Diabetes Standards of Care 2025

1.1 Ensure treatment decisions are timely, rely on evidence-based guidelines, capture key elements within the social determinants of health, and are made collaboratively with people with or at risk for diabetes and caregivers based on individual preferences, prognoses, comorbidities, and informed financial considerations. B

1.2 Align approaches to diabetes management with evidence-based care models. These models emphasize person-centered team care, integrated long-term treatment approaches to diabetes and comorbidities, and ongoing collaborative communication and goal setting between all team members and with people with diabetes. A

1.3 Care systems should facilitate in-person and virtual team-based care, include those knowledgeable and experienced in diabetes management as part of the team, and utilize patient registries, decision support tools, proactive care planning, and community involvement to meet needs of individuals with diabetes. B

1.4 Assess diabetes management, risk factors, and complications (Table 4.1) using reliable and relevant data metrics to improve processes of care and health outcomes, with attention to care costs, individual preferences and goals for care, and treatment burden. B

1.5 Health systems should adopt a culture of quality improvement, implement benchmarking programs, and engage interprofessional teams to support sustainable and scalable process changes to improve quality of care and health outcomes. A

1.6 Health systems should assess and address disparities in diabetes care and health outcomes (e.g., by stratifying clinical quality data by factors such as insurance status, race, ethnicity, preferred language for health care discussions, disability, and other social determinants of health). C (104)

1.7 During clinical encounters, assess for social determinants of health, including food insecurity, A housing insecurity, financial barriers, health insurance and health care access, environmental and neighborhood factors, and social capital/social community support, B to inform treatment decisions, with referral to appropriate local community resources.

1.8 Provide people with diabetes additional self-management support from lay health coaches, navigators, or community health workers when available. A

1.9 Consider the involvement of community health workers to support management of diabetes and cardiovascular risk factors, especially in underserved communities and health care systems. B

2.1a Diagnose diabetes based on A1C or plasma glucose criteria. Plasma glucose criteria include either the fasting plasma glucose (FPG), 2-h plasma glucose (2-h PG) during a 75-g oral glucose tolerance test (OGTT), or random glucose accompanied by classic hyperglycemic symptoms/crises (Table 2.1). B

2.1b In the absence of unequivocal hyperglycemia (e.g., hyperglycemic crises), diagnosis requires confirmatory testing (Table 2.1). B

2.2a The A1C test should be performed using a method that is certified by the National Glycohemoglobin Standardization Program (NGSP) as traceable to the Diabetes Control and Complications Trial (DCCT) reference assay. B

2.2b Point-of-care A1C testing for diabetes screening and diagnosis should be restricted to devices approved for diagnosis by the U.S. Food and Drug Administration at Clinical Laboratory Improvement Amendments–certified laboratories that perform testing of moderate complexity or higher by trained personnel. B

2.3 Evaluate for the possibility of a problem or interference with either test when there is consistent and substantial discordance between blood glucose values and A1C test results. B

2.4 In conditions associated with an altered relationship between A1C and glycemia, such as some hemoglobin variants, pregnancy (second and third trimesters and the postpartum period), glucose-6-phosphate dehydrogenase deficiency, HIV, hemodialysis, recent blood loss or transfusion, hemolysis, or erythropoietin therapy, plasma glucose criteria should be used to diagnose diabetes. B

2.5 Classify people with hyperglycemia into appropriate diagnostic categories to aid in personalized management. E

2.6 Screening for presymptomatic type 1 diabetes may be done by detection of autoantibodies to insulin, glutamic acid decarboxylase (GAD), islet antigen 2 (IA-2), or zinc transporter 8 (ZnT8). B

2.7 Autoantibody-based screening for presymptomatic type 1 diabetes should be offered to those with a family history of type 1 diabetes or otherwise known elevated genetic risk. B

2.8 Having multiple confirmed islet autoantibodies is a risk factor for clinical diabetes. Testing for dysglycemia may be used to further forecast near-term risk (Table 2.4). When multiple islet autoantibodies are identified, referral to a specialized center for further evaluation and/or consideration of a clinical trial or approved therapy to potentially delay development of clinical diabetes should be considered. B

2.9 Standardized islet autoantibody tests are recommended for classification of diabetes in adults who have phenotypic risk factors that overlap with those for type 1 diabetes (e.g., younger age at diagnosis, unintentional weight loss, ketoacidosis, or short time to insulin treatment). E

2.10 Screening for risk of prediabetes and type 2 diabetes with an assessment of risk factors or validated risk calculator should be done in asymptomatic adults. B

2.11a Testing for prediabetes or type 2 diabetes in asymptomatic people should be considered in adults of any age with overweight or obesity who have one or more risk factors (Table 2.5). B

2.11b For all other people, screening should begin at age 35 years. B

2.11c In people without prediabetes or diabetes after screening, repeat screening recommended at a minimum of 3-year intervals is reasonable, sooner with symptoms or change in risk (e.g., weight gain). C

2.12 To screen for prediabetes and type 2 diabetes, FPG, 2-h PG during 75-g OGTT, and A1C are each appropriate (Table 2.1 and Table 2.2). B

2.13 When using OGTT as a screening tool for prediabetes or diabetes, adequate carbohydrate intake (at least 150 g/day) should be assured for 3 days prior to testing. E

2.14 Risk-based screening for prediabetes or type 2 diabetes should be considered after the onset of puberty or after 10 years of age, whichever occurs earlier, in children and adolescents with overweight (BMI ≥85th percentile) or obesity (BMI ≥95th percentile) and who have one or more risk factors for diabetes. (See Table 2.6 for evidence grading of risk factors.) B

2.15a Consider screening people for prediabetes or diabetes if they are on certain medications, such as glucocorticoids, statins, thiazide diuretics, some HIV medications, and second-generation antipsychotic medications, as these agents are known to increase the risk of these conditions. C

2.15b In people who are prescribed second-generation antipsychotic medications, screen for prediabetes and diabetes at baseline and repeat 12–16 weeks after medication initiation or sooner, if clinically indicated, and annually thereafter. B

2.16 People with HIV should be screened for diabetes and prediabetes with an FPG test before starting antiretroviral therapy, at the time of switching antiretroviral therapy, and 3–6 months after starting or switching antiretroviral therapy. If initial screening results are normal, FPG should be checked annually. E

2.17 Screen people for diabetes within 3–6 months following an episode of acute pancreatitis and annually thereafter. Screening for diabetes is recommended annually for people with chronic pancreatitis. E

2.18 Annual screening for cystic fibrosis–related diabetes (CFRD) with an OGTT should begin by age 10 years in all people with cystic fibrosis not previously diagnosed with CFRD. B

2.19 A1C is not recommended as a screening test for CFRD due to low sensitivity. However, a value of ≥6.5% (≥48 mmol/mol) is consistent with a diagnosis of CFRD. B

2.20 Beginning 5 years after the diagnosis of CFRD, annual monitoring for complications of diabetes is recommended. E

2.21 After organ transplantation, screening for hyperglycemia should be done. A formal diagnosis of posttransplantation diabetes mellitus (PTDM) is best made once the individual is stable on an immunosuppressive plan and in the absence of an acute infection. B

2.22 The OGTT is the preferred test to make a diagnosis of PTDM. B

2.23 Immunosuppressive plans shown to provide the best outcomes for individuals and graft survival should be used, irrespective of PTDM risk. E

2.24a Regardless of current age, all people diagnosed with diabetes in the first 6 months of life should have genetic testing for neonatal diabetes. B

2.24b Children and young adults who do not have typical characteristics of type 1 or type 2 diabetes and family history of diabetes in successive generations (suggestive of an autosomal dominant pattern of inheritance) should have genetic testing for maturity-onset diabetes of the young (MODY). B

2.24c In both instances, consultation with a center specializing in diabetes genetics is recommended to understand the significance of genetic mutations and how best to approach further evaluation, treatment, and genetic counseling. E

2.25 In individuals who are planning pregnancy, screen those with risk factors (Table 2.5) B and consider testing all individuals of childbearing potential for undiagnosed prediabetes or diabetes. E

2.26a Before 15 weeks of gestation, test individuals with risk factors (Table 2.5) B and consider testing all individuals E for undiagnosed diabetes at the first prenatal visit using standard diagnostic criteria if not screened preconception.

2.26b Before 15 weeks of gestation, screen for abnormal glucose metabolism to identify individuals who are at higher risk of adverse pregnancy and neonatal outcomes, are more likely to need insulin, and are at high risk of a later gestational diabetes mellitus (GDM) diagnosis. B

2.26c Screen for early abnormal glucose metabolism with dysglycemia using FPG 110–125 mg/dL (6.1–6.9 mmol/L) or A1C 5.9–6.4% (41–47 mmol/mol). B

2.27 Screen for GDM at 24–28 weeks of gestation in pregnant individuals not previously found to have diabetes or high-risk abnormal glucose metabolism detected earlier in the current pregnancy. A

2.28 Screen individuals with GDM for prediabetes or diabetes at 4–12 weeks postpartum, using the 75-g OGTT and clinically appropriate nonpregnancy diagnostic criteria. B

2.29 Individuals with a history of GDM should have lifelong screening for the development of prediabetes or diabetes every 1–3 years. B

3.1 In people with prediabetes, monitor for the development of type 2 diabetes at least annually; modify frequency of testing based on individual risk assessment. E

3.2 In people with presymptomatic type 1 diabetes, monitor for disease progression using A1C approximately every 6 months and 75-g oral glucose tolerance test (i.e., fasting and 2-h plasma glucose) annually; modify frequency of monitoring based on individual risk assessment based on age, number and type of autoantibodies, and glycemic metrics. E

3.3 Refer adults with overweight or obesity at high risk of type 2 diabetes, as seen in the Diabetes Prevention Program (DPP), to an intensive lifestyle behavior change program to achieve and maintain a weight reduction of at least 7% of initial body weight through healthy reduced-calorie diet and ≥150 min/week of moderate-intensity physical activity. A

3.4 Prescribe an eating pattern known to be effective in preventing type 2 diabetes to individuals with prediabetes. A variety of eating patterns, such as Mediterranean style, intermittent fasting, and low carbohydrate, have shown benefit. B

3.5 Given the cost-effectiveness of lifestyle behavior modification programs for diabetes prevention, such diabetes prevention programs should be offered to adults at high risk of type 2 diabetes. A Diabetes prevention programs should be covered by third-party payors, and inconsistencies in access should be addressed. E

3.6 Based on individual preference, certified technology-assisted diabetes prevention programs may be effective in preventing type 2 diabetes and should be considered. B

3.7 Metformin for the prevention of type 2 diabetes should be considered in adults at high risk of type 2 diabetes, as typified by the DPP, especially those aged 25–59 years with BMI ≥35 kg/m2, higher fasting plasma glucose (e.g., ≥110 mg/dL [≥6 mmol/L]), and higher A1C (e.g., ≥6.0% [≥42 mmol/mol]), and in individuals with prior gestational diabetes mellitus. A

3.8 Long-term use of metformin may be associated with vitamin B12 deficiency; consider periodic assessment of vitamin B12 level in metformin-treated individuals, especially in those with anemia or peripheral neuropathy. B

3.9 Prediabetes is associated with heightened cardiovascular risk; therefore, screening for and treatment of modifiable risk factors for cardiovascular disease are suggested. B

3.10 Statin therapy may increase the risk of type 2 diabetes in people at high risk of developing type 2 diabetes. In such individuals, glucose status should be monitored regularly and diabetes prevention approaches reinforced. It is not recommended that statins be avoided or discontinued for this adverse effect. B

3.11 In people with a history of stroke and evidence of insulin resistance and prediabetes, pioglitazone may be considered to lower the risk of stroke or myocardial infarction. However, this benefit needs to be balanced with the increased risk of weight gain, edema, and fractures. A Lower doses may mitigate the risk of adverse effects but may be less effective. C

3.12 In adults with overweight or obesity at high risk of type 2 diabetes, care goals should include weight loss and maintenance, minimizing the progression of hyperglycemia, and attention to cardiovascular risk. B

3.13 Pharmacotherapy (e.g., for weight management, minimizing the progression of hyperglycemia, and cardiovascular risk reduction) should be considered to support person-centered care goals. B

3.14 More intensive preventive approaches should be considered in individuals who are at particularly high risk of progression to diabetes, including individuals with BMI ≥35 kg/m2, those at higher glucose levels (e.g., fasting plasma glucose 110–125 mg/dL [6.1–6.9 mmol/L], 2-h postchallenge glucose 173–199 mg/dL [9.6–11.0 mmol/L], and A1C ≥6.0% [≥42 mmol/mol]), and individuals with a history of gestational diabetes mellitus. A

3.15 Teplizumab-mzwv infusion to delay the onset of symptomatic type 1 diabetes (stage 3) should be discussed with selected individuals aged ≥8 years with stage 2 type 1 diabetes. Treatment should be in a setting with appropriately trained personnel. B

4.1 A communication style that uses person-centered, culturally sensitive, and strength-based language and active listening; elicits individual preferences and beliefs; and assesses literacy, numeracy, and potential barriers to care should be used to optimize health outcomes and health-related quality of life. B

4.2 People with diabetes can benefit from a coordinated interprofessional team that may include but is not limited to diabetes care and education specialists, primary care and subspecialty clinicians, nurses, registered dietitian nutritionists, exercise specialists, pharmacists, dentists, podiatrists, and behavioral health professionals. C

4.3 A complete medical evaluation should be performed at the initial visit and follow-up, as appropriate, to:
-Confirm the diagnosis and classify diabetes. A
-Assess glycemic status and previous treatment. A
-Evaluate for diabetes complications, potential comorbid conditions, and overall health status. A
-Identify care partners and support system. E
-Assess social determinants of health and structural barriers to optimal health and health care. A
-Review risk factor management in the person with diabetes. A
-Begin engagement with the person with diabetes in the formulation of a care management plan including initial goals of care. A
-Develop a plan for continuing care. A

4.4 Ongoing management should be guided by the assessment of overall health and functional status, diabetes complications, cardiovascular risk, hypoglycemia risk, and shared decision-making to set therapeutic goals. B

4.5 Provide routinely recommended vaccinations for children and adults with diabetes as indicated by age (see Table 4.3). A

4.6 Screen people with type 1 diabetes for autoimmune thyroid disease soon after diagnosis and thereafter at repeated intervals if clinically indicated. B

4.7 Adults with type 1 diabetes should be screened for celiac disease in the presence of gastrointestinal symptoms, signs, laboratory manifestations, or clinical suspicion suggestive of celiac disease. B

4.8 Assess fracture risk in older adults with diabetes as a part of routine care in diabetes clinical practice, according to risk factors and comorbidities. A

4.9 Monitor bone mineral density using dual-energy X-ray absorptiometry in older adults with diabetes (aged ≥65 years) and younger individuals with diabetes and multiple risk factors every 2–3 years (Table 4.4). A

4.10 Consider the potential adverse impact on skeletal health when selecting pharmacological options to lower glucose levels in people with diabetes. Avoiding medications with a known association with higher fracture risk (e.g., thiazolidinediones and sulfonylureas) is recommended, particularly for those at elevated risk for fractures. B

4.11 To reduce the risk of falls and fractures, glycemic management goals should be individualized for people with diabetes at a higher risk of fracture. C Prioritize use of glucose-lowering medications that are associated with low risk for hypoglycemia to avoid falls. B

4.12 Advise people with diabetes on their intake of calcium (1,000–1,200 mg/day) and vitamin D to ensure it meets the recommended daily allowance for those at risk for fracture, either through their diet or supplemental means. B

4.13 Antiresorptive medications and osteoanabolic agents should be recommended for older adults with diabetes who are at higher risk of fracture, including those with low bone mineral density with a T-score ≤−2.0, history of fragility fracture, or elevated Fracture Risk Assessment Tool score (≥3% for hip fracture or ≥20% for major osteoporotic fracture). B

4.14 In the presence of cognitive impairment, diabetes treatment plans should be simplified as much as possible and tailored to minimize the risk of hypoglycemia. B

4.15 People with diabetes should be referred for a dental exam at least once per year. E

4.16 Coordinate efforts between the medical and dental teams to appropriately adjust glucose-lowering medication and treatment plans prior to and in the post–dental procedure period as needed. B

4.17 Assess for disability at the initial visit and for decline in function at each subsequent visit in people with diabetes. If a disability is impacting functional ability or capacity to manage their diabetes, a referral should be made to an appropriate health care professional specializing in disability (e.g., physical medicine and rehabilitation specialist, physical therapist, occupational therapist, or speech-language pathologist). C

4.18 In men with diabetes or prediabetes, inquire about sexual health (e.g., low libido and erectile dysfunction [ED]). If symptoms and/or signs of hypogonadism are detected (e.g., low libido, ED, and depression), screen with a morning serum total testosterone level. B

4.19 In men with diabetes or prediabetes, screen for ED, particularly in those with high cardiovascular risk, retinopathy, cardiovascular disease, chronic kidney disease, peripheral or autonomic neuropathy, longer duration of diabetes, depression, and hypogonadism, and in those who are not meeting glycemic goals. B

4.20 In women with diabetes or prediabetes, inquire about sexual health by screening for desire (libido), arousal, and orgasm difficulties, particularly in those who experience depression and/or anxiety and those with recurrent urinary tract infections. B

4.21 In postmenopausal women with diabetes or prediabetes, screen for symptoms and/or signs of genitourinary syndrome of menopause, including vaginal dryness and dyspareunia. B

4.22a Screen adults with type 2 diabetes or with prediabetes, particularly those with obesity or other cardiometabolic risk factors or established cardiovascular disease, for their risk of having or developing cirrhosis related to metabolic dysfunction–associated steatohepatitis (MASH) using a calculated fibrosis-4 index (FIB-4) (derived from age, ALT, AST, and platelets, even if they have normal liver enzymes. B

4.22b Adults with diabetes or prediabetes with persistently elevated plasma aminotransferase levels for >6 months and low FIB-4 should be evaluated for other causes of liver disease. B

4.23 Adults with type 2 diabetes or prediabetes with a FIB-4 ≥1.3 should have additional risk stratification by liver stiffness measurement with transient elastography, or, if unavailable, the enhanced liver fibrosis (ELF) test. B

4.24 Refer adults with type 2 diabetes or prediabetes at higher risk for significant liver fibrosis (i.e., as indicated by FIB-4, liver stiffness measurement, or ELF) to a gastroenterologist or hepatologist for further evaluation and management. B

4.25 Adults with type 2 diabetes or prediabetes, particularly with overweight or obesity, who have metabolic dysfunction–associated steatotic liver disease (MASLD) should be recommended lifestyle changes using an interprofessional approach that promotes weight loss, ideally within a structured nutrition plan and physical activity program for cardiometabolic benefits B and histological improvement. C

4.26 In adults with type 2 diabetes, MASLD, and overweight or obesity, consider using a glucagon-like peptide 1 (GLP-1) receptor agonist (RA) or a dual glucose-dependent insulinotropic polypeptide (GIP) and GLP-1 RA for the treatment of obesity with potential benefits in MASH as an adjunctive therapy to lifestyle interventions for weight loss. B

4.27a In adults with type 2 diabetes and biopsy-proven MASH or those at high risk for liver fibrosis (based on noninvasive tests), pioglitazone, a GLP-1 RA, or a dual GIP and GLP-1 RA is preferred for glycemic management because of potential beneficial effects on MASH. B

4.27b Combination therapy with pioglitazone plus GLP-1 RA can be considered for the treatment of hyperglycemia in adults with type 2 diabetes with biopsy-proven MASH or those at high risk of liver fibrosis (identified with noninvasive tests) because of potential beneficial effects on MASH.B

4.28 For consideration of treatment with a thyroid hormone receptor-β agonist in adults with type 2 diabetes or prediabetes with MASLD with moderate (F2) or advanced (F3) liver fibrosis on liver histology, or by a validated imaging-based or blood-based test, refer to a gastroenterologist or hepatologist with expertise in MASLD management. A

4.29 Treatment initiation and monitoring should be individualized and within the context of an interprofessional team that includes a gastroenterologist or hepatologist, consideration of individual preferences, and a careful shared-decision cost-benefit discussion. B

4.30a In adults with type 2 diabetes and MASLD, use of glucose-lowering therapies other than pioglitazone or GLP-1 RAs may be continued as clinically indicated, but these therapies lack evidence of benefit in MASH. B

4.30b Insulin therapy is the preferred agent for the treatment of hyperglycemia in adults with type 2 diabetes with decompensated cirrhosis. C

4.31a Adults with type 2 diabetes and MASLD are at increased cardiovascular risk; therefore, comprehensive management of cardiovascular risk factors is recommended. B

4.31b Statin therapy is safe in adults with type 2 diabetes and compensated cirrhosis from MASLD and should be initiated or continued for cardiovascular risk reduction as clinically indicated. B In people with decompensated cirrhosis, statin therapy should be used with caution, and close monitoring is needed, given limited safety and efficacy data. B

4.32a Consider metabolic surgery in appropriate candidates as an option to treat MASH in adults with type 2 diabetes B and to improve cardiovascular outcomes. B

4.32b Metabolic surgery should be used with caution in adults with type 2 diabetes with compensated cirrhosis from MASLD B and is not recommended in decompensated cirrhosis. B

5.1 All people with diabetes should be advised to participate in developmentally and culturally appropriate diabetes self-management education and support (DSMES) to facilitate informed decision-making, self-care behaviors, problem-solving, and active collaboration with the health care team. A

5.2 Provide DSMES at diagnosis, annually and/or when not meeting treatment goals, when complicating factors develop (e.g., medical, functional, and psychosocial), and when transitions in life and care occur. E

5.3 Routinely assess clinical outcomes, health status, and well-being as key goals of DSMES. C

5.4 Screen for behavioral health concerns at the same critical times as evaluating the need for DSMES and refer to a qualified behavioral health professional if indicated to increase engagement in DSMES. E

5.5 DSMES should be culturally appropriate and responsive to individual preferences, needs, and values and may be offered in group or individual settings. A Such education and support should be documented and made available to members of the entire diabetes care team. E

5.6 Consider offering DSMES via telehealth and/or digital interventions as needed to meet individual preferences, address barriers to access, and improve satisfaction. B

5.7 DSMES can improve outcomes and reduce costs, so reimbursement by third-party payors is recommended. B

5.8 Identify and address barriers to DSMES that exist at the payor, health system, clinic, health care professional, and individual levels. E

5.9 Screen for and include social determinants of health in guiding design and delivery of DSMES C with the ultimate goal of health equity across all populations.

5.10 An individualized medical nutrition therapy program, as needed to achieve treatment goals and provided by a registered dietitian nutritionist, preferably one who has comprehensive knowledge and experience in diabetes care, is recommended for all people with type 1 or type 2 diabetes, prediabetes, and gestational diabetes mellitus. A

5.11 Because diabetes medical nutrition therapy can result in cost savings B and improved cardiometabolic outcomes, A medical nutrition therapy should be adequately reimbursed by insurance. E

5.12 Provide weight management treatment based on nutrition, physical activity, and behavioral therapy for all people with overweight or obesity, aiming for at least 3–7% weight loss. A

5.13 For diabetes prevention and management of people with prediabetes or diabetes, recommend individualized meal plans that keep nutrient quality, total calories, and metabolic goals in mind, B as data do not support a specific macronutrient pattern.

5.14 Eating patterns should emphasize key nutrition principles (inclusion of nonstarchy vegetables, whole fruits, legumes, lean proteins, whole grains, nuts and seeds, and low-fat dairy or nondairy alternatives) and minimize consumption of red meat, sugar-sweetened beverages, sweets, refined grains, processed and ultraprocessed foods in people with prediabetes and diabetes. B

5.15 Consider reducing overall carbohydrate intake for adults with diabetes to improve glycemia, as this approach may be applied to a variety of eating patterns that meet individual needs and preferences. B

5.16 Health care professionals should inquire about intake of dietary supplements and counsel as necessary. Supplementation with micronutrients (e.g., vitamins and minerals, such as magnesium or chromium) or herbs or spices (e.g., cinnamon and aloe vera) for glycemic benefits is not recommended. C

5.17 Counsel against β-carotene supplementation, as there is evidence of harm for certain individuals and it confers no benefit. B

5.18 Advise adults with diabetes and those at risk for diabetes who consume alcohol to not exceed the recommended daily limits. B Advise abstainers to not start drinking alcohol, even in moderation.

5.19 Educate people with diabetes about the signs, symptoms, and self-management of delayed hypoglycemia after drinking alcohol, especially when using insulin or insulin secretagogues. The importance of monitoring glucose after drinking alcoholic beverages to reduce hypoglycemia risk should be emphasized. B

5.20 Counsel people with diabetes to limit sodium consumption to <2,300 mg/day, as clinically appropriate, B and that the best way to achieve this is through limiting consumption of processed foods. B

5.21 Counsel people with prediabetes and diabetes that water is recommended over nutritive and nonnutritive sweetened beverages. A

5.22 Counsel people with diabetes and those at risk for diabetes that nonnutritive sweeteners can be used instead of sugar-sweetened products if consumed in moderation and for the short term to reduce overall calorie and carbohydrate intake. B

5.23 Screen people with diabetes and those at risk for diabetes for malnutrition, especially those who have undergone metabolic surgery A and those being treated with weight loss pharmacologic therapies. B

Carbohydrates
5.24 Emphasize minimally processed, nutrient-dense, high-fiber sources of carbohydrate (at least 14 g fiber per 1,000 kcal). B

5.25 Advise people with diabetes and those at risk to replace sugar-sweetened beverages (including fruit juices) with water or low-calorie or no-calorie beverages
as much as possible to manage glycemia and reduce risk for cardiometabolic disease B and minimize consumption of foods with added sugar that have the capacity to displace healthier, more nutrient-dense food choices. A

5.26 Regardless of diabetes classification, individuals treated with sodium–glucose cotransporter 2 inhibitors should avoid a ketogenic eating pattern, be educated on the signs of ketoacidosis and methods of risk mitigation and provided with appropriate tools for accurate ketone measurement (i.e., serum β-hydroxybutyrate), and be instructed to avoid fasting and maintain appropriate insulin therapy. E

5.27 Provide education on the glycemic impact of carbohydrate, A fat, and protein B tailored to an individual’s needs, insulin plan, and preferences to optimize mealtime insulin dosing.

5.28 When using fixed insulin doses, individuals should be provided with education about consistent patterns of carbohydrate intake with respect to time and amount while considering the insulin action time, as it can result in improved glycemia and reduce the risk for hypoglycemia. B


Proteins
5.29 People with diabetes and those at risk for diabetes are advised to incorporate more plant-based protein sources (e.g., nuts, seeds, and legumes) as part of an overall diverse eating pattern to reduce cardiovascular disease risk. B

5.30 Counsel people with diabetes to consider an eating plan emphasizing elements of a Mediterranean eating pattern, which is rich in monounsaturated and polyunsaturated fats and long-chain fatty acids such as fatty fish, nuts, and seeds, to reduce cardiovascular disease risk A and improve glucose metabolism. B


Fats
5.31 Counsel people with diabetes and those at risk for diabetes to limit intake of foods high in saturated fat (e.g., red meat, full-fat dairy, butter, and coconut oil) to help reduce cardiovascular disease risk. A

5.32 Use the International Diabetes Federation along with Diabetes and Ramadan International Alliance comprehensive prefasting risk assessment to generate a risk score for the safety of religious fasting. Provide fasting-focused education to minimize risks. B

5.33 Assess and optimize treatment plan, dose, and timing for people with diabetes well in advance of religious fasting to reduce risk of hypoglycemia, dehydration, hyperglycemia, and/or ketoacidosis. B

5.34 Counsel youth with type 1 diabetes C or type 2 diabetes B to engage in 60 min/day or more of moderate- or vigorous-intensity aerobic activity, with muscle-strengthening and bone-strengthening activities at least 3 days/week, and to limit the amount of time being spent sedentary, including recreational screen time. C

5.35 Counsel most adults with type 1 diabetes C and type 2 diabetes B to engage in 150 min or more of moderate- to vigorous-intensity aerobic activity per week, spread over at least 3 days/week, with no more than 2 consecutive days without activity. Shorter durations (minimum 75 min/week) of vigorous-intensity or interval training may be sufficient for more physically fit individuals.

5.36 Counsel adults with type 1 diabetes C and type 2 diabetes B to engage in 2–3 sessions/week of resistance exercise on nonconsecutive days.

5.37 Recommend flexibility training and balance training 2–3 times/week for older adults with diabetes. Yoga and tai chi may be included based on individual preferences to increase flexibility, muscular strength, and balance. C

5.38 For all people with diabetes, evaluate baseline physical activity and time spent in sedentary behavior (i.e., quiet sitting, lying, and leaning). For people who do not meet activity guidelines, encourage an increase in physical activities (e.g., walking, yoga, housework, gardening, swimming, and dancing) above baseline. B Counsel that prolonged sitting should be interrupted at least every 30 min for blood glucose benefits. C

5.39 Counsel adults and youth treated with weight management pharmacotherapy or metabolic surgery that meeting physical activity recommendations, and in particular muscle-strengthening exercises, may be beneficial for maintaining lean body mass. E

5.40 Advise all people with diabetes not to use cigarettes and other tobacco products or e-cigarettes. A

5.41 Ask people with diabetes routinely about the use of cigarettes or other tobacco products. After identification of use, recommend and refer for combination treatment consisting of both tobacco/smoking cessation counseling and pharmacologic therapy. A

5.42 Advise people with type 1 diabetes C and those with other forms of diabetes at risk for diabetic ketoacidosis E not to use recreational cannabis in any form.

5.43 Behavioral strategies should be used to support diabetes self-management and engagement in health behaviors (e.g., taking medications, using diabetes technologies, and engaging in physical activity and healthy eating) to promote optimal health-related quality of life and health outcomes. A

5.44 Psychosocial care should be provided to all people with diabetes, with the goal of optimizing health-related quality of life and health outcomes. Such care should be integrated with routine medical care and delivered by trained health care professionals using a collaborative, person-centered, culturally informed approach. A

5.45 Implement screening protocols for psychosocial concerns, including diabetes distress, depression, anxiety, fear of hypoglycemia, and disordered eating behaviors. Screen at least annually or when there is a change in disease, treatment, or life circumstances. C

5.46 When indicated, refer to behavioral health professionals or other trained health care professionals, ideally those with experience in diabetes, for further assessment and treatment for symptoms of diabetes distress, depression, suicidality, anxiety, treatment-related fear of hypoglycemia, disordered eating, and/or cognitive capacities. Such specialized psychosocial care should use age-appropriate standardized and validated tools and treatment approaches. B

5.47 Consider developmental factors and use age-appropriate validated tools for psychosocial screening in people with diabetes. E

5.48 Screen for diabetes distress at least annually in people with diabetes, caregivers, and family members, and repeat screening when treatment goals are not met, at transitional times, and/or in the presence of diabetes complications. Health care professionals can address diabetes distress and may consider referral to a qualified behavioral health professional, ideally one with experience in diabetes, for further assessment and treatment if indicated. B

5.49 Screen people with diabetes for anxiety symptoms. Health care professionals can discuss diabetes-related worries and should consider referral to a qualified behavioral health professional for further assessment and treatment if anxiety symptoms indicate interference with diabetes self-management behaviors or quality of life. B

5.50 Screen people with diabetes at risk for hypoglycemia or fear of hypoglycemia, especially if they have experienced severe and/or frequent hypoglycemic events. B

5.51 Conduct at least annual screening of depressive symptoms in all people with diabetes and more frequently among those with a history of depression. Use age-appropriate, validated depression screening measures, recognizing that further evaluation will be necessary for individuals who have a positive screen. B

5.52 Rescreen for depression at diagnosis of complications or when there are significant changes in medical status. B

5.53 Refer to qualified behavioral health professionals or other trained health care professionals with experience using evidence-based treatment approaches for depression in conjunction with collaborative care with the diabetes treatment team. A

5.54 Screen for disordered or disrupted eating using validated screening measures. In addition, a review of the medical treatment plan is recommended to identify potential treatment-related effects on hunger/caloric intake. B

5.55 Consider reevaluating the treatment plan of people with diabetes who present with symptoms of disordered eating behavior, an eating disorder, or disrupted patterns of eating, in consultation with a qualified professional. Key qualifications include familiarity with diabetes disease physiology, treatments for diabetes and disordered eating behaviors, and weight-related and psychological risk factors for disordered eating behaviors. B

5.56 Provide an increased level of support for people with diabetes and serious mental illness through enhanced monitoring of and assistance with diabetes self-management behaviors. B

5.57 Monitor changes in body weight, glycemia, and lipids in adolescents and adults with diabetes who are prescribed second-generation antipsychotic medications; adjust the treatment plan accordingly, if needed. C

5.58 Cognitive capacity should be monitored throughout the life span for all individuals with diabetes, particularly in those who have documented cognitive disabilities, those who experience severe hypoglycemia, very young children, and older adults. B

5.59 If cognitive capacity changes or appears to be suboptimal for decision-making and/or behavioral self-management, referral for a formal assessment should be considered. E

5.60 Consider screening for sleep health in people with diabetes, including symptoms of sleep disorders, disruptions to sleep due to diabetes symptoms or management needs, and worries about sleep. Refer to sleep medicine specialists and/or qualified behavioral health professionals as indicated. B

5.61 Counsel people with diabetes to practice sleep-promoting routines and habits. A

6.1 Assess glycemic status by A1C A and/or continuous glucose monitoring (CGM) metrics such as time in range, time above range, and time below range. B Fructosamine or CGM can be used for glycemic monitoring when an alternative to A1C is required. B

6.2 Assess glycemic status at least two times a year, and more frequently (e.g., every 3 months) for individuals not meeting glycemic goals or with recent treatment changes, frequent or severe hypoglycemia or hyperglycemia, or changes in health status, or during periods of rapid growth and development in youth. E

6.3a An A1C goal of <7% (<53 mmol/mol) is appropriate for many nonpregnant adults without severe hypoglycemia or frequent hypoglycemia affecting health or quality of life. A

6.3b A goal time in range of >70% in people using CGM is appropriate for many nonpregnant adults. B

6.3c A goal percent time <70 mg/dL (<3.9 mmol/L) of <4% (or <1% for older adults) and a goal percent time <54 mg/dL (<3.0 mmol/L) of <1% are recommended in people using CGM to prevent hypoglycemia. Deintensify or modify therapy if these goals are not met. B

6.4 Based on health care professional judgment and the preference of the person with diabetes, achievement of lower A1C levels than the goal of 7% (53 mmol/mol) may be acceptable and even beneficial if it can be achieved safely without frequent or severe hypoglycemia or other adverse effects of treatment. B

6.5 Less stringent glycemic goals may be appropriate for individuals with limited life expectancy or where the harms of treatment are greater than the benefits. B

6.6 Deintensify hypoglycemia-causing medications (insulin, sulfonylureas, or meglitinides), or switch to a medication class with lower hypoglycemia risk, for individuals who are at high risk for hypoglycemia, within individualized glycemic goals. B

6.7 Deintensify diabetes medications for individuals for whom the harms and/or burdens of treatment may be greater than the benefits, within individualized glycemic goals. B

6.8 Reassess glycemic goals based on the individualized criteria shown in Fig. 6.2. E

6.9 Set a glycemic goal during consultations to improve outcomes. A

6.10 Review history of hypoglycemia at every clinical encounter for all individuals at risk for hypoglycemia, and evaluate hypoglycemic events as indicated. C

6.11 Screen individuals at risk for hypoglycemia for impaired hypoglycemia awareness at least annually and when clinically appropriate. E Refer to a trained health care professional for evidence-based intervention to improve hypoglycemia awareness. A

6.12 Screen individuals at high risk for hypoglycemia or with severe and/or frequent hypoglycemia for fear of hypoglycemia at least annually and when clinically appropriate. E Refer to a trained health care professional for evidence-based intervention. A

6.13 Clinicians should consider an individual’s risk for hypoglycemia (see Table 6.5) when selecting diabetes medications and glycemic goals. E

6.14 Use of CGM is beneficial and recommended for individuals at high risk for hypoglycemia. A

6.15 Glucose is the preferred treatment for the conscious individual with glucose <70 mg/dL (<3.9 mmol/L), although any form of carbohydrate that contains glucose may be used. Avoid using foods or beverages high in fat and/or protein for initial treatment of hypoglycemia. Fifteen minutes after initial treatment, repeat the treatment if hypoglycemia persists. B

6.16 Glucagon should be prescribed for all individuals taking insulin or at high risk for hypoglycemia. A Family, caregivers, school personnel, and others providing support to these individuals should know its location and be educated on how to administer it. Glucagon preparations that do not have to be reconstituted are preferred. B

6.17 All individuals taking insulin A or at risk for hypoglycemia C should receive structured education for hypoglycemia prevention and treatment, with ongoing education for those who experience hypoglycemic events.

6.18 One or more episodes of level 2 or 3 hypoglycemia should prompt reevaluation of the treatment plan, including deintensifying or switching diabetes medications if appropriate. E

6.19 Regularly assess cognitive function; if impaired or declining cognition is found, the clinician, person with diabetes, and caregiver should increase vigilance for hypoglycemia. B

6.20 Review history of hyperglycemic crises (i.e., diabetic ketoacidosis and hyperglycemic hyperosmolar state) at every clinical encounter for all individuals with diabetes at risk for these events. C

6.21 Provide structured education on the recognition, prevention, and management of hyperglycemic crisis to all individuals with type 1 diabetes, those with type 2 diabetes who have experienced these events, and people at high risk for these events. B

7.1 Diabetes devices should be offered to people with diabetes. A

7.2 Initiation of continuous glucose monitoring (CGM) should be offered to people with type 1 diabetes early in the disease, even at time of diagnosis. A

7.3 The type(s) and selection of devices should be individualized based on a person’s specific needs, circumstances, preferences, and skill level. In the setting of an individual whose diabetes is partially or wholly managed by someone else (e.g., a young child or a person with cognitive impairment or dexterity, psychosocial issues, and/or physical limitations), the caregiver’s skills and preferences are integral to the decision-making process. E

7.4 When prescribing a device, ensure that people with diabetes and caregivers receive initial and ongoing education and training, either in person or remotely, and ongoing evaluation of technique, results, and the ability to utilize data, including uploading or sharing data (if applicable), to monitor and adjust therapy. C

7.5 Health care professionals working with diabetes technology should ensure that competencies are established within the health care team based on their specific roles and within specific settings. E

7.6 People with diabetes who have been using CGM, continuous subcutaneous insulin infusion (CSII), and/or automated insulin delivery (AID) for diabetes management should have continued access across third-party payors, regardless of age or A1C levels. E

7.7 Students should be supported at school in the use of diabetes technology, such as CGM systems, CSII, connected insulin pens, and AID systems, as recommended or prescribed by their health care team. E

7.8 Recommend early initiation, including at diagnosis, of CGM, CSII, and AID depending on a person’s or caregiver’s needs and preferences. C

7.9 Standardized reports for all CGM, CSII, AID, and connected insulin devices with a minimum of a single-page report, such as the ambulatory glucose profile and weekly summary, should be available and utilized. Options for daily and weekly reports and raw data should be available. E

7.10 People with diabetes should be provided with blood glucose monitoring (BGM) devices as indicated by their circumstances, preferences, and treatment. People using CGM devices must also have access to BGM at all times. A

7.11 People who are taking insulin and using BGM should be encouraged to check their blood glucose levels when appropriate based on their insulin therapy. This may include checking when fasting, prior to meals and snacks, after meals, at bedtime, in the middle of the night, prior to, during, and after exercise, when hypoglycemia is suspected, after treating low blood glucose levels until they are normoglycemic, when hyperglycemia is suspected, and prior to and while performing critical tasks such as driving. B

7.12 Health care professionals should be aware of the differences in accuracy among blood glucose meters. Only meters approved by the U.S. Food and Drug Administration (FDA) (or comparable regulatory agencies for other geographical locations) with proven accuracy should be used, with unexpired test strips purchased from a pharmacy or licensed distributor and properly stored. E

7.13 Although BGM in people on noninsulin therapies has not consistently shown clinically significant reductions in A1C levels, it may be helpful when modifying meal plans, physical activity plans, and/or medications (particularly medications that can cause hypoglycemia) in conjunction with a treatment adjustment program. E

7.14 Consider potential interference of medications and substances on glucose levels measured by blood glucose meters. B

7.15 Recommend real-time CGM (rtCGM) A or intermittently scanned CGM (isCGM) for diabetes management to youth C and adults B with diabetes on any type of insulin therapy. The choice of CGM device should be made based on the individual’s circumstances, preferences, and needs.

7.16 Consider using rtCGM and isCGM in adults with type 2 diabetes treated with glucose-lowering medications other than insulin to achieve and maintain individualized glycemic goals. The choice of device should be made based on the individual’s circumstances, preferences, and needs. B

7.17 In people with diabetes on insulin therapy, rtCGM devices should be used as close to daily as possible for maximal benefit. A isCGM devices should be scanned frequently, at minimum once every 8 h, to avoid gaps in data. A People with diabetes should have uninterrupted access to their supplies to minimize gaps in CGM. A

7.18 CGM can help achieve glycemic goals (e.g., time in range and time above range) A and A1C goal B in type 1 diabetes and pregnancy and may be beneficial for other types of diabetes in pregnancy. E

7.19 In circumstances when consistent use of CGM is not feasible, consider periodic use of personal or professional CGM to adjust medication and/or lifestyle. C

7.20 Skin reactions, either due to irritation or allergy, should be assessed and addressed to aid in successful use of devices. E

7.21 People who wear CGM devices should be educated on potential interfering substances and other factors that may affect accuracy. C

7.22 For people with insulin-requiring diabetes on multiple daily injections (MDI), insulin pens are preferred in most cases. Still, insulin syringes may be used for insulin delivery considering individual and caregiver preference, insulin type, availability in vials, dosing therapy, cost, and self-management capabilities. C

7.23 Insulin pens or insulin injection aids are recommended for people with dexterity issues or vision impairment or when decided by shared decision-making to facilitate the accurate dosing and administration of insulin. C

7.24 Offer connected insulin pens for people with diabetes taking multiple daily insulin injections. B

7.25 FDA-approved insulin dose calculators/decision support systems may be helpful for calculating insulin doses. B

7.26 AID systems should be the preferred insulin delivery method to improve glycemic outcomes and reduce hypoglycemia and disparities in youth and adults with type 1 diabetes A and other types of insulin-deficient diabetes E who are capable of using the device (either by themselves or with a caregiver). Choice of an AID system should be made based on the individual’s circumstances, preferences, and needs. A

7.27 Insulin pump therapy, preferably with CGM, should be offered for diabetes management to youth and adults on MDI with type 2 diabetes who can use the device safely (either by themselves or with a caregiver). The choice of device should be made based on the individual’s circumstances, preferences, and needs. A

7.28 Individuals with diabetes who have been using CSII should have continued access across third-party payors. E

7.29 Support and provide diabetes management advice to people with diabetes who choose to use an open-source closed-loop system. B

7.30 Consider combining technology (CGM, insulin pump, and/or diabetes apps) with online or virtual coaching to improve glycemic outcomes in individuals with diabetes or prediabetes. B

7.31 In people with diabetes wearing personal CGM, the use of CGM should be continued when clinically appropriate during hospitalization, with confirmatory point-of-care glucose measurements for insulin dosing and hypoglycemia assessment and treatment under an institutional protocol. B

7.32 Continue use of insulin pump or AID in people with diabetes who are hospitalized when clinically appropriate, with confirmatory point-of-care blood glucose measurements for insulin dose decisions and hypoglycemia assessment and treatment. This is contingent upon availability of necessary supplies, resources, and training, ongoing competency assessments, and implementation of institutional diabetes technology protocols. C

8.1 Use person-centered, nonjudgmental language that fosters collaboration between individuals and health care professionals, including person-first language (e.g., “person with obesity” rather than “obese person” and “person with diabetes” rather than “diabetic person”). E

8.2a To support the diagnosis of obesity, measure height and weight to calculate BMI and perform additional measurements of body fat distribution, like waist circumference, waist-to-hip ratio, and/or waist-to-height ratio if BMI is indeterminant. E

8.2b Monitor obesity-related anthropometric measurements at least annually to inform treatment considerations. During active weight management treatment, increase monitoring to at least every 3 months. E

8.3 Accommodations should be made to provide privacy during anthropometric measurements. E

8.4 In people with type 2 diabetes and overweight or obesity, weight management should represent a primary goal of treatment along with glycemic management. A

8.5 Provide weight management treatment, aiming for any magnitude of weight loss. Weight loss of 3–7% of baseline weight improves glycemia and other intermediate cardiovascular risk factors. A Sustained loss of >10% of body weight usually confers greater benefits, including disease-modifying effects and possible remission of type 2 diabetes, and may improve long-term cardiovascular outcomes and mortality. B

8.6 Individualize initial treatment approaches for obesity (i.e., lifestyle and nutritional therapy, pharmacologic agents, or metabolic surgery) A based on the person’s medical history, life circumstances, preferences, and motivation. C Consider combining treatment approaches if appropriate. E

8.7 Nutrition, physical activity, and behavioral therapy are recommended for people with type 2 diabetes and overweight or obesity to achieve both weight and health outcome goals. B

8.8a Interventions including high frequency of counseling (≥16 sessions in 6 months) with focus on nutrition changes, physical activity, and behavioral strategies to achieve a 500–750 kcal/day energy deficit should be recommended for weight loss and should be considered when available. A

8.8b If access to such interventions is limited, consider alternative structured programs delivering behavioral counseling (face-to-face or remote). E

8.9 Nutrition recommendations should be individualized to the person’s preferences and nutritional needs. Use nutritional plans that create an energy deficit, regardless of macronutrient composition, to achieve weight loss. A

8.10 When developing a plan of care, consider systemic, structural, cultural, and socioeconomic factors that may impact nutrition patterns and food choices, such as food insecurity and hunger, access to healthful food options, and other social determinants of health. C

8.11 For those who achieve weight loss goals, continue to monitor progress, provide ongoing support, and recommend continuing interventions to maintain weight goals long term. E Effective long-term (≥1 year) weight maintenance programs provide monthly contact and support, include frequent self-monitoring of body weight (weekly or more frequently) and other self-monitoring strategies (e.g., food diaries or wearables), and encourage regular physical activity (200–300 min/week). A

8.12 Short-term nutrition intervention using structured, very-low-calorie meals (800–1,000 kcal/day) should be prescribed only to carefully selected individuals by trained practitioners in medical settings with close monitoring. Long-term, comprehensive weight maintenance strategies and counseling should be integrated to maintain weight loss. B

8.13 Nutritional supplements have not been shown to be effective for weight loss and are not recommended. A

8.14 Whenever possible, minimize medications for comorbid conditions that are associated with weight gain. E

8.15 When choosing glucose-lowering medications for people with type 2 diabetes and overweight or obesity, prioritize medications with beneficial effect on weight. B

8.16 Weight management pharmacotherapy should be considered for people with diabetes and overweight or obesity along with lifestyle changes. Potential benefits and risks must be considered. A

8.17 In people with diabetes and overweight or obesity, the preferred pharmacotherapy should be a glucagon-like peptide 1 receptor agonist or dual glucose-dependent insulinotropic polypeptide and glucagon-like peptide 1 receptor agonist with greater weight loss efficacy (i.e., semaglutide or tirzepatide), especially considering their added weight-independent benefits (e.g., glycemic and cardiometabolic). A

8.18 Screen people with diabetes and obesity who have lost significant weight for malnutrition, especially those who have undergone metabolic surgery A and those treated with weight management pharmacologic therapy. B

8.19 Weight management pharmacotherapy indicated for chronic therapy should be continued beyond reaching weight loss goals to maintain the health benefits. Sudden discontinuation of weight management pharmacotherapy often results in weight gain and worsening of cardiometabolic risk factors. A

8.20 For those not reaching treatment goals, reevaluate weight management therapies and intensify treatment with additional approaches (e.g., metabolic surgery, additional pharmacologic agents, and structured lifestyle management programs). A

8.21 Consider metabolic surgery as a weight and glycemic management approach in people with diabetes with BMI ≥30.0 kg/m2 (or ≥27.5 kg/m2 in Asian American individuals) who are otherwise good surgical candidates. A

8.22 Metabolic surgery should be performed in high-volume centers with interprofessional teams knowledgeable about and experienced in managing obesity, diabetes, and gastrointestinal surgery (www.facs.org/quality-programs/accreditation-and-verification/metabolic-and-bariatric-surgery-accreditation-and-quality-improvement-program/). E

8.23 People being considered for metabolic surgery should be evaluated for comorbid psychological conditions and social and situational circumstances that have the potential to interfere with surgery outcomes. B

8.24 People who undergo metabolic surgery should receive long-term medical and behavioral support and routine micronutrient, nutritional, and metabolic status monitoring. B

8.25 If post–metabolic surgery hypoglycemia is suspected, clinical evaluation should exclude other potential disorders contributing to hypoglycemia, and management should include education, medical nutrition therapy with a registered dietitian nutritionist experienced in post–metabolic surgery hypoglycemia, and medication treatment, as needed. A In individuals with post–metabolic surgery hypoglycemia, use continuous glucose monitoring to improve safety. C

8.26 In people who undergo metabolic surgery, routinely screen for psychosocial and behavioral health changes and refer to a qualified behavioral health professional as needed. C

8.27 Monitor individuals who have undergone metabolic surgery for insufficient weight loss or weight recurrence at least every 6–12 months. E In those who have insufficient weight loss or experience weight recurrence, assess for potential predisposing factors and, if appropriate, consider additional weight loss interventions (e.g., weight management pharmacotherapy). C

9.1 Treat most adults with type 1 diabetes with continuous subcutaneous insulin infusion or multiple daily doses of prandial (injected or inhaled) and basal insulin. A

9.2 For most adults with type 1 diabetes, insulin analogs (or inhaled insulin) are preferred over injectable human insulins to minimize hypoglycemia risk. A

9.3 Early use of continuous glucose monitoring is recommended for adults with type 1 diabetes to improve glycemic outcomes and quality of life and to minimize hypoglycemia. B

9.4 Automated insulin delivery systems should be offered to all adults with type 1 diabetes. A

9.5 To improve glycemic outcomes and quality of life and to minimize hypoglycemia risk, most adults with type 1 diabetes should receive education on how to match mealtime insulin doses to carbohydrate intake and fat and protein intake. They should also be taught how to modify the insulin dose (correction dose) based on concurrent glycemia, glycemic trends (if available), sick-day management, and anticipated physical activity. B

9.6 Insulin treatment plan and insulin-taking behavior should be reevaluated at regular intervals (e.g., every 3–6 months) and adjusted to incorporate specific factors that impact choice of treatment and ensure achievement of individualized glycemic goals. E

9.7 Healthy behaviors, diabetes self-management education and support, avoidance of therapeutic inertia, and social determinants of health should be included in the glucose-lowering management of type 2 diabetes. A

9.8 A person-centered shared decision-making approach should guide the choice of glucose-lowering medications for adults with type 2 diabetes. Use medications that provide sufficient effectiveness to achieve and maintain intended treatment goals with consideration of the effects on cardiovascular, kidney, weight, and other relevant comorbidities; hypoglycemia risk; cost and access; risk for adverse reactions and tolerability; and individual preferences (Fig. 9.3 and Table 9.2). E

9.9 Combination therapy can be considered in adults with type 2 diabetes at treatment initiation to shorten time to attainment of individualized treatment goals. A

9.10 In adults with type 2 diabetes and established or high risk of atherosclerotic cardiovascular disease, the treatment plan should include medications with demonstrated benefits to reduce cardiovascular events (e.g., glucagon-like peptide 1 receptor agonist [GLP-1 RA] and/or sodium–glucose cotransporter 2 [SGLT2] inhibitor) for glycemic management and comprehensive cardiovascular risk reduction (irrespective of A1C) (Fig. 9.3 and Table 9.2). A

9.11 In adults with type 2 diabetes who have heart failure (HF) (with either reduced or preserved ejection fraction), an SGLT2 inhibitor is recommended for both glycemic management and prevention of HF hospitalizations (irrespective of A1C) (Fig. 9.3). A

9.12 In adults with type 2 diabetes and symptomatic heart failure with preserved ejection fraction (HFpEF) and obesity, a GLP-1 RA with demonstrated benefits for both glycemic management and reduction of HF-related symptoms (irrespective of A1C) is recommended. A

9.13 In adults with type 2 diabetes who have CKD (with confirmed estimated glomerular filtration rate [eGFR] 20–60 mL/min/1.73 m2 and/or albuminuria), an SGLT2 inhibitor or GLP-1 RA with demonstrated benefit in this population should be used for both glycemic management (irrespective of A1C) and for slowing progression of CKD and reduction in cardiovascular events (Fig. 9.3). The glycemic benefits of SGLT2 inhibitors are reduced at eGFR <45 mL/min/1.73 m2. A

9.14 In adults with type 2 diabetes and advanced CKD (eGFR <30 mL/min/1.73 m2), a GLP-1 RA is preferred for glycemic management due to lower risk of hypoglycemia and for cardiovascular event reduction. B

9.15 In adults with type 2 diabetes, metabolic dysfunction–associated steatotic liver disease (MASLD), and overweight or obesity, consider using a GLP-1 RA or a dual glucose-dependent insulinotropic polypeptide (GIP) and GLP-1 RA with potential benefits in metabolic dysfunction–associated steatohepatitis (MASH) for glycemic management and as an adjunctive to healthy interventions for weight loss. B

9.16a In adults with type 2 diabetes and biopsy-proven MASH or those at high risk for liver fibrosis (based on noninvasive tests), pioglitazone, a GLP-1 RA, or a dual GIP and GLP-1 RA is preferred for glycemic management due to potential beneficial effects on MASH. B

9.16b Combination therapy with pioglitazone plus a GLP-1 RA can be considered for the treatment of hyperglycemia in adults with type 2 diabetes with biopsy-proven MASH or those at high risk of liver fibrosis (identified with noninvasive tests) due to potential beneficial effects on MASH. B

9.17 Medication plan and medication-taking behavior should be reevaluated at regular intervals (e.g., every 3–6 months) and adjusted as needed to incorporate specific factors that impact choice of treatment (Fig. 4.1 and Table 9.2). E

9.18 Treatment modification (intensification or deintensification) for adults not meeting individualized treatment goals should not be delayed. A

9.19 Choice of glucose-lowering therapy modification should take into consideration individualized glycemic and weight goals, presence of comorbidities (cardiovascular, kidney, liver, and other metabolic comorbidities), and the risk of hypoglycemia. A

9.20 When initiating a new glucose-lowering medication, reassess the need for and/or dose of medications with higher hypoglycemia risk (i.e., sulfonylureas, meglitinides, and insulin) to minimize the risk of hypoglycemia and treatment burden. A

9.21 Concurrent use of dipeptidyl peptidase 4 (DPP-4) inhibitors with a GLP-1 RA or a dual GIP and GLP-1 RA is not recommended due to lack of additional glucose lowering beyond that of a GLP-1 RA alone. B

9.22 In adults with type 2 diabetes who have not achieved their individualized weight goals, additional weight management interventions (e.g., intensification of lifestyle modifications, structured weight management programs, pharmacologic agents, or metabolic surgery, as appropriate) are recommended. A

9.23 In adults with type 2 diabetes, initiation of insulin should be considered regardless of background glucose-lowering therapy or disease stage if symptoms of hyperglycemia are present or when A1C or blood glucose levels are very high (i.e., A1C >10% [>86 mmol/mol] or blood glucose ≥300 mg/dL [≥16.7 mmol/L]). E

9.24 In adults with type 2 diabetes and no evidence of insulin deficiency, a GLP-1 RA, including a dual GIP and GLP-1 RA, is preferred to insulin (Fig. 9.4). A

9.25 If insulin is used, combination therapy with a GLP-1 RA, including a dual GIP and GLP-1 RA, is recommended for greater glycemic effectiveness as well as beneficial effects on weight and hypoglycemia risk for adults with type 2 diabetes. Insulin dosing should be reassessed upon addition or dose escalation of a GLP-1 RA or dual GIP and GLP-1 RA. A

9.26 In adults with type 2 diabetes who are initiating insulin therapy, continue glucose-lowering agents (unless contraindicated or not tolerated) for ongoing glycemic and metabolic benefits (i.e., weight, cardiometabolic, or kidney benefits). A

9.27 Monitor for signs of overbasalization during insulin therapy, such as significant bedtime-to-morning or postprandial-to-preprandial glucose differential, occurrences of hypoglycemia (aware or unaware), and high glycemic variability. When overbasalization is suspected, a thorough reevaluation should occur promptly to further tailor therapy to the individual’s needs. E

9.28 Glucagon should be prescribed for all individuals requiring intensive insulin therapy or at high risk for hypoglycemia. Family, caregivers, school personnel, and others providing support to these individuals should know its location and be educated on how to administer it. Glucagon preparations that do not require reconstitution are preferred. B

9.29 Routinely assess all people with diabetes for financial obstacles that could impede their diabetes management. Clinicians, members of the diabetes care team, and social services professionals should work collaboratively, as appropriate and feasible, to support these individuals by implementing strategies to reduce costs, thereby improving their access to evidence-based care. E

9.30 In adults with diabetes and cost-related barriers, consider use of lower-cost medications for glycemic management (i.e., metformin, sulfonylureas, thiazolidinediones, and human insulin) within the context of their risks for hypoglycemia, weight gain, cardiovascular and kidney events, and other adverse effects. E

9.31a Use of compounded products that are not approved by the FDA is not recommended due to uncertainty about their content and resulting concerns about safety, quality, and effectiveness. E

9.31b If a glucose-lowering medication is unavailable (e.g., in shortage), it is recommended to switch to a different FDA-approved medication with similar efficacy, as clinically appropriate. E

9.31c Upon resolution of the unavailability (e.g., shortage), reassess the appropriateness of resuming the original FDA-approved medication. E

9.32a Individuals with diabetes of childbearing potential should be counseled on contraception options A and the impact of some glucose-lowering medications on contraception efficacy. C

9.32b A person-centered shared decision-making approach to preconception planning is essential for all individuals with diabetes and of childbearing potential. A Preconception planning should address attainment of glycemic goals, A the time frame for discontinuing noninsulin glucose-lowering medications, E and optimal glycemic management in preparation for pregnancy. A

9.33 Educate individuals with diabetes who are at risk for developing diabetic ketoacidosis and/or follow a ketogenic eating pattern and who are treated with SGLT inhibitors on the risks and signs of ketoacidosis and methods of risk mitigation management, and provide them with appropriate tools for accurate ketone measurement (i.e., serum β-hydroxybutyrate). E

10.35 Use aspirin therapy (75–162 mg/day) as a secondary prevention strategy in those with diabetes and a history of ASCVD. A

10.36a For individuals with ASCVD and documented aspirin allergy, clopidogrel (75 mg/day) should be used. B

10.36b The length of treatment with dual antiplatelet therapy using low-dose aspirin and a P2Y12 inhibitor in individuals with diabetes after an acute coronary syndrome, acute ischemic stroke, or transient ischemic attack should be determined by an interprofessional team approach that includes a cardiovascular or neurological specialist, respectively. E

10.37 Combination therapy with aspirin plus low-dose rivaroxaban should be considered for individuals with stable coronary and/or peripheral artery disease (PAD) and low bleeding risk to prevent major adverse limb and cardiovascular events. A

10.38 Aspirin therapy (75–162 mg/day) may be considered as a primary prevention strategy in those with diabetes who are at increased cardiovascular risk after a comprehensive discussion with the individual on the benefits versus the comparable increased risk of bleeding. A

11.1a Assess kidney function (i.e., spot urine albumin-to-creatinine ratio [UACR]) and estimated glomerular filtration rate [eGFR] in people with type 1 diabetes with duration of ≥5 years and in all people with type 2 diabetes regardless of treatment. B

11.1b In people with established chronic kidney disease (CKD), monitor urinary albumin (e.g., spot UACR) and eGFR 1–4 times per year depending on the stage of the kidney disease (Fig. 11.1). B

11.2 Optimize glucose management to reduce the risk or slow the progression of CKD (Fig. 9.3). A

11.3 Optimize blood pressure management (aim for <130/80 mmHg [Fig. 10.2]) and reduce blood pressure variability to reduce the risk or slow the progression of CKD and reduce cardiovascular risk. A

11.4a In nonpregnant people with diabetes and hypertension, either an ACE inhibitor or an angiotensin receptor blocker (ARB) is recommended for those with moderately increased albuminuria (UACR 30–299 mg/g creatinine) B and is strongly recommended for those with severely increased albuminuria (UACR ≥300 mg/g creatinine) and/or eGFR <60 mL/min/1.73 m2 to maximally tolerated dose to prevent the progression of kidney disease and reduce cardiovascular events. A

11.4b Monitor for increased serum creatinine and for increased serum potassium levels when ACE inhibitors, ARBs, and mineralocorticoid receptor antagonists (MRAs) are used, or for hypokalemia when diuretics are used at routine visits and 7–14 days after initiation or after a dose change. B

11.4c An ACE inhibitor or an ARB is not recommended for the primary prevention of CKD in people with diabetes who have normal blood pressure, normal UACR (<30 mg/g creatinine), and normal eGFR. A

11.4d Continue renin-angiotensin system blockade for mild to moderate increases in serum creatinine (≤30%) in individuals who have no signs of extracellular fluid volume depletion. A

11.5a For people with type 2 diabetes and CKD, use of a sodium–glucose cotransporter 2 (SGLT2) inhibitor with demonstrated benefit is recommended to reduce CKD progression and cardiovascular events in individuals with eGFR ≥20 mL/min/1.73 m2. A

11.5b To reduce cardiovascular risk and kidney disease progression in people with type 2 diabetes and CKD, a glucagon-like peptide 1 agonist with demonstrated benefit in this population is recommended. A

11.5c To reduce cardiovascular events and CKD progression in people with CKD and albuminuria, a nonsteroidal MRA that has been shown to be effective in clinical trials is recommended (if eGFR is ≥25 mL/min/1.73 m2). Potassium levels should be monitored. A

11.6 Potentially harmful antihypertensive medications in pregnancy should be avoided in sexually active individuals of childbearing potential who are not using reliable contraception and, if used, should be switched prior to conception to antihypertensive medications considered safer during pregnancy. B

11.7 Aim to reduce urinary albumin by ≥30% in people with CKD and albuminuria ≥300 mg/g to slow CKD progression. B

11.8 For people with non–dialysis-dependent stage G3 or higher CKD, protein intake should be 0.8 g/kg body weight per day, as for the general population. A For individuals on dialysis, protein intake of 1.0–1.2 g/kg/day should be considered since protein energy wasting is a major problem for some individuals on dialysis. B

11.9 Individuals should be referred for evaluation by a nephrologist if they have continuously increasing urinary albumin levels and/or continuously decreasing eGFR and/or if the eGFR is <30 mL/min/1.73 m2. A

11.10 Refer to a nephrologist for uncertainty about the etiology of kidney disease, difficult management issues, and rapidly progressing kidney disease. B

12.1 Implement strategies to help people with diabetes reach glycemic goals to reduce the risk or slow the progression of diabetic retinopathy. A

12.2 Implement strategies to help people with diabetes reach blood pressure and lipid goals to reduce the risk or slow the progression of diabetic retinopathy. A

12.3 Adults with type 1 diabetes should have an initial dilated and comprehensive eye examination by an ophthalmologist or optometrist within 5 years after the onset of diabetes. B

12.4 People with type 2 diabetes should have an initial dilated and comprehensive eye examination by an ophthalmologist or optometrist at the time of the diabetes diagnosis. B

12.5 If there is no evidence of retinopathy from one or more annual eye exams and glycemic indicators are within the goal range, then screening every 1–2 years may be considered. If any level of diabetic retinopathy is present, subsequent dilated retinal examinations should be repeated at least annually by an ophthalmologist or optometrist. If retinopathy is progressing or sight-threatening, then examinations by an ophthalmologist will be required more frequently. B

12.6 Programs that use retinal photography with remote reading or the use of U.S. Food and Drug Administration–approved artificial intelligence algorithms to improve access to diabetic retinopathy screening are appropriate screening strategies for diabetic retinopathy. Such programs need to provide pathways for timely referral for a comprehensive eye examination when indicated. B

12.7 Counsel individuals of childbearing potential with preexisting type 1 or type 2 diabetes who are planning pregnancy or who are pregnant on the risk of development and/or progression of diabetic retinopathy. B

12.8 Individuals with preexisting type 1 or type 2 diabetes should receive an eye exam before pregnancy as well as in the first trimester and may need to be monitored every trimester and for 1 year postpartum as indicated by the degree of retinopathy. B

12.9 Promptly refer individuals with any level of diabetic macular edema, moderate or worse nonproliferative diabetic retinopathy (a precursor of proliferative diabetic retinopathy [PDR]), or any PDR to an ophthalmologist who is knowledgeable and experienced in the management of diabetic retinopathy. A

12.10 Panretinal laser photocoagulation therapy is indicated to reduce the risk of vision loss in individuals with high-risk PDR and, in some cases, severe nonproliferative diabetic retinopathy. A

12.11 Intravitreous injections of anti–vascular endothelial growth factor (anti-VEGF) are a reasonable alternative to traditional panretinal laser photocoagulation for some individuals with PDR and also reduce the risk of vision loss in these individuals. A

12.12 Intravitreous injections of anti-VEGF are indicated as first-line treatment for most eyes with diabetic macular edema that involves the foveal center and impairs vision acuity. A

12.13 Macular focal/grid photocoagulation and intravitreal injections of corticosteroid are reasonable treatments in eyes with persistent diabetic macular edema despite previous anti-VEGF therapy or eyes that are not candidates for this first-line approach. A

12.14 The presence of retinopathy is not a contraindication to aspirin therapy for cardioprotection, as aspirin does not increase the risk of retinal hemorrhage. A

12.15 People who experience vision loss from diabetes should be counseled on the availability and scope of vision rehabilitation care and provided, or referred for, a comprehensive evaluation of their visual impairment by a practitioner experienced in vision rehabilitation. E

12.16 People with vision loss from diabetes should receive educational materials and resources for eye care support in addition to self-management education (e.g., glycemic management and hypoglycemia awareness). E

12.17 All people with diabetes should be assessed for diabetic peripheral neuropathy starting at diagnosis of type 2 diabetes and 5 years after the diagnosis of type 1 diabetes and at least annually thereafter. B

12.18 Assessment for distal symmetric polyneuropathy should include a careful history and assessment of either temperature or pinprick sensation (small-fiber function) and vibration sensation using a 128-Hz tuning fork (for large-fiber function). All people with diabetes should have annual 10-g monofilament testing to identify feet at risk for ulceration and amputation. B

12.19 Symptoms and signs of autonomic neuropathy should be assessed in people with diabetes starting at diagnosis of type 2 diabetes and 5 years after the diagnosis of type 1 diabetes, and at least annually thereafter, and with evidence of other microvascular complications, particularly kidney disease and diabetic peripheral neuropathy. Screening can include asking about orthostatic dizziness, syncope, early satiety, erectile dysfunction, changes in sweating patterns, or dry cracked skin in the extremities. Signs of autonomic neuropathy include orthostatic hypotension, a resting tachycardia, or evidence of peripheral dryness or cracking of skin. E

12.20 Optimize glucose management to prevent or delay the development of neuropathy in people with type 1 diabetes A and to slow the progression of neuropathy in people with type 2 diabetes. C Optimize weight, blood pressure, and serum lipid management to reduce the risk or slow the progression of diabetic neuropathy. B

12.21 Assess and treat pain related to diabetic peripheral neuropathy B and symptoms of autonomic neuropathy to improve quality of life. E

12.22 Gabapentinoids, serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants, and sodium channel blockers are recommended as initial pharmacologic treatments for neuropathic pain in diabetes. A Opioids, including tramadol and tapentadol, should not be used for neuropathic pain treatment in diabetes given the potential for adverse events. B

12.23 Perform a comprehensive foot evaluation at least annually to identify risk factors for ulcers and amputations. A

12.24 The examination should include inspection of the skin, assessment of foot deformities, neurological assessment (10-g monofilament testing or Ipswich touch test with at least one additional assessment: pinprick, temperature, or vibration), and vascular assessment, including pulses in the legs and feet. B

12.25 Individuals with evidence of sensory loss or prior ulceration or amputation should have their feet inspected at every visit. A

12.26 Obtain a prior history of ulceration, amputation, Charcot foot, angioplasty or vascular surgery, cigarette smoking, retinopathy, and renal disease and assess current symptoms of neuropathy (pain, burning, numbness) and vascular disease (leg fatigue, claudication). B

12.27 Initial screening for peripheral arterial disease (PAD) should include assessment of lower-extremity pulses, capillary refill time, rubor on dependency, pallor on elevation, and venous filling time. Individuals with a history of leg fatigue, claudication, and rest pain relieved with dependency or decreased or absent pedal pulses should be referred for ankle-brachial index with toe pressures and for further vascular assessment as appropriate. B

12.28 An interprofessional approach facilitated by a podiatrist in conjunction with other appropriate team members is recommended for individuals with foot ulcers and high-risk feet (e.g., those on dialysis, those with Charcot foot, those with a history of prior ulcers or amputation, and those with PAD). B

12.29 Refer individuals who smoke and have a history of prior lower-extremity complications, loss of protective sensation, structural abnormalities, or PAD to foot care specialists for ongoing preventive care and lifelong surveillance. B These individuals should also be provided with information on the importance of smoke cessation and referred for counseling on smoke cessation. A

12.30 Provide general preventive foot self-care education to all people with diabetes, including those with loss of protective sensation, on appropriate ways to examine their feet (palpation or visual inspection with an unbreakable mirror) for daily surveillance of early foot problems. B

12.31 The use of specialized therapeutic footwear is recommended for people with diabetes at high risk for ulceration, including those with loss of protective sensation, foot deformities, ulcers, callous formation, poor peripheral circulation, or history of amputation. B

12.32 For chronic diabetic foot ulcers that have failed to heal with optimal standard care alone, adjunctive treatment with randomized controlled trial–proven advanced agents should be considered. Considerations might include negative-pressure wound therapy, placental membranes, bioengineered skin substitutes, several acellular matrices, autologous fibrin and leukocyte platelet patches, and topical oxygen therapy. A

13.1 Assess the medical, psychological, functional (self-management abilities), and social domains in older adults with diabetes to provide a framework to determine goals and therapeutic approaches for diabetes management. B

13.2 Screen at least annually for geriatric syndromes (e.g., cognitive impairment, depression, urinary incontinence, falls, persistent pain, and frailty), hypoglycemia, and polypharmacy in older adults with diabetes, as they may affect diabetes management and diminish quality of life. B

13.3 Screening for early detection of mild cognitive impairment or dementia should be performed for adults 65 years of age or older at the initial visit, annually, and as appropriate. B

13.4 Ascertain and address episodes of hypoglycemia at routine visits because older adults with diabetes have a greater risk of hypoglycemia, especially when treated with hypoglycemic agents (e.g., sulfonylureas, meglitinides, and insulin). B

13.5 Recommend continuous glucose monitoring (CGM) for older adults with type 1 diabetes to improve glycemic outcomes, reduce hypoglycemia, and reduce treatment burden. A

13.6 Offer CGM for older adults with type 2 diabetes on insulin therapy to improve glycemic outcomes and reduce hypoglycemia. B

13.7 Consider the use of automated insulin delivery systems, A mechanical insulin delivery systems, E and other advanced insulin delivery devices such as connected pens E to reduce risk of hypoglycemia for older adults, based on individual ability and support system.

13.8a Older adults with diabetes who are otherwise healthy with few and stable coexisting chronic illnesses and intact cognitive and functional status should have lower glycemic goals (such as A1C <7.0–7.5% [<53–58 mmol/mol]) and/or time in range [TIR] 70–180 mg/dL [3.9–10.0 mmol] of ∼70% and time below range ≤70 mg/dL [3.9 mmol/L] of ≤4%) if CGM is used. C

13.8b Older adults with diabetes and intermediate or complex health are clinically heterogeneous with variable life expectancy. Selection of glycemic goals should be individualized and should prioritize avoidance of hypoglycemia, with less stringent goals (such as A1C <8.0% [<64 mmol/mol] and/or TIR 70–180 mg/dL [3.9–10.0 mmol] of ∼50% and time below range <70 mg/dL [3.9 mmol/L] of <1%) for those with significant cognitive and/or functional limitations, frailty, severe comorbidities, and a less favorable risk-to-benefit ratio of diabetes medications. C

13.8c Older adults with very complex or poor health receive minimal benefit from stringent glycemic goals. Clinicians should focus on avoiding hypoglycemia and symptomatic hyperglycemia rather than achieving stringent glycemic goals. C

13.9 Screening for diabetes complications should be individualized in older adults with diabetes. Particular attention should be paid to complications that would lead to impairment of functional status or quality of life. C

13.10 Treatment of hypertension to individualized goal levels is indicated in most older adults with diabetes. B

13.11 Treatment of other cardiovascular risk factors should be individualized in older adults with diabetes, considering the time frame of benefit. Lipid-lowering therapy and antiplatelet agents may benefit those with life expectancies at least equal to the time frame of primary prevention or secondary intervention trials. E

13.12 Recommend healthful eating with adequate protein intake for older adults with diabetes. Recommend regular exercise, including aerobic activity, weight-bearing exercise, and/or resistance training as tolerated in those who can safely engage in such activities. B

13.13 For older adults with type 2 diabetes, overweight or obesity, and capacity to exercise safely, an intensive lifestyle intervention focused on dietary changes, physical activity, and modest weight loss (e.g., 5–7%) should be considered for its benefits on quality of life, mobility and physical functioning, and cardiometabolic risk. A

13.14 Select medications with low risk of hypoglycemia in older adults with type 2 diabetes, specifically for those with hypoglycemia risk factors. B

13.15 Overtreatment of diabetes is common in older adults and should be avoided. B

13.16a Deintensify hypoglycemia-causing medications (e.g., insulin, sulfonylureas, or meglitinides) or switch to a medication class with low hypoglycemia risk for individuals who are at high risk for hypoglycemia, using individualized glycemic goals. B

13.16b In older adults with diabetes, deintensify diabetes medications for individuals for whom the harms and/or burdens of treatment may be greater than the benefits, within individualized glycemic goals. E

13.16c Simplify complex treatment plans (especially insulin) to reduce the risk of hypoglycemia and polypharmacy and decrease the treatment burden if it can be achieved within the individualized glycemic goals. B

13.16d In older adults with type 2 diabetes and established or high risk of atherosclerotic cardiovascular disease, heart failure, and/or chronic kidney disease, the treatment plan should include agents that reduce cardiovascular and kidney disease risk, irrespective of glycemia. A

13.17 Consider costs of care and coverage when developing treatment plans in order to reduce risk of cost-related barriers to medication taking and self-management behaviors. B

13.18 Recommend diabetes education/training (including that for CGM devices, insulin pumps, and advanced insulin delivery systems) for the staff of long-term care and rehabilitation facilities to improve the management of older adults with diabetes. E

13.19 People with diabetes residing in long-term care facilities need careful assessment of mobility, mentation, medications, and management preferences to establish individualized glycemic goals and to make appropriate choices of glucose-lowering agents and devices (including CGM devices, insulin pumps, and advanced insulin delivery systems) based on their clinical and functional status. E See Fig. 13.1 for the 4Ms framework to address person-specific issues that affect diabetes management in older individuals.

13.20 When palliative care is needed in older adults with diabetes, health care professionals should initiate conversations with people with diabetes and their care partners regarding the goals and intensity of care. Strict glucose and blood pressure management are not necessary, and simplification of medication plans can be considered. Similarly, the intensity of lipid management can be relaxed, and withdrawal of lipid-lowering therapy may be appropriate. E

13.21 Overall comfort, prevention of distressing symptoms, and preservation of quality of life and dignity are primary goals for diabetes management at the end of life. C

14.106 Diabetes care teams should implement transition preparation programs for youth beginning in early adolescence and, at the latest, at least 1 year before the anticipated transfer from pediatric to adult health care. E

14.107 Interprofessional adult and pediatric health care teams should provide support and resources for adolescents, young adults, and their families prior to and during the transfer process from pediatric to adult health care. C

14.108 Pediatric diabetes specialists should partner with youth with diabetes and their caregivers to engage in shared decision-making for the timing of transfer to an adult diabetes specialist. There is no age-specific cutoff for youth with diabetes to transfer to an adult diabetes specialist. E

15.1 Starting at puberty and continuing in all people with diabetes and childbearing potential, preconception counseling should be incorporated into routine diabetes care. A

15.2 Family planning should be discussed, and effective contraception (with consideration of long-acting, reversible contraception) should be prescribed and used until an individual’s treatment plan and A1C are optimized for pregnancy. A

15.3 Preconception counseling should address the importance of achieving glucose levels as close to normal as is safely possible, ideally A1C <6.5% (<48 mmol/mol), to reduce the risk of congenital anomalies, preeclampsia, macrosomia, preterm birth, and other complications. A

15.4 Individuals with a history of gestational diabetes mellitus (GDM) should seek preconception screening for diabetes and preconception care to identify and treat hyperglycemia and prevent congenital malformations. E

15.5 Individuals with preexisting diabetes who are planning a pregnancy should ideally begin receiving interprofessional care for preconception, which includes an endocrinology health care professional, maternal-fetal medicine specialist, registered dietitian nutritionist, and diabetes care and education specialist, when available. B

15.6 In addition to focused attention on achieving glycemic goals, A standard preconception care should be augmented with extra focus on nutrition, physical activity, diabetes self-care education, and screening for diabetes comorbidities and complications. B

15.7 Individuals with preexisting diabetes who are planning a pregnancy or who have become pregnant should be counseled on the risk of development and/or progression of diabetic retinopathy. Dilated eye examinations should occur ideally before pregnancy as well as in the first trimester, and then pregnant individuals should be monitored every trimester and for 1 year postpartum as indicated by the degree of retinopathy and as recommended by the eye care health care professional. B

15.8 Fasting, preprandial, and postprandial blood glucose monitoring are recommended in individuals with diabetes in pregnancy to achieve optimal glucose levels. Glucose goals are fasting plasma glucose <95 mg/dL (<5.3 mmol/L) and either 1-h postprandial glucose <140 mg/dL (<7.8 mmol/L) or 2-h postprandial glucose <120 mg/dL (<6.7 mmol/L). B

15.9 Due to increased red blood cell turnover, A1C is slightly lower during pregnancy in people with and without diabetes. Ideally, the A1C goal in pregnancy is <6% (<42 mmol/mol) if this can be achieved without significant hypoglycemia, but the goal may be relaxed to <7% (<53 mmol/mol) if necessary to prevent hypoglycemia. B

15.10 Continuous glucose monitoring (CGM) can help to achieve glycemic goals (e.g., time in range, time above range) A and A1C goal B in type 1 diabetes and pregnancy and may be beneficial for other types of diabetes in pregnancy. E

15.11 Recommend CGM to pregnant individuals with type 1 diabetes. A In conjunction with aims to achieve traditional pre- and postprandial glycemic goals, real-time CGM can reduce the risk for large-for-gestational-age infants and neonatal hypoglycemia in pregnancy complicated by type 1 diabetes. A

15.12 CGM metrics may be used in combination with blood glucose monitoring to achieve optimal pre- and postprandial glycemic goals. E

15.13 Commonly used estimated A1C and glucose management indicator calculations should not be used in pregnancy as estimates of A1C. C

15.14 Nutrition counseling before and during pregnancy should promote an eating pattern including fruits, vegetables, legumes, whole grains, nuts, seeds, fish, and other lean protein, which will provide a balance of macronutrients and healthy n-3 fatty acids. C

15.15 Lifestyle behavior change is an essential component of management of GDM and may suffice as treatment for many individuals. Insulin should be added if needed to achieve glycemic goals. A

15.16 Telehealth visits used in combination with in-person visits for pregnant people with GDM can improve outcomes compared with standard in-person care alone. A

15.17 Insulin should be used to manage type 1 diabetes in pregnancy A and is the preferred agent for the management of GDM A and type 2 diabetes in pregnancy. B

15.18 Either multiple daily injections or insulin pump technology can be used in pregnancy complicated by type 1 diabetes. C

15.19 Automated insulin delivery (AID) systems with pregnancy-specific glucose targets are recommended for pregnant individuals with type 1 diabetes. A

15.20 AID systems without pregnancy-specific glucose targets or a pregnancy-specific algorithm may be considered for select pregnant individuals with type 1 diabetes when used with assistive techniques and working with experienced health care teams. B

15.21 Metformin and glyburide, individually or in combination, should not be used as first-line agents for management of diabetes in pregnancy, as both cross the placenta to the fetus A and may not be sufficient to achieve glycemic goals. B Other oral and noninsulin injectable glucose-lowering medications lack long-term safety data and are not recommended. E

15.22 Metformin, when used to treat polycystic ovary syndrome and induce ovulation, should be discontinued by the end of the first trimester. A

15.23 Pregnant individuals with type 1 or type 2 diabetes should be prescribed low-dose aspirin 100–150 mg/day starting at 12–16 weeks of gestation to lower the risk of preeclampsia. E A dosage of 162 mg/day may be acceptable; E currently, in the U.S., low-dose aspirin is available in 81-mg tablets.

15.24 In pregnant individuals with diabetes and chronic hypertension, a blood pressure threshold of 140/90 mmHg for initiation or titration of therapy is associated with better pregnancy outcomes than reserving treatment for severe hypertension, with no increase in risk of small-for-gestational-age birth weight. A There are limited data on the optimal lower limit, but therapy should be deintensified for blood pressure <90/60 mmHg. E A blood pressure goal of 110–135/85 mmHg is suggested in the interest of reducing the risk for accelerated maternal hypertension. A

15.25a Potentially harmful medications in pregnancy (e.g., ACE inhibitors, angiotensin receptor blockers, mineralocorticoid receptor antagonists) should be stopped prior to conception and avoided in sexually active individuals of childbearing potential who are not using reliable contraception. B

15.25b In most circumstances, lipid-lowering medications should be stopped prior to conception and avoided in sexually active individuals of childbearing potential with diabetes who are not using reliable contraception. B In some circumstances (familial hypercholesterolemia, prior atherosclerotic cardiovascular disease event), statin therapy may be continued when the benefits outweigh risks. E

15.26 Insulin requirements need to be evaluated and adjusted for individuals requiring insulin after delivery because insulin resistance decreases dramatically immediately postpartum. C

15.27 A contraceptive plan should be discussed and implemented with all people with diabetes of childbearing potential. A

15.28 Breastfeeding efforts are recommended for all individuals with diabetes. A Breastfeeding is recommended for individuals with a history of GDM for multiple benefits, A including a reduced risk for type 2 diabetes later in life. B

15.29 Postpartum care should include psychosocial assessment and support for self-care. E

15.30 Screen individuals with a recent history of GDM at 4–12 weeks postpartum, using the 75-g oral glucose tolerance test and clinically appropriate nonpregnancy diagnostic criteria. B

15.31 Individuals with a history of GDM should have lifelong screening for the development of type 2 diabetes or prediabetes every 1–3 years. B

15.32 Individuals with overweight or obesity and a history of GDM found to have prediabetes should receive intensive lifestyle interventions and/or metformin to prevent diabetes. A

16.1 Perform an A1C test on all people with diabetes or hyperglycemia (random blood glucose >140 mg/dL [>7.8 mmol/L]) admitted to the hospital if no A1C test result is available from the prior 3 months. B

16.2 Institutions should implement protocols using validated written or computerized provider order entry sets for management of dysglycemia in the hospital that allow for a personalized approach. B

16.3 When caring for hospitalized people with diabetes (with an existing or new diagnosis) or stress hyperglycemia, consult with a specialized diabetes or glucose management team when available. B

16.4a Insulin should be initiated or intensified for treatment of persistent hyperglycemia starting at a threshold of ≥180 mg/dL (≥10.0 mmol/L) (confirmed on two occasions within 24 h) for the majority of critically ill individuals (those in the intensive care unit [ICU]). A

16.4b Insulin and/or other glucose-lowering therapies should be initiated or intensified for treatment of persistent hyperglycemia starting at a threshold of ≥180 mg/dL (≥10.0 mmol/L) (confirmed on two occasions within 24 h) for the majority of noncritically ill individuals (those not in the ICU). B

16.5a Once therapy is initiated, a glycemic goal of 140–180 mg/dL (7.8–10.0 mmol/L) is recommended for most critically ill individuals (those in the ICU) with hyperglycemia. A More stringent individualized glycemic goals may be appropriate for selected critically ill individuals if they can be achieved without significant hypoglycemia. B

16.5b For noncritically ill individuals (those not in the ICU), a glycemic goal of 100–180 mg/dL (5.6-10.0 mmol/L) is recommended if it can be achieved without significant hypoglycemia. B

16.6 In people with diabetes using a personal continuous glucose monitoring (CGM) device, the use of CGM should be continued during hospitalization if clinically appropriate, with confirmatory point-of-care (POC) blood glucose measurements for insulin dosing decisions and hypoglycemia assessment, if resources and training are available, and according to an institutional protocol. B

16.7 Continue use of insulin pump or automated insulin delivery in people with diabetes who are hospitalized when clinically appropriate, with confirmatory POC blood glucose measurements for insulin dosing decisions and hypoglycemia assessment and treatment. This is contingent upon availability of necessary supplies, resources, and training, ongoing competency assessments, and implementation of institutional diabetes technology protocols. C

16.8a Continuous intravenous insulin infusion is recommended for achieving glycemic goals and avoiding hypoglycemia in critically ill individuals. A

16.8b Basal insulin or a basal plus bolus correction insulin plan is the preferred treatment for noncritically ill hospitalized individuals with poor or no oral intake. A

16.9 An insulin plan with basal, prandial, and correction components is the preferred treatment for most noncritically ill hospitalized individuals with adequate nutritional intake. A

16.10 For most individuals, sole use of a correction or supplemental insulin without basal insulin (formerly referred to as a sliding scale) in the inpatient setting is discouraged. A

16.11 For people with type 2 diabetes hospitalized with heart failure, it is recommended that use of a sodium–glucose cotransporter 2 inhibitor be initiated or continued during hospitalization and upon discharge, if there are no contraindications and after recovery from the acute illness. A

16.12 A hypoglycemia management surveillance protocol should be adopted by all health systems. A plan for identifying, treating, and preventing hypoglycemia should be established for each individual. Episodes of hypoglycemia in the hospital should be documented in the health record and tracked to inform quality improvements. C

16.13 Treatment plans should be reviewed and changed as necessary to prevent hypoglycemia and recurrent hypoglycemia when a blood glucose value of <70 mg/dL (<3.9 mmol/L) is documented. C

16.16 A structured discharge plan should be tailored to the individual with diabetes. B

Advocacy Statements
The following is a partial list of advocacy statements ordered by publication date, with the most recent statement appearing first. A comprehensive list of advocacy statements is available at professional.diabetes.org/content/key-statements-and-reports.

Diabetes Care in the School Setting
A sizable portion of a child’s day is spent in school, so close communication with and training and cooperation of school personnel are essential to optimize diabetes management, safety, and access to all school-sponsored opportunities. Additionally, the updated statement further details optimal use of technologies, management of diabetes, behavioral health considerations, and guidance for diabetes care in special situations (e.g., emergency situations or clinical trial participation). Refer to the published ADA statement for diabetes management information for students with diabetes in elementary and secondary school settings (1).

Diabetes and Driving
People with diabetes who wish to operate on-road motor vehicles are subject to various licensing requirements applied by both state and federal jurisdictions. For an overview of existing licensing rules for people with diabetes, factors that impact driving for this population, diabetes technology use, and general guidelines for assessing driver fitness and determining appropriate licensing restrictions, refer to the published ADA statement (2).

Diabetes Management in Detention Facilities
People with diabetes who are in detention facilities deserve equitable care that meets national standards. As many facilities differ and have unique challenges, written policies and procedures are essential to create a solid foundation and infrastructure for diabetes management and the training of medical and security staff. Policies should address considerations such as security needs, transfers, access to medical personnel, needed supplies and equipment, and empowering diabetes self-management. For a comprehensive discussion on these considerations, refer to the published ADA statement (3).

Care of Young Children With Diabetes in the Childcare and Community Setting
Very young children (aged <5 years) with diabetes have legal protections and can be safely cared for by childcare professionals with appropriate training, access to resources, and a communication system with parents or guardians and the child’s diabetes health care professional. Refer to the published ADA advocacy statement for information on young children aged <5 years in settings such as childcare centers, preschools, camps, and other programs (4).

Insulin Access and Affordability
The ADA’s Insulin Access and Affordability Working Group compiled public information and convened a series of meetings with stakeholders throughout the insulin supply chain to learn how each entity affects the cost of insulin for the consumer. Their conclusions and recommendations are published in an ADA statement (5).

Diabetes and Employment
Any person with diabetes, whether insulin treated or noninsulin treated, should be eligible for any employment for which they are otherwise qualified. Employment decisions should never be based on generalizations or stereotypes regarding the effects of diabetes. For a general set of guidelines for evaluating individuals with diabetes for employment, including how an assessment should be performed and what changes (accommodations) in the workplace may be needed for an individual with diabetes, refer to the published ADA statement (6).