{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,15]],"date-time":"2026-09-15T19:24:47Z","timestamp":1789500287906,"version":"build-2803163510"},"reference-count":69,"publisher":"Korean Diabetes Association","issue":"6","license":[{"start":{"date-parts":[[2025,10,28]],"date-time":"2025-10-28T00:00:00Z","timestamp":1761609600000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"content-domain":{"domain":["e-dmj.org"],"crossmark-restriction":true},"short-container-title":["Diabetes Metab J"],"published-print":{"date-parts":[[2025,11,1]]},"abstract":"<jats:p>Diabetes mellitus comprises a heterogeneous group of metabolic disorders differing in etiology, clinical course, and outcomes. Traditional classifications, such as type 1 and type 2 diabetes mellitus, fail to capture the full heterogeneity, including variation in insulin deficiency, insulin resistance, and complication burden. To address these limitations, we propose the Diabetes Grade\u2013Stage Classification, an integrated system that combines pathophysiology-based grading with complication-based staging. Grading quantifies metabolic dysfunction through the assessment of insulin deficiency and insulin resistance. In parallel, staging assesses the extent of target organ damage, particularly in the cardiovascular, renal, ocular, and nervous systems. Together, this framework enables a comprehensive assessment of disease status, identification of vulnerable or high-risk phenotypes, and implementation of risk-adapted management strategies. Clinically, it facilitates personalized care, promotes collaborative coordination, and strengthens physician\u2013patient communication. Furthermore, this framework provides a scalable structure for integrating disease severity into both individual- and population-level interventions. Although the current criteria for grading and staging are based on expert consensus and selected clinical indicators, such as low C-peptide levels and advanced complications, further validation and refinement are needed. In conclusion, the grading and staging system provides an operational tool for classifying the severity of diabetes mellitus and has the potential to extend life expectancy and improve quality of life for people living with diabetes mellitus.<\/jats:p>","DOI":"10.4093\/dmj.2025.0739","type":"journal-article","created":{"date-parts":[[2025,10,29]],"date-time":"2025-10-29T04:40:38Z","timestamp":1761712838000},"page":"1141-1154","update-policy":"https:\/\/doi.org\/10.4093\/crossmark_policy","source":"Crossref","is-referenced-by-count":4,"title":["Defining Severe Diabetes Mellitus: A Consensus Framework for Grading and Staging Diabetes Based on Pathophysiology and Complications"],"prefix":"10.4093","volume":"49","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-1384-6123","authenticated-orcid":true,"given":"Jae Hyun","family":"Bae","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5318-0859","authenticated-orcid":true,"given":"Hun Jee","family":"Choe","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ye Seul","family":"Yang","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mi Hae","family":"Seo","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jong Han","family":"Choi","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gyuri","family":"Kim","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Young Sang","family":"Lyu","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jeung Hun","family":"Han","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Shinae","family":"Kang","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Won Jun","family":"Kim","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kyung-Soo","family":"Kim","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2331-6126","authenticated-orcid":true,"given":"Young Min","family":"Cho","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bong Soo","family":"Cha","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"name":"for the Severe Diabetes Mellitus Task Force of the Korean Diabetes Association","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"2567","reference":[{"key":"ref1","doi-asserted-by":"publisher","DOI":"10.1016\/s2213-8587(23)00159-6"},{"key":"ref2","doi-asserted-by":"publisher","DOI":"10.2337\/dci23-0036"},{"key":"ref3","first-page":"S27","volume-title":"2. Diagnosis and classification of diabetes: standards of care in diabetes-2025","year":"2025"},{"key":"ref4","doi-asserted-by":"publisher","DOI":"10.1016\/s0140-6736(94)92340-x"},{"key":"ref5","doi-asserted-by":"publisher","DOI":"10.2337\/dci23-0038"},{"key":"ref6","doi-asserted-by":"publisher","DOI":"10.1038\/s41571-019-0253-x"},{"key":"ref7","doi-asserted-by":"publisher","DOI":"10.1161\/cir.0000000000001184"},{"key":"ref8","first-page":"1757","volume-title":"2022 AHA\/ACC\/HFSA guideline for the management of heart failure: executive summary: a report of the American College of Cardiology\/American Heart Association Joint Committee on Clinical Practice Guidelines","author":"Heidenreich","year":"2022"},{"key":"ref9","first-page":"S117","volume-title":"KDIGO 2024 clinical practice guideline for the evaluation and management of chronic kidney disease","year":"2024"},{"key":"ref10","doi-asserted-by":"publisher","DOI":"10.1016\/s2213-8587(18)30051-2"},{"key":"ref11","doi-asserted-by":"publisher","DOI":"10.1007\/s00125-017-4210-x"},{"key":"ref12","first-page":"138","volume-title":"Precision subclassification of type 2 diabetes: a systematic review","author":"Misra","year":"2023"},{"key":"ref13","doi-asserted-by":"publisher","DOI":"10.1007\/s00125-014-3369-7"},{"key":"ref14","doi-asserted-by":"publisher","DOI":"10.1016\/s2213-8587(23)00225-5"},{"key":"ref15","doi-asserted-by":"publisher","DOI":"10.1007\/s00125-021-05625-x"},{"key":"ref16","first-page":"1448","volume-title":"GWAS of random glucose in 476,326 individuals provide insights into diabetes pathophysiology, complications and treatment stratification","author":"Lagou","year":"2023"},{"key":"ref17","first-page":"347","volume-title":"Genetic drivers of heterogeneity in type 2 diabetes pathophysiology","author":"Suzuki","year":"2024"},{"key":"ref18","doi-asserted-by":"publisher","DOI":"10.1210\/clinem\/dgaf234"},{"key":"ref19","first-page":"S181","volume-title":"9. Pharmacologic approaches to glycemic treatment: standards of care in diabetes-2025","year":"2025"},{"key":"ref20","first-page":"582","volume-title":"2025 Clinical practice guidelines for diabetes management in Korea: recommendation of the Korean Diabetes Association","author":"Kang","year":"2025"},{"key":"ref21","doi-asserted-by":"publisher","DOI":"10.1038\/nrdp.2016.12"},{"key":"ref22","doi-asserted-by":"publisher","DOI":"10.2337\/dci22-0027"},{"key":"ref23","doi-asserted-by":"publisher","DOI":"10.2337\/diacare.17.11.1281"},{"key":"ref24","doi-asserted-by":"publisher","DOI":"10.2337\/dci22-0034"},{"key":"ref25","doi-asserted-by":"publisher","DOI":"10.1007\/s00125-002-1009-0"},{"key":"ref26","doi-asserted-by":"publisher","DOI":"10.1038\/nrendo.2017.151"},{"key":"ref27","doi-asserted-by":"publisher","DOI":"10.1038\/nrm2327"},{"key":"ref28","doi-asserted-by":"publisher","DOI":"10.2337\/dc09-s301"},{"key":"ref29","doi-asserted-by":"publisher","DOI":"10.1038\/s41591-022-01790-7"},{"key":"ref30","doi-asserted-by":"publisher","DOI":"10.1111\/dom.14785"},{"key":"ref31","doi-asserted-by":"publisher","DOI":"10.2337\/diacare.21.12.2191"},{"key":"ref32","doi-asserted-by":"publisher","DOI":"10.1016\/j.diabres.2010.06.025"},{"key":"ref33","doi-asserted-by":"publisher","DOI":"10.1007\/bf00280883"},{"key":"ref34","doi-asserted-by":"publisher","DOI":"10.1016\/0026-0495(79)90146-x"},{"key":"ref35","doi-asserted-by":"publisher","DOI":"10.1210\/clinem\/dgae038"},{"key":"ref36","doi-asserted-by":"publisher","DOI":"10.2337\/diacare.26.12.3320"},{"key":"ref37","doi-asserted-by":"publisher","DOI":"10.1016\/j.jvs.2016.05.060"},{"key":"ref38","doi-asserted-by":"publisher","DOI":"10.2337\/diacare.27.6.1487"},{"key":"ref39","doi-asserted-by":"publisher","DOI":"10.1111\/dme.13142"},{"key":"ref40","doi-asserted-by":"publisher","DOI":"10.1007\/s00125-017-4449-2"},{"key":"ref41","first-page":"2165","volume-title":"The Diabetes Prevention Program (DPP): description of lifestyle intervention","year":"2002"},{"key":"ref42","doi-asserted-by":"publisher","DOI":"10.1056\/nejmoa2200433"},{"key":"ref43","first-page":"278","volume-title":"Comparative effectiveness of glucose-lowering drugs for type 2 diabetes: a systematic review and network meta-analysis","author":"Tsapas","year":"2020"},{"key":"ref44","first-page":"1257","volume-title":"Hyperglycemic crises in adults with diabetes: a consensus report","author":"Umpierrez","year":"2024"},{"key":"ref45","doi-asserted-by":"publisher","DOI":"10.1210\/clinem\/dgac596"},{"key":"ref46","doi-asserted-by":"publisher","DOI":"10.1056\/nejmoa2205225"},{"key":"ref47","doi-asserted-by":"publisher","DOI":"10.1038\/s41591-022-02144-z"},{"key":"ref48","doi-asserted-by":"publisher","DOI":"10.1016\/s2213-8587(22)00114-0"},{"key":"ref49","first-page":"4043","volume-title":"2023 ESC guidelines for the management of cardiovascular disease in patients with diabetes","author":"Marx","year":"2023"},{"key":"ref50","first-page":"S59","volume-title":"4. Comprehensive medical evaluation and assessment of comorbidities: standards of care in diabetes-2025","year":"2025"},{"key":"ref51","doi-asserted-by":"publisher","DOI":"10.1016\/j.amepre.2019.02.005"},{"key":"ref52","first-page":"S14","volume-title":"1. Improving care and promoting health in populations: standards of care in diabetes-2025","year":"2025"},{"key":"ref53","first-page":"2404","volume-title":"Role of insulin secretion and sensitivity in the evolution of type 2 diabetes in the diabetes prevention program: effects of lifestyle intervention and metformin","author":"Kitabchi","year":"2005"},{"key":"ref54","doi-asserted-by":"publisher","DOI":"10.1210\/jc.2018-02685"},{"key":"ref55","doi-asserted-by":"publisher","DOI":"10.2337\/diabetes.44.11.1249"},{"key":"ref56","doi-asserted-by":"publisher","DOI":"10.2337\/db10-1392"},{"key":"ref57","doi-asserted-by":"publisher","DOI":"10.2337\/figshare.24250429.v1"},{"key":"ref58","doi-asserted-by":"publisher","DOI":"10.1038\/s41574-025-01114-y"},{"key":"ref59","doi-asserted-by":"publisher","DOI":"10.1038\/s41574-020-00435-4"},{"key":"ref60","doi-asserted-by":"publisher","DOI":"10.1038\/s41574-022-00683-6"},{"key":"ref61","doi-asserted-by":"publisher","DOI":"10.1038\/s41572-023-00421-w"},{"key":"ref62","doi-asserted-by":"publisher","DOI":"10.1038\/s41574-022-00690-7"},{"key":"ref63","first-page":"2019","volume-title":"The Lancet Commission on diabetes: using data to transform diabetes care and patient lives","author":"Chan","year":"2021"},{"key":"ref64","doi-asserted-by":"publisher","DOI":"10.1126\/sciadv.abj2836"},{"key":"ref65","doi-asserted-by":"publisher","DOI":"10.1016\/s0140-6736(23)00001-6"},{"key":"ref66","doi-asserted-by":"publisher","DOI":"10.2337\/dc24-0270"},{"key":"ref67","doi-asserted-by":"publisher","DOI":"10.1016\/s2213-8587(21)00111-x"},{"key":"ref68","doi-asserted-by":"publisher","DOI":"10.1016\/s2213-8587(23)00164-x"},{"key":"ref69","doi-asserted-by":"publisher","DOI":"10.2337\/dc08-0097"}],"container-title":["Diabetes &amp; Metabolism Journal"],"original-title":[],"language":"en","link":[{"URL":"http:\/\/e-dmj.org\/upload\/pdf\/dmj-2025-0739.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"http:\/\/e-dmj.org\/journal\/view.php?doi=10.4093\/dmj.2025.0739","content-type":"unspecified","content-version":"vor","intended-application":"text-mining"},{"URL":"http:\/\/e-dmj.org\/upload\/pdf\/dmj-2025-0739.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,11,13]],"date-time":"2025-11-13T01:13:47Z","timestamp":1762996427000},"score":1,"resource":{"primary":{"URL":"http:\/\/e-dmj.org\/journal\/view.php?doi=10.4093\/dmj.2025.0739"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,11,1]]},"references-count":69,"journal-issue":{"issue":"6","published-print":{"date-parts":[[2025,11]]}},"URL":"https:\/\/doi.org\/10.4093\/dmj.2025.0739","relation":{},"ISSN":["2233-6079","2233-6087"],"issn-type":[{"value":"2233-6079","type":"print"},{"value":"2233-6087","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,11,1]]},"assertion":[{"value":"2025-08-09","order":0,"name":"received","label":"Received","group":{"name":"publication_history","label":"Publication History"}},{"value":"2025-10-20","order":1,"name":"accepted","label":"Accepted","group":{"name":"publication_history","label":"Publication History"}},{"value":"2025-10-28","order":2,"name":"published","label":"Published online","group":{"name":"publication_history","label":"Publication History"}},{"value":"2025-11-01","order":3,"name":"published","label":"Print publication","group":{"name":"publication_history","label":"Publication History"}}]}}