The Standards of Care in Diabetes—2023 includes new recommendations on achieving more intensive weight loss goals using newer medications, targeting lower blood pressure and cholesterol goals, using SGLT2 inhibitors for patients with heart failure, and addressing social determinants of health in the delivery of care, according to the American Diabetes Association (ADA).
“It is no longer just glycemic control, it is really glycemic control plus weight management and cardiorenal protection,” said Robert A. Gabbay, MD, PhD, FACP, chief scientific and medical officer for the ADA.
Dr Gabbay highlighted 3 themes in the updated recommendations that may have the greatest effects on patient health: more aggressive weight management, the importance of the diabetes care team in addressing social determinants of health [economic stability, health care quality, social and community context, neighborhood and environment, education access], and more aggressive strategies to reduce cardiovascular disease through lower blood pressure and LDL cholesterol goals.
Weight Management in Diabetes
The recommendations emphasize the importance of weight management and include more intensive weight loss goals (up to 15%) based on the efficacy of and access to newer medications when appropriate. The first step is lifestyle changes and when those are insufficient to reach goals, use of pharmacologic therapy should be considered, primarily glucagon-like peptide-1 (GLP-1) agonists and the dual GLP-1/glucose-dependent insulinotropic polypeptide receptor agonist tirzepatide, Dr Gabbay explained.
However, these newer weight loss pharmacotherapies are underused, Dr Gabbay said. “We have a lot more data on GLP-1 agonists and if you look at the number of people who could benefit from their use in cardiovascular risk reduction, probably only 20% of people are on [these agents],” he said. Insurance coverage of these agents is one barrier to their use, he added.
“We at the ADA have been advocating for access to appropriate treatments to help people manage their diabetes and insurance coverage is certainly one of those barriers we would like to see removed,” Dr Gabbay noted.
Blood Pressure and LDL Cholesterol Goals in Diabetes
“Cardiovascular disease is still the number 1 killer among people with diabetes and so we need to be more aggressive in their management, including reducing LDL cholesterol to lower levels while also paying attention to blood pressure,” Dr Gabbay explained.
The updated blood pressure treatment goal for people with diabetes is less than 130/80 mm Hg. High-intensity statin therapy is recommended in high-risk people with diabetes aged 40 to 75 years (including those with at least 1 atherosclerotic cardiovascular disease risk factor) to reduce the LDL cholesterol by 50% or greater of baseline and to an LDL cholesterol goal of less than 70 mg/dL. For those with established heart disease, the LDL cholesterol goal is 55 mg/dL
For individuals with the lowest LDL cholesterol goals (55 mg/dL), “high-intensity statin therapy in many cases is not likely to be enough,” Dr Gabbay said. “We discuss the treatment with ezetimibe or a PCSK9 inhibitor in conjunction with maximally tolerated statin therapy to reach those LDL goals.”
Other notable updates to the Standards of Care in Diabetes─2023 include recommendations to:
- Screen for sleep health in people with diabetes and make referrals to sleep medicine and/or qualified behavioral health professionals as indicated
- Include social determinants of health in the planning and delivery of diabetes self-management education and support
- Use sodium-glucose cotransporter 2 (SGLT2) inhibitors to reduce the risk of worsening heart failure and cardiovascular death as well as improve symptoms, physical limitations, and quality of life in people with type 2 diabetes and established heart failure with either preserved (HFpEF) or reduced ejection fraction (HFrEF)
- Use finerenone in individuals with type 2 diabetes and chronic kidney disease with albuminuria treated with maximum tolerated doses of ACE inhibitor or angiotensin receptor blocker
- Screen for symptoms of peripheral arterial disease using recommended assessment tools
Improving Diabetes Care in Vulnerable Populations
“This year’s annual report provides necessary guidance that considers the role health inequities play in the development of diabetes, particularly for vulnerable communities and communities of color [that have been] disproportionately impacted by the disease. This guidance will ensure health care teams, clinicians, and researchers treat the whole person,” said Chuck Henderson, chief executive officer for the ADA.
The recommendations elevate the role of community health workers in screening for food insecurity. “Anybody on the health care team can screen for food insecurity and we need to take a holistic view of how to solve these challenges including designing educational programs for patients with social determinants of health in mind,” Dr Gabbay said.
Noteworthy updates directed at vulnerable populations include:
- Encourage telehealth to be used alongside in-person visits to optimize glycemic management in people with unmanaged diabetes
- Screen for food insecurity
- Consider continuous glucose monitoring for older adults with type 2 diabetes on multiple daily doses of insulin
- Use community health workers to support the management of diabetes and cardiovascular risk factors, especially in underserved communities and health care systems
Other updates include a recommendation that “point-of-care A1C testing should be restricted to devices approved by the US Food and Drug Administration and at laboratories proficient in performing testing of moderate complexity or higher by trained personnel.” A section on intermittent fasting was added that summarizes study findings of a mild to moderate weight loss (3%-8% loss from baseline) with the 3 main forms of restrictive eating over short durations (8 to 12 weeks) with no significant differences in weight loss when compared with continuous calorie restriction.
“Evidence-based recommendations drive better care for all people with diabetes, including vulnerable communities and those at high risk. The ADA’s Standards of Care are the gold standard for diabetes care and prevention that allows clinicians around the world to remain abreast of the rapidly changing health care landscape,” said Dr Gabbay.
American Diabetes Association Resources
|Standards of Care in Diabetes—2023 |
Abridged Standards of Care
Standards of Care app
ElSayed NA, Aleppo G, Aroda VR, et al. Summary of revisions: Standards of Care in Diabetes-2023. Diabetes Care. 2023;46(Supplement_1):S5-S9. doi:10.2337/dc23-Srev.