The field of diabetes care is advancing rapidly, with new research, technologies, and treatments continuously emerging to improve the health and well-being of people with diabetes. Since 1989, the American Diabetes Association (ADA) guidelines have been updated annually, long leading global practice and reflecting the latest progress in the field. The 2026 ADA Standards of Care in Diabetes continue to uphold the principles of person-centered care and inclusive language, striving to unify respectful terminology for people with diabetes and emphasize individualized care. Minor updates have been made to tables and figures to align with current accessibility standards. Although the evidence levels of many recommendations have been revised, only substantive changes to clinical recommendations are detailed below; updates to evidence levels (e.g., from Level E to Level C) without changes to recommendations are not noted. In addition to numerous clarifications and minor adjustments reflecting new evidence, the 2026 Standards include the following substantive revisions.
- Improving Care and Promoting Population Health Recommendation 1.1 (revised): Emphasizes shared decision-making based on individual values, preferences, prognosis, comorbidities, and informed financial considerations.
Recommendation 1.5 (updated): Highlights the importance of continuous quality improvement in healthcare systems to enhance care quality and health outcomes.
Recommendation 1.8 (revised): Incorporates consideration of digital self-management tools or health coaches to support people with diabetes, as appropriate.
Recommendation 1.9 (revised): Strengthens the role of community health workers in underserved communities and healthcare settings in managing kidney disease risk factors, in addition to diabetes and cardiovascular disease risk factors.
Table 1.1 (expanded): Specifies additional healthcare team members whose expertise may benefit older adults with diabetes. - Classification and Diagnosis of Diabetes Recommendation 2.8 (split):
2.8a: Emphasizes timely evaluation for stage 3 (clinical) type 1 diabetes in individuals with one or more islet autoantibodies.
2.8b: Retains guidance to refer individuals with multiple islet autoantibodies to specialized centers for education and potential preventive intervention.
New Recommendation 2.9: Individuals with isolated IA-2 autoantibody positivity should undergo monitoring similar to those with stage 2 type 1 diabetes who are IA-2 autoantibody-negative, due to comparable risk of progression to stage 3.
New Recommendation 2.18: Reinforces monitoring of postprandial or random glucose during long-term or repeated glucocorticoid therapy.
New Recommendation 2.19: Provides counseling and education on hyperglycemia risk for patients initiating immune checkpoint inhibitors, phosphoinositide 3-kinase alpha (PI3Kα) inhibitors, and other anticancer agents.
New Recommendation 2.20: Guides glucose monitoring at each visit for patients on immune checkpoint inhibitors.
New Recommendation 2.21: Emphasizes close glucose monitoring for patients initiating PI3Kα inhibitors, due to very high hyperglycemia risk in the first few weeks of treatment.
New Recommendation 2.22: Advises monitoring fasting or random glucose at each visit for patients on mammalian target of rapamycin (mTOR) inhibitors.
Recommendation 2.24a (updated): Reaffirms annual oral glucose tolerance test (OGTT) starting at age 10 years as the preferred screening for cystic fibrosis-related diabetes, when feasible.
Recommendation 2.24b (revised): Notes that HbA1c may be used as part of an alternative two-step screening strategy for cystic fibrosis-related diabetes when OGTT is not feasible.
Prior Recommendations 2.26b and 2.26c on gestational diabetes screening are consolidated and updated as Recommendation 2.31b; related text has been moved to Chapter 15, Diabetes Management in Pregnancy, and updated to reflect recent evidence and controversies in early pregnancy dysglycemia. - Prevention or Delay of Diabetes and Complications Recommendation 3.1 (expanded): Includes monitoring progression from prediabetes to all types of diabetes (not just type 2).
Recommendation 3.2 (strengthened): Incorporates continuous glucose monitoring (CGM) data when monitoring disease progression in presymptomatic type 1 diabetes.
Recommendation 3.3 (clarified): Recommends referring overweight/obese individuals at high risk for type 2 diabetes to diabetes prevention programs, with a goal of achieving and maintaining at least 5–7% weight loss from baseline.
Recommendation 3.4 (revised): Focuses on eating patterns with the strongest evidence for type 2 diabetes prevention, including Mediterranean and low-carbohydrate patterns.
Recommendation 3.6 (clarified): Notes that accredited technology-assisted diabetes prevention programs may be delivered via smartphones, web-based apps, and telehealth.
New Recommendation 3.8: Consider metformin to prevent hyperglycemia in high-risk patients receiving PI3Kα inhibitors (e.g., alpelisib, inavolisib).
New Recommendation 3.9: Consider metformin to prevent hyperglycemia in high-risk patients receiving high-dose glucocorticoids. - Comprehensive Medical Evaluation and Assessment of Complications Recommendation 4.3 (revised): Includes assessment of glycemic status and past/current therapy at initial and appropriate follow-up visits; adds evaluation of support systems and available resources, in addition to identifying care partners.
Recommendation 4.5 (vaccinations, revised): Expanded to include adolescents.
Recommendation 4.13a (revised): Consider pharmacologic treatment for osteoporosis in older adults with T-score ≤ −2.5 and increased fracture risk.
New Recommendation 4.13b: Consider treatment for adults with diabetes with T-score −2.0 to −2.5 and additional fracture risk factors.
Recommendation 4.26 (updated): Specifies that glucagon-like peptide 1 receptor agonists (GLP-1 RAs) with proven benefit in metabolic dysfunction-associated steatohepatitis (MASH) may be used in adults with type 2 diabetes, metabolic dysfunction-associated steatotic liver disease (MASLD), and overweight/obesity.
Recommendation 4.27a (updated): Prioritizes GLP-1 RAs with proven benefit for glycemic management in patients with type 2 diabetes and biopsy-proven MASH or high liver fibrosis risk, due to benefits on MASH.
Figure 4.1: Adds MASLD as a specific consideration influencing treatment choices.
Figure 4.2 (revised): Clarifies that individuals with Fibrosis-4 (FIB-4) index >2.67 should be managed by a hepatologist.
Figure 4.3 (revised): Includes GLP-1 RAs with proven benefit for MASH as pharmacologic options for individuals with MASLD and high MASH risk. - Promoting Health Behaviors and Well-being to Improve Health Outcomes Recommendation 5.4 (revised): Advises using behavioral strategies to support Diabetes Self-Management Education and Support (DSMES) and engagement in positive health behaviors.
Recommendation 5.5 (revised): States that DSMES should be individualized to preferences and needs, culturally and socially appropriate, and participation should be communicated to the diabetes care team.
Recommendation 5.12 (revised): Recommends overweight/obesity treatment programs including nutrition, physical activity, and behavioral health support, with a goal of at least 5–7% weight loss from baseline.
Recommendation 5.23 (revised): Provides counseling and regular monitoring of adequate nutrient intake for individuals seeking weight loss.
Recommendation 5.32 (revised): Uses an updated comprehensive pre-fasting risk assessment to generate a risk score for safety of religious fasting.
Recommendation 5.34 (revised): Encourages increasing physical activity to meet guideline targets; updates discussion on physical activity in obesity management.
Recommendation 5.40 (revised): Recommends routine assessment and avoidance of tobacco and e-cigarette/vaping products; provides or refers to combined treatment including cessation counseling and pharmacotherapy.
Recommendation 5.45 (updated): Refers to a qualified behavioral health specialist if diabetes distress is not adequately addressed during visits.
Recommendation 5.46 (updated): Recommends annual screening for anxiety symptoms in people with diabetes; encourages clinicians to address anxiety within scope of practice.
Recommendation 5.47 (updated): Recommends annual or clinically indicated screening for fear of hypoglycemia in individuals at high risk or with severe/frequent hypoglycemia, with referral for evidence-based interventions.
Recommendation 5.56 (revised): Recommends sleep health screening for people with diabetes and those at risk.
Table 5.3: Updated criteria for comprehensive pre-fasting risk assessment for people with diabetes fasting during Ramadan. - Glycemic Targets, Hypoglycemia, and Hyperglycemic Crises New Recommendation 6.17: Advocates including oral glucose in first-aid kits in workplaces, schools, institutions, and public settings for hypoglycemia treatment.
Section “Intercurrent Illness” (expanded): Adds criteria for holding specific classes of diabetes medications during acute illness.
Section “Hyperglycemic Crises: Diagnosis, Management, and Prevention” (revised): Expanded content on outpatient prevention and management of diabetic ketoacidosis (DKA); “Hyperglycemic Crises” added to the section title.
Figure 6.1 (expanded): Individualized approach to glycemic targets now includes individualized CGM metrics based on health status and other patient- and therapy-specific factors. - Diabetes Technology New recommendations on education and training for people with diabetes and clinicians by device type; details added on device-specific education.
Recommendation 7.3 (split):
7.3a: Prescription, initiation, and follow-up of CGM devices.
7.3b: Prescription, initiation, and follow-up of automated insulin delivery (AID) systems.
Recommendation 7.6 (revised): Supports use of diabetes technology (CGM, continuous subcutaneous insulin infusion [CSII], connected insulin pens, AID) for children and adolescents in school settings.
New Recommendation 7.7: For students ≥18 years and adults in the workplace, reasonable accommodations include adequate time to manage devices and treat hyper/hypoglycemia.
Recommendation 7.8: Early initiation of all devices individualized to the person.
New Recommendation 7.8a: CSII or AID initiation should not be restricted by C-peptide level, presence of islet autoantibodies, or duration of insulin therapy.
Section “Glycemic Monitoring”: Updated literature emphasizing benefits for people with type 2 diabetes; stresses the importance of blood glucose monitoring for individuals using CGM.
Recommendation 7.15: CGM is recommended at diagnosis and any time thereafter for children, adolescents, and adults on insulin therapy, non-insulin therapies with hypoglycemia risk, or therapies where CGM facilitates management.
Recommendation 7.17: Brief discussion of devices in pregnancy (detailed in Chapter 15).
Recommendation 7.25a: AID systems are the preferred insulin delivery system for type 1 diabetes, adults and children with type 2 diabetes on multiple daily injections, CSII, or sensor-augmented pump therapy, and other forms of insulin-deficient diabetes.
Recommendation 7.25b: AID systems may be considered for people with type 2 diabetes on basal insulin not meeting individualized glycemic targets.
CGM benefits are independent of age, sex, education, income, or baseline diabetes characteristics.
Table 7.3: Updated CGM device categories: real-time CGM (rtCGM), over-the-counter CGM (OTC-CGM), and professional CGM (intermittently scanned CGM [isCGM] no longer discussed). - Obesity and Weight Management for the Prevention and Treatment of Diabetes Recommendation 8.2a (updated): Annual screening for overweight and obesity using BMI; additional body fat measures (e.g., anthropometric assessment, direct measurement) when feasible to confirm excess adiposity.
Recommendation 8.5 (revised): Clarifies that 5–7% weight loss from baseline improves glycemia and intermediate cardiovascular risk factors.
Recommendation 8.8b (updated): Clarifies examples of components and delivery of alternative structured lifestyle programs.
Recommendation 8.14 (revised): Counseling and regular monitoring of adequate nutrient intake for individuals seeking weight loss.
Recommendation 8.15 (revised): Involve other care team members to minimize use of weight-promoting medications when clinically appropriate.
New Recommendation 8.20: Individualized dosing and titration of anti-obesity medications balancing efficacy, benefits, and tolerability.
Recommendation 8.21: Treatment adjustment/intensification now includes consideration of alternative formulations.
New Recommendation 8.29: GLP-1 RA–based therapy and/or metabolic surgery as options for obesity in type 1 diabetes.
Table 8.2: Updated anti-obesity medication costs through July 15, 2025. - Pharmacologic Approaches to Glycemic Treatment New Recommendation 9.9a: Glucose-dependent insulinotropic polypeptide (GIP)/GLP-1 RA with proven benefit for reducing heart failure events and improving symptoms in type 2 diabetes with symptomatic heart failure with preserved ejection fraction (HFpEF).
Recommendation 9.9b (revised): GLP-1 RA with proven benefit for reducing heart failure events and/or improving symptoms.
Recommendation 9.11 (updated): Guidance on initiating and continuing GLP-1–based therapy in type 2 diabetes with advanced chronic kidney disease (CKD).
Recommendation 9.12 (revised): GLP-1 RAs with proven benefit or GIP/GLP-1 RAs with potential benefit in MASH for glycemic management in type 2 diabetes, MASLD, and overweight/obesity.
Recommendation 9.13a (revised): Prioritize GLP-1 RAs with proven benefit for MASH; pioglitazone or GIP/GLP-1 RAs with potential benefit may be considered.
Recommendation 9.24 (revised): Health behaviors, DSMES, avoidance of therapeutic inertia, and social determinants of health as core components of glycemic treatment plans.
Recommendation 9.25 (updated): CGM at diagnosis and any time for adults on insulin, non-insulin therapies with hypoglycemia risk, or therapies where CGM helps management.
Recommendation 9.27 (revised): AID systems should be offered to all adults with type 1 or type 2 diabetes on insulin.
New recommendations for glucose management in cancer therapy:
9.33: Assess need for insulin to prevent DKA in patients on immunotherapy with hyperglycemia; use additional testing to identify immune-related diabetes.
9.34, 9.35a: Metformin as first-line for hyperglycemia from mTOR or PI3K inhibitors.
9.35b: Reserve insulin for severe hyperglycemia and hyperglycemic crises (may affect PI3K inhibitor efficacy).
9.36: Adjust or add antihyperglycemic agents for patients on glucocorticoids based on regimen and glucose levels.
New recommendations for glucose management in organ transplantation:
9.37: Insulin preferred postoperatively; DPP-4 inhibitors may be considered for mild hyperglycemia.
9.38a: Non-insulin agents may be used long-term, choice dependent on transplanted organ.
9.38b: GLP-1 RAs may be considered for cardiometabolic benefits.
9.38c: Add insulin if individualized long-term targets not met with non-insulin agents.
Figure 9.2: New insulin treatment algorithm for type 1 diabetes.
Figure 9.4 (revised): Includes GIP/GLP-1 RA or GLP-1 RA for type 2 diabetes with symptomatic HFpEF, MASLD/MASH, and obesity.
Figure 9.5 (revised): Consider CGM for people with type 2 diabetes on basal insulin.
Tables 9.3, 9.4: Updated antihyperglycemic agent and insulin costs through July 15, 2025. - Cardiovascular Disease and Risk Management Recommendation 10.4 (updated): Encourage systolic blood pressure (SBP) target <120 mmHg for individuals at high cardiovascular or kidney risk. Recommendation 10.6 (revised): Antihypertensive therapy titrated to individualized BP targets. Recommendation 10.10 (revised): Strong recommendation for ACE inhibitor (ACEI) or angiotensin receptor blocker (ARB) for hypertension in patients with severe albuminuria and/or eGFR <60 mL/min/1.73m², titrated to maximum tolerated dose to reduce kidney disease progression and cardiovascular events. Recommendation 10.11 (revised): Specifies monitoring frequency for eGFR decline and hyperkalemia with ACEI, ARB, or mineralocorticoid receptor antagonist (MRA), and hypokalemia with diuretics. Recommendation 10.32 (revised): Avoid combination of fibrate, niacin, or n-3 fatty acid dietary supplements with statins (no additional cardiovascular benefit). Recommendation 10.40c (revised): Includes type 2 diabetes with CKD; GLP-1 RAs with proven cardiovascular benefit recommended to reduce cardiovascular events. Recommendation 10.44c (updated): GLP-1 RAs with heart failure prevention benefit for type 2 diabetes with asymptomatic (Stage B) heart failure and high/established cardiovascular disease risk. Recommendations 10.44d, 10.44e (revised/new): GIP/GLP-1 RA or GLP-1 RA with proven benefit for reducing heart failure events or improving symptoms in type 2 diabetes, obesity, and symptomatic HFpEF. New Recommendation 10.44h: Nonsteroidal MRA (nsMRA) with proven benefit for reducing heart failure worsening events in diabetes and symptomatic Stage C heart failure (ejection fraction >40%).
Figure 10.5 (new): Prevention and management of symptomatic heart failure in diabetes.
Figure 10.6 (new): Approach to atherosclerotic cardiovascular disease (ASCVD) prevention in type 2 diabetes. - Chronic Kidney Disease and Risk Management Recommendation 11.1a (revised): Clarified frequency of kidney function assessment.
Recommendation 11.5 (revised): Clarified BP targets, with emphasis on SBP.
Recommendation 11.6a (updated): Clarified guidance on medication intolerance in non-pregnant people with diabetes and hypertension.
Recommendation 11.6b (revised): Specified monitoring frequency for eGFR decline, hyperkalemia (ACEI/ARB/MRA), and hypokalemia (diuretics).
Recommendation 11.8 (revised): Clearer guidance on potassium monitoring after initiating nsMRA to slow CKD progression and reduce cardiovascular risk.
New Recommendation 11.9: Consider concurrent initiation of sodium-glucose cotransporter 2 inhibitor (SGLT2i) and nsMRA in type 2 diabetes, UACR ≥100 mg/g, eGFR 30–90 mL/min/1.73m², and on renin-angiotensin-aldosterone system inhibitor (RASi).
Recommendation 11.10 (revised): Clarified guidance on kidney-protective medications with potential fetal risk in pregnant or potentially pregnant individuals.
New Recommendation 11.11a: SGLT2i in non-dialysis patients to reduce CKD progression and provide cardiovascular benefit.
New Recommendation 11.11b: Initiate or continue GLP-1–based therapy in dialysis patients to reduce cardiovascular risk.
Figure 11.2 (revised): Reordered RASi dosing to reflect that most subjects in kidney outcome trials of SGLT2i, GLP-1 RA, and nsMRA were on optimized background RASi. - Retinopathy, Neuropathy, and Foot Care New introductory text providing pathophysiologic background, including discussion of 40-year results from the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications (DCCT/EDIC) study.
Expanded discussion of GLP-1 RA effects on eye health: nonarteritic anterior ischemic optic neuropathy, glaucoma, neovascular age-related macular degeneration, and diabetic retinopathy progression.
Expanded role of adjuvant therapies; emphasizes holistic, multifactorial approach to diabetic eye health.
Updated neuropathy diagnosis aligned with foot care, including Ipswich touch test.
Recommendation 12.22 (updated): Emphasizes combination therapy for neuropathic pain relief.
Strengthened content on diabetic foot complication prevention and management; increased focus on infection and timely treatment.
Emerging foot care technologies: self-monitoring of foot temperature with smart mats, insoles, or socks for early ulcer detection.
Adjunctive advanced therapies for diabetic foot ulcers unresponsive to standard/surgical care; expanded discussion of Wound, Ischemia, foot Infection (WIfI) staging for peripheral artery disease severity, ulcer healing prediction, and amputation risk assessment.
Updated text on holistic, interventional approach to diabetes with peripheral artery disease; new evidence that GLP-1 RA may reduce lower-extremity amputation risk. - Older Adults Section “Hypoglycemia”: Recommendation 13.5: CGM recommended for older adults with type 1 or type 2 diabetes on insulin to improve glycemic outcomes, reduce hypoglycemia, and lessen treatment burden.
Section “Treatment Goals”: Recommendation 13.9: Target BP <130/80 mmHg for most older adults if safely achievable; more lenient targets (e.g., <140/90 mmHg) for those with poor health, limited life expectancy, or high adverse event risk.
Section “Lifestyle Management”:
Recommendation 13.11a: Specific protein intake ≥0.8 g/kg/day.
Recommendation 13.11b (new separate rec): Physical activity and exercise types to preserve lean mass, especially in those seeking weight loss.
Standardized terminology for nursing home and assisted living settings using “Post-Acute and Long-Term Care (PALTC).”
Table 13.1 (new): Specific guidance to screen for geriatric syndromes and functional impairments using example questions and validated language.
Figure 13.2 (new): Step-by-step framework to assess regimen complexity, re-evaluate glycemic targets via shared decision-making, deprescribe, simplify, or modify regimens, and reassess safety and burden. - Children and Adolescents Chapter 14 restructured to clearly distinguish type 1 vs. type 2 diabetes guidance, with merged sections applicable to both.
Expanded discussion of developmental considerations, obesity, and psychosocial factors.
Recommendation 14.1 (strengthened): Emphasizes child- and family-centered care, ongoing reassessment of self-management transfer, and training for daycare and school staff.
Recommendation 14.2 (revised): Strengthened comprehensive nutrition education at diagnosis and annually, individualized to growth, eating patterns, and risk factors.
Recommendation 14.3 (expanded): Evidence on macronutrient composition (carbohydrate, fat, protein) and effects on insulin dosing, glycemic variability, and long-term outcomes.
Section “Physical Activity and Exercise”: ≥60 minutes/day moderate-to-vigorous activity; ≥3 days/week bone and muscle strengthening. New guidance on preventing exercise-related hypo/hyperglycemia and treatment access during activity.
Section “Psychosocial Management”: Behavioral health specialists as core team members; routine screening for food security, housing stability, literacy, social support; confidential care for adolescents; screening for diabetes distress, depression, anxiety, fear of hypoglycemia, and disordered eating starting at 7–8 years; individualized interventions (CBT, mindfulness).
Table 14.1 (new): Side-by-side comparison of type 1 and type 2 diabetes recommendations. Updated screening for dyslipidemia, microalbuminuria, retinopathy, neuropathy using evidence from SEARCH, TODAY, and T1D Exchange.
Expanded guidance on CGM, AI-based retinal screening, and pharmacotherapy (GLP-1 RA, SGLT2i, GIP/GLP-1 RA).
Section “Type 2 Diabetes in Children and Adolescents”: New pharmacotherapy data, FDA labeling for GLP-1 RA, SGLT2i, GIP/GLP-1 RA; updated metabolic and bariatric surgery outcomes including ≥10-year follow-up.
Updated transition from pediatric to adult care: structured transition programs, improved clinic attendance, digital tools for continuity. - Diabetes Management in Pregnancy Recommendation 15.3 (revised): Preconception counseling includes avoiding excessive hypoglycemia while achieving preconception glycemic targets.
Reorganized “Preconception Counseling” and “Preconception Management” integrating weight management.
Updated text: preconception glycemic targets (in addition to HbA1c) to guide therapy adjustment.
Updated guidance: discontinue GLP-1 RA and GIP/GLP-1 RA before conception; achieve preconception targets after stopping.
Early dysglycemia content moved from Chapter 2 to Chapter 15; updated with latest evidence and controversies.
Updated text: latest randomized controlled trials on CGM in pregnancy.
Updated information on currently available insulin formulations in pregnancy.
Combined content on CGM and AID in pregnancy (previously in Chapters 7 and 15) into this chapter only.
Recommendation 15.24 (revised): BP threshold for initiating/adjusting antihypertensive therapy is 140/90 mmHg, consistent with recent trial data.
Recommendation 15.25b (updated): Severe hypertriglyceridemia as an additional factor that may warrant continuing lipid-lowering therapy in pregnancy.
HbA1c may be considered 6–12 months postpartum for those who cannot undergo or decline postpartum OGTT, but does not replace the gold-standard postpartum OGTT. - Diabetes Care in the Hospital New perioperative glycemic target recommendations:
Recommendation 16.14: Preoperative HbA1c <8% (<64 mmol/mol) within 3 months before elective surgery; alternatively, 14-day glycemic management indicator <8% or time in range >50%.
Recommendation 16.15: Perioperative glucose target 100–180 mg/dL (5.6–10.0 mmol/L).
Recommendation 16.18 (updated): For patients not discharged home, consider the diabetes care capacity of the destination facility.
Tables 16.1, 16.2: Diagnostic criteria and clinical features of DKA and hyperglycemic hyperosmolar state.
Updated text: expanded content on hospital technology use and perioperative non-insulin therapies. - Diabetes Advocacy
No revisions to the 2026 Standards of Care.