Standards of Medical Care in Diabetes—2022
Evidence Table
2021 Recommendation 2022 Recommendation
(Use Tracked Changes
if updating 2021
recommendation)
Example: No Change
For all patients, testing
should begin at age 45
years. B
Example: For all patients, testing
For all patients, testing should begin at age 40
should begin at age 45 years. A
years. B
Example: All patients with
New recommendation diabetes should have
home blood pressure
monitored to identify
masked or white coat
hypertension. B
Improving Care and Promoting Health in Populations
Diabetes and Population Health
1.1 Ensure treatment 1.1 Ensure treatment
decisions are timely, rely decisions are timely,
on evidence-based rely on evidence-based
guidelines, and are made guidelines, include
collaboratively with social community
patients based on support, and are made
individual preferences, collaboratively with
prognoses, and patients based on
comorbidities. B individual preferences,
prognoses,
comorbidities, and
informed financial
considerations. B
Reason for 2022 Citations & New
Change/Rationale for References
New
Recommendation
https://doi.org/10.101
6/S0140-
6736(09)62162-0
https://doi.org/10.233
7/diacare.26.2007.S5
New RCT indicates https://doi.org/10.101
that starting to test at 6/S0140-
age 40 is cost- 6736(09)62162-0
effective and prevents
long-term diabetes https://doi.org/10.233
complications 7/diacare.26.2007.S5
New 2018 reference:
https://doi.org/XXXXX
XX
Hypertension position New 2018 reference:
statement https://doi.org/XXXXX
recommendation with XX
wide applicability,
higher level evidence
grade, and long-term
benefits
Higher levels of social Social Determinants of
support are associated Health and Diabetes: A
with better glycemic Scientific Review
control, knowledge, Felicia Hill-
treatment adherence, Briggs, Nancy
and quality of life; and E. Adler, Seth
important for A. Berkowitz, Marshall
diagnosis awareness H. Chin, Tiffany
and acceptance and L. Gary-
reducing stress Webb, Ana Navas-
Acien, Pamela
L. Thornton, Debra Hai
re-Joshu
 Diabetes Care Jan
2021, 44 (1) 258-
279; DOI: 10.2337/dci
20-0053

1.2 Align approaches to No change

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 Care systems should The Community Diabetes Prevention:
facilitate team-based care facilitate team-based Preventive Services Interventions
and utilization of patient care, including those Task Force Engaging Community
registries, decision knowledgeable and (CPSTF) recommends i Health Workers
support tools, and experienced in nterventions that
community involvement diabetes management engage community https://www.thecom
to meet patient needs. B as part of the team, health workers for munityguide.org/findi
and utilization of diabetes prevention ngs/diabetes-
patient registries, to improve glycemic prevention-
decision support tools, (blood sugar) control interventions-
and community and weight-related engaging-community-
involvement to meet outcomes among health-workers
patient needs. B people at increased
risk for type 2 Annals of Internal
diabetes. medicine article on
PAs—Anne can send
the paper
1.4 Assess diabetes health No Change
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
Tailoring Treatment for Social Context
1.5 Assess food insecurity,
housing
insecurity/homelessness,
financial barriers, and
social capital/social
community support and
apply that information to
treatment decisions. A
1.6 Provide patients with
self-management support
from lay health coaches,
navigators, or community
health workers when
available. A
1.5 Assess food Create a learning Social Determinants of
insecurity, housing environment for Health and Diabetes: A
insecurity/homelessnes health professionals Scientific Review
s, financial barriers, to foster community Felicia Hill-
and social capital/social collaborations Briggs, Nancy
community support to E. Adler, Seth
inform treatment A. Berkowitz, Marshall
decisions, with referral H. Chin, Tiffany
to appropriate local L. Gary-
community resources. Webb, Ana Navas-
A Acien, Pamela
L. Thornton, Debra Hai
re-Joshu
Diabetes Care Jan
2021, 44 (1) 258-
279; DOI: 10.2337/dci
20-0053
No change The Community Diabetes Prevention:
Preventive Services Interventions
Task Force Engaging Community
(CPSTF) recommends i Health Workers
nterventions that
engage community https://www.thecom
health workers for munityguide.org/findi
diabetes prevention ngs/diabetes-
to improve glycemic prevention-
(blood sugar) control interventions-
and weight-related engaging-community-
outcomes among health-workers
people at increased
risk for type 2 https://www.ncbi.nlm.
diabetes. nih.gov/pmc/articles/P
MC4837952/
Classification and Diagnosis of Diabetes
Diagnostic Tests for Diabetes
2.1 To avoid misdiagnosis No change
or missed diagnosis, the Gujral UP,
A1C test should be Jagannathan R, He S,
performed using a Huang M, Staimez LR,
method that is certified Wei J, Singh N,
by the NGSP and Narayan KMV.
standardized to the Association between
Diabetes Control and varying cut-points of
Complications Trial intermediate
(DCCT) assay. B hyperglycemia and risk
of mortality,
cardiovascular events
and chronic kidney
disease: a systematic
review and meta-
analysis. BMJ Open
Diabetes Res Care.
2021
Apr;9(1):e001776. doi:
10.1136/bmjdrc-2020-
001776. PMID:
33906835.
Identifying sustainable
lifestyle strategies for
maintaining good
glycemic control: a
validation of
qualitative findings.

Huang SH, Huang PJ, Li

JY, Su YD, Lu CC, Shih
CL. Hemoglobin A1c
Levels Associated with
Age and Gender in
Taiwanese Adults
without Prior
Diagnosis with
Diabetes. Int J Environ
Res Public Health.
2021 Mar
 25;18(7):3390. doi:
10.3390/ijerph180733
90. PMID: 33805890;
PMCID: PMC8038122.

Li GY, Li HY, Li Q. Use

of glycated albumin
for the identification
of diabetes in subjects
from northeast China.
World J Diabetes. 2021
Feb 15;12(2):149-157.
doi:
10.4239/wjd.v12.i2.14
9. PMID: 33594334;
PMCID: PMC7839171.
2.2 Marked discordance No change Khosla L, Bhat S,
between measured A1C Fullington LA, Horlyck-
and plasma glucose levels Romanovsky MF.
should raise the HbA1c Performance in
possibility of A1C assay African Descent
interference and Populations in the
consideration of using an United States With
assay without Normal Glucose
interference or plasma Tolerance,
blood glucose criteria to Prediabetes, or
diagnose diabetes. B Diabetes: A Scoping
Review. Prev Chronic
Dis. 2021 Mar
11;18:E22. doi:
10.5888/pcd18.20036
5. PMID: 33705304;
PMCID: PMC7986971.

This review
demonstrates that
current HbA1c cutoffs
overestimate glycemic
status in African
Americans and
underestimate
glycemic status in
Afro-Caribbeans and
Africans. It identifies
gaps in the scientific
literature, especially
among Afro-

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 ALTE
RING THE RELATIONSHIP OF A1
C AND GLYCEMIA below for
more information.) B
Type 1 Diabetes
2.4 Screening for type 1
diabetes risk with a panel
of islet autoantibodies is
currently recommended
in the setting of a
research trial. or can be
offered as an option for
first-degree family
members of a proband
with type 1 diabetes. B
Caribbeans.
(n=thousands)
1. He D, Kuang W,
Yang X, Xu M.
Association of
hemoglobin H (HbH)
disease with
hemoglobin A1c and
glycated albumin in
diabetic and non-
diabetic patients. Clin
Chem Lab Med. 2021
Jan 13:cclm-2020-
1563. doi:
10.1515/cclm-2020-
1563. Epub ahead of
print. PMID:
33554549.
Hemoglobin H (HbH)
disease lower A1c and
Glc albumin is
accurate
New recommendation:
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
2.4 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
2.5 Persistence of Development of and
autoantibodies is a risk persistence of multiple
factor for clinical diabetes islet auto-antibodies is
and may serve as an a risk factor for
indication for intervention clinical diabetes and
in the setting of a clinical may serve as an
trial. B 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 2.6 Screening for 1. 1 Bardenheier BH, Wu
prediabetes and type 2 prediabetes and type 2 WC, Zullo AR,
diabetes with an informal diabetes with an Gravenstein S, Gregg
assessment of risk factors informal assessment of EW. Progression to
or validated tools should risk factors or validated diabetes by baseline
be considered in risk calculator should glycemic status among
asymptomatic adults. B be done asymptomatic middle-aged and older
adults. B adults in the United
States, 2006-2014.
Diabetes Res Clin
Pract. 2021 Mar
1;174:108726. doi:
10.1016/j.diabres.202
1.108726. Epub ahead
of print. PMID:
33662490..

Screening and DM RF
esp in mobility ltd
adults warrant
intervention for DM
prevention(n = 3,313)

2.8 Testing for 1. Lin CH, Wei JN, Fan

prediabetes and/or type 2 KC, Fang CT, Wu WC,
diabetes in asymptomatic Yang CY, Lin MS, Shih
people should be SR, Hua CH, Hsein YC,
considered in adults of Lin JW, Chuang LM, Li
any age who are HY. Different cutoffs of
overweight or obese (BMI hypertension, risk of
incident diabetes and
≥25 kg/m2 or ≥23 kg/m2
in Asian Americans) and
who have one or more
additional risk factors for
diabetes
(Table 2.3). B
2.8 Testing for
prediabetes and/or type 2
diabetes should be
considered in women
with overweight or
obesity planning
pregnancy and/or who
have one or more
additional risk factor for
diabetes (Table 2.3). C
2.9 For all people, testing
should begin at age 45
years. B
2.10 If tests are normal,
repeat testing carried out
at a minimum of 3-year
intervals is reasonable,
sooner with symptoms or
change in risk. C
2.11 To test 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
progression of insulin
resistance: A
prospective cohort
study. J Formos Med
Assoc. 2021 Mar
22:S0929-
6646(21)00105-4. doi:
10.1016/j.jfma.2021.0
2.022. Epub ahead of
print. PMID:
33766449.
New recommendation: https://jamanetwork.c
2.9 For all people, om/journals/jama/full
screening should begin article/2783414
at age 35 years. B
2.9 For all people, Without RF Khunti
testing for diabetes
should begin at age 45
years. B
If tests are normal, New weight gain is a
repeat screening reason to decrease
recommended at a screening to annual
minimum of 3-year screening
intervals is reasonable,
sooner with symptoms
or change in risk
(i.e., weight gain). C
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
 New recommendation: 1. Klein KR, Walker CP,
2.12 When using oral McFerren AL, Huffman
glucose tolerance H, Frohlich F, Buse JB.
testing as a screen for Carbohydrate Intake
diabetes, adequate Prior to Oral Glucose
carbohydrate intake (at Tolerance Testing. J
least 150 g/day) should Endocr Soc. 2021 Mar
be assured for 3 days 29;5(5):bvab049. doi:
prior to testing. A 10.1210/jendso/bvab0
49. PMID: 33928207;
PMCID: PMC8059359.

Conn JW.
Interpretation of the
glucose tolerance test.
The necessity of a
standard preparatory
diet. Am J Med Sci.
1940;199:555-564.
3. Wilkerson HL,
Butler FK, Francis JO.
The effect of prior
carbohydrate intake
on the oral glucose
tolerance test.
Diabetes. 1960;9:386-
391
2.13 In patients with In people with
prediabetes and type 2 prediabetes and type 2
diabetes, identify and diabetes, identify and
treat other cardiovascular treat cardiovascular
disease risk factors. A disease risk factors. A
2.14 Risk-based screening No change
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 Patients with HIV People with HIV should
should be screened for be screened for
diabetes and prediabetes diabetes and
with a fasting glucose test prediabetes with a
before starting fasting glucose test
antiretroviral therapy, at before starting
the time of switching antiretroviral therapy,
antiretroviral therapy, at the time of switching
and 3−6 months after antiretroviral therapy,
starting or switching and 3−6 months after
antiretroviral therapy. If starting or switching
initial screening results antiretroviral therapy.
are normal, fasting If initial screening
glucose should be results are normal,
checked annually. E fasting glucose should
be checked annually. E
Cystic Fibrosis-Related Diabetes
2.16 Annual screening for No change 1. A1c not correlated 1. Darukhanavala A,
cystic fibrosis–related with dynamic testing Van Dessel F, Ho J,
diabetes (CFRD) with an (retrospective n=56) Hansen M, Kremer T,
oral glucose tolerance Alfego D. Use of
test should begin by age hemoglobin A1c to
10 years in all patients identify dysglycemia in
with cystic fibrosis not cystic fibrosis. PLoS
previously diagnosed with One. 2021 Apr
CFRD. B 21;16(4):e0250036.
doi:
10.1371/journal.pone.
0250036. PMID:
33882078.
2.
2.17 A1C is not No change
recommended as a
screening test for cystic
fibrosis–related
diabetes. B
2.18 Patients with cystic People with cystic
fibrosis– related diabetes fibrosis– related
should be treated with diabetes should be
insulin to attain treated with insulin to
individualized glycemic attain individualized
goals. A glycemic goals. A
2.19 Beginning 5 years No change
after the diagnosis of
cystic fibrosis–related
diabetes, annual
monitoring for
complications of diabetes
is recommended. E
Posttransplantation Diabetes Mellitus
2.20 Patients should be 19 After organ 1. 251 renal transplant Pham Vu T, Nguyen
screened after organ transplantation, pts (12%) NODAT Thi Thuy D, Truong
transplantation for screening for hSCRP pred Quy K, Nguyen Thi Thu
hyperglycemia, with a hyperglycemia should 2. Review of peds lit H, Nguyen Van D,
formal diagnosis of be done. A formal 3. ~80 pts comparing Diem Thi V, Do Manh
posttransplantation diagnosis of different interventions H, Nguyen Trung K, Do
diabetes mellitus being posttransplantation (point ~7.8% Q, Tran Viet T, Do Nhu
best made once a patient diabetes mellitus is incidence of PTDM ) B, Pham Quoc T, Can
is stable on an best made once the Van M, Le Viet T.
immunosuppressive individual is stable on Serum hs-CRP
regimen and in the an immunosuppressive measured prior
absence of an acute regimen and in the transplantation
infection. B absence of an acute predicts of new-onset
infection. B diabetes after
transplantation in
renal transplant
recipients. Transpl
Immunol. 2021
Jun;66:101392. doi:
10.1016/j.trim.2021.1
01392. Epub 2021 Apr
7. PMID: 33838297.

Grundman JB,
Wolfsdorf JI, Marks BE.
Post-Transplantation
Diabetes Mellitus in
Pediatric Patients.
Horm Res Paediatr.
2020;93(9-10):510-
518. doi:
10.1159/000514988.
Epub 2021 Mar 31.
PMID: 33789298.

Kim HD, Chang JY,

Chung BH, Kim CD, Lee
SH, Kim YH, Yang CW.
Effect of Everolimus
with Low-Dose
Tacrolimus on
Development of New-
Onset Diabetes After
 Transplantation and
Allograft Function in
Kidney
Transplantation: A
Multicenter, Open-
Label, Randomized
Trial. Ann Transplant.
2021 Jan
22;26:e927984. doi:
10.12659/AOT.927984
. PMID: 33479188;
PMCID: PMC7836319.
2.21 The oral glucose No change
tolerance test is the
preferred test to make a
diagnosis of
posttransplantation
diabetes mellitus. B
2.22 Immunosuppressive No cahnge Risk for PTDM and Cheng CY, Chen CH,
regimens shown to poor outcomes and Wu MF, Wu MJ, Chen
provide the best some differences JP, Liu YM, Hou YC,
outcomes for patient and based on Wang HY. Risk Factors
graft survival should be immunosuppression in and Long-Term
used, irrespective of regimen (n=92 PTDM Survival of Patients
posttransplantation and 333 no DM) with Post-
diabetes mellitus risk. E Transplantation
Diabetes Mellitus: A
Retrospective Cohort
Study. Int J Environ
Res Public Health.
2020 Jun
25;17(12):4581. doi:
10.3390/ijerph171245
81. PMID: 32630562;
PMCID: PMC7345656.
Monogenic Diabetes Syndromes
2.23 All children Regardless of current Holt RIG, DeVries JH,
diagnosed with diabetes age, all people Hess-Fischl A, et al.
in the first 6 months of diagnosed with The management of
life should have diabetes in the first 6 type 1 diabetes in
immediate genetic testing months of life should adults. A consensus
for neonatal diabetes. A have immediate report by the
genetic testing for American Diabetes
neonatal diabetes. A Association (ADA) and
the European
Association for the
Study of Diabetes
(EASD). Diabetes Care.

2.24 Children and those
diagnosed in early
adulthood who have
diabetes not
characteristic of type 1 or
type 2 diabetes that
occurs 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 these
mutations and how best
to approach further
evaluation, treatment,
and genetic counseling. E
Gestational Diabetes Mellitus
2.26 Test for undiagnosed 2.26a In women who
prediabetes and diabetes are planning
at the first prenatal visit in pregnancy, screen
those with risk factors
using standard diagnostic B and consider testing
criteria. B
11 October 2021
[Epub ahead of print].
DOI:
10.2337/dci21-0043
Children and young Holt RIG, DeVries JH,
adults who do not have Hess-Fischl A, et al.
typical characteristics The management of
of type 1 or type 2 type 1 diabetes in
diabetes and who often adults. A consensus
have a family history of report by the
diabetes in successive American Diabetes
generations (suggestive Association (ADA) and
of an autosomal the European
dominant pattern of Association for the
inheritance) should Study of Diabetes
have genetic testing for (EASD). Diabetes Care.
maturity-onset 11 October 2021
diabetes of the young. [Epub ahead of print].
A DOI:
10.2337/dci21-0043
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
Cho NH, Shaw JE,
Karuranga S, Huang Y,
da Rocha Fernandes
those with risk factors JD, Ohlrogge AW,
Malanda B. IDF
all women for undiag- Diabetes Atlas: Global
nosed diabetes. E estimates of diabetes
prevalence for 2017
2.26b Before 15 weeks and projections for
of gestation, test 2045. Diabetes Res
women with risk Clin Pract. 2018
factors B and consider Apr;138:271-281. doi:
testing all women E for 10.1016/j.diabres.201
undiagnosed diabetes 8.02.023. Epub 2018
at the first prenatal
visit using standard Feb 26. PMID:
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not screened Britton LE, Hussey JM,
preconception. Crandell JL, Berry DC,
Brooks JL, Bryant AG.
2.26c Women Racial/Ethnic
identified as having Disparities in Diabetes
diabetes should be Diagnosis and
treated as such. A Glycemic Control
Among Women of
2.26d Before 15 weeks Reproductive Age. J
of gestation, screen for Womens Health
abnormal glucose (Larchmt). 2018
metabolism to identify Oct;27(10):1271-1277.
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higher risk of adverse 10.1089/jwh.2017.684
pregnancy and neona- 5. Epub 2018 May 14.
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and are at high risk of a Yuen L, Wong VW,
later gestational Simmons D. Ethnic
diabetes mellitus Disparities in
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may provide some Curr Diab Rep. 2018
benefit. E Jul 23;18(9):68. doi:
10.1007/s11892-018-
2.26e Screen for early 1040-2. PMID:
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fasting glucose of 110– Morgan I, D'Angelo
125 mg/dL (6.1 DV, Zapata LB,
mmol/L) or A1C 5.9– Morrow B, Sharma A,
6.4% (41–47 Kroelinger CD.
mmol/mol). B Disparities in
Preconception Health
Indicators -
Behavioral Risk
Factor Surveillance
System, 2013-2015,
and Pregnancy Risk
Assessment
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10.15585/mmwr.ss67
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MMWR Morb Mortal
Wkly Rep. 2018 Apr
27;67(16):479. PMID:
29346340; PMCID:
PMC5829866.

Zhu WW, Yang HX,

Wei YM, Yan J, Wang
ZL, Li XL, Wu HR, Li N,
Zhang MH, Liu XH,
Zhang H, Wang YH,
Niu JM, Gan YJ, Zhong
LR, Wang YF, Kapur A.
Evaluation of the value
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glucose in the first
prenatal visit to
diagnose gestational
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27. PMID: 23193214;
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Chen L, Pocobelli G, Yu
O, Shortreed SM,
Osmundson SS, Fuller
S, Wartko PD,
Mcculloch D, Warwick
S, Newton KM, Dublin
S. Early Pregnancy
Hemoglobin A1C and
Pregnancy Outcomes:
A Population-Based
Study. Am J Perinatol.
2019 Aug;36(10):1045-
1053. doi: 10.1055/s-
0038-1675619. Epub
2018 Nov 30. PMID:
30500961; PMCID:
PMC6612540.
Osmundson SS, Zhao
BS, Kunz L, Wang E,
Popat R, Nimbal VC,
Palaniappan LP. First
Trimester Hemoglobin
A1c Prediction of
Gestational Diabetes.
Am J Perinatol. 2016
Aug;33(10):977-82.
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1581055. Epub 2016
Apr 27. PMID:
27120479
Hughes RC, Moore
MP, Gullam JE,
Mohamed K, Rowan J.
An early pregnancy
HbA1c ≥5.9% (41
mmol/mol) is optimal
for detecting diabetes
and identifies women
at increased risk of
adverse pregnancy
outcomes. Diabetes
Care. 2014
Nov;37(11):2953-9.
doi: 10.2337/dc14-
1312. Epub 2014 Sep
4. PMID: 25190675.
Mañé L, Flores-Le
Roux JA, Gómez N,
Chillarón JJ, Llauradó
G, Gortazar L, Payà A,
Pedro-Botet J,
Benaiges D.
Association of first-
trimester HbA1c levels
with adverse
pregnancy outcomes
in different ethnic
groups. Diabetes Res
Clin Pract. 2019
Apr;150:202-210. doi:
10.1016/j.diabres.201
9.03.017. Epub 2019
Mar 15. PMID:
30880095.
Boe B, Barbour LA,
Allshouse AA,
Heyborne KD.
Universal early
pregnancy
glycosylated
hemoglobin A1c as an
adjunct to Carpenter-
 Coustan screening: an
observational cohort
study. Am J Obstet
Gynecol MFM. 2019
Mar;1(1):24-32. doi:
10.1016/j.ajogmf.2019
.02.003. Epub 2019
Mar 6. PMID:
33319754.
Immanuel J, Simmons
D. Screening and
Treatment for Early-
Onset Gestational
Diabetes Mellitus: a
Systematic Review and
Meta-analysis. Curr
Diab Rep. 2017 Oct
2;17(11):115. doi:
10.1007/s11892-017-
0943-7. PMID:
28971305.

2.27 Test for gestational Screen for gestational Hillier TA, Pedula KL,
diabetes mellitus at 24–28 diabetes mellitus at Ogasawara KK, Vesco
weeks of gestation in 24–28 weeks of KK, Oshiro CES,
pregnant women not gestation in pregnant Lubarsky SL, Van
previously found to have women not previously Marter J. A Pragmatic,
diabetes. A found to have diabetes Randomized Clinical
or high-risk abnormal Trial of Gestational
glucose metabolism Diabetes Screening. N
detected earlier in the Engl J Med. 2021 Mar
current pregnancy. A 11;384(10):895-904.
doi:
10.1056/NEJMoa2026
028. PMID: 33704936.

Saccone G, Khalifeh A,
Al-Kouatly HB, Sendek
K, Berghella V.
Screening for
gestational diabetes
mellitus: one step
versus two step
approach. A meta-
analysis of randomized
trials. J Matern Fetal
Neonatal Med. 2020
May;33(9):1616-1624.
doi:
10.1080/14767058.20
18.1519543. Epub
2018 Sep 25. PMID:
30173594.

Casey BM, Rice MM,

Landon MB, Varner
MW, Reddy UM,
Wapner RJ, Rouse DJ,
Biggio JR Jr, Thorp JM
Jr, Chien EK, Saade GR,
Peaceman AM,
Blackwell SC, Van
Dorsten JP; Eunice
Kennedy Shriver
National Institute of
Child Health and
Human Development
Maternal-Fetal
Medicine Units
(MFMU) Network.
Effect of Treatment of
Mild Gestational
Diabetes on Long-
Term Maternal
Outcomes. Am J
Perinatol. 2020
Apr;37(5):475-482.
doi: 10.1055/s-0039-
1681058. Epub 2019
Mar 13. PMID:
30866027; PMCID:
PMC6744360.
Josefson JL, Scholtens
DM, Kuang A, Catalano
PM, Lowe LP, Dyer AR,
Petito LC, Lowe WL Jr,
Metzger BE; HAPO
Follow-up Study
Cooperative Research
Group. Newborn
Adiposity and Cord
Blood C-Peptide as
Mediators of the
Maternal Metabolic
 Environment and
Childhood Adiposity.
Diabetes Care. 2021
Feb 22:dc202398. doi:
10.2337/dc20-2398.
Epub ahead of print.
PMID: 33619125
2.28 Test women with Screen women with
gestational diabetes gestational diabetes
mellitus for prediabetes mellitus for
or diabetes at 4–12 weeks prediabetes or
postpartum, using the 75- diabetes at 4–12 weeks
g oral glucose tolerance postpartum, using
test and clinically the 75-g oral glucose
appropriate tolerance test and
nonpregnancy diagnostic clinically appropriate
criteria. B nonpregnancy
diagnostic criteria. B
2.29 Women with a No change
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 No change
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
3.1 At least annual 3.1 Monitor for the In a publication from Risk of Progression to
monitoring for the development of type 2 the ARIC Diabetes Among Older
development of type 2 diabetes in those with (Atherosclerosis Risk Adults
diabetes in those with prediabetes at least in Communities) With Prediabetes.
prediabetes is annually, modified study, prevalence of Rooney MR, Rawlings
suggested. E based on individual prediabetes was high AM, Pankow JS,
risk/benefit in older community Echouffo Tcheugui JB,
assessment. E dwelling adults (mean Coresh J, Sharrett AR,
age 75.6, with 73% Selvin E.JAMA Intern
meeting A1c or IFG Med. 2021 Apr
criteria for 1;181(4):511-519. doi:
prediabetes). 10.1001/jamainternm
However, over the 6.5 ed.2020.8774.PMID: 3
year follow-up period, 3555311
progression to
diabetes was
relatively low (9% in
those with A1c 5.7-
6.4%), compared to
regression to
normoglycemia (13%)
or death (19%). Of
those with IFG at
baseline, 112 (8%)
progressed to
diabetes, 647 (44%)
regressed to
normoglycemia (FG,
<100 mg/dL), and 236
(16%) died.

Behavior Change Interventions

3.2 Refer patients with 3.2 Refer adults with It is important to (1) PMID: 169361
prediabetes to an overweight/obesity at establish care goals 60
intensive lifestyle high risk of type 2 for this population. In (2) Factors
behavior change program diabetes, as typified by patients with associated
modeled on the Diabetes the Diabetes overweight/obesity at with diabetes
Prevention Program to Prevention Program, to high risk of type 2 onset during
achieve and maintain 7% an intensive lifestyle diabetes (as typified metformin
loss of initial body weight behavior change by the DPP/DPPOS), versus placebo
and increase moderate- program consistent key principles therapy in the
intensity physical activity with the Diabetes emerged, relevant to diabetes
(such as brisk walking) to Prevention Program to care and care goals: prevention
at least 150 min/week A achieve and maintain 1) Weight loss program.
7% loss of initial body was an Lachin JM, et
weight and increase important al. Diabetes.
moderate-intensity mediator of 2007. PMID: 17395752
physical activity (such diabetes
as brisk walking) to at prevention/de
least 150 min/week A lay, with • (3) PMID: 26377054
greater • PMCID: PMC4623946
metabolic • DOI: 10.1016/S2213-
benefit seen 8587(15)00291-0
with greater
weight loss PMID: 22683134
2) Progression to
diabetes, PMID: 31320445
duration of
diabetes and
mean level of https://pubmed.ncbi.n
glycemia were lm.nih.gov/33608769/
main
determinants https://pubmed.ncbi.n
of lm.nih.gov/31036503/
development
of https://pubmed.ncbi.n
microvascular lm.nih.gov/30104301/
complications
3) Ability to https://www.ahajourn
achieve als.org/doi/full/10.116
normal 1/JAHA.120.019045
glucose
regulation,
even once,
during the
DPP (any arm)
was
associated
with lower
risk of
diabetes and
lower risk of
microvascular
complications.
Furthermore, levels of
glycemia, even within
the prediabetes range,
are associated with
increased risk of
 diabetes, CHD, stroke,
and mortality.

Studies suggest that

regression from
prediabetes to
normoglycemia is
associated with lower
risk of cardiovascular
disease. (Da Qing
2021), and even in
people who do
progress, minimizing
progression of
hyperglycemia (mean
a1c < 6.5%) is
associated with lower
risk of
micro/macro/and
mortality.
3.3 A variety of eating No change
patterns can be
considered to prevent
diabetes in individuals
with prediabetes. B
3.4 Given the cost- Given the cost-
effectiveness of lifestyle effectiveness of
behavior modification lifestyle behavior
programs for diabetes modification programs
prevention A, such for diabetes prevention
diabetes prevention , such diabetes
programs should be prevention programs
covered by third-party should be offered to
payers. patients. A Diabetes
prevention programs
should be covered by
third-party payers and
inconsistencies in
access should be
addressed.

3.5 Based on patient No change

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 3.6 Metformin therapy Original and follow up
prevention of type 2 for prevention of type subgroup analyses by Diabetes Prevention
diabetes should be 2 diabetes should be both glucose and A1c Program Research
considered in those with considered in those criteria consistently Group; Diabetes Care
prediabetes, especially for with prediabetes, as highlight benefit of 2019; 42(4):601-608.
those with BMI ≥35 typified by the metformin in these
2
kg/m , those aged <60 Diabetes Prevention subgroups,
years, and women with Program, especially in particularly higher
prior gestational diabetes those aged 25-59 fasting glucose, higher
mellitus. A years, with BMI ≥35 a1c, and women with
kg/m2, higher fasting history of GDM.
plasma glucose (eg >=
110 mg/dl), higher
HbA1c (eg >= 6.0%),
and in women with
prior gestational
diabetes mellitus. A
3.7 Long-term use of No change
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 CVD
3.8 Prediabetes is No change
associated with
heightened cardiovascular
risk; therefore, screening Association between p
for and treatment of rediabetes and risk of
modifiable risk factors for all cause mortality and
cardiovascular disease are cardiovascular disease:
suggested. B updated meta-
analysis.
Cai X, Zhang Y, Li M,
Wu JH, Mai L, Li J,
Yang Y, Hu Y, Huang
Y.BMJ. 2020 Jul
15;370:m2297. doi:
 10.1136/bmj.m2297.P
MID: 32669282

J Clin Endocrinol
Metab
•
•
•
. 2020 Apr
1;105(4):e1772-e1780.
doi:
10.1210/clinem/dgaa0
17.
Comprehensive Medical Evaluation and Assessment of Comorbidities
Patient-Centered Collaborative Care
4.1 A patient-centered No change
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 No change
can benefit from a
coordinated
multidisciplinary team
that may draw from
diabetes care and
education specialists,
primary care providers,
subspecialty providers,
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 No change
and classify diabetes.
A
• Evaluate for diabetes No change
complications and
potential comorbid
conditions. A
• Review previous No change
treatment and risk
factor control in
patients with
 established diabetes.
A
• Begin patient No change
engagement in the
formulation of a care
management plan. A
• Develop a plan for No change
continuing care. A
4.4 A follow-up visit No change
should include most
components of the initial
comprehensive medical
evaluation (see Table 4.1).
A
4.5 Ongoing 4.5 Ongoing
management should be management should be
guided by the assessment guided by the
of overall health status, assessment of overall
diabetes complications, health status, diabetes
cardiovascular risk (see complications,
the risk calculator, Section cardiovascular risk,
10 “Cardiovascular hypoglycemia risk, and
Disease and Risk shared decision-making
Management,” to set therapeutic
https://doi.org/10.2337/d goals. B
c21-S010), hypoglycemia
risk, and shared decision-
making to set therapeutic
goals. B
Immunization
4.6 Provide routinely No change
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 No change
diabetes should be
screened for autoimmune
thyroid disease soon after
diagnosis and periodically
thereafter. B
4.8 Adult patients with No change
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 No change
cognitive impairment,
diabetes treatment
regimens should be
simplified as much as
possible and tailored to
minimize the risk of
hypoglycemia. B
Non-alcoholic Fatty Liver Disease
4.10 Patients with type 2 No change
diabetes or prediabetes https://care.diabetesj
and elevated liver ournals.org/content/e
enzymes (ALT) or fatty arly/2021/07/22/dci21
liver on ultrasound should -0020.full-text.pdf
be evaluated for presence
of nonalcoholic
steatohepatitis and liver
fibrosis. C
Low Testosterone in Men
4.18 In men with diabetes No change
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 Behavior Change and Well-being to Improve Health Outcomes
Add most of these references here (confirmed once the group reviews these references), but refer to
this section in section 1 (telemedicine) and 7 (digital coaching). Needs to be a comment about tailoring
these methods to the needs of populations in section 1 and consideration of patient access (digital
divide)

Dack, C., Ross, J., Stevenson, F., Pal, K., Gubert, E., Michie, S., Yardley, L., Barnard, M., May, C., Farmer,
A., Wood, B., & Murray, E. (2019).
A digital self-management intervention for adults with type 2 diabetes: Combining theory, data and
participatory design to develop HeLP-Diabetes.
Internet interventions, 17, 100241. https://doi.org/10.1016/j.invent.2019.100241

Lee, M. K., Lee, D. Y., Ahn, H. Y., & Park, C. Y. (2021). A Novel User Utility Score for Diabetes
Management Using Tailored Mobile Coaching: Secondary Analysis of a Randomized Controlled Trial.
JMIR mHealth and uHealth, 9(2), e17573. https://doi.org/10.2196/17573
RCT. Small study (N=72) Based on user engagement, there was a significant difference with lower of
Acc at 3,6, and 12mos. User engagement was measured using the core components of frequency of
self-monitoring of glucose, dietary and exercise records and message reading rate.

Dening, J., Islam, S., George, E., & Maddison, R. (2020). Web-Based Interventions for Dietary Behavior
in Adults With Type 2 Diabetes: Systematic Review of Randomized Controlled Trials. Journal of medical
Internet research, 22(8), e16437. https://doi.org/10.2196/16437
Meta-analysis based on 5 studies with a total n= 1056 adults.
Conclusions: This review provided evidence that web-based interventions may be an effective way to
improve dietary behavior in people with T2DM. The results also suggest improvements in glycemic
control and clinical outcomes may be possible, although the studies in this review yielded inconsistent
results. While this preliminary evidence showed promise of a positive effect, the small number of
studies and the fact they are highly heterogeneous makes it difficult to draw any firm conclusions. The
field requires more well-designed web-based dietary interventions that report dietary prescription and
adherence in people with T2DM to confirm their effectiveness in optimizing dietary behavior and
improving clinical outcomes.

Omar, M. A., Hasan, S., Palaian, S., & Mahameed, S. (2020). The impact of a self-management
educational program coordinated through WhatsApp on diabetes control. Pharmacy practice, 18(2),
1841. https://doi.org/10.18549/PharmPract.2020.2.1841

RCT. Achieved a clinically significant reduction in A1c of.6% between control (standard DSME delivery)
and intervention (WhatsApp) grps (p<.05). 218 recruited, final n = 164.
Diabetes Self-Management Education and Support
5.1 In accordance with No Change
the national standards for
diabetes self-
management education
and support, 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 necessary
for diabetes self-care. A
5.2 There are four critical No Change
times to evaluate the
need for diabetes self-
management education
to promote skills
acquisition in support of
regimen 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, No Change
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- Diabetes self-
Use of technology:
management education management edu-
and support should be cation and support Gershkowitz BD,
patient centered, may be should be patient- Hillert CJ, Crotty BH.
given in group or centered, may be Digital Coaching
individual settings and/or offered in group or Strategies to Facilitate
use technology, and individual settings, Behavioral Change in
should be communicated and should be Type 2 Diabetes: A
with the entire diabetes communicated with the Systematic Review. J
care team. A entire diabetes care Clin Endocrinol Metab.
team. A 2021 Mar
25;106(4):e1513-
 e1520. doi:
10.1210/clinem/dgaa8
50. PMID: 33206975.
(or use in telemedicine
approach in 5.7)

Liang K, Xie Q, Nie J,

Deng J. Study on the
effect of education for
insulin injection in
diabetic patients with
new simulation tools.
Medicine (Baltimore).
2021 Apr
9;100(14):e25424. doi:
10.1097/MD.0000000
000025424. PMID:
33832143; PMCID:
PMC8036090.

New recommendation:
5.5 Digital coaching and
digital self-
management
interventions can be
effective methods to
deliver diabetes self-
management education
and support. B
5.6 Because diabetes self- No Change Cost effectiveness
management education analysis-although
and support can improve related to behavioral
outcomes and reduce health,
costs B, reimbursement Radcliff TA, Côté MJ,
by third-party payers is Whittington MD,
recommended. C Daniels MJ, Bobroff LB,
Janicke DM, Perri MG.
Cost-Effectiveness of
Three Doses of a
Behavioral
Intervention to
Prevent or Delay Type
2 Diabetes in Rural
Areas. J Acad Nutr
Diet. 2020
Jul;120(7):1163-1171.
 doi:
10.1016/j.jand.2019.1
0.025. Epub 2019 Dec
30. PMID: 31899170;
PMCID: PMC7321861.

5.7 Barriers to diabetes No Change

self-management
education and support
exist at the health system,
payor, provider, and
patient levels A and
efforts need to be made
to identify and address
them. E
5.7 Some barriers to No Change
https://journals.sagep
diabetes self-
management education ub.com/doi/abs/10.11
and support access may 77/014572172093512
be mitigated through 5
telemedicine
approaches. B
Digital Coaching
Strategies to Facilitate
Behavioral Change in
Type 2 Diabetes: A
Systematic Review.
Gershkowitz BD,
Hillert CJ, Crotty BH.
J Clin Endocrinol
Metab. 2021 Mar
25;106(4):e1513-
e1520. doi:
10.1210/clinem/dgaa8
50
Nutrition Therapy
Effectiveness of Nutrition Therapy
5.9 An individualized No Change
medical nutrition therapy
program as needed to
achieve treatment goals,
provided by a registered
dietitian nutritionist
(RD/RDN), 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
5.10 Because diabetes No Change
medical nutrition therapy
can result in cost
savings B and improved
outcomes (e.g., A1C
reduction, reduced
weight, decrease in
cholesterol) A, medical
nutrition therapy should
be adequately reimbursed
by insurance and other
payers. E
Energy Balance
5.11 For all patients with No Change
overweight or obesity,
lifestyle modification to
achieve and maintain a
minimum weight loss of
5% is recommended for
all patients with diabetes
and prediabetes. A
Eating Patterns and Macronutrient Distribution
5.12 There is no single 5.12 There is no ideal
ideal dietary distribution micronutrient pattern
of calories among for people with
carbohydrates, fats, and diabetes; although
proteins for people with carbohydrates have the
diabetes; therefore, meal greatest impact on
plans should be glycemia; overall, meal
individualized while plans should be
keeping total calorie and individualized while
metabolic goals in mind. E keeping total calorie
and metabolic goals in
mind. E
5.13 A variety of eating No change
patterns can be
considered for the
management of type 2
diabetes and to prevent
diabetes in individuals
with prediabetes. B
5.14 Reducing overall
carbohydrate intake for
individuals with diabetes
has demonstrated the
most evidence for
improving glycemia and
may be applied in a
variety of eating patterns
that meet individual
needs and preferences. B
No change Carbohydrate
restriction for
diabetes:
rediscovering
centuries-old wisdom.
Lennerz BS, Koutnik
AP, Azova S, Wolfsdorf
JI, Ludwig DS.
J Clin Invest. 2021 Jan
4;131(1):e142246. doi:
10.1172/JCI142246.

Efficacy and safety of

low and very low
carbohydrate diets for
type 2 diabetes
remission: systematic
review and meta-
analysis of published
and unpublished
randomized trial data.
Goldenberg JZ, Day A,
Brinkworth GD, Sato J,
Yamada S, Jönsson T,
Beardsley J, Johnson
JA, Thabane L,
Johnston BC.
BMJ. 2021 Jan
13;372:m4743. doi:
10.1136/bmj.m4743.

Carbohydrates
5.15 Carbohydrate intake 5.13 Carbohydrate Hu Y, Ding M,
should emphasize intake should Sampson L, Willett
nutrient-dense emphasize nutrient- WC, Manson JE, Wang
carbohydrate sources that dense carbohydrate M, Rosner B, Hu FB,
are high in fiber and sources that are high in Sun Q. Intake of whole
minimally processed. fiber (at least 14g fiber grain foods and risk of
Eating plans should per 1,000 kcal) and type 2 diabetes:
emphasize nonstarchy minimally processed. results from three
vegetables, minimal Eating plans should prospective cohort
added sugars, fruits, emphasize nonstarchy studies. BMJ. 2020 Jul
whole grains, as well as vegetables, , fruits, 8;370:m2206. doi:
dairy products. B whole grains, as well as 10.1136/bmj.m2206.
dairy products with PMID: 32641435;
minimally added PMCID: PMC7341349.
sugars. B
 Partula V, Deschasaux
M, Druesne-Pecollo N,
Latino-Martel P,
Desmetz E, Chazelas E,
Kesse-Guyot E, Julia C,
Fezeu LK, Galan P,
Hercberg S, Mondot S,
Lantz O, Quintana-
Murci L, Albert ML,
Duffy D; Milieu
Intérieur Consortium,
Srour B, Touvier M.
Associations between
consumption of
dietary fibers and the
risk of cardiovascular
diseases, cancers, type
2 diabetes, and
mortality in the
prospective NutriNet-
Santé cohort. Am J Clin
Nutr. 2020 Jul
1;112(1):195-207. doi:
10.1093/ajcn/nqaa063
. PMID: 32369545.
5.16 People with diabetes No change
and those at risk are
advised to replace sugar-
sweetened beverages
(including fruit juices)
with water as much as
possible in order to
control glycemia and
weight and reduce their
risk for cardiovascular
disease and fatty liver B
and should minimize the
consumption of foods
with added sugar that
have the capacity to
displace healthier, more
nutrient-dense food
choices. A
5.17 For people with When using a flexible https://care.diabetesj
diabetes who are insulin therapy ournals.org/content/4
prescribed a flexible program, education on 3/1/59?ijkey=97eb0fbf
insulin therapy program, the glycemic impact of 0b6a57246c12639037
education on how to use carbohydrate A, fat and
carbohydrate
counting A and on dosing
for fat and protein
content B should be used
to determine mealtime
insulin dosing.
5.18 For adults using fixed
insulin doses, consistent
pattern of carbohydrate
intake with respect to
time and amount, while
considering the insulin
action time, can result in
improved glycemia and
reduce the risk for
hypoglycemia. B
Protein
5.19 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
5.20 An eating plan
emphasizing elements of
a Mediterranean-style
eating pattern rich in
monounsaturated and
polyunsaturated fats may
be considered to improve
glucose metabolism and
lower cardiovascular
disease risk. B
protein B should be 9c5f7f3e88cb99&keyt
tailored to an ype2=tf_ipsecsha
individual’s needs and
preferences and used
to optimize mealtime
insulin dosing .
5.18 When using fixed
insulin doses,
individuals should be
provided education
about consistent
pattern of
carbohydrate intake
with respect to time
and amount, while
considering the insulin
action time, can result
in improved glycemia
and reduce the risk for
hypoglycemia. B
No change
No Change Effect of dairy
consumption and its
fat content on
glycemic control and
cardiovascular disease
risk factors in patients
with type 2 diabetes: a
randomized controlled
study.
Mitri J, Tomah S,
Mottalib A, Salsberg V,
Ashrafzadeh S, Pober
DM, Eldib AH,
 Tasabehji MW, Hamdy
O.
Am J Clin Nutr. 2020
Aug 1;112(2):293-302.
doi:
10.1093/ajcn/nqaa138
.
5.20 Eating foods rich in No change
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
5.22 There is no clear No Change Meta-analysis showed
evidence that dietary vitamin D
supplementation with supplementation O, Bala A, Alabdouh A,
vitamins, minerals (such reduced incidence risk Gakhal I, Rizk F,
as chromium and vitamin of T2DM compared Alkasasbeh M,
D), herbs, or spices (such with placebo. Bachuwa G, Manson
as cinnamon or aloe vera) JE. Effect of Vitamin D
can improve outcomes in Perhaps add to the Supplementation on
people with diabetes who commentary, keep the Incidence of
do not have underlying rec the same since Diabetes Mellitus. J
deficiencies, and they are this refers to pre-dm? Clin Endocrinol Metab.
not generally mic 2020 Aug
recommended for 1;105(8):dgaa335. doi:
glycemic control. C 10.1210/clinem/dgaa3
35. PMID: 32491181.
Alcohol
5.23 Adults with diabetes No Change
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
5.24 Educating people No Change
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. C
Sodium
5.25 As for the general
population, people with
diabetes and prediabetes
should limit sodium
consumption to <2,300
mg/day. B
Nonnutritive Sweeteners
5.26 The use of
nonnutritive sweeteners
may have the potential to
reduce overall calorie and
carbohydrate intake if
substituted for caloric
(sugar) sweeteners and
without compensation by
intake of additional
calories from other food
sources. For those who
consume sugar-
sweetened beverages
regularly, a low-calorie or
nonnutritive-sweetened
beverage may serve as a
short-term replacement
strategy, but overall,
people are encouraged to
decrease both sweetened
and nonnutritive-
sweetened beverages and
use other alternatives,
with an emphasis on
water intake. B
5.24 Sodium
consumption should be
limited to <2,300
mg/day. B
The use of nonnutritive For those who Sylvetsky AC,
sweeteners as a regularly consume Chandran A,
replacement for sugar- SSB, educate Talegawkar SA, Welsh
sweetened products individuals on the JA, Drews K, El
may reduce overall potential glycemic Ghormli L.
calorie and benefits to replacing Consumption of
carbohydrate intake as Beverages Containing
long as there is not a Low-Calorie
compensatory increase Sweeteners, Diet, and
of energy intake from Cardiometabolic
other sources. Overall, Health in Youth With
people are encouraged Type 2 Diabetes. J
to decrease both Acad Nutr Diet. 2020
sweetened and Aug;120(8):1348-
nonnutritive- 1358.e6. doi:
sweetened beverages, 10.1016/j.jand.2020.0
with an emphasis on 4.005. PMID:
water intake. B 32711855.
Copy
Conclusion:
LCSB consumption
was associated with
higher energy intake in
youth with type 2
diabetes, with the
highest energy intakes
reported in high LCSB
consumers. Those who
reduced LCSB
consumption tended
to report greater
increases in sugar
intake during follow-
 up, but further studies
are needed to better
understand this trend

Physical Activity
5.27 Children and No Change
adolescents with type 1 or
type 2 diabetes or
prediabetes 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. C
5.28 Most adults with No Change Frediani JK, Bienvenida
type 1 C and type AF, Li J, Higgins MK,
2 B diabetes should Lobelo F. Physical
engage in 150 min or fitness and activity
more of moderate- to changes after a 24-
vigorous-intensity aerobic week soccer-based
activity per week, spread adaptation of the U.S
over at least 3 days/week, diabetes prevention
with no more than 2 program intervention
consecutive days without in Hispanic men. Prog
activity. Shorter durations Cardiovasc Dis. 2020
(minimum 75 min/week) Nov-Dec;63(6):775-
of vigorous-intensity or 785. doi:
interval training may be 10.1016/j.pcad.2020.0
sufficient for younger and 6.012. Epub 2020 Jun
more physically fit 27. PMID: 32603753.
individuals.
5.29 Adults with type No Change
1 C and type 2 B diabetes
should engage in 2–3
sessions/week of
resistance exercise on
nonconsecutive days.
5.30 All adults, and No Change
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
5.31 Flexibility training No Change
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

5.32 Evaluate baseline No Change

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.
Smoking Cessation: Tobacco and e-Cigarettes
5.33 Advise all patients No Change
not to use cigarettes and
other tobacco products or
e-cigarettes. A
5.34 After identification No Change
of tobacco or e-cigarette
use, include smoking
cessation counseling and
other forms of treatment
as a routine component
of diabetes care. A

5.35 Address smoking No Change

cessation as part of
diabetes education
programs for those in
need. B
Psychological Issues
5.36 Psychosocial care No Change This article provides Guerrero Fernández
should be integrated with evidence that all de Alba, I., Gimeno-
a collaborative, patient- cause mortality Miguel, A., Poblador-
centered approach and increases by 118% in Plou, B. et al.
provided to all people patients with mental Association between
with diabetes, with the health co-morbidities mental health
goals of optimizing health in persons with T2D. comorbidity and
outcomes and health- health outcomes in
related quality of life. A type 2 diabetes
mellitus patients. Sci
Rep 10, 19583 (2020).
https://doi.org/10.103
8/s41598-020-76546-9
5.37 Psychosocial No Change Need to look for
screening and follow-up effects of COVID on
may include, but are not mental health in this
limited to, attitudes about population. Found
diabetes, expectations for one but on Brazil
medical management and population with small
outcomes, affect or N……
mood, general and
diabetes-related quality
of life, available resources
(financial, social, and
emotional), and
psychiatric history. E
5.38 Providers should No Change
consider assessment for
symptoms of diabetes
distress, depression,
anxiety, disordered
eating, and cognitive
capacities using
appropriate standardized
and validated tools at the
initial visit, at periodic
intervals, and when there
is a change in disease,
treatment, or life
circumstance. Including
caregivers and family
members in this
assessment is
recommended. B
5.39 Consider screening 5.39 Consider screening References support Carmichael OT,
older adults (aged ≥65 older adults (aged ≥65 that diabetes or Neiberg RH, Dutton
years) with diabetes for years) with diabetes for worsening glycemic GR, Hayden KM,
cognitive impairment control is associated Horton E, Pi-Sunyer
cognitive impairment and and depression. B with cognitive FX, Johnson KC, Rapp
depression. B Monitoring of impairment. SR, Spira AP, Espeland
cognitive capacity, i.e., MA. Long-term
the ability to actively Change in
engage in decision- Physiological Markers
making regarding and Cognitive
regimen behaviors, is Performance in Type 2
advised. B Diabetes: The Look
AHEAD Study. J Clin
Endocrinol Metab.
2020 Dec
1;105(12):e4778–91.
doi:
10.1210/clinem/dgaa5
91. PMID: 32845968;
PMCID: PMC7566388.

Avila JC, Mejia-

Arangom S, Jupiter D,
Downer B, Wong R.
The Effect of Diabetes
on the Cognitive
Trajectory of Older
Adults in Mexico and
the United States. J
Gerontol B Psychol Sci
Soc Sci. 2021 Mar
14;76(4):e153-e164.
doi:
10.1093/geronb/gbaa
094. PMID: 32678911;
PMCID: PMC7955990.
Diabetes Distress
5.40 Routinely monitor No Change
people with diabetes for
diabetes distress,
particularly when
treatment targets are not
met and/or at the onset
of diabetes
complications. B
Anxiety Disorders
5.41 Consider screening No Change Health related quality Liu, X., Haagsma, J.,
for anxiety in people of life inversely Sijbrands, E. et al.
exhibiting anxiety or related to presence of Anxiety and
worries regarding anxiety/depression in depression in diabetes
diabetes complications, both type 1 and type care: longitudinal
insulin administration, 2 patients. associations with
and taking medications, health-related quality
as well as fear of of life. Sci Rep 10,
hypoglycemia and/or 8307 (2020).
hypoglycemia https://doi.org/10.103
unawareness that 8/s41598-020-57647-x
interferes with self-
management behaviors,
and in those who express
fear, dread, or irrational
thoughts and/or show
anxiety symptoms such as
avoidance behaviors,
excessive repetitive
behaviors, or social
withdrawal. Refer for
treatment if anxiety is
present. B
5.42 People with No Change
hypoglycemia
unawareness, which can
co-occur with fear of
hypoglycemia, should be
treated using blood
glucose awareness
training (or other
evidence-based
intervention) to help re-
establish awareness of
symptoms of
hypoglycemia and reduce
fear of hypoglycemia. A
Depression
5.43 Providers should No Change Watson SE, Spurling
consider annual screening SE, Fieldhouse AM,
of all patients with Montgomery VL,
diabetes, especially those Wintergerst KA.
with a self-reported Depression and
history of depression, for Anxiety Screening in
depressive symptoms Adolescents With
with age-appropriate Diabetes. Clin Pediatr
depression screening (Phila). 2020
measures, recognizing May;59(4-5):445-449.
that further evaluation doi:
will be necessary for 10.1177/00099228209
individuals who have a 05861. Epub 2020 Feb
positive screen. B 17. PMID: 32066264.
5.44 Beginning at No Change
diagnosis of complications
or when there are
significant changes in
medical status, consider
assessment for
depression. B
5.45 Referrals for No Change Ali MK, Chwastiak L,
treatment of depression Poongothai S,
should be made to mental Emmert-Fees KMF,
health providers with Patel SA, Anjana RM,
experience using Sagar R, Shankar R,
cognitive behavioral Sridhar GR, Kosuri M,
therapy, interpersonal Sosale AR, Sosale B,
therapy, or other Rao D, Tandon N,
evidence-based Narayan KMV, Mohan
treatment approaches in V; INDEPENDENT
conjunction with Study Group. Effect of
collaborative care with a Collaborative Care
the patient’s diabetes Model on Depressive
treatment team. A Symptoms and
Glycated Hemoglobin,
Blood Pressure, and
Serum Cholesterol
Among Patients With
Depression and
Diabetes in India: The
INDEPENDENT
Randomized Clinical
Trial. JAMA. 2020 Aug
18;324(7):651-662.
doi:
10.1001/jama.2020.11
747. PMID: 32809002;
PMCID: PMC7435347.
Disordered Eating Behavior
5.46 Providers should No Change
consider reevaluating the
treatment regimen of
people with diabetes who
present with symptoms of
disordered eating
behavior, an eating
disorder, or disrupted
patterns of eating. B
5.47 Consider screening No Change Maybe add 5.47 or Merwin, R.M.,
for disordered or just add to narrative? Moskovich, A.A.,
disrupted eating using Pilot study of Babyak, M. et al. An
validated screening individual sessions open trial of app-
measures when and use of mobile app assisted acceptance
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 regimen is
recommended to identify
potential treatment-
related effects on
hunger/caloric intake. B
Serious Mental Illness
5.48 Incorporate active
monitoring of diabetes
self-care activities into
treatment goals for
people with diabetes and
serious mental illness. B
to address and commitment
psychological therapy (iACT) for
flexibility to deal with eating disorders in
needed management type 1 diabetes. J Eat
behaviors and weight Disord 9, 6 (2021).
control. Outpatient. https://doi.org/10.118
Acceptable and 6/s40337-020-00357-6
feasible, Minimal
complications.
https://www.therecov
I AM CONCERNED eryvillage.com/mental
THAT DIABULEMIA -health/diabulimia/
CONTINUES TO BE A “Diabulimia
DOG WHISTLE TERM Read more to learn
FOR THE PUBLIC AND about what diabulimia
I AM NOT SURE HOW is, the dangerous
WE, THE ADA SHOULD medical complications
HANDLE THIS, it can cause, and how
it is treated.”
“Diabulimia is not an
official eating disorder https://www.eatingrec
diagnosis or a overycenter.com/cond
medically recognized itions/diabulimia/sym
term. It is a non- ptoms-signs
clinical term that used
to describe an eating
disorder affecting
some people with
type 1 diabetes. It is
sometimes referred
to as the Dual
Diagnosis of Eating
Disorder and Diabetes
Mellitus Type 1 (ED-
DMT1).”
No Change DK if this is already in Mulligan, K., McBain,
our reference list…. H., Lamontagne-
It’s 2018 and British. Godwin, F. et al.
Documents that over Barriers to effective
half of the sample, all diabetes management
with serious MH – a survey of people
disorders were with severe mental
experiencing at least illness. BMC Psychiatry
moderate 18, 165 (2018).
psychological distress https://doi.org/10.118
in the previous week. 6/s12888-018-1744-5
This indicates
 pervasive intrusion of
mental health issues
into daily functioning.
5.49 In people who are No Change
prescribed atypical
antipsychotic
medications, screen for
prediabetes and diabetes
4 months after
medication initiation and
at least annually
thereafter. B
5.50 If a second- No Change
generation antipsychotic
medication is prescribed
for adolescents or adults
with diabetes, changes in
weight, glycemic control,
and cholesterol levels
should be carefully
monitored and the
treatment regimen should
be reassessed. C
New recommendation
5.51 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
New recommendation
5.52 If cognitive
capacity changes or
appears to be
suboptimal for
provider-patient
decision-making and/or
behavioral self-
management, referral
for a formal
assessment should be
considered. E
Glycemic Targets
Glycemic Testing
6.1 Assess glycemic Assess glycemic status 1. CGM Lower A1c 1. Simonson GD,
status (A1C or other (A1C or other glycemic T2D (68 subjects) Bergenstal RM,
glycemic measurement) measurement such as 2. TIR Aic relationships Johnson ML, Davidson
at least two times a year time in range or good but slightly JL, Martens TW. Effect
in patients who are glucose management different by CGM type of Professional CGM
meeting treatment goals indicator) at least two (n=148) (pCGM) on Glucose
(and who have stable times a year in 3. TIR can be used to Management in Type 2
glycemic control). E patients who are estimate A1c with Diabetes Patients in
meeting treatment good accuracy in 6 Primary Care. J
goals (and who have mos window (n=125) Diabetes Sci Technol.
stable glycemic 2021 Mar
control). E (these papers and 10:193229682199872
more below relate to 4. doi:
use of CGM as a 10.1177/19322968219
surrogate for A1c) 98724.
2. BMJ Open Diabetes
Res Care . 2021
Jan;9(1):e001045.
doi: 10.1136/bmjdrc-
2019-001045.
3. Fabris C, Heinemann
L, Beck R, Cobelli C,
Kovatchev B.
Estimation of
Hemoglobin A1c from
Continuous Glucose
Monitoring Data in
Individuals with Type 1
Diabetes: Is Time In
Range All We Need?
Diabetes Technol Ther.
2020 Jul;22(7):501-
508. doi:
10.1089/dia.2020.023
6. PMID: 32459124;
PMCID: PMC7336887.
6.2 Assess glycemic No change
status at least quarterly,
and as needed, in patients
whose therapy has
recently changed and/or Unable to find data on
who are not meeting the time interval and
glycemic goals. E optimal outcomes
Glucose Assessment by Continuous Glucose Monitoring
6.3 Standardized, single- No change These papers shed 1. Simonson GD,
page glucose reports from additional light on the Bergenstal RM,
continuous glucose usefulness and A1c Johnson ML, Davidson
monitoring (CGM) devices equivalency of CGM. JL, Martens TW. Effect
with visual cues, such as of Professional CGM
the ambulatory glucose (pCGM) on Glucose
profile (AGP), should be 1. Lower A1c T2D Management in Type 2
considered as a standard (68 subjects) Diabetes Patients in
printout for all CGM 2. TIR Aic relationships Primary Care. J
devices. E good but slightly Diabetes Sci Technol.
different by CGM type 2021 Mar
(n=148) 10:193229682199872
3. Review of how to 4. doi:
use CGM TIR TBR 10.1177/19322968219
4. TIR and glycated 98724.
hgb alignment (n=180) 2. BMJ Open Diabetes
5. CGM in adolescents Res Care . 2021
decreased A1c Jan;9(1):e001045.
(n=105) doi: 10.1136/bmjdrc-
6. rtCGM better for 2019-001045.
A1c than SMBG 3. Postgrad Med .
(n~100) 2021 Apr;133(3):253-
7. Real World data 264. doi:
(n=233) CGM add 10.1080/00325481.20
value to a1c rt>is 20.1851946. Epub
8. virtual DM center 2020 Dec 14.
CGM TIR led to lower 4. Cutruzzolà A, Irace
A1c (n=55) C, Parise M, Fiorentino
9. CGM in UK +10K R, Pio Tripodi PF,
people in 102 Ungaro S, Babinsky V,
practices real world Gnasso A. Time spent
improved A1c in target range
assessed by self-
monitoring blood
glucose associates
with glycated
hemoglobin in insulin
treated patients with
diabetes. Nutr Metab
Cardiovasc Dis. 2020
Sep 24;30(10):1800-
1805. doi:
10.1016/j.numecd.202
0.06.009. Epub 2020
Jun 21. PMID:
32669240.
5. Nwosu BU, Yeasmin
S, Ayyoub S, Rupendu
S, Villalobos-Ortiz TR,
Jasmin G, Parajuli S,
Zahedi B, Zitek-
Morrison E, Alonso LC,
Barton BA. Continuous
glucose monitoring
reduces pubertal
hyperglycemia of type
1 diabetes. J Pediatr
Endocrinol Metab.
2020 Jul 28;33(7):865-
872. doi:
10.1515/jpem-2020-
0057. PMID:
32634109.
6. Šoupal J,
Petruželková L,
Grunberger G,
Hásková A, Flekač M,
Matoulek M, Mikeš O,
Pelcl T, Škrha J Jr,
Horová E, Škrha J,
Parkin CG, Svačina Š,
Prázný M. Glycemic
Outcomes in Adults
With T1D Are
Impacted More by
Continuous Glucose
Monitoring Than by
Insulin Delivery
Method: 3 Years of
Follow-Up From the
COMISAIR Study.
Diabetes Care. 2020
Jan;43(1):37-43. doi:
10.2337/dc19-0888.
Epub 2019 Sep 17.
PMID: 31530663.
7. Sandig D,
Grimsmann J,
Reinauer C, Melmer A,
Zimny S, Müller-
Korbsch M, Forestier
N, Zeyfang A,
Bramlage P, Danne T,
Meissner T, Holl RW.
Continuous Glucose
Monitoring in Adults
with Type 1 Diabetes:
Real-World Data from
the German/Austrian
Prospective Diabetes
Follow-Up Registry.
Diabetes Technol Ther.
2020 Aug;22(8):602-
612. doi:
10.1089/dia.2020.001
9. Epub 2020 Jul 6.
PMID: 32522039.
8. Majithia AR, Kusiak
CM, Armento Lee A,
Colangelo FR,
Romanelli RJ,
Robertson S, Miller
DP, Erani DM, Layne
JE, Dixon RF, Zisser H.
Glycemic Outcomes in
Adults With Type 2
Diabetes Participating
in a Continuous
Glucose Monitor-
Driven Virtual
Diabetes Clinic:
Prospective Trial. J
Med Internet Res.
2020 Aug
28;22(8):e21778. doi:
10.2196/21778. PMID:
32856597; PMCID:
PMC7486672.
9. Deshmukh H,
Wilmot EG, Gregory R,
Barnes D, Narendran
P, Saunders S, Furlong
N, Kamaruddin S,
Banatwalla R, Herring
R, Kilvert A, Patmore J,
Walton C, Ryder REJ,
Sathyapalan T. Effect
of Flash Glucose
Monitoring on
Glycemic Control,

6.4 Time in range (TIR) is
associated with the risk of
microvascular
complications and can be
used for assessment of
glycemic control.
Additionally, time below
target (<70 and <54
mg/dL [3.9 and 3.0
mmol/L]) and time above
target (>180 mg/dL [10.0
mmol/L]) are useful
parameters for
reevaluation of the
treatment regimen. C
Hypoglycemia,
Diabetes-Related
Distress, and Resource
Utilization in the
Association of British
Clinical Diabetologists
(ABCD) Nationwide
Audit. Diabetes Care.
2020 Sep;43(9):2153-
2160.
6.4 Time in range (TIR) 1. microalbuminuria 1.Improved Time in
is associated with the decrease (n-55) Range Over
risk of microvascular 2. T2D CGM profiles 1 Year Is Associated
complications and can and prevalent With Reduced
be used for assessment complications (n- Albuminuria in
of glycemic control. 5000) India Individuals With
Additionally, time 3. TIR and A1c Sensor-Augmented
below target and time relationships hold; low Insulin Pump–
above target are useful TIR predicited Treated Type 1
parameters for prevalent Diabetes
evaluation of the complications 2. Varghese JS, Ho JC,
treatment regimen (n=3300) Anjana RM, Pradeepa
(Table 6.2). C 4. Expert consensus R, Patel SA, Jebarani S,
on use of TIR and GV Baskar V, Narayan
in a patient centered DKMV, Mohan V.
strategy (Expert) Profiles of intra-day
5. TIR and prevalent glucose in Type 2
lower extremity Diabetes and their
disease (PVD)(n=333) association with
6. TIR and GV not complications: an
assoc with analysis of continuous
multimorbidity at glucose monitoring
baseline in T2D data. Diabetes Technol
(n=279) australia Ther. 2021 Mar 15.
7. TIR and neuropathy doi:
in T2D (n=740) 10.1089/dia.2020.067
2. Epub ahead of print.
PMID: 33720761.
3. Sheng X, Xiong GH,
Yu PF, Liu JP. The
Correlation between
Time in Range and
Diabetic Microvascular
Complications Utilizing
Information
Management
Platform. Int J
Endocrinol. 2020 Dec
15;2020:8879085. doi:
10.1155/2020/887908
5. PMID: 33381172;
PMCID: PMC7755494.
4. Kalra S, Shaikh S,
Priya G, Baruah MP,
Verma A, Das AK, Shah
M, Das S, Khandelwal
D, Sanyal D, Ghosh S,
Saboo B, Bantwal G,
Ayyagari U, Gardner D,
Jimeno C, Barbary NE,
Hafidh KA, Bhattarai J,
Minulj TT, Zufry H,
Bulugahapitiya U,
Murad M, Tan A,
Shahjada S, Bello MB,
Katulanda P, Podgorski
G, AbuHelaiqa WI, Tan
R, Latheef A, Govender
S, Assaad-Khalil SH,
Kootin-Sanwu C, Joshi
A, Pathan F, Nkansah
DA. Individualizing
Time-in-Range Goals in
Management of
Diabetes Mellitus and
Role of Insulin: Clinical
Insights From a
Multinational Panel.
Diabetes Ther. 2021
Feb;12(2):465-485.
doi: 10.1007/s13300-
020-00973-0. Epub
2020 Dec 26. PMID:
33367983; PMCID:
PMC7846622.
5 Li J, Li Y, Ma W, Liu Y,
Yin X, Xie C, Bai J,
Zhang M. Association
of Time in Range levels
with Lower Extremity
Arterial Disease in
patients with type 2
diabetes. Diabetes
Metab Syndr. 2020
Nov-Dec;14(6):2081-
2085. doi:
 10.1016/j.dsx.2020.09.
028. Epub 2020 Sep
28. PMID: 33137566.
6. Chiang JI, Manski-
Nankervis JA,
Thuraisingam S,
Jenkins A, O'Neal D,
Mair FS, Jani BD,
Nicholl BI, Furler J.
Multimorbidity,
glycaemic variability
and time in target
range in people with
type 2 diabetes: A
baseline analysis of
the GP-OSMOTIC trial.
Diabetes Res Clin
Pract. 2020
Nov;169:108451. doi:
10.1016/j.diabres.202
0.108451. Epub 2020
Sep 17. PMID:
32949650.
7. Li F, Zhang Y, Li H,
Lu J, Jiang L, Vigersky
RA, Zhou J, Wang C,
Bao Y, Jia W. TIR
generated by
continuous glucose
monitoring is
associated with
peripheral nerve
function in type 2
diabetes. Diabetes Res
Clin Pract. 2020
Aug;166:108289. doi:
10.1016/j.diabres.202
0.108289. Epub 2020
Jun 29. PMID:
32615278.
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 is a time in range of
>70% with time below
range <4% and time less
than 54 less than 1% (Fig.
6.1). B
6.5b If using 1. Simonson GD,
ambulatory glucose 1. Lower A1c T2D Bergenstal RM,
profile/glucose (68 subjects) Johnson ML, Davidson
management indicator 2. TIR Aic relationships JL, Martens TW. Effect
to assess glycemia, a good but slightly of Professional CGM
parallel goal for many different by CGM type (pCGM) on Glucose
nonpregnant adults is a (n=148) Management in Type 2
time in range of >70% 3. Review of how to Diabetes Patients in
with time below range use CGM TIR TBR Primary Care. J
<4% and time less than 4. TIR and glycated Diabetes Sci Technol.
54 mg/dL less than 1% hgb alignment (n=180) 2021 Mar
(Fig. 6.1 and Table 5. CGM in adolescents 10:193229682199872
6.2). B decreased A1c 4. doi:
(n=105) 10.1177/19322968219
6. rtCGM better for 98724.
A1c than SMBG 2. BMJ Open Diabetes
(n~100) Res Care . 2021
7. Real World data Jan;9(1):e001045.
(n=233) CGM add doi: 10.1136/bmjdrc-
value to a1c rt>is 2019-001045.
8. virtual DM center 3. Postgrad Med .
CGM TIR led to lower 2021 Apr;133(3):253-
A1c (n=55) 264. doi:
9. CGM in UK +10K 10.1080/00325481.20
people in 102 20.1851946. Epub
practices real world 2020 Dec 14.
improved A1c 4. Cutruzzolà A, Irace
C, Parise M, Fiorentino
R, Pio Tripodi PF,
Ungaro S, Babinsky V,
Gnasso A. Time spent
in target range
assessed by self-
monitoring blood
glucose associates
with glycated
hemoglobin in insulin
treated patients with
diabetes. Nutr Metab
Cardiovasc Dis. 2020
Sep 24;30(10):1800-
1805. doi:
10.1016/j.numecd.202
0.06.009. Epub 2020
Jun 21. PMID:
32669240.
5. Nwosu BU, Yeasmin
S, Ayyoub S, Rupendu
S, Villalobos-Ortiz TR,
Jasmin G, Parajuli S,
Zahedi B, Zitek-
Morrison E, Alonso LC,
Barton BA. Continuous
glucose monitoring
reduces pubertal
hyperglycemia of type
1 diabetes. J Pediatr
Endocrinol Metab.
2020 Jul 28;33(7):865-
872. doi:
10.1515/jpem-2020-
0057. PMID:
32634109.
6. Šoupal J,
Petruželková L,
Grunberger G,
Hásková A, Flekač M,
Matoulek M, Mikeš O,
Pelcl T, Škrha J Jr,
Horová E, Škrha J,
Parkin CG, Svačina Š,
Prázný M. Glycemic
Outcomes in Adults
With T1D Are
Impacted More by
Continuous Glucose
Monitoring Than by
Insulin Delivery
Method: 3 Years of
Follow-Up From the
COMISAIR Study.
Diabetes Care. 2020
Jan;43(1):37-43. doi:
10.2337/dc19-0888.
Epub 2019 Sep 17.
PMID: 31530663.
7. Sandig D,
Grimsmann J,
Reinauer C, Melmer A,
Zimny S, Müller-
Korbsch M, Forestier
N, Zeyfang A,
Bramlage P, Danne T,
Meissner T, Holl RW.
Continuous Glucose
Monitoring in Adults
with Type 1 Diabetes:
Real-World Data from
the German/Austrian
Prospective Diabetes
Follow-Up Registry.
Diabetes Technol Ther.
2020 Aug;22(8):602-
612. doi:
10.1089/dia.2020.001
9. Epub 2020 Jul 6.
PMID: 32522039.
8. Majithia AR, Kusiak
CM, Armento Lee A,
Colangelo FR,
Romanelli RJ,
Robertson S, Miller
DP, Erani DM, Layne
JE, Dixon RF, Zisser H.
Glycemic Outcomes in
Adults With Type 2
Diabetes Participating
in a Continuous
Glucose Monitor-
Driven Virtual
Diabetes Clinic:
Prospective Trial. J
Med Internet Res.
2020 Aug
28;22(8):e21778. doi:
10.2196/21778. PMID:
32856597; PMCID:
PMC7486672.
9. Deshmukh H,
Wilmot EG, Gregory R,
Barnes D, Narendran
P, Saunders S, Furlong
N, Kamaruddin S,
Banatwalla R, Herring
R, Kilvert A, Patmore J,
Walton C, Ryder REJ,
Sathyapalan T. Effect
of Flash Glucose
Monitoring on
Glycemic Control,
Hypoglycemia,
Diabetes-Related
Distress, and Resource
Utilization in the
 Association of British
Clinical Diabetologists
(ABCD) Nationwide
Audit. Diabetes Care.
2020 Sep;43(9):2153-
2160.
6.6 On the basis of Level of evidence (base 1. This is a cautionary 1. Polonsky WH,
provider judgment and for better ACCORD, message that I will Fortmann AL, Price D,
patient preference, VADT, UKPDS) changed place in the text Fisher
achievement of lower A1C to B L.Hyperglycemia
levels than the goal of 7% aversiveness":
may be acceptable, and Investigating an
even beneficial, if it can overlooked problem
be achieved safely among adults with
without significant type 1 diabetes. J
hypoglycemia or other Diabetes
adverse effects of Complications. 2021
treatment. C Mar 29:107925. doi:
10.1016/j.jdiacomp.20
21.107925. Epub
ahead of print. PMID:
33836966.
6.7 Less stringent A1C No change 1. Japanese elderly 1. Omura T, Tamura Y,
goals (such as <8% [64 DM study (n=843) Sakurai T, Umegaki H,
mmol/mol]) may be observational low Iimuro S, Ohashi Y, Ito
appropriate for patients functional status and H, Araki A; Japanese
with limited life mortality Elderly Diabetes
expectancy, or where the 2. frailty and de- Intervention Trial
harms of treatment are escalation (expert Research Group.
greater than the benefits. review) with proposed Functional categories
B medication algorithm based on cognition
3. Glycemic variability and activities of daily
is the greatest risk of living predict all-cause
lows mortality in older
adults with diabetes
mellitus: The Japanese
Elderly Diabetes
Intervention Trial.
Geriatr Gerontol Int.
2021 Apr 22. doi:
10.1111/ggi.14171.
Epub ahead of print.
PMID: 33890351.
2. Strain WD, Down S,
Brown P, Puttanna A,
Sinclair A. Diabetes
and Frailty: An Expert
Consensus Statement
 on the Management
of Older Adults with
Type 2 Diabetes.
Diabetes Ther. 2021
Apr 8. doi:
10.1007/s13300-021-
01035-9. Epub ahead
of print. PMID:
33830409.
3. Handa T, Nakamura
A, Miya A, Nomoto H,
Kameda H, Cho KY,
Nagai S, Yoshioka N,
Miyoshi H, Atsumi T.
The association
between
hypoglycemia and
glycemic variability in
elderly patients with
type 2 diabetes: a
prospective
observational study.
Diabetol Metab Syndr.
2021 Apr 1;13(1):37.
doi: 10.1186/s13098-
021-00656-1. PMID:
33794984; PMCID:
PMC8017873.
6.8 Reassess glycemic 6.8 Reassess glycemic
targets based on the targets based on the
individualized criteria in individualized criteria
Fig. 6.2 in Fig. 6.2.E

Hypoglycemia
6.9 Occurrence and risk 1. Glycemic variability 1. Handa T, Nakamura
for hypoglycemia should is a the optimal A, Miya A, Nomoto H,
be reviewed at every predictor of lows Kameda H, Cho KY,
encounter and (n=171) Japanese Nagai S, Yoshioka N,
investigated as indicated. 2. CGM in T2D in Miyoshi H, Atsumi T.
C Saudi Arabia The association
decreased Aic and between
lows (n=105) hypoglycemia and
3. blinded CGM in glycemic variability in
poorly controlled T2D elderly patients with
id lows and GV type 2 diabetes: a
4. Elderly, glucose and prospective
frailty 22K 5K on SU observational study.
Diabetol Metab Syndr.
2.5 HR for severe hypo 2021 Apr 1;13(1):37.
observational doi: 10.1186/s13098-
5. Validated hypo 021-00656-1. PMID:
unaware scales 33794984; PMCID:
compared (n=100) PMC8017873.
observational 2. 2.
(different result 3. Ribeiro RT, Andrade
depending on screen) R, Nascimento do Ó D,
6. Flash CGM and Lopes AF, Raposo JF.
decreased hypo 10k Impact of blinded
people form 102 retrospective
practices real world continuous glucose
7. Dutch study with monitoring on clinical
high hypoglycemia decision making and
(10%), hypounaware glycemic control in
and severe hypo event persons with type 2
in insulin treated T2D diabetes on insulin
noting regimen therapy. Nutr Metab
complexity (n=2300) Cardiovasc Dis. 2021
observational (risk Apr 9;31(4):1267-
greatest with highest 1275. doi:
A1C) 10.1016/j.numecd.202
8 Cost of hypos 0.12.024. Epub 2020
systematic review Dec 31. PMID:
33612381.
4. Ling S, Zaccardi F,
Lawson C, Seidu SI,
Davies MJ, Khunti K.
Glucose Control,
Sulfonylureas, and
Insulin Treatment in
Elderly People With
Type 2 Diabetes and
Risk of Severe
Hypoglycemia and
Death: An
Observational Study.
Diabetes Care. 2021
Apr;44(4):915-924.
doi: 10.2337/dc20-
0876. Epub 2021 Feb
4. PMID: 33541857.
5. Ghandi K, Pieri B,
Dornhorst A, Hussain
S. A Comparison of
Validated Methods
Used to Assess
Impaired Awareness of
Hypoglycaemia in Type
1 Diabetes: An
Observational Study.
Diabetes Ther. 2021
Jan;12(1):441-451. doi:
10.1007/s13300-020-
00965-0. Epub 2020
Nov 20. PMID:
33219468; PMCID:
PMC7843675.
6. Deshmukh H,
Wilmot EG, Gregory R,
Barnes D, Narendran
P, Saunders S, Furlong
N, Kamaruddin S,
Banatwalla R, Herring
R, Kilvert A, Patmore J,
Walton C, Ryder REJ,
Sathyapalan T. Effect
of Flash Glucose
Monitoring on
Glycemic Control,
Hypoglycemia,
Diabetes-Related
Distress, and Resource
Utilization in the
Association of British
Clinical Diabetologists
(ABCD) Nationwide
Audit. Diabetes Care.
2020 Sep;43(9):2153-
2160. doi:
10.2337/dc20-0738.
Epub 2020 Jul 15.
PMID: 32669277;
PMCID: PMC7440900.
7. van Meijel LA, de
Vegt F, Abbink EJ,
Rutters F, Schram MT,
van der Klauw MM,
Wolffenbuttel BHR,
Siegelaar S, DeVries
JH, Sijbrands EJG,
Özcan B, de Valk HW,
Silvius B, Schaper N,
Stehouwer CDA, Elders
PJM, Tack CJ, de Galan
BE. High prevalence of
 impaired awareness of
hypoglycemia and
severe hypoglycemia
among people with
insulin-treated type 2
diabetes: The Dutch
Diabetes Pearl Cohort.
BMJ Open Diabetes
Res Care. 2020
Feb;8(1):e000935. doi:
10.1136/bmjdrc-2019-
000935. PMID:
32107264; PMCID:
PMC7206921.
8. Shi L, Fonseca V,
Childs B. Economic
burden of diabetes-
related hypoglycemia
on patients, payors,
and employers. J
Diabetes
Complications. 2021
Jun;35(6):107916. doi:
10.1016/j.jdiacomp.20
21.107916. Epub 2021
Mar 22. PMID:
33836965.
6.10 Glucose No change
(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 self-
monitoring of blood
glucose (SMBG) shows
continued hypoglycemia,
the treatment should be
repeated. Once the SMBG
or glucose pattern is
trending up, the
individual should
consume a meal or snack
to prevent recurrence of
hypoglycemia. B
6.11 Glucagon should be No cahnge 1. Dasiglucagon Phase 1. Pieber TR, Aronson
prescribed for all 3 trial (no real R, Hövelmann U,
individuals at increased difference form Willard J, Plum-
risk of level 2 or 3 glucagon in outcomes Mörschel L, Knudsen
hypoglycemia so that it is (n=140) add to text KM, Bandak B,
available should it be from newer glucagon Tehranchi R.
needed. Caregivers, prep from last year Dasiglucagon: A Next-
school personnel, or Generation Glucagon
family members of these Analog for Rapid and
individuals should know ? Helmsley Effective Treatment of
where it is and when and Severe Hypoglycemia
how to administer it. Results of Phase 3
Glucagon administration Randomized Double-
is not limited to health Blind Clinical Trial.
care professionals. E Diabetes Care. 2021
Apr 21:dc202995. doi:
10.2337/DC20-2995.
Epub ahead of print.
PMID: 33883196.
6.12 Hypoglycemia No change 1. This is a cautionary 1. Polonsky WH,
unawareness or one or message that I will Fortmann AL, Price D,
more episodes of level 3 place in the text Fisher
hypoglycemia should 2. CGM in T2D in L.Hyperglycemia
trigger hypoglycemia Saudi Arabia aversiveness":
avoidance education, decreased Aic and Investigating an
psychological /behavioral lows (n=105) overlooked problem
support and reevaluation 3. Education program among adults with
of the treatment to decrease fear of type 1 diabetes. J
regimen. (C) lows and phys activity Diabetes
(pilot n=117) Complications. 2021
4. systematic meta- Mar 29:107925. doi:
analysis which 10.1016/j.jdiacomp.20
somehow does not 21.107925. Epub
show increased hypo ahead of print. PMID:
risk with SU?? 33836966.
5. Intervention 2. Al Hayek A, Robert
program I think it was AA, Al Dawish M.
included last year Impact of the
(n=96) decreased SH FreeStyle Libre flash
glucose monitoring
system on diabetes-
self-management
practices and glycemic
control among
patients with type 2
diabetes in Saudi
Arabia: A prospective
study. Diabetes Metab
Syndr. 2021 Mar-
Apr;15(2):557-563.
doi:
10.1016/j.dsx.2021.02.
027. Epub 2021 Feb
24. PMID: 33689937.
3. Brennan MC,
Albrecht MA, Brown
JA, Leslie GD,
Ntoumanis N. Self-
Management Group
Education to Reduce
Fear of Hypoglycemia
as a Barrier to Physical
Activity in Adults
Living With Type 1
Diabetes: A Pilot
Randomized
Controlled Trial. Can J
Diabetes. 2021 Jan
13:S1499-
2671(21)00001-0. doi:
10.1016/j.jcjd.2021.01
.001. Epub ahead of
print. PMID:
33648863.
4. Mannucci E,
Naletto L, Vaccaro G,
Silverii A, Dicembrini I,
Pintaudi B, Monami M.
Efficacy and safety of
glucose-lowering
agents in patients with
type 2 diabetes: A
network meta-analysis
of randomized, active
comparator-controlled
trials. Nutr Metab
Cardiovasc Dis. 2021
Apr 9;31(4):1027-
1034. doi:
10.1016/j.numecd.202
0.12.030. Epub 2021
Jan 11. PMID:
33618919.
 5. Amiel SA,
Choudhary P, Jacob P,
Smith EL, De Zoysa N,
Gonder-Frederick L,
Kendall M, Heller S,
Brooks A, Toschi E,
Kariyawasam D, Potts
L, Healy A, Rogers H,
Sevdalis N, Stadler M,
Qayyum M, Bakolis I,
Goldsmith K.
Hypoglycaemia
Awareness
Restoration
Programme for People
with Type 1 Diabetes
and Problematic
Hypoglycaemia
Persisting Despite
Optimised Self-care
(HARPdoc): protocol
for a group
randomised controlled
trial of a novel
intervention
addressing cognitions.
BMJ Open. 2019 Jun
16;9(6):e030356. doi:
10.1136/bmjopen-
2019-030356. PMID:
31209097; PMCID:
PMC6588968.

6.13 Insulin-treated No change 1. This is a cautionary 1. Polonsky WH,

patients with message that I will Fortmann AL, Price D,
hypoglycemia place in the text Fisher
unawareness, one level 3 L.Hyperglycemia
hypoglycemic event, or a 2. Hypo unaware aversiveness":
pattern of unexplained common at transition Investigating an
level 2 hypoglycemia to adult care and overlooked problem
should be advised to raise responsive to among adults with
their glycemic targets to educational type 1 diabetes. J
strictly avoid intervention (n=55) Diabetes
hypoglycemia for at least Complications. 2021
several weeks in order to Mar 29:107925. doi:
partially reverse 10.1016/j.jdiacomp.20
hypoglycemia 21.107925. Epub
unawareness and reduce ahead of print. PMID:
risk of future episodes. A 33836966.
2. Vidal M, Jansà M,
Roca D, Yoldi C,
Cardona-Hernández R,
Giménez M, Conget I.
Hypoglycaemia
unawareness in young
people with type 1
diabetes transferred
to an adult center.
Endocrinol Diabetes
Nutr. 2020 Jun-
Jul;67(6):394-400.
English, Spanish. doi:
10.1016/j.endinu.2019
.07.009. Epub 2019
Oct 23. PMID:
31668682.
6.14 Ongoing assessment 6.14 Ongoing Bąk E, Młynarska A,
of cognitive function is assessment of Marcisz C, Bobiński R,
suggested with increased cognitive function is Sternal D, Młynarski R.
vigilance for suggested with The influence of frailty
hypoglycemia by the increased vigilance for syndrome on quality
clinician, patient, and hypoglycemia by the of life in elderly
caregivers if impaired or clinician, patient, and patients with type 2
declining cognition is caregivers if impaired diabetes. Qual Life
found. B or declining cognition is Res. 2021 Apr 8. doi:
found. B 10.1007/s11136-021-
02829-x. Epub ahead
of print. PMID:
33834352.

Yokote K, Suzuki R,
Gouda M, Iijima H,
Yamazaki A, Inagaki M.
Association between
Glycemic Control and
Cardiovascular Events
in Older Japanese
Adults with Diabetes
Mellitus: An Analysis
of the Japanese
Medical
Administrative
Database. J Diabetes
Investig. 2021 May 14.
doi:
 10.1111/jdi.13575.
Epub ahead of print.
PMID: 33988907.

Monteiro C, Silvestre
S, Duarte AP, Alves G.
Assessment of
suspected adverse
drug reactions in
elderly patients with
diabetes mellitus
based on a Portuguese
spontaneous reporting
database: analysis of
reporting from 2008 to
2018. Expert Opin
Drug Saf. 2021 May 7.
doi:
10.1080/14740338.20
21.1928072. Epub
ahead of print. PMID:
33962523.

Omura T, Tamura Y,
Sakurai T, Umegaki H,
Iimuro S, Ohashi Y, Ito
H, Araki A; Japanese
Elderly Diabetes
Intervention Trial
Research Group.
Functional categories
based on cognition
and activities of daily
living predict all-cause
mortality in older
adults with diabetes
mellitus: The Japanese
Elderly Diabetes
Intervention Trial.
Geriatr Gerontol Int.
2021 Apr 22. doi:
10.1111/ggi.14171.
Epub ahead of print.
PMID: 33890351.

TIR deteriorates with age, duration of DM and hypoglycemia increase with the same
Kuroda N, Kusunoki Y, Osugi K, et al. Relationships between time in range, glycemic variability including
hypoglycemia, and types of diabetes therapy in Japanese patients with type 2 diabetes mellitus:
 HDHCC study [published online ahead of print, 2020 Jun 28]. J Diabetes Investig.
2020;10.1111/jdi.13336. doi:10.1111/jdi.13336

glucagon products for subcutaneous injection (Gvoke; formulation in the organic solvent DMSO)
intranasal dry powder administration (Baqsimi)
Ready to inject Dasiglucagon (phose 3)

An American Diabetes Association (ADA) consensus statement recommends that a patient’s treatment
regimen be reviewed any time a blood glucose value of <70 mg/dL (3.9 mmol/L) occurs, as such
readings often predict subsequent level 3 hypoglycemia (2). Episodes of hypoglycemia in the hospital
should be documented in the medical record and tracked (3).

Section 7—Diabetes Technology

Obesity and Weight Managment for the Prevention and Treatment of Type 2 Diabetes
Assessment
8.1 Use patient-centered, 8.1 Use person-centered, (replaced
nonjudgmental language that nonjudgmental language that “patient” with
fosters collaboration between fosters collaboration between “person”)
patients and providers, patients and providers,
including people-first language including people-first
(e.g., “person with obesity” language (e.g., “person with
rather than “obese person”). E obesity” rather than “obese
person”). E
8.2 Measure height and weight No change
and calculate BMI at annual
visits or more frequently.
Assess weight trajectory to
inform treatment
considerations. E
8.3 Based on clinical No change
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 the
association between
medication use, food intake,
and glycemic status. E
8.4 Accommodations should be No change
made to provide privacy during
weighing. E
Additional References/Potential Updates

- Edits to narrative section included in document.

Diet, Physical Activity, and Behavioral Therapy
8.5 Diet, physical activity, and 8.5 Diet, physical activity, and (replaced
behavioral therapy designed to behavioral therapy designed “patient” with
achieve and maintain ≥5% to achieve and maintain ≥5% “person”)
weight loss is recommended weight loss is recommended
for most patients with type 2 for most persons with type 2
diabetes who have overweight diabetes who have overweight
or obesity and are ready to or obesity and are ready to
achieve weight loss. Greater achieve weight loss. Greater
benefits in control of diabetes benefits in control of diabetes
and cardiovascular risk may be and cardiovascular risk may be
gained from even greater gained from even greater
weight loss. B weight loss. B
8.6 Such interventions should No change
include a high frequency of
counseling (≥16 sessions in 6
months) and focus on dietary
changes, physical activity, and
behavioral strategies to
achieve a 500–750 kcal/day
energy deficit. A
8.7 An individual's preferences, No change
motivation, and life
circumstances should be
considered, along with medical
status, when weight loss
interventions are
recommended. C
8.8 Behavioral changes that No change
create an energy deficit,
regardless of macronutrient
composition, will result in
weight loss. Dietary
recommendations should be
individualized to the patient's
preferences and nutritional
needs. A
8.9 Evaluate systemic, No change
structural, and socioeconomic
factors that may impact dietary
patterns and food choices, such
as food insecurity and hunger,
access to healthful food
options, cultural circumstances,
and social determinants of
health. C
8.10 For patients 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 high
levels of physical activity (200–
300 min/week).A
8.11 Short-term dietary
intervention using structured,
very-low-calorie diets (800–
1,000 kcal/day) may be
prescribed for carefully
selected patients 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
New recommendation 8.12
8.10 For those who achieve (replaced
weight-loss goals, long-term “patients” with
(≥1 year) weight-maintenance “those”)
programs are recommended
when available. Such Deleted “short-
programs should, at minimum, term”
provide monthly contact and
support, recommend ongoing
monitoring of body weight
(weekly or more frequently)
and other self-monitoring
strategies, and encourage high
levels of physical activity
(200–300 min/week).A
8.11 Short-term dietary (replaced
intervention using structured, “patients” with
very-low-calorie diets (800– “individuals”)
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
There is no clear evidence that A Systematic Review of
dietary supplements are Dietary Supplements and
effective for weight loss (A) Alternative Therapies for
Weight Loss.
PMID: 34159755.
Efficacy of dietary
supplements containing
isolated organic
compounds for weight
loss: a systematic review
and meta-analysis of
randomised placebo-
controlled trials.
PMID: 33976376.
Effectiveness of herbal
medicines for weight loss:
A systematic review and
meta-analysis of
randomized controlled
 trials.
PMID: 31984610.

Additional References/Potential Updates

- Edits to narrative section included in document.

[NEED TO RENUMBER BELOW HERE]

Pharmacotherapy
8.13 When choosing glucose- 8.13 When choosing glucose- (replaced
lowering medications for lowering medications for “patients” with
patients with type 2 diabetes persons with type 2 diabetes “persons”)
and overweight or obesity, and overweight or obesity,
consider the medication's consider the medication's
effect on weight. B effect on weight. B
8.14 Whenever possible, No change
minimize medications for
comorbid conditions that are
associated with weight gain. E
8.15 Weight-loss medications 8.15 Weight-loss medications (replaced
are effective as adjuncts to are effective as adjuncts to “patients” with
diet, physical activity, and diet, physical activity, and “persons”)
behavioral counseling for behavioral counseling for
selected patients with type 2 selected persons with type 2
diabetes and BMI ≥27 kg/m2. diabetes and BMI ≥27 kg/m2.
Potential benefits and risk must Potential benefits and risk
be considered. A must be considered. A
8.16 If a weight-loss No change
medication 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
Additional References/Potential Updates

- Edits to narrative section included in document.

Metabolic Surgery
8.17 Metabolic surgery should No change
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 Americans) and
in adults with BMI 35.0–39.9
kg/m2 (32.5–37.4 kg/m2 in
Asian Americans) who do not
achieve durable weight loss
and improvement in
comorbidities (including
hyperglycemia) with
nonsurgical methods. A
8.18 Metabolic surgery may be No cahnge
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
Americans) who do not achieve
durable weight loss and
improvement in comorbidities
(including hyperglycemia) with
nonsurgical methods. A
8.19 Metabolic surgery should 8.19 Metabolic surgery should 2019 Reference(s)
be performed in high-volume be performed in high-volume https://doi.org/10.1056/NE
centers with multidisciplinary centers with multidisciplinary JMsa1300625
teams knowledgeable about teams knowledgeable about
and experienced in the and experienced in the
management of diabetes and management of obesity,
gastrointestinal surgery. E diabetes, and gastrointestinal
surgery. E
8.20 People being considered No change
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
8.121 Long-term lifestyle 8.21 People who undergo 2019 Reference(s)
support and routine monitoring metabolic surgery should https://doi.org/10.1038/ob
of micronutrient and receive long-term medical and y.2009.28
nutritional status must be behavioral support and
provided to patients after routine monitoring of
surgery, according to guidelines micronutrient, nutritional, and
for postoperative management metabolic status. B
of metabolic surgery by
national and international
professional societies. C
8.22 New recommendation:
8.23 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
Additional References/Potential Updates
https://doi.org/10.1002/ob
y.20461
8.22 If post-bariatric References:
hypoglycemia (PBH) is
suspected, clinical evaluation Sheehan A, Patti ME.
should exclude other potential PMID: 33239898
disorders contributing to
hypoglycemia, and Salehi M, et al. PMID:
management includes 30101281.
education, medical nutrition
therapy with a dietitian Lee, et al. PMID:
experienced in PBH, and 33974064.
medication treatment, as
needed. A. Continuous
glucose monitoring (CGM)
should be considered as an
important adjunct to improve
safety by alerting patients to
hypoglycemia, especially for
those with severe
hypoglycemia or
hypoglycemia unawareness. E.
2019 Reference(s)
https://doi.org/10.1038/ob
y.2008.571

- Edits to narrative section included in document.

Pharmacologic Approaches To Glycemic Treatment
Pharmacologic Therapy For Adults with Type 1 Diabetes
9.1 Most people with type No change
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 No change
type 1 diabetes should
use rapid-acting insulin
analogs to reduce
hypoglycemia risk. A
9.3 Patients with type 1 9.3 Individuals with
diabetes should receive type 1 diabetes
education on how to should receive
match prandial insulin education on how to
doses to carbohydrate match mealtime
intake, premeal blood insulin doses to
glucose, and anticipated carbohydrate intake,
physical activity. C fat and protein
content, and
anticipated physical
activity. B
Pharmacologic Therapy for Adults with Type 2 Diabetes
9.4 Metformin is the Rationale: Anne Peters
preferred initial 9.4a. First-line comment sums it up :):
pharmacologic agent for therapy depends on . A. BECAUSE IF WE
the treatment of type 2 comorbidities, HAVE SOMEONE WITH
diabetes. A patient-centered T2DM AND CVD WITH
treatment factors, A NEW DIAGNOSIS OF
and management T2DM AND AN A1C OF
needs, but will 6.7% DO WE REALLY
generally include ADVOCATE
metformin and METFORMIN + SGLT-2
comprehensive I? DO WE NEED
lifestyle METFORMIN IN THIS
modification. A A CASE?

VA: rationale for

prioritizing cv risk
9.4b Other reducing agents when
medications (GLP-1 indicated rather than
RA, SGLT2-i), with or deferring
without metformin
based on glycemic
 needs, are
appropriate initial
therapy for patients
with T2DM with or at
high risk for ASCVD,
heart failure, and/or
CKD. (Figure 9.3) A
9.5 Once initiated, Metformin should be VA: looking at the
metformin should be continued upon history, this
continued as long as it is initiation of insulin recommendation was
tolerated and not therapy (unless incorporated in 2018
contraindicated; other contraindicated or not Standards, with the
agents, including insulin, tolerated) for ongoing following wording:
should be added to glycemic and
metformin. A metabolic benefits. A “Metformin should be
continued when used in
combination with other
agents, including
insulin, if not
contraindicated and if
tolerated. A”

The text stated (no

references):
“Metformin should be
continued in patients
on combination
injectable insulin
therapy, if not
contraindicated and if
tolerated, for further
glycemic benefits.”

Then in 2019:
Recommendation:
9.6 Once initiated,
metformin should be
continued as long as it
is tolerated and not
contraindicated; other
agents, including
insulin, should be
added to metformin. A

Text:
When initiating
combination injectable
therapy, metformin
 therapy should be
maintained while
sulfonylureas and DPP-
4 inhibitors are typically
discontinued.

2020: text:
“When initiating
combination injectable
therapy, metformin
therapy should be
maintained, while
sulfonylureas and DPP-
4 inhibitors are typically
weaned or
discontinued.
9.6 Early combination Remission studies – consider
therapy can be for text.
considered in some No change
patients at treatment Mcinnes N et al JCEM 2021
initiation to extend the PMID 32403130
time to treatment
failure. A

9.7 The early introduction No change Consider adding insulin pk

of insulin should be table
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 patient-centered No change Tsapas A et al; Ann Intern
approach should be used Med 2020; 173:278-286.
to guide the choice of
pharmacologic agents.
Considerations include
effect on cardiovascular
and renal comorbidities,
efficacy, hypoglycemia
risk, impact on weight,
cost, risk for side effects,
and patient preferences
(Table 9.1 and Fig. 9.1). E
9.9 Among patients with
type 2 diabetes who have
established
atherosclerotic
cardiovascular disease or
indicators of high risk,
established kidney
disease, or heart failure, a
sodium–glucose
cotransporter 2 inhibitor
or glucagon-like peptide 1
receptor agonist with
demonstrated
cardiovascular disease
benefit (Table 9.1, Table
10.3B, Table 10.3C) is
recommended as part of
the glucose-lowering
regimen independent of
A1C and in consideration
of patient-specific factors
(Figure 9.1 and Section
10). A
9.10 In patients with type
2 diabetes, a glucagon-
like peptide 1 receptor
agonist is preferred to
insulin when possible. A
9.9 Zaccardi F et al; Diabetes Care
9.9: 2021; 44:e32-e34
“Among individuals
with t2 who have
established ascvd or
established kidney
disease, an sglt2i
and/or glp-1 ra with
demonstrated cv
disease benefit (Table
10.3b and table 10.3c)
is recommended as
part of the
comprehensive
cardiovascular risk
reduction and/or
glucose-lowering
regimens (Figure 9.1).
A
9.9a = same as 10.42a
(soc 2021) (Figure 9.1)
9.9b = same as 10.42b
(soc 2021) (Figure 9.1)
New 9.10 = same as
10.43 soc 2021
(Figure 9.1)
No change
New recommendation References 54-60 in current
9.11. If insulin is used, section
combination therapy Additional sentence:
with GLP-1 RA is
recommended for
greater efficacy and
 durability of Durability of insulin degludec
treatment effect. A plus liraglutide versus insulin
glargine U100 as initial
injectable therapy in type 2
diabetes (DUAL VIII): a
multicentre, open-label,
phase 3b, randomised
controlled trial.
Aroda VR, González-Galvez G,
Grøn R, Halladin N, Haluzík M,
Jermendy G, Kok A, Őrsy P,
Sabbah M, Sesti G, Silver
R.Lancet Diabetes Endocrinol.
2019 Aug;7(8):596-605. doi:
10.1016/S2213-
8587(19)30184-6. Epub 2019
Jun 9.

A greater proportion of
participants with type 2
diabetes achieve treatment
targets with insulin
degludec/liraglutide versus
insulin glargine 100 units/mL
at 26 weeks: DUAL VIII, a
randomized trial designed to
resemble clinical practice.
Sesti G, Bardtrum L, Dagdelen
S, Halladin N, Haluzík M, Őrsy
P, Rodríguez M, Aroda
VR.Diabetes Obes Metab.
2020 May;22(5):873-878. doi:
10.1111/dom.13957. Epub
2020 Jan 29.PMID: 31903724

9.12 Recommendation for No change

treatment intensification
for patients not meeting
treatment goals should
not be delayed. A
9.13 The medication No change
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 9.1). 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 IU/kg, high bedtime-
morning or post-
preprandial glucose
differential, hypoglycemia
(aware or unaware), and
high variability. Indication
of overbasalization should
prompt reevaluation to
further individualize
therapy. 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
IU/kg/day, high
bedtime-morning or
post-preprandial
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
Hypertension/Blood Pressure Control
Screening and Diagnosis
10.1 Blood pressure 10.1 Blood pressure New supportive
should be measured at should be measured at reference:
every routine clinical visit. every routine clinical
Patients found to have visit. When possible, Unger T, Borghi C,
elevated blood pressure patients found to have Charchar F, Khan NA,
(≥140/90 mmHg) should elevated blood Poulter NR,
have blood pressure pressure (≥140/90 Prabhakaran D,
confirmed using multiple mmHg) should have Ramirez A, Schlaich M,
readings, including blood pressure Stergiou GS,
measurements on a confirmed using Tomaszewski M,
separate day, to diagnose multiple readings, Wainford RD, Williams
hypertension. B including B, Schutte AE. 2020
measurements on a International Society
separate day, to of Hypertension
diagnose hypertension. Global Hypertension
A Patients with BP ≥ Practice Guidelines.
180/110 mmHg and Hypertension. 2020
cardiovascular disease Jun;75(6):1334-1357.
could be diagnosed doi:
with hypertension at a 10.1161/HYPERTENSIO
single visit. E NAHA.120.15026.
Epub 2020 May 6.
PMID: 32370572.
10.2 All hypertensive 10.2 All hypertensive
patients with diabetes patients with diabetes
should monitor their should monitor their
blood pressure at blood pressure at
home. B home. A
Treatment Goals
10.3 For patients with For patients with Text: low DBP should
diabetes and diabetes and not be an obstacle to
hypertension, blood hypertension, blood treatment
pressure targets should pressure targets should
be individualized through be individualized Ilkun OL, Greene T,
a shared decision-making through a shared Cheung AK, Whelton
process that addresses decision-making PK, Wei G, Boucher RE,
cardiovascular risk, process that addresses Ambrosius W,
potential adverse effects cardiovascular risk, Chertow GM, Beddhu
of antihypertensive potential adverse S. The Influence of
medications, and patient effects of Baseline Diastolic
preferences. C antihypertensive Blood Pressure on the
medications, and Effects of Intensive
patient preferences. B Blood Pressure
Lowering on
 Cardiovascular
Outcomes and All-
Cause Mortality in
Type 2 Diabetes.
Diabetes Care. 2020
Aug;43(8):1878-1884.
doi: 10.2337/dc19-
2047. Epub 2020 May
4. PMID: 32366577;
PMCID: PMC7372050.
10.4 For individuals with For individuals with
diabetes and diabetes and
hypertension at higher hypertension at higher
cardiovascular risk cardiovascular risk
(existing atherosclerotic (existing
cardiovascular disease atherosclerotic
[ASCVD] or 10-year cardiovascular disease
ASCVD risk ≥15%), a blood [ASCVD] or 10-year
pressure target of ASCVD risk ≥15%), a
<130/80 mmHg may be blood pressure target
appropriate, if it can be of <130/80 mmHg may
safely attained. C be appropriate, if it can
be safely attained. B
10.5 For individuals with No change
diabetes and
hypertension at lower risk
for cardiovascular disease
(10-year atherosclerotic
cardiovascular disease
risk <15%), treat to a
blood pressure target of
<140/90 mmHg. A
10.6 In pregnant patients No change
with diabetes and
preexisting hypertension,
a blood pressure target of
110–135/85 mmHg is
suggested in the interest
of reducing the risk for
accelerated maternal
hypertension A and
minimizing impaired fetal
growth. E
Lifestyle Intervention
10.7 For patients with No change Text – mention meta-
blood pressure >120/80 analysis showing
mmHg, lifestyle complementary
intervention consists of benefit of digital
weight loss when health intervention:
indicated, a Dietary
Approaches to Stop Mao Y, Lin W, Wen J,
Hypertension (DASH)- Chen G. Impact and
style eating pattern efficacy of mobile
including reducing sodium health intervention in
and increasing potassium the management of
intake, moderation of diabetes and
alcohol intake, and hypertension: a
increased physical systematic review and
activity. A meta-analysis. BMJ
Open Diabetes Res
Care. 2020
Sep;8(1):e001225. doi:
10.1136/bmjdrc-2020-
001225. PMID:
32988849; PMCID:
PMC7523197.

Stogios N, Kaur B,
Huszti E, Vasanthan J,
Nolan RP. Advancing
Digital Health
Interventions as a
Clinically Applied
Science for Blood
Pressure Reduction: A
Systematic Review and
Meta-analysis. Can J
Cardiol. 2020
May;36(5):764-774.
doi:
10.1016/j.cjca.2019.11
.010. Epub 2019 Nov
15. PMID: 32249065.
Pharmacologic Intervention
10.8 Patients with No change
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 No change
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 No change George will send
hypertension should updated JAMA
include drug classes reference re:
demonstrated to reduce outcomes with ACE or
cardiovascular events in ARB, to be added to
patients with diabetes. A text
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 No change
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 No change
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 No change
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
10.14 Patients with No change
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. B
Lipid Management
Lifestyle Intervention
10.15 Lifestyle No change Text – include
modification focusing on reference to 2019
weight loss (if indicated); ACC/AHA primary
application of a prevention guidelines.
Mediterranean style or Circulation.
Dietary Approaches to 2019;140:e563–e595.
Stop Hypertension (DASH) DOI:
eating pattern; reduction 10.1161/CIR.00000000
of saturated fat and trans 00000677 September
fat; increase of dietary n-3 10, 2019 e563
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 No change
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 No change
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 No change
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
Statin Treatment
10.19 For patients with No change
diabetes aged 40–75
years without
atherosclerotic
cardiovascular disease,
use moderate-intensity
statin therapy in addition
to lifestyle therapy. A
10.20 For patients with No change
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
10.21 In patients with No change
diabetes at higher risk,
especially those with
multiple atherosclerotic
cardiovascular disease
risk factors or aged 50–70
years, it is reasonable to
use high-intensity statin
therapy. B
10.22 In adults with No change
diabetes and 10-year
atherosclerotic
cardiovascular disease
risk of 20% or higher, it
may be reasonable to add
ezetimibe to maximally
tolerated statin therapy
to reduce LDL cholesterol
levels by 50% or more. C
Secondary prevention
10.23 For patients of all No change
ages with diabetes and
atherosclerotic
cardiovascular disease,
high-intensity statin
therapy should be added
to lifestyle therapy. A
10.24 For patients with 10.24 For patients with Consider text referring
diabetes and diabetes and to bempedoic acid;
atherosclerotic atherosclerotic however, no outcomes
cardiovascular disease cardiovascular disease data available at this
considered very high risk considered very high time. Indicated as an
using specific criteria, if risk using specific adjunct to diet and
LDL cholesterol is ≥70 criteria, if LDL maximally tolerated
mg/dL on maximally cholesterol is ≥70 statin therapy for the
tolerated statin dose, mg/dL on maximally
consider adding tolerated statin dose, treatment of adults
additional LDL-lowering consider adding with heterozygous
therapy (such as additional LDL-lowering familial HC or
ezetimibe or PCSK9 therapy (such as established ASCVD
inhibitor). A Ezetimibe ezetimibe or PCSK9 who require additional
may be preferred due to inhibitor). A lowering of LDL-C
lower cost.
Di Minno A, Lupoli R,
Calcaterra I, Poggio P,
Forte F, Spadarella G,
Ambrosino P, Iannuzzo
G, Di Minno MND.
Efficacy and Safety of
Bempedoic Acid in
Patients With
Hypercholesterolemia:
Systematic Review and
Meta-Analysis of
Randomized
Controlled Trials. J Am
Heart Assoc. 2020 Aug
4;9(15):e016262. doi:
10.1161/JAHA.119.016
262. Epub 2020 Jul 21.
PMID: 32689862;
PMCID: PMC7792250.

Text – reduction in risk

stroke in FOURIER:
Giugliano RP,
Pedersen TR, Saver JL,
Sever PS, Keech AC,
Bohula EA, Murphy SA,
Wasserman SM,
Honarpour N, Wang H,
Lira Pineda A, Sabatine
MS; FOURIER
Investigators. Stroke
Prevention With the
PCSK9 (Proprotein
Convertase Subtilisin-
Kexin Type 9) Inhibitor
Evolocumab Added to
Statin in High-Risk
Patients With Stable
Atherosclerosis.
Stroke. 2020
May;51(5):1546-1554.
 doi:
10.1161/STROKEAHA.
119.027759. Epub
2020 Apr 21. PMID:
32312223.
10.25 For patients who do No change
not tolerate the intended
intensity, the maximally
tolerated statin dose
should be used. E
10.26 In adults with No change
diabetes aged >75 years
already on statin therapy,
it is reasonable to
continue statin
treatment. B
10.27 In adults with No change
diabetes aged >75 years,
it may be reasonable to
initiate statin therapy
after discussion of
potential benefits and
risks. C
10.28 Statin therapy is No change
contraindicated in
pregnancy. B
Treatment of Other Lipoprotein Fractions or Targets
10.29 For patients with No change Mention STRENGTH
fasting triglyceride levels trial findings in text
≥500 mg/dL, evaluate for
secondary causes of
hypertriglyceridemia and
consider medical therapy
to reduce the risk of
pancreatitis. C
10.30 In adults with No change
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
10.31 In patients with No change
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
10.32 Statin plus fibrate No change
combination therapy has
not been shown to
improve atherosclerotic
cardiovascular disease
outcomes and is generally
not recommended. A
10.33 Statin plus niacin No change
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
10.34 Use aspirin therapy No change
(75–162 mg/day) as a
secondary prevention
strategy in those with
diabetes and a history of
atherosclerotic
cardiovascular disease. A
10.35 For patients with No change
atherosclerotic
cardiovascular disease
and documented aspirin
allergy, clopidogrel (75
mg/day) should be
used. B
10.36 Dual antiplatelet No change
therapy (with low-dose
aspirin and a P2Y12 Will keep fundamental
inhibitor) is reasonable recommendations re:
for a year after an acute antiplatelet, AC
coronary syndrome and therapy but indicate in
may have benefits beyond text that field is
this period. A rapidly evolving
10.37 Long-term No change Mention in text Text –
treatment with dual information about this
antiplatelet therapy field changing rapidly, Wiebe J, Ndrepepa G,
should be considered for as are the definitions Kufner S, Lahmann AL,
patients with prior of optimal care Xhepa E, Kuna C, Voll
coronary intervention, F, Gosetti R, Laugwitz
high ischemic risk, and KL, Joner M, Kastrati A,
low bleeding risk to Cassese S. Early
prevent major adverse Aspirin
cardiovascular events. A Discontinuation After
Coronary Stenting: A
Systematic Review and
Meta-Analysis. J Am
Heart Assoc. 2021 Jan
19;10(2):e018304. doi:
10.1161/JAHA.120.018
304. Epub 2021 Jan 7.
PMID: 33410332;
PMCID: PMC7955304.

Angiolillo DJ, Baber U,

Sartori S, Briguori C,
Dangas G, Cohen DJ,
Mehta SR, Gibson CM,
Chandiramani R,
Huber K, Kornowski R,
Weisz G, Kunadian V,
Oldroyd KG, Ya-Ling H,
Kaul U, Witzenbichler
B, Dudek D, Sardella G,
Escaned J, Sharma S,
Shlofmitz RA, Collier T,
Pocock S, Mehran R.
Ticagrelor With or
Without Aspirin in
High-Risk Patients
With Diabetes Mellitus
 Undergoing
Percutaneous
Coronary Intervention.
J Am Coll Cardiol. 2020
May 19;75(19):2403-
2413. doi:
10.1016/j.jacc.2020.03
.008. Epub 2020 Mar
30. PMID: 32240760.
10.38 Combination No change
therapy with aspirin plus
low-dose rivaroxaban
should be considered for
patients with stable
coronary and/or
peripheral artery disease
and low bleeding risk to
prevent major adverse
limb and cardiovascular
events. A
10.39 Aspirin therapy No change
(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
10.40 In asymptomatic No change
patients, 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
10.41 Consider No change
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
Treatmeant
10.42 Among patients
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
No change Another meta-analysis New BMJ meta-
(suggested by Dr. analysis:
Note – for this section Gabbay) The presence Palmer SC, Tendal B,
need to add: or absence of Mustafa RA, Vandvik
atherosclerotic CV PO, Li S, Hao Q,
VERTIS disease did not modify Tunnicliffe D, Ruospo
Emperor-Reduced the association with M, Natale P,
outcomes for major Saglimbene V,
Will add SOLOIST, adverse CV events Nicolucci A, Johnson
SCORED discussion to JAMA Cardiol. DW, Tonelli M, Rossi
text but not table, 2021;6(2):148-158. MC, Badve SV, Cho Y,
with emphasis on doi:10.1001/jamacardi Nadeau-Fredette AC,
evolving knowledge re: o.2020.4511 Burke M, Faruque LI,
SGLT2i use in HFpEF Lloyd A, Ahmad N, Liu
and in hospitalized Y, Tiv S, Millard T,
patients Gagliardi L, Kolanu N,
Barmanray RD,
Harmony: remove McMorrow R, Raygoza
from table, but include Cortez AK, White H,
in text as a short Chen X, Zhou X, Liu J,
mention of outcomes Rodríguez AF,
benefits demonstrated González-Colmenero
with use of a GLP-1RA AD, Wang Y, Li L,
that did not Sutanto S, Solis RC,
(comparatively) Díaz González-
convey marked Colmenero F,
metabolic Rodriguez-Gutierrez R,
improvements. Walsh M, Guyatt G,
Strippoli GFM.
Sodium-glucose
cotransporter protein-
2 (SGLT-2) inhibitors
and glucagon-like
peptide-1 (GLP-1)
 receptor agonists for
type 2 diabetes:
systematic review and
network meta-analysis
of randomised
controlled trials. BMJ.
2021 Jan
13;372:m4573. doi:
10.1136/bmj.m4573.
PMID: 33441402;
PMCID: PMC7804890.
10.42a In patients with No change In text will outline
type 2 diabetes and approach to use of
established SGLT2i, GLP1RA in
atherosclerotic patients with
cardiovascular disease, indications for same
multiple atherosclerotic under various
cardiovascular disease scenarios (new
risk factors, or diabetic diagnosis DM in
kidney disease, a sodium– patient with
glucose cotransporter 2 comorbidities; pt with
inhibitor with DM who develops
demonstrated comorbidities, etc.
cardiovascular benefit is Emphasize
recommended to reduce importance of use
the risk of major adverse irrespective of A1c,
cardiovascular events metformin. Also
and/or heart failure reproduce ACC/AHA
hospitalization. A consensus document
figure 1 (endorsed by
ADA)
10.42b In patients with No change
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
10.43 In patients with
type 2 diabetes and
established heart failure
with 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
10.44 In patients 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 patients with
prior myocardial
infarction, β-blockers
should be continued for 3
years after the event. B
10.46 Treatment of
patients with heart failure
No change
No change Section 10 or
elsewhere: influenza
vaccine in adults with
cardiovascular disease
reduces mortality and
cardiovascular events
(new meta-analysis;
31% had DM):
Yedlapati SH, Khan SU,
Talluri S, Lone AN,
Khan MZ, Khan MS,
Navar AM, Gulati M,
Johnson H, Baum S,
Michos ED. Effects of
Influenza Vaccine on
Mortality and
Cardiovascular
Outcomes in Patients
With Cardiovascular
Disease: A Systematic
Review and Meta-
Analysis. J Am Heart
Assoc. 2021 Mar
16;10(6):e019636. doi:
10.1161/JAHA.120.019
636. Epub 2021 Mar
13. PMID: 33719496.
No change
No change In text: consider
expanding discussion
with reduced ejection
fraction should include a
β-blocker with proven
cardiovascular outcomes
benefit, unless otherwise
contraindicated. A
10.47 In patients 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
patients with heart
failure. B
OTHER CONSIDERATIONS
(primarily for text)
Association between A1c
variability and mortality
of HF risks in patients
with DM:
Suthahar N, Lau ES,
Blaha MJ, Paniagua
SM, Larson MG, Psaty
BM, Benjamin EJ,
Allison MA, Bartz TM,
Januzzi JL Jr, Levy D,
Meems LMG, Bakker
SJL, Lima JAC,
Cushman M, Lee DS,
Wang TJ, deFilippi CR,
Herrington DM, Nayor
M, Vasan RS, Gardin
JM, Kizer JR, Bertoni
AG, Allen NB,
Gansevoort RT, Shah
SJ, Gottdiener JS, Ho
JE, de Boer RA. Sex-
Specific Associations
of Cardiovascular Risk
Factors and
Biomarkers With
Incident Heart Failure.
J Am Coll Cardiol. 2020
Sep 22;76(12):1455-
1465. doi:
10.1016/j.jacc.2020.07
.044. PMID: 32943164;
PMCID: PMC7493711.
No change
Sheng CS, Tian J, Miao
Y, Cheng Y, Yang Y,
Reaven PD,
 Bloomgarden ZT, Ning
G. Prognostic
Significance of Long-
term HbA1c Variability
for All-Cause Mortality
in the ACCORD Trial.
Diabetes Care. 2020
Jun;43(6):1185-1190.
doi: 10.2337/dc19-
2589. Epub 2020 Mar
30. PMID: 32229597.
Bariatric surgery and
impact on outcomes (DM
remission; micro and
macrovascular
complications)? Consider
for section which
focusses on weight loss in
DM
Chronic Kidney Disease and Risk Management
Diabetic Kidney Disease
Screening
11.1a At least annually, urinary No change
albumin (e.g., spot urinary
albumin-to-creatinine ratio) and
estimated glomerular filtration
rate should be assessed in
patients with type 1 diabetes
with duration of ≥5 years and in
all patients with type 2 diabetes
regardless of treatment. B
11.1b Patients with diabetes 11.1b Patients with
and urinary albumin >300 mg/g diabetes and urinary
creatinine and/or an estimated albumin ≥300 mg/g
glomerular filtration rate 30–60 creatinine and/or an
mL/min/1.73 m2 should be estimated glomerular
monitored twice annually to filtration rate 30–60
guide therapy. B mL/min/1.73 m2 should
be monitored twice
annually to guide
therapy. B
Treatment
11.2 Optimize glucose control to No change
reduce the risk or slow the
progression of chronic kidney
disease. A
11.3a For patients with type 2 11.3a For patients with ADD-
diabetes and diabetic kidney type 2 diabetes and 1.Heerspink HJL, Stefansson
disease, use of a sodium– diabetic kidney disease, BV, Correa-Rotter R, et al.
glucose cotransporter 2 use of a sodium– Dapagliflozin in Patients
inhibitor in patients with an glucose cotransporter 2 with Chronic Kidney
estimated glomerular filtration inhibitor in patients Disease. N Engl J Med
rate ≥25 mL/min/1.73 m2 and with an estimated 2020;383(15):1436-1446.
urinary albumin >200 mg/g glomerular filtration DOI:10.1056/NEJMoa20248
creatinine is recommended to rate ≥25 mL/min/1.73 16.
reduce CKD progression and m2 and urinary albumin
cardiovascular events. A ≥300 mg/g creatinine is
recommended to
reduce CKD
progression and
cardiovascular
events. A
11.3b In patients with Add DECLARE data to 1.Heerspink HJL, Stefansson
type 2 diabetes and text—emerging data BV, Correa-Rotter R, et al.
diabetic kidney disease, to support earlier use Dapagliflozin in Patients
consider use of with Chronic Kidney

11.3c In patients with chronic
kidney disease who are at
increased risk for cardiovascular
events, use of a glucagon-like
peptide 1 receptor agonist
reduces renal end point,
sodium–glucose Disease. N Engl J Med
cotransporter 2 2020;383(15):1436-1446.
inhibitors additionally DOI:10.1056/NEJMoa20248
for cardiovascular risk 16.
reduction when Jardine M, Zhou Z, Lambers
estimated glomerular Heerspink HJ, et al. Kidney,
filtration rate and Cardiovascular, and Safety
urinary albumin Outcomes of Canagliflozin
creatinine are ≥25 according to Baseline
mL/min/1.73 m2 or Albuminuria: A CREDENCE
>300 mg/g, Secondary Analysis. Clin J
respectively. A Am Soc Nephrol
2021;16(3):384-395. DOI:
10.2215/CJN.15260920.
Zelniker TA, Raz I,
Mosenzon O, et al. Effect of
Dapagliflozin on
Cardiovascular Outcomes
According to Baseline
Kidney Function and
Albuminuria Status in
Patients With Type 2
Diabetes: A Prespecified
Secondary Analysis of a
Randomized Clinical Trial.
JAMA Cardiol 2021. DOI:
10.1001/jamacardio.2021.0
660.
Eickhoff MK, Olsen FJ,
Frimodt-Moller M, et al.
Effect of dapagliflozin on
cardiac function in people
with type 2 diabetes and
albuminuria - A double
blind randomized placebo-
controlled crossover trial. J
Diabetes Complications
2020;34(7):107590. DOI:
10.1016/j.jdiacomp.2020.1
07590.
In patients with chronic 1-Mann JFE, Hansen T,
kidney disease who are Idorn
at increased risk for T, et al. Effects of once-
cardiovascular events weekly subcutaneous
or chronic kidney semaglutide on kidney
disease progression function and safety in
primarily albuminuria,
progression of albuminuria, and
cardiovascular events (Table
9.1). A
11.4 Optimize blood pressure
control to reduce the risk or
slow the progression of chronic
kidney disease. A
and are unable to use a patients with type 2
sodium–glucose diabetes: a post-hoc
cotransporter 2 analysis of the SUSTAIN 1-7
inhibitor, a nonsteroi- randomised controlled
dal mineralocorticoid trials. Lancet Diabetes
receptor antagonist Endocrinol 2020;8(11):880-
(finerenone) is 893. DOI: 10.1016/S2213-
recommended to 8587(20)30313-2.
reduce chronic kidney 2-Mann JFE, Muskiet MHA.
disease progression Incretin-based drugs and
and cardiovascular the kidney in type 2
events (Table diabetes: choosing between
9.2). A DPP-4 inhibitors and GLP-1
receptor agonists. Kidney
Int 2021;99(2):314-318.
DOI:
10.1016/j.kint.2020.08.036.
New recommendation
11.3d In patients 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
Optimization of blood Viazzi F, Russo E, Mirijello
pressure control and A, et al. Long-term blood
reduction in blood pressure variability,
pressure variability to incidence of hypertension
reduce the risk or slow and changes in renal
the progression of function in type 2 diabetes.
chronic kidney disease J Hypertens
is recommended. A 2020;38(11):2279-2286.
DOI:
10.1097/HJH.00000000000
02543.
Chiriaco M, Pateras K, Virdis
A, et al. Association
between blood pressure
variability, cardiovascular
disease and mortality in
type 2 diabetes: A
systematic review and
 meta-analysis. Diabetes
Obes Metab
2019;21(12):2587-2598.
DOI: 10.1111/dom.13828.

11.5 Do not discontinue renin- Qiao Y, Shin JI, Chen TK, et

angiotensin system blockade for al. Association Between
minor increases in serum Renin-Angiotensin System
creatinine (<30%) in the Blockade Discontinuation
absence of volume depletion. A and All-Cause Mortality
Among Persons With Low
Estimated Glomerular
Filtration Rate. JAMA Intern
Med 2020;180(5):718-726.
DOI:
10.1001/jamainternmed.20
20.0193.
Collard D, Brouwer TF,
Peters RJG, Vogt L, van den
Born BH. Creatinine Rise
During Blood Pressure
Therapy and the Risk of
Adverse Clinical Outcomes
in Patients With Type 2
Diabetes Mellitus.
Hypertension
2018;72(6):1337-1344. DOI:
10.1161/HYPERTENSIONAH
A.118.11944.
Ohkuma T, Jun M, Rodgers
A, et al. Acute Increases in
Serum Creatinine After
Starting Angiotensin-
Converting Enzyme
Inhibitor-Based Therapy
and Effects of its
Continuation on Major
Clinical Outcomes in Type 2
Diabetes Mellitus.
Hypertension
2019;73(1):84-91. DOI:
10.1161/HYPERTENSIONAH
A.118.12060.

11.6 For people with For people with

nondialysis-dependent chronic nondialysis-dependent
kidney disease, dietary protein stage 3 or higher
intake should be approximately chronic kidney disease,
0.8 g/kg body weight per day dietary protein intake
(the recommended daily should be a maximum
allowance). A For patients on of 0.8 g/kg body weight
dialysis, higher levels of dietary per day (the
protein intake should be recommended daily
considered, since malnutrition is allowance). A For
a major problem in some patients on dialysis,
dialysis patients. B higher levels of dietary
protein intake should
be considered, since
malnutrition is a major
problem in some
dialysis patients. B
11.7 In nonpregnant patients No change
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) B 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. A
11.8 Periodically monitor serum No change
creatinine and potassium levels
for the development of
increased creatinine or changes
in potassium when ACE
inhibitors, angiotensin receptor
blockers, or diuretics are
used. B
11.9 An ACE inhibitor or an No change
angiotensin receptor blocker is
not recommended for the
primary prevention of chronic
kidney disease in patients with
diabetes who have normal
blood pressure, normal urinary
albumin-to-creatinine ratio (<30
mg/g creatinine), and normal
estimated glomerular filtration
rate. A
11.10 Patients should be
referred for evaluation by a
nephrologist if they have an
estimated glomerular filtration
rate <30 mL/min/1.73 m2. A
11.11 Promptly refer to a
physician experienced in the
care of kidney disease for
uncertainty about the etiology
of kidney disease, difficult
management issues, and rapidly
progressing kidney disease. A
No change
Promptly refer to a
nephrologist for
uncertainty about the
etiology of kidney
disease, difficult
management issues,
and rapidly progressing
kidney disease. A
Diabetic Retinopathy, Neuropathy, and Foot Care
Diabetic Retinopathy
12.1 Optimize glycemic No change
control to reduce the risk
or slow the progression of
diabetic retinopathy. A
12.2 Optimize blood No change
pressure and serum lipid
control to reduce the risk
or slow the progression of
diabetic retinopathy. A
Screening
12.3 Adults with type 1 No change
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 No change
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 No change
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 No change
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 No change
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 No change
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
Treatment
12.9 Promptly refer Promptly refer patients
patients with any level of with any level of
macular edema, severe diabetic macular
nonproliferative diabetic edema, moderate or
retinopathy (a precursor worse nonproliferative
of proliferative diabetic diabetic retinopathy (a
retinopathy), or any precursor of
proliferative diabetic
retinopathy to an
ophthalmologist who is
knowledgeable and
experienced in the
management of diabetic
retinopathy. A
12.10 The traditional
standard treatment,
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 not inferior to
traditional panretinal
laser photocoagulation
and are also indicated to
reduce the risk of vision
loss in patients with
proliferative diabetic
retinopathy. A
12.12 Intravitreous
injections of anti–vascular
endothelial growth factor
are indicated for central
involved diabetic macular
edema, which occurs
beneath the foveal center
and may threaten reading
vision. A
proliferative diabetic
retinopathy), or any
proliferative diabetic
retinopathy to an
ophthalmologist who is
knowledgeable and
experienced in the
management of
diabetic retinopathy. A
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
Intravitreous injections
of anti–vascular
endothelial growth
factor are a reasonable
alternative to
panretinal laser
photocoagulation for
some patients with
proliferative diabetic
retinopathy and may
also reduce the risk of
vision loss in these
patients. A
Intravitreous injections
of anti–vascular
endothelial growth
factor are indicated as
first line treatment for
most eyes with diabetic
macular edemathat
involves the foveal
center and that impairs
vision acuity. A
NEW REC:
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 that
are not candidates for
this first-line approach.
A
12.14 The presence of No change
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 patients should No change
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 No change
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 patients
should have annual 10-g
monofilament testing to
identify feet at risk for
ulceration and
amputation. B
12.17 Symptoms and No change
signs of autonomic
neuropathy should be
assessed in patients with
microvascular
complications. E
Treatment
12.18 Optimize glucose No change
control to prevent or
delay the development of
neuropathy in patients
with type 1
diabetes A and to slow
the progression of
neuropathy in patients
with type 2 diabetes. B
12.19 Assess and treat No change
patients to reduce pain
related to diabetic
peripheral neuropathy B
and symptoms of
autonomic neuropathy
and to improve quality of
life. E
12.20 Pregabalin, No change
duloxetine, or gabapentin
are recommended as
initial pharmacologic
treatments for
neuropathic pain in
diabetes. A
Foot Care
12.21 Perform a No change
comprehensive foot
evaluation at least
annually to identify risk
factors for ulcers and
amputations. B
12.22 Patients with No change
evidence of sensory loss
or prior ulceration or
amputation should have
their feet inspected at
every visit. B
12.23 Obtain a prior No change
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
12.24 The examination No change
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
12.25 Patients with No change
symptoms of claudication
or decreased or absent
pedal pulses should be
referred for ankle-brachial
index and for further
vascular assessment as
appropriate. C
12.26 A multidisciplinary No change
approach is
recommended for
individuals with foot
ulcers and high-risk feet
(e.g., dialysis patients and
those with Charcot foot or
prior ulcers or
amputation). B
12.27 Refer patients who No change
smoke or who have
histories 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. C
12.28 Provide general No change
preventive foot self-care
education to all patients
with diabetes. B
12.29 The use of No change
specialized therapeutic
footwear is
recommended for high-
risk patients with diabetes
including those with
severe neuropathy, foot
deformities, ulcers,
callous formation, poor
peripheral circulation, or
history of amputation. B
Older Adults

Assessment and Screening

13.1 Consider the
assessment of medical,
psychological, functional
(self-management
abilities), and social
geriatric domains in older
adults to provide a
framework to determine
targets and therapeutic
approaches for diabetes
management. B
12.1 Consider the In the text, add new
assessment of medical, reference from Mary https://doi.org/10.10
psychological, Tinetti on goals of 01/jamanetworkopen
functional (self- multi-morbid older .2021.1271
management abilities), patients.
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 No change

syndromes (i.e.,
polypharmacy, cognitive
impairment, depression,
urinary incontinence,
falls, and persistent pain)
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 and
annually as appropriate. B
12.3 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 No change
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 No change Add citation from new https://doi.org/10.23
type 1 diabetes, paper about how CGM 37/dc20-0016
continuous glucose improves accuracy of
monitoring should be hypoglycemia
considered to reduce prediction.
hypoglycemia. A

Treatment Goals
13.6 Older adults who are 12.6 Older adults who Some amount of https://doi.org/10.10
otherwise healthy with are otherwise healthy activity in this space 93/gerona/glab141
few coexisting chronic with few coexisting about clinical
illnesses and intact chronic illnesses and classification of older https://doi.org/10.23
cognitive function and intact cognitive patients with 37/dc20-3045
functional status should function and functional diabetes. Probably not
have lower glycemic goals status should have enough to change the
(such as A1C <7.0–7.5% lower glycemic goals way we think about
[53–58 mmol/mol]), while (such as A1C less than glucose goals but
those with multiple 7.0–7.5% [53–58 definitely moves us
coexisting chronic mmol/mol]), while towards better
illnesses, cognitive those with multiple defining groups.
impairment, or functional coexisting chronic
dependence should have illnesses, cognitive Propose to revised
less stringent glycemic impairment, or text of section on
goals (such as A1C <8.0– functional dependence complex patients.
8.5% [64–69 mmol/mol]). should have less
C stringent glycemic Very complex are
goals (such as A1C less long-term care
than 8.0% [64 patients or those
mmol/mol]). C enrolled in
hospice/palliative
care.

The example of less

stringent A1C has
been changed to just
A1C<8.0%.

13.7 Glycemic goals for No change

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 patients. C
13.8 Screening for No change
diabetes complications
should be individualized
in older adults. Particular
attention should be paid
to complications that
would lead to functional
impairment. C

13.9 Treatment of No change New OPTIMISE trial https://doi.org/10.10

hypertension to shows that 01/jama.2020.4871
individualized target deintensification of
levels is indicated in most blood pressure
older adults. C regimen does not
cause any harm in
octogenarians. Not
sure this is in the right
place.
13.10 Treatment of other No change New review in Lancet https://doi.org/10.10
cardiovascular risk factors shows that statins 16/S0140-
should be individualized have benefits in 6736(20)32332-1
in older adults people over 75.
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
13.11 Optimal nutrition No change We wanted to expand
and protein intake is this section of the
recommended for older Chapter.
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
13.12 For older adults No change https://doi.org/10.11
with type 2 diabetes, 11/jgs.16672
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
13.13 In older adults with No change Lots of new https://doi.org/10.10
type 2 diabetes at references about the 01/jamainternmed.20
increased risk of comparative efficacy 20.9176
hypoglycemia, medication and safety of
classes with low risk of alternative drugs. https://doi.org/10.11
hypoglycemia are 11/dom.14261
preferred. B
https://doi.org/10.23
37/dc20-1464

https://doi.org/10.10
16/j.diabres.2021.108
737

13.14 Overtreatment of No change

diabetes is common in
older adults and should
be avoided. B
13.15 Deintensification No change
(or simplification) of
complex regimens is
recommended to reduce
the risk of hypoglycemia
and polypharmacy, if it
can be achieved within
the individualized A1C
target. B
13.16 Consider costs of No change
care and insurance
coverage rules when
developing treatment
plans in order to reduce
risk of cost-related
nonadherence. B
Treatment in Skilled Nursing Facilities and Nursing Homes

13.17 Consider diabetes No change

education for the staff of
long-term care and
rehabilitation facilities to
improve the management
of older adults with
diabetes. E

13.18 Patients with No change

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

End-of-life care
13.19 When palliative No change
care is needed in older
adults with diabetes,
providers should initiate
conversations regarding
the goals and intensity of
care. Strict glucose and
blood pressure control
may not be necessary E,
and reduction of therapy
may be appropriate.
Similarly, the intensity of
lipid management can be
relaxed, and withdrawal
of lipid-lowering therapy
may be appropriate. A
13.20 Overall comfort, No change
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
Diabetes Self-management Education and Support
14.1 Youth with type 1 No Change
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 No Change
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 14.3 Monitoring
carbohydrate intake, carbohydrate intake,
whether by carbohydrate whether by
counting or experience- carbohydrate
based estimation, is key to counting or
achieving optimal glycemic experience-based
control. B estimation, is a key
component to
optimizing glycemic
management. B

14.4 Comprehensive No Change

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 Exercise is 14.5 Physical activity
recommended for all is recommended for
children and adolescents all youth with type 1
with type 1 diabetes with diabetes with the goal
the goal of 60 min of of 60 min of
moderate- to vigorous- moderate- to
intensity aerobic activity vigorous-intensity
daily, with vigorous aerobic activity daily,
muscle-strengthening and with vigorous muscle-
bone-strengthening strengthening and
activities at least 3 days bone-strengthening
per week. C activities at least 3
days per week. C
14.6 Frequent glucose Frequent glucose More children are using Moser, O et al.
monitoring before, during, monitoring before, sensors non- Glucose management
and after exercise, with or during, and after adjunctively to manage for exercise using
without use of continuous exercise, via blood pre-exercise glucose continuous glucose
glucose monitoring, is glucose meter or levels. The ADA (along monitoring (CGM) and
important to prevent, continuous glucose with EASD and ISPAD) intermittently scanned
detect, and treat monitoring, is released a consensus CGM (isCGM) systems
hypoglycemia and important to prevent, statement in October in type 1 diabetes:
hyperglycemia with detect, and treat 2020. We should be position statement of
exercise. C hypoglycemia and consistent with the the European
hyperglycemia guidelines. Association for the
associated with Study of Diabetes
exercise. C (EASD) and of the
International Society
for Pediatric and
Adolescent Diabetes
(ISPAD) endorsed by
JDRF and supported by
the American Diabetes
Association (ADA).
Diabetologia 63, 2501-
2520.
14.7 Education about
frequent patterns of
glycemia during and after
exercise, which may
include initial transient
hyperglycemia followed by
hypoglycemia, is essential.
Families should also
receive education on
prevention and
management of
hypoglycemia during and
after exercise, including
ensuring patients have a
preexercise glucose level
of 90–250 mg/dL (5.0–
13.9 mmol/L) and
accessible carbohydrates
before, during, and after
engaging in activity,
individualized according to
the type/intensity of the
planned physical activity. E
14.7 Patients should be
educated on strategies to
prevent hypoglycemia
during exercise, after
exercise, and overnight
following 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. C
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
Youth and their
parents/care-
givers should be
educated on
strategies to prevent
hypoglycemia during,
after, and over-
night 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 Issues
14.9 At diagnosis and No Change
during routine follow-up
care, assess psychosocial
issues and family stresses
that could impact diabetes
management and provide
appropriate referrals to
trained mental health
professionals, preferably
experienced in childhood
diabetes. E
14.10 Mental health No Change
professionals should be
considered integral
members of the pediatric
diabetes multidisciplinary
team. E
14.11 Encourage No Change
developmentally
appropriate family
involvement in diabetes
management tasks for
children and adolescents,
recognizing that
premature transfer of
diabetes care to the child
can result in diabetes
burnout, nonadherence
and deterioration in
glycemic control. A
14.12 Providers should No Change
assess food security,
housing
stability/homelessness,
health literacy, financial
barriers, and
social/community support
and apply that information
to treatment decisions. E
14.13 Providers should No Change
consider asking youth and
their parents about social
adjustment (peer
relationships) and school
performance to determine
whether further
intervention is needed. B
14.14 Assess youth with No Change
diabetes for psychosocial
and diabetes-related
distress, generally starting
at 7–8 years of age. B
14.15 Offer adolescents No Change
time by themselves with
their care provider(s)
starting at age 12 years, or
when developmentally
appropriate. E
14.16 Starting at puberty, No Change
preconception counseling
should be incorporated
into routine diabetes care
for all girls of childbearing
potential. A
14.17 Begin screening No Change
youth with type 1 diabetes
for eating disorders
between 10 and 12 years
of age. The Diabetes
Eating Problems Survey-
Revised (DEPS-R) is a
reliable, valid, and brief
screening tool for
identifying disturbed
eating behavior. B

Glycemic Monitoring, Insulin Delivery, and Targets

Whenever possible,
children and adolescents
with type 1 diabetes
should be treated with
intensive insulin regimens,
either via multiple daily
injections or continuous
subcutaneous insulin
infusion. A
Concept incorporated Bergenstal, RM et al. A
below comparison of two
hybrid closed-loop
systems in adolescents
and young adults with
type 1 diabetes (FLAIR):
a multicentre,
randomized, crossover
trial. Lancet 2021 Jan
16;397(10270):208-
219.

14.18 All children and
adolescents with type 1
diabetes should monitor
glucose levels multiple
times daily (up to 6–10
times/day by glucose
meter or continuous
glucose monitoring),
including prior to meals
and snacks, at bedtime,
and as needed for safety
in specific situations such
as exercise, driving, or the
presence of symptoms of
hypoglycemia. B
When used properly, real-
time continuous glucose
monitoring (RT CGM) in
conjunction with insulin
therapy is a useful tool to
lower and/or maintain
A1C levels and/or reduce
hypoglycemia. A
When used properly,
intermittently scanned
continuous glucose
monitoring in conjunction
with insulin therapy can
be useful to replace self-
monitoring of blood
glucose. B
14.20 Automated insulin
delivery systems may be
considered to improve
glycemic control. A
Breton et al. A
Randomized Trial of
Closed-Loop Control in
Children with Type 1
Diabetes. NEJM 2020
Aug 27;383(9):836-845.
No Change
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 patient
circumstances,
desires, and needs.
Automated insulin Bergenstal, RM et al. A
delivery systems comparison of two
should be offered for hybrid closed-loop
diabetes management systems in adolescents
and young adults with
 to youth with type 1 type 1 diabetes (FLAIR):
diabetes who are a multicentre,
capable of using the randomized, crossover
device safely (either trial. Lancet 2021 Jan
by themselves or 16;397(10270):208-
with caregivers). The 219.
choice of device
should be made Breton et al. A
based on patient Randomized Trial of
circumstances, Closed-Loop Control in
desires, and needs. A Children with Type 1
Diabetes. NEJM 2020
Aug 27;383(9):836-845.
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 care-givers).
The choice of device
should be made
based on patient
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 No Change
individualized and
reassessed over time. An
A1C of <7% (53
mmol/mol) is appropriate
for many children. B
14.24 Less-stringent A1C No Change
goals (such as <7.5% [58
mmol/mol]) may be
appropriate for patients
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 No Change
A1C goals (such as <8% [64
mmol/mol]) may be
appropriate for patients
with a history of severe
hypoglycemia, limited life
expectancy, or where the
harms of treatment are
greater than the benefits.
B
14.26 Providers may No Change
reasonably suggest more-
stringent A1C goals (such
as <6.5% [48 mmol/mol])
for selected individual
patients 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 Continuous glucose POC A1C study, home
monitoring (CGM) metrics monitoring metrics A1C kits, and GMI—
derived from CGM use derived from continu- looking at correlation—
over the most recent 14
days (or longer for
patients with more
glycemic variability),
including time in ranges
(within target, below
target, and above target)
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
glycemic control has been
established. If normal,
suggest rechecking every
1–2 years or sooner if the
patient has positive
thyroid antibodies or
develops symptoms or
signs suggestive of thyroid
dysfunction, thyromegaly,
an abnormal growth rate,
ous glucose monitor Priya will consider
use over the most adding this study
recent 14 days (or We would also want to
longer for patients add this ref to Glycemic
with more glycemic Targets, section 6
variability), including
time in range (70–180
mg/dL), time below
target (<70 and
<54 mg/dL), and time
above target (>180
mg/dL)], are rec-
ommended to be
used in conjunction
with A1C whenever
possible. E
No change
No Change
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 patient
has positive thyroid
antibodies or
develops symptoms
or signs suggestive of
thyroid dysfunction,
or unexplained glycemic thyromegaly, an
variability. B abnormal growth
rate, or unexplained
glycemic variability. B
Celiac Disease
14.31Screen children with 14.Screen children
type 1 diabetes for celiac with type 1 diabetes
disease by measuring IgA for celiac disease by
tissue transglutaminase measuring IgA tissue
(tTG) antibodies, with transglutaminase
documentation of normal (tTG) antibodies, with
total serum IgA levels, documentation of
soon after the diagnosis of normal total serum
diabetes, or IgG to tTG and IgA levels, soon after
deamidated gliadin the diagnosis of
antibodies if IgA diabetes, or IgG tTG
deficient. B and deamidated
gliadin antibodies if
IgA deficient. B
14.32 Repeat screening No change
within 2 years of diabetes
diagnosis and then again
after 5 years and consider
more frequent screening
in children who have
symptoms or a first-
degree relative with celiac
disease. B
14.33 Individuals with No Change
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

Management of Cardiovascular Risk Factors

Hypertension: Screening
14.34 Blood pressure Blood pressure should Make 1. Flynn JT, Clinical
should be measured at be measured at every recommendations Practice Guideline for
each routine visit. Children routine visit. In youth consistent with the AAP Screening and
found to have elevated with high blood guidelines. Management of High
blood pressure (systolic pressure (blood Blood Pressure in
blood pressure or diastolic
blood pressure ≥90th
percentile for age, sex,
and height or, in
adolescents ≥13 years,
systolic blood pressure
120–129 mmHg with
diastolic blood pressure
<80 mmHg) or
hypertension (systolic
blood pressure or diastolic
blood pressure ≥95th
percentile for age, sex,
and height or, in
adolescents ≥13 years,
systolic blood pressure
≥130 mmHg or diastolic
blood pressure ≥80
mmHg) should have
elevated blood pressure
confirmed on three
separate days. B
Hypertension: Treatment
14.35 Initial treatment of
elevated blood pressure
(systolic blood pressure or
diastolic blood pressure
consistently ≥90th
percentile for age, sex,
and height or ≥120/80
mmHg in adolescents ≥13
years) includes dietary
modification and
increased exercise, if
appropriate, aimed at
weight control. If target
blood pressure is not
reached within 3–6
months of initiating
lifestyle intervention,
pharmacologic treatment
should be considered. E
pressure ≥90th Children and
percentile for age, Adolescents. Pediatrics.
sex, and height or, in 2017 Sep;140(3). PMID
adolescents aged ≥13 28827377
years, blood pressure
≥120/80 mmHg) on 2. Whelton PK,
three separate Circulation. 2018 Oct
measurements, 23;138(17):e426-e483.
ambulatory blood PMID: 30354655.
pressure monitoring
should be strongly
considered. B
13.Treatment of Flynn JT, Clinical
elevated blood Practice Guideline for
pressure (defined as Screening and
90th to <95th Management of High
percentile for age, Blood Pressure in
sex, and height or, in Children and
adolescents >/=13 Adolescents. Pediatrics.
years, 120-129/<80 2017 Sep;140(3). PMID
mmHg)is lifestyle 28827377
modification focused
on healthy nutrition,
physical activity,
sleep, and, if
appropriate, weight
management. C
14.36 In addition to
lifestyle modification,
pharmacologic treatment
of hypertension (systolic
blood pressure or diastolic
blood pressure
consistently ≥95th
percentile for age, sex,
and height or ≥140/90
mmHg in adolescents ≥13
years) should be
considered as soon as
hypertension is
confirmed. E
ACE inhibitors or
angiotensin receptor
blockers should be
considered for the initial
pharmacologic treatment
of hypertension E in
children and adolescents,
following reproductive
counseling due to the
potential teratogenic
effects of both drug
classes. E
14.37 The goal of
treatment is blood
pressure consistently
<90th percentile for age,
sex, and height or
<120/<80 mmHg in
children ≥13 years. E
In addition to lifestyle Flynn JT, Clinical
modification, ACE Practice Guideline for
inhibitors or Screening and
angiotensin receptor Management of High
blockers should be Blood Pressure in
started for treatment Children and
of confirmed Adolescents. Pediatrics.
hypertension (defined 2017 Sep;140(3). PMID
as blood pressure 28827377
consistently ≥95th
percentile for age,
sex, and height or, in
adolescents ≥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
(Deleted as combined
above.)
14.38 The goal of Flynn JT, Clinical
treatment is blood Practice Guideline for
pressure <90th Screening and
percentile for age, Management of High
sex, and height or, in Blood Pressure in
adolescents ≥13 Children and
years, <130/80 mmHg Adolescents. Pediatrics.
.C 2017 Sep;140(3). PMID
28827377

Dyslipidemia: Screening
14.38 Initial lipid testing
should be performed
when initial glycemic
control has been achieved
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
Dislipidemia: Treatment
14.40 If lipids are
abnormal, initial therapy
should consist of
optimizing glucose control
and medical nutrition
therapy to limit the
amount of calories from
fat to 25–30%, saturated
fat to <7%, cholesterol
<200 mg/day, avoidance
of trans fats, and aim for
The goal of treatment
is blood pressure
<90th percentile for
age, sex, and height
or, in adolescents ≥13
years, <130/80
mmHg. C
14.39 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.
If LDL cholesterol
value is within the
accepted risk level
(<100 mg/dL [2.6
mmol/L]), a lipid
profile repeated every
3 years is
reasonable. E
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%, saturated fat
to <7%, cholesterol
<200 mg/day,
avoidance
∼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,
following reproductive
counseling for females
because of the potential
teratogenic effects of
statins. E
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
of trans fats, and aim
for ∼10% calories
from
monounsaturated
fats. A
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,
following
reproductive
counseling. E Due to
the potential terato-
genic effects, females
should receive
reproductive
counseling and statins
should be avoided
in females of
childbearing age who
are not using reliable
contraception. B
No Change
No Change
14.44 E-cigarette use Electronic cigarette use should be discouraged. A
should be discouraged. A
Microvascular Complications
Nephropathy: Screening
14.45 Annual screening for No change
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
Nephropathy: Treatment
14.46 An ACE inhibitor or An ACE inhibitor or an
an angiotensin receptor angiotensin receptor
blocker, titrated to blocker, titrated to
normalization of albumin normalization of
excretion, may be albumin excretion,
considered when elevated may be considered
urinary albumin-to- when elevated urinary
creatinine ratio (>30 mg/g) albumin-to-creatinine
is documented (two of ratio (>30 mg/g) is
three urine samples documented (two of
obtained over a 6-month three urine samples
interval following efforts obtained over a 6-
to improve glycemic month interval
control and normalize following efforts to
blood pressure). E 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 glycemic control
with A1C <8%. B
Neuropathy
No Change
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
New recommendation
14.49 Programs that
use non-dilated
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
14.50 Consider an annual No Change
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. B

Type 2 Diabetes
Screening and Diagnosis
14.51 Risk-based No Change
screening for prediabetes
and/or type 2 diabetes
should be considered in
children and adolescents
after the onset of puberty
or ≥10 years of age,
whichever occurs earlier,
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 tests are normal, 14.52 If screening is .
repeat testing at a normal, repeat
minimum of 3-year screening at a
intervals E, or more minimum of 3-year
frequently if BMI is intervals E, or more
increasing. C frequently if BMI is
increasing. C

14.53 Fasting plasma No Change

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 No Change
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 No Change
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 No Change
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
7–10% decrease in excess
weight. C
14.57 Given the necessity No Change
of long-term weight
management for children
and adolescents 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 No Change
prediabetes and type 2
diabetes, like all children
and adolescents, should
be encouraged to
participate in at least 60
minutes 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 No Change
with prediabetes and type
2 diabetes, like for all
children, 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 Monitoring and Targets
14.60 Home self- 14.60 Blood glucose
monitoring of blood monitoring should be
glucose regimens should individualized, taking
be individualized, taking into consideration the
into consideration the pharmacologic
pharmacologic treatment treatment of the
of the patient. E patient. E

New recommendation
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 No Change
should be assessed every
3 months. E
14.63 A reasonable A1C No Change .
target for most children
and adolescents with type
2 diabetes treated with
oral agents alone 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 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 No Change
goals (such as 7.5% [58
mmol/mol]) may be
appropriate if there is
increased risk of
hypoglycemia. E
14.65 A1C targets for No Change
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 No Change
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 No Change
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 No Change
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 No Change
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 No Change
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 No Change
are no longer met with
metformin (with or
without basal insulin),
liraglutide (a glucagon-like
peptide 1 receptor
agonist) therapy 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 No Change
with basal insulin who
do not meet glycemic
target should be moved to
multiple daily injections
with basal
and premeal bolus
insulins. E
14.73 In patients initially 14.72 In patients
treated with insulin and initially treated with
metformin who are insulin and metformin
meeting glucose targets who are meeting
based on home blood glucose targets based
glucose monitoring, insulin on blood glucose
can be tapered over 2–6 monitoring, insulin
weeks by decreasing the can be tapered over
insulin dose 10–30% every 2–6 weeks by
few days. B decreasing the insulin
dose 10–30% every
few days. B

14.74 Use of medications No Change

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 No Change
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 No Change
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
Prevention and Management of Diabetes Complications
Nephropathy
14.77 Blood pressure Blood pressure should
should be measured at be measured at every
every visit. A visit. In youth with
high blood pressure
(blood pressure ≥90th
percentile for age,
sex, and height or, in
adolescents ≥13
years, >120/80
mmHg) on three
separate
measurements,
ambulatory blood
pressure monitoring
should be strongly
considered. B

Blood pressure should be Deleted and moved Position Statement by

optimized to reduce risk concept to text
and/or slow the
progression of diabetic
kidney disease. A
14.78 If blood pressure is
≥90th percentile for age,
sex, and height or, in
adolescents ≥13 years,
blood pressure is ≥120/80
mmHg, increased
emphasis should be placed
on lifestyle management
to promote weight loss. If
blood pressure remains
above the 90th percentile
or, in adolescents ≥13
years, blood pressure is
≥120/80 after 6 months,
antihypertensive therapy
should be initiated. C
14.79 In addition to
lifestyle modification,
pharmacologic treatment
of hypertension (systolic
blood pressure or diastolic
blood pressure
consistently ≥95th
percentile for age, sex,
and height or ≥140/90
mmHg in adolescents ≥13
years) should be
considered as soon as
hypertension is
confirmed. E
Initial therapeutic options
include ACE inhibitors or
angiotensin receptor
14.78 Treatment of Changed to match the 1. Flynn JT, Clinical
elevated blood AAP guidelines Practice Guideline for
pressure (defined as Screening and
90th to <95th Management of High
percentile for age, Blood Pressure in
sex, and height or, in Children and
adolescents >/=13 Adolescents. Pediatrics.
years, 120-129/<80 2017 Sep;140(3). PMID
mmHg) is lifestyle 28827377
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 ≥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
Deleted as combined
with other recs
blockers. Other blood
pressure–lowering agents
may be added as
needed. C
14.80 The goal of
treatment is blood
pressure <90th
percentile for age,
sex, and height or, in
adolescents ≥13
years, <130/80
mmHg. C

14.81 Protein intake No Change

should be at the
recommended daily
allowance of 0.8
g/kg/day. E
14.82 Urine albumin-to- No Change
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 No Change
glomerular filtration rate
should be determined at
the time of diagnosis and
annually thereafter. E
14.84 In nonpregnant In patients with
patients with diabetes and diabetes and
hypertension, either an hypertension, either
ACE inhibitor or an an ACE inhibitor or an
angiotensin receptor angiotensin receptor
blocker is recommended blocker is
for those with modestly recommended
elevated urinary albumin- for those with
to-creatinine ratio (30– modestly elevated
299 mg/g creatinine) and urinary albumin-to-
is strongly recommended creatinine ratio (30–
for those with urinary 299 mg/g creatinine)
albumin-to-creatinine and is strongly
ratio >300 mg/g creatinine recommended for
and/or estimated those with urinary
glomerular filtration rate albumin-to-creatinine
<60 mL/min/1.73 m2. E 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 No Change
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 No Change Position Statement by
nephrology is the ADA – Diabetes
recommended in case of Care 2018; 41:2648-68.
uncertainty of etiology,
worsening urinary
albumin-to-creatinine
ratio, or decrease in
estimated glomerular
filtration rate. E
Neuropathy
14.87 Youth with type 2 No Change
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
Retinopathy
14.89 Screening for
retinopathy should be
performed by dilated
fundoscopy or retinal
photography 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 there is adequate
glycemic control and a
normal eye exam. C
No Change
14.89 Screening for
retinopathy should be
performed by dilated
fundoscopy at or soon
after diagnosis and
annually thereafter. C
No Change
14.91 Less frequent
examination (every 2
years) may be
considered if
achieving glycemic
control targets and a
normal eye exam. C
New recommendation
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 No Change
nonalcoholic fatty liver
disease (by measuring AST
and ALT) should be done
at diagnosis and annually
thereafter. B
14.94 Referral to No Change
gastroenterology should
be considered for
persistently elevated or
worsening
transaminases. B
Obstructive Sleep Apnea
14.95 Screening for No Change
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 No Change
polycystic ovary syndrome
in female adolescents with
type 2 diabetes, including
laboratory studies when
indicated. B
14.97 Oral contraceptive No Change
pills for treatment of
polycystic ovary syndrome
are not contraindicated
for girls with type 2
diabetes. C
14.98 Metformin in No Change
addition to lifestyle
modification is likely to
improve the menstrual
cyclicity and
hyperandrogenism in girls
with type 2 diabetes. E
CVD
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 testing should
be performed when initial
glycemic control has been
achieved 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%, saturated
fat to <7%, cholesterol
<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
No Change
Lipid screening should
be performed initially
after optimizing
glycemia and annually
thereafter. B
No Change
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 No change
remains >130 mg/dL after
6 months of dietary
intervention, initiate
therapy with statin, with a
goal of LDL <100 mg/dL,
following reproductive
counseling for females
because of the potential
teratogenic effects of
statins. B
14.104 If triglycerides are No Change
>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 No Change
for heart disease with
electrocardiogram,
echocardiogram, or stress
testing is not
recommended in
asymptomatic youth with
type 2 diabetes. B
Psychosocial Factors
14.106 Providers should No Change
assess food security,
housing
stability/homelessness,
health literacy, financial
barriers, and
social/community support
and apply that information
to treatment decisions. E
14.107 Use patient- No Change
appropriate standardized
and validated tools to
assess for diabetes
distress and
mental/behavioral health
in youth with type 2
diabetes, with attention to
symptoms of depression
and eating disorders, and
refer to specialty care
when indicated. B
14.108 When choosing No Change
glucose-lowering or other
medications for youth
with overweight or obesity
and type 2 diabetes,
consider medication-
taking behavior and their
effect on weight. E
14.109 Starting at puberty, No Change
preconception counseling
should be incorporated
into routine diabetes clinic
visits for all females of
childbearing potential
because of the adverse
pregnancy outcomes in
this population. A
14.110 Patients 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 No Change Kapellen et al.
providers should begin to Transition to adult
prepare youth for diabetes care in
transition to adult health Germany—High risk for
care in early adolescence acute complications
and, at the latest, at least and declining
1 year before the metabolic control
transition. E during the transition
phase. Pediatric
Diabetes.
2018;19:1094–1099.
14.112 Both pediatric and
adult diabetes care
providers should provide
support and resources for
transitioning young
adults. E
14.113 Youth with type 2 No Change
diabetes should be
transferred to an adult-
oriented diabetes
specialist when deemed
appropriate by the patient
and provider. E
No Change
Type 2 diabetes:
Agarwal et al. Transfer
from paediatric to
adult care for young
adults with Type 2
diabetes: the SEARCH
for Diabetes in Youth
Study. Diabet. Med.
35, 504–512 (2018)
Management of Diabetes in Pregnancy
Preconception Counseling
15.1 Starting at puberty No change
and continuing in all
women with diabetes and
reproductive potential,
preconception counseling
should be incorporated
into routine diabetes
care. A
15.2 Family planning No change
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 Change level of A systematic review Wahabi HA, Fayed A,
counseling should address evidence A and meta-analysis of Esmaeil S, Elmorshedy
the importance of observational studies H, Titi MA, Amer YS,
achieving glucose levels as of preconception care Alzeidan RA,
close to normal as is safely Add supporting for women with Alodhayani AA, Saeed
possible, ideally A1C sentence and reference preexisting diabetes E, Bahkali KH, Kahili-
<6.5% (48 mmol/mol), to Wahabi etal after demonstrated lower Heede MK, Jamal A,
reduce the risk of reference 7 in text. HbA1c and reduced Sabr Y. Systematic
congenital anomalies, risk of birth defects, review and meta-
preeclampsia, preterm delivery, analysis of the
macrosomia, and other perinatal mortality, effectiveness of pre-
complications. B small for gestational pregnancy care for
age and neonatal women with diabetes
intensive care unit for improving maternal
admission. and perinatal
outcomes. PLoS One.
2020 Aug
18;15(8):e0237571.
doi:
10.1371/journal.pone.0
237571. PMID:
32810195; PMCID:
PMC7433888.
Preconception Care
15.4 Women with No change
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 No change
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 No change
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 No change
postprandial self-
monitoring of blood
glucose 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 women
with preexisting diabetes
should also test blood
glucose preprandially. B
15.8 Due to increased red No change
blood cell turnover, A1C is
slightly lower in normal
pregnancy than in normal
nonpregnant women.
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 No change
addition to pre- and
postprandial self-
monitoring of blood
glucose, continuous
glucose monitoring can
help to achieve A1C
targets in diabetes and
pregnancy. B
15.10 When used in No change
addition to self-monitoring
of blood glucose targeting
traditional pre- and
postprandial targets,
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 as an adjunct but
should not be used as a
substitute for self-
monitoring of blood
glucose 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
Management of Gestational Diabetes Mellitus
15.13 Lifestyle behavior No change Hernandez TL, Mande
change is an essential A, Barbour LA.
component of Nutrition therapy
management of within and beyond
gestational diabetes gestational diabetes.
mellitus and may suffice Diabetes Res Clin Pract.
for the treatment of many 2018 Nov;145:39-50.
women. Insulin should be doi:
added if needed to 10.1016/j.diabres.2018
achieve glycemic .04.004. Epub 2018 Apr
targets. A 19. PMID: 29679625;
PMCID: PMC6195478.
Hernandez TL, Van Pelt
RE, Anderson MA,
Daniels LJ, West NA,
Donahoo WT,
Friedman JE, Barbour
LA. A higher-complex
carbohydrate diet in
gestational diabetes
mellitus achieves
glucose targets and
lowers postprandial
lipids: a randomized
crossover study.
Diabetes Care.
2014;37(5):1254-62.
doi: 10.2337/dc13-

15.14 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.
2411. Epub 2014 Mar
4. PMID: 24595632;
PMCID: PMC3994935.
Laredo-Aguilera JA,
Gallardo-Bravo M,
Rabanales-Sotos JA,
Cobo-Cuenca AI,
Carmona-Torres JM.
Physical Activity
Programs during
Pregnancy Are Effective
for the Control of
Gestational Diabetes
Mellitus. Int J Environ
Res Public Health. 2020
Aug 24;17(17):6151.
doi:
10.3390/ijerph1717615
1. PMID: 32847106;
PMCID: PMC7503359.
No change Systematic review and Tarry-Adkins JL, Aiken
meta-analysis Tarry- CE, Ozanne SE.
Adkins confirms Comparative impact of
glyburide treatment pharmacological
finding of treatments for
macrosomia, does not gestational diabetes on
evaluate neonatal neonatal
hypoglycemia, anthropometry
addsneonatal independent of
anthropometric maternal glycaemic
measurements. AC is control: A systematic
increase with review and meta-
glyburide. Continue analysis. PLoS Med.
Basalls reference. Add 2020 May
Tarry-Adkins 2020 22;17(5):e1003126.
doi:
10.1371/journal.pmed.
1003126. PMID:
32442232; PMCID:
PMC7244100.
Reference 76Feig DS,
Donovan LE, Zinman B,
Sanchez JJ, Asztalos E,
Ryan EA, Fantus IG,
Hutton E, Armson AB,
Lipscombe LL, Simmons
D, Barrett JFR,
 Karanicolas PJ, Tobin S,
McIntyre HD, Tian SY,
Tomlinson G, Murphy
KE; MiTy Collaborative
Group. Metformin in
women with type 2
diabetes in pregnancy
(MiTy): a multicentre,
international,
randomised, placebo-
controlled trial. Lancet
Diabetes Endocrinol.
2020 Oct;8(10):834-
844. doi:
10.1016/S2213-
8587(20)30310-7.
Erratum in: Lancet
Diabetes Endocrinol.
2020 Nov;8(11):e6.
PMID: 32946820.

15.15 Metformin, when Griffith RJ, Alsweiler J,

used to treat polycystic Moore AE, Brown S,
ovary syndrome and Middleton P, Shepherd
induce ovulation, should E, Crowther CA.
be discontinued by the Interventions to
end of the first prevent women from
trimester. A developing gestational
diabetes mellitus: an
overview of Cochrane
Reviews. Cochrane
Database Syst Rev.
2020 Jun
11;6(6):CD012394. doi:
10.1002/14651858.CD0
12394.pub3. PMID:
32526091; PMCID:
PMC7388385.
Doi SAR, Furuya-
Kanamori L, Toft E,
Musa OAH, Islam N,
Clark J, Thalib L.
Metformin in
pregnancy to avert
gestational diabetes in
women at high risk:
Meta-analysis of
randomized controlled
 trials. Obes Rev. 2020
Jan;21(1):e12964. doi:
10.1111/obr.12964.
Epub 2019 Oct 31.
PMID: 31667980.

New recommendation Xie W, Dai P, Qin Y, Wu

15.16 Telehealth visits M, Yang B, Yu X.
for pregnant women Effectiveness of
with gestational telemedicine for
diabetes mellitus pregnant women with
improve outcomes gestational diabetes
compared with mellitus: an updated
standard in-person meta-analysis of 32
care. A randomized controlled
trials with trial
sequential analysis.
BMC Pregnancy
Childbirth. 2020 Apr
6;20(1):198. doi:
10.1186/s12884-020-
02892-1. PMID:
32252676; PMCID:
PMC7137255.
Management of Preexisting Type 1 Diabetes and Type 2 Diabetes in Pregnancy
Insulin Use
15.17 Insulin should be Change 2nd part of New RCT (MiTy)with Feig DS, Donovan LE,
used for management of recommendation 14.16 positive and negative Zinman B, Sanchez JJ,
type 1 diabetes in from E to B. findings. I prioritize Asztalos E, Ryan EA,
pregnancy. A Insulin is the Insulin should be used the doubling of SGA Fantus IG, Hutton E,
preferred agent for the for management of risk as the biggest Armson AB, Lipscombe
management of type 2 type 1 diabetes in concern and this LL, Simmons D, Barrett
diabetes in pregnancy.E pregnancy. A Insulin is overrides benefits in JFR, Karanicolas PJ,
the preferred agent for reduction in cesarean Tobin S, McIntyre HD,
the management of delivery and Tian SY, Tomlinson G,
type 2 diabetes in macrosomia. In Murphy KE; MiTy
pregnancy. B addition, we know for Collaborative Group.
numerous other Metformin in women
studies that increased with type 2 diabetes in
adiposity and catch up pregnancy (MiTy): a
growth in children multicentre,
exposed to metformin international,
in pregnancy is a randomised, placebo-
major concern. controlled trial. Lancet
I think we can upgrade Diabetes Endocrinol.
recommendation 14.6 2020 Oct;8(10):834-
to at least a level B. 844. doi:
Not sure that we can 10.1016/S2213-
 say A because of the + 8587(20)30310-7.
and – of this study. Erratum in: Lancet
Diabetes Endocrinol.
2020 Nov;8(11):e6.
PMID: 32946820.

15.18 Either multiple daily No change

injections or insulin pump
technology can be used in
pregnancy complicated by
type 1 diabetes. C
Preeclampsia and Aspirin
15.19 Women with type 1 No change
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;
currently in the U.S., low-
dose aspirin is available in
81-mg tablets. E
Pregnancy and Drug Considerations
15.20 In pregnant patients No change
with diabetes and chronic
hypertension, a blood
pressure target of 110–
135/85 mmHg is
suggested in the interest
of reducing the risk for
accelerated maternal
hypertension A and
minimizing impaired fetal
growth. E
15.21 Potentially harmful No change
medications in pregnancy
(i.e., ACE inhibitors,
angiotensin receptor
blockers, statins) should
be stopped at conception
and avoided in sexually
active women of
childbearing age who are
not using reliable
contraception. B
Postpartum care
15.22 Insulin resistance No change
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
15.23 A contraceptive plan No change
should be discussed and
implemented with all
women with diabetes of
reproductive potential. A
15.24 Screen women with No change
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
15.25 Women with a No change
history of gestational
diabetes mellitus found to
have prediabetes should
receive intensive lifestyle
interventions and/or
metformin to prevent
diabetes. A
15.26 Women with a No change
history of gestational
diabetes mellitus should
have lifelong screening for
the development of type 2
diabetes or prediabetes
every 1–3 years. B
15.27 Women with a No change
history of gestational
diabetes mellitus should
seek preconception
screening for diabetes and
preconception care to
identify and treat
hyperglycemia and
prevent congenital
malformations. E
15.28 Postpartum care No change
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 No Change
on all patients 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
Physician Order Entry
16.2 Insulin should be No Change
administered using
validated written or
computerized protocols
that allow for predefined
adjustments in the insulin
dosage based on glycemic
fluctuations. B
Diabetes Care Providers in the Hospital
16.3 When caring for No Change
hospitalized patients with
diabetes, consult with a
specialized diabetes or
glucose management
team when possible. C
Glycemic Targets in Hospitalized Patients
16.4 Insulin therapy 16.4 Insulin therapy
should be initiated for should be initiated for
treatment of persistent treatment of persistent
hyperglycemia starting at hyperglycemia starting
a threshold ≥180 mg/dL at a threshold ≥180
(10.0 mmol/L). Once mg/dL (10.0 mmol/L)
insulin therapy is started, (checked on two
a target glucose range of occasions). Once
140–180 mg/dL (7.8–10.0 insulin therapy is
mmol/L) is recommended started, a target
for the majority of glucose range of 140–
critically ill patients and 180 mg/dL (7.8–10.0
noncritically ill patients. A mmol/L) is
recommended for the
majority of critically ill
patients and
noncritically ill
patients. A
16.5 More stringent goals, No Change
such as 110–140 mg/dL
(6.1–7.8 mmol/L), may be
appropriate for selected
patients if they can be
achieved without
significant
hypoglycemia. C
Glucose-lowering Treatment in Hosptalized Patients
16.6 Basal insulin or a No Change
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 No Change
with basal, prandial, and
correction components is
the preferred treatment
for noncritically ill
hospitalized patients with
good nutritional intake. A
16.8 Use of only a sliding No Change
scale insulin regimen in
the inpatient hospital
setting is strongly
discouraged. A

Hypoglycemia
16.9 A hypoglycemia 16.9 A hypoglycemia
management protocol management protocol
should be adopted and should be adopted and
implemented by each implemented by each
hospital or hospital hospital or hospital
system. A plan for system. A plan for
preventing and treating preventing and treating
hypoglycemia should be hypoglycemia should
established for each be established for each
patient. Episodes of patient. Episodes of
hypoglycemia in the hypoglycemia in the
hospital should be hospital should be
documented in the documented in the
medical record and medical record and
tracked. E tracked for quality
improvement/quality
assessment. E
16.10 The treatment 16.10 For individual
regimen should be patients, treatment
reviewed and changed as regimens should be
necessary to prevent reviewed and changed
further hypoglycemia as necessary to prevent
when a blood glucose further hypoglycemia
value of <70 mg/dL (3.9 when a blood glucose
mmol/L) is documented. C value of <70 mg/dL (3.9
mmol/L) is
documented. C
Transition from the Acute Care Setting
16.11 There should be a
structured discharge plan
tailored to the individual
patient with diabetes. B