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Sleep Health\nRecommendations\n5.50 Consider screening for sleep health\nin people with diabetes, including symp-\ntoms of sleep disorders, disruptions to\nsleep due to diabetes symptoms or\nmanagement needs, and worries aboutsleep. Refer to sleep medicine specialists\nand/or quali fied behavioral health pro-\nfessional... | [
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and/or quali fied behavioral health pro-\nfessionals as indicated. B\n5.51 Counsel people with diabetes\nto practice sleep-promoting routinesand habits (e.g., maintaining consis-\ntent sleep schedule and limiting caf-feine in the afternoon). A\nThe associations between sleep prob-\nlems and diabetes are complex: sleep | [
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lems and diabetes are complex: sleep\ndisorders are a risk factor for developingtype 2 diabetes (520,521) and possiblygestational diabetes mellitus (522,523).People with diabetes across the life spanoften experience sleep disruptions andreduced sleep quality (524,525), andsleep problems are also common in pa-rents of y... | [
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soon after diagnosis (526,527). Disrupted\nsleep and sleep disorders, including ob-structive sleep apnea (528), insomnia,and sleep disturbances (529), are com-mon among people with diabetes. Intype 1 diabetes, estimates of poor sleeprange from 30% to 50% (530), and esti-mates of moderate to severe obstructivesleep apne... | [
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diabetes, 24 –86% of people are esti-\nmated to have obstructive sleep apnea(532), 39% to have insomnia, and 8 –45%\nto have restless leg syndrome (i.e., anuncontrollable urge to move legs) (533).Further, people with type 2 diabetes andrestless leg syndrome are more likely to\nexperience microvascular and macrovas- | [
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experience microvascular and macrovas-\ncular complications (534) as well as de-pression (535). Additionally, people withdiabetes who perform shift work in-crease their risk for circadian rhythm dis-orders, which are associated with higherA1C (536), neuropathy (537), and de- | [
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creased psychological well-being (537).Health care professionals should con-sider a comprehensive evaluation of thedaily lifestyles of people with diabetes to\ndecrease risk factors, including low sleep\nduration, shift work, and days off, giventheir associations with hyperglycemia,hypertension, dyslipidemia, and weigh... | [
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gain (538).\nSleep disturbances are associated\nwith less engagement in diabetes self-\nmanagement and may interfere with glu-cose levels within the target range among\npeople with type 1 and type 2 diabetes\n(525,529,531,533,539,540). Risk of hypo-glycemia poses speci fic challenges for sleep\nin people with type 1 dia... | [
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in people with type 1 diabetes and may re-\nquire targeted assessment and treatment\napproaches (541). People with type 1 dia-betes and their family members alsodescribe diabetes management needs in-terfering with sleep and experiencing wor-\nries about poor sleep (542). Both helpful | [
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ries about poor sleep (542). Both helpful\nand challenging aspects of diabetes tech-nology use have been described in rela-tion to sleep (542), with the greatest\nperceived bene fits being related to auto-\nmated insulin delivery systems (543 –545).\nFor these reasons, detection and treat-\nment of sleep disorders shoul... | [
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ment of sleep disorders should be consid-\nered a part of standardized care for\npeople with type 1 and type 2 diabetes.\nAs for the general population, there\nare evidence-based strategies to improvesleep for people with diabetes. CBT shows\nbenefits for sleep in people with diabetes\n(429), including CBT for insomnia,... | [
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(429), including CBT for insomnia, which\ndemonstrates improvements in sleep out-comes and possible small improvementsin A1C and fasting glucose (546). There is\nalso evidence that sleep extension and\npharmacological treatments for sleep canimprove sleep outcomes and possibly in-sulin resistance (541,546). Lastly, sle... | [
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education, or sleep hygiene, improves\nsleep quality, reduces A1C, and decreasesinsulin resistance in adults with type 2 di-abetes (547). Thus, diabetes care profes-\nsionals are encouraged to counsel people | [
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sionals are encouraged to counsel people\nwith diabetes to use sleep-promoting rou-tines and practices, such as establishing aregular bedtime and rise time, creating adark, quiet area for sleep with tempera-\nture and humidity control, establishing | [
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ture and humidity control, establishing\na pre-sleep routine, putting electronic de-vices (except diabetes management devi-ces) in silent/off mode, exercising during\nthe day, avoiding daytime naps, limiting\ncaffeine and nicotine in the evening,diabetesjournals.org/care Facilitating Positive Health Behaviors and Well-... | [
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©AmericanDiabetesAssociation | [
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avoiding spicy foods at night, and avoiding\nalcohol before bedtime (548). For peoplew i t hd i a b e t e sw h oh a v es i g n i ficant sleep\ndifficulties, referral to sleep specialists to\naddress the medical and behavioral as-pects of sleep is recommended, ideally incollaboration with the diabetes care pro-fessional (... | [
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35. Glazier RH, Bajcar J, Kennie NR, Willson K. A\nsystematic review of interventions to improve\ndiabetes care in socially disadvantaged populations.Diabetes Care 2006;29:1675 –1688 | [
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3 6 .H a w t h o r n eK ,R o b l e sY ,C a n n i n g s - J o h nR ,Edwards AG. Culturally appropriate health educationfor type 2 diabetes mellitus in ethnic minoritygroups. Cochrane Database Syst Rev 2008;3:CD006424\n37. Chodosh J, Morton SC, Mojica W, et al.\nMeta-analysis: chronic disease self-management | [
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39. Peyrot M, Rubin RR. Behavioral andpsychosocial interventions in diabetes: a conceptual\nreview. Diabetes Care 2007;30:2433 –2440\n40. Naik AD, Palmer N, Petersen NJ, et al.\nComparative effectiveness of goal setting in diabetesmellitus group clinics: randomized clinical trial. ArchIntern Med 2011;171:453– 459 | [
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43. Odgers-Jewell K, Ball LE, Kelly JT , Isenring EA,\nReidlinger DP , Thomas R. Effectiveness of group-based self-management education for individualswith type 2 diabetes: a systematic review withmeta-analyses and meta-regression. Diabet Med\n2017;34:1027– 1039\n44. Zhao X, Huang H, Zheng S. Effectiveness | [
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©AmericanDiabetesAssociation | [
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6. Glycemic Goals and\nHypoglycemia: Standards of Care\nin Diabetes— 2024\nDiabetes Care 2024;47(Suppl. 1):S111 –S125 |https://doi.org/10.2337/dc24-S006American Diabetes Association\nProfessional Practice Committee *\nThe American Diabetes Association (ADA) “Standards of Care in Diabetes ” | [
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includes the ADA ’s current clinical practice recommendations and is intended to\nprovide the components of diabetes care, general treatment goals and guide-\nlines, and tools to evaluate quality of care. Members of the ADA ProfessionalPractice Committee, an interprofessional expert committee, are responsible for | [
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updating the Standards of Care annually, or more frequently as warranted. For a\ndetailed description of ADA standards, statements, and reports, as well as theevidence-grading system for ADA ’s clinical practice recommendations and a full | [
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list of Professional Practice Committee members, please refer to Introductionand Methodology. Readers who wish to comment on the Standards of Care areinvited to do so at professional.diabetes.org/SOC.\nASSESSMENT OF GLYCEMIC STATUS\nGlycemic status is assessed by A1C measurement, blood glucose monitoring (BGM) | [
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by capillary ( finger-stick) devices, and continuous glucose monitoring (CGM) using\ntime in range (TIR) or mean CGM glucose. Clinical trials of interventions that lowerA1C have demonstrated the bene fits of improved glycemia. Glucose monitoring via\nCGM or BGM (discussed in detail in Section 7, “Diabetes Technology ”)i ... | [
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abetes self-management, can provide nuanced information on glucose responses tomeals, physical activity, and medication changes, and may be particularly useful in in-dividuals taking insulin. CGM serves an increasingly important role in optimizing theeffectiveness and safety of treatment in many people with type 1 diab... | [
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lected people with type 2 diabetes or other forms of diabetes (e.g., cystic fibrosis –related\ndiabetes). Individuals on a variety of insulin treatment plans can bene fitf r o mC G Mw i t h\nimproved glucose levels, decreased hypoglycemia, and enhanced self-effi cacy (Section 7,\n“Diabetes Technology ”)( 1 ) .\nGlycemic A... | [
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“Diabetes Technology ”)( 1 ) .\nGlycemic Assessment\nRecommendations\n6.1Assess glycemic status by A1C and/or appropriate continuous glucose\nmonitoring (CGM) metrics at least two times a year. Assess more frequently\n(e.g., every 3 months) for individuals not meeting treatment goals, with fre- | [
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quent or severe hypoglycemia or hyperglycemia, changing health status, or\ngrowth and development in youth. E\n6.2Assess glycemic status at least quarterly and as needed in individuals\nwhose therapy has recently changed and/or who are not meeting glycemicgoals. E*A complete list of members of the American | [
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Diabetes Association Professional PracticeCommittee can be found at https://doi.org/10.2337/dc24-SINT.\nDuality of interest information for each author is\navailable at https://doi.org/10.2337/dc24-SDIS.\nSuggested citation: American Diabetes Association | [
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Suggested citation: American Diabetes Association\nProfessional Practice Committee. 6. Glycemic goalsand hypoglycemia: Standards of Care in Diabetes —\n2024 . Diabetes Care 2024;47(Suppl. 1):S111 –S125 | [
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2024 . Diabetes Care 2024;47(Suppl. 1):S111 –S125\n© 2023 by the American Diabetes Association.Readers may use this article as long as thework is properly cited, the use is educationaland not for profi t, and the work is not altered. | [
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More information is available at https://www.diabetesjournals.org/journals/pages/license.6. GLYCEMIC GOALS AND HYPOGLYCEMIADiabetes Care Volume 47, Supplement 1, January 2024 S111\n©AmericanDiabetesAssociation | [
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0.06013879552483559,
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0.013673707842826843,
0.028856437653303146,
0.037251587957143784,
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-0.049673181027173996,
-0.058654800057411194,
0.02490445040166378,
-0.030276518315076828,
-0.08... |
Glycemic Assessment by A1C\nThe A1C test is the primary tool for assess-\ning glycemic status in both clinical practiceand clinical trials, and it is strongly linked\nto diabetes complications (2 –4). A1C re-\nflects average glycemia over approxi-\nmately 2 –3 months. The performance of\nlaboratory tests for A1C is gene... | [
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-0.... |
laboratory tests for A1C is generally\nexcellent for National GlycohemoglobinStandardization Program (NGSP) –certified\nassays (ngsp.org). Thus, A1C testing shouldbe performed routinely in all people withdiabetes at initial assessment and as partof continuing care. Measurement approxi-\nmately every 3 months determines ... | [
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0.05430614948272705,
-0.11859872192144394,
0.0... |
mately every 3 months determines whether\nglycemic goals have been reached andmaintained. Adults with type 1 diabetes or\ntype 2 diabetes with stable glycemia within\ngoal may do well with A1C testing or otherglucose assessment only twice per year. Un-stable or intensively managed individuals or\npeople not at goal wit... | [
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0.05397643521428108,
-0.05821814015507698,
... |
people not at goal with treatment adjust-\nments may require testing more frequently(every 3 months, with interim assessments\nas needed) (5). The use of point-of-care A1C\ntesting may provide an opportunity formore timely treatment changes during en-\ncounters between individuals with diabetes\nand health care profess... | [
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and health care professionals.\nThe A1C test is an indirect measure of\naverage glycemia. Factors that affect he-moglobin or red blood cell characteristics\nor turnover may affect A1C. For example,\nconditions that affect red blood cell turn-over (hemolytic anemia and other ane-\nmias, glucose-6-phosphate dehydrogenase | [
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-0.08998706191778183,
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mias, glucose-6-phosphate dehydrogenase\ndeficiency, recent blood transfusion, use of\ndrugs that stimulate erythropoiesis, end-\nstage kidney disease, and pregnancy) can\ninterfere with the accuracy of A1C (6).Some hemoglobin variants can interferewith some A1C assays; however, most as-\nsays in use in the U.S. are acc... | [
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-... |
says in use in the U.S. are accurate in indi-\nviduals who are heterozygous for the mostcommon variants (7). A1C cannot be mea-\ns u r e di ni n d i v i d u a l sw i t hs i c k l ec e l ld i s e a s e\n(HbSS) or other homozygous hemoglobinvariants (e.g., HbEE), since these individu-\nals lack HbA (8). In individuals wi... | [
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0.06739816069602966,
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0.02... |
als lack HbA (8). In individuals with condi-\ntions that interfere with the interpretationof A1C, alternative approaches to monitor-ing glycemic status should be used, includ-\ning self-monitoring of blood glucose, CGM,\nand/or the use of glycated serum proteinassays (discussed below). A1C does not\nprovide a measure o... | [
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... |
provide a measure of glycemic variability\nor hypoglycemia. For individuals prone toglycemic variability, especially people withtype 1 diabetes or type 2 diabetes with se-\nvere insulin de ficiency, glycemic status isbest evaluated by the combination of re- | [
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sults from BGM or CGM and A1C. Discor-dant results between BGM/CGM and A1Ccan be the result of the conditions outlinedabove or glycemic variability, with BGM/CGM missing the extremes.\nAs discussed in Section 2, “Diagnosis\nand Classifi cation of Diabetes, ”there is\ncontroversy regarding the clinical signi fi- | [
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controversy regarding the clinical signi fi-\ncance of racial differences in A1C (9 –12).\nThere is an emerging understanding ofgenetic determinants that may modifythe association between A1C and glu-cose levels (13). However, race is not a\ngood proxy for these genetic differences | [
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good proxy for these genetic differences\nthat are likely present in a small minorityof individuals of all racial groups. There-fore, race should not be a considerationfor how A1C is used clinically for glyce-mic monitoring. Limitations of laboratorytests and within-person variability in glu-\ncose and A1C underscore t... | [
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0.03454948589205742,
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-0.... |
cose and A1C underscore the importance\nof using multiple approaches to glycemicmonitoring and further evaluation ofdiscordant results in all racial or ethnicgroups.\nSerum Glycated Protein Assays as\nAlternatives to A1C\nFructosamine and glycated albumin are | [
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-0.... |
Alternatives to A1C\nFructosamine and glycated albumin are\nalternative measures of glycemia that areapproved for clinical use for monitoringglycemic status in people with diabetes.Fructosamine re flects total glycated se-\nrum proteins (mostly albumin). Glycated\nalbumin assays re flect the proportion of\ntotal albumin ... | [
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-0.06731220334768295,
-... |
total albumin that is glycated. Due to the\nturnover rate of serum protein, fructos-amine and glycated albumin refl ect glyce-\nmia over the past 2 –4w e e k s ,as h o r t e r -\nterm time frame than that of A1C. Fruc-tosamine and glycated albumin are highly\ncorrelated in people with diabetes, and | [
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0.04743484407663345,
0.11904365569353104,
0.02821396291255951,
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0.06150633096694946,
-0.05763467028737068,
-0.00405... |
correlated in people with diabetes, and\nthe performance of modern assays is typi-cally excellent. Fructosamine and glycatedalbumin have been linked to long-termcomplications in epidemiologic cohortstudies (14 –18). However, there have\nbeen few clinical trials, and the evidence\nbase supporting the use of these bio- | [
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0.13799670338630676,
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0.05... |
base supporting the use of these bio-\nmarkers to monitor glycemic status ismuch weaker than that for A1C. In peo-ple with diabetes who have conditionswhere the interpretation of A1C may beproblematic or when A1C cannot be mea-\nsured (e.g., homozygous hemoglobin var- | [
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-0.012295491062104702,
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0.02312331460416317,
0.025821374729275703,
0.1006150096654892,
0.01325862854719162,
0.017752375453710556,
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0.006542569026350975,
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sured (e.g., homozygous hemoglobin var-\niants), fructosamine or glycated albuminmay be useful alternatives to monitor gly-cemic status (8).Correlation Between A1C and Blood\nGlucose Monitoring and Continuous\nGlucose Monitoring\nTable 6.1 provides rough equivalents of\nA1C and mean glucose levels based on data | [
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-0.008138332515954971,
0.02298336662352085,
0.10964974761009216,
-0.029751457273960114,
0.012038779444992542,
-0.012273086234927177,
0.0040837181732058525,
-0.10207562148571014,
... |
A1C and mean glucose levels based on data\nfrom the international A1C-Derived Average\nGlucose (ADAG) study. The ADAG study as-\nsessed the correlation between A1C andfrequent BGM and CGM in 507 adults(83% non-Hispanic White) with type 1,type 2, and no diabetes (19,20). TheAmerican Diabetes Association (ADA)\nand the A... | [
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0.0932173877954483,
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0.039957113564014435,
0.04481878876686096,
0.10082446783781052,
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0.0005945019656792283,
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0.008264468051493168,
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-0.02... |
and the American Association for Clinical\nChemistry have determined that the cor-relation ( r= 0.92) in the ADAG trial is\nstrong enough to justify reporting boththe A1C result and the estimated aver-\nage glucose (eAG) result when a clinician | [
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0.12002857029438019,
0.011633038520812988,
0.013739166781306267,
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0.017865311354398727,
-0.1221507266163826,
0.02237... |
age glucose (eAG) result when a clinician\norders the A1C test. Clinicians shouldnote that the mean plasma glucose num-bers in Table 6.1 are based on /C242,700\nreadings per A1C measurement in theADAG trial.\nGlycemic Assessment by Blood\nGlucose Monitoring\nFor many people with diabetes, glucose\nmonitoring, either us... | [
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0.049043066799640656,
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0.035888951271772385,
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0.005085354205220938,
0.01781042106449604,
0.11763455718755722,
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0.060024674981832504,
-0.01319056935608387,
-0.020814571529626846,
-0.09560699015855789,
-0... |
monitoring, either using BGM by capil-\nlary ( finger-stick) devices or CGM in addi-\ntion to regular A1C testing, is key for\nachieving glycemic goals. Major clinicaltrials of insulin-treated individuals haveincluded BGM as part of multifactorialinterventions to demonstrate the benefi t\nof intensive glycemic control on... | [
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0.025097303092479706,
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0.02263730950653553,
0.10841429978609085,
0.08432558923959732,
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-... |
of intensive glycemic control on diabetes\nTable 6.1 —Equivalent A1C levels and\nestimated average glucose (eAG)\nA1C (%) mg/dL* mmol/L\n5 97 (76 –120) 5.4 (4.2 –6.7)\n6 126 (100–152) 7.0 (5.5 –8.5)\n7 154 (123–185) 8.6 (6.8 –10.3)\n8 183 (147–217) 10.2 (8.1 –12.1)\n9 212 (170–249) 11.8 (9.4 –13.9)\n10 240 (193–282) 13... | [
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-0.023997582495212555,
-0.056813232600688934,
0.07100287824869156,
-0.046217598021030426,
-0.03779356926679611,
0.0390172004699707,
0.11230971664190292,
-0.021899638697504997,
0.003739357693120837,
-0.0742282047867775,
-0.005460003390908241,
-0.07175956666469574,
-0.0... |
9 212 (170–249) 11.8 (9.4 –13.9)\n10 240 (193–282) 13.4 (10.7 –15.7)\n11 269 (217–314) 14.9 (12.0 –17.5)\n12 298 (240–347) 16.5 (13.3 –19.3)\nData in parentheses are 95% CI. A calcula-\ntor for converting A1C results into eAG, in\neither mg/dL or mmol/L, is available at | [
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-0.0069897896610200405,
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-0.02079225331544876,
0.00020792489522136748,
0.11499606817960739,
0.014861105009913445,
0.01917077973484993,
0.042413704097270966,
-0.08779548108577728,
-0.05251064896583557,
-0... |
either mg/dL or mmol/L, is available at\nprofessional.diabetes.org/eAG. *These esti-m a t e sa r eb a s e do nA D A Gd a t ao f/C24 2,700\nglucose measurements over 3 months per\nA1C measurement in 507 adults with type 1,\ntype 2, or no diabetes. The correlation be-tween A1C and average glucose was 0.92 | [
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0.02071893960237503,
0.09568500518798828,
-0.007027045823633671,
0.024434521794319153,
-0.04112912714481354,
-0.011510375887155533,
-0.07024684548377991,
-0.0... |
(19,20). Adapted from Nathan et al. (19).S112 Glycemic Goals and Hypoglycemia Diabetes Care Volume 47, Supplement 1, January 2024\n©AmericanDiabetesAssociation | [
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0.01266695000231266,
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-0.0789... |
complications (21). BGM is thus an integral\ncomponent of effective therapy for individ-\nuals taking insulin. In recent years, CGM\nhas become a standard method for glucose\nmonitoring for most people with type 1\ndiabetes. Both approaches to glucose mon-\nitoring allow people with diabetes to evalu-ate individual res... | [
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0.013071565888822079,
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0.030272439122200012,
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0.058459196239709854,
0.14509670436382294,
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0.00804087519645691,
-0.04867156967520714,
0.0422917976975441,
-0.05032746493816376,
0.03275370... |
assess whether glycemic goals are being\nsafely achieved. The speci ficn e e d sa n d\ngoals of individuals with diabetes shoulddictate BGM frequency and timing. Please\nrefer to Section 7, “Diabetes Technology, ”\nfor a more complete discussion of the use\nof BGM and CGM.\nGlycemic Assessment by Continuous\nGlucose Mon... | [
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0.011150434613227844,
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0.06253725290298462,
0.07205197960138321,
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-0.02... |
Glycemic Assessment by Continuous\nGlucose Monitoring\nRecommendations\n6.3 Standardized, single-page glucose\nreports from CGM devices with visual\ncues, such as the ambulatory glucose\nprofile, should be considered as a stan-\ndard summary for all CGM devices. E\n6.4Time in range (TIR) is associated | [
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0.0058500561863183975,
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0.02060745097696781,
0.009417178109288216,
0.14033618569374084,
-0.055591825395822525,
-0.04041244462132454,
-0.003188609378412366,
-0.046239905059337616,
-0.06055571138858795,
-... |
6.4Time in range (TIR) is associated\nwith the risk of microvascular compli-cations and can be used for assess-\nment of glycemic status. Additionally, | [
0.046953752636909485,
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0.018294701352715492,
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0.16548515856266022,
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0.019768351688981056,
-0.013984045945107937,
-0.03873418644070625,
... |
ment of glycemic status. Additionally,\ntime below range and time aboverange are useful parameters for theevaluation of the treatment plan(Table 6.2 ).CCGM is particularly useful in people with dia-betes who are at risk for hypoglycemia and iscommonly used in people with type 1 diabe-\ntes (21). Use of CGM in type 2 di... | [
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0.037727657705545425,
0.047560568898916245,
0.1653212159872055,
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-0.01020614430308342,
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-0.07118728756904602,
-0.0167... |
tes (21). Use of CGM in type 2 diabetes (as\nwell as in several other forms of diabetes) isgrowing, especially in people who are taking\ninsulin. TIR is a useful metric of glycemic sta-\ntus. A 10- to 14-day CGM assessment of TIR,\nwith CGM wear of 70% or higher, and other | [
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0.04156190901994705,
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0.0018522011814638972,
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0.0058209653943777084,
-0.014236025512218475,
0.06... |
with CGM wear of 70% or higher, and other\nCGM metrics can be used to assess glycemicstatus and are useful in clinical management\n(22–26). TIR, especially mean CGM glucose,\ncorrelates with A1C (27 –31). Time below\nrange ( <70 and <54 mg/dL [ <3.9 and\n<3.0 mmol/L]) and time above range\n(>180 mg/dL [ >10.0 mmol/L]) ... | [
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-0.055557746440172195,
0... |
(>180 mg/dL [ >10.0 mmol/L]) are useful\nparameters for insulin dose adjustments\nand reevaluation of the treatment plan.\nThe international consensus on CGM\nprovides guidance on standardized CGMmetrics ( Table 6.2 ) and their clinical inter-\npretation (32). To make these metrics ac-\ntionable, standardized reports w... | [
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0.0372... |
tionable, standardized reports with visual\nsummaries, such as the ambulatory glucoseprofile (Fig. 6.1), are recommended (32)\nand can help individuals with diabetes andhealth care professionals interpret the data\nto guide treatment decisions (27,30). BGM\nand CGM can be useful to guide medicalnutrition therapy and phy... | [
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0.02202235721051693,
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0.005787048023194075,
-0.07010204344987869,
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0.005796361248940229,
-0.04751186817884445,
-0.009371166117489338,
-0.0783562883734703,
0.042... |
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