Deepak L. Bhatt, MD, MPH on the New NDEP Diabetes Guiding Principles

Deepak L. Bhatt, MD, MPH

Last week, the National Diabetes Education Program (NEDP), under the National Institute of Diabetes and Digestive Kidney Diseases (NIDDK) released an updated list of their Guiding Principles for the Care of People With or at Risk For Diabetes.

The principles, a ten-item list of generally agreed-to practices among prominent healthcare providers and agency guidelines, have included new and updated evidence over recent years in the field of diabetes self-management, education, and support, as well as shared decision-making skills and individualized care for patients. Supporting organizations of the principles include the American Diabetes Association, American Academy of Family Physicians, the Endocrine Society, National Institute on Minority Health and Health Disparities, and dozens more.

Deepak L. Bhatt, MD, MPH, of the American Heart Association, executive director of Interventional Cardiovascular Programs at Brigham and Women’s Hospital Heart & Vascular Center and professor of medicine at Harvard Medical School, assisted in the writing, reviewing and research behind the updated principles. In an interview with MD Magazine®, Bhatt detailed the creation of the new guidelines, as well as the meaning behind all 10 principles.

MD Mag: What led to the creation of these new principles? What is the goal behind the update?

Bhatt: The idea was to produce something that is useful to people, both to healthcare providers and for people who are caring for others with diabetes and those at risk for it. That actually applies to a lot of people, and it was meant to be evidenced-based, focusing on all aspects of diabetes including the management—and hopefully, the prevention.

Our goal was to try to distill it down to 10 principles, because 10 is a nice number. There’s a lot of top-ten lists that are easier to remember, and they get attention from the media.

On the Guiding Principles:

1. Identify People with Undiagnosed Diabetes and Prediabetes — That’s a pretty big deal. A substantial number of people show up with, say, a heart attack. And they have diabetes but they never knew. Now they’re in the hospital, we check their sugar, we check their hemoglobin A1C, and it’s confirmed. There’s a lot of data out there suggesting people have diabetes for a few years before it’s confirmed.
2. Manage Prediabetes to Prevent or Delay the Onset of Type 2 Diabetes — In those people that are prediabetic—that is blood sugars not quite in the range, but have glucose intolerance. Sometimes those folks, just by having them lose a little bit of weight, getting them on a diet or becoming more physically active, can ward off diabetes altogether. At least part of it is in their control, and sometimes that can motivate people from going from prediabetes to diabetes stage.
3. Provide Comprehensive, Patient-centered Diabetes Care &
4. Provide Ongoing Self-management Education and Support for People with Diabetes — These are about making sure patients understand the value of measuring their own blood sugars, making sure they’re aware of all the risks, like developing heart disease or blindness, kidney dysfunction, problem with feet leading up to amputation. It’s making sure they’re aware of all those risks and the things they can do to prevent it, as well as seeing specialists outside of physicians.
5. Encourage Lifestyle Modification for People with Diabetes — I talked before about people being at risk for diabetes, but this is about people already with diabetes. It’s just about how important it is to keep from gaining any additional weight and, if possible, losing weight. It’s about setting a healthy diet and regular exercise, and additionally, quitting smoking if it applies.
6. Address Overweight and Obesity in the Management of Diabetes - Specifically—and this is new from the previous principles—just addressing the issues of being overweight or obese is important.
7. Individualize Blood Glucose Management for People with Diabetes — Realizing that a young, healthy person with diabetes who has a glucose level might make it appropriate to be really aggressive for the hemoglobin A1C target, whereas with a frail person in their late 80s on multiple medication, it might backfire. It depends on the person’s age, what other comorbidities they have, what medications they’re on. It’s a matter of individualizing blood glucose level management as opposed to just saying, “This is the hemoglobin A1C cutoff, and everyone needs to shoot for it.”
8. Provide Multifactorial Cardiovascular Disease Risk Reduction — Not just being glycemic-centric in a person with diabetes, but also emphasizing LDL cholesterol control and reduction in diabetes. Making sure they’re not smoking, making sure their blood pressure is optimally controlled, and focusing on the other risk factors, not just the blood sugar, is important as well.
9. Detect and Monitor Diabetes Microvascular Complications and Provide Treatment to Slow Their Progression — Thinking about things like retinopathy which could lead to vision loss, nephropathy which might lead to kidney failure, problems with the peripheral circulation which might lead to amputation—these are all important aspects.
10. Consider the Needs of Special Populations with Diabetes — A little bit of focus on the populations that may be particularly at risk of complications from diabetes, such as people that are older, and adolescents with type 2 diabetes —where the clock is starting much earlier. Also, women of child-bearing age. It’s been shown where glucose intolerance developing around the time of pregnancy isn’t a trivial, minor thing, but could predict future diabetes risk or cardiovascular disease. Another is special minority groups at particular risk for diabetes.

There’s really a lot of ground covered there, and hopefully presented in a way that it’s useful for people on the front line practicing, or for patients and people at risk, or those who care for those with diabetes.

Is there anything you can imagine from these updated principles that may need to be updated again in the future?

One thing that’s rapidly changing right now, in terms of medications, there’s a lot of data coming out from different cardiovascular outcome trials from diabetes drugs, and their effect on cardiovascular outcomes including heart failure and even death. There’s going to be, every 6 months or so over the next few years, at least 1 mega-trial coming out with thousands of patients studied, randomized to some diabetes drug or placebo or an older drug. That’s really going to change the care of diabetic patients and really improve their outcomes tremendously.

Is there anything else you wanted to add?

I focused a lot on lifestyle, but there’s also discussion of medications in there, and even procedures like bariatric surgery and what its role might be in folks that are very overweight with out-of-control diabetes. It’s pretty comprehensive ranging, from lifestyle management through medical therapy, through even procedural care.

The guiding principles are available for free PDF download at the NIDDK website.