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Management of Hypoglycemia Using Continuous Glucose Monitoring During Tirzepatide Initiation or Uptitration When Used in Addition to Other Glucose-Lowering Agents

The use of injectable incretin-based therapies is becoming more common. Diabetes and obesity are prevalent disease states that can lead to mortality and further health complications. Tirzepatide is a glucose-dependent insulinotropic polypeptide (GIP)/glucagon-like peptide 1 (GLP-1) receptor agonist used in the management of type 2 diabetes, obesity, and overweight (with at least one weight-related complication). Tirzepatide selectively binds to and activates both the GIP and GLP-1 receptors, which are the targets for native GIP and GLP-1. Tirzepatide enhances first- and second-phase insulin secretion and reduces glucagon levels in a glucose-dependent manner ( 1 ). The mechanism of dual agonism results in reductions in blood glucose and body weight. Administered as a once-weekly subcutaneous injection, tirzepatide was approved by the U.S. Food and Drug Administration in May 2022 for the management of type 2 diabetes, in November 2023 for weight management in adults with obesity (BMI >30 kg/m 2 ) or overweight (BMI >27 kg/m 2 ) with at least one weight-related condition, and in December 2024 for the treatment of obstructive sleep apnea (OSA) ( 2, 3 ).

“I Just Wish That It Would Be Easier”: Caregivers’ Perspectives on Barriers and Proposed Solutions to Diabetes Technology Use for Non-Hispanic Black and Hispanic Youth With Type 1 Diabetes

OBJECTIVE We sought to examine barriers to diabetes technology use in underserved non-Hispanic Black and Hispanic youth with type 1 diabetes from the caregivers’ perspectives and to co-create solutions to overcome barriers. RESEARCH DESIGN AND METHODS Using user-centered design methodology, we held virtual workshops with caregivers to identify barriers and solutions associated with diabetes technology use. Three independent coders analyzed workshop recordings using an inductive coding approach. RESULTS Twenty-three caregivers of non-Hispanic Black and Hispanic youth with type 1 diabetes participated. The majority of participants were mothers ( n = 21), were publicly insured ( n = 18), and had social needs ( n = 13). We uncovered novel barriers to diabetes technology use, including 1 ) health-related social needs specific to diabetes technology use, 2 ) insufficient diabetes technology support at school, 3 ) disjointed care integration, and 4 ) the need for personalized diabetes device education. Proposed solutions included resources for social needs, more technology education for schools, enhanced care coordination, and a nonmedical person to deliver tailored device education. CONCLUSION This study revealed new approaches to support caregivers of non-Hispanic Black and Hispanic youth with type 1 diabetes with persistent barriers to device use. Integrating interventions that align with caregivers’ needs will facilitate the adoption and sustained use of diabetes technology by non-Hispanic Black and Hispanic youth with type 1 diabetes.

Impact of Demographic Features on Glycemic Management With Tubeless Automated Insulin Delivery Systems in Youth With Type 1 Diabetes

OBJECTIVE Automated insulin delivery (AID) systems have been shown to improve glycemic time in range (TIR) and A1C; however, there are limited data on their use among historically marginalized groups, technology-naive individuals, and young children. This study evaluated whether certain patient features affect the influence of tubeless AID on glycemic metrics in youth with type 1 diabetes. RESEARCH DESIGN AND METHODS This was a retrospective chart review involving patients 2–26 years of age with type 1 diabetes who were prescribed a tubeless AID system between January 2021 and May 2023. Demographic and diabetes treatment data were abstracted from the electronic medical record system. Cluster analysis methodology was used to identify clinically relevant patient groups based on demographics and medical history. Generalized mixed-effects modeling was used to compare TIR and A1C between groups. RESULTS Through review of cluster-identified patient characteristics, 133 participants were assigned to one of four groups. Group 1 ( n = 42) was predominantly White and privately insured, group 2 ( n = 26) had public insurance or was uninsured and was largely non-White, group 3 ( n = 44) had the lowest prior pump usage, and group 4 ( n = 21) had the youngest median age at diagnosis and at pump initiation. All groups had an increase in TIR and a decrease in A1C after pump initiation, and there was no difference in the improvement between groups (TIR from 46–47 to 60%, P <0.001 for all groups, and A1C from 8.41–8.44 to 7.45–7.49%, P <0.05 for all groups). CONCLUSION Improvements in glycemic management were consistent across groups, despite intragroup differences historically associated with barriers to diabetes management. These findings suggest the importance and potential impact of offering tubeless AID in mitigating care disparities and support its implementation for all youth with type 1 diabetes.

Association of Social Support With Glycemic Control Among American Indians With Type 2 Diabetes: The Strong Heart Family Study

Few studies have examined associations of social support with blood glucose control in American Indians (AIs), a population with a high burden of type 2 diabetes and related complications. This study examined the association of perceived social support with A1C among AIs in the Strong Heart Study. This cross-sectional study included 431 AI participants. Social support was measured using questions adapted from the National Comorbidity Survey and validated for use in AIs. A1C was measured using high-performance liquid chromatography. Generalized estimating equations were used to examine the association of social support with A1C. Participants who reported greater levels of social support had lower A1C levels. After adjustment for potential confounders, for every 1-SD increase in social support (6.8 points), A1C was 0.21% lower (β = −0.21%, 95% CI −0.40 to −0.01, P = 0.04). These data suggest that higher levels of social support are associated with better control of blood glucose. Further studies are needed to determine the mechanism by which perceived social support affects A1C.

Relationship Between Material Needs Security and Quality of Life in Adults With Type 2 Diabetes in Lebanon

OBJECTIVE Despite their documented significance in type 2 diabetes management, social determinants of health (SDOH), including material needs security and quality of life (QoL), are understudied in the Middle East and North Africa (MENA) region. Material needs security refers to the consistent availability of essential material resources required to sustain health and manage diseases. This study aimed to assess the relation between material needs security and QoL in Lebanese adults with type 2 diabetes. RESEARCH DESIGN AND METHODS Using convenience sampling, 300 participants with type 2 diabetes were recruited. Demographic and material need variables were self-reported, and QoL was assessed using the abbreviated World Health Organization Quality of Life Scale (WHOQOL-BREF). WHOQOL-BREF score was the outcome variable used. Regression models were used to examine associations between material needs security and WHOQOL-BREF score, controlling for relevant confounding variables. RESULTS Most of the participants were men and married and had lower education levels. Multivariate analyses revealed that having material needs security was associated with physical health (β = 0.32, 95% CI 0.14–0.51), psychological health (β = 0.33, 95% CI 0.15–0.50), social relationships (β = 0.29, 95% CI 0.08–0.50), environment (β = 0.53, 95% CI 0.39–0.67), and overall perception of QoL (β = 0.09, 95% CI 0.04–0.14) after controlling for all relevant confounding variables. Other significant correlates of good QoL included lower age, higher education, higher income, and being employed. CONCLUSION This study highlights the important influence of material needs security on QoL in adults with type 2 diabetes in the MENA region. Further research is needed to understand potential pathways and mechanisms, as well as options for effective interventions.

Oral Hygiene Practices and Glucose Profiles Assessed Through Continuous Glucose Monitoring in Adults With Type 2 Diabetes

OBJECTIVE Taking into account the potential link between oral hygiene and glycemic management in individuals with type 2 diabetes, this study aimed to investigate the relationship between oral hygiene practices, namely, tooth brushing, interdental cleaning, dental visits, and remaining teeth, and glycemic variability measured by continuous glucose monitoring (CGM) in people with type 2 diabetes, with a particular focus on the role of inflammation. RESEARCH DESIGN AND METHODS This cross-sectional study included 104 adults with type 2 diabetes visiting an internal medicine clinic. Questionnaires were used to collect data on oral hygiene practices, dental visit frequency, and the number of remaining teeth. Blood and urine samples were obtained, and CGM was performed for 2 weeks. The relationship between oral hygiene practices and diabetes management indicators, as well as inflammation markers, was analyzed. RESULTS The frequency of tooth brushing was negatively correlated with BMI, inflammation-related markers such as high-sensitivity C-reactive protein and tumor necrosis factor-α, and urine albumin-to-creatinine ratio. Interdental cleaning three or more times per week compared with less frequent cleaning was associated with lower fasting blood glucose, lower A1C, and improve CGM-related metrics, including greater time in range (TIR), lower glucose management indicator (GMI), and lower time above range. In logistic regression analysis, interdental cleaning showed associations with achieving TIR and GMI goals, even after adjusting for background factors and inflammatory markers. CONCLUSION This study highlights the crucial role of oral hygiene practices in type 2 diabetes. Regular dental visits and effective oral self-care are paramount for promoting optimal oral health and managing diabetes.

“Older Adult Diabetes”: A Conceptual Proposal for a Distinct Clinical Entity

The prevalence of diabetes among older adults is steadily rising, especially in aging populations. Although the term “diabetes in older adults” is widely used in clinical guidelines and epidemiological research, it remains largely descriptive, lacking the precision needed to support the development of age-specific treatment strategies. This article proposes the term “older adult diabetes” as a distinct disease entity. By examining the conceptual and linguistic differences between the two terms, the article suggests that the broader adoption of “older adult diabetes” can enhance clinical decision-making, sharpen research focus, and more effectively inform policy development tailored to aging populations.

Insulin Insecurity and Its Subsequent Impact on Emerging Adults and Families of Children With Type 1 Diabetes

OBJECTIVE Multiple states have passed legislation limiting out-of-pocket insulin costs for individuals on private insurance, including Colorado in 2020. Because disruptions in insulin access are life-threatening for people with type 1 diabetes, this study examined the real-world impact of Colorado’s law on patient/parent-reported outcomes. RESEARCH DESIGN AND METHODS Patient/parent-reported frequency of insulin insecurity (insulin rationing, running out early, or finding alternative sources of insulin), cost concerns, and most recent insulin out-of-pocket cost were assessed by a clinic-developed survey. Demographics, A1C, and glycemic time in range (TIR; 70–180 mg/dL) were obtained from medical record review. Linear regression models were fit to compare out-of-pocket costs, A1C, and TIR, adjusting for sex, diabetes duration, race/ethnicity, insurance, and age. RESULTS Of 184 enrolled participants, 149 responded to insulin insecurity questions, with 34% reporting at least one insulin insecurity behavior. Insulin insecurity was associated with higher monthly insulin costs ($77.60 vs. $19.30, P = 0.004) and A1C (+0.69 ± 0.23%, P = 0.003) and lower TIR (−9.78 ± 4.03%, P = 0.02) compared with insulin security. Similar rates of insecurity were seen in emerging adults (46%, n = 18/39) and those publicly insured (43.5%, n = 10/23). There was no difference in mean copayments between those on public versus private insurance ($39.40 vs. $38.00). CONCLUSION Despite costs falling below the out-of-pocket cap, insulin insecurity remains common among emerging adults and families of youth with type 1 diabetes and is associated with worse glycemia. Further research into root causes of insecurity, such as limitations on early refills, is required.

Screening for Metabolic Dysfunction–Associated Steatotic Liver Disease in Patients With Type 2 Diabetes: Are We Doing Enough?

OBJECTIVE Patients with type 2 diabetes are at an elevated risk for metabolic dysfunction–associated steatotic liver disease and advanced liver fibrosis. Multiple professional societies recommend initiating screening with a fibrosis-4 (FIB-4) index score calculation. This study aimed to evaluate the frequency of laboratory assessments necessary for FIB-4 score calculation in patients with type 2 diabetes. RESEARCH DESIGN AND METHODS A retrospective analysis of de-identified electronic medical records from 337,094 patients aged 40–75 years with type 2 diabetes was conducted to evaluate the completion rate of FIB-4 scoring and adherence to other recommended measurements and medications, including urinary albumin measurement and statin use. RESULTS Only 33% of patients with type 2 diabetes had all necessary components for FIB-4 score calculation, although this rate increased significantly over time (odds ratio 2.51, 95% CI 2.44–2.58) in the period from 2020 to April 2024 compared with 2010–2014. Urinary albumin measurements also increased but remained low at 13% during the period from 2020 to April 2024. Prescriptions for statin and newer antihyperglycemic medications significantly increased. CONCLUSION Our findings indicate that, although testing frequency for liver health in patients with type 2 diabetes is gradually increasing, substantial gaps in clinical practice persist.

System Failure in Type 1 Diabetes: What Stakeholders Need to Know to Expedite Therapeutic Options

There has been a systemic failure in type 1 diabetes. Regulatory barriers and clinical trial design challenges discourage development of new type 1 diabetes therapies and can compromise the potential for securing approval of new treatments. As a result, there continues to be a pervasive unmet need for those living with type 1 diabetes, resulting in long-term complications, extreme disease management burdens, and psychosocial consequences. People with type 1 diabetes continue to make multiple daily decisions about dosing insulin, a drug that can kill with a single mistake and that at best only manages symptoms without changing the underlying progression of the disease. Furthermore, beyond regulatory challenges, gaps in health care professionals’ (HCPs’) knowledge and understanding of the disease affect quality of care. The goal of this article is to educate stakeholders on the extent of this systemic failure and to encourage consideration and dialogue among industry, regulatory agencies, patients, and HCPs to expedite approval of breakthrough therapies that fundamentally change the equation in type 1 diabetes.

Reproductive Health Counseling in the T1D Exchange Quality Improvement Collaborative

OBJECTIVE Preconception planning can reduce complications in pregnancy with type 1 diabetes. However, high periconception A1C is not uncommon and increases maternal and fetal risks. Because of limited data regarding preconception counseling, questions about education and contraception use were added to the 2022 T1D Exchange Quality Improvement Collaborative (T1DX-QI) survey. RESEARCH DESIGN AND METHODS The annual T1DX-QI survey was conducted in August and September 2022 with a center response rate of 94% of 50 centers, including 33 pediatric centers (66%) and 17 adult centers (34%). Representatives from each center answered questions relating to center resources and practices. The study includes females of reproductive age (13–50 years) diagnosed with type 1 diabetes who had at least one A1C value in 2022 in the T1DX-QI database. RESULTS Most centers report discussing contraception (74%) and pregnancy planning (72%) at least once per year. Among pediatric centers, 42% report always asking about menstruation history, compared with 6% of adult centers. Only 12% of adult centers and 6% of pediatric centers have a formal preconception counseling protocol. Only 12% of adult centers and 9% of pediatric centers estimated that >80% of their patients of childbearing potential were using contraception. Of females aged 13–50 years of age with type 1 diabetes, 15% at pediatric centers and 24.4% at adult centers had an A1C <6.5% at the time of the survey. CONCLUSION Although most centers reported discussing contraception and pregnancy planning, estimated rates of formal preconception counseling programs, contraception use, and attaining goal A1C remain low. Quality improvement efforts are needed to determine rates of preconception counseling and implement best practices to improve pregnancy outcomes.

Factors Associated With Initiation of Sodium–Glucose Cotransporter 2 Inhibitor and Glucagon-Like Peptide 1 Receptor Agonists in Patients With Diabetes and Kidney Disease: A Post Hoc Analysis of the Kidney CHAMP Trial

OBJECTIVE Negative social determinants of health (SDOH) are associated with greater kidney disease incidence and progression, partly because of suboptimal management. We studied the association of demographic, clinical, and individual- and contextual-level SDOH factors with sodium–glucose cotransporter 2 (SGLT2) inhibitor and glucagon-like peptide 1 (GLP-1) receptor agonist initiation in patients with type 2 diabetes and whether these associations were modified by the Kidney Coordinated HeAlth Management Partnership (K-CHAMP) population health management (PHM) program. RESEARCH DESIGN AND METHODS Using data from the K-CHAMP trial, which cluster-randomized 101 primary care offices to a control arm or the PHM intervention (including nephology electronic consultation, chronic kidney disease education, and pharmacist medication review), we explored associations between SGLT2 inhibitor and GLP-1 receptor agonist initiation with a priori patient factors using adjusted Poisson regression. Enrolled patients with type 2 diabetes who were not prescribed an SGLT2 inhibitor or a GLP-1 receptor agonist at baseline were included. Effect modification by K-CHAMP was assessed using interaction terms. RESULTS The cohort had 891 patients (402 receiving the PHM intervention and 489 in the control group). Of the participants, 55% were female and 89% were White; the cohort had a mean age of 73 ± 9 years, mean BMI of 33 ± 7 kg/m 2, mean A1C of 7.3 ± 1.5%, and mean estimated glomerular filtration rate of 37.4 ± 8.3 mL/min/1.73 m 2; and 24% were rural living. Over a median follow-up of 17.7 months (interquartile range [IQR] 12.4–23.8 months), 238 (26.7%) initiated an SGLT2 inhibitor or GLP-1 receptor agonist. In adjusted analysis, age (incidence rate ratio [IRR] 0.92, 95% CI 0.85–0.99) and A1C (IRR 1.15, 95% CI 1.07–1.24) were significantly associated with SGLT2 inhibitor or GLP-1 receptor agonist initiation. The K-CHAMP PHM intervention did not significantly modify association of any factors. CONCLUSION Younger age and higher A1C were associated with increased likelihood of initiating an SGLT2 inhibitor or GLP-1 receptor agonist. Other demographic, clinical, and SDOH factors were not significantly associated with medication initiation. The K-CHAMP PHM intervention did not moderate the association of patient-level or SDOH factors with initiation of an SGLT2 inhibitor or GLP-1 receptor agonist.

Type 1 Diabetes Management in the Female Population: Evaluation of the Impact of Sex on Glycemic Control and the Perceived Performance of Diabetes Technology Across the Menstrual Cycle

OBJECTIVE We aimed to explore sex differences in type 1 diabetes management and investigate the perceived need for improved diabetes technology to mitigate the effect of the menstrual cycle on glycemic control in females with type 1 diabetes. RESEARCH DESIGN AND METHODS A REDCap survey was designed to ask adults with type 1 diabetes about demographics, medical history, diabetes management, and, when applicable, the impact of the menstrual cycle on glycemic control and the extent to which currently available diabetes technology is successful at regulating blood glucose levels across cycle phases. RESULTS A total of 299 respondents completed the survey. Of these, 218 (72.9%) reported being female. No significant sex differences were detected in reported A1C, glycemic time in range, or diabetes technology used (χ 2 tests, all P >0.3). One hundred and thirty-six female respondents reported actively menstruating. Of these, 97 (71.3%) indicated the luteal phase of the menstrual cycle to be the cycle phase that most affected their glycemic control, and 102 (75.0%) reported increased exposure to hyperglycemia during this phase. When asked about technology satisfaction, 68 respondents (50.0%) reported that their diabetes technology was not successful at regulating blood glucose levels across the menstrual cycle, and 88 (64.7%) indicated that the technology they used could be better at mitigating cycle-related metabolic variability. CONCLUSION Most investigated type 1 diabetes management outcomes showed no significant sex differences. Importantly, 65% of female respondents who were actively menstruating indicated the need for improved diabetes technology to stabilize glycemic control across the menstrual cycle.

Nutrition, Pregnancy, and Preexisting Diabetes: Exploring What Has Changed and What Remains the Same

Nutrition is a key component in the management of pregnancy. If diabetes is also involved, the maternal physiological and hormonal changes can have a profound effect on glycemic levels. Eating habits, which include what and how foods are consumed, and even culture are other contributing factors that influence maternal and fetal outcomes. Most nutrition recommendations can be applied to all pregnancies; however, adjustments may be necessary if diabetes predated the pregnancy. This article provides an update, addressing both what has and has not changed in recent years in the nutrition management of pregnancy and preexisting diabetes.

Perinatal Diabetes Care

The prevalence of pregestational diabetes in pregnancy is increasing ( 1, 2 ), as a reflection of the steadily increasing prevalence of type 1 diabetes and type 2 diabetes in the U.S. adult population ( 3–5 ). As a result, a growing population of pregnant individuals will become susceptible to the maternal and neonatal morbidity and mortality that remain associated with pregestational diabetes. These complications include hypertensive disorders of pregnancy (e.g., preeclampsia), cesarean delivery, excessive birth weight, birth injury, major congenital malformations, and perinatal death ( 6–10 ). Infants born to people with pregestational diabetes are also at risk for long-term health issues, including obesity, type 2 diabetes, and metabolic syndrome in adolescence or adulthood ( 11–14 ).