ADA Diabetes Guidelines: HCP Guide to Standards of Care in Diabetes

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The 2025 American Diabetes Association (ADA) Guidelines highlight the importance of collaborative goal setting between healthcare providers and patients for enhanced self-management and outcomes. Effective diabetes management starts with setting clear, individualized goals for each patient and regularly re-evaluating and making adjustments. This guide aligns with the Standards of Care in Diabetes to provide tips on setting patient goals and leveraging resources for diabetes management.

Patient Goal Setting

Patient goal setting is a crucial part of diabetes self-management education and support. By setting clear, achievable goals, healthcare providers can guide patients toward self-care. A diabetes self-management plan empowers patients to take control of their health and adopt lifestyle changes that support them in managing diabetes effectively. This approach helps ensure that each patient has diabetes management tips that are personalized, realistic, and focused on long-term success.

Individualized Goals

Tailor goals to the patient’s age, health status, diabetes type, preferences, and motivation.

Key considerations include:

• Glycemic targets (e.g., A1C levels)
• Weight management and use of medications that impact both weight and blood glucose
• Blood pressure and cholesterol levels
• Family history and socioeconomic factors
• Mental health and ability to self-manage complex chronic diseases
• Overall quality of life and better understanding the patient’s “why” for long term health
• Reduction in pain or physical impairment
• Reduction of cardiovascular risks such as future heart attacks, strokes, or cognitive impairment

SMART Goals

Encourage patients to create Specific, Measurable, Achievable, Relevant, and Time-bound (SMART) goals. Using personalized values can help align provider goals with patient motivations. This can include tricks like “habit stacking” to build new behaviors and habits.

Habit Stacking

Habit stacking is a powerful strategy for building new behaviors and goals by pairing them with existing habits. For example, having a patient review their CGM data upon waking up and drinking their usual morning coffee/beverage, then writing out a quick protein and fiber rich meal plan for their day ahead.

Education and Self-Management

Ongoing, culturally appropriate diabetes self-management education and support (DSMES) is crucial for long-term control of diabetes.

This includes:

• Utilizing technology like Continuous Glucose Monitors (CGMs), artificial intelligence (AI), and connected devices for real-time feedback.
• Patient understanding of blood glucose monitoring and normal ranges 
• Meal planning and nutritional therapy with a strong focus on the impact of nutrition on blood sugar
• Physical activity, mobility, and guided exercise prescriptions focuses on both cardiovascular and strength training 
• Leveraging community resources and peer support for enhanced education

Regular Monitoring

Establish a routine for monitoring progress. Tools like CGMs offer real-time feedback, helping patients visualize the impact of their lifestyle on glucose levels. Especially with the expansion of GLP-1 (glucagon-like peptide-1) receptor agonists and combination GLP-1/GIP agonist medications, it is extremely important to have close monitoring of blood sugars, side effects, and symptoms. This is especially crucial for patients with diabetes who are on insulin or other glucose-lowering medications.

Support Systems

Encourage participation in diabetes education programs and support groups to enhance motivation and share experiences. Regular monthly individual check-ins paired with group diabetes education can be the best combination for wrap-around support.

Tips for Primary Care Providers

Primary care providers (PCPs) play a vital role in helping patients manage diabetes effectively. Following the ADA Diabetes Guidelines and the latest Standards of Care in Diabetes, PCPs can foster open communication, leverage technology, and set realistic expectations to support long-term success. Regular follow-ups and access to educational resources further empower patients to take control of their health. The following tips provide practical strategies to enhance patient engagement and improve diabetes management outcomes.

Open Communication

Creating a supportive, judgment-free space is key to meaningful conversations with patients about their diabetes management journey. Patients should feel comfortable sharing their struggles and successes, knowing their provider is there to guide them, not criticize them. One of the best ways to foster this trust is by approaching each discussion as a team effort.

Think of yourself and your patient as partners, sitting on the same side of the table, working toward a common goal. Instead of simply giving instructions, take time to explore their daily habits, medications, and lifestyle choices with curiosity. What’s working well? What challenges are holding them back? By asking thoughtful questions and truly listening, you can uncover the obstacles they face and collaborate on realistic solutions that fit their unique needs.

CGM Patient Education

Introducing CGMs early in a patient’s diabetes journey can be a game-changer, giving them real-time insights into how diet, exercise, and medications affect their blood sugar levels. While CGMs and insulin pumps are commonly used for patients with Type 1 Diabetes, more patients with Type 2 Diabetes are showing interest in these tools as well. Even those with diabetes from other causes, such as diseases of the exocrine pancreas or drug-induced diabetes, may benefit greatly from CGM technology.

However, access isn’t always straightforward—insurance coverage can be challenging for those not on insulin, making it important to explore individual plans or newer cash-based CGM options. No matter how advanced the technology, its success relies on proper CGM patient education. Teaching patients how to interpret their data, recognize trends, and make informed adjustments ensures they get the most out of their device, leading to better long-term management and improved health outcomes.

Setting Realistic Expectations

Diabetes management is a journey that unfolds over time, with progress happening in small, meaningful steps. It’s important to remind patients that every positive change, no matter how minor it may seem, can add up to significant improvements in their health. Whether it’s choosing water over soda, taking a short walk after meals, or consistently checking their glucose levels, these small wins help build lasting habits. By shifting the focus away from quick fixes and toward sustainable progress, patients can stay motivated and feel empowered rather than overwhelmed.

Regular Follow-Ups

Regular check-ins are essential for keeping patients on track and ensuring their diabetes management plan evolves with their needs. These appointments provide a valuable opportunity to celebrate progress, address any challenges, and make necessary adjustments based on patient feedback, medications, lab results, and CGM data. Rather than simply reviewing numbers, use these moments to have open, collaborative conversations—what’s working well? Where are they struggling? By personalizing each follow-up and adapting goals as needed, you help patients stay engaged and confident in their ability to manage their diabetes effectively.

Empower Patients with Resources

Empowering patients with the right tools and resources can make a world of difference in their diabetes management journey. With so much information available online, it’s important to guide them toward reliable sources, whether it’s diabetes management apps, educational materials, or meal-planning tools.

Patients will often seek out their own information, but not all of it is accurate or helpful. By recommending trusted resources and connecting them with support groups, you can help them make informed decisions and feel more confident in managing their condition. Providing these tools not only enhances their understanding but also encourages them to take an active role in their health.

Conclusion

When a patient is newly diagnosed with diabetes, setting and achieving realistic goals becomes a cornerstone of effective management and a better quality of life. Using ADA Diabetes Guidelines as a foundation, primary care providers can help patients navigate their diagnosis with confidence. Tools like CGMs make it easier for patients to understand their glucose patterns and see the impact of their daily choices.

Beyond the tools, ongoing support and regular follow-ups truly make a difference. Open, honest communication keeps patients motivated and ensures their management plan evolves with their needs. By working together, providers and patients can create a clear path toward a healthier, more balanced life.

Citations

1) American Diabetes Association Professional Practice Committee. Standards of Care in Diabetes—2025. Diabetes Care 2025.
2) Friedman JG, Coyne K, Aleppo G, Szmuilowicz ED. Beyond A1C: exploring continuous glucose monitoring metrics in managing diabetes. Endocr Connect 2023;12:e230085
3) Diabetes Prevention Program (DPP) Research Group. The Diabetes Prevention Program (DPP): description of lifestyle intervention. Diabetes Care 2002;25:2165–2171
4) Brunisholz KD, Briot P, Hamilton S, et al. Diabetes self-management education improves quality of care and clinical outcomes determined by a diabetes bundle measure. J Multidiscip Healthc 2014;7:533–542
5) Chrvala CA, Sherr D, Lipman RD. Diabetes self-management education for adults with type 2 diabetes mellitus: a systematic review of the effect on glycemic control. Patient Educ Couns 2016;99:926–943

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