Raveendhara R. Bannuru

OBJECTIVE: The value of adding continuous glucose monitoring (CGM) to blood glucose monitoring (BGM) during pregnancy is unclear. PURPOSE: To clarify CGM's role in pregnancy using meta-analysis, Grading of Recommendations Assessment, Development and Evaluation (GRADE) ratings, harmonized neonate size definitions, and trial sequential analysis (TSA). DATA SOURCES: We performed bibliographic database and hand searches. We selected clinically relevant randomized controlled trials (RCTs) comparing CGM and BGM in pregnancy. DATA EXTRACTION: Neonate size measures were primary; additional maternal, obstetric, and neonatal outcomes data were also extracted. DATA SYNTHESIS: Seventeen RCTs (n = 2,672 participants) met inclusion criteria. Incidence of macrosomia was reduced overall (risk ratio [RR] 0.67 [95% CI 0.48, 0.94]; strength of evidence [SOE], moderate) and for gestational diabetes mellitus (GDM) (RR 0.55 [95% CI 0.35, 0.86]; SOE, high); incidence of large for gestational age was also reduced overall (RR 0.77 [95% CI 0.61, 0.98]; SOE, very low) and for GDM (RR 0.65 [95% CI 0.45, 0.96]; SOE, very low). Incidence of small for gestational age (SGA) was elevated with CGM but not statistically significant (RR 1.37 [95% CI 0.96, 1.95]; SOE, moderate). The TSA showed no neonate size outcome met the required information size (RIS) to draw firm conclusions, and no cumulative Z curve crossed the adjusted monitoring boundary. Summary statistical significance may fluctuate with the publication of new studies. CONCLUSIONS: CGM benefits mothers with preexisting diabetes and GDM and their neonates for varying outcomes, including reducing large size at birth. Our TSA found that the RIS for neonate size outcomes has not been reached. Literature should be monitored particularly for RCTs reporting SGA in GDM, which the TSA shows cannot be conclusively ruled out as a risk.

OBJECTIVE: The escalating global diabetes epidemic necessitates an effective diabetes management workforce. Professional education can play a crucial role in strengthening clinical competency among physicians, ensuring effective guideline implementation, particularly in countries like the Kingdom of Saudi Arabia (KSA), where the high prevalence of diabetes and complex health care challenges demand enhanced expertise. This study assessed the impact of an asynchronous, multimodal online program to enhance physicians’ diabetes care competency implemented by the KSA Ministry of Health in an international cohort of physicians from 22 countries practicing in KSA. RESEARCH DESIGN AND METHODS: A comprehensive needs assessment informed the design of the educational content, focusing on diabetes management, prevention, and complications. The program used a backward design approach, emphasizing critical thinking, clinical decision-making, and behavior change through case-based learning, reflective practice, and interactive activities. The effectiveness of the intervention was assessed through a cluster randomized trial comparing the online program against traditional continuing medical education (CME) methods. Clinical competency was measured using a timed, validated online case-based examination before and after the intervention. The comparator group continued routine clinical practice without access to the structured educational program during the study period. No restrictions were placed on participation in other CME activities, and such activities were not systematically tracked. This design reflected real-world usual care conditions. Computerized cluster randomization was performed at the health center level. RESULTS: A total of 43 health centers (22 intervention; 21 comparator) were randomized as clusters. Of the 246 physicians randomly assigned (134 intervention; 112 comparator), 178 completed the study (98 intervention; 80 comparator). No health center dropped out of the study. Postintervention, the intervention group demonstrated a significant improvement in clinical competency scores compared with the comparator group (mean score 17.5 [95% CI 14.0–20.9]). Satisfaction ratings averaged 4.8 of 5, indicating high program approval. The study highlighted the potential of the program to effectively bridge knowledge gaps and enhance clinical competency in a diverse cohort. CONCLUSIONS: The asynchronous online educational program significantly improved clinical competency among physicians in diabetes care, underscoring the effectiveness of innovative educational strategies in addressing global health care challenges. The design of the program, emphasizing interactive and reflective learning, offers a scalable model for professional education in diabetes management and potentially other areas of health care.

OBJECTIVE: To describe the Disease Prevention and Treatment Microsimulation Model (DPTMM) for projecting long-term clinical and economic outcomes of obesity interventions across diverse U.S. populations. RESEARCH DESIGN AND METHODS: The DPTMM uses a Markov microsimulation framework projecting health and economic trajectories through annual cycles. The model covers nearly 40 clinical outcomes and comprehensive economic impacts, including medical costs, productivity, quality-adjusted life-years, and mortality benefits. The synthetic population uses nationally representative data, with model inputs from published clinical trials, observational studies, and national data sources. The framework addresses how treatment effects vary across populations with different baseline characteristics, complex time-dependent weight loss relationships, and multiple interconnected pathways of obesity’s health effects. Model outputs were compared with published studies. RESULTS: The analysis focused on 97.7 million insured adults with obesity in 2025 (57.6 million commercially insured individuals, 25.2 million Medicare beneficiaries, and 14.9 million Medicaid enrollees). Ten-year per-person benefits varied substantially by intervention type, baseline health status, and insurance population. Among commercially insured adults with complications receiving modern obesity medications (GLP-1 and GIP/GLP-1 receptor agonists), cumulative benefits totaled $326,021, including $32,600 in medical savings, $101,238 in productivity improvements, $50,935 in health-related quality-of-life improvements among survivors, and $141,247 in mortality reduction value. Modern obesity medications achieved 50–52% diabetes risk reduction among commercially insured and Medicaid-enrolled adults vs. 19% among Medicare beneficiaries. Health-related quality of life and mortality reductions comprised 50–70% of total benefits. CONCLUSIONS: Obesity treatment value extends substantially beyond medical cost savings to encompass workplace productivity, health-related quality of life, and mortality improvements.

BACKGROUND: Achieving and maintaining a glycated hemoglobin (HbA1c) level <7% in patients with type 2 diabetes (T2D) remains challenging, partly because of the daily insulin injection burden. Insulin efsitora alfa is a long-acting insulin Fc–fusion protein designed for once-weekly administration, which may reduce injection burden. PURPOSE: The purpose of this analysis is to evaluate the efficacy and safety of once-weekly insulin efsitora alfa compared with once-daily basal insulin in adults with T2D, stratified by baseline insulin use. DATA SOURCES: PubMed, Web of Science, Scopus, and Cochrane CENTRAL were searched from inception through July 2025, along with ClinicalTrials.gov. STUDY SELECTION: Randomized controlled trials (RCTs) enrolling adults with T2D that compared once-weekly insulin efsitora alfa with once-daily basal insulin for ≥12 weeks were included. Six trials met eligibility criteria. DATA EXTRACTION: Two authors independently extracted data using a standardized form. The primary outcome was the mean change in HbA1c (%). Secondary outcomes included fasting plasma glucose, body weight, time in range, hypoglycemia, and adverse events. Risk of bias was assessed using the Cochrane Risk of Bias 2 tool. DATA SYNTHESIS: Six RCTs, including 4,116 participants, were analyzed. Efsitora demonstrated HbA1c reduction comparable to daily basal insulin in insulin-treated patients (mean difference [MD] –0.06% [95% CI –0.24, 0.11]; P = 0.48) and insulin-naive patients (MD –0.03% [95% CI –0.12, 0.06]; P = 0.51). Nocturnal hypoglycemia episodes were fewer with efsitora in both insulin-treated patients (risk ratio [RR] 0.82 [95% CI 0.68, 0.98]; P = 0.03) and insulin-naive patients (RR 0.71 [95% CI 0.52, 0.95]; P = 0.02). LIMITATIONS: All included trials were open-label, and follow-up duration was limited. Long-term outcomes, real-world adherence, and cost-effectiveness could not be fully assessed. CONCLUSIONS: Once-weekly insulin efsitora alfa demonstrates glycemic control and overall safety comparable to once-daily basal insulin in adults with T2D, with fewer nocturnal hypoglycemia episodes. Longer-term RCTs and real-world studies are needed to define its long-term clinical and economic impact.

OBJECTIVE: To assess awareness, participation, and perceptions of clinical trials and regulatory processes among people with diabetes and their caregivers, with a focus on identifying barriers and motivators to participation and evaluating disparities by race, ethnicity, and diabetes type. RESEARCH DESIGN AND METHODS: A cross-sectional survey was conducted in two phases (August–September 2023 and April–May 2024) among adults with diabetes or their caregivers. The 31-item questionnaire, developed by the research team, assessed awareness, motivators, barriers, understanding, and satisfaction with clinical trial participation. A total of 5,487 responses were analyzed using descriptive statistics. RESULTS: Although clinical trial awareness was generally high, people from racial and ethnic minority communities (PREM) were less likely than White participants to know what a clinical trial was (1.2 times less), be informed by their care team (1.5 times less), or have participated in a trial (3.3 times less). PREM more often cited financial compensation (74.5%) as motivation and fear of harm (39.4%) or participation costs (34.9%) as barriers, compared with White participants. They had lower understanding of trial purposes (70% vs. 99.6%), receipt of results after participation (57% vs. 99.5%), and awareness of study design and regulatory engagement opportunities (22.7% vs. 97.7%), compared with White participants. CONCLUSIONS: Significant disparities in clinical trial awareness, engagement, and satisfaction exist among racial and ethnic minority populations with diabetes. These inequities reflect social determinants of health including limited access to care, economic barriers, and historical mistrust and underscore the need for proactive clinician communication, culturally responsive outreach, and equitable inclusion across all stages of research.

OBJECTIVE: To assess clinical, economic, and social impacts of treating obesity among adult Medicaid beneficiaries, including budget implications and value of intensive lifestyle management, obesity medications, and metabolic/bariatric surgery. RESEARCH DESIGN AND METHODS: A Markov-based microsimulation model estimated 5-year (2025–2029) outcomes associated with evidence-based obesity treatments. The model simulated changes in body weight and cardiometabolic risk factors, projecting impacts on disease incidence and resulting social benefits, including medical cost savings, productivity improvements, quality-adjusted life-years, and mortality reductions. Model inputs were informed by clinical trials, economic studies, and nationally representative data sets. RESULTS: Obesity treatment could generate social return on investment of $3.81 per dollar nationally and $8.57 from states’ perspective. Among 9.6 million Medicaid adult beneficiaries with obesity lacking qualifying obesity-related complications, 5.9 million could be referred for intervention, yielding ∼2 million treatment person-years over 5 years. Treatment would produce 75,800 quality-adjusted life-years ($7 billion value), $11.8 billion in mortality reductions, $847 million in productivity benefits, and nearly $1 billion in medical cost savings, totaling $15 billion in net social value nationally. Based on modeled treatment initiation and continuation rates, achieving these benefits would cost $5.4 billion nationally ($2.3 billion for states). CONCLUSIONS: While medical savings offset only a portion of treatment costs, obesity interventions generate substantial social value through improved long-term health and productivity. These findings support expanded Medicaid coverage as a strategic investment in population health, demonstrating value that challenges conventional short-term, budget-focused coverage decisions that currently limit access to evidence-based obesity treatments for millions of adults.

Objectives: The objective of this systematic review and meta-analysis was to synthesize evidence from randomized controlled trials (RCTs) evaluating the use of continuous glucose monitoring (CGM) to guide lifestyle choices, particularly nutrition, in the management of T2D. Methods: PubMed and Cochrane CENTRAL were searched from inception to June 6, 2025. Randomized controlled trials were included if their intervention involved the use of a CGM device and education or feedback intended to modify nutrition choices, either as part of a nutrition intervention or a multicomponent lifestyle intervention. Random-effects meta-analyses were performed, and certainty of evidence was rated in alignment with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Results: A total of 21 RCTs involving 2734 adults in groups of interest were included, with 20 RCTs eligible for meta-analysis. Results from meta-analysis showed statistically significant improvements in HbA1c (MD: –0.46%, 95% CI: –0.71, –0.22), time in range (TIR) 70–180 mg/dL (MD: 7.18%, 95% CI: 2.77, 11.58), time above range (TAR) >180 mg/dL (MD: –7.32%, 95% CI: –12.98, –1.66), fasting glucose (MD: –7.86 mg/dL, 95% CI: –15.06, –0.65), body weight (MD: –2.06 kg, 95% CI: –3.74, –0.38), with moderate certainty of evidence, and for mean CGM glucose (MD: –11.57 mg/dL, 95% CI: –22.58, –0.56), and standard deviation (SD) glucose (MD: –4.06 mg/dL, 95% CI: –6.54, –1.58), with low certainty of evidence. No statistically significant differences were found for other outcomes, typically with low certainty of evidence. Conclusions: Findings from this systematic review and meta-analysis support the use of CGM as a tool to guide lifestyle choices with a focus on nutrition in the management of T2D, with significant benefits related to glycemia and body weight.

Metabolic dysfunction–associated steatotic liver disease (MASLD), formerly referred to as nonalcoholic fatty liver disease (NAFLD), is a growing but often unrecognized medical problem for people with diabetes (particularly type 2 diabetes, especially when associated with obesity). Liver health has not been at the forefront of complications tracked for disease prevention, as traditionally done for diabetic retinopathy, nephropathy, or neuropathy. However, liver steatosis affects approximately two out of three people with type 2 diabetes and places them at an increased risk for metabolic dysfunction–associated steatohepatitis (MASH), cirrhosis, hepatocellular carcinoma (HCC), and overall liver-related mortality. MASLD is also associated with extrahepatic cancers, atherosclerotic cardiovascular disease, and progression from prediabetes to type 2 diabetes and negatively impacts health-related quality of life. However, most individuals and their health care professionals remain unaware of the severe hepatic or extrahepatic health risks associated with MASLD and the need for early identification. In recognition of this knowledge gap and the rising prevalence of MASLD, this consensus report is a call to action to screen for liver fibrosis and risk stratify people with prediabetes or type 2 diabetes, in particular if obesity is also present. This consensus report explains the rationale for the recent MASLD nomenclature change, how to best risk stratify, current treatment and long-term monitoring options, the value of an interprofessional approach to disease management, and the impact of alcohol intake on liver health. More awareness about the health risks associated with MASLD and broad adoption of screening for liver fibrosis as a new standard of care hold promise for a future without cirrhosis for people with prediabetes and type 2 diabetes.

Obesity is a chronic, relapsing, and progressive disease requiring long-term, interprofessional treatment strategies to improve health outcomes. With over 40% of US adults and nearly 20% of children affected, obesity remains a significant public health concern. Despite the American Medical Association’s recognition of obesity as a chronic disease, gaps persist in education, training, and access to effective treatments. These gaps contribute to inadequate obesity management and reinforce stigma and weight bias in healthcare settings. The Standards of Care in Overweight and Obesity—2025, developed by The Obesity Association^TM, a division of the American Diabetes Association^(R), (ADA’s Obesity Association), will provide evidence-based recommendations for screening, diagnosis, and management of obesity and related complications. These guidelines will emphasize a complication-centric, risk-reduction approach rather than solely focusing on weight loss. The recommendations will be intended for healthcare professionals, including but not limited to primary care physicians, endocrinologists, obesity medicine physicians, dietitians, and behavioral health specialists, as well as policymakers and insurers. The guideline development will follow a rigorous methodology, incorporating evidence from systematic literature reviews, expert consensus, and public feedback. Recommendations will be graded based on the quality and certainity of supporting evidence, with the goal of annual updates to ensure alignment with the latest research. A stringent conflict-of-interest policy will be maintained to uphold guideline integrity. By promoting personalized and equitable obesity care, these guidelines will aim to bridge existing gaps in clinical practice, enhance treatment accessibility, and improve long-term health outcomes for individuals with overweight or obesity.

Weight bias involves negative attitudes and stereotypes towards individuals based on their weight, which can be explicit or implicit. This bias contributes to weight stigma, or the mistreatment and social devaluation of individuals based on weight. Weight stigma is linked to adverse physical and mental health outcomes, leading to reduced access and quality of healthcare for individuals with obesity. The American Diabetes Association (ADA)’s Obesity Association developed guidelines on recognizing and addressing weight bias and stigma. All healthcare professionals and staff should receive training on weight bias and stigma to improve care for individuals with obesity. Training should start early and continue throughout medical education and practice. Multicomponent training that combines education with hands-on learning is recommended to reduce explicit and implicit weight bias. Clinical practices, a potential source of stigmatization for people living with obesity, should be equipped with appropriate furniture and equipment to establish an inclusive environment. Privacy and sensitivity during anthropometric measurements are essential to minimize stigmatization. Healthcare professionals should use person-centered, non-judgmental language and engage individuals in shared decision-making to consider their health and goals. Asking permission to discuss weight and respecting individual preferences is crucial. The ADA’s Obesity Association encourages adopting these guidelines to reduce weight bias and stigma, emphasizing education, inclusive clinical environments, and effective communication to improve obesity care.