Your Guide to the 2023 ADA Standards of Care
Your Guide to the 2023 ADA Standards of Care
In December, the American Diabetes Association (ADA) released its 2023 Standards of Care, which offer the ADA’s annual update on how healthcare providers should implement diabetes care and counsel individuals with all types of diabetes. Learn how these standards continue to evolve.
On December 12, the American Diabetes Association (ADA) released its 2023 Standards of Care in Diabetes. The ADA’s Professional Practice Committee (PPC) has updated these standards annually since 1989. To produce these updates, committee members and ADA staff search for and review new research, use their own expertise, and consult with subject matter experts. This year’s PPC represented a more diverse than ever group of diabetes experts, including clinicians, researchers, psychologists, and diabetes care and education specialists.
The Standards offer guidelines to healthcare providers, researchers, insurers, and people with diabetes and their loved ones on the optimal management of all types of diabetes and its complications. Having knowledge of optimal diabetes care could help people with diabetes and their loved ones advocate for and obtain the best possible care to live a healthy life.
To gain further details, view the standards online, the summary of revisions, an abridged version aimed at primary care providers, or the 30-minute highlights video by Robert Gabbay, MD, Chief Science and Medical Officer of ADA. Also be aware that through the year, ADA provides updates to the Standards as needed in ADA’s Living Standards, which are interim updates.
Due particularly to new research and treatments that have emerged over the last 20 years, diabetes management has evolved from being focused solely on glucose to placing much more importance on weight management, blood pressure, and blood lipids, as well as care of the cardiovascular system (heart and blood vessels) and protection of the body’s organs and systems that are typically affected by diabetes.
Revisions to the 2023 Standards range from major overarching themes to more minor changes, as detailed below.
- Diagnosis and prevention of diabetes
- Encourage the use of the more accessible point-of-care A1C testing to offer more rapid and available screening and diagnosis of diabetes rather than a lab-drawn A1C, which can delay diagnosis and discussion of treatment for months. With a quick A1C result in hand, a provider can discuss the A1C result in real time and use shared decision-making to discuss, if deemed necessary, a person’s next step in care. This recommendation came with the message to healthcare providers to be more aggressive about preventing type 2 diabetes and diagnosing pre-diabetes and early type 2 diabetes.
- Management of people with pre-diabetes and high risk for type 2 diabetes
- Emphasize the use of more intensive approaches in the care of people at high risk of developing diabetes. This includes people with a BMI ≥35, those with higher-than-normal glucose levels and A1C, as well as people with a history of gestational diabetes.
- Consider a multi-pronged approach to management that includes weight management, slowing disease progression, reducing cardiovascular risk factors, and using medications to adequately achieve and maintain management goals.
- In people who have had a stroke or have evidence of insulin resistance and prediabetes, consider prescribing the glucose-lowering medication pioglitazone. This medication can reduce the risk for stroke or heart attack as long as it can be taken without side effects.
- Raise caution that the use of statin medication to improve lipid levels may, as a side effect, increase the risk for type 2 diabetes. Providers are encouraged to regularly monitor glucose levels in those without diabetes but not discontinue the use of statin medication because of its cardiovascular benefits.
- Emphasis on weight management and obesity treatment
- Manage obesity as a chronic disease that is progressive and often associated with medical, physical, and psychosocial complications.
- Weight management—both weight loss and the maintenance of lost weight—is now considered just as important in prediabetes and diabetes management, as is glucose management.
- Documented in these standards with greater clarity is the impact of various levels of weight loss. It is noted that both smaller (~3-7%) and larger (>10%) weight loss provides improvements in glucose management. More significant weight loss (up to 15%) can lead to greater health benefits that include reduction in risk factors for cardiovascular or related problems, like strokes and heart attacks, as well as the possibility of reversing type 2 diabetes. Four different approaches to achieve and maintain weight management should be considered to support people with obesity, including: 1) healthy behavior and lifestyle changes, 2) intensive evidence-based structured weight management programs, 3) medications for weight loss, and 4) metabolic surgery.
- Greater weight loss (up to 15%) is more achievable today with newer medications that assist with weight loss and long-term management, including tirzepatide and semaglutide. These medications are listed in the ADA medication guidelines as having “very high efficacy” for both glucose and weight management.
- Reduction of cardiovascular risk factors and disease management
- This has become an increasingly important and encompassing area of diabetes management because of the high incidence of health problems and death due to cardiovascular disease in people at risk for and who have diabetes. In addition, there are medications that can help reduce risk factors and incidence of heart-related diseases.
- Greater emphasis is placed on reducing the risk of developing heart and kidney problems and protecting these organs from damage with specific recommendations. The recommendations focus on proper choice of medications, generally SGLT2 inhibitors or GLP-1 receptor agonists for people with atherosclerotic cardiovascular disease (ASCVD), and/or those with high risk for heart and kidney disease, heart failure, and chronic kidney disease. Today, more than ever before, there are medications that lower glucose levels and assist in the prevention or management of these other conditions.
- The Standards aligned the target for blood pressure to be in sync with other major organizations that set these guidelines. High blood pressure is now defined as a systolic blood pressure ≥130 mmHg or a diastolic blood pressure ≥80 mmHg (<130/80 mmHg).
- The target for LDL-cholesterol is <70 mg/dL in people ages 40-75 years with diabetes and risk factors for ASCVD and <55 mg/dL in people with diabetes and existing ASCVD. In addition, a LDL reduction of 50% or greater from the starting point LDL with a high intensity statin medication and then use of an additional medication, such as ezetimibe or a PCSK9, is recommended if the goal level is not attained. This underscores the importance of cardiovascular disease prevention and management.
- Reduction of chronic kidney disease risk factors and disease management
- With the use of SGLT2 inhibitors playing a role in protecting the health of kidneys, the levels of kidney function for which it is recommended were lowered.
- A newer medication, finerenone (a nonsteroidal mineralocorticoid receptor antagonist), is more widely recommended in this set of Standards to reduce the progression of chronic kidney disease and reduce cardiovascular events.
- In people with established kidney disease, more frequent monitoring of urinary albumin creatinine ratio (UACR) and estimated glomerular filtration rate (eGRF)—1 to 4 times per year—is recommended, based on disease severity.
- Criteria for referral to a nephrologist (a doctor specializing in kidneys) were broadened to include people with continuously rising levels of UACR and eGFR.
- Screening and management of nonalcoholic fatty liver disease (NAFLD)
- Prevalence of NAFLD is increasing among people with type 2 diabetes, but it is often not screened for or detected. Early screening and management can reduce disease risk and improve outcomes. The recommendation was made to encourage use of the FIB-4 test to screen individuals at high risk, including people with obesity, chronic kidney disease, and older age.
- Weight management is an important first step to managing NAFLD. The goal is to achieve at least 5% but preferably 10% weight loss. However, to significantly impact the progression of NAFLD, most people will need obesity management medications or weight loss surgery. In addition, the use of a GLP-1 receptor agonist and/or pioglitazone can further improve glucose management and lipid levels and reduce fat in the liver in people with pre-diabetes or type 2 diabetes.
- Neuropathy and amputation prevention, and screening for peripheral artery disease
- The Standards recommend increased focus on the prevention of amputations with an emphasis on screening for peripheral arterial disease (narrowing or blockage of the vessels that carry blood from the heart to the legs) as a means of detecting problems early.
- Initial screening for peripheral arterial disease should include a number of simple assessment tests and checks, including lower-extremity pulses, capillary refill time, venous filling time, and other checks of blood flow.
- As a preventive measure, a comprehensive foot evaluation should be done at least annually and at every visit in individuals with evidence of sensory loss, prior ulceration, or a prior amputation.
- Use and integration of diabetes technology into care
- A strong recommendation was made for offering the use of continuous glucose monitoring (CGM) in people with type 2 diabetes on basal-only insulin therapy (once-daily, long-acting insulin) in addition to people on all other types of insulin regimens. Of note is that Medicare is currently considering coverage of CGM for this population.
- People who use CGM should be made aware of and educated about interfering substances that can negatively impact sensor accuracy. A new table lists six interfering substances.
- The importance of considering a person’s preference for certain diabetes devices as well as assuring that they have access to uninterrupted supplies was stated.
- The relatively new FreeStyle Libre 3 CGM is now designated a real-time CGM option, whereas the FreeStyle Libre 1 and 2 are considered flash glucose monitoring, which requires intermittent scanning of the sensor. This real-time designation is important for reimbursement.
- The Standards recommend that, when hospitalized, people should be supported by their healthcare providers and others in the hospital setting to continue using their devices.
- Incorporation of psychosocial care into diabetes care
- The Standards more strongly promote the importance of mental well-being as part of diabetes care and access to mental health resources to support well-being.
- The use of psychosocial screening is advocated with referral to mental health providers or other trained healthcare providers when a person has symptoms of diabetes distress, depression, suicidality, anxiety, treatment-related fear of hypoglycemia, disordered eating, and/or diminished cognitive capacity.
- Achieving glucose targets
- Healthcare providers are encouraged to help people set goals for glycemic management during appointments as one means to achieve success.
- A more relaxed goal for glucose targets was recommended for people with frailty and high risk for hypoglycemia: >50% time in range and <1% time below range are recommended.
- Consider social determinants of health among one of the factors when choosing a glucose-lowering medication. Metformin is mentioned as an inexpensive medication that is both safe and effective.
- Screening for sleep problems and achieving sleep health
- People with diabetes and pre-diabetes should be screened for sleep disorders and be referred, if necessary, to a sleep specialist for management. Assessing sleep patterns and duration is considered by ADA as part of a comprehensive medical evaluation. Sleep disorders, including insomnia and obstructive sleep apnea, are risk factors for type 2 diabetes and are common in people with diabetes.
- Advocacy for team-based diabetes care
- An emphasis on the use of non-physician healthcare providers to provide care, counsel, and support to people at risk for and with diabetes is highlighted throughout the guidelines. As part of this guidance, there is a broader recognition of the important role social determinants of health have on a person’s ability to implement and continually execute their diabetes care plan.
- The Standards recommend that all people receive counseling in healthy lifestyle behaviors and diabetes self-management education and support (DSMES). These services must be provided in culturally appropriate ways based on race, ethnic/cultural background, sexual orientation, gender identity, technology access, education, literacy, and numeracy. Social determinants of health should guide the design and delivery of DSMES programs with the goal of achieving health equity across populations.
- It is suggested that wider delivery of DSMES may be provided through the use of telehealth and other modes of technology-enabled delivery.
- The Standards encourage the use of community health workers, who often serve as a workforce for outreach, advocacy, social support, health education, and more. Community health workers can support diabetes and cardiovascular risk factor management, especially in underserved communities and health care systems.
- Screening for food insecurity
- It is important that people are screened regularly for food insecurity. The Standards state that any member of the diabetes healthcare team can screen for food insecurity using a two-question screening tool.
- The ADA suggests addressing food insecurity by seeking out and integrating community resources into primary care (for example: medically tailored meals, fruit and vegetables prescriptions, etc.) as well as addressing food deserts in underserved communities.
The 2023 ADA Standards reinforce previous iterations of the Standards in emphasizing that the delivery of quality care to people at risk for or who have diabetes requires regular comprehensive assessment and referral to specialists and special exams when necessary. In addition, continuity of care and regular assessment of the current care plan—with changes as needed to achieve target goals and prevent or delay diabetes complications—is all essential.
Lastly, these 2023 Standards place particular emphasis on considering the individual, their well-being, and myriad factors that impact life and quality of life when providing comprehensive diabetes care and counsel.
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With so many things happening in the diabetes tech world, it can be hard to keep up. Stay up to date here with the latest diabetes tech news and alerts.
Type 2 diabetes, a condition marked by chronically high blood sugar levels, is a leading driver of metabolic disease in America. While conventional medical advice recommends taking medications to control blood sugar levels, this is only a temporary measure at best. ļ»æ Diabetes is compounded by several factors, and recent research notes that nutritional deficiencies is a commonly overlooked aspect, and that when these deficiencies are addressed, managing and controlling this disease becomes easier.
Telemedicine can make diabetes care less expensive and easier to access, but it may not always be a suitable replacement for an in-person visit. Learn what happens during a telehealth visit and see if you could benefit from using telemedicine for your diabetes care. The pandemic upended a lot about life as we knew it. Notably, it was responsible for a 63-fold increase in telehealth visits . For people managing diabetes, however, having a doctor visit over video brings up a host of questions and potential issues. How can a doctor properly check my eyes and feet through a computer screen? Will telehealth replace in-person discussions about my blood sugar? Will I get the same level of care through a computer? According to a 2022 article in American Family Physician , telehealth is promising for diabetes treatment and has been shown to help improve glucose management. In a separate analysis of glucose data from people with type 2 diabetes, people who received remote monitoring of their glucose levels saw significant improvements in A1C over a period of three months. That being said, no study or physician is implying that telehealth fully replaces in-person medical care for diabetes. Here’s what to consider and who might be the best candidates for telediabetes care. What happens during a diabetes telehealth visit? Telediabetes care involves two types of interactions. One is a video meeting with a physician or care team to discuss challenges and potential solutions. During this type of visit, the healthcare provider can see some physical signs or changes, such as rashes or wounds. The second type of interaction is virtual monitoring of glucose levels through a monitoring device that sends data to the care provider. The provider might also follow up with a video call to discuss the data. “Many of the things that are important for diabetes care – blood glucose data review, medication review, insulin teaching – can all happen over video,” said Dr. Varsha Vimalananda, an endocrinologist and associate professor of medicine at Boston University. “CGM data can be uploaded and reviewed remotely, which is also very helpful.” Different providers use different video platforms for telehealth appointments, but most will look and function much like a Zoom call. The benefits of telehealth in diabetes care Not all elements of diabetes care are best suited for telehealth, but many lend themselves naturally to the conversation and convenience that an electronic visit facilitates. For type 2 diabetes in particular, telehealth has been shown to be more effective than in-person care at helping people manage their condition. One reason for the improved outcomes is simply better access to care. Dr. Keta Pandit, an endocrinologist at Texas Diabetes & Endocrinology in Austin, Texas, says continuous glucose monitoring (CGM), along with telehealth options, have changed the landscape of diabetes care. “One of the benefits of being able to offer telemedicine to our patient population is that it has increased the access to care, especially with any ongoing illnesses, hospitalizations, COVID, post-COVID, or any other situations when patients notice their glucose levels are going out of their standard range. Patients often contact us for these types of situations, and we can quickly get them seen via telemedicine to make adjustments to their diabetes medications,” she says. “While this was still an option prior to telemedicine days, the opportunity to see their provider on short notice, not having to worry about transportation, and not having to put in advance notice to take time off of work to travel to the doctor’s office, are some of the ways access to care has increased.” Pandit says this is particularly true for older patients who require frequent visits and women who are pregnant, as well as those who need to optimize their glucose levels before and after surgery. Jasmine Meidas, 51, of Cleveland, Ohio, is one such patient. She was diagnosed with type 2 diabetes 15 years ago. “During the COVID-19 pandemic, I was much more comfortable with telehealth than going into my endocrinologist’s office, which is in a hospital. I still am,” she says. Meidas has a one-hour telehealth visit every three months. “They can order blood work to be taken locally, [and] we review [the results] together. We also review food choices, lifestyle challenges, stressors, and more. We set action steps and goals for the next 90 days,” she says. Meidas periodically sees her endocrinologist in person as well. At Vimalananda’s clinic in Boston, specific groups are making great strides with telehealth options. “Veterans, mostly,” she says. “I have a few [Veteran patients] who have severe [post-traumatic stress disorder]. Driving out to the clinic, dealing with traffic, and navigating the hospital are all things that cause a lot of distress. It’s been a game-changer for them to be able to have the visit from home.” When is telehealth not the best option? “If you have diabetes, please remove your socks and shoes.” This type of sign is frequently displayed in doctors’ offices. How would a foot exam work in telehealth? This is a real concern for people with diabetes, as up to 15% of patients will have a foot ulcer in their lifetime. Pandit and other experts acknowledge the limitations telehealth can have. “The medical team [must depend] on the patient [to provide] data and limited access to other parameters that are needed, including blood pressure measurements or foot examinations. When visits are conducted via telemedicine…care is not as comprehensive,” says Pandit. “There are times when the telemedicine model may pose risks. The limitation is clearly noted in visits with patients who are not technologically savvy, may have hearing issues, or [have] poor [internet] connection at the time of the visit.” Telehealth can also give health care providers a direct view into the home environment, which may result in a patient’s hesitancy to share openly — with family members potentially nearby — and impede the building of relationships and rapport. For these reasons, Pandit recommends that at least every other visit be conducted in person. ļ»æ
We are delighted to announce a groundbreaking partnership between Diabetic Supplies Inc. and eddii-Care , the virtual endocrine care clinic hosted by eddii—the leading diabetes management platform.
These protein- and fiber-packed spinach, ricotta, and mozzarella egg muffins are a filling yet healthy weekday breakfast option.
Key takeaways The FDA has issued a warning to users of continuous glucose monitors after reports of missed urgent blood sugar alarms on smartphones. Free apps can act as a backup for CGM alerts on your phone. A secondary alert system, like a CGM receiver or the SugarPixel standalone display, can ensure critical alerts are noticed. The FDA recently issued a safety notice after receiving reports from CGM users who missed critical low and high blood sugar alerts on their smartphones. Some of the causes for the missed alerts included: changes to phone settings, operating system upgrades, and using Bluetooth accessories. The safety warning coincided with my own experience. Following an update to my smartphone, I missed two critical low blood sugar alerts during the night. After missing those notices, I realized that I could back up my CGM alarms the same way I back up photos on my phone or laptop's hard drive. I then went about researching and testing other backup options, including these apps and devices I now use to make sure alarms are heard consistently, especially at night.
Marcia Kadanoff, who lives with type 2 diabetes, shares her top five tips for enjoying a Valentine’s Day meal out. Pink and red hearts everywhere, overpriced dinners, wondering if you’ll have a date (or if you got your partner an appropriate gift) – ah, the joys of Valentine’s Day. I’m stressed just thinking about it. As a person with diabetes, my stress may be a bit different than general Valentine’s Day anxiety. By this point, my spouse knows enough not to get me chocolates, my biggest landmine food. But the hard thing for Valentine's Day or any other romantic occasion is getting a reservation at the right kind of restaurant and – as always when living with diabetes – planning out my meal. Special occasion meals take special skills to navigate. The good news is that there are definitely strategies that can help make a romantic dinner somewhere special enjoyable without diabetes taking center stage. Where I live – the San Francisco Bay Area – many restaurants have Valentine’s Day dinner specials that consist of three to five courses. There’s nothing wrong with eating a multi-course meal, but it does make diabetes management more difficult. From bread to creamy soups and crouton-laden salads to heavy entrées to a dessert that’s potentially cake-filled, multi-course meals can quickly add up to a large amount of carbohydrates, which is a major driver of high blood sugars. The reality is that even if I choose the “healthier” set menu for a celebratory multi-course meal, I still make a point to think about what each portion is bringing (quite literally) to the table. Here are my best tips for navigating a Valentine's Day dinner out.
Figuring out when and how to exercise can be one of the most difficult parts of living with diabetes. Hear from experts who discuss the benefits and share strategies for safely exercising. Having diabetes doesn’t mean you have to let go of the things you love doing, which may include playing sports. Exercise is an essential part of diabetes management, leading to improved weight management, reduction in cardiovascular disease risk factors, and great mental health benefits. Experts like Dr. Lori Laffel, chief of the pediatric, adolescent and young adult section at Joslin Diabetes Center, discussed the benefits and strategies for safely exercising with diabetes. Laffel pointed to the ADA’s Standards of Care, which recommend adults get 150-300 minutes per week of moderate-to-vigorous exercise and youth get 420 minutes per week of moderate-to-vigorous exercise. But even with all of the evidence pointing to its benefits, managing exercise can be one of the most difficult parts of living with diabetes. There are multiple challenges to consider, such as abnormal insulin delivery and glucagon physiology, how stress hormones affect blood glucose, hydration, and more. The good news is that you can still stay active with diabetes and engage in the sports you love. Famous athletes who have diabetes include five-time Olympic gold medalist Gary Wayne Hall Jr., recent Super Bowl champion Noah Gray, and the Women’s National Basketball Association’s 2022 third overall pick Lauren Cox. Exercising just might mean a little more planning on your part. This includes paying special attention to the type of physical activity you’re doing, carb intake, and your insulin regimen, said Laffel. How does exercise impact blood sugar? It’s still difficult to know the degree to which exercise affects your blood glucose levels. According to Michael Riddell, professor of kinesiology and health sciences at York University, an optimal glycemic range is “unclear and very individualized for the athlete with diabetes.” Factors that influence one’s glucose response to exercise include the type of activity, time of day, whether you’ve recently taken insulin, what food was recently consumed, stress, sleep, and more. Athletes who compete may want to consider how their levels vary between training days versus competitions. While it might not always be doable in practice, Riddell recommends a time in range of 70% during training and 75% on competition days – while paying special attention to minimizing hypoglycemia to less than 1%. For competitive athletes, other important things to manage include sleep, meals, basal/bolus insulin, hydration, and workout schedules. The type, duration, and intensity of exercise are main factors that influence glucose response. Different forms of physical activity cause different glycemic trends that ultimately affect how you respond to diabetes management. For example, endurance activities (like walking, jogging, and cycling) tend to reduce glucose levels, whereas high-intensity interval training (HIIT) and resistance training tend to vary more so. Laffel said that if you are engaging in intense exercise, know it can cause hyperglycemia and may increase your insulin needs during recovery time. The amount of carbs you should eat to maintain your desired glucose levels will depend on the intensity of your exercise. Lower-intensity exercise typically means more carbs and less insulin needed and vice versa for higher-intensity exercise, explained Riddell. For context, about 50% of recreational athletes with type 1 diabetes prefer training and sometimes competing with a moderately low (100-200 grams per day), low (40-99 grams per day), or very low (<40 grams per day) carb diet. Helpful guidelines and tech for exercise Activity monitors and devices can significantly help with diabetes management while exercising. Connected pens and insulin pumps provide timely dosage; continuous glucose monitors (CGM) let you follow trends to guide your insulin dosing and carb intake; and automated insulin delivery (AID) can protect you from hypoglycemia and possible hyperglycemia. Laffel provided a few basic guidelines if you’re engaging in aerobic exercise for more than 40 minutes. If you’re on multiple daily injections (MDI) or an open-loop pump, consider the following insulin adjustments: For those on MDI, start with a 20% reduction in basal insulin dose. For people on insulin pump therapy, reduce basal rate by about 50% (as a starting point) 1-2 hours before, during, and about one hour after exercise. Reduce bolus insulin by 50% for meals or snacks two hours before and up to two hours after exercise. At bedtime (or 7-11 hours following afternoon exercise) reduce your basal rate by 20% for up to six hours. If you are engaging in unplanned aerobic exercise, eat a few extra carbs. Use a CGM or monitor to check glucose before, during, and after physical activity. According to Laffel, an overlooked but important part of exercising with diabetes is the cool-down period, which can be any sort of exercise that you consider easy, such as walking or a slow jog. Cooling down can reduce your risk of hyperglycemia after vigorous exercise. You should cool down for about 20 minutes. If your glucose levels remain high, you can consider conservative insulin correction (greater than 220 mg/dL). Ultimately, there are many ways you can tailor diabetes management to work for your exercise plan. You should discuss your exercise regime with your doctor, as everyone’s needs are individualized and dependent on their lifestyle.
Game day is fast approaching. Here are six diabetes-friendly healthy snack recipes that are all sure to be instant crowd-pleasers. Are you ready for the big game? Whether you're a raving football enthusiast, solely a fan of the commercials, or just around for the food and comradery, it's impossible to deny that the Super Bowl is a big deal. It's important to make sure you'll stay healthy while helping yourself to a few delicious bites. “Traditional Super Bowl snack foods are less than ideal, even if you aren't living with diabetes,” says Heather Hanks, a certified nutritionist and medical adviser at Medical Solutions BCN. Hanks acknowledges that it's always a challenge to eat healthy on Super Bowl Sunday. “The key here is to find snacks that contain no refined sugars and fewer carbs, a good source of protein, healthy fats, and fiber to keep you full and stabilize blood sugar levels.” Diabetes-friendly snacks for game day Bearing these pointers in mind, we have six low-carb finger food options, from cheese dips to buffalo-style cauliflower bites. These healthy snack options will have you partaking in the party without feeling too full or weighed down. ļ»æ
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Consuming dark chocolate is linked to a 21% reduction in the risk of developing Type 2 diabetes, while milk chocolate does not offer the same benefit and is associated with weight gain
