Introduction and Methodology: Standards of Care in Diabetes—2025

Diabetes is a complex, chronic condition requiring continuous medical care with comprehensive risk-reduction strategies beyond glycemic management. Ongoing diabetes self-management education and support are critical to empowering people, 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 (ADA) “Standards of Care in Diabetes,” referred to here as the Standards of Care, serves as a comprehensive resource to clinicians, researchers, policy makers, and other stakeholders. It outlines key elements of diabetes care, sets treatment goals, and provides tools to assess care quality, all aimed at improving diabetes care and outcomes across diverse populations.

The ADA Professional Practice Committee (PPC) updates the Standards of Care annually and includes discussion of emerging clinical considerations in the text, and as evidence evolves, clinical guidance is added to the recommendations in the Standards of Care. The Standards of Care is a “living” document where important updates are published online should the PPC determine that new evidence or regulatory changes (e.g., drug or technology approvals, label changes) merit immediate inclusion. More information on the “Living Standards” can be found on the ADA professional website DiabetesPro at professional.diabetes.org/standards-of-care/living-standards-update. The Standards of Care supersedes all previously published ADA statements—and the recommendations therein—on clinical topics within the purview of the Standards of Care; while still containing valuable analysis, ADA statements should not be considered the current position of the ADA. The Standards of Care receives annual review and approval by the ADA Board of Directors and is reviewed by the ADA scientific team and clinical leadership. The Standards of Care also undergoes external peer review annually.

The recommendations in the Standards of Care include screening, diagnostic, and therapeutic actions that are scientifically proved or known based on expert clinical practice or believed to favorably affect health outcomes of people with diabetes. They also cover the prevention, screening, diagnosis, and management of diabetes-associated complications and comorbidities. The recommendations encompass care throughout the life span for youth (children aged birth to 11 years and adolescents aged 12–17 years), adults (aged 18–64 years), and older adults (aged ≥65 years). The recommendations cover the management of type 1 diabetes, type 2 diabetes, gestational diabetes mellitus, and other types of diabetes and/or hyperglycemic conditions.

The Standards of Care does not provide comprehensive treatment plans for complications associated with diabetes, such as diabetic retinopathy or diabetic foot ulcers, but offers guidance on how and when to screen for diabetes complications, management of complications in the primary care and diabetes care settings, and referral to specialists as appropriate. Similarly, regarding the psychosocial and behavioral health factors often associated with diabetes and that can affect diabetes care, the Standards of Care provides guidance on how and when to screen, management in the primary care and diabetes care settings, and referral but does not provide comprehensive management plans for conditions that require specialized care, such as mental illness.

The intended audience for the Standards of Care includes primary care physicians, endocrinologists, nurse practitioners, physician associates/assistants, pharmacists, registered dietitian nutritionists, diabetes care and education specialists, and all members of the diabetes care team. The Standards of Care also provides guidance to specialists caring for people with diabetes and its multitude of complications, such as cardiologists, nephrologists, emergency physicians, internists, pediatricians, psychologists, neurologists, ophthalmologists, and podiatrists. Additionally, these recommendations help payors, policy makers, researchers, research funding organizations, and advocacy groups to align their policies and resources and deliver optimal care for people living with diabetes.

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 it as the most authoritative source for current guidelines for diabetes care. The Standards of Care recommendations are not intended to preclude clinical judgment. They 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 the management of diabetes, please refer to Medical Management of Type 1 Diabetes (1) and Medical Management of Type 2 Diabetes (2).

The Standards of Care includes discussion of evidence and clinical practice recommendations intended to optimize care for people with diabetes by assisting health care professionals and individuals in making shared decisions about diabetes care. The recommendations are informed by a systematic review of evidence and an assessment of the benefits and risks of alternative care options.

The PPC of the ADA is responsible for the Standards of Care content. The PPC is an interprofessional expert committee comprising physicians, nurse practitioners, pharmacists, diabetes care and education specialists, registered dietitian nutritionists, behavioral health scientists, and others who have expertise in a range of areas including but not limited to adult and pediatric endocrinology, epidemiology, public health, behavioral health, cardiovascular risk management, microvascular complications, nephrology, neurology, ophthalmology, podiatry, clinical pharmacology, preconception and pregnancy care, weight management and diabetes prevention, and use of technology in diabetes management. Each year, ADA conducts a national call for applications to recruit members of the PPC. Appointment to the PPC is based on excellence in clinical practice and research, with attention to appropriate representation of members based on considerations including but not limited to demographic, geographic, work setting, or identity characteristics (e.g., gender, race and ethnicity, ability level). A PPC chair or co-chairs are appointed by the ADA (N.A.E. and R.G.M. are co-chairs for the 2025 Standards of Care) and oversee the committee. In addition to the PPC members, several professionals serve as designated subject matter experts to support the PPC in the development of specific content areas of the Standards of Care. While designated subject matter experts assist with content development, only PPC members formally vote on Standards of Care recommendations for final approval.

Additionally, several organizations have endorsed specific sections of the 2025 Standards of Care. The American College of Cardiology (ACC) reviewed and approved Section 10, “Cardiovascular Disease and Risk Management.” The American Society for Bone and Mineral Research reviewed and approved the “Bone Health” subsection in Section 4, “Comprehensive Medical Evaluation and Assessment of Comorbidities.” The Obesity Society reviewed and approved Section 8, “Obesity and Weight Management for the Prevention and Treatment of Type 2 Diabetes.” New to the 2025 Standards of Care, the American Geriatrics Society reviewed and approved Section 13, “Older Adults.”

Each section of the Standards of Care is reviewed annually and updated with the latest evidence-based recommendations by a subcommittee. The subcommittees perform systematic literature reviews and identify and summarize the scientific evidence. An information specialist with knowledge and experience in literature searching (a librarian) is consulted as necessary. A guideline methodologist (R.R.B. for the 2025 Standards of Care) with expertise and training in evidence-based medicine and guideline development methodology oversees all methodological aspects of the development of the Standards of Care and serves as a statistical analyst.

All members of the expert panel (the PPC members and subject matter experts) and ADA scientific team are required to comply with the ADA policy on duality of interest, which requires disclosure of any financial, intellectual, or other interests that might be construed as constituting an actual, potential, or apparent conflict, regardless of relevancy to the guideline topic. For transparency, ADA requires full disclosure of all relationships. Full disclosure statements from all committee members are solicited and reviewed during the appointment process. Disclosures are then updated throughout the guideline development process (specifically before the start of every meeting), and disclosure statements are submitted by every Standards of Care contributor upon submission of the updated Standards of Care section. Members are required to disclose conflicts for a time frame that includes 1 year prior to initiation of the committee appointment process until publication of that year’s Standards of Care. Potential dualities of interest are evaluated by a designated review panel and, if necessary, the Legal Affairs Division of the ADA. The duality of interest assessment is based on the relative weight of the financial relationship (i.e., the monetary amount) and the relevance of the relationship (i.e., the degree to which an independent observer might reasonably interpret an association as related to the topic or recommendation of consideration). In addition, the ADA adheres to section 7 of the Council of Medical Specialty Societies “Code for Interactions with Companies” (3). The duality of interest review panel also ensures the majority of the PPC and the PPC chair or co-chairs are without potential conflict relevant to the subject area. Furthermore, the PPC chair or co-chairs are required to remain unconflicted for 1 year after the publication of the Standards of Care. Members of the committee who disclose a potential duality of interest pertinent to any specific recommendation are prohibited from participating in discussions related to those recommendations and their votes are excluded. No expert panel members were employees of any pharmaceutical or medical device company during the development of the 2025 Standards of Care. Members of the PPC, their employers, and their disclosed potential dualities of interest are listed in the section “Disclosures: Standards of Care in Diabetes—2025.”

The Standards of Care guideline is funded by ADA general revenue. No other entity, including industry, provides financial support for the guideline. Committee members received no remuneration for their participation in development of this guideline.

The Standards of Care subcommittee for each section creates an initial list of relevant clinical questions that is reviewed and discussed by the expert panel. In consultation with a systematic review expert and librarian, each subcommittee devises and executes systematic literature searches. For the 2025 Standards of Care, PubMed, Medline, and EMBASE were searched for the time periods of 1 June 2023 to 19 July 2024. Searches are limited to studies published in English. Subcommittee members also manually search journals, reference lists of conference proceedings, and regulatory agency websites. All potentially relevant citations are then subjected to a full-text review. In consultation with the methodologist, the subcommittees prepare the evidence summaries and grading for each section of the Standards of Care. All PPC members discuss and review the evidence summaries and make revisions as appropriate. The final evidence summaries are then deliberated on by the PPC, and the recommendations that will appear in the Standards of Care are drafted.

A grading system (Table 1) developed by the ADA and modeled after existing methods is used to clarify and codify the evidence that forms the basis for the recommendations in the Standards of Care. All recommendations in the Standards of Care are critical to comprehensive care regardless of rating. ADA recommendations are assigned ratings of A, B, or C, depending on the quality of the evidence in support of the recommendation. Expert opinion E is a separate category for recommendations in which there is no evidence from clinical trials, clinical trials may be impractical, or there is conflicting evidence. Recommendations assigned an E level of evidence are informed by key opinion leaders in diabetes (members of the PPC and external subject matter experts) and cover important elements of clinical care. All Standards of Care recommendations receive a rating for the strength of the evidence and not for the strength of the recommendation. Recommendations with A-level evidence are based on large, well-designed randomized controlled trials or well-done meta-analyses of randomized controlled trials. Generally, these recommendations have the best chance of improving outcomes when applied to the population for which they are appropriate. Recommendations with lower levels of evidence may be equally important but are not as well supported.

Of course, published evidence is only one component of clinical decision-making. Clinicians care for people, not populations; guidelines must always be interpreted with the individual person in mind. Individual circumstances, such as comorbid and coexisting diseases, age, education, disability, and, above all, the values and preferences of the person with diabetes, must be considered and may lead to different treatment goals 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.

All accumulated evidence was reviewed and discussed by all PPC members and external subject matter experts during multiple virtual meetings and a 2-day in-person meeting in Arlington, Virginia, in July 2024. Standards of Care recommendations were updated based on the newly acquired evidence, and each recommendation was voted on by the PPC, with 80% consensus required for any recommendation to be approved.

Public comment is particularly important in the development of clinical practice recommendations; it promotes transparency and provides key stakeholders, including people with diabetes and their caregivers, the opportunity to identify and address gaps in care. The ADA holds a year-long public comment period requesting feedback on the Standards of Care. The PPC reviews compiled feedback from the public in preparation for the annual update but considers more pressing updates throughout the year, which may be published as “living” Standards updates. Feedback from the larger clinical community and general public was invaluable for the revision of the 2024 Standards of Care. Readers who wish to comment on the 2025 Standards of Care are invited to do so at professional.diabetes.org/SOC.

Feedback for the Standards of Care is also obtained from external peer reviewers. The Standards of Care is reviewed by ADA clinical leadership and scientific and medical team and is approved by the ADA Board of Directors, which includes health care professionals, scientists, and other stakeholders. The ACC performs an independent external peer review, and the ACC provides endorsement of Section 10, “Cardiovascular Disease and Risk Management.” In addition, the American Society for Bone and Mineral Research provides endorsement for the “Bone Health” subsection of Section 4, “Comprehensive Medical Evaluation and Assessment of Comorbidities,” The Obesity Society provides endorsement for Section 8, “Obesity and Weight Management for the Prevention and Treatment of Type 2 Diabetes,” and the American Geriatrics Society provides endorsement for Section 13, “Older Adults.” Feedback received from every stakeholder is adequately addressed by the committee, and the final version is approved by all parties prior to publication. The ADA adheres to the Council of Medical Specialty Societies revised “CMSS Principles for the Development of Specialty Society Clinical Guidelines” (4).

The ADA has been actively involved in developing and disseminating diabetes care clinical practice recommendations and related documents for more than 35 years. The ADA Standards of Care is an essential resource for health care professionals caring for people with diabetes. ADA Statements, Consensus Reports, and Scientific Reviews support the recommendations included in the Standards of Care.

The annual Standards of Care supplement to Diabetes Care contains the official ADA position, is authored by the ADA, and provides all of the ADA’s current clinical practice recommendations.

An ADA statement is an official ADA point of view or position 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 external peer review and review by the appropriate ADA national committee, ADA clinical leadership, ADA scientific team, and, as warranted, the ADA Board of Directors.

An ADA consensus report is a document on a particular topic that is authored by a technical expert panel under the auspices of ADA. The document does not reflect the official ADA position but rather represents the panel’s collective analysis, evaluation, and expert opinion. The primary objective of a consensus report is to provide clarity and insight on a medical or scientific matter related to diabetes for which the evidence is contradictory, emerging, or incomplete. The report also aims to highlight evidence gaps and to propose avenues for future research. Consensus reports undergo a formal review process, including external peer review and review by the ADA PPC and ADA scientific team, for publication.

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 ADA 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.

Members of the PPC

Nuha Ali ElSayed, MD, MMSc (Co-Chair)

Rozalina G. McCoy, MD, MS (Co-Chair)

Grazia Aleppo, MD

Elizabeth A. Beverly, PhD

Kathaleen Briggs Early, PhD, CDCES

Dennis Bruemmer, MD, PhD

Justin B. Echouffo-Tcheugui, MD, PhD

Laya Ekhlaspour, MD

Rajesh Garg, MD

Kamlesh Khunti, MD, FMedSci

Rayhan Lal, MD

Ildiko Lingvay, MD, MPH

Glenn Matfin, MB ChB, MSc (Oxon)

Naushira Pandya, MD, FACP

Scott J. Pilla, MD, MHS

Sarit Polsky, MD, MPH

Alissa R. Segal, PharmD, CDCES

Jane Jeffrie Seley, DNP, MPH

Robert C. Stanton, MD

Raveendhara R. Bannuru, MD, PhD (Chief Methodologist)

Designated Subject Matter Experts

Brian C. Callaghan, MD, MS (Section 12)

Kenneth Cusi, MD (Section 4)

Sandeep R. Das, MD, MPH (Section 10)

Osagie Ebekozien, MD, MPH (Sections 1, 2, and 3)

Barbara Eichorst, MS, RD (Section 5)

Talya K. Fleming, MD (Section 4)

Robert G. Frykberg, DPM, MPH (Section 12)

Robert A. Gabbay, MD, PhD (until 6 September 2024)

Jason L. Gaglia, MD, MMSc (Sections 2, 3, and 9)

Rodolfo J. Galindo, MD (Section 16)

Sunir J. Garg, MD, FACS (Section 12)

Monica Girotra, MD (Section 9)

John M. Giurini, DPM (Section 12)

Mohamed Hassanein, FRCP, CCST (U.K.) (Section 5)

Mikhail N. Kosiborod, MD (Section 10)

Robert F. Kushner, MD, MS (Section 8)

Seymour R. Levin, MD (Section 4)

Roeland J.W. Middlebeek, MD, MSc (Section 5)

Lisa Murdock (Section 17)

Nicola Napoli, MD, PhD (Sections 4 and 13)

Sharon J. Parish, MD (Section 4)

Flavia Q. Pirih, DDS, PhD (Section 4)

Elizabeth Selvin, PhD, MPH (Sections 2 and 6)

Shylaja Srinivasan, MD (Section 14)

Molly L. Tanenbaum, PhD (Section 5)

Monica Verduzco-Gutierrez, MD (Section 4)

Crystal C. Woodward, MPS (Section 17)

Zobair M. Younossi, MD, MPH (Section 4)

ADA Scientific Team

Kirthikaa Balapattabi, PhD

Raveendhara R. Bannuru, MD, PhD (corresponding author, [email protected])

Nuha Ali ElSayed, MD, MMSc

Robert A. Gabbay, MD, PhD (until 6 September 2024)

Elizabeth J. Pekas, PhD

Acknowledgments

The ADA thanks the following external peer reviewers: Mohammed K. Ali, MD, MSc

Joseph A. Aloi, MD

Vanita Aroda, MD

Ian H. de Boer, MD, MS

Wenche S. Borgnakke, DDS, PhD

Anders L. Carlson, MD

James Flory, MD

Om Ganda, MD

Thomas W. Gardner, MD, MS

Sherita Hill Golden, MD

Amy Hess-Fischl, MS, RDN

Ahmet Hoke, MD, PhD

Korey K. Hood, PhD

Eric L. Johnson, MD

M. Sue Kirkman, MD

Cecilia C. Low Wang, MD, FACP

Brynn E. Marks, MD, MSHPEd

Leigh Perreault, MD

Anne L. Peters, MD

Moshe Phillip, MD

Jane E.B. Reusch, MD

Connie M. Rhee, MD, MSc

Jo-Anne Rizzotto, MEd, RDN

Laura Shin, DPM, PhD

Alpana Shukla, MD

Richard Siegel, MD

Emily D. Szmuilowicz, MD

Tracey H. Taveira, PharmD, CDOE

Guillermo E. Umpierrez, MD, CDCES

Jenise C. Wong, MD, PhD

Chloe Zera, MD

ACC peer reviewers (Section 10):

James L. Januzzi, Jr., MD, FACC

Richard J. Kovacs, MD, MACC

Dave L. Dixon, PharmD, FACC

Prakash C. Deedwania, MD, FACC

AGS peer reviewers (Section 13):

Alyce Adams, MD

Alexandra Lee, MD

Sei Lee, MD

The ADA thanks the ADA Presidents and Presidents-elect:

Mandeep Bajaj, MBBS, President, Medicine & Science

Patti Urbanski, MEd, RD, President, Heath Care & Education

Rita Rastogi Kalyani, MD, MHS, President-elect, Medicine & Science

Joshua J. Neumiller, PharmD, CDCESPresident-elect, Heath Care & Education

The ADA thanks the following individuals for their support:

Celeste Durnwald, MD

Anastassios G. Pittas, MD, MS

Alexandra M. Yacoubian

The ADA thanks the following individuals for figure design:

Michael Bonar

Charlie Franklin