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Medicine â€ș Endocrinology, Diabetes and Metabolism

Diabetes Management and Research

Works Count: 98138

Description

This cluster of papers focuses on the management of diabetes mellitus, with an emphasis on intensive insulin therapy, continuous glucose monitoring, and the impact of glycemic control on cardiovascular disease and complications. It also covers the prevalence and management of hypoglycemia, especially in pediatric patients, and the development of artificial pancreas systems for improved diabetes management.

Keywords

Diabetes; Hypoglycemia; Insulin Therapy; Continuous Glucose Monitoring; Cardiovascular Disease; Type 1 Diabetes; Glycemic Control; Complications; Pediatric Care; Artificial Pancreas

Continuous Glucose Monitoring and Intensive Treatment of Type 1 Diabetes

2008-09-09
Tamborlane Wv , Beck Rw , Bode Bw +7 more
The value of continuous glucose monitoring in the management of type 1 diabetes mellitus has not been determined. The value of continuous glucose monitoring in the management of type 1 diabetes mellitus has not been determined.
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Effects of Intensive Glucose Lowering in Type 2 Diabetes

2008-06-06
Hertzel C. Gerstein , Michael E. Miller , Robert P. Byington +7 more
Epidemiologic studies have shown a relationship between glycated hemoglobin levels and cardiovascular events in patients with type 2 diabetes. We investigated whether intensive therapy to target normal glycated hemoglobin levels 
 Epidemiologic studies have shown a relationship between glycated hemoglobin levels and cardiovascular events in patients with type 2 diabetes. We investigated whether intensive therapy to target normal glycated hemoglobin levels would reduce cardiovascular events in patients with type 2 diabetes who had either established cardiovascular disease or additional cardiovascular risk factors.
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Intensive Diabetes Treatment and Cardiovascular Disease in Patients with Type 1 Diabetes

2005-12-21
David M. Nathan , Patricia A. Cleary , Jye-Yu C. Backlund +5 more
Intensive diabetes therapy aimed at achieving near normoglycemia reduces the risk of microvascular and neurologic complications of type 1 diabetes. We studied whether the use of intensive therapy as compared 
 Intensive diabetes therapy aimed at achieving near normoglycemia reduces the risk of microvascular and neurologic complications of type 1 diabetes. We studied whether the use of intensive therapy as compared with conventional therapy during the Diabetes Control and Complications Trial (DCCT) affected the long-term incidence of cardiovascular disease.The DCCT randomly assigned 1441 patients with type 1 diabetes to intensive or conventional therapy, treating them for a mean of 6.5 years between 1983 and 1993. Ninety-three percent were subsequently followed until February 1, 2005, during the observational Epidemiology of Diabetes Interventions and Complications study. Cardiovascular disease (defined as nonfatal myocardial infarction, stroke, death from cardiovascular disease, confirmed angina, or the need for coronary-artery revascularization) was assessed with standardized measures and classified by an independent committee.During the mean 17 years of follow-up, 46 cardiovascular disease events occurred in 31 patients who had received intensive treatment in the DCCT, as compared with 98 events in 52 patients who had received conventional treatment. Intensive treatment reduced the risk of any cardiovascular disease event by 42 percent (95 percent confidence interval, 9 to 63 percent; P=0.02) and the risk of nonfatal myocardial infarction, stroke, or death from cardiovascular disease by 57 percent (95 percent confidence interval, 12 to 79 percent; P=0.02). The decrease in glycosylated hemoglobin values during the DCCT was significantly associated with most of the positive effects of intensive treatment on the risk of cardiovascular disease. Microalbuminuria and albuminuria were associated with a significant increase in the risk of cardiovascular disease, but differences between treatment groups remained significant (P< or =0.05) after adjusting for these factors.Intensive diabetes therapy has long-term beneficial effects on the risk of cardiovascular disease in patients with type 1 diabetes.
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Nonlinear model predictive control of glucose concentration in subjects with type 1 diabetes

2004-07-23
Roman Hovorka , Valentina Canonico , Ludovic J. Chassin +7 more
A nonlinear model predictive controller has been developed to maintain normoglycemia in subjects with type 1 diabetes during fasting conditions such as during overnight fast. The controller employs a compartment 
 A nonlinear model predictive controller has been developed to maintain normoglycemia in subjects with type 1 diabetes during fasting conditions such as during overnight fast. The controller employs a compartment model, which represents the glucoregulatory system and includes submodels representing absorption of subcutaneously administered short-acting insulin Lispro and gut absorption. The controller uses Bayesian parameter estimation to determine time-varying model parameters. Moving target trajectory facilitates slow, controlled normalization of elevated glucose levels and faster normalization of low glucose values. The predictive capabilities of the model have been evaluated using data from 15 clinical experiments in subjects with type 1 diabetes. The experiments employed intravenous glucose sampling (every 15 min) and subcutaneous infusion of insulin Lispro by insulin pump (modified also every 15 min). The model gave glucose predictions with a mean square error proportionally related to the prediction horizon with the value of 0.2 mmol L−1 per 15 min. The assessment of clinical utility of model-based glucose predictions using Clarke error grid analysis gave 95% of values in zone A and the remaining 5% of values in zone B for glucose predictions up to 60 min (n = 1674). In conclusion, adaptive nonlinear model predictive control is promising for the control of glucose concentration during fasting conditions in subjects with type 1 diabetes.

Basal Insulin and Cardiovascular and Other Outcomes in Dysglycemia

2012-06-14
Origin Trial Investigators , Hertzel C. Gerstein , Jackie Bosch +7 more
The provision of sufficient basal insulin to normalize fasting plasma glucose levels may reduce cardiovascular events, but such a possibility has not been formally tested.We randomly assigned 12,537 people (mean 
 The provision of sufficient basal insulin to normalize fasting plasma glucose levels may reduce cardiovascular events, but such a possibility has not been formally tested.We randomly assigned 12,537 people (mean age, 63.5 years) with cardiovascular risk factors plus impaired fasting glucose, impaired glucose tolerance, or type 2 diabetes to receive insulin glargine (with a target fasting blood glucose level of ≀95 mg per deciliter [5.3 mmol per liter]) or standard care and to receive n-3 fatty acids or placebo with the use of a 2-by-2 factorial design. The results of the comparison between insulin glargine and standard care are reported here. The coprimary outcomes were nonfatal myocardial infarction, nonfatal stroke, or death from cardiovascular causes and these events plus revascularization or hospitalization for heart failure. Microvascular outcomes, incident diabetes, hypoglycemia, weight, and cancers were also compared between groups.The median follow-up was 6.2 years (interquartile range, 5.8 to 6.7). Rates of incident cardiovascular outcomes were similar in the insulin-glargine and standard-care groups: 2.94 and 2.85 per 100 person-years, respectively, for the first coprimary outcome (hazard ratio, 1.02; 95% confidence interval [CI], 0.94 to 1.11; P=0.63) and 5.52 and 5.28 per 100 person-years, respectively, for the second coprimary outcome (hazard ratio, 1.04; 95% CI, 0.97 to 1.11; P=0.27). New diabetes was diagnosed approximately 3 months after therapy was stopped among 30% versus 35% of 1456 participants without baseline diabetes (odds ratio, 0.80; 95% CI, 0.64 to 1.00; P=0.05). Rates of severe hypoglycemia were 1.00 versus 0.31 per 100 person-years. Median weight increased by 1.6 kg in the insulin-glargine group and fell by 0.5 kg in the standard-care group. There was no significant difference in cancers (hazard ratio, 1.00; 95% CI, 0.88 to 1.13; P=0.97).When used to target normal fasting plasma glucose levels for more than 6 years, insulin glargine had a neutral effect on cardiovascular outcomes and cancers. Although it reduced new-onset diabetes, insulin glargine also increased hypoglycemia and modestly increased weight. (Funded by Sanofi; ORIGIN ClinicalTrials.gov number, NCT00069784.).
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Assessment of Insulin Sensitivity<i>in Vivo</i>*

1985-01-01
Richard N. Bergman , Diane T. Finegood , Marilyn Ader
HISTORICALLY, the study of the pathogenesis of diabetes mellitus was in the traditional pattern of endocrinology: removal of the pancreas led to experimental diabetes, and administration of insulin, a pancreatic 
 HISTORICALLY, the study of the pathogenesis of diabetes mellitus was in the traditional pattern of endocrinology: removal of the pancreas led to experimental diabetes, and administration of insulin, a pancreatic isolate, ameliorated the diabetic symptoms (1, 2). These observations led to the widely held belief that human diabetes was primarily a disease of the pancreas, characterized by the inability of the B cell to secrete sufficient insulin to control glycemia. After insulin became available, evidence emerged suggesting that human diabetes mellitus has a multifactorial etiology. Early investigators identified an unexpected variability among diabetics in the ability of injected insulin to ameliorate hyperglycemia (3–5). Larger doses of insulin were required to normalize the blood sugar in patients with the milder nonketotic form of the disease common in the older population, whereas smaller doses were adequate for younger, ketosis-prone diabetics.

Hypoglycemic Episodes and Risk of Dementia in Older Patients With Type 2 Diabetes Mellitus

2009-04-14
Rachel A. Whitmer , Andrew J. Karter , Kristine Yaffe +2 more
Although acute hypoglycemia may be associated with cognitive impairment in children with type 1 diabetes, no studies to date have evaluated whether hypoglycemia is a risk factor for dementia in 
 Although acute hypoglycemia may be associated with cognitive impairment in children with type 1 diabetes, no studies to date have evaluated whether hypoglycemia is a risk factor for dementia in older patients with type 2 diabetes.To determine if hypoglycemic episodes severe enough to require hospitalization are associated with an increased risk of dementia in a population of older patients with type 2 diabetes followed up for 27 years.A longitudinal cohort study from 1980-2007 of 16,667 patients with a mean age of 65 years and type 2 diabetes who are members of an integrated health care delivery system in northern California.Hypoglycemic events from 1980-2002 were collected and reviewed using hospital discharge and emergency department diagnoses. Cohort members with no prior diagnoses of dementia, mild cognitive impairment, or general memory complaints as of January 1, 2003, were followed up for a dementia diagnosis through January 15, 2007. Dementia risk was examined using Cox proportional hazard regression models, adjusted for age, sex, race/ethnicity, education, body mass index, duration of diabetes, 7-year mean glycated hemoglobin, diabetes treatment, duration of insulin use, hyperlipidemia, hypertension, cardiovascular disease, stroke, transient cerebral ischemia, and end-stage renal disease.At least 1 episode of hypoglycemia was diagnosed in 1465 patients (8.8%) and dementia was diagnosed in 1822 patients (11%) during follow-up; 250 patients had both dementia and at least 1 episode of hypoglycemia (16.95%). Compared with patients with no hypoglycemia, patients with single or multiple episodes had a graded increase in risk with fully adjusted hazard ratios (HRs): for 1 episode (HR, 1.26; 95% confidence interval [CI], 1.10-1.49); 2 episodes (HR, 1.80; 95% CI, 1.37-2.36); and 3 or more episodes (HR, 1.94; 95% CI, 1.42-2.64). The attributable risk of dementia between individuals with and without a history of hypoglycemia was 2.39% per year (95% CI, 1.72%-3.01%). Results were not attenuated when medical utilization rates, length of health plan membership, or time since initial diabetes diagnosis were added to the model. When examining emergency department admissions for hypoglycemia for association with risk of dementia (535 episodes), results were similar (compared with patients with 0 episodes) with fully adjusted HRs: for 1 episode (HR, 1.42; 95% CI, 1.12-1.78) and for 2 or more episodes (HR, 2.36; 95% CI, 1.57-3.55).Among older patients with type 2 diabetes, a history of severe hypoglycemic episodes was associated with a greater risk of dementia. Whether minor hypoglycemic episodes increase risk of dementia is unknown.
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Pharmacologic Therapy for Type 2 Diabetes Mellitus

1999-08-17
Ralph A. DeFronzo
Type 2 diabetes mellitus is a chronic metabolic disorder that results from defects in both insulin secretion and insulin action. An elevated rate of basal hepatic glucose production in the 
 Type 2 diabetes mellitus is a chronic metabolic disorder that results from defects in both insulin secretion and insulin action. An elevated rate of basal hepatic glucose production in the presence of hyperinsulinemia is the primary cause of fasting hyperglycemia; after a meal, impaired suppression of hepatic glucose production by insulin and decreased insulin-mediated glucose uptake by muscle contribute almost equally to postprandial hyperglycemia. In the United States, five classes of oral agents, each of which works through a different mechanism of action, are currently available to improve glycemic control in patients with type 2 diabetes. The recently completed United Kingdom Prospective Diabetes Study (UKPDS) has shown that type 2 diabetes mellitus is a progressive disorder that can be treated initially with oral agent monotherapy but will eventually require the addition of other oral agents, and that in many patients, insulin therapy will be needed to achieve targeted glycemic levels. In the UKPDS, improved glycemic control, irrespective of the agent used (sulfonylureas, metformin, or insulin), decreased the incidence of microvascular complications (retinopathy, neuropathy, and nephropathy). This review examines the goals of antihyperglycemic therapy and reviews the mechanism of action, efficacy, nonglycemic benefits, cost, and safety profile of each of the five approved classes of oral agents. A rationale for the use of these oral agents as monotherapy, in combination with each other, and in combination with insulin is provided.

Type 2 diabetes among North adolescents: An epidemiologic health perspective

2000-05-01
A. Fagot‐Campagna , David J. Pettitt , Michael M. Engelgau +7 more

Role of glucose and insulin resistance in development of type 2 diabetes mellitus: results of a 25-year follow-up study

1992-10-01
Blaise C. Martin , James H. Warram , Andrzej S. KrĂłlewski +3 more

American College of Endocrinology Position Statement on the Insulin Resistance Syndrome

2003-09-01
Daniel Einhorn

Oral Antihyperglycemic Therapy for Type 2 Diabetes

2002-01-16
Silvio E. Inzucchi
Diabetes mellitus affects more than 6% of the US population, with the great majority having type 2 diabetes mellitus (DM). 1 In some older groups, the prevalence of DM and 
 Diabetes mellitus affects more than 6% of the US population, with the great majority having type 2 diabetes mellitus (DM). 1 In some older groups, the prevalence of DM and its metabolic forerunner, impaired glucose tolerance (IGT), approaches 25%. 2 Throughout the past decade, a 30% increase in the prevalence of DM has been recorded in the United States, with the most dramatic increases in younger individuals. 3When the long-term complications of this disease and their costs are considered, the implications of these statistics are sobering. 46][7] Whether such a relationship exists for macrovascular complications, such as myocardial infarction and stroke, is less clear. 7Simultaneously, a rapidly expanding therapeutic armamentarium is now available to treat hyperglycemia in type 2 DM.The number of oral antihyperglycemic agent classes, each with its unique mechanism of action, has increased 5-fold throughout the past 6 years-an often confusing increase in new categories of drugs: biguanides, ␣-glucosidase inhibitors, thiazolidinediones (TZDs), and nonsulfonylurea insulin secretagogues.More therapeutic options translate into more complex decision making for primary care physicians and diabetic pa-tients.In this article I review the individual oral-agent drug classes and the published evidence demonstrating their

Glycated Hemoglobin, Diabetes, and Cardiovascular Risk in Nondiabetic Adults

2010-03-03
Elizabeth Selvin , Michael W. Steffes , Hong Zhu +5 more
Fasting glucose is the standard measure used to diagnose diabetes in the United States. Recently, glycated hemoglobin was also recommended for this purpose. Fasting glucose is the standard measure used to diagnose diabetes in the United States. Recently, glycated hemoglobin was also recommended for this purpose.
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Severe Hypoglycemia and Risks of Vascular Events and Death

2010-10-06
Sophia Zoungas , Anushka Patel , John Chalmers +7 more
Severe hypoglycemia may increase the risk of a poor outcome in patients with type 2 diabetes assigned to an intensive glucose-lowering intervention. We analyzed data from a large study of 
 Severe hypoglycemia may increase the risk of a poor outcome in patients with type 2 diabetes assigned to an intensive glucose-lowering intervention. We analyzed data from a large study of intensive glucose lowering to explore the relationship between severe hypoglycemia and adverse clinical outcomes.
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Current State of Type 1 Diabetes Treatment in the U.S.: Updated Data From the T1D Exchange Clinic Registry

2015-05-12
Kellee M. Miller , Nicole C. Foster , Roy W. Beck +5 more
To examine the overall state of metabolic control and current use of advanced diabetes technologies in the U.S., we report recent data collected on individuals with type 1 diabetes participating 
 To examine the overall state of metabolic control and current use of advanced diabetes technologies in the U.S., we report recent data collected on individuals with type 1 diabetes participating in the T1D Exchange clinic registry. Data from 16,061 participants updated between 1 September 2013 and 1 December 2014 were compared with registry enrollment data collected from 1 September 2010 to 1 August 2012. Mean hemoglobin A1c (HbA1c) was assessed by year of age from &amp;lt;4 to &amp;gt;75 years. The overall average HbA1c was 8.2% (66 mmol/mol) at enrollment and 8.4% (68 mmol/mol) at the most recent update. During childhood, mean HbA1c decreased from 8.3% (67 mmol/mol) in 2–4-year-olds to 8.1% (65 mmol/mol) at 7 years of age, followed by an increase to 9.2% (77 mmol/mol) in 19-year-olds. Subsequently, mean HbA1c values decline gradually until ∌30 years of age, plateauing at 7.5–7.8% (58–62 mmol/mol) beyond age 30 until a modest drop in HbA1c below 7.5% (58 mmol/mol) in those 65 years of age. Severe hypoglycemia (SH) and diabetic ketoacidosis (DKA) remain all too common complications of treatment, especially in older (SH) and younger patients (DKA). Insulin pump use increased slightly from enrollment (58–62%), and use of continuous glucose monitoring (CGM) did not change (7%). Although the T1D Exchange registry findings are not population based and could be biased, it is clear that there remains considerable room for improving outcomes of treatment of type 1 diabetes across all age-groups. Barriers to more effective use of current treatments need to be addressed and new therapies are needed to achieve optimal metabolic control in people with type 1 diabetes.

Hypoglycemia and Diabetes: A Report of a Workgroup of the American Diabetes Association and The Endocrine Society

2013-04-13
Elizabeth R. Seaquist , John E. Anderson , Belinda P. Childs +7 more
To review the evidence about the impact of hypoglycemia on patients with diabetes that has become available since the past reviews of this subject by the American Diabetes Association and 
 To review the evidence about the impact of hypoglycemia on patients with diabetes that has become available since the past reviews of this subject by the American Diabetes Association and The Endocrine Society and to provide guidance about how this new information should be incorporated into clinical practice.Five members of the American Diabetes Association and five members of The Endocrine Society with expertise in different aspects of hypoglycemia were invited by the Chair, who is a member of both, to participate in a planning conference call and a 2-day meeting that was also attended by staff from both organizations. Subsequent communications took place via e-mail and phone calls. The writing group consisted of those invitees who participated in the writing of the manuscript. The workgroup meeting was supported by educational grants to the American Diabetes Association from Lilly USA, LLC and Novo Nordisk and sponsorship to the American Diabetes Association from Sanofi. The sponsors had no input into the development of or content of the report.The writing group considered data from recent clinical trials and other studies to update the prior workgroup report. Unpublished data were not used. Expert opinion was used to develop some conclusions.Consensus was achieved by group discussion during conference calls and face-to-face meetings, as well as by iterative revisions of the written document. The document was reviewed and approved by the American Diabetes Association's Professional Practice Committee in October 2012 and approved by the Executive Committee of the Board of Directors in November 2012 and was reviewed and approved by The Endocrine Society's Clinical Affairs Core Committee in October 2012 and by Council in November 2012.The workgroup reconfirmed the previous definitions of hypoglycemia in diabetes, reviewed the implications of hypoglycemia on both short- and long-term outcomes, considered the implications of hypoglycemia on treatment outcomes, presented strategies to prevent hypoglycemia, and identified knowledge gaps that should be addressed by future research. In addition, tools for patients to report hypoglycemia at each visit and for clinicians to document counseling are provided.
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Meta-Analysis: Glycosylated Hemoglobin and Cardiovascular Disease in Diabetes Mellitus

2004-09-21
Elizabeth Selvin , Spyridon S Marinopoulos , Gail Berkenblit +4 more
Background: In persons with diabetes, chronic hyperglycemia (assessed by glycosylated hemoglobin level) is related to the development of microvascular disease; however, the relation of glycosylated hemoglobin to macrovascular disease is 
 Background: In persons with diabetes, chronic hyperglycemia (assessed by glycosylated hemoglobin level) is related to the development of microvascular disease; however, the relation of glycosylated hemoglobin to macrovascular disease is less clear. Purpose: To conduct a meta-analysis of observational studies of the association between glycosylated hemoglobin and cardiovascular disease in diabetic persons. Data Sources: Search of the MEDLINE database by using Medical Subject Heading search terms and key words related to glycosylated hemoglobin, diabetes, and cardiovascular disease. Study Selection: Prospective cohort studies with data on glycosylated hemoglobin levels and incident cardiovascular disease. Data Extraction: Relative risk estimates were derived or abstracted from each cohort study that met the inclusion criteria. Data Synthesis: Adjusted relative risk estimates for glycosylated hemoglobin (total glycosylated hemoglobin, hemoglobin A1, or hemoglobin A1c levels) and cardiovascular disease events (coronary heart disease and stroke) were pooled by using random-effects models. Three studies involved persons with type 1 diabetes (n = 1688), and 10 studies involved persons with type 2 diabetes (n = 7435). The pooled relative risk for cardiovascular disease was 1.18; this represented a 1–percentage point increase in glycosylated hemoglobin level (95% CI, 1.10 to 1.26) in persons with type 2 diabetes. Results in persons with type 1 diabetes were similar but had a wider CI (pooled relative risk, 1.15 [CI, 0.92 to 1.43]). Limitations: This review largely reflects the limitations of the literature. Important concerns were residual confounding, the possibility of publication bias, the small number of studies, and the heterogeneity of study results. Conclusions: Pending confirmation from large, ongoing clinical trials, this analysis shows that observational studies are consistent with limited clinical trial data and suggests that chronic hyperglycemia is associated with an increased risk for cardiovascular disease in persons with diabetes.

Evaluation and Management of Adult Hypoglycemic Disorders: An Endocrine Society Clinical Practice Guideline

2008-12-17
Philip E. Cryer , Lloyd Axelrod , Ashley Grossman +4 more
The aim is to provide guidelines for the evaluation and management of adults with hypoglycemic disorders, including those with diabetes mellitus.Using the recommendations of the Grading of Recommendations, Assessment, Development 
 The aim is to provide guidelines for the evaluation and management of adults with hypoglycemic disorders, including those with diabetes mellitus.Using the recommendations of the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system, the quality of evidence is graded very low (plus sign in circle ooo), low (plus sign in circle plus sign in circle oo), moderate (plus sign in circle plus sign in circle plus sign in circle o), or high (plus sign in circle plus sign in circle plus sign in circle plus sign in circle).We recommend evaluation and management of hypoglycemia only in patients in whom Whipple's triad--symptoms, signs, or both consistent with hypoglycemia, a low plasma glucose concentration, and resolution of those symptoms or signs after the plasma glucose concentration is raised--is documented. In patients with hypoglycemia without diabetes mellitus, we recommend the following strategy. First, pursue clinical clues to potential hypoglycemic etiologies--drugs, critical illnesses, hormone deficiencies, nonislet cell tumors. In the absence of these causes, the differential diagnosis narrows to accidental, surreptitious, or even malicious hypoglycemia or endogenous hyperinsulinism. In patients suspected of having endogenous hyperinsulinism, measure plasma glucose, insulin, C-peptide, proinsulin, beta-hydroxybutyrate, and circulating oral hypoglycemic agents during an episode of hypoglycemia and measure insulin antibodies. Insulin or insulin secretagogue treatment of diabetes mellitus is the most common cause of hypoglycemia. We recommend the practice of hypoglycemia risk factor reduction--addressing the issue of hypoglycemia, applying the principles of intensive glycemic therapy, and considering both the conventional risk factors and those indicative of compromised defenses against falling plasma glucose concentrations--in persons with diabetes.
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Translating the A1C Assay Into Estimated Average Glucose Values

2008-06-08
David M. Nathan , J.C. Kuenen , Rikke Borg +3 more
The A1C assay, expressed as the percent of hemoglobin that is glycated, measures chronic glycemia and is widely used to judge the adequacy of diabetes treatment and adjust therapy. Day-to-day 
 The A1C assay, expressed as the percent of hemoglobin that is glycated, measures chronic glycemia and is widely used to judge the adequacy of diabetes treatment and adjust therapy. Day-to-day management is guided by self-monitoring of capillary glucose concentrations (milligrams per deciliter or millimoles per liter). We sought to define the mathematical relationship between A1C and average glucose (AG) levels and determine whether A1C could be expressed and reported as AG in the same units as used in self-monitoring.
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Prevalence of the Metabolic Syndrome in American Adolescents

2004-10-12
Sarah D. de Ferranti , Kimberlee Gauvreau , David S. Ludwig +3 more
Metabolic syndrome (MetS) is defined by the Third Report of the Adult Treatment Panel (ATP III) using criteria easily applied by clinicians and researchers. There is no standard pediatric definition.We 
 Metabolic syndrome (MetS) is defined by the Third Report of the Adult Treatment Panel (ATP III) using criteria easily applied by clinicians and researchers. There is no standard pediatric definition.We defined pediatric MetS using criteria analogous to ATP III as > or =3 of the following: (1) fasting triglycerides > or =1.1 mmol/L (100 mg/dL); (2) HDL <1.3 mmol/L (50 mg/dL), except in boys aged 15 to 19 years, in whom the cutpoint was <1.2 mmol/L (45 mg/dL); (3) fasting glucose > or =6.1 mmol/L (110 mg/dL); (4) waist circumference >75th percentile for age and gender; and (5) systolic blood pressure >90th percentile for gender, age, and height. MetS prevalence in US adolescents was estimated with the Third National Health and Nutritional Survey 1988 to 1994. Among 1960 children aged > or =12 years who fasted > or =8 hours, two thirds had at least 1 metabolic abnormality, and nearly 1 in 10 had MetS. The racial/ethnic distribution was similar to adults: Mexican-Americans, followed by non-Hispanic whites, had a greater prevalence of MetS compared with non-Hispanic blacks (12.9%, [95% CI 10.4% to 15.4%]; 10.9%, [95% CI 8.4% to 13.4%]; and 2.5%, [95% CI 1.3% to 3.7%], respectively). Nearly one third (31.2% [95% CI 28.3% to 34.1%]) of overweight/obese adolescents had MetS.Our definition of pediatric MetS, designed to be closely analogous to ATP III, found MetS is common in adolescents and has a similar racial/ethnic distribution to adults in this representative national sample. Because childhood MetS likely tracks into adulthood, early identification may help target interventions to improve future cardiovascular health.
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Quantitative estimation of insulin sensitivity.

1979-06-01
Richard N. Bergman , Y.Z. Ider , C R Bowden +1 more
We have evaluated the feasibility of using a mathematical model of glucose disappearance to estimate insulin sensitivity. Glucose was injected into conscious dogs at 100, 200, or 300 mg/kg. The 
 We have evaluated the feasibility of using a mathematical model of glucose disappearance to estimate insulin sensitivity. Glucose was injected into conscious dogs at 100, 200, or 300 mg/kg. The measured time course of insulin was regarded as the "input," and the falling glucose concentration as the "output" of the physiological system storing and using glucose. Seven mathematical models of glucose uptake were compared to identify the representation most capable of simulating glucose disappearance. One specific nonlinear model was superior in that it 1) predicted the time course of glucose after glucose injection, 2) had four parameters that could be precisely estimated, and 3) described individual experiments with similar parameter values. Insulin sensitivity index (SI), defined as the dependence of fractional glucose disappearance on plasma insulin, was the ratio of two parameters of the chosen model and could be estimated with good reproducibility from the 300 mg/kg injection experiments (SI = 7.00 X 10(-4) +/- 24% (coefficient of variation) min-1/(microU/ml) (n = 8)). Thus, from a single glucose injection it is possible to obtain a quantitative index of insulin sensitivity that may have clinical applicability.

The Treat-to-Target Trial

2003-11-01
Matthew C. Riddle , Julio Rosenstock , John Gerich
To compare the abilities and associated hypoglycemia risks of insulin glargine and human NPH insulin added to oral therapy of type 2 diabetes to achieve 7% HbA(1c).In a randomized, open-label, 
 To compare the abilities and associated hypoglycemia risks of insulin glargine and human NPH insulin added to oral therapy of type 2 diabetes to achieve 7% HbA(1c).In a randomized, open-label, parallel, 24-week multicenter trial, 756 overweight men and women with inadequate glycemic control (HbA(1c) >7.5%) on one or two oral agents continued prestudy oral agents and received bedtime glargine or NPH once daily, titrated using a simple algorithm seeking a target fasting plasma glucose (FPG) <or=100 mg/dl (5.5 mmol/l). Outcome measures were FPG, HbA(1c), hypoglycemia, and percentage of patients reaching HbA(1c) <or=7% without documented nocturnal hypoglycemia.Mean FPG at end point was similar with glargine and NPH (117 vs. 120 mg/dl [6.5 vs. 6.7 mmol/l]), as was HbA(1c) (6.96 vs. 6.97%). A majority of patients ( approximately 60%) attained HbA(1c) <or=7% with each insulin type. However, nearly 25% more patients attained this without documented nocturnal hypoglycemia (<or=72 mg/dl [4.0 mmol/l]) with glargine (33.2 vs. 26.7%, P < 0.05). Moreover, rates of other categories of symptomatic hypoglycemia were 21-48% lower with glargine.Systematically titrating bedtime basal insulin added to oral therapy can safely achieve 7% HbA(1c) in a majority of overweight patients with type 2 diabetes with HbA(1c) between 7.5 and 10.0% on oral agents alone. In doing this, glargine causes significantly less nocturnal hypoglycemia than NPH, thus reducing a leading barrier to initiating insulin. This simple regimen may facilitate earlier and effective insulin use in routine medical practice, improving achievement of recommended standards of diabetes care.
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Care of Children and Adolescents With Type 1 Diabetes

2005-01-01
Janet Silverstein , Georgeanna J. Klingensmith , Kenneth C. Copeland +7 more
During recent years, the American Diabetes Association (ADA) has published detailed guidelines and recommendations for the management of diabetes in the form of technical reviews, position statements, and consensus statements. 
 During recent years, the American Diabetes Association (ADA) has published detailed guidelines and recommendations for the management of diabetes in the form of technical reviews, position statements, and consensus statements. Recommendations regarding children and adolescents have generally been included as only a minor portion of these documents. For example, the most recent ADA position statement on “Standards of Medical Care for Patients With Diabetes Mellitus” (last revised October 2003) included “special considerations” for children and adolescents (1). Other position statements included age-specific recommendations for screening for nephropathy (2) and retinopathy (3) in children with diabetes. In addition, the ADA has published guidelines pertaining to certain aspects of diabetes that apply exclusively to children and adolescents, including care of children with diabetes at school (4) and camp (5) and a consensus statement on type 2 diabetes in children and adolescents (6). The purpose of this document is to provide a single resource on current standards of care pertaining specifically to children and adolescents with type 1 diabetes. It is not meant to be an exhaustive compendium on all aspects of the management of pediatric diabetes. However, relevant references are provided and current works in progress are indicated as such. The information provided is based on evidence from published studies whenever possible and, when not, supported by expert opinion or consensus (7). Several excellent detailed guidelines and chapters on type 1 diabetes in pediatric endocrinology texts exist, including those by the International Society of Pediatric and Adolescent Diabetes (ISPAD) (8), by the Australian Pediatric Endocrine Group (www.chw.edu/au/prof/services/endocrinology/apeg), in Lifshitz’s Pediatric Endocrinology (9–11), and by Plotnick and colleagues (12,13). Children have characteristics and needs that dictate different standards of care. The management of diabetes in children must take the major differences between children of various ages and 


Contributions of Fasting and Postprandial Plasma Glucose Increments to the Overall Diurnal Hyperglycemia of Type 2 Diabetic Patients

2003-03-01
L. Monnier , H Lapinski , C Colette
The exact contributions of postprandial and fasting glucose increments to overall hyperglycemia remain controversial. The discrepancies between the data published previously might be caused by the interference of several factors. 
 The exact contributions of postprandial and fasting glucose increments to overall hyperglycemia remain controversial. The discrepancies between the data published previously might be caused by the interference of several factors. To test the effect of overall glycemic control itself, we analyzed the diurnal glycemic profiles of type 2 diabetic patients investigated at different levels of HbA(1c).In 290 non-insulin- and non-acarbose-using patients with type 2 diabetes, plasma glucose (PG) concentrations were determined at fasting (8:00 A.M.) and during postprandial and postabsorptive periods (at 11:00 A.M., 2:00 P.M., and 5:00 P.M.). The areas under the curve above fasting PG concentrations (AUC(1)) and >6.1 mmol/l (AUC(2)) were calculated for further evaluation of the relative contributions of postprandial (AUC(1)/AUC(2), %) and fasting [(AUC(2) - AUC(1))/AUC(2), %] PG increments to the overall diurnal hyperglycemia. The data were compared over quintiles of HbA(1c).The relative contribution of postprandial glucose decreased progressively from the lowest (69.7%) to the highest quintile of HbA(1c) (30.5%, P < 0.001), whereas the relative contribution of fasting glucose increased gradually with increasing levels of HbA(1c): 30.3% in the lowest vs. 69.5% in the highest quintile (P < 0.001).The relative contribution of postprandial glucose excursions is predominant in fairly controlled patients, whereas the contribution of fasting hyperglycemia increases gradually with diabetes worsening. These results could therefore provide a unifying explanation for the discrepancies as observed in previous studies.
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Insulin sensitivity indices obtained from oral glucose tolerance testing: comparison with the euglycemic insulin clamp.

1999-09-01
Masafumi Matsuda , Ralph A. DeFronzo
Several methods have been proposed to evaluate insulin sensitivity from the data obtained from the oral glucose tolerance test (OGTT). However, the validity of these indices has not been rigorously 
 Several methods have been proposed to evaluate insulin sensitivity from the data obtained from the oral glucose tolerance test (OGTT). However, the validity of these indices has not been rigorously evaluated by comparing them with the direct measurement of insulin sensitivity obtained with the euglycemic insulin clamp technique. In this study, we compare various insulin sensitivity indices derived from the OGTT with whole-body insulin sensitivity measured by the euglycemic insulin clamp technique.In this study, 153 subjects (66 men and 87 women, aged 18-71 years, BMI 20-65 kg/m2) with varying degrees of glucose tolerance (62 subjects with normal glucose tolerance, 31 subjects with impaired glucose tolerance, and 60 subjects with type 2 diabetes) were studied. After a 10-h overnight fast, all subjects underwent, in random order, a 75-g OGTT and a euglycemic insulin clamp, which was performed with the infusion of [3-3H]glucose. The indices of insulin sensitivity derived from OGTT data and the euglycemic insulin clamp were compared by correlation analysis.The mean plasma glucose concentration divided by the mean plasma insulin concentration during the OGTT displayed no correlation with the rate of whole-body glucose disposal during the euglycemic insulin clamp (r = -0.02, NS). From the OGTT, we developed an index of whole-body insulin sensitivity (10,000/square root of [fasting glucose x fasting insulin] x [mean glucose x mean insulin during OGTT]), which is highly correlated (r = 0.73, P < 0.0001) with the rate of whole-body glucose disposal during the euglycemic insulin clamp.Previous methods used to derive an index of insulin sensitivity from the OGTT have relied on the ratio of plasma glucose to insulin concentration during the OGTT. Our results demonstrate the limitations of such an approach. We have derived a novel estimate of insulin sensitivity that is simple to calculate and provides a reasonable approximation of whole-body insulin sensitivity from the OGTT.

Effect of 6-week course of glucagon-like peptide 1 on glycaemic control, insulin sensitivity, and ÎČ-cell function in type 2 diabetes: a parallel-group study

2002-03-01
Mette Zander , Sten Madsbad , Jan Lysgaard Madsen +1 more

Mean Amplitude of Glycemic Excursions, a Measure of Diabetic Instability

1970-09-01
F. John Service , George D. Molnar , John W. Rosevear +3 more
Three normal, three stable diabetic, and eight unstable diabetic subjects were investigated, with continuous automated blood glucose analysis for forty-eight-hour periods, during metabolic balance studies of six days' duration under 
 Three normal, three stable diabetic, and eight unstable diabetic subjects were investigated, with continuous automated blood glucose analysis for forty-eight-hour periods, during metabolic balance studies of six days' duration under near normal conditions (fed and ambulatory) after the attainment of clinically optimal diabetic regulation. The studies on unstable diabetics were performed during constant dietary intake, with one or two daily injections of intermediate-acting insulin and then repeated with four daily injections of short-acting insulin. A characteristic of blood glucose behavior, the mean amplitude of glycemic excursion (MAGE), was measured. MAGE was small for normals (range, 22 to 60 mg./100 ml.), larger for stable diabetics (67 to 82 mg./100 ml.), and largest for unstable diabetics (119 to 200 mg./100 ml.). Associated with a significant decrease (p = 0.004) in the mean diurnal glycemic level (from 146 to 244 mg,/100 ml. to 101 to 152 mg./100 ml.) achieved through the use of four daily doses of short-acting insulin there was a significant increase (p = 0.006) in hypoglycemic episodes (from 0 to 4/48 hr. to 3 to 6/48 hr.) without significant change in MAGE. The persistently large value of MAGE despite therapy with multiple injections of short-acting insulin appears to be a characteristic of unstable diabetes.

The Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications Study at 30 Years: Overview

2013-12-11
David M. Nathan
OBJECTIVE The Diabetes Control and Complications Trial (DCCT) was designed to test the glucose hypothesis and determine whether the complications of type 1 diabetes (T1DM) could be prevented or delayed. 
 OBJECTIVE The Diabetes Control and Complications Trial (DCCT) was designed to test the glucose hypothesis and determine whether the complications of type 1 diabetes (T1DM) could be prevented or delayed. The Epidemiology of Diabetes Interventions and Complications (EDIC) observational follow-up determined the durability of the DCCT effects on the more-advanced stages of diabetes complications including cardiovascular disease (CVD). RESEARCH DESIGN AND METHODS The DCCT (1982–1993) was a controlled clinical trial in 1,441 subjects with T1DM comparing intensive therapy (INT), aimed at achieving levels of glycemia as close to the nondiabetic range as safely possible, with conventional therapy (CON), which aimed to maintain safe asymptomatic glucose control. INT utilized three or more daily insulin injections or insulin pump therapy guided by self-monitored glucose. EDIC (1994–present) is an observational study of the DCCT cohort. RESULTS The DCCT followed &amp;gt;99% of the cohort for a mean of 6.5 years and demonstrated a 35–76% reduction in the early stages of microvascular disease with INT, with a median HbA1c of 7%, compared with CONV, with a median HbA1c of 9%. The major adverse effect of INT was a threefold increased risk of hypoglycemia, which was not associated with a decline in cognitive function or quality of life. EDIC showed a durable effect of initial assigned therapies despite a loss of the glycemic separation (metabolic memory) and demonstrated that the reduction in early-stage complications during the DCCT translated into substantial reductions in severe complications and CVD. CONCLUSIONS DCCT/EDIC has demonstrated the effectiveness of INT in reducing the long-term complications of T1DM and improving the prospects for a healthy life span.
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Prevalence of Type 1 and Type 2 Diabetes Among Children and Adolescents From 2001 to 2009

2014-05-03
Dana Dabelea , Elizabeth J. Mayer‐Davis , Sharon Saydah +7 more
IMPORTANCE Despite concern about an "epidemic," there are limited data on trends in prevalence of either type 1 or type 2 diabetes across US race and ethnic groups.OBJECTIVE To estimate 
 IMPORTANCE Despite concern about an "epidemic," there are limited data on trends in prevalence of either type 1 or type 2 diabetes across US race and ethnic groups.OBJECTIVE To estimate changes in the prevalence of type 1 and type 2 diabetes in US youth, by sex, age, and race/ethnicity between 2001 and 2009.DESIGN, SETTING, AND PARTICIPANTS Case patients were ascertained in 4 geographic areas and 1 managed health care plan.The study population was determined by the 2001 and 2009 bridged-race intercensal population estimates for geographic sites and membership counts for the health plan.MAIN OUTCOMES AND MEASURES Prevalence (per 1000) of physician-diagnosed type 1 diabetes in youth aged 0 through 19 years and type 2 diabetes in youth aged 10 through 19 years. RESULTSIn 2001, 4958 of 3.3 million youth were diagnosed with type 1 diabetes for a prevalence of 1.48 per 1000 (95% CI, 1.44-1.52).In 2009, 6666 of 3.4 million youth were diagnosed with type 1 diabetes for a prevalence of 1.93 per 1000 (95% CI, 1.88-1.97).In 2009, the highest prevalence of type 1 diabetes was 2.55 per 1000 among white youth (95% CI, 2.48-2.62)and the lowest was 0.35 per 1000 in American Indian youth (95% CI, 0.26-0.47)and type 1 diabetes increased between 2001 and 2009 in all sex, age, and race/ethnic subgroups except for those with the lowest prevalence (age 0-4 years and American Indians).Adjusted for completeness of ascertainment, there was a 21.1% (95% CI, 15.6%-27.0%)increase in type 1 diabetes over 8 years.In 2001, 588 of 1.7 million youth were diagnosed with type 2 diabetes for a prevalence of 0.34 per 1000 (95% CI, 0.31-0.37).In 2009, 819 of 1.8 million were diagnosed with type 2 diabetes for a prevalence of 0.46 per 1000 (95% CI, 0.43-0.49).In 2009, the prevalence of type 2 diabetes was 1.20 per 1000 among American Indian youth (95% CI, 0.96-1.51);1.06 per 1000 among black youth (95% CI, 0.93-1.22);0.79 per 1000 among Hispanic youth (95% CI, 0.70-0.88);and 0.17 per 1000 among white youth (95% CI, 0.15-0.20).Significant increases occurred between 2001 and 2009 in both sexes, all age-groups, and in white, Hispanic, and black youth, with no significant changes for Asian Pacific Islanders and American Indians.Adjusted for completeness of ascertainment, there was a 30.5% (95% CI, 17.3%-45.1%)overall increase in type 2 diabetes.Between 2001 and 2009 in 5 areas of the United States, the prevalence of both type 1 and type 2 diabetes among children and adolescents increased.Further studies are required to determine the causes of these increases. CONCLUSIONS AND RELEVANCE
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Tests of Glycemia in Diabetes

2003-01-01
David E. Goldstein , Randie R. Little , Rodney A. Lorenz +4 more
Monitoring of glycemic status, as performed by patients and health care providers, is considered a cornerstone of diabetes care.Results of monitoring are used to assess the efficacy of therapy and 
 Monitoring of glycemic status, as performed by patients and health care providers, is considered a cornerstone of diabetes care.Results of monitoring are used to assess the efficacy of therapy and to guide adjustments in medical nutrition therapy (MNT), exercise, and medications to achieve the best possible blood glucose control.This position statement presents the recommendations of the American Diabetes Association on the tests used most widely in monitoring the glycemic status of people with diabetes and addresses both patient and physician/laboratorybased testing.It does not address tests for diabetes screening and diagnosis.The recommendations are based on the American Diabetes Association's technical review on the subject, which should be consulted for further information (1). BLOOD GLUCOSE TESTINGBY PATIENTS -Within only a few years, self-monitoring of blood glucose (SMBG) by patients has revolutionized management of diabetes.Using SMBG, patients with diabetes can work to achieve and maintain specific glycemic goals.Given the results of the Diabetes Control and Complications Trial (DCCT) and other studies, there is broad consensus on the health benefits of normal or nearnormal blood glucose levels and on the importance, especially in insulin-treated patients, of SMBG in treatment efforts designed to achieve such glycemic goals.The subject of SMBG has been addressed extensively by two American Diabetes Association Consensus Conferences, which provide a comprehensive review of the subject (2,3).
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Toward Physiological Understanding of Glucose Tolerance: Minimal-Model Approach

1989-12-01
Richard N. Bergman
Glucose tolerance depends on a complex interaction among insulin secretion from the ÎČ-cells, clearance of the hormone, and the actions of insulin to accelerate glucose disappearance and inhibit endogenous glucose 
 Glucose tolerance depends on a complex interaction among insulin secretion from the ÎČ-cells, clearance of the hormone, and the actions of insulin to accelerate glucose disappearance and inhibit endogenous glucose production. An additional factor, less well recognized, is the ability of glucose per se, independent of changes in insulin, to increase glucose uptake and suppress endogenous output (glucose effectiveness). These factors can be measured in the intact organism with physiologically based minimal models of glucose utilization and insulin kinetics. With the glucose minimal model, insulin sensitivity (SI) and glucose effectiveness (SG) are measured by computer analysis of the frequently sampled intravenous glucose tolerance test. The test involves intravenous injection of glucose followed by tolbutamide or insulin and frequent blood sampling. SI varied from a high of 7.6 × 10−4 min−1 · ÎŒU−1 · ml−1 in young Whites to 2.3 × 10−4 min−1 · ÎŒU−1 · ml−1 in obese nondiabetic subjects; in all of the nondiabetic subjects, SG was normal. In subjects with non-insulin-dependent diabetes mellitus (NIDDM), not only was SI reduced 90% below normal (0.61 ± 0.16 × 10−4 min−1 · ÎŒU−1 · ml−1), but in this group alone, SG was reduced (from 0.026 ± 0.008 to 0.014 ± 0.002 min−1); thus, defects in SI and SG are synergistic in causing glucose intolerance in NIDDM. One assumption of the minimal model is that the time delay in insulin action on glucose utilization in vivo is due to sluggish insulin transport across the capillary endothelium. This was tested by comparing insulin concentrations in plasma with those in lymph (representing interstitial fluid) during euglycemic-hyperinsulinemic glucose clamps. Lymph insulin was lower than plasma insulin at basal (12 vs. 18 ÎŒU/ml) and at steady state, indicating significant loss of insulin from the interstitial space, presumably due to cellular uptake of the insulin-receptor complex. Additionally, during clamps, lymph insulin changed more slowly than plasma insulin, but the rate of glucose utilization followed a time course identical with that of lymph (r = .96) rather than plasma (r = .71). Thus, lymph insulin, which may be reflective of interstitial fluid, is the signal to which insulin-sensitive tissues are responding. These studies support the concept that, at physiological insulin levels, the time for insulin to cross the capillary endothelium is the process that determines the rate of insulin action in vivo. In separate experiments, a similar intimate relationship was found between lymph insulin and glucose utilization estimated from the minimal model, supporting the accuracy of the minimal model as a mathematical representation of insulin action in vivo. Additional factors in glucose tolerance are insulin secretion and clearance. We proposed a model of insulin/C-peptide kinetics, derived from the original conception of Eaton and Polonsky, in which determination of C-peptide kinetics in each individual is unnecessary if insulin and C-peptide kinetics are modeled simultaneously. Prehepatic insulin secretion after glucose injection was calculated in healthy women; total insulin secretion was 22.2 nmol; first-phase insulin averaged 38% of total, but there was wide variation among healthy subjects. The ability to determine insulin secretion, insulin action, and glucose effectiveness from modeling allowed us to investigate their interaction. We propose that in healthy individuals, there is a balance between secretion and insulin action such that insulin secretion × insulin sensitivity = constant. Thus, with insulin resistance, it is proposed that a normal ÎČ-cell will increase its sensitivity to glucose appropriately, staving off impaired glucose tolerance. This concept is supported by data in healthy pregnant women, in whom the reciprocal relationship is shown to exist and impaired glucose tolerance is not observed despite substantial insulin resistance (S, reduced to 1.8 × 10−4 min−1 · ÎŒU−1 · ml−1). In subjects at risk for diabetes, e.g., HLA-identical siblings of insulin-dependent diabetic subjects and Pima Indians, insulin sensitivity × secretion &amp;lt; normal constant value. Additionally, Pima Indians with the lowest sensitivity/secretion product appear to be at highest risk for developing NIDDM. Finally, with simulation of the models, we examined the relative importance of individual and compound defects of SI, SG, and insulin secretion to glucose intolerance. Although no individual defect (≀80%) of these factors causes diabetic glucose tolerance (KG &amp;lt; 1), compound defects are remarkably synergistic, with a combined SI/SG defect being the most severe (KG = 0.60), and an SG defect being a requisite component for diabetic glucose tolerance.

Standards of Medical Care in Diabetes 2014

2014-02-01
Diabetes is a chronic illness that requires continuing medical care and patient self-management education to prevent acute complications and to reduce the risk of long-term complications. Diabetes care is complex 
 Diabetes is a chronic illness that requires continuing medical care and patient self-management education to prevent acute complications and to reduce the risk of long-term complications. Diabetes care is complex and requires that many issues, beyond glycemic control, be addressed. A large body of evidence exists that supports a range of interventions to improve diabetes outcomes. These standards of care are intended to provide clinicians, patients, researchers, payors, and other interested individuals with the components of diabetes care, treatment goals, and tools to evaluate the quality of care. While individual preferences, comorbidities, and other patient factors may require modification of goals, targets that are desirable for most patients with diabetes are provided. These standards are not intended to preclude more extensive evaluation and management of the patient by other specialists as needed. For more detailed information, refer to references 1‐3.

Defining and Reporting Hypoglycemia in Diabetes

2005-05-01
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The Pathobiology of Diabetic Complications

2005-06-01
Michael Brownlee
It’s a great honor to join the exceptional club of Banting Award winners, many of whom were my role models and mentors. In addition, giving the Banting Lecture also has 
 It’s a great honor to join the exceptional club of Banting Award winners, many of whom were my role models and mentors. In addition, giving the Banting Lecture also has a very personal meaning to me, because without Frederick Banting, I would have died from type 1 diabetes when I was 8 years old. However, it was already apparent at the time I was diagnosed that for too many people like me, Banting’s discovery of insulin only allowed them to live just long enough to develop blindness, renal failure, and coronary disease. For example, when I started college, the American Diabetes Association’s Diabetes Textbook had this to say to my parents: “The person with type 1 diabetes can be reassured that it is highly likely that he will live at least into his 30s.” Not surprisingly, my parents did not find this particularly reassuring. At the same time we were reading this in 1967, however, the first basic research discovery about the pathobiology of diabetic complications had just been published in Science the previous year. In my Banting Lecture today, I am thus going to tell you a scientific story that is also profoundly personal. I’ve divided my talk into three parts. The first part is called “pieces of the puzzle,” and in it I describe what was learned about the pathobiology of diabetic complications starting with that 1966 Science paper and continuing through the end of the 1990s. In the second part, I present a unified mechanism that links together all of the seemingly unconnected pieces of the puzzle. Finally, in the third part, I focus on three examples of novel therapeutic approaches for the prevention and treatment of diabetic complications, which are all based on the new paradigm of a unifying mechanism for the pathogenesis of diabetic complications. 

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Standards of Medical Care in Diabetes—2013

2012-12-10
AClear evidence from well-conducted, generalizable RCTs that are adequately powered, including: c Evidence from a well-conducted multicenter trial c Evidence from a meta-analysis that incorporated quality ratings in the analysis 
 AClear evidence from well-conducted, generalizable RCTs that are adequately powered, including: c Evidence from a well-conducted multicenter trial c Evidence from a meta-analysis that incorporated quality ratings in the analysis Compelling nonexperimental evidence, i.e., "all or none" rule developed by the Centre for Evidence-Based Medicine at the University of Oxford Supportive evidence from well-conducted RCTs that are adequately powered, including:c Evidence from a well-conducted trial at one or more institutions c Evidence from a meta-analysis that incorporated quality ratings in the analysis B Supportive evidence from well-conducted cohort studies c Evidence from a well-conducted prospective cohort study or registry c Evidence from a well-conducted meta-analysis of cohort studies Supportive evidence from a well-conducted case-control study C Supportive evidence from poorly controlled or uncontrolled studies c Evidence from randomized clinical trials with one or more major or three or more minor methodological flaws that could invalidate the results c Evidence from observational studies with high potential for bias (such as case series with comparison with historical controls) c Evidence from case series or case reports Conflicting evidence with the weight of evidence supporting the recommendation E Expert consensus or clinical experience S12
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Diagnosis and Classification of Diabetes Mellitus

2010-12-30
OF DIABETES MELLITUS -Diabetes is a group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, insulin action, or both.The chronic hyperglycemia of diabetes is associated with 
 OF DIABETES MELLITUS -Diabetes is a group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, insulin action, or both.The chronic hyperglycemia of diabetes is associated with long-term damage, dysfunction, and failure of differentorgans, especially the eyes, kidneys, nerves, heart, and blood vessels.Several pathogenic processes are involved in the development of diabetes.These range from autoimmune destruction of the ␀-cells of the pancreas with consequent insulin deficiency to abnormalities that result in resistance to insulin action.The basis of the abnormalities in carbohydrate, fat, and protein metabolism in diabetes is deficient action of insulin on target tissues.Deficient insulin action results from inadequate insulin secretion and/or diminished tissue responses to insulin at one or more points in the complex pathways of hormone action.Impairment of insulin secretion and defects in insulin action frequently coexist in the same patient, and it is often unclear which abnormality, if either alone, is the primary cause of the hyperglycemia.Symptoms of marked hyperglycemia include polyuria, polydipsia, weight loss, sometimes with polyphagia, and blurred vision.Impairment of growth and susceptibility to certain infections may also accompany chronic hyperglycemia.Acute, life-threatening consequences of uncontrolled diabetes are hyperglycemia with ketoacidosis or the nonketotic hyperosmolar syndrome.Long-term complications of diabetes include retinopathy with potential loss of vision; nephropathy leading to renal failure; peripheral neuropathy with risk of foot ulcers, amputations, and Charcot joints; and autonomic neuropathy causing gastrointestinal, genitourinary, and Section on gestational diabetes diagnosis
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Physical Activity/Exercise and Diabetes: A Position Statement of the American Diabetes Association

2016-10-11
Sheri R. Colberg , Ronald J. Sigal , Jane E. Yardley +6 more
The adoption and maintenance of physical activity are critical foci for blood glucose management and overall health in individuals with diabetes and prediabetes. Recommendations and precautions vary depending on individual 
 The adoption and maintenance of physical activity are critical foci for blood glucose management and overall health in individuals with diabetes and prediabetes. Recommendations and precautions vary depending on individual characteristics and health status. In this Position Statement, we provide a clinically oriented review and evidence-based recommendations regarding physical activity and exercise in people with type 1 diabetes, type 2 diabetes, gestational diabetes mellitus, and prediabetes. Physical activity includes all movement that increases energy use, whereas exercise is planned, structured physical activity. Exercise improves blood glucose control in type 2 diabetes, reduces cardiovascular risk factors, contributes to weight loss, and improves well-being (1,2). Regular exercise may prevent or delay type 2 diabetes development (3). Regular exercise also has considerable health benefits for people with type 1 diabetes (e.g., improved cardiovascular fitness, muscle strength, insulin sensitivity, etc.) (4). The challenges related to blood glucose management vary with diabetes type, activity type, and presence of diabetes-related complications (5,6). Physical activity and exercise recommendations, therefore, should be tailored to meet the specific needs of each individual. Physical activity recommendations and precautions may vary by diabetes type. The primary types of diabetes are type 1 and type 2. Type 1 diabetes (5%–10% of cases) results from cellular-mediated autoimmune destruction of the pancreatic ÎČ-cells, producing insulin deficiency (7). Although it can occur at any age, ÎČ-cell destruction rates vary, typically occurring more rapidly in youth than in adults. Type 2 diabetes (90%–95% of cases) results from a progressive loss of insulin secretion, usually also with insulin resistance. Gestational diabetes mellitus occurs during pregnancy, with screening typically occurring at 24–28 weeks of gestation in pregnant women not previously known to have diabetes. Prediabetes is diagnosed when blood glucose levels are above the normal range but not high enough to be classified as 

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Effect of Continuous Glucose Monitoring on Glycemic Control in Adults With Type 1 Diabetes Using Insulin Injections

2017-01-24
Roy W. Beck , Tonya D. Riddlesworth , Katrina J. Ruedy +7 more
<h3>Importance</h3> Previous clinical trials showing the benefit of continuous glucose monitoring (CGM) in the management of type 1 diabetes predominantly have included adults using insulin pumps, even though the majority 
 <h3>Importance</h3> Previous clinical trials showing the benefit of continuous glucose monitoring (CGM) in the management of type 1 diabetes predominantly have included adults using insulin pumps, even though the majority of adults with type 1 diabetes administer insulin by injection. <h3>Objective</h3> To determine the effectiveness of CGM in adults with type 1 diabetes treated with insulin injections. <h3>Design, Setting, and Participants</h3> Randomized clinical trial conducted between October 2014 and May 2016 at 24 endocrinology practices in the United States that included 158 adults with type 1 diabetes who were using multiple daily insulin injections and had hemoglobin A<sub>1c</sub>(HbA<sub>1c</sub>) levels of 7.5% to 9.9%. <h3>Interventions</h3> Random assignment 2:1 to CGM (n = 105) or usual care (control group; n = 53). <h3>Main Outcomes and Measures</h3> Primary outcome measure was the difference in change in central-laboratory–measured HbA<sub>1c</sub>level from baseline to 24 weeks. There were 18 secondary or exploratory end points, of which 15 are reported in this article, including duration of hypoglycemia at less than 70 mg/dL, measured with CGM for 7 days at 12 and 24 weeks. <h3>Results</h3> Among the 158 randomized participants (mean age, 48 years [SD, 13]; 44% women; mean baseline HbA<sub>1c</sub>level, 8.6% [SD, 0.6%]; and median diabetes duration, 19 years [interquartile range, 10-31 years]), 155 (98%) completed the study. In the CGM group, 93% used CGM 6 d/wk or more in month 6. Mean HbA<sub>1c</sub>reduction from baseline was 1.1% at 12 weeks and 1.0% at 24 weeks in the CGM group and 0.5% and 0.4%, respectively, in the control group (repeated-measures model<i>P</i> &lt; .001). At 24 weeks, the adjusted treatment-group difference in mean change in HbA<sub>1c</sub>level from baseline was –0.6% (95% CI, –0.8% to –0.3%;<i>P</i> &lt; .001). Median duration of hypoglycemia at less than &lt;70 mg/dL was 43 min/d (IQR, 27-69) in the CGM group vs 80 min/d (IQR, 36-111) in the control group (<i>P</i> = .002). Severe hypoglycemia events occurred in 2 participants in each group. <h3>Conclusions and Relevance</h3> Among adults with type 1 diabetes who used multiple daily insulin injections, the use of CGM compared with usual care resulted in a greater decrease in HbA<sub>1c</sub>level during 24 weeks. Further research is needed to assess longer-term effectiveness, as well as clinical outcomes and adverse effects. <h3>Trial Registration</h3> clinicaltrials.gov Identifier:NCT02282397

Standards of Medical Care in Diabetes—2011

2010-12-30
A. Classification of diabetes B. Diagnosis of diabetes C. Categories of increased risk for diabetes (prediabetes) II A. Classification of diabetes B. Diagnosis of diabetes C. Categories of increased risk for diabetes (prediabetes) II
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Standards of Medical Care in Diabetes—2010

2009-12-30
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International Consensus on Use of Continuous Glucose Monitoring

2017-11-10
Thomas Danne , Revital Nimri , Tadej Battelino +7 more
Measurement of glycated hemoglobin (HbA Measurement of glycated hemoglobin (HbA
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Brain insulin resistance in type 2 diabetes and Alzheimer disease: concepts and conundrums

2018-01-29
Steven E. Arnold , Zoe Arvanitakis , Shannon L. Macauley +7 more

State of Type 1 Diabetes Management and Outcomes from the T1D Exchange in 2016–2018

2019-01-18
Nicole C. Foster , Roy W. Beck , Kellee M. Miller +7 more
Objective: To provide a snapshot of the profile of adults and youth with type 1 diabetes (T1D) in the United States and assessment of longitudinal changes in T1D management and 
 Objective: To provide a snapshot of the profile of adults and youth with type 1 diabetes (T1D) in the United States and assessment of longitudinal changes in T1D management and clinical outcomes in the T1D Exchange registry. Research Design and Methods: Data on diabetes management and outcomes from 22,697 registry participants (age 1–93 years) were collected between 2016 and 2018 and compared with data collected in 2010–2012 for 25,529 registry participants. Results: Mean HbA1c in 2016–2018 increased from 65 mmol/mol at the age of 5 years to 78 mmol/mol between ages 15 and 18, with a decrease to 64 mmol/mol by age 28 and 58–63 mmol/mol beyond age 30. The American Diabetes Association (ADA) HbA1c goal of <58 mmol/mol for youth was achieved by only 17% and the goal of <53 mmol/mol for adults by only 21%. Mean HbA1c levels changed little between 2010–2012 and 2016–2018, except in adolescents who had a higher mean HbA1c in 2016–2018. Insulin pump use increased from 57% in 2010–2012 to 63% in 2016–2018. Continuous glucose monitoring (CGM) increased from 7% in 2010–2012 to 30% in 2016–2018, rising >10-fold in children <12 years old. HbA1c levels were lower in CGM users than nonusers. Severe hypoglycemia was most frequent in participants ≄50 years old and diabetic ketoacidosis was most common in adolescents and young adults. Racial differences were evident in use of pumps and CGM and HbA1c levels. Conclusions: Data from the T1D Exchange registry demonstrate that only a minority of adults and youth with T1D in the United States achieve ADA goals for HbA1c.
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Clinical Targets for Continuous Glucose Monitoring Data Interpretation: Recommendations From the International Consensus on Time in Range

2019-06-08
Tadej Battelino , Thomas Danne , Richard M. Bergenstal +7 more
Improvements in sensor accuracy, greater convenience and ease of use, and expanding reimbursement have led to growing adoption of continuous glucose monitoring (CGM). However, successful utilization of CGM technology in 
 Improvements in sensor accuracy, greater convenience and ease of use, and expanding reimbursement have led to growing adoption of continuous glucose monitoring (CGM). However, successful utilization of CGM technology in routine clinical practice remains relatively low. This may be due in part to the lack of clear and agreed-upon glycemic targets that both diabetes teams and people with diabetes can work toward. Although unified recommendations for use of key CGM metrics have been established in three separate peer-reviewed articles, formal adoption by diabetes professional organizations and guidance in the practical application of these metrics in clinical practice have been lacking. In February 2019, the Advanced Technologies & Treatments for Diabetes (ATTD) Congress convened an international panel of physicians, researchers, and individuals with diabetes who are expert in CGM technologies to address this issue. This article summarizes the ATTD consensus recommendations for relevant aspects of CGM data utilization and reporting among the various diabetes populations.
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Standards of Medical Care in Diabetes—2007

2006-12-27
Cardiovascular disease 1. Hypertension/blood pressure control 2. Dyslipidemia/lipid management 3. Antiplatelet agents 4. Smoking cessation 5. C o r o n a r y h e a r t d 
 Cardiovascular disease 1. Hypertension/blood pressure control 2. Dyslipidemia/lipid management 3. Antiplatelet agents 4. Smoking cessation 5. C o r o n a r y h e a r t d i s e a s e screening and treatment B. Nephropathy screening and treatment C
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Diagnosis and Classification of Diabetes Mellitus

2011-12-13
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Diagnosis and Classification of Diabetes Mellitus

2013-12-16
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Standards of Medical Care in Diabetes—2014

2013-12-16
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Metformin

1996-02-29
Clifford J. Bailey , Robert C. Turner
Metformin (dimethylbiguanide) is an orally administered drug used to lower blood glucose concentrations in patients with non-insulin-dependent diabetes mellitus (NIDDM).1 It improves insulin sensitivity and thus decreases the insulin resistance 
 Metformin (dimethylbiguanide) is an orally administered drug used to lower blood glucose concentrations in patients with non-insulin-dependent diabetes mellitus (NIDDM).1 It improves insulin sensitivity and thus decreases the insulin resistance that is prevalent in NIDDM. The efficacy of glycemic control achieved with metformin is similar to that achieved with sulfonylureas, although their modes of action differ. Metformin can be used either as initial therapy or as an additional drug when sulfonylurea therapy alone is inadequate. In this article we shall discuss the pharmacology and clinical use of metformin, which is now available in the United States.The Burden of Non-Insulin-Dependent . . .

Hypoglycemia in Diabetes

2003-06-01
Philip E. Cryer , Stephen N. Davis , Harry Shamoon
Iatrogenic hypoglycemia causes recurrent morbidity in most people with type 1 diabetes and many with type 2 diabetes, and it is sometimes fatal. The barrier of hypoglycemia generally precludes maintenance 
 Iatrogenic hypoglycemia causes recurrent morbidity in most people with type 1 diabetes and many with type 2 diabetes, and it is sometimes fatal. The barrier of hypoglycemia generally precludes maintenance of euglycemia over a lifetime of diabetes and thus precludes full realization of euglycemia’s long-term benefits. While the clinical presentation is often characteristic, particularly for the experienced individual with diabetes, the neurogenic and neuroglycopenic symptoms of hypoglycemia are nonspecific and relatively insensitive; therefore, many episodes are not recognized. Hypoglycemia can result from exogenous or endogenous insulin excess alone. However, iatrogenic hypoglycemia is typically the result of the interplay of absolute or relative insulin excess and compromised glucose counterregulation in type 1 and advanced type 2 diabetes. Decrements in insulin, increments in glucagon, and, absent the latter, increments in epinephrine stand high in the hierarchy of redundant glucose counterregulatory factors that normally prevent or rapidly correct hypoglycemia. In insulin-deficient diabetes (exogenous) insulin levels do not decrease as glucose levels fall, and the combination of deficient glucagon and epinephrine responses causes defective glucose counterregulation. Reduced sympathoadrenal responses cause hypoglycemia unawareness. The concept of hypoglycemia-associated autonomic failure in diabetes posits that recent antecedent hypoglycemia causes both defective glucose counterregulation and hypoglycemia unawareness. By shifting glycemic thresholds for the sympathoadrenal (including epinephrine) and the resulting neurogenic responses to lower plasma glucose concentrations, antecedent hypoglycemia leads to a vicious cycle of recurrent hypoglycemia and further impairment of glucose counterregulation. Thus, short-term avoidance of hypoglycemia reverses hypoglycemia unawareness in most affected patients. The clinical approach to minimizing hypoglycemia while improving glycemic control includes 1) addressing the issue, 2) applying the principles of aggressive glycemic therapy, including flexible and individualized drug regimens, and 3) considering the risk factors for iatrogenic hypoglycemia. The latter include factors that result in absolute or relative insulin excess: drug dose, timing, and type; patterns of food ingestion and exercise; interactions with alcohol and other drugs; and altered sensitivity to or clearance of insulin. They also include factors that are clinical surrogates of compromised glucose counterregulation: endogenous insulin deficiency; history of severe hypoglycemia, hypoglycemia unawareness, or both; and aggressive glycemic therapy per se, as evidenced by lower HbA1c levels, lower glycemic goals, or both. In a patient with hypoglycemia unawareness (which implies recurrent hypoglycemia) a 2- to 3-week period of scrupulous avoidance of hypoglycemia is advisable. Pending the prevention and cure of diabetes or the development of methods that provide glucose-regulated insulin replacement or secretion, we need to learn to replace insulin in a much more physiological fashion, to prevent, correct, or compensate for compromised glucose counterregulation, or both if we are to achieve near-euglycemia safely in most people with diabetes.
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Diabetes tipo 1 em crianças: anålise qualitativa das percepçÔes e estratégias de enfrentamento

2025-06-25
Eleny Rosa Guimarães Gonçalves , Elídia Fabiana de Souza Xavier , Mariana Furio Franco Bernardes +7 more | Caderno Pedagógico
Introdução: O Diabetes Mellitus tipo 1 (DM1) Ă© uma doença crĂŽnica autoimune que acomete principalmente crianças e adolescentes, exigindo mudanças significativas na rotina e no comportamento desde o diagnĂłstico. O 
 Introdução: O Diabetes Mellitus tipo 1 (DM1) Ă© uma doença crĂŽnica autoimune que acomete principalmente crianças e adolescentes, exigindo mudanças significativas na rotina e no comportamento desde o diagnĂłstico. O enfrentamento precoce de uma condição complexa, como o DM1, desafia nĂŁo apenas o manejo clĂ­nico, mas tambĂ©m o equilĂ­brio emocional e social da criança, demandando suporte contĂ­nuo e uma abordagem humanizada e multiprofissional. Objetivo: Compreender as perspectivas e os modos de enfrentamento adotados por crianças diagnosticadas com DM1, identificando os impactos emocionais, sociais e comportamentais decorrentes da condição crĂŽnica. MĂ©todo: Trata-se de uma pesquisa de campo, qualitativa, realizada com 15 crianças e adolescentes acompanhados no Centro Interdisciplinar em Diabetes (CENID) da UNIMAR. Os dados foram coletados por meio de entrevistas semiestruturadas e analisados pela tĂ©cnica de anĂĄlise de conteĂșdo, com base na anĂĄlise temĂĄtica. Resultados e DiscussĂŁo: Os relatos evidenciaram que o diagnĂłstico provoca um rompimento na vivĂȘncia infantil, com sentimentos de medo, insegurança e exclusĂŁo social. O ambiente escolar, por vezes acolhedor, tambĂ©m pode ser palco de estigmatização. A adaptação ao tratamento ocorre gradualmente, com participação ativa da famĂ­lia e orientação da equipe de saĂșde. As crianças desenvolvem estratĂ©gias de autocuidado e ressignificação da doença, ainda que enfrentem dificuldades como o medo de complicaçÔes, acesso limitado a insumos e falta de preparo das instituiçÔes escolares. O suporte afetivo e educativo se mostrou essencial para promover autonomia, segurança e bem-estar. ConsideraçÔes Finais: O enfrentamento do DM1 na infĂąncia exige escuta ativa, empatia e açÔes integradas que valorizem o protagonismo infantil. O fortalecimento das redes de apoio – famĂ­lia, escola e profissionais – Ă© fundamental para garantir uma convivĂȘncia saudĂĄvel com a doença e melhor qualidade de vida.

The relationship between perceived executive function and self-reported self-management behaviour in adults with type 1 diabetes

2025-06-25
Lynne Shanley , Daniel Powell , Julia Allan | Journal of Health Psychology
This mixed-method study examined whether and how perceived executive function (EF) is linked to self-reported self-management in 173 people diagnosed with Type 1 diabetes (T1D) during adulthood, combining a cross-sectional 
 This mixed-method study examined whether and how perceived executive function (EF) is linked to self-reported self-management in 173 people diagnosed with Type 1 diabetes (T1D) during adulthood, combining a cross-sectional survey with thematic analysis of 11 interviews. Stronger global EF significantly predicted better self-management ( B = −0.04, t (165) = 4.15; p &lt; 0.001) after controlling for demographic factors. Stronger perceptions of EF correlated with better self-reported adherence to dietary behaviour, glucose monitoring and physical activity, but not medication-taking or cooperation with healthcare teams. Qualitative interviews identified key challenges in self-management requiring stronger EF including planning behaviours, maintaining attention and vigilance over time and responding flexibly to changing demands. Strategies which reduce demands on EF, such as establishing routines and delegating control of tasks, helped to improve self-management. Adults with perceived EF impairments may struggle to effectively manage T1D, suggesting supportive interventions should aim to reduce the cognitive demands of self-management.

Executive function and quality of life in children and adolescents with type 1 diabetes: The mediating role of the Child Behavior Checklist Dysregulation Profile

2025-06-25
Nuria MartĂ­n-MartĂ­nez , Irene Caro‐Cañizares , Juan J. Carballo +1 more | European Journal of Pediatrics
Abstract Type 1 diabetes (T1D) is a common childhood disease with a complex management that could adversely impact the quality of life of young sufferers. Executive functioning problems and psychopathology 
 Abstract Type 1 diabetes (T1D) is a common childhood disease with a complex management that could adversely impact the quality of life of young sufferers. Executive functioning problems and psychopathology are factors that appear to have a detrimental effect on T1D-related quality of life (T1D-QoL). However, research on these factors is limited, and the pathways through which they do so remain unclear. This study aims to replicate the relationship between EF and T1D-QoL and to explore the possible mediating role of the clinical dysregulation profile (CBCL-DP) in this relationship. A total of 68 children and adolescents aged 10–18 living with T1D were recruited for this cross-sectional study. Parents reported on youth executive functioning, T1D-QoL, CBCL-DP, and socio-demographic data. In addition, clinical records of the youth were consulted to collect endocrinological information. Statistical analyses encompassed bivariate correlations, linear regressions, and bootstrap analyses to test the mediation model. Results demonstrate that executive function, CBCL-DP, and T1D-QoL are significantly correlated. The mediation model of the CBCL-DP variable in the relationship between executive function and T1D-QoL is significant. In linear regressions, executive function ceases to be significant on T1D-QoL when CBCL-DP is taken into account. The CBCL-DP significantly accounts for 55% of the variance in T1D-QoL. Conclusion : This study identifies the CBCL-DP as a full mediator between executive function and T1D-QoL, highlighting the importance of emotional and behavioral regulation for quality of life in youth with T1D. The CBCL-DP scale may be useful in identifying regulatory issues and guiding early interventions to improve outcomes in children and adolescents with T1D. What is Known: ‱ Previous studies have suggested that EF problems may negatively affect T1D-QoL; however, no studies have investigated the underlying mechanisms by which these variables are associated and the mediating role of CBCL-DP . What is New: ‱ This study suggests that there is an absence of a direct association between EF problems and T1D-QoL and identifies the CBCL-DP as a complete mediator between these variables. Furthermore, the study indicates that clinical dysregulation acts as a risk factor for diminished T1D-QoL in children and adolescents with T1D .

Personalized machine learning models for noninvasive hypoglycemia detection in people with type 1 diabetes using a smartwatch: Insights into feature importance during waking and sleeping times

2025-06-25
Y. Mohamed , José Mancera , Andreas Brandenberg +2 more | PLoS ONE
Hypoglycemia is a major challenge for people with diabetes. Therefore, glycemic monitoring is an important aspect of diabetes management. However, current methods such as finger pricking and continuous glucose monitoring 
 Hypoglycemia is a major challenge for people with diabetes. Therefore, glycemic monitoring is an important aspect of diabetes management. However, current methods such as finger pricking and continuous glucose monitoring systems (CGMS) are invasive, and hypoglycemia has still been shown to occur despite advancements in CGMS. Consequently, a growing body of research has been directed toward noninvasive hypoglycemia detection, relying on data from medical devices and wearables that can record physiological changes elicited by hypoglycemia. Consumer-grade wearables such as smartwatches remain an attractive yet underexplored candidate for such applications. Therefore, we explored the potential of a consumer-grade wearable for hypoglycemia prediction and investigated differing feature importance during waking and sleeping times. Smartwatch data from 18 adults with type 1 diabetes was collected, preprocessed, and imputed. Machine learning (ML) models were built using a tree-based ensemble algorithm to detect hypoglycemic events registered by CGMS. Models were built in a personalized manner using the same participant’s data for training and testing, with separate modeling for daytime and nighttime. The relative importance of input features on model decisions was analyzed using SHAP (SHapley Additive exPlanations). Seventeen personalized models were built with an average area under the receiver operating characteristic curve (AUROC) score of 0.74 ± 0.08. Average specificity and sensitivity were 0.76 ± 0.18 and 0.71 ± 0.15, respectively. Time-of-day, activity, and cardiac features showed comparable importance in daytime models (29.9%, 28.5%, and 24%, respectively), while in nighttime models, cardiac features demonstrated the highest importance (42.2%) followed by time-of-day features (37.5%) and respiratory features (15.2%). In summary, we demonstrate the potential of consumer-grade wearables in noninvasive hypoglycemia detection. By additionally considering different physiological states (waking and sleeping) during modeling, our results offer further insights into differences in relative feature importance influencing the model’s decision, guiding future research in this area.

O DIABETES MELLITUS E A INSULINOTERAPIA NA ATENÇÃO PRIMÁRIA DE SAÚDE: RELATO DE EXPERIÊNCIA

2025-06-24
Luiz Roberto Medina dos Santos , JoĂŁo Santos , Ana Rosa BotĂȘlho Pontes +5 more | Revista Foco
Introdução: O diabetes mellitus tipo 2 (DM2) Ă© um problema de saĂșde pĂșblica global, com prevalĂȘncia crescente, especialmente entre a população idosa. A insulinoterapia subcutĂąnea apresenta desafios de autoadministração para 
 Introdução: O diabetes mellitus tipo 2 (DM2) Ă© um problema de saĂșde pĂșblica global, com prevalĂȘncia crescente, especialmente entre a população idosa. A insulinoterapia subcutĂąnea apresenta desafios de autoadministração para este grupo: dificuldades visuais, motoras, cognitivas e lacunas de conhecimento sobre tĂ©cnica, conservação e descarte de material, podendo levar a controle glicĂȘmico inadequado e a complicaçÔes. A educação em saĂșde na Atenção PrimĂĄria Ă  SaĂșde (APS) Ă© ferramenta crucial para o empoderamento do paciente, promoção do autocuidado e adesĂŁo terapĂȘutica, capacitando-o para um manejo eficaz. Objetivo: Relatar a experiĂȘncia de acadĂȘmicos de enfermagem na realização de açÔes educativas sobre autoadministração de insulina subcutĂąnea para idosos diabĂ©ticos tipo 2, insulinodependentes. Metodologia: Trata-se de um relato de experiĂȘncia de projeto de extensĂŁo universitĂĄria sobre açÔes educativas em saĂșde e oficina com a temĂĄtica: O diabetes mellitus e a insulinoterapia, em unidade de saĂșde de BelĂ©m do ParĂĄ, nos dias 03 e 04/02/2025. Abordou-se: 1) Conceitos bĂĄsicos sobre diabetes (fisiopatologia, sinais/sintomas hiper/hipoglicemia, controle glicĂȘmico); 2) TĂ©cnica de preparo, administração da insulina, conservação e descarte de materiais contaminados. Utilizou-se tecnologias educacionais de baixo custo: banner ilustrativo, boneco de tecido e materiais demonstrativos (seringas, frascos vazios). Resultados: Participaram 49 idosos (predominantemente 40-65 anos), com grande interesse e participação ativa. Relataram dificuldades de acesso Ă  insulina/glicosĂ­metro e significativas lacunas no conhecimento sobre tĂ©cnica correta (escolha da seringa, rodĂ­zio de locais, Ăąngulo), conservação da insulina e descarte seguro de perfurocortantes. PrĂĄticas como reutilização de seringas e aplicação no mesmo local foram comuns. ConclusĂŁo: A experiĂȘncia evidenciou o potencial das açÔes de extensĂŁo universitĂĄria, com tecnologias educacionais acessĂ­veis e metodologias participativas, para promover conhecimento e autocuidado em idosos com DM2 em insulinoterapia. Identificou-se a premente necessidade de educação continuada para corrigir prĂĄticas inadequadas, reforçar a tĂ©cnica correta de aplicação, rodĂ­zio dos locais e descarte seguro dos insumos.

Sustained improvements in glycaemic and psychosocial outcomes for youth and caregivers using Omnipod 5 <scp>AID</scp> for 12 months

2025-06-24
Cari Berget , Erin Cobry , Estella Escobar +6 more | Diabetes Obesity and Metabolism
Abstract Aims Glycaemic benefits of automated insulin delivery for youth with type 1 diabetes (T1D) are well established; however, additional data on psychosocial impacts are needed. The study aims to 
 Abstract Aims Glycaemic benefits of automated insulin delivery for youth with type 1 diabetes (T1D) are well established; however, additional data on psychosocial impacts are needed. The study aims to evaluate the real‐world glycaemic and psychosocial impacts for youth with T1D using the Omnipod 5 AID system for 1 year. Materials and Methods One hundred forty‐one youth who were prescribed the Omnipod 5 AID system for their diabetes care were enrolled in a prospective, observational study. Youth and caregivers completed the hypoglycaemia fear survey (HFS), insulin delivery systems: perceptions, ideas, reflections and expectations survey (INSPIRE) and the problem areas in diabetes survey (PAID) to assess psychosocial impacts. Insulin pump and glycaemic data were collected from Glooko. Results A1c (HbA1c) improved from 7.5% (0.9%) at baseline to 7.1% (0.1%) at month 12 ( p &lt; 0.001). Time in Range (TIR) increased from 58.3% (2.8%) to 64.0 (1.4%) ( p &lt; 0.001) and time below range (TBR) &lt;70 mg/dL decreased from 3.1% (0.2%) to 2.1% (0.2%) ( p &lt; 0.001). Caregivers reported improvements in all psychosocial measures. From baseline to month 12, INSPIRE scores improved from 77.4 (1.4) to 83.6 (1.4), HFS scores improved in all three subscales and PAID scores improved from 53.3 (1.7) to 44.2 (1.8) ( p &lt; 0.001). Youth reported improvements in HFS scores in all three subscales, and PAID scores improved from 51.9 (2.8) to 46.9 (2.9) ( p &lt; 0.001). There was no change in INSPIRE scores. Conclusions This study demonstrates sustained improvements in glycaemic and psychosocial outcomes for youth and caregivers using the Omnipod 5 AID system for 12 months, the longest real‐world evaluation of Omnipod 5 to date.

Impact of social disadvantage on clinical and health care use indicators in adults with type 1 diabetes using insulin pumps in Ontario, Canada

2025-06-24
Youstina Soliman , Karl Everett , Rayzel Shulman +4 more | Diabetes Obesity and Metabolism
Abstract Background Social disadvantage is associated with worse diabetes outcomes among individuals with type 1 diabetes (T1D). Insulin pump therapy in the context of a publicly funded programme may mitigate 
 Abstract Background Social disadvantage is associated with worse diabetes outcomes among individuals with type 1 diabetes (T1D). Insulin pump therapy in the context of a publicly funded programme may mitigate the effects of social disadvantage on outcomes of diabetes. We investigated the effects of social disadvantage on health care use indicators and outcomes among pump users. Methods We conducted a population‐based retrospective cohort study using administrative health data in Ontario, Canada. Adults with T1D who initiated pump therapy between 1 April 2012 and 30 March 2020 were included. Multivariable Poisson and linear regressions were used to evaluate associations between social disadvantage (defined by the material resources quintile of the Ontario marginalization index) and the following outcomes: health care use indicators (number of HbA1c tests and endocrinologist outpatient visits per year), and clinical outcomes (HbA1c and hospitalization/emergency department visits for hyperglycaemia and hypoglycaemia). All models were adjusted for age, sex, diabetes duration, baseline HbA1c, immigrant status, rural residence, diabetes physician specialty, clinic type and were estimated using generalized estimating equations (GEE) models to account for clustering by region. Results Among 15 755 adults with T1D who initiated pump therapy, 14% were from the most socially disadvantaged quintile. There were no associations between social disadvantage and health care use indicators. Individuals with greater disadvantage had poorer diabetes outcomes, including 0.12% higher HbA1c (95% CI 0.06–0.17) and a higher rate for hospitalization/emergency department visits for hyperglycaemia [adjusted rate ratio (aRR) 2.07 (95% CI 1.64–2.62)] and hypoglycaemia [aRR 1.76 (95% CI 1.41–2.19)] comparing the most versus least socially disadvantaged quintiles. Conclusions Social disadvantage was associated with worse clinical outcomes but not health care use indicators among pump users with T1D in Ontario. Social disadvantage remains a risk factor for poorer clinical outcomes among pump users, but pump use may sustain greater engagement with the diabetes care team.

Novel Inpatient Automated Self-Adjusting Subcutaneous Insulin Algorithm: Three-Year Experience. An observational study

2025-06-24
Robert J Rushakoff , Esther Rov-Ikpah , Gwendolyn Lee +6 more | The Journal of Clinical Endocrinology & Metabolism
Achieving inpatient glycemic control in patients who are nil per os (NPO), on enteral tube feeds (TF), or total parental nutrition (TPN) remains extremely challenging. To determine if, for inpatients 
 Achieving inpatient glycemic control in patients who are nil per os (NPO), on enteral tube feeds (TF), or total parental nutrition (TPN) remains extremely challenging. To determine if, for inpatients with hyperglycemia who are NPO, on TF, or on TPN, an automated self-adjusting subcutaneous rapid acting insulin algorithm (SQIA) we developed and programmed into the EMR leads to improvements in glucose control compared to conventional insulin treatment (CI).Design/Intervention/Setting/PatientsRetrospective cohort study using EMR data from 9/3/2020 to 9/2/2023, of all adult inpatients, comparing point-of-care (POC) glucose measurements between patients on SQIA versus CI and either NPO, or on TF, or on TPN. The analysis looked at the proportion of q4 hour POC glucose levels in the following ranges: hypoglycemia (<70 mg/dL), in range (71-180 mg/dL), moderate hyperglycemia (181-250 mg/dL), and severe hyperglycemia (>250 mg/dL). There were 5,031 intervals (associated with 4310 hospitalizations) in which the patient was NPO or on TF or TPN and on the SQIA (73.5%) or CI (26.5%). The proportion of glucose values in the hypoglycemic and severely hyperglycemic ranges were significantly lower in the SQIA group vs. the CI group (hypoglycemia: 0.65% vs. 1.10%; difference -0.45%; -0.62 to -0.28%; p < 0.001; hyperglycemia: 5.40% vs. 6.65%; difference -1.25%; -2.03% to -0.46%; p = 0.002). With glucocorticoids, rates of severe hyperglycemia were lower for patients on the SQIA, particularly those receiving high-dose glucocorticoids (11.1% lower). Patients had a lower proportion of both hypoglycemic and severely hyperglycemic measurements when their blood glucose levels were managed using the SQIA than when managed using conventional physician-driven insulin orders.

Diabetes Compliance Management Revolution in Indonesia: Uncovering the Latest Trends in Continuous Glucose Monitoring (CGM) Usage

2025-06-24
Dwight Mahaputera Marulitua Hutapea | Maneggio
The prevalence of diabetes in Indonesia continues to increase along with changes in the lifestyle of urban communities who are less active and consume high-sugar and fat foods. Low awareness 
 The prevalence of diabetes in Indonesia continues to increase along with changes in the lifestyle of urban communities who are less active and consume high-sugar and fat foods. Low awareness of early detection and minimal patient compliance with blood glucose monitoring are major challenges in managing this disease. This study uses a qualitative approach with a phenomenological method to explore the subjective experiences of diabetes patients in using Continuous Glucose Monitoring (CGM) technology. The results of the study show that CGM is not only a real-time glucose monitoring tool, but also a trigger for behavioral transformation, self-empowerment, and increased patient compliance. However, structural challenges such as the high price of the device, the fact that CGM has not been guaranteed by BPJS, low digital literacy, and the gap in access between the upper and lower middle economic groups still hinder the widespread implementation of this technology. The adoption of CGM in Indonesia tends to be limited to certain groups, and has not become an integrated national strategy. Therefore, inclusive and data-based health policies, ongoing education, and financial support are needed to ensure equitable access. With a comprehensive systemic approach, CGM has the potential to revolutionize diabetes management towards a more preventive, personal, and sustainable paradigm in Indonesia..

RISKS OF HYPOGLYCEMIC PHARMACOTHERAPY IN ELDERLY PATIENTS WITH NEUROLOGICAL AND PSYCHIATRIC DISORDERS

2025-06-24
В. Е. ĐĐŸĐČĐžĐșĐŸĐČ | Psychopharmacology & biological narcology
ABSTRAKT Based on the results of the analysis of scientific studies by domestic and foreign authors over the past 5 years, a description and discussion of the possible risks of 
 ABSTRAKT Based on the results of the analysis of scientific studies by domestic and foreign authors over the past 5 years, a description and discussion of the possible risks of pharmacotherapy by various groups of sugar-lowering drugs for type 2 diabetes mellitus in elderly and senile patients with neurological and mental disorders is presented. The pharmacodynamic parameters of the main representatives of hypoglycemic agents are given, which make it possible to assess the safety of their use in geriatric patients. The requirements and principles of hypoglycemic pharmacotherapy in elderly patients are described to reduce the risks of adverse reactions. For elderly and senile patients with impaired central nervous system function in the treatment of type 2 diabetes, metformin is the hypoglycemic drug with the lowest risk of adverse reactions. There are prospects for the use of modern groups of sugar-lowering drugs, such as incretinomimetics and gliflozines. Sulfonylurea derivatives, glitazones and glinides are not indicated for the elderly. Keywords: hypoglycemic agents, type 2 diabetes mellitus, geriatric patient, adverse drug reaction

Correlation of HbA1c and Continuous Glucose Monitor Time in Range

2025-06-24
Hannah DePasquale , Alexander DeLucenay , Nabila Ahmed‐Sarwar | Journal of Pharmacy Technology
Background: Current literature is limited to describing the correlation of continuous glucose monitor (CGM) use and improved HbA1cs in patients with type 2 diabetes. There is a lack of literature 
 Background: Current literature is limited to describing the correlation of continuous glucose monitor (CGM) use and improved HbA1cs in patients with type 2 diabetes. There is a lack of literature correlating HbA1c and time in range (TIR). In addition, data such as time spent with low or very low blood glucose levels are not assessed in existing literature. Objective: To assess the correlation between reduction of HbA1c and increase in TIR for patients using CGMs meeting with an interdisciplinary team. Methods: This retrospective chart review includes adult patients seen in an interdisciplinary internal medicine clinic consisting of a pharmacist and nurse practitioner. Data collection included patients with diabetes using CGMs for at least 3 months, who had a visit with the team in the last 12 months. Information collected included demographics, insurance, comorbidities, diabetes medications, HbA1c and CGM data at baseline and 3-month visit, and number of pharmacist medication interventions. Fisher’s exact, chi-square, and Mann-Whitney U tests were used where appropriate. Results: HbA1c decreased from 8.6% to 7.5% 3 months later ( P = 0.002). The average increase in TIR was 55.5% to 65.1% ( P = 0.007). The overall decrease in HbA1c and increase in TIR had a high inverse correlation at baseline and 3 months ( r = −0.7 and r = −0.7, P &lt; 0.001). Conclusion: There is a strong inverse relationship between HbA1c and TIR, reduction in glucose variability with a slightly higher incidence time in low/very low following intervention. The type and frequency of pharmacist-initiated interventions support the clinical decision-making potential for pharmacotherapy adjustments.

Insulin Glargine U-300 in Type 1 Diabetes Mellitus: Single-Center Experience

2025-06-23
Özge Polat Korkmaz , Zeynep OƟar ƞiva | Namık Kemal Tıp Dergisi

Does a healthy lifestyle reduce the risk of obesity in type 1 diabetes?

2025-06-23
Mateusz Michalski , Dorota ZozuliƄska‐ZióƂkiewicz | Journal of Medical Science
A healthy lifestyle is recommended for every people with type 1 diabetes. Unfortunately, the incidence of type 1 diabetes is steadily increasing. There are many studies confirming that maintaining a 
 A healthy lifestyle is recommended for every people with type 1 diabetes. Unfortunately, the incidence of type 1 diabetes is steadily increasing. There are many studies confirming that maintaining a balanced diet or incorporating physical activity helps to maintain good health over the long term. It helps to metabolically balance the diabetes and to prevent the development of excessive body weight. Making appropriate lifestyle modifications, as recommended by researchers and associations, will certainly help with this. The aim of this study is to analyse the impact of a healthy lifestyle, including a balanced diet, sleep hygiene, psychological conditions, insulin therapy and physical activity, on metabolic control and the prevention of excess body weight in patients with type 1 diabetes. The introduction and alignment of the described components in patients with type 1 diabetes contributes to better metabolic control of the disease and reduces the risk of excessive body weight.

Subclasses of Glucose Trajectories in Early Childhood Stratified the Risk of Abnormal Glucose Tolerance in Adolescence and Young Adulthood

2025-06-23
Yingchai Zhang , Eric S. H. Lau , Claudia H.T. Tam +7 more | Diabetes
Early-life exposures may shape long-term effects on glucose regulation. This study aimed to stratify long-term abnormal glucose tolerance (AGT) risk from early childhood. A total of 906 children were enrolled 
 Early-life exposures may shape long-term effects on glucose regulation. This study aimed to stratify long-term abnormal glucose tolerance (AGT) risk from early childhood. A total of 906 children were enrolled at baseline and reevaluated in adolescence and young adulthood. By using the latent class trajectory analysis, glucose trajectories of children were measured via five-time point oral glucose tolerance tests and then grouped into three latent subclasses: mild excursion-normal reversion (MN), moderate excursion-delayed reversion (MD), and severe excursion-delayed reversion (SD). Logistic regression was performed to estimate the risk of AGT and associations between cardiometabolic factors and subclasses. In adolescence, compared with the MN subclass, the risk of AGT was 1.7-fold in the MD subclass and 5.5-fold in the SD subclass, after adjusting for age, sex, BMI, and Tanner stage. In young adulthood, the adjusted risk of AGT was 3.6-fold and 11.6-fold in the MD and SD subclasses, respectively. During the full natural history of glucose tolerance, the risk of AGT was 3.6-fold in the MD subclass and 18.1-fold in the SD subclass, after adjusting for childhood covariates. MD and SD subclass membership was strongly associated with childhood hypertension, maternal gestational diabetes, and maternal hypertension during pregnancy. Glucose trajectory subclasses in early childhood effectively stratified the long-term risk of AGT. The association between maternal cardiometabolic health and childhood subclass membership highlighted that prenatal exposures may influence metabolic outcomes in offspring. Abnormal glucose tolerance (AGT) in youth has become an alarming global public health issue; however, approaches to identify high-risk population among young people have not been well-established. Can the long-term risk of AGT be stratified by the subclasses of glucose trajectories defined in childhood? Subclasses defined in childhood can efficiently stratify the risk of AGT in adolescence and young adulthood. The subclass membership was strongly associated with cardiometabolic disorders in childhood and maternal cardiometabolic disorders during pregnancy. This subclass method provides a potential strategy to identify those at risk of later cardiometabolic disorders from childhood for more intensive evaluation of intervention. The close relationship between maternal cardiometabolic disorders and subclass membership of children highlighted the potential influence of gestational cardiometabolic health on the development of cardiometabolic disorders in offspring.

Intervention through an intelligent technological platform for socio-emotional development and health promotion in adolescents with Type 1 Diabetes Mellitus (emoTICare): A study protocol for randomized controlled trial

2025-06-23
Javier MartĂ­n-Ávila , Esther RodrĂ­guez-JimĂ©nez , Selene Valero‐Moreno +3 more | PLoS ONE
During adolescence, individuals face various challenges that require adequate psychosocial and emotional adjustment. Additionally, the presence of a chronic illness during this stage, such as Type 1 Diabetes Mellitus (T1DM), 
 During adolescence, individuals face various challenges that require adequate psychosocial and emotional adjustment. Additionally, the presence of a chronic illness during this stage, such as Type 1 Diabetes Mellitus (T1DM), introduces additional medical and psychological needs, which can increase vulnerability. In this context, serious games emerge as a promising tool to address educational and psychoemotional aspects while maintaining the motivation and playability typical of a video game. Currently, no technological tool simultaneously addresses both the educational and psycho-emotional needs of adolescents with T1DM. This study aims to design and validate a psychological intervention program using a technological platform that incorporates artificial intelligence. Through the serious game emoTICare, the goal is to promote physical and emotional health in adolescents with T1DM by enhancing the development of socio-emotional skills. Test this tool, adolescents with T1DM will be recruited through diabetes associations across Spain. The participants, 372 adolescents aged between 12 and 16, will be randomly assigned to either a control or an experimental group. The experimental group will complete the emoTICare program. Over six weeks, participants will engage in psychoeducational activities using the tools provided by the serious game. Data Will be collected at three points: baseline (T1) and after six weeks (T2) (for the control group, T2 will be at the same time as the experimental group's post-intervention), and aT3 (after six months of T2). The program's effectiveness will be analyzed using various statistical packages. The study hypothesizes that adolescents will maintain or improve their physical and emotional health indicators following the emoTICare program. Specifically, statistically significant improvements (p ≀ .05) are expected in the following variables: health-related quality of life, social skills and communication, emotional awareness, resilience, self-esteem, and coping and problem-solving abilities. Additionally, a statistically significant reduction (p ≀ .05) is anticipated in variables related to the perceived threat of the disease, as well as emotional and behavioral problems. The experimental group is expected to present improvements in all these areas when comparing pre- and posttreatment evaluations, and also in comparison to the control group on the waiting list.

Neurocognition in youth with versus without prediabetes

2025-06-23
Jade Quillian , Tuki Attuquayefio , Justin Sung +7 more
Aims/Hypothesis: Type 2 diabetes has a well-established link to cognitive impairment in older adults; however, studies often do not control for adiposity and co-morbid conditions which might mediate this cognitive 
 Aims/Hypothesis: Type 2 diabetes has a well-established link to cognitive impairment in older adults; however, studies often do not control for adiposity and co-morbid conditions which might mediate this cognitive impairment. To overcome these limitations, we investigated the relation between prediabetes and cognition in youth with overweight/obesity while controlling for adiposity in a cross-sectional ancillary study to the Pathogenesis of Youth Onset Diabetes (PYOD) study. We reasoned that if glucose control directly impacts brain health, then cognitive function should be worse in youth with versus without prediabetes. We also predicted that this effect should be greater on tasks that depend on dopaminergic function, such as working memory and that it may be related to central insulin sensitivity. Methods: We evaluated 69 youth with overweight/obesity for anthropomorphic and metabolic measures, abdominal adiposity, comprehensive cognitive testing, and the effects of intranasal insulin on cognition, resting state brain activity, and functional connectivity. Oral glucose tolerance tests classified 22 participants as having prediabetes (preT2D+) and 44 participants as having normal glucose control (preT2D-). Results: Groups did not differ in age, sex, race, diet, or adiposity measures. IQ was significantly lower (p=0.032) in the preT2D+ group compared to the preT2D- group. The preT2D+ group performed worse than the preT2D- group in tasks of working memory (p&lt;.0.001), reaction time (p=0.01), and visuospatial processing (p=0.02). After considering IQ as a model covariate, only spatial working memory showed a significant difference between groups (p=0.002). Insulin sensitivity across the entire sample was negatively correlated with processing speed in two tasks (reaction time index: p=0.022; and trail making test A: p=0.022) and with the sensitivity of the intraparietal sulcus to intranasal insulin administration. Administration of intranasal insulin showed no effect on cognition within or between groups. However, the extent to which intranasal insulin administration influenced caudate functional connectivity with the right intraparietal sulcus (p(FWE) =0.018) and bilateral medial precuneus (p(FWE) =0.03) was correlated with performance on the spatial working memory task. Conclusions/interpretation: We find evidence for the presence of global cognitive impairment in youth with prediabetes that cannot be accounted for by adiposity, as well as a specific deficit in spatial working memory that is not attributable to global cognitive impairment. We identified associations between central insulin sensitivity and both cognition and peripheral insulin sensitivity; however, central insulin sensitivity did not appear to account for the effect of prediabetes on cognition. These findings show that the association between peripheral glucose intolerance and cognition exists early in the course of the disease, prior to the onset of significant comorbid conditions and independently of adiposity. It also suggests the involvement of both generalized and specific mechanisms contributing to cognitive change.

Little Loopers – a case series of automated insulin delivery usage with standard and diluted insulin in very young children with diabetes mellitus

2025-06-23
Benjamin G. Fisher , Julia Fuchs , Paul Geetha Paul Nicholsion +6 more | Hormone Research in Paediatrics
Management of diabetes mellitus in very young children presents challenges due to variable insulin sensitivity, unpredictable carbohydrate intake, and low insulin requirements. An automated insulin delivery (AID) system addresses some 
 Management of diabetes mellitus in very young children presents challenges due to variable insulin sensitivity, unpredictable carbohydrate intake, and low insulin requirements. An automated insulin delivery (AID) system addresses some of these challenges, and can be used with diluted insulin where indicated. Retrospective case series of children aged <6 years with diabetes starting CamAPS FX AID with standard (U100) or diluted (U5 or U10) insulin at a single UK clinical centre between October 2020 and April 2022. AID was started for seven children with diluted insulin (median [IQR] age 1.5 [0.6, 2.8] years, mean ± SD HbA1c 83 ± 18 mmol/mol) and four with standard insulin (age 4.6 [3.9, 5.4] years, HbA1c 62 ± 13 mmol/mol). AID was started at a median (IQR) of 0.2 (0.1, 0.2) months post-diagnosis in the diluted group, and 17.8 (7.7, 23.6) months in the standard group. At the most recent clinic visit (9.3 ± 4.8 months after starting AID in the diluted group and 12.0 ± 2.1 months in the standard group), time in target range (3.9-10.0 mmol/L) was 66.5 ± 6.8% and 54.0 ± 5.0%, respectively. Median time in hypoglycaemia (<3.9 mmol/L) was <4% in both groups. Glucose variability (CV) was 37.5 ± 4.2% in the diluted and 43.5 ± 4.7% in the standard group. There were no episodes of DKA or severe hypoglycaemia. AID with both standard and diluted insulin can be used to safely manage diabetes in very young children with low total insulin requirements.

Diabetes Deprescribing in Older Adults

2025-06-23
Richard W. Grant , Ilana Peterson , Jodi K. McCloskey +4 more | JAMA Internal Medicine
Medication-related hypoglycemia is the leading cause of iatrogenic complications among older adults with type 2 diabetes. To compare physician academic detailing (AD) with or without patient previsit activation for insulin 
 Medication-related hypoglycemia is the leading cause of iatrogenic complications among older adults with type 2 diabetes. To compare physician academic detailing (AD) with or without patient previsit activation for insulin and/or sulfonylurea deprescribing in older patients with diabetes. This randomized clinical trial was conducted from September 2020 to March 2024 with 6 and 12 months of follow-up in a large integrated health care system in Northern California. Primary care physicians (PCPs) and their patients with type 2 diabetes who were 75 years and older, had hemoglobin A1c of 8.0% or lower, and were treated with insulin and/or sulfonylureas were included. Participating PCPs attended at least 1 AD session that provided evidence to support diabetes medication reassessment and potential deprescribing strategies in older patients with type 2 diabetes. Prior to their visit with a participating PCP, trial patients were randomly assigned to receive either a previsit activation deprescribing handout (AD plus previsit arm) or an attention control healthy lifestyle handout (AD-only arm). Primary outcomes (assessed at 6 months) were diabetes medication deprescribing (an aggregate measure) and any patient-reported severe hypoglycemia episodes. A total of 211 PCPs were able to attend at least 1 AD session and treated 450 eligible patients (mean [SD] age, 79.9 [4.0] years; 223 [49.6%] female; mean [SD] concurrent chronic conditions, 6.2 [3.6]; and mean [SD] hemoglobin A1c, 7.5% [1.1%]). At 6 months, there was a statistically significant higher diabetes medication deprescribing rate in the AD plus previsit activation arm compared with the AD-only arm (36 of 232 patients [15.8%] vs 19 of 218 patients [9.0%]; adjusted risk difference [RD], 7.5%; 95% CI, 1.5%-13.6%; P = .01); this difference persisted at 12 months (50 of 232 patients [22.8%] vs 33 of 218 patients [16.3%]; adjusted RD, 7.9%; 95% CI, 0.4%-15.5%; P = .04). There was not a statistically significant difference in severe self-reported hypoglycemia at 6 months between the AD plus previsit and AD-only arms (10 of 232 patients [4.7%] vs 13 of 218 patients [6.5%]; adjusted RD, -2.3%; 95% CI, -7.1% to 2.5%; P = .04). In this randomized clinical trial, AD with previsit activation was a simple and effective strategy for increasing diabetes medication deprescribing in older patients with type 2 diabetes. ClinicalTrials.gov Identifier: NCT04585191.

Scratching the Surface of Deprescribing in Diabetes

2025-06-23
Scott J. Pilla , Nancy L. Schoenborn | JAMA Internal Medicine

Continuous Glucose Monitoring Metrics as a Predictor of Acute Complications in Youth with Type 1 Diabetes

2025-06-23
Julie Sklar , Lisa K. Volkening , Liane J. Tinsley +1 more | Diabetes Technology & Therapeutics
Continuous glucose monitors (CGMs) offer insight into glycemic control but have not been established as predictors of acute diabetes complications. Using data from 120 youth with type 1 diabetes (ages 
 Continuous glucose monitors (CGMs) offer insight into glycemic control but have not been established as predictors of acute diabetes complications. Using data from 120 youth with type 1 diabetes (ages 8-17) enrolled in a 24-month study, we investigated associations of CGM-derived metrics (time-in-range [TIR] 70-180 mg/dL, time <70, time >180, time >250, mean glucose, glucose coefficient of variation [CV]) with incidence rates of severe hypoglycemia and diabetic ketoacidosis (DKA)/severe hyperglycemia. Over 285 person-years of follow-up, there were 75 events of severe hypoglycemia and 15 events of DKA/severe hyperglycemia. TIR and CV were significantly associated with severe hypoglycemia. Those with <45% TIR had 2.09 times the rate of severe hypoglycemia than those with ≄45% TIR (P = 0.003). Those with CV ≄41% had 2.03 times the rate of severe hypoglycemia than those with CV <41% (P = 0.006). No CGM metrics were significantly associated with DKA/severe hyperglycemia. CGM data could serve as additional predictors for acute complications, particularly severe hypoglycemia.

Perceptions of Suboptimal Insulin Dosing from People with Diabetes and Healthcare Professionals in Germany

2025-06-23
Alfonso Ponce-Ibarra , Nora Hennies , Rachel S. Newson +3 more | Diabetes Therapy
Despite advancements in diabetes therapeutics and innovations, suboptimal dosing continues to be a barrier to glycaemic control for people with diabetes (PwD). This study aimed to understand the extent of 
 Despite advancements in diabetes therapeutics and innovations, suboptimal dosing continues to be a barrier to glycaemic control for people with diabetes (PwD). This study aimed to understand the extent of suboptimal insulin dosing and the factors underlying this behaviour from the perspective of PwD and healthcare professionals (HCPs) in Germany. This analysis included 400 German PwD employing analogue insulin pens (type 1 diabetes, n = 100; type 2 diabetes, n = 300) and 160 HCPs (general practitioners, n = 80; specialists, n = 80), and was part of a cross-sectional, multinational, noninterventional web-based survey (1150 PwD and 640 HCPs). The proportion of PwD reporting missed/mistimed/miscalculated insulin doses and the mean ± SD number of insulin doses missed/mistimed/miscalculated within the last 30 days were analysed. Among the 400 PwD (69.5% male, 30.5% female), the mean age was 47.1 ± 13.0 years. Within the last 30 days, 47.3% of PwD missed basal insulin doses (3.5 ± 2.9 mean number of insulin doses missed) and 58.0% missed bolus insulin doses (5.0 ± 10.1). Additionally, 47.3% and 51.0% mistimed basal insulin doses (3.9 ± 4.3 mean number of insulin doses mistimed) and bolus insulin doses (5.0 ± 7.1), respectively, and 47.5% and 63.3% PwD miscalculated basal insulin doses (4.5 ± 5.0 mean number of insulin doses miscalculated) and bolus insulin doses (5.5 ± 7.5), respectively. Of the 160 HCPs (73.1% male, 26.9% female), 98.1% were qualified for > 5 years. Overall, ≄ 67% HCPs indicated that up to 30% of PwD missed/forgot/skipped, mistimed, or miscalculated an insulin dose in the last 30 days. Reasons reported by PwD and HCPs included forgetting, being out of their normal routine, being too busy or distracted, or being unsure of how much insulin to take. PwD and HCPs suggested that having a device that automatically records glucose measurements, insulin doses, and timing and having dosing calculation guidance and real-time feedback on how insulin dosing impacts glucose levels would optimise insulin dosing. PwD are mismanaging insulin doses largely for preventable reasons. Integrated and automated insulin dosing support may optimise insulin management and improve communication between PwD and HCPs.

Effectiveness and safety of AI-driven closed-loop systems in diabetes management: a systematic review and meta-analysis

2025-06-23
Xiaoya Wang , Jiayong Si , Yihao Li +7 more | Diabetology & Metabolic Syndrome
Diabetes is a metabolic disease that can lead to severe cardiovascular diseases and neuropathy. The associated medical costs and complications make timely and effective management particularly important. Traditional diagnostic and 
 Diabetes is a metabolic disease that can lead to severe cardiovascular diseases and neuropathy. The associated medical costs and complications make timely and effective management particularly important. Traditional diagnostic and management methods, like frequent glucose sampling and insulin injections, impose physical injuries on subjects. The development of artificial intelligence (AI) has opened new opportunities for diabetes management. We conducted a meta-analysis integrating existing research, identifying a total of 1156 subjects to assess the effectiveness and safety of AI-based wearable devices, specifically closed-loop insulin delivery systems, in diabetes treatment. Compared to standard controls, AI-based closed-loop systems can analyze glucose data in real-time and automatically adjust insulin delivery, resulting in reduced time outside target glucose ranges (SMD = 0.90, 95% CI = 0.69 to 1.10, I2 = 58%, P < 0.001). AI-based closed-loop systems enhance the precision and convenience of diabetes treatment. This meta-analysis providing essential references for clinical treatment and policymaking in diabetes care.

Weekly Insulins and Therapeutic Burden in Type 2 Diabetes

2025-06-22
Julie R. Ingelfinger , Clifford J. Rosen | New England Journal of Medicine

Weekly Fixed-Dose Insulin Efsitora in Type 2 Diabetes without Previous Insulin Therapy

2025-06-22
Julio Rosenstock , Timothy S. Bailey , Lisa Connery +7 more | New England Journal of Medicine
In previous treat-to-target trials, adjustments to the dose of basal insulin have been made at least weekly, according to fasting blood glucose levels. A fixed-dose regimen of insulin efsitora alfa 
 In previous treat-to-target trials, adjustments to the dose of basal insulin have been made at least weekly, according to fasting blood glucose levels. A fixed-dose regimen of insulin efsitora alfa (efsitora), a once-weekly basal insulin, may provide a benefit in adults with type 2 diabetes who have not received previous insulin therapy. We conducted a 52-week, phase 3, open-label, treat-to-target trial involving adults with type 2 diabetes who had not previously received insulin therapy. Participants were randomly assigned in a 1:1 ratio to receive once-weekly efsitora or once-daily insulin glargine U100 (glargine). Treatment with efsitora was initiated as a single dose of 100 U administered once weekly, with dose adjustments made every 4 weeks, as needed, at fixed doses of 150, 250, and 400 U to achieve fasting blood glucose levels of 80 to 130 mg per deciliter. Doses of glargine were adjusted weekly or more often according to a standard algorithm to reach the same glycemic goals. The primary end point, tested for noninferiority (noninferiority margin, 0.4 percentage points), was the change from baseline in the glycated hemoglobin level at 52 weeks. A total of 795 participants underwent randomization. The mean glycated hemoglobin level decreased from 8.20% at baseline to 7.05% at week 52 with efsitora (least-squares mean change, -1.19 percentage points) and from 8.28% to 7.08% with glargine (least-squares mean change, -1.16 percentage points); the estimated between-group difference of -0.03 percentage points (95% confidence interval [CI], -0.18 to 0.12) confirmed the noninferiority of efsitora to glargine. Superiority was not shown (P = 0.68). The rate of combined clinically significant hypoglycemia (glucose level, <54 mg per deciliter) or severe hypoglycemia (level 3; requiring assistance for treatment) was lower with efsitora than with glargine (0.50 events per participant-year of exposure with efsitora vs. 0.88 with glargine; estimated rate ratio, 0.57 [95% CI, 0.39 to 0.84]). At week 52, the mean total weekly insulin dose was 289.1 U per week with efsitora and 332.8 U per week with glargine (estimated between-group difference, -43.7 U per week; 95% CI, -62.4 to -25.0); the median number of dose adjustments needed was 2 with efsitora and 8 with glargine. In adults with type 2 diabetes who had not previously received insulin, once-weekly efsitora, administered in a fixed-dose regimen, was noninferior to once-daily glargine in reducing glycated hemoglobin levels. (Funded by Eli Lilly; ClinicalTrials.gov number, NCT05662332.).

Insulin

2025-06-21
| Reactions Weekly

Association between continuous glucose monitoring metrics and cardiovascular autonomic neuropathy in diabetic patients: a systematic review

2025-06-21
Yifan Jia , Dan Long , Wei Song +2 more | Reviews in Endocrine and Metabolic Disorders

Effects of fear of hypoglycemia on quality of life of children/adolescents with type 1 diabetes- evaluation from the perspectives of children and their parents: A descriptive cross-sectional study

2025-06-20
Nesrin ƞen Celasın , Hasret Yağmur Sevinç Akın , Duygu Karaarslan +1 more | Journal of Pediatric Nursing

Retrospective Rates of Positive Depression Screens in Pediatric Diabetes Using Two PHQ-9 Cutoff Scores: A Brief Report

2025-06-20
Alexandra D. Monzon , Susana R. Patton , Shilpa Gurnurkar +2 more | Clinical Practice in Pediatric Psychology
Objective: Compare two empirically supported cutoff scores for the Patient Health Questionnaire (PHQ-9) in a clinical sample of youth with type 1 diabetes (T1D). Methods: The sample comprises 212 youth 
 Objective: Compare two empirically supported cutoff scores for the Patient Health Questionnaire (PHQ-9) in a clinical sample of youth with type 1 diabetes (T1D). Methods: The sample comprises 212 youth with T1D aged 12–18. We retroactively collected PHQ-9 scores from electronic health records. We compared the normative cutoff score of 10 on the PHQ-9 to a newly modified score of 5. Results: Using the cutoff score of 5 on the PHQ-9, 44.3% of patients screened positive for symptoms of depression, while 22.6% of patients screened positive for symptoms of depression using the cutoff score of 10. Conclusions: The modified cutoff score of 5 on the PHQ-9 resulted in twice as many patients screening positive for symptoms of depression as the normative cutoff score of 10. However, it is important to consider these findings in the context of the healthcare system and the overall impact of false positives.

Study to evaluate the safety, performance and ease of use of a continuous glucose monitoring (CGM) solution in everyday life for people with diabetes

2025-06-20
Katrin Mueller | http://isrctn.com/

131-OR: Safety and Effectiveness Outcomes after One Year with T:slim X2 Control-IQ Technology in Children with Type 1 Diabetes Under Six Years

2025-06-20
Valentino Cherubini , Roberto Franceschi , Marco Marigliano +1 more | Diabetes
Introduction and Objective: To determine the safety and effectiveness of the t:slim X2 with Control-IQ Technology (CIQ) in children with T1D under the age of six in a real-life setting. 
 Introduction and Objective: To determine the safety and effectiveness of the t:slim X2 with Control-IQ Technology (CIQ) in children with T1D under the age of six in a real-life setting. Methods: Despite CIQ being off label for children under six years of age, many parents request an automated insulin delivery system for their younger children. Several pediatric centers have started using these systems in children under six, provided they obtain signed informed consent from the parents. In this multicenter prospective study, we compared clinical outcomes and CGM-derived results of children under six to those aged six to ten years who have used CIQ for at least one year. Before starting CIQ, all children were using CGM. Anonymous data were collected locally and centralized for analysis. Results: A total of 131 children aged &amp;lt;6 and 190 aged 6 to 10 years were recruited from 30 pediatric centers. Clinical characteristics and CGM-derived metrics at baseline and one year after CIQ usage are shown in Table 1. No serious hypoglycemic events occurred in either the pre-CIQ or post-CIQ groups. An episode of DKA has been reported in a child aged 6 to 10 years. Conclusion: CIQ is safe and effective for children under six. Given the challenges of glycemic control in this age group, it's essential to embrace advanced technological systems for improving outcomes. Disclosure V. Cherubini: Research Support; Lilly Diabetes, AstraZeneca. Advisory Panel; Novo Nordisk, Sanofi. R. Franceschi: Other Relationship; Medtronic. M. Marigliano: Speaker's Bureau; Medtronic, Novo Nordisk, Ypsomed AG. R. Gesuita: None.

Associations of age at T2D detection with hemoglobin A1c in a national inception cohort of U.S. Veterans with diabetes

2025-06-20
Sanja Avramovic , Xumin Li , Daniel A. Enquobahrie +4 more | Diabetes Research and Clinical Practice

Glucose variability measured by continuous glucose monitoring is associated with skin autofluorescence: the Maastricht Study

2025-06-20
Nefeli M Dimitropoulou , Simone J.P.M. Eussen , Casper G. Schalkwijk +1 more | Diabetologia
Abstract Aims/hypothesis Glucose variability in people with type 2 diabetes has been associated with increased risk of CVD, and AGEs might be an underlying mechanism. Therefore, this study investigates associations 
 Abstract Aims/hypothesis Glucose variability in people with type 2 diabetes has been associated with increased risk of CVD, and AGEs might be an underlying mechanism. Therefore, this study investigates associations of glucose variability with AGEs in the skin in people with and without impaired fasting glucose, impaired glucose tolerance or diabetes. Methods We used data from the Maastricht Study, a population-based cohort study. Glucose variability and AGEs in skin were measured by continuous glucose monitoring (CGM) and skin autofluorescence (SAF), respectively. Multiple linear regression was used to test the association of CGM-metrics CV and SD with SAF and adjusted for age, sex, CVD risk factors, nutritional factors and educational level. Interaction analysis was used to test the effect of glucose metabolism status on the association of CV and SD with SAF. Results We included 795 participants (mean ± SD age 59 ± 8.7 years; 49% were female). Glucose metabolism status was stratified into normal glucose metabolism ( n = 459), prediabetes ( n = 174) and type 2 diabetes ( n = 162). Individuals with type 2 diabetes had higher values of SAF (mean ± SD 2.3 ± 0.6 arbitrary units [AU]) than those with prediabetes (2.1 ± 0.4 AU, p = 0.014) and normal glucose metabolism (2.0 ± 0.4 AU, p = 0.007). In the cohort, both SD (0.152 AU [IQR 0.088–0.217]) and CV (0.014 AU [IQR 0.005–0.017]) were significantly associated with SAF in fully adjusted analyses. Glucose metabolism status did not modify the associations of SD and CV with SAF. Conclusions/interpretation A higher glucose variability is associated with higher levels of SAF, suggesting that glucose variability plays a role in the formation of AGEs. Graphical Abstract

2051-LB: Predictive Modeling for Presymptomatic Type 1 Diabetes Detection Using Open Claims Data

2025-06-20
DANIEL EINOR , OLEKSANDR BUIKO , K Lee +4 more | Diabetes
Introduction and Objective: Type 1 Diabetes mellitus (T1D) progresses through distinct stages before clinical diagnosis, with early stages being asymptomatic. Integrating pre-symptomatic T1D detection can enable the proactive identification of 
 Introduction and Objective: Type 1 Diabetes mellitus (T1D) progresses through distinct stages before clinical diagnosis, with early stages being asymptomatic. Integrating pre-symptomatic T1D detection can enable the proactive identification of patients at higher risk and facilitate earlier interventions. This study employed machine learning approaches on a U.S. open claims dataset to identify people at risk of presymptomatic T1D. Methods: A retrospective cohort analysis was conducted on 89,453 patients selected based on the modified Klompas algorithm with initial T1D diagnosis or insulin prescription between Jan 2016 and Dec 2023. The study utilized tree-based (XGBoost) and transformer-based (BERT) models. The performance was evaluated using Precision, Recall, Bayes factor, and Number Needed to Test (NNT). Feature importance was assessed using Shapley values. Results: BERT was found to have better performance than tree-based models featuring Precision of 0.09 vs 0.05; Recall of 0.8 vs 0.72; Bayes factor of 19.92 vs 10.75; NNT values of 11.6 vs 22.7, respectfully. In both models, elevated risk of T1D was most associated with lower age and male gender. Tree-based model showed that elevated occurrence of diagnoses related to digestive system and thyroid tests were also associated with presymptomatic T1D. Conclusion: Our findings suggest the potential for using claims records to identify presymptomatic T1D individuals. The models improved the detection rate from the standard prevalence of 1:200 to less than 1:23, significantly enhancing early detection efforts. Existing demographic, frequent digestive system diagnoses and routine endocrine tests could signal T1D risk. Utilizing the recency and frequency of medical events may enhance the predictability of early T1D onset. Such models could enable more targeted screening and access to timely interventions for improved clinical outcomes. Disclosure D. Einor: None. O. Buiko: None. K.C.S. Lee: Employee; Sanofi. L. Adamek: Employee; Sanofi. B. Rufino: Employee; Sanofi. I. Yarova: None. J. Josleyn: Employee; Sanofi.

Knowledge and practices related to insulin injections among diabetes patients on insulin therapy from a tertiary care center in North India

2025-06-19
B. K. Nath , Sameer Aggarwal , Naima Parveen +3 more | International Journal of Diabetes in Developing Countries

Hypoglycemia, Arrythmia and Mortality in Diabetes, an underestimated risk?

2025-06-19
Bartosz Kasperek , Patrycja Tymoszuk , Katarzyna Augustowska +6 more | Quality in Sport
Introduction and purpose Hypoglycemia, characterized by a decrease in blood glucose levels below 70mg/dl, is a dangerous condition, especially in individuals with diabetes mellitus. This condition can trigger a variety 
 Introduction and purpose Hypoglycemia, characterized by a decrease in blood glucose levels below 70mg/dl, is a dangerous condition, especially in individuals with diabetes mellitus. This condition can trigger a variety of symptoms such as changes in mental status, activation of the sympathetic nervous system and, in severe cases, life-threatening arrhythmias. The aim of the study was to provide an overview of literature linking hypoglycemia with cardiac arrhythmias and increased mortality. A search of the PubMed and Google Schoolar databases was carried out using key words: ‘hypoglycemia’, ‘arrhythmia’, ‘Type 1 diabetes’, ‘Type 2 diabetes’ in order to find the latest publications. Description The harmful effects of hypoglycemia on the cardiovascular system are well-documented, with recent studies indicating an association between recurrent hypoglycemic episodes and increased mortality, particularly in individuals with type 1 and type 2 diabetes. Hypoglycemia may contribute to cardiac arrhythmias through multiple mechanisms, including dysregulation of ion channels, catecholamine release, and electrolyte imbalances. Notably, the impact of hypoglycemia on heart rhythm appears to differ between daytime and nighttime episodes, with nocturnal hypoglycemia often leading to bradycardia, while daytime hypoglycemia is more commonly associated with tachycardia. Summary Despite advancements in understanding the correlation between hypoglycemia and arrythmias the underling mechanisms remain unclear. With the increasing number of diabetes patients treated with insulin, further research is required.

Safety and efficacy of continuous glucose monitoring devices in individuals with diabetes undergoing hyperbaric oxygen therapy: a scoping review

2025-06-18
Glen Katsnelson , Marcus Salvatori , George Djaiani +3 more | Diving and Hyperbaric Medicine Journal
Introduction: Continuous glucose monitoring devices (CGMs) have emerged as an effective approach to optimise glycaemic control for individuals living with diabetes mellitus. Despite CGMs offering improved patient satisfaction and quality 
 Introduction: Continuous glucose monitoring devices (CGMs) have emerged as an effective approach to optimise glycaemic control for individuals living with diabetes mellitus. Despite CGMs offering improved patient satisfaction and quality of life, they have been primarily validated for outpatient and home use. This has posed a challenge for patients and providers who wish to incorporate CGMs into clinical settings such as hyperbaric oxygen therapy (HBOT). Those with advanced diabetes mellitus who have diabetic foot ulcers that are refractory to treatment are among the most prevalent users of HBOT. However, those who prefer to use their CGM during HBOT face uncertainty regarding the accuracy and safety of their device under hyperbaric conditions. Methods: The product specifications of commonly used CGMs were collated. In addition, a scoping review of the literature was conducted where Medline, Embase, and Scopus were searched for reports that assess the accuracy or safety of CGMs in hyperbaric conditions. Results: The product specifications of commonly used CGMs by Dexcom, Abbott, Medtronic, and Senseonics demonstrate a maximum validated pressure of approximately 106 kPa (1.06 atmospheres absolute). Our literature search identified five reports, of which four focused on accuracy and one focused on safety of CGMs in hyperbaric conditions. Treatments were conducted in multiplace chambers and cumulatively described 39 participants, of whom 12 have diabetes. Although heterogeneous in nature, the reports generally supported the safety and accuracy of CGMs in hyperbaric conditions. Conclusions: The safety and accuracy of using CGMs during HBOT warrants further investigation. CGMs have not been validated for repeated exposure to hyperbaric conditions and should not be used in oxygen pressurised monoplace chambers until further safety data is available. We provide practical recommendations for use of CGMs in multiplace chambers.

TRAINING PROTOCOL ON CHANGES IN BLOOD GLUCOSE LEVELS AND BLOOD PRESSURE IN TYPE 1 DIABETES PATIENTS

2025-06-18
Victor Fernandes Camilo , Matheus AndrĂ© Ribeiro da Costa , Estela UrzĂȘda VitĂłria +3 more | CIPEEX
Type 1 Diabetes Mellitus (T1DM) is an endocrine condition resulting from the autoimmune destruction of pancreatic beta cells, leading to severe insulin deficiency. Clinically, T1DM manifests with symptoms such as 
 Type 1 Diabetes Mellitus (T1DM) is an endocrine condition resulting from the autoimmune destruction of pancreatic beta cells, leading to severe insulin deficiency. Clinically, T1DM manifests with symptoms such as polyuria, polydipsia, xerostomia, unexplained weight loss, fatigue, polyphagia, and blurred vision. Glycemic self-monitoring is a critical process for these patients, allowing the measurement of glucose in different contexts such as home, school, and work environments, and adjusting the insulin dose as needed. According to data from the International Diabetes Federation, in 2019, Brazil ranked fifth globally in terms of diabetes prevalence, with 16.8 million adults affected in the age group of 20 to 79 years. The American Diabetes Association recommends that adults with T1D engage in at least 150 minutes per week of moderate to vigorous physical activities. For children and adolescents with T1D, it is recommended to engage in at least 60 minutes of daily physical activity, including muscle and bone strengthening exercises three times a week. Regular physical activity is associated with a reduced risk of future cardiovascular diseases, improved long-term glycemic control, better cardiovascular conditioning, quality of life, reduced daily insulin needs, and better weight control. Moreover, it plays a crucial role in the primary and secondary prevention of diabetes-related cardiovascular diseases. This study aims to evaluate the effects of strength training on glycemic parameters after a single exercise session in adults with T1DM.

The overlooked cardiovascular burden of type 1 diabetes: from atherosclerosis to myocardial infarction

2025-06-18
Jenyfer MarĂ­a Fuentes-Mendoza , Roger Gonzales-Valdivieso , Marcio JosĂ© ConcepciĂłn‐Zavaleta +1 more | Expert Review of Cardiovascular Therapy

Safety and Efficacy of Inhaled TechnosphereÂź Insulin in the Postprandial Period With Modified Initial Dose Conversion

2025-06-18
Christopher Jacobson , Kevin B. Kaiserman , Johanna Ulloa +7 more | Diabetes Therapy
A post hoc analysis from a 90-day proof-of-concept study demonstrated increased efficacy and no new safety concerns for an ultra-rapid-acting inhaled insulin, Technosphere¼ Insulin (TI), when a higher modified conversion 
 A post hoc analysis from a 90-day proof-of-concept study demonstrated increased efficacy and no new safety concerns for an ultra-rapid-acting inhaled insulin, Technosphere¼ Insulin (TI), when a higher modified conversion dose was compared to the conversion dose in the current US prescribing insert (approx. 2 × vs approx. 1.3 × TI per rapid-acting insulin analogue [RAA] unit [U] across the 1-24 U range). This post hoc analysis evaluates the safety and efficacy of the modified conversion dose in the postprandial period. Participants with type 1 diabetes (T1D) were randomly assigned to administer TI using the modified dosing (TI group) or continue using their automated insulin delivery (AID) system (AID controls) in this in-clinic standardized meal challenge. Postprandial glucose was measured via capillary self-monitored blood glucose over 2 h post-meal to evaluate mean peak glucose and mean peak glucose excursion. The TI group (n = 21) demonstrated faster and lower mean peak glucose and mean peak glucose excursion vs AID controls (n = 5). Mean peak glucose and glucose excursion were reached 30 min earlier with TI. One TI + AID participant (modified dose) experienced one level 1 hypoglycemia event in the 2-h postprandial period and recovered in-clinic. No serious adverse events were reported. TI group demonstrated a more favorable glycemic response in the 2-h postprandial period vs AID control. Data from this and previous studies suggest this higher modified conversion TI dose from subcutaneous RAA may help further reduce postprandial hyperglycemia in T1D. ClinicalTrials.gov NCT05243628.

Detecting Disordered Eating Behaviors in Greek Youth with Type 1 Diabetes Mellitus by Using the Diabetes Eating Problem Survey—Revised (DEPS-R): Associations with Insulin Restriction, Glycemic Control, and Anthropometric Parameters

2025-06-18
Anastasia Oikonomou , Athanasios Christoforidis , Eleni P. Kotanidou +6 more | Children
Background/Objectives: This study assesses the prevalence of diabulimia in Greek children and adolescents with Type 1 Diabetes Mellitus (T1DM) by using the Diabetes Eating Problem Survey-Revised (DEPS-R) questionnaire and addresses 
 Background/Objectives: This study assesses the prevalence of diabulimia in Greek children and adolescents with Type 1 Diabetes Mellitus (T1DM) by using the Diabetes Eating Problem Survey-Revised (DEPS-R) questionnaire and addresses a gap in the literature on eating disorders (EDs) and disordered eating behaviors (DEBs) in this population. The DEPS-R threshold score of ≄20, although originally established in international studies, has also been applied in Greek adult validation studies. However, it has not yet been formally validated in Greek youth. Methods: Participants aged 9-18 years, diagnosed with T1DM a minimum of one year before the start of the study, were recruited from three pediatric departments in Thessaloniki and were asked to complete the Greek version of the DEPS-R questionnaire. Appropriate statistical analysis was employed to investigate the association of the DEPS-R score with anthropometric, demographic, and glycemic variables derived from the clinical assessment and the patient's medical records. Results: Girls had significantly higher DEPS-R scores compared with boys. Significant positive associations were observed between the DEPS-R score and both age (r = 0.212, p = 0.020) and Body Mass Index (BMI) (r = 0.419, p < 0.001). A significant association with Glycated Hemoglobin (HbA1c) (r = 0.182, p = 0.047) suggested that poorer glycemic control may be linked to disordered eating, although no significant associations were identified with physical activity or type of insulin therapy. Conclusions: Older age, higher Body Mass Index (BMI) and elevated Glycated Hemoglobin (HbA1c) levels are associated with increased risk of disordered eating in youth with T1DM, especially in girls. Therefore, the implementation of early screening and targeted interventions is imperative.

Freestyle Libre‐Derived Metrics in Assessing Glycemic Control in Diabetic Dogs

2025-06-18
Francesca Del Baldo , Antonio Maria Tardo , Chen Gilor +4 more | Journal of Veterinary Internal Medicine
ABSTRACT Background The FreeStyle Libre provides several metrics that are currently recommended for assessing glycemic status and guiding therapy in human medicine. Hypothesis/Objective To evaluate the use of various FreeStyle 
 ABSTRACT Background The FreeStyle Libre provides several metrics that are currently recommended for assessing glycemic status and guiding therapy in human medicine. Hypothesis/Objective To evaluate the use of various FreeStyle Libre derived metrics for monitoring glycemic control (GC) in diabetic dogs. Animals Eighty‐five client‐owned dogs with diabetes mellitus (DM). Methods A retrospective review of medical records was performed to search for dogs with DM on insulin treatment and monitored with FreeStyle Libre. To clinically assess GC, the Agreeing Language in Veterinary Endocrinology diabetic clinical score was used (ALIVE‐DCS). Metrics evaluated were: percent time in range (TIR%), percent time above range (TAR%), percent time below range (TBR%), mean glucose (MG), percent coefficient of variation (CV%). Results TIR%, TAR%, and MG were correlated with the ALIVE‐DCS (rs = −0.35, p = 0.02; rs = 0.31, p = 0.038; rs = 0.36; p = 0.016, respectively). The CV% was correlated with MG (rs = −0.70, p &lt; 0.0001). CV% was higher in dogs experiencing low IG values compared to dogs that did not (44% [19–65] vs. 28% [8–67]; p &lt; 0.0001). Dogs with optimal GC had significantly lower MG (240 [108–411] vs. 290 mg/dL [155–478]; p = 0.006) and TAR% (48% [0–93] vs. 64% [12–100]; p = 0.006) and significantly higher TIR% (49.5% [7–100] vs. 35.0% [0–85]; p = 0.009) compared with dogs with sub‐optimal GC. Conclusions and Clinical Importance FreeStyle Libre derived metrics, particularly TIR%, TAR%, MG, and CV%, have potential utility in assessing GC in diabetic dogs.

Current trends in insulin therapy

2025-06-18
Kateƙina Ơtechová | Česká a slovenská farmacie

Consensus statement on novel glucose-related metrics obtained through advanced medical devices: English version

2025-06-18
Rimei Nishimura , Yosuke Okada , Akio Kuroda +7 more | Diabetology International

Time in target range of fasting blood glucose ranges defined by WHO and ADA guidelines and cardiorenal Risk: Insights from two cohorts

2025-06-18
Jiaheng Zhang , Haibao Xu , Yezhou Liu +7 more | Diabetes Research and Clinical Practice
Through the utilization of the time in target range (TTR), our study aims to reassess the differential risks of cardiorenal diseases associated with inconsistent pre-diabetes criteria, as defined by the 
 Through the utilization of the time in target range (TTR), our study aims to reassess the differential risks of cardiorenal diseases associated with inconsistent pre-diabetes criteria, as defined by the World Health Organization (WHO) and the American Diabetes Association (ADA). We performed a pooled analysis from the Atherosclerosis Risk in Communities study and the Multi-Ethnic Study of Atherosclerosis study. TTR for each patient was calculated using linear interpolation before the outcome. Cox regression models were used to assess the association of FPG TTR with the clinical outcomes. A total of 14 346 patients were included. Using adjusted Cox regression model, both ADA (HR: 1.17, 95 % CI: 1.09 to 1.25) and WHO (HR: 1.37, 95 % CI: 1.21 to 1.57) defined pre-diabetes range were associated with an increased risk of major adverse cardiovascular events (MACE). Additionally, individuals with FPG levels in the range between the two standards (100-110 mg/dL) also had a higher risk of MACE (HR: 1.24, 95 % CI: 1.09 to 1.40). Meanwhile, no significant relation was found between FPG threshold and Chronic kidney disease (CKD). The threshold defined by the ADA guidelines serves to protect cardiovascular health across a broader population while not increasing the risk of CKD.

Primed for Precision: A Review of the Evidence for Heterogeneous Treatment Effects in Diabetes Distress Treatments Among Adults with Type 1 Diabetes and Recommendations for Future Research

2025-06-18
Anna R. Kahkoska , Gabriella Ercolino , Jacob Ortega +3 more | Current Diabetes Reports

Insulin Out‐of‐Pocket Spending Caps and Employer‐Sponsored Insurance: Changes in Out‐of‐Pocket and Total Costs for Insulin and Healthcare

2025-06-17
Khrysta Baig , Carrie Fry , Melinda Beeuwkes Buntin +2 more | Health Services Research
ABSTRACT Objective To estimate the impact of state‐level insulin out‐of‐pocket caps on changes in out‐of‐pocket and total costs of insulin and healthcare for insulin users with employer‐sponsored insurance. Study Setting 
 ABSTRACT Objective To estimate the impact of state‐level insulin out‐of‐pocket caps on changes in out‐of‐pocket and total costs of insulin and healthcare for insulin users with employer‐sponsored insurance. Study Setting and Design We evaluated changes in costs using a quasi‐experimental (triple difference‐in‐differences; “DDD”) design to analyze multi‐carrier claims from insulin users enrolled in fully insured (state‐regulated) and self‐funded (generally exempt) employer‐sponsored plans in 10 states with caps by January 2021 compared to no‐cap states pre‐/post‐cap implementation. Primary outcomes were changes in insulin out‐of‐pocket spending, total (plan + member) paid for insulin, and total healthcare costs. Secondary outcomes were intermediary (e.g., pharmaceutical) changes in out‐of‐pocket and total costs. Data Sources and Analytic Sample In the policy year (no‐cap states: 2021), we identified 218,441 insulin‐users in the Health Care Cost Institute 2.0 Dataset (cap states: 27,834 in fully insured and 22,131 in self‐funded plans; no‐cap states: 97,239 in fully insured and 71,237 in self‐funded plans) and 215,635 in the year prior. Principal Findings We found evidence of modest decreases in 30‐day standardized (DDD: −$5 [95% CI: −$6 to −$4]; p &lt; 0.001) and annual (DDD: −$67 [95% CI: −$82 to −$51]; p &lt; 0.001) insulin out‐of‐pocket spending. Savings increased by spending quantile (e.g., 95th‐percentile change:−$347 [95% CI: −$460 to $233]). Difference‐in‐differences (DiD) comparing fully insured to self‐funded plans within cap‐states showed larger changes (e.g., 95th‐percentile annual insulin out‐of‐pocket:−$484 [95% CI: −$651 to −$318]), likely due to policy spillover effects (i.e., fully insured plans decreased out‐of‐pocket in no‐cap states). Change in annual total paid for healthcare was not statistically significant (DDD:‐$1082 [95% CI: −$2918 to $755]; p &lt; 0.25). We saw no evidence of caps increasing out‐of‐pocket or total spending on insulin, prescriptions, or healthcare. Conclusions Our findings suggest early caps had modest effects on out‐of‐pocket spending among fully insured insulin users, with larger savings for those at the top of the spending distribution and no total cost increases. Policy effects may be greater than observed; they likely lag implementation and develop over time.

Efficacy and safety of a tubeless open‐source hybrid automated insulin delivery use at home among adults with type 1 diabetes mellitus: Results from a 26‐week, free‐living, randomized crossover trial

2025-06-17
Mengyun Lei , Ping Ling , Beisi Lin +7 more | Diabetes Obesity and Metabolism
Abstract Aim This study aims to evaluate the efficacy and safety of a tubeless open‐source hybrid automated insulin delivery (OS‐AID) in managing adults with type 1 diabetes mellitus (T1DM) in 
 Abstract Aim This study aims to evaluate the efficacy and safety of a tubeless open‐source hybrid automated insulin delivery (OS‐AID) in managing adults with type 1 diabetes mellitus (T1DM) in China, where commercial AID systems are not accessible. Methods In this open‐label randomized crossover study, adults with T1DM aged 18–75 years, glycated haemoglobin (HbA1c) 7%–11% (53‐97 mmol/mol) and who have never used AID previously, were assigned to either Android‐version hybrid OS‐AID (AAPS) or sensor‐augmented insulin pump (SAP) therapy for three months, followed by a crossover to the alternative treatment for an additional three months. The primary endpoint was the percentage of time in range (TIR, 70‐180 mg/dL [3.9–10.0 mmol/L]) during the final two weeks of each treatment phase. Results A total of 28 adults with T1DM, with a mean age of 33.6 ± 10.4 years and a T1DM duration of 12.6 ± 7.0 years, were enrolled in this study. The percentage of TIR (70‐180 mg/dL [3.9–10.0 mmol/L]) during the AAPS phase was 75.6 ± 10.3%, significantly higher than the 60.4 ± 15.1% observed during the SAP phase ( p &lt; 0.01). AAPS was notably more effective in managing nocturnal glucose levels compared to diurnal glucose levels (80.9 ± 13.6% vs. 73.8 ± 10.2%, p &lt; 0.01). No significant differences in time below range were observed between the two phases. No severe hypoglycaemia or serious adverse events occurred in either treatment phase. Conclusion In this 26‐week trial involving adults with T1DM who had never previously used AID, the tubeless AAPS use at home resulted in a significantly higher percentage of time in the target glucose range without increasing hypoglycaemia risk compared to SAP therapy.