Standards of Medical Care in Diabetesd2017:Summary of RevisionsDiabetes Care 2017;40(Suppl. 1):S4–S5 | DOI: 10.2337/dc17-S003

GENERAL CHANGES

In light of the American Diabetes Associa-tion’s (ADA’s) new position statement onpsychosocial care in the treatment of di-abetes, the “Standards of Medical Care inDiabetes,” referred to as the “Standards ofCare,” has been updated to address psy-chosocial issues in all aspects of care in-cluding self-management, mental health,communication, complications, comorbid-ities, and life-stage considerations.Although levels of evidence for several

recommendations have been updated,these changes are not addressed belowas the clinical recommendations have re-mained the same. Changes in evidencelevel from, for example, E to C are notnoted below. The 2017 Standards ofCare contains, in addition to many minorchanges that clarify recommendations orreflect new evidence, the following moresubstantive revisions.

SECTION CHANGES

Section 1. Promoting Health andReducing Disparities in PopulationsThis section was renamed and now fo-cuses on improving outcomes and re-ducing disparities in populations withdiabetes.Recommendations were added to as-

sess patients’ social context as well asrefer to local community resources andprovide self-management support.

Section 2. Classification and Diagnosisof DiabetesThe section was updated to include anew consensus on the staging of type 1diabetes (Table 2.1) and a discussion of aproposed unifying diabetes classificationscheme that focuses on b-cell dysfunc-tion and disease stage as indicated byglucose status.Language was added to clarify screen-

ing and testing for diabetes. Screening

approaches were described, and Fig. 2.1was included to provide an example of avalidated tool to screen forprediabetes andpreviously undiagnosed type 2 diabetes.

Due to recent data, delivering a babyweighing 9 lb or more is no longer listedas an independent risk factor for thedevelopment of prediabetes and type 2diabetes.

A section was added that discussesrecent evidence on screening for diabe-tes in dental practices.

The recommendation to test womenwith gestational diabetes mellitus forpersistent diabetes was changed from6–12 weeks’ postpartum to 4–12 weeks’postpartum to allow the test to be sched-uled just before the standard 6-week post-partum obstetrical checkup so that theresults can be discussed with the patientat that time of the visit or to allow the testto be rescheduled at the visit if the patientdid not get the test.

Additional detail was added to thesection on monogenic diabetes syn-dromes, and a new table was added (Ta-ble 2.7) describing the most commonforms of monogenic diabetes.

A new section was added on post-transplantation diabetes mellitus.

Section 3. Comprehensive MedicalEvaluation and Assessment ofComorbiditiesThis new section, including componentsof the 2016 section “Foundations ofCare and Comprehensive Medical Eval-uation,” highlights the importance ofassessing comorbidities in the contextof a patient-centered comprehensivemedical evaluation.

A newdiscussion of the goals of provider-patient communication is included.

The Standards of Care now recom-mends the assessment of sleep patternand duration as part of the comprehensive

medical evaluation based on emerging ev-idence suggesting a relationship betweensleep quality and glycemic control.

An expanded list of diabetes comorbid-ities now includes autoimmune diseases,HIV, anxiety disorders, depression, disor-dered eating behavior, and seriousmentalillness.

Section 4. Lifestyle ManagementThis section, previously entitled “Foun-dations of Care and ComprehensiveMedical Evaluation,” was refocused onlifestyle management.

The recommendation for nutritiontherapy in people prescribed flexible in-sulin therapy was updated to include fatand protein counting in addition to car-bohydrate counting for some patients toreflect evidence that these dietary fac-tors influence insulin dosing and bloodglucose levels.

Based on new evidence of glycemicbenefits, the Standards of Care nowrecommends that prolonged sitting beinterrupted every 30 min with shortbouts of physical activity.

A recommendation was added tohighlight the importance of balanceand flexibility training in older adults.

A new section and table provide infor-mation on situations that might warrantreferral to a mental health provider.

Section 5. Prevention or Delay ofType 2 DiabetesTo help providers identify those patientswho would benefit from prevention ef-forts, new text was added emphasizingthe importance of screening for prediabe-tes using an assessment tool or informalassessment of risk factors and performinga diagnostic test when appropriate.

To reflect new evidence showing anassociation between B12 deficiency andlong-term metformin use, a recommen-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 profit,and the work is not altered. More information is available at http://www.diabetesjournals.org/content/license.

S4 Diabetes Care Volume 40, Supplement 1, January 2017

SUMMARYOFREV

ISIONS

measurement of B12 levels and supple-mentation as needed.

Section 6. Glycemic TargetsBased on recommendations from the In-ternational Hypoglycaemia Study Group,serious, clinically significant hypoglycemiais now defined as glucose ,54 mg/dL(3.0mmol/L), while the glucose alert valueis defined as#70mg/dL (3.9mmol/L) (Ta-ble 6.3). Clinical implications are discussed.

Section 7. Obesity Management forthe Treatment of Type 2 DiabetesTo be consistent with other ADA positionstatements and to reinforce the role ofsurgery in the treatment of type 2 diabe-tes, bariatric surgery is now referred to asmetabolic surgery.To reflect the results of an international

workgroup report endorsed by the ADAandmany other organizations, recommen-dations regarding metabolic surgeryhave been substantially changed, in-cluding those related to BMI thresholdsfor surgical candidacy (Table 7.1), men-tal health assessment, and appropriatesurgical venues.

Section 8. Pharmacologic Approachesto Glycemic TreatmentThe title of this section was changed from“Approaches to Glycemic Treatment” to“Pharmacologic Approaches to GlycemicTreatment” to reinforce that the sectionfocuses on pharmacologic therapy alone.Lifestyle management and obesity manage-ment are discussed in separate chapters.To reflect new evidence showing an as-

sociation between B12 deficiency and long-term metformin use, a recommendationwas added to consider periodic measure-ment of B12 levels and supplementationas needed.A section was added describing the

role of newly available biosimilar insu-lins in diabetes care.Based on the results of two large clin-

ical trials, a recommendation was addedto consider empagliflozin or liraglutide inpatients with established cardiovasculardisease to reduce the risk of mortality.Figure 8.1, antihyperglycemic ther-

apy in type 2 diabetes, was updated toacknowledge the high cost of insulin.

The algorithm for the use of combina-tion injectable therapy in patients withtype2diabetes (Fig. 8.2) hasbeen changedto reflect studies demonstrating the non-inferiority of basal insulin plus glucagon-likepeptide1 receptor agonist versus basalinsulin plus rapid-acting insulin versus twodaily injections of premixed insulin, as wellas studies demonstrating the noninferior-ity of multiple dose premixed insulin regi-mens versus basal-bolus therapy.

Due to concerns about the affordabilityof antihyperglycemic agents, new tableswere added showing the median costs ofnoninsulin agents (Table 8.2) and insulins(Table 8.3).

Section 9. Cardiovascular Disease andRisk ManagementTo better align with existing data, the hy-pertension treatment recommendationfor diabetes now suggests that, for pa-tients without albuminuria, any of thefour classes of bloodpressuremedications(ACE inhibitors, angiotensin receptorblockers, thiazide-like diuretics, or dihy-dropyridine calcium channel blockers)that have shown beneficial cardiovascularoutcomes may be used.

To optimize maternal health withoutrisking fetal harm, the recommendationfor the treatment of pregnant patientswith diabetes and chronic hypertensionwas changed to suggest a blood pressuretarget of 120–160/80–105 mmHg.

Asectionwasaddeddescribing thecardio-vascular outcome trials that demonstratedbenefits of empagliflozin and liraglutide incertain high-risk patients with diabetes.

Section 10. MicrovascularComplications and Foot CareA recommendation was added to high-light the importance of provider commu-nication regarding the increased risk ofretinopathy in women with preexistingtype 1 or type 2 diabetes who are plan-ning pregnancy or who are pregnant.

The section now includes specific rec-ommendations for the treatment ofneuropathic pain.

A new recommendation highlightsthe benefits of specialized therapeutic

footwear for patients at high risk forfoot problems.

Section 12. Children and AdolescentsAdditional recommendations highlightthe importance of assessment and re-ferral for psychosocial issues in youth.

Due to the risk of malformations asso-ciated with unplanned pregnancies andpoor metabolic control, a new recom-mendation was added encouraging pre-conception counseling starting at pubertyfor all girls of childbearing potential.

To address diagnostic challenges asso-ciated with the current obesity epidemic,a discussion was added about distinguish-ing between type 1 and type 2 diabetes inyouth.

A section was added describing recentnonrandomized studies of metabolic sur-gery for the treatment of obese adoles-cents with type 2 diabetes.

Section 13. Management of Diabetesin PregnancyInsulin was emphasized as the treatmentof choice in pregnancy based on concernsabout the concentration of metformin onthe fetal side of the placenta and glyburidelevels in cord blood.

Based on available data, preprandialself-monitoring of blood glucose wasdeemphasized in the management ofdiabetes in pregnancy.

In the interest of simplicity, fasting andpostprandial targets for pregnant womenwith gestational diabetes mellitus andpreexisting diabetes were unified.

Section 14. Diabetes Care in theHospitalThis section was reorganized for clarity.

A treatment recommendation was up-dated to clarify that either basal insulin orbasal plus bolus correctional insulinmay be used in the treatment of non-critically ill patients with diabetes in ahospital setting, but not sliding scalealone.

The recommendations for insulin dos-ing for enteral/parenteral feedings wereexpanded to provide greater detail on in-sulin type, timing, dosage, correctional, andnutritional considerations.

care.diabetesjournals.org Summary of Revisions S5