Text-message responsiveness to blood glucose monitoring reminders is associated with HbA1c benefit in teenagers with Type 1 diabetes

Text messaging to enhance glucose monitoring and self-care in teens with type 1 diabetes: Teens' perceptions predict outcomes

AIMS

We assessed association between how teens with type 1 diabetes (T1D) perceived a text-messaging (TM) reminder system to check glucose levels and how their perceptions related to their responsiveness to TM reminders to check glucose levels.

METHODS

Teens received TM reminders 1-4 times daily to check glucose levels and to reply with the result. Qualitative assessments were performed quarterly. Teens were categorized by perceptions expressed at the majority of the visits and their TM responsiveness over 18 months.

RESULTS

There were 135 teens (51 % male), with a mean age of 14.8 ± 1.2 years, receiving TM reminders. Distribution of participants' perceptions was 37 % positive (POS), 35 % neutral (with both positive and negative responses (POS/NEG)), and 28 % negative (NEG). Teens with POS perceptions about TM reminders were more likely to respond with a glucose value to the TM reminders than teens with NEG or POS/NEG perceptions (p = 0.002). Youth with POS perceptions and TM responsiveness on ≥ 50 % of days had an 0.81 % improvement in their HbA1c (p = 0.004) over 18 months.

CONCLUSIONS

Teens with POS perceptions to TM reminders were likely to respond and their responsiveness yielded glycemic benefit, suggesting need to consider opinions of teens with T1D to maximize their intervention engagement and resulting benefits.

Feasibility and Acceptability of a Meditation Mobile App Intervention for Adolescent and Young Adult Survivors of Childhood Cancer

BACKGROUND

Adolescent and young adult (AYA) survivors of childhood cancer are increasingly recognized as a vulnerable group with unique emotional, social, and practical needs due to the intersection of cancer survivorship and normal developmental processes. Mindfulness meditation has shown early efficacy in improving psychological distress among cancer patients. However, the overall scientific study of app-based mindfulness-based interventions is still in its early stages. The goal of this study was to evaluate the feasibility and acceptability of a commercially available mindfulness mobile app intervention "Ten Percent Happier" among AYA survivors of childhood cancer.

METHODS

We conducted a single-arm pilot intervention with 25 AYA survivors of childhood cancer ages 18-29 years.

RESULTS

A total of 108 potentially eligible individuals were initially identified for screening. Of the 45 individuals reached (contact rate = 41.67%), 20 declined to participate; 25 were enrolled in the study and completed the baseline survey (enrollment rate = 55.56%). Twenty-one participants completed the study (retention rate = 84%). Changes in several outcomes were promising, with medium to large effect sizes: Mindfulness (d = 0.74), Negative Emotion (d = 0.48), Perceived Stress (d = 0.52), and Mental Health (d = 0.45). Furthermore, results suggested that participants with consistent app usage showed greater improvement in reported outcomes than those who stopped their usage (e.g., Mindfulness: d = 0.74, Perceived Stress: d = 0.83, Mental Health: d = 0.51; Meaning and Purpose: d = 0.84; and Sleep Disturbance: d = 0.81). Qualitative feedback indicated high satisfaction, but participants suggested adding group or individual peer support to improve their experience with the app.

CONCLUSIONS

AYA survivors can be difficult to reach, but a mindfulness app was feasible and acceptable to this group. In particular, the robust retention rate and high satisfaction ratings indicate that the meditation mobile app was well received. Preliminary results suggest positive changes in health-related quality of life outcomes, warranting a larger efficacy trial.

Testing 3 Digital Health Platforms to Improve Mental Health Outcomes in Adults With Type 1 Diabetes: A Pilot Trial

OBJECTIVE

Our aim in this study was to examine the potential impact of a 3-pronged digital health pilot intervention (TRIFECTA) on diabetes distress and depressive symptoms among adults with type 1 diabetes (T1D) in British Columbia.

METHODS

We recruited 60 adults with T1D (mean age 38.9±15.1 years, 75% female, 77% Caucasian) who participated in the 6-month pilot intervention involving 3 digital health platforms: monthly, provider-led, group-based sessions over Zoom (virtual huddles); a WhatsApp peer texting group; and a web-based "Ask-the-expert" portal. Assessments were conducted at baseline and 6 months and measured diabetes distress (T1D Diabetes Distress Scale), depressive symptoms (9-item Personal Health Questionnaire), and TRIFECTA engagement metrics.

RESULTS

Participation in TRIFECTA was associated with significant reductions in Overall Distress (p=0.011) and 4 distress subscales: Powerlessness (p=0.006), Management Distress (p=0.001), Hypoglycemia Distress (p=0.029), and Eating Distress (p<0.001). A higher number of virtual huddles attended predicted lower Overall Distress (p=0.019) and Family/Friends Distress (p=0.023). A higher number of "Ask-the-expert" posts viewed predicted lower Overall Distress (p=0.046), whereas a higher number of WhatsApp messages posted predicted lower Management Distress (p=0.006). Furthermore, engagement in all 3 metrics was a predictor for lower Negative Social Perceptions Distress (p<0.05). No associations were seen in other distress subscales or for depressive symptoms.

CONCLUSIONS

Participation in TRIFECTA was linked to reduced diabetes distress levels, but not depressive symptoms, in a platform-dependent manner. This study provides promising pilot data for a subsequent large-scale and fully powered randomized controlled trial.

The Report of Access and Engagement With Digital Health Interventions Among Children and Young People: Systematic Review

BACKGROUND

Digital health interventions are increasingly used to deliver health-related interventions for children and young people to change health behaviors and improve health outcomes. Digital health interventions have the potential to enhance access to and engagement with children and young people; however, they may also increase the divide between those who can access technology and are supported to engage and those who are not. This review included studies that reported on the access to or engagement with digital health interventions among children and young people.

OBJECTIVE

This review aims to identify and report on access and engagement in studies involving digital health interventions among children and young people.

METHODS

A systematic review following the Joanna Briggs Institute methods for conducting systematic reviews was conducted. An electronic literature search was conducted for all studies published between January 1, 2010, and August 2022, across sources, including MEDLINE, CINAHL, and PsycINFO. Studies were included if they examined any aspect of access or engagement in relation to interventions among children and young people. The quality of the included papers was assessed, and data were extracted. Data were considered for meta-analysis, where possible.

RESULTS

A total of 3292 references were identified using search terms. Following the exclusion of duplicates and review by inclusion criteria, 40 studies were independently appraised for their methodological quality. A total of 16 studies were excluded owing to their low assessed quality and flawed critical elements in the study design. The studies focused on a variety of health conditions; type 1 diabetes, weight management and obesity, mental health issues, and sexual health were the predominant conditions. Most studies were conducted in developed countries, with most of them being conducted in the United States. Two studies reported data related to access and considered ethnicity and social determinants. No studies used strategies to enhance or increase access. All studies included in the review reported on at least 1 aspect of engagement. Engagement with interventions was measured in relation to frequency of engagement, with no reference to the concept of effective engagement.

CONCLUSIONS

Most digital health interventions do not consider the factors that can affect access and engagement. Of those studies that measured either access or engagement or both, few sought to implement strategies to improve access or engagement to address potential disparities between groups. Although the literature to date provides some insight into access and engagement and how these are addressed in digital health interventions, there are major limitations in understanding how both can be enhanced to promote equity. Consideration of both access and engagement is vital to ensure that children and young people have the ability to participate in studies.

TRIAL REGISTRATION

PROSPERO CRD42020170874; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=170874.

7. Diabetes Technology: Standards of Care in Diabetes-2024

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Factors Associated With Consenting to Receive an Automated Email Summary After a Sexual Health Clinic Visit

BACKGROUND

Electronic health records allow for inexpensive communication with patients. In March 2021, the Melbourne Sexual Health Centre implemented an automated email summary ("Sexual Health Automated Visit Email" [SHAVE]) of a client's visit. This study evaluates the proportion of attendees at a sexual health service who opted in or out of SHAVE.

METHODS

This study was conducted at the Melbourne Sexual Health Centre in Australia between March 2021 and June 2022. Univariable and multivariable logistic regression analyses were used to examine the client characteristics associated with consenting to SHAVE.

RESULTS

There were 18,528 clients (men, 12,700; women, 5828) included in the final analysis and 55.2% (n = 10,233) consented to receiving SHAVE. Comparing with those who did not have a new sexually transmitted infection diagnosis, clients with a new diagnosis of a sexually transmitted infection, but not HIV, had lower odds of consenting to receiving SHAVE (chlamydia: adjusted odds ratio [aOR], 0.64 [95% confidence interval {CI}, 0.57-0.72]; gonorrhea: aOR, 0.71 [95% CI, 0.62-0.82]; syphilis: aOR, 0.75 [95% CI, 0.59-0.96]). Men had lower odds of consenting when compared with women (men who have sex with women only: aOR, 0.77 [95% CI, 0.71-0.84]; men who have sex with men: aOR, 0.68 [95% CI, 0.62-0.75]). Comparing with those born in Australia or Oceania, clients born in Europe had lower odds of consenting (aOR, 0.81; 95% CI, 0.70-0.94), whereas those born in Latin America or Caribbean had higher odds of consenting (aOR, 1.25; 95% CI, 1.04-1.51).

CONCLUSIONS

Email summaries may serve as a valuable strategy to improve health communication and record keeping for clients. Understanding the client characteristics associated with consenting SHAVE will allow for the implementation of strategies to better communicate with clients.

7. Diabetes Technology: Standards of Care in Diabetes-2023

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Observed Characteristics Associated with Diabetes Device Use Among Teens with Type 1 Diabetes

BACKGROUND

Despite advancements in diabetes technologies, disparities remain with respect to diabetes device use in youth with type 1 diabetes (T1D). We compared sociodemographic, diabetes, and psychosocial characteristics associated with device (pump and continuous glucose monitor [CGM]) use in 13- to 17-year-old teens with T1D.

MATERIALS/METHODS

Data were derived from a multicenter clinical trial to optimize self-care and glycemic control in teens with T1D. We categorized teens as pump users versus non-users and CGM users versus non-users based on their diabetes device usage. Chi-square and t-tests compared characteristics according to device use.

RESULTS

The sample comprised 301 teens (50% female) with baseline mean ± SD age 15.0 ± 1.3 years, T1D duration 6.5 ± 3.7 years, and HbA1c 8.5 ± 1.1% (69 ± 12 mmol/mol). Two-thirds (65%) were pump users, and 27% were CGM users. Pump users and CGM users (vs. non-users) were more likely to have a family annual household income ≥$150,000, private health insurance, and a parent with a college education (all P < .001). Pump users and CGM users (vs. non-users) also performed more frequent daily blood glucose (BG) checks (both P < .001) and reported more diabetes self-care behaviors (both P < .05). Pump users were less likely to have baseline HbA1c ≥9% (75 mmol/mol) (P = .005) and to report fewer depressive symptoms (P = .02) than pump non-users. Parents of both CGM and pump users reported a higher quality of life in their youth (P < .05).

CONCLUSION

There were many sociodemographic, diabetes-specific, and psychosocial factors associated with device use. Modifiable factors can serve as the target for clinical interventions; youth with non-modifiable factors can receive extra support to overcome potential barriers to device use.

7. Diabetes Technology: Standards of Medical Care in Diabetes-2022

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc22-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc22-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

A Text Messaging Intervention With Financial Incentive for Adolescents With Type 1 Diabetes

BACKGROUND

Adolescents with type 1 diabetes (T1D) have higher hemoglobin A1C (HbA1c) levels than others. In general, adolescents engage with text messaging (TM) and financial incentives, both associated with improved diabetes outcomes. This study aimed to assess the impact of a TM intervention with financial incentives on self-care behaviors and HbA1c.

METHODS

A six-month randomized controlled trial compared MyDiaText™, a TM education and support application, with standard care. The sample included 166 teens with T1D, 12-18 years old, attending a diabetes clinic. The intervention group received one daily TM and were instructed to respond. Participants who responded to TMs for the most consecutive days were eligible for a financial reward biweekly via lottery. All participants received prompts to complete the self-care inventory (SCI) at baseline, 90, and 180 days. HbA1c was collected at clinic visits. Changes in SCI and HbA1c were analyzed using a multilevel mixed-effects linear regression model. Intention-to-treat and per-protocol analyses were performed.

RESULTS

The median TM response rate was 59% (interquartile range 40.1%-85.2%) and decreased over time. After adjustment for baseline characteristics, in per-protocol analysis, there was a statistically significant difference in SCI score increase in those receiving one TM per day vs control (P = .035). HbA1c decreased overall, without significant difference between groups (P = .786).

CONCLUSIONS

A TM intervention with financial incentives for adolescents with T1D in suboptimal control was associated with increasing self-care report; however, glycemic control did not differ from controls. Further research is needed to develop digital health interventions that will impact glycemic control.

Contextual Predictors of Engagement in a Tailored mHealth Intervention for Adolescent and Young Adult Cancer Survivors

BACKGROUND

Despite the promise of mobile health (mHealth), engagement is often too low for durable health behavior change, and little is known regarding why certain individuals abandon mHealth tools.

PURPOSE

Guided by a mHealth engagement framework, we evaluated contextual predictors of objective engagement with an app for adolescents and young adults (AYA) who survived cancer.

METHODS

One hundred and ten AYA survivors (M age = 20.5, 43% female, 30% racial/ethnic minority) were randomized to receive a disease self-management app that delivered 1-2 tailored messages/day for 16 weeks, and contained a survivorship care plan (SCP). Demographic, disease, psychosocial, and setting characteristics were examined as predictors of three objective engagement outcomes: (a) % of active app days, (b) % of messages read, and (c) viewed SCP in the app versus not. A subsample (n = 10) completed qualitative interviews to further assess engagement barriers.

RESULTS

Self-reported uninterrupted app access (β = -0.56, p < .001), iPhone (vs. Android) ownership (β = 0.30, p < .001), and receiving the intervention in the summer (β = -0.20, p = .01) predicted more active days. Lower depressed mood (β = -0.30, p = .047) and uninterrupted app access (β = -0.50, p < .001) predicted more messages read. Qualitatively, technical glitches and competing priorities were described as engagement barriers, whereas certain types of messages (e.g., health goal messages) were perceived as engaging. Among participants who had uninterrupted app access (n = 76), higher baseline motivation to change, better health perceptions, using the app during the summer, and iPhone ownership predicted higher engagement.

CONCLUSIONS

Findings demonstrate the importance of comprehensively assessing and planning for multi-level ecological determinants of mHealth engagement in future trials.

CLINICALTRIALS.GOV IDENTIFIER

NCT03363711.

Using mHealth Applications to Promote Self-Managed Health Behaviors Among Teens

THEORETICAL PRINCIPLES

As technology use increasingly expands, the opportunity to capitalize on it for healthcare education, monitoring, and assessment has grown rapidly, especially among adolescent patients. As apps are developed, consideration should be given to self-management theory concepts.

PHENOMENA ADDRESSED

The proliferation of mobile health (mHealth) applications allows adolescents to access healthcare information in new, innovative ways. Many health applications focus on health promotion, fitness, and nutrition and others help persons with chronic disease. This article offers a compelling case for incorporating mHealth into teen healthcare by reviewing current data on teens' technology use, showing how mHealth aligns with self-management theory concepts, and offering a case scenario on mHealth-enhanced self-management care.

RESEARCH LINKAGES

The ability to combine accurate and immediate healthcare information with continual social support could radically improve teen's self-management behaviors, especially when mHealth apps use connectivity, a feedback loop, and concepts known to enhance self-management behaviors.

[The smartphone as a therapeutic tool in adolescents with type 1 diabetes]

Over the past 15 years, the literature on mobile phone-based interventions for adolescents with type 1 diabetes has increased. While the majority of these interventions focus on therapeutic education of patients, others encourage them to take care of themselves in a broader sense. Young people express great satisfaction with these interventions, but the effectiveness in terms of metabolic control remains to be confirmed.

Text message reminders for adolescents with poorly controlled type 1 diabetes: A randomized controlled trial

Background

Among adolescents with type 1 diabetes, some experience great difficulties with treatment adherence, putting them at high risk of complications. We assessed the effect of text messaging (Short Messaging Service [SMS]) on glycemic control.

Methods

A two-arm open label randomized controlled trial enrolled adolescents with type 1 diabetes aged 12–21 years with baseline HbA1c ≥ 69 mmol/mol (8.5%). The intervention group received daily SMS reminders at self-selected times about insulin injections while the control group received standard of care. The patients allocated to the control group were not aware of the intervention.

Results

92 patients were randomized, 45 in the SMS arm and 47 in the control arm. After 6 months, median HbA1c level was significantly lower in the intervention arm: 73 mmol/mol (8.8%) in the SMS arm and 83 mmol/mol (9.7%) in the control arm in the intent-to-treat analysis (P = 0.03) but no longer in the per protocol analysis (P = 0.65). When we consider the proportions of patients whose HbA1c level decreased by at least 1% between baseline and 6 months, we find a significant difference among patients whose baseline HbA1c was ≥ 80 mmol/mol (9.5%) (n = 56): 60% in the SMS arm and 30.6% in the control arm had lowered their HbA1c level (P = 0.03) in the intent-to-treat analysis but not in the per-protocol analysis (P = 0.50). Patients in the SMS arm reported high satisfaction with the intervention.

Conclusions

While there is a trend to lower HbA1c in the intervention group, no firm conclusions can yet be drawn. Further studies are needed to address methodological issues as we believe these interventions can support behavior change among adolescents with poorly controlled type 1 diabetes. ClinicalTrials.gov identifier: NCT02230137.

Association of habits, triggers, glycaemic control, routines, stress and impulse control among emerging adults with type 1 diabetes

AIM

Glycaemic control is known to be poor among emerging adults with type 1 diabetes, but the reasons for this are poorly understood. Examination of diabetes self-management-related habits, triggers and daily routines within the context of impulse control and perceived daily stress may provide increased understanding of glycaemic control during this transitional period. This study examined associations among checking blood glucose (CBG) habits, eating a meal (EAM) habits and glycaemic control within the context of CBG triggers, daily routines, impulse control and perceived daily stress, in emerging adults with type 1 diabetes.

METHODS

A cross-sectional convenience sample of 100 emerging adults with type 1 diabetes was recruited from an outpatient diabetes care clinic for this age group. Participants self-reported frequency of CBG and EAM habits, CBG triggers, daily routines, perceived daily stress and impulse control. Glycaemic control values were obtained from medical records. Path analysis was performed.

RESULTS

Better glycaemic control was positively and significantly associated with greater frequency of CBG and EAM habits. CBG habits were positively and significantly associated with CBG triggers and EAM habits. EAM habits were positively and significantly associated with daily routines.

CONCLUSIONS

We suggest interventional research targeting CBG and EAM habits and daily routines to examine the impact on diabetes self-management and glycaemic control.

7. Diabetes Technology: Standards of Medical Care in Diabetes-2021

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc21-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc21-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Enhancing Patient Activation and Self-Management Activities in Patients With Type 2 Diabetes Using the US Department of Defense Mobile Health Care Environment: Feasibility Study

Background

Past mobile health (mHealth) efforts to empower type 2 diabetes (T2D) self-management include portals, text messaging, collection of biometric data, electronic coaching, email, and collection of lifestyle information.

Objective

The primary objective was to enhance patient activation and self-management of T2D using the US Department of Defense’s Mobile Health Care Environment (MHCE) in a patient-centered medical home setting.

Methods

A multisite study, including a user-centered design and a controlled trial, was conducted within the US Military Health System. Phase I assessed preferences regarding the enhancement of the enabling technology. Phase II was a single-blinded 12-month feasibility study that randomly assigned 240 patients to either the intervention (n=123, received mHealth technology and behavioral messages tailored to Patient Activation Measure [PAM] level at baseline) or the control group (n=117, received equipment but not messaging. The primary outcome measure was PAM scores. Secondary outcome measures included Summary of Diabetes Self-Care Activities (SDSCA) scores and cardiometabolic outcomes. We used generalized estimating equations to estimate changes in outcomes.

Results

The final sample consisted of 229 patients. Participants were 61.6% (141/229) male, had a mean age of 62.9 years, mean glycated hemoglobin (HbA_1c) of 7.5%, mean BMI of 32.7, and a mean duration of T2D diagnosis of 9.8 years. At month 12, the control group showed significantly greater improvements compared with the intervention group in PAM scores (control mean 7.49, intervention mean 1.77; P=.007), HbA_1c (control mean −0.53, intervention mean −0.11; P=.006), and low-density lipoprotein cholesterol (control mean −7.14, intervention mean 4.38; P=.01). Both groups showed significant improvement in SDSCA, BMI, waist size, and diastolic blood pressure; between-group differences were not statistically significant. Except for patients with the highest level of activation (PAM level 4), intervention group patients exhibited significant improvements in PAM scores. For patients with the lowest level of activation (PAM level 1), the intervention group showed significantly greater improvement compared with the control group in HbA_1c (control mean −0.09, intervention mean −0.52; P=.04), BMI (control mean 0.58, intervention mean −1.22; P=.01), and high-density lipoprotein cholesterol levels (control mean −4.86, intervention mean 3.56; P<.001). Significant improvements were seen in AM scores, SDSCA, and waist size for both groups and in diastolic and systolic blood pressure for the control group; the between-group differences were not statistically significant. The percentage of participants who were engaged with MHCE for ≥50% of days period was 60.7% (68/112; months 0-3), 57.4% (62/108; months 3-6), 49.5% (51/103; months 6-9), and 43% (42/98; months 9-12).

Conclusions

Our study produced mixed results with improvement in PAM scores and outcomes in both the intervention and control groups. Structural design issues may have hampered the influence of tailored behavioral messaging within the intervention group.

Trial Registration

ClinicalTrials.gov NCT02949037; https://clinicaltrials.gov/ct2/show/NCT02949037

International Registered Report Identifier (IRRID)

RR2-10.2196/resprot.6993

7. Diabetes Technology: Standards of Medical Care in Diabetes-2020

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc20-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc20-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.