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sion of behavioral health issues into daily\nfunctioning (499). Serious mental illness is\noften associated with the inability to eval-\nuate and apply information to make judg-\nments about treatment options. When a\nperson has an established diagnosis of a\nmental illness that impacts judgment, ac-\ntivities of daily... | [
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tivities of daily living, and ability to estab-\nlish a collaborative relationship with care\nprofessionals, it is helpful to include anonmedical caretaker in decision-making\nregarding the medical treatment plan.\nThis caretaker can help improve the per-\nson’s ability to follow the agreed-upon | [
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son’s ability to follow the agreed-upon\ntreatment plan through both monitoringand caretaking functions (500).\nCoordinated management of prediabe-\ntes or diabetes and serious mental illness isrecommended to achieve diabetes treat-\nment targets. The diabetes care team, in\ncollaboration with other care professionals, | [
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collaboration with other care professionals,\nshould work to provide an enhanced level\nof care and self-management support for\npeople with diabetes and serious mental\nillness based on individual capacity and\nneeds. Such care may include remotemonitoring, facilitating health care aides,\nand providing diabetes train... | [
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and providing diabetes training for family\nmembers, community support person-\nnel, and other caregivers. Qualitative re-\nsearch suggests that educational and\nbehavioral intervention may provide ben-\nefit via group support, accountability, and\nassistance with applying diabetes knowl-edge (501).\nCognitive Capacity/... | [
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Cognitive Capacity/Impairment\nRecommendations\n5.48 Cognitive capacity should be\nmonitored throughout the life span\nfor all individuals with diabetes, par-\nticularly in those who have docu-mented cognitive disabilities, thosewho experience severe hypoglyce-mia, very young children, and olderadults. B\n5.49 If cogni... | [
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5.49 If cognitive capacity changes or\nappears to be suboptimal for decision-making and/or behavioral self-man-agement, referral for a formal assess-ment should be considered. E\nCognitive capacity is generally de fined as\nattention, memory, logic and reasoning,\nand auditory and visual processing, all of\nwhich are in... | [
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which are involved in diabetes self-\nmanagement behavior (502). Having dia-betes (type 1 or type 2) over decades has\nbeen shown to be associated with cogni-\ntive decline (503 –505). A host of factors\nhave been linked with cognitive impair-ment in people with type 1 diabetes, in-cluding diabetes-speci fic (e.g., youn... | [
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age at diagnosis, longer disease duration,more time in glycemic extremes, recur-\nrent diabetic ketoacidosis, higher A1C,\nand presence of microvascular complica-\ntions), other medical (e.g., dyslipidemia,\nintestinal flora, and poorer sleep quality),\nand sociodemographic (e.g., female gen-\nder and lower educational ... | [
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der and lower educational level) factors\n(506). Declines have been shown to im-\npact executive function and information\nprocessing speed; they are not consistentbetween people, and evidence is lacking\nregarding a known course of decline (507).\nDiagnosis of dementia is more prevalent\namong people with diabetes, bo... | [
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among people with diabetes, both type 1\nand type 2 (508). Executive functioning is\nan aspect of cognitive capacity that has\nparticular relevance to diabetes manage-ment. Attention de ficit hyperactivity disor-\nder has been linked with twice the risk oftype 2 diabetes (509). Among youth and\nyoung adults with type 1 ... | [
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young adults with type 1 diabetes, lower\nexecutive functioning has been linked withmore dif ficulties with diabetes self-man-\nagement and higher A1C (510). In contrast,higher self-regulation has been linked with\nbetter emotional and diabetes-speci fic\nfunctioning (511). Thus, monitoring of cog-\nnitive capacity and s... | [
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nitive capacity and skills among individuals\nwith or at risk for diabetes is recom-\nmended, particularly regarding their ability\nto self-monitor and make judgments\nabout their symptoms, physical status, and\nneeded alterations to their self-manage-\nment behaviors, all of which are mediatedby executive function (50... | [
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ment behaviors, all of which are mediatedby executive function (508).\nAs with other disorders affecting men-\ntal capacity (e.g., major psychiatricS96 Facilitating Positive Health Behaviors and Well-being Diabetes Care Volume 47, Supplement 1, January 2024\n©AmericanDiabetesAssociation | [
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disorders), the key issue is whether the\nperson can collaborate with the careteam to achieve optimal metabolic out-comes and prevent complications, bothshort and long term (499). When this abil-\nity is shown to be altered, declining, or | [
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ity is shown to be altered, declining, or\nabsent, a lay care professional should beintroduced into the care team who servesin the capacities of a day-to-day monitor\nas well as a liaison with the rest of the\ncare team (1). Cognitive capacity also con-tributes to ability to bene fitf r o md i a b e t e s\neducation and... | [
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education and may indicate the need for\nalternative teaching approaches as well\nas remote monitoring. Youth will needsecond-party monitoring (e.g., parentsand adult caregivers) until they are de-velopmentally able to evaluate neces-\nsary information for self-management\ndecisions and to inform resultant behav-ior ch... | [
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decisions and to inform resultant behav-ior changes.\nEpisodes of severe hypoglycemia are in-\ndependently associated with decline as\nwell as the more immediate symptoms of\nmental confusion (512). Early-onset type 1diabetes has been shown to be associ-ated with potential long-term de ficits in | [
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intellectual abilities, especially in the con-text of repeated episodes of severe hypo-glycemia (513), and is correlated withhigher A1C and sensor glucose values\n(514). (See Section 14, “Children and\nAdolescents, ”for information on early-\nonset diabetes and cognitive abilities and | [
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onset diabetes and cognitive abilities and\nthe effects of severe hypoglycemia onchildren ’s cognitive and academic perfor-\nmance.) Thus, for myriad reasons, cogni-tive capacity should be assessed duringr o u t i n ec a r et oa s c e r t a i nt h ep e r s o n ’s\nability to maintain and adjust self-\nmanagement behavi... | [
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management behaviors, such as dosing\nof medications, remediation approachesto glycemic excursions, etc., and to de-termine whether to enlist a caregiver in\nmonitoring and decision-making regarding | [
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monitoring and decision-making regarding\nmanagement behaviors. If cognitive ca-pacity to carry out self-maintenance be-haviors is questioned, an age-appropriatetest of cognitive capacity is recommended\n(1). Cognitive capacity should be evalu-\nated in the context of the person ’sa g e , | [
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ated in the context of the person ’sa g e ,\nfor example, in very young children whoare not expected to manage their disease\nindependently and in older adults who\nmay need active monitoring of treatmentplan behaviors.\nCognitive decline is more severe in\nolder adults with type 2 diabetes (515).\nLongitudinal epidemi... | [
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Longitudinal epidemiological studies have\ndocumented that chronic hyperglycemia,older age, less education, retinopathy, | [
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and nephropathy are associated with dia-betes-related cognitive dysfunction (516).Importantly, the risk of cognitive declinec a nb er e d u c e dt h r o u g hi m p r o v e dA 1 C(517). Exercise may be a potential non-pharmacological treatment pathway forcognitive impairment in older adults withtype 2 diabetes (518,519)... | [
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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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0.08943016827106476,
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-0.06293561309576035,
0.05023772269487381,
-0.06830853223800659,
-0.01639... |
31. Johnson TM, Murray MR, Huang Y. Associations\nbetween self-management education and com-\nprehensive diabetes clinical care. DiabetesSpectr 2010;23:41 –46\n3 2 . D u n c a nI ,B i r k m e y e rC ,C o u g h l i nS ,L iQ E ,Sherr D, Boren S. Assessing the value of diabeteseducation. Diabetes Educ 2009;35:752 –760 | [
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-0.025... |
33. Piatt GA, Anderson RM, Brooks MM, et al.3-Year follow-up of clinical and behavioralimprovements following a multifaceted diabetes\ncare intervention: results of a randomized controlled\ntrial. Diabetes Educ 2010;36:301 –309 | [
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trial. Diabetes Educ 2010;36:301 –309\n34. Dallosso H, Mandalia P, Gray LJ, et al. Theeffectiveness of a structured group educationprogramme for people with established type 2diabetes in a multi-ethnic population in primarycare: a cluster randomised trial. Nutr MetabCardiovasc Dis 2022;32:1549 –1559\n35. Glazier RH, Ba... | [
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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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Meta-analysis: chronic disease self-management\nprograms for older adults. Ann Intern Med2005;143:427– 438\n38. Sarkisian CA, Brown AF, Norris KC, Wintz RL,Mangione CM. A systematic review of diabetesself-care interventions for older, African American,or Latino adults. Diabetes Educ 2003;29:467 –479 | [
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0.06977325677871704,
-0.08348128944635391,
-0.01031... |
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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0.044521037489175797,
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-0.00... |
41. Mannucci E, Giaccari A, Gallo M, et al. Self-management in patients with type 2 diabetes:group-based versus individual education. Asystematic review with meta-analysis of randomizedtrails. Nutr Metab Cardiovasc Dis 2022;32:330 –336 | [
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42. Duke SA, Colagiuri S, Colagiuri R. Individualpatient education for people with type 2diabetes mellitus. Cochrane Database Syst Rev2009;2009:Cd005268\n43. Odgers-Jewell K, Ball LE, Kelly JT , Isenring EA, | [
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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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-0.01617... |
2017;34:1027– 1039\n44. Zhao X, Huang H, Zheng S. Effectiveness\nof internet and phone-based interventions ondiabetes management of children and adolescentswith type 1 diabetes: a systematic review.Worldviews Evid Based Nurs 2021;18:217 –225\nS98 Facilitating Positive Health Behaviors and Well-being Diabetes Care Volum... | [
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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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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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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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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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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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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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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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