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What's new in the 2013 guidelines for diabetes care?

Funnell, Martha MS, RN, CDE

doi: 10.1097/01.NURSE.0000430642.18365.d7
Department: CLINICAL QUERIES
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New recommendations from the 2013 guidelines for diabetes care

Martha Funnell is an associate research scientist in the Department of Medical Education at the University of Michigan Medical School in Ann Arbor, Mich.

Supported in part by Grant Number P30DK092926 (MCDTR) from the National Institute of Diabetes and Digestive and Kidney Diseases.

The author has disclosed that she has no financial relationships related to this article.

I heard that the American Diabetes Association (ADA) raised the recommended BP target to 140/80 mm Hg. Is that true?—M.C., MASS.

Martha Funnell, MS, RN, CDE, replies: Well, not completely. Each year an expert committee, which includes nurses, reviews the evidence and updates the ADA Standards of Medical Care in Diabetes based on the latest research. Among other changes for 2013, it was suggested that a systolic BP target of less than 140 mm Hg may be appropriate for many people with diabetes and hypertension.1 The systolic BP target remains less than 130 mm Hg for younger people, if it can be obtained without an undue burden from the treatment, such as cost or adverse reactions. The diastolic BP target remains at less than 80 mm Hg.

This change was made based on a careful review of the evidence. Studies have shown that reducing BP to less than 140/80 mm Hg reduces coronary heart disease events, stroke, and nephropathy.24 However, the evidence for the benefit of further lowering the systolic BP is limited. In addition, many patients will require more than two medications to achieve the lower level, which increases the risk of adverse reactions and adds to the cost of treatment.

What does this mean for your patients? A BP greater than 120/80 mm Hg is still considered elevated. People with diabetes and a BP greater than 120/80 but less than 140/80 mm Hg should be taught how to make lifestyle changes, including losing weight (if overweight), following a Dietary Approaches to Stop Hypertension (DASH) diet, reducing sodium intake to less than 1,500 mg/day, and increasing physical activity.1 Patients with a confirmed BP of 140/80 mm Hg or higher should begin pharmacologic therapy. Because of their protective effects on the kidneys, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers are recommended.1 Most patients will need two or more medications to achieve the target.

Tell your patients about one more important change: It's now recommended that all unvaccinated adults with diabetes age 19 through 59 receive hepatitis B vaccination.1 Hepatitis B vaccination should be considered for unvaccinated adults with diabetes who are age 60 or older.

The Standards of Medical Care in Diabetes—2013 continue to recommend that all patients with diabetes be referred for both diabetes self-management education and support, and medical nutrition therapy, at diagnosis and as needed.1 See Recommendations for macronutrients.

Of particular interest for nurses are the changes in the “National Standards for Diabetes Self-Management Education and Support,” which also include standards for prediabetes.5 These are also based on the evidence from educational, behavioral, and psychosocial research studies. Since 2007, the standards have emphasized the need for both diabetes self-management education and ongoing diabetes self-management support to sustain changes made during diabetes self-management education. Assessing and referring patients for education and support is an essential role for all nurses who care for people with all types of diabetes.

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Recommendations for macronutrients1

  • The mix of carbohydrate, protein, and fat can be adjusted to meet the metabolic goals and preferences of patients with diabetes.
  • To achieve glycemic control, a key strategy is to monitor carbohydrates by counting carbohydrate grams or choices, or estimating based on experience.
  • Adults with diabetes who consume alcohol should limit their intake to one drink per day or less for women and two drinks per day or less for men and take extra precautions to prevent hypoglycemia.
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REFERENCES

1. American Diabetes Association. Standards of medical care in diabetes—2013. Diabetes Care. 2013;36(suppl 1):S11-S66.
2. Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA. 2003;289(19):2560–2572.
3. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. UK Prospective Diabetes Study Group. BMJ. 1998;317(7160):703–713.
4. Hansson L, Zanchetti A, Carruthers SG, et al. Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomised trial. HOT Study Group. Lancet. 1998;351(9118):1755–1762.
5. Haas L, Maryniuk M, Beck J, et al.National standards for diabetes self-management education and support. Diabetes Care. 2012;35(11):2393–2401.
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