Guideline / position statementindependent cross-checkfull text checked★ key study I-INS-10 in-depth review
ADA guideline 2026: blood sugar goals and emergencies
6. Glycemic Goals, Hypoglycemia, and Hyperglycemic Crises: Standards of Care in Diabetes-2026.
Overview
American Diabetes Association Professional Practice Committee for Diabetes* . Diabetes Care 2026 · PMID 41358894 · DOI 10.2337/dc26-S006
Most adults should aim for HbA1c below 7%, avoid low sugar, and measure ketones when at risk.
Does the study support the specific claim? Partly · Methodological quality: high
Plain-language summary
Study explained simply
- What did the researchers want to find out?
Glycaemic goals, hypoglycaemia and hyperglycaemic crises
- How was the study done?
Clinical practice guideline (ADA Standards of Care 2026, Section 6)
- How many people, animals or samples were studied?
not applicable; People with diabetes
- What was actually found?
Individual targets; do not stop basal insulin when not eating.
- How large was the observed effect?
not applicable
- What do the results mean in everyday life?
Moderate targets and safety rules.
- What are the study's limitations?
US-centred; Partially read
- What does it say about Elawady's specific claim?
Supports C-INS-04, C-INS-11; contradicts C-FAST-01, C-FAST-03, C-DIAB-02.
- Do the results apply to Germany and Europe?
Consistent with EASD guidance.
- What can explicitly not be concluded from this study?
Not applicable.
Scientific in-depth review
1. Full reference
- Authors
- American Diabetes Association Professional Practice Committee for Diabetes*
- Journal
- Diabetes Care
- Year
- 2026
- Identifier
- PMID 41358894 DOI 10.2337/dc26-S006
- Verification
- verified – PubMed efetch 2026-10-25 (this agent)
- Retracted
- no
- Corrections
- none
- Extent checked
- full text
- Conflicts of interest and funding
Duality of interest at doi 10.2337/dc26-SDIS.
2. Research question
Glycaemic goals, hypoglycaemia and hyperglycaemic crises
3. Study design and population
- Study design
- Guideline / position statement – Clinical practice guideline (ADA Standards of Care 2026, Section 6)
- Population
People with diabetes
- Country
USA (international use)
- Period
2026
- Sample size
not applicable
- Inclusion and exclusion criteria
As described in the abstract; details not available in abstract.
4. Methods and endpoints
- Exposure / intervention
not applicable
- Comparator
not applicable
- Endpoints
not applicable
- Statistical methods
Graded recommendations
5. Actual results
- Results
Full text (PMC12690178, read via PMC web page, first part): Rec 6.3a A1C goal <7% for many nonpregnant adults; 6.4 lower goals (e.g. <6.5%) may be appropriate if safe; 6.5 less stringent goals for significant limitations; 6.6 deintensify hypoglycaemia-causing medications; ACCORD stopped for higher mortality; 'should not aggressively attempt to achieve near-normal A1C levels' where unsafe. DKA risk with SGLT2 in type 1 diabetes 5-17 times higher; consider holding metformin and SGLT2 inhibitors when oral intake cannot be maintained; 'Individuals at risk for DKA should measure ketones'; 'Individuals treated with intensive insulin therapy should not stop or hold their basal insulin even if not eating'.
- Absolute risks
not reported
- Authors' conclusion
Individualised glycaemic targets, hypoglycaemia avoidance, ketone monitoring.
6. Strengths
- Annual evidence-graded guideline
7. Weaknesses
- US-centred
- Partially read
8. Risk of bias
- Orienting tool
- none applicable
- Type of assessment
- simplified assessment (abstract only)
- Full formal assessment
- no
- Overall risk of bias
- low
- Rationale
Guideline.
9. Assessment of the statistical interpretation
not applicable
10. Relevance to the specific claim
Supports C-INS-04, C-INS-11; contradicts C-FAST-01, C-FAST-03, C-DIAB-02.
11. Independent contrary findings
12. Transferability to Germany and Europe
Consistent with EASD guidance.
13. Overall methodological judgement
Current standard.
| Multidimensional assessment | |
|---|---|
| Authenticity of the source | verified |
| Methodological quality | high |
| Risk of bias | low |
| Precision of results | not applicable |
| Directness | direct |
| Reproducibility | replicated |
| Consistency with the overall evidence | consistent |
| Regional transferability | high |
| Adequacy of the interpretation (by the archive) | not applicable |
14. Open questions
None beyond those stated.
15. Linked fact checks
- Large trials in type 2 diabetes showed that intensive glucose lowering towards normal HbA1c can be harmful: ACCORD was stopped after intensive therapy raised all-cause mortality by 22%, and severe hypoglycaemia was associated with roughly doubled mortality. – Studies supporting the claim
- Diabetic ketoacidosis (DKA) does not kill anyone; it should be treated with corticosteroids and complete fasting from food and drink for days, without insulin and without intravenous fluids; giving insulin in this situation is 'the black disaster'. – Studies contradicting or limiting the claim
- Archive conclusion: insulin is indispensable in type 1 diabetes; in type 2 diabetes, evidence supports caution with intensive dosing, prioritising metformin, weight loss and dietary change before insulin escalation, and aiming for moderate rather than near-normal HbA1c; this is not the same as rejecting insulin. – Studies supporting the claim
- Metformin (Glucophage) disrupts normal metabolism and causes lactic acidosis (automatically, by blocking the Cori cycle). – Studies supporting the claim
- SGLT2 inhibitors such as dapagliflozin (Forxiga) can cause ketoacidosis, sometimes with normal or low blood glucose. – Studies supporting the claim
- Fasting brings gut hormones, above all insulin, to zero ('your fasting insulin equals zero'). – Studies contradicting or limiting the claim
- Rising blood glucose and acetone (ketones) during fasting are evidence that the liver is working properly, not a danger; high glucose plus acetone is not insulin deficiency. – Studies contradicting or limiting the claim
- Laboratory values such as blood glucose and acetone are only signs of the body's changing strategy and not causes; there is no need to measure glucose or blood pressure. – Studies contradicting or limiting the claim