Alicia J. Jenkins

Globally ≈422 million people live with diabetes, with rising incidence and prevalence. Most common are Type 2 diabetes, Type 1 diabetes, which affects ≈9-million people, and gestational diabetes occurring in ≈15 % of pregnant women [1]. The personal and socioeconomic costs are high, particularly if acute complications (e.g. glucose extremes and infections) and chronic complications (ocular, renal, neural and cardiovascular damage) occur. Multiple factors contribute to health outcomes, including weight, lifestyle, blood pressure, lipids, diabetes education, health literacy and access to clinical care, medicines and technology such as continuous glucose monitors (CGM), insulin pumps and artificial intelligence (AI) [2]. As ≈81 % of people with diabetes globally live in less advantaged regions [1] consideration of their circumstances is key.

Delayed identification of impending diabetic ketoacidosis (DKA) often results in hospitalizations. We describe a case where continuous ketone monitor (CKM) use facilitated prompt identification and intervention for impending DKA, avoiding hospitalization. A 55-year-old male (total daily insulin dose of 0.5 units/kg/day; HbA1c 6.9% [51.9 mmol/mol]) with type 1 diabetes using automated insulin delivery (AID) wore a CKM (Abbott) and was educated in responses to ketone information as part of a clinical trial (ACTRN12624000448549). Insulin pump cannula dislodgement resulted in a rapid rise in ketone levels. Initial CKM alarm notification for elevated ketones >1.0 mmol/L prompted initiation of management, including cannula replacement and additional insulin administration. Ketosis resolved following a rise to >3.1 mmol/L without need for hospitalization. He remained asymptomatic throughout. This case highlights the potential for CKM to act as an early warning system to facilitate timely intervention for ketonemia and reduce the risk of DKA and associated hospitalizations

Background: Sodium-glucose co-transporter inhibitors have potential glycaemic and non-glycaemic benefits in people with type 1 diabetes (T1D). However, the increased risk of diabetic ketoacidosis (DKA) limits their widespread use. We hypothesise that dapagliflozin 10 mg daily, combined with the use of continuous ketone monitoring (CKM) and education strategies to mitigate progression to DKA, will demonstrate improved glycaemic control without increasing DKA events. Methods: PARTNER is a multisite 6-month randomised crossover double-masked study involving Australian adults with T1D who have a Haemoglobin A1c (HbA1c) <85.8 mmol/mol (<10%), minimum total daily insulin dose ≥0.4 IU/kg, consume ≥100 g carbohydrates/day and have not had DKA in the last 3 months. All participants will undergo a 2-week run-in period wearing the Abbott FreeStyle Libre 2 Continuous Glucose Monitor (CGM) and Abbott CKM device. Following this, participants are randomised to receive dapagliflozin or placebo for 12 weeks, followed by crossover for a further 12 weeks separated by a 2-week washout period. The primary effectiveness outcome is the Abbott FreeStyle Libre 2 CGM time in range during the final 2 weeks of each stage. The primary safety outcome is the number of episodes of DKA requiring hospitalisation or emergency department presentation. 60 participants will be recruited across five sites. Background: The study has received ethical approval from the St Vincent's Hospital Melbourne Human Research Ethics Committee (HREC reference 302/23). The results will be published in peer-reviewed journals and presented at national and international diabetes conferences. Background: ACTRN12624000448549.

Background: Relative telomere length (rTL), a biomarker of biological ageing, has been implicated in type 2 diabetes and its complications. We aimed to identify the associates of rTL change over 4 years (∆rTL), and to investigate whether rTL and ∆rTL are associated with complications and mortality in adults with type 2 diabetes from the Australian observational community-based Fremantle Diabetes Study Phase II (FDS2). Methods: Participants (n = 819) from the FDS2 cohort had baseline and Year-4 (mean ± SD 4.2 ± 0.4 years) rTL measured by qPCR (intra- and inter-assay %CV: 0.56% and 2.69%, respectively). The rTL change (∆rTL; % change/year) was categorised as Shortened (< - 2.69%), Unchanged (- 2.69% to + 2.69%) or Lengthened (> + 2.69%). Multiple logistic regression identified clinical and biochemical determinants of ∆rTL Shortened versus Not Shortened (Unchanged plus Lengthened). rTL and ∆rTL (continuous and categorical) were added to Cox and competing risk regression models of conventional predictors of major complications, CVD death and all-cause mortality during a mean ± SD 11.5 ± 2.1 years of follow-up. Results: rTL was inversely correlated with age (r = - 0.186, P < 0.001). ∆rTL was shortened in 25.5% subjects, unchanged in 10.5%, and lengthened in 64.0%. Shortening was associated with older age, male sex, smoking, obesity, lipid-modifying drug use, and higher platelet count and serum bilirubin levels (P < 0.05). There were no statistically significant unadjusted or age- and sex-adjusted associations between baseline rTL, Year-4 rTL, or ∆rTL, and any incident micro- or macrovascular complications. In unadjusted Cox regression, ∆rTL lengthening was associated with a lower risk of CVD death (hazard ratio 0.98 (0.97, 0.99), P = 0.042) but this association became non-significant after adjustment for conventional risk factors. Conclusions: In adults with type 2 diabetes, rTL does not always shorten over time. rTL and ∆rTL were associated with baseline conventional cardiometabolic risk factors but not independently with major incident complications. There was a weak association between ∆rTL and CVD mortality. These findings question the utility of rTL and ∆rTL in usual type 2 diabetes care.

Objective: Globally, symptomatic type 1 diabetes (T1D) prevalence varies markedly. The International Diabetes Federation 11thEdition Atlas/T1D Index Version 3.0 estimated 2025 numbers for 202 countries/territories ("countries"), and projected to2040. Methods: The T1D Index model, a Markov model with sub-models for incidence-over-time, adult incidence, and mortality-over-time, was updated with recent population-based T1D incidence, mortality and prevalence studies. For countries without studies, data were extrapolated from countries with similarsettings. Results: There are estimated 9.5 million people living with T1D globally (compared to 8.4 million in 2021, a 13 % increase), with 1.0 million of these aged 0-14, and 0.8 million aged 15-19 years. In lower-income countries, prevalent cases increased by 20 % from 1.8 million in 2021 to 2.1 million in 2025. Incident cases in 2025 are an estimated 513,000 (164,000 aged 0-14 and 58,000 aged 15-19 years), with incidence increasing by 2.4 % in the last year. Premature deaths are estimated at 174,000, with 17.2 % of these due to non-diagnosis soon after clinical onset. The estimated remaining life expectancy of a 10-year-old child diagnosed with T1D in 2025 varies between countries from 6 to 66 years. There are still no data available for 119 countries. The projectedT1D population for 2040 is estimated to be14.7 million. Conclusions: The number of global T1D cases is rising quickly, especially in lower-income settings, due to increasing diagnosed incidence, falling mortality and ageing, and population growth. Contemporary data are unavailable for over 50% of all countries, highlighting need for epidemiological studies.

A Randomised Trial to Evaluate the Efficacy on Retinopathy and Safety of Fenofibrate in Adults With Type 1 Diabetes. A Multicentre Double-blind Placebo-controlled Study in Australia and Internationally.