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1.0.0.0In­tro­duc­tion:

1.1.0.0 Overview

Di­a­betes is a com­plex, chron­ic ill­ness re­quir­ing con­tin­u­ous med­i­cal care with mul­ti­fac­to­ri­al risk-‍re­duc­tion strate­gies be­yond glycemic con­trol. On­go­ing pa­tient self-‍man­age­ment ed­u­ca­tion and sup­port are crit­i­cal to pre­vent­ing acute com­pli­ca­tions and re­duc­ing the risk of long-‍term com­pli­ca­tions. Significant ev­i­dence ex­ists that sup­ports a range of in­ter­ven­tions to im­prove di­a­betes out­comes. The Amer­i­can Di­a­betes As­so­ci­a­tion’s (ADA’s) “Stan­dards of Med­i­cal Care in Di­a­betes,”re­ferred to as the Stan­dards of Care, is in­tend­ed to pro­vide clin­i­cians, pa­tients, re­searchers, pay­ers, and other in­ter­est­ed in­di­vid­u­als with the com­po­nents of di­a­betes care, gen­er­al treat­ment goals, and tools to eval­u­ate the qual­i­ty of care. The Stan­dards of Care rec­om­men­da­tions are not in­tend­ed to pre­clude clin­i­cal judg­ment and must be ap­plied in the con­text of ex­cel­lent clin­i­cal care, with ad­just­ments for in­di­vid­u­al pref­er­ences, co­mor­bidi­ties, and other pa­tient fac­tors. For more de­tailed in­for­ma­tion about man­age­ment of di­a­betes, please refer to Med­i­cal Man­age­ment of Type 1 Di­a­betes (1) and Med­i­cal Man­age­ment of Type 2 Di­a­betes (2). The rec­om­men­da­tions in­clude screen­ing, di­ag­nos­tic, and ther­a­peu­tic ac­tions that are known or be­lieved to fa­vor­ably af­fect health out­comes of pa­tients with di­a­betes. Many of these in­ter­ven­tions have also been shown to be cost-‍ef­fec­tive (3).

The ADA strives to im­prove and up­date the Stan­dards of Care to en­sure that clin­i­cians, health plans, and pol­i­cy mak­ers can con­tin­ue to rely on them as the most au­thor­i­ta­tive and cur­rent guide­lines for di­a­betes care. To im­prove ac­cess, the Stan­dards of Care is now avail­able through ADA’s new in­ter­ac­tive app, along with tools and cal­cu­la­tors that can help guidepa­tientcare. To down­load the app, please visit pro­fes­sion­al.di­a­betes.org/‍SOCapp. Read­ers who wish to com­ment on the 2019 Stan­dards of Care are in­vit­ed to do so at pro­fes­sion­al.di­a­betes.org/‍SOC.

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1.2.0.0 ADA Stan­dards, State­ments, Re­ports, and Re­views

The ADA has been ac­tive­ly in­volved in the de­vel­op­ment and dis­sem­i­na­tion of di­a­betes care stan­dards, guide­lines, and re­lat­ed doc­u­ments for over 25 years. The ADA’s clin­i­cal prac­tice rec­om­men­da­tions are viewed as im­por­tant re­sources for health care pro­fes­sion­als who care for peo­ple with di­a­betes.

Stan­dards of Care

This doc­u­ment is an official ADA po­si­tion, is au­thored by the ADA, and pro­vides all of the ADA’s cur­rent clin­i­cal prac­tice rec­om­men­da­tions.

To up­date the Stan­dards of Care, the ADA’s Pro­fes­sion­al Prac­tice Com­mit­tee (PPC) per­forms an ex­ten­sive clin­i­cal di­a­betes lit­er­a­ture search, sup­ple­ment­ed with input from ADA staff and the med­i­cal com­mu­ni­ty at large. The PPC up­dates the Stan­dards of Care an­nu­al­ly. How­ev­er, the Stan­dards of Care is a “liv­ing” doc­u­ment, where no­table up­dates are in­cor­po­rat­ed on­line should the PPC de­ter­mine that new ev­i­dence or reg­u­la­to­ry changes (e.g., drug ap­provals, label changes) merit im­me­di­ate in­clu­sion. More in­for­ma­tion on the liv­ing Stan­dards” can be found on Di­a­betesPro at pro­fes­sion­al.di­a­betes.org/content-page/liv­ing-stan­dards. The Stan­dards of Care su­per­sedes all pre­vi­ous ADA po­si­tion state­ments­dand the rec­om­men­da­tions therein­don clin­i­cal top­ics with­in the purview of the Stan­dards of Care; ADA po­si­tion state­ments, while still con­tain­ing valu­able anal­y­sis, should not be con­sid­ered the ADA’s cur­rent po­si­tion. The Stan­dards of Care re­ceives an­nu­al re­view and ap­proval by the ADA Board of Di­rec­tors.

ADA State­ment

An ADA state­ment is an official ADA point of view or be­lief that does not con­tain clin­i­cal prac­tice rec­om­men­da­tions and may be is­sued on ad­vo­ca­cy, pol­i­cy, eco­nom­ic, or med­i­cal is­sues re­lat­ed to di­a­betes.

ADA state­ments un­der­go a for­mal re­view pro­cess, in­clud­ing a re­view by the ap­pro­pri­ate na­tion­al com­mit­tee, ADA mis­sion staff, and the ADA Board of Di­rec­tors.

Con­sen­sus Re­port

A con­sen­sus re­port of a par­tic­u­lar topic con­tains a com­pre­hen­sive ex­am­i­na­tion and is au­thored by an ex­pert panel (i.e., con­sen­sus panel) and rep­re­sents the panel’s col­lec­tive anal­y­sis, eval­u­a­tion, and opin­ion.

The need for a con­sen­sus re­port aris­es when clin­i­cians, sci­en­tists, reg­u­la­tors, and/‍or pol­i­cy mak­ers de­sire guid­ance and/‍or clar­i­ty on a med­i­cal or sci­en­tific issue re­lat­ed to di­a­betes for which the ev­i­dence is con­tra­dic­to­ry, emerg­ing, or in­com­plete. Con­sen­sus re­ports may also high­light gaps in ev­i­dence and pro­pose areas of fu­ture re­search to ad­dress these gaps. A con­sen­sus re­port is not an ADA po­si­tion and rep­re­sents ex­pert opin­ion only but is pro­duced under the aus­pices of the As­so­ci­a­tion by in­vit­ed ex­perts. A con­sen­sus re­port may be de­vel­oped after an ADA Clin­i­cal Con­fer­ence or Re­search Sym­po­sium.

Sci­en­tific Re­view

A sci­en­tific re­view is a bal­anced re­view and anal­y­sis of the lit­er­a­ture on a sci­en­tific or med­i­cal topic re­lat­ed to di­a­betes. A sci­en­tific re­view is not an ADA po­si­tion and does not con­tain clin­i­cal prac­tice rec­om­men­da­tions but is pro­duced under the aus­pices of the As­so­ci­a­tion by in­vit­ed ex­perts. The sci­en­tific re­view may pro­vide a sci­en­tific ra­tio­nale for clin­i­cal prac­tice rec­om­men­da­tions in the Stan­dards of Care. The cat­e­go­ry may also in­clude task force and ex­pert com­mit­tee re­ports.

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1.3.0.0 Grad­ing of Sci­en­tific Ev­i­dence

Since the ADA first began pub­lish­ing prac­tice guide­lines, there has been con­sid­er­able evo­lu­tion in the eval­u­a­tion of sci­en­tific ev­i­dence and in the de­vel­op­ment of ev­i­dence-‍based guide­lines. In 2002, the ADA de­vel­oped a clas­sification sys­tem to grade the qual­i­ty of sci­en­tific ev­i­dence sup­porting ADA rec­om­men­da­tions. A 2015 anal­y­sis of the ev­i­dence cited in the Stan­dards of Care found steady im­provement in qual­i­ty over the pre­vi­ous 10 years, with the 2014 Stan­dards of Care for the first time hav­ing the ma­jor­i­ty of bul­let­ed rec­om­men­da­tions sup­ported by A- or B-‍level ev­i­dence (4). A grad­ing sys­tem (Table 1) de­vel­oped by the ADA and mo­de­led after ex­ist­ing meth­ods was used to clar­i­fy and cod­i­fy the ev­i­dence that forms the basis for the rec­om­men­da­tions. ADA rec­om­men­da­tions are as­signed rat­ings of A, B, or C, de­pend­ing on the qual­i­ty of ev­i­dence. Ex­pert opin­ion E is a sep­a­rate cat­e­go­ry for rec­om­men­da­tions in which there is no ev­i­dence from clin­i­cal tri­als, in which clin­i­cal tri­als may be im­prac­ti­cal, or in which there is conflict­ing ev­i­dence. Rec­om­men­da­tions with an A rat­ing are based on large well-‍de­signed clin­i­cal tri­als or well-‍done meta-‍anal­y­ses. Gen­er­al­ly, these rec­om­men­da­tions have the best chance of im­prov­ing out­comes when ap­plied to the pop­u­la­tion to which they are ap­pro­pri­ate. Rec­om­men­da­tions with lower lev­els of ev­i­dence may be equal­ly im­por­tant but are not as well sup­ported. Of course, ev­i­dence is only one com­po­nent of clin­i­cal de­ci­sion mak­ing. Clin­i­cians care for pa­tients, not pop­u­la­tions; guide­lines must al­ways be in­ter­pret­ed with the in­di­vid­u­al pa­tient in mind. In­di­vid­u­al cir­cum­stances, such as co­mor­bid and coex­ist­ing dis­eases, age, ed­u­ca­tion, dis­abil­i­ty, and, above all, pa­tients’ val­ues and pref­er­ences, must be con­sid­ered and may lead to dif­fer­ent treat­ment tar­gets and strate­gies. Fur­ther­more, con­ven­tion­al ev­i­dence hi­er­ar­chies, such as the one adapt­ed by the ADA, may miss nu­ances im­por­tant in di­a­betes care. For ex­am­ple, al­though there is ex­cel­lent ev­i­dence from clin­i­cal tri­als sup­porting the im­por­tance of achiev­ing mul­ti­ple risk fac­tor con­trol, the op­ti­mal way to achieve this re­sult is less clear. It is difficult to as­sess each com­po­nent of such a com­plex in­ter­ven­tion.

Table 1—ADA ev­i­dence-‍grad­ing sys­tem for “Stan­dards of Med­i­cal Care in Di­a­betes”

Table 1

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1.4.0.0Ref­er­ences

  1. Amer­i­can Di­a­betes As­so­ci­a­tion. Med­i­cal Man­age­ment of Type 1 Di­a­betes. 7th ed. Wang CC, Shah AC, Eds. Alexan­dria, VA, Amer­i­can Di­a­betes As­so­ci­a­tion, 2017

  2. Amer­i­can Di­a­betes As­so­ci­a­tion. Med­i­cal Man­age­ment of Type 2 Di­a­betes. 7th ed. Bu­rant CF, Young LA, Eds. Alexan­dria, VA, Amer­i­can Di­a­betes As­so­ci­a­tion, 2012
  3. Li R, Zhang P, Bark­er LE, Chowd­hury FM, Zhang X. Cost-‍ef­fec­tive­ness of in­ter­ven­tions to pre­vent and con­trol di­a­betes mel­li­tus: a sys­tematic re­view. Di­a­betes Care 2010;33:1872– 1894
  4. Grant RW, Kirk­man MS. Trends in the ev­i­dence level for the Amer­i­can Di­a­betes As­so­ci­a­tion’s “Stan­dards of Med­i­cal Care in Di­a­betes” from 2005 to 2014. Di­a­betes Care 2015;38:6–8

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2.0.0.0 Pro­fes­sion­al Prac­tice Com­mit­tee

The Pro­fes­sion­al Prac­tice Com­mit­tee (PPC) of the Amer­i­can Di­a­betes As­so­ci­a­tion (ADA) is re­spon­si­ble for the “Stan­dards of Med­i­cal Care in Di­a­betes,” re­ferred to as the Stan­dards of Care. The PPC is a mul­ti­dis­ci­plinary ex­pert com­mit­tee com­prised of physi­cians, di­a­betes ed­u­ca­tors, and oth­ers who have ex­pertise in a range of areas, in­clud­ing adult and pe­di­atric en­docrinol­o­gy, epi­demi­ol­o­gy, pub­lic health, lipid re­search, hy­per­ten­sion, pre­con­cep­tion plan­ning, and preg­nan­cy care. Ap­point­ment to the PPC is based on ex­cel­lence in clin­i­cal prac­tice and re­search. Al­though the pri­ma­ry role of the PPC is to re­view and up­date the Stan­dards of Care, it may also be in­volved in ADA state­ments, re­ports, and re­views.

The ADA ad­he­res to the Na­tion­al Acade­my of Medicine Stan­dards for De­vel­op­ing Trust­wor­thy Clin­i­cal Prac­tice Guide­lines. All mem­bers of the PPC are re­quired to dis­close po­ten­tial conflicts of in­ter­est with in­dus­try and/‍or other rel­e­vant or­ga­ni­za­tions. These dis­clo­sures are dis­cussed at the onset of each Stan­dards of Care re­vi­sion meet­ing. Mem­bers of the com­mit­tee, their em­ploy­ers, and their dis­closed conflicts of in­ter­est are list­ed in the “Dis­clo­sures: Stan­dards of Med­i­cal Care in Di­a­betes – 2019” table (see pp. S184–S186). The ADA funds de­vel­op­ment of the Stan­dards of Care out of its gen­er­al rev­enues and does not use in­dus­try sup­port for this pur­pose.

For the cur­rent re­vi­sion, PPC mem­bers sys­tematically searched MED­LINE for human stud­ies re­lat­ed to each sec­tion and pub­lished since 15 Oc­to­ber 2017. Rec­om­men­da­tions were re­vised based on new ev­i­dence or, in some cases, to clar­i­fy the prior rec­om­men­da­tion or match the strength of the word­ing to the strength of the ev­i­dence. A table link­ing the changes in rec­om­men­da­tions to new ev­i­dence can be re­viewed at pro­fes­sion­al.di­a­betes.org/‍SOC. The Stan­dards of Care was ap­proved by ADA’s Board of Di­rec­tors, which in­cludes health care pro­fes­sion­als, sci­en­tists, and lay peo­ple. Feed­back from the larg­er clin­i­cal com­mu­ni­ty was valu­able for the 2018 re­vi­sion of the Stan­dards of Care. Read­ers who wish to com­ment on the 2019 Stan­dards of Care are in­vit­ed to do so at pro­fes­sion­al .di­a­betes.org/‍SOC.

The PPC would like to thank the fol­low­ing in­di­vid­u­als who pro­vided their ex­pertise in re­viewing and/‍or con­sult­ing with the com­mit­tee: Ann Al­bright, PhD, RD; Pamela All­weiss, MD, MPH; Bar­bara J. An­der­son, PhD; George Bakris, MD; Richard Bergen­stal, MD; Stu­art Brink, MD; Do­nald R. Cous­tan, MD; Ellen D. Davis, MS, RN, CDE, FAADE; Jesse Dinh, Phar­mD; Steven Edel­man, MD; Barry H. Gins­berg, MD, PhD; Irl B. Hirsch, MD; Scott Kahan, MD, MPH; David Klonoff, MD; Joyce Lee, MD, MPH; Randie Lit­tle, PhD; Alexan­dra Migdal, MD; Anne Pe­ters, MD; Amy Roth­berg, MD; Jen­nifer Sherr, MD, PhD; Hood Thabit, MB, BCh, MD, PhD; Stu­art Alan Weinz­imer, MD; and Neil White, MD.

Mem­bers of the PPC

Joshua J. Neu­miller, Phar­mD, CDE, FASCP* (Chair)

Christo­pher P. Can­non, MD Jill Cran­dall, MD

David D’Alessio, MD

Ian H. de Boer, MD, MS* Mary de Groot, PhD Ju­dith Frad­kin, MD

Kathryn Evans Krei­der, DNP, APRN, FNP-‍BC, BC-‍ADM

David Maahs, MD, PhD Nisa Maruthur, MD, MHS Medha N. Mun­shi, MD*

Maria Jose Re­don­do, MD, PhD, MPH Guiller­mo E. Umpier­rez, MD, CDE, FACE, FACP*

Jen­nifer Wyck­off, MD

*Sub­group lead­ers

ADA Nu­tri­tion Con­sen­sus Re­port Writ­ing GroupdLi­ai­son

Melin­da Maryniuk, MEd, RDN, CDE

Amer­i­can Col­lege of Car­di­ol­o­gy­d­Des­ig­nat­ed Rep­re­sen­ta­tives (Sec­tion 10)

Sandeep Das, MD, MPH, FACC Mikhail Kosi­borod, MD, FACC

ADA Staff

Erika Gebel Berg, PhD (cor­re­spond­ing au­thor: eberg@di­a­betes.org) Mindy Sara­co, MHA

Matthew P. Pe­tersen Sacha Uel­men, RDN, CDE

Sham­era Robin­son, MPH, RDN William T. Ce­falu, MD

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3.0.0.0 Sum­ma­ry of Re­vi­sions 2019

3.1.0.0 Gen­er­al Changes

The field of di­a­betes care is rapid­ly chang­ing as new re­search, tech­nol­o­gy, and treat­ments that can im­prove the health and well-‍being of peo­ple with di­a­betes con­tin­ue to emerge. With an­nu­al up­dates since 1989, the Amer­i­can Di­a­betes As­so­ci­a­tion (ADA) has long been a lead­er in pro­duc­ing guide­lines that cap­ture the most cur­rent state of the field. To that end, the “Stan­dards of Med­i­cal Care in Di­a­betes” (Stan­dards of Care) now in­cludes a ded­i­cat­ed sec­tion on Di­a­betes Tech­nol­o­gy, which con­tains preex­ist­ing ma­te­ri­al that was pre­vi­ously in other sec­tions that has been con­sol­i­dat­ed, as well as new rec­om­men­da­tions. An­oth­er gen­er­al change is that each rec­om­men­da­tion is now as­so­ci­at­ed with a num­ber (i.e., the sec­ond rec­om­men­da­tion in Sec­tion 7 is now rec­om­men­da­tion 7.2). Fi­nal­ly, the order of the pre­vention sec­tion was changed (from Sec­tion 5 to Sec­tion 3) to fol­low a more log­i­cal pro­gres­sion.

Al­though lev­els of ev­i­dence for sev­er­al rec­om­men­da­tions have been up­dated, these changes are not ad­dressed below as the clin­i­cal rec­om­men­da­tions have re­mained the same. Changes in ev­i­dence level from, for ex­am­ple, E to Care not noted below. The 2019 Stan­dards of Care con­tains, in ad­di­tion to many minor changes that clar­i­fy rec­om­men­da­tions or reflect new ev­i­dence, the fol­low­ing more sub­stan­tive re­vi­sions.

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3.2.0.0.Sec­tion Changes

3.2.1.0 Sec­tion 1

Ad­di­tion­al in­for­ma­tion was in­cluded on the finan­cial costs of di­a­betes to in­di­vid­u­als and so­ci­ety.

Be­cause telemedicine is a grow­ing field that may in­crease ac­cess to care forpa­tients withdi­a­betes, dis­cus­sion was added on its use to fa­cil­i­tate re­mote de­liv­ery of health-‍re­lat­ed ser­vices and clin­i­cal in­for­ma­tion.

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3.2.2.0 Sec­tion 2

Based on new data, the cri­te­ria for the

di­ag­no­sis of di­a­betes was changed to in­clude two ab­nor­mal test re­sults from the same sam­ple (i.e., fast­ing plas­ma glu­cose and A1C from same sam­ple). The sec­tion was re­or­ga­nized to im­prove flow and re­duce re­dun­dan­cy. Ad­di­tion­al con­di­tions were iden­tified that may af­fect A1C test ac­cu­ra­cy in­clud­ing the post­par­tum period.

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3.2.3.0 Sec­tion 3

This sec­tion was moved (pre­vi­ously it was Sec­tion 5) and is now lo­cat­ed be­fore the Lifestyle Man­age­ment sec­tion to bet­ter reflect the pro­gres­sion of type 2 di­a­betes. The nu­tri­tion sec­tion was up­dated to high­light the im­por­tance of weight loss for those at high risk for de­vel­op­ing type 2 di­a­betes who have over­weight or obe­sity.

Be­cause smok­ing may in­crease the risk of type 2 di­a­betes, a sec­tion on to­bac­co use and ces­sa­tion was added.

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3.2.4.0 Sec­tion 4

On the basis of a new con­sen­sus re­port on di­a­betes and lan­guage, new text was added to guide health care pro­fes­sion­als’ use of lan­guage to com­mu­ni­cate about di­a­betes with peo­ple with di­a­betes and pro­fes­sion­al au­di­ences in an in­for­ma­tive, em­pow­er­ing, and ed­u­ca­tional style.

A new figure from the ADA-‍Eu­ro­pean As­so­ci­a­tion for the Study of Di­a­betes(EASD) con­sen­sus re­port about the di­a­betes care de­ci­sion cycle was added to em­pha­size the need for on­go­ing as­sessment and shared de­ci­sion mak­ing to achieve the goals of health care and avoid clin­i­cal in­er­tia.

A new rec­om­men­da­tion was added to ex­p­li­cit­ly call out the im­por­tance of the di­a­betes care team and to list the pro­fes­sion­als that make up the team.

The table list­ing the com­po­nents of a com­pre­hen­sive med­i­cal eval­u­a­tion was re­vised, and the sec­tion on as­sessment and plan­ning was used to cre­ate a new table (Table 4.2).

A new table was added list­ing fac­tors that in­crease risk of treat­ment-‍as­so­ci­at­ed hy­po­glycemia (Table 4.3).

A rec­om­men­da­tion was added to in­clude the 10-year atheroscle­rot­ic car­dio­vas­cu­lar dis­ease (ASCVD) risk as part of over­all risk as­sessment.

The fatty liver dis­ease sec­tion was re­vised to in­clude up­dated text and a new rec­om­men­da­tion re­gard­ing when to test for liver dis­ease.

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3.2.5.0 Sec­tion 5

Ev­i­dence con­tin­ues to sug­gest that there is not an ideal per­cent­age of calo­ries from car­bo­hy­drate, pro­tein, and fat for all peo­ple with di­a­betes. There­fore, more dis­cus­sion was added about the im­por­tance of macronu­tri­ent dis­tri­bu­tion based on an in­di­vid­u­alized as­sessment of cur­rent eat­ing pat­terns, pref­er­ences, and metabol­ic goals. Ad­di­tion­al con­sid­er­a­tions were added to the eat­ing pat­terns, macronu­tri­ent dis­tri­bu­tion, and meal plan­ning sec­tions to bet­ter iden­tify can­di­dates for meal plans, specif­i­cal­ly for low-‍car­bo­hy­drate eat­ing pat­terns and peo­ple who are preg­nant or lac­tat­ing, who have or are at risk for dis­or­dered eat­ing, who have renal dis­ease, and who are tak­ing sodi­um–glu­cose co­trans­porter 2 in­hibitors. There is not a one-‍size-‍fits-‍all eat­ing pat­tern for in­di­vid­u­als with di­a­betes, and meal plan­ning should be in­di­vid­u­alized.

A rec­om­men­da­tion was modified to en­cour­age peo­ple with di­a­betes to de­crease con­sump­tion of both sugar sweet­ened and nonnutritive-sweet­ened bev­er­ages and use other al­ter­na­tives, with an em­pha­sis on water intake.

The sodi­um con­sump­tion rec­om­men­da­tion was modified to elim­i­nate the fur­ther re­stric­tion that was po­ten­tially in­di­cat­ed for those with both di­a­betes and hy­per­ten­sion.

Ad­di­tion­al dis­cus­sion was added to the phys­i­cal ac­tiv­i­ty sec­tion to in­clude the benefit of a va­ri­ety of leisure-‍time phys­i­cal ac­tiv­i­ties and flex­i­bil­i­ty and bal­ance ex­er­cis­es. The dis­cus­sion about e-‍cigarettes was ex­pand­ed to in­clude more on pub­lic per­cep­tion and how their use to aide smok­ing ces­sa­tion was not more effec-‍

tive than “usual care.”

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3.2.6.0 Sec­tion 6

This sec­tion now be­gins with a dis­cus­sion of A1C tests to high­light the cen­tral­i­ty of A1C test­ing in glycemic man­age­ment. The self-‍mon­i­tor­ing of blood glu­cose and con­tin­u­ous glu­cose mon­i­tor­ing text and rec­om­men­da­tions were moved to the new Di­a­betes Tech­nol­o­gy sec­tion.

To em­pha­size that the risks and benefits of glycemic tar­gets can change as di­a­betes pro­gress­es and pa­tients age, a rec­om­men­da­tion was added to reeval­u­ate glycemic tar­gets over time.

The sec­tion was modified to align with the liv­ing Stan­dards up­dates made in April 2018 re­gard­ing the con­sen­sus defini­tion of hy­po­glycemia.

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3.2.7.0 Sec­tion 7

This new sec­tion in­cludes new rec­om­men­da­tions, the self-‍mon­i­tor­ing of blood glu­cose sec­tion for­mer­ly in­cluded in Sec­tion 6 “Glycemic Tar­gets,” and a dis­cus­sion of in­sulin de­liv­ery de­vices (sy­ringes, pens, and in­sulin pumps), blood glu­cose me­ters, con­tin­u­ous glu­cose mon­i­tors (real-‍time and in­ter­mit­tent­ly scanned [“flash”]), and au­to­mat­ed in­sulin de­liv­ery de­vices.

The rec­om­men­da­tion to use selfmon­i­tor­ing of blood glu­cose in peo­ple who are not using in­sulin was changed to ac­knowl­edge that rou­tine glu­cose mon­i­tor­ing is of lim­it­ed ad­di­tional clin­i­cal benefit in this pop­u­la­tion.

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3.2.8.0 Sec­tion 8

A rec­om­men­da­tion was modified to

ac­knowl­edge the benefits of track­ing weight, ac­tiv­i­ty, etc., in the con­text of achiev­ing and main­tain­ing a healthy weight.

A brief sec­tion was added on med­i­cal de­vices for weight loss, which are not cur­rently rec­om­mend­ed due to lim­it­ed data in peo­ple with di­a­betes.

The rec­om­men­da­tions for metabol­ic surgery were modified to align with re­cent guide­lines, cit­ing the im­por­tance of con­sid­er­ing co­mor­bidi­ties be­yond di­a­betes when con­tem­plat­ing the ap­pro­pri­ateness of metabol­ic surgery for a given pa­tient.

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3.2.9.0 Sec­tion 9

The sec­tion on the phar­ma­co­log­ic treat­ment of type 2 di­a­betes was significant­ly changed to align, as per the liv­ing Stan­dards up­date in Oc­to­ber 2018, with the ADA-‍EASD con­sen­sus re­port on this topic, sum­ma­rized in the new Figs. 9.1 and 9.2. This in­cludes con­sid­er­a­tion of key pa­tient fac­tors:

a) im­por­tant co­mor­bidi­ties such as ASCVD, chron­ic kid­ney dis­ease, and heart fail­ure, b) hy­po­glycemia risk, c) ef­fects on body weight, d side ef­fects, e) costs, and f) pa­tient pref­er­ences. To align with the ADA-‍EASD con­sen­sus re­port, the ap­proach to in­jectable med­i­ca­tion ther­a­py was re­vised (Fig. 9.2). A rec­om­men­da­tion that, for most pa­tients who need the greater efficacy of an in­jectable med­i­ca­tion, a glucagon-‍like pep­tide 1 re­cep­tor ag­o­nist should be the first choice, ahead of in­sulin.

A new sec­tion was added on in­sulin in­jec­tion tech­nique, em­pha­siz­ing the im­por­tance of tech­nique for ap­pro­pri­ate in­sulin dos­ing and the avoid­ance of com­pli­ca­tions (lipodys­tro­phy, etc.).

The sec­tion on nonin­sulin phar­ma­co­log­ic treat­ments for type 1 di­a­betes was ab­bre­vi­at­ed, as these are not gen­er­ally rec­om­mend­ed.

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3.2.10.0 Sec­tion 10

For the first time, this sec­tion is en­dorsed

by the Amer­i­can Col­lege of Car­di­ol­o­gy. Ad­di­tion­al text was added to ac­knowl­edge heart fail­ure as an im­por­tant type of car­dio­vas­cu­lar dis­ease in peo­ple with di­a­betes for con­sid­er­a­tion when de­ter­min­ing op­ti­mal di­a­betes care.

The blood pres­sure rec­om­men­da­tions were modified to em­pha­size the im­por­tance of in­di­vid­u­alization of tar­gets based on car­dio­vas­cu­lar risk.

A dis­cus­sion of the ap­pro­pri­ate use of the ASCVD risk cal­cu­la­tor was in­cluded, and rec­om­men­da­tions were modified to in­clude as­sessment of 10-year ASCVD risk as part of over­all risk as­sessment and in de­ter­min­ing op­ti­mal treat­ment ap­proaches.

The rec­om­men­da­tion and text re­gard­ing the use of as­pirin in pri­ma­ry pre­vention was up­dated with new data.

For align­ment with the ADA-‍EASDcon­sen­sus re­port, two rec­om­men­da­tions were added for the use of med­i­ca­tions thathave proven car­dio­vas­cu­lar benefit in peo­ple with ASCVD, with and with­out heart fail­ure.

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3.2.11.0 Sec­tion 11

To align with the ADA-‍EASD con­sen­sus

re­port, a rec­om­men­da­tion was added for peo­ple with type 2 di­a­betes and chron­ic kid­ney dis­ease to con­sid­er agents with proven benefit with re­gard to renal out­comes.

The rec­om­men­da­tion on the use of telemedicine in reti­nal screen­ing was modified to ac­knowl­edge the util­i­ty of this ap­proach, so long as ap­pro­pri­ate re­fer­rals are made for a com­pre­hen­sive eye ex­am­i­na­tion.

Gabapentin was added to the list of agents to be con­sid­ered for the treat­ment of neu­ro­path­ic pain in peo­ple with di­a­betes based on data on efficacy and the po­ten­tial for cost sav­ings.

The gas­tro­pare­sis sec­tion in­cludes a dis­cus­sion of a few ad­di­tional treat­ment modal­i­ties.

The rec­om­men­da­tion for pa­tients with di­a­betes to have their feet in­spect­ed at every visit was modified to only in­clude those at high risk for ul­cer­a­tion. An­nu­al ex­am­i­na­tions re­main rec­om­mend­ed for ev­ery­one.

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3.2.12.0 Sec­tion 12

A new sec­tion and rec­om­men­da­tion on lifestyle man­age­ment was added to ad­dress the unique nu­tri­tional and phys­i­cal ac­tiv­i­ty needs and con­sid­er­a­tions for older adults. With­in the phar­ma­co­log­ic ther­a­py dis­cus­sion, dein­ten­sification of in­sulin regimes was in­tro­duced to help sim­pli­fy in­sulin reg­i­men to match in­di­vid­u­al’s self-‍man­age­ment abil­i­ties. A new figure was added (Fig. 12.1) that pro­vides a path for sim­plification. A new table was also added (Table 12.2) to help guide pro­viders con­sid­er­ing med­i­ca­tion reg­i­men sim­plification and dein­ten­sification/‍deprescribing in older adults with di­a­betes.

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3.2.13.0 Sec­tion 13

In­tro­duc­to­ry lan­guage was added to the be­gin­ning of this sec­tion re­mind­ing the read­er that the epi­demi­ol­o­gy, patho­phys­i­ol­o­gy, de­vel­op­mental con­sid­er­a­tions, and re­sponse to ther­a­py in pe­di­atric-‍onset di­a­betes are dif­fer­ent from adult di­a­betes, and that there are also dif­fer­ences in rec­om­mend­ed care for chil­dren and ado­les­cents with type 1 as op­posed to type 2 di­a­betes.

A rec­om­men­da­tion was added to em­pha­size the need for dis­or­dered eat­ing screen­ing in youth with type 1 di­a­betes be­gin­ning at 10–12 years of age.

Based on new ev­i­dence, a rec­om­men­da­tion was added dis­cour­ag­ing e-‍cigarette use in youth.

The dis­cus­sion of type 2 di­a­betes in chil­dren and ado­les­cents was significant­ly ex­pand­ed, with new rec­om­men­da­tions in a num­ber of areas, in­clud­ing screen­ing and di­ag­no­sis, lifestyle man­age­ment, phar­ma­co­log­ic man­age­ment, and tran­si­tion of care to adult pro­viders. New sec­tions and/‍or rec­om­men­da­tions for type 2 di­a­betes in chil­dren and ado­les­cents were added for glycemic tar­gets, metabol­ic surgery, nephropa­thy, neu­ropa­thy, retinopa­thy, non­al­co­holic fatty liver dis­ease, ob­struc­tive sleep apnea, poly­cys­tic ovary syn­drome, car­dio­vas­cu­lar dis­ease, dys­lipi­demia, car­diac func­tion test­ing, and psy­choso­cial fac­tors. Fig­ure 13.1 was added to pro­vide guid­ance on the man­age­ment of di­a­betes in over­weight youth.

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3.2.14.0 Sec­tion 14

Women with preex­ist­ing di­a­betes are now rec­om­mend­ed to have their care man­aged in a mul­ti­dis­ci­plinary clin­ic to im­prove di­a­betes and preg­nan­cy out­comes.

Greater em­pha­sis has been placed on the use of in­sulin as the pre­ferred med­i­ca­tion for treat­ing hy­per­glycemia in ges­ta­tion­al di­a­betes mel­li­tus as it does not cross the pla­cen­ta to a mea­sur­able ex­tent and how met­formin and gly­buride should not be used as first­line agents as both cross the pla­cen­ta to the fetus.

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3.2.15.0 Sec­tion 15

Be­cause of their abil­i­ty to im­prove hos­pi­tal readmis­sion rates and cost of care, a new rec­om­men­da­tion was added call­ing for pro­viders to con­sid­er con­sult­ing with a spe­cial­ized di­a­betes or glu­cose man­age­ment team where pos­si­ble when car­ing for hos­pi­talized pa­tients with di­a­betes.

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3.2.16.0 Sec­tion 16

The “In­sulin Ac­cess and Affordabil­i­ty Work­ing Group: Con­clu­sions andRec­om­men­da­tions” ADA state­ment was added to this sec­tion. Pub­lished in 2018, this state­ment com­piled pub­lic in­for­ma­tion and con­vened a se­ries of meet­ings with stake­hold­ers through­out the in­sulin sup­ply chain to learn how each en­ti­ty af­fects the cost of in­sulin for the con­sumer, an im­por­tant topic for the ADA and peo­ple liv­ing with di­a­betes.