Diabetes Standards of Care 2023
Improving Care and Promoting Health in Populations
1.1 Ensure treatment decisions are timely, rely on evidence-based guidelines, include social community support, and are made collaboratively with patients based on individual preferences, prognoses, comorbidities, and informed financial considerations. B
1.2 Align approaches to diabetes management with the Chronic Care Model. This model emphasizes person-centered team care, integrated long-term treatment approaches to diabetes and comorbidities, and ongoing collaborative communication and goal setting between all team members. A
1.3 Care systems should facilitate team-based care, including those knowledgeable and experienced in diabetes management as part of the team, and utilization of patient registries, decision support tools, and community involvement to meet patient needs. B
1.4 Assess diabetes health care maintenance (see Table 4.1) using reliable and relevant data metrics to improve processes of care and health outcomes, with attention to care costs. B
1.5 Assess food insecurity, housing insecurity/homelessness, financial barriers, and social capital/social community support to inform treatment decisions, with referral to appropriate local community resources. A
1.6 Provide patients with self-management support from lay health coaches, navigators, or community health workers when available. A
1.7 Consider the involvement of community health workers to support the management of diabetes and cardiovascular risk factors, especially in underserved communities and health care systems. B
1.2 Align approaches to diabetes management with the Chronic Care Model. This model emphasizes person-centered team care, integrated long-term treatment approaches to diabetes and comorbidities, and ongoing collaborative communication and goal setting between all team members. A
1.3 Care systems should facilitate team-based care, including those knowledgeable and experienced in diabetes management as part of the team, and utilization of patient registries, decision support tools, and community involvement to meet patient needs. B
1.4 Assess diabetes health care maintenance (see Table 4.1) using reliable and relevant data metrics to improve processes of care and health outcomes, with attention to care costs. B
1.5 Assess food insecurity, housing insecurity/homelessness, financial barriers, and social capital/social community support to inform treatment decisions, with referral to appropriate local community resources. A
1.6 Provide patients with self-management support from lay health coaches, navigators, or community health workers when available. A
1.7 Consider the involvement of community health workers to support the management of diabetes and cardiovascular risk factors, especially in underserved communities and health care systems. B
Classification and Diagnosis of Diabetes
A1C
2.1a To avoid misdiagnosis or missed diagnosis, the A1C test should be performed using a method that is certified by the National Glycohemoglobin Standardization Program (NGSP) and standardized to the Diabetes Control and Complications Trial (DCCT) assay. B
2.1b Point-of-care A1C testing for diabetes screening and diagnosis should be restricted to U.S. Food and Drug Administration–approved devices at laboratories proficient in performing testing of moderate complexity or higher by trained personnel. B
2.3 In conditions associated with an altered relationship between A1C and glycemia, such as hemoglobinopathies including sickle cell disease, pregnancy (second and third trimesters and the postpartum period), glucose-6-phosphate dehydrogenase deficiency, HIV, hemodialysis, recent blood loss or transfusion, or erythropoietin therapy, only plasma blood glucose criteria should be used to diagnose diabetes. (See other conditions altering the relationship of a1c and glycemia below for more information.) B
2.4 Adequate carbohydrate intake (at least 150 g/day) should be assured for 3 days prior to oral glucose tolerance testing as a screen for diabetes. A
2.1b Point-of-care A1C testing for diabetes screening and diagnosis should be restricted to U.S. Food and Drug Administration–approved devices at laboratories proficient in performing testing of moderate complexity or higher by trained personnel. B
2.3 In conditions associated with an altered relationship between A1C and glycemia, such as hemoglobinopathies including sickle cell disease, pregnancy (second and third trimesters and the postpartum period), glucose-6-phosphate dehydrogenase deficiency, HIV, hemodialysis, recent blood loss or transfusion, or erythropoietin therapy, only plasma blood glucose criteria should be used to diagnose diabetes. (See other conditions altering the relationship of a1c and glycemia below for more information.) B
2.4 Adequate carbohydrate intake (at least 150 g/day) should be assured for 3 days prior to oral glucose tolerance testing as a screen for diabetes. A
Type 1 Diabetes
2.5 Screening for presymptomatic type 1 diabetes using screening tests that detect autoantibodies to insulin, glutamic acid decarboxylase (GAD), islet antigen 2, or zinc transporter 8 is currently recommended in the setting of a research study or can be considered an option for first-degree family members of a proband with type 1 diabetes. B
2.6 Development of and persistence of multiple islet autoantibodies is a risk factor for clinical diabetes and may serve as an indication for intervention in the setting of a clinical trial or screening for stage 2 type 1 diabetes. B
2.6 Development of and persistence of multiple islet autoantibodies is a risk factor for clinical diabetes and may serve as an indication for intervention in the setting of a clinical trial or screening for stage 2 type 1 diabetes. B
Prediabetes and Type 2 Diabetes
2.7 Screening for prediabetes and type 2 diabetes with an informal assessment of risk factors or validated risk calculator should be done in asymptomatic adults. B
2.8 Testing for prediabetes and/or type 2 diabetes in asymptomatic people should be considered in adults of any age with overweight or obesity (BMI ≥25 kg/m2 or ≥23 kg/m2 in Asian Americans) who have one or more risk factors (Table 2.3). B
2.9 For all people, screening should begin at age 35 years. B
2.10 If tests are normal, repeat screening recommended at a minimum of 3-year intervals is reasonable, sooner with symptoms or change in risk (i.e., weight gain). C
2.11 To screen for prediabetes and type 2 diabetes, fasting plasma glucose, 2-h plasma glucose during 75-g oral glucose tolerance test, and A1C are each appropriate (Table 2.2 and Table 2.5). B
2.12 When using oral glucose tolerance testing as a screen for diabetes, adequate carbohydrate intake (at least 150 g/day) should be assured for 3 days prior to testing. A
2.13 In people with prediabetes and type 2 diabetes, identify and treat cardiovascular disease risk factors. A
2.14 Risk-based screening for prediabetes and/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 factor for diabetes. (See Table 2.4 for evidence grading of risk factors.) B
2.15 People with HIV should be screened for diabetes and prediabetes with a fasting glucose 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, fasting glucose should be checked annually. E
2.8 Testing for prediabetes and/or type 2 diabetes in asymptomatic people should be considered in adults of any age with overweight or obesity (BMI ≥25 kg/m2 or ≥23 kg/m2 in Asian Americans) who have one or more risk factors (Table 2.3). B
2.9 For all people, screening should begin at age 35 years. B
2.10 If tests are normal, repeat screening recommended at a minimum of 3-year intervals is reasonable, sooner with symptoms or change in risk (i.e., weight gain). C
2.11 To screen for prediabetes and type 2 diabetes, fasting plasma glucose, 2-h plasma glucose during 75-g oral glucose tolerance test, and A1C are each appropriate (Table 2.2 and Table 2.5). B
2.12 When using oral glucose tolerance testing as a screen for diabetes, adequate carbohydrate intake (at least 150 g/day) should be assured for 3 days prior to testing. A
2.13 In people with prediabetes and type 2 diabetes, identify and treat cardiovascular disease risk factors. A
2.14 Risk-based screening for prediabetes and/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 factor for diabetes. (See Table 2.4 for evidence grading of risk factors.) B
2.15 People with HIV should be screened for diabetes and prediabetes with a fasting glucose 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, fasting glucose should be checked annually. E
Cystic Fibrosis–Related Diabetes
2.16 Annual screening for cystic fibrosis–related diabetes with an oral glucose tolerance test should begin by age 10 years in all patients with cystic fibrosis not previously diagnosed with cystic fibrosis-related diabetes. B
2.17 A1C is not recommended as a screening test for cystic fibrosis–related diabetes. B
2.18 People with cystic fibrosis–related diabetes should be treated with insulin to attain individualized glycemic goals. A
2.19 Beginning 5 years after the diagnosis of cystic fibrosis–related diabetes, annual monitoring for complications of diabetes is recommended. E
2.17 A1C is not recommended as a screening test for cystic fibrosis–related diabetes. B
2.18 People with cystic fibrosis–related diabetes should be treated with insulin to attain individualized glycemic goals. A
2.19 Beginning 5 years after the diagnosis of cystic fibrosis–related diabetes, annual monitoring for complications of diabetes is recommended. E
Posttransplantation Diabetes Mellitus
2.20 After organ transplantation, screening for hyperglycemia should be done. A formal diagnosis of posttransplantation diabetes mellitus is best made once the individual is stable on an immunosuppressive regimen and in the absence of an acute infection. B
2.21 The oral glucose tolerance test is the preferred test to make a diagnosis of posttransplantation diabetes mellitus. B
2.22 Immunosuppressive regimens shown to provide the best outcomes for patient and graft survival should be used, irrespective of posttransplantation diabetes mellitus risk. E
2.21 The oral glucose tolerance test is the preferred test to make a diagnosis of posttransplantation diabetes mellitus. B
2.22 Immunosuppressive regimens shown to provide the best outcomes for patient and graft survival should be used, irrespective of posttransplantation diabetes mellitus risk. E
Monogenic Diabetes Syndromes
2.23 Regardless of current age, all people diagnosed with diabetes in the first 6 months of life should have immediate genetic testing for neonatal diabetes. A
2.24 Children and young adults who do not have typical characteristics of type 1 or type 2 diabetes and who often have a 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. A
2.25 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
2.24 Children and young adults who do not have typical characteristics of type 1 or type 2 diabetes and who often have a 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. A
2.25 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
Gestational Diabetes Mellitus
2.26a In women who are planning pregnancy, screen those with risk factors B and consider testing all women for undiagnosed diabetes. E
2.26b Before 15 weeks of gestation, test women with risk factors B and consider testing all women E for undiagnosed diabetes at the first prenatal visit using standard diagnostic criteria, if not screened preconception.
2.26c Women identified as having diabetes should be treated as such. A
2.26d Before 15 weeks of gestation, screen for abnormal glucose metabolism to identify women 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 diagnosis. B Treatment may provide some benefit. E
2.26e Screen for early abnormal glucose metabolism using fasting glucose of 110–125 mg/dL (6.1 mmol/L) or A1C 5.9–6.4% (41–47 mmol/mol). B
2.27 Screen for gestational diabetes mellitus at 24–28 weeks of gestation in pregnant women not previously found to have diabetes or high-risk abnormal glucose metabolism detected earlier in the current pregnancy. A
2.28 Screen women with gestational diabetes mellitus for prediabetes or diabetes at 4–12 weeks postpartum, using the 75-g oral glucose tolerance test and clinically appropriate nonpregnancy diagnostic criteria. B
2.29 Women with a history of gestational diabetes mellitus should have lifelong screening for the development of diabetes or prediabetes at least every 3 years. B
2.30 Women with a history of gestational diabetes mellitus found to have prediabetes should receive intensive lifestyle interventions and/or metformin to prevent diabetes. A
2.26b Before 15 weeks of gestation, test women with risk factors B and consider testing all women E for undiagnosed diabetes at the first prenatal visit using standard diagnostic criteria, if not screened preconception.
2.26c Women identified as having diabetes should be treated as such. A
2.26d Before 15 weeks of gestation, screen for abnormal glucose metabolism to identify women 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 diagnosis. B Treatment may provide some benefit. E
2.26e Screen for early abnormal glucose metabolism using fasting glucose of 110–125 mg/dL (6.1 mmol/L) or A1C 5.9–6.4% (41–47 mmol/mol). B
2.27 Screen for gestational diabetes mellitus at 24–28 weeks of gestation in pregnant women not previously found to have diabetes or high-risk abnormal glucose metabolism detected earlier in the current pregnancy. A
2.28 Screen women with gestational diabetes mellitus for prediabetes or diabetes at 4–12 weeks postpartum, using the 75-g oral glucose tolerance test and clinically appropriate nonpregnancy diagnostic criteria. B
2.29 Women with a history of gestational diabetes mellitus should have lifelong screening for the development of diabetes or prediabetes at least every 3 years. B
2.30 Women with a history of gestational diabetes mellitus found to have prediabetes should receive intensive lifestyle interventions and/or metformin to prevent diabetes. A
Prevention or Delay of Type 2 Diabetes and Associated Comorbidities
Lifestyle Behavior Change for Diabetes Prevention
3.1 Monitor for the development of type 2 diabetes in those with prediabetes at least annually, modified based on individual risk/benefit assessment. E
3.2 Refer adults with overweight/obesity at high risk of type 2 diabetes, as typified by the Diabetes Prevention Program (DPP), to an intensive lifestyle behavior change program consistent with the DPP to achieve and maintain 7% loss of initial body weight, and increase moderate-intensity physical activity (such as brisk walking) to at least 150 min/week. A
3.3 A variety of eating patterns can be considered to prevent diabetes in individuals with prediabetes. B
3.4 Given the cost-effectiveness of lifestyle behavior modification programs for diabetes prevention, such diabetes prevention programs should be offered to patients. A Diabetes prevention programs should be covered by third-party payers and inconsistencies in access should be addressed.
3.5 Based on patient preference, certified technology-assisted diabetes prevention programs may be effective in preventing type 2 diabetes and should be considered. B
3.2 Refer adults with overweight/obesity at high risk of type 2 diabetes, as typified by the Diabetes Prevention Program (DPP), to an intensive lifestyle behavior change program consistent with the DPP to achieve and maintain 7% loss of initial body weight, and increase moderate-intensity physical activity (such as brisk walking) to at least 150 min/week. A
3.3 A variety of eating patterns can be considered to prevent diabetes in individuals with prediabetes. B
3.4 Given the cost-effectiveness of lifestyle behavior modification programs for diabetes prevention, such diabetes prevention programs should be offered to patients. A Diabetes prevention programs should be covered by third-party payers and inconsistencies in access should be addressed.
3.5 Based on patient preference, certified technology-assisted diabetes prevention programs may be effective in preventing type 2 diabetes and should be considered. B
Pharmacologic Interventions
3.6 Metformin therapy for prevention of type 2 diabetes should be considered in adults with prediabetes, as typified by the Diabetes Prevention Program, especially those aged 25–59 years with BMI ≥35 kg/m2, higher fasting plasma glucose (e.g., ≥110 mg/dL), and higher A1C (e.g., ≥6.0%), and in women with prior gestational diabetes mellitus. A
3.7 Long-term use of metformin may be associated with biochemical vitamin B12 deficiency; consider periodic measurement of vitamin B12 levels in metformin-treated patients, especially in those with anemia or peripheral neuropathy. B
3.7 Long-term use of metformin may be associated with biochemical vitamin B12 deficiency; consider periodic measurement of vitamin B12 levels in metformin-treated patients, especially in those with anemia or peripheral neuropathy. B
Prevention of Vascular Disease and Mortality
3.8 Prediabetes is associated with heightened cardiovascular risk; therefore, screening for and treatment of modifiable risk factors for cardiovascular disease are suggested. B
3.9 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 discontinued. B
3.10 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 fracture. A Lower doses may mitigate the risk of adverse effects. C
3.9 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 discontinued. B
3.10 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 fracture. A Lower doses may mitigate the risk of adverse effects. C
Person-Centered Care Goals
3.11 In adults with overweight/obesity at high risk of type 2 diabetes, care goals should include weight loss or prevention of weight gain, minimizing the progression of hyperglycemia, and attention to cardiovascular risk and associated comorbidities. B
3.12 Pharmacotherapy (e.g., for weight management, minimizing the progression of hyperglycemia, cardiovascular risk reduction) may be considered to support person-centered care goals. B
3.13 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, 2-h postchallenge glucose 173–199 mg/dL, A1C ≥6.0%), and individuals with a history of gestational diabetes mellitus. A
3.12 Pharmacotherapy (e.g., for weight management, minimizing the progression of hyperglycemia, cardiovascular risk reduction) may be considered to support person-centered care goals. B
3.13 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, 2-h postchallenge glucose 173–199 mg/dL, A1C ≥6.0%), and individuals with a history of gestational diabetes mellitus. A
Comprehensive Medical Evaluation and Assessment of Comorbidities
Patient-Centered Collaborative Care
4.1 A patient-centered communication style that uses person-centered and strength-based language and active listening; elicits patient preferences and beliefs; and assesses literacy, numeracy, and potential barriers to care should be used to optimize patient health outcomes and health-related quality of life. B
4.2 People with diabetes can benefit from a coordinated multidisciplinary team that may include and is not limited to diabetes care and education specialists, primary care and subspecialty clinicians, nurses, dietitians, exercise specialists, pharmacists, dentists, podiatrists, and mental health professionals. E
4.2 People with diabetes can benefit from a coordinated multidisciplinary team that may include and is not limited to diabetes care and education specialists, primary care and subspecialty clinicians, nurses, dietitians, exercise specialists, pharmacists, dentists, podiatrists, and mental health professionals. E
Comprehensive Medical Evaluation
4.3 A complete medical evaluation should be performed at the initial visit to:
- Confirm the diagnosis and classify diabetes. A
- Evaluate for diabetes complications, potential comorbid conditions, and overall health status. A
- Review previous treatment and risk factor management in people with established 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 A follow-up visit should include most components of the initial comprehensive medical evaluation (see Table 4.1). A
4.5 Ongoing management should be guided by the assessment of overall health status, diabetes complications, cardiovascular risk, hypoglycemia risk, and shared decision-making to set therapeutic goals. B
- Confirm the diagnosis and classify diabetes. A
- Evaluate for diabetes complications, potential comorbid conditions, and overall health status. A
- Review previous treatment and risk factor management in people with established 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 A follow-up visit should include most components of the initial comprehensive medical evaluation (see Table 4.1). A
4.5 Ongoing management should be guided by the assessment of overall health status, diabetes complications, cardiovascular risk, hypoglycemia risk, and shared decision-making to set therapeutic goals. B
Immunizations
4.6 Provide routinely recommended vaccinations for children and adults with diabetes as indicated by age (see Table 4.5 for highly recommended vaccinations for adults with diabetes). A
Autoimmune Diseases
4.7 Patients with type 1 diabetes should be screened for autoimmune thyroid disease soon after diagnosis and periodically thereafter. B
4.8 Adult patients with type 1 diabetes should be screened for celiac disease in the presence of gastrointestinal symptoms, signs, or laboratory manifestations suggestive of celiac disease. B
4.8 Adult patients with type 1 diabetes should be screened for celiac disease in the presence of gastrointestinal symptoms, signs, or laboratory manifestations suggestive of celiac disease. B
Cognitive Impairment/Dementia
4.9 In the presence of cognitive impairment, diabetes treatment regimens should be simplified as much as possible and tailored to minimize the risk of hypoglycemia. B
Nonalcoholic Fatty Liver Disease
4.10 Patients with type 2 diabetes or prediabetes and elevated liver enzymes (ALT) or fatty liver on ultrasound should be evaluated for presence of nonalcoholic steatohepatitis and liver fibrosis. C
Low Testosterone in Men
4.11 In men with diabetes who have symptoms or signs of hypogonadism, such as decreased sexual desire (libido) or activity, or erectile dysfunction, consider screening with a morning serum testosterone level. B
Facilitating Positive Health Behaviors and Well-being to Improve Health Outcomes
Diabetes Self-Management Education and Support
5.1 All people with diabetes should participate in diabetes self-management education and support to facilitate the knowledge, decision-making, and skills mastery for diabetes self-care. A
5.2 There are four critical times to evaluate the need for diabetes self-management education and support to promote skills acquisition to aid treatment plan implementation, medical nutrition therapy, and well-being: at diagnosis, annually and/or when not meeting treatment targets, when complicating factors develop (medical, physical, psychosocial), and when transitions in life and care occur. E
5.3 Clinical outcomes, health status, and well-being are key goals of diabetes self-management education and support that should be measured as part of routine care. C
5.4 Diabetes self-management education and support should be person-centered, may be offered in group or individual settings, and should be communicated with the entire diabetes care team. A
5.5 Digital coaching and digital self-management interventions can be effective methods to deliver diabetes self-management education and support. B
5.6 Reimbursement by third-party payers is recommended C because diabetes self-management education and support can improve outcomes and reduce costs. B
5.7 Identify and address barriers to diabetes self-management education and support that exist at the health system, payer, health care professional, and individual levels. E
5.8 Include social determinants of health of the target population in guiding design and delivery of diabetes self-management education and support C with the ultimate goal of health equity across all populations.
5.9 Consider addressing barriers to diabetes self-management education and support access through telehealth delivery of care B and other digital health solutions. C
5.2 There are four critical times to evaluate the need for diabetes self-management education and support to promote skills acquisition to aid treatment plan implementation, medical nutrition therapy, and well-being: at diagnosis, annually and/or when not meeting treatment targets, when complicating factors develop (medical, physical, psychosocial), and when transitions in life and care occur. E
5.3 Clinical outcomes, health status, and well-being are key goals of diabetes self-management education and support that should be measured as part of routine care. C
5.4 Diabetes self-management education and support should be person-centered, may be offered in group or individual settings, and should be communicated with the entire diabetes care team. A
5.5 Digital coaching and digital self-management interventions can be effective methods to deliver diabetes self-management education and support. B
5.6 Reimbursement by third-party payers is recommended C because diabetes self-management education and support can improve outcomes and reduce costs. B
5.7 Identify and address barriers to diabetes self-management education and support that exist at the health system, payer, health care professional, and individual levels. E
5.8 Include social determinants of health of the target population in guiding design and delivery of diabetes self-management education and support C with the ultimate goal of health equity across all populations.
5.9 Consider addressing barriers to diabetes self-management education and support access through telehealth delivery of care B and other digital health solutions. C
Medical Nutrition Therapy
|
Topic
|
Recommendations |
| Effectiveness of nutrition therapy | 5.10 An individualized medical nutrition therapy program as needed to achieve treatment goals, 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 and other payers. E | |
| Energy balance | 5.12 For all people with overweight or obesity, behavioral modification to achieve and maintain a minimum weight loss of 5% is recommended. A |
| Eating patterns and macronutrient distribution | 5.13 There is no ideal macronutrient pattern for people with diabetes; meal plans should be individualized while keeping nutrient quality, total calorie, and metabolic goals in mind. E |
| 5.14 A variety of eating patterns can be considered for the management of type 2 diabetes and to prevent diabetes in individuals with prediabetes. B | |
| 5.15 Reducing overall carbohydrate intake for individuals with diabetes has demonstrated the most evidence for improving glycemia and may be applied to a variety of eating patterns that meet individual needs and preferences. B | |
| Carbohydrates | 5.16 Carbohydrate intake should emphasize nutrient-dense carbohydrate sources that are high in fiber (at least 14 g fiber per 1,000 kcal) and minimally processed. Eating plans should emphasize nonstarchy vegetables, fruits, legumes, and whole grains, as well as dairy products, with minimal added sugars. B |
| 5.17 People with diabetes and those at risk are advised to replace sugar-sweetened beverages (including fruit juices) with water or low calorie, 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 | |
| 5.18 When using a flexible insulin therapy program, education on the glycemic impact of carbohydrate A, fat, and protein B should be tailored to an individual’s needs and preferences and used to optimize mealtime insulin dosing. | |
| 5.19 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 | |
| Protein | 5.20 In individuals with type 2 diabetes, ingested protein appears to increase insulin response without increasing plasma glucose concentrations. Therefore, carbohydrate sources high in protein should be avoided when trying to treat or prevent hypoglycemia. B |
| Dietary fat | 5.21 An eating plan emphasizing elements of a Mediterranean eating pattern rich in monounsaturated and polyunsaturated fats may be considered to improve glucose metabolism and lower cardiovascular disease risk. B |
| 5.22 Eating foods rich in long-chain n-3 fatty acids, such as fatty fish (EPA and DHA) and nuts and seeds (ALA), is recommended to prevent or treat cardiovascular disease. B | |
| Micronutrients and herbal supplements | 5.23 There is no clear evidence that dietary supplementation with vitamins, minerals (such as chromium and vitamin D), herbs, or spices (such as cinnamon or aloe vera) can improve outcomes in people with diabetes who do not have underlying deficiencies, and they are not generally recommended for glycemic control. C There may be evidence of harm for certain individuals with β carotene supplementation. B |
| Alcohol | 5.24 Adults with diabetes who drink alcohol should do so in moderation (no more than one drink per day for adult women and no more than two drinks per day for adult men). C |
| 5.25 Educating people with diabetes about the signs, symptoms, and self-management of delayed hypoglycemia after drinking alcohol, especially when using insulin or insulin secretagogues, is recommended. The importance of glucose monitoring after drinking alcoholic beverages to reduce hypoglycemia risk should be emphasized. B | |
| Sodium | 5.26 Sodium consumption should be limited to <2,300 mg/day. B |
| Nonnutritive sweeteners | 5.27 The use of nonnutritive sweeteners as a replacement for sugar-sweetened products may reduce overall calorie and carbohydrate intake as long as there is not a compensatory increase in energy intake from other sources. There is evidence that low- and no-calorie sweetened beverages are a viable alternative to water. B |
Physical Activity
5.28 Children and adolescents with type 1 diabetes C or type 2 diabetes or prediabetes B should engage in 60 min/day or more of moderate- or vigorous-intensity aerobic activity, with vigorous muscle-strengthening and bone-strengthening activities at least 3 days/week.
5.29 Most adults with type 1 diabetes C and type 2 diabetes B should 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 younger and more physically fit individuals.
5.30 Adults with type 1 diabetes C and type 2 diabetes B should engage in 2–3 sessions/week of resistance exercise on nonconsecutive days.
5.31 All adults, and particularly those with type 2 diabetes, should decrease the amount of time spent in daily sedentary behavior. B Prolonged sitting should be interrupted every 30 min for blood glucose benefits. C
5.32 Flexibility training and balance training are recommended 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
5.33 Evaluate baseline physical activity and sedentary time. Promote increase in nonsedentary activities above baseline for sedentary individuals with type 1 diabetes E and type 2 diabetes. B Examples include walking, yoga, housework, gardening, swimming, and dancing.
5.29 Most adults with type 1 diabetes C and type 2 diabetes B should 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 younger and more physically fit individuals.
5.30 Adults with type 1 diabetes C and type 2 diabetes B should engage in 2–3 sessions/week of resistance exercise on nonconsecutive days.
5.31 All adults, and particularly those with type 2 diabetes, should decrease the amount of time spent in daily sedentary behavior. B Prolonged sitting should be interrupted every 30 min for blood glucose benefits. C
5.32 Flexibility training and balance training are recommended 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
5.33 Evaluate baseline physical activity and sedentary time. Promote increase in nonsedentary activities above baseline for sedentary individuals with type 1 diabetes E and type 2 diabetes. B Examples include walking, yoga, housework, gardening, swimming, and dancing.
Smoking Cessation: Tobacco and e-Cigarettes
5.34 Advise all individuals not to use cigarettes and other tobacco products or e-cigarettes. A
5.35 After identification of tobacco or e-cigarette use, include smoking cessation counseling and other forms of treatment as a routine component of diabetes care. A
5.36 Address smoking cessation as part of diabetes education programs for those in need. B
5.35 After identification of tobacco or e-cigarette use, include smoking cessation counseling and other forms of treatment as a routine component of diabetes care. A
5.36 Address smoking cessation as part of diabetes education programs for those in need. B
Supporting Positive Health Behaviors
5.37 Behavioral strategies should be used to support diabetes self-management and engagement in health behaviors (e.g., taking medications, using diabetes technologies, physical activity, healthy eating) to promote optimal diabetes health outcomes. A
Psychosocial Care
5.38 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 When indicated and available, qualified mental health professionals should provide additional targeted mental health care. B
5.39 Diabetes care teams should implement psychosocial screening protocols that may include but are not limited to attitudes about diabetes, expectations for treatment and outcomes, general and diabetes-related mood, stress and/or quality of life, available resources (financial, social, family, and emotional), and/or psychiatric history. Screening should occur at periodic intervals and when there is a change in disease, treatment, or life circumstances. C
5.40 When indicated, refer to mental health professionals or other trained health care professionals 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
5.41 Consider screening older adults (aged ≥65 years) with diabetes for cognitive impairment, frailty, and depressive symptoms. Monitoring of cognitive capacity, i.e., the ability to actively engage in decision-making regarding treatment plan behaviors, is advised. B
5.39 Diabetes care teams should implement psychosocial screening protocols that may include but are not limited to attitudes about diabetes, expectations for treatment and outcomes, general and diabetes-related mood, stress and/or quality of life, available resources (financial, social, family, and emotional), and/or psychiatric history. Screening should occur at periodic intervals and when there is a change in disease, treatment, or life circumstances. C
5.40 When indicated, refer to mental health professionals or other trained health care professionals 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
5.41 Consider screening older adults (aged ≥65 years) with diabetes for cognitive impairment, frailty, and depressive symptoms. Monitoring of cognitive capacity, i.e., the ability to actively engage in decision-making regarding treatment plan behaviors, is advised. B
Diabetes Distress
5.42 Routinely monitor people with diabetes, caregivers, and family members for diabetes distress, particularly when treatment targets are not met and/or at the onset of diabetes complications. Refer to a qualified mental health professional or other trained health care professional for further assessment and treatment if indicated. B
Anxiety
5.43 Consider screening people with diabetes for anxiety symptoms or diabetes-related worries. Health care professionals can discuss diabetes-related worries and may refer to a qualified mental health professional for further assessment and treatment if anxiety symptoms indicate interference with diabetes self-management behaviors or quality of life. B
5.44 Refer people with hypoglycemia unawareness, which can co-occur with fear of hypoglycemia, to a trained professional to receive evidence-based intervention to help re-establish awareness of symptoms of hypoglycemia and reduce fear of hypoglycemia. A
5.44 Refer people with hypoglycemia unawareness, which can co-occur with fear of hypoglycemia, to a trained professional to receive evidence-based intervention to help re-establish awareness of symptoms of hypoglycemia and reduce fear of hypoglycemia. A
Depression
5.45 Consider at least annual screening of depressive symptoms in all people with diabetes, especially those with a self-reported 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
5.46 Beginning at diagnosis of complications or when there are significant changes in medical status, consider assessment for depression. B
5.47 Refer to qualified mental 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
5.46 Beginning at diagnosis of complications or when there are significant changes in medical status, consider assessment for depression. B
5.47 Refer to qualified mental 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
Disordered Eating Behavior
5.48 Consider screening for disordered or disrupted eating using validated screening measures when hyperglycemia and weight loss are unexplained based on self-reported behaviors related to medication dosing, meal plan, and physical activity. In addition, a review of the medical treatment plan is recommended to identify potential treatment-related effects on hunger/caloric intake. B
5.49 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 as available. Key qualifications include familiarity with the diabetes disease physiology, treatments for diabetes and disordered eating behaviors, and weight-related and psychological risk factors for disordered eating behaviors. B
5.49 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 as available. Key qualifications include familiarity with the diabetes disease physiology, treatments for diabetes and disordered eating behaviors, and weight-related and psychological risk factors for disordered eating behaviors. B
Serious Mental Illness
5.50 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
5.51 In people who are prescribed atypical antipsychotic medications, screen for prediabetes and diabetes 4 months after medication initiation and sooner if clinically indicated, at least annually. B
5.52 If a second-generation antipsychotic medication is prescribed for adolescents or adults with diabetes, changes in weight, glycemia, and cholesterol levels should be carefully monitored, and the treatment plan should be reassessed accordingly. C
5.51 In people who are prescribed atypical antipsychotic medications, screen for prediabetes and diabetes 4 months after medication initiation and sooner if clinically indicated, at least annually. B
5.52 If a second-generation antipsychotic medication is prescribed for adolescents or adults with diabetes, changes in weight, glycemia, and cholesterol levels should be carefully monitored, and the treatment plan should be reassessed accordingly. C
Cognitive Capacity/Impairment
5.53 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
5.54 If cognitive capacity changes or appears to be suboptimal for patient decision-making and/or behavioral self-management, referral for a formal assessment should be considered. E
5.54 If cognitive capacity changes or appears to be suboptimal for patient decision-making and/or behavioral self-management, referral for a formal assessment should be considered. E
Sleep Health
5.55 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 and/or a qualified behavioral health professional as indicated. B
Glycemic Targets
Glycemic Assessment
6.1 Assess glycemic status (A1C or other glycemic measurement such as time in range or glucose management indicator) at least two times a year in patients who are meeting treatment goals (and who have stable glycemic control). E
6.2 Assess glycemic status at least quarterly and as needed in patients whose therapy has recently changed and/or who are not meeting glycemic goals. E
6.2 Assess glycemic status at least quarterly and as needed in patients whose therapy has recently changed and/or who are not meeting glycemic goals. E
Glucose Assessment by Continuous Glucose Monitoring
6.3 Standardized, single-page glucose reports from continuous glucose monitoring (CGM) devices with visual cues, such as the ambulatory glucose profile, should be considered as a standard summary for all CGM devices. E
6.4 Time in range is associated with the risk of microvascular complications and can be used for assessment of glycemic control. Additionally, time below target and time above target are useful parameters for the evaluation of the treatment regimen (Table 6.2). C
6.4 Time in range is associated with the risk of microvascular complications and can be used for assessment of glycemic control. Additionally, time below target and time above target are useful parameters for the evaluation of the treatment regimen (Table 6.2). C
Glycemic Goals
6.5a An A1C goal for many nonpregnant adults of <7% (53 mmol/mol) without significant hypoglycemia is appropriate. A
6.5b If using ambulatory glucose profile/glucose management indicator to assess glycemia, a parallel goal for many nonpregnant adults is time in range of >70% with time below range <4% and time <54 mg/dL <1%. For those with frailty or at high risk of hypoglycemia, a target of >50% time in range with <1% time below range is recommended. (See Fig. 6.1 and Table 6.2 .) B
6.6 On the basis of health care professional judgment and patient preference, achievement of lower A1C levels than the goal of 7% may be acceptable and even beneficial if it can be achieved safely without significant hypoglycemia or other adverse effects of treatment. B
6.7 Less stringent A1C goals (such as <8% [64 mmol/mol]) may be appropriate for patients with limited life expectancy or where the harms of treatment are greater than the benefits. Health care professionals should consider deintensification of therapy if appropriate to reduce the risk of hypoglycemia in patients with inappropriate stringent A1C targets. B
6.8 Reassess glycemic targets based on the individualized criteria in Fig. 6.2 . E
6.9 Setting a glycemic goal during consultations is likely to improve patient outcomes. E
6.5b If using ambulatory glucose profile/glucose management indicator to assess glycemia, a parallel goal for many nonpregnant adults is time in range of >70% with time below range <4% and time <54 mg/dL <1%. For those with frailty or at high risk of hypoglycemia, a target of >50% time in range with <1% time below range is recommended. (See Fig. 6.1 and Table 6.2 .) B
6.6 On the basis of health care professional judgment and patient preference, achievement of lower A1C levels than the goal of 7% may be acceptable and even beneficial if it can be achieved safely without significant hypoglycemia or other adverse effects of treatment. B
6.7 Less stringent A1C goals (such as <8% [64 mmol/mol]) may be appropriate for patients with limited life expectancy or where the harms of treatment are greater than the benefits. Health care professionals should consider deintensification of therapy if appropriate to reduce the risk of hypoglycemia in patients with inappropriate stringent A1C targets. B
6.8 Reassess glycemic targets based on the individualized criteria in Fig. 6.2 . E
6.9 Setting a glycemic goal during consultations is likely to improve patient outcomes. E
Hypoglycemia
6.10 Occurrence and risk for hypoglycemia should be reviewed at every encounter and investigated as indicated. Awareness of hypoglycemia should be considered using validated tools. C
6.11 Glucose (approximately 15–20 g) is the preferred treatment for the conscious individual with blood glucose <70 mg/dL (3.9 mmol/L), although any form of carbohydrate that contains glucose may be used. Fifteen minutes after treatment, if blood glucose monitoring (BGM) shows continued hypoglycemia, the treatment should be repeated. Once the BGM or glucose pattern is trending up, the individual should consume a meal or snack to prevent recurrence of hypoglycemia. B
6.12 Glucagon should be prescribed for all individuals at increased risk of level 2 or 3 hypoglycemia, so that it is available should it be needed. Caregivers, school personnel, or family members providing support to these individuals should know where it is and when and how to administer it. Glucagon administration is not limited to health care professionals. E
6.13 Hypoglycemia unawareness or one or more episodes of level 3 hypoglycemia should trigger hypoglycemia avoidance education and reevaluation and adjustment of the treatment plan to decrease hypoglycemia. E
6.14 Insulin-treated patients with hypoglycemia unawareness, one level 3 hypoglycemic event, or a pattern of unexplained level 2 hypoglycemia should be advised to raise their glycemic targets to strictly avoid hypoglycemia for at least several weeks in order to partially reverse hypoglycemia unawareness and reduce risk of future episodes. A
6.15 Ongoing assessment of cognitive function is suggested with increased vigilance for hypoglycemia by the clinician, patient, and caregivers if impaired or declining cognition is found. B
6.11 Glucose (approximately 15–20 g) is the preferred treatment for the conscious individual with blood glucose <70 mg/dL (3.9 mmol/L), although any form of carbohydrate that contains glucose may be used. Fifteen minutes after treatment, if blood glucose monitoring (BGM) shows continued hypoglycemia, the treatment should be repeated. Once the BGM or glucose pattern is trending up, the individual should consume a meal or snack to prevent recurrence of hypoglycemia. B
6.12 Glucagon should be prescribed for all individuals at increased risk of level 2 or 3 hypoglycemia, so that it is available should it be needed. Caregivers, school personnel, or family members providing support to these individuals should know where it is and when and how to administer it. Glucagon administration is not limited to health care professionals. E
6.13 Hypoglycemia unawareness or one or more episodes of level 3 hypoglycemia should trigger hypoglycemia avoidance education and reevaluation and adjustment of the treatment plan to decrease hypoglycemia. E
6.14 Insulin-treated patients with hypoglycemia unawareness, one level 3 hypoglycemic event, or a pattern of unexplained level 2 hypoglycemia should be advised to raise their glycemic targets to strictly avoid hypoglycemia for at least several weeks in order to partially reverse hypoglycemia unawareness and reduce risk of future episodes. A
6.15 Ongoing assessment of cognitive function is suggested with increased vigilance for hypoglycemia by the clinician, patient, and caregivers if impaired or declining cognition is found. B
Diabetes Technology
General Device Principles
7.1 The type(s) and selection of devices should be individualized based on a person’s specific needs, 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, and/or physical limitations), the caregiver’s skills and preferences are integral to the decision-making process. E
7.2 When prescribing a device, ensure that people with diabetes/caregivers receive initial and ongoing education and training, either in-person or remotely, and ongoing evaluation of technique, results, and their ability to utilize data, including uploading/sharing data (if applicable), to monitor and adjust therapy. C
7.3 People with diabetes who have been using continuous glucose monitoring, continuous subcutaneous insulin infusion, and/or automated insulin delivery for diabetes management should have continued access across third-party payers, regardless of age or A1C levels. E
7.4 Students should be supported at school in the use of diabetes technology, such as continuous glucose monitoring systems, continuous subcutaneous insulin infusion, connected insulin pens, and automated insulin delivery systems, as prescribed by their health care team. E
7.5 Initiation of continuous glucose monitoring, continuous subcutaneous insulin infusion, and/or automated insulin delivery early in the treatment of diabetes can be beneficial depending on a person’s/caregiver’s needs and preferences. C
7.2 When prescribing a device, ensure that people with diabetes/caregivers receive initial and ongoing education and training, either in-person or remotely, and ongoing evaluation of technique, results, and their ability to utilize data, including uploading/sharing data (if applicable), to monitor and adjust therapy. C
7.3 People with diabetes who have been using continuous glucose monitoring, continuous subcutaneous insulin infusion, and/or automated insulin delivery for diabetes management should have continued access across third-party payers, regardless of age or A1C levels. E
7.4 Students should be supported at school in the use of diabetes technology, such as continuous glucose monitoring systems, continuous subcutaneous insulin infusion, connected insulin pens, and automated insulin delivery systems, as prescribed by their health care team. E
7.5 Initiation of continuous glucose monitoring, continuous subcutaneous insulin infusion, and/or automated insulin delivery early in the treatment of diabetes can be beneficial depending on a person’s/caregiver’s needs and preferences. C
Blood Glucose Monitoring
7.6 People with diabetes should be provided with blood glucose monitoring devices as indicated by their circumstances, preferences, and treatment. People using continuous glucose monitoring devices must also have access to blood glucose monitoring at all times. A
7.7 People who are on insulin using blood glucose monitoring 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, prior to 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
7.8 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 (or comparable regulatory agencies for other geographical locations) with proven accuracy should be used, with unexpired strips purchased from a pharmacy or licensed distributor. E
7.9 Although blood glucose monitoring in individuals on noninsulin therapies has not consistently shown clinically significant reductions in A1C, it may be helpful when altering nutrition plan, physical activity, and/or medications (particularly medications that can cause hypoglycemia) in conjunction with a treatment adjustment program. E
7.10 Health care professionals should be aware of medications and other factors, such as high-dose vitamin C and hypoxemia, that can interfere with glucose meter accuracy and provide clinical management as indicated. E
7.7 People who are on insulin using blood glucose monitoring 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, prior to 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
7.8 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 (or comparable regulatory agencies for other geographical locations) with proven accuracy should be used, with unexpired strips purchased from a pharmacy or licensed distributor. E
7.9 Although blood glucose monitoring in individuals on noninsulin therapies has not consistently shown clinically significant reductions in A1C, it may be helpful when altering nutrition plan, physical activity, and/or medications (particularly medications that can cause hypoglycemia) in conjunction with a treatment adjustment program. E
7.10 Health care professionals should be aware of medications and other factors, such as high-dose vitamin C and hypoxemia, that can interfere with glucose meter accuracy and provide clinical management as indicated. E
Continuous Glucose Monitoring Devices
7.11 Real-time continuous glucose monitoring A or intermittently scanned continuous glucose monitoring B should be offered for diabetes management in adults with diabetes on multiple daily injections or continuous subcutaneous insulin infusion who are capable of using the devices safely (either by themselves or with a caregiver). The choice of device should be made based on the individual’s circumstances, preferences, and needs.
7.12 Real-time continuous glucose monitoring A or intermittently scanned continuous glucose monitoring C should be offered for diabetes management in adults with diabetes on basal insulin who are capable of using the devices safely (either by themselves or with a caregiver). The choice of device should be made based on the individual’s circumstances, preferences, and needs.
7.13 Real-time continuous glucose monitoring B or intermittently scanned continuous glucose monitoring E should be offered for diabetes management in youth with type 1 diabetes on multiple daily injections or continuous subcutaneous insulin infusion who are capable of using the devices safely (either by themselves or with a caregiver). The choice of device should be made based on the individual’s circumstances, preferences, and needs.
7.14 Real-time continuous glucose monitoring or intermittently scanned continuous glucose monitoring should be offered for diabetes management in youth with type 2 diabetes on multiple daily injections or continuous subcutaneous insulin infusion who are capable of using the devices safely (either by themselves or with a caregiver). The choice of device should be made based on the individual’s circumstances, preferences, and needs. E
7.15 In people with diabetes on multiple daily injections or continuous subcutaneous insulin infusion, real-time continuous glucose monitoring devices should be used as close to daily as possible for maximal benefit. A Intermittently scanned continuous glucose monitoring devices should be scanned frequently, at a minimum once every 8 h. A People with diabetes should have uninterrupted access to their supplies to minimize gaps in continuous glucose monitoring. A
7.16 When used as an adjunct to pre- and postprandial blood glucose monitoring, continuous glucose monitoring can help to achieve A1C targets in diabetes and pregnancy. B
7.17 Periodic use of real-time or intermittently scanned continuous glucose monitoring or use of professional continuous glucose monitoring can be helpful for diabetes management in circumstances where continuous use of continuous glucose monitoring is not appropriate, desired, or available. C
7.18 Skin reactions, either due to irritation or allergy, should be assessed and addressed to aid in successful use of devices. E
7.19 Continuous glucose monitoring device users should be educated on potential interfering substances and other factors that may affect accuracy. C
7.12 Real-time continuous glucose monitoring A or intermittently scanned continuous glucose monitoring C should be offered for diabetes management in adults with diabetes on basal insulin who are capable of using the devices safely (either by themselves or with a caregiver). The choice of device should be made based on the individual’s circumstances, preferences, and needs.
7.13 Real-time continuous glucose monitoring B or intermittently scanned continuous glucose monitoring E should be offered for diabetes management in youth with type 1 diabetes on multiple daily injections or continuous subcutaneous insulin infusion who are capable of using the devices safely (either by themselves or with a caregiver). The choice of device should be made based on the individual’s circumstances, preferences, and needs.
7.14 Real-time continuous glucose monitoring or intermittently scanned continuous glucose monitoring should be offered for diabetes management in youth with type 2 diabetes on multiple daily injections or continuous subcutaneous insulin infusion who are capable of using the devices safely (either by themselves or with a caregiver). The choice of device should be made based on the individual’s circumstances, preferences, and needs. E
7.15 In people with diabetes on multiple daily injections or continuous subcutaneous insulin infusion, real-time continuous glucose monitoring devices should be used as close to daily as possible for maximal benefit. A Intermittently scanned continuous glucose monitoring devices should be scanned frequently, at a minimum once every 8 h. A People with diabetes should have uninterrupted access to their supplies to minimize gaps in continuous glucose monitoring. A
7.16 When used as an adjunct to pre- and postprandial blood glucose monitoring, continuous glucose monitoring can help to achieve A1C targets in diabetes and pregnancy. B
7.17 Periodic use of real-time or intermittently scanned continuous glucose monitoring or use of professional continuous glucose monitoring can be helpful for diabetes management in circumstances where continuous use of continuous glucose monitoring is not appropriate, desired, or available. C
7.18 Skin reactions, either due to irritation or allergy, should be assessed and addressed to aid in successful use of devices. E
7.19 Continuous glucose monitoring device users should be educated on potential interfering substances and other factors that may affect accuracy. C
Insulin Syringes and Pens
7.20 For people with insulin-requiring diabetes on multiple daily injections, insulin pens are preferred in most cases. Still, insulin syringes may be used for insulin delivery considering individual and caregiver preference, insulin type, dosing therapy, cost, and self-management capabilities. C
7.21 Insulin pens or insulin injection aids should be considered for people with dexterity issues or vision impairment to facilitate the accurate dosing and administration of insulin. C
7.22 Connected insulin pens can be helpful for diabetes management and may be used in people with diabetes using injectable therapy. E
7.23 U.S. Food and Drug Administration–approved insulin dose calculators/decision support systems may be helpful for titrating insulin doses. C
7.21 Insulin pens or insulin injection aids should be considered for people with dexterity issues or vision impairment to facilitate the accurate dosing and administration of insulin. C
7.22 Connected insulin pens can be helpful for diabetes management and may be used in people with diabetes using injectable therapy. E
7.23 U.S. Food and Drug Administration–approved insulin dose calculators/decision support systems may be helpful for titrating insulin doses. C
Insulin Pumps and Automated Insulin Delivery Systems
7.24 Automated insulin delivery systems should be offered for diabetes management to youth and adults with type 1 diabetes A and other types of insulin-deficient diabetes E who are capable of using 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.
7.25 Insulin pump therapy alone with or without sensor-augmented pump low glucose suspend feature and/or automated insulin delivery systems should be offered for diabetes management to youth and adults on multiple daily injections with type 1 diabetes A or other types of insulin-deficient diabetes E who are capable of using the device safely (either by themselves or with a caregiver) and are not able to use or do not choose an automated insulin delivery system. The choice of device should be made based on the individual’s circumstances, preferences, and needs. A
7.26 Insulin pump therapy can be offered for diabetes management to youth and adults on multiple daily injections with type 2 diabetes who are capable of using 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
7.27 Individuals with diabetes who have been using continuous subcutaneous insulin infusion should have continued access across third-party payers. E
7.25 Insulin pump therapy alone with or without sensor-augmented pump low glucose suspend feature and/or automated insulin delivery systems should be offered for diabetes management to youth and adults on multiple daily injections with type 1 diabetes A or other types of insulin-deficient diabetes E who are capable of using the device safely (either by themselves or with a caregiver) and are not able to use or do not choose an automated insulin delivery system. The choice of device should be made based on the individual’s circumstances, preferences, and needs. A
7.26 Insulin pump therapy can be offered for diabetes management to youth and adults on multiple daily injections with type 2 diabetes who are capable of using 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
7.27 Individuals with diabetes who have been using continuous subcutaneous insulin infusion should have continued access across third-party payers. E
Do-It-Yourself Closed-Loop Systems
7.28 Individuals with diabetes may be using systems not approved by the U.S. Food and Drug Administration, such as do-it-yourself closed-loop systems and others; health care professionals cannot prescribe these systems but should assist in diabetes management to ensure the safety of people with diabetes. E
Digital Health Technology
7.29 Systems that combine technology and online coaching can be beneficial in treating prediabetes and diabetes for some individuals. B
Inpatient Care
7.30 People with diabetes who are competent to safely use diabetes devices such as insulin pumps and continuous glucose monitoring systems should be supported to continue using them in an inpatient setting or during outpatient procedures, once competency is established and proper supervision is available. E
Obesity and Weight Management for the Prevention and Treatment of Type 2 Diabetes
Assessment
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”). E
8.2 Measure height and weight and calculate BMI at annual visits or more frequently. Assess weight trajectory to inform treatment considerations. E
8.3 Based on clinical considerations, such as the presence of comorbid heart failure or significant unexplained weight gain or loss, weight may need to be monitored and evaluated more frequently. B If deterioration of medical status is associated with significant weight gain or loss, inpatient evaluation should be considered, especially focused on associations between medication use, food intake, and glycemic status. E
8.4 Accommodations should be made to provide privacy during weighing. E
8.5 Individuals with diabetes and overweight or obesity may benefit from modest or larger magnitudes of weight loss. Relatively small weight loss (approximately 3–7% of baseline weight) improves glycemia and other intermediate cardiovascular risk factors. A Larger, sustained weight losses (>10%) usually confer greater benefits, including disease-modifying effects and possible remission of type 2 diabetes, and may improve long-term cardiovascular outcomes and mortality. B
8.2 Measure height and weight and calculate BMI at annual visits or more frequently. Assess weight trajectory to inform treatment considerations. E
8.3 Based on clinical considerations, such as the presence of comorbid heart failure or significant unexplained weight gain or loss, weight may need to be monitored and evaluated more frequently. B If deterioration of medical status is associated with significant weight gain or loss, inpatient evaluation should be considered, especially focused on associations between medication use, food intake, and glycemic status. E
8.4 Accommodations should be made to provide privacy during weighing. E
8.5 Individuals with diabetes and overweight or obesity may benefit from modest or larger magnitudes of weight loss. Relatively small weight loss (approximately 3–7% of baseline weight) improves glycemia and other intermediate cardiovascular risk factors. A Larger, sustained weight losses (>10%) usually confer greater benefits, including disease-modifying effects and possible remission of type 2 diabetes, and may improve long-term cardiovascular outcomes and mortality. B
Nutrition, Physical Activity, and Behavioral Therapy
8.6 Nutrition, physical activity, and behavioral therapy to achieve and maintain ≥5% weight loss are recommended for most people with type 2 diabetes and overweight or obesity. Additional weight loss usually results in further improvements in the management of diabetes and cardiovascular risk. B
8.7 Such interventions should include a high frequency of counseling (≥16 sessions in 6 months) and focus on nutrition changes, physical activity, and behavioral strategies to achieve a 500–750 kcal/day energy deficit. A
8.8 An individual’s preferences, motivation, and life circumstances should be considered, along with medical status, when weight loss interventions are recommended. C
8.9 Behavioral changes that create an energy deficit, regardless of macronutrient composition, will result in weight loss. Nutrition recommendations should be individualized to the person’s preferences and nutritional needs. A
8.10 Evaluate systemic, structural, and socioeconomic factors that may impact nutrition patterns and food choices, such as food insecurity and hunger, access to healthful food options, cultural circumstances, and social determinants of health. C
8.11 For those who achieve weight loss goals, long-term (≥1 year) weight maintenance programs are recommended when available. Such programs should, at minimum, provide monthly contact and support, recommend ongoing monitoring of body weight (weekly or more frequently) and other self-monitoring strategies, 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) may be prescribed for 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 There is no clear evidence that nutrition supplements are effective for weight loss. A
8.7 Such interventions should include a high frequency of counseling (≥16 sessions in 6 months) and focus on nutrition changes, physical activity, and behavioral strategies to achieve a 500–750 kcal/day energy deficit. A
8.8 An individual’s preferences, motivation, and life circumstances should be considered, along with medical status, when weight loss interventions are recommended. C
8.9 Behavioral changes that create an energy deficit, regardless of macronutrient composition, will result in weight loss. Nutrition recommendations should be individualized to the person’s preferences and nutritional needs. A
8.10 Evaluate systemic, structural, and socioeconomic factors that may impact nutrition patterns and food choices, such as food insecurity and hunger, access to healthful food options, cultural circumstances, and social determinants of health. C
8.11 For those who achieve weight loss goals, long-term (≥1 year) weight maintenance programs are recommended when available. Such programs should, at minimum, provide monthly contact and support, recommend ongoing monitoring of body weight (weekly or more frequently) and other self-monitoring strategies, 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) may be prescribed for 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 There is no clear evidence that nutrition supplements are effective for weight loss. A
Pharmacotherapy
8.14 When choosing glucose-lowering medications for people with type 2 diabetes and overweight or obesity, consider the medication’s effect on weight. B
8.15 Whenever possible, minimize medications for comorbid conditions that are associated with weight gain. E
8.16 Obesity pharmacotherapy is effective as an adjunct to nutrition, physical activity, and behavioral counseling for selected people with type 2 diabetes and BMI ≥27 kg/m2. Potential benefits and risks must be considered. A
8.17 If obesity pharmacotherapy is effective (typically defined as ≥5% weight loss after 3 months’ use), further weight loss is likely with continued use. When early response is insufficient (typically <5% weight loss after 3 months’ use) or if there are significant safety or tolerability issues, consider discontinuation of the medication and evaluate alternative medications or treatment approaches. A
8.15 Whenever possible, minimize medications for comorbid conditions that are associated with weight gain. E
8.16 Obesity pharmacotherapy is effective as an adjunct to nutrition, physical activity, and behavioral counseling for selected people with type 2 diabetes and BMI ≥27 kg/m2. Potential benefits and risks must be considered. A
8.17 If obesity pharmacotherapy is effective (typically defined as ≥5% weight loss after 3 months’ use), further weight loss is likely with continued use. When early response is insufficient (typically <5% weight loss after 3 months’ use) or if there are significant safety or tolerability issues, consider discontinuation of the medication and evaluate alternative medications or treatment approaches. A
Metabolic Surgery
8.18 Metabolic surgery should be a recommended option to treat type 2 diabetes in screened surgical candidates with BMI ≥40 kg/m2 (BMI ≥37.5 kg/m2 in Asian American individuals) and in adults with BMI 35.0–39.9 kg/m2 (32.5–37.4 kg/m2 in Asian American individuals) who do not achieve durable weight loss and improvement in comorbidities (including hyperglycemia) with nonsurgical methods. A
8.19 Metabolic surgery may be considered as an option to treat type 2 diabetes in adults with BMI 30.0–34.9 kg/m2 (27.5–32.4 kg/m2 in Asian American individuals) who do not achieve durable weight loss and improvement in comorbidities (including hyperglycemia) with nonsurgical methods. A
8.20 Metabolic surgery should be performed in high-volume centers with multidisciplinary teams knowledgeable about and experienced in managing obesity, diabetes, and gastrointestinal surgery. E
8.21 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
8.22 People who undergo metabolic surgery should receive long-term medical and behavioral support and routine micronutrient, nutritional, and metabolic status monitoring. B
8.23 If postbariatric hypoglycemia is suspected, clinical evaluation should exclude other potential disorders contributing to hypoglycemia, and management includes education, medical nutrition therapy with a dietitian experienced in postbariatric hypoglycemia, and medication treatment, as needed. A Continuous glucose monitoring should be considered as an important adjunct to improve safety by alerting individuals to hypoglycemia, especially for those with severe hypoglycemia or hypoglycemia unawareness. E
8.24 People who undergo metabolic surgery should routinely be evaluated to assess the need for ongoing mental health services to help with the adjustment to medical and psychosocial changes after surgery. C
8.19 Metabolic surgery may be considered as an option to treat type 2 diabetes in adults with BMI 30.0–34.9 kg/m2 (27.5–32.4 kg/m2 in Asian American individuals) who do not achieve durable weight loss and improvement in comorbidities (including hyperglycemia) with nonsurgical methods. A
8.20 Metabolic surgery should be performed in high-volume centers with multidisciplinary teams knowledgeable about and experienced in managing obesity, diabetes, and gastrointestinal surgery. E
8.21 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
8.22 People who undergo metabolic surgery should receive long-term medical and behavioral support and routine micronutrient, nutritional, and metabolic status monitoring. B
8.23 If postbariatric hypoglycemia is suspected, clinical evaluation should exclude other potential disorders contributing to hypoglycemia, and management includes education, medical nutrition therapy with a dietitian experienced in postbariatric hypoglycemia, and medication treatment, as needed. A Continuous glucose monitoring should be considered as an important adjunct to improve safety by alerting individuals to hypoglycemia, especially for those with severe hypoglycemia or hypoglycemia unawareness. E
8.24 People who undergo metabolic surgery should routinely be evaluated to assess the need for ongoing mental health services to help with the adjustment to medical and psychosocial changes after surgery. C
Pharmacologic Approaches to Glycemic Treatment
Pharmacologic Therapy for Adults With Type 1 Diabetes
9.1 Most individuals with type 1 diabetes should be treated with multiple daily injections of prandial and basal insulin, or continuous subcutaneous insulin infusion. A
9.2 Most individuals with type 1 diabetes should use rapid-acting insulin analogs to reduce hypoglycemia risk. A
9.3 Individuals with type 1 diabetes should receive education on how to match mealtime insulin doses to carbohydrate intake, fat and protein content, and anticipated physical activity. B
9.2 Most individuals with type 1 diabetes should use rapid-acting insulin analogs to reduce hypoglycemia risk. A
9.3 Individuals with type 1 diabetes should receive education on how to match mealtime insulin doses to carbohydrate intake, fat and protein content, and anticipated physical activity. B
Pharmacologic Therapy for Adults with Type 2 Diabetes
9.4a Healthy lifestyle behaviors, diabetes self-management education and support, avoidance of clinical inertia, and social determinants of health should be considered in the glucose-lowering management of type 2 diabetes. Pharmacologic therapy should be guided by person-centered treatment factors, including comorbidities and treatment goals. A
9.4b In adults with type 2 diabetes and established/high risk of atherosclerotic cardiovascular disease, heart failure, and/or chronic kidney disease, the treatment regimen should include agents that reduce cardiorenal risk (Fig. 9.3 and Table 9.2 ). A
9.4c Pharmacologic approaches that provide adequate efficacy to achieve and maintain treatment goals should be considered, such as metformin or other agents, including combination therapy (Fig. 9.3 and Table 9.2 ). A
9.4d Weight management is an impactful component of glucose-lowering management in type 2 diabetes. The glucose-lowering treatment regimen should consider approaches that support weight management goals (Fig. 9.3 and Table 9.2 ). A
9.5 Metformin should be continued upon initiation of insulin therapy (unless contraindicated or not tolerated) for ongoing glycemic and metabolic benefits. A
9.6 Early combination therapy can be considered in some individuals at treatment initiation to extend the time to treatment failure. A
9.7 The early introduction of insulin should be considered if there is evidence of ongoing catabolism (weight loss), if symptoms of hyperglycemia are present, or when A1C levels (>10% [86 mmol/mol]) or blood glucose levels (≥300 mg/dL [16.7 mmol/L]) are very high. E
9.8 A person-centered approach should guide the choice of pharmacologic agents. Consider the effects on cardiovascular and renal comorbidities, efficacy, hypoglycemia risk, impact on weight, cost and access, risk for side effects, and individual preferences (Fig. 9.3 and Table 9.2 ). E
9.9 Among individuals with type 2 diabetes who have established atherosclerotic cardiovascular disease or indicators of high cardiovascular risk, established kidney disease, or heart failure, a sodium–glucose cotransporter 2 inhibitor and/or glucagon-like peptide 1 receptor agonist with demonstrated cardiovascular disease benefit (Fig. 9.3 , Table 9.2 , Table 10.3B, and Table 10.3C) is recommended as part of the glucose-lowering regimen and comprehensive cardiovascular risk reduction, independent of A1C and in consideration of person-specific factors (Fig. 9.3 ) (see Section 10, “Cardiovascular Disease and Risk Management,” for details on cardiovascular risk reduction recommendations). A
9.10 In adults with type 2 diabetes, a glucagon-like peptide 1 receptor agonist is preferred to insulin when possible. A
9.11 If insulin is used, combination therapy with a glucagon-like peptide 1 receptor agonist is recommended for greater efficacy, durability of treatment effect, and weight and hypoglycemia benefit. A
9.12 Recommendation for treatment intensification for individuals not meeting treatment goals should not be delayed. A
9.13 Medication regimen and medication-taking behavior should be reevaluated at regular intervals (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
9.14 Clinicians should be aware of the potential for overbasalization with insulin therapy. Clinical signals that may prompt evaluation of overbasalization include basal dose more than ∼0.5 units/kg/day, high bedtime–morning or postpreprandial glucose differential, hypoglycemia (aware or unaware), and high glycemic variability. Indication of overbasalization should prompt reevaluation to further individualize therapy. E
9.4b In adults with type 2 diabetes and established/high risk of atherosclerotic cardiovascular disease, heart failure, and/or chronic kidney disease, the treatment regimen should include agents that reduce cardiorenal risk (Fig. 9.3 and Table 9.2 ). A
9.4c Pharmacologic approaches that provide adequate efficacy to achieve and maintain treatment goals should be considered, such as metformin or other agents, including combination therapy (Fig. 9.3 and Table 9.2 ). A
9.4d Weight management is an impactful component of glucose-lowering management in type 2 diabetes. The glucose-lowering treatment regimen should consider approaches that support weight management goals (Fig. 9.3 and Table 9.2 ). A
9.5 Metformin should be continued upon initiation of insulin therapy (unless contraindicated or not tolerated) for ongoing glycemic and metabolic benefits. A
9.6 Early combination therapy can be considered in some individuals at treatment initiation to extend the time to treatment failure. A
9.7 The early introduction of insulin should be considered if there is evidence of ongoing catabolism (weight loss), if symptoms of hyperglycemia are present, or when A1C levels (>10% [86 mmol/mol]) or blood glucose levels (≥300 mg/dL [16.7 mmol/L]) are very high. E
9.8 A person-centered approach should guide the choice of pharmacologic agents. Consider the effects on cardiovascular and renal comorbidities, efficacy, hypoglycemia risk, impact on weight, cost and access, risk for side effects, and individual preferences (Fig. 9.3 and Table 9.2 ). E
9.9 Among individuals with type 2 diabetes who have established atherosclerotic cardiovascular disease or indicators of high cardiovascular risk, established kidney disease, or heart failure, a sodium–glucose cotransporter 2 inhibitor and/or glucagon-like peptide 1 receptor agonist with demonstrated cardiovascular disease benefit (Fig. 9.3 , Table 9.2 , Table 10.3B, and Table 10.3C) is recommended as part of the glucose-lowering regimen and comprehensive cardiovascular risk reduction, independent of A1C and in consideration of person-specific factors (Fig. 9.3 ) (see Section 10, “Cardiovascular Disease and Risk Management,” for details on cardiovascular risk reduction recommendations). A
9.10 In adults with type 2 diabetes, a glucagon-like peptide 1 receptor agonist is preferred to insulin when possible. A
9.11 If insulin is used, combination therapy with a glucagon-like peptide 1 receptor agonist is recommended for greater efficacy, durability of treatment effect, and weight and hypoglycemia benefit. A
9.12 Recommendation for treatment intensification for individuals not meeting treatment goals should not be delayed. A
9.13 Medication regimen and medication-taking behavior should be reevaluated at regular intervals (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
9.14 Clinicians should be aware of the potential for overbasalization with insulin therapy. Clinical signals that may prompt evaluation of overbasalization include basal dose more than ∼0.5 units/kg/day, high bedtime–morning or postpreprandial glucose differential, hypoglycemia (aware or unaware), and high glycemic variability. Indication of overbasalization should prompt reevaluation to further individualize therapy. E
Cardiovascular Disease and Risk Management
Screening and Diagnosis
10.1 Blood pressure should be measured at every routine clinical visit. When possible, individuals found to have elevated blood pressure (systolic blood pressure 120–129 mmHg and diastolic <80 mmHg) should have blood pressure confirmed using multiple readings, including measurements on a separate day, to diagnose hypertension. A Hypertension is defined as a systolic blood pressure ≥130 mmHg or a diastolic blood pressure ≥80 mmHg based on an average of ≥2 measurements obtained on ≥2 occasions. A Individuals with blood pressure ≥180/110 mmHg and cardiovascular disease could be diagnosed with hypertension at a single visit. E
10.2 All people with hypertension and diabetes should monitor their blood pressure at home. A
10.2 All people with hypertension and diabetes should monitor their blood pressure at home. A
Treatment Goals
10.3 For people with diabetes and hypertension, blood pressure targets should be individualized through a shared decision-making process that addresses cardiovascular risk, potential adverse effects of antihypertensive medications, and patient preferences. B
10.4 People with diabetes and hypertension qualify for antihypertensive drug therapy when the blood pressure is persistently elevated ≥130/80 mmHg. The on-treatment target blood pressure goal is <130/80 mmHg, if it can be safely attained. B
10.5 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 lessened for blood pressure <90/60 mmHg. E A blood pressure target of 110–135/85 mmHg is suggested in the interest of reducing the risk for accelerated maternal hypertension. A
10.4 People with diabetes and hypertension qualify for antihypertensive drug therapy when the blood pressure is persistently elevated ≥130/80 mmHg. The on-treatment target blood pressure goal is <130/80 mmHg, if it can be safely attained. B
10.5 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 lessened for blood pressure <90/60 mmHg. E A blood pressure target of 110–135/85 mmHg is suggested in the interest of reducing the risk for accelerated maternal hypertension. A
Lifestyle Intervention
10.6 For people with blood pressure >120/80 mmHg, lifestyle intervention consists of weight loss when indicated, a Dietary Approaches to Stop Hypertension (DASH)-style eating pattern including reducing sodium and increasing potassium intake, moderation of alcohol intake, and increased physical activity. A
Pharmacologic Interventions
10.7 Individuals with confirmed office-based blood pressure ≥130/80 mmHg qualify for initiation and titration of pharmacologic therapy to achieve the recommended blood pressure goal of <130/80 mmHg. A
10.8 Individuals with confirmed office-based blood pressure ≥160/100 mmHg should, in addition to lifestyle therapy, have prompt initiation and timely titration of two drugs or a single-pill combination of drugs demonstrated to reduce cardiovascular events in people with diabetes. A
10.9 Treatment for hypertension should include drug classes demonstrated to reduce cardiovascular events in people with diabetes. A ACE inhibitors or angiotensin receptor blockers are recommended first-line therapy for hypertension in people with diabetes and coronary artery disease. A
10.10 Multiple-drug therapy is generally required to achieve blood pressure targets. However, combinations of ACE inhibitors and angiotensin receptor blockers and combinations of ACE inhibitors or angiotensin receptor blockers with direct renin inhibitors should not be used. A
10.11 An ACE inhibitor or angiotensin receptor blocker, at the maximum tolerated dose indicated for blood pressure treatment, is the recommended first-line treatment for hypertension in people with diabetes and urinary albumin-to-creatinine ratio ≥300 mg/g creatinine A or 30–299 mg/g creatinine. B If one class is not tolerated, the other should be substituted. B
10.12 For patients treated with an ACE inhibitor, angiotensin receptor blocker, or diuretic, serum creatinine/estimated glomerular filtration rate and serum potassium levels should be monitored at least annually. B
10.8 Individuals with confirmed office-based blood pressure ≥160/100 mmHg should, in addition to lifestyle therapy, have prompt initiation and timely titration of two drugs or a single-pill combination of drugs demonstrated to reduce cardiovascular events in people with diabetes. A
10.9 Treatment for hypertension should include drug classes demonstrated to reduce cardiovascular events in people with diabetes. A ACE inhibitors or angiotensin receptor blockers are recommended first-line therapy for hypertension in people with diabetes and coronary artery disease. A
10.10 Multiple-drug therapy is generally required to achieve blood pressure targets. However, combinations of ACE inhibitors and angiotensin receptor blockers and combinations of ACE inhibitors or angiotensin receptor blockers with direct renin inhibitors should not be used. A
10.11 An ACE inhibitor or angiotensin receptor blocker, at the maximum tolerated dose indicated for blood pressure treatment, is the recommended first-line treatment for hypertension in people with diabetes and urinary albumin-to-creatinine ratio ≥300 mg/g creatinine A or 30–299 mg/g creatinine. B If one class is not tolerated, the other should be substituted. B
10.12 For patients treated with an ACE inhibitor, angiotensin receptor blocker, or diuretic, serum creatinine/estimated glomerular filtration rate and serum potassium levels should be monitored at least annually. B
Lipid Management
10.15 Lifestyle modification focusing on weight loss (if indicated); application of a Mediterranean style or Dietary Approaches to Stop Hypertension (DASH) eating pattern; reduction of saturated fat and trans fat; increase of dietary n-3 fatty acids, viscous fiber, and plant stanols/sterols intake; and increased physical activity should be recommended to improve the lipid profile and reduce the risk of developing atherosclerotic cardiovascular disease in patients with diabetes. A
10.16 Intensify lifestyle therapy and optimize glycemic control for patients with elevated triglyceride levels (≥150 mg/dL [1.7 mmol/L]) and/or low HDL cholesterol (<40 mg/dL [1.0 mmol/L] for men, <50 mg/dL [1.3 mmol/L] for women). C
10.16 Intensify lifestyle therapy and optimize glycemic control for patients with elevated triglyceride levels (≥150 mg/dL [1.7 mmol/L]) and/or low HDL cholesterol (<40 mg/dL [1.0 mmol/L] for men, <50 mg/dL [1.3 mmol/L] for women). C
Ongoing Therapy and Monitoring With Lipid Panel
10.17 In adults not taking statins or other lipid-lowering therapy, it is reasonable to obtain a lipid profile at the time of diabetes diagnosis, at an initial medical evaluation, and every 5 years thereafter if under the age of 40 years, or more frequently if indicated. E
10.18 Obtain a lipid profile at initiation of statins or other lipid-lowering therapy, 4–12 weeks after initiation or a change in dose, and annually thereafter as it may help to monitor the response to therapy and inform medication adherence. E
10.18 Obtain a lipid profile at initiation of statins or other lipid-lowering therapy, 4–12 weeks after initiation or a change in dose, and annually thereafter as it may help to monitor the response to therapy and inform medication adherence. E
Pharmacologic Interventions
10.8 Patients with confirmed office-based blood pressure ≥140/90 mmHg should, in addition to lifestyle therapy, have prompt initiation and timely titration of pharmacologic therapy to achieve blood pressure goals. A
10.9 Patients with confirmed office-based blood pressure ≥160/100 mmHg should, in addition to lifestyle therapy, have prompt initiation and timely titration of two drugs or a single-pill combination of drugs demonstrated to reduce cardiovascular events in patients with diabetes. A
10.10 Treatment for hypertension should include drug classes demonstrated to reduce cardiovascular events in patients with diabetes. A ACE inhibitors or angiotensin receptor blockers are recommended first-line therapy for hypertension in people with diabetes and coronary artery disease. A
10.11 Multiple-drug therapy is generally required to achieve blood pressure targets. However, combinations of ACE inhibitors and angiotensin receptor blockers and combinations of ACE inhibitors or angiotensin receptor blockers with direct renin inhibitors should not be used. A
10.12 An ACE inhibitor or angiotensin receptor blocker, at the maximum tolerated dose indicated for blood pressure treatment, is the recommended first-line treatment for hypertension in patients with diabetes and urinary albumin-to-creatinine ratio ≥300 mg/g creatinine A or 30–299 mg/g creatinine. B If one class is not tolerated, the other should be substituted. B
10.13 For patients treated with an ACE inhibitor, angiotensin receptor blocker, or diuretic, serum creatinine/estimated glomerular filtration rate and serum potassium levels should be monitored at least annually. B
10.9 Patients with confirmed office-based blood pressure ≥160/100 mmHg should, in addition to lifestyle therapy, have prompt initiation and timely titration of two drugs or a single-pill combination of drugs demonstrated to reduce cardiovascular events in patients with diabetes. A
10.10 Treatment for hypertension should include drug classes demonstrated to reduce cardiovascular events in patients with diabetes. A ACE inhibitors or angiotensin receptor blockers are recommended first-line therapy for hypertension in people with diabetes and coronary artery disease. A
10.11 Multiple-drug therapy is generally required to achieve blood pressure targets. However, combinations of ACE inhibitors and angiotensin receptor blockers and combinations of ACE inhibitors or angiotensin receptor blockers with direct renin inhibitors should not be used. A
10.12 An ACE inhibitor or angiotensin receptor blocker, at the maximum tolerated dose indicated for blood pressure treatment, is the recommended first-line treatment for hypertension in patients with diabetes and urinary albumin-to-creatinine ratio ≥300 mg/g creatinine A or 30–299 mg/g creatinine. B If one class is not tolerated, the other should be substituted. B
10.13 For patients treated with an ACE inhibitor, angiotensin receptor blocker, or diuretic, serum creatinine/estimated glomerular filtration rate and serum potassium levels should be monitored at least annually. B
Resistant Hypertension
10.13 Individuals with hypertension who are not meeting blood pressure targets on three classes of antihypertensive medications (including a diuretic) should be considered for mineralocorticoid receptor antagonist therapy. A
Lipid Management
10.14 Lifestyle modification focusing on weight loss (if indicated); application of a Mediterranean or Dietary Approaches to Stop Hypertension (DASH) eating pattern; reduction of saturated fat and trans fat; increase of dietary n-3 fatty acids, viscous fiber, and plant stanols/sterols intake; and increased physical activity should be recommended to improve the lipid profile and reduce the risk of developing atherosclerotic cardiovascular disease in people with diabetes. A
10.15 Intensify lifestyle therapy and optimize glycemic control for patients with elevated triglyceride levels (≥150 mg/dL [1.7 mmol/L]) and/or low HDL cholesterol (<40 mg/dL [1.0 mmol/L] for men, <50 mg/dL [1.3 mmol/L] for women). C
10.15 Intensify lifestyle therapy and optimize glycemic control for patients with elevated triglyceride levels (≥150 mg/dL [1.7 mmol/L]) and/or low HDL cholesterol (<40 mg/dL [1.0 mmol/L] for men, <50 mg/dL [1.3 mmol/L] for women). C
Ongoing Therapy and Monitoring With Lipid Panel
10.16 In adults not taking statins or other lipid-lowering therapy, it is reasonable to obtain a lipid profile at the time of diabetes diagnosis, at an initial medical evaluation, and every 5 years thereafter if under the age of 40 years, or more frequently if indicated. E
10.17 Obtain a lipid profile at initiation of statins or other lipid-lowering therapy, 4–12 weeks after initiation or a change in dose, and annually thereafter as it may help to monitor the response to therapy and inform medication taking. E
10.17 Obtain a lipid profile at initiation of statins or other lipid-lowering therapy, 4–12 weeks after initiation or a change in dose, and annually thereafter as it may help to monitor the response to therapy and inform medication taking. E
Statin Treatment - Primary Prevention
10.18 For people with diabetes aged 40–75 years without atherosclerotic cardiovascular disease, use moderate-intensity statin therapy in addition to lifestyle therapy. A
10.19 For people with diabetes aged 20–39 years with additional atherosclerotic cardiovascular disease risk factors, it may be reasonable to initiate statin therapy in addition to lifestyle therapy. C
10.20 For people with diabetes aged 40–75 at higher cardiovascular risk, including those with one or more atherosclerotic cardiovascular disease risk factors, it is recommended to use high-intensity statin therapy to reduce LDL cholesterol by ≥50% of baseline and to target an LDL cholesterol goal of <70 mg/dL. B
10.21 For people with diabetes aged 40–75 years at higher cardiovascular risk, especially those with multiple atherosclerotic cardiovascular disease risk factors and an LDL cholesterol ≥70 mg/dL, it may be reasonable to add ezetimibe or a PCSK9 inhibitor to maximum tolerated statin therapy. C
10.22 In adults with diabetes aged >75 years already on statin therapy, it is reasonable to continue statin treatment. B
10.23 In adults with diabetes aged >75 years, it may be reasonable to initiate moderate-intensity statin therapy after discussion of potential benefits and risks. C
10.24 Statin therapy is contraindicated in pregnancy. B
10.19 For people with diabetes aged 20–39 years with additional atherosclerotic cardiovascular disease risk factors, it may be reasonable to initiate statin therapy in addition to lifestyle therapy. C
10.20 For people with diabetes aged 40–75 at higher cardiovascular risk, including those with one or more atherosclerotic cardiovascular disease risk factors, it is recommended to use high-intensity statin therapy to reduce LDL cholesterol by ≥50% of baseline and to target an LDL cholesterol goal of <70 mg/dL. B
10.21 For people with diabetes aged 40–75 years at higher cardiovascular risk, especially those with multiple atherosclerotic cardiovascular disease risk factors and an LDL cholesterol ≥70 mg/dL, it may be reasonable to add ezetimibe or a PCSK9 inhibitor to maximum tolerated statin therapy. C
10.22 In adults with diabetes aged >75 years already on statin therapy, it is reasonable to continue statin treatment. B
10.23 In adults with diabetes aged >75 years, it may be reasonable to initiate moderate-intensity statin therapy after discussion of potential benefits and risks. C
10.24 Statin therapy is contraindicated in pregnancy. B
Statin Treatment - Secondary Prevention
10.25 For people of all ages with diabetes and atherosclerotic cardiovascular disease, high-intensity statin therapy should be added to lifestyle therapy. A
10.26 For people with diabetes and atherosclerotic cardiovascular disease, treatment with high-intensity statin therapy is recommended to target an LDL cholesterol reduction of ≥50% from baseline and an LDL cholesterol goal of <55 mg/dL. Addition of ezetimibe or a PCSK9 inhibitor with proven benefit in this population is recommended if this goal is not achieved on maximum tolerated statin therapy. B
10.27 For individuals who do not tolerate the intended intensity, the maximum tolerated statin dose should be used. E
10.26 For people with diabetes and atherosclerotic cardiovascular disease, treatment with high-intensity statin therapy is recommended to target an LDL cholesterol reduction of ≥50% from baseline and an LDL cholesterol goal of <55 mg/dL. Addition of ezetimibe or a PCSK9 inhibitor with proven benefit in this population is recommended if this goal is not achieved on maximum tolerated statin therapy. B
10.27 For individuals who do not tolerate the intended intensity, the maximum tolerated statin dose should be used. E
Treatment of Other Lipoprotein Fractions or Targets
10.28 For individuals with fasting triglyceride levels ≥500 mg/dL, evaluate for secondary causes of hypertriglyceridemia and consider medical therapy to reduce the risk of pancreatitis. C
10.29 In adults with moderate hypertriglyceridemia (fasting or nonfasting triglycerides 175–499 mg/dL), clinicians should address and treat lifestyle factors (obesity and metabolic syndrome), secondary factors (diabetes, chronic liver or kidney disease and/or nephrotic syndrome, hypothyroidism), and medications that raise triglycerides. C
10.30 In individuals with atherosclerotic cardiovascular disease or other cardiovascular risk factors on a statin with controlled LDL cholesterol but elevated triglycerides (135–499 mg/dL), the addition of icosapent ethyl can be considered to reduce cardiovascular risk. A
10.29 In adults with moderate hypertriglyceridemia (fasting or nonfasting triglycerides 175–499 mg/dL), clinicians should address and treat lifestyle factors (obesity and metabolic syndrome), secondary factors (diabetes, chronic liver or kidney disease and/or nephrotic syndrome, hypothyroidism), and medications that raise triglycerides. C
10.30 In individuals with atherosclerotic cardiovascular disease or other cardiovascular risk factors on a statin with controlled LDL cholesterol but elevated triglycerides (135–499 mg/dL), the addition of icosapent ethyl can be considered to reduce cardiovascular risk. A
Other Combination Therapy
10.31 Statin plus fibrate combination therapy has not been shown to improve atherosclerotic cardiovascular disease outcomes and is generally not recommended. A
10.32 Statin plus niacin combination therapy has not been shown to provide additional cardiovascular benefit above statin therapy alone, may increase the risk of stroke with additional side effects, and is generally not recommended. A
10.32 Statin plus niacin combination therapy has not been shown to provide additional cardiovascular benefit above statin therapy alone, may increase the risk of stroke with additional side effects, and is generally not recommended. A
Antiplatelet Agents
10.33 Use aspirin therapy (75–162 mg/day) as a secondary prevention strategy in those with diabetes and a history of atherosclerotic cardiovascular disease. A
10.34 For individuals with atherosclerotic cardiovascular disease and documented aspirin allergy, clopidogrel (75 mg/day) should be used. B
10.35 Dual antiplatelet therapy (with low-dose aspirin and a P2Y12 inhibitor) is reasonable for a year after an acute coronary syndrome and may have benefits beyond this period. A
10.36 Long-term treatment with dual antiplatelet therapy should be considered for individuals with prior coronary intervention, high ischemic risk, and low bleeding risk to prevent major adverse cardiovascular events. A
10.37 Combination therapy with aspirin plus low-dose rivaroxaban should be considered for individuals with stable coronary and/or peripheral artery disease 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 patient on the benefits versus the comparable increased risk of bleeding. A
10.34 For individuals with atherosclerotic cardiovascular disease and documented aspirin allergy, clopidogrel (75 mg/day) should be used. B
10.35 Dual antiplatelet therapy (with low-dose aspirin and a P2Y12 inhibitor) is reasonable for a year after an acute coronary syndrome and may have benefits beyond this period. A
10.36 Long-term treatment with dual antiplatelet therapy should be considered for individuals with prior coronary intervention, high ischemic risk, and low bleeding risk to prevent major adverse cardiovascular events. A
10.37 Combination therapy with aspirin plus low-dose rivaroxaban should be considered for individuals with stable coronary and/or peripheral artery disease 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 patient on the benefits versus the comparable increased risk of bleeding. A
Cardiovascular Disease - Screening
10.39 In asymptomatic individuals, routine screening for coronary artery disease is not recommended as it does not improve outcomes as long as atherosclerotic cardiovascular disease risk factors are treated. A
10.40 Consider investigations for coronary artery disease in the presence of any of the following: atypical cardiac symptoms (e.g., unexplained dyspnea, chest discomfort); signs or symptoms of associated vascular disease including carotid bruits, transient ischemic attack, stroke, claudication, or peripheral arterial disease; or electrocardiogram abnormalities (e.g., Q waves). E
10.40 Consider investigations for coronary artery disease in the presence of any of the following: atypical cardiac symptoms (e.g., unexplained dyspnea, chest discomfort); signs or symptoms of associated vascular disease including carotid bruits, transient ischemic attack, stroke, claudication, or peripheral arterial disease; or electrocardiogram abnormalities (e.g., Q waves). E
Cardiovascular Disease - Treatment
10.41 Among people with type 2 diabetes who have established atherosclerotic cardiovascular disease or established kidney disease, a sodium–glucose cotransporter 2 inhibitor or glucagon-like peptide 1 receptor agonist with demonstrated cardiovascular disease benefit (Table 10.3B and Table 10.3C ) is recommended as part of the comprehensive cardiovascular risk reduction and/or glucose-lowering regimens. A
10.41a In people with type 2 diabetes and established atherosclerotic cardiovascular disease, multiple atherosclerotic cardiovascular disease risk factors, or diabetic kidney disease, a sodium–glucose cotransporter 2 inhibitor with demonstrated cardiovascular benefit is recommended to reduce the risk of major adverse cardiovascular events and/or heart failure hospitalization. A
10.41b In people with type 2 diabetes and established atherosclerotic cardiovascular disease or multiple risk factors for atherosclerotic cardiovascular disease, a glucagon-like peptide 1 receptor agonist with demonstrated cardiovascular benefit is recommended to reduce the risk of major adverse cardiovascular events. A
10.41c In people with type 2 diabetes and established atherosclerotic cardiovascular disease or multiple risk factors for atherosclerotic cardiovascular disease, combined therapy with a sodium–glucose cotransporter 2 inhibitor with demonstrated cardiovascular benefit and a glucagon-like peptide 1 receptor agonist with demonstrated cardiovascular benefit may be considered for additive reduction in the risk of adverse cardiovascular and kidney events. A
10.42a In people with type 2 diabetes and established heart failure with either preserved or reduced ejection fraction, a sodium–glucose cotransporter 2 inhibitor with proven benefit in this patient population is recommended to reduce risk of worsening heart failure and cardiovascular death. A
10.42b In people with type 2 diabetes and established heart failure with either preserved or reduced ejection fraction, a sodium–glucose cotransporter 2 inhibitor with proven benefit in this patient population is recommended to improve symptoms, physical limitations, and quality of life. A
10.43 For people with type 2 diabetes and chronic kidney disease with albuminuria treated with maximum tolerated doses of ACE inhibitor or angiotensin receptor blocker, addition of finerenone is recommended to improve cardiovascular outcomes and reduce the risk of chronic kidney disease progression. A
10.44 In people with known atherosclerotic cardiovascular disease, particularly coronary artery disease, ACE inhibitor or angiotensin receptor blocker therapy is recommended to reduce the risk of cardiovascular events. A
10.45 In people with prior myocardial infarction, β-blockers should be continued for 3 years after the event. B
10.46 Treatment of individuals with heart failure with reduced ejection fraction should include a β-blocker with proven cardiovascular outcomes benefit, unless otherwise contraindicated. A
10.47 In people with type 2 diabetes with stable heart failure, metformin may be continued for glucose lowering if estimated glomerular filtration rate remains >30 mL/min/1.73 m2 but should be avoided in unstable or hospitalized individuals with heart failure. B
10.41a In people with type 2 diabetes and established atherosclerotic cardiovascular disease, multiple atherosclerotic cardiovascular disease risk factors, or diabetic kidney disease, a sodium–glucose cotransporter 2 inhibitor with demonstrated cardiovascular benefit is recommended to reduce the risk of major adverse cardiovascular events and/or heart failure hospitalization. A
10.41b In people with type 2 diabetes and established atherosclerotic cardiovascular disease or multiple risk factors for atherosclerotic cardiovascular disease, a glucagon-like peptide 1 receptor agonist with demonstrated cardiovascular benefit is recommended to reduce the risk of major adverse cardiovascular events. A
10.41c In people with type 2 diabetes and established atherosclerotic cardiovascular disease or multiple risk factors for atherosclerotic cardiovascular disease, combined therapy with a sodium–glucose cotransporter 2 inhibitor with demonstrated cardiovascular benefit and a glucagon-like peptide 1 receptor agonist with demonstrated cardiovascular benefit may be considered for additive reduction in the risk of adverse cardiovascular and kidney events. A
10.42a In people with type 2 diabetes and established heart failure with either preserved or reduced ejection fraction, a sodium–glucose cotransporter 2 inhibitor with proven benefit in this patient population is recommended to reduce risk of worsening heart failure and cardiovascular death. A
10.42b In people with type 2 diabetes and established heart failure with either preserved or reduced ejection fraction, a sodium–glucose cotransporter 2 inhibitor with proven benefit in this patient population is recommended to improve symptoms, physical limitations, and quality of life. A
10.43 For people with type 2 diabetes and chronic kidney disease with albuminuria treated with maximum tolerated doses of ACE inhibitor or angiotensin receptor blocker, addition of finerenone is recommended to improve cardiovascular outcomes and reduce the risk of chronic kidney disease progression. A
10.44 In people with known atherosclerotic cardiovascular disease, particularly coronary artery disease, ACE inhibitor or angiotensin receptor blocker therapy is recommended to reduce the risk of cardiovascular events. A
10.45 In people with prior myocardial infarction, β-blockers should be continued for 3 years after the event. B
10.46 Treatment of individuals with heart failure with reduced ejection fraction should include a β-blocker with proven cardiovascular outcomes benefit, unless otherwise contraindicated. A
10.47 In people with type 2 diabetes with stable heart failure, metformin may be continued for glucose lowering if estimated glomerular filtration rate remains >30 mL/min/1.73 m2 but should be avoided in unstable or hospitalized individuals with heart failure. B
Chronic Kidney Disease and Risk Management
Chronic Kidney Disease - Screening
11.1a At least annually, urinary albumin (e.g., spot urinary albumin-to-creatinine ratio) and estimated glomerular filtration rate should be assessed 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 diabetic kidney disease, urinary albumin (e.g., spot urinary albumin-to-creatinine ratio) and estimated glomerular filtration rate should be monitored 1–4 times per year depending on the stage of the disease (Fig. 11.1 ). B
11.1b In people with established diabetic kidney disease, urinary albumin (e.g., spot urinary albumin-to-creatinine ratio) and estimated glomerular filtration rate should be monitored 1–4 times per year depending on the stage of the disease (Fig. 11.1 ). B
Chronic Kidney Disease - Treatment
11.2 Optimize glucose control to reduce the risk or slow the progression of chronic kidney disease. A
11.3 Optimize blood pressure control and reduce blood pressure variability to reduce the risk or slow the progression of chronic kidney disease. A
11.4a In nonpregnant people with diabetes and hypertension, either an ACE inhibitor or an angiotensin receptor blocker is recommended for those with moderately increased albuminuria (urinary albumin-to-creatinine ratio 30–299 mg/g creatinine) B and is strongly recommended for those with severely increased albuminuria (urinary albumin-to-creatinine ratio ≥300 mg/g creatinine) and/or estimated glomerular filtration rate <60 mL/min/1.73 m2. A
11.4b Periodically monitor serum creatinine and potassium levels for the development of increased creatinine and hyperkalemia when ACE inhibitors, angiotensin receptor blockers, and mineralocorticoid receptor antagonists are used, or hypokalemia when diuretics are used. B
11.4c An ACE inhibitor or an angiotensin receptor blocker is not recommended for the primary prevention of chronic kidney disease in people with diabetes who have normal blood pressure, normal urinary albumin-to-creatinine ratio (<30 mg/g creatinine), and normal estimated glomerular filtration rate. A
11.4d Do not discontinue renin-angiotensin system blockade for increases in serum creatinine (≤30%) in the absence of volume depletion. A
11.5a For people with type 2 diabetes and diabetic kidney disease, use of a sodium–glucose cotransporter 2 inhibitor is recommended to reduce chronic kidney disease progression and cardiovascular events in patients with an estimated glomerular filtration rate ≥20 mL/min/1.73 m2 and urinary albumin ≥200 mg/g creatinine. A
11.5b For people with type 2 diabetes and diabetic kidney disease, use of a sodium–glucose cotransporter 2 inhibitor is recommended to reduce chronic kidney disease progression and cardiovascular events in patients with an estimated glomerular filtration rate ≥20 mL/min/1.73 m2 and urinary albumin ranging from normal to 200 mg/g creatinine. B
11.5c In people with type 2 diabetes and diabetic kidney disease, consider use of sodium–glucose cotransporter 2 inhibitors (if estimated glomerular filtration rate is ≥20 mL/min/1.73 m2), a glucagon-like peptide 1 agonist, or a nonsteroidal mineralocorticoid receptor antagonist (if estimated glomerular filtration rate is ≥25 mL/min/1.73 m2) additionally for cardiovascular risk reduction. A
11.5d In people with chronic kidney disease and albuminuria who are at increased risk for cardiovascular events or chronic kidney disease progression, a nonsteroidal mineralocorticoid receptor antagonist shown to be effective in clinical trials is recommended to reduce chronic kidney disease progression and cardiovascular events. A
11.6 In people with chronic kidney disease who have ≥300 mg/g urinary albumin, a reduction of 30% or greater in mg/g urinary albumin is recommended to slow chronic kidney disease progression. B
11.7 For people with non–dialysis-dependent stage 3 or higher chronic kidney disease, dietary protein intake should be aimed to a target level of 0.8 g/kg body weight per day. A For patients on dialysis, higher levels of dietary protein intake should be considered since protein energy wasting is a major problem in some individuals on dialysis. B
11.8 Patients should be referred for evaluation by a nephrologist if they have continuously increasing urinary albumin levels and/or continuously decreasing estimated glomerular filtration rate and if the estimated glomerular filtration rate is <30 mL/min/1.73 m2. A
11.9 Promptly refer to a nephrologist for uncertainty about the etiology of kidney disease, difficult management issues, and rapidly progressing kidney disease. A
11.3 Optimize blood pressure control and reduce blood pressure variability to reduce the risk or slow the progression of chronic kidney disease. A
11.4a In nonpregnant people with diabetes and hypertension, either an ACE inhibitor or an angiotensin receptor blocker is recommended for those with moderately increased albuminuria (urinary albumin-to-creatinine ratio 30–299 mg/g creatinine) B and is strongly recommended for those with severely increased albuminuria (urinary albumin-to-creatinine ratio ≥300 mg/g creatinine) and/or estimated glomerular filtration rate <60 mL/min/1.73 m2. A
11.4b Periodically monitor serum creatinine and potassium levels for the development of increased creatinine and hyperkalemia when ACE inhibitors, angiotensin receptor blockers, and mineralocorticoid receptor antagonists are used, or hypokalemia when diuretics are used. B
11.4c An ACE inhibitor or an angiotensin receptor blocker is not recommended for the primary prevention of chronic kidney disease in people with diabetes who have normal blood pressure, normal urinary albumin-to-creatinine ratio (<30 mg/g creatinine), and normal estimated glomerular filtration rate. A
11.4d Do not discontinue renin-angiotensin system blockade for increases in serum creatinine (≤30%) in the absence of volume depletion. A
11.5a For people with type 2 diabetes and diabetic kidney disease, use of a sodium–glucose cotransporter 2 inhibitor is recommended to reduce chronic kidney disease progression and cardiovascular events in patients with an estimated glomerular filtration rate ≥20 mL/min/1.73 m2 and urinary albumin ≥200 mg/g creatinine. A
11.5b For people with type 2 diabetes and diabetic kidney disease, use of a sodium–glucose cotransporter 2 inhibitor is recommended to reduce chronic kidney disease progression and cardiovascular events in patients with an estimated glomerular filtration rate ≥20 mL/min/1.73 m2 and urinary albumin ranging from normal to 200 mg/g creatinine. B
11.5c In people with type 2 diabetes and diabetic kidney disease, consider use of sodium–glucose cotransporter 2 inhibitors (if estimated glomerular filtration rate is ≥20 mL/min/1.73 m2), a glucagon-like peptide 1 agonist, or a nonsteroidal mineralocorticoid receptor antagonist (if estimated glomerular filtration rate is ≥25 mL/min/1.73 m2) additionally for cardiovascular risk reduction. A
11.5d In people with chronic kidney disease and albuminuria who are at increased risk for cardiovascular events or chronic kidney disease progression, a nonsteroidal mineralocorticoid receptor antagonist shown to be effective in clinical trials is recommended to reduce chronic kidney disease progression and cardiovascular events. A
11.6 In people with chronic kidney disease who have ≥300 mg/g urinary albumin, a reduction of 30% or greater in mg/g urinary albumin is recommended to slow chronic kidney disease progression. B
11.7 For people with non–dialysis-dependent stage 3 or higher chronic kidney disease, dietary protein intake should be aimed to a target level of 0.8 g/kg body weight per day. A For patients on dialysis, higher levels of dietary protein intake should be considered since protein energy wasting is a major problem in some individuals on dialysis. B
11.8 Patients should be referred for evaluation by a nephrologist if they have continuously increasing urinary albumin levels and/or continuously decreasing estimated glomerular filtration rate and if the estimated glomerular filtration rate is <30 mL/min/1.73 m2. A
11.9 Promptly refer to a nephrologist for uncertainty about the etiology of kidney disease, difficult management issues, and rapidly progressing kidney disease. A
Retinopathy, Neuropathy, and Foot Care
Diabetic Retinopathy
12.1 Optimize glycemic control to reduce the risk or slow the progression of diabetic retinopathy. A
12.2 Optimize blood pressure and serum lipid control to reduce the risk or slow the progression of diabetic retinopathy. A
12.2 Optimize blood pressure and serum lipid control to reduce the risk or slow the progression of diabetic retinopathy. A
Diabetic Retinopathy Screening
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 Patients 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 for one or more annual eye exams and glycemia is well controlled, 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 will be required more frequently. B
12.6 Programs that use retinal photography (with remote reading or use of a validated assessment tool) to improve access to diabetic retinopathy screening can be 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 Women with preexisting type 1 or type 2 diabetes who are planning pregnancy or who are pregnant should be counseled on the risk of development and/or progression of diabetic retinopathy. B
12.8 Eye examinations should occur before pregnancy or in the first trimester in patients with preexisting type 1 or type 2 diabetes, and then patients should be monitored every trimester and for 1 year postpartum as indicated by the degree of retinopathy. B
12.4 Patients 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 for one or more annual eye exams and glycemia is well controlled, 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 will be required more frequently. B
12.6 Programs that use retinal photography (with remote reading or use of a validated assessment tool) to improve access to diabetic retinopathy screening can be 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 Women with preexisting type 1 or type 2 diabetes who are planning pregnancy or who are pregnant should be counseled on the risk of development and/or progression of diabetic retinopathy. B
12.8 Eye examinations should occur before pregnancy or in the first trimester in patients with preexisting type 1 or type 2 diabetes, and then patients should be monitored every trimester and for 1 year postpartum as indicated by the degree of retinopathy. B
Diabetic Retinopathy Treatment
12.9 Promptly refer patients with any level of diabetic macular edema, moderate or worse nonproliferative diabetic retinopathy (a precursor of proliferative diabetic retinopathy), or any proliferative diabetic retinopathy 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 patients with high-risk proliferative diabetic retinopathy and, in some cases, severe nonproliferative diabetic retinopathy. A
12.11 Intravitreous injections of anti–vascular endothelial growth factor are a reasonable alternative to traditional panretinal laser photocoagulation for some patients with proliferative diabetic retinopathy and also reduce the risk of vision loss in these patients. A
12.12 Intravitreous injections of anti–vascular endothelial growth factor 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–vascular endothelial growth factor 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
12.10 Panretinal laser photocoagulation therapy is indicated to reduce the risk of vision loss in patients with high-risk proliferative diabetic retinopathy and, in some cases, severe nonproliferative diabetic retinopathy. A
12.11 Intravitreous injections of anti–vascular endothelial growth factor are a reasonable alternative to traditional panretinal laser photocoagulation for some patients with proliferative diabetic retinopathy and also reduce the risk of vision loss in these patients. A
12.12 Intravitreous injections of anti–vascular endothelial growth factor 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–vascular endothelial growth factor 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
Neuropathy Screening
12.15 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
12.16 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
12.17 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, 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
12.16 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
12.17 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, 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
Neuropathy Treatment
12.18 Optimize glucose control 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 blood pressure and serum lipid control to reduce the risk or slow the progression of diabetic neuropathy. B
12.19 Assess and treat pain related to diabetic peripheral neuropathy B and symptoms of autonomic neuropathy to improve quality of life. E
12.20 Gabapentinoids, serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants, and sodium channel blockers are recommended as initial pharmacologic treatments for neuropathic pain in diabetes. A Refer to neurologist or pain specialist when pain control is not achieved within the scope of practice of the treating physician. E
12.19 Assess and treat pain related to diabetic peripheral neuropathy B and symptoms of autonomic neuropathy to improve quality of life. E
12.20 Gabapentinoids, serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants, and sodium channel blockers are recommended as initial pharmacologic treatments for neuropathic pain in diabetes. A Refer to neurologist or pain specialist when pain control is not achieved within the scope of practice of the treating physician. E
Foot Care
12.21 Perform a comprehensive foot evaluation at least annually to identify risk factors for ulcers and amputations. A
12.22 The examination should include inspection of the skin, assessment of foot deformities, neurological assessment (10-g monofilament testing with at least one other assessment: pinprick, temperature, vibration), and vascular assessment, including pulses in the legs and feet. B
12.23 Individuals with evidence of sensory loss or prior ulceration or amputation should have their feet inspected at every visit. A
12.24 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
12.25 Initial screening for peripheral arterial disease 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 and for further vascular assessment as appropriate. B
12.26 A multidisciplinary approach 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 peripheral arterial disease). B
12.27 Refer individuals who smoke and have a history of prior lower-extremity complications, loss of protective sensation, structural abnormalities, or peripheral arterial disease to foot care specialists for ongoing preventive care and lifelong surveillance. B
12.28 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
12.29 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
12.30 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
12.22 The examination should include inspection of the skin, assessment of foot deformities, neurological assessment (10-g monofilament testing with at least one other assessment: pinprick, temperature, vibration), and vascular assessment, including pulses in the legs and feet. B
12.23 Individuals with evidence of sensory loss or prior ulceration or amputation should have their feet inspected at every visit. A
12.24 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
12.25 Initial screening for peripheral arterial disease 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 and for further vascular assessment as appropriate. B
12.26 A multidisciplinary approach 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 peripheral arterial disease). B
12.27 Refer individuals who smoke and have a history of prior lower-extremity complications, loss of protective sensation, structural abnormalities, or peripheral arterial disease to foot care specialists for ongoing preventive care and lifelong surveillance. B
12.28 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
12.29 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
12.30 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
Older Adults
Older Adults Overview
13.1 Consider the assessment of medical, psychological, functional (self-management abilities), and social domains in older adults to provide a framework to determine targets and therapeutic approaches for diabetes management. B
13.2 Screen for geriatric syndromes (i.e., polypharmacy, cognitive impairment, depression, urinary incontinence, falls, persistent pain, and frailty) in older adults, as they may affect diabetes self-management and diminish quality of life. B
13.2 Screen for geriatric syndromes (i.e., polypharmacy, cognitive impairment, depression, urinary incontinence, falls, persistent pain, and frailty) in older adults, as they may affect diabetes self-management and diminish quality of life. B
Neurocognitive Function
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
Hypoglycemia
13.4 Because older adults with diabetes have a greater risk of hypoglycemia than younger adults, episodes of hypoglycemia should be ascertained and addressed at routine visits. B
13.5 For older adults with type 1 diabetes, continuous glucose monitoring is recommended to reduce hypoglycemia. A
13.6 For older adults with type 2 diabetes on multiple daily doses of insulin, continuous glucose monitoring should be considered to improve glycemic outcomes and decrease glucose variability. B
13.7 For older adults with type 1 diabetes, consider the use of automated insulin delivery systems B and other advanced insulin delivery devices such as connected pens E to reduce risk of hypoglycemia, based on individual ability.
13.5 For older adults with type 1 diabetes, continuous glucose monitoring is recommended to reduce hypoglycemia. A
13.6 For older adults with type 2 diabetes on multiple daily doses of insulin, continuous glucose monitoring should be considered to improve glycemic outcomes and decrease glucose variability. B
13.7 For older adults with type 1 diabetes, consider the use of automated insulin delivery systems B and other advanced insulin delivery devices such as connected pens E to reduce risk of hypoglycemia, based on individual ability.
Treatment Goals
13.8 Older adults who are otherwise healthy with few coexisting chronic illnesses and intact cognitive function and functional status should have lower glycemic goals (such as A1C <7.0–7.5% [53–58 mmol/mol]), while those with multiple coexisting chronic illnesses, cognitive impairment, or functional dependence should have less-stringent glycemic goals (such as A1C <8.0% [64 mmol/mol]). C
13.9 Glycemic goals for some older adults might reasonably be relaxed as part of individualized care, but hyperglycemia leading to symptoms or risk of acute hyperglycemia complications should be avoided in all people with diabetes. C
13.10 Screening for diabetes complications should be individualized in older adults. Particular attention should be paid to complications that would lead to functional impairment. C
13.11 Treatment of hypertension to individualized target levels is indicated in most older adults. C
13.12 Treatment of other cardiovascular risk factors should be individualized in older adults considering the time frame of benefit. Lipid-lowering therapy and aspirin therapy may benefit those with life expectancies at least equal to the time frame of primary prevention or secondary intervention trials. E
13.9 Glycemic goals for some older adults might reasonably be relaxed as part of individualized care, but hyperglycemia leading to symptoms or risk of acute hyperglycemia complications should be avoided in all people with diabetes. C
13.10 Screening for diabetes complications should be individualized in older adults. Particular attention should be paid to complications that would lead to functional impairment. C
13.11 Treatment of hypertension to individualized target levels is indicated in most older adults. C
13.12 Treatment of other cardiovascular risk factors should be individualized in older adults considering the time frame of benefit. Lipid-lowering therapy and aspirin therapy may benefit those with life expectancies at least equal to the time frame of primary prevention or secondary intervention trials. E
Lifestyle Management
13.13 Optimal nutrition and protein intake is recommended for older adults; regular exercise, including aerobic activity, weight-bearing exercise, and/or resistance training, should be encouraged in all older adults who can safely engage in such activities. B
13.14 For older adults with type 2 diabetes, overweight/obesity, and capacity to safely exercise, 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 factor control. A
13.14 For older adults with type 2 diabetes, overweight/obesity, and capacity to safely exercise, 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 factor control. A
Pharmacologic Therapy
13.15 In older adults with type 2 diabetes at increased risk of hypoglycemia, medication classes with low risk of hypoglycemia are preferred. B
13.16 Overtreatment of diabetes is common in older adults and should be avoided. B
13.17 Deintensification of treatment goals is recommended to reduce the risk of hypoglycemia if it can be achieved within the individualized A1C target. B
13.18 Simplification of complex treatment plans (especially insulin) is recommended to reduce the risk of hypoglycemia and polypharmacy and decrease the burden of the disease if it can be achieved within the individualized A1C target. B
13.19 Consider costs of care and insurance coverage rules when developing treatment plans in order to reduce risk of cost-related barriers to adherence. B
13.16 Overtreatment of diabetes is common in older adults and should be avoided. B
13.17 Deintensification of treatment goals is recommended to reduce the risk of hypoglycemia if it can be achieved within the individualized A1C target. B
13.18 Simplification of complex treatment plans (especially insulin) is recommended to reduce the risk of hypoglycemia and polypharmacy and decrease the burden of the disease if it can be achieved within the individualized A1C target. B
13.19 Consider costs of care and insurance coverage rules when developing treatment plans in order to reduce risk of cost-related barriers to adherence. B
Treatment in Skilled Nursing Facilities and Nursing Homes
13.20 Consider diabetes education for the staff of long-term care and rehabilitation facilities to improve the management of older adults with diabetes. E
13.21 People with diabetes residing in long-term care facilities need careful assessment to establish individualized glycemic goals and to make appropriate choices of glucose-lowering agents based on their clinical and functional status. E
13.22 Consider use of continuous glucose monitoring to assess risk for hypoglycemia in older adults treated with sulfonylureas or insulin. E
13.21 People with diabetes residing in long-term care facilities need careful assessment to establish individualized glycemic goals and to make appropriate choices of glucose-lowering agents based on their clinical and functional status. E
13.22 Consider use of continuous glucose monitoring to assess risk for hypoglycemia in older adults treated with sulfonylureas or insulin. E
End-of-Life Care
13.23 When palliative care is needed in older adults with diabetes, health care professionals should initiate conversations regarding the goals and intensity of care. Strict glucose and blood pressure control are not necessary E, and simplification of regimens can be considered. Similarly, the intensity of lipid management can be relaxed, and withdrawal of lipid-lowering therapy may be appropriate. A
13.24 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
13.24 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
Children and Adolescents
Type 1 Diabetes
Diabetes Self-Management Education and Support
14.1 Youth with type 1 diabetes and their parents/caregivers (for patients aged <18 years) should receive culturally sensitive and developmentally appropriate individualized diabetes self-management education and support according to national standards at diagnosis and routinely thereafter. B
Nutrition Therapy
14.2 Individualized medical nutrition therapy is recommended for children and adolescents with type 1 diabetes as an essential component of the overall treatment plan. A
14.3 Monitoring carbohydrate intake, whether by carbohydrate counting or experience-based estimation, is a key component to optimizing glycemic management. B
14.4 Comprehensive nutrition education at diagnosis, with annual updates, by an experienced registered dietitian nutritionist, is recommended to assess caloric and nutrition intake in relation to weight status and cardiovascular disease risk factors and to inform macronutrient choices. E
14.3 Monitoring carbohydrate intake, whether by carbohydrate counting or experience-based estimation, is a key component to optimizing glycemic management. B
14.4 Comprehensive nutrition education at diagnosis, with annual updates, by an experienced registered dietitian nutritionist, is recommended to assess caloric and nutrition intake in relation to weight status and cardiovascular disease risk factors and to inform macronutrient choices. E
Physical Activity and Exercise
14.5 Physical activity is recommended for all youth with type 1 diabetes with the goal of 60 min of moderate- to vigorous-intensity aerobic activity daily, with vigorous muscle-strengthening and bone-strengthening activities at least 3 days per week. C
14.6 Frequent glucose monitoring before, during, and after exercise, via blood glucose meter or continuous glucose monitoring, is important to prevent, detect, and treat hypoglycemia and hyperglycemia associated with exercise. C
14.7 Youth and their parents/caregivers should receive education on targets and management of glycemia before, during, and after physical activity, individualized according to the type and intensity of the planned physical activity. E
14.8 Youth and their parents/caregivers should be educated on strategies to prevent hypoglycemia during, after, and overnight following physical activity and exercise, which may include reducing prandial insulin dosing for the meal/snack preceding (and, if needed, following) exercise, reducing basal insulin doses, increasing carbohydrate intake, eating bedtime snacks, and/or using continuous glucose monitoring. Treatment for hypoglycemia should be accessible before, during, and after engaging in activity. C
14.6 Frequent glucose monitoring before, during, and after exercise, via blood glucose meter or continuous glucose monitoring, is important to prevent, detect, and treat hypoglycemia and hyperglycemia associated with exercise. C
14.7 Youth and their parents/caregivers should receive education on targets and management of glycemia before, during, and after physical activity, individualized according to the type and intensity of the planned physical activity. E
14.8 Youth and their parents/caregivers should be educated on strategies to prevent hypoglycemia during, after, and overnight following physical activity and exercise, which may include reducing prandial insulin dosing for the meal/snack preceding (and, if needed, following) exercise, reducing basal insulin doses, increasing carbohydrate intake, eating bedtime snacks, and/or using continuous glucose monitoring. Treatment for hypoglycemia should be accessible before, during, and after engaging in activity. C
Psychosocial Care
14.9 At diagnosis and during routine follow-up care, screen for psychosocial issues and family stresses that could impact diabetes management and provide appropriate referrals to trained mental health professionals, preferably experienced in childhood diabetes. C
14.10 Mental health professionals should be considered integral members of the pediatric diabetes multidisciplinary team. E
14.11 Encourage developmentally appropriate family involvement in diabetes management tasks for children and adolescents, recognizing that premature transfer of diabetes care responsibility to the youth can result in diabetes burnout, suboptimal diabetes management, and deterioration in glycemia. A
14.12 Health care professionals should screen for food security, housing stability/homelessness, health literacy, financial barriers, and social/community support and apply that information to treatment decisions. E
14.13 Health care professionals should consider asking youth and their parents/caregivers about social adjustment (peer relationships) and school performance to determine whether further intervention is needed. B
14.14 Screen youth with diabetes for psychosocial and diabetes-related distress, generally starting at 7–8 years of age. Refer to a qualified mental health professional for further assessment and treatment if indicated. B
14.15 Offer adolescents time by themselves with their health care professional(s) starting at age 12 years or when developmentally appropriate. E
14.16 Starting at puberty, preconception counseling should be incorporated into routine diabetes care for all individuals of childbearing potential. A
14.17 Begin screening youth with type 1 diabetes for disordered eating between 10 and 12 years of age. Refer to a qualified mental health professional for further assessment and treatment if indicated. B
14.10 Mental health professionals should be considered integral members of the pediatric diabetes multidisciplinary team. E
14.11 Encourage developmentally appropriate family involvement in diabetes management tasks for children and adolescents, recognizing that premature transfer of diabetes care responsibility to the youth can result in diabetes burnout, suboptimal diabetes management, and deterioration in glycemia. A
14.12 Health care professionals should screen for food security, housing stability/homelessness, health literacy, financial barriers, and social/community support and apply that information to treatment decisions. E
14.13 Health care professionals should consider asking youth and their parents/caregivers about social adjustment (peer relationships) and school performance to determine whether further intervention is needed. B
14.14 Screen youth with diabetes for psychosocial and diabetes-related distress, generally starting at 7–8 years of age. Refer to a qualified mental health professional for further assessment and treatment if indicated. B
14.15 Offer adolescents time by themselves with their health care professional(s) starting at age 12 years or when developmentally appropriate. E
14.16 Starting at puberty, preconception counseling should be incorporated into routine diabetes care for all individuals of childbearing potential. A
14.17 Begin screening youth with type 1 diabetes for disordered eating between 10 and 12 years of age. Refer to a qualified mental health professional for further assessment and treatment if indicated. B
Glycemic Monitoring, Insulin Delivery, and Targets
14.18 All youth with type 1 diabetes should monitor glucose levels multiple times daily (up to 6–10 times/day by blood glucose meter or continuous glucose monitoring), including prior to meals and snacks, at bedtime, and as needed for safety in specific situations such as physical activity, driving, or the presence of symptoms of hypoglycemia. B
14.19 Real-time continuous glucose monitoring B or intermittently scanned continuous glucose monitoring E should be offered for diabetes management in youth with diabetes on multiple daily injections or insulin pump therapy who are capable of using the device safely (either by themselves or with caregivers). The choice of device should be made based on the individual’s and family’s circumstances, desires, and needs.
14.20 Automated insulin delivery systems should be offered for diabetes management to youth with type 1 diabetes who are capable of using the device safely (either by themselves or with caregivers). The choice of device should be made based on the individual’s and family’s circumstances, desires, and needs. A
14.21 Insulin pump therapy alone should be offered for diabetes management to youth on multiple daily injections with type 1 diabetes who are capable of using the device safely (either by themselves or with caregivers). The choice of device should be made based on the individual’s and family’s circumstances, desires, and needs. A
14.22 Students must be supported at school in the use of diabetes technology, including continuous glucose monitors, insulin pumps, connected insulin pens, and automated insulin delivery systems as prescribed by their diabetes care team. E
14.23 A1C goals must be individualized and reassessed over time. An A1C of <7% (53 mmol/mol) is appropriate for many children and adolescents. B
14.24 Less stringent A1C goals (such as <7.5% [58 mmol/mol]) may be appropriate for youth who cannot articulate symptoms of hypoglycemia; have hypoglycemia unawareness; lack access to analog insulins, advanced insulin delivery technology, and/or continuous glucose monitoring; cannot check blood glucose regularly; or have nonglycemic factors that increase A1C (e.g., high glycators). B
14.25 Even less stringent A1C goals (such as <8% [64 mmol/mol]) may be appropriate for individuals with a history of severe hypoglycemia, limited life expectancy, or where the harms of treatment are greater than the benefits. B
14.26 Health care professionals may reasonably suggest more stringent A1C goals (such as <6.5% [48 mmol/mol]) for selected individuals if they can be achieved without significant hypoglycemia, negative impacts on well-being, or undue burden of care or in those who have nonglycemic factors that decrease A1C (e.g., lower erythrocyte life span). Lower targets may also be appropriate during the honeymoon phase. B
14.27 Continuous glucose monitoring metrics derived from continuous glucose monitor use over the most recent 14 days (or longer for youth with more glycemic variability), including time in range (70–180 mg/dL), time below target (<70 and <54 mg/dL), and time above target (>180 and >250 mg/dL), are recommended to be used in conjunction with A1C whenever possible. E
14.19 Real-time continuous glucose monitoring B or intermittently scanned continuous glucose monitoring E should be offered for diabetes management in youth with diabetes on multiple daily injections or insulin pump therapy who are capable of using the device safely (either by themselves or with caregivers). The choice of device should be made based on the individual’s and family’s circumstances, desires, and needs.
14.20 Automated insulin delivery systems should be offered for diabetes management to youth with type 1 diabetes who are capable of using the device safely (either by themselves or with caregivers). The choice of device should be made based on the individual’s and family’s circumstances, desires, and needs. A
14.21 Insulin pump therapy alone should be offered for diabetes management to youth on multiple daily injections with type 1 diabetes who are capable of using the device safely (either by themselves or with caregivers). The choice of device should be made based on the individual’s and family’s circumstances, desires, and needs. A
14.22 Students must be supported at school in the use of diabetes technology, including continuous glucose monitors, insulin pumps, connected insulin pens, and automated insulin delivery systems as prescribed by their diabetes care team. E
14.23 A1C goals must be individualized and reassessed over time. An A1C of <7% (53 mmol/mol) is appropriate for many children and adolescents. B
14.24 Less stringent A1C goals (such as <7.5% [58 mmol/mol]) may be appropriate for youth who cannot articulate symptoms of hypoglycemia; have hypoglycemia unawareness; lack access to analog insulins, advanced insulin delivery technology, and/or continuous glucose monitoring; cannot check blood glucose regularly; or have nonglycemic factors that increase A1C (e.g., high glycators). B
14.25 Even less stringent A1C goals (such as <8% [64 mmol/mol]) may be appropriate for individuals with a history of severe hypoglycemia, limited life expectancy, or where the harms of treatment are greater than the benefits. B
14.26 Health care professionals may reasonably suggest more stringent A1C goals (such as <6.5% [48 mmol/mol]) for selected individuals if they can be achieved without significant hypoglycemia, negative impacts on well-being, or undue burden of care or in those who have nonglycemic factors that decrease A1C (e.g., lower erythrocyte life span). Lower targets may also be appropriate during the honeymoon phase. B
14.27 Continuous glucose monitoring metrics derived from continuous glucose monitor use over the most recent 14 days (or longer for youth with more glycemic variability), including time in range (70–180 mg/dL), time below target (<70 and <54 mg/dL), and time above target (>180 and >250 mg/dL), are recommended to be used in conjunction with A1C whenever possible. E
Autoimmune Conditions
14.28 Assess for additional autoimmune conditions soon after the diagnosis of type 1 diabetes and if symptoms develop. B
Thyroid Disease
14.29 Consider testing children with type 1 diabetes for antithyroid peroxidase and antithyroglobulin antibodies soon after diagnosis. B
14.30 Measure thyroid-stimulating hormone concentrations at diagnosis when clinically stable or soon after optimizing glycemia. If normal, suggest rechecking every 1–2 years or sooner if the youth has positive thyroid antibodies or develops symptoms or signs suggestive of thyroid dysfunction, thyromegaly, an abnormal growth rate, or unexplained glycemic variability. B
Celiac Disease
14.31 Screen youth with type 1 diabetes for celiac disease by measuring IgA tissue transglutaminase (tTG) antibodies, with documentation of normal total serum IgA levels, soon after the diagnosis of diabetes, or IgG tTG and deamidated gliadin antibodies if IgA is deficient. B
14.32 Repeat screening within 2 years of diabetes diagnosis and then again after 5 years and consider more frequent screening in youth who have symptoms or a first-degree relative with celiac disease. B
14.33 Individuals with confirmed celiac disease should be placed on a gluten-free diet for treatment and to avoid complications; they should also have a consultation with a dietitian experienced in managing both diabetes and celiac disease. B
Thyroid Disease
14.29 Consider testing children with type 1 diabetes for antithyroid peroxidase and antithyroglobulin antibodies soon after diagnosis. B
14.30 Measure thyroid-stimulating hormone concentrations at diagnosis when clinically stable or soon after optimizing glycemia. If normal, suggest rechecking every 1–2 years or sooner if the youth has positive thyroid antibodies or develops symptoms or signs suggestive of thyroid dysfunction, thyromegaly, an abnormal growth rate, or unexplained glycemic variability. B
Celiac Disease
14.31 Screen youth with type 1 diabetes for celiac disease by measuring IgA tissue transglutaminase (tTG) antibodies, with documentation of normal total serum IgA levels, soon after the diagnosis of diabetes, or IgG tTG and deamidated gliadin antibodies if IgA is deficient. B
14.32 Repeat screening within 2 years of diabetes diagnosis and then again after 5 years and consider more frequent screening in youth who have symptoms or a first-degree relative with celiac disease. B
14.33 Individuals with confirmed celiac disease should be placed on a gluten-free diet for treatment and to avoid complications; they should also have a consultation with a dietitian experienced in managing both diabetes and celiac disease. B
Hypertension
14.34 Blood pressure should be measured at every routine visit. In youth with high blood pressure (blood pressure ≥90th percentile for age, sex, and height or, in adolescents aged ≥13 years, blood pressure ≥120/80 mmHg) on three separate measurements, ambulatory blood pressure monitoring should be strongly considered. B
14.35 Treatment of elevated blood pressure (defined as 90th to <95th percentile for age, sex, and height or, in adolescents aged ≥13 years, 120–129/<80 mmHg) is lifestyle modification focused on healthy nutrition, physical activity, sleep, and, if appropriate, weight management. C
14.36 In addition to lifestyle modification, ACE inhibitors or angiotensin receptor blockers should be started for treatment of confirmed hypertension (defined as blood pressure consistently ≥95th percentile for age, sex, and height or, in adolescents aged ≥13 years, ≥130/80 mmHg). Due to the potential teratogenic effects, females should receive reproductive counseling and ACE inhibitors and angiotensin receptor blockers should be avoided in females of childbearing age who are not using reliable contraception. B
14.37 The goal of treatment is blood pressure <90th percentile for age, sex, and height or, in adolescents aged ≥13 years, <130/80 mmHg. C
14.35 Treatment of elevated blood pressure (defined as 90th to <95th percentile for age, sex, and height or, in adolescents aged ≥13 years, 120–129/<80 mmHg) is lifestyle modification focused on healthy nutrition, physical activity, sleep, and, if appropriate, weight management. C
14.36 In addition to lifestyle modification, ACE inhibitors or angiotensin receptor blockers should be started for treatment of confirmed hypertension (defined as blood pressure consistently ≥95th percentile for age, sex, and height or, in adolescents aged ≥13 years, ≥130/80 mmHg). Due to the potential teratogenic effects, females should receive reproductive counseling and ACE inhibitors and angiotensin receptor blockers should be avoided in females of childbearing age who are not using reliable contraception. B
14.37 The goal of treatment is blood pressure <90th percentile for age, sex, and height or, in adolescents aged ≥13 years, <130/80 mmHg. C
Dyslipidemia
14.38 Initial lipid profile should be performed soon after diagnosis, preferably after glycemia has improved and age is ≥2 years. If initial LDL cholesterol is ≤100 mg/dL (2.6 mmol/L), subsequent testing should be performed at 9–11 years of age. B Initial testing may be done with a nonfasting non-HDL cholesterol level with confirmatory testing with a fasting lipid panel.
14.39 If LDL cholesterol values are within the accepted risk level (<100 mg/dL [2.6 mmol/L]), a lipid profile repeated every 3 years is reasonable. E
14.40 If lipids are abnormal, initial therapy should consist of optimizing glycemia and medical nutrition therapy to limit the amount of calories from fat to 25–30% and saturated fat to <7%, limit cholesterol to <200 mg/day, avoid trans fats, and aim for ∼10% calories from monounsaturated fats. A
14.41 After the age of 10 years, addition of a statin may be considered in patients who, despite medical nutrition therapy and lifestyle changes, continue to have LDL cholesterol >160 mg/dL (4.1 mmol/L) or LDL cholesterol >130 mg/dL (3.4 mmol/L) and one or more cardiovascular disease risk factors. E Due to the potential teratogenic effects, females should receive reproductive counseling and statins should be avoided in females of childbearing age who are not using reliable contraception. B
14.42 The goal of therapy is an LDL cholesterol value <100 mg/dL (2.6 mmol/L). E
14.39 If LDL cholesterol values are within the accepted risk level (<100 mg/dL [2.6 mmol/L]), a lipid profile repeated every 3 years is reasonable. E
14.40 If lipids are abnormal, initial therapy should consist of optimizing glycemia and medical nutrition therapy to limit the amount of calories from fat to 25–30% and saturated fat to <7%, limit cholesterol to <200 mg/day, avoid trans fats, and aim for ∼10% calories from monounsaturated fats. A
14.41 After the age of 10 years, addition of a statin may be considered in patients who, despite medical nutrition therapy and lifestyle changes, continue to have LDL cholesterol >160 mg/dL (4.1 mmol/L) or LDL cholesterol >130 mg/dL (3.4 mmol/L) and one or more cardiovascular disease risk factors. E Due to the potential teratogenic effects, females should receive reproductive counseling and statins should be avoided in females of childbearing age who are not using reliable contraception. B
14.42 The goal of therapy is an LDL cholesterol value <100 mg/dL (2.6 mmol/L). E
Smoking
14.43 Elicit a smoking history at initial and follow-up diabetes visits; discourage smoking in youth who do not smoke and encourage smoking cessation in those who do smoke. A
14.44 Electronic cigarette use should be discouraged. A
14.44 Electronic cigarette use should be discouraged. A
Microvascular Complications
Nephropathy
14.45 Annual screening for albuminuria with a random (morning sample preferred to avoid effects of exercise) spot urine sample for albumin-to-creatinine ratio should be considered at puberty or at age >10 years, whichever is earlier, once the child has had diabetes for 5 years. B
14.46 An ACE inhibitor or an angiotensin receptor blocker, titrated to normalization of albumin excretion, may be considered when elevated urinary albumin-to-creatinine ratio (>30 mg/g) is documented (two of three urine samples obtained over a 6-month interval following efforts to improve glycemic control and normalize blood pressure). E Due to the potential teratogenic effects, females should receive reproductive counseling and ACE inhibitors and angiotensin receptor blockers should be avoided in females of childbearing age who are not using reliable contraception. B
Retinopathy
14.47 An initial dilated and comprehensive eye examination is recommended once youth have had type 1 diabetes for 3–5 years, provided they are aged ≥11 years or puberty has started, whichever is earlier. B
14.48 After the initial examination, repeat dilated and comprehensive eye examination every 2 years. Less frequent examinations, every 4 years, may be acceptable on the advice of an eye care professional and based on risk factor assessment, including a history of A1C <8%. B
14.49 Programs that use retinal photography (with remote reading or use of a validated assessment tool) to improve access to diabetic retinopathy screening can be appropriate screening strategies for diabetic retinopathy. Such programs need to provide pathways for timely referral for a comprehensive eye examination when indicated. E
Neuropathy
14.50 Consider an annual comprehensive foot exam at the start of puberty or at age ≥10 years, whichever is earlier, once the youth has had type 1 diabetes for 5 years. The examination should include inspection, assessment of foot pulses, pinprick, and 10-g monofilament sensation tests, testing of vibration sensation using a 128-Hz tuning fork, and ankle reflex tests. B
14.45 Annual screening for albuminuria with a random (morning sample preferred to avoid effects of exercise) spot urine sample for albumin-to-creatinine ratio should be considered at puberty or at age >10 years, whichever is earlier, once the child has had diabetes for 5 years. B
14.46 An ACE inhibitor or an angiotensin receptor blocker, titrated to normalization of albumin excretion, may be considered when elevated urinary albumin-to-creatinine ratio (>30 mg/g) is documented (two of three urine samples obtained over a 6-month interval following efforts to improve glycemic control and normalize blood pressure). E Due to the potential teratogenic effects, females should receive reproductive counseling and ACE inhibitors and angiotensin receptor blockers should be avoided in females of childbearing age who are not using reliable contraception. B
Retinopathy
14.47 An initial dilated and comprehensive eye examination is recommended once youth have had type 1 diabetes for 3–5 years, provided they are aged ≥11 years or puberty has started, whichever is earlier. B
14.48 After the initial examination, repeat dilated and comprehensive eye examination every 2 years. Less frequent examinations, every 4 years, may be acceptable on the advice of an eye care professional and based on risk factor assessment, including a history of A1C <8%. B
14.49 Programs that use retinal photography (with remote reading or use of a validated assessment tool) to improve access to diabetic retinopathy screening can be appropriate screening strategies for diabetic retinopathy. Such programs need to provide pathways for timely referral for a comprehensive eye examination when indicated. E
Neuropathy
14.50 Consider an annual comprehensive foot exam at the start of puberty or at age ≥10 years, whichever is earlier, once the youth has had type 1 diabetes for 5 years. The examination should include inspection, assessment of foot pulses, pinprick, and 10-g monofilament sensation tests, testing of vibration sensation using a 128-Hz tuning fork, and ankle reflex tests. B
Type 2 Diabetes
Screening and Diagnosis
14.51 Risk-based screening for prediabetes and/or type 2 diabetes should be considered after the onset of puberty or ≥10 years of age, whichever occurs earlier, in youth with overweight (BMI ≥85th percentile) or obesity (BMI ≥95th percentile) and who have one or more additional risk factors for diabetes (see Table 2.4 for evidence grading of other risk factors).
14.52 If screening is normal, repeat screening at a minimum of 3-year intervals E, or more frequently if BMI is increasing. C
14.53 Fasting plasma glucose, 2-h plasma glucose during a 75-g oral glucose tolerance test, and A1C can be used to test for prediabetes or diabetes in children and adolescents. B
14.54 Children and adolescents with overweight or obesity in whom the diagnosis of type 2 diabetes is being considered should have a panel of pancreatic autoantibodies tested to exclude the possibility of autoimmune type 1 diabetes. B
14.52 If screening is normal, repeat screening at a minimum of 3-year intervals E, or more frequently if BMI is increasing. C
14.53 Fasting plasma glucose, 2-h plasma glucose during a 75-g oral glucose tolerance test, and A1C can be used to test for prediabetes or diabetes in children and adolescents. B
14.54 Children and adolescents with overweight or obesity in whom the diagnosis of type 2 diabetes is being considered should have a panel of pancreatic autoantibodies tested to exclude the possibility of autoimmune type 1 diabetes. B
Lifestyle Management
14.55 All youth with type 2 diabetes and their families should receive comprehensive diabetes self-management education and support that is specific to youth with type 2 diabetes and is culturally appropriate. B
14.56 Youth with overweight/obesity and type 2 diabetes and their families should be provided with developmentally and culturally appropriate comprehensive lifestyle programs that are integrated with diabetes management to achieve a 7–10% decrease in excess weight. C
14.57 Given the necessity of long-term weight management for youth with type 2 diabetes, lifestyle intervention should be based on a chronic care model and offered in the context of diabetes care. E
14.58 Youth with prediabetes and type 2 diabetes, like all children and adolescents, should be encouraged to participate in at least 60 min of moderate to vigorous physical activity daily (with muscle and bone strength training at least 3 days/week) B and to decrease sedentary behavior. C
14.59 Nutrition for youth with prediabetes and type 2 diabetes, like for all children and adolescents, should focus on healthy eating patterns that emphasize consumption of nutrient-dense, high-quality foods and decreased consumption of calorie-dense, nutrient-poor foods, particularly sugar-added beverages. B
14.56 Youth with overweight/obesity and type 2 diabetes and their families should be provided with developmentally and culturally appropriate comprehensive lifestyle programs that are integrated with diabetes management to achieve a 7–10% decrease in excess weight. C
14.57 Given the necessity of long-term weight management for youth with type 2 diabetes, lifestyle intervention should be based on a chronic care model and offered in the context of diabetes care. E
14.58 Youth with prediabetes and type 2 diabetes, like all children and adolescents, should be encouraged to participate in at least 60 min of moderate to vigorous physical activity daily (with muscle and bone strength training at least 3 days/week) B and to decrease sedentary behavior. C
14.59 Nutrition for youth with prediabetes and type 2 diabetes, like for all children and adolescents, should focus on healthy eating patterns that emphasize consumption of nutrient-dense, high-quality foods and decreased consumption of calorie-dense, nutrient-poor foods, particularly sugar-added beverages. B
Glycemic Targets
14.60 Blood glucose monitoring should be individualized, taking into consideration the pharmacologic treatment of the patient. E
14.61 Real-time continuous glucose monitoring or intermittently scanned coninuous glucose monitoring should be offered for diabetes management in youth with type 2 diabetes on multiple daily injections or continuous subcutaneous insulin infusion who are capable of using the device safely (either by themselves or with a caregiver). The choice of device should be made based on patient circumstances, desires, and needs. E
14.62 Glycemic status should be assessed every 3 months. E
14.63 A reasonable A1C target for most children and adolescents with type 2 diabetes is <7% (53 mmol/mol). More stringent A1C targets (such as <6.5% [48 mmol/mol]) may be appropriate for selected individual patients if they can be achieved without significant hypoglycemia or other adverse effects of treatment. Appropriate patients might include those with a short duration of diabetes and lesser degrees of β-cell dysfunction and patients treated with lifestyle or metformin only who achieve significant weight improvement. E
14.64 Less stringent A1C goals (such as 7.5% [58 mmol/mol]) may be appropriate if there is an increased risk of hypoglycemia. E
14.65 A1C targets for patients on insulin should be individualized, taking into account the relatively low rates of hypoglycemia in youth-onset type 2 diabetes. E
14.61 Real-time continuous glucose monitoring or intermittently scanned coninuous glucose monitoring should be offered for diabetes management in youth with type 2 diabetes on multiple daily injections or continuous subcutaneous insulin infusion who are capable of using the device safely (either by themselves or with a caregiver). The choice of device should be made based on patient circumstances, desires, and needs. E
14.62 Glycemic status should be assessed every 3 months. E
14.63 A reasonable A1C target for most children and adolescents with type 2 diabetes is <7% (53 mmol/mol). More stringent A1C targets (such as <6.5% [48 mmol/mol]) may be appropriate for selected individual patients if they can be achieved without significant hypoglycemia or other adverse effects of treatment. Appropriate patients might include those with a short duration of diabetes and lesser degrees of β-cell dysfunction and patients treated with lifestyle or metformin only who achieve significant weight improvement. E
14.64 Less stringent A1C goals (such as 7.5% [58 mmol/mol]) may be appropriate if there is an increased risk of hypoglycemia. E
14.65 A1C targets for patients on insulin should be individualized, taking into account the relatively low rates of hypoglycemia in youth-onset type 2 diabetes. E
Pharmacologic Management
14.66 Initiate pharmacologic therapy, in addition to behavioral counseling for healthful nutrition and physical activity changes, at diagnosis of type 2 diabetes. A
14.67 In incidentally diagnosed or metabolically stable patients (A1C <8.5% [69 mmol/mol] and asymptomatic), metformin is the initial pharmacologic treatment of choice if renal function is normal. A
14.68 Youth with marked hyperglycemia (blood glucose ≥250 mg/dL [13.9 mmol/L], A1C ≥8.5% [69 mmol/mol]) without acidosis at diagnosis who are symptomatic with polyuria, polydipsia, nocturia, and/or weight loss should be treated initially with basal insulin while metformin is initiated and titrated. B
14.69 In patients with ketosis/ketoacidosis, treatment with subcutaneous or intravenous insulin should be initiated to rapidly correct the hyperglycemia and the metabolic derangement. Once acidosis is resolved, metformin should be initiated while subcutaneous insulin therapy is continued. A
14.70 In individuals presenting with severe hyperglycemia (blood glucose ≥600 mg/dL [33.3 mmol/L]), consider assessment for hyperglycemic hyperosmolar nonketotic syndrome. A
14.71 If glycemic targets are no longer met with metformin (with or without basal insulin), glucagon-like peptide 1 receptor agonist therapy approved for youth with type 2 diabetes should be considered in children 10 years of age or older if they have no past medical history or family history of medullary thyroid carcinoma or multiple endocrine neoplasia type 2. A
14.72 Patients treated with metformin, a glucagon-like peptide 1 receptor agonist, and basal insulin who do not meet glycemic targets should be moved to multiple daily injections with basal and premeal bolus insulins or insulin pump therapy. E
14.73 In patients initially treated with insulin and metformin who are meeting glucose targets based on blood glucose monitoring, insulin can be tapered over 2–6 weeks by decreasing the insulin dose 10–30% every few days. B
14.74 Use of medications not approved by the U.S. Food and Drug Administration for youth with type 2 diabetes is not recommended outside of research trials. B
14.67 In incidentally diagnosed or metabolically stable patients (A1C <8.5% [69 mmol/mol] and asymptomatic), metformin is the initial pharmacologic treatment of choice if renal function is normal. A
14.68 Youth with marked hyperglycemia (blood glucose ≥250 mg/dL [13.9 mmol/L], A1C ≥8.5% [69 mmol/mol]) without acidosis at diagnosis who are symptomatic with polyuria, polydipsia, nocturia, and/or weight loss should be treated initially with basal insulin while metformin is initiated and titrated. B
14.69 In patients with ketosis/ketoacidosis, treatment with subcutaneous or intravenous insulin should be initiated to rapidly correct the hyperglycemia and the metabolic derangement. Once acidosis is resolved, metformin should be initiated while subcutaneous insulin therapy is continued. A
14.70 In individuals presenting with severe hyperglycemia (blood glucose ≥600 mg/dL [33.3 mmol/L]), consider assessment for hyperglycemic hyperosmolar nonketotic syndrome. A
14.71 If glycemic targets are no longer met with metformin (with or without basal insulin), glucagon-like peptide 1 receptor agonist therapy approved for youth with type 2 diabetes should be considered in children 10 years of age or older if they have no past medical history or family history of medullary thyroid carcinoma or multiple endocrine neoplasia type 2. A
14.72 Patients treated with metformin, a glucagon-like peptide 1 receptor agonist, and basal insulin who do not meet glycemic targets should be moved to multiple daily injections with basal and premeal bolus insulins or insulin pump therapy. E
14.73 In patients initially treated with insulin and metformin who are meeting glucose targets based on blood glucose monitoring, insulin can be tapered over 2–6 weeks by decreasing the insulin dose 10–30% every few days. B
14.74 Use of medications not approved by the U.S. Food and Drug Administration for youth with type 2 diabetes is not recommended outside of research trials. B
Metabolic Surgery
14.75 Metabolic surgery may be considered for the treatment of adolescents with type 2 diabetes who have severe obesity (BMI >35 kg/m2) and who have uncontrolled glycemia and/or serious comorbidities despite lifestyle and pharmacologic intervention. A
14.76 Metabolic surgery should be performed only by an experienced surgeon working as part of a well-organized and engaged multidisciplinary team, including a surgeon, endocrinologist, dietitian nutritionist, behavioral health specialist, and nurse. A
14.76 Metabolic surgery should be performed only by an experienced surgeon working as part of a well-organized and engaged multidisciplinary team, including a surgeon, endocrinologist, dietitian nutritionist, behavioral health specialist, and nurse. A
Hypertension
14.77 Blood pressure should be measured at every visit. In youth with high blood pressure (blood pressure ≥90th percentile for age, sex, and height or, in adolescents aged ≥13 years, ≥120/80 mmHg) on three separate measurements, ambulatory blood pressure monitoring should be strongly considered. B
14.78 Treatment of elevated blood pressure (defined as 90th to <95th percentile for age, sex, and height or, in adolescents aged ≥13 years, 120–129/<80 mmHg) is lifestyle modification focused on healthy nutrition, physical activity, sleep, and, if appropriate, weight management. C
14.79 In addition to lifestyle modification, ACE inhibitors or angiotensin receptor blockers should be started for treatment of confirmed hypertension (defined as blood pressure consistently ≥95th percentile for age, sex, and height or, in adolescents aged ≥13 years, ≥130/80 mmHg). Due to the potential teratogenic effects, females should receive reproductive counseling and ACE inhibitors and angiotensin receptor blockers should be avoided in females of childbearing age who are not using reliable contraception. B
14.80 The goal of treatment is blood pressure <90th percentile for age, sex, and height or, in adolescents aged ≥13 years, <130/80 mmHg. C
14.78 Treatment of elevated blood pressure (defined as 90th to <95th percentile for age, sex, and height or, in adolescents aged ≥13 years, 120–129/<80 mmHg) is lifestyle modification focused on healthy nutrition, physical activity, sleep, and, if appropriate, weight management. C
14.79 In addition to lifestyle modification, ACE inhibitors or angiotensin receptor blockers should be started for treatment of confirmed hypertension (defined as blood pressure consistently ≥95th percentile for age, sex, and height or, in adolescents aged ≥13 years, ≥130/80 mmHg). Due to the potential teratogenic effects, females should receive reproductive counseling and ACE inhibitors and angiotensin receptor blockers should be avoided in females of childbearing age who are not using reliable contraception. B
14.80 The goal of treatment is blood pressure <90th percentile for age, sex, and height or, in adolescents aged ≥13 years, <130/80 mmHg. C
Nephropathy
14.81 Protein intake should be at the recommended daily allowance of 0.8 g/kg/day. E
14.82 Urine albumin-to-creatinine ratio should be obtained at the time of diagnosis and annually thereafter. An elevated urine albumin-to-creatinine ratio (>30 mg/g creatinine) should be confirmed on two of three samples. B
14.83 Estimated glomerular filtration rate should be determined at the time of diagnosis and annually thereafter. E
14.84 In patients with diabetes and hypertension, either an ACE inhibitor or an angiotensin receptor blocker is recommended for those with modestly elevated urinary albumin-to-creatinine ratio (30–299 mg/g creatinine) and is strongly recommended for those with urinary albumin-to-creatinine ratio >300 mg/g creatinine and/or estimated glomerular filtration rate <60 mL/min/1.73 m2. E Due to the potential teratogenic effects, females should receive reproductive counseling and ACE inhibitors and angiotensin receptor blockers should be avoided in females of childbearing age who are not using reliable contraception. B
14.85 For those with nephropathy, continued monitoring (yearly urinary albumin-to-creatinine ratio, estimated glomerular filtration rate, and serum potassium) may aid in assessing adherence and detecting progression of disease. E
14.86 Referral to nephrology is recommended in case of uncertainty of etiology, worsening urinary albumin-to-creatinine ratio, or decrease in estimated glomerular filtration rate. E
14.82 Urine albumin-to-creatinine ratio should be obtained at the time of diagnosis and annually thereafter. An elevated urine albumin-to-creatinine ratio (>30 mg/g creatinine) should be confirmed on two of three samples. B
14.83 Estimated glomerular filtration rate should be determined at the time of diagnosis and annually thereafter. E
14.84 In patients with diabetes and hypertension, either an ACE inhibitor or an angiotensin receptor blocker is recommended for those with modestly elevated urinary albumin-to-creatinine ratio (30–299 mg/g creatinine) and is strongly recommended for those with urinary albumin-to-creatinine ratio >300 mg/g creatinine and/or estimated glomerular filtration rate <60 mL/min/1.73 m2. E Due to the potential teratogenic effects, females should receive reproductive counseling and ACE inhibitors and angiotensin receptor blockers should be avoided in females of childbearing age who are not using reliable contraception. B
14.85 For those with nephropathy, continued monitoring (yearly urinary albumin-to-creatinine ratio, estimated glomerular filtration rate, and serum potassium) may aid in assessing adherence and detecting progression of disease. E
14.86 Referral to nephrology is recommended in case of uncertainty of etiology, worsening urinary albumin-to-creatinine ratio, or decrease in estimated glomerular filtration rate. E
Neuropathy
14.87 Youth with type 2 diabetes should be screened for the presence of neuropathy by foot examination at diagnosis and annually. The examination should include inspection, assessment of foot pulses, pinprick and 10-g monofilament sensation tests, testing of vibration sensation using a 128-Hz tuning fork, and ankle reflex tests. C
14.88 Prevention should focus on achieving glycemic targets. C
14.88 Prevention should focus on achieving glycemic targets. C
Retinopathy
14.89 Screening for retinopathy should be performed by dilated fundoscopy at or soon after diagnosis and annually thereafter. C
14.90 Optimizing glycemia is recommended to decrease the risk or slow the progression of retinopathy. B
14.91 Less frequent examination (every 2 years) may be considered if achieving glycemic targets and a normal eye exam. C
14.92 Programs that use retinal photography (with remote reading or use of a validated assessment tool) to improve access to diabetic retinopathy screening can be appropriate screening strategies for diabetic retinopathy. Such programs need to provide pathways for timely referral for a comprehensive eye examination when indicated. E
14.90 Optimizing glycemia is recommended to decrease the risk or slow the progression of retinopathy. B
14.91 Less frequent examination (every 2 years) may be considered if achieving glycemic targets and a normal eye exam. C
14.92 Programs that use retinal photography (with remote reading or use of a validated assessment tool) to improve access to diabetic retinopathy screening can be appropriate screening strategies for diabetic retinopathy. Such programs need to provide pathways for timely referral for a comprehensive eye examination when indicated. E
Nonalcoholic Fatty Liver Disease
14.93 Evaluation for nonalcoholic fatty liver disease (by measuring AST and ALT) should be done at diagnosis and annually thereafter. B
14.94 Referral to gastroenterology should be considered for persistently elevated or worsening transaminases. B
14.94 Referral to gastroenterology should be considered for persistently elevated or worsening transaminases. B
Obstructive Sleep Apnea
14.95 Screening for symptoms of sleep apnea should be done at each visit, and referral to a pediatric sleep specialist for evaluation and a polysomnogram, if indicated, is recommended. Obstructive sleep apnea should be treated when documented. B
Polycystic Ovary Syndrome
14.96 Evaluate for polycystic ovary syndrome in female adolescents with type 2 diabetes, including laboratory studies, when indicated. B
14.97 Oral contraceptive pills for treatment of polycystic ovary syndrome are not contraindicated for female individuals with type 2 diabetes. C
14.98 Metformin, in addition to lifestyle modification, is likely to improve the menstrual cyclicity and hyperandrogenism in female individuals with type 2 diabetes. E
14.97 Oral contraceptive pills for treatment of polycystic ovary syndrome are not contraindicated for female individuals with type 2 diabetes. C
14.98 Metformin, in addition to lifestyle modification, is likely to improve the menstrual cyclicity and hyperandrogenism in female individuals with type 2 diabetes. E
Cardiovascular Disease
14.99 Intensive lifestyle interventions focusing on weight loss, dyslipidemia, hypertension, and dysglycemia are important to prevent overt macrovascular disease in early adulthood. E
Dyslipidemia
14.100 Lipid screening should be performed initially after optimizing glycemia and annually thereafter. B
14.101 Optimal goals are LDL cholesterol <100 mg/dL (2.6 mmol/L), HDL cholesterol >35 mg/dL (0.91 mmol/L), and triglycerides <150 mg/dL (1.7 mmol/L). E
14.102 If lipids are abnormal, initial therapy should consist of optimizing glucose control and medical nutritional therapy to limit the amount of calories from fat to 25–30% and saturated fat to <7%, limit cholesterol to <200 mg/day, avoid trans fats, and aim for ∼10% calories from monounsaturated fats for elevated LDL. For elevated triglycerides, medical nutrition therapy should also focus on decreasing simple sugar intake and increasing dietary n-3 fatty acids in addition to the above changes. A
14.103 If LDL cholesterol remains >130 mg/dL after 6 months of dietary intervention, initiate therapy with statin, with a goal of LDL <100 mg/dL. Due to the potential teratogenic effects, females should receive reproductive counseling and statins should be avoided in females of childbearing age who are not using reliable contraception. B
14.104 If triglycerides are >400 mg/dL (4.7 mmol/L) fasting or >1,000 mg/dL (11.6 mmol/L) nonfasting, optimize glycemia and begin fibrate, with a goal of <400 mg/dL (4.7 mmol/L) fasting (to reduce risk for pancreatitis). C
Cardiac Function Testing
14.105 Routine screening for heart disease with electrocardiogram, echocardiogram, or stress testing is not recommended in asymptomatic youth with type 2 diabetes. B
Dyslipidemia
14.100 Lipid screening should be performed initially after optimizing glycemia and annually thereafter. B
14.101 Optimal goals are LDL cholesterol <100 mg/dL (2.6 mmol/L), HDL cholesterol >35 mg/dL (0.91 mmol/L), and triglycerides <150 mg/dL (1.7 mmol/L). E
14.102 If lipids are abnormal, initial therapy should consist of optimizing glucose control and medical nutritional therapy to limit the amount of calories from fat to 25–30% and saturated fat to <7%, limit cholesterol to <200 mg/day, avoid trans fats, and aim for ∼10% calories from monounsaturated fats for elevated LDL. For elevated triglycerides, medical nutrition therapy should also focus on decreasing simple sugar intake and increasing dietary n-3 fatty acids in addition to the above changes. A
14.103 If LDL cholesterol remains >130 mg/dL after 6 months of dietary intervention, initiate therapy with statin, with a goal of LDL <100 mg/dL. Due to the potential teratogenic effects, females should receive reproductive counseling and statins should be avoided in females of childbearing age who are not using reliable contraception. B
14.104 If triglycerides are >400 mg/dL (4.7 mmol/L) fasting or >1,000 mg/dL (11.6 mmol/L) nonfasting, optimize glycemia and begin fibrate, with a goal of <400 mg/dL (4.7 mmol/L) fasting (to reduce risk for pancreatitis). C
Cardiac Function Testing
14.105 Routine screening for heart disease with electrocardiogram, echocardiogram, or stress testing is not recommended in asymptomatic youth with type 2 diabetes. B
Psychosocial Factors
14.106 Health care professionals should screen for food insecurity, housing instability/homelessness, health literacy, financial barriers, and social/community support and apply that information to treatment decisions. E
14.107 Use age-appropriate standardized and validated tools to screen for diabetes distress, depressive symptoms, and mental/behavioral health in youth with type 2 diabetes, with attention to symptoms of depression and disordered eating, and refer to a qualified mental health professional when indicated. B
14.108 When choosing glucose-lowering or other medications for youth with overweight or obesity and type 2 diabetes, consider medication-taking behavior and the medications’ effect on weight. E
14.109 Starting at puberty, preconception counseling should be incorporated into routine diabetes clinic visits for all individuals of childbearing potential because of the adverse pregnancy outcomes in this population. A
14.110 Adolescents and young adults should be screened for tobacco, electronic cigarettes, and alcohol use at diagnosis and regularly thereafter. C
14.107 Use age-appropriate standardized and validated tools to screen for diabetes distress, depressive symptoms, and mental/behavioral health in youth with type 2 diabetes, with attention to symptoms of depression and disordered eating, and refer to a qualified mental health professional when indicated. B
14.108 When choosing glucose-lowering or other medications for youth with overweight or obesity and type 2 diabetes, consider medication-taking behavior and the medications’ effect on weight. E
14.109 Starting at puberty, preconception counseling should be incorporated into routine diabetes clinic visits for all individuals of childbearing potential because of the adverse pregnancy outcomes in this population. A
14.110 Adolescents and young adults should be screened for tobacco, electronic cigarettes, and alcohol use at diagnosis and regularly thereafter. C
Transition from Pediatric to Adult Care
14.111 Pediatric diabetes care teams should begin to prepare youth for transition to adult health care in early adolescence and, at the latest, at least 1 year before the transition. E
14.112 Both pediatric and adult diabetes care professionals should provide support and resources for transitioning young adults. E
14.113 Youth with type 2 diabetes should be transferred to an adult-oriented diabetes specialist when deemed appropriate by the young adult and health care professional. E
14.112 Both pediatric and adult diabetes care professionals should provide support and resources for transitioning young adults. E
14.113 Youth with type 2 diabetes should be transferred to an adult-oriented diabetes specialist when deemed appropriate by the young adult and health care professional. E
Management of Diabetes in Pregnancy
Preconception Counseling
15.1 Starting at puberty and continuing in all women with diabetes and reproductive 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 a woman’s treatment regimen 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
15.2 Family planning should be discussed, and effective contraception (with consideration of long-acting, reversible contraception) should be prescribed and used until a woman’s treatment regimen 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
Preconception Care
15.4 Women with preexisting diabetes who are planning a pregnancy should ideally be managed beginning in preconception in a multidisciplinary clinic including an endocrinologist, maternal-fetal medicine specialist, registered dietitian nutritionist, and diabetes care and education specialist, when available. B
15.5 In addition to focused attention on achieving glycemic targets A, standard preconception care should be augmented with extra focus on nutrition, diabetes education, and screening for diabetes comorbidities and complications. E
15.6 Women with preexisting type 1 or type 2 diabetes who are planning 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 or in the first trimester, and then patients should be monitored every trimester and for 1 year postpartum as indicated by the degree of retinopathy and as recommended by the eye care provider. B
15.5 In addition to focused attention on achieving glycemic targets A, standard preconception care should be augmented with extra focus on nutrition, diabetes education, and screening for diabetes comorbidities and complications. E
15.6 Women with preexisting type 1 or type 2 diabetes who are planning 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 or in the first trimester, and then patients should be monitored every trimester and for 1 year postpartum as indicated by the degree of retinopathy and as recommended by the eye care provider. B
Glycemic Targets in Pregnancy
15.7 Fasting and postprandial blood glucose monitoring are recommended in both gestational diabetes mellitus and preexisting diabetes in pregnancy to achieve optimal glucose levels. Glucose targets 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). Some individuals with preexisting diabetes should also check blood glucose preprandially. B
15.8 Due to increased red blood cell turnover, A1C is slightly lower during pregnancy in people with and without diabetes. Ideally, the A1C target in pregnancy is <6% (42 mmol/mol) if this can be achieved without significant hypoglycemia, but the target may be relaxed to <7% (53 mmol/mol) if necessary to prevent hypoglycemia. B
15.9 When used in addition to pre- and postprandial blood glucose monitoring, continuous glucose monitoring can help to achieve the A1C target in diabetes and pregnancy. B
15.10 When used in addition to blood glucose monitoring, targeting traditional pre- and postprandial targets, real-time continuous glucose monitoring can reduce macrosomia and neonatal hypoglycemia in pregnancy complicated by type 1 diabetes. B
15.11 Continuous glucose monitoring metrics may be used in addition to but should not be used as a substitute for blood glucose monitoring to achieve optimal pre- and postprandial glycemic targets. E
15.12 Commonly used estimated A1C and glucose management indicator calculations should not be used in pregnancy as estimates of A1C. C
15.13 Nutrition counseling should endorse a balance of macronutrients including nutrient-dense fruits, vegetables, legumes, whole grains, and healthy fats with n-3 fatty acids that include nuts and seeds and fish in the eating pattern. E
15.8 Due to increased red blood cell turnover, A1C is slightly lower during pregnancy in people with and without diabetes. Ideally, the A1C target in pregnancy is <6% (42 mmol/mol) if this can be achieved without significant hypoglycemia, but the target may be relaxed to <7% (53 mmol/mol) if necessary to prevent hypoglycemia. B
15.9 When used in addition to pre- and postprandial blood glucose monitoring, continuous glucose monitoring can help to achieve the A1C target in diabetes and pregnancy. B
15.10 When used in addition to blood glucose monitoring, targeting traditional pre- and postprandial targets, real-time continuous glucose monitoring can reduce macrosomia and neonatal hypoglycemia in pregnancy complicated by type 1 diabetes. B
15.11 Continuous glucose monitoring metrics may be used in addition to but should not be used as a substitute for blood glucose monitoring to achieve optimal pre- and postprandial glycemic targets. E
15.12 Commonly used estimated A1C and glucose management indicator calculations should not be used in pregnancy as estimates of A1C. C
15.13 Nutrition counseling should endorse a balance of macronutrients including nutrient-dense fruits, vegetables, legumes, whole grains, and healthy fats with n-3 fatty acids that include nuts and seeds and fish in the eating pattern. E
Management of Gestational Diabetes Mellitus
15.14 Lifestyle behavior change is an essential component of management of gestational diabetes mellitus and may suffice as treatment for many individuals. Insulin should be added if needed to achieve glycemic targets. A
15.15 Insulin is the preferred medication for treating hyperglycemia in gestational diabetes mellitus. Metformin and glyburide should not be used as first-line agents, as both cross the placenta to the fetus. A Other oral and noninsulin injectable glucose-lowering medications lack long-term safety data.
15.16 Metformin, when used to treat polycystic ovary syndrome and induce ovulation, should be discontinued by the end of the first trimester. A
15.17 Telehealth visits for pregnant people with gestational diabetes mellitus improve outcomes compared with standard in-person care. A
15.15 Insulin is the preferred medication for treating hyperglycemia in gestational diabetes mellitus. Metformin and glyburide should not be used as first-line agents, as both cross the placenta to the fetus. A Other oral and noninsulin injectable glucose-lowering medications lack long-term safety data.
15.16 Metformin, when used to treat polycystic ovary syndrome and induce ovulation, should be discontinued by the end of the first trimester. A
15.17 Telehealth visits for pregnant people with gestational diabetes mellitus improve outcomes compared with standard in-person care. A
Management of Preexisting Type 1 Diabetes and Type 2 Diabetes in Pregnancy - Insulin Use
15.18 Insulin should be used to manage type 1 diabetes in pregnancy. A Insulin is the preferred agent for the management of type 2 diabetes in pregnancy. B
15.19 Either multiple daily injections or insulin pump technology can be used in pregnancy complicated by type 1 diabetes. C
15.19 Either multiple daily injections or insulin pump technology can be used in pregnancy complicated by type 1 diabetes. C
Preeclampsia and Aspirin
15.20 Pregnant individuals with type 1 or type 2 diabetes should be prescribed low-dose aspirin 100–150 mg/day starting at 12 to 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.
Pregnancy and Drug Considerations
15.21 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 lessened for blood pressure <90/60 mmHg. E A blood pressure target of 110–135/85 mmHg is suggested in the interest of reducing the risk for accelerated maternal hypertension. A
15.22 Potentially harmful medications in pregnancy (i.e., ACE inhibitors, angiotensin receptor blockers, statins) should be stopped prior to conception and avoided in sexually active individuals of childbearing potential who are not using reliable contraception. B
15.22 Potentially harmful medications in pregnancy (i.e., ACE inhibitors, angiotensin receptor blockers, statins) should be stopped prior to conception and avoided in sexually active individuals of childbearing potential who are not using reliable contraception. B
Postpartum Care
15.23 Insulin resistance decreases dramatically immediately postpartum, and insulin requirements need to be evaluated and adjusted as they are often roughly half the prepregnancy requirements for the initial few days postpartum. C
15.24 A contraceptive plan should be discussed and implemented with all people with diabetes of reproductive potential. A
15.25 Screen individuals with a recent history of gestational diabetes mellitus at 4–12 weeks postpartum, using the 75-g oral glucose tolerance test and clinically appropriate nonpregnancy diagnostic criteria. B
15.26 Individuals with overweight/obesity and a history of gestational diabetes mellitus found to have prediabetes should receive intensive lifestyle interventions and/or metformin to prevent diabetes. A
15.27 Breastfeeding is recommended to reduce the risk of maternal type 2 diabetes and should be considered when choosing whether to breastfeed or formula feed. B
15.28 Individuals with a history of gestational diabetes mellitus should have lifelong screening for the development of type 2 diabetes or prediabetes every 1–3 years. B
15.29 Individuals with a history of gestational diabetes mellitus should seek preconception screening for diabetes and preconception care to identify and treat hyperglycemia and prevent congenital malformations. E
15.30 Postpartum care should include psychosocial assessment and support for self-care. E
15.24 A contraceptive plan should be discussed and implemented with all people with diabetes of reproductive potential. A
15.25 Screen individuals with a recent history of gestational diabetes mellitus at 4–12 weeks postpartum, using the 75-g oral glucose tolerance test and clinically appropriate nonpregnancy diagnostic criteria. B
15.26 Individuals with overweight/obesity and a history of gestational diabetes mellitus found to have prediabetes should receive intensive lifestyle interventions and/or metformin to prevent diabetes. A
15.27 Breastfeeding is recommended to reduce the risk of maternal type 2 diabetes and should be considered when choosing whether to breastfeed or formula feed. B
15.28 Individuals with a history of gestational diabetes mellitus should have lifelong screening for the development of type 2 diabetes or prediabetes every 1–3 years. B
15.29 Individuals with a history of gestational diabetes mellitus should seek preconception screening for diabetes and preconception care to identify and treat hyperglycemia and prevent congenital malformations. E
15.30 Postpartum care should include psychosocial assessment and support for self-care. E
Diabetes Care in the Hospital
Hospital Care Delivery Standards
16.1 Perform an A1C test on all people with diabetes or hyperglycemia (blood glucose >140 mg/dL [7.8 mmol/L]) admitted to the hospital if not performed in the prior 3 months. B
16.2 Insulin should be administered using validated written or computerized protocols that allow for predefined adjustments in the insulin dosage based on glycemic fluctuations. B
16.2 Insulin should be administered using validated written or computerized protocols that allow for predefined adjustments in the insulin dosage based on glycemic fluctuations. B
Diabetes Care Specialists in the Hospital
16.3 When caring for hospitalized people with diabetes, consult with a specialized diabetes or glucose management team when possible. C
Glycemic Targets In Hospitalized Patients
16.4 Insulin therapy should be initiated for the treatment of persistent hyperglycemia starting at a threshold ≥180 mg/dL (10.0 mmol/L) (checked on two occasions). Once insulin therapy is started, a target glucose range of 140–180 mg/dL (7.8–10.0 mmol/L) is recommended for most critically ill and noncritically ill patients. A
16.5 More stringent goals, such as 110–140 mg/dL (6.1–7.8 mmol/L) or 100–180 mg/dL (5.6–10.0 mmol/L), may be appropriate for selected patients and are acceptable if they can be achieved without significant hypoglycemia. C
16.5 More stringent goals, such as 110–140 mg/dL (6.1–7.8 mmol/L) or 100–180 mg/dL (5.6–10.0 mmol/L), may be appropriate for selected patients and are acceptable if they can be achieved without significant hypoglycemia. C
Glucose-Lowering Treatment in Hospitalized Patients
16.6 Basal insulin or a basal plus bolus correction insulin regimen is the preferred treatment for noncritically ill hospitalized patients with poor oral intake or those who are taking nothing by mouth. A
16.7 An insulin regimen with basal, prandial, and correction components is the preferred treatment for most noncritically ill hospitalized patients with adequate nutritional intake. A
16.8 Use of a correction or supplemental insulin without basal insulin (often referred to as a sliding scale) in the inpatient setting is discouraged. A
16.7 An insulin regimen with basal, prandial, and correction components is the preferred treatment for most noncritically ill hospitalized patients with adequate nutritional intake. A
16.8 Use of a correction or supplemental insulin without basal insulin (often referred to as a sliding scale) in the inpatient setting is discouraged. A
Hypoglycemia
16.9 A hypoglycemia management protocol should be adopted and implemented by each hospital or hospital system. A plan for preventing and treating hypoglycemia should be established for each individual. Episodes of hypoglycemia in the hospital should be documented in the medical record and tracked for quality improvement/quality assessment. E
16.10 Treatment regimens should be reviewed and changed as necessary to prevent further hypoglycemia when a blood glucose value of <70 mg/dL (3.9 mmol/L) is documented. C
16.10 Treatment regimens should be reviewed and changed as necessary to prevent further hypoglycemia when a blood glucose value of <70 mg/dL (3.9 mmol/L) is documented. C
Transition From the Hospital to the Ambulatory Setting
16.11 A structured discharge plan should be tailored to the individual with diabetes. B
Diabetes Advocacy
Advocacy Statements
The following is a partial list of advocacy statements ordered by publication date, with the most recent statement appearing first.
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 the following ADA statement: Cefalu WT, Dawes DE, Gavlak G, et al.; Insulin Access and Affordability Working Group. Insulin Access and Affordability Working Group: conclusions and recommendations. Diabetes Care 2018;41:1299–1311 [published correction appears in Diabetes Care 2018;41:1831]; https://doi.org/10.2337/dci18-0019 (first publication 2018).
Diabetes Care in the School Setting
A sizable portion of a child’s day is spent in school, so close communication with and cooperation of school personnel are essential to optimize diabetes management, safety, and academic opportunities. See the following ADA position statement for diabetes management information for students with diabetes in the elementary and secondary school settings.
Jackson CC, Albanese-O’Neill A, Butler KL, et al.; American Diabetes Association. Diabetes care in the school setting: a position statement of the American Diabetes Association. Diabetes Care 2015;38:1958–1963; https://doi.org/10.2337/dc15-1418 (first publication 1998; latest revision 2015).
Care of Young Children With Diabetes in the Childcare Setting
Very young children (aged <6 years) with diabetes have legal protections and can be safely cared for by childcare providers with appropriate training, access to resources, and a system of communication with parents and the child’s diabetes provider. See the following ADA position statement for information on young children aged <6 years in settings such as day care centers, preschools, camps, and other programs.
Siminerio LM, Albanese-O’Neill A, Chiang JL, et al.; American Diabetes Association. Care of young children with diabetes in the childcare setting: a position statement of the American Diabetes Association. Diabetes Care 2014;37:2834–2842; https://doi.org/10.2337/dc14-1676 (first publication 2014).
Diabetes and Driving
People with diabetes who wish to operate motor vehicles are subject to a great variety of 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, and general guidelines for assessing driver fitness and determining appropriate licensing restrictions, see the following ADA position statement.
Editor’s note: Federal commercial driving rules for individuals with insulin-treated diabetes changed on 19 November 2018. These changes will be reflected in a future updated ADA statement.
Lorber D, Anderson J, Arent S, et al.; American Diabetes Association. Diabetes and driving. Diabetes Care 2014;37(Suppl. 1):S97–S103; https://doi.org/10.2337/dc14-S097 (first publication 2012).
Diabetes and Employment
Any person with diabetes, whether insulin treated or non–insulin treated, should be eligible for any employment for which he or she is 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, see the following ADA position statement.
Anderson JE, Greene MA, Griffin JW Jr, et al.; American Diabetes Association. Diabetes and employment. Diabetes Care 2014;37(Suppl. 1):S112–S117; https://doi.org/10.2337/dc14-S112 (first publication 1984; latest revision 2009).
American Diabetes Association. Diabetes management in correctional institutions. Diabetes Care 2014;37(Suppl. 1):S104–S111; https://doi.org/10.2337/dc14-S104 (first publication 1989; latest revision 2008)
The following is a partial list of advocacy statements ordered by publication date, with the most recent statement appearing first.
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 the following ADA statement: Cefalu WT, Dawes DE, Gavlak G, et al.; Insulin Access and Affordability Working Group. Insulin Access and Affordability Working Group: conclusions and recommendations. Diabetes Care 2018;41:1299–1311 [published correction appears in Diabetes Care 2018;41:1831]; https://doi.org/10.2337/dci18-0019 (first publication 2018).
Diabetes Care in the School Setting
A sizable portion of a child’s day is spent in school, so close communication with and cooperation of school personnel are essential to optimize diabetes management, safety, and academic opportunities. See the following ADA position statement for diabetes management information for students with diabetes in the elementary and secondary school settings.
Jackson CC, Albanese-O’Neill A, Butler KL, et al.; American Diabetes Association. Diabetes care in the school setting: a position statement of the American Diabetes Association. Diabetes Care 2015;38:1958–1963; https://doi.org/10.2337/dc15-1418 (first publication 1998; latest revision 2015).
Care of Young Children With Diabetes in the Childcare Setting
Very young children (aged <6 years) with diabetes have legal protections and can be safely cared for by childcare providers with appropriate training, access to resources, and a system of communication with parents and the child’s diabetes provider. See the following ADA position statement for information on young children aged <6 years in settings such as day care centers, preschools, camps, and other programs.
Siminerio LM, Albanese-O’Neill A, Chiang JL, et al.; American Diabetes Association. Care of young children with diabetes in the childcare setting: a position statement of the American Diabetes Association. Diabetes Care 2014;37:2834–2842; https://doi.org/10.2337/dc14-1676 (first publication 2014).
Diabetes and Driving
People with diabetes who wish to operate motor vehicles are subject to a great variety of 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, and general guidelines for assessing driver fitness and determining appropriate licensing restrictions, see the following ADA position statement.
Editor’s note: Federal commercial driving rules for individuals with insulin-treated diabetes changed on 19 November 2018. These changes will be reflected in a future updated ADA statement.
Lorber D, Anderson J, Arent S, et al.; American Diabetes Association. Diabetes and driving. Diabetes Care 2014;37(Suppl. 1):S97–S103; https://doi.org/10.2337/dc14-S097 (first publication 2012).
Diabetes and Employment
Any person with diabetes, whether insulin treated or non–insulin treated, should be eligible for any employment for which he or she is 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, see the following ADA position statement.
Anderson JE, Greene MA, Griffin JW Jr, et al.; American Diabetes Association. Diabetes and employment. Diabetes Care 2014;37(Suppl. 1):S112–S117; https://doi.org/10.2337/dc14-S112 (first publication 1984; latest revision 2009).
American Diabetes Association. Diabetes management in correctional institutions. Diabetes Care 2014;37(Suppl. 1):S104–S111; https://doi.org/10.2337/dc14-S104 (first publication 1989; latest revision 2008)
Recommendation Grading
Overview
Title
Diabetes Standards of Care 2023
Authoring Organization
American Diabetes Association
Publication Month/Year
December 12, 2022
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Document Objectives
The American Diabetes Association (ADA) “Standards of Medical Care in Diabetes,” referred to as the Standards of Care, is intended to provide clinicians, patients, researchers, payers, and other interested individuals with the components of diabetes care, general treatment goals, and tools to evaluate the quality of care.
Target Patient Population
Patients with diabetes
Target Provider Population
Providers caring for patients with diabetes
Inclusion Criteria
Male, Female, Adolescent, Adult, Older adult
Health Care Settings
Ambulatory, Home health, Hospital, Outpatient, School
Intended Users
Diabetes educator, nurse, nurse practitioner, physician, physician assistant
Scope
Diagnosis, Assessment and screening, Treatment, Management
Diseases/Conditions (MeSH)
D003920 - Diabetes Mellitus, D003922 - Diabetes Mellitus, Type 1, D048909 - Diabetes Complications, D003924 - Diabetes Mellitus, Type 2, D016640 - Diabetes, Gestational
Keywords
diabetes, diabetes mellitus, gestational diabetes, diabetes complications
Source Citation
Nuha A. ElSayed, Grazia Aleppo, Vanita R. Aroda, Raveendhara R. Bannuru, Florence M. Brown, Dennis Bruemmer, Billy S. Collins, Kenneth Cusi, Sandeep R. Das, Christopher H. Gibbons, John M. Giurini, Marisa E. Hilliard, Diana Isaacs, Eric L. Johnson, Scott Kahan, Kamlesh Khunti, Mikhail Kosiborod, Jose Leon, Sarah K. Lyons, Lisa Murdock, Mary Lou Perry, Priya Prahalad, Richard E. Pratley, Jane Jeffrie Seley, Robert C. Stanton, Jennifer K. Sun, Crystal C. Woodward, Deborah Young-Hyman, Robert A. Gabbay; on behalf of the American Diabetes Association, Introduction and Methodology: Standards of Care in Diabetes—2023. Diabetes Care 1 January 2023; 46 (Supplement_1): S1–S4. https://doi.org/10.2337/dc23-Sint