The 2023 Standards of Care in Diabetes includes all of ADA's current clinical practice recommendations and is intended to provide clinicians, patients, researchers, payers, and others with the components of diabetes care, general treatment goals, and tools to evaluate the quality of care. The recommendations are based on an extensive review of the clinical diabetes literature, supplemented with input from ADA staff and the medical community at large. The Standards of Care in Diabetes is updated annually, or more frequently online if new evidence or regulatory changes merit immediate incorporation, and is published in Diabetes Care.
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This is an abridged version of the current Standards of Care containing the evidence-based recommendations most pertinent to primary care. The recommendations, tables, and figures included here retain the same numbering used in the complete Standards. All of the recommendations included here are substantively the same as in the complete Standards. The abridged version does not include references. The complete 2022 Standards of Care, including all supporting references, is available at professional.diabetes.org/standards.
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
Telemedicine may increase access to care for people with diabetes. Increasingly, evidence suggests that various telemedicine modalities may be effective at reducing A1C in people with type 2 diabetes compared with or in addition to usual care. Interactive strategies that facilitate communication between providers and patients appear more effective.
Health inequities related to diabetes and its complications are well documented and have been associated with greater risk for diabetes, higher population prevalence, and poorer diabetes outcomes. SDOH are defined as the economic, environmental, political, and social conditions in which people live and are responsible for a major part of health inequality worldwide. In addition, cost-related medication nonadherence continues to contribute to health disparities.
Diabetes can be classified into the following general categories: Type 1 diabetes (due to autoimmune β-cell destruction, usually leading to absolute insulin deficiency including latent autoimmune diabetes of adulthood)
Specific types of diabetes due to other causes, e.g., monogenic diabetes syndromes (such as neonatal diabetes and maturity-onset diabetes of the young), diseases of the exocrine pancreas (such as cystic fibrosis and pancreatitis), and drug- or chemical-induced diabetes (such as with glucocorticoid use, in the treatment of HIV/AIDS, or after organ transplantation)
It is important for providers to realize that classification of diabetes type is not always straightforward at presentation, and misdiagnosis may occur. Children with type 1 diabetes typically present with polyuria/polydipsia, and approximately half present with diabetic ketoacidosis (DKA). Adults with type 1 diabetes may not present with classic symptoms and may have a temporary remission from the need for insulin. The diagnosis may become more obvious over time and should be reevaluated if there is concern.
After the onset of puberty or after 10 years of age, whichever occurs earlier. If tests are normal, repeat testing at a minimum of 3-year intervals, or more frequently if BMI is increasing or risk factor profile deteriorating, is recommended. Reports of type 2 diabetes before age 10 years exist, and this can be considered with numerous risk factors.
Certain medications such as glucocorticoids, thiazide diuretics, some HIV medications, and atypical antipsychotics are known to increase the risk of diabetes and should be considered when deciding whether to screen.
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 minutes/week. A
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
The strongest evidence supporting lifestyle intervention for diabetes prevention in the U.S. comes from the DPP trial, which demonstrated that intensive lifestyle intervention could reduce the risk of incident type 2 diabetes by 58% over 3 years. Evidence suggests that there is not an ideal percentage of calories from carbohydrate, protein, and fat to prevent diabetes.
The Centers for Disease Control and Prevention (CDC) developed the National DPP, a resource designed to bring evidence-based lifestyle change programs for preventing type 2 diabetes to communities, including eligible Medicare patients. An online resource includes locations of CDC-recognized diabetes prevention lifestyle change programs (cdc.gov/diabetes/prevention/find-a-program.html).
Various pharmacologic agents have been evaluated for diabetes prevention, and metformin has the strongest evidence base. However, no agents have been approved by the U.S. Food and Drug Administration (FDA) for diabetes prevention.
3.8 Prediabetes is associated with heightened cardiovascular (CV) risk; therefore, screening for and treatment of modifiable risk factors for cardiovascular disease (CVD) are suggested. B
3.9 In adults with overweight/obesity at high risk of type 2 diabetes, care goals should include weight loss or prevention of weight gain, minimizing progression of hyperglycemia, and attention to CV risk and associated comorbidities. B
A successful medical evaluation depends on beneficial interactions between the patient and the care team. Individuals with diabetes must assume an active role in their care. The person with diabetes, family or support people, and health care team should together formulate the management plan, which includes lifestyle management, to improve disease outcomes and well-being.
4.5 Ongoing management should be guided by the assessment of overall health status, diabetes complications, CV risk, hypoglycemia risk, and shared decision-making to set therapeutic goals. B
The importance of routine vaccinations for people living with diabetes has been elevated by the coronavirus disease 2019 (COVID-19) pandemic. Preventing avoidable infections not only directly prevents morbidity but also reduces hospitalizations, which may additionally reduce risk of acquiring infections such as COVID-19. Children and adults with diabetes should receive vaccinations according to age-appropriate recommendations.
Patients with diabetes should be encouraged to undergo recommended age- and sex-appropriate cancer screenings and to reduce their modifiable cancer risk factors (obesity, physical inactivity, and smoking).
4.10 Patients with type 2 diabetes or prediabetes and elevated liver enzymes or fatty liver on ultrasound should be evaluated for presence of nonalcoholic steatohepatitis and liver fibrosis. C
Building positive health behaviors and maintaining psychological well-being are foundational for achieving diabetes treatment goals and maximizing quality of life. Essential to achieving these goals are DSMES, medical nutrition therapy (MNT), routine physical activity, smoking cessation counseling when needed, and psychosocial care
5.1 In accordance with the national standards for DSMES, all people with diabetes should participate in diabetes self-management education and receive the support needed 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 to promote skills acquisition in support of regimen implementation, MNT, 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
5.27 Children and adolescents with type 1 or type 2 diabetes or prediabetes should engage in 60 minutes/day or more of moderate- or vigorous-intensity aerobic activity, with vigorous muscle-strengthening and bone-strengthening activities at least 3 days/week. C
5.28 Most adults with type 1 C and type 2 B diabetes should engage in 150 minutes 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 minutes/week) of vigorous-intensity or interval training may be sufficient for younger and more physically fit individuals.
5.30 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 minutes for blood glucose benefits. C
5.32 Evaluate baseline physical activity and sedentary time. Promote increase in nonsedentary activities above baseline for sedentary individuals with type 1 E and type 2 B diabetes. Examples include walking, yoga, housework, gardening, swimming, and dancing. 2ff7e9595c
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