Standards of Care in Diabetes 2025 PDF

THE JOURNAL OF CLINICAL AND APPLIED RESEARCH AND EDUCATION JA N UA RY 2 02 5 n...

THE JOURNAL OF CLINICAL AND APPLIED RESEARCH AND EDUCATION JA N UA RY 2 02 5 n tio ia oc JA N UA RY 2025 | VO LU M E 4 8 | S U P P L E M E N T 1 DIABETESJOURNALS.ORG/CARE A ss es et i ab nD ica VO LUM E 48 | SU PP LEM ENT 1 | PAGE S S1– S352 er m Standards of Care ©A in Diabetes 2025 ISSN 0149-5992  American Diabetes Association n io Standards of Care in t Diabetesd2025 ia oc A ss es et i ab nD ica er m ©A © 2024 by the American Diabetes Association. Readers may use this work as long as the work is properly cited, the use is educational and not for profit, and the work is not altered. Readers may link to the version of record of this work on https://diabetesjournals.org/care but ADA permission is required to post this work on any third-party website or platform. Requests to reuse or repurpose; adapt or modify; or post, display, or distribute this work may be sent to [email protected]. January 2025 Volume 48, Supplement 1 [T]he simple word Care may suffice to express [the journal's] philosophical mission. The new journal is designed to promote better patient care by n serving the expanded needs of all health professionals committed to the care of patients with diabetes. As such, the American Diabetes Association views io Diabetes Care as a reaffirmation of Francis Weld Peabody's contention that “the secret of the care of the patient is in caring for the patient.” t —Norbert Freinkel, Diabetes Care, January-February 1978 ia EDITOR IN CHIEF Steven E. Kahn, MB, ChB oc DEPUTY EDITORS Cheryl A.M. Anderson, PhD, MPH, MS John B. Buse, MD, PhD Elizabeth Selvin, PhD, MPH ss AD HOC EDITORS Mark A. Atkinson, PhD M. Sue Kirkman, MD Matthew C. Riddle, MD Frank B. Hu, MD, MPH, PhD Stephen S. Rich, PhD A ASSOCIATE EDITORS Sonia Y. Angell, MD, MPH, DTM&H, FACP Vanita R. Aroda, MD Alice Y.Y. Cheng, MD, FRCPC Matthew J. Crowley, MD, MHS es Michael J. Haller, MD Ania M. Jastreboff, MD, PhD Alka M. Kanaya, MD Namratha R. Kandula, MD, MPH Casey M. Rebholz, PhD, MS, MNSP, MPH, FAHA Michael R. Rickels, MD, MS Naveed Sattar, FMedSci, FRCPath, FRCPGlas, FRSE Jonathan E. Shaw, MD, MRCP (U.K.), FRACP Thomas P.A. Danne, MD Csaba P. Kovesdy, MD, FASN David Simmons, FRACP, FRCP, MD (Cantab) et Justin B. Echouffo Tcheugui, MD, PhD, MPhil Neda Laiteerapong, MD, MS Emily K. Sims, MD Stephanie L. Fitzpatrick, PhD Kristen J. Nadeau, MD, MS Kristina M. Utzschneider, MD Meghana D. Gadgil, MD, MPH Jeremy Pettus, MD Adrian Vella, MD, FRCP (Edin) ab Amalia Gastaldelli, PhD Rodica Pop-Busui, MD, PhD Cuilin Zhang, MD, MPH, PhD Anna L. Gloyn, DPhil Jennifer E. Posey, MD, PhD, FACMG Jennifer B. Green, MD Camille E. Powe, MD i EDITORIAL BOARD nD David Aguilar, MD Anna Kahkoska, MD, PhD Archana R. Sadhu, MD, FACE Mohammed K. Ali, MD, MSc, MBA Alice Pik Shan Kong, MD Brian M. Schmidt, DPM Fida Bacha, MD Kamlesh Khunti, MD Christina M. Scifres, MD Harpreet Bajaj, MD, MPH, FACE Britta Larson, PhD Viral Shah, MD A. Sidney Barritt IV, MD, MSCR, FACG, FAASLD Richard David Graham Leslie, MD, FRCP, FAoP Jennifer Sherr, MD, PhD ica Rita Basu, MD Ildiko Lingvay, MD, MPH, MSCS Jung-Im Shin, MD, PhD Fiona Bragg, MBChB, MRCP, DPhil, FFPH Andrea Luk, MD Cate Speake, PhD Sonia Caprio, MD Viswanathan Mohan, MD, PhD, DSc, Til Sturmer, MD, MPH, PhD April Carson, PhD, MSPH FACE, MACP Keiichi Sumida, MD, MPH, PhD, FASN Ranee Chatterjee, MD, MPH Helen R. Murphy, MBBChBAO, FRACP, MD Sathish Thirunavukkarasu, MBBS, MPH, PhD Mark Emmanuel Cooper, MB BS, PhD Michael A. Nauck, MD Eva Tseng, MD, MPH er Ian de Boer, MD, MS Matthew J. O’Brien, MD, MSc Kohjiro Ueki, MD, PhD Alessandro Doria, MD, PhD, MPH Neha J. Pagidipati, MD, MPH Daniel van Raalte, MD, PhD Denice Feig, MD, MSc, FRCPC Elisabetta Patorno, DrPH, MD Eva Vivian, PharmD, MS, PhD, CDCES, BC-ADM m Hermes J. Florez, MD, PhD, MPH Monica E. Peek, MD, MPH, MS Elizabeth Vrany, PhD Juan Pablo Frias, MD Frederik Persson, MD, DMSc Pandora L. Wander, MD, MS, FACP Emily J. Gallagher, MB BCh BAO, MRCPI, PhD Richard E. Pratley, MD Deborah J. Wexler, MD, MSc Ahmad Haidar, PhD David Preiss, PhD, FRCPath, MRCP Joseph Wolfsdorf, MB, BCh ©A Jessica Lee Harding, PhD Jonathan Q. Purnell, MD, FTOS Geng Zong, PhD Marie-France Hivert, MD, MMSc Qibin Qi, PhD Allyson Hughes, PhD Maria J. Redondo, MD, PhD, MPH Silvio E. Inzucchi, MD Ravi Retnakaran, MD, MSc Linong Ji, MD Peter Rossing, MD, DMSc The mission of the American Diabetes Association is to prevent and cure diabetes and to improve the lives of all people affected by diabetes.  Diabetes Care is a journal for the health care practitioner that is intended to increase knowledge, stimulate research, and promote better management of people n with diabetes. To achieve these goals, the journal publishes original research on human studies in the following categories: Clinical Care/Education/Nutrition/ io Psychosocial Research, Epidemiology/Health Services Research, Emerging Technologies and Therapeutics, Pathophysiology/Complications, and Cardiovascular and Metabolic Risk. The journal also publishes ADA statements, consensus reports, t clinically relevant review articles, letters to the editor, and health/medical news or points ia of view. Topics covered are of interest to clinically oriented physicians, researchers, epidemiologists, psychologists, diabetes educators, and other health professionals. More information about the journal can be found online at diabetesjournals.org/care. oc Copyright © 2024 by the American Diabetes Association, Inc. All rights reserved. Printed in the USA. Requests for permission to reuse content should be sent to Copyright Clearance Center at www.copyright.com or 222 Rosewood Dr., Danvers, MA 01923; phone: (978) 750-8400; fax: ss (978) 646-8600. Requests for permission to translate should be sent to Permissions Editor, American Diabetes Association, at [email protected]. The American Diabetes Association reserves the right to reject any advertisement for any reason, which need not be disclosed to the party submitting the advertisement. 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Please call the numbers listed above, e-mail [email protected], or visit the online journal for et more information about submitting manuscripts, publication charges, ordering reprints, PRINT ISSN 0149-5992 subscribing to the journal, becoming an ADA member, advertising, permission to reuse ONLINE ISSN 1935-5548 content, and the journal’s publication policies. ab PRINTED IN THE USA Periodicals postage paid at Arlington, VA, and additional mailing offices. i AMERICAN DIABETES ASSOCIATION OFFICERS nD CHAIR OF THE BOARD CHAIR OF THE BOARD-ELECT CHIEF EXECUTIVE OFFICER Rhodes B. Ritenour, JD Todd F. Brown, PMP Charles D. Henderson PRESIDENT, MEDICINE & SCIENCE PRESIDENT-ELECT, MEDICINE & SCIENCE Mandeep Bajaj, MBBS Rita Rastogi Kalyani, MD, MHS ica PRESIDENT, HEALTH CARE & EDUCATION PRESIDENT-ELECT, HEALTH CARE & EDUCATION Patti Urbanski, MEd, RD, LD, CDCES, Joshua J. Neumiller, PharmD, CDCES, FADCES FADCES, FASCP SECRETARY/TREASURER SECRETARY/TREASURER-ELECT James Tai Robin Richardson er AMERICAN DIABETES ASSOCIATION PERSONNEL AND CONTACTS m VICE PRESIDENT & PUBLISHER, DIRECTOR, PEER REVIEW PHARMACEUTICAL & CONSUMER ADVERTISING PROFESSIONAL PUBLICATIONS Shannon C. Potts Tina Auletta Christian S. Kohler MANAGER, PEER REVIEW Senior Account Manager Larissa M. Pouch [email protected] ©A MANAGING DIRECTOR, PROFESSIONAL PUBLICATIONS ASSOCIATE MANAGER, PEER REVIEW PHARMACEUTICAL & DEVICE DIGITAL ADVERTISING Heather Norton Blackburn Kayla R. Fulkerson eHealthcare Solutions DIGITAL PRODUCTION MANAGER DIRECTOR, PRODUCTION & DESIGN R.J. Lewis Amy Moran PROFESSIONAL PUBLICATIONS President and CEO Keang Hok MANAGER, EDITORIAL & PRODUCTION [email protected] Meaghan Foley (609) 882-8887, ext. 101 ASSOCIATE DIRECTOR, EDITORIAL CREATIVE DIRECTOR Theresa M. Cooper Julie DeVoss Graff SENIOR MANAGER, BILLING & COLLECTIONS TECHNICAL EDITOR [email protected] Jim Harrington Sandro Vitaglione (703) 299-5511 [email protected]  January 2025 Volume 48, Supplement 1 Standards of Care in Diabetes—2025 n io S1 Introduction and Methodology Scope of the Guidelines S146 7. Diabetes Technology Intended Audience General Device Principles Blood Glucose Monitoring t Methodology and Procedure ADA Standards, Statements, Reports, and Reviews Continuous Glucose Monitoring Devices ia Insulin Delivery S6 Summary of Revisions General Changes S167 8. Obesity and Weight Management for the Prevention oc Section Changes and Treatment of Type 2 Diabetes Assessment and Monitoring of the Individual With S14 1. Improving Care and Promoting Health in Overweight or Obesity Populations Nutrition, Physical Activity, and Behavioral Therapy Diabetes and Population Health ss Pharmacotherapy Tailoring Treatment for Social Context Medical Devices for Weight Loss Summary Metabolic Surgery S27 2. Diagnosis and Classification of Diabetes S181 9. Pharmacologic Approaches to Glycemic Treatment Diagnostic Tests for Diabetes A Pharmacologic Therapy for Adults With Type 1 Diabetes Classification Surgical Treatment of Type 1 Diabetes Type 1 Diabetes Pharmacologic Therapy for Adults With Type 2 Diabetes Prediabetes and Type 2 Diabetes Pancreatic Diabetes or Diabetes in the es Context of Disease of the Exocrine Pancreas Additional Recommendations for All Individuals With Diabetes Special Circumstances and Populations Posttransplantation Diabetes Mellitus Monogenic Diabetes Syndromes 10. Cardiovascular Disease and Risk Management et S207 Gestational Diabetes Mellitus Hypertension and Blood Pressure Management Lipid Management S50 3. Prevention or Delay of Diabetes and Associated Statin Treatment Comorbidities ab Antiplatelet Agents Lifestyle Behavior Change for Type 2 Diabetes Cardiovascular Disease Prevention Pharmacologic Interventions to Delay Type 2 Diabetes S239 11. Chronic Kidney Disease and Risk Management Prevention of Vascular Disease and Mortality Chronic Kidney Disease i Person-Centered Care Goals Epidemiology of Diabetes and Chronic Kidney Disease nD Prevention or Delay of Symptomatic Type 1 Diabetes Assessment of Albuminuria and Estimated Glomerular S59 4. Comprehensive Medical Evaluation and Filtration Rate Assessment of Comorbidities Diagnosis of Chronic Kidney Disease in People With Person-Centered Collaborative Care Diabetes Comprehensive Medical Evaluation Staging of Chronic Kidney Disease ica Immunizations Acute Kidney Injury Assessment of Comorbidities Surveillance Interventions S86 5. Facilitating Positive Health Behaviors and Well-being Referral to a Nephrologist to Improve Health Outcomes er Diabetes Self-management Education and Support S252 12. Retinopathy, Neuropathy, and Foot Care Medical Nutrition Therapy Diabetic Retinopathy Physical Activity Neuropathy Smoking Cessation: Tobacco, E-cigarettes, Foot Care m and Cannabis Supporting Positive Health Behaviors S266 13. Older Adults Psychosocial Care Neurocognitive Function Hypoglycemia ©A S128 6. Glycemic Goals and Hypoglycemia Treatment Goals Assessment of Glycemic Status Lifestyle Management Glycemic Goals Pharmacologic Therapy Hypoglycemia Assessment, Prevention, Special Considerations for Older Adults With Type 1 and Treatment Diabetes Intercurrent Illness Treatment in Post-Acute and Long-Term Hyperglycemic Crises: Diagnosis, Management, Care Settings and Prevention End-of-Life Care This issue is freely accessible online at https://diabetesjournals.org/care/issue/48/Supplement_1. Keep up with the latest information for Diabetes Care and other ADA titles via Facebook (/ADAPublications) and X (@ADA_Pubs and @DiabetesCareADA). S283 14. Children and Adolescents S335 17. Diabetes Advocacy Type 1 Diabetes Advocacy Statements n Type 2 Diabetes Substance Use in Pediatric Diabetes S337 Disclosures io Transition From Pediatric to Adult Care S344 Index S306 15. Management of Diabetes in Pregnancy Diabetes in Pregnancy t Glycemic Goals in Pregnancy ia Management of Diabetes in Pregnancy Preeclampsia and Aspirin Pregnancy and Drug Considerations oc Postpartum Care S321 16. Diabetes Care in the Hospital Hospital Care Delivery Standards Glycemic Goals in Hospitalized Adults ss Glucose Monitoring Glucose-Lowering Treatment in Hospitalized Individuals Hypoglycemia Medical Nutrition Therapy in the Hospital A Self-management in the Hospital Standards for Special Situations Preventing Admissions and Readmissions The Future es Transition From the Hospital to the Ambulatory Setting et i ab nD ica er m ©A Diabetes Care Volume 48, Supplement 1, January 2025 S1 Introduction and Methodology: American Diabetes Association Professional Practice Committee* n Standards of Care in Diabetes—2025 io Diabetes Care 2025;48(Suppl. 1):S1–S5 | https://doi.org/10.2337/dc25-SINT t ia Diabetes is a complex, chronic condition DiabetesPro at professional.diabetes.org/ The Standards of Care does not pro- requiring continuous medical care with standards-of-care/living-standards-update. vide comprehensive treatment plans for comprehensive risk-reduction strategies The Standards of Care supersedes all previ- complications associated with diabetes, oc beyond glycemic management. Ongoing ously published ADA statements—and the such as diabetic retinopathy or diabetic diabetes self-management education and recommendations therein—on clinical foot ulcers, but offers guidance on how support are critical to empowering peo- topics within the purview of the Stand- and when to screen for diabetes complica- ss INTRODUCTION AND METHODOLOGY ple, preventing acute complications, and ards of Care; while still containing valu- tions, management of complications in the reducing the risk of long-term complica- able analysis, ADA statements should primary care and diabetes care settings, tions. Significant evidence exists that sup- not be considered the current position and referral to specialists as appropriate. A ports a range of interventions to improve of the ADA. The Standards of Care re- Similarly, regarding the psychosocial and diabetes outcomes. ceives annual review and approval by behavioral health factors often associated The American Diabetes Association the ADA Board of Directors and is re- es with diabetes and that can affect diabetes (ADA) “Standards of Care in Diabetes,” viewed by the ADA scientific team and care, the Standards of Care provides guid- referred to here as the Standards of clinical leadership. The Standards of ance on how and when to screen, man- Care, serves as a comprehensive re- Care also undergoes external peer re- agement in the primary care and diabetes et source to clinicians, researchers, policy view annually. care settings, and referral but does not makers, and other stakeholders. It out- provide comprehensive management plans lines key elements of diabetes care, SCOPE OF THE GUIDELINES for conditions that require specialized care, ab sets treatment goals, and provides tools The recommendations in the Standards such as mental illness. to assess care quality, all aimed at im- of Care include screening, diagnostic, and proving diabetes care and outcomes therapeutic actions that are scientifically INTENDED AUDIENCE i across diverse populations. proved or known based on expert clinical The intended audience for the Standards nD The ADA Professional Practice Com- practice or believed to favorably affect of Care includes primary care physicians, mittee (PPC) updates the Standards of health outcomes of people with diabetes. endocrinologists, nurse practitioners, phy- Care annually and includes discussion They also cover the prevention, screening, sician associates/assistants, pharmacists, of emerging clinical considerations in the diagnosis, and management of diabetes- registered dietitian nutritionists, diabetes ica text, and as evidence evolves, clinical associated complications and comorbid- care and education specialists, and all guidance is added to the recommenda- ities. The recommendations encompass members of the diabetes care team. The tions in the Standards of Care. The Stand- care throughout the life span for youth Standards of Care also provides guidance ards of Care is a “living” document where (children aged birth to 11 years and to specialists caring for people with diabe- important updates are published online er adolescents aged 12–17 years), adults tes and its multitude of complications, such should the PPC determine that new evi- (aged 18–64 years), and older adults as cardiologists, nephrologists, emergency dence or regulatory changes (e.g., drug (aged $65 years). The recommendations physicians, internists, pediatricians, psychol- m or technology approvals, label changes) cover the management of type 1 diabe- ogists, neurologists, ophthalmologists, and merit immediate inclusion. More informa- tes, type 2 diabetes, gestational diabetes podiatrists. Additionally, these recommen- tion on the “Living Standards” can be mellitus, and other types of diabetes dations help payors, policy makers, re- ©A found on the ADA professional website and/or hyperglycemic conditions. searchers, research funding organizations, The “Standards of Care in Diabetes,” formerly called “Standards of Medical Care in Diabetes,” was originally published in 1988. The most recent full review and revision was in December 2024. *A complete list of members of the American Diabetes Association Professional Practice Committee is provided in this section. Duality of interest information for each author is available at https://doi.org/10.2337/dc25-SDIS. Suggested citation: American Diabetes Association Professional Practice Committee. Introduction and methodology: Standards of Care in Diabetes—2025. Diabetes Care 2025;48(Suppl. 1):S1–S5 © 2024 by the American Diabetes Association. Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered. More information is available at https://www.diabetesjournals.org/journals/pages/license. S2 Introduction and Methodology Diabetes Care Volume 48, Supplement 1, January 2025 and advocacy groups to align their policies race and ethnicity, ability level). A PPC chair Full disclosure statements from all com- and resources and deliver optimal care for or co-chairs are appointed by the ADA mittee members are solicited and re- people living with diabetes. (N.A.E. and R.G.M. are co-chairs for the viewed during the appointment process. The ADA strives to improve and up- 2025 Standards of Care) and oversee the Disclosures are then updated through- date the Standards of Care to ensure committee. In addition to the PPC mem- out the guideline development process that clinicians, health plans, and policy bers, several professionals serve as desig- (specifically before the start of every n makers can continue to rely on it as the nated subject matter experts to support meeting), and disclosure statements are most authoritative source for current the PPC in the development of specific io submitted by every Standards of Care guidelines for diabetes care. The Stand- content areas of the Standards of Care. contributor upon submission of the up- ards of Care recommendations are not While designated subject matter experts dated Standards of Care section. Mem- t intended to preclude clinical judgment. assist with content development, only PPC bers are required to disclose conflicts ia They must be applied in the context of members formally vote on Standards of for a time frame that includes 1 year excellent clinical care, with adjustments Care recommendations for final approval. prior to initiation of the committee ap- for individual preferences, comorbidities, Additionally, several organizations have pointment process until publication of oc and other patient factors. For more de- endorsed specific sections of the 2025 that year’s Standards of Care. Potential tailed information about the management Standards of Care. The American College of dualities of interest are evaluated by a of diabetes, please refer to Medical Man- Cardiology (ACC) reviewed and approved designated review panel and, if neces- Section 10, “Cardiovascular Disease and ss agement of Type 1 Diabetes (1) and Med- sary, the Legal Affairs Division of the ical Management of Type 2 Diabetes (2). Risk Management.” The American Society ADA. The duality of interest assessment for Bone and Mineral Research reviewed is based on the relative weight of the fi- and approved the “Bone Health” sub- A METHODOLOGY AND PROCEDURE nancial relationship (i.e., the monetary section in Section 4, “Comprehensive amount) and the relevance of the rela- The Standards of Care includes discussion Medical Evaluation and Assessment of tionship (i.e., the degree to which an in- of evidence and clinical practice recom- mendations intended to optimize care for people with diabetes by assisting health es Comorbidities.” The Obesity Society re- viewed and approved Section 8, “Obesity dependent observer might reasonably interpret an association as related to the and Weight Management for the Prevention care professionals and individuals in mak- topic or recommendation of consider- and Treatment of Type 2 Diabetes.” New to et ing shared decisions about diabetes care. ation). In addition, the ADA adheres to the 2025 Standards of Care, the American The recommendations are informed by section 7 of the Council of Medical Spe- Geriatrics Society reviewed and approved a systematic review of evidence and an cialty Societies “Code for Interactions with Section 13, “Older Adults.” ab assessment of the benefits and risks of Companies” (3). The duality of interest re- Each section of the Standards of Care is alternative care options. view panel also ensures the majority of reviewed annually and updated with the the PPC and the PPC chair or co-chairs latest evidence-based recommendations by are without potential conflict relevant to i Professional Practice Committee a subcommittee. The subcommittees per- nD The PPC of the ADA is responsible for the subject area. Furthermore, the PPC form systematic literature reviews and iden- the Standards of Care content. The PPC chair or co-chairs are required to remain tify and summarize the scientific evidence. is an interprofessional expert committee unconflicted for 1 year after the publica- An information specialist with knowledge comprising physicians, nurse practitioners, and experience in literature searching (a li- tion of the Standards of Care. Members of the committee who disclose a poten- ica pharmacists, diabetes care and education brarian) is consulted as necessary. A guide- specialists, registered dietitian nutritionists, line methodologist (R.R.B. for the 2025 tial duality of interest pertinent to any behavioral health scientists, and others Standards of Care) with expertise and train- specific recommendation are prohib- who have expertise in a range of areas ing in evidence-based medicine and guide- ited from participating in discussions including but not limited to adult and pedi- related to those recommendations and er line development methodology oversees all atric endocrinology, epidemiology, public methodological aspects of the development their votes are excluded. No expert panel health, behavioral health, cardiovascular of the Standards of Care and serves as a sta- members were employees of any phar- risk management, microvascular complica- maceutical or medical device company m tistical analyst. tions, nephrology, neurology, ophthalmol- during the development of the 2025 ogy, podiatry, clinical pharmacology, pre- Disclosure and Duality of Interest Standards of Care. Members of the PPC, ©A conception and pregnancy care, weight Management their employers, and their disclosed po- management and diabetes prevention, and All members of the expert panel (the tential dualities of interest are listed in use of technology in diabetes manage- PPC members and subject matter ex- the section “Disclosures: Standards of ment. Each year, ADA conducts a national perts) and ADA scientific team are re- Care in Diabetes—2025.” call for applications to recruit members of quired to comply with the ADA policy on the PPC. Appointment to the PPC is based duality of interest, which requires disclo- Funding Source on excellence in clinical practice and re- sure of any financial, intellectual, or other The Standards of Care guideline is funded search, with attention to appropriate interests that might be construed as con- by ADA general revenue. No other entity, representation of members based on stituting an actual, potential, or apparent including industry, provides financial sup- considerations including but not limited conflict, regardless of relevancy to the port for the guideline. Committee members to demographic, geographic, work setting, guideline topic. For transparency, ADA re- received no remuneration for their partici- or identity characteristics (e.g., gender, quires full disclosure of all relationships. pation in development of this guideline. diabetesjournals.org/care Introduction and Methodology S3 Evidence Review evidence that forms the basis for the rec- Clinicians care for people, not populations; The Standards of Care subcommittee for ommendations in the Standards of Care. guidelines must always be interpreted with each section creates an initial list of rele- All recommendations in the Standards of the individual person in mind. Individual cir- vant clinical questions that is reviewed and Care are critical to comprehensive care re- cumstances, such as comorbid and coexist- discussed by the expert panel. In consulta- gardless of rating. ADA recommendations ing diseases, age, education, disability, and, tion with a systematic review expert and li- are assigned ratings of A, B, or C, depend- above all, the values and preferences of the n brarian, each subcommittee devises and ing on the quality of the evidence in person with diabetes, must be considered executes systematic literature searches. io support of the recommendation. Ex- and may lead to different treatment goals For the 2025 Standards of Care, PubMed, pert opinion E is a separate category for and strategies. Furthermore, conventional Medline, and EMBASE were searched for recommendations in which there is no evidence hierarchies, such as the one t the time periods of 1 June 2023 to 19 July evidence from clinical trials, clinical trials adapted by the ADA, may miss nuances ia 2024. Searches are limited to studies pub- important in diabetes care. For example, may be impractical, or there is conflicting lished in English. Subcommittee members evidence. Recommendations assigned an E although there is excellent evidence from also manually search journals, reference clinical trials supporting the importance of oc level of evidence are informed by key opin- lists of conference proceedings, and reg- achieving multiple risk factor control, the ion leaders in diabetes (members of the ulatory agency websites. All potentially optimal way to achieve this result is less PPC and external subject matter experts) relevant citations are then subjected to a and cover important elements of clinical clear. It is difficult to assess each compo- ss full-text review. In consultation with the care. All Standards of Care recommenda- nent of such a complex intervention. methodologist, the subcommittees pre- pare the evidence summaries and grad- tions receive a rating for the strength of the evidence and not for the strength of Evidence to Recommendations ing for each section of the Standards of A the recommendation. Recommendations All accumulated evidence was reviewed Care. All PPC members discuss and re- view the evidence summaries and make with A-level evidence are based on large, and discussed by all PPC members and es well-designed randomized controlled trials external subject matter experts during revisions as appropriate. The final evi- or well-done meta-analyses of randomized multiple virtual meetings and a 2-day in- dence summaries are then deliberated controlled trials. Generally, these recom- person meeting in Arlington, Virginia, in on by the PPC, and the recommenda- mendations have the best chance of im- July 2024. Standards of Care recommen- tions that will appear in the Standards of et Care are drafted. proving outcomes when applied to the dations were updated based on the population for which they are appropri- newly acquired evidence, and each rec- ate. Recommendations with lower levels ommendation was voted on by the PPC, ab Grading of Evidence and Recommendation Development of evidence may be equally important with 80% consensus required for any A grading system (Table 1) developed by but are not as well supported. recommendation to be approved. the ADA and modeled after existing meth- Of course, published evidence is only i ods is used to clarify and codify the one component of clinical decision-making. Revision Process nD Public comment is particularly important in the development of clinical practice recom- Table 1—ADA evidence-grading system for “Standards of Care in Diabetes” mendations; it promotes transparency and Level of provides key stakeholders, including people evidence Description with diabetes and their caregivers, the op- ica A Clear evidence from well-conducted, generalizable randomized controlled trials portunity to identify and address gaps in that are adequately powered, including: care.The ADA holds a year-long public com- Evidence from a well-conducted multicenter trial ment period requesting feedback on the Evidence from a meta-analysis that incorporated quality ratings in the Standards of Care. The PPC reviews com- er analysis Supportive evidence from well-conducted randomized controlled trials that are piled feedback from the public in prepara- adequately powered, including: tion for the annual update but considers Evidence from a well-conducted trial at one or more institutions more pressing updates throughout the m Evidence from a meta-analysis that incorporated quality ratings in the year, which may be published as “living” analysis Standards updates. Feedback from the B Supportive evidence from well-conducted cohort studies, including: ©A larger clinical community and general Evidence from a well-conducted prospective cohort study or registry public was invaluable for the revision Evidence from a well-conducted meta-analysis of cohort studies Supportive evidence from a well-conducted case-control study of the 2024 Standards of Care. Readers who wish to comment on the 2025 C Supportive evidence from poorly controlled or uncontrolled studies, including: Standards of Care are invited to do so at Evidence from randomized clinical trials with one or more major or three or more minor methodological flaws that could invalidate the results professional.diabetes.org/SOC. Evidence from observational studies with high potential for bias (such as Feedback for the Standards of Care is case series with comparison with historical controls) also obtained from external peer reviewers. Evidence from case series or case reports The Standards of Care is reviewed by ADA Conflicting evidence with the weight of evidence supporting the recommendation clinical leadership and scientific and medi- E Expert consensus or clinical experience cal team and is approved by the ADA Board of Directors, which includes health care S4 Introduction and Methodology Diabetes Care Volume 48, Supplement 1, January 2025 professionals, scientists, and other stake- Consensus Report Robert G. Frykberg, DPM, MPH (Section 12) holders. The ACC performs an independent An ADA consensus report is a document Robert A. Gabbay, MD, PhD (until on a particular topic that is authored by a 6 September 2024) external peer review, and the ACC provides Jason L. Gaglia, MD, MMSc (Sections 2, 3, endorsement of Section 10, “Cardiovascular technical expert panel under the auspices and 9) Disease and Risk Management.” In addition, of ADA. The document does not reflect Rodolfo J. Galindo, MD (Section 16) the American Society for Bone and Mineral the official ADA position but rather repre- Sunir J. Garg, MD, FACS (Section 12) n sents the panel’s collective analysis, eval- Monica Girotra, MD (Section 9) Research provides endorsement for the John M. Giurini, DPM (Section 12) “Bone Health” subsection of Section 4, uation, and expert opinion. The primary io Mohamed Hassanein, FRCP, CCST (U.K.) (Section 5) “Comprehensive Medical Evaluation and objective of a consensus report is to pro- Mikhail N. Kosiborod, MD (Section 10) vide clarity and insight on a medical or Robert F. Kushner, MD, MS (Section 8) Assessment of Comorbidities,” The Obe- t scientific matter related to diabetes for Seymour R. Levin, MD (Section 4) sity Society provides endorsement for Sec- ia which the evidence is contradictory, Roeland J.W. Middlebeek, MD, MSc tion 8, “Obesity and Weight Management (Section 5) emerging, or incomplete. The report also for the Prevention and Treatment of Type 2 Lisa Murdock (Section 17) aims to highlight evidence gaps and to Nicola Napoli, MD, PhD (Sections 4 and 13) oc Diabetes,” and the American Geriatrics So- propose avenues for future research. Sharon J. Parish, MD (Section 4) ciety provides endorsement for Section 13, Consensus reports undergo a formal re- Flavia Q. Pirih, DDS, PhD (Section 4) “Older Adults.” Feedback received from ev- view process, including external peer re- Elizabeth Selvin, PhD, MPH (Sections 2 and 6) ery stakeholder is adequately addressed by Shylaja Srinivasan, MD (Section 14) ss view and review by the ADA PPC and the committee, and the final version is ap- ADA scientific team, for publication. Molly L. Tanenbaum, PhD (Section 5) Monica Verduzco-Gutierrez, MD (Section 4) proved by all parties prior to publication. Crystal C. Woodward, MPS (Section 17) The ADA adheres to the Council of Medical Scientific Review Zobair M. Younossi, MD, MPH (Section 4) A Specialty Societies revised “CMSS Principles A scientific review is a balanced review for the Development of Specialty Society and analysis of the literature on a scien- ADA Scientific Team Clinical Guidelines” (4). ADA STANDARDS, STATEMENTS, es tific or medical topic related to diabetes. A scientific review is not an ADA position and does not contain clinical practice rec- Kirthikaa Balapattabi, PhD Raveendhara R. Bannuru, MD, PhD (corresponding author, [email protected]) Nuha Ali ElSayed, MD, MMSc REPORTS, AND REVIEWS ommendations but is produced under et Robert A. Gabbay, MD, PhD (until The ADA has been actively involved in the auspices of the ADA by invited ex- 6 September 2024) developing and disseminating diabetes perts. The scientific review may provide a Elizabeth J. Pekas, PhD ab care clinical practice recommendations scientific rationale for clinical practice and related documents for more than recommendations in the Standards of Acknowledgments 35 years. The ADA Standards of Care is Care. The category may also include task The ADA thanks the following external peer force and expert committee reports. reviewers: an essential resource for health care pro- i Mohammed K. Ali, MD, MSc fessionals caring for people with diabe- nD Joseph A. Aloi, MD tes. ADA Statements, Consensus Reports, Vanita Aroda, MD Members of the PPC Ian H. de Boer, MD, MS and Scientific Reviews support the rec- Nuha Ali ElSayed, MD, MMSc (Co-Chair) Wenche S. Borgnakke, DDS, PhD ommendations included in the Standards Rozalina G. McCoy, MD, MS (Co-Chair) Anders L. Carlson, MD of Care. Grazia Aleppo, MD James Flory, MD ica Elizabeth A. Beverly, PhD Om Ganda, MD Kathaleen Briggs Early, PhD, CDCES Thomas W. Gardner, MD, MS Standards of Care Dennis Bruemmer, MD, PhD Sherita Hill Golden, MD The annual Standards of Care supplement Justin B. Echouffo-Tcheugui, MD, PhD Amy Hess-Fischl, MS, RDN to Diabetes Care contains the official ADA Laya Ekhlaspour, MD Ahmet Hoke, MD, PhD er position, is authored by the ADA, and pro- Rajesh Garg, MD Korey K. Hood, PhD Kamlesh Khunti, MD, FMedSci Eric L. Johnson, MD vides all of the ADA’s current clinical prac- Rayhan Lal, MD M. Sue Kirkman, MD tice recommendations. Ildiko Lingvay, MD, MPH m Cecilia C. Low Wang, MD, FACP Glenn Matfin, MB ChB, MSc (Oxon) Brynn E. Marks, MD, MSHPEd ADA Statement Naushira Pandya, MD, FACP Leigh Perreault, MD An ADA statement is an official ADA Scott J. Pilla, MD, MHS Anne L. Peters, MD ©A Sarit Polsky, MD, MPH Moshe Phillip, MD point of view or position that does not Alissa R. Segal, PharmD, CDCES Jane E.B. Reusch, MD contain clinical practice recommenda- Jane Jeffrie Seley, DNP, MPH Connie M. Rhee, MD, MSc tions and may be issued on advocacy, Robert C. Stanton, MD Jo-Anne Rizzotto, MEd, RDN Raveendhara R. Bannuru, MD, PhD Laura Shin, DPM, PhD policy, economic, or medical issues re- (Chief Methodologist) Alpana Shukla, MD lated to diabetes. ADA statements un- Richard Siegel, MD dergo a formal review process, including Designated Subject Matter Experts Emily D. Szmuilowicz, MD external peer review and review by the Brian C. Callaghan, MD, MS (Section 12) Tracey H. Taveira, PharmD, CDOE appropriate ADA national committee, Kenneth Cusi, MD (Section 4) Guillermo E. Umpierrez, MD, CDCES Sandeep R. Das, MD, MPH (Section 10) Jenise C. Wong, MD, PhD ADA clinical leadership, ADA scientific Osagie Ebekozien, MD, MPH (Sections 1, 2, and 3) Chloe Zera, MD team, and, as warranted, the ADA Board Barbara Eichorst, MS, RD (Section 5) ACC peer reviewers (Section 10): of Directors. Talya K. Fleming, MD (Section 4) James L. Januzzi, Jr., MD, FACC diabetesjournals.org/care Introduction and Methodology S5 Richard J. Kovacs, MD, MACC Joshua J. Neumiller, PharmD, CDCES MS, Ed. Arlington, VA, American Diabetes Dave L. Dixon, PharmD, FACC President-elect, Heath Care & Education Association, 2022 Prakash C. Deedwania, MD, FACC 2. American Diabetes Association. Medical AGS peer reviewers (Section 13): The ADA thanks the following individuals for Management of Type 2 Diabetes. 8th ed. Alyce Adams, MD their support: Meneghini L, Ed. Arlington, VA, American Diabetes Alexandra Lee, MD Celeste Durnwald, MD Association, 2020 Sei Lee, MD Anastassios G. Pittas, MD, MS 3. Council of Medical Specialty Societies. CMSS n Alexandra M. Yacoubian code for interactions with companies. Accessed 2 The ADA thanks the ADA Presidents and The ADA thanks the following individuals for August 2024. Available from https://cmss.org/ io Presidents-elect: figure design: code-for-interactions-with-companies/ Mandeep Bajaj, MBBS, President, Medicine & Michael Bonar 4. Council for Medical Specialty Societies. CMSS Science Charlie Franklin principles for the development of specialty society t Patti Urbanski, MEd, RD, President, clinical guidelines. Accessed 2 August 2024. ia Heath Care & Education References Available from https://cmss.org/wp-content/ Rita Rastogi Kalyani, MD, MHS, President-elect, 1. American Diabetes Association. Medical uploads/2017/11/Revised-CMSS-Principles-for- Medicine & Science Management of Type 1 Diabetes. 8th ed. Kirkman Clinical-Practice-Guideline-Development.pdf oc A ss es et i ab nD ica er m ©A  S6 Diabetes Care Volume 48, Supplement 1, January 2025 Summary of Revisions: Standards American Diabetes Association Professional Practice Committee* n of Care in Diabetes—2025 io Diabetes Care 2025;48(Suppl. 1):S6–S13 | https://doi.org/10.2337/dc25-SREV t ia oc GENERAL CHANGES for Bone and Mineral Research and how to implement and sustain interven- The field of diabetes care is rapidly chang- Section 8, “Obesity and Weight Manage- tions that improve care delivery and pop- ing as new research, technology, and treat- ment for the Prevention of Type 2 Dia- ulation health. ss ments that can improve the health and betes,” received endorsement from The Recommendation 1.6 was added to SUMMARY OF REVISIONS well-being of people with diabetes con- Obesity Society. For the seventh consec- emphasize the importance of assessing tinue to emerge. With annual updates utive year, Section 10, “Cardiovascular Dis- and addressing disparities in diabetes care A since 1989, the American Diabetes Associ- ease and Risk Management,” received and health outcomes. The text includes ac- ation has long been a leader in producing endorsement from the American College of tionable guidance on measuring health guidelines that capture the most current Cardiology. For the first time, Section 13, es disparities and engaging interprofessional state of the field. “Older Adults,” received endorsement teams and community partners to address The 2025 “Standards of Care in Dia- from the American Geriatrics Society. them. betes” has continued to incorporate Recommendation 1.7 was revised to et person-first and inclusive language. Efforts Section 1. Improving Care and emphasize the importance of screening were made to consistently apply terminol- Promoting Health in Populations for and addressing multiple social deter- ogy that empowers people with diabetes (https://doi.org/10.2337/dc25-S001) minants of health that impact diabetes ab and recognizes the individual at the center Recommendation 1.1 was expanded to management, health outcomes, and qual- of diabetes care. include people at risk for diabetes in ad- ity of life. Although levels of evidence for several dition to those with diabetes. The narrative text now includes an ex- i recommendations have been updated, Recommendation 1.2 was revised to in- panded discussion of cost and affordability nD these changes are not outlined below clude, in addition to the Chronic Care considerations as well as health disparities where the clinical recommendation has Model, other evidence-based care delivery and social determinants of health. remained the same. That is, changes in ev- models and frameworks that have been Table 1.1 was added to highlight the idence level from, for example, E to C, are demonstrated to improve diabetes care importance of engaging an interprofes- ica not noted below. The 2025 Standards of delivery and health outcomes. These in- sional team approach to person-centered Care contains, in addition to many minor clude the Patient-Centered Medical Home care for people with diabetes across the changes that clarify recommendations or model, Accountable Care Organizations, life span. reflect new evidence, more substantive re- and value-based payment models and are visions detailed below. discussed in the text. er Section 2. Diagnosis and Recommendation 1.5 was added to em- Classification of Diabetes SECTION CHANGES phasize the importance of quality improve- (https://doi.org/10.2337/dc25-S002) ment initiatives and interprofessional teams Table 2.3 was added to provide consid- m Endorsements For the second consecutive year, the for supporting sustainable and scalable erations related to the use and inter- “Bone Heath” subsection in Section 4, process changes that improve quality of pretation of laboratory measurement of ©A “Comprehensive Medical Evaluation and care and health outcomes. Implementa- glucose and A1C. Assessment of Comorbidities,” received tion concepts were added throughout the The “Classification” subsection has been endorsement from the American Society section to provide actionable guidance on updated to provide a pragmatic approach *A complete list of members of the American Diabetes Association Professional Practice Committee can be found at https://doi.org/10.2337/dc25-SINT. Duality of interest information for each author is available at 10.2337/dc25-SDIS. Suggested citation: American Diabetes Association Professional Practice Committee. Summary of revisions: Standards of Care in Diabetes—2025. Diabetes Care 2025;48(Suppl. 1):S6–S13 © 2024 by the American Diabetes Association. Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered. More information is available at https://www.diabetesjournals.org/journals/pages/license. diabetesjournals.org/care Summary of Revisions S7 to management of individuals who have previous treatment at the initial visit and urinary tract infections. Recommendation features of both type 1 and type 2 diabetes. follow-up visits as appropriate. 4.21 was added to state that health care In the “Type 1 Diabetes” subsection, Table 4.2 was amended to include es- professionals should screen for symptoms Recommendation 2.7 was added to em- sential components for assessment, plan- and/or signs of genitourinary syndrome of phasize the importance of antibody-based ning, and referral as appropriate. menopause. screening for presymptomatic type 1 dia- Changes were made in the “Immu- The terminology for nonalcoholic fatty n betes in individuals with a family history nizations” subsection to reflect updates liver disease (NAFLD) and nonalcoholic stea- of type 1 diabetes or otherwise known el- for COVID-19, pneumococcal pneumonia, tohepatitis (NASH) was updated to meta- io evated genetic risk. The associated text influenza, and respiratory syncytial virus. bolic dysfunction–associated steatotic liver was also updated and expanded to reflect Table 4.3 was revised to include impor- disease (MASLD) and metabolic dysfunction– t these changes. tant vaccination updates. associated steatohepatitis (MASH), respec- ia The “Gestational Diabetes Mellitus” Recommendation 4.6 was modified to tively. This updated nomenclature was incor- subsection was completely updated to fa- specify initial and repeat screening for porated throughout the section. cilitate understanding and implementa- autoimmune thyroid disease. Recommendation 4.22a was revised oc tion of the current various approaches to Recommendation 4.10 was updated to to specify when to screen for the risk of screening for and diagnosis of gestational specify avoiding medications with known having or developing cirrhosis related to diabetes mellitus (GDM). association with higher fracture risk. MASH using the calculated fibrosis-4 in- ss The text in various other subsections, Recommendation 4.12 was revised to dex (FIB-4). including those that discuss diabetes and include the recommended intake of cal- Recommendation 4.23 was amended immune checkpoint inhibitors, the role of cium for people with diabetes. to state that adults with type 2 diabetes or the gut microbiome in diabetes risk, and Recommendation 4.13 was updated to prediabetes and a FIB-4 >1.3 should have A monogenic diabetes, was updated. specify when antiresorptive medications and additional risk stratification performed. osteoanabolic agents should be considered. Recommendation 4.24 was revised to Section 3. Prevention or Delay of Diabetes and Associated es Table 4.4 was updated to specify when bone mineral density testing should be state that individuals with a higher risk for significant liver fibrosis should be referred Comorbidities performed. to a gastroenterologist or hepatologist. (https://doi.org/10.2337/dc25-S003) A new subsection, “Dental Care,” was Recommendation 4.25 was revised to in- et In the “Lifestyle Behavior Change for added and includes two new recommen- clude an interprofessional team approach Type 2 Diabetes Prevention” subsection, dations. Recommendation 4.15 was added when promoting weight loss, particularly ab text pertaining to sleep health in relation to state people with diabetes should be re- with a structured nutrition plan and physi- to risk of type 2 diabetes was added. This ferred for a dental exam at least once per cal activity program for cardiometabolic addition highlights sleep as a central year. Recommendation 4.16 was added to benefits and histological improvement. component in the management of predi- state that efforts between medical and Recommendation 4.26 was revised to i abetes and type 2 diabetes, placing it on dental teams should be coordinated so include a dual glucose-dependent insuli- nD a level playing field with other lifestyle that glucose-lowering medications can be notropic polypeptide (GIP) and glucagon behaviors (e.g., physical activity and eat- appropriately adjusted prior to and in the like peptide 1 (GLP-1) receptor agonist (RA) ing patterns). post–dental procedure period as needed. with potential benefits in MASH as an ad- In the “Pharmacologic Interventions to Recommendation 4.17 was updated junctive therapy to lifestyle interventions ica Delay Type 2 Diabetes” subsection, the to reflect that an assessment for disabil- for weight loss in adults with type 2 diabe- text on the proposed use of vitamin D ity should be performed at the initial tes, MASLD, and overweight or obesity. therapy to prevent type 2 diabetes was ex- visit and an assessment for decline in Recommendation 4.27a was revised tensively updated. The text related to long- function should be performed at each to state that in adults with type 2 diabe- er term metformin therapy and associated subsequent visit. tes and biopsy-proven MASH or those vitamin B12 deficiency was also updated. Recommendation 4.18 was modified to at high risk for liver fibrosis, use of pio- The language in Recommendation 3.15 include inquiring about sexual health in glitazone or a GLP-1 RA or a dual GIP m was strengthened to facilitate discussion men and to screen with a morning serum and GLP-1 RA is preferred for glycemic with selected individuals aged $8 years with total testosterone if symptoms and/or management due to potential beneficial stage 2 type 1 diabetes about the role of te- signs of hypogonadism are present. effects on MASH. ©A plizumab-mzwv infusion to delay the onset Recommendation 4.19 was added to Recommendation 4.27b was added to of symptomatic type 1 diabetes (stage 3). specifically state that men with diabetes state that combination therapy with pio- or prediabetes should be screened for glitazone and a GLP-1 RA can be consid- Section 4. Comprehensive Medical erectile dysfunction, and new text was ered for treatment of hyperglycemia in Evaluation and Assessment of added on erectile dysfunction. adults with type 2 diabetes with biopsy- Comorbidities A new subsection, “Female Sexual Dys- proven MASH or those at high risk of (https://doi.org/10.2337/dc25-S004) function,” was added and includes two liver fibrosis because of potential benefi- Language in Fig. 4.1 was updated, and new recommendations. Recommendation cial effects of such a combination on Table 4.1 was modified to include changes 4.20 states that health care professionals MASH. made throughout Section 4. should inquire about sexual health, particu- Recommendation 4.28 was added to Recommendation 4.3 was changed to larly in women who experience depression state that treatment with a thyroid hor- include assessment for glycemic status and and/or anxiety and those with recurrent mone receptor-b agonist in adults with S8 Summary of Revisions Diabetes Care Volume 48, Supplement 1, January 2025 type 2 diabetes or prediabetes with MASLD with overweight or obesity, aiming for at Additionally, newly added Fig. 5.1 il- with moderate (F2) or advanced (F3) liver least 3–7% weight loss. lustrates differences and similarities be- fibrosis may be considered and that the in- Recommendation 5.14 on eating pat- tween religious and intermittent fasting dividual should be referred to a gastroen- terns now has revised verbiage to include for people with diabetes. Table 5.4 in- terologist or hepatologist with expertise in processed foods, lean proteins, and non- cludes a risk calculation and suggested MASLD management for the initiation and dairy alternatives. risk score for people with diabetes who n monitoring of this therapy. Recommendation 5.16 was updated seek to fast during Ramadan, and Table 5.5 Recommendation 4.29 was added to to include actionable language and clar- includes information about medication io emphasize that treatment initiation and ity regarding the use of dietary supple- changes during fasting. monitoring should be individualized and ments for glycemic benefits. In the “Physical Activity” subsection, t within the context of an interprofessional Recommendations 5.17 and 5.18 were Recommendation 5.34 was updated to ia team for MASLD and MASH management. updated to have revised and actionable include a statement about limiting the Figure 4.2 was revised to reflect impor- language, respectively. amount of time spent sedentary, which tant updates to the diagnostic algorithm Recommendation 5.19 was updated includes recreational screen time. oc for risk stratification and the prevention to use actionable language. Recommendation 5.38 was modified of cirrhosis in individuals MASLD, and new Recommendation 5.20 was revised to to state that prolonged sitting should Fig. 4.3 includes the MASLD treatment recommend limiting sodium as clinically be interrupted at least every 30 min for ss algorithm. appropriate, which can be done, in part, glycemic benefits. by limiting consumption of processed Recommendation 5.39 was added to Section 5. Facilitating Positive Health foods. counsel adults and youth receiving weight Behaviors and Well-being to Improve Recommendation 5.21 was modified to management pharmacotherapy or meta- A Health Outcomes recommend water over nutritive and non- bolic surgery to meet physical activity rec- (https://doi.org/10.2337/dc25-S005) nutritive sweetened beverages, and Rec- ommendations. The accompanying text In the “Diabetes Self-Management Educa- tion and Support” subsection, Recom- es ommendation 5.22 was added to state that nonnutritive sweeteners can be used addresses the concern of sarcopenic obe- sity with use of incretin therapies and mendation 5.1 was updated to emphasize instead of sugar-sweetened products in metabolic surgery. that all people with diabetes should be moderation and for short term to reduce In the “Smoking Cessation: Tobacco, et advised to participate in diabetes self- overall calorie and carbohydrate intake. E-cigarettes, and Cannabis” subsection, management education and support Recommendation 5.23 was added to Recommendation 5.42 was added to advise ab (DSMES) rather than being just encour- emphasize the screening for malnutrition, people with type 1 diabetes and those with aged to participate. especially for those who have undergone other forms of diabetes at risk for diabetic Recommendation 5.2 was updated to metabolic surgery and for those being ketoacidosis (DKA) to not use recreational clarify when to provide DSMES. treated with weight management phar- cannabis in any form due to the risk of can- i Recommendation 5.3 was revised to macological therapies. nabis hyperemesis syndrome. The accompa- nD be more succinct and action-oriented, Recommendation 5.25 was revised to nying text describes cannabis hyperemesis placing emphasis on routine assessment use actionable language. syndrome and its diagnostic criteria. of key goals of DSMES. Recommendation 5.26 was added to Recommendation 5.43 in “Supporting Recommendation 5.4 was added to address the issue of sodium–glucose co- Positive Health Behaviors” was updated to ica emphasize the importance of screening transporter (SGLT) inhibition being asso- include health-related quality of life as an for behavioral health concerns at the ciated with ketoacidosis under certain outcome when using behavioral health same time points as evaluating the need conditions. It provides guidance on aware- strategies to support self-management and for DSMES. ness, prevention, risk mitigation, and die- healthy behaviors. Recommendation 5.45 in “Psychosocial er Language in Recommendation 5.5 was tary adjustments. updated to state that DSMES should be Recommendation 5.29 was added to Care” was revised to state the specific psy- culturally appropriate and responsive to encourage intake of plant-based proteins chosocial concerns health care professio- and fiber, and Recommendation 5.31 was m individual preferences, needs, and values. n