2017 Standards of Medical Care in Diabetes
Every year the American Diabetes Association (ADA) revises standards of care in the management of both type 1 and type 2 diabetes. Though, as naturopathic physicians, we see a lot of patients with metabolic syndrome, many seeking us out for adjunctive care. However, at times limited, it is important for us to be aware of the information and treatment options our diabetic patients are being offered by their conventional care providers. Included in this article are the highlights of the 2017 Standards of Medical Care in Diabetes (Standards). 1 Of specific interest are the changes to the assessment of psychological health, and lifestyle management.
Psychological Assessment for Psychological/Emotional Stress and Disorders
The ADA acknowledges that there is a greater risk of emotional stress disorders in people with diabetes, and the 2017 Standards include guidelines for screening adults and youth for diabetes distress, depression, anxiety, and eating disorders – also included is a list of when to refer to a mental health specialist.
Recommendations for physical activity now will include a specific recommendation to interrupt prolonged sedentary behavior every 30 minutes. Practitioners are also advised to assess sleep patterns as part of overall care – an acknowledgment that sleep quality may be associated with blood glucose regulation.
The new standards actually recommend that diabetic patients receive self-management support from the holistic health profession – under the terms “health coaches.”
Expanded List of Comorbidities
The importance of screening for comorbidities in diabetic patients is stressed. The 2017 expands its list of comorbidities to include: autoimmune diseases, HIV, anxiety disorders, depression, disordered eating and serious mental illness.
The new 2017 guidelines specify that 54 mg/dL be the new marker for clinically significant hypoglycemia, whether associated with symptoms or not.
Increased Choice in Treatment Options (Allopathic)
- Metabolic Surgery
Indications for metabolic surgery have been expanded to include patients with inadequately controlled type 2 diabetes and a BMI as low as 30 kg/m2 (27.5 kg/m2 in Asian Americans).
- Hypertension Medications
Hypertension medications have been expanded to include 4 classes as first-line treatment options: ACE inhibitors, angiotensin receptor blockers, thiazide-like diuretics or dihydropyridine calcium channel blockers.
- New Insulin Algorithm
There have been updates for patients using insulin to meet their HbA1C goals.
- Cardiovascular Comorbidities
Patients with a history of stroke or MI, acute coronary syndromes or peripheral arterial disease are considered at high risk of complications from diabetes and death. The Standards include new recommendations to consider GLP-1 receptor agonist liraglutide and the SGLT-2 inhibitor empagliflozin.
- Standards of Medical Care in Diabetes-2017 Abridged for Primary Care Providers. Clin Diabetes. 2017;35(1):5-26.
Node Smith, associate editor for NDNR, is a fifth year naturopathic medical student at NUNM, where he has been instrumental in maintaining a firm connection to the philosophy and heritage of naturopathic medicine amongst the next generation of docs. He helped found the first multi-generational experiential retreat, which brings elders, alumni, and students together for a weekend campout where naturopathic medicine and medical philosophy are experienced in nature. Three years ago he helped found the non-profit, Association for Naturopathic ReVitalization (ANR), for which he serves as the board chairman. ANR has a mission to inspire health practitioners to embody the naturopathic principles through experiential education. Node also has a firm belief that the next era of naturopathic medicine will see a resurgence of in-patient facilities which use fasting, earthing, hydrotherapy and homeopathy to bring people back from chronic diseases of modern living; he is involved in numerous conversations and projects to bring about this vision.