The document provides an overview of the Standards of Care in Diabetes - 2023 guidelines. It includes 17 sections that cover various aspects of diabetes care, treatment goals, and quality evaluation tools. The sections include classification and diagnosis of diabetes, prevention or delay of type 2 diabetes, medical evaluation and assessment of comorbidities, facilitating positive health behaviors, glycemic targets, pharmacologic treatment approaches, management of cardiovascular disease and other complications, and more. The guidelines are intended to provide clinicians, patients, and other stakeholders with an evidence-based framework for diabetes care and management.

1. Standards of Care
in Diabetes—2023

2. 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.

3. | 3
Introduction:
Standards of Care in Diabetes - 2023. Diabetes Care 2023;46(Suppl. 1):S1-S4

4. | 4
Table of Contents.
1. Improving Care and Promoting Health in
Populations
2. Classification and Diagnosis of Diabetes
3. Prevention or Delay of T2D and Associated
Comorbidities
4. Comprehensive Medical Evaluation and
Assessment of Comorbidities
5. Facilitating Positive Health Behaviors and Well-
being to Improve Health Outcomes
6. Glycemic Targets
7. Diabetes Technology
8. Obesity and Weight Management for the
Prevention and Treatment of Type 2 Diabetes
9. Pharmacologic Approaches to Glycemic
Treatment
10. CVD and Risk Management
11. CKD and Risk Management
12. Retinopathy, Neuropathy, and Foot Care
13. Older Adults
14. Children and Adolescents
15. Management of Diabetes in Pregnancy
16. Diabetes Care in the Hospital
17. Diabetes and Advocacy

5. Section 2.
Classification and
Diagnosis of
Diabetes

6. | 6
Classification
CLASSIFICATION AND DIAGNOSIS OF DIABETES
Diabetes can be classified into the following general categories:
1. Type 1 diabetes (due to autoimmune ß-cell destruction, usually leading to absolute
insulin deficiency, including latent autoimmune diabetes of adulthood)
2. Type 2 diabetes (due to a non-autoimmune progressive loss of adequate ß-cell
insulin secretion frequently on the background of insulin resistance and metabolic
syndrome)
3. Specific types of diabetes due to other causes, e.g., monogenic diabetes
syndromes (such as neonatal diabetes and maturity-onset diabetes of the young),
diseases of the exocrine pancreas (such as cystic fibrosis and pancreatitis), and
drug- or chemical-induced diabetes (such as with glucocorticoid use, in the
treatment of HIV/AIDS, or after organ transplantation)
4. Gestational diabetes mellitus (diabetes diagnosed in the second or third trimester
of pregnancy that was not clearly overt diabetes prior to gestation)

7. | 7
CLASSIFICATION AND DIAGNOSIS OF DIABETES
Hold for table 2.1
Classification and Diagnosis of Diabetes:
Standards of Care in Diabetes - 2023. Diabetes Care 2023;46(Suppl. 1):S19-S40

8. | 8
 No mention of hybride forms of diabetes
ADA vs WHO classification of DM
Latent autoimmune diabetes
of adult
Ketosis prone diabetes

9. | 9
CLASSIFICATION AND DIAGNOSIS OF DIABETES
Table 2.2
Classification and Diagnosis of Diabetes:
Standards of Care in Diabetes - 2023. Diabetes Care 2023;46(Suppl. 1):S19-S40

10. | 10
Classic symptoms of hyperglycemia
 Polyuria
 Polydipsia
 Weight loss
Polyphagia no longer considered a classic symptom

11. | 11
Screening for type 2 DM
Screening of high risk population
Screening of subject with pre – diabetes
Screening of women with GDM
Universal screening of population

12. | 12
CLASSIFICATION AND DIAGNOSIS OF DIABETES
Classification and Diagnosis of Diabetes:
Standards of Care in Diabetes - 2023. Diabetes Care 2023;46(Suppl. 1):S19-S40

13. | 13
CLASSIFICATION AND DIAGNOSIS OF DIABETES
Classification and Diagnosis of Diabetes:
Standards of Care in Diabetes - 2023. Diabetes Care 2023;46(Suppl. 1):S19-S40

14. | 14
 HBA1C maintained < 6.5 % for 3 months without use of OHA and INSULIN
Remission of DM

15. | 15
 2.1b Point-of-care A1C testing for diabetes screening and diagnosis should
be restricted to U.S. Food and Drug Administration–approved devices at
laboratories proficient in performing testing of moderate complexity or
higher by trained personnel. B
UPDATE 2023

16. Section 3.
Prevention or
Delay of Type 2
Diabetes and
Associated
Comorbidities

17. Prevention of DM
Life style
changes
• 150 min / week
• 7 % weight loss
Metformin
• Age 25 to 59
years with
• BMI > 35
• FBS > 110
• HBAIC >6
• Previous GDM
Pioglitazone
• Lower the risk of
stroke , MI and
progression to
DM

18.  3.1 Monitor for the development of type 2 diabetes in those with
prediabetes at least annually; modified based on individual
risk/benefit assessment. E
 3.9 Statin therapy may increase the risk of type 2 diabetes in
people at high risk of developing type 2 diabetes. In such individuals,
glucose status should be monitored regularly and diabetes
prevention approaches reinforced. It is not recommended that
statins be discontinued. B
 3.10 In people with a history of stroke and evidence of insulin
resistance and prediabetes, pioglitazone may be considered to
lower the risk of stroke or myocardial infarction. However, this
benefit needs to be balanced with the increased risk of weight gain,
edema, and fracture. A Lower doses may mitigate the risk of
adverse effects. C
UPDATE 2023

19. Section 4.
Comprehensive
Medical
Evaluation and
Assessment of
Comorbidities

20. Comordities in DM
Systemic HTN
DLP
NAFLD
CAD
Cognitive impairment
Fractures
Hearing loss
Peridontal disease
Hypogonadism / pcod

21. | 21
Immunizations
COMPREHENSIVE MEDICAL EVALUATION AND ASSESSMENT OF COMORBIDITIES

22. | 22
Immunizations
COMPREHENSIVE MEDICAL EVALUATION AND ASSESSMENT OF COMORBIDITIES

23. | 23
Immunizations
COMPREHENSIVE MEDICAL EVALUATION AND ASSESSMENT OF COMORBIDITIES

24. Section 5.
Facilitating
Positive
Behaviors and
Well-being to
Improve Health
Outcomes

25.  Should engage in 150 min or more of moderate – to vigorous intensity activity
weekly , spread over atleast 3 days / week
 No more than 2 consecutive days without activity
 Resistance training in 2 -3 sessions / week on non consecutive days
 Flexibility training and balance training are recommended 2-3 times / week for older
adult with DM
EXERCISE PLAN

26. | 26
FACILITATING POSITIVE HEALTH BEHAVIORS AND WELL-BEING TO IMPROVE HEALTH
OUTCOMES
Medical Nutrition Therapy
Facilitating Positive Health Behaviors and Well-being to Improve Health Outcomes:
Standards of Care in Diabetes - 2023. Diabetes Care 2023;46(Suppl. 1):S68-S96

27. | 27
FACILITATING POSITIVE HEALTH BEHAVIORS AND WELL-BEING TO IMPROVE HEALTH
OUTCOMES
Medical Nutrition Therapy (continued)
Facilitating Positive Health Behaviors and Well-being to Improve Health Outcomes:
Standards of Care in Diabetes - 2023. Diabetes Care 2023;46(Suppl. 1):S68-S96

28. | 28
FACILITATING POSITIVE HEALTH BEHAVIORS AND WELL-BEING TO IMPROVE HEALTH
OUTCOMES
Medical Nutrition Therapy (continued)
Facilitating Positive Health Behaviors and Well-being to Improve Health Outcomes:
Standards of Care in Diabetes - 2023. Diabetes Care 2023;46(Suppl. 1):S68-S96

29. | 29
 Time restricted eating and intermittent fasting
 Time restricted eating is generally easier to follow compared with alternative day
fasting or the 5:2 plan
 No significant difference in weight loss when compared with contious calorie
restriction
Update 2023

30. Section 6.
Glycemic Targets

31. Glycemic targets
FBS
• 80 – 130 mg/dl
PPBS
• < 180 mg/dl
HBA1C
• < 7%
• < 7.5 % type 1 DM
with hypoglycemia
• < 8 % Elderly , frail
individual

32. TIME IN RANGE Target blood glucose range in DM
Non pregnant : 70 – 180 mg/dl
Pregnant : 63 – 140 mg/dl

33. Section 8.
Obesity and Weight
Management for the
Treatment of Type 2
Diabetes

34. Obesity management
5 % weight loss improves glycemia
> 10 % weight loss has disease modifying
effects and impact on long term CV mortality
500 – 750 kcal deficit required for significant
weight loss

35. | 35
OBESITY MANAGEMENT FOR THE TREATMENT OF TYPE 2 DIABETES
Obesity Management for the Treatment of Type 2 Diabetes:
Standards of Care in Diabetes - 2023. Diabetes Care 2023;46(Suppl. 1):S128-S139

36. | 36
Pharmacotherapy

37. Section 9.
Pharmacologic
Approaches to
Glycemic
Treatment

38. Insulin as default
HBA1C > 10 % / RBS > 300 mg/dl
Features of catabolism ( significant weight loss )
Ongoing ketosis
Pregnancy
HBA1C > 9 % with 3 or more OHA
Severe organ involvement
Perioperative patients

39. | 39
PHARMACOLOGIC APPROACHES TO GLYCEMIC TREATMENT
Pharmacologic Approaches to Glycemic Management:
Standards of Care in Diabetes - 2023. Diabetes Care 2023;46(Suppl. 1):S140-S157

40. | 40
Tirzepatide
GIP/GLP -1
CO AGONIST
Glycemic
weight
cvs

41. Section 10.
Cardiovascular
Disease and Risk
Management

42. | 42
CARDIOVASCULAR DISEASE AND RISK MANAGEMENT
Cardiovascular Disease and Risk Management:
Standards of Care in Diabetes - 2023. Diabetes Care 2023;46(Suppl. 1):S158-S190

43. Hypertension management
•BP target < 130/80 mmhg if 10 year ASCVD > 15 %
•OTHERS < 140/9O mmhg
2022
•Target < 130/80 mmhg
2023

44. | 44
CARDIOVASCULAR DISEASE AND RISK MANAGEMENT
Recommendations
for the Treatment of
Confirmed
Hypertension in
People with
Diabetes (1 of 2)
Cardiovascular Disease and Risk Management:
Standards of Care in Diabetes - 2023. Diabetes Care 2023;46(Suppl. 1):S158-S190

45. | 45
CARDIOVASCULAR DISEASE AND RISK MANAGEMENT
Recommendations
for the Treatment of
Confirmed
Hypertension in
People with
Diabetes (2 of 2)
Cardiovascular Disease and Risk Management:
Standards of Care in Diabetes - 2023. Diabetes Care 2023;46(Suppl. 1):S158-S190

46. | 46
Lipid management – statins for primary prevention
Age CV risk
factors
40 - 75 nil Moderate intensity statin LDL < 100 mg/dl
40 -75 1 or
more
High intensity statin LDL < 70
Reduce LDL 50%
from base line
20- 39 + Reasonable to initiate statin
> 75 Nil Reasonable to initiate moderate intensity
statin
> 75 + Continue statin therapy

47. | 47
 For people of all age with diabetes and ASCVD , high intensity
statin therapy should be added to lifestyle therapy
 Target LDL < 55mg / dl ( add ezetimibe / PCSK9 inhibitors if
target not achieved
 ASCVD or other CV risk factors on a statin with controlled LDL
cholesterol but elevated triglycerides ( 135 – 499) the addition of
icosapent ethyl can be considered to reduce CV risk
Lipid management – statins for
secondary prevention

48. | 48
CARDIOVASCULAR DISEASE AND RISK MANAGEMENT
Cardiovascular Disease and Risk Management:
Standards of Care in Diabetes - 2023. Diabetes Care 2023;46(Suppl. 1):S158-S190

49. | 49
Reduce cardiovascular risk
Controll of hypertension
Lipid goal achievement
Aspirin use
Avoidance of smoking
Anti hyperglycemic with CV risk reduction
Primary prevention

50. | 50
Reduce cardiovascular risk
ASPIRIN
HIGH INTENSITY STATINS
BETA BLOCKERS
Avoidance of smoking
ACEI/ARBs
GLP 1RA/ SGLT 2i
SECONDARY
prevention

51. | 51
Aspirin in DM
Secondary
prevention
• HTN
• DLP
• SMOKING
• FAMILY H/O CAD
• ALBUMINURIA
Primary prevention
DM > 50 YR with one
or more hish risk

52. Section 11.
Chronic Kidney
Disease and Risk
Management

53.  ACEI/ARB
recommended in moderately increased albuminuria ( 30 -299 mg/g cr)
strongly recommened in severly increased albuminuria ( >300 mg/g cr )
and or e GFR < 60
 SGLT2i
In all patients with DKD , recommended to reduce CKD progression and
CV events in patient with an e GFR > 20 Ml/min/1.73m2 and urinary
albumin > 200mg/g cr
CKD and risk management

54.  FINERENONE
used if e GFR > 25 Ml /min/1,73m2 and k+ < 5 mEq/L
10 mg / 20 mg once weekly
weekly e GFR , K + monitoring
CKD and risk management

55. Section 12.
Retinopathy,
Neuropathy, and
Foot Care

56.  12.20 Gabapentinoids, serotoninnorepinephrine reuptake inhibitors,
tricyclic antidepressants, and sodium channel blockers are recommended as
initial pharmacologic treatments for neuropathic pain in diabetes. A Refer to
neurologist or pain specialist when pain control is not achieved within the
scope of practice of the treating physician. E
 SNRI – duloxetine , venlafaxine , all selective SNRI
 TCA – amitriptyline
 Capsaicin – FDA approved for pain as 8% patch
Neuropathy

57.  Sodium channel blockers – lamotrigine , lacosamide , oxcarbamazepine ,
and valproic acid
 Carbamazepine not approved
Neuropathy

58. | 58
 Fatty infiltration of > 5 %
 Hepatic steatosis associated with inflammation and hepatocyte injury with or
without fibrosis – NASH
 ASSESSMENT
FIB 4 SCORE – age , SGOT, SGPT, platelet count
Fibroelastography
NAFLD

59. | 59

60. | 60

61. THANK YOU