Background:There has been increasing public interest in a functional medicine (FM) approach to the care of type 2 diabetes (T2D). However, it is unclear if this approach can further improve diabetes management beyond conventional diabetes care. This study compared the addition of a FM approach (intensive lifestyle modifications and tailored dietary supplements) plus usual care (FM) to conventional endocrinology management alone (usual care, UC). Methods:In a 24-month unblinded randomized trial, participants with type 2 diabetes (T2D) were randomized to receive either FM or UC. The primary endpoint was discontinuation of insulin with no increase in HbA1c or HbA1c < 7% at 12 months. Secondary endpoints included changes in HbA1c, insulin dosage by weight, cardiometabolic biomarkers, hypoglycemic episodes, total number of medications and quality-of-life scores. Results:A total of 107 individuals were screened - 34 were randomized into FM and 37 into UC. Participants were 46% female and median age was 62 years. Median baseline HbA1c was 7.75%. Of those randomized, 47 participants completed the study (FM: 20; UC: 27); 15.8% of patients in FM arm achieved the primary endpoint compared to 11.1% in the UC arm (p = 0.68). Secondary exploratory endpoints including change in HbA1c, insulin dosage by weight, hypoglycemia, BMI, weight and quality-of-life did not differ significantly between arms. Conclusion:The addition of FM did not lead to significant improvement in glycemic, metabolic or quality-of-life outcomes compared to usual care for individuals with type 2 diabetes.

CONTEXT:Over the last decade, diabetes management tools such as continuous glucose monitors, automated insulin delivery systems, and connected insulin pens have experienced exponential growth. These technologies are more readily being adopted to manage diabetes due to increased availability. This mini-review provides information about recent innovations available in the United States for diabetes management to improve patient outcomes. EVIDENCE ACQUISITION:A systematic search was conducted using Medline, PubMed, ScienceDirect, and Embase databases, as well as the Cochrane Library to identify peer-reviewed articles published between 2014 and 2024, in English, and focused on treatment using technology in diabetes care. EVIDENCE SYNTHESIS:Diabetes technology has significantly eased the burden of both glucose measurement and insulin delivery, which has, overall, improved diabetes management. Advancements in accuracy and glycemic outcomes have been demonstrated through rigorous clinical and observational trials, underscoring their potential to transform diabetes care. The literature suggests that the use of diabetes technologies promotes patient self-efficacy and enhances the quality of life for individuals with both type 2 and type 1 diabetes. CONCLUSION:Diabetes technology has been shown to improve important aspects of diabetes care, from glycemic control to patient satisfaction and quality of life. It is important to assess the role of technology in type 1 and type 2 diabetes and individualize treatment goals and objectives.

CONTEXT:Diabetes mellitus is a global health burden, with factors contributing to its prevalence and costs. Educating people with diabetes improves outcomes and affects the economic burden on the individual and health systems. EVIDENCE ACQUISITION:We included recent diabetes data from the Centers for Disease Control and Prevention and articles from PubMed and Ovid MEDLINE. EVIDENCE SYNTHESIS:Diabetes prevalence in the United States increased from 10.3% in 2001 to 14.7% in 2021. Factors contributing are an aging population, increased obesity, and social determinants of health. Total costs for diabetes in 2022 reached $412.9 billion, consisting of 74% direct medical and around 26% indirect costs. The highest medical expenses were hospital inpatient services ($96.2 billion), and indirect costs were decreased productivity while at work ($35.8 billion). The effect on the health economy in the United States and globally is only increasing. Interventions to improve disease outcomes such as diabetes education programs that teach self-management skills, healthy lifestyle behaviors, and coping strategies have improved glycated hemoglobin A1c and other outcomes. The economic effect of education is not well studied. However, the Diabetes Prevention Program demonstrated the benefits of lifestyle-based education in preventing or delaying the development of type 2 diabetes in high-risk people and in being cost-effective long term. CONCLUSION:High direct and indirect costs and the prevalence of diabetes require urgent global awareness and interventions from many angles. We encourage clinicians and agencies to prioritize the education of people living with diabetes to prevent and treat diabetes and its complications.

(Abstracted from N Engl J Med 2025;392:1801-1812) Automated insulin delivery (AID) systems improve outcomes in type 1 diabetes mellitus (T1DM), but their role in type 2 diabetes mellitus (T2DM) remains uncertain due to limited, small, or uncontrolled studies. Many patients achieve glycated hemoglobin (HbA1c) <7% with glucagon-like peptide 1 agonists or sodium-glucose cotransporter 2 inhibitors, but those who do not may benefit from AID.

CONTEXT:Current diabetes care and education programs and expert clinical diabetes management guidelines focus on diabetes self-care behaviors and have yet to incorporate complementary therapies. Complementary therapies, such as music therapy, yoga, mindfulness, and art therapy, have been used globally for centuries and have positive metabolic and glycemic outcomes. In this mini-review, we describe complementary therapies successfully used in diabetes, identify current evidence-based practice gaps, and provide recommendations for incorporating complementary therapies into diabetes care. EVIDENCE ACQUISITION:We thoroughly searched relevant PubMed and Google Scholar studies from 2004 to 2024. Our inclusion criteria were clinical trial studies using the search terms "diabetes self-management" OR "metabolic outcomes" OR "diabetes" OR "type of complementary therapy (music therapy, mindfulness, yoga or art therapy) OR population (type 1 diabetes, type 2 diabetes, prediabetes, diabetes)." EVIDENCE SYNTHESIS:We synthesized the evidence to determine complementary therapies (music therapy, mindfulness, yoga, or art therapy) that benefit individuals with diabetes. Findings showed that complementary therapies support diabetes-related psychological and cardiometabolic outcomes and enhance the Association of Diabetes Care and Education Specialists 7 Self-Care Behaviors for diabetes self-management, specifically healthy coping, monitoring, reducing risks, and problem-solving. Critical gaps included the lack of large-scale randomized controlled trials in North American diabetes self-management education programs. CONCLUSION:Complementary therapies have positive psychological and physiological health benefits for people living with diabetes, yet more randomized controlled trials are needed to assess their effectiveness on a large scale. In the interim, complementary therapies can be integrated into diabetes education, specifically as adjunctive hands-on therapies to enhance self-management behaviors and meet self-management goals.

CONTEXT:Insulin therapy is first-line therapy for people with type 1 diabetes and often used for people with type 2 diabetes. Over the years, there has been a surge in insulin products available for use. As a result, clinicians need to have a strong understanding of the differences between insulin agents to provide proper patient care. EVIDENCE ACQUISITION:We included population-level data and searched PubMed and Google Scholar databases for recent systematic reviews, meta-analyses, and original research articles. EVIDENCE SYNTHESIS:Patients who present with severe hyperglycemia or signs consistent with a catabolic state such as weight loss or ketonuria should be initiated on insulin. Furthermore, patients with a hemoglobin A1c (HbA1c) level >10% or an unclear diagnosis of type 1 diabetes should typically be treated with insulin. Insulin products differ mainly in their pharmacokinetic profiles and not mechanism of action. The literature suggests that differences in pharmacokinetics allow certain insulin products to be well equipped to address different clinical situations such as steroid-induced hyperglycemia, managing patients with severe chronic kidney disease or dialysis, and insulin pump therapy. CONCLUSION:Understanding kinetic profiles of different insulin agents will allow clinicians to properly navigate options for either fasting or mealtime coverage. Furthermore, this foundational knowledge will be critical when applying insulin therapy in clinical scenarios such as steroid-induced hyperglycemia, kidney disease, and insulin pump management. Ultimately, this will allow clinicians and patients to create proper diabetes care plans and self-management skills.

Introduction: Emerging adults (EA) ages 18-30 with type 1 diabetes (T1D) experience unique challenges navigating the healthcare system and health insurance. Financial stress and health insurance literacy (HIL) are lower among racially/ethnically diverse EA and contribute to less optimal self-management outcomes and quality of life. The purpose of this study is to understand how to tailor a financial and HIL toolkit to racially/ethnically diverse EA with T1D. Methods: A community advisory board (CAB) engaged in five 60-minute focus groups. Transcripts were de-identified and coded by three team members for a deductive thematic analysis using a priori codes. An independent investigator cross-checked codes and resolved discrepancies to minimize bias. Member-checking was performed using a structured guide to validate findings. Results: The CAB had 100% retention and was comprised of six EAs with T1D (50% female, 66.6% racially/ethnically diverse, 50% Medicaid, mean age 26.6 ± 7.26 years) and four financial/insurance/diabetes experts (mean age 50.75 ± 7.04 years). The following key themes to tailor the toolkit to racially/ethnically diverse EA with T1D emerged: 1) addressing clinician bias (ableism, technology/therapy recommendation bias), 2) community and support systems, 3) self-advocacy (empowerment, mental health impacts of T1D), 4) acknowledging health disparities (navigating financial and insurance stress, geographic area, health and insurance literacy) and 4) representation (culture and family dynamics, healthcare providers with T1D, racial/ethnic media representation). Conclusion: The CAB emphasized addressing clinician bias, community/support systems, self-advocacy, health disparities and representation to tailor the toolkit to racially/ethnically diverse EA with T1D. A 13-part mixed-media toolkit has been developed incorporating the key themes identified by the CAB and will be tested for efficacy in a randomized controlled trial. Disclosure C.S. Shannon: None. A.K. Kanchibhatla: None. M. Roche: None. J. Rieke: None. C. Lewis: None. D.A. Williams: None. E.L. Lundgrin: None. B. Hatipoglu: Research Support; Tandem Diabetes Care, Inc. M.L. Litchman: Research Support; American Diabetes Association, Association of Diabetes Care & Education Specialists, Dexcom, Inc. Other Relationship; Association of Diabetes Care & Education Specialists. Research Support; National Institutes of Health. N.A. Allen: Research Support; Dexcom, Inc. Consultant; Diathrive Health. J.E. Blanchette: Speaker's Bureau; Insulet Corporation. Board Member; Juvenile Diabetes Research Foundation (JDRF). Research Support; American Heart Association, Association of Diabetes Care & Education Specialists, National Institute of Diabetes and Digestive and Kidney Diseases, Leona M. and Harry B. Helmsley Charitable Trust. Advisory Panel; LifeScan Diabetes Institute. Consultant; WellDoc. Advisory Panel; Cardinal Health/Edgepark. Funding The Leona M. and Harry B. Helmsley Charitable Trust (G-2305-05992)

Introduction & Objective: Hypoglycemia is known to increase morbidity, mortality, and lengthen hospital stay leading to increased health care costs. The purpose of our study is to investigate the prevalence and identify causes and risk factors contributing to inpatient hypoglycemia. We report findings from two of our largest community hospitals in combination with our previously reported data from a tertiary referral center to better represent the general population. Methods: We performed a retrospective cross sectional analysis of adult patients 18 years and older who were admitted to two of our community hospitals and had a hypoglycemic event, defined as glucose ≤55 mg/dL. A chart review, during a six month period in 2022 and 2023, was conducted to identify causes and associated comorbidities. We incorporated data from our previously reported tertiary care center findings. Results: We evaluated 1,928 episodes of hypoglycemia occurring in 1,044 adult patients hospitalized across 3 hospitals. 57% of the patients had diabetes mellitus. Hypoglycemia occurred most frequently due to decreased caloric intake related to critical illness (53%) followed by insulin-induced hypoglycemia (39%). In patients without diabetes, 75% of hypoglycemic events were due to decreased caloric intake and critical illness. Kidney failure (32%), coronary artery disease (20%) and malignancy (15%) were the comorbidities most frequently associated with hypoglycemia. Conclusion: Hypoglycemic events were most frequently caused by decreased caloric intake and insulin administration. Within the 40% of patients who did not have diabetes, 75% had hypoglycemia due to decreased caloric intake. This sheds light onto a population which has traditionally not been associated with hypoglycemia. Identifying patients at risk for hypoglycemia, improving nutritional status in critically ill patients and optimizing glycemic monitoring/insulin management are areas where intervention can improve inpatient hypoglycemia rates. Disclosure I.C. Zonfa: None. C. Lewis: None. N.R. Galloway: Consultant; Tidepool. Board Member; Association Diabetes Care and Education Specialists. B. Hatipoglu: Research Support; Tandem Diabetes Care, Inc. Y. Tsushima: None.

Abstract Disclosure: E.N. Haddad: None. M. Lansang: None. H. Xiao: None. R. Walsh: None. R. Simon: None. B.A. Hatipoglu: None. K. Zhou: None. Background: There is a lack of information regarding the immediate post-operative period as a predictor of early and long-term insulin independence after total pancreatectomy and islet auto-transplantation (TPIAT). This study examined the baseline and peri-operative variables that are associated with one-year and longer-term insulin independence following TPIAT. Methods: This was a retrospective study of 46 TPIAT patients in a single hospital system between 2010 and 2022. Perioperative variables were compared between short- (one year) and long-term (last follow up outside of year one) insulin-independent versus dependent patients. Multivariable models were used to adjust for clinically important variables. Results: The median age of the cohort at time of TPIAT was 38.5 years (IQR 30, 49). Patients were predominantly white (91%) and 50% were female. Nine (20%) and seven (15%) patients achieved short- and long-term insulin independence, respectively. The patients were followed for a median of 2.8 years (IQR 1.0, 4.7). There were no significant differences in patient demographics (age, sex, ethnicity), duration of pancreatitis, HbA1c, or mixed meal testing results (area under c-peptide curve from 0 to 4 hours) between those achieving insulin independence and those who did not. Short term insulin-independence was associated with higher median transplanted islet equivalents (IEQ)/kg (6,981 vs 4,493, p=0.02), lower units of basal insulin on discharge (7 vs 12, p=0.009), and lower rates of discharge from the hospital with an insulin regimen (67% vs 100%, p=0.006). Short-term insulin independence was also associated with decreased median insulin use in the immediate 24-hour post-operative period (14.3 vs 45.3 units, p=0.03), though this was not statistically significant when adjusting for patient weight (0.23 vs 0.56 units/kg, p=0.13). The odds of having short term insulin independence increased by 80% for every 1,000 increase in IEQ/kg (OR 1.80, CI 1.18 to 3.12, p=0.005) and decreased by 32% for every additional basal unit of insulin on discharge (OR 0.68, CI 0.42 to 0.91, p=0.003). This was no longer statistically significant after adjusting for sex, age, mixed meal testing area under c-peptide curve at 4 hours, and HbA1c. Long-term insulin independence was also associated with transplanted IEQ/kg and basal insulin units at discharge in univariable analysis. None of the patients on insulin or any other antihyperglycemic medication prior to surgery achieved short- or long-term insulin independence. Conclusion: Short- and long-term insulin independence after TPIAT is associated with a higher transplanted IEQ/kg and fewer units of basal insulin at discharge. Immediate post-operative variables can be used to inform the discussions clinicians have with their patients regarding glycemic prognosis following TPIAT. Presentation: 6/2/2024

ObjectiveThis study examined the pre- and post-operative variables that are associated with one-year and long-term insulin independence following total pancreatectomy and islet auto-transplantation (TPIAT). Methods: Charts of 46 TPIAT patients seen from 2010 to 2022 in a single hospital system were retrospectively analyzed. Pre- and post-operative variables were compared between short- (one year) and long-term (last follow up outside of year one) insulin-independent versus dependent patients.ResultsNine (20%) and seven (15%) patients achieved short- and long-term insulin independence, respectively. The patients were followed for a median of 2.8 years (IQR 1.0, 4.7). Short term insulin-independence was associated with higher median transplanted islet equivalents IEQ/kg (6,981 vs 4,493, p=0.02), lower units of basal insulin on discharge (7 vs 12, p=0.009), and lower rates of discharge from the hospital with an insulin regimen (67% vs 100%, p=0.006). The odds of having short term insulin independence increased by 80% for every 1,000 increase in IEQ/kg (OR 1.80, CI 1.18 to 3.12, p=0.005) and decreased by 32% for every additional basal unit of insulin on discharge (OR 0.68, CI 0.42 to 0.91, p=0.003) on average. Long-term insulin independence was also associated with transplanted IEQ/kg in univariable analysis. No patient on antihyperglycemic medication prior to surgery achieved insulin independence.ConclusionShort- and long-term insulin independence after TPIAT is associated with higher transplanted IEQ/kg and immediate post-operative variables that can be used to inform the discussions clinicians have with their patients regarding glycemic prognosis following TPIAT. Complete insulin independence remains low following TPIAT.

Total pancreatectomy and autologous islet transplantation (TPAIT) is a procedure to ameliorate dysglycemia associated with post-pancreatectomy. Patients who undergo TPAIT are at risk of developing hypoglycemia postoperatively. The current literature suggests that hypoglycemia may be due to a glucagon-deficiency state. To date, there is minimal literature available that explores treatment options to minimize hypoglycemia in these patients. In this case, a 29-year-old female patient was administered a microdosing glucagon protocol post TPAIT and experienced improvements in hypoglycemia. We describe the dosing regimen of the protocol and provide continuous glucose monitoring data to support our findings. This case adds to the limited evidence on effective treatment options for these rare patients. To our knowledge, this is the first application of a microdosing glucagon protocol to treat hypoglycemia associated with TPAIT.

Health care systems need to work with their government agencies to plan prediabetes and diabetes strategies and policies at a national level. Moreover, public health ser-vices need to focus on diabetes screening prevention and remission, as well as delay-related complications by encouraging patients with chronic diseases, such as diabetes and hypertension, to use health care services. Health care agencies must redesign their consultative services and use a team care approach with referrals to secondary/tertiary care when needed and heavily consider psychosocial determinants of health as part of chronic health care. Environmental health is important for human health and EDCs should be a top priority for environmental agencies. Within the large universal health care system, the impact of one system on another could not have been better realized than during our experience with the COVID-19 pandemic.Of course, diabetes prevention is our first strategy against this disease. Yet, knowing that 1 out of 2 people in the world is an undiagnosed diabetic, remission of diabetes rekindles our hope as we battle increasing prevalence across the world.

Background It is known that survivors of acute SARS-CoV-2 infection can experience a complex disease known as post-acute sequelae of .The clinical manifestations of acute COVID-19 have been well characterized; however, less is known about the risk of new-onset diabetes mellitus (DM) in the post-acute phase of COVID-19.Methods An adult cohort with either confirmed COVID-19 (by diagnosis or positive test) or without COVID-19 was sampled from a large national health research network between January 1 st , 2020, and July 8 th , 2022.We investigated the outcomes of a new diagnosis of DM (type 1 or 2) occurring after COVID-19 through 12 months after infection.Risk estimates [incidence, relative risk (RR), attributable risk] were used to describe the probability of new post-COVID diabetes.Hazard ratios and 95% confidence intervals were used to describe the risk factors associated with new diabetes. FindingsThe 3-month probability of new diabetes was 2.48/1,000 among COVID+, and the RR of new diabetes was highest at 12 months [8.94 (8.54, 9.36)].Vitamin D deficiency [HR: 1.52 (95% CI: 1.42, 1.63)] was associated with an increased risk of T2DM and having vitamin D deficiency with either obesity (BMI > 30 kg/m 2 ) or kidney dysfunction (GFR < 60) was associated with more than five times increased risk of T1DM.Interpretation A large proportion of excess diabetes (type 1 and 2) may be attributed to SARS-CoV-2 infection.Traditional risk factors for diabetes and vitamin D deficiency are associated with an increased risk of new diabetes outcomes.PASC care should involve the identification and management of diabetes.

Objective: To review the evidence of existing literature on the management of statin intolerance. Methods: We searched for literature pertaining to statin intolerance and treatments in PubMed. We reviewed articles published between 2005 and 2022. Results: Statin-associated myalgia is the most common adverse effect of statin therapy and the most common reason for statin discontinuation. The risk factors for statin intolerance include unexplained muscle pain with other lipid-lowering therapy, unexplained cramps, a history of increased creatine kinase levels, a family history of muscle symptoms, and a family history of muscle symptoms with lipid therapy. Vitamin D repletion and coenzyme Q supplementation may help alleviate the musculoskeletal effects of statins. Trials of different types of statins and different dosing regimens are recommended to improve tolerability. The use of statins in individuals who perform regular exercise requires closer attention to muscular symptoms and creatine kinase levels; however, it does not preclude the use of statins. Conclusion: Management of the adverse effects of statin therapy and improving statin tolerability are key to achieving optimum cardiovascular benefits. Identifying statin-associated adverse effects and managing them appropriately can reduce unnecessary statin discontinuation and subsequently provide longer cardiovascular protection. & COPY; 2023 AACE. Published by Elsevier Inc. All rights reserved.

CONTEXT:Total pancreatectomy with islet autotransplantation (TPIAT) is a definitive management for intractable pain in patients with chronic pancreatitis (CP). Islet autotransplantation (IAT) allows for the preservation of beta cells to prevent complications of long-term diabetes. OBJECTIVE:Our study follows TPIAT recipients for up to 12 years to determine the efficacy of the procedure completed with an off-site islet isolation facility. METHODS:Patient demographics, mixed meal tolerance test measures, glycosylated hemoglobin, insulin requirements, and homeostatic model assessment for insulin resistance values were collected prior to surgery and at the most recent follow-up assessment. RESULTS:Forty-four patients (median age, 46.0 years; range, 20-78 years) underwent TPIAT for CP. At an overall median follow-up time of 845.5 days (range, 195-4470 days) 8 patients were insulin independent and 36 patients were insulin dependent. At the most recent follow-up time point, islet yield per kilogram was the strongest indicator of insulin independence. Homeostatic model assessment for insulin resistance values were comparable between insulin independent and dependent cohorts. CONCLUSIONS:Our long-term follow-up data suggest that IAT can effectively reduce insulin requirements and improve postoperative glycemic control.

Objective To review evidence of existing and new pharmacological therapies for lowering lipoprotein(a) (Lp[a]) concentrations and their impact on clinically relevant outcomes. Methods We searched for literature pertaining to Lp(a) and pharmacological treatments in PubMed. We reviewed articles published between 1963 and 2020. Results We found that statins significantly increased Lp(a) concentrations. Therapies that demonstrated varying degrees of Lp(a) reduction included ezetimibe, niacin, proprotein convertase subtilisin/kexin type 9 inhibitors, lipoprotein apheresis, fibrates, aspirin, hormone replacement therapy, antisense oligonucleotide therapy, and small interfering RNA therapy. There was limited data from large observational studies and post hoc analyses showing the potential benefits of these therapies in improving cardiovascular outcomes. Conclusion There are multiple lipid-lowering agents currently being used to treat hyperlipidemia that also have a Lp(a)-lowering effect. Two RNA therapies specifically targeted to lower Lp(a) are being investigated in phase 3 clinical trials and, thus far, have shown promising results. However, evidence is lacking to determine the clinical relevance of reducing Lp(a). At present, there is a need for large-scale, randomized, controlled trials to evaluate cardiovascular outcomes associated with lowering Lp(a).

Type 1 diabetes is a chronic autoimmune disorder that results in destruction of insulin-producing cells in the pancreas. The autoimmune process is thought to be waxing and waning resulting in variable endogenous insulin secretion ability. An example of this is the honeymoon phase or partial remission phase of type 1 diabetes, during which optimal control of blood glucoses can be maintained with significantly reduced exogenous insulin, and occasionally exogenous insulin can be temporarily discontinued altogether. Understanding this phase is important because even fairly small amounts of endogenous insulin secretion is associated with reduced risk of severe hypoglycemia and microvascular complications.

Cures for T1D are finally on the horizon, and the advances addressed above result from tremendous efforts to change the lives of people living with T1D. However, we still wait for the day we can administer therapies to those early on in T1D progression or who have recently been diagnosed with T1D to improve the course of their disease management significantly. For now, technologies, such as the bionic pancreas, are exciting and give us promise to improve the lives of people with T1D.