Where can I find the latest clinical guidelines for caring for patients with diabetes?

Every year for the past 25 years, the American Diabetes Association publishes Standards of Medical Care in Diabetes in the form of a position statement that includes key clinical practice or research recommendations. This document covers a variety of topics including the classification and diagnosis of diabetes, medical evaluation and treatment, and guidelines for specific populations such as the elderly, children, and those hospitalized. The standards of care provide clinical practice recommendations based on the most recent evidence in the literature.

The Professional Practice Committee (PPC) is responsible for the development of this position statement. The PPC is a multidisciplinary group made up of experts in the area of diabetes and includes physicians, nurses, diabetes educators, and registered dietitians, as well as others. The group reviews the current evidence and then updates the standards to reflect this expertise.

There is a one-page summary that highlights the specific updates that can be found in the full document. Although the entire document is helpful in the management and care of persons with diabetes, there are several sections that may be of particular interest to the home healthcare professional. These include Section 1: Promoting health and reducing disparities in populations; Section 3: Comprehensive medical evaluation and assessment of comorbidities; Section 4: Lifestyle management; Section 6: Glycemic targets; Section 7: Obesity management; Section 8: Pharmacological approaches to glycemic treatment; Section 9: Cardiovascular disease and risk management; and Section 10: Microvascular complications and foot care. Please see the entire document for additional topics.

Here is a brief summary of each previously identified section. Section 1 was renamed and focuses on improving outcomes and reducing disparity. In this section, you will find recommendations to assess the patient's social context and references to resources and self-management support. Section 3 focuses on the importance of assessing comorbidities. The expanded list of comorbidities includes human immunodeficiency virus, anxiety, depression, autoimmune diseases, disordered eating behaviors, and serious mental illness. There is also information on patient-provider communication and the importance of assessing sleep pattern and duration. Section 4 includes information on lifestyle management. This section was updated to include fat and protein counting, in addition to carbohydrate counting. It includes nutrition therapy for some patients who are prescribed flexible insulin therapy. This section also includes information on the benefits of physical activity, such as the need to interrupt prolonged sitting (greater than 30 minutes) with bursts of activity and balance and flexibility training in older adults. Finally, you will also find a recommendation to refer patients to a mental health provider for certain situations. Section 6 focuses on glycemic targets. Changes in this section include the definition of clinically significant hypoglycemia, which is now understood to be <54 mg/dL, while the glucose alert value is measured at <70 mg/dL.

Section 7 provides information on obesity management. Bariatric surgery is now called metabolic surgery. Criteria for surgical candidates are outlined with specific BMI thresholds for surgery. Section 8: Pharmacology-new evidence to associate B12 deficiency with long-term metformin use and the importance of assessing B12. Concerns about costs of antihyperglycemic agents are also described. Section 9: Patients without albuminuria can utilize any of the four classes of drugs used for hypertension treatment, which include ace inhibitors, angiotensin receptor blockers, thiazide-like diuretics, and dihydropyridine calcium channel blockers. Finally, Section 10 defines specialized treatment for neuropathy as well as benefits for therapeutic footwear (American Diabetes Association, 2017).

Home care professionals encounter many patients with diabetes and an understanding of the current standards is important as care delivered. In future columns, we will explore each of these sections in more detail.

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