New Diabetes Guide (ADA) 2019 – Articles

Among the changes from last year's recommendations:

• For type 2 diabetic patients requiring an injectable drug, a glucagon receptor agonist similar to peptide 1 is more desirable than insulin.
• For non-insulin-type patients with type 2 diabetes, routine self-monitoring of glucose has limited additional benefit.
• The risk of ten-year atherosclerotic disease (ASCVD) should be part of the overall patient risk assessment.
• Emphasis should be placed on water intake, and the consumption of sugar of sweetened and unsweetened drinks should be discouraged.

CLASSIFICATION

Diabetes can be classified into the following general categories:

• Type 1 diabetes (due to autoimmune destruction of β cells, which generally results in an absolute insulin deficiency).
• Type 2 diabetes (due to the progressive loss of insulin secretion from β cells often at the bottom of the insulin resistance).
• Gestational diabetes mellitus (GDM, for acronym in English) diabetes diagnosed in the second or third trimester of pregnancy that was not apparent in diabetes before pregnancy.
• Specific types of diabetes due to other causes, for example, a monogenic diabetes syndrome (such as neonatal diabetes and the onset of diabetes in adulthood) [MODY]) exocrine pancreatic disease (such as cystic fibrosis and pancreatitis) and chemical-induced diabetes (such as the use of glucocorticoids, in the treatment of HIV / AIDS, or after organ transplantation).

Nutrition

• Structured weight loss therapy, which includes a meal plan reduced calories and physical activity is of utmost importance for people at high risk of developing type 2 diabetes who have excess weight or obesity.
• Since weight loss through lifestyle changes can be difficult to maintain only in the long run, people who receive therapy with weight loss therapy should have access to ongoing support and additional therapeutic options (such as pharmacotherapy). if necessary.
• According to the interventions, nutritional patterns that may be useful for people with pre-diabetes include a diet plan Mediterraneanor a food plan a little calories and a bit of fat.
• Further research is needed on whether the nutrition plan is low carbohydrates It is useful for people with pre-diabetes.
• In addition, the evidence suggests that it is quality consumed food (measured by the Healthy Food Index), with emphasis on whole grains, legumes, nuts, fruits and vegetables, and minimum processed and refined foodsIt's also important.
• While healthy and low calorie forms of nutrition should be encouraged, there is some evidence that certain nutritional components affect the risk of diabetes in observational studies.
• Higher consumption of walnuts, berries, yogurt, coffee and tea is associated with reduced risk diabetes. On the contrary, red meat and sweet drinks are associated with an increased risk of type 2 diabetes.

Factors that increase the risk of hypoglycaemia associated with the treatment

• Use of insulin or insulin secretagogue (sulphonylurea, meglitinide).

• Disturbed kidney or liver function.

• Longer duration of diabetes.

• Frugality and advanced age.

• Cognitive impairment.

• Impaired kontraregulativni odgovor, nepoznavanje hipoglikemije.

• Physical or intellectual damage that can affect the behavioral response to hypoglycaemia.

• Use of alcohol.

• Polypharmacy (especially ACE inhibitors, angiotensin receptor blockers, non-selective β-blockers).

Immunizations
Recommendations

• Provide vaccines that are routinely recommended to children and adults with diabetes by age.
• Annual vaccination against flu All people ≥6 months, especially people with diabetes.
• Vaccination against pneumococcal diseaseincluding pneumococcal pneumonia, with a 13-valent pneumococcal conjugate vaccine (PCV13) for children up to 2 years of age. People with diabetes between the ages of 2 and 64 should also receive 23 valent pneumococcal polysaccharide vaccines (PPSV23). In the age of ≥65 years, regardless of the history of vaccination, additional vaccination with PPSV23 is required.
• Apply a series of 2 or 3 doses of the vaccine hepatitis B, depending on the vaccine, for adults who have not been vaccinated with diabetes between 18 and 59 years of age.
• Consider applying a 3-dose vaccine series hepatitis B adults who have not been vaccinated with diabetes at age> 60 years.
• Children and adults with diabetes should receive vaccines in accordance with appropriate recommendations for their age.
• People with diabetes are at increased risk of hepatitis B infection and are more likely to experience complications in influenza and pneumococcal disease. The Advice Committee for Immunization Practice (ACIP) of the Center for Disease Control and Prevention (CDC) recommends vaccination against influenza, pneumococcal and hepatitis B especially for people with diabetes.
• Vaccines against tetanus, diphtheria, hoarseness, measles, mumps and rubella, human papillomavirus and herpes are also important for adults with diabetes, and for the general population.

Carbohydrates

Studies exploring the ideal amount of carbohydrate intake for people with diabetes they are not finalalthough control of carbohydrate intake and consideration of blood glucose response to carbohydrate in nutrition is key to improving postprandial glucose control.

Bibliography at glycemic index and glycemic load in people with diabetes it is complex because it often gives mixed results, although in some studies the reduction in glycemic load of spent carbohydrates showed a decrease in A1C from 0.2% to 0.5% (84.85).

Studies for more than 12 weeks do not show a significant effect of glycemic index or glycemic load, regardless of weight loss in A1C; however, mixed results for glucose levels and endogenous insulin levels were recorded.

For people with type 2 diabetes or prediabetes, meal plans low carbohydrates demonstrate the potential for improving blood glucose and lipid blood glucose up to 1 year.

A part of the challenge in interpreting low-carbohydrate research is due to the wide range of definitions for a diet plan with a low carbohydrate content. Since research studies on low-carb nutrition plans generally point to challenges with long-term sustainability, it is important to regularly evaluate and individualize meal plan management for those who are interested in this approach.

Providers must maintain ongoing medical control and recognize that certain groups are not suitable for low-carbohydrate diet plans, including pregnant women or nursing mothers, children and kidneys or diabetic behavioral disorders. and these plans should be used with caution in those taking SGLT2 inhibitors due to the potential risk ketoacidosis. There is insufficient research on nutritional patterns for type 1 diabetes that support a diet plan in relation to the other at this time.

Most people with diabetes report moderate carbohydrate intake (44 to 46% of total calories). Efforts to modify conventional foods often fail in the long run; People mostly return to their usual distribution of macronutrients.

Therefore, the recommended approach is individualize meal plans for achieving calorie goals with distribution of macronutrients that are more in line with the usual taking of an individual in order to increase the likelihood of long-term maintenance.

As for all people in developed countries, it is recommended that both children and adults with diabetes Minimize the intake of refined carbohydrates and added sugars and, instead, focus on carbohydrates of vegetables, legumes, fruits, dairy products (milk and yogurt) and whole grains.

Consumption of sweet drinks (including fruit juices) and processed low-fat or fat-free foods with high amounts of refined grains and added sugar is highly discouraged.

People with type 1 or type 2 diabetes receiving them insulin At mealtime, intensive and continuous education should be offered on the need to combine the use of insulin with carbohydrate intake.

For people whose diet or consumption of carbohydrates is variable, regular counseling is important to help them understand the complex relationship between carbohydrate intake and insulin requirements.

In addition, education on the use of insulin and carbohydrate ratio for meal planning can help them effectively modify the dose of insulin from one meal to another and improve glycemic control.

People who consume foods that contain more protein and fat than usual should adjust the dose of insulin at meal time to compensate for the postprandial glycemic excursion postponement. For people with a fixed daily schedule of insulin, meal planning should emphasize the relatively fixed consumption of carbohydrates in relation to time and quantity.

The goals of nutritional therapy for adults with diabetes

Promote and support healthy eating habits, highlighting different foods with dense nutrients in appropriate areas, in order to improve general health and

• Achieve and keep your body weight goals.
• Achieve the goals of glycemia, blood pressure and individualized lipids
• Postpone or prevent diabetes complications.
• In order to respond to individual nutritional needs based on personal and cultural preferences, knowledge and arithmetic of health, access to healthy food, readiness and ability to change behaviors and obstacles to change.
• For maintenance eating pleasure, providing impartial messages about food choices.
• Provide a person with diabetes with practical tools to develop healthy eating habits instead of focusing on macronutrients, micronutrients, or individual foods.

Recommendations

• Perform the A1C test at least twice a year in patients who satisfy the treatment goals (and who have stable glycemic control).
• Perform the A1C test quarterly in patients whose therapy has been altered or that do not meet glycemic goals.
• At-the-point tests for A1C provide the possibility for timely changes in treatment.

Objectives Hb A1C

Recommendations

• A sensible A1C goal for many non-pregnant adults <7% (53 mmol / mol).
• Providers could reasonably submit A1C targets stricter (as <6.5% [48 mmol / mol]for selected individual patients if this can be achieved without significant hypoglycaemia or other adverse effects of treatment (eg polypharmacy). Appropriate patients may include those with short-term diabetes, Type 2 diabetes that is treated only with lifestyle or metformin, long life or without significant cardiovascular disease.
• Objectives A1C less strict (as <8% [64 mmol / mol]) may be appropriate for patients with a history of the disease hypoglycaemia severe, limited life expectancy, advanced microvascular or macrovascular complications, large comorbid conditions, or long-term diabetes that is difficult to achieve despite education for self-management of diabetes, adequate glucose control and dose effective with multiple glucose-lowering agents, including insulin.

Иницијална терапија (метформин)

The метформин треба је започети у вријеме када се дијагностицира дијабетес типа 2 осим ако нема контраиндикација.

За већину пацијената то ће бити монотерапија у комбинацији са модификацијама начина живота. Метформин је ефикасан и безбедан, јефтин и може смањити ризик од кардиоваскуларних догађаја и смрти. Метформин је доступан у облику са тренутним ослобађањем за дозирање два пута дневно или као облик са продуженим ослобађањем који се може применити једном дневно.

У поређењу са сулфонилуреама, метформин као третман прве линије има позитивне ефекте на А1Ц, тежину и кардиоваскуларни морталитет. Постоји неколико систематских података за друга орална средства као почетни третман за дијабетес типа 2. т

Главне нуспојаве метформина су гастроинтестинална нетолеранција услед отока, нелагодности у стомаку и дијареје.

Лек се елиминише путем бубрежне филтрације и веома висок ниво циркулације (на пример, као последица предозирања или акутне бубрежне инсуфицијенције) је повезан са лацтиц ацидосис. Међутим, сада је познато да је појава ове компликације веома ретка, и метформин се може безбедно користити код пацијената са процењеном ниском брзином гломеруларне филтрације (еГФР); ФДА је прегледала ознаку метформина да би одразила његову безбедност код пацијенатаГФР ≥30 мл / мин / 1,73 м2.

Недавно рандомизирано испитивање потврдило је претходна запажања са којима је употреба метформина повезана недостатак витамина Б12 и погоршање симптома неуропатије. Ово је у складу са недавним извештајем из Студије о исходу програма за превенцију дијабетеса (ДППОС) који сугерише периодично тестирање витамина Б12.

Код пацијената са контраиндикације или нетолеранције за метформин, иницијална терапија треба да се заснива на факторима пацијента; размотрите лек друге врсте.

Када је А1ц> 1,5% (12,5 ммол / мол) изнад гликемијског циља, за многе пацијенте ће бити потребна комбинована комбинована терапија да би достигли свој циљни ниво А1Ц.

Инсулин

The инсулин Предност је да је ефикасна када друга средства нису и треба да се сматрају као део било ког режима комбинације када је хипергликемија тешка, нарочито ако су присутне катаболичке карактеристике (губитак тежине, хипертриглицеридемија, кетоза).

Узмите у обзир почетак лечења инсулин када је глукоза у крви ≥ 300 мг / дл (16,7 ммол / Л) или А1Ц ≥10% (86 ммол / мол) или ако пацијент има симптоме хипергликемије (тј. полиурију или полидипсију), чак иу овом тренутку дијагнозе. или рано у току третмана. Пошто је токсичност глукозе разрешена, често је могуће поједноставити режим и / или прећи на орална средства.