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6. Glycemic Targets: Standards of Care in Diabetes—2023

Open access
ElSayed, Nuha A., Aleppo, Grazia, Aroda, Vanita R., Bannuru, Raveendhara R., Brown, Florence M., Bruemmer, Dennis, Collins, Billy S., Hilliard, Marisa E. +12 more·2023·Diabetes Care
DOI 10.2337/dc23-s006PMC PMC9810469
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Abstract

The American Diabetes Association (ADA) “Standards of Care in Diabetes” includes the ADA’s current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA’s clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

AI snapshot

Written from the paper’s full text.

TL;DR

This ADA *Standards of Care in Diabetes—2023* section provides evidence-based recommendations for assessing glycemic control and setting individualized glycemic targets in diabetes. It emphasizes A1C, CGM-derived time in range/GMI, hypoglycemia prevention, and balancing benefits against risks.

Key findings

  • For many nonpregnant adults, the A1C goal is <7% (53 mmol/mol) without significant hypoglycemia; a parallel CGM goal is time in range >70%, time below range <4%, and time <54 mg/dL <1%. Less stringent A1C goals such as <8% (64 mmol/mol) may be appropriate for limited life expectancy or when harms outweigh benefits.
  • DCCT intensive versus standard glycemic control (mean A1C about 7% vs. about 9%) reduced development and progression of microvascular complications by 50–76%; EDIC follow-up showed a 57% reduction in nonfatal MI, stroke, or cardiovascular death in the intensive arm. ACCORD was halted early for increased mortality in the intensive arm (1.41% vs. 1.14% per year; hazard ratio 1.22 [95% CI 1.01–1.46]).
  • The ADAG study in 507 adults (83% non-Hispanic White) found an A1C–average glucose correlation of r = 0.92 based on 2,700 readings per A1C measurement; retrospective data suggest 70% time in range aligns with an A1C of 7%. CGM improved A1C by 0.3–0.6% in people with type 1 or type 2 diabetes above target.
  • Hypoglycemia is classified as level 1: glucose <70 mg/dL (3.9 mmol/L) and ≥54 mg/dL (3.0 mmol/L); level 2: <54 mg/dL (3.0 mmol/L); level 3: a severe event requiring assistance. Treatment is approximately 15–20 g glucose, repeated after 15 minutes if BGM shows continued hypoglycemia.

Methods

  • Design: ADA clinical practice recommendations, updated annually by the multidisciplinary Professional Practice Committee, with evidence-graded recommendations.
  • Data: narrative synthesis of trials and studies including DCCT/EDIC, UKPDS, Kumamoto, ACCORD, ADVANCE, VADT, and ADAG, plus consensus reports; no new primary data collection.
  • Analysis: expert consensus and evidence review; detailed evidence-grading methodology is referred to the Introduction and Methodology section.

Limitations

  • Stated: A1C is an indirect measure affected by red blood cell turnover, hemoglobin variants, pregnancy, end-stage kidney disease, and other conditions, and it does not measure glycemic variability or hypoglycemia. CGM studies had differing entry A1C and endpoints and must be interpreted carefully; no study reported a decrease in level 3 hypoglycemia, and type 2 diabetes CGM evidence on hypoglycemic events is limited.
  • Evident: This is a guideline/standards chapter rather than a primary systematic review; methods and evidence grading are deferred to another section, and the recommendations are intended to be individualized rather than applied rigidly.

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Integrity signals

Registry

Crossref · 10.2337/dc23-s006

Cites

136 of 136 references verified0 citation errors · 0 not checkable

Statistics

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Claims the paper makes

0 of 133 cited sources checked · 0 supported · 0 flagged

  • Findingnone given
    § Use of CGM Technology in Hypoglycemia Prevention

    No study to date has reported a decrease in level 3 hypoglycemia.

    “No study to date has reported a decrease in level 3 hypoglycemia.”
    Quote in the paperNot a substantial claim
  • Premisecitation
    § A1C Differences in Ethnic Populations and Children

    Another genetic variant, X-linked glucose-6-phosphate dehydrogenase G202A, carried by 11% of African American individuals, was associated with a decrease in A1C of about 0.8% in hemizygous men and 0.7% in homozygous women compared with those without the trait.

    “Another genetic variant, X-linked glucose-6-phosphate dehydrogenase G202A, carried by 11% of African American individuals, was associated with a decrease in A1C of about 0.8% in hemizygous men and 0.7% in homozygous women compared with those without the trait (20).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [20] Wheeler, 2017, Impact of common genetic determinants of hemoglobin A1c on type 2 diabetes risk and diagnosis in ancestrally diverse populations: a transethnic genome-wide meta-analysis, PLoS Med source

      Not checked in the free run.

  • Premisecitation
    § Correlation Between BGM and A1C

    The ADAG study assessed the correlation between A1C and frequent BGM and CGM in 507 adults (83% non-Hispanic White) with type 1, type 2, and no diabetes.

    “the international A1C-Derived Average Glucose (ADAG) study, which assessed the correlation between A1C and frequent BGM and CGM in 507 adults (83% non-Hispanic White) with type 1, type 2, and no diabetes (13)”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [13] Nathan, 2008, Translating the A1C assay into estimated average glucose values, Diabetes Care source

      Not checked in the free run.

  • Premisecitation
    § Correlation Between BGM and A1C

    In a report, mean glucose measured with CGM versus central laboratory-measured A1C in 387 participants in three randomized trials demonstrated that A1C may underestimate or overestimate mean glucose in individuals.

    “In a report, mean glucose measured with CGM versus central laboratory-measured A1C in 387 participants in three randomized trials demonstrated that A1C may underestimate or overestimate mean glucose in individuals (12).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [12] Beck, 2017, The fallacy of average: how using HbA1C alone to assess glycemic control can be misleading, Diabetes Care source

      Not checked in the free run.

  • Interpretationreasoning
    § A1C Differences in Ethnic Populations and Children

    A1C and glucose parameters are essential for the optimal assessment of glycemic status.

    “Taken together, A1C and glucose parameters are essential for the optimal assessment of glycemic status.”
    Quote in the paperSubstantial claim
  • Classified as probably not a substantial claim. 23
  • May combine two claims. 29
  • The quote only partly states this claim. 1

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation
    § Correlation Between BGM and A1C

    The mean plasma glucose numbers in Table 6.1 are based on 2,700 readings per A1C measurement in the ADAG trial.

    “Clinicians should note that the mean plasma glucose numbers in Table 6.1 are based on 2,700 readings per A1C measurement in the ADAG trial.”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [13] Nathan, 2008, Translating the A1C assay into estimated average glucose values, Diabetes Care source

      Not checked in the free run.

    • cites [14] Wei, 2014, Empirically establishing blood glucose targets to achieve HbA1c goals, Diabetes Care source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation
    § A1C Differences in Ethnic Populations and Children

    A small study comparing A1C to CGM data in children with type 1 diabetes found a highly statistically significant correlation between A1C and mean blood glucose, although the correlation (r = 0.7) was significantly lower than that in the ADAG trial.

    “A small study comparing A1C to CGM data in children with type 1 diabetes found a highly statistically significant correlation between A1C and mean blood glucose, although the correlation (r = 0.7) was significantly lower than that in the ADAG trial (21).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [21] Diabetes Research in Children Network (DirecNet) Study Group, 2008, Relationship of A1C to glucose concentrations in children with type 1 diabetes: assessments by high-frequency glucose determinations by sensors, Diabetes Care source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Interpretationnone given
    § A1C Limitations

    Other measures of average glycemia such as fructosamine and 1,5-anhydroglucitol are available, but their translation into average glucose levels and their prognostic significance are not as clear as for A1C and CGM.

    “Other measures of average glycemia such as fructosamine and 1,5-anhydroglucitol are available, but their translation into average glucose levels and their prognostic significance are not as clear as for A1C and CGM.”
    Quote in the paperNot a substantial claim

  • May combine two claims. The quote only partly states this claim.

    Interpretationreasoning
    § A1C Limitations

    Discordant results between BGM/CGM and A1C can be the result of conditions that affect red blood cell turnover or glycemic variability, with BGM missing the extremes.

    “Discordant results between BGM/CGM and A1C can be the result of the conditions outlined above or glycemic variability, with BGM missing the extremes.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation
    § 6.3 Standardized, single-page glucose

    Time in range (TIR) is a useful metric of glycemic control and glucose patterns, and it correlates well with A1C in most studies.

    “As stated in the recommendations, time in range (TIR) is a useful metric of glycemic control and glucose patterns, and it correlates well with A1C in most studies (24)(25)(26)(27)(28)(29).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites (24)(25)(26)(27)(28)(29)

      Not checked in the free run.

  • May combine two claims.

    Premisecitation
    § 6.3 Standardized, single-page glucose

    Cross-sectional data and cohort studies demonstrate TIR as an acceptable end point for clinical trials moving forward and that it can be used for assessment of glycemic control.

    “they include crosssectional data and cohort studies (30)(31)(32) demonstrating TIR as an acceptable end point for clinical trials moving forward and that it can be used for assessment of glycemic control.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites (30)(31)(32)

      Not checked in the free run.

  • May combine two claims.

    Premisecitation
    § 6.3 Standardized, single-page glucose

    Published data from two retrospective studies suggest a strong correlation between TIR and A1C, with a goal of 70% TIR aligning with an A1C of 7%.

    “Published data from two retrospective studies suggest a strong correlation between TIR and A1C, with a goal of 70% TIR aligning with an A1C of 7% (8,26).”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [8] Beck, 2019, The relationships between time in range, hyperglycemia metrics, and HbA1c, J Diabetes Sci Technol source

      Not checked in the free run.

    • cites [26] Vigersky, 2019, The relationship of hemoglobin A1C to time-in-range in patients with diabetes, Diabetes Technol Ther source

      Not checked in the free run.

  • May combine two claims.

    Interpretationreasoning
    § GLYCEMIC GOALS

    Further lowering of A1C from 7 to 6% (53 mmol/mol to 42 mmol/mol) is associated with further reduction in the risk of microvascular complications, although the absolute risk reductions become much smaller.

    “These analyses also suggest that further lowering of A1C from 7 to 6% (53 mmol/mol to 42 mmol/mol) is associated with further reduction in the risk of microvascular complications, although the absolute risk reductions become much smaller.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation
    § Cardiovascular Disease and Type 2 Diabetes

    The glycemic control comparison in ACCORD was halted early due to an increased mortality rate in the intensive compared with the standard treatment arm (1.41% vs. 1.14% per year; hazard ratio 1.22 [95% CI 1.01-1.46]), with a similar increase in cardiovascular deaths.

    “The glycemic control comparison in ACCORD was halted early due to an increased mortality rate in the intensive compared with the standard treatment arm (1.41% vs. 1.14% per year; hazard ratio 1.22 [95% CI 1.01-1.46]),with a similar increase in cardiovascular deaths.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation
    § Cardiovascular Disease and Type 2 Diabetes

    After 10 years of observational follow-up, those originally randomized to intensive glycemic control had significant long-term reductions in MI (15% with sulfonylurea or insulin as initial pharmacotherapy, 33% with metformin as initial pharmacotherapy) and in all-cause mortality (13% and 27%, respectively).

    “Similar to the DCCT/EDIC, after 10 years of observational followup, those originally randomized to intensive glycemic control had significant long-term reductions in MI (15% with sulfonylurea or insulin as initial pharmacotherapy, 33% with metformin as initial pharmacotherapy) and in all-cause mortality (13% and 27%, respectively) (47).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [47] Holman, 2008, 10-year follow-up of intensive glucose control in type 2 diabetes, N Engl J Med source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation
    § Cardiovascular Disease and Type 1 Diabetes

    The benefit of intensive glycemic control in the type 1 diabetes cohort has been shown to persist for several decades and to be associated with a modest reduction in all-cause mortality.

    “The benefit of intensive glycemic control in this cohort with type 1 diabetes has been shown to persist for several decades (55) and to be associated with a modest reduction in all-cause mortality (56).”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [55] Nathan, 2009, Modern-day clinical course of type 1 diabetes mellitus after 30 years’ duration: the diabetes control and complications trial/epidemiology of diabetes interventions and complications and Pittsburgh epidemiology of diabetes complications experience (1983-2005), Arch Intern Med source

      Not checked in the free run.

    • cites [56] Emerging Risk Factors Collaboration, 2015, Association of cardiometabolic multimorbidity with mortality, JAMA source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation
    § Cardiovascular Disease and Type 2 Diabetes

    Data from the Swedish National Diabetes Registry and the Joint Asia Diabetes Evaluation (JADE) demonstrate greater proportions of people with diabetes being diagnosed at <40 years of age and a demonstrably increased burden of heart disease and years of life lost in people diagnosed at a younger age.

    “In addition, data from the Swedish National Diabetes Registry (56) and the Joint Asia Diabetes Evaluation (JADE) demonstrate greater proportions of people with diabetes being diagnosed at <40 years of age and a demonstrably increased burden of heart disease and years of life lost in people diagnosed at a younger age (57)(58)(59)(60).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites (57)(58)(59)(60)

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  • May combine two claims.

    Premisecitation
    § Cardiovascular Disease and Type 2 Diabetes

    During the UKPDS, there was a 16% reduction in CVD events (combined fatal or nonfatal MI and sudden death) in the intensive glycemic control arm that did not reach statistical significance (P = 0.052), and there was no suggestion of benefit on other CVD outcomes (e.g., stroke).

    “During the UKPDS, there was a 16% reduction in CVD events (combined fatal or nonfatal MI and sudden death) in the intensive glycemic control arm that did not reach statistical significance (P = 0.052), and there was no suggestion of benefit on other CVD outcomes (e.g., stroke).”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [45] UK Prospective Diabetes Study (UKPDS) Group, 1998, Effect of intensive blood-glucose control with metformin on complications in overweight patients with type 2 diabetes (UKPDS 34), Lancet source

      Not checked in the free run.

    • cites [46] UK Prospective Diabetes Study (UKPDS) Group, 1998, Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33), Lancet source

      Not checked in the free run.

  • May combine two claims.

    Interpretationcitation
    § GLYCEMIC GOALS

    Randomized clinical trials examining GLP-1 receptor agonists and SGLT2 inhibitors for cardiovascular safety were not designed to test higher versus lower A1C; therefore, beyond post hoc analysis of these trials, we do not have evidence that it is the glucose lowering by these agents that confers the CVD and renal benefit.

    “Randomized clinical trials examining these agents for cardiovascular safety were not designed to test higher versus lower A1C; therefore, beyond post hoc analysis of these trials, we do not have evidence that it is the glucose lowering by these agents that confers the CVD and renal benefit (53).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [53] Buse, 2020, Cardiovascular risk reduction with liraglutide: an exploratory mediation analysis of the LEADER trial, Diabetes Care source

      Not checked in the free run.

    • Rests on an assumption: GLP-1 receptor agonists and SGLT2 inhibitors were not approved at the time of the ACCORD, ADVANCE, and VADT trials.

  • Probably not a substantial claim: may not pass S4 (based). May combine two claims.

    Interpretationnone given
    § Setting and Modifying A1C Goals

    With longer disease duration, diabetes may become more difficult to control, with increasing risks and burdens of therapy.

    “Also, with longer disease duration, diabetes may become more difficult to control, with increasing risks and burdens of therapy.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation
    § Setting and Modifying A1C Goals

    An analysis of data from 470 participants in the ADAG study found that the glucose ranges highlighted in Table 6.1 are adequate to meet targets and decrease hypoglycemia.

    “An analysis of data from 470 participants in the ADAG study (237 with type 1 diabetes and 147 with type 2 diabetes) found that the glucose ranges highlighted in Table 6.1 are adequate to meet targets and decrease hypoglycemia (14).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [14] Wei, 2014, Empirically establishing blood glucose targets to achieve HbA1c goals, Diabetes Care source

      Not checked in the free run.

  • Classified as probably not a substantial claim. May combine two claims.

    Interpretationcitation
    § Setting and Modifying A1C Goals

    Recurrent level 2 hypoglycemia and/or level 3 hypoglycemia is an urgent medical issue and requires intervention with medical treatment plan adjustment, behavioral intervention, and, in some cases, use of technology to assist with hypoglycemia prevention and identification.

    “Recurrent level 2 hypoglycemia and/or level 3 hypoglycemia is an urgent medical issue and requires intervention with medical treatment plan adjustment, behavioral intervention, and, in some cases, use of technology to assist with hypoglycemia prevention and identification (76,(79)(80)(81)(82).”
    Quote in the paperSubstantial claim0 of 5 sources checked
    • cites [76] Ghandi, 2021, A comparison of validated methods used to assess impaired awareness of hypoglycaemia in type 1 diabetes: an observational study, Diabetes Ther source

      Not checked in the free run.

    • cites [79] Amiel, 2022, A parallel randomised controlled trial of the Hypoglycaemia Awareness Restoration Programme for adults with type 1 diabetes and problematic hypoglycaemia despite optimised self-care (HARPdoc), Nat Commun source

      Not checked in the free run.

    • cites [80] Khunti, 2017, Impact of hypoglycaemia on patient-reported outcomes from a global, 24-country study of 27,585 people with type 1 and insulin-treated type 2 diabetes, Diabetes Res Clin Pract source

      Not checked in the free run.

    • cites [81] Choudhary, 2018, Hypoglycaemia in type 1 diabetes: technological treatments, their limitations and the place of psychology, Diabetologia source

      Not checked in the free run.

    • cites [82] Hopkins, 2012, Improved biomedical and psychological outcomes 1 year after structured education in flexible insulin therapy for people with type 1 diabetes: the U.K. DAFNE experience, Diabetes Care source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Premisenone given
    § Setting and Modifying A1C Goals

    Hypoglycemia is reversed by administration of rapid-acting glucose or glucagon.

    “Hypoglycemia is reversed by administration of rapid-acting glucose or glucagon.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Premisenone given
    § Setting and Modifying A1C Goals

    Hypoglycemia can cause acute harm to the person with diabetes or others, especially if it causes falls, motor vehicle accidents, or other injury.

    “Hypoglycemia can cause acute harm to the person with diabetes or others, especially if it causes falls, motor vehicle accidents, or other injury.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Premisecitation
    § Setting and Modifying A1C Goals

    These data prompted the revision in the ADA-recommended premeal glucose target to 80-130 mg/dL (4.4-7.2 mmol/L) but did not affect the definition of hypoglycemia.

    “These data prompted the revision in the ADArecommended premeal glucose target to 80-130 mg/dL (4.4-7.2 mmol/L) but did not affect the definition of hypoglycemia.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [14] Wei, 2014, Empirically establishing blood glucose targets to achieve HbA1c goals, Diabetes Care source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Interpretationreasoning
    § Setting and Modifying A1C Goals

    Because many people with diabetes demonstrate impaired counterregulatory responses to hypoglycemia and/or experience hypoglycemia unawareness, a measured glucose level <70 mg/dL (3.9 mmol/L) is considered clinically important independent of the severity of acute hypoglycemic symptoms.

    “Because many people with diabetes demonstrate impaired counterregulatory responses to hypoglycemia and/or experience hypoglycemia unawareness, a measured glucose level <70 mg/dL (3.9 mmol/L) is considered clinically important (independent of the severity of acute hypoglycemic symptoms).”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisenone given
    § Setting and Modifying A1C Goals

    Level 3 hypoglycemia may be recognized or unrecognized and can progress to loss of consciousness, seizure, coma, or death.

    “Level 3 hypoglycemia may be recognized or unrecognized and can progress to loss of consciousness, seizure, coma, or death.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S4 (based).

    Premisenone given
    § Setting and Modifying A1C Goals

    A blood glucose concentration of 70 mg/dL (3.9 mmol/L) has been recognized as a threshold for neuroendocrine responses to falling glucose in people without diabetes.

    “A blood glucose concentration of 70 mg/dL (3.9 mmol/L) has been recognized as a threshold for neuroendocrine responses to falling glucose in people without diabetes.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Premisenone given
    § Hypoglycemia Prevention

    BGM and, for some individuals, CGM are essential tools to assess therapy and detect incipient hypoglycemia.

    “BGM and, for some individuals, CGM are essential tools to assess therapy and detect incipient hypoglycemia.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation
    § Hypoglycemia Prevention

    Teaching people with diabetes to balance insulin use and carbohydrate intake and physical activity are necessary, but these strategies are not always sufficient for prevention.

    “Teaching people with diabetes to balance insulin use and carbohydrate intake and physical activity are necessary, but these strategies are not always sufficient for prevention (77,(103)(104)(105).”
    Quote in the paperSubstantial claim0 of 4 sources checked
    • cites [77] Li, 2019, Early hypoglycaemia and adherence after basal insulin initiation in a nationally representative sample of Medicare beneficiaries with type 2 diabetes, Diabetes Obes Metab source

      Not checked in the free run.

    • cites [103] Stanton-Fay, 2021, The DAFNEplus programme for sustained type 1 diabetes self management: intervention development using the Behaviour Change Wheel, Diabet Med source

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    • cites [104] Farrell, 2021, Clinical approaches to treat impaired awareness of hypoglycaemia, Ther Adv Endocrinol Metab source

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    • cites [105] Cox, 1994, Long-term follow-up evaluation of blood glucose awareness training, Diabetes Care source

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  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisereasoning
    § Glucagon

    Intranasal glucagon and ready-to-inject glucagon preparations for subcutaneous injection are available and may be beneficial in view of safety, efficacy, and ease of use.

    “In addition to traditional glucagon injection powder that requires reconstitution prior to injection, intranasal glucagon and ready-toinject glucagon preparations for subcutaneous injection are available and may be beneficial in view of safety, efficacy, and ease of use.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationcitation
    § Setting and Modifying A1C Goals

    Individualized glucose targets, patient education, nutrition intervention, physical activity management, medication adjustment, glucose monitoring, and routine clinical surveillance may improve patient outcomes.

    “Individualized glucose targets, patient education, nutrition intervention (e.g., bedtime snack to prevent overnight hypoglycemia when specifically needed to treat low blood glucose), physical activity management, medication adjustment, glucose monitoring, and routine clinical surveillance may improve patient outcomes (94).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [94] Seaquist, 2013, Hypoglycemia and diabetes: a report of a workgroup of the American Diabetes Association and the Endocrine Society, Diabetes Care source

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  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Premisenone given
    § Hypoglycemia Treatment

    Added fat may retard and then prolong the acute glycemic response.

    “Added fat may retard and then prolong the acute glycemic response.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisenone given
    § Glucagon

    An individual does not need to be a health care professional to safely administer glucagon.

    “An individual does not need to be a health care professional to safely administer glucagon.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationcitation
    § Setting and Modifying A1C Goals

    For people with type 1 diabetes with level 3 hypoglycemia and hypoglycemia unawareness that persists despite medical treatment, human islet transplantation may be an option, but the approach remains experimental.

    “For people with type 1 diabetes with level 3 hypoglycemia and hypoglycemia unawareness that persists despite medical treatment, human islet transplantation may be an option, but the approach remains experimental (96,97).”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [96] Hering, 2016, Phase 3 trial of transplantation of human islets in type 1 diabetes complicated by severe hypoglycemia, Diabetes Care source

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    • cites [97] Harlan, 2016, Islet transplantation for hypoglycemia unawareness/severe hypoglycemia: caveat emptor, Diabetes Care source

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  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisenone given
    § Hypoglycemia Prevention

    Hypoglycemia may increase the risk of harm to self or others, such as when driving.

    “Hypoglycemia may increase the risk of harm to self or others, such as when driving.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Premisenone given
    § Glucagon

    The use of glucagon is indicated for the treatment of hypoglycemia in people unable or unwilling to consume carbohydrates by mouth.

    “The use of glucagon is indicated for the treatment of hypoglycemia in people unable or unwilling to consume carbohydrates by mouth.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisenone given
    § Hypoglycemia Prevention

    Hypoglycemia unawareness syndrome is characterized by deficient counterregulatory hormone release, especially in older adults, and a diminished autonomic response, which are both risk factors for and caused by hypoglycemia.

    “This syndrome is characterized by deficient counterregulatory hormone release, especially in older adults, and a diminished autonomic response, which are both risk factors for and caused by hypoglycemia.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing), S4 (based).

    Interpretationnone given
    § Hypoglycemia Prevention

    Regardless of the factors contributing to hypoglycemia and hypoglycemia unawareness, this represents an urgent medical issue requiring intervention.

    “Regardless of the factors contributing to hypoglycemia and hypoglycemia unawareness, this represents an urgent medical issue requiring intervention.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Interpretationcitation
    § Hypoglycemia Prevention

    Individuals with one or more episodes of clinically significant hypoglycemia may benefit from at least short-term relaxation of glycemic targets and availability of glucagon.

    “Hence, individuals with one or more episodes of clinically significant hypoglycemia may benefit from at least short-term relaxation of glycemic targets and availability of glucagon (107).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [107] Mitchell, 2016, Glucagon prescription patterns in patients with either type 1 or 2 diabetes with newly prescribed insulin, Endocr Pract source

      Not checked in the free run.

  • May combine two claims.

    Premisenone given
    § Use of CGM Technology in Hypoglycemia Prevention

    To date, there have been a number of randomized controlled trials in adults with type 1 diabetes and studies in adults and children with type 1 diabetes using real-time CGM.

    “To date, there have been a number of randomized controlled trials in adults with type 1 diabetes and studies in adults and children with type 1 diabetes using realtime CGM (see Section 7, “Diabetes Technology”).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning
    § Use of CGM Technology in Hypoglycemia Prevention

    These CGM studies had differing A1C at entry and differing primary end points and thus must be interpreted carefully.

    “These studies had differing A1C at entry and differing primary end points and thus must be interpreted carefully.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisenone given
    § INTERCURRENT ILLNESS

    Stressful events (e.g., illness, trauma, surgery) may worsen glycemic control and precipitate diabetic ketoacidosis or nonketotic hyperglycemic hyperosmolar state, life-threatening conditions that require immediate medical care to prevent complications and death.

    “Stressful events (e.g., illness, trauma, surgery) may worsen glycemic control and precipitate diabetic ketoacidosis or nonketotic hyperglycemic hyperosmolar state, life-threatening conditions that require immediate medical care to prevent complications and death.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation
    § Use of CGM Technology in Hypoglycemia Prevention

    In a single study using intermittently scanned CGM, adults with type 1 diabetes with A1C near goal and impaired awareness of hypoglycemia demonstrated no change in A1C and decreased level 2 hypoglycemia.

    “In a single study using intermittently scanned CGM, adults with type 1 diabetes with A1C near goal and impaired awareness of hypoglycemia demonstrated no change in A1C and decreased level 2 hypoglycemia (115).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [115] Reddy, 2018, A randomized controlled pilot study of continuous glucose monitoring and flash glucose monitoring in people with Type 1 diabetes and impaired awareness of hypoglycaemia, Diabet Med source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Premisenone given
    § INTERCURRENT ILLNESS

    Infection or dehydration are more likely to necessitate hospitalization of individuals with diabetes versus those without diabetes.

    “Infection or dehydration are more likely to necessitate hospitalization of individuals with diabetes versus those without diabetes.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). May combine two claims.

    Premisenone given
    § INTERCURRENT ILLNESS

    Any condition leading to deterioration in glycemic control necessitates more frequent monitoring of blood glucose; ketosis-prone patients also require urine or blood ketone monitoring.

    “Any condition leading to deterioration in glycemic control necessitates more frequent monitoring of blood glucose; ketosis-prone patients also require urine or blood ketone monitoring.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisenone given
    § INTERCURRENT ILLNESS

    If accompanied by ketosis, vomiting, or alteration in the level of consciousness, marked hyperglycemia requires temporary adjustment of the treatment plan and immediate interaction with the diabetes care team.

    “If accompanied by ketosis, vomiting, or alteration in the level of consciousness, marked hyperglycemia requires temporary adjustment of the treatment plan and immediate interaction with the diabetes care team.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Premisenone given
    § INTERCURRENT ILLNESS

    The patient treated with noninsulin therapies or medical nutrition therapy alone may require insulin.

    “The patient treated with noninsulin therapies or medical nutrition therapy alone may require insulin.”
    Quote in the paperNot a substantial claim
43 of 43

  • The paper relies on this without support.

    A1C reflects average glycemia over approximately 3 months.

    “A1C reflects average glycemia over approximately 3 months.”

  • The paper relies on this without support.

    The A1C test is an indirect measure of average glycemia and is subject to limitations.

    “The A1C test is an indirect measure of average glycemia and, as such, is subject to limitations.”

  • The paper relies on this without support.

    A1C does not provide a measure of glycemic variability or hypoglycemia.

    “A1C does not provide a measure of glycemic variability or hypoglycemia.”

  • The paper relies on this without support.

    A1C assays are available that do not demonstrate a statistically significant difference in individuals with hemoglobin variants.

    “A1C assays are available that do not demonstrate a statistically significant difference in individuals with hemoglobin variants.”

  • The paper relies on this without support.

    Other A1C assays have statistically significant interference, but the difference is not clinically significant.

    “Other assays have statistically significant interference, but the difference is not clinically significant.”

  • The paper relies on this without support.

    GLP-1 receptor agonists and SGLT2 inhibitors were not approved at the time of the ACCORD, ADVANCE, and VADT trials.

    “glucagon-like peptide 1 (GLP-1) receptor agonists and sodium-glucose cotransporter 2 (SGLT2) inhibitors were not approved at the time of these trials.”

  • The paper relies on this without support.

    Diabetes is a chronic disease that progresses over decades.

    “Diabetes is a chronic disease that progresses over decades.”

  • The paper relies on this without support.

    Postprandial hyperglycemia contributes to elevated A1C levels, with its relative contribution being greater at A1C levels closer to 7%.

    “It is clear that postprandial hyperglycemia, like preprandial hyperglycemia, contributes to elevated A1C levels, with its relative contribution being greater at A1C levels that are closer to 7% (53 mmol/mol).”

  • The paper relies on this without support.

    Hypoglycemia is the major limiting factor in the glycemic management of type 1 and type 2 diabetes.

    “Hypoglycemia is the major limiting factor in the glycemic management of type 1 and type 2 diabetes.”
9 of 9

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • Habit formation usually takes 2-3 months, and significant HbA1c changes require at least 3 months.

    “This can be because habit formation usually takes 2-3 months [86], and significant HbA1c changes require at least 3 months [87].”

    From Digital Health Interventions to Prevent Type 2 Diabetes Mellitus: Systematic Review (2025) · cites this paper as [87]

    The citation [87] applies only to the HbA1c clause, not the separate habit-formation claim [86]. The Correlation Between BGM and A1C section discusses A1C as a measure of average glucose, and Table 6.1 describes glucose readings collected over three months per A1C measurement. Neither establishes that a significant HbA1c change requires at least three months; that minimum is unsupported. (LLM, conf=0.83)

    Experimental — accuracy not yet measured

  • Achievement of acceptable levels of glycemia is critical to avoid the acute and long-term complications associated with T2DM.

    “One of the critical goals of modern diabetes management remains the achievement of acceptable levels of glycemia to avoid the acute and long-term complications associated with T2DM [9].”

    From Digital Interventions for Self-Management of Type 2 Diabetes Mellitus: Systematic Literature Review and Meta-Analysis (2024) · cites this paper as [9]

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Reference number 21 is assigned to two different studies

    Minor

    The reference list assigns number 21 to both a study of glucose concentrations in children with type 1 diabetes and a different study of diabetes screening in a middle-school cohort, making citations to (21) ambiguous.

1 of 1

Cites

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Related

Authors
ElSayed, N. A., Aleppo, G., Aroda, V. R., Bannuru, R. R., Brown, F. M., Bruemmer, D., Collins, B. S., Hilliard, M. E., Isaacs, D., Johnson, E. L., Kahan, S., Khunti, K., Leon, J., Lyons, S. K., Perry, M. L., Prahalad, P., Pratley, R. E., Seley, J. J., Stanton, R. C., & Gabbay, R. A.
ORCID
Venue
Diabetes Care
Publisher
American Diabetes Association
Published
2022-12-12
Volume
46
Issue
Supplement_1
Pages
S97-S110
ISSN
0149-5992 (ISSN-L)
DOI
10.2337/dc23-s006
PMC
PMC9810469
OpenAlex
W4311158234
Semantic Scholar
6be81498eb5426b9aadb2bc1d684bc2e4062b4af
Cited by
684
References
136
Citations by year
2026: 77 · 2025: 170 · 2024: 269 · 2023: 168
FWCI
21.64
Type
journal article
Language
en
Open access
Licence
www.diabetesjournals.org/journals/pages/license (vor)
Locations
  • Diabetes Care (publishedVersion)
  • PubMed Central (publishedVersion)
  • PubMed (publishedVersion)
Topics
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Research
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Treatment and Management
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Education
Keywords
glycemic targets, diabetes management, American Diabetes Association standards of care, clinical guidelines, quality of care, treatment goals, level of evidence
MeSH terms
Diabetes Mellitus, Endocrinology, Humans, Reference Standards, Societies, Medical, Standard of Care

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-10.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-10.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

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