Vitamin D plays a critical role in many physiological functions, including calcium metabolism and musculoskeletal health. This commentary aims to explore the intricate relationships among skin complexion, race, and 25-hydroxyvitamin D (25[OH]D) levels, focusing on challenges the Endocrine Society encountered during clinical practice guideline development. Given that increased melanin content reduces 25(OH)D production in the skin in response to UV light, the guideline development panel addressed the potential role for 25(OH)D screening in individuals with dark skin complexion. The panel discovered that no randomized clinical trials have directly assessed vitamin D related patient-important outcomes based on participants' skin pigmentation, although race and ethnicity often served as presumed proxies for skin pigmentation in the literature. In their deliberations, guideline panel members and selected Endocrine Society leaders underscored the critical need to distinguish between skin pigmentation as a biological variable and race and ethnicity as socially determined constructs. This differentiation is vital to maximize scientific rigor and, thus, the validity of resulting recommendations. Lessons learned from the guideline development process emphasize the necessity of clarity when incorporating race and ethnicity into clinical guidelines. Such clarity is an essential step toward improving health outcomes and ensuring equitable healthcare practices.

A long-held precept is that vitamin D supplementation primarily, if not exclusively, benefits individuals with low circulating 25-hydroxyvitamin D (25[OH]D) concentrations at baseline. However, the most appropriate 25(OH)D threshold to distinguish unacceptably low vs reliably adequate concentrations remains controversial. Such threshold proposals have largely been based on observational studies, which provide less robust evidence compared to randomized clinical trials (RCTs). Since the Endocrine Society's first vitamin D-related guideline was published in 2011, several large vitamin D-related RCTs have been published, and a newly commissioned guideline development panel (GDP) prioritized 4 clinical questions related to the benefits and harms of vitamin D supplementation in generally healthy individuals with 25(OH)D levels below a threshold. The GDP determined that available clinical trial evidence does not permit the establishment of 25(OH)D thresholds that specifically predict meaningful benefit with vitamin D supplementation. The panel noted important limitations in the available evidence, and the panel's overall certainty in the available evidence was very low. Nonetheless, based on the GDP's analyses and judgments, the Endocrine Society no longer endorses its previously proposed definition of vitamin D "sufficiency" (ie, at least 30 ng/mL [75 nmol/L]) or its previously proposed definition of vitamin D "insufficiency" (ie, greater than 20 ng/mL [50 nmol/L] but lower than 30 ng/mL [75 nmol/L]). The Endocrine Society's rationale for such is the subject of this Guideline Communication.

Given the proven benefits of screening to reduce diabetic ketoacidosis (DKA) likelihood at the time of stage 3 type 1 diabetes diagnosis, and emerging availability of therapy to delay disease progression, type 1 diabetes screening programmes are being increasingly emphasised. Once broadly implemented, screening initiatives will identify significant numbers of islet autoantibody-positive (IAb+) children and adults who are at risk of (confirmed single IAb+) or living with (multiple IAb+) early-stage (stage 1 and stage 2) type 1 diabetes. These individuals will need monitoring for disease progression; much of this care will happen in non-specialised settings. To inform this monitoring, JDRF in conjunction with international experts and societies developed consensus guidance. Broad advice from this guidance includes the following: (1) partnerships should be fostered between endocrinologists and primary-care providers to care for people who are IAb+; (2) when people who are IAb+ are initially identified there is a need for confirmation using a second sample; (3) single IAb+ individuals are at lower risk of progression than multiple IAb+ individuals; (4) individuals with early-stage type 1 diabetes should have periodic medical monitoring, including regular assessments of glucose levels, regular education about symptoms of diabetes and DKA, and psychosocial support; (5) interested people with stage 2 type 1 diabetes should be offered trial participation or approved therapies; and (6) all health professionals involved in monitoring and care of individuals with type 1 diabetes have a responsibility to provide education. The guidance also emphasises significant unmet needs for further research on early-stage type 1 diabetes to increase the rigour of future recommendations and inform clinical care.

Background: Hypoglycemia from overtreatment is a serious but underrecognized complication among older adults with type 2 diabetes. However, diabetes treatment is seldom deintensified. We assessed the effectiveness of a Clinical Decision Support (CDS) tool and shared decision-making (SDM) in decreasing the number of patients at risk for hypoglycemia and reducing the impact of non-severe hypoglycemic events. Methods: HypoPrevent was a pre-post, single arm study at a five-site primary care practice. We identified at-risk patients (>= 65 years-old, with type 2 diabetes, treated with insulin or sulfonylureas, and HbA(1c) < 7.0%). During three clinic visits over 6 months, clinicians used the CDS tool and SDM to assess hypoglycemic risk, set individualized HbA(1c) goals, and adjust use of hypoglycemic agents. We assessed the number of patients setting individualized HbA(1c) goals or modifying medication use, changes in the population at risk for hypoglycemia, and changes in impact of non-severe hypoglycemic events using a validated patient-reported outcome tool (TRIM-HYPO). Results: We enrolled 94 patients (mean age-74; mean HbA(1c) (+/- SD)-6.36% +/- 0.43), of whom 94% set an individualized HbA(1c) goal at either the baseline or first follow-up visit. Ninety patients completed the study. Insulin or sulfonylurea use was decreased or eliminated in 20%. An HbA(1c) level before and after goal setting was obtained in 53% (N = 50). Among these patients, the mean HbA(1c) increased 0.53% (p < 0.0001) and the number of patients at-risk decreased by 46% (p < 0.0001). Statistically significant reductions in the impact of hypoglycemia during daily activities occurred in both the total score and each functional domain of TRIM-HYPO. Conclusions: In a population of older patients at risk for hypoglycemia, the use of a CDS tool and SDM reduced the population at risk and decreased the use of insulin and sulfonylureas. Using a patient-reported outcome tool, we demonstrated significant reductions in the impact of hypoglycemia on daily life.

In an effort to enhance the trustworthiness of its clinical practice guidelines, the Endocrine Society has recently adopted new policies and more rigorous methodologies for its guideline program. In this Clinical Practice Guideline Communication, we describe these recent enhancements-many of which reflect greater adherence to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach to guideline development-in addition to the rationale for such changes. Improvements to the Society's guideline development practices include, but are not limited to, enhanced inclusion of nonendocrinologist experts, including patient representatives, on guideline development panels; implementation of a more rigorous conflict/duality of interest policy; a requirement that all formal recommendations must be demonstrably underpinned by systematic evidence review; the explicit use of GRADE Evidence-to-Decision frameworks; greater use and explanation of standardized guideline language; and a more intentional approach to guideline updating. Lastly, we describe some of the experiential differences our guideline readers are most likely to notice.

The rising prevalence of endocrine disorders over the past two decades -primarily driven by chronic conditions like diabetes- has resulted in a shortage of adult endocrinologists. Despite the wide gap between workforce supply and clinical care demand, a career in endocrinology is not viewed as an attractive choice for internal medicine (IM) residents. Indeed, the number of applicants to endocrinology training programs relative to available positions has declined since 2008, and endocrinology is now one of the least sought-after IM subspecialties. The reduction of endocrinology fellowship applicants is even more pronounced for three-year research positions aimed at training physician-scientists. While compensation, workload, and an increasingly competitive funding environment are major contributors to these trends, we believe other factors are also responsible. These include a lack of exposure to outpatient endocrinology in medical school and residency, excessive service work on inpatient diabetes teams, increasing levels of dissatisfaction and burnout among endocrinology attendings, and insufficient exposure to endocrine mentors during pre-clinical and clinical training. Without intervention, these trends will result in: deleterious public health consequences due to suboptimal delivery of endocrinological care (especially in rural areas); inadequate training of future generations of endocrine clinical educators and scientists; and blunted development of innovative research activity. Concerted efforts involving all stakeholders are necessary to tackle this set of challenges and reenergize the field. In summary, we analyze root causes for the waning interest in endocrinology training, review anticipated consequences on the configuration of the endocrinology community, and propose 'real world' interventions.

The Society and Avalere Health are working to develop and test interventions in clinical settings that will improve early identification and management of T2D patients at high risk for hypoglycemia.

I n the United States, slightly more than half of all adults with diabetes receive guideline-consistent care (1).A smaller proportion has adequate cardiovascular risk factor control (2).Current care of individuals with diabetes and its complications and comorbidities exemplifies many of the challenges facing the U.S. healthcare system (3).Based on the care costs relative to the outcomes achieved, Americans deserve greater value for our healthcare expenditures.Acknowledging the convergence of the diabetes epidemic and the passage of the Affordable Care Act (ACA), the Endocrine Society (ES) seized the opportunity to convene a Washington, DC, Summit on September 12, 2014, to explore the law's impact on patients with diabetes.Summit attendees and speakers included leading diabetes stakeholders, patient advocacy and community-based groups, health plans, research institutions, federal agencies, and policy makers.The agenda featured potential policy solutions as well as challenges and opportunities resulting from ACA implementation.In the following paragraphs, the ES briefly summarizes the proceedings.

Critical illness provides major stresses on all body systems, including those serving important regulatory functions. Endocrinologic and metabolic abnormalities are common on presentation and during hospitalization in the intensive care unit. Some of these abnormalities are the focus of this article. The authors review abnormalities of the adrenal and thyroid glands and in the metabolism of glucose, and include a brief review of abnormalities of sodium and calcium metabolism.

The proposed mechanisms of RTH are not mutually exclusive. In fact, there is considerable experimental evidence that many if not all of these complex receptor interactions with elements of the transcriptional unit are involved in RTH. Several aspects of RTH remain unclear, in particular on a clinical level. We still do not completely understand the seeming paradox of a tight distribution of receptor mutations and wide variability in phenotypic presentation. The discovery that many of the RTH receptors have defects in corepressor interaction makes it tempting to speculate that the variability in RTH phenotype within kindreds is secondary to differences in corepressor expression. These issues may be better understood as research further proceeds into cofactors and their control of transcription. We also need better tools to determine thyroid status at a peripheral level. Basal metabolic rate, serum measurement of thyroid-responsive gene products, echocardiographic techniques, and other clinical measures have for the most part been unhelpful in determining thyroid status of specific organ systems. Consequently, therapeutic interventions for RTH are directed toward normalizing biochemical indices of thyroid homeostasis, without really knowing whether these efforts correct imbalances within crucial tissues. These studies, and the more widespread investigation of hormone receptor action in general, are moving at a breathtaking pace, and there is a keen interest in applying these principals to understanding the pathophysiologic mechanism of a variety of diseases.