Tag Archives: american diabetes association

January 11, 2015 · 11:25 PM

Updated “Standards of Medical Care in Diabetes” Now Available Free Online

The American Diabetes Association every January updates their Standards of Medical Care in Diabetes. The document is lengthy, highly technical, and written for healthcare providers. Some of you may appreciate it. If I were a non-physician with diabetes, I’d learn as much about it as possible. Remember, no one cares about your health as much as you do. The 2015 version of the standards is called, appropriately enough, Standards of Medical Care in Diabetes—2015.

Updates to the guidlelines include:

  • recommendation not to sit inactively for over 90 minutes
  • pre-meal blood sugar target is now 80 to 130 mg/dl (4.4 to 7.2 mmol/l) instead of the old 70 to 130 mg/dl
  • added SGLT2 inhibitors to the drug treatment algorithm
  • recommended a diastolic blood pressure goal of 90 mmHg or less instead of the old 80 mmHg or less
  • increased the potential pool of statin drug users
  • added a section on management of diabetes during pregnancy

Steve Parker, M.D.

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April 13, 2013 · 2:00 AM

Periodic Tests, Treatments, and Goals for PWDs (Persons With Diabetes)

If you don't like your physician, find a new one

If you don’t like your physician, find a new one

So, you’ve got diabetes. You’re trying to deal with it or you wouldn’t be here. You’ve got a heck of a lot of medical information to master.

Unless you have a good diabetes specialist physician on your team, you may not be getting optimal care. Below are some guidelines you may find helpful. The goal is to prevent diabetes complications. Many primary care physicians will not be up-to-date on the guidelines. Don’t hesitate to discuss them with your doctor. Nobody cares as much about your health as you do.

Annual Tests

The American Diabetes Association (ADA) recommends the following items be done yearly (except as noted) in non-pregnant adults with diabetes. (Incidentally, I don’t necessarily agree with all ADA guidelines.) The complete ADA guidelines are available on the Internet.

  • Lipid profile (every two years if results are fine and stable)
  • Comprehensive foot exam
  • Screening test for distal symmetric polyneuropathy: pinprick, vibration, monofilament pressure sense
  • Serum creatinine and estimate of glomerular filtration rate (MDRD equation)
  • Test for albumin in the urine, such as measurement of albumin-to-creatinine ratio in a random spot urine specimen
  • Comprehensive eye exam by an ophthalmologist or optometrist (if exam is normal, every two or three years is acceptable)
  • Hemoglobin A1c at least twice a year, but every three months if therapy has changed or glucose control is not at goal
  • Flu shots

Other Vaccinations, Weight Loss, Diabetic Diet, Prediabetes, Alcohol, Exercise, Etc.

Additionally, the 2013 ADA guidelines recommend:

  • Pneumococcal vaccination. “A one time re-vaccination is recommended for individuals >64 years of age previously immunized when they were <65 years of age if the vaccine was administered >5 years ago.” Also repeat the vaccination after five years for patients with nephrotic syndrome, chronic kidney disease, other immunocompromised states (poor ability to fight infection), or transplantation.
  • Hepatitis B vaccination to unvaccinated adults who are 19 through 59 years of age.
  • Weight loss for all overweight diabetics. “For weight loss, either low-carbohydrate, low-fat calorie-restricted, or Mediterranean diets may be effective in the short-term (up to two years).” For those on low-carb diets, monitor lipids, kidney function, and protein consumption, and adjust diabetic drugs as needed. The optimal macronutrient composition of weight loss diets has not been established. (Macronutrients are carbohydrates, proteins, and fats.)
  • “The mix of carbohydrate, protein, and fat may be adjusted to meet the metabolic goals and individual preferences of the person with diabetes.” “It must be clearly recognized that regardless of the macronutrient mix, total caloric intake must be appropriate to weight management goal.”
  • “A variety of dietary meal patterns are likely effective in managing diabetes including Mediterranean-style, plant-based (vegan or vegetarian), low-fat and lower-carbohydrate eating patterns.”
  • “Monitoring carbohydrate, whether by carbohydrate counting, choices, or experience-based estimation, remains a key strategy in achieving glycemic control.”
  • Limit alcohol to one (women) or two (men) drinks a day.
  • Limit saturated fat to less than seven percent of calories.
  • During the initial diabetic exam, screen for peripheral arterial disease (poor circulation). Strongly consider calculation of the ankle-brachial index for those over 50 years of age; consider it for younger patients if they have risk factors for poor circulation.
  • Those at risk for diabetes, including prediabetics, should aim for moderate weight loss (about seven percent of body weight) if overweight. Either low-carbohydrate, low-fat calorie-restricted, or Mediterranean diets may be effective in the short-term (up to 2 years). Also important is exercise: at least 150 minutes per week of moderate-intensity aerobic activity. “Individuals at risk for type 2 diabetes should be encouraged to achieve the U.S. Department of Agriculture (USDA) recommendation for dietary fiber (14 g fiber/1,000 kcal) and foods containing whole grains (one-half of grain intake).” Limit intake of sugar-sweetened beverages.
  • “Adults with diabetes should be advised to perform at least 150 min/week of moderate-intensity aerobic physical activity (50–70% of maximum heart rate), spread over at least 3 days/week with no more than two consecutive days without exercise. In the absence of contraindications, adults with type 2 diabetes should be encouraged to perform resistance training at least twice per week.”
  • Screening for coronary artery disease before an exercise program is depends on the physician judgment on a case-by-case basis. Routine screening is not recommended.
Steve Parker MD, low-carb diet, diabetic diet

Olive, olive oil, and vinegar: classic Mediterranean foods

Obviously, some of my dietary recommendations conflict with ADA guidelines. The experts assembled by the ADA to compose guidelines were well-intentioned, intelligent, and hard-working. The guidelines are supported by 528 scientific journal references. I greatly appreciate the expert panel’s work. We’ve simply reached some different conclusions. By the same token, I’m sure the expert panel didn’t have unanimous agreement on all the final recommendations. I invite you to review the dietary guidelines yourself, discuss with your personal physician, then decide where you stand.

General Blood Glucose Treatment Goals

The ADA in 2013 suggests these therapeutic goals for non-pregnant adults:

  • Fasting blood glucoses: 70 to 130 mg/dl (3.9 to 7.2 mmol/l)
  • Peak glucoses one to two hours after start of meals: under 180 mg/dl (10 mmol/l)
  • Hemoglobin A1C: under 7%
  • Blood pressure: under 140/80 mmHg
  • LDL cholesterol: under 100 mg/dl (2.6 mmol/l). (In established cardiovascular disease: <70 mg/dl or 1.8 mmol/l may be a better goal.)
  • HDL cholesterol: over 40 mg/dl (1.0 mmol/l) for men and over 50 mg/dl (1.3 mmol/l) for women
  • Triglycerides: under 150 mg/dl (1.7 mmol/l)

The American Association of Clinical Endocrinologists (AACE) in 2011 proposed somewhat “tighter” blood sugar goals for non-pregnant adults:

  • Fasting blood glucoses: under 110 mg/dl (6.11 mmol/l)
  • Peak glucoses 2 hours after start of meals: under 140 mg/dl (7.78 mmol/l)
  • Hemoglobin A1C: 6.5% or less

The ADA reminds clinicians, and I’m sure the AACE guys agree, that diabetes control goals should be individualized, based on age and life expectancy of the patient, duration of diabetes, other diseases that are present, individual patient preferences, and whether the patient is able to easily recognize and deal with hypoglycemia. I agree completely.

Steve Parker, M.D.

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Filed under Diabetes Complications, Exercise, Fat in Diet, Fiber, Mediterranean Diet, Overweight and Obesity, Prediabetes, Prevention of T2 Diabetes

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May 29, 2012 · 6:45 AM

Hot Off the Press: New ADA Hyperglycemia Management Guidelines

I’ll get to the following article when time allows.  It’s in a June, 2012, issue of Diabetes Care.  (Didn’t they publish management principles just six months ago?  Jeez.)

Management of Hyperglycemia in Type 2 Diabetes: A Patient-Centered Approach:  Position Statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD)

-Steve

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March 30, 2011 · 2:00 AM

Two-Minute Online Diabetes and Prediabetes Risk Test

In the U.S., 24 million people have diabetes, mostly type 2.  That’s one in 10 adults.  The number for those over 60 is two in 10. 

Fifty-seven million have prediabetes; that’s one of every three adults.  Most of them are unaware of it.

The American Diabetes Association offers an online diabetes and prediabetes risk assesment.  The Centers for Disease Control says one of every three people born in 2000 will develop diabetes.   A few risk factors are age over 45, family history of diabetes, sedentary lifestyle, and overweight or obese.  Why not recommend the test to someone you know who may be at risk? 

Steve Parker, M.D., author of Conquer Diabetes and Prediabetes: The Low-Carb Mediterranean Diet

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January 17, 2011 · 9:31 PM

ADA Weight-Loss Guidelines for 2011

Earlier this month the American Diabetes Association published its Standards of Care in Diabetes—2011. 

The ADA recommends weight loss for all overweight diabetics.

For weight loss, either low-carbohydrate [under 130 g/day], low-fat calorie-restricted, or Mediterranean diets may be effective in the short-term (up to two years).  For those on low-carb diets, monitor lipids, kidney function, and protein consumption, and adjust diabetic drugs as needed…The optimal macronutrient composition of weight loss diets has not been established. [Macronutients are carbohydrates, proteins, and fats.]

Until three years ago, the ADA recommended against carbohydrate-restricted diets for overweight diabetics.  In January, 2008, their position statement noted that such diets may be effective for up to one year.  My recollection is that their 2010 guidelines also said “up to one year” and didn’t mention the  Mediterranean diet. 

Progress!

Looks like the timing of my Low-Carb Mediterranean Diet is good.

Steve Parker, M.D.

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June 2, 2010 · 2:00 AM

Using Hemoglobin A1c to Diagnose Diabetes

In July, 2009, an expert committee composed partially of representatives from the American Diabetes Association proposed that hemoglobin A1c be used as a diagnostic test for diabetes in non-pregnant adults and children. 

The expert committee proposed that diabetes is present when hemoglobin A1c is 6.5% or greater.  The test should be repeated for confirmation unless the individual has clear symptoms of diabetes.

The committee also recommended that the term “prediabetes” be phased out.  They indicated that a person with hemoglobin A1c of at least 6% but less that 6.5% is at risk (high risk?) of developing diabetes, yet they don’t want to give that condition a name (such as prediabetes). 

In December, 2009, the American Diabetes Association established a hemoglobin A1c criterion for the diagnosis of diabetes: 6.5% or higher.  Diagnosis of prediabetes involves hemoglobin A1c between 5.7 and 6.4%.  These numbers don’t apply to pregnant women. 

Previously established  blood sugar criteria can also be used to diagnose diabetes and prediabetes.

This step is a major change in the diagnosis of diabetes.   

Steve Parker, M.D.

Reference:  International Expert Committee.  International Expert Committee report on the role of the A1c assay in the diagnosis of diabetes.  Diabetes Care, 32 (2009): 1-8.

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December 22, 2009 · 2:00 AM

Top 10 Diabetes Superfoods

The American Diabetes Association has published a list of  Top 10 Diabetes Superfoods.  They share a low glycemic index and provide key nutrients, according to the ADA.  Click the link for details.  Here they are in no particular order:

  • beans
  • dark green leafy vegetables
  • citrus fruit
  • sweet potatoes
  • berries
  • tomatoes
  • fish high in omega-3 fatty acids
  • whole grains
  • nuts
  • fat-free milk and yogurt

Regular readers here know I have no problem generally with regular or high-fat versions of dairy products.  An exception would be for people trying to lose weight while still eating lots of carbohydrates; the low- and no-fat versions could have lower calorie counts, which might help with weight management.

But compare non-fat and whole milk versions of yogurt in the USDA nutrient database.  One cup of non-fat fruit variety yogurt has 233 calories, compared to 149 calories in plain whole milk yogurt.  The “non-fat” version  reduced the fat from 8 to 2.6 g (not zero g) and replaced it with sugars (47 g versus 11 g). 

Unfortunately, your typical supermarket yogurts are low-fat yet loaded with sugar or high fructose corn syrup that impede weight loss.

Nevertheless, this superfoods list may give us some guidance in design of a Diabetic Mediterranean Diet.  Except for “fat-free,” everything else on the list is a component of the traditional healthy Mediterranean diet.  “Fat-free” is a modern invention and not necessarily an improvement.

Steve Parker, M.D.

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September 13, 2009 · 3:41 AM

Low-Carb Mediterranean Diet Beats Low-Fat For Recent-Onset Type 2 Diabetes

MPj03417870000[1]A low-carbohydrate Mediterranean diet dramatically reduced the need for diabetic drug therapy, compared to a low-fat American Heart Association diet.  The Italian researchers also report that the Mediterranean dieters also lost  more weight over the first two years of the study.

Investigators suggest that the benefit of the Mediterranean-style diet is due to greater weight loss, olive oil (monunsaturated fats increase insulin sensitivity), and increased adiponectin levels.

The American Diabetes Association recommends both low-carbohydrate and low-fat diets for overweight diabetics.  The investigators wondered which of the two might be better, as judged by the need to institute drug therapy in newly diagnosed people with diabetes.

Methodology

Newly diagnosed type 2 diabetics who had never been treated with diabetes drugs were recruited into the study, which was done in Naples, Italy.  At the outset, the 215 study participants were 30 to 75 years of age, had body mass index over 25 (average 29.5), had average hemoglobin A1c levels of 7.73, and average glucose levels of 170 mg/dl.

Participants were randomly assigned to one of two diets:

  1. Low-carb Mediterranean diet (“MED diet”, hereafter):  rich in vegetables and whole grains, low in red meat (replaced with poultry and fish), no more than 50% of calories from complex carbohydrates, no less than 30% of calories from fat (main source of added fat was 30 to 50 g of olive oil daily).  [No mention of fruits or wine.  BTW, the traditional Mediterranean diet derives 50-60% of energy from carbohydrates.]
  2. Low-fat diet based on American Heart Association guidelines:  rich in whole grains, restricted additional fats/sweets/high-fat snacks, no more than 30% of calories from fat, no more than 10% of calories from saturated fats.

Both diet groups were instructed to limit daily energy intake to 1500 (women) or 1800 (men) calories.

All participants were advised to increase physical activity, mainly walking for at least 30 minutes a day.

Drug therapy was initiated when hemoglobin A1c levels persisted above 7% despite diet and exercise.

The study lasted four years.

Results

By the end of 18 months, twice as many low-fat dieters required diabetes drug therapy compared to the MED dieters—24% versus 12%.

By the end of four years, seven of every 10 low-fat dieters were on drug therapy compared to four of every 10 MED dieters. 

The MED dieters lost 2 kg (4.4 lb) more weight by the end of one year, compared to the low-fat group.  The groups were no different in net weight loss when measured at four years: down 3–4 kg (7–9 lb).

Compared to the low-fat group, the MED diet cohort achieved significantly lower levels of fasting glucose and hemoglobin A1c throughout the four years.

The MED diet group saw greater increases in insulin sensitivity, i.e., they had less insulin resistance.

The MED group had significantly greater increases in HDL cholesterol and decreases in trigylcerides throughout the study.  Total cholesterol decreased more in the MED dieters, but after the first two years the difference from the low-fat group was not significantly different. 

The Mediterranean group’s intake of carbohydrates was 8-9% lower than baseline, monounsaturated fat was 5.5% higher than baseline, and polyunsaturated fat was 2.5% higher than baseline.  Compared with their baseline, the low-fat group didn’t make much change in these nutrient groups.  These numbers hold up for all four years of the study. 

Comments

The MED diet here includes “no more than 50% of calories from complex carbohydrates.”  The authors don’t define complex carbs.  Simple carbohydrates are monosaccharides and disaccharides.  Complex carbs are oligosaccharides and polysaccharides.  Another definition of complex carbs is “fruits, vegetables, and whole grains,” which I think is definition of complex carbs applicable to this study. 

The editors of the Annals of Internal Medicine conclude that:

A low-carbohydrate, Mediterranean-style diet seems to be preferable to a low-fat diet for glycemic control in patients with newly diagnosed type 2 diabetes.

I’m sure the American Diabetes Association will take heed of this study when they next revise their diet guidelines.  If I were newly diagnosed with type 2 diabetes, I wouldn’t wait until then.

This study dovetails nicely with others that show prevention of type 2 diabetes with the Mediterranean diet, reversal of metabolic syndrome—a risk factor for diabetes—with the Mediterranean diet (supplemented with nuts), and prevention of type 2 diabetes and pre-diabetes in people who have had a heart attack.

For instruction on how to lose weight with a Mediterranean-style diet, click here (it’s not the low-carb diet used in the study at hand).

For general information on Mediterranean eating, visit Oldways.

Steve Parker, M.D.

Reference:  Esposito, Katherine, et al.  Effects of a Mediterranean-style diet on the need for antihyperglycemic drug therapy in patients with newly diagnosed type 2 diabetes.  Annals of Internal Medicine, 151 (2009): 306-314.

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August 22, 2009 · 11:19 AM

Estimate Your Risk of Type 2 Diabetes, Heart Disease, and Stroke

"Who's next?"

"Who's next?"

The American Diabetes Association has just unveiled an online calculator that estimates your risk of developing type 2 diabetes, heart disease, or stroke over the next 30 years.  It’s at My Health Advisor.  Anyone can use it.

You use the calculator anonymously, although I assume they will capture the IP address of your computer.  You don’t have to know the following data about yourself, but the ADA says the results will be more accurate if you provide more information [certainly makes sense]:

  • cholesterol levels: total, HDL, LDL
  • most recent fasting plasma glucose level
  • recent blood pressure
  • results of oral glucose tolerance test
  • hemoglobin A1c result
  • estimate of average glucose levels

I have no idea of the accuracy of this calculator.  But I rather doubt the ADA would offer it without substantial validation.

I’m always trying to figure out how to motivate people to take better care of themselves.  This calculator could help.  The print-out of your results suggests ways you might reduce your risk. 

Remember that the Mediterranean diet has been shown to reduce risk of type 2 diabetes, heart attack, and stroke.

Steve Parker, M.D.

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July 5, 2009 · 2:00 AM

ADA Now Says Low-Carb Diets OK for Overweight Type 2 Diabetics

CB037166Eighty-five percent of type 2 diabetics are overweight or obese.  Overweight either causes or aggravates many cases of diabetes.

For the last quarter-century, many U.S. government agencies and healthcare organizations have advocated a low-fat diet for overweight people, including type 2 diabetics.  Recent studies have documented that low-carbohydrate diets can also be effective in weight loss.  Low-carb diets replace carbohydrates with either fats or proteins, or both.  The A to Z Weight Loss Study compared the Atkins, Ornish, LEARN, and Zone diets in 311 overweight pre-menopausal women.  The Atkins group tended to lose a bit more weight. Changes in lipid profiles, waist-hip ratios, fasting insulin and glucose levels, blood pressure, and percentage of body fat were comparable or better with Atkins versus the other diets.

The Amerian Diabetes Association now gives the go-ahead for use of low-carb diets as a weight-control method for type 2 diabetics.  Previously, the organization had recommended against diets that restrict carbohydrates to less than 130 grams daily.  (A baked potatoe without the skin has 30 grams.)  Understand that the ADA does not endorse low-carb diets for weight loss or diabetes management.  They simply say that either low-carb or low-fat calorie-restricted diets might be effective for up to one year.

I caution you that low-carb diets may be deficient in fiber, minerals, vitamins, and phytonutrients that may be very beneficial in terms of long-term health and longevity.

The tide has been turning against low-fat diets for the last six years.

Steve Parker, M.D.

Reference: American Diabetes Association.  Clinical Practice Recommendations 2008.  Diabetes Care, 31 (2008): S61-S78.

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