First-Ever ADA Guidance Specifically for Type 1 Diabetes

Here is a link to "Type 1 Diabetes Through the Life Span: A Position Statement of the American Diabetes Association."

Below is the text from Medscape promoting the new position statement:

A new position statement from the American Diabetes Association (ADA) provides the first-ever guidance specific to the management of type 1 diabetes in all age groups, including a new HbA1c target for children.
"Type 1 Diabetes Through the Life Span: A Position Statement of the American Diabetes Association" was released June 16 at a press briefing held during the American Diabetes Association 2014 Scientific Sessions and also simultaneously published online in Diabetes Care.

A new pediatric glycemic control target of HbA1c less than 7.5% across all ages replaces previous guidelines that had called for different targets by age (less than 8.5% for children aged under 6 years, less than 8% for those aged 6 to 12 years, and less than 7.5% for adolescents between the ages of 13 and 19 years).

The previous guidance is based on outdated information, Lori M.B. Laffel, MD, chief of the pediatric, adolescent, and young adult section of the Joslin Diabetes Center and associate professor of pediatrics at Harvard Medical School, said at the briefing.

"Those targets were based on experience with severe hypoglycemia in a distant era," Dr. Laffel said, noting that modern technology such as insulin analogs, insulin pumps, and continuous glucose monitoring now allow for tighter control with less risk for hypoglycemia.

Moreover, new evidence suggests that rates of hypoglycemia aren't increased in the youngest patients, nor in those with lower HbA1c levels. And research now shows increased evidence of acute adverse central nervous system effects of hyperglycemia, Dr. Laffel said.

The new HbA1c target of less than 7.5% across all pediatric age groups is now harmonized with that of the International Society for Pediatric and Adolescent Diabetes, the Pediatric Endocrine Society, and the International Diabetes Federation.

The adult HbA1c target of less than 7% for type 1 diabetes remains the same, with individualized lower or higher targets based on patient need.

"We are so pleased to be able to have offered a unified target for the pediatric population and even more pleased to have a single set of guidelines that will cross the entire lifespan for our patients with type 1 diabetes so we can be assured as we pass our patients to our adult providers we will all be singing the same song," Dr. Laffel said.

Addressing Adults' Need for Diabetes Supplies

The impetus for the new statement came from recognition of the dearth of information specific to type 1 diabetes in adults and the frequent and often inappropriate extrapolation of evidence from type 2 diabetes studies to type 1.

"We have this growing population of type 1s who are being treated like type 2s, and it's not the same disease," coauthor Anne L. Peters, MD, professor of medicine at the Keck School of Medicine, University of Southern California, Los Angeles, told Medscape Medical News.

Examples include universal recommendations for statin use and LDL-cholesterol targets derived from type 2 populations and for which there is little evidence in type 1 patients, and limitations on insurance reimbursement for test strips.

The new statement says that "regardless of age, individuals may require 10 or more strips daily to monitor for hypoglycemia, assess insulin needs prior to eating, and determine if their blood glucose levels [are] safe enough for overnight sleeping."

It also gives level A evidence that continuous glucose monitoring "is a useful tool to reduce HbA1c levels in adults without increasing hypoglycemia and can reduce glycemic excursions in children."

"The point of this was to allow type 1s to get the supplies they need," Dr. Peters told Medscape Medical News.

There are an estimated 3 million individuals with type 1 diabetes in the US, of whom only about 160,000 are children. But the exact number of adults — including both those diagnosed in childhood and in adulthood — is unknown, because many are seen in primary-care settings.

"The pediatric type 1s get all the press, but many more are adults," said Dr. Peters, adding that the diagnosis among those with adult-onset diabetes is often unclear.

M. Sue Kirkman, MD, professor of medicine at the University of North Carolina, Chapel Hill, agrees.

"I have to say as an adult endocrinologist, it has driven me crazy for a long time that everyone refers to type 1 diabetes as a pediatric disease....We do need to remember the vast majority of people with type 1 in this country are adults."

It's estimated that between a third and a half of new-onset type 1 cases are diagnosed after age 18, and that most who are diagnosed as children are living to adulthood and old age. [NOTE from Melitta: numbers of adults are actually higher, but no one is counting]

"Once they turn 18 or 21 they don't just disappear," Dr. Kirkman said.

Advice for Primary-Care Physicians on Managing Type 1

Dr. Peters noted that much of the new clinical research in type 1 diabetes is now being funded by the Leona M. and Harry B. Helmsley Charitable Trust. "Part of this process is to drive research, and the other part is to take the data we know and make it clinical. So, the document includes management guidance for primary-care physicians in particular," she noted.

The statement is meant to serve as a checklist for clinicians. It provides detailed information about diagnosis and management, screening for long-term complications, workplace management, diabetes in older adults, and pregnancy.

"At the very least, if [clinicians] evaluate a patient the way we ask, it will be a big step forward," Dr. Peters told Medscape Medical News.

Jane L. Chiang, MD, senior vice president for medical and community affairs at the American Diabetes Association, told the media during the press briefing, "We want all of you to know the ADA is very committed to patients with type 1 diabetes. We really want to separate out the two types of diabetes."

"Reimbursement is different, care is different, and we really want to highlight that....There really aren't very clear evidence-based recommendations on what patients with type 1 diabetes need. We think a lot of clinical research needs to be done. This is just the beginning."

Praise Be to God!!!

I know, isn't it simply astonishing? And so spot on.


Did someone grab the ADA in a dark alley and threaten them?

My guess is that there are now adult, established, professional (and rich) T1s on the ADA board of directors or somewhere that supplies their funding. Now that's an incentive!

Sounds a little too neat to me.

There are millions of us who do not use the "tech" they are so strongly marketing! CGM. Pumps. What of us, I wonder? Do these magic goals still apply then? Glad someone finally became consistent, but...

What magic goals? I don't see anything on there that a person on MDI with no cgm would have problems with, unless I'm missing something?

This is a strong statement in favor of all T1s, regardless of the tech they may or may not use:

The new statement says that "regardless of age, individuals may require 10 or more strips daily to monitor for hypoglycemia, assess insulin needs prior to eating, and determine if their blood glucose levels [are] safe enough for overnight sleeping."

I will share this info with some Board members of the Canadian Diabetes Association , especially the requirement of strips ( 8 suggested by CDA ) ..I located this link in the Clinical Practice Guidelines can look up the targets for different ages ( lower then US targets ???)

Melitta , do you have US numbers available how many are diagnosed after age 18 compared to under 18 ? I am an advocate for people being covered for insulin pumps by our BC Pharmacare program .Presently up to age 25 are covered ...and I know many who would benefit and are well over that age .It maybe helpful if I can supply figures ,( knowing that I have to include that we have about 36 million living in Canada ) to those who set the rules .I have asked a person , who is involved with JDRF , however nothing came out of that discussion ...hope you can help !

The guidelines asks good questions (I tried it out), but there are some glitches. If you put in "adult with diabetes" it assumes T2. If you try to correct, it only gives guidelines for kids and then asks the age. As often happens, they omit the fact that kids with T1 eventually become adults.

On the other hand, they do acknowledge that there are things that can affect a1c other than glucose levels, including altered glycation caused by kidney issues. I'm impressed. But they do tend to stick with the "less than 7%" guideline.

these are the questions I read : patient is an adult ,..yes next question : pregnant ...etc , click no , next question patient frail therapies ..last one on the page ...insulin pump ( that's me LOL)

Agreed, Shadow Dragon. I particularly like the bulleted paragraph that precedes your quote:

Patients with type 1 diabetes should perform SMBG [self-monitoring of blood glucose] prior to meals and snacks, at a minimum, and at other times, including postprandially to assess insulin-to-carbohydrate ratios; at bed- time; midsleep; prior to, during, and/or after exercise; when they suspect low blood glucose; after treating low blood glucose until they have restored normo- glycemia; when correcting a high blood glucose level; prior to critical tasks such as driving; and at more frequent inter- vals during illness or stress. (B)

I would put in writing your quote, the sentence that came before your quote as well as the one I cited if I were ever in an argument with a US payer about their blocking my access to sufficient quantity of test strips to comply with this sentiment expressed by the ADA. The sentence before your quote is also a strong one:

Individuals with type 1 diabetes need to have unimpeded access to glucose test strips for blood glucose testing. (emphasis is mine)

will this work for Cora ??Individualizing your Patient’s A1C Target
For Patients with Type 1 and Type 2 Diabetes

A1C Target for most patients with type 1 and type 2 diabetes

Continue to answer the questions below for a patient specific A1C target recommendation

Which of the following applies to your patient?

Patient is an adult with diabetes
Patient is a child with type 1 diabetes
Patient is a child with type 2 diabetes
Is the patient with diabetes pregnant or desiring pregnancy?

Yes No
Is the patient with diabetes "frail" or does the patient with diabetes have limited life expectancy?

Yes No
Which of the following therapies is the patient with diabetes on?

SU +/- others
Insulin +/- others
Insulin pump

I went through it, and in the conclusions it actually said I was a T2 because I said I was an adult with D. But I tried various combinations and if you are frail, or subject to severe hypos, or are hypo unaware, or a few other things it sets a higher tolerance for a1c. It makes sense.

I did that nel, but when you put in "adult with D", no matter what else you put in at the end it actually calls you a T2. Or at least it did for me. But I did find the guidelines made sense as I tried various combinations and the more "delicate" you were or had problems with hypos, it reasonably allowed for a higher a1c.

I can't find the reference right now, but between 5 and 10 years ago the CDC came out with a report suggesting that about 50% of the T1 diagnoses were in adults. I'll keep looking.

ETA: found one reference of a study found in italy where they found the incidence of T1 in age 30 - 49 was the same as ages 15 - 29.

And this was from another thread on another board:

The U.S. Centers for Disease Control and Prevention’s (CDC’s) most current information on the prevalence and incidence of Type 1 diabetes comes from Diabetes in America, Chapter 3, “Prevalence and Incidence of Insulin-Dependent Diabetes” (Diabetes in America, Second Edition, 1995). Although people who use that reference as a source of incidence statistics state that there are about 30,000 new cases of Type 1 diabetes each year and that half of those cases are children. In fact, that source states that children (<20 years of age) account for 13,171 cases and adults (>20 years of age) account for 16,542 cases, for a total of 29,713 new cases of Type 1 diabetes per year, 56% seen in adults. Furthermore, that source states that there is an “unknown number of adults identified as NIDDM (non-insulin dependent diabetes mellitus, now called Type 2 diabetes) who have slowly progressive IDDM (insulin dependent diabetes mellitus, now called Type 1 diabetes).” In summary, of those new onset Type 1 diabetics who are correctly diagnosed, 56% are adults, and an unknown number of new onset Type 1 diabetics have been misdiagnosed as having Type 2 diabetes and thus the majority of new onset Type 1 diabetes is seen in adults.

According to diabetes researcher Jerry Palmer MD in Type 1 Diabetes in Adults: Principles and Practice (Informa Healthcare, 2008), page 27, adult-onset Type 1 diabetes is two to three times more common than childhood-onset Type 1 diabetes.

Thank you very much Cora for this information and your promise to look further !

and you are from Canada , nice . Are you in the Canada Group . BJ Clancy has asked for help with signing this petition

I think maybe I got it ?? went at least one step further than I ..I clicked on " insulin pump " ..see the copy/paste comment above your comment , then click on calculate...wishing you were here sitting next to me and explaining would be much simpler .

Nel: Cora is referencing one of my posts, with the latest stats from the CDC. Again, that says that 56% of new-onset Type 1 is seen >20 years of age, and the CDC states that that 56% does not include slowly progressive Type 1 diabetes.

Slowly progressive Type 1 diabetes represents ~10% of "Type 2" diabetes--study after study since the first published in 1977 in The Lancet show that 10% of "Type 2" diabetics are autoantibody positive, have been misdiagnosed, and in fact have Type 1 autoimmune diabetes. That 10% represents a huge number. Nel, if you need some of the studies that document the 10%, I can provide them.