big believer in the power of optimism (my e-mail tagline for many years has been “make encouragement and gratitude a way of life”), I was left wondering about the boundary between hopeful optimism and toxic positivity, as I don’t want to be a contributor to a toxically positive workplace or home. In doing some research, I learned that hopeful optimism is a process of anticipating positive circumstances and desirable outcomes. Research has shown that imagining the future in such ways can help promote thriving and sustain us during challenging times.

Forced optimism or toxic positivity, on the other hand, encourages us to deny any dark emotions we might be experiencing, even if they seem appropriate to the circumstances.                              And we’ve had plenty of those over the past 2 years! As Peter Pronovost, MD, PhD, chief quality and clinical transformation officer at University Hospitals in Cleveland recently said, “We need … the balance of hopeful and humble. Hopeful that we will get through this. But also the courage to confront our current reality: It sucks. Let's not pretend this isn't really hard.” Or, as a colleague said to me

during the course of the pandemic, “I don’t expect it to be awesome. I just want for it to suck less!”

How do we emphasize the positive without denying or suppressing the negative so we can break this all too pervasive tendency toward toxicity? By practicing! I found this wonderful resource on the website positivepsychology.com called “Harmful to Helpful Toxic Positivity Phrases” that is a great place to start. Harmful to Helpful Phrases

This upcoming week, be aware of any tendencies you might have to dismiss or minimize the struggles of those around you … and yourself!                           It’s not “all good” right now. Far from it. Pretending isn’t fooling anyone. But there is good news. You don’t have to navigate this “really hard” alone. The antidotes to our present challenges are hopeful optimism and positive connection. As we sense some hope on the horizon, let’s use them generously and frequently to ensure that no one cares alone …. Not now, not ever.

______________

Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org