The management of type 1 diabetes in adults. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD)

Sleep disturbances including poor sleep quality and shorter sleep duration are associated with worsening glycemic levels in type 1 diabetes.

“On the other hand, sleep disturbances including poor sleep quality and shorter sleep duration are associated with worsening glycemic levels in type 1 diabetes (154,155).”

• cites [154] Denic-Roberts, 2016, Subjective sleep disturbances and glycemic control in adults with long-standing type 1 diabetes: the Pittsburgh’s Epidemiology of Diabetes Complications study, Diabetes Res Clin Pract sourcePartly supported

  The Results (§3.2; page not provided) find that shorter sleep duration was associated with higher HbA1c only among participants with good glycemic control; the association ran in the opposite direction among those with poor control. The same section reports no association between poor sleep quality and poor glycemic control, so the sentence overgeneralizes the duration finding and does not support its poor-sleep-quality component. (LLM, conf=0.86)

  Experimental — accuracy not yet measured
• cites [155] van Dijk, 2011, Disturbed subjective sleep characteristics in adult patients with long-standing type 1 diabetes mellitus, Diabetologia sourceDisputed

  The Discussion reports that poor sleep quality was more common in adults with long-standing type 1 diabetes, but sleep duration did not differ from controls. Crucially, it states that subjective sleep characteristics were not associated with impaired glucoregulation; the proposed relationship with HbA1c was not detectable in this study. (LLM, conf=0.90)

  Checked by a reasoning model — may be wrong.

  Experimental — accuracy not yet measured

The likelihood that an older adult with low BMI has type 2 diabetes is even higher when the person's ethnicity is associated with high type 2 diabetes risk.

“The majority of older adults with low BMI will have type 2 diabetes (9,12,13), even more so when a person's ethnicity is associated with high type 2 diabetes risk (14).”

• cites [14] Nakagami, 2003, Age, body mass index and type 2 diabetes-associations modified by ethnicity, Diabetologia sourceSupported

In people with clinical features suggesting type 1 diabetes, the presence of one or more positive islet autoantibodies is highly predictive of rapid progression and severe insulin deficiency.

“In people with clinical features suggesting type 1 diabetes, the presence of one or more positive islet autoantibodies is highly predictive of rapid progression and severe insulin deficiency and these individuals should be considered to have type 1 diabetes, even if they did not require insulin at diagnosis (23,24).”

• cites [23] Littorin, 1999, Islet cell and glutamic acid decarboxylase antibodies present at diagnosis of diabetes predict the need for insulin treatment. A cohort study in young adults whose disease was initially labeled as type 2 or unclassifiable diabetes, Diabetes Care sourceNot checked — no full text of the source
• cites [24] Lynam, 2019, Development and validation of multivariable clinical diagnostic models to identify type 1 diabetes requiring rapid insulin therapy in adults aged 18-50 years, BMJ Open sourcePartly supported

  The Results report that positive islet autoantibodies were more common in participants meeting the study’s criteria for type 1 diabetes (71% versus 5%), supporting their diagnostic value. But the paper says these features overlap between diabetes types and describes GADA-positive participants who took more than three years to start insulin, suggesting slow-onset autoimmune diabetes. It therefore does not support treating antibody positivity alone as highly predictive of rapid progression in every person with suggestive clinical features. (LLM, conf=0.86)

  Experimental — accuracy not yet measured

Rapid progression to insulin treatment (<3 years) is strongly suggestive of type 1 diabetes at any age.

“Rapid progression to insulin treatment (<3 years) is strongly suggestive of type 1 diabetes at any age (6,8,15).”

• cites [6] Thomas, 2019, Type 1 diabetes defined by severe insulin deficiency occurs after 30 years of age and is commonly treated as type 2 diabetes, Diabetologia sourceSupported
• cites [8] Hope, 2016, Practical classification guidelines for diabetes in patients treated with insulin: a cross-sectional study of the accuracy of diabetes diagnosis, Br J Gen Pract sourcePartly supported

  The Results (Optimal clinical criteria; page not available) identify time from diagnosis to insulin as the strongest individual discriminator, supporting the link between rapid insulin treatment and type 1 diabetes. But the optimal cut-off was 12 months, not three years. The Discussion (Implications for research and practice; page not available) also reports substantial misclassification among people diagnosed at age 35 or older and treated with insulin from diagnosis, so the unqualified claim that this is strongly suggestive at any age is not supported. (LLM, conf=0.88)

  Experimental — accuracy not yet measured
• cites [15] Prior, 1993, C-peptide and the classification of diabetes mellitus patients in the Early Treatment Diabetic Retinopathy Study. Report number 6, Ann Epidemiol sourceNot checked — no full text of the source

The likelihood of monogenic diabetes rises to 20% where islet antibodies are negative and C-peptide secretion is maintained.

“Monogenic diabetes is found in approximately 4% of those diagnosed with diabetes before the age of 30 years; the likelihood of monogenic diabetes rises to 20% where islet antibodies are negative and C-peptide secretion is maintained (18).”

• cites [18] Shields, 2017, Population-based assessment of a biomarker-based screening pathway to aid diagnosis of monogenic diabetes in young-onset patients, Diabetes Care sourceSupported

No single clinical feature confirms type 1 diabetes in isolation.

“No single clinical feature confirms type 1 diabetes in isolation (9,10).”

• Also stated in: § SECTION 17: CONCLUSION · plain

  “No single clinical feature confirms type 1 diabetes in isolation.”

• cites [9] Shields, 2015, Can clinical features be used to differentiate type 1 from type 2 diabetes? A systematic review of the literature, BMJ Open sourceSupported
• cites [10] Jones AG , HillAV, TrippettPW, HattersleyAT, McDonaldTJ, ShieldsBM. The utility of clinical features and glycaemia at diagnosis in classifying young adult onset diabetes (Abstract). Published 19 September 2019. Accessed 23 August 2021. Available from www.easd.org/virtualmeeting/home.html#!resources/the-utility-of-clinical- features-and-glycaemia-at-diagnosis-in-classifying- young-adult-onset-diabetesNot checked yet

  Not checked in the free run.

The very strong relationship between type 2 diabetes incidence and age means that even classical features of type 1 diabetes may have limited predictive value in older adults.

“The very strong relationship between type 2 diabetes incidence and age means that even”

• cites [11] Thomas, 2018, Frequency and phenotype of type 1 diabetes in the first six decades of life: a cross-sectional, genetically stratified survival analysis from UK Biobank, Lancet Diabetes Endocrinol sourceSupported

The overall prevalence of type 1 diabetes is higher in adults than in children.

“Although the incidence peaks in puberty and early adulthood, new-onset type 1 diabetes occurs in all age-groups and people with type 1 diabetes live for many decades after onset of the disease, such that the overall prevalence of type 1 diabetes is higher in adults than in children, justifying our focus on type 1 diabetes in adults (1).”

• cites [1] Miller, 2012, Improvements in the life expectancy of type 1 diabetes: the Pittsburgh Epidemiology of Diabetes Complications study cohort, Diabetes sourceCould not verify

  The Abstract reports life expectancy in a cohort with childhood-onset type 1 diabetes, which supports the surrounding point that people can live for decades after diagnosis. Neither it nor the retrieved passages compare type 1 diabetes prevalence in adults and children (searched: prevalence, adults, children, age distribution). (LLM, conf=0.73)

  Experimental — accuracy not yet measured

Profound insulin deficiency associated with immune checkpoint inhibitor use may present with hyperglycemia and diabetic ketoacidosis.

“A new and emerging issue is the development of profound insulin deficiency associated with the use of immune check-point inhibitors, which may present with hyperglycemia and diabetic ketoacidosis (DKA) (4).”

• cites [4] Stamatouli, 2018, Collateral damage: insulin-dependent diabetes induced with checkpoint inhibitors, Diabetes sourceSupported

Monogenic diabetes is found in approximately 4% of those diagnosed with diabetes before the age of 30 years.

“Monogenic diabetes is found in approximately 4% of those diagnosed with diabetes before the age of 30 years; the likelihood of monogenic diabetes rises to 20% where islet antibodies are negative and C-peptide secretion is maintained (18).”

• cites [18] Shields, 2017, Population-based assessment of a biomarker-based screening pathway to aid diagnosis of monogenic diabetes in young-onset patients, Diabetes Care sourcePartly supported

  The Results section reports a 3.6% prevalence, approximately 4%, among patients diagnosed before age 30, but the study also restricted this group to those currently under 50. The Results section on pathway performance reports a 20% positive predictive value after screening for maintained C-peptide secretion and negative islet antibodies. The citing sentence omits the current-age restriction on the prevalence estimate. (LLM, conf=0.86)

  Experimental — accuracy not yet measured

The majority of older adults with low BMI will have type 2 diabetes.

“The majority of older adults with low BMI will have type 2 diabetes (9,12,13), even more so when a person's ethnicity is associated with high type 2 diabetes risk (14).”

• cites [9] Shields, 2015, Can clinical features be used to differentiate type 1 from type 2 diabetes? A systematic review of the literature, BMJ Open sourcePartly supported

  The Discussion (Principal findings; page unavailable) says age at diagnosis is more useful than BMI for distinguishing diabetes type, and that BMI adds less than 1% to classification based on age. This supports the point that low BMI need not indicate type 1 diabetes, but the paper does not establish that a majority of older adults with low BMI have type 2 diabetes. (LLM, conf=0.78)

  Experimental — accuracy not yet measured
• cites [12] Hillier, 2001, Characteristics of an adult population with newly diagnosed type 2 diabetes: the relation of obesity and age of onset, Diabetes Care sourceNot checked — no full text of the source
• cites [13] Westphal, 1996, The occurrence of diabetic ketoacidosis in non-insulin-dependent diabetes and newly diagnosed diabetic adults, Am J Med sourceNot checked — no full text of the source

Within an individual, HbA1c and blood glucose correlate over time.

“Variability exists between individuals, but the HbA 1c and blood glucose within an individual correlate over time (68).”

• cites [68] Beck, 2017, The fallacy of average: how using hba1c alone to assess glycemic control can be misleading, Diabetes Care sourceSupported

The use of an implanted sensor can help avoid skin reactions in those who are sensitive to tape.

“In some instances, the use of an implanted sensor can help avoid skin reactions in those who are sensitive to tape (84,85).”

• cites [84] Deiss, 2020, Real-world safety of an implantable continuous glucose sensor over multiple cycles of use: a post-market registry study, Diabetes Technol Ther sourcePartly supported

  The Discussion (page unavailable) says skin reactions with the implanted Eversense system were less clinically significant than allergic contact dermatitis reported with some transcutaneous systems. But the Results report adhesive-patch irritation in 20 patients, and the paper does not establish that the system helps people sensitive to tape avoid skin reactions. (LLM, conf=0.82)

  Experimental — accuracy not yet measured
• cites [85] Sanchez, 2019, Real-world data from the first u.s. commercial users of an implantable continuous glucose sensor, Diabetes Technol Ther sourcePartly supported

  The discussion (page unavailable) attributes a low rate of skin reactions to the implanted system’s short-duration adhesive use, and the Safety results report patch or adhesive irritation in 2.5% of users. The paper does not report outcomes specifically for people sensitive to tape, so the claim’s application to that group is not directly supported. (LLM, conf=0.82)

  Experimental — accuracy not yet measured

Routine C-peptide testing in those with clinically diagnosed type 1 diabetes of at least 3 years duration has led to reclassification in 11% of those with adult-onset diabetes.

“Routine C-peptide testing in those with clinically diagnosed type 1 diabetes of at least 3 years duration has led to reclassification in 11% of those with adult-onset diabetes (31).”

• cites [31] Foteinopoulou, 2021, Impact of routine clinic measurement of serum C-peptide in people with a clinician-diagnosis of type 1 diabetes, Diabet Med sourcePartly supported

  The Results passage in our copy reports routine C-peptide testing in people with a clinician-diagnosis of type 1 diabetes of at least 3 years’ duration and reclassification in 58 of 859 tested individuals (6.8%). It does not report an 11% reclassification rate for the adult-onset subgroup; searches for that figure and subgroup found no supporting passage. The overall 6.8% figure does not, by itself, contradict a possible subgroup rate. (LLM, conf=0.83)

  Experimental — accuracy not yet measured

More than 80% of people with diabetes diagnosed under 6 months of age have monogenic neonatal diabetes.

“As monogenic diabetes was less likely to have been considered in the past, molecular genetic testing for neonatal diabetes should be considered for all people with type 1 diabetes, regardless of current age, who were diagnosed under 6 months of age as more than 80% have monogenic neonatal diabetes, and the 30-50% with ATP-sensitive potassium (K ATP ) channel mutations can replace insulin with sulf”

• cites [32] De Franco, 2015, The effect of early, comprehensive genomic testing on clinical care in neonatal diabetes: an international cohort study, Lancet sourceSupported
• cites [33] Pearson, 2006, Switching from insulin to oral sulfonylureas in patients with diabetes due to Kir6.2 mutations, N Engl J Med sourcePartly supported

  The introductory passage (page not provided) says KCNJ11 mutations account for 30–58% of permanent diabetes diagnosed before six months of age. The paper also recommends genetic testing for everyone diagnosed before six months, regardless of current age. Neither passage establishes the claimed figure that more than 80% have monogenic neonatal diabetes. (LLM, conf=0.82)

  Experimental — accuracy not yet measured

HbA1c is inappropriate as the only method of glucose evaluation in type 1 diabetes.

“Although HbA 1c is an indicator of mean glucose, it does not inform glycemic variability and hypoglycemia and, therefore, is inappropriate as the only method of glucose evaluation in type 1 diabetes (68,69).”

• cites [68] Beck, 2017, The fallacy of average: how using hba1c alone to assess glycemic control can be misleading, Diabetes Care sourceSupported
• cites [69] Beck, 2019, The relationships between time in range, hyperglycemia metrics, and HbA1c, J Diabetes Sci Technol sourceNot checked — no full text of the source

Antibodies may disappear over time.

“Furthermore, antibodies may disappear over time (26).”

• cites [26] Tridgell, 2011, Interaction of onset and duration of diabetes on the percent of GAD and IA-2 antibody-positive subjects in the type 1 diabetes genetics consortium database, Diabetes Care sourceSupported

TIR is associated with microvascular complications.

“TIR is associated with microvascular complications (45,46), and a TIR of 70% roughly corresponds to an HbA 1c of 53 mmol/mol (7.0%).”

• cites [45] Beck, 2019, Validation of time in range as an outcome measure for diabetes clinical trials, Diabetes Care sourceSupported
• cites [46] Ranjan, 2020, Improved time in range over 1 year is associated with reduced albuminuria in individuals with sensor-augmented insulin pump-treated type 1 diabetes, Diabetes Care sourceNot checked — no full text of the source

The latest basal analogs may cause less hypoglycemia than first-generation basal analogs and NPH insulin.

“Trials have demonstrated that the latest basal analogs may cause less hypoglycemia than first-generation basal analogs and NPH insulin, while rapid-acting analogs achieve better mealtime coverage and less post-meal hypoglycemia than short-acting (regular) human insulin (87,88).”

• cites [87] Danne, 2020, Lower risk of severe hypoglycaemia with insulin glargine 300 U/mL versus glargine 100 U/mL in participants with type 1 diabetes: a meta-analysis of 6-month phase 3 clinical trials, Diabetes Obes Metab sourcePartly supported

  The Introduction reports that the second-generation basal analog Gla-300 had reduced hypoglycaemia compared with first-generation Gla-100, and the Discussion describes a reduced risk of severe hypoglycaemia in that comparison. The paper does not provide a comparison with NPH insulin, so it supports only part of the basal-insulin claim. (LLM, conf=0.87)

  Experimental — accuracy not yet measured
• cites [88] Lane, 2017, Effect of insulin degludec vs insulin glargine u100 on hypoglycemia in patients with type 1 diabetes: the SWITCH 1 randomized clinical trial, JAMA sourcePartly supported

  The Discussion reports less hypoglycemia with insulin degludec than with first-generation insulin glargine U100 in patients with type 1 diabetes. It compares the size of that reduction with findings from a separate meta-analysis of glargine or detemir versus NPH, but SWITCH 1 did not directly compare degludec with NPH. The paper therefore supports the first-generation-analog comparison, not the full comparison attributed to it. (LLM, conf=0.83)

  Experimental — accuracy not yet measured

30-50% of people with ATP-sensitive potassium channel mutations can replace insulin with sulfonylureas.

“As monogenic diabetes was less likely to have been considered in the past, molecular genetic testing for neonatal diabetes should be considered for all people with type 1 diabetes, regardless of current age, who were diagnosed under 6 months of age as more than 80% have monogenic neonatal diabetes, and the 30-50% with ATP-sensitive potassium (K ATP ) channel mutations can replace insulin with sulf”

• cites [32] De Franco, 2015, The effect of early, comprehensive genomic testing on clinical care in neonatal diabetes: an international cohort study, Lancet sourcePartly supported

  The Discussion reports that about 40% of the neonatal-diabetes cohort had potassium-channel mutations and that most of those patients achieved improved glycaemic control after switching from insulin to sulfonylureas. The cited 30–50% range therefore describes the proportion with mutations, not the proportion of mutation carriers who can replace insulin, as the quoted claim states. (LLM, conf=0.86)

  Experimental — accuracy not yet measured
• cites [33] Pearson, 2006, Switching from insulin to oral sulfonylureas in patients with diabetes due to Kir6.2 mutations, N Engl J Med sourceSupported

Even with frequent BGM, most people with type 1 diabetes have undetected and unacceptably high frequency of hyper- and hypoglycemia.

“However, even with frequent BGM, most people with type 1 diabetes will have undetected and an unacceptable high frequency of hyper-and hypoglycemia (72).”

• cites [72] Bode, 2005, Glycemic characteristics in continuously monitored patients with type 1 and type 2 diabetes: normative values, Diabetes Care sourcePartly supported

  The Results report frequent fingerstick testing (about nine times daily), substantial hyperglycemia and more than two hours per day of hypoglycemia among subjects with type 1 diabetes. The discussion says nocturnal hypoglycemia often goes undetected by standard monitoring and postprandial hyperglycemia is underappreciated by conventional monitoring. But the paper describes these patterns in an intensively managed study cohort; it does not establish that most people with type 1 diabetes experience both at this frequency. (LLM, conf=0.85)

  Experimental — accuracy not yet measured

In conditions with altered erythrocyte turnover or hemoglobinopathies, HbA1c does not reflect mean glucose.

“In several conditions, however, HbA 1c does not reflect mean glucose; these are mainly situations where erythrocyte turnover is altered or in the presence of hemoglobinopathies (Table 4) (67).”

• cites [67] Radin, 2014, Pitfalls in hemoglobin A1c measurement: when results may be misleading, J Gen Intern Med sourcePartly supported

  The FALSELY LOWERED A1C and FALSELY ELEVATED A1C sections explain that altered red-cell turnover can make HbA1c misrepresent average glycemia. The HEMOGLOBIN VARIANTS section says variants can also distort HbA1c, but qualifies the claim: measurement can be used for heterozygous variants when an appropriate assay is used. The citing sentence overgeneralizes the hemoglobinopathy part. (LLM, conf=0.87)

  Experimental — accuracy not yet measured

Approximately 5-10% of White European people with new-onset type 1 diabetes have negative islet antibodies.

“The absence of autoantibodies does not exclude type 1 diabetes, since approximately 5-10% of White European people with new-onset type 1 diabetes have negative islet antibodies (8,9,25), and further consideration of the diagnosis is necessary.”

• cites [8] Hope, 2016, Practical classification guidelines for diabetes in patients treated with insulin: a cross-sectional study of the accuracy of diabetes diagnosis, Br J Gen Pract sourceCould not verify

  The Results describe white European patients who had diabetes for at least five years, not people with new-onset diabetes. The Discussion (Implications for research and practice) proposes studies using islet antibodies at diagnosis, but gives no estimate of how often people with new-onset type 1 diabetes test negative. Searches for antibody-negative cases and the 5–10% figure found no supporting passage in our copy. (LLM, conf=0.75)

  Experimental — accuracy not yet measured
• cites [9] Shields, 2015, Can clinical features be used to differentiate type 1 from type 2 diabetes? A systematic review of the literature, BMJ Open sourceCould not verify

  The Methods (Inclusion and exclusion criteria; page unavailable) say that studies examining islet autoantibodies alone were excluded. The Discussion (Implications and future work; page unavailable) mentions antibodies as a possible diagnostic test but gives no estimate for antibody-negative, newly diagnosed White European patients. Searches for the 5–10% figure and antibody-negative type 1 diabetes found no supporting passage in our copy. (LLM, conf=0.76)

  Experimental — accuracy not yet measured
• cites [25] Thomas, The absence of islet autoantibodies in clinically diagnosed older-adult onset type 1 diabetes suggests an alternative pathology, advocating for routine testing in this age group, medRxivNot matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

The absence of autoantibodies does not exclude type 1 diabetes.

“The absence of autoantibodies does not exclude type 1 diabetes, since approximately 5-10% of White European people with new-onset type 1 diabetes have negative islet antibodies (8,9,25), and further consideration of the diagnosis is necessary.”

• cites [8] Hope, 2016, Practical classification guidelines for diabetes in patients treated with insulin: a cross-sectional study of the accuracy of diabetes diagnosis, Br J Gen Pract sourceCould not verify

  The Introduction and Abstract Method define type 1 diabetes using insulin deficiency and treatment history, but do not report whether patients lacked autoantibodies. The Discussion (Implications for research and practice; page unavailable) proposes studying islet antibodies to improve diagnosis, without saying whether a negative result excludes type 1 diabetes. Searches for antibody-negative type 1 diabetes and antibody-test sensitivity found no passage addressing the claim. (LLM, conf=0.72)

  Experimental — accuracy not yet measured
• cites [9] Shields, 2015, Can clinical features be used to differentiate type 1 from type 2 diabetes? A systematic review of the literature, BMJ Open sourcePartly supported

  The Background (page unavailable) describes islet autoantibodies as imperfect measures for distinguishing type 1 from type 2 diabetes, which supports caution about using them to rule out type 1 diabetes. The paper does not state that an antibody-negative result fails to exclude type 1 diabetes, or give the citing sentence’s 5–10% figure; its Methods say antibody-only studies were excluded. (LLM, conf=0.78)

  Experimental — accuracy not yet measured
• cites [25] Thomas, The absence of islet autoantibodies in clinically diagnosed older-adult onset type 1 diabetes suggests an alternative pathology, advocating for routine testing in this age group, medRxivNot matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Available evidence on the safety and effectiveness of diabetes health apps remains limited.

“Although widely used, the available evidence on the safety and effectiveness of diabetes health apps remains limited, with issues ranging from inadequate evidence on app accuracy and clinical validity to lack of training provision, poor interoperability and standardization, and insufficient data security (65).”

• cites [65] Fleming, 2020, Diabetes digital app technology: benefits, challenges, and recommendations. A consensus report by the European Association for the Study of Diabetes (EASD) and the American Diabetes Association (ADA) Diabetes Technology Working Group, Diabetologia sourceSupported

The importance of glycemic management was demonstrated convincingly by the DCCT and the EDIC follow-up study.

“The importance of glycemic management was demonstrated convincingly by the DCCT (39) and the Epidemiology of Diabetes Interventions and Complications (EDIC) follow-up study (40).”

• cites [39] Nathan, 1993, The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus, N Engl J Med sourceNot checked — no full text of the source
• cites [40] The Diabetes Control and Complications Trial (DCCT)/Epidemiology of Diabetes Interventions and Complications (EDIC) Study Research Group, 2016, Intensive diabetes treatment and cardiovascular outcomes in type 1 diabetes: the DCCT/EDIC study 30-year follow-up, Diabetes Care sourceSupported

In registry studies, increased BGM testing frequency is associated with lower HbA1c.

“In registry studies, increased testing frequency is associated with lower HbA 1c (71).”

• cites [71] Miller, 2013, Evidence of a strong association between frequency of self-monitoring of blood glucose and hemoglobin A1c levels in T1D exchange clinic registry participants, Diabetes Care sourceSupported

None of fructosamine, 1,5-anhydroglucitol and glycated albumin are as well associated with diabetes complications as HbA1c.

“None of these are as well associated with diabetes complications as HbA 1c (70).”

• cites [70] Krhač, 2019, Update on biomarkers of glycemic control, World J Diabetes sourcePartly supported

  The Glycated Proteins section (page unavailable) says evidence linking fructosamine and glycated albumin to long-term outcomes was insufficient, and the Conclusion (page unavailable) calls HbA1c the key biomarker while saying long-term complication associations for alternative markers need further study. The paper also reports associations of all three alternatives with microvascular complications, but it does not establish that each is less strongly associated with complications than HbA1c. (LLM, conf=0.82)

  Experimental — accuracy not yet measured

There is a strong correlation (r >0.9) between HbA1c and mean blood glucose levels during the preceding 3 months when glucose levels are stable.

“There is a strong correlation (r 5 >0.9) between HbA 1c and mean blood glucose levels during the preceding 3 months when glucose levels are stable (66).”

• cites [66] Nathan, 2008, Translating the A1C assay into estimated average glucose values, Diabetes Care sourceSupported

In the U.S., inhaled human insulin is an alternative to subcutaneous rapid-acting analogs.

“In the U.S., inhaled human insulin is an alternative to subcutaneous rapid-acting analogs (3).”

• cites [3] Hirsch, 2020, The evolution of insulin and how it informs therapy and treatment choices, Endocr Rev sourceSupported

Independent of other risk factors and comorbidities, more episodes of severe hypoglycemia were associated with greater decrements in psychomotor and mental efficiency that were most notable after 32 years of follow-up.

“However, independent of other risk factors and comorbidities, more episodes of severe hypoglycemia were associated with greater decrements in psychomotor and mental efficiency that were most notable after 32 years of follow-up (110).”

• cites [110] Jacobson, 2021, Cognitive performance declines in older adults with type 1 diabetes: results from 32 years of follow-up in the DCCT and EDIC Study, Lancet Diabetes Endocrinol sourceSupported

Postprandial glucose measurements for up to 3 h or more may be needed to determine initial dose adjustments.

“Since this is highly variable between individuals, postprandial glucose measurements for up to 3 h or more may be needed to determine initial dose adjustments (134).”

• cites [134] Evert, 2019, Nutrition therapy for adults with diabetes or prediabetes: a consensus report, Diabetes Care sourceSupported

The pathophysiology of IAH includes a partial or total loss of sympathoadrenal reactions to hypoglycemia that prevent catecholaminergic stimulation of hepatic glucose output and restraint of muscle glucose uptake.

“The pathophysiology of IAH is still not fully understood but includes a partial or total loss of sympathoadrenal reactions to hypoglycemia that prevent catecholaminergic stimulation of hepatic glucose output and restraint of muscle glucose uptake (104).”

• cites [104] Cryer, 2013, Mechanisms of hypoglycemia-associated autonomic failure in diabetes, N Engl J Med sourcePartly supported

  The Summary (page unavailable) identifies attenuated sympathoadrenal responses as central to hypoglycemia-associated autonomic failure and says that a reduced epinephrine response causes defective glucose counterregulation. The Compromised Defenses section links this process to hypoglycemia unawareness and increased glucose production, but our copy does not establish total loss of the response or the claimed restraint of muscle glucose uptake. (LLM, conf=0.85)

  Experimental — accuracy not yet measured

Sleep may be disrupted in people with type 1 diabetes as a result of both behavioral and physiological aspects of diabetes and its management.

“Sleep may be disrupted in people with type 1 diabetes as a result of both behavioral and physiological aspects of diabetes and its management (153).”

• cites [153] Reutrakul, 2016, Sleep characteristics in type 1 diabetes and associations with glycemic control: systematic review and meta-analysis, Sleep Med sourceSupported

Several clinical trials have not shown a reduction of IAH by using CGM despite a reduced incidence of level 3 hypoglycemia.

“Several clinical trials have not shown a reduction of IAH by using CGM despite a reduced incidence of level 3 hypoglycemia (101,112,124,126-128).”

• cites [101] Heinemann, 2018, Real-time continuous glucose monitoring in adults with type 1 diabetes and impaired hypoglycaemia awareness or severe hypoglycaemia treated with multiple daily insulin injections (HypoDE): a multicentre, randomised controlled trial, Lancet sourceNot checked — no full text of the source
• cites [112] Lin, 2020, Hypoglycemia unawareness and autonomic dysfunction in diabetes: Lessons learned and roles of diabetes technologies, J Diabetes Investig sourceSupported
• cites [124] Cranston, 1994, Restoration of hypoglycaemia awareness in patients with long-duration insulin-dependent diabetes, Lancet sourceNot checked — no full text of the source
• cites [126] Cox, 2006, Blood glucose awareness training: what is it, where is it, and where is it going?, Diabetes Spectr sourceCould not verify

  The Multicenter Trials and Hypoglycemia Anticipation, Awareness, and Treatment Training sections (pages unavailable) discuss BGAT and HAATT, not CGM trials. Searches for continuous glucose monitoring, impaired hypoglycemia awareness, and severe hypoglycemia found no passage addressing whether CGM reduces IAH despite reducing level 3 hypoglycemia. (LLM, conf=0.76)

  Experimental — accuracy not yet measured
• cites [127] Rondags, 2016, Effectiveness of HypoAware, a brief partly web-based psychoeducational intervention for adults with type 1 and insulin-treated type 2 diabetes and problematic hypoglycemia: a cluster randomized controlled trial, Diabetes Care sourcePartly supported

  The Conclusions state that RT-CGM has been found effective in preventing severe hypoglycemia. They do not say that CGM trials failed to reduce impaired hypoglycemia awareness (IAH), or report that pattern across several trials. This paper’s own trial tested HypoAware, not CGM. (LLM, conf=0.83)

  Experimental — accuracy not yet measured
• cites [128] Hermanns, 2010, Long-term effect of an education program (HyPOS) on the incidence of severe hypoglycemia in patients with type 1 diabetes, Diabetes Care sourcePartly supported

  The HyPOS study reports fewer severe hypoglycemic episodes in its education-program group than in the control group at 31 months (main text; page unavailable). It does not study CGM or report that CGM trials failed to reduce impaired awareness of hypoglycemia. The main text instead notes improved awareness after six months of HyPOS. (LLM, conf=0.83)

  Experimental — accuracy not yet measured

Hybrid closed-loop systems are the most effective means of maintaining glucose in the normal range in people with type 1 diabetes.

“Hybrid closedloop systems are the most effective means of maintaining glucose in the normal range in people with type 1 diabetes (90,91).”

• cites [90] Bergenstal, 2016, Safety of a hybrid closed-loop insulin delivery system in patients with type 1 diabetes, JAMA sourceNot checked — no full text of the source
• cites [91] Brown, 2019, Six-month randomized, multicenter trial of closed-loop control in type 1 diabetes, N Engl J Med sourcePartly supported

  The Results (p. 1) show that the closed-loop group spent more time in the target glucose range than the sensor-augmented pump group. But the trial compared one closed-loop system with one alternative; it does not establish that hybrid closed-loop systems are the most effective means among all options. (LLM, conf=0.88)

  Experimental — accuracy not yet measured

The greatest benefits from adding CGM to MDI or pump are seen with hybrid closed-loop therapy.

“HbA 1c , TIR, and TBR are improved further when physiological MDI or pump regimens are augmented with CGM usage (89), with the greatest benefits seen with algorithm-driven automated basal (and in some systems correction) insulin delivery, which is commonly called hybrid closed-loop therapy (90,91).”

• cites [90] Bergenstal, 2016, Safety of a hybrid closed-loop insulin delivery system in patients with type 1 diabetes, JAMA sourceNot checked — no full text of the source
• cites [91] Brown, 2019, Six-month randomized, multicenter trial of closed-loop control in type 1 diabetes, N Engl J Med sourceSupported

Structured education programs, such as DAFNE and BGAT, lead to sustained falls in level 3 hypoglycemia rates in those at high risk.

“Structured education programs, such as Dose Adjustment For Normal Eating (DAFNE) and blood glucose awareness training (BGAT), which provide informed support for active insulin dose self-adjustment, are the key to the prevention of hypoglycemia and lead to sustained falls in level 3 hypoglycemia rates in those at high risk (122,123).”

• cites [122] Little, 2018, Sustained reduction in severe hypoglycemia in adults with type 1 diabetes complicated by impaired awareness of hypoglycemia: two-year follow-up in the HypoCOMPaSS randomized clinical trial, Diabetes Care sourceNot checked — no full text of the source
• cites [123] Iqbal, 2018, The role of structured education in the management of hypoglycaemia, Diabetologia sourcePartly supported

  The DTTP-based programmes section reports about a 50% reduction in severe hypoglycaemia after DAFNE at one-year follow-up. The BGAT section and comparison table report a substantial reduction in a Swiss BGAT study followed for 12 months, where people with recurrent severe hypoglycaemia were encouraged to participate. However, the paper does not establish sustained reductions specifically in high-risk participants for both programmes: the DAFNE follow-up was not restricted to that group, and the Swiss BGAT study enrolled an unselected type 1 diabetes population. (LLM, conf=0.84)

  Experimental — accuracy not yet measured

If an individual has proliferative diabetic retinopathy or severe nonproliferative diabetic retinopathy, then vigorous activity requiring straining may be contraindicated because of the risk of vitreous hemorrhage or retinal detachment.

“If an individual has proliferative diabetic retinopathy or severe nonproliferative diabetic retinopathy, then vigorous activity requiring straining may be contraindicated because of the risk of vitreous hemorrhage or retinal detachment (151).”

• cites [151] Riddell, 2017, Exercise management in type 1 diabetes: a consensus statement, Lancet Diabetes Endocrinol sourcePartly supported

  The Diabetes-related complications section (page not supplied) says vigorous exercise and heavy weight lifting are contraindicated in certain people with long-standing diabetes or HbA1c well above target, particularly those with unstable proliferative retinopathy. It does not address severe nonproliferative retinopathy or identify vitreous hemorrhage or retinal detachment as the reason for the restriction. (LLM, conf=0.88)

  Experimental — accuracy not yet measured

Those responding 'less than 3.0 mmol/L (54 mg/dL)' or not experiencing symptoms have a >4-fold increased risk of level 3 hypoglycemia.

“Those responding, “less than 3.0 mmol/L (54 mg/dL)” or not experiencing symptoms have a >4-fold increased risk of level 3 hypoglycemia (120).”

• cites [120] Hopkins, 2012, Improved biomedical and psychological outcomes 1 year after structured education in flexible insulin therapy for people with type 1 diabetes: the U.K. DAFNE experience, Diabetes Care sourcePartly supported

  The Results section (‘Changes in self-reported hypoglycemia awareness’; page unavailable) defines impaired awareness as symptom onset below 3 mmol/L or no symptoms and reports a higher frequency of severe hypoglycemia in that group. It says the frequency was more than threefold higher, not that the risk was more than fourfold higher. (LLM, conf=0.88)

  Experimental — accuracy not yet measured

Self-reported awareness agrees well with the autonomic glucose threshold.

“Self-reported awareness, however, agrees well with the autonomic glucose threshold (116).”

• cites [116] Janssen, 2000, Assessing impaired hypoglycemia awareness in type 1 diabetes: agreement of self-report but not of field study data with the autonomic symptom threshold during experimental hypoglycemia, Diabetes Care sourceSupported

Adjunctive use of SGLT inhibitors in adults with type 1 diabetes increases the risk of DKA by an absolute rate of about 4% per year.

“Adjunctive use of sodium-glucose cotransporter (SGLT) inhibitors (see below) in adults with type 1 diabetes increases the risk of DKA by an absolute rate of about 4% per year, suggesting the need for intensive diabetes self-management education and monitoring (216,217).”

• cites [216] Danne, 2019, International consensus on risk management of diabetic ketoacidosis in patients with type 1 diabetes treated with sodium-glucose cotransporter (SGLT) inhibitors, Diabetes Care sourceSupported
• cites [217] Goldenberg, 2019, Sodium-glucose co-transporter inhibitors, their role in type 1 diabetes treatment and a risk mitigation strategy for preventing diabetic ketoacidosis: The STOP DKA Protocol, Diabetes Obes Metab sourceNot checked — no full text of the source

Psychological distress, including mild to major depression, is a risk factor for poor self-care, hyperglycemia, complications, and excess mortality.

“Psychological distress, including mild to major depression, is a risk factor for poor self-care, hyperglycemia, complications, and excess mortality (174-176).”

• cites [174] Snoek, 2015, Constructs of depression and distress in diabetes: time for an appraisal, Lancet Diabetes Endocrinol sourceNot checked — no full text of the source
• cites [175] Pouwer, 2020, How 25 years of psychosocial research has contributed to a better understan ding of the links between depression and diabetes, Diabet Med sourcePartly supported

  The sections “Mechanisms linking depression and diabetes” and “Depression in diabetes and long-term health outcomes” link depression in people with diabetes to poorer self-care, complications, and higher mortality. They describe hyperglycaemia as part of a hypothesized mechanism, not as an established outcome of psychological distress, and do not establish the claimed range from mild to major depression. Page numbers are unavailable in our copy. (LLM, conf=0.85)

  Experimental — accuracy not yet measured
• cites [176] Fisher, 2016, Prevalence of depression in type 1 diabetes and the problem of over-diagnosis, Diabet Med sourceNot checked — no full text of the source

Regardless of the b-cell replacement approach (pancreas or islets), the majority of recipients experience reliable prevention of problematic hypoglycemia with near-normal glycemic levels.

“Regardless of the b-cell replacement approach (pancreas or islets), the majority of recipients experience reliable prevention of problematic hypoglycemia with near-normal glycemic levels.”

• cites [242] Choudhary, 2015, Evidence-informed clinical practice recommenda tions for treatment of type 1 diabetes complicated by problematic hypoglycemia, Diabetes Care sourceSupported

Careful patient selection and protocol optimization have led to substantial clinical improvements in islet transplantation.

“Careful patient selection and protocol optimization have led to substantial clinical improvements (224).”

• cites [224] Barton, 2012, Improvement in outcomes of clinical islet transplantation: 1999-2010, Diabetes Care sourcePartly supported

  The Results describe changes in recipient selection and transplantation protocols, and the Conclusions report better outcomes in 2007–2010 than in 1999–2006. The paper does not establish that those changes caused the improvements: its Statistics section says comparisons across eras were not randomized, and the Conclusions describe the potential benefit of newer immunosuppression strategies as a possibility. (LLM, conf=0.84)

  Experimental — accuracy not yet measured

The association between generalized anxiety and suboptimal blood glucose levels is less clear.

“The association between generalized anxiety and suboptimal blood glucose levels is less clear (177,178).”

• cites [177] Sultan, 2008, A longitudinal study of coping, anxiety and glycemic control in adults with type 1 diabetes, Psychol Health sourceNot checked — no full text of the source
• cites [178] Nefs, 2019, Comorbid elevated symptoms of anxiety and depression in adults with type 1 or type 2 diabetes: results from the international diabetes MILES study, J Diabetes Complications sourceCould not verify

  The available passages labeled Abstract contain bibliographic information but no findings about blood glucose levels. Searches for generalized anxiety, glycemic control, and HbA1c found no passage addressing whether that association is unclear. (LLM, conf=0.72)

  Experimental — accuracy not yet measured

Islet and pancreas transplants are the only approaches to date that confer both sustained recovery from IAH and restoration of glucose counterregulation and, thereby, reliable protection from level 3 hypoglycemia in people with long-standing type 1 diabetes.

“Islet and pancreas transplants are the only approaches to date that confer both sustained recovery from IAH and restoration of glucose counterregulation and, thereby, reliable protection from level 3 hypoglycemia in people with long-standing type 1 diabetes (242).”

• cites [242] Choudhary, 2015, Evidence-informed clinical practice recommenda tions for treatment of type 1 diabetes complicated by problematic hypoglycemia, Diabetes Care sourceSupported

DKA in the setting of SGLT inhibitor use is often euglycemic DKA, with initial case reports describing admission glucose levels of 5.3-12.4 mmol/L (96-224 mg/dL).

“DKA in the setting of SGLT inhibitor use is often so-called euglycemic DKA, with initial case reports describing admission glucose levels of 5.3-12.4mmol/L (96-224 mg/dL) (218).”

• cites [218] Peters, 2015, Euglycemic diabetic ketoacidosis: a potential complication of treatment with sodium-glucose cotransporter 2 inhibition, Diabetes Care sourcePartly supported

  The Results table and Conclusions describe euglycemic DKA associated with SGLT-2 inhibitor use. But the stated admission-glucose range is not accurate for these cases: the 96 mg/dL event was treated as an outpatient, while the table lists a presenting glucose of 233 mg/dL (12.9 mmol/L) for another case. (LLM, conf=0.89)

  Experimental — accuracy not yet measured

No risk mitigation strategies have been proven to lower the risk of DKA.

“While no risk mitigation strategies have been proven to lower the risk of DKA, a consensus statement on SGLT2 inhibitors and DKA suggested careful patient selection, appropriate insulin dose adjustment to avoid insulinopenia, starting with a low dose of SGLT2 inhibitors, and regular ketone measurements with prompt action to address elevated values as sensible precautions aimed at preventing DKA (”

• cites [216] Danne, 2019, International consensus on risk management of diabetic ketoacidosis in patients with type 1 diabetes treated with sodium-glucose cotransporter (SGLT) inhibitors, Diabetes Care sourcePartly supported

  The Patient Selection, Insulin Dose Adjustments, Initiation and Dosing, and Ketone Monitoring sections recommend the precautions listed in the citing sentence. The Research Questions section says there is no evidence that daily ketone monitoring prevents DKA, but does not establish the broader claim that no risk-mitigation strategy has been proven to lower risk. The Initiation and Dosing section also reports lower DKA rates with lower SGLT inhibitor doses in clinical trials. Page numbers were not available in our copy. (LLM, conf=0.84)

  Experimental — accuracy not yet measured

Insulin independence can be maintained for 5 years in 50% of islet transplant recipients.

“Insulin independence can be maintained for 5 years in 50% of recipients (236,237).”

• cites [236] Bellin, 2012, Potent induction immunotherapy promotes long-term insulin independence after islet transplantation in type 1 diabetes, Am J Transplant sourcePartly supported

  The Results report 50% insulin independence at five years in two groups of islet transplant recipients given potent induction immunotherapy. The citing sentence omits that treatment condition, so the 50% figure is not established for islet transplant recipients generally. (LLM, conf=0.85)

  Experimental — accuracy not yet measured
• cites [237] Qi, 2014, Five-year follow-up of patients with type 1 diabetes transplanted with allogeneic islets: the UIC experience, Acta Diabetol sourcePartly supported

  The Introduction and Discussion report a 50% five-year insulin-independence rate in another study, but that rate applies to patients receiving particular immunosuppressive regimens. This paper’s own UIC cohort had a 60% rate at five years, so it does not establish 50% as a general rate for islet transplant recipients. (LLM, conf=0.84)

  Experimental — accuracy not yet measured

Lack of social support or feeling 'policed' by family, friends, or coworkers also evokes emotional distress in individuals with type 1 diabetes.

“Lack of social support or feeling “policed” by family, friends, or coworkers also evokes emotional distress in individuals with type 1 diabetes (170).”

• cites [170] de Wit, 2020, State of the art: understanding and integration of the social context in diabetes care, Diabet Med sourcePartly supported

  The ‘Diabetes in youth’ section links family conflict and peer relationships to psychosocial outcomes in adolescents with type 1 diabetes; the work-life section reports work-related distress in people with type 1 diabetes. The paper does not specifically describe feeling ‘policed’ by family, friends, or coworkers, or establish that those interactions evoke emotional distress across individuals with type 1 diabetes. (LLM, conf=0.84)

  Experimental — accuracy not yet measured

Trials in people with type 2 diabetes have shown convincing reductions in cardiovascular events with some GLP-1 RA.

“Trials in people with type 2 diabetes have shown convincing reductions in cardiovascular events with some GLP-1 RA (259); whether these benefits would also be seen in people with type 1 diabetes is unknown.”

• cites [259] Sheahan, 2020, An overview of GLP-1 agonists and recent cardiovascular outcomes trials, Postgrad Med J sourceSupported

The largest study to date assessed metformin 1 g twice daily in 428 people with type 1 diabetes for 3 years, with a primary end point of changes in mean carotid intima-media thickness.

“The largest study to date assessed the use of metformin 1 g, twice daily, in 428 people with type 1 diabetes who were treated for 3 years, with a primary end point of changes in mean carotid intima-media thickness, a marker of cardiovascular disease risk.”

• cites [246] Petrie, 2017, Cardiovascular and metabolic effects of metformin in patients with type 1 diabetes (REMOVAL): a double-blind, randomised, placebo-controlled trial, Lancet Diabetes Endocrinol sourceSupported

The CONCEPTT trial showed that when CGM was used in conjunction with BGM, CGM was associated with better pregnancy outcomes.

“the Continuous Glucose Monitoring in Women With Type 1 Diabetes in Pregnancy Trial (CONCEPTT) showed that when CGM was used in conjunction with BGM, CGM was associated with better pregnancy outcomes (266)”

• cites [266] Feig, 2017, Continuous glucose monitoring in pregnant women with type 1 diabetes (CONCEPTT): a multicentre international randomised controlled trial, Lancet sourceSupported

People with type 1 diabetes, particularly those with concomitant chronic kidney disease, are at higher risk of hypoglycemia.

“People with type 1 diabetes, particularly those with concomitant chronic kidney disease, are at higher risk of hypoglycemia, which should be avoided by careful insulin and carbohydrate matching (129).”

• cites [129] Cryer, 2010, Hypoglycemia in type 1 diabetes mellitus, Endocrinol Metab Clin North Am sourcePartly supported

  The Conventional Risk Factors section identifies reduced insulin clearance in renal failure as a hypoglycemia risk factor, and the Summary of Recommendations advises matching insulin action to glucose availability to avoid hypoglycemia. The paper does not extend the renal-failure finding to all chronic kidney disease, so the claim's broader CKD qualifier is not fully supported. No page numbers are available in our copy. (LLM, conf=0.84)

  Experimental — accuracy not yet measured

People with gastroparesis have unpredictable rates of food absorption.

“and in people with gastroparesis and unpredictable rates of food absorption (277).”

• cites [277] Aleppo, 2017, Reported gastroparesis in adults with type 1 diabetes (T1D) from the T1D Exchange clinic registry, J Diabetes Complications sourcePartly supported

  The Introduction describes delayed solid-food transit in people with type 1 diabetes and gastroparesis. The Discussion says that a mismatch between food transit or absorption and insulin action can affect glycemic control, but it does not establish that absorption rates are unpredictable or extend that finding to all people with gastroparesis. Page numbers are unavailable in our copy. (LLM, conf=0.78)

  Experimental — accuracy not yet measured

Misclassification of type 1 diabetes in adults is common.

“Misclassification of type 1 diabetes in adults is common, and over 40% of those developing type 1 diabetes after age 30 years are initially treated as having type 2 diabetes (6)(7)(8).”

• cites (6)(7)(8)Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Over 40% of those developing type 1 diabetes after age 30 years are initially treated as having type 2 diabetes.

“Misclassification of type 1 diabetes in adults is common, and over 40% of those developing type 1 diabetes after age 30 years are initially treated as having type 2 diabetes (6)(7)(8).”

• cites (6)(7)(8)Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Other features classically associated with type 1 diabetes, such as ketosis without acidosis, osmotic symptoms, family history, or a history of autoimmune diseases, are weak discriminators.

“Other features classically associated with type 1 diabetes, such as ketosis without acidosis, osmotic symptoms, family history, or a history of autoimmune diseases are weak discriminators (8)(9)(10).”

• Also stated in: § SECTION 17: CONCLUSION · plain

  “Other features classically associated with type 1 diabetes, such as ketosis without acidosis, osmotic symptoms, family history, or a history of autoimmune diseases are weak discriminators.”

• cites (8)(9)(10)Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Diagnosis of type 1 diabetes can be more difficult in adults who progress to insulin therapy more slowly.

“The diagnosis of type 1 diabetes can be more difficult in adults who progress to insulin therapy more slowly.”

Large areas of clinical practice in type 1 diabetes are based on expert opinion and cohort studies rather than RCTs.

“Large areas of clinical practice in type 1 diabetes are based on expert opinion and cohort studies rather than RCTs and so the writing group considered both observational and clinical trial findings, rather than relying solely on unbiased RCTs and meta-analyses.”

Younger age at diagnosis (<35 years) is the most discriminative feature for type 1 diabetes.

“The most discriminative feature is younger age at diagnosis (<35 years), with lower BMI (<25 kg/m 2 ), unintentional weight loss, ketoacidosis, and glucose >20 mmol/L (>360 mg/dL) at presentation also being informative.”

• cites (8)(9)(10)Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

There is a paucity of trials of lipid-lowering therapy in people with type 1 diabetes.

“Similar to the situation for blood pressure, there is a paucity of trials of lipid-lowering therapy in people with type 1 diabetes, but an observational study reported that lipid-lowering therapy is associated with a 22-44% reduction in the risk of cardiovascular disease and death among individuals with type 1 diabetes without a prior history of cardiovascular disease (48).”

An observational study reported that lipid-lowering therapy is associated with a 22-44% reduction in the risk of cardiovascular disease and death among individuals with type 1 diabetes without a prior history of cardiovascular disease.

“Similar to the situation for blood pressure, there is a paucity of trials of lipid-lowering therapy in people with type 1 diabetes, but an observational study reported that lipid-lowering therapy is associated with a 22-44% reduction in the risk of cardiovascular disease and death among individuals with type 1 diabetes without a prior history of cardiovascular disease (48).”

• cites [48] Hero, 2016, Association between use of lipid-lowering therapy and cardiovascular diseases and death in individuals with type 1 diabetes, Diabetes Care sourceNot checked — no full text of the source

There is an absence of high-quality data to guide blood pressure targets in type 1 diabetes.

“There is an absence of high-quality data to guide blood pressure targets in type 1 diabetes, but RCTs in other populations have demonstrated that treatment of hypertension to a blood pressure <140/90 mmHg reduces cardiovascular events and microvascular complications.”

In those aged over 35 years, type 2 diabetes becomes increasingly likely with absent islet autoantibodies and older age.

“In those aged over 35 years, type 2 diabetes becomes increasingly likely with absent islet autoantibodies and older age.”

In those diagnosed below the age of 35 years, type 1 diabetes is still the most likely diagnosis, particularly if there are no clinical features of type 2 diabetes or monogenic diabetes.

“In those diagnosed below the age of 35 years, type 1 diabetes is still the most likely diagnosis, particularly if there are no clinical features of type 2 diabetes or monogenic diabetes.”

Persistent C-peptide >600 pmol/L (nonfasting) is strongly suggestive of type 2 diabetes.

“Persistent C-peptide >600 pmol/L (nonfasting) is strongly suggestive of type 2 diabetes, and people with C-peptide in this range are often able to replace insulin with other agents (27)(28)(29)(30).”

• cites (27)(28)(29)(30)Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Achieving and maintaining glucose levels in the target range has become possible with fewer episodes of hypoglycemia.

“Increasingly, achieving and maintaining glucose levels in the target range have become possible with fewer episodes of hypoglycemia (41)(42)(43)(44).”

• cites (41)(42)(43)(44)Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Prevention of long-term complications of diabetes, particularly cardiovascular disease, extends beyond glycemic management to include optimal management of blood pressure and use of lipid-lowering medication.

“The prevention of long-term complications of diabetes, particularly cardiovascular disease, extends beyond glycemic management to include the optimal management of blood pressure and use of lipid-lowering medication.”

People with C-peptide >600 pmol/L are often able to replace insulin with other agents.

“Persistent C-peptide >600 pmol/L (nonfasting) is strongly suggestive of type 2 diabetes, and people with C-peptide in this range are often able to replace insulin with other agents (27)(28)(29)(30).”

• cites (27)(28)(29)(30)Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Other biomarkers such as fructosamine, 1,5-anhydroglucitol and glycated albumin provide measures of mean glucose with shorter durations than HbA1c.

“Other biomarkers, such as fructosamine, 1,5-anhydroglucitol and glycated albumin, provide measures of mean glucose, albeit with shorter durations than HbA 1c .”

A TIR of 70% roughly corresponds to an HbA1c of 53 mmol/mol (7.0%).

“TIR is associated with microvascular complications (45,46), and a TIR of 70% roughly corresponds to an HbA 1c of 53 mmol/mol (7.0%).”

It can be hard to differentiate between type 1 diabetes and type 2 diabetes based on age and clinical features in non-White European populations.

“However, it can be hard to differentiate between type 1 diabetes and type 2 diabetes based on age and clinical features in non-White European populations.”

Capillary blood glucose monitoring can help people with type 1 diabetes achieve HbA1c goals.

“Capillary blood glucose monitoring (BGM) can help people with type 1 diabetes achieve these HbA 1c goals.”

In type 1 diabetes, remote monitoring, education, and provider visits have the potential to improve outcomes, quality of life, and self-management.

“Pre-COVID-19, results from a limited number of studies using telemedicine in different subgroups of people with type 1 diabetes suggested that remote monitoring, education, and provider visits have the potential to: improve outcomes, quality of life, and selfmanagement; increase access to care and reduce costs; and are well-accepted with improved treatment satisfaction (54)(55)(56)(57).”

• cites (54)(55)(56)(57)Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

The insulin doses needed to prevent hyperglycemia are associated with a high risk of hypoglycemia.

“Furthermore, the insulin doses needed to prevent hyperglycemia are associated with a high risk of hypoglycemia, leaving people with type 1 diabetes walking a tightrope between high and low glucose levels.”

Most people with type 1 diabetes can benefit from CGM with appropriate initial and ongoing education.

“Most people with type 1 diabetes can benefit from this technology with appropriate initial and ongoing education, including frequent observation of the glucose trends.”

Contact dermatitis (both irritant and allergic) may occur with all CGM devices that attach to the skin.

“People with type 1 diabetes should be warned that contact dermatitis (both irritant and allergic) may occur with all CGM devices that attach to the skin (81)(82)(83).”

• cites (81)(82)(83)Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Low or absent C-peptide confirms the diagnosis of type 1 diabetes.

“By contrast, low or absent C-peptide confirms the diagnosis of type 1 diabetes.”

Any reduction in HbA1c from high initial levels has significant benefit even if the goal is not reached.

“It should be recognized that any reduction in HbA 1c from high initial levels has significant benefit even if the”

Urine C-peptide measurement may be confounded by impaired renal function.

“The latter may be confounded by impaired renal function.”

• AssumptionRests on an assumption: Urine C-peptide measurement may be confounded by impaired renal function.

Intensive insulin therapy lowered HbA1c by 2% to a mean of 7.0% over a mean of 6.5 years compared with standard care mean HbA1c of 9.0%.

“With the use of intensive insulin therapy that aimed to achieve blood glucose levels close to the nondiabetes range, HbA 1c was lowered by 2% (22 mmol/mol) to a mean HbA 1c of 7.0% (53 mmol/mol) over a mean of 6.5 years, compared with standard care (mean HbA 1c 9.0% [75 mmol/mol]) (39).”

• cites [39] Nathan, 1993, The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus, N Engl J Med sourceNot checked — no full text of the source

Level 3 DSMES programs for adults with type 1 diabetes have proven effective in improving glycemic outcomes and psychosocial outcomes.

“Several level 3 programs have been developed for adults with type 1 diabetes and have proven to be effective, both in terms of improved glycemic outcomes and improved psychosocial outcomes (61).”

• cites [61] Diabetes UK . Diabetes self-management education. Accessed 11 February 2021. Available from www.diabetes.org.uk/professionals/resourc es/resources-to-improve-your-clinical-practice/ diabetes-self-management-educationNot checked yet

  Not checked in the free run.

RCTs in other populations have demonstrated that treatment of hypertension to a blood pressure <140/90 mmHg reduces cardiovascular events and microvascular complications.

“There is an absence of high-quality data to guide blood pressure targets in type 1 diabetes, but RCTs in other populations have demonstrated that treatment of hypertension to a blood pressure <140/90 mmHg reduces cardiovascular events and microvascular complications.”

IAH increases the risk of level 3 hypoglycemia by sixfold.

“IAH increases the risk of level 3 hypoglycemia by sixfold (114)”

• cites [114] Gold, 1994, Frequency of severe hypoglycemia in patients with type I diabetes with impaired awareness of hypoglycemia, Diabetes Care sourceNot checked — no full text of the source

Mortality from hypoglycemia in type 1 diabetes is not trivial.

“Mortality from hypoglycemia in type 1 diabetes is not trivial.”

• cites [107] Gagnum, 2017, Causes of death in childhood-onset type 1 diabetes: long-term follow-up, Diabet Med sourceNot checked — no full text of the source

A secondary analysis of the IN CONTROL trial demonstrated an increase in the rate of level 3 hypoglycemia with lower HbA1c.

“A secondary analysis of the IN CONTROL trial, where the primary analysis showed a reduction in level 3 hypoglycemia in people using CGM, demonstrated an increase in the rate of level 3 hypoglycemia with lower HbA 1c , similar to what was reported in the DCCT (106).”

• cites [106] van Beers, 2018, The relation between HbA1c and hypoglycemia revisited; a secondary analysis from an intervention trial in patients with type 1 diabetes and impaired awareness of hypoglycemia, J Diabetes Complications sourceNot checked — no full text of the source

In the DCCT and EDIC study, after 18 years of follow-up, severe hypoglycemia in middle-aged adults did not appear to affect neurocognitive function.

“With regard to cognitive function, in the DCCT and EDIC study, after 18 years of follow-up, severe hypoglycemia in middleaged adults did not appear to affect neurocognitive function (109).”

• cites [109] Jacobson, 2007, Long-term effect of diabetes and its treatment on cognitive function, N Engl J Med sourceNot checked — no full text of the source

The Gold questionnaire and Clarke questionnaire, showing a score equal or above 4, are indicative of IAH.

“The Gold questionnaire and Clarke questionnaire, showing a score equal or above 4 are indicative of IAH (114,117)”

• cites [114] Gold, 1994, Frequency of severe hypoglycemia in patients with type I diabetes with impaired awareness of hypoglycemia, Diabetes Care sourceNot checked — no full text of the source
• cites [117] Clarke, 1995, Reduced awareness of hypoglycemia in adults with IDDM. A prospective study of hypoglycemic frequency and associated symptoms, Diabetes Care sourceNot checked — no full text of the source

Needles as short as 4 mm, injected at a 90 angle, enter the subcutaneous space with minimal risk of intramuscular injection in most adults.

“Needles as short as 4 mm, injected at a 90 angle, enter the subcutaneous space with minimal risk of intramuscular injection in most adults (92).”

• cites [92] Gibney, 2010, Skin and subcutaneous adipose layer thickness in adults with diabetes at sites used for insulin injections: implications for needle length recommendations, Curr Med Res Opin sourceNot checked — no full text of the source

Walking does not increase the risk of ulceration in people with peripheral neuropathy.

“However, walking does not increase the risk of ulceration in people with peripheral neuropathy (150).”

• cites [150] Lemaster, 2003, Daily weight-bearing activity does not increase the risk of diabetic foot ulcers, Med Sci Sports Exerc sourceNot checked — no full text of the source

An association between recent recreational cannabis consumption and a more than twofold increased risk of DKA has been reported from countries where cannabis has been legalized.

“An association between recent recreational cannabis consumption and a more than twofold increased risk of DKA has been reported from countries where cannabis has been legalized, possibly related to the emergence of higher potency formulations of cannabis and other synthetic cannabinoids (138).”

• cites [138] Pastor, 2020, Alcohol and illicit drug use in people with diabetes, Lancet Diabetes Endocrinol sourceNot checked — no full text of the source

Lowering HbA1c may still come with a higher risk of level 3 hypoglycemia.

“This implies that lowering HbA 1c may still come with a higher risk of level 3 hypoglycemia.”

Medical nutrition therapy delivered by a registered dietitian is associated with a reduction in HbA1c of 1.0-1.9% for people with suboptimally managed type 1 diabetes when integrated into an overall management program.

“Medical nutrition therapy delivered by a registered dietitian is associated with a reduction in HbA 1c of 1.0-1.9%(11-21 mmol/mol) for people with suboptimally managed type 1 diabetes when integrated into an overall management program (131).”

• cites [131] American Diabetes Association, 2019, 5. Lifestyle management: Standards of Medical Care in Diabetes—2019, Diabetes Care sourceNot checked — no full text of the source

One recent trial noted more than 8% of deaths for those younger than 56 years were from hypoglycemia.

“One recent trial noted more than 8% of deaths for those younger than 56 years were from hypoglycemia (107).”

• cites [107] Gagnum, 2017, Causes of death in childhood-onset type 1 diabetes: long-term follow-up, Diabet Med sourceNot checked — no full text of the source

Strict avoidance of hypoglycemia can help to restore hypoglycemia awareness.

“Strict avoidance of hypoglycemia can help to restore hypoglycemia awareness (124).”

• cites [124] Cranston, 1994, Restoration of hypoglycaemia awareness in patients with long-duration insulin-dependent diabetes, Lancet sourceNot checked — no full text of the source

Level 3 hypoglycemia occurred in 12% of adults with type 1 diabetes over a 6-month period in a recent global observational analysis.

“Level 3 hypoglycemia is less common but occurred in 12% of adults with type 1 diabetes over a 6-month period in a recent global observational analysis (102).”

• cites [102] Renard, The SAGE study: global observational analysis of glycaemic control, hypoglycaemia and diabetes management in T1DM, Diabetes Metab Res RevNot matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

The Pedersen-Bjergaard et al. questionnaire and Hypoglycemia Awareness Questionnaire (HypoA-Q) can also identify IAH.

“The Pedersen-Bjergaard et al. questionnaire and Hypoglycemia Awareness Questionnaire (HypoA-Q) can also identify IAH (118,119).”

• cites [118] Pedersen-Bjergaard, 2003, Recall of severe hypoglycaemia and self-estimated state of awareness in type 1 diabetes, Diabetes Metab Res Rev sourceNot checked — no full text of the source
• cites [119] Speight, 2016, Characterizing problematic hypoglycaemia: iterative design and preliminary psychometric validation of the Hypoglycaemia Awareness Questionnaire (HypoA-Q), Diabet Med sourceNot checked — no full text of the source

HbA1c, TIR, and TBR are improved further when physiological MDI or pump regimens are augmented with CGM usage.

“HbA 1c , TIR, and TBR are improved further when physiological MDI or pump regimens are augmented with CGM usage (89), with the greatest benefits seen with algorithm-driven automated basal (and in some systems correction) insulin delivery, which is commonly called hybrid closed-loop therapy (90,91).”

• cites [89] Šoupal, 2020, Glycemic outcomes in adults with T1D are impacted more by continuous glucose monitoring than by insulin delivery method: 3 years of follow-up from the COMISAIR study, Diabetes Care sourceNot checked — no full text of the source

Carbohydrate counting and insulin:carbohydrate ratios can be a useful method for adjusting mealtime insulin dosing for optimal glycemic outcomes.

“Carbohydrate counting and insulin:carbohydrate ratios can be a useful method for adjusting mealtime insulin dosing for optimal glycemic outcomes (132,133).”

• cites [132] Bell, 2014, Efficacy of carbohydrate counting in type 1 diabetes: a systematic review and meta-analysis, Lancet Diabetes Endocrinol sourceNot checked — no full text of the source
• cites [133] Schmidt, 2014, Effects of advanced carbohydrate counting in patients with type 1 diabetes: a systematic review, Diabet Med sourceNot checked — no full text of the source

Hypoglycemia with glucose levels below 3.0 mmol/L (54 mg/dL) occurs much more often than previously appreciated.

“Hypoglycemia with glucose levels below 3.0 mmol/L (54 mg/dL) occurs much more often than previously appreciated (46,101).”

• cites [46] Ranjan, 2020, Improved time in range over 1 year is associated with reduced albuminuria in individuals with sensor-augmented insulin pump-treated type 1 diabetes, Diabetes Care sourceNot checked — no full text of the source
• cites [101] Heinemann, 2018, Real-time continuous glucose monitoring in adults with type 1 diabetes and impaired hypoglycaemia awareness or severe hypoglycaemia treated with multiple daily insulin injections (HypoDE): a multicentre, randomised controlled trial, Lancet sourceNot checked — no full text of the source

More recent studies have not found a higher risk of DKA in those using insulin pumps.

“However, more recent studies have not found this to be the case (41,210,215).”

• cites [41] Weinstock, 2013, Severe hypoglycemia and diabetic ketoacidosis in adults with type 1 diabetes: results from the T1D Exchange clinic registry, J Clin Endocrinol Metab sourceNot checked — no full text of the source
• cites [210] Kalscheuer, 2019, Event rates and risk factors for the development of diabetic ketoacidosis in adult patients with type 1 diabetes: analysis from the DPV Registry based on 46,966 patients, Diabetes Care sourceNot checked — no full text of the source
• cites [215] Hoshina, 2018, Treatment modality-dependent risk of diabetic ketoacidosis in patients with type 1 diabetes: Danish adult diabetes database study, Diabetes Technol Ther sourceNot checked — no full text of the source

With an SPK transplant, most recipients can expect amelioration of problematic hypoglycemia for more than a decade.

“With an SPK transplant, most recipients can expect amelioration of problematic hypoglycemia for more than a decade (229-231).”

• cites [229] Gruessner, 2012, Long-term outcome after pancreas trans plantation, Curr Opin Organ Transplant sourceNot checked — no full text of the source
• cites [230] Sollinger, 2009, One thousand simultaneous pancreas-kidney transplants at a single center with 22-year follow-up, Ann Surg sourceNot checked — no full text of the source
• cites [231] Lehmann, 2015, Glycemic control in simultaneous islet-kidney versus pancreas-kidney transplantation in type 1 diabetes: a prospective 13-year follow-up, Diabetes Care sourceNot checked — no full text of the source

Fear of hypoglycemia affects up to 10% of adults with type 1 diabetes, particularly among those experiencing repeated episodes of level 3 hypoglycemia.

“Fear of hypoglycemia affects up to 10% of adults with type 1 diabetes, particularly among those experiencing repeated episodes of level 3 hypoglycemia (190).”

• cites [190] Wild, 2007, A critical review of the literature on fear of hypoglycemia in diabetes: implications for diabetes management and patient education, Patient Educ Couns sourceNot checked — no full text of the source

Islet and pancreas transplants have not been compared with hybrid closed-loop technology in large long-term studies.

“However, these approaches have not been compared with the newer systems of hybrid closed-loop technology, which might render immunosuppression requiring therapies less necessary, in large long-term studies (243).”

• cites [243] Lablanche, 2018, Islet transplantation versus insulin therapy in patients with type 1 diabetes with severe hypoglycaemia or poorly controlled glycaemia after kidney transplan tation (TRIMECO): a multicentre, randomised controlled trial, Lancet Diabetes Endocrinol sourceNot checked — no full text of the source

Some known risk factors for DKA are nonmodifiable, such as low socioeconomic status, younger age, female sex, and ethnicity.

“Some known risk factors are nonmodifiable, such as low socioeconomic status, younger age, female sex, and ethnicity (41,210)”

• cites [41] Weinstock, 2013, Severe hypoglycemia and diabetic ketoacidosis in adults with type 1 diabetes: results from the T1D Exchange clinic registry, J Clin Endocrinol Metab sourceNot checked — no full text of the source
• cites [210] Kalscheuer, 2019, Event rates and risk factors for the development of diabetic ketoacidosis in adult patients with type 1 diabetes: analysis from the DPV Registry based on 46,966 patients, Diabetes Care sourceNot checked — no full text of the source

Metformin has been evaluated in numerous small trials in people with type 1 diabetes with hopes that its insulin-sensitizing properties would improve glycemic management and/or reduce cardiovascular risk.

“Metformin has been evaluated in numerous small trials in people with type 1 diabetes with hopes that its insulin-sensitizing properties would improve glycemic management and/or reduce cardiovascular risk (244,245).”

• cites [244] Snaith, 2020, Reducing type 1 diabetes mortality: role for adjunctive therapies?, Trends Endocrinol Metab sourceNot checked — no full text of the source
• cites [245] Liu, 2020, Vascular and metabolic effects of metformin added to insulin therapy in patients with type 1 diabetes: a systematic review and meta-analysis, Diabetes Metab Res Rev sourceNot checked — no full text of the source

Evidence of effectiveness of adjunctive therapies on clinically relevant outcomes other than blood glucose levels, such as cardiovascular and renal disease, is limited.

“To date, although several drugs have been licensed as adjunctive therapies, the evidence of their effectiveness on clinically relevant outcomes other than blood glucose levels, such as cardiovascular and renal disease, is limited.”

Fear of hypoglycemia may translate into avoidance behaviors aimed at keeping blood glucose at a 'safe' level, resulting in persistent hyperglycemia.

“Fear of hypoglycemia may translate into avoidance behaviors aimed at keeping blood glucose at a “safe” level, resulting in persistent hyperglycemia (191).”

• cites [191] Snoek, 2014, Psychological effects of hypoglycaemia sourceNot checked — no full text of the source

Older studies demonstrated a higher risk of DKA in those using insulin pumps, likely due to the lack of depot insulin when continuous delivery of insulin is disrupted.

“Older studies demonstrated a higher risk of DKA in those using insulin pumps, likely due to the lack of depot insulin when continuous delivery of insulin is disrupted (214).”

• cites [214] Garg, 2004, Glycemic parameters with multiple daily injections using insulin glargine versus insulin pump, Diabetes Technol Ther sourceNot checked — no full text of the source

The second indication for GLP-1 RA is as adjunctive therapy in established type 1 diabetes by blunting glucagon secretion, decreasing gastric emptying, and promoting satiety and weight loss.

“The second indication is as an adjunctive therapy in established type 1 diabetes by blunting glucagon secretion, decreasing gastric emptying, and promoting satiety and weight loss (256).”

• cites [256] Nauck, 2020, GLP-1 receptor agonists in type 1 diabetes: a MAG1C bullet?, Lancet Diabetes Endocrinol sourceNot checked — no full text of the source

Increased rates of hypoglycemia and ketosis were shown with liraglutide.

“However, increased rates of hypoglycemia and ketosis were shown.”

• cites [257] Mathieu, 2016, Efficacy and safety of liraglutide added to insulin treatment in type 1 diabetes: the ADJUNCT ONE treat-to-target randomized trial, Diabetes Care sourceNot checked — no full text of the source
• cites [258] Ahrén, 2016, Efficacy and safety of liraglutide added to capped insulin treatment in subjects with type 1 diabetes: the ADJUNCT TWO randomized trial, Diabetes Care sourceNot checked — no full text of the source

Insulin omission as a weight-loss strategy ('diabulimia') often starting in teenage years warrants special attention.

“Insulin omission as a weight-loss strategy (“diabulimia”) often starting in teenage years warrants special attention (195,196).”

• cites [195] Luyckx, 2019, Disturbed eating behaviors in adolescents and emerging adults with type 1 diabetes: a one-year prospective study, Diabetes Care sourceNot checked — no full text of the source
• cites [196] Wisting, 2017, Eating patterns in adolescents with type 1 diabetes: associations with metabolic control, insulin omission, and eating disorder pathology, Appetite sourceNot checked — no full text of the source

In one study of 308 people with recently diagnosed type 1 diabetes, liraglutide in combination with anti-IL-21 preserved b-cell function.

“In one study of 308 people with recently diagnosed type 1 diabetes, liraglutide, when used in combination with anti-IL-21, preserved b-cell function (255).”

• cites [255] von Herrath, 2021, Anti-interleukin-21 antibody and liraglutide for the preservation of β-cell function in adults with recent-onset type 1 diabetes: a randomised, double-blind, placebo-controlled, phase 2 trial, Lancet Diabetes Endocrinol sourceNot checked — no full text of the source

There is no evidence that intensive glycemic management slows the progression of late microvascular complications of diabetes.

“As there is no evidence that intensive glycemic management slows the progression of late microvascular complications of diabetes, glycemic targets in individuals with advanced complications should be individualized and based on the balance of risks and benefits (39,275).”

• cites [39] Nathan, 1993, The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus, N Engl J Med sourceNot checked — no full text of the source
• cites [275] Wang, 1993, Meta-analysis of effects of intensive blood-glucose control on late complications of type I diabetes, Lancet sourceNot checked — no full text of the source

In those diagnosed below the age of 35 years who have no clinical features of type 2 diabetes or monogenic diabetes, a negative antibody result does not change the diagnosis of type 1 diabetes since 5-10% of people with type 1 diabetes do not have antibodies.

“In those diagnosed below the age of 35 years who have no clinical features of type 2 diabetes or monogenic diabetes, a negative result does not change the diagnosis of type 1 diabetes since 5-10% of people with type 1 diabetes do not have antibodies.”

People with type 1 diabetes are at high risk of developing ketosis if insulin is withheld.

“Furthermore, people with type 1 diabetes are at high risk of developing ketosis if insulin is withheld (282).”

• cites [282] Umpierrez, 2003, Diabetic ketoacidosis: risk factors and management strategies, Treat Endocrinol sourceNot checked — no full text of the source

Pregnant women with type 1 diabetes are at risk for DKA at lower blood glucose levels than in the nonpregnant state.

“Pregnant women with type 1 diabetes are at risk for DKA at lower blood glucose levels than in the nonpregnant state and should receive education on DKA prevention and detection (268).”

• cites [268] Sibai, 2014, Diabetic ketoacidosis in pregnancy, Obstet Gynecol sourceNot checked — no full text of the source