Different strokes for different folks?How the latest US standards of diabetes care could impact UK practice

NICE is expected to update its type 2 diabetes guidelines in July this year (2025) but in the meantime, clinicians could do worse than to see what the latest guidance from the American Diabetes Association has to say

As we await an update to the NICE guidelines on the management of type 2 diabetes, the American Diabetes Association (ADA) has published its latest Standards of Care (SoC) document for 2025.1 This guidance adds new recommendations based on recent research and latest developments. In this article, the key changes in the ADA standards will be explained, along with suggestions as to if and how they might be implemented in the UK. Comparisons will be made with the current NICE guidelines and UK standards.

LEARNING OUTCOMES

After reading through this article, you should be able to:

• Reflect on the recommendations in the existing NICE guidance on the management of T2D
• Summarise the key standards of care from the updated ADA document
• Appraise the relevance of these recommendations to clinicians working in the UK
• Consider how to implement changes in your own area of practice

A REMINDER – KEY MESSAGES FROM NICE 2022

NICE now stresses the importance of identifying and managing cardiorenal metabolic (CRM) risk factors in diabetes care.² The 2022 guidelines (updated from 2015) recommend the use of the QRisk cardiovascular risk assessment tool as a route to identifying those most likely to benefit from CRM risk management. Although the guidelines specifically mention QRISK2, clinicians are increasingly using QRISK3 (www.qrisk.org) or QRISK lifetime (www.qrisk.org/lifetime/) to assess risk as these tools are more specifically tailored to an increased number of risk factors and consideration of lifetime risk rather than 10-year risk. NICE supports the evidence that optimal risk reduction is most likely to be achieved through lifestyle interventions augmented by the use of sodium glucose co-transporter 2 inhibitor (SGLT2i) and lipid lowering drugs. Once the new NICE guidelines are released it is hoped that they will also reflect the increasing body of evidence for the use of GLP-1 receptor agonist drugs for cardiorenal protection, as the omission of these drugs from the current guidelines is a cause for significant concern for many clinicians.³

ADA STANDARDS OF CARE 2025

Quality improvement

The SoC document stresses the importance of quality improvement (QI) in diabetes care and Practice Nurse recently highlighted the importance of audit as a QI tool.⁴ All nurses, and especially those working at an advanced level, should be engaged in some form of QI work and there are tools available online and through national audit programmes to ensure that any gaps in care are identified and addressed. The Quality and Outcomes Framework (QOF) and National Diabetes Audit (NDA) can both be used as basic audit tools but there are also QI tools available from the Royal College of General Practitioners, Diabetes UK and the Primary Care Cardiovascular Society.

It is important to know where the gaps in care are so that appropriate QI projects can be undertaken. For example, it is known that too many people who require an SGLT2 inhibitor for long-term health benefits are not being offered one, so this could be one area that practices could choose to review.⁵ The SoC recognises that interdisciplinary team working is an important part of optimising diabetes care, with doctors, practice and community nurses, diabetes specialist nurses, pharmacists, dieticians, podiatrists, the health and wellbeing team and others all being key to supporting people living with diabetes. Working together, with agreed, co-created aims and objectives is central to improving outcomes for people living with diabetes.

Overlapping with these aims of improving outcomes is the call to identify social determinants of health and health disparities as a cause of poor diabetes management. Arguably this is a greater concern for a country that does not have free access to healthcare for all, but the impact of health inequalities in the UK is still an issue. According to the NDA report from 2023, the likelihood of receiving all key care processes (see Box 1) for type 1 diabetes (T1D) were lower in people who are younger than the reference group of 40-49 years and in those living in the most deprived areas of the country.⁶ In type 2 diabetes (T2D) younger age when compared with the same reference group of 40-49 years, living in the most deprived areas, being female and having had T2D for less than a year (versus diabetes duration of 15 years and over) were all associated with a greater risk of not receiving the key care processes.

Prevention of diabetes

The ADA SOC reminds clinicians that rather than focusing solely on people living with diabetes, many of the standards also apply to those at risk of diabetes. In the UK, the drive to identify people with non-diabetic hyperglycaemia (NDH or ‘pre-diabetes’) and reduce the risk of progression to type 2 diabetes led to the development of the National Diabetes Prevention Programme (NDPP), which is reported to have led to a reduced risk of developing T2D of around 20%. In one study, the chance of developing T2D at 3 years was 12.7% in those who attended the NDPP versus 15.4% for those who did not.⁷ Weight management is credited as being the leading reason for non-progression to T2D, and the NDPP focuses on lifestyle interventions as a way of achieving this. However, a fascinating section in the SoC on prevention refers to other less well-recognised interventions that can prevent or delay diabetes and associated comorbidities. It includes advice on sleep health, saying that its impact is on a par with other lifestyle behaviours such as physical activity and diet. An analysis by Nôga et al reported data from 247,867 adults in the UK Biobank which found that people who regularly slept for less than 6 hours a day had a significantly higher risk of developing T2D compared with those who slept for longer, with this risk persisting even in people with healthy eating habits.⁸ There is also a body of evidence that suggests that low vitamin D levels may be associated with insulin resistance,9 but caution is advised regarding the use of vitamin D supplementation to prevent T2D as both the appropriate doses and the risk: benefit ratio remain unclear.

Lifestyle

The ADA SoC obviously offers key recommendations about lifestyle interventions. There is an extended section on nutrition, based on the evidence for plant-based proteins and fibre, along with the importance of keeping nutrient quality, total calories, and metabolic goals in mind. The SoC recommends that people following ketogenic diets, especially people with T1D, those taking SGLT2i drugs and those with latent autoimmune diabetes in adults (LADA) diets should be advised about recognising the risks and signs of diabetic ketoacidosis (DKA) and should be provided with ketone monitors. In the UK routine monitoring of ketones in people on SGLT2i medication is not recommended but dietary approaches to diabetes management should be discussed and advice given for those who have chosen a ketogenic option.

With respect to physical activity, and being mindful of the increased tendency towards sedentary behaviour, it is recommended that people get up and move at least once every 30 minutes during extended periods of inactivity, such as when working at a desk.

NICE recently updated its smoking cessation guideline, and included the use of cytisine, varenicline and dual nicotine replacement therapy as the interventions most likely to support a quit attempt.¹⁰ Included in the ADA SoC advice about smoking cessation, there is also a recommendation about the non-medicinal use of cannabis in people with type 1 diabetes due to the risk of cannabis hyperemesis syndrome.

Glycaemic control and glucose monitoring

The issue of managing glycaemic control in the light of potential or existing comorbidities in T2D is a recurring theme throughout the guidelines. The ADA joint recommendations with the European Society for the Study of Diabetes (EASD) on pharmacological management of hyperglycaemic offer guiding principles for clinicians working in the field of diabetes,¹¹ and these are reiterated in the ADA SoC.¹ It is hoped that the next NICE update of NG28 will do the same. The essence of the evidence and the recommendations is that the drugs most likely to have the greatest holistic impact on people living with T2D are the SGLT2i drugs, the GLP-1 RAs and the dual glucose dependent insulinotropic polypeptide (GIP) GLP1-RAs (e.g., tirzepatide). In the UK, NICE recommends SGLT2i’s as cardiorenal protection for those at risk, advising that they may be added to metformin, as metformin will address the underlying insulin resistance which is a key driver of T2D.² In older people with diabetes, the ADA reminds clinicians to consider annual screening for issues that might affect diabetes management, including cognitive impairment, depression, urinary incontinence, falls, persistent pain, frailty, hypoglycemia, and polypharmacy. They suggest implementing the 4M approach – considering Mentation (cognitive abilities), Medications, Mobility and what Matters most.

An interesting recommendation in the ADA SoC is that continuous glucose monitoring (CGM) should be considered for adults with type 2 diabetes on glucose-lowering agents other than insulin. The specifics of this recommendation, and the evidence for it, can be seen in section 7 of the standards document. In the UK, the national position is that flash or CGM devices can be prescribed in certain cases although local recommendations may be different, so it is worth checking. Currently, flash or CGM can be prescribed for all cases of type 1 diabetes and also in insulin-treated type 2 diabetes where there are added complications such as recurrent and/or severe hypos, reduced hypo awareness, needing to test eight or more times a day or an inability to carry out finger prick tests. Diabetes UK has updated its CGM information for patients, parents and clinicians here: https://www.diabetes.org.uk/about-diabetes/looking-after-diabetes/technology

Moving beyond glycaemic control

The SoC document also focuses on cardiovascular disease and risk management. It includes recommendations about lipid lowering therapy (in the UK it is recommended for primary prevention in anyone with a CVD risk score of 10% or more). The definition of hypertension, in line with the European Society of Cardiology definition, is a blood pressure of 130/80 mmHg or more. The pharmacological recommendations are not unlike those made by NICE, with ACE inhibitors and angiotensin receptor blockers (ARBs) advised as first-line treatment.

The document also recommends considering screening for cardiovascular disease in asymptomatic high-risk individuals living with diabetes. In the UK people with asymptomatic CVD are increasingly being identified through the lung screening programme. The advice in this situation is that people with asymptomatic CVD should still be treated as their future risk of a cardiovascular event is high.¹² As chronic kidney disease (CKD) and specifically albuminuria is known to increase the risk of cardiovascular events,13 the ADA has included advice about managing these two comorbidities, stressing the importance of glycaemic and blood pressure control. In the UK, it is recommended that people living with diabetes and CKD should be offered a statin, without the need for risk assessment, along with an SGLT2 inhibitor and ACE inhibitors or angiotensin receptor blockers. Finerenone is also licensed for diabetic nephropathy once these measures are in place. Other microvascular complications include neuropathy and it is interesting to see mention of the Ipswich touch test (also known as the Touch the Toes test) in the ADA SoC. More information on this test can be found here: https://www.diabetes.org.uk/about-diabetes/complications/feet/touch-the-toes

The ADA SoC provides some horizon-scanning for clinicians by reminding them that there is an increasing body of evidence for additional benefits from the use of GLP-1 RAs beyond CRM protection and weight loss. The document states that GLP-1 RAs and dual GIP/GLP1-RAs should be offered to people with diabetes and metabolic associated steatotic hepatitis (MASH), heart failure with preserved ejection fraction and/or chronic kidney disease.

We covered metabolic-associated steatotic liver disease (MASLD) and MASH in a previous edition of Practice Nurse,¹⁴ and it is likely that there will be new treatments available for MASH imminently. NHS England is working to develop pathways to support clinicians and people living with this diagnosis. In the meantime, clinicians in the UK should be mindful of ADA recommendations while awaiting further guidance from the NHS on this topic.

A question many clinicians struggle with in the UK, is when and whether diabetes medication with additional CRM benefits, such as SGLT2i drugs and GIP +/- GLP-1 RAs, should ever be stopped, particularly if relevant goals, such as HbA1c or weight, have been achieved. This question is possibly based on cost – if people reach a good HbA1c or weight target, why would we continue to prescribe medication which has helped them to achieve these goals? It is interesting that we do not consider the same thing with other medications such as lipid lowering therapy, recognising, as we do, that stopping medication is likely to lead to disadvantages to health. However, statins are cheap and the cost-benefits are clearly in favour of continuing to prescribe, something that may feel less obvious with more expensive medications. It is helpful, then, that the ADA SoC advises clinicians that drugs with CRM benefits should be continued, even if the HbA1c is at target. However, screening for malnutrition in people who have had metabolic surgery or who are using weight loss-related drugs is recommended.

Sexual health, contraception, pregnancy and menopause

There are frequent mentions of sexual health, contraception, pregnancy and menopause throughout the SoC, and it is important that clinicians recognise the impact of diabetes and diabetes-related medication use in women of child-bearing age. In the UK, there was a recent reminder from the Faculty of Sexual and Reproductive Healthcare regarding the need to counsel women using GLP-1 RAs about using reliable contraception (including adding a barrier method to hormonal contraception). The leaflet can be found here: https://fsrh.org/Common/Uploaded%20files/documents/Patient-information-GLP-1-agonists-and-contraception.pdf. The ADA SoC also includes an update for clinicians regarding potentially harmful medications in pregnancy. In the UK, non-medical prescribers should be aware of the recommendations regarding prescribing for pregnant and breastfeeding women and consider whether they are competent to do so. There are some useful resources available such as BUMPS – best use of medicines in pregnancy at https://www.medicinesinpregnancy.org/ and the Specialist Pharmacy Service, Principles of Prescribing in Pregnancy at https://www.sps.nhs.uk/articles/the-principles-of-prescribing-in-pregnancy/

Menopause comes with an increased risk of diabetes and CVD as a result of associated changes in metabolic status.¹⁵ Clinicians should recognise this and be proactive about discussing the increased risk with perimenopausal, menopausal and post-menopausal women, particularly in those who have experienced a premature menopause (below the age of 40 years) where CVD risk is even greater.¹⁶ Lifestyle changes and medication can reduce risk, but hormone replacement therapy is not typically recommended in guidelines for cardiovascular protection.

Clinicians should be aware of other potential risks in people with diabetes. In type 1, other autoimmune conditions such as thyroid and coeliac disease should be considered.

Other recommendations include screening for B12 deficiency in people on metformin, recommending dental checks at least annually and assessing fracture risk, bone health and falls risk within a holistic review (See Box 2).

Calcium and Vitamin D supplements should be considered for bone protection in people with diabetes, especially in those at high risk of falls and fractures.

Linked in to reducing the risk of complications from diabetes is the ADA’s recommendation on vaccinations. The UK vaccination programme differs from these so UK-based clinicians will need to be familiar with, and work to, national guidance.

Mental health

The risks to mental health from long-term conditions, including diabetes, is well documented and there is a NICE guideline for clinicians to refer to on this topic.¹⁷ The ADA SoC highlights the need to assess for diabetes distress, depression, anxiety, fear of hypoglycaemia and eating disorders. This is not included in QOF in the UK although it is clear that any individual struggling with mental health either prior to or following a diagnosis of diabetes is more likely to struggle with the lifestyle changes and pharmacological interventions that are associated with a reduced risk of complications. Diabetes UK is an excellent source of information about these topics and includes links to different tools that can be used to assess for mental health issues. The Diabetes UK guidance on this topic can be found at https://www.diabetes.org.uk/for-professionals/improving-care/good-practice/psychological-care/emotional-health-professionals-guide

CONCLUSION

The ADA Standards of Care for Primary Care provides a sound basis for UK-based clinicians to compare and contrast approaches to diabetes prevention and management on both sides of the Atlantic. This article highlights some of the key areas that are likely to be of interest, with each area being covered in more depth in the document itself. It behoves clinicians supporting people living with diabetes in this country to consider if and how the recommendations within this document can improve standards of care in the UK.

REFERENCES

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2. NICE NG28. Type 2 diabetes in adults: management; 2015 (updated 2022) https://www.nice.org.uk/guidance/ng28

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8. Nôga DA, Meth EM, Pacheco AP, et al. (2024). Habitual short sleep duration, diet, and development of Type 2 Diabetes in adults. JAMA network open 2024;7(3):e241147. https://doi.org/10.1001/jamanetworkopen.2024.1147

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10.NICE NG209. Tobacco: preventing uptake, promoting quitting and treating dependence; 4 February 2025 https://www.nice.org.uk/guidance/ng209

11. Davies MJ, Aroda VR, Collins BS, et al. Management of hypoglycaemia in type 2 diabetes, 2022. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care November 2022;45(11): https://diabetesjournals.org/care/article/45/11/2753/147671/Management-of-Hyperglycemia-in-Type-2-Diabetes

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17. NICE CG91. Depression in adults with a chronic physical health problem: recognition and management; 2009 https://www.nice.org.uk/guidance/cg91