09:30 AM

481 - Diabetes Standards of Care 2023: Part 1, Going “Fast”

Take 3 – Practical Practice Pointers©

From the Guidelines and the American Diabetes Association (ADA)

1) ADA Diabetes Standards of Care 2023 Highlights – Part 1


According to the CDC, 10.4% of Virginia adults have been diagnosed with T2D and another 2.8% have it but are undiagnosed.  Additionally, 33.3% have prediabetes. This trend is similar for other states as well. Given this prevalence, it is essential that we who are providing primary health care become “experts” in the management and prevention of T2D. To that end, this week’s (and next week’s) Take 3 will highlight the recently published ADA 2023 Diabetes Standards of Care.

The ADA evidence-grading system includes levels, A, B, C, and E, with “A” having the strongest evidence and “E” being based on expert opinion. Some recommendations are underlined to provide additional emphasis.

Screening: Recommendations

·         Testing for T2D in asymptomatic people should be considered in adults of any age who are overweight or obese (BMI ≥25 or ≥23 in Asian Americans) and who have one or more additional risk factors. B

·         For all people, screening should begin at age 35 years. B

·         If tests are normal, repeating at a minimum of 3-year intervals is reasonable. C

·         To screen for T2D, fasting plasma glucose, 2-h plasma glucose after 75-g oral glucose tolerance test, and A1C are equally appropriate. B

·         Risk-based screening for prediabetes and/or type 2 diabetes should be considered after the onset of puberty or after 10 years of age, whichever occurs earlier, in children and adolescents with overweight (BMI ≥85th percentile) or obesity (BMI ≥95th percentile) and who have one or more risk factors for diabetes. B

·         At least annual monitoring in those with prediabetes. E

Diagnosis: Recommendations:

·         A1C:  Prediabetes:  5.7-6.4%    Diabetes: > 6.5%

·         Fasting Plasma Glucose (FPG)

                Prediabetes: 100-125 mg/dl    Diabetes:  > 126 ng/dl

·         Random Plasma Glucose:  Diabetes:  > 200 mg/dl

Lifestyle Interventions for Weight Loss in T2D: Recommendations

·         Refer patients with prediabetes to an intensive behavioral lifestyle intervention program modeled on the Diabetes Prevention Program (DPP) to achieve and maintain 7% loss of initial bodyweight and increase moderate-intensity physical activity (such as brisk walking) to at least 150 min/week. A

·         A variety of eating patterns are acceptable for persons with prediabetes. B

·         Based on patient preference, technology-assisted diabetes prevention interventions may be effective in preventing T2D and should be considered. B

Glycemic Monitoring: Recommendations

·         Assess glycemic status (A1C or other glycemic measurement such as time in range [TIR] or glucose management indicator [GMI]) at least two times a year in patients who are meeting treatment goals (and who have stable glycemic control). E

·         Assess glycemic status at least quarterly and as needed in patients whose therapy has recently changed and/or who are not meeting glycemic goals. E

·         An A1C goal for many nonpregnant adults of <7% without significant hypoglycemia is appropriate. A

·         Less stringent A1C goals (such as <8% may be appropriate for patients with limited life expectancy or where the harms of treatment are greater than the benefits. B

·         If using Ambulatory Glucose Profile (AGP)/GMI to assess glycemia, a parallel goal for many nonpregnant adults is TIR of >70% with time below range <4% and time <54 mg/dL <1% B

Pharmacologic Interventions for Diabetes Prevention: Recommendations

·        Metformin therapy for the prevention of T2D should be considered in adults at high risk, especially those aged 25–59 years with BMI ≥35 kg/m2, higher fasting plasma glucose (e.g., ≥110 mg/dL), and higher A1C (e.g., ≥6.0%), and in individuals with prior gestational diabetes mellitus. A

·         Periodic measurement of vitamin B12 levels should be considered in metformin- treated patients, especially in those with anemia or peripheral neuropathy. B

Blood Glucose Monitoring (BGM):  Recommendations

·         People who are on insulin using BGM should be encouraged to check when appropriate based on their insulin regimen. This may include checking when fasting, prior to meals and snacks, at bedtime, prior to exercise, when low blood glucose is suspected, after treating low blood glucose levels until they are normoglycemic, and prior to and while performing critical tasks such as driving. B

·         When prescribed as part of a Diabetes Self-Management Education and Support (DSMES) program, SMBG may help to guide treatment decisions and/or self- management for patients taking less-frequent insulin injections. B

·         Although BGM in patients on noninsulin therapies has not shown clinically significant reductions in A1C, it may be helpful when altering diet, physical activity, and/or medications (particularly medications that can cause hypoglycemia) in conjunction with a treatment adjustment program. E

Continuous Glucose Monitoring (CGM) Devices:  Recommendations

·         Real-time CGM (rtCGM) A or intermittently scanned CGM (isCGM) B should be offered for diabetes management in adults with diabetes on multiple daily injections (MDI) who are capable of using the devices safely (either by themselves or with a caregiver).  Likewise for those on basal insulin (A/C).  The choice of device should be made based on the individual’s circumstances, preferences, and needs.  (See 3rd Reference below)

·         Periodic use of rtCGM or isCGM or use of professional CGM can be helpful for diabetes management in circumstances where continuous use of CGM is not appropriate, desired, or available. C

Obesity and Weight Management: Recommendations

·         Nutrition, physical activity, and behavioral therapy to achieve and maintain ≥5% weight loss are recommended for most people with type 2 diabetes and overweight or obesity. Additional weight loss usually results in further improvements in the management of diabetes and CV risk. B

·         Obesity pharmacotherapy is effective as an adjunct to nutrition, physical activity, and behavioral counseling for selected people with type 2 diabetes and BMI ≥27 kg/m2. Potential benefits and risks must be considered. A

·        Metabolic surgery should be a recommended option to treat T2D in screened surgical candidates with BMI ≥40 kg/m2 (BMI ≥37.5 kg/m2 in Asian American individuals) and in adults with BMI 35.0–39.9 kg/m2 (32.5–37.4 kg/m2 in Asian American individuals) who do not achieve durable weight loss and improvement in comorbidities (including hyperglycemia) with nonsurgical methods. A

Hypertension/Blood Pressure Control and CVD Risk in T2D: Recommendations

·         The ACC/AHA ASCVD risk calculator (Risk Estimator Plus) is a useful tool to estimate 10-year ASCVD risk.  ASCVD Risk-Estimator Plus

·        Individuals with confirmed office-based blood pressure ≥130/80 mmHg qualify for initiation and titration of pharmacologic therapy to achieve the recommended blood pressure goal of <130/80 mmHg. A

·         An ACE inhibitor or ARB, at the maximum tolerated dose indicated for BP treatment, is the recommended first-line treatment for HTN in people with DM and urinary albumin-to-creatinine ratio (UACR) ≥300 mg/g creatinine A or 30–299 mg/g creatinine. B 

·         For patients treated with an ACE-I, ARB, or diuretic, serum Cr, estimated glomerular filtration rate (eGFR) and potassium levels should be monitored at least annually. B

Chronic Kidney Disease: Recommendations

·         At least annually, a spot urinary albumin-to-creatinine ratio and estimated GFR should be assessed in people with type 1 diabetes with duration of ≥5 years and in all people withT2D regardless of treatmentB

·         In people with established diabetic kidney disease, a spot urinary albumin-to-creatinine ratio and estimated GFR should be monitored 1–4 times per year depending on the stage of the disease. B

·        For people with non–dialysis-dependent stage 3 or higher CKD, dietary protein intake should be aimed to a target level of 0.8 g/kg body weight per day. A 

·         An ACE inhibitor or an ARB is not recommended for the primary prevention of diabetic kidney disease in patients with diabetes who have normal blood pressure, normal urinary albumin–to–creatinine ratio (<30), and normal e-GFR. A

Diabetic Retinopathy: Recommendations

·         Patients with T2D should have an initial dilated and comprehensive eye examination by an ophthalmologist or optometrist at the time of the diabetes diagnosis. B

·         If there is no evidence of retinopathy for one or more annual eye exams and glycemia is well-controlled, then screening every 1–2 years may be considered. B

 Foot Care:

·         Perform a comprehensive foot evaluation at least annually. B

·         Assessment for distal symmetric polyneuropathy should include a careful history and assessment of either temperature or pinprick sensation (small fiber function) and vibration sensation using a 128-Hz tuning fork (for large-fiber function). All patients should have annual 10-g monofilament testing to identify feet at risk for ulceration and amputation. B

·         Patients with evidence of sensory loss or prior ulceration or amputation should have their feet inspected at every visit. B

 Mark’s Comments:

I have selectively chosen recommendations from the much longer document. The abridged document referenced below may be one worth investing the time in reading the entire document.  It’s packed full of information and some helpful tables.  Given the number of patients we care for who have diabetes, it is imperative that we are experts in their care.  Next week I’ll highlight the medication recommendations from the guideline.


·         ElSayed N, et al.  American Diabetes Association Standards of Care in Diabetes – 2023.  Diabetes Care January 2023;46(Supl 1).  Link

·         American Diabetes Association Standards of Care in Diabetes—2023 Abridged for Primary Care Providers.  Clin Diabetes 2023;41(1):4–31.  Link

·         ADA Consumer Guide (for DM Devices and Products):  Link

From PeerRxMed ( www.PeerRxMed.org )

2)  When Going “Fast” May Be Exactly What You Need


“What the eyes are for the outer world, fasts are for the inner.” ~ Mahatma Gandhi

What’s been your experiencing with fasting?  More than 2 decades ago I started to do a water-only fast for one day each week to enhance my physical, psychological, and spiritual health.  Over time, that pattern has evolved and for the past few years, in addition to my weekly fast I added longer quarterly fasts of 3-5 days, usually done around the time of the solstices and equinoxes.  In fact, I just completed a modified 5-day fast 3 weeks ago, and the experience, as is often the case, was a powerful one.

Though some form of fasting is common in many religious traditions and scientific data indicate that various forms of water-only fasting have the potential to provide many health benefits, when I share with people that I do this, the most common response is one of either amazement (“Wow, I could never do that!”) or caution (“Isn’t that dangerous?”).  Fortunately, fasting has become more mainstream in the past 20 years, with articles being more commonplace in both the scientific literature and the popular press.

However, it’s important to acknowledge that going for an extended period without food or any caloric intake is not for everyone and may not be safe for some.  It is therefore encouraging to note that “fasting” from other activities or patterns of living can also have important physical, psychological, and spiritual benefits.  This commonly might include abstinence from social media, the news, television, or a particular habit, such as drinking alcohol or caffeine, or even from complaining.   

What any form of fasting has the potential to do is provide a break from our usual routine and allow us to be more present and aware.  We “go without” in order to recalibrate ourselves and be reminded once again that much of what we think we “need” is not only unnecessary, but often harmful or at the least, a distraction.  That has certainly been the case for me, and since the impact often “wears off” over time, repeating at regular intervals has served as a necessary and essential “reminder”.      

This week, consider what “need” or distraction in your life could use a break and whether “fasting” from it might be worth a try.  If you do, pay attention to what shows up in the space you’ve “emptied,” whether that space is in your stomach, your mind, or your schedule.  There may be an important message there for you.  You can thank me later …


Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org