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Introduction Previous research has found that the percentage of US adults with diabetes achieving a glycated hemoglobin (HbA1c) target of <7.0% with currently available treatments has been fairly constant from 2003 to 2010, remaining at just over 50% [ 1 ]. The objective of this study was to compare the most recent data (2011–2014) with earlier data to track progress on HbA1c target achievement, for both the general target of <7.0% and inferred individualized targets based on age and the presence of complications. Methods Data from 2677 adults with self-reported diabetes from the National Health and Nutrition Examination Survey (NHANES) from 2007 to 2014 were examined to determine the percentage of adults who achieved HbA1c targets of <7% and an individualized target based on age and comorbidities. National estimates are reported by using weights that account for the complex sampling design of the NHANES. Results The percentage of people with diabetes and HbA1c <7.0% slightly declined from 52.2% (95% CI 48.7–55.7%) to 50.9% (95% CI 47.2–54.7%) between the two most recent waves of data. Achievement of individualized targets declined from 69.8% (95% CI 66.5–73.0%) to 63.8% (95% CI 60.1–67.5%). The percentage with HbA1c >9.0% increased from 12.6% (95% CI 10.5–14.8%) to 15.5% (95% CI 12.9–18.2%). Achievement of individualized targets varied by age group and presence of comorbidities, but exhibited similar trends as general target achievement. Conclusions Despite the development of many new medications to treat diabetes during the past decade, the proportion of patients achieving glycemic control targets has not improved. Funding Intarcia Therapeutics.

Improved Glucose Excursions Using an Implantable Real-Time Continuous Glucose Sensor in Adults With Type 1 Diabetes Satish K. Garg , MD 1 , Sherwyn Schwartz , MD 2 and Steven V. Edelman , MD 3 1 Department of Medicine and Pediatrics, Barbara Davis Center for Childhood Diabetes, University of Colorado Health Sciences Center, Denver, Colorado 2 Diabetes & Glandular Disease Research Associates, San Antonio, Texas 3 Department of Medicine, University of California, San Diego, California Address correspondence and reprint requests to Satish K. Garg, MD, Barbara Davis Center for Childhood Diabetes, University of Colorado Health Sciences Center, 4200 East 9th Ave., Campus Box B-140, Denver, CO 80262. E-mail: satish.garg{at}uchsc.edu Abstract OBJECTIVE —The capability of emerging glucose sensor technology to continuously monitor glucose levels may provide ways to achieve glycemic targets while reducing hypoglycemia. RESEARCH DESIGN AND METHODS —A first-generation, long-term continuous glucose sensor (DexCom, San Diego, CA) was implanted subcutaneously in 15 patients with type 1 diabetes. Safety, efficacy, and potential benefits were evaluated during a blinded control period and in a study period during which patients had real-time access to the glucose data. RESULTS —The bias differences between self-monitored blood glucose (SMBG) and sensor data were <15% at 2.8, 4.4, 5.6, 8.3, and 11.1 mmol/l. No procedure or device-related adverse events were observed. Of 15 patients, 13 (87%) had functional sensors during the 12-h simulated home use study with 96% of points in the A and B regions of the Clarke error grid, an R value of 0.88, and a mean absolute relative difference of 16% when retrospectively compared with SMBG. In actual home use, during the blinded control period (50 ± 16 days) data were not displayed to the patient, whereas during the unblinded study period (44 ± 17 days) the data were presented to the patient, and alerts were set at 3.1, 5.6, and 11.1 mmol/l. Patients spent a median of 47% less time below 3.1 mmol/l ( P < 0.05) and 25% less time above 13.3 mmol/l ( P < 0.05) during the nonblinded study period compared with the blinded control period. CONCLUSIONS —The availability of real-time continuous glucose values may help patients reduce their hyperglycemic excursions and lower the risk of hypoglycemia. DCCT, Diabetes Control and Complications Trial MARD, mean absolute relative difference SHU, simulated home use SMBG, self-monitored blood glucose YSI, Yellow Springs Instrument Footnotes S.K.G. and S.E. have received consulting fees from DexCom for serving on the advisory board and grant research funds for conducting the study. S.S. has received grant research funds from DexCom for conducting the study. Accepted December 16, 2003. Received August 20, 2002. DIABETES CARE

Overconsumption of added sugars is a key contributor to the growing obesity, prediabetes, and type 2 diabetes pandemics. The nutrition therapy guidance of the American Diabetes Association recognizes that using low- and no-calorie sweeteners (LNCS) to reduce consumption of added sugars can reduce low–nutrient-density sources of calories and carbohydrate to beneficially affect glycemia, weight, and cardiometabolic health. This article provides information for primary care providers, diabetes care and education specialists, and other diabetes clinicians on the safety of LNCS and summarizes research evidence on the role of LNCS in glycemic and weight management. It also provides practical strategies for counseling individuals about how to integrate LNCS into their healthy eating pattern. The increasing number of adults and children/adolescents who are overweight and obese in the United States is a national health concern. Numerous studies have shown that overweight and obesity are significant risk factors for several interrelated health conditions, including prediabetes, type 2 diabetes, cardiovascular and cerebrovascular disease, hypertension, stroke, and other significant health conditions of increasing concern (1,2), such as nonalcoholic steatohepatitis and nonalcoholic fatty liver disease (3). Excessive weight is a concern in individuals with type 1 or type 2 diabetes and is a leading risk factor for prediabetes (4) because it decreases insulin sensitivity, which creates additional challenges in achieving and maintaining management of glycemia and other cardiometabolic health metrics (5). Given the growing pandemics of type 1 and type 2 diabetes, prediabetes, and obesity and their associated costs (6), it is imperative that primary care providers (PCPs), diabetes care and education specialists, and other diabetes clinicians provide people who have or are at risk for developing diabetes with practical strategies for weight management and healthier eating. For many people, the most challenging part of their diabetes care plan is knowing what to eat and adhering to a healthy eating plan over time (7). Some individuals can achieve some success by reducing consumption of added sugars by choosing foods and beverages sweetened with low- and no-calorie sweeteners (LNCS) and using their preferred type and forms of table-top LNCS to sweeten foods and beverages. LNCS, the term used throughout this publication, are also referred to as low-calorie sweeteners, nonnutritive sweeteners, sugar substitutes, and high-intensity sweeteners (8). As sweetening ingredients, LNCS add no or negligible calories to foods and beverages. This article reviews evidence supporting the safety and efficacy of LNCS in glycemic and weight management. It also provides practical strategies for clinicians to help people with diabetes and prediabetes effectively use LNCS to replace full-calorie sources of added sugars to assist with weight management and glycemic goals.

Abstract Diabetes can be an arduous journey both for people with diabetes (PWD) and their caregivers. While the journey of every person with diabetes is unique, common themes emerge in managing this disease. To date, the experiences of PWD have not been fully considered to successfully implement the recommended standards of diabetes care in practice. It is critical for health-care providers (HCPs) to recognize perspectives of PWD to achieve optimal health outcomes. Further, existing tools are available to facilitate patient-centered care but are often underused. This statement summarizes findings from multistakeholder expert roundtable discussions hosted by the Endocrine Society that aimed to identify existing gaps in the management of diabetes and its complications and to identify tools needed to empower HCPs and PWD to address their many challenges. The roundtables included delegates from professional societies, governmental organizations, patient advocacy organizations, and social enterprises committed to making life better for PWD. Each section begins with a clinical scenario that serves as a framework to achieve desired health outcomes and includes a discussion of resources for HCPs to deliver patient-centered care in clinical practice. As diabetes management evolves, achieving this goal will also require the development of new tools to help guide HCPs in supporting PWD, as well as concrete strategies for the efficient uptake of these tools in clinical practice to minimize provider burden. Importantly, coordination among various stakeholders including PWD, HCPs, caregivers, policymakers, and payers is critical at all stages of the patient journey.

To understand how patients use continuous glucose monitoring (CGM) data in their diabetes management. We surveyed patients who regularly used CGM (>6 days per week), using 70 questions, many scenario-based. The survey had 6 sections: patient characteristics, general CGM use, hypoglycemia prevention and management, hyperglycemia prevention and management, insulin dosing adjustments (both for incidental hyperglycemia not at meals and at mealtimes), and real-time use versus retrospective analysis. The survey was completed by 222 patients with type 1 diabetes. In response to a glucose of 220 mg/dL, the average correction dose adjustment based on rate of change arrows varied dramatically. Specifically, when the CGM device showed 2 arrows up (glucose increasing >3 mg/dL/minute), respondents stated they would increase their correction bolus, on average, by 140% (range, 0 to 600%). Conversely, 2 arrows down (glucose decreasing >3 mg/dL/minute) caused respondents to reduce their dose by 42%, with 24% omitting their dose entirely. Furthermore, 59% of respondents stated they would delay a meal in response to rapidly rising glucose, whereas 60% would wait until after a meal to bolus in response to falling glucose levels. With a glucose value of 120 mg/dL and a falling glucose trend, 70% of respondents would prophylactically consume carbohydrates to avoid hypoglycemia. CGM users utilize CGM data to alter multiple aspects of their diabetes care, including insulin dose timing, dose adjustments, and in hypoglycemia prevention. The insulin adjustments are much larger than common recommendations. Additional studies are needed to determine appropriate insulin adjustments based on glucose trend data.

Polonsky et al develop and distribute a psychological insulin resistance (PIR) self-report survey to a large multicity sample of patients with type 2 diabetes who were not taking insulin. They examine their willingness to take insulin if it was prescribed and to identify perceived attitudinal barriers to insulin therapy. After discussing the results, they learn that PIR is common.

The growing prevalence of type 2 diabetes (T2D) remains a leading health concern in the US. Despite new medications and technologies, glycemic control in this population remains suboptimal, which increases the risk of poor outcomes, increased healthcare resource utilization, and associated costs. This article reviews the clinical and economic impacts of suboptimal glycemic control in patients on basal-bolus insulin or multiple daily injections (MDI) and discusses how new technologies, such as tubeless insulin delivery devices, referred to as “patch pumps”, have the potential to improve outcomes in patients with T2D.

We performed a survey of 305 patients with type 2 diabetes receiving basal insulin and 240 physicians to measure key contrasts and similarities in patients' preferences and providers' beliefs and perceptions regarding insulin use. Many patients reported being more frustrated with their lack of treatment progress than physicians were aware of. Patients were also more likely to say they would do more than their physicians believed they would to better manage their diabetes. Identifying priorities and setting clear goals and timelines for achieving glycemic control could provide an opportunity to address these differences and reduce patients' frustration.

Studies on acute complications in adult T1D were previously reported from the United States (U.S.) and from Germany. The aim was to compare demographic characteristics and patterns of severe hypoglycaemia (SH) and diabetic ketoacidosis (DKA) between Germany and the U.S. Descriptive comparison on individuals aged ≥18 years, with T1D duration ≥2 years were made between the German diabetes-patient registry (DPV) and the U.S. electronic-health-record database (T1PCO). Individuals in both databases were divided into patients with haemoglobin A1c (HbA1c) <7% and HbA1c ≥7%. 5190 (DPV) and 31,430 individuals (T1PCO) fulfilled the inclusion criteria. DPV patients were younger, more often male and had lower body-mass index. In both databases, more males than females had HbA1c <7%. Individuals had higher HbA1c in T1PCO compared to DPV. The relationship between HbA1c and DKA was similar in both databases. SH revealed a U-shaped curve in T1PCO, but no clear pattern was present in DPV. SH events increased with higher age in DPV, but not in T1PCO. Patterns of SH differ between Germany and U.S. Differences in capture of SH among the databases cannot be excluded, but differences in health care including patient education and level of care by specialists are likely. •HbA1c- and age-related patterns of SH differ between Germany and U.S.•Possibly, due to differences in capture of SH.•Metabolic control (especially in young adults) is worse in T1PCO compared to DPV.•Patient education and level of care by specialists may play a role.

To provide clinicians with an overview of similar biologic products including biosimilars and new insulin versions available in the U.S. and of key issues associated with such products, including differences in manufacturing and regulatory approaches and their impact on clinical use. We reviewed the relevant clinical and regulatory literature. Patent protections for many biologics including several insulin preparations have or will expire shortly. This opens the door for new insulin versions to enter the U.S. and global marketplace. The development, manufacturing, and approval process for similar biologic products is more complex than for generic versions of small molecules. Most similar biologic products in the U.S. will be submitted for approval under section 351(k), a newly created biosimilar regulatory pathway. However, some biologics, including new insulin versions, will be submitted via the existing 505(b)(2) regulatory pathway. These regulatory pathways have implications for how such products may be labeled, how they may be dispensed, and how patients may perceive them. The immunogenicity of biologics can affect safety and efficacy and can be altered through subtle changes in manufacturing. With the arrival of new insulin versions, health care providers will need to understand the implications of interchangeability, therapeutic equivalence, substitution, switching, and new delivery devices. An understanding of the above topics will be important as physicians, payers, and patients choose between similar versions of a reference listed biologic product.