Standards of Care in Diabetes
The American Diabetes Association (ADA) continues to recommend metabolic surgery to treat type 2 diabetes in patients with severe obesity (BMI>40), regardless the level of glycemic control or complexity of glucose-lowering regimens. This is among the treatment strategies included in the ADA’s Standards of Medical Care in Diabetes – 2018, issued this month.
The standards also say metabolic surgery should be an option for those with BMI 30.0 to 34.9, when hyperglycemia is inadequately controlled despite lifestyle and optimal medical therapy.
"The Standards of Care are the primary resource for the optimal management of diabetes and include updated guidelines for diabetes diagnosis and for evidence-based prevention of diabetes and diabetes-related complications," said William T. Cefalu MD, ADA’s chief scientific, medical and mission officer in a news release.
The standards note strong and consistent evidence that managing obesity can delay the progression of prediabetes to type 2 diabetes and may be beneficial in the treatment of
type 2 diabetes.
It provides recommendations on lifestyle interventions including diet, physical activity, and behavioral therapy, and pharmacotherapy for obesity, though noting that pharmacological treatment “has been limited by low adherence, modest efficacy, adverse effects, and weight regain after medication cessation.”
The recommendations on metabolic surgery conclude that the safety of operations has improved significantly over the last two decades, with morbidity declining “dramatically” and mortality rates now similar to cholecystectomy or hysterectomy.
Here are the recommendations:
Metabolic surgery should be recommended as an option to treat type 2 diabetes in appropriate surgical candidates with BMI≥40 kg/m2 (BMI≥37.5 kg/m2 in Asian Americans), regardless of the level of glycemic control or complexity of glucose-lowering regimens, and in adults with BMI 35.0–39.9 kg/m2 (32.5–37.4 kg/m2 in Asian Americans) when hyperglycemia is inadequately controlled despite lifestyle and optimal medical therapy.
Metabolic surgery should be considered as an option 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).
Metabolic surgery should be performed in high-volume centers with multidisciplinary teams that understand and are experienced in the management of diabetes and gastrointestinal surgery.
Long-term lifestyle support and routine monitoring of micronutrient and nutritional status must be provided to patients after surgery, according to guidelines for postoperative management of metabolic surgery by national and international professional societies.
People presenting for metabolic surgery should receive a comprehensive mental health assessment. Surgery should be postponed in patients with histories of alcohol or substance abuse, significant depression, suicidal ideation, or other mental health conditions until these conditions have been fully addressed.
People who undergo metabolic surgery should be evaluated to assess the need for ongoing mental health services to help them adjust to medical and psychosocial changes after surgery.
The ADA included bariatric surgery, which it now exclusively calls metabolic surgery, in its standards for the first time in 2011 when it said bariatric surgery may be considered for adults with BMI>35 and type 2 diabetes, especially if the diabetes or associated comorbidities are difficult to control with lifestyle and pharmacologic therapy.
Samer Mattar, MD
“The recent update from the ADA on its Standards of Medical Care in Diabetes is further validation of the significant effect that metabolic surgery has on type 2 diabetes,” said Samer Mattar, MD, ASMBS president. “The ADA is the world’s foremost organization of health care providers dedicated to the prevention and treatment of diabetes. This strong and clear endorsement of bariatric surgery serves to underscore the safety, durability and efficacy of this life-saving therapy.”
Beyond metabolic surgery, notable new recommendations involve advances in cardiovascular disease risk management including hypertension; an updated care algorithm that is patient-focused; the integration of new technology into diabetes management; and routine screening for type 2 diabetes in high-risk youth.
According to the ADA, nearly half of American adults have diabetes or prediabetes; more than 30 million adults and children have diabetes; and every 21 seconds, another individual is diagnosed with diabetes in the U.S.
The Standards of Care are established and revised annually by the ADA’s Professional Practice Committee. The committee is a multidisciplinary team of 12 leading U.S. experts in the field of diabetes care, and includes physicians, diabetes educators, registered dietitians and others with experience in adult and pediatric endocrinology, epidemiology, public health, lipid research, hypertension, preconception planning and pregnancy care.
“Since 1989, the American Diabetes Association has provided annual updates to the Standards of Care, and the Standards are accepted as the global standard for diabetes care. As new technology, research and treatments continue to improve and emerge, we are pleased that we will have the capacity to provide real-time updates to the Standards of Care throughout the year,” said Dr. Cefalu.