1. Dr Shahjada Selim Assistant Professor Department of Endocrinology Bangabandhu Sheikh Mujib Medical University, Dhaka

2. Introduction

3. Clinical Practice Recommendations Evidence Grading System
Clear evidence from adequately-powered, well-conducted, generalizable RCTs, including evidence from a multicenter trial or meta-analysis that incorporated quality ratings in the analysis;
Compelling nonexperimental evidence;
Supportive evidence from adequately-powered, well-conducted RCTs. B
Supportive evidence from a well-conducted cohort studies
Supportive evidence from a well-conducted case-control study C
Supportive evidence from poorly controlled or uncontrolled studies or evidence from observational studies with high potential for bias
Evidence from case series or case reports
Conflicting evidence with the weight of evidence supporting the recommendation E
Expert consensus or clinical experience
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Here is the Association’s evidence grading system in use for these clinical practice recommendations, used to clarify and codify the evidence that forms the basis for each of the recommendations in the 2016 Standards of Medical Care in Diabetes.
The level of evidence that supports each recommendation is listed after each recommendation using the letters A, B, C, or E. As we proceed through this presentation you’ll see these grades next to each of the recommendations listed. I won’t call them out each time, but they’re there for your reference.
[SLIDE]
American Diabetes Association Standards of Medical Care in Diabetes. Introduction. Diabetes Care 2016; 39 (Suppl. 1): S1-S2
Reference
American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care 2014;37(suppl 1):S15; Table 1 3

4. ……………..Introduction
Diabetes is a complex, chronic illness requiring continuous medical care with multifactorial risk-reduction strategies beyond glycemic control.
Ongoing patient self-management education and support are critical to preventing acute complications and reducing the risk of long-term complications.

5. What is new in the 2017 American Diabetes Association Standards of Care?
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The Association made one point of clarification this year which we hope clinicians, advocates, journalists, and the general public will adopt:
In alignment with our longstanding informal policy Association-wide, the Standards of Care will no longer use the term “diabetic” to refer to patients with diabetes. This decision is in alignment with the American Diabetes Association’s position that diabetes does not define people.
Those with diabetes are individuals with diabetes, not “diabetics.”
ADA will continue to use the term “diabetic” as an adjective for complications related to diabetes (e.g., diabetic retinopathy).
[SLIDE]
American Diabetes Association Standards of Medical Care in Diabetes. Introduction. Diabetes Care 2017; 39 (Suppl. 1): S1-S4 5

6. This year’s Standards of Care includes new recommendations for global assessment and management, prediabetes, hypoglycemia, and pregnancy, as well as some tweaks to diabetes nomenclature and updates to medication advice to reflect the latest clinical trial findings.
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7. 1. Global assessment, lifestyle management and psychosocial care
The 2017 Standards of Care discuss a more global assessment of the person with diabetes, balancing individualization of treatment with population health. This includes a discussion of care systems and a focus on the environmental and system factors contributing to diabetes. Health literacy, numeracy, and social determinants of health are all important factors to assess.
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8. Lifestyle Management: The Standards of Care have been reorganized to highlight the importance of lifestyle management of diabetes. This section discusses the goals of nutrition therapy, weight management, physical activity, psychosocial care, and sleep. Diabetes self-management education (DSME) and diabetes self-management support (DSMS) are recommended for all people with diabetes throughout the progression of the disease. Key times for DSME and DSMS include: time of diagnosis; annually for assessment of ongoing needs; when new complicating factors arise such as a change in health; and when transitions in care occur.
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9. Based on new evidence of glycemic benefits, the Standards of Care now recommend that prolonged sitting be interrupted every 30 minutes with short bouts of physical activity. A recommendation has been added to highlight the importance of balance and flexibility training in older adults.
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10. Psychosocial care: In late 2016 the ADA published a new position statement on psychosocial carefor people with diabetes, which is reflected in this year’s Standards of Care. Highlights include adding key mental health conditions (depression, anxiety, bipolar disorder) to the list of important co-morbid illnesses that should be assessed and addressed in people with diabetes. There are also new recommendations for when to refer to a mental health professional. (Table 1).
Finally it is recommended that people should be monitored for diabetes distress, especially when treatment targets are not met and at the onset of any complication.
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12. Sleep in glucose metabolism and control: The Standards of Care now suggest that health care providers consider the assessment of sleep pattern and duration as part of the comprehensive medical evaluation for people with diabetes. This is based on emerging evidence that poor sleep quality, short sleep, and long sleep are associated with suboptimal glycemic control.
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13. 2. Prediabetes Recommendations on screening for prediabetes:
To help providers identify those patients who would benefit from prevention efforts, new text has been added emphasizing the importance of screening for prediabetes using an assessment tool or informal assessment of risk factors and performing a diagnostic test when appropriate. (Tables 2 and 3)
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16. New definition of hypoglycemia:
The definition of hypoglycemia has been adjusted based on recommendations from the International Hypoglycemia Study Group. Serious clinically significant hypoglycemia is now defined as blood glucose < 54 mg/dL (3.0 mmol/L), while the blood glucose alert value is defined as < 70 mg/dL (3.9 mmol/L). (Table 4)
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18. Staging of type 1 diabetes:
Various genetic and environmental factors can result in the progressive loss of β-cell mass and/or function that manifests clinically as hyperglycemia. Three distinct stages of type 1 diabetes can be identified and serve as a framework for future research and regulatory decision making. (Table 5).
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21. B12 supplementation in those taking metformin:
 Changes to medication-related recommendations
B12 supplementation in those taking metformin: 
To reflect new evidence showing that long-term metformin may lead to vitamin B12 deficiency, a recommendation has been added to consider periodic measurement of B12 levels and supplementation as needed.
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22. Section 7. Obesity Management for the Treatment of Type 2 Diabetes
To be consistent with other ADA position statements and to reinforce the role of surgery in the treatment of type 2 diabetes, bariatric surgery is now referred to as metabolic surgery.
To reflect the results of an international workgroup report endorsed by the ADA and many other organizations, recommendations regarding metabolic surgery have been substantially changed, including those related to BMI thresholds for surgical candidacy (Table 7.1), mental health assessment, and appropriate surgical venues.
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23. Additional recommendation based on EMPA-REG OUTCOME and LEADER trials:
Based on the results of two large clinical trials, a recommendation has been added to consider empagliflozin or liraglutide in patients with cardiovascular disease to reduce cardiovascular and all-cause mortality.
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24. Other pharmacologic updates:
Combination injectable therapy recommendations for type 2 diabetes (Figure 1) have been changed to reflect studies demonstrating the noninferiority of basal insulin plus GLP-1 receptor agonist to basal insulin plus rapid-acting insulin or to two daily injections of premixed insulin, as well as studies demonstrating the noninferiority of a premixed analog insulin three times daily regimen versus basal-bolus therapy.
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25. Approach to start and adjust insulin in T2DM
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27. THANKS
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