1. Standards of Medical Care in Diabetes – 2017: Summary of Revisions Ma
Standards of Medical Care in Diabetes – 2017: Summary of Revisions Ma. Haidee L. Ibanez MD

2. Diabetes is a complex, chronic illness which not only requires continuous medical care but also requires a multifaceted approach. Treatment strategies should not only be limited to glycemic control but patient self-management education and support is critical in prevention of acute complications and reduction of long-term risk complications.

3. For 25 years, ADA has made every effort to improve and update the Standards of Care to ensure that they would be the most authoritative and authors of the current guidelines for diabetes care. The recommendations consist of screening tools, diagnostic tools and treatment actions that are proven or believed to improve the quality of life of diabetic patients.

4. Through the years ADA has improved and updated the Standards of Care through a classification system that grades the quality of scientific evidence.

5. The Professional Practice Committee (PPC) of ADA is responsible for the review, revision and update of the Standards of Care. They are composed of a multidisciplinary committee comprised of physicians, diabetic educators, dietitians and others who have expertise in the range of areas concerned with diabetes.

6. General changes The ADA’s has a new position statement from “Standards of Medical Care in Diabetes” to “Standards Care”. This update was made to address all aspects of care from medical issues to psychosocial issues including Self-management, mental health, communication, complications, comorbidities, and life-stage considerations. The revisions made in the 2017 Standards of Care were made to clarify recommendations of the previous year and the minor changes were also based to reflect on the new evidence gathered.

7. Section 1. Promoting Health and Reducing Disparities in Populations
ADA highlights the importance of patient-centered care, defined as care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions .
A few recommendations were added in this section that would help to assess the social context of the patient as well as to refer to local community resources and to provide self-management support.
Disparities such as access to health care, lack of health insurance, ethnicity, culture, sex differences, community support, food insecurity, language barrier, financial constraints and homelessness were suggested to be considered in tailoring treatments for each patient.
The section was renamed and is now centered on improving outcomes and reducing differences in populations with diabetes.
ADA highlights the importance of patient-centered care, defined as care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions .
A few recommendations were added in this section that would help to assess the social context of the patient as well as to refer to local community resources and to provide self-management support.
Disparities such as access to health care, lack of health insurance, ethnicity, culture, sex differences, community support, food insecurity, language barrier, financial constraints and homelessness were suggested to be considered in tailoring treatments for each patient.

8. Section 2. Classification and Diagnosis of Diabetes
A new consensus on the staging of type 1 diabetes (Table 2.1) is updated in this section.
Recent studies/ data have indicated that delivering a baby weighing 9 lb or more is no longer listed as an independent risk factor for the development of prediabetes and type 2 diabetes.
Previously the recommendation to test women with GDM for persistent diabetes was changed from 6–12 weeks’ postpartum to 4–12 weeks’postpartum.
A new table describing the most common form of monogenic was added in this section
A new section was added on post transplantation diabetes mellitus. Patients should be screened after organ transplantation for hyperglycemia. The preferred test to make a diagnosis of post transplantation DM is the oral glucose tolerance test.
A new consensus on the staging of type 1 diabetes (Table 2.1) is updated in this section. Recent studies/ data have indicated that delivering a baby weighing 9 lb or more is no longer listed as an independent risk factor for the development of prediabetes and type 2 diabetes.
Previously the recommendation to test women with GDM for persistent diabetes was changed from 6–12 weeks’ postpartum to 4–12 weeks’postpartum. This recommendation was made to allow the test to be scheduled just before the standard 6-week postpartum obstetrical checkup so that the results can be discussed with the patient at that time of the visit.
A new table (table 2.7) describing the most common form of monogenic was added in this section
A new section was added on post transplantation diabetes mellitus. Patients should be screened after organ transplantation for hyperglycemia. The preferred test to make a diagnosis of post transplantation DM is the oral glucose tolerance test.

9. Section 3. Comprehensive Medical Evaluation
The beneficial interactions between the patient and health care provider would determine the success of a medical evaluation.
This section includes the components of the 2016 section “Foundations of Care and Comprehensive Medical Evaluation,” it emphasizes the importance of assessing comorbidities in the context of a patient-centered comprehensive medical evaluation.
assessment of sleep pattern and duration as part of the comprehensive medical evaluation.
Diabetes comorbidities have now expanded to a list which includes autoimmune diseases, HIV, anxiety disorders, depression, disordered eating behavior, and serious mental illness.
The beneficial interactions between the patient and health care provider would determine the success of a medical evaluation. To optimize patient health outcomes and health-related quality of life, a patient-centered communication style that uses active listening, elicits patient preferences and beliefs, and assesses literacy, numeracy, and potential barriers to care.
This section includes the components of the 2016 section “Foundations of Care and Comprehensive Medical Evaluation,” it emphasizes the importance of assessing comorbidities in the context of a patient-centered comprehensive medical evaluation.
Due to the emergence of evidence suggesting a relationship between sleep quality and glycemic control the Standard of Care now recommends the assessment of sleep pattern and duration as part of the comprehensive medical evaluation.
Diabetes comorbidities have now expanded to a list which includes autoimmune diseases, HIV, anxiety disorders, depression, disordered eating behavior, and serious mental illness.

10. Section 4. Lifestyle Management
Previously this section was entitled “Foundations of Care and Comprehensive Medical Evaluation,” but now it is now focused on lifestyle management.
In this section it has been recommended that all adults especially those with type 2 diabetes, should decrease sedentary lifestyle. Prolonged sitting in type 2 adult diabetic patients should have a break every 30 minutes for blood glucose benefits.it has also been emphasized type 2 diabetes patients should have flexibility training and balance training 2-3 times/ week. 
Another revision done in this section are information’s on situations that may warrant referral of a person with diabetes to a mental health provider for evaluation and treatment  
Previously this section was entitled “Foundations of Care and Comprehensive Medical Evaluation,” but now it is now focused on lifestyle management. Lifestyle management is a multifactorial aspect of diabetes care that includes self-managements education, nutrition therapy, physical activity, smoking cessation counseling, and psychosocial care.
Physical activity includes all movement that increases energy use and is an important part of the diabetes management plan. In this section it has been recommended that all adults especially those with type 2 diabetes, should decrease sedentary lifestyle. Prolonged sitting in type 2 adult diabetic patients should have a break every 30 minutes for blood glucose benefits.it has also been emphasized type 2 diabetes patients should have flexibility training and balance training 2-3 times/ week.
Another revision done in this section are information’s on situations that may warrant referral of a person with diabetes to a mental health provider for evaluation and treatment (Table 4.2)

11. Section 5. Prevention or Delay of Type 2 Diabetes
It has been recommended that patients undergoes informal or assessment tool screening from prediabetes and type 2 diabetes inorder to guide health care providers if diagnostic tests should be performed.
Pharmaclogic agents such as metformin has demonstrated long term safety as pharmacologic therapy in disease prevention. However new evidence has shown that long term use of metformin is associated with B12 deficiency hence there should be a periodic measurement of B12 levels.
It has been recommended that patients undergoes informal or assessment tool screening from prediabetes and type 2 diabetes inorder to guide health care providers if diagnostic tests should be performed. The Diabetes Prevention Program (DPP) provides the strongest evidence for diabetes prevention. They have demonstrated that intensive lifestyle prevention could reduce the incidence of type 2 diabetes by 58% in the span of 3 years.
Pharmaclogic agents such as metformin has demonstrated long term safety as pharmacologic therapy in disease prevention. However new evidence has shown that long term use of metformin is associated with B12 deficiency hence there should be a periodic measurement of B12 levels.

12. Section 6. Glycemic Targets Recommendations from the International Hypoglycaemia Study Group, regarding the classification of hypoglycemia is shown in table 6.3.
Section 6. Glycemic Targets
Recommendations from the International Hypoglycaemia Study Group, regarding the classification of hypoglycemia is shown in table 6.3. Clinically significant hypoglycemia is now defined as glucose ,54 mg/dL (3.0 mmol/L), while the glucose alert value is defined as<70 mg/dL (3.9 mmol/L).

13. Section 7. Obesity Management for the Treatment of Type 2 Diabetes
Obesity management has been proven to delay the progression from prediabetes to type 2 diabetes. It has also been proved to be beneficial in the treatment of type 2 diabetes. This section aims to provide evidence-based recommendations for the treatment of hyperglycemia in type 2 diabetes. An approach for treatment includes dietary, pharmacological and surgical interventions for obesity management.
Bariatric surgery has a great role in the treatments of type 2 diabetes and to reinforce its part ADA now refers to it as metabolic surgery. The changes in this section include recommendations regarding metabolic surgery such as BMI thresholds for surgical candidacy, mental health assessment and appropriate surgical venues.
Metabolic surgery should be considered for adults with type 2 diabetes and BMI 30.0–34.9 kg/m2 (27.5–32.4 kg/m2 in Asian Americans)
Obesity management has been proven to delay the progression from prediabetes to type 2 diabetes. It has also been proved to be beneficial in the treatment of type 2 diabetes. This section aims to provide evidence-based recommendations for the treatment of hyperglycemia in type 2 diabetes. An approach for treatment includes dietary, pharmacological and surgical interventions for obesity management.
Bariatric surgery has a great role in the treatments of type 2 diabetes and to reinforce its part ADA now refers to it as metabolic surgery. The changes in this section include recommendations regarding metabolic surgery such as BMI thresholds for surgical candidacy, mental health assessment and appropriate surgical venues. Metabolic surgery should be considered for adults with type 2 diabetes and BMI 30.0–34.9 kg/m2 (27.5–32.4 kg/m2 in Asian Americans) if hyperglycemia is inadequately controlled despite optimal medical control by either oral or injectable medications (including insulin).

14. Section 8. Pharmacologic Approaches to Glycemic Treatment
From “Approaches to Glycemic Treatment” the title was changed to “Pharmacologic Approaches to Glycemic Treatment” to emphasize that the section focuses on pharmacologic therapy alone.
This section recommends that there should be a periodic measurement of B12 levels and supplementation if needed to reflect new evidence showing an association between B12 deficiency and long term metformin use.
Results of two large clinical trials indictaed that pharmacologic therapy of empagliflozin or liraglutide in patients with established cardiovascular disease to reduce the risk of mortality.
Antihyperglycemic therapy in type 2 diabetes, was updated to acknowledge the high cost of insulin
New tables were added showing the median costs of noninsulin agents and insulins inorder to address concerns about the affordability of antihyperglycemic agents.
From “Approaches to Glycemic Treatment” the title was changed to “Pharmacologic Approaches to Glycemic Treatment” to emphasize that the section focuses on pharmacologic therapy alone. This section recommends that there should be a periodic measurement of B12 levels and supplementation if needed to reflect new evidence showing an association between B12 deficiency and long term metformin use.
Results of two large clinical trials indictaed that pharmacologic therapy of empagliflozin or liraglutide in patients with established cardiovascular disease to reduce the risk of mortality.
Antihyperglycemic therapy in type 2 diabetes, was updated to acknowledge the high cost of insulin (Figure 8.1).
New tables were added showing the median costs of noninsulin agents and insulins inorder to address concerns about the affordability of antihyperglycemic agents.

15. Section 9. Cardiovascular Disease and Risk Management
The hypertension treatment recommendation for diabetes now suggests that, for patients without albuminuria, any of the four classes of blood pressure medications (ACE inhibitors, angiotensin receptor blockers, thiazide-like diuretics, or dihydropyridine calcium channel blockers) that have shown beneficial cardiovascular outcomes may be used.
In pregnant patients with diabetes and chronic hypertension, blood pressure targets of 120–160/80–105 mmHg are recommended in the interest of optimizing long-term maternal health and minimizing impaired fetal growth.

16. Section 10. Microvascular Complications and Foot Care
This section was added with a recommendation to focus on the importance of provider communication regarding the increased risk of retinopathy in women with preexisting type 1 or type 2 diabetes who are planning pregnancy or who are pregnant.
A recommendation on treatment of neuropathic pain was included in this section. There has been no strong evidence that glycemic control or lifestyle management can cure neuropathic pain which means that the only option is pharmaceutical interventions. (pregabalin, duloxetine , tapentadol)
This section was added with a recommendation to focus on the importance of provider communication regarding the increased risk of retinopathy in women with preexisting type 1 or type 2 diabetes who are planning pregnancy or who are pregnant. Eye examinations should occur before pregnancy or in the first trimester in patients with preexisting type 1 or type 2 diabetes, and then patients should be monitored every trimester and for 1 year postpartum as indicated by the degree of retinopathy.
A recommendation on treatment of neuropathic pain was included in this section. Neuropathic pain can be severe and may impact the quality of life of a patient. There has been no strong evidence that glycemic control or lifestyle management can cure neuropathic pain which means that the only option is pharmaceutical interventions. Pregabalin is the most studied drug and it has 30-50% improvement in pain. Duloxetine on the other hand has appeared to improve neuropathy related quality of life. Tapentadol is an opioid analgesic, it is highly addictive and it only offers a modest pain reduction.

17. Section 12. Children and Adolescents
In this section additional recommendations were added to highlight the importance of assessment and referral of psychosocial issues of children and adolescents.
A new recommendation was added to encourage preconception counseling starting at puberty for all girls who are childbearing potential.
Seventy five percent of type 1 diabetes cases are diagnosed in individuals less than 18 years of age. In this section additional recommendations were added to highlight the importance of assessment and referral of psychosocial issues of children and acolsecents.is is advised that upon diagnosis and during routine follow up care, an assessment should be done to address psychosocial issues and family stresses that could impact the patients’ health condition.
A new recommendation was added to encourage preconception counseling starting at puberty for all girls who are childbearing potential. Counseling could decrease the risk of malformations associated with unplanned pregnancies and poor metabolic control.

18. Section 13. Management of Diabetes in Pregnancy
Insulin is the preferred medication for treating diabetes in pregnancy, because it does not cross the placenta to a measurable extent.  
To achieve glycemic control in both GDM and preexisting diabetes it is recommended to monitor both fasting and postprandial blood glucose however preprandial self-monitoring of blood glucose was deemphasized I the management of diabetes in pregnancy. 
Fasting and postprandial targets for pregnant women with GDM and preexisting diabetes were unified as follows
  ○ Fasting #95 mg/dL (5.3 mmol/L) and either
○ One-hour postprandial #140 mg/dL (7.8 mmol/L) or
○ Two-hour postprandial #120 mg/d (6.7 mmol/L)
Majority of diabetes in pregnancy is gestational diabetes mellitus (GDM) with the remainder primarily preexisting type 1 and type 2 diabetes. Insulin is the preferred medication for treating diabetes in pregnancy, because it does not cross the placenta to a measurable extent. Metformin and glyburide can still be used but both cross the placenta to the fetus. All oral agents lack data on its safety for long term use.
To achieve glycemic control in both GDM and preexisting diabetes it is recommended to monitor both fasting and postprandial blood glucose however preprandial self-monitoring of blood glucose was deemphasized I the management of diabetes in pregnancy.
Fasting and postprandial targets for pregnant women with GDM and preexisting diabetes were unified as follows
○ Fasting #95 mg/dL (5.3 mmol/L) and either
○ One-hour postprandial #140 mg/dL (7.8 mmol/L) or
○ Two-hour postprandial #120 mg/d (6.7 mmol/L)

19. Section 14. Diabetes Care in the Hospital
The changes made in this section was mainly to reorganize its structure for further clarity.
A treatment recommendation was updated inorder to clarify that basal insulin or basal plus bolus correction insulin is the preferred treatment for noncritically ill patients or those who re in NPO., but not sliding scale alone. Table shows the recommended insulin dosing for enteral and parenteral feedings.
Hospitals have a duty to provide the shortest, safe hospital stay and promote an effective home that prevents acute complications and possible readmission. The changes made in this section was mainly to reorganize its structure for further clarity.
A treatment recommendation was updated inorder to clarify that basal insulin or basal plus bolus correction insulin is the preferred treatment for noncritically ill patients or those who re in NPO., but not sliding scale alone. Sole use of sliding scale insulin treatment in the inpatient hospital setting is discouraged. Table shows the recommended insulin dosing for enteral and parenteral feedings.