Frameworks that classify the financial burdens of managing pediatric type 1 diabetes (T1D) primarily focus on measurable material hardship, affordability, and cost-related distress and therefore do not sufficiently detail the household-level resources that care requires from families. This study is a conceptual narrative review that aims to integrate the missing elements into a new three-level burden model, thereby linking the costs visible in clinical care, the household implementation burden borne by families, and the lived everyday experience of the child-parent-family triad. The proposed contribution of the model is to interpret the sustainability of modern T1D care not exclusively in terms of technology access, reimbursement, or clinical effectiveness, but also as a function of families’ temporal, digital, organizational, and decision-making capacity in relation to everyday self-management, educational-setting coordination, caregiver time investment, digital health literacy, and the digital divide. The literature documents direct healthcare costs, out-of-pocket expenses, informal care, dietary adaptation, technology-related costs, parental distress, and time burden well when considered separately. However, these elements often do not appear as an integrated, cumulative household implementation burden. In pediatric T1D, the actual usability and sustainability of technology depend not only on device availability and reimbursement but also on the family’s organizational, digital, temporal, and decision-making capacity. The T1D-ELB-P framework interprets the burdens placed on families as an organizing principle: it does not merely list domains but shows how financial, digital, temporal, decision-making, and institutional requirements can accumulate as household implementation burdens. The proposed Type 1 Diabetes Everyday-Life Burden-Pediatric framework (T1D-ELB-P) conceptualizes the everyday-life economic burden of pediatric type 1 diabetes as a complementary dimension interpretable at the household and caregiver levels. It highlights five interrelated domains: lifestyle and dietary adaptation; non-reimbursed or partially reimbursed consumables and accessories; digital infrastructure and digital health literacy; time, attention, and decision burden; and educational, extracurricular, and workplace coordination. In this model, technology is not a separate focus but a cross-cutting factor that makes the implementation work borne by families visible across several domains. The clinical and health-policy significance of the framework lies in its highlighting of how the real-world use of modern T1D care is embedded in the everyday functioning of the child-parent-family triad. Future cost-of-illness, health technology assessment, and patient-centered studies would benefit from explicitly measuring family implementation costs and capacities.
Consistent medication adherence is fundamental for achieving favorable health outcomes in diabetes care; however, attaining optimal adherence remains a challenge. This review summarized recent evidence on digital behavioral interventions designed to improve medication adherence in type 2 diabetes (T2D) and identified key components commonly incorporated in these interventions. Thirty-two studies evaluating digital strategies to support medication adherence were identified. Interventions were delivered through a range of digital platforms, including mobile apps, short message service messaging, telemedicine systems, conversational artificial intelligence, and remote monitoring technologies. Medication adherence was assessed using a variety of measures, including self-reported adherence questionnaires, medication-taking records, and refill-based measures. Most studies reported improvements in medication adherence, and several also observed improvements in glycemic outcomes, most commonly A1C. Effective interventions frequently combined reminders, educational content, self-monitoring tools, and patient-provider communication. Digital behavioral interventions represent increasingly utilized strategies to promote medication adherence among individuals with T2D. Multifaceted digital approaches that integrate behavioral support, monitoring, and communication may enhance long-term diabetes self-management and treatment engagement. Recent advances have focused on improving personalization, integration across digital platforms, and interactive patient support rather than introducing entirely new digital modalities.
Persistence with glucagon-like peptide-1 (GLP-1)–based therapies is important for sustained weight loss and glycemic control in adults with coexisting obesity and type 2 diabetes. This narrative review examined how persistence has been defined and measured, real-world patterns of continuation and discontinuation, factors associated with persistence, reasons for discontinuation, and supportive strategies in this population. Seven studies met the inclusion criteria, with follow-up ranging from 6 months to 2 years. Persistence generally declined over time and often fell below 60
Continuous glucose monitoring (CGM) has increasingly been incorporated into studies examining cognitive function in people with diabetes. This scoping review systematically maps how CGM has been applied in cognitive research among individuals with diabetes to characterize current methodological approaches, identify key knowledge gaps, and inform future research. A scoping review was conducted following Arksey and O’Malley’s framework. A systematic search of five electronic databases (PubMed, CINAHL, Cochrane Library, EMBASE, PsycINFO) was performed. Cognitive outcomes were extracted and mapped to the International Classification of Functioning, Disability and Health framework. Twenty-one studies met the inclusion criteria. CGM data completeness was consistently high, with 84–100
Determine whether and how alternative payment models (APMs) impact diabetes care and outcomes. Explain what APMs are and highlight key principles of effective APMs. Provide a conceptual model for how APMs can support transformation to evidence-based population health delivery models that improve diabetes outcomes. Advanced APMs with shared savings or global budgets, along with quality incentives, tended to improve diabetes and composite chronic condition outcomes, and can reduce Medicare Part A hospital and Part B outpatient costs. Advanced APMs, particularly models with global budgets that hold health care organizations accountable for total cost of care and quality of care, can improve diabetes outcomes and reduce costs. Careful design and implementation of APMs are essential to provide the appropriate mix of incentives, support, and risk for participants to succeed in APMs and develop effective population health management models.
Diabetes care is characterized by the widespread use of plastics. With plastic-associated endocrine-disrupting chemicals (EDCs) implicated in diabetes pathogenesis, this review examines how medical plastics relate to diabetes and related disorders and proposes interventions to improve the situation. Plastic-associated EDCs and micro-/nanoplastics (MNPs) are linked to metabolic dysfunction. Medical care exposes patients to these agents; however, the precise contribution of diabetes care to these exposures and their associated adverse health effects remains poorly defined. Diabetes care is an increasingly important contributor to plastic pollution and climate change, yet inadequate systems exist to mitigate its environmental impact. Plastic-associated EDCs and MNPs remain an underappreciated metabolic health threat. Mitigating the deleterious impacts of plastics on human and planetary health requires concerted actions from manufacturers, scientists, policymakers, professional organizations, healthcare providers, and patients. Doing so has the potential to improve metabolic health and promote health equity.
This review summarizes recent evidence on continuous glucose monitoring (CGM) in adults with type 2 diabetes mellitus (T2D), focusing on clinical effectiveness, patient-reported outcomes, disparities in use, and policy and economic considerations. Studies from 2020 to 2025 show that CGM use in T2D is associated with consistent improvements in glycosylated hemoglobin (HbA1c), time in range, and diabetes self-management across insulin and non-insulin treatment regimens. Emerging observational data suggest reductions in mortality and health care utilization, and cost-effectiveness analyses consistently demonstrate that CGM represents a high-value intervention across payer settings. Despite these benefits, CGM uptake remains variable, with persistent disparities by age, race, and ethnicity, insurance coverage, and care setting. CGM is an effective and cost-effective tool for T2D management, but inequities in access limit its impact. Future research should address implementation in safety-net and primary care settings, evaluate over-the-counter CGM, and assess long-term clinical and health system outcomes.
Adults with inflammatory bowel disease (IBD) demonstrate a high prevalence of obesity, metabolic dysfunction-associated steatotic liver disease (MASLD) and cardiometabolic comorbidities. Cardiovascular disease (CVD) is a leading cause of mortality in IBD. This review examines cardiometabolic and obesity screening, and management within IBD models of care to optimise chronic disease management. Obesity prevalence in IBD has increased to 40
Climate change is progressively recognized as an emerging determinant of metabolic health outcomes, particularly in relation to diabetes mellitus. This review summarizes mechanistic and epidemiological evidence linking climate-related exposures to diabetes outcomes: namely, 1) heat stress, 2) air pollution, and 3) extreme weather-related disruption of diabetes care. Warming temperatures, worsening air quality, and more frequent extreme weather events are intensifying exposures that disproportionately affect populations with pre-existing chronic diseases; patients with diabetes may be at the center of climate-related vulnerability. While the greatest burden of diabetes is shouldered by countries in the Global South, these same regions are also at the front lines of climate change, facing extreme environmental conditions. Together, diabetes and climate change can converge to create compounding pressures on already strained public health systems in the world’s most climate-vulnerable regions. Using global case studies from climate-vulnerable settings, we show the pathways through which diabetes outcomes and climate change can be connected highlighting the need for climate-informed diabetes prevention and management.
Recently developed once-weekly basal insulin analogs, including insulin icodec and insulin efsitora alpha (efsitora), aim to improve treatment adherence and patient convenience compared with daily basal insulin. This systematic review and meta-analysis evaluated the efficacy and safety of once-weekly basal insulin analogs compared with daily basal insulin analogs in adults with type 2 diabetes mellitus (T2DM) and included 14 randomized controlled trials (RCTs), comprising 8,487 subjects. Evidence supports that once-weekly basal insulin analogs achieve comparable glycemic control to daily basal insulin analogs in adults with T2DM, offering greater reductions in HbA1c and improvements in time in range, with a safety profile similar to that of daily insulin regimens. In our analysis, once-weekly basal insulin resulted in a greater reduction in HbA1c compared with daily basal insulin (mean difference [MD] -0.09
To address the clinical dilemma of how best to counsel women with type 2 diabetes (T2D) using glucagon-like peptide-1 receptor agonists (GLP-1RA) regarding pregnancy. Animal studies raise concern for fetal loss, malformations and adverse fetal growth after GLP-1RA exposure. Nonetheless, three cohort studies and one prospective study including 2,994 women with T2D exposed to GLP-1RA in early pregnancy indicate no increased risk of malformations compared with unexposed pregnancies, and observational data in 168 GLP-1RA exposed pregnancies are reassuring regarding miscarriage and fetal growth. Women with T2D are advised to use contraception and to discontinue GLP-1RAs two months before planned pregnancy. Despite concerns in animal studies, GLP-1RA exposure in early T2D pregnancy has not been associated with increased risk of malformations. If a woman with T2D inadvertently becomes pregnant while using GLP-1RA, the existing human evidence does not support a recommendation of terminating pregnancy.
Synthesize data on whether existing behavioral interventions can improve health equity among youth with type 1 diabetes. While existing behavioral interventions demonstrated efficacy in improving health and/or psychosocial outcomes, evidence that these same interventions may improve health equity were lacking. Most interventions were evaluated using predominantly White and affluent samples and some studies did not report on racial, ethnic, or sociodemographic characteristics of their sample. Only a few interventions have been adapted for youth from minoritized backgrounds. Recent multisystemic and technology/mHealth interventions recruited samples that were sociodemographically representative of youth experiencing disparities, suggesting that these interventions could improve health and/or psychosocial outcomes for these sociodemographic groups. However, no studies conducted subgroup analyses to examine whether the effect of the intervention might vary as a function of sociodemographic characteristics. The prevalence and persistence of disparities in psychosocial and glycemic outcomes among youth with T1D underscore the urgent need for effective, evidence-based behavioral interventions for populations in most need of this care. There is a critical need for research that prioritizes recruitment of samples that represent youth most impacted by health disparities. Additionally, existing interventions can be adapted for youth from minoritized backgrounds. Future research would benefit from leveraging existing intervention development/adaptation frameworks and engaging community partners through the research process.
The purpose of this review is to synthesize literature investigating the relationship between type 2 diabetes (T2D) and obstructive airway diseases and to identify implications for clinical care. Type 2 diabetes is a common and challenging comorbidity in patients with asthma and chronic obstructive pulmonary disease (COPD). Basic, translational and clinical studies support a bidirectional association between T2D and the lung. In animal models and human studies, insulin resistance and hyperglycemia are associated with pulmonary inflammation, respiratory exacerbation risk and disease severity. Corticosteroids are a mainstay for respiratory disease control and exacerbation treatment but promote ongoing metabolic dysregulation. Randomized, placebo-controlled trials of glucose-lowering medications for asthma are actively ongoing. Additional studies addressing clinical pathways to co-manage respiratory and metabolic risk are needed. Patients with comorbid T2D and asthma or COPD are at risk for worse outcomes. There are opportunities to improve cross-disciplinary care, potentially reducing risk and multimorbidity associated with both conditions.
To examine the role of pharmacologic obesity treatment in people with type 2 diabetes (T2D), with a focus on efficacy, safety, and clinical positioning in the context of T2D-specific metabolic and therapeutic challenges. Contemporary incretin receptor agonists enable clinically meaningful weight loss in people with T2D while improving glycemic control and cardio-renal, hepatic, and functional outcomes, including improvements in physical performance and symptoms in heart failure with preserved ejection fraction (HFpEF). However, weight loss is consistently attenuated compared with obesity without diabetes, reflecting reduced metabolic flexibility (impaired ability to appropriately adjust fuel utilization), background therapies, and social determinants of health rather than treatment failure. Obesity pharmacotherapy should be considered a disease-modifying component of T2D care. Treatment success should be defined by improvements in adiposity-related complications, organ protection, and patient-centered outcomes, not by fixed weight-loss thresholds. A complication-focused, individualized approach is essential to optimize long-term benefit in T2D.
Metabolic dysfunction-associated steatotic liver disease (MASLD) is a hepatic manifestation of metabolic syndrome, frequently occurring alongside type 2 diabetes (T2D), and it can present in varied phenotypes. This review provides a critical analysis of gut-adipose tissue-liver axis (GALA) dysregulation in MASLD pathogenesis, contextualizing the discussion within both established and emerging paradigms. The review elucidates how GALA dysregulation shapes the interplay between MASLD and T2D, emphasizing inter-organ crosstalk among the gut, liver, and adipose tissue, and highlighting the role of microbial metabolites, notably bile acids. The review further summarizes recent advances in stratifying MASLD into distinct clusters, examining intricate associations with cardiometabolic comorbidities, and critically evaluates novel therapeutic approaches targeting GALA modulation. MASLD can show heterogeneous phenotypes. It significantly increases the risk of developing new-onset T2D, and both conditions often coexist due to their shared pathophysiological basis in insulin resistance. The gut microbiota influences immune function and modulates host metabolism by regulating glucose tolerance and insulin sensitivity through a specific crosstalk between the gut, liver, and adipose tissue. The dysregulation of the GALA may be a mechanism underlying the interplay between MASLD and T2D, influencing IR and metabolic syndrome. A thorough investigation of GALA's role in the physiopathogenesis of MASLD and T2D highlights its potential to distinguish specific MASLD clusters and to identify personalized therapeutic strategies.
Lipolysis regulates lipid distribution, energy availability, and metabolic homeostasis in organisms that store triacylglycerols. In multicellular organisms, adipose tissue evolved as a specialized organ that centralizes lipid storage and release, buffers nutrient fluctuations, and protects non-adipose tissues from lipid overload. Dysregulated adipocyte lipolysis occurs across diverse metabolic conditions, including obesity, diabetes, lipodystrophy, and inflammatory states. This review synthesizes evidence that defective suppression of basal lipolysis and impaired responsiveness to physiological stimuli disrupt lipid partitioning, promote insulin resistance, and drive ectopic lipid accumulation. Research shows that metabolic dysfunction arises in both obese and non-obese settings and correlates more closely with impaired control of fatty acid flux than with adiposity itself. Higher expression of lipolytic receptors, including those targeted by weight-loss medications, together with genes that regulate lipolysis through insulin signaling, is associated with greater weight loss and improved systemic metabolic health. In this review, we highlight canonical and noncanonical mechanisms governing lipolytic regulation and contrast pathological lipolysis with the tightly controlled lipolysis observed during weight loss. Together, these findings reframe lipolysis as a central determinant of metabolic health and a therapeutic target when precisely regulated.
To provide an updated review of the fear of hypoglycemia (FOH) literature published from 2016 to 2025, in youth with type 1 diabetes (T1D) and their caregivers. The Hypoglycemia Fear Surveys (HFS) are the most used questionnaires to assess FOH in studies conducted in the United States and internationally. The factor structure of the Parent and Child versions of the HFS have been updated to better reflect only maladaptive aspects of managing FOH. Diabetes technology studies routinely include the HFS to assess FOH as a secondary outcome. Only two randomized clinical trials (RCT) to reduce FOH have been conducted with youth with T1D and their caregivers. FOH is a common psychological complication occurring in youth with T1D and their caregivers. More research is needed to update the HFS to reflect modern T1D self-management and test interventions that aim to reduce FOH in RCTs.
Metabolic dysfunction–associated steatotic liver disease (MASLD) is highly prevalent among individuals with type 2 diabetes (T2D). This review summarizes current evidence on the pharmacologic treatment of MASLD, with emphasis on agents currently approved for the management of T2D. Among glucose-lowering therapies, GLP-1 RAs, dual GIP/GLP-1 RAs, pioglitazone, and SGLT2 inhibitors demonstrate meaningful benefits in steatohepatitis. Semaglutide provides the most robust evidence for fibrosis benefit, while data suggest potential antifibrotic effects of tirzepatide and dapagliflozin. Resmetirom and semaglutide are the only agents specifically approved for MASLD. An expanding pipeline of dual glucagon/GLP-1 and triple GIP/GLP-1/glucagon agonists such as retatrutide has shown marked reductions in liver fat and signals of MASH benefit. Additional therapies, including pan-PPAR agonists, and FGF21 analogues are advancing through phase 3 development. The therapeutic landscape is rapidly evolving toward integrated metabolic, hepatic, and cardiovascular risk reduction in T2D and MASLD.
Diabetes self-management is accompanied by time-varying emotional and motivational challenges that impact mental health. These day-to-day fluctuations can be assessed via ecological momentary assessment (EMA), that allows the repeated sampling of psychosocial variables in everyday life. The benefits of EMA over questionnaires mirror the benefits of continuous glucose monitoring (CGM) over HbA1c. We describe the insights generated by combining EMA and CGM and highlight its potential. Research shows that glucose levels can influence subsequent mood, stress, cognitive functioning, and symptom reporting, with nocturnal hypoglycemia and overnight glucose being particularly relevant. Studies demonstrated the importance of differentiating between subjective person-interpreted and objectively sensor-assessed glucose levels. N-of-1 analyses revealed relevant intraindividual differences in the association between glycemic and psychosocial parameters. Combining EMA and CGM can enhance our understanding of the dynamic relationship between glycemic and psychosocial variables, supporting precision medicine approaches for mental health in diabetes.
Peripheral artery disease (PAD) is a serious complication in type 2 diabetes, increasing vascular morbidity and mortality. While glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP) receptor agonists show cardiovascular benefits in diabetes, their effects on PAD-related outcomes are unclear. This meta-analysis assessed the impact of these therapies on vascular outcomes in type 2 diabetes with PAD. A systematic review and meta-analysis were conducted per PRISMA guidelines (PROSPERO CRD420251083622). PubMed, Embase, and Cochrane Central were searched. A random-effects model pooled data. Primary outcomes were major adverse limb events, peripheral revascularization, and amputation. Secondary outcomes included major adverse cardiovascular events (MACE), all-cause mortality, myocardial infarction, stroke, HbA1c, and weight changes. Six studies (four RCTs, two propensity score-matched cohorts) with 25,866 patients were included. Incretin-based therapies significantly reduced all-cause mortality (RR 0.52 [0.28–0.95], p = 0.032) and HbA1c (MD − 0.73
