Experts agree on principles of diabetes care

Leaders from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) at the National Institute of Health (NIH) and other organizations involved in diabetes care recently accomplished something almost as difficult as herding cats. They got several major organizations to agree on 10 principles of diabetes care.

The “Guiding Principles for the Care of People With or at Risk for Diabetes” were released by the National Diabetes Education Program (NDEP) in November 2014. Each principle addresses a broad topic, for example, “Consider special populations,” and then offers more specific underlying advice, such as how care should be tailored for children, women of childbearing age, older adults, and certain racial or ethnic groups, as well as references for more information.

The principles were published on the NDEP's website and supported by a number of specialty societies. (ACP contributed to the development of the principles, through the participation of Paul Dallas, MD, FACP, but as a matter of policy, the College does not endorse other organization's guidelines.)

To learn more about the principles and how they can help internists, ACP Internist spoke to Judith Fradkin, MD, director of the Division of Diabetes, Endocrinology and Metabolic Diseases at the NIDDK.

Q: What motivated the development of the principles?

A: Everybody focuses on the minor differences between guidelines. There are so many areas of agreement, and there are so many areas where we have evidence that certain treatments can improve outcomes for people with diabetes, and yet people always want to focus on controversy: Should the HbA1c goal be 7% or 6.5%? Should the blood pressure goal be 130 [mm Hg systolic] or 140? With Guiding Principles, we aren't creating new guidelines, but clarifying where there is general agreement across myriad diabetes guidelines.

Q: What are some particularly important aspects of the principles?

A: Diabetes is the quintessential disease where the person with the disease is managing it. It's the decisions that they're making every day about whether they are physically active, what they are eating, whether they're taking their medications that are going to influence their health outcomes. Because type 2 diabetes comprises such a large proportion of people with or at risk for diabetes, the Guiding Principles focuses primarily on prevention and management of type 2 diabetes. A major focus of this document is on individualization—to consider the care of diabetes in the context of the patient with diabetes and where they are along the course of their disease. Maybe early in the course of the disease the focus may be on the management of blood glucose, but as cardiovascular disease risk increases over time hypertension and statin therapy become increasingly important.

Q: How would you like to see physicians use the principles?

A: One advantage of the guiding principles is that first of all, they're concise. While the document is not as comprehensive, for example, as the American Diabetes Association's standards of care, these principles are probably about one-tenth the length and they have links to more detailed information. For example a link to the National Diabetes Education Program's Diabetes HealthSense website provides a wealth of resources that support behavior change, such as smoking cessation and weight management. Guiding principles references are carefully curated with a focus on links to more in-depth pieces on any particular component of diabetes care. Guiding Principles does, of course, include the seminal clinical trials that have informed diabetes care.

Q: Are the principles meant for patients to use?

A: While the target audience is health care professionals, it would provide a patient with an overview of what is important in terms of their diabetes care. The NDEP has a large number of resources to help a person with or at risk for diabetes and the Guiding Principles provides links to key materials developed for patients.

Q: Is this kind of resource a model for other diseases or specific to diabetes?

A: Diabetes is particularly well suited to this kind of an approach, because diabetes touches so many different facets of medical practice from primary care to specialists, such as podiatrists, ophthalmologists, cardiologists and obstetricians, in addition to endocrinologists, diabetes educators and registered dietitians. Diabetes is such a multi-organ disease that [the principles are] particularly useful to guide optimal care across so many provider specialties.

Q: What lessons should internists particularly take from the principles?

A: The writing group included representatives from the ACP, the American Academy of Family Physicians, the American Heart Association, and the American Geriatrics Society, as well as the major diabetes organizations. Having these primary care experts participate in the development of the principles helped to shape them in a way that would be useful to primary care doctors, who provide care for the majority of people with diabetes. One big emphasis of the guiding principles is on providing comprehensive care, while also focusing on those aspects which will have the greatest health impact in people with diabetes.

Q: Will the principles be updated as practice changes?

A: That will certainly be a challenge. We will need to work with all of the groups that helped to develop and support the principles to review new evidence as it becomes available and update the guidelines as appropriate. It will be important to keep Guiding Principles up-to-date.