Medha N. Munshi

Most diabetes care is delivered in primary care, yet diabetes technologies remain inconsistently integrated. Workforce, training, time, data infrastructure, and insurance barriers contribute to inequitable access and adoption. This scientific statement provides evidence-informed recommendations for integrating diabetes technology into primary care practices. The American Diabetes Association (ADA) convened an interdisciplinary panel that met in person at the Diabetes Technology Meeting in October 2025. Panelists reviewed available evidence, published between 2020 and 2025, on diabetes technology implementation in primary care, with a focus on clear statements and recommendations addressing technology access and adoption, team-based workflows, continuous glucose monitoring, connected insulin delivery, and implementation barriers and opportunities. Virtual meetings were convened over the next 2 months to further develop and finalize statements and recommendations. Together, the ADA and interdisciplinary panel developed 16 consensus statements and 10 key recommendations. Diabetes technologies can be safely and effectively integrated into primary care practices when supported by standardized workflows, appropriate training, defined team roles, and access to specialty expertise. Equitable implementation also requires addressing coverage, affordability, digital literacy, broadband access, interoperability, and workforce development. Integrating diabetes technology into primary care is feasible and necessary to advance equitable, person-centered, data-informed care. Health systems, practices, payors, professional organizations, manufacturers, and policymakers should align resources, training, workflows, payment, and infrastructure to support sustainable implementation and improve outcomes for people with diabetes.

Most diabetes care is delivered in primary care, yet diabetes technologies remain inconsistently integrated. Workforce, training, time, data infrastructure, and insurance barriers contribute to inequitable access and adoption. This scientific statement provides evidence-informed recommendations for integrating diabetes technology into primary care practices. The American Diabetes Association (ADA) convened an interdisciplinary panel that met in person at the Diabetes Technology Meeting in October 2025. Panelists reviewed available evidence, published between 2020 and 2025, on diabetes technology implementation in primary care, with a focus on clear statements and recommendations addressing technology access and adoption, team-based workflows, continuous glucose monitoring, connected insulin delivery, and implementation barriers and opportunities. Virtual meetings were convened over the next 2 months to further develop and finalize statements and recommendations. Together, the ADA and interdisciplinary panel developed 16 consensus statements and 10 key recommendations. Diabetes technologies can be safely and effectively integrated into primary care practices when supported by standardized workflows, appropriate training, defined team roles, and access to specialty expertise. Equitable implementation also requires addressing coverage, affordability, digital literacy, broadband access, interoperability, and workforce development. Integrating diabetes technology into primary care is feasible and necessary to advance equitable, person-centered, data-informed care. Health systems, practices, payors, professional organizations, manufacturers, and policymakers should align resources, training, workflows, payment, and infrastructure to support sustainable implementation and improve outcomes for people with diabetes.

Importance: Metformin may influence risk of dementia, with prior conflicting observations of protection or harm. Objective: To determine the association of randomization to metformin vs. placebo or intensive lifestyle intervention (ILS) in the Diabetes Prevention Program (DPP) with cognitive outcomes (cognitive impairment syndromes and trajectories of cognitive test performance) during the DPP Outcomes Study (DPPOS). Design, Setting & Participants: Prospective long-term follow-up of DPP/DPPOS participants at 27 U.S. centers among adults who were at high risk for type 2 diabetes (T2D) at baseline. Exposures: Randomization to metformin, placebo, or ILS (1996–1999) for 3.2 years followed by open-label metformin in the original randomized metformin group until 2021. Main Outcomes & Measures: Cognitive impairment syndromes were adjudicated in 2022– 2024 in 1,483 participants (median age 74 [IQR 68, 80]) using the National Alzheimer’s Coordinating Center Uniform Dataset version 3. Cognitive performance in executive and memory domains was ascertained with repeated cognitive tests between 2009 and 2024. Multinomial logistic regression and mixed-effects models were fit to examine associations of randomization to metformin with cognitive outcomes. Results: Total metformin exposure (mean ± SD) was 15.5 ±7.7 years/person in the metformin group. Persons in the placebo and ILS groups received out-of-study metformin usually after developing diabetes with mean metformin total exposure of 4.5 ±5.1 and 3.8 ±4.8 years/person in the placebo and ILS groups, respectively. Overall, the frequency distributions of the cognitive syndromes did not differ significantly by treatment group; however, randomization to metformin was associated with a 60% (OR 0.40 [95%CI 0.17, 0.97]) and 62% (OR 0.38 [95%CI 0.16, 0.89]) lower odds of dementia compared with placebo and ILS, respectively, after adjustment for demographics, education, income, and APOE-ε4 genotype. Randomization to metformin was also associated with significantly better memory performance over time (β=0.58; 95%CI: 0.09, 1.1; p=0.02; Cohen’s d=0.1). Conclusions and Relevance: Long-term metformin treatment is associated with a reduced risk of dementia and better memory performance among persons with pre-diabetes or T2D. Estimates were imprecise due to a limited number of dementia cases. Longer follow-up with more dementia cases is needed to confirm our findings. KEY POINTS: Question: Is chronic metformin treatment related to the risk of dementia and cognitive impairment? Findings: Randomization to metformin in the Diabetes Prevention Program was associated with a lower risk of dementia in the Diabetes Prevention Program Outcomes Study compared with the randomization to placebo or randomization to intensive lifestyle intervention, but the overall distribution of cognitive impairment syndromes did not differ significantly by treatment group. Randomization to metformin was also related to modestly better longitudinal performance in a memory test. Meaning: Chronic metformin treatment may decrease the risk of dementia.

As care for type 1 diabetes (T1D) advances, the number of adults with T1D living into older adulthood (ages ≥65 years) continues to grow. The population of older adults with T1D is highly heterogeneous, and over the life span, various factors may change over time while others may not, necessitating an individualized approach to management. A key care consideration for people with T1D is the ongoing need for exogenous insulin replacement intensive self-monitoring for effective management. At the same time, growing older may bring changes such as increased risk of misdiagnosis of T1D as type 2 diabetes, greater vulnerability to hypoglycemia, accumulating comorbidities and complications, declining independence due to geriatric syndromes, and a growing need for support in using diabetes technologies and navigating complex care transitions. Given the unique clinical and management needs of this population, we sought to present key care challenges in this population and suggest strategies to optimize quality of care in older adults with T1D, including 1) integrating geriatric screenings, age-friendly care frameworks, and regular reassessments into routine T1D management; 2) developing tailored care approaches for cognitive impairment; 3) establishing support systems for diabetes technology use in primary and long-term care settings; and 4) ensuring insurance coverage and access to diabetes technologies and therapies. Forward-thinking strategies to optimize care include individualized glycemic goal setting, the development and adoption of care models that support continuity of diabetes technology use, and individualized management strategies that consider of the goals and capabilities of the person living with T1D and care partners.

Continuous glucose monitoring with simplification strategies reduces hypoglycemia in older adults with type 1 diabetes (T1D), however the impact on postmeal glycemia is not known. A post-hoc analysis of older adults with T1D randomized to intervention with mealtime simplification strategies, or control, assessed weekly postmeal hypoglycemia and hyperglycemia. At baseline, 88 older adults with T1D (71 ± 5 years) in intervention (n = 47) and control (n = 41) had similar number of episodes of postmeal hypo- and hyperglycemia. The mean decrease from baseline to 6 months in episodes of postmeal hypoglycemia was: after breakfast (−0.77 vs. −0.32; P = 0.02), lunch (−0.80 vs. −0.32; P = 0.05), and dinner (−0.73 vs. −0.22; P = 0.04); and the mean change in episodes of postmeal hyperglycemia was: after breakfast (−2.05 vs. −1; P = 0.04), lunch (−1.23 vs. −0.87; P = 0.09), and dinner (−1.45 vs. −1.66; P = 0.33), respectively in intervention and control. Simplification strategies in older adults with T1D resulted in fewer episodes of postmeal hypoglycemia without worsening episodes of postmeal hyperglycemia.

Background: Since the discovery of the life-saving hormone insulin in 1921 by Dr Frederick Banting in 1921, there have been many critical discoveries and technical breakthroughs that have enabled people living with type 1 diabetes (T1D) to live longer, healthier lives. The development of insulin pumps, continuous glucose monitoring (CGM) systems, and automated insulin delivery (AID) systems have enabled people living with T1D to safely manage their glucose, reduce their HbA1c, and improve their overall health and quality of life. Nevertheless, AID systems are not yet designed for all people with T1D, and they perform best during the overnight period when meals and exercise are not occurring. AID systems are not fully automated in that they require the person using the system to announce meals and exercise to the system to avoid dangerous hyper- or hypoglycemia, respectively. Methods: In this review, which is one of a collection of manuscripts to commemorate the 75th anniversary of the National Institute for Diabetes and Digestive and Kidney Diseases, we celebrate the commercialization of the AID and discuss the major challenges and research gaps that remain to be solved to enable single- and multi-hormone AID systems to more fully support glucose management in people living with T1D. Results: More research is required to design and evaluate more intelligent AID systems that do not require accurate carbohydrate estimations or announcements for meals and exercise. Current AID systems are also not designed to be used by older adults or pregnant people. Results are presented on new AID systems that can automatically respond to meals and exercise. Results are also presented on evaluations of AID systems in older adults and pregnant people. Conclusions: Next-generation AID systems will need to support all people, including older adults, people during pregnancy, athletes, and people who may be too busy to announce carbohydrates or exercise to the system. Solutions are now becoming available that will enable AID systems to support a broader range of people living with T1D by leveraging the latest technologies in artificial intelligence and adaptive control.

Since the discovery of the life-saving hormone insulin in 1921 by Dr. Frederick Banting in 1921, there have been many critical discoveries and technical breakthroughs that have enabled people living with type 1 diabetes (T1D) to live longer, healthier lives. The development of insulin pumps, continuous glucose monitoring systems, and automated insulin delivery (AID) systems has enabled people living with T1D to safely manage their glucose, reduce their HbA1c, and improve their overall health and quality of life. Nevertheless, AID systems are not yet designed for all people with T1D, and they perform best during the overnight period when meals and exercise are not occurring. AID systems are not fully automated in that they require the person using the system to announce meals and exercise to the system to avoid dangerous hyper- or hypoglycemia, respectively. In this review, which is one of a collection of articles to commemorate the 75th anniversary of the National Institute for Diabetes and Digestive and Kidney Diseases, we celebrate the commercialization of the AID and discuss the major challenges and research gaps that remain to be solved to enable single- and multihormone AID systems to more fully support glucose management in people living with T1D. More research is required to design and evaluate more intelligent AID systems that do not require accurate carbohydrate estimations or announcements for meals and exercise. Current AID systems are also not designed to be used by older adults or pregnant people. Results are presented on new AID systems that can automatically respond to meals and exercise. Results are also presented on evaluations of AID systems in older adults and pregnant people. Next-generation AID systems will need to support all people, including older adults, people during pregnancy, athletes, and people who may be too busy to announce carbohydrates or exercise to the system. Solutions are now becoming available that will enable AID systems to support a broader range of people living with T1D by leveraging the latest technologies in artificial intelligence and adaptive control.

OBJECTIVE: To assess prescribing trends of glucose-lowering medications in the last year of life among older adults with type 2 diabetes (T2D) and explore whether frailty is associated with differential prescribing. RESEARCH DESIGN AND METHODS: In this observational cohort study of Medicare beneficiaries aged ≥67 years (2015–2019) with T2D, we assessed temporal trends in prescribing a glucose-lowering medication, stratified by frailty. The main outcome included glucose-lowering medication fills within 1 year of death. RESULTS: Among 975,407 community-dwelling Medicare beneficiaries with T2D, the use of glucose-lowering medications within 1 year of death slightly increased from 71.4% during the first 6-month period in 2015 to 72.9% (standardized mean difference [SMD] −0.03) during the second 6-month period in 2019. The most pronounced increase in use was observed for metformin (40.7% to 46.5%, SMD −0.12), whereas the largest decrease was observed for sulfonylureas (37.0% to 31.8%, SMD 0.11). Overall glucose-lowering medication use decreased from 66.1% in the 9 to 12 months before death to 60.8% in the last 4 months of life (SMD 0.11; P < 0.01), driven by reduced noninsulin medication use. The use of short-acting and long-acting insulin both increased near death, with frailer individuals more likely to receive insulin. Sodium–glucose cotransporter-2 inhibitors and glucagon-like peptide 1 receptor agonists, although less common, became more frequent in more recent years. CONCLUSIONS: The use of glucose-lowering medications declined in the last year of life, mainly due to reduced noninsulin use. Insulin use increased near death, particularly among frailer individuals, highlighting the need for careful end-of-life management.