Diabetes Core Update: Standards of Care Special Edition January 2015

Podcast Date: February 13, 2015
Hosts: Dr. Neal Skolnik & Dr. John Russell
Guest: Dr. Richard Grant, Chair, ADA Standards of Care Committee

Episode Overview

This special edition of the Diabetes Core Update podcast focuses exclusively on the American Diabetes Association (ADA) Standards of Care as published in the January 2015 issue of Diabetes Care. Dr. Neal Skolnik interviews Dr. Richard Grant, Chair of the committee responsible for updating the standards. The episode highlights the process behind developing the standards, key updates for 2015, and the practical implications for clinicians treating patients with diabetes.

Key Discussion Points & Insights

1. How the ADA Standards of Care Are Developed

[02:08]

• Committee Composition: Includes endocrinologists, primary care physicians, nurses, pharmacists, diabetes educators (12–15 members, staggered two-year terms).
• Evidence Review: Committee members review the latest literature, assign sections, and discuss necessary updates.
• Emphasis on Evidence Levels: All recommendations are accompanied by a grading of evidence, from A (strong, RCT-based) to E (expert opinion).
  • Quote:

    "We really focused on making sure that all of our recommendations...are accompanied by a level of evidence."
    — Dr. Grant [03:42]

2. Diagnostic Criteria for Diabetes

[04:34]

• Approved Tests: Fasting plasma glucose, A1C, and 2-hour oral glucose tolerance test.
• No Major Changes: Each test comes with specific pros and cons; test selection depends on clinical context.
• Important Practice Note: Different tests may diagnose different patients. Diagnosis should be confirmed with the same test type.
  • Quote:

    "If you were to give all three tests to the same group of patients, you wouldn't identify exactly the same set of patients with diabetes..."
    — Dr. Grant [05:39]

3. Screening Recommendations & Notable Update for Asian Americans

[06:17]

• Who to Screen: All individuals with obesity, family history, or other risk factors as listed in the standards.
• BMI Threshold Change:
  • General: Test if BMI >25 kg/m²
  • Asian Americans: Lowered threshold to BMI >23 kg/m², based on evidence of increased diabetes risk at lower BMIs.
    • Quote:

      "For Asian Americans, we lowered that to 23 kilograms per meter squared. So that's the one notable change..."
      — Dr. Grant [06:53]

4. Understanding and Managing Prediabetes

[07:41]

• Definition: Intermediate glycemic state—A1C between 5.7–6.4%.
• Implications: High risk for progression to diabetes and associated complications.
• Recommendation: Strongly advocate lifestyle modification programs (exercise and weight loss), emphasizing importance enough to recommend insurance coverage.
  • Quote:

    "We strongly recommend that they engage in a lifestyle change program involving exercise and weight loss. And in fact, we recommend that that should probably be paid for..."
    — Dr. Grant [08:37]

5. Self-Monitoring of Blood Glucose (SMBG)

[09:36]

• Type 1 & Insulin-Treated Type 2: Frequent testing vital, especially during medication adjustments.
• Type 2 Not on Insulin: SMBG not universally necessary; should be targeted and integrated into education for behavior change.
  • Quote:

    "Self-monitoring of blood glucose does not lower your A1C levels. It's a tool to provide information, but it doesn't itself... It's not at all therapeutic."
    — Dr. Grant [10:19]

  • Quote:

    "Self-monitoring...really has to go hand in hand with a planned educational program...Short of that, it's really actually not necessary because it's not going to change outcomes."
    — Dr. Grant [11:32]

6. Individualized A1C Targets

[12:14]

• Moving Away from 'One-Size-Fits-All':
  • Tight control recommended for younger, healthier patients at diagnosis.
  • Looser control for elderly, comorbid, or limited life expectancy patients—higher targets (A1C up to 8-9%) may be appropriate.
• Policy Implication: Insurance or quality measures should reflect nuances in individualized care.
  • Quote:

    "Our approach has been to look at evidence...and look at the larger context when it's not...We've tried in these standards to give some guidance into what's sort of the ideal patient to maybe try for a little bit lower than seven and other kinds of patients where seven is a reasonable goal, and then other patients where maybe you want to loosen it to 8 or 9%."
    — Dr. Grant [13:11]

7. Hypoglycemia: Greater Focus

[16:25]

• Increased Awareness: Large cohort studies reveal hypoglycemia is more prevalent—especially among older adults—than previously thought.
• Cognitive Concerns: New research links hypoglycemic events to cognitive decline.
  • Quote:

    "There's another body of research...that has shown that hypoglycemic events predict future cognitive decline. And so...it's very important to monitor for and ask about hypoglycemia."
    — Dr. Grant [16:58]

8. Blood Pressure Goals

[17:32]

• Update for 2015:
  • Diastolic BP target raised from <80 mmHg to <90 mmHg, aligning with highest level of available evidence and general population guidelines.
• Rationale: Evidence-based practice avoids over-treatment when lower BP does not provide extra benefit.
  • Quote:

    "This year we changed the diastolic target from 80...to 90...By the strict letter of the evidence, we moved from 80 to 90 so that we can say this is a level recommendation that makes sense."
    — Dr. Grant [18:01]

9. Lipid (Cholesterol) Management

[19:10]

• Major Change: Shift towards fixed statin dose strategies (moderate vs. high intensity) based on risk, not LDL titration, aligning with 2013 ACC/AHA guidelines.
• Application:
  • Most patients with type 2 diabetes: At least moderate-intensity statin.
  • Higher-risk groups (e.g., prior CVD): High-intensity statin.
• Type 1 Diabetes: Recommendations made by analogy given lack of RCT evidence.
  • Quote:

    "Virtually all patients with type 2 diabetes should be started on at least a moderate dose. And then a subset who are at higher risk...should be started on high intensity dose."
    — Dr. Grant [21:10]

Notable Quotes

• "Each year in the January issue of Diabetes Care, the American Diabetes association publishes the Standards of Medical Care in Diabetes, which essentially establishes the ongoing standard of care nationwide."
  — Dr. Skolnick [00:29]

• "One thing that we really focused on is making sure that all of our recommendations...are accompanied by a level of evidence..."
  — Dr. Grant [03:42]

• "This old fashioned idea of every single patient has to be sticking their fingers every single day doesn't take into account the variation and the use of this tool to its greatest effect."
  — Dr. Grant [11:41]

• "The benefits that come from tight control would occur decades later...so we've tried to lay out a landscape where the clinician could make reasonable decisions about how tightly to control..."
  — Dr. Grant [14:27]

• "Effective blood pressure control probably has more benefit than effective glycemic control."
  — Dr. Grant [17:40]

Timestamps for Important Segments

• [02:08] – How ADA updates the Standards of Care
• [04:34] – Diagnostic tests and their nuances
• [06:17] – Screening criteria and new BMI cutoff for Asian Americans
• [07:41] – What is prediabetes and what do about it
• [09:36] – Who should self-monitor blood glucose?
• [12:14] – Individualizing A1C targets in diabetes management
• [16:25] – The emerging focus on hypoglycemia
• [17:32] – New blood pressure goals for people with diabetes
• [19:10] – Lipid management: intensity-based statin recommendations

Memorable Moments

• Clarity on diagnostic criteria, especially with updated BMI threshold for Asian Americans.
• Strong advocacy for lifestyle intervention coverage for prediabetes.
• Clear demystification of SMBG—emphasizing education and individual need rather than universal prescription.
• Insightful explanation for raising the diastolic BP goal and harmonizing statin recommendations with cardiology guidelines.

Further Information

For comprehensive details—including management of neuropathy, nephropathy, retinopathy, diabetes during illness and admissions, nutrition, and exercise—visit www.diabetesjournals.org to access the full Standards of Care.

Summary prepared for clinicians, educators, and all diabetes care professionals seeking an actionable and up-to-date overview of the 2015 ADA Standards of Care.