Hello and welcome to today's webinar, Standards of Care and Diabetes 2025 Update for Early Career Professionals. This session is brought to you by the American Diabetes Association's ADA Scholars Program. We'll be providing additional information on how you can join the ADA Scholars Program to get access to great sessions like this. Please note that today's presentation is geared for early career health care professionals and endocrine and diabetes fellows. My name is Rong-Mei Zhang, and I will be moderating today's program. To share a little bit about myself, I'm currently an adult endocrinologist in junior faculty at Cleveland Clinic. I'm also a translational researcher studying how inflammation can contribute to chronic kidney disease and diabetes. Of course, none of this would be possible without the guidance of the ADA's Early Career Advisory Group. We would like to thank all the members for their hard work to develop the ADA Scholars Program. We're also very grateful for the support of the Leona M. and Harriet B. Helmsley Charitable Trust who have made this session a possibility. ADA Scholars offers a career development program for graduate students, endocrine and diabetes fellows, and early career clinicians who treat diabetes and its complications. The main ADA Scholars Program will take place in person at the ADA's 85th Scientific Sessions in Chicago, Illinois this June, so you won't want to miss it. The ADA Scholars Program will include sprint lectures and mini-workshops, in addition to networking opportunities. Attendees who participate in the ADA Scholars Program will be eligible for complimentary registration to the 85th Scientific Sessions. If you're not already a part of our ADA Scholars Program, we encourage you to join this free program. A link will be provided in the chat where you can visit our website to learn more and submit your application. By joining the ADA Scholars Program, you also become a professional member of the American Diabetes Association. This free membership will provide even more opportunities to network and grow professionally. The ADA memberships include a variety of professional member benefits, which include meeting discounts, interest groups, Diabetes Pro member forum, professional journals, and many more. As you can see, you'll have access to lots of great resources as an ADA professional member. Now, we'll transition to today's program with Dr. Nouha El-Sayed, presenting on 2025 Updates in Standards of Care Geared for Early Career Professionals. I now have the privilege of introducing Dr. El-Sayed. Dr. El-Sayed is the Interim Chief Scientific and Medical Officer at the American Diabetes Association, where she leads the ADA's efforts to drive discovery within the world of diabetes research, care, and prevention. We're so excited to have Dr. El-Sayed presenting on 2025 Updates of the Standards of Care in Diabetes. With that said, I'll turn it over to you, Dr. El-Sayed. Thank you so much, Dr. Zeng. What a pleasure to be among my favorite audience today. I am Nouha El-Sayed. I am an endocrinologist at the Brigham and Women's Hospital. I just started there. I've just completed 15 years at the Joslin Diabetes Center. So it is my pleasure to be here with you. I will quickly let you know that it takes a tribe to get this document in your hands or on your phones. We go over an extensive literature search over the past year, sometimes even further back if we are tackling something new. And then what happens is our committee that is 21 voting members in 2025 are more than 30 experts, actually. They go over the recommendations that you see on top of every paragraph, and they go and revise it based on new evidence. The Professional Practice Committee is an amazing group of interprofessionals that joined us for two years, and some may be asked to stay for a third, as well as invited experts. And after we are done, this document goes through an extensive process of peer review. There is invited external reviews, there is ADA scientific reviews, and then there is our boards. And as you know, in the field of diabetes, there has been a lot of change. So if something will change care, then we do what we call the living standard. Funding of this particular document and all of our standards in consensus statements are from ADA's general revenues, and they do not in any form or shape accept any form of support outside of that. So no industry or any other similar entities. I will start with sort of a thematic introduction to the standards. And there is no way that we can cover, I think we have 600 plus recommendations, and every year a significant number of them are updated. So there was a one big theme, which is equity, personalization in diabetes care. So we really focused on addressing social determinants of health, reducing care disparities, tailoring interventions to individual preferences, cultural context, health conditions, and also empowering individuals with diabetes and their caregivers through education, behavioral health support, and evidence-based lifestyle interventions. So these were the key concepts, and these come from many chapters in the standards. We have health equity and health care delivery. We really added more actionable care delivery models, and I'll show you in a minute, staying person-centric, shared decision-making, something we don't want to forget about, collaborative care teams, community resources, of course, updates in DSMES. And there's a lot of emphasis on many things, sleep, nutrition, physical activity, psychosocial well-being. I'll give you a quick scenario just to ground this into our everyday life. So if we see here, and I apologize, I have two screens so that I read the full case for you. So this is Dr. Patel. He's a primary care physician. He works in a diverse urban community clinic, as many of us. He sees patients with varying cultural backgrounds, socioeconomic challenges, health literacy levels. And one of his patients here, Mrs. Johnson, is a 56-year-old woman, and she was recently diagnosed with type 2 diabetes. She struggles with food insecurity, lives in a low-income neighborhood, and she has no access to a personal vehicle. And Mrs. Johnson is hesitant about starting insulin therapy. Her A1C is high, and it is at insulin level for her, and she reports high levels of stress related to caregiving responsibility for her elderly mother. Very common scenarios that we all see every day. Dr. Patel wants to provide effective person-centered care while addressing the social determinants of health and implementing strategies to improve outcomes for Mrs. Johnson. So I will ask you this. What immediate steps should Dr. Patel take to ensure a person or a patient-centered approach in managing Mrs. Johnson's diabetes? And please use the chat if you can. Number one is prescribe insulin immediately without discussing her concerns. Engage Mrs. Johnson in shared decision-making. Look at all these brilliant responses. God, I love it. I'm not going to even read till the end. Absolutely. So everybody, very accurately, quickly. Number two, shared decision-making cannot be more important. We can decide whatever we want to decide, but that decision has to hit reality, and we have to work with Mrs. Johnson's preferences. And here's another question, and from that, I'm going to take you to our section one. How can Dr. Patel's clinic improve care delivery for people with diabetes like Mrs. Johnson? So if we think about Mrs. Johnson as a tree, now let's think about the entire forest, our entire clinic. What would you do? One is use clinical data to identify other people with diabetes facing similar challenges and create targeted interventions. Focus solely on Mrs. Johnson. Prioritize medication over addressing social. Look at you. Brilliant. Or delay the intervention. So absolutely, it is number one. So that takes us to section one in the standards, which talks about improving care and promoting health. So if you go through this particular chapter, and I'm going to give you the gist. I know that some of you have already read some of it. Some have read some chapters, some not so much. I'm here to give you some of the gist about what we've updated. So one is we incorporated diverse evidence-based care models. Really, we wanted to be more actionable. We highlighted quality improvement initiatives and interprofessional teams and then implemented concepts that were added to guide sustainable care improvement and enhance population health. We talked about many things from decisions being timely, relying on evidence-based guidelines, looking at social determinants of health, making sure that your health care system has a way to assess that, and then us in clinic addressing that, and that decisions are made collaboratively with people with diabetes and people at risk for diabetes. For people who are interested in this type of science, looking at the evidence-based care models, and they emphasize person-centered teams, integrated long-term treatment approaches to diabetes and comorbidities, and ongoing collaborative communication. And really, it's calling for a culture of quality improvement. You may not be a quality improvement expert, but we can all be a part to improve outcomes through many, many things, whether it's benchmarking programs or engaging teams, looking at scalable processes, and of course, based on your particular organization and institutions, priorities based on people with diabetes priorities. Please assess and address disparities. Encourage your clinics, if they're not doing that, to do that, and assess for social determinants of health. If we do not assess, how can we address from housing insecurity, financial barriers, health insurance access, environmental and neighborhood factors, and social and community support? And then from that, just to keep with the theme, we're going to go to Chapter 5, and Chapter 5 talks about facilitating positive health behaviors and well-beings to improve health outcomes. And I just picked some things for you. There are a lot of updates in this chapter, but here, they really emphasize that all people with diabetes should be advised to participate in developmentally and culturally appropriate DSMES. We talk about this a lot, but again, let's put a stake in the ground and talk about this. If it's not culturally appropriate, if it is not a good fit for people, then they will not engage, and there will not be the outcomes that we need. This is the cadence of when DSMES should be provided. This was simply a clarification, but for people who do not remember, it's a diagnosis annually and or when not meeting treatment goals, when complicating factors develop, and of course, if there are any forms of transitions in life and care. We also want routinely for people to assess clinical outcomes, health status, and well-being. Behavioral health is a huge concern in people with diabetes, so screening is very important, and implementing these in clinics are very important. And this particular group have suggested actionable tools and things that are available and accessible to all of us using telehealth or digital interventions for DSMES. We do not all have extensive DSMES support, so looking into that is also something that may be helpful to people with diabetes. When we talk about medical nutrition therapy, eating patterns should emphasize certain key nutritional principles, and as you can see here, they have it all outlined using SGLT2 inhibitors, and we know that there is a ketogenic diet sort of interest or eating patterns in the population, so we need to educate people about the science of ketoacidosis, methods for risk mitigation, and of course, the appropriate tools for accurate ketone testing. The other thing is we all know that carbohydrates impact our glycemia, but also we have to look into other things that can do that, especially that we're seeing eating patterns that emphasize high protein intake, high fat intake. We know that fat and protein can also impact that, so that should be accounted for. And then there's a whole section. We know also that intermittent fasting is a rising pattern of utilization for health reasons or for weight reasons, and the intersection of this, we included religious fasting because a lot of the literature that we use in intermittent fasting gets, you know, there's some form of inferring from religious fasting, and of course, for those who fast, that section can be helpful, so that's something to also, you know, look at quickly. Physical activity is another section that had updates, as you can see here. Some of it was clarifications, whether it's youth with type 1 diabetes or type 2 diabetes and how much exercise they need, so take a look at that. This is on our app, so it should be a quick search. For all people with diabetes, please evaluate baseline physical activity and time spent in sedentary behavior, many of us, and for those who work remote, that is a big, big, big problem since the COVID pandemic. Counsel on that prolonged sitting should be interrupted at least every 30 minutes for glucose benefits, and again, one big one is we all know that there is a lot of medications from a weight management or a glycemic management perspective, and the weight loss that it results in losing a lot of our lean mass, whether it's muscle or bone, so really counseling on what form of exercise is important is something that we've emphasized here and elsewhere, so they talk here about muscle strength and weight-bearing exercises, and, you know, the accompanying text also has a lot of details. One other one here is smoking cessation. There's a whole section, but I'm pointing out this particular one for people with type 1 diabetes. You know, using cannabis is a problem, so the use of it in any form is a risk for DKA, so that's something to keep in mind as people come into the hospital with that or as you care for people with type 1 diabetes, And then when it comes to supporting positive health behaviors, they talk about behavioral strategies that should be used to support diabetes self-management and engagement in health behaviors, using technologies to do that, implementing screening. That's something that you'll find all across our standards. Again, if you do not screen, you will not know what's going on with people with diabetes. Screening for diabetes distress at least annually, and you'll find also the cadence of repeating the screenings as to when and how frequently you should be doing these in clinic. And then from there, there's another sort of big theme, which is comprehensive health management. And the focus area here is we don't have to be holistic when you're addressing health and comorbidities. You should have preventive strategies. And when we look at diabetes, it does not affect one health, like one system. It really is a multi-system health impact. So if you look here, I mean, we have partnered with many other associations and experts. So you'll see that we talk about bone health and diabetes. You can see exactly, Dr. Stein, you will see that we talk about liver health in a very comprehensive way and sexual health. And I'll show you in a minute because we need to be equitable. Vaccination is something where there is change. And the one big one that we have added recommendation to is dental care. And of course, we always expand on the management of obesity, cardiovascular disease, and chronic kidney disease. So you go to chapter four, and this is what we call the comprehensive medical evaluation and assessment of comorbidities. And it's one of our longest chapters because it has a lot in there. But I will only highlight things that have changed and encourage you to go over the standards. Don't hate us as you read 600 recommendations. You can have it on your phone through an app, and you can simply search. And I am working with a group to hopefully have an AI-powered solution for you to make your life even easier. So if you look at immunization in general, we want immunization to be routinely recommended. Children, adults, as indicated. And you'll find that there have been some changes here. So we have the COVID-19 vaccine. We used to call it boosters, but as you can imagine now, it's the updated vaccine because you may get a whole other vaccine, the pneumococcal vaccine and RSV. And we are not going through this in detail, but I just wanted to point them out that there is a table that you may want to consult with. It has the COVID vaccine and it has where the changes have occurred. I'm just pointing them out for you here because it's very important. It's one of the things we should screen for in clinic. Are you up to date? Just to work collaboratively along with our primary care colleagues. Bone health section was endorsed by the American Society for Bone and Mineral Research. So if you have this dual interest, that's for you. And of course, it's for our general trainees who see people with diabetes. So one is to consider the potential adverse impact on skeletal health when selecting pharmacological options. As of course, your goal is to lower glycemia and other things. So avoiding medication with a known association with high risk fractures, as TZDs and sulfonylurea, is recommended in those with an elevated risk. I'm sure people in endocrine can teach us about this, but reminding people of intake of calcium and vitamin D and then anti-resorptive medications and osteoanabolic agents should be recommended for older adults with diabetes who are at high risk of fractures, including those with low bone mineral density, T-score of less than or equal to minus two, history of fragility fractures, or elevated frac score. So as you can see here, this particular section has been updated. This is a whole new section, dental care. In this one, we worked collaboratively with our colleagues from dentistry to bring this very, very important relationship because as we all know that there is a relationship between diabetes and periodontal disease, and it's what we call bi-directional. Diabetes increases the risk and severity of periodontal disease due to hyperglycemia-driven inflammation, while periodontal disease worsens glycemic control by increasing systemic inflammation. So treating periodontal diseases can improve A1C by around 0.4% and reduce inflammatory markers. So very, very important. And the two big takes here is people with diabetes should be referred for a dental exam at least once a year. So please make sure you keep that as you see them. Coordinate efforts between medical and dental teams to appropriately adjust glucose-lowering medications and treatment plans prior to and in the post-dental procedure period as needed. So something that we are very grateful that our dental people have contributed. And then another one. So when I took, honestly, it's an honor to be in charge of the guidelines. I was chair of the guidelines, and now I'm actually responsible for the guidelines from a development perspective, is disability. I mean, diabetes increases the risk of disability by 50 to 80%, driven by complications like neuropathy, amputation, cardiovascular disease. And this impairs mobility and quality of life. And poor glycemic control also intensifies your infection risk. So really, assessment of disability and what do you do from there is very, very important. So disability has been added. And again, our colleagues from PM&R have contributed to this, and I'm very grateful for them. And they updated this this year. So the big take here from this year is to assess for disability at the initial visit and for decline and function at each subsequent visit in people with diabetes. If disability is impacting functional ability or capacity to manage diabetes, then please refer to appropriate healthcare professionals specializing in disability. And these are our PM&R occupational therapists or whatever it is, you know, per that person's particular disability. And then sexual health in general. So sexual health in men is something that was updated. So as you can see here, so in men with diabetes or prediabetes, inquire about sexual health. Look for signs and symptoms of hypogonadism and screen. And then in men with diabetes or prediabetes, screen for erectile dysfunction, specifically for those with a high risk, high cardiovascular risk, retinopathy, cardiovascular disease, CKD, peripheral or autonomic neuropathy, long duration of diabetes, depression, hypogonadism. And to be equitable, I said, we are doing male sexual dysfunction. Where's the female sexual dysfunction? So we also have a new expert with us. And here is your female sexual dysfunction. Diabetes significantly affects female sexual health with higher rates of dysfunction, like low desire, inadequate lubrication, pain during intercourse, difficulty achieving orgasm. And these issues can be linked to hyperglycemia, neuropathy, psychosocial factors, and many other things. So we have recommendations now that says that in women with diabetes and prediabetes, please inquire about sexual health by screening for desire, arousal, orgasm difficulties. And then in postmenopausal women, just another complicating layer in people with diabetes and prediabetes, screen for symptoms and signs of genitourinary syndrome of menopause, including vaginal dryness and dyspareunia. And so the liver health has been updated last year, but this year we just wanted to affirm that we have an updated terminology. Updated terminology sometimes can be a challenge, but it is the right direction. So one is to unify the way we speak about disease. And also this is the right representation of pathophysiology. So you will find that the terms NAFLD and NASH have been updated to be NASLD and NASH. So bear with us and stay aware. I will not go through recommendation by recommendation, but I would love for you to look at this figure, figure two. So this is, we try to make it as simple as possible. Again, this is really from our subgroup who are all liver health experts. This is the diagnostic algorithm for the prevention of cirrhosis in people with metabolic dysfunction associated steatotic liver disease or MASLD. So you look here. So what are the groups that we're handling? These three groups, type two, prediabetes and obesity with one or more cardiovascular risk factor. So you rule out secondary causes of steatosis or increase ALTs that are obvious. So that's of course it goes without saying, but we all have FIP4. FIP4 is an easy test. If you have EPIC or if you're on one of EMRs, it can calculate it for you if it has what it needs. And you basically look and say, is it more than or equal to 1.3? If yes, then this is a higher risk for further cirrhosis. If no, then it's lower risk for future cirrhosis. And then you go down the algorithm and it guides you here when to refer. And after the FIP4 calculation, it really varies depending on our healthcare professionals' comfort dealing with this. There are people who are comfortable taking this down one more step, others who refer people with diabetes after you get that test. So we've kept it vague in referral, but of course, if LSM is higher, then referral is warranted. And then I really like this one as well. And it took the committee some time to work on this. So this is the Mastel-D treatment algorithm. And you can see here that you need to individualize care targeting adoption of a healthy lifestyle, of course, weight loss, optimal diabetes medication, cardiovascular risk reduction, and if surgery is warranted, so be it. And it goes here by levels, whether it's Mastel-D, and I apologize because I'm getting some of your messages from the chat here. It's wonderful. And then the level of fibrosis, whether it's F0 to F1, minimal fibrosis, and then you're going to F2 to F3. And then it will go through recommendations for medications. There is obesity pharmacotherapy, and there is diabetes pharmacotherapy, which medication makes the most sense as you are lowering their glucose. Because we don't just lower glucose, we look for glucose lowering and risk reduction. And of course, this is one of them. So I hope you find this helpful as well. And with that, I'm going to give you another quick, very quick case. You have Mrs. Thompson, 52-year-old woman diagnosed with type 2 diabetes, BMI of 34, waist circumference is 105. Over the past year, she's gained 10 pounds due to a sedentary lifestyle and dietary habits. A1C is not a goal, reports fatigue, difficulty achieving and maintaining weight loss. She's open to discussing weight. And I'm saying she's open to discussing weight because we always have to ask permission before we discuss weight and hopefully people would be ready. And of course, we have to maintain their autonomy. Mrs. Thompson has tried lifestyle changes in the past with limited success, and she's now asking about medication or metabolic surgery. So a question here is, say, okay, we've reached monitoring LEND. How often do you need to monitor people? Is it once every six months for active weight management, annually during routine checkups, every three months or weekly until significant weight loss is achieved? And that will take us to chapter eight, which is our obesity and weight management for the prevention of type 2 diabetes. And I'm going to share something with you. We are developing standards of care for obesity, obesity only, not obesity and type 2 diabetes, but obesity only. So stay tuned. You should see something in the spring coming out. So in section eight, you can see here to support the diagnosis of obesity, you need to measure height and weight to calculate BMI, which we've been doing forever, but this has limitations. So performing additional measurements of body fat distribution, like waist circumference, waist to hip ratio, waist to height ratio, if BMI is indeterminate. Monitor obesity-related anthropometric measures at least annually to inform treatment consideration. And just like you all answered wonderfully, if we're having active weight management treatments ongoing, then the monitoring should be every three months. So you guys are wonderful. You guessed it. For those who achieve weight loss goals, continue to monitor progress, provide ongoing support, and please, please, please continue the interventions to maintain weight goals. The worst thing is when people are on something effective and we stop it altogether because we know that obesity is a chronic disease and it needs an intervention. Effective long-term, which basically means more than one year, weight maintenance programs provide monthly contact. So that's what we are sort of suggesting and support and frequent self-monitoring of body weight. So we're talking about weekly or more frequently. And then other self-monitoring strategies, whether it's food diaries or wearables. And of course, we have to encourage everyone to keep regular physical activity. So again, we're going to go back to this big issue with malnutrition. So please screen people with diabetes and obesity who have lost significant weight for malnutrition, especially those who've undergone metabolic surgery and those who are treated with our newer medications. Weight management pharmacotherapy is really indicated for chronic therapy and should be continued beyond reaching weight loss goals to maintain health benefits. So this is not something we go on for a short period of time and you get what you need and then you discontinue. Sudden discontinuation of weight management pharmacotherapy results in weight gain and worsening of cardiometabolic risk factors. So let's all think, teach, and make sure that the people with diabetes know that this is a disease. This is not something that needs a transient intervention. And if post-metabolic surgery hypoglycemia is suspected, we need people to have a clinical evaluation, and of course, CGM can improve safety. One of our most downloaded chapters is Chapter 9, which is the Pharmacological Approaches to Glycemic Treatment. Instead of going through one-by-one recommendations, I just wanted to draw your attention to this. I would hope that we all know this algorithm. This algorithm basically is the use of glucose-lowering medications in the management of type 2. How do you need to think about it? If you look here, we will work our way from top all the way down. It's an algorithm that's basically saying healthy lifestyle behaviors are very important. Don't forget DSMES, and of course, do not forget social determinants of health because we can't talk to people about food, and they have food insecurity. We can't talk to people about, oh, go out and run down the street, and it is not safe to do so. Unless we know, we cannot be the right people to advise. We really need to screen, and we really need to customize our approach. Then we look and say, okay, our goal is to lower glucose. That's great, but we have to think about that from a risk reduction perspective. If our goal is cardiovascular and kidney risk reduction in people who are high-risk individuals with type 2, then you go down here. This one talks about ASCVD, and this one talks about indicators of high-risk CVD. What do you do in this population? You will find that there is GLP-1 receptor agonist with proven cardiovascular benefits. If you dig down in our narrative, it's there, or SGLT-2 with proven cardiovascular benefit as well. Then, how about if A1C is still above goal? Then for individuals who are on GLP-1, you can add another agent, and in that case, of course, an SGLT-2 would make the most sense. Same applies if somebody has heart failure. You'll find that this is your preferred CKD, same thing. There's definitions of anything that we have here. You'll find a clear definition. It takes you through which ones, any alternatives, and then if the goal is to achieve and maintain weight and glycemic goals, for weight management, we go by efficacy, by which agents are more efficacious than others. Of course, if it's just achieving and maintaining glycemic goals, then again, we go by efficacy. Where is glycemia right now, and how much do I need to reduce? Because if I'm going to reduce two points, then maybe an agent that will only reduce it by 0.5 is not the right decision. Then I'm going to take you down, and I apologize, I asked our graphic design to put this on one page, but it's hard because it's going to be tiny. We also included mitigating the risk of MESL-D or MASH. While the studies are still accumulating about the benefits in MESL-D and MASH, we have to think that I need to reduce glycemia, so why don't I think of an agent with a potential benefit? We've added this, so please don't miss it at the tail end of the algorithm. I encourage you to look at this algorithm, to think about it as you're seeing patients, because our main goal is risk reduction and the burden of disease reduction. I just wanted to touch on this really quickly. Compounding products are something that have been a huge issue. You can go online and get something, you can get medications that have not even been FDA approved, so we wanted to clearly say that the use of compounded products that are not FDA approved are not recommended. We went on a big quest to answer one question, can I prescribe compounding medications safely and will the patient get quality and effectiveness? The answer has been unanimously, no. We don't know what's in these medications, even the administration techniques, the dosage mistakes, we have worked with many, many organizations, it just came down to it is not safe. If glucose lowering medications are unavailable, that is, there is a shortage, we are recommending that you switch to a different FDA approved medication and upon resolution of this unavailability, reassess for the appropriateness of resuming the original FDA approved medication. We know that compounding for other products is a different story, but what we're seeing unfortunately in our landscape for weight management and for diabetes, they are not safe and I don't know if you've seen in our various ERs, overdosages, the wrong medications, the wrong pharmacological agents in there, it is not safe, unfortunately. If we jump to cardiovascular disease risk management, I just wanted to quickly show you something that we're proud of. We have a primary care advisory group that takes the standards and turns it into actionable images or actionable algorithms. Last year, what they've done is they've taken the lipid management for primary prevention and secondary preventions and they've created these images and then our main committee, we felt that these were fantastic to use and you can use them and these are available for, it's the abridged standards, the abridged standards 2025 is not out yet, it should be out in the spring. If you can see here, it basically tells you by age group and what step in therapy you need to consider and same thing, lipid management for secondary prevention, they've created this very, very simple algorithm here for you guys to take a look at. The same thing, screening for undiagnosed cardiovascular disease, coronary heart failure, coronary heart disease, heart failure, or PAD, as you can see here, they've also made the recommendations and it includes some of our recommendations for screening for heart failure from last year. Other things as well, recommendations to reduce the risk of symptomatic heart failure in people with diabetes and also they have put down the various agents and how you can go about thinking about this. I hope you find these helpful and again, the 2025 will be updated with more exciting things to use. Another big theme was leveraging technology and innovation, so integrating diabetes technology and advanced tools to improve care outcomes. You'll find that the theme in general, and again, we're not going to go recommendation by recommendation, but there is early adoption of CGM, there's an expansion and who gets CGM, insulin pumps and AID systems, digital tools, virtual coaching, technology-aided management in general. Technology is something that makes life easier if used appropriately and not in a burdensome way. As you can see here, there's a lot of standardized, there's a lot of early initiation and, of course, many other actionable things as what interferes and what doesn't. One big one that I also want to draw your attention to is to actually consider CGM in people with type 2 diabetes who are not on insulin, actually, in people who are on glucose lowering medications other than insulin. As you can see, it's very exciting as this is becoming more and more, there's more and more data and hopefully for more and more people to benefit. The choice of device really, of course, should always be made based on this individual circumstances, needs and preferences. The other big one is to please support and provide diabetes management advice to people who choose to be on open-source closed-loop system. They are ahead and they're doing it, so really supporting and providing that kind of advice is something that's very important. I know that people are talking about over-the-counter, some of the over-the-counter are not for people with diabetes, so that's why we're not including them, but it's very exciting, of course. Combining technologies is something, and also, if people are hospitalized and they're on technology, you'll find that there is a call from us to please continue, if appropriate, of course, with all forms of safety measures and, of course, working with your institutional policies, but getting people off of their devices when it's not warranted is definitely not the right way to go. Another big schematic area is evidence-driven clinical practices. You'll see standardization, standardization, screening standardization, technology standardization. We know about screening for type 1. That's not new. That's from last year, but we did tweak some of the guidance. You'll see that. Of course, medication is always recommended based on comorbidities and individual needs. Safety, safety, safety. There was a consensus statement for hyperglycemic crises, so if you haven't read that, I recommend you do, so we did some alignment in that, and these are the updates in inpatient care. These are very quick things. Don't forget that now we're screening for type 1 in those who have a family history or an elevated genetic risk, and you'll find that in the standards, how to screen, what antibodies to order, all of these things are there. Glycemic goals and hypoglycemia was a big one that we have tackled, so you'll see here that we need to review for both hyperglycemic crises that I just mentioned and for hypoglycemia in every clinical encounter, and we really, really are emphasizing providing structured education on recognition, prevention, and management of these crises. We don't want to be dealing with them. We actually want to prevent them. There's a ton of individualization things, and this is one schematic, and it shows you between here very stringent control to less stringent control based on people, where they are, and you'll see that there's favoring more stringent goals versus favoring less stringent goals, so please go through this, and we hope that these schematics can help you remember and teach, and let's all remember that diabetes goes through all of our life stages, so whether it's pediatric to adult transitions, age-appropriate goals and therapies, or, of course, pregnancy and older populations, and I encourage you to go over because today it's virtually impossible to go over everything, and I want to give you a chance to ask questions. In the hospital, you'll see that there's clarification of when to initiate insulin, and this one is specifically talking about initiation and intensification for treatment of persistent hyperglycemia, and this is the threshold, which is more than or equal to 180 milligrams per deciliter, and it goes by what type of individuals we're talking about, whether it's critically ill or non-critically ill, and critically ill is usually people in the intensive care units, and again, this is, you know, the second one here is people who are non-critically ill, and then what do you do once therapy is initiated? Then we talk about glycemic goals, and glycemic goals of 140 to 180 for most critically ill individuals with hyperglycemia, and you could be more stringent when appropriate in those critically ill who do not have significant risk for hypoglycemia. You know, you'll find that there are more goals. I already went over the use of technology to continue that if appropriate, and again, you know, a hypoglycemia management surveillance protocol is something that should be adopted by health systems because we want to identify, we want to treat, and it takes us back to the very first case that we talked about, Dr. Patel, when he's dealing with one person with diabetes, but this is to think about everyone because when something happens and an event like that happens, we really have to think, okay, how can we improve on a system level? Again, diabetic ketoacidosis and hyperglycemic hyperosmolar state is something that we have addressed, but I would love for you to read the consensus statement because it has some updated definitions and content that you really need to be aware of, especially if you go inpatient, and if you guys are all trainees, then I'm sure you're seeing a lot of that. There's an algorithm that the group have created. This is the same algorithm from that paper, so please take a look at it. It goes through IV fluids, insulin, potassium, you know, our bread and butter of every day, but please do take a look. It does have some tweaks. In adolescence, I'm going to tell you the very, very highlights so we have time. It's talking about stringent versus less stringent goals in some of our youth. Less stringent A1C goals may be appropriate for youth who cannot articulate symptoms of hypoglycemia, and then we also mentioned that it may be reasonable to be more stringent, and we're talking about an A1C of less than 6.5 for selected individuals that can be achieved without significant hypoglycemia, excessive weight loss, or negative impacts on well-being, and all of that, we're talking in the realm of type 1 diabetes, and if we move into the type 2 diabetes realm, also consider an A1C that is more, again, more stringent control for most kids, most children and adolescents with type 2 diabetes who have low risk for hypoglycemia. If you think about it, these are children that have type 2 very early in life, and the trajectory of complications is really quite concerning. Older adults, I just want to show you that we use something called the 4M framework of age-friendly health systems, so they talk about looking at people's mentation, mobility, medication, and what matters most. Please take a look at it, so you're able to customize an approach that is appropriate to each person. Not every person who's older is the same, and we should make no assumptions, and based on that, we need to customize therapy, and we talk a lot here, as you can see, if somebody is healthy with few and stable coexisting chronic illnesses, intact cognition, have a good functional status, then maybe an A1C that is lower is more appropriate, while if we have somebody with intermediate or complex health and clinically heterogeneous or variable life expectancies, we need to be agile and think of that differently, and this section was endorsed by the American Geriatric Society, and we are very appreciative of their partnership.

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