Diabetes Mellitus: Overview + ADA 2026 Guidelines

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pres.title = "Diabetes Mellitus – ADA 2026 Guidelines";
pres.author = "Medical Education";

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  s.addText("DIABETES MELLITUS", {
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  s.addText("Comprehensive Review & ADA 2026 Standards of Care", {
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  s.addText("Updated per ADA Standards of Care in Diabetes – 2026\nDiabetes Care, Vol. 49 (Supplement 1), January 2026", {
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// SLIDE 2 — OVERVIEW / AGENDA
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    ["01", "Definition, Epidemiology & Classification"],
    ["02", "Pathophysiology"],
    ["03", "Diagnosis & Screening"],
    ["04", "Glycemic Targets"],
    ["05", "Lifestyle Management"],
    ["06", "Pharmacologic Treatment – Drug Classes"],
    ["07", "ADA 2026 – Key Updates"],
    ["08", "Technology: CGM & AID Systems"],
    ["09", "Complications & Organ Protection"],
    ["10", "Special Populations & Conclusion"],
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// ═════════════════════════════════════════════
// SLIDE 3 — DEFINITION & EPIDEMIOLOGY
// ═════════════════════════════════════════════
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  addHeader(s, "Definition & Global Burden", "Diabetes mellitus – scope of the problem");

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  s.addText("Diabetes mellitus (DM) is a group of metabolic diseases characterized by chronic hyperglycemia resulting from defects in insulin secretion, insulin action, or both, leading to long-term micro- and macrovascular complications.", {
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    ["537M+", "Adults with diabetes\nworldwide (2021)"],
    ["~10%", "Global adult\nprevalence"],
    ["90–95%", "Cases are\nType 2 DM"],
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    "Type 1 DM — Autoimmune beta-cell destruction; absolute insulin deficiency",
    "Type 2 DM — Progressive insulin secretory defect on insulin-resistance background",
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    "Other — MODY, pancreatic DM, drug-induced (steroids, immunotherapy, mTOR inhibitors)",
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// SLIDE 4 — PATHOPHYSIOLOGY
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    "Obesity, inactivity, and genetics are key risk factors",
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// SLIDE 5 — DIAGNOSIS
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    ["2-hr OGTT (75g)", "≥ 200 mg/dL\n(11.1 mmol/L)", "140–199 mg/dL\n(IGT)", "< 140 mg/dL"],
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// SLIDE 6 — GLYCEMIC TARGETS
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// ═════════════════════════════════════════════
// SLIDE 7 — LIFESTYLE MANAGEMENT
// ═════════════════════════════════════════════
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        "Weight loss goal ≥ 5–10% for T2DM",
        "Sodium < 2,300 mg/day",
        "Avoid routine antioxidant supplements",
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        "Resistance + flexibility + balance training ≥ 3×/week",
        "Reduce sedentary time throughout the day",
        "Monitor for exercise-related hypo/hyperglycemia",
        "Pre-exercise glucose check for T1DM patients"
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    {
      title: "BEHAVIORAL & EDUCATION", color: "6A4C9C", x: 6.85, points: [
        "Diabetes Self-Management Education & Support (DSMES)",
        "Structured program at diagnosis & annually",
        "Tobacco & e-cigarette cessation (2026 update)",
        "Refer to behavioral health if diabetes distress persists",
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// ═════════════════════════════════════════════
// SLIDE 8 — PHARMACOLOGY OVERVIEW
// ═════════════════════════════════════════════
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  addHeader(s, "Pharmacologic Treatment – Drug Classes", "Type 2 DM antihyperglycemic agents");

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    { cls: "Biguanides", eg: "Metformin", mech: "↓ Hepatic glucose output", hba1c: "~1.5%", wt: "Neutral/↓", hypo: "No", note: "First-line; avoid if GFR <30" },
    { cls: "GLP-1 RAs", eg: "Semaglutide, Liraglutide", mech: "Incretin mimetic; ↑ insulin, ↓ glucagon", hba1c: "1.0–1.5%", wt: "↓↓", hypo: "No", note: "CV & renal benefit; injectable/oral" },
    { cls: "Dual GIP/GLP-1", eg: "Tirzepatide", mech: "GIP + GLP-1 receptor agonism", hba1c: "1.7–2.4%", wt: "↓↓↓", hypo: "No", note: "Best weight loss; HFpEF benefit" },
    { cls: "SGLT2i", eg: "Empagliflozin, Dapagliflozin", mech: "↑ Urinary glucose excretion", hba1c: "0.5–1.0%", wt: "↓", hypo: "No", note: "HF & CKD protection; DKA risk" },
    { cls: "DPP-4i", eg: "Sitagliptin, Saxagliptin", mech: "↑ Endogenous GLP-1/GIP", hba1c: "0.6–0.8%", wt: "Neutral", hypo: "No", note: "Well tolerated; weight-neutral" },
    { cls: "Sulfonylureas", eg: "Glipizide, Glimepiride", mech: "Stimulate β-cell insulin secretion", hba1c: "1.0–1.5%", wt: "↑", hypo: "YES", note: "Cheap; hypoglycemia risk" },
    { cls: "Thiazolidinediones", eg: "Pioglitazone", mech: "PPAR-γ agonist; ↑ insulin sensitivity", hba1c: "0.5–1.4%", wt: "↑", hypo: "No", note: "Fluid retention; CHF risk" },
    { cls: "Insulin", eg: "Basal / Bolus / Premix", mech: "Exogenous insulin replacement", hba1c: "Unlimited", wt: "↑", hypo: "YES", note: "T1DM mandatory; T2DM step-up" },
  ];

  const cols = ["Drug Class", "Examples", "HbA1c ↓", "Weight", "Hypo?", "Key Note"];
  const cw = [1.7, 2.3, 0.9, 0.85, 0.7, 3.28];
  let xPos = 0.15;
  // Header
  cols.forEach((h, ci) => {
    s.addShape(pres.shapes.RECTANGLE, {
      x: xPos, y: 1.2, w: cw[ci], h: 0.38,
      fill: { color: C.navy }, line: { color: C.navy }
    });
    s.addText(h, { x: xPos, y: 1.2, w: cw[ci], h: 0.38, fontSize: 10, bold: true, color: C.white, align: "center", valign: "middle", margin: 0 });
    xPos += cw[ci];
  });

  const rowH = 0.48;
  drugs.forEach((d, ri) => {
    const yRow = 1.58 + ri * rowH;
    const bg = ri % 2 === 0 ? C.white : "EBF3FB";
    xPos = 0.15;

    const cells = [d.cls, d.eg, d.hba1c, d.wt, d.hypo === "YES" ? "⚠ YES" : "No", d.note];
    cells.forEach((cell, ci) => {
      s.addShape(pres.shapes.RECTANGLE, {
        x: xPos, y: yRow, w: cw[ci], h: rowH,
        fill: { color: bg }, line: { color: C.rule, pt: 1 }
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      const isHypo = ci === 4 && cell.includes("YES");
      const isClass = ci === 0;
      s.addText(cell, {
        x: xPos + 0.04, y: yRow, w: cw[ci] - 0.08, h: rowH,
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        bold: isClass,
        color: isHypo ? "C0392B" : isClass ? C.navyMid : C.text,
        valign: "middle", align: ci === 0 ? "left" : "center", margin: 0
      });
      xPos += cw[ci];
    });
  });

  addFooter(s);
}

// ═════════════════════════════════════════════
// SLIDE 9 — ADA 2026 KEY UPDATES (Part 1)
// ═════════════════════════════════════════════
{
  const s = pres.addSlide();
  setLightBg(s);
  addHeader(s, "ADA 2026 Standards of Care — Major Updates (Part 1)", "Published: Diabetes Care, January 2026");

  const updates = [
    {
      icon: "📱", title: "Technology – CGM Now Universal",
      points: [
        "CGM recommended at/soon after diagnosis for ALL adults on insulin or hypoglycemia-risk drugs",
        "CGM use with AID updated with new clinical trial data in gestational diabetes"
      ]
    },
    {
      icon: "🤖", title: "Automated Insulin Delivery (AID) – Preferred for All",
      points: [
        "AID is now the PREFERRED insulin delivery method for T1DM AND T2DM on insulin (not just T1DM)",
        "Open-source AID systems are explicitly supported for the first time"
      ]
    },
    {
      icon: "💊", title: "GLP-1 / Dual GIP-GLP-1 for Type 1 DM (NEW 2026)",
      points: [
        "First-ever recommendation: GLP-1 RAs for T1DM patients with obesity",
        "Must be paired with education on hypoglycemia and DKA risk management"
      ]
    },
    {
      icon: "❤️", title: "Cardiovascular Disease – Organ-Protective Strategy",
      points: [
        "Four drug classes at center: GLP-1 RAs, GIP/GLP-1 agonists, SGLT2i, nsAMRAs",
        "For HFpEF + T2DM: recommend dual GIP/GLP-1 (tirzepatide) or GLP-1 RA",
        "Chosen for organ protection — not just glucose lowering"
      ]
    },
    {
      icon: "🫘", title: "Kidney Disease – Simultaneous Combination",
      points: [
        "For CKD: start SGLT2i + nsAMRA + RAS inhibitor SIMULTANEOUSLY (not step-up)",
        "GLP-1–based therapy now explicitly recommended in advanced CKD"
      ]
    },
  ];

  updates.forEach((u, i) => {
    const y = 1.2 + i * 0.83;
    s.addShape(pres.shapes.RECTANGLE, {
      x: 0.25, y, w: 9.5, h: 0.78,
      fill: { color: i % 2 === 0 ? C.white : "EBF3FB" }, line: { color: C.rule, pt: 1 }
    });
    s.addShape(pres.shapes.RECTANGLE, {
      x: 0.25, y, w: 0.12, h: 0.78,
      fill: { color: i < 2 ? C.teal : i < 3 ? C.amber : i < 4 ? "C0392B" : "2980B9" },
      line: { color: C.rule }
    });
    s.addText(`${u.icon}  ${u.title}`, {
      x: 0.45, y: y + 0.02, w: 9.1, h: 0.28,
      fontSize: 12, bold: true, color: C.navyMid, valign: "top", margin: 0
    });
    s.addText(u.points.map((p, pi) => ({
      text: `• ${p}`,
      options: { color: C.text, fontSize: 10, breakLine: pi < u.points.length - 1 }
    })), { x: 0.5, y: y + 0.3, w: 9.1, h: 0.45, valign: "top", margin: 0 });
  });

  addFooter(s, "ADA Standards of Care in Diabetes – 2026 | Diabetes Care 49(Suppl 1) Jan 2026");
}

// ═════════════════════════════════════════════
// SLIDE 10 — ADA 2026 KEY UPDATES (Part 2)
// ═════════════════════════════════════════════
{
  const s = pres.addSlide();
  setLightBg(s);
  addHeader(s, "ADA 2026 Standards of Care — Major Updates (Part 2)", "Published: Diabetes Care, January 2026");

  const updates2 = [
    {
      icon: "🔪", title: "Perioperative Care (NEW Section)",
      points: [
        "HbA1c ≤ 8% recommended before elective surgery",
        "Perioperative glucose target: 100–180 mg/dL (before, during, and after)",
        "Explicitly discontinue GLP-1s before elective surgery"
      ]
    },
    {
      icon: "🤰", title: "Pregnancy Updates",
      points: [
        "Discontinue GLP-1 RAs and dual GIP/GLP-1 agonists before conception",
        "BP threshold for starting antihypertensives in pregnancy: 140/90 mmHg",
        "Updated preconception planning and CGM data in GDM"
      ]
    },
    {
      icon: "🫀", title: "Liver Disease (MASH/NAFLD)",
      points: [
        "GLP-1 RAs now recommended for MASH (metabolic-associated steatohepatitis) in T2DM"
      ]
    },
    {
      icon: "🧬", title: "Cancer / Immunotherapy Hyperglycemia (NEW)",
      points: [
        "Screen patients on immune checkpoint inhibitors for insulin-dependent DM (DKA risk)",
        "Metformin: first-line for mTOR/PI3K inhibitor–induced hyperglycemia",
        "Insulin reserved for severe hyperglycemia (avoids PI3K inhibitor interaction)"
      ]
    },
    {
      icon: "👴", title: "Older Adults",
      points: [
        "CGM recommended for older adults with T1DM or insulin-treated T2DM",
        "BP goal: <130/80 for most; relaxed to <140/90 for frail/limited life expectancy",
        "Protein intake: ≥ 0.8 g/kg/day; HbA1c <8% acceptable for complex patients"
      ]
    },
  ];

  updates2.forEach((u, i) => {
    const y = 1.2 + i * 0.83;
    s.addShape(pres.shapes.RECTANGLE, {
      x: 0.25, y, w: 9.5, h: 0.78,
      fill: { color: i % 2 === 0 ? C.white : "EBF3FB" }, line: { color: C.rule, pt: 1 }
    });
    s.addShape(pres.shapes.RECTANGLE, {
      x: 0.25, y, w: 0.12, h: 0.78,
      fill: { color: [C.teal, C.navyMid, "C0392B", "8E44AD", C.amber][i] },
      line: { color: C.rule }
    });
    s.addText(`${u.icon}  ${u.title}`, {
      x: 0.45, y: y + 0.02, w: 9.1, h: 0.28,
      fontSize: 12, bold: true, color: C.navyMid, valign: "top", margin: 0
    });
    s.addText(u.points.map((p, pi) => ({
      text: `• ${p}`,
      options: { color: C.text, fontSize: 10, breakLine: pi < u.points.length - 1 }
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  });

  addFooter(s, "ADA Standards of Care in Diabetes – 2026 | Diabetes Care 49(Suppl 1) Jan 2026");
}

// ═════════════════════════════════════════════
// SLIDE 11 — CGM & AID TECHNOLOGY
// ═════════════════════════════════════════════
{
  const s = pres.addSlide();
  setLightBg(s);
  addHeader(s, "Diabetes Technology: CGM & Automated Insulin Delivery", "ADA 2026 – Technology as standard of care");

  // Left: CGM
  s.addShape(pres.shapes.RECTANGLE, {
    x: 0.25, y: 1.2, w: 4.55, h: 0.38,
    fill: { color: C.teal }, line: { color: C.teal }
  });
  s.addText("CONTINUOUS GLUCOSE MONITORING (CGM)", {
    x: 0.25, y: 1.2, w: 4.55, h: 0.38,
    fontSize: 10, bold: true, color: C.white, align: "center", valign: "middle", margin: 0
  });
  s.addShape(pres.shapes.RECTANGLE, {
    x: 0.25, y: 1.58, w: 4.55, h: 3.65,
    fill: { color: C.white }, line: { color: C.rule, pt: 1 }
  });
  const cgmPts = [
    "Recommended at diagnosis for all adults on insulin",
    "Also recommended for any treatment with hypoglycemia risk",
    "Time-in-Range (TIR) target: >70% (70–180 mg/dL) for T1DM",
    "TIR >50% minimum; Time Below Range <4%",
    "Real-time CGM enables proactive dose adjustments",
    "Strongly recommended for older adults (reduces hypoglycemia)",
    "Updated guidance for use in gestational diabetes (2026)",
    "Flash/intermittent CGM also acceptable where RT-CGM not available"
  ];
  s.addText(cgmPts.map((p, i) => ({
    text: p, options: { bullet: true, color: C.text, fontSize: 10.5, breakLine: i < cgmPts.length - 1 }
  })), { x: 0.35, y: 1.65, w: 4.35, h: 3.5, valign: "top", margin: [4, 4, 4, 8] });

  // Right: AID
  s.addShape(pres.shapes.RECTANGLE, {
    x: 5.2, y: 1.2, w: 4.55, h: 0.38,
    fill: { color: C.navyMid }, line: { color: C.navyMid }
  });
  s.addText("AUTOMATED INSULIN DELIVERY (AID)", {
    x: 5.2, y: 1.2, w: 4.55, h: 0.38,
    fontSize: 10, bold: true, color: C.white, align: "center", valign: "middle", margin: 0
  });
  s.addShape(pres.shapes.RECTANGLE, {
    x: 5.2, y: 1.58, w: 4.55, h: 3.65,
    fill: { color: C.white }, line: { color: C.rule, pt: 1 }
  });
  const aidPts = [
    "AID = CGM + algorithm + insulin pump working together",
    "ADA 2026: PREFERRED insulin delivery for ALL T1DM",
    "ADA 2026: Now also recommended for T2DM on insulin",
    "Open-source AID systems explicitly supported (new 2026)",
    "Reduces HbA1c, hypoglycemia, and glycemic variability",
    "Improves quality of life and reduces caregiver burden",
    "Components: CGM sensor, pump, control algorithm (hybrid/fully closed loop)",
    "Key systems: MiniMed 780G, Omnipod 5, Tandem Control-IQ, DIY (Loop, AAPS)"
  ];
  s.addText(aidPts.map((p, i) => ({
    text: p, options: { bullet: true, color: C.text, fontSize: 10.5, breakLine: i < aidPts.length - 1 }
  })), { x: 5.3, y: 1.65, w: 4.35, h: 3.5, valign: "top", margin: [4, 4, 4, 8] });

  addFooter(s);
}

// ═════════════════════════════════════════════
// SLIDE 12 — COMPLICATIONS
// ═════════════════════════════════════════════
{
  const s = pres.addSlide();
  setLightBg(s);
  addHeader(s, "Complications of Diabetes & Organ Protection", "Monitoring, prevention, and management");

  // Two rows of complication cards
  const cards = [
    { title: "Retinopathy", color: C.teal, points: ["Dilated eye exam at T2DM diagnosis;\nT1DM after 5 years", "Annual exam if any retinopathy found", "Strict glycemic + BP control prevents progression"] },
    { title: "Nephropathy / CKD", color: C.navyMid, points: ["uACR + eGFR at least annually", "SGLT2i + nsAMRA + RAS inhibitor\nsimultaneously (ADA 2026)", "BP target <130/80; ACE-i/ARB preferred"] },
    { title: "Neuropathy", color: "6A4C9C", points: ["Foot exam at every visit", "10-g monofilament + vibration testing annually", "Pregabalin / duloxetine / gabapentin for painful neuropathy"] },
    { title: "Cardiovascular", color: "C0392B", points: ["High-intensity statin ≥ age 40 with any CV risk", "GLP-1 RA + SGLT2i for established ASCVD", "Aspirin only for established CVD (not primary prevention)"] },
    { title: "Heart Failure", color: "E67E22", points: ["SGLT2i reduces HF hospitalization regardless of EF", "GLP-1 RA / Tirzepatide for HFpEF (NEW 2026)", "Diuretics + neurohormonal therapy per HF guidelines"] },
    { title: "Liver (MASH)", color: "27AE60", points: ["Screen for MASH/NAFLD with liver enzymes + imaging", "GLP-1 RAs recommended for MASH in T2DM (2026)", "Treat metabolic risk factors: weight loss, BP, lipids"] },
  ];

  const perRow = 3;
  const cw2 = 3.05, ch = 1.75;
  cards.forEach((card, i) => {
    const col = i % perRow;
    const row = Math.floor(i / perRow);
    const x = 0.25 + col * (cw2 + 0.2);
    const y = 1.25 + row * (ch + 0.15);
    s.addShape(pres.shapes.RECTANGLE, {
      x, y, w: cw2, h: ch,
      fill: { color: C.white }, line: { color: C.rule, pt: 1 },
      shadow: { type: "outer", color: "000000", blur: 5, offset: 2, angle: 135, opacity: 0.1 }
    });
    s.addShape(pres.shapes.RECTANGLE, {
      x, y, w: cw2, h: 0.35,
      fill: { color: card.color }, line: { color: card.color }
    });
    s.addText(card.title, { x, y, w: cw2, h: 0.35, fontSize: 12, bold: true, color: C.white, align: "center", valign: "middle", margin: 0 });
    s.addText(card.points.map((p, pi) => ({
      text: p, options: { bullet: true, color: C.text, fontSize: 9.5, breakLine: pi < card.points.length - 1 }
    })), { x: x + 0.1, y: y + 0.38, w: cw2 - 0.2, h: ch - 0.42, valign: "top", margin: [3, 3, 3, 6] });
  });

  addFooter(s);
}

// ═════════════════════════════════════════════
// SLIDE 13 — SPECIAL POPULATIONS
// ═════════════════════════════════════════════
{
  const s = pres.addSlide();
  setLightBg(s);
  addHeader(s, "Special Populations", "Individualized care across the lifespan");

  const pops = [
    {
      title: "Children & Adolescents", icon: "🧒", color: C.teal,
      points: ["AID preferred for all pediatric T1DM", "Screen for T2DM: BMI ≥85th percentile + risk factors ≥ age 10", "Psychosocial screening from age 7–8 (anxiety, distress)"]
    },
    {
      title: "Pregnancy & GDM", icon: "🤰", color: "E91E8C",
      points: ["Stop GLP-1 RAs before conception", "GDM screening at 24–28 weeks; screen early if high risk", "BP threshold for treatment in pregnancy: 140/90 mmHg", "CGM guidance updated for GDM (ADA 2026)"]
    },
    {
      title: "Older Adults (≥65)", icon: "👴", color: C.amber,
      points: ["HbA1c target 7–8% (individualize)", "BP <130/80 if tolerated; <140/90 for frail", "Protein ≥ 0.8 g/kg/day (NEW 2026)", "CGM recommended to prevent hypoglycemia"]
    },
    {
      title: "Diabetes + Obesity", icon: "⚖️", color: C.navyMid,
      points: ["Weight loss ≥15% can achieve T2DM remission", "GLP-1 RAs / tirzepatide: preferred agents", "Personalized dosing — most effective dose ≠ highest dose (2026)", "Bariatric surgery: consider if BMI ≥35 + T2DM uncontrolled"]
    },
    {
      title: "Hospitalized / Surgical", icon: "🏥", color: "C0392B",
      points: ["Glucose target 140–180 mg/dL inpatient (non-ICU)", "ICU target: 140–180 mg/dL", "Pre-surgery: HbA1c ≤8%; periop glucose 100–180 (2026)", "Hold metformin; manage GLP-1 around surgery"]
    },
    {
      title: "Diabetes + Cancer Tx", icon: "🧬", color: "6A4C9C",
      points: ["Checkpoint inhibitors: screen for T1DM/DKA risk (NEW)", "mTOR/PI3K inhibitors: metformin first-line (NEW)", "Steroids: basal or correctional insulin; monitor closely", "Individualize targets based on cancer prognosis"]
    },
  ];

  const cw3 = 3.02, ch3 = 1.7;
  pops.forEach((pop, i) => {
    const col = i % 3;
    const row = Math.floor(i / 3);
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    const y = 1.22 + row * (ch3 + 0.18);
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      x, y, w: cw3, h: ch3,
      fill: { color: C.white }, line: { color: C.rule, pt: 1 },
      shadow: { type: "outer", color: "000000", blur: 4, offset: 2, angle: 135, opacity: 0.1 }
    });
    s.addShape(pres.shapes.RECTANGLE, {
      x, y, w: cw3, h: 0.35,
      fill: { color: pop.color }, line: { color: pop.color }
    });
    s.addText(`${pop.icon} ${pop.title}`, { x, y, w: cw3, h: 0.35, fontSize: 11.5, bold: true, color: C.white, align: "center", valign: "middle", margin: 0 });
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      text: p, options: { bullet: true, color: C.text, fontSize: 9.5, breakLine: pi < pop.points.length - 1 }
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  });

  addFooter(s);
}

// ═════════════════════════════════════════════
// SLIDE 14 — T2DM TREATMENT ALGORITHM
// ═════════════════════════════════════════════
{
  const s = pres.addSlide();
  setLightBg(s);
  addHeader(s, "T2DM Glycemic Treatment Algorithm", "ADA 2026 – Comorbidity-driven approach");

  // Step boxes
  const steps = [
    { step: "STEP 1", title: "At Diagnosis", content: "Lifestyle modification\n+ Metformin (if tolerated)\n+ DSMES referral\n+ CGM initiation", color: C.teal, x: 0.25 },
    { step: "STEP 2", title: "HbA1c Above Target\n(+CVD / CKD / HF / Obesity)", content: "Add evidence-based agent:\n• GLP-1 RA (ASCVD, weight)\n• SGLT2i (HF, CKD)\n• Dual GIP/GLP-1 (obesity, HFpEF)\n• Consider organ-specific benefit", color: C.navyMid, x: 3.55 },
    { step: "STEP 3", title: "HbA1c Still Above Target", content: "Intensify or combine agents:\n• Add basal insulin if needed\n• Consider TZD / DPP-4i / SU\n• AID if on insulin\n• Address SDOH & adherence", color: "6A4C9C", x: 6.85 },
  ];

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      x: st.x, y: 1.2, w: 3.1, h: 3.8,
      fill: { color: C.white }, line: { color: C.rule, pt: 1 },
      shadow: { type: "outer", color: "000000", blur: 6, offset: 2, angle: 135, opacity: 0.12 }
    });
    s.addShape(pres.shapes.RECTANGLE, {
      x: st.x, y: 1.2, w: 3.1, h: 0.72,
      fill: { color: st.color }, line: { color: st.color }
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    s.addText(st.step, { x: st.x, y: 1.2, w: 3.1, h: 0.32, fontSize: 16, bold: true, color: C.white, align: "center", valign: "middle", margin: 0, charSpacing: 3 });
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    s.addText(st.content, { x: st.x + 0.15, y: 1.98, w: 2.82, h: 2.9, fontSize: 11.5, color: C.text, valign: "top", margin: [4, 6, 4, 4] });

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        fill: { color: C.amber }, line: { color: C.amber }
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      s.addText("▶", { x: st.x + 3.38, y: 2.7, w: 0.2, h: 0.32, fontSize: 14, color: C.amber, margin: 0 });
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  addCallout(s, "🔑 ADA 2026 Principle: Choose drugs based on COMORBIDITIES (CVD, CKD, HF, obesity) and ORGAN PROTECTION — not just glucose-lowering potency. Shared decision-making is essential.", 0.25, 5.1, 9.5, 0.42);

  addFooter(s);
}

// ═════════════════════════════════════════════
// SLIDE 15 — CONCLUSION
// ═════════════════════════════════════════════
{
  const s = pres.addSlide();
  // Dark BG
  s.addShape(pres.shapes.RECTANGLE, {
    x: 0, y: 0, w: 10, h: 5.625,
    fill: { color: C.navy }, line: { color: C.navy }
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  s.addShape(pres.shapes.RECTANGLE, {
    x: 0, y: 0, w: 0.35, h: 5.625,
    fill: { color: C.teal }, line: { color: C.teal }
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  s.addShape(pres.shapes.RECTANGLE, {
    x: 0.35, y: 2.55, w: 9.65, h: 0.05,
    fill: { color: C.amber }, line: { color: C.amber }
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  s.addText("KEY TAKEAWAYS", {
    x: 0.5, y: 0.25, w: 9, h: 0.52,
    fontSize: 28, bold: true, color: C.white, charSpacing: 4, margin: 0
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  s.addText("ADA Standards of Care in Diabetes — 2026", {
    x: 0.5, y: 0.8, w: 9, h: 0.32,
    fontSize: 14, color: C.teal, italic: true, margin: 0
  });

  const takeaways = [
    "Diabetes care is now COMORBIDITY-DRIVEN — organ protection trumps HbA1c alone",
    "CGM + AID systems are standard of care; AID is PREFERRED for T1DM and T2DM on insulin",
    "GLP-1 RAs now recommended for T1DM with obesity — a historic first (ADA 2026)",
    "CKD: Start SGLT2i + nsAMRA + RAS inhibitor simultaneously",
    "New perioperative targets: HbA1c ≤8% pre-op; glucose 100–180 mg/dL peri-op",
    "Personalized, shared decision-making remains the foundation of all diabetes care",
    "Mediterranean + low-carbohydrate diets: strongest evidence for T2DM prevention",
  ];

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  s.addText("Source: ADA Standards of Care in Diabetes 2026 | Diabetes Care 49(Suppl 1) Jan 2026 | Harrison's Principles of Internal Medicine 22E", {
    x: 0.5, y: 5.22, w: 9, h: 0.3,
    fontSize: 8.5, color: "6A8AA8", margin: 0
  });
}

// ═════════════════════════════════════════════
// WRITE FILE
// ═════════════════════════════════════════════
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pres.layout = "LAYOUT_16x9";
pres.title = "Diabetes Mellitus – Management & Treatment Guidelines 2026";
pres.author = "Medical Education";

// ═══════════════════════════════════════════════
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// ─── HELPERS ───────────────────────────────────

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// ══════════════════════════════════════════════════════
// SLIDE 1 ── TITLE
// ══════════════════════════════════════════════════════
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    {text:"ADA Standards of Care 2026", options:{bold:true, color:C.white}},
    {text:"\nDiabetes Care, Vol 49, Supplement 1, January 2026", options:{color:"8ABCD8"}},
    {text:"\nHarrison's Principles of Internal Medicine, 22nd Ed. (2025)", options:{color:"8ABCD8"}},
    {text:"\nBMJ Living Clinical Practice Guideline, Aug 2025", options:{color:"8ABCD8"}},
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// ══════════════════════════════════════════════════════
// SLIDE 2 ── OVERVIEW
// ══════════════════════════════════════════════════════
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  hdr(s, "Presentation Contents", "A management-focused clinical review");

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    ["9","Cardiovascular & Renal Protection", C.blue],
    ["10","Complication Management", C.mid],
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// ══════════════════════════════════════════════════════
// SLIDE 3 ── DIAGNOSIS & TARGETS
// ══════════════════════════════════════════════════════
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  hdr(s, "Diagnosis & Glycemic Targets", "ADA 2026 diagnostic criteria and individualized goals");

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}

// ══════════════════════════════════════════════════════
// SLIDE 4 ── COMPREHENSIVE CARE FRAMEWORK
// ══════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  bg(s);
  hdr(s, "Comprehensive Diabetes Care Framework", "Harrison's Principles of Internal Medicine 22E + ADA 2026");

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    {label:"Lifestyle\nManagement", sub:"Nutrition, exercise, wt", color:C.green, x:7.5, y:1.2},
    {label:"Complication\nMonitoring", sub:"Eye, kidney, nerve, foot", color:C.blue, x:7.5, y:3.2},
    {label:"Pharmacotherapy\nOptimization", sub:"Organ-protective agents", color:"8E44AD", x:3.6, y:4.5},
    {label:"Behavioral &\nMental Health", sub:"Distress, depression, DSMES", color:C.gold.replace("F0","C0"), x:3.6, y:0.15},
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    {text:"Key Principle: ", options:{bold:true, color:C.gold}},
    {text:"Comprehensive diabetes care goes beyond glucose control. ADA 2026 emphasizes comorbidity-driven treatment, organ protection, shared decision-making, and addressing social determinants of health (SDOH). The team includes: PCP/Endocrinologist, Diabetes Educator, Pharmacist, Dietitian, Behavioral Health, Ophthalmologist, Nephrologist, Cardiologist, Podiatrist.", options:{color:C.white}},
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  footer(s);
}

// ══════════════════════════════════════════════════════
// SLIDE 5 ── NON-PHARMACOLOGIC MANAGEMENT
// ══════════════════════════════════════════════════════
{
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  hdr(s, "Non-Pharmacologic Management", "Lifestyle intervention — the foundation of diabetes treatment");

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      title:"MEDICAL NUTRITION\nTHERAPY (MNT)", color:C.teal, x:0.2,
      items:[
        "No single best diet — individualize to patient",
        "Mediterranean diet: strongest evidence for CV protection & T2DM prevention (ADA 2026)",
        "Low-carbohydrate: rapid glucose lowering in new T2DM",
        "Weight loss ≥ 5–10% improves glycemia, BP, lipids",
        "Very-low-calorie/bariatric-like diets: can induce T2DM remission",
        "Reduce saturated fat; avoid trans fats",
        "Sodium < 2,300 mg/day",
        "Older adults: protein ≥ 0.8 g/kg/day (NEW 2026)",
        "Routine antioxidant supplements: NOT recommended",
      ]
    },
    {
      title:"PHYSICAL ACTIVITY\n& EXERCISE", color:C.mid, x:3.42,
      items:[
        "150 min/week moderate aerobic activity (≥ 3 days)",
        "ADA 2026: ≥ 60 min/day moderate-to-vigorous encouraged",
        "No > 2 consecutive days without exercise",
        "Resistance training ≥ 2–3×/week",
        "Bone-strengthening ≥ 3×/week (2026)",
        "Reduce prolonged sitting; break sedentary periods",
        "T1DM: monitor glucose pre/during/post exercise",
        "New 2026: strategies to prevent exercise-induced\nhypo- and hyperglycemia specified",
      ]
    },
    {
      title:"BEHAVIORAL HEALTH\n& EDUCATION", color:C.red, x:6.64,
      items:[
        "DSMES (Diabetes Self-Management Education & Support)",
        "Provide at diagnosis, annually, and at transitions of care",
        "Screen for diabetes distress, depression, anxiety",
        "Screening from age 7–8 in T1DM (ADA 2026)",
        "Refer to behavioral health if distress persists after visit (2026)",
        "Tobacco & e-cigarette cessation counseling (updated 2026)",
        "Address food insecurity, cost barriers, health literacy",
        "Peer support programs improve outcomes",
      ]
    }
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  });

  footer(s);
}

// ══════════════════════════════════════════════════════
// SLIDE 6 ── TYPE 2 DM PHARMACOTHERAPY
// ══════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  bg(s);
  hdr(s, "Type 2 DM Pharmacotherapy — Drug Classes", "Mechanism, efficacy, and organ-specific benefits");

  // Full drug table
  const cols2 = ["Drug Class","Key Agents","HbA1c ↓","Weight","Hypo Risk","Organ Benefit","Key Notes"];
  const cw2 = [1.6, 2.05, 0.78, 0.7, 0.72, 1.5, 2.4];
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    ["Metformin","Metformin 500–2000 mg/d","~1.5%","Neutral / ↓","None","—","First-line; avoid GFR <30; lactic acidosis rare"],
    ["GLP-1 RA","Semaglutide, Liraglutide,\nDulaglutide","1.0–1.8%","↓↓","None","CV ✓ Renal ✓","Injectable/oral; nausea common; stop pre-surgery"],
    ["GIP/GLP-1\n(Dual)","Tirzepatide","1.7–2.4%","↓↓↓","None","CV ✓ HFpEF ✓","Best weight loss; preferred in obesity + HFpEF"],
    ["SGLT2i","Empagliflozin,\nDapagliflozin","0.5–1.0%","↓","None","HF ✓ CKD ✓","DKA risk; UTI/genital infx; hold peri-op"],
    ["DPP-4i","Sitagliptin,\nSaxagliptin","0.6–0.8%","Neutral","None","—","Well tolerated; saxagliptin: ↑HF risk (caution)"],
    ["Sulfonylureas","Glipizide, Glimepiride,\nGlyburide","1.0–1.5%","↑","HIGH","—","Cheap; avoid in elderly; hypoglycemia risk"],
    ["TZD","Pioglitazone","0.5–1.4%","↑","None","Lipids ✓","Fluid retention; CHF CI; fracture risk; bladder Ca?"],
    ["α-Glucosidase\nInhibitors","Acarbose, Miglitol","0.5–0.8%","Neutral","None","—","GI side effects; take with first bite of meal"],
    ["nsAMRA","Finerenone","—","Neutral","None","CKD ✓ CV ✓","NEW 2026 – start simultaneously with SGLT2i in CKD"],
    ["Insulin","Basal/Bolus/Premixed/\nConcentrated","Unlimited","↑","HIGH","—","Needed when other agents fail; AID preferred (2026)"],
  ];

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    s.addText(h, {x:xPos, y:yH, w:cw2[ci], h:0.35, fontSize:9.5, bold:true, color:C.white, align:"center", valign:"middle", margin:0});
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  footer(s);
}

// ══════════════════════════════════════════════════════
// SLIDE 7 ── T2DM TREATMENT ALGORITHM
// ══════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  bg(s);
  hdr(s, "T2DM Glycemic Treatment Algorithm — ADA 2026", "Comorbidity-driven, organ-protective approach");

  // Step 1
  s.addShape(pres.shapes.RECTANGLE, {
    x:0.2, y:1.12, w:9.6, h:0.42,
    fill:{color:C.teal}, line:{color:C.teal}
  });
  s.addText("STEP 1 — AT DIAGNOSIS: Lifestyle Modification + Metformin (if tolerated) + DSMES referral + CGM initiation", {
    x:0.3, y:1.12, w:9.4, h:0.42,
    fontSize:11.5, bold:true, color:C.white, valign:"middle", margin:0
  });

  // Step 2 — decision branches
  s.addText("STEP 2 — HbA1c ABOVE TARGET: Add agent based on comorbidity/priority:", {
    x:0.2, y:1.62, w:9.6, h:0.32,
    fontSize:11, bold:true, color:C.mid, margin:0
  });

  const branches = [
    {
      label:"ASCVD /\nHigh CV Risk", color:C.red, x:0.2, y:2.0,
      drugs:["GLP-1 RA with proven CV benefit\n(semaglutide, liraglutide, dulaglutide)",
             "OR dual GIP/GLP-1 (tirzepatide)",
             "SGLT2i if HF also present"],
      key:"EMPA-REG, LEADER,\nDECLARE trials"
    },
    {
      label:"Heart Failure\n(HF)", color:"8E44AD", x:2.6, y:2.0,
      drugs:["SGLT2i (empagliflozin/dapagliflozin)\n— reduces HF hospitalization",
             "For HFpEF: tirzepatide or GLP-1 RA\n(NEW ADA 2026)",
             "Avoid: TZDs, saxagliptin"],
      key:"EMPEROR, DAPA-HF,\nSURMOUNT-4 trials"
    },
    {
      label:"CKD", color:C.blue, x:5.0, y:2.0,
      drugs:["SGLT2i + nsAMRA (finerenone)\n+ RAS inhibitor SIMULTANEOUSLY\n(NEW ADA 2026)",
             "GLP-1 RA: safe in advanced CKD",
             "Avoid metformin if GFR <30"],
      key:"FIDELIO-DKD,\nFIGARO-DKD, CREDENCE"
    },
    {
      label:"Obesity /\nWeight Loss", color:C.green, x:7.4, y:2.0,
      drugs:["Tirzepatide (GIP/GLP-1) — best wt loss",
             "Semaglutide 2.4 mg SC weekly",
             "Personalized dosing — most effective dose ≠\nhighest dose (NEW 2026)"],
      key:"SURMOUNT, STEP\ntrials"
    },
  ];

  branches.forEach(b=>{
    s.addShape(pres.shapes.RECTANGLE, {
      x:b.x, y:b.y, w:2.28, h:2.88,
      fill:{color:C.white}, line:{color:C.rule, pt:1},
      shadow:{type:"outer", color:"000000", blur:5, offset:2, angle:135, opacity:0.1}
    });
    s.addShape(pres.shapes.RECTANGLE, {
      x:b.x, y:b.y, w:2.28, h:0.45, fill:{color:b.color}, line:{color:b.color}
    });
    s.addText(b.label, {x:b.x+0.06, y:b.y, w:2.16, h:0.45, fontSize:11.5, bold:true, color:C.white, align:"center", valign:"middle", margin:0});
    s.addText(b.drugs.map((d,i)=>({
      text:d, options:{bullet:true, color:C.text, fontSize:9.5, breakLine:i<b.drugs.length-1}
    })), {x:b.x+0.1, y:b.y+0.48, w:2.1, h:2.0, valign:"top", margin:[2,2,2,6]});
    s.addShape(pres.shapes.RECTANGLE, {
      x:b.x, y:b.y+2.5, w:2.28, h:0.38,
      fill:{color: b.color+"33"||"EEF"}, line:{color:C.rule}
    });
    s.addText("Evidence: "+b.key, {x:b.x+0.06, y:b.y+2.52, w:2.16, h:0.34, fontSize:8.5, color:b.color, italic:true, valign:"middle", margin:0});
  });

  // Step 3
  s.addShape(pres.shapes.RECTANGLE, {
    x:0.2, y:5.0, w:9.6, h:0.38,
    fill:{color:C.mid}, line:{color:C.mid}
  });
  s.addText("STEP 3 — STILL ABOVE TARGET: Intensify / combine agents → Add basal insulin → Consider AID if on insulin → Review adherence, SDOH", {
    x:0.3, y:5.0, w:9.4, h:0.38,
    fontSize:10.5, bold:true, color:C.white, valign:"middle", margin:0
  });

  footer(s, "ADA 2026 Algorithm | EMPA-REG OUTCOME, LEADER, DECLARE-TIMI 58, FIDELIO-DKD, CREDENCE trials");
}

// ══════════════════════════════════════════════════════
// SLIDE 8 ── TYPE 1 DM MANAGEMENT
// ══════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  bg(s);
  hdr(s, "Type 1 DM — Insulin Management", "Physiology-based insulin therapy");

  // Left: Insulin regimens
  s.addText("INSULIN REGIMENS", {
    x:0.2, y:1.12, w:4.6, h:0.3,
    fontSize:13, bold:true, color:C.mid, margin:0, charSpacing:1
  });

  const insulins = [
    {type:"Rapid-acting", agents:"Aspart, Lispro, Glulisine", onset:"5–15 min", peak:"30–90 min", dur:"3–5 h", use:"Bolus (meal/correction)"},
    {type:"Short-acting", agents:"Regular insulin", onset:"30–60 min", peak:"2–4 h", dur:"6–8 h", use:"IV infusion; pump (older)"},
    {type:"Intermediate", agents:"NPH (isophane)", onset:"1–4 h", peak:"4–12 h", dur:"12–18 h", use:"Twice-daily regimen"},
    {type:"Long-acting", agents:"Glargine, Detemir, Degludec", onset:"2–4 h", peak:"Flat", dur:"20–42 h", use:"Basal insulin (once daily)"},
    {type:"Ultra-long", agents:"Degludec U200, Glargine U300", onset:"6 h", peak:"None", dur:">42 h", use:"Flexible dosing"},
  ];

  // Mini table
  const itcols=["Type","Agents","Onset","Peak","Duration","Use"];
  const itcw=[1.25,1.6,0.72,0.72,0.88,1.18];
  let xI=0.2, yI=1.45;
  itcols.forEach((h,ci)=>{
    s.addShape(pres.shapes.RECTANGLE, {x:xI,y:yI,w:itcw[ci],h:0.33,fill:{color:C.mid},line:{color:C.mid}});
    s.addText(h,{x:xI,y:yI,w:itcw[ci],h:0.33,fontSize:9,bold:true,color:C.white,align:"center",valign:"middle",margin:0});
    xI+=itcw[ci];
  });
  insulins.forEach((row,ri)=>{
    xI=0.2;
    const yR=yI+0.33+ri*0.45;
    const bg2=ri%2===0?C.white:"EDF2F7";
    [row.type,row.agents,row.onset,row.peak,row.dur,row.use].forEach((cell,ci)=>{
      s.addShape(pres.shapes.RECTANGLE, {x:xI,y:yR,w:itcw[ci],h:0.45,fill:{color:bg2},line:{color:C.rule,pt:0.8}});
      s.addText(cell,{x:xI+0.03,y:yR,w:itcw[ci]-0.06,h:0.45,fontSize:9.5,color:ci===0?C.mid:C.text,bold:ci===0,align:ci<2?"left":"center",valign:"middle",margin:0});
      xI+=itcw[ci];
    });
  });

  // Right panel
  s.addText("T1DM MANAGEMENT PRINCIPLES", {
    x:5.15, y:1.12, w:4.6, h:0.3,
    fontSize:13, bold:true, color:C.mid, margin:0, charSpacing:1
  });

  const principles = [
    {head:"Basal-Bolus Regimen (MDI)", body:"Gold standard: long-acting basal + rapid-acting bolus at each meal. Carbohydrate counting determines bolus dose."},
    {head:"AID Systems (PREFERRED – ADA 2026)", body:"Automated Insulin Delivery = CGM + algorithm + pump. Recommended for ALL T1DM. Reduces HbA1c, TBR, and burden."},
    {head:"GLP-1 RAs in T1DM (NEW 2026)", body:"For T1DM with obesity — first-ever ADA recommendation. Educate on DKA risk; monitor closely."},
    {head:"Honeymoon Phase", body:"Partial β-cell recovery after diagnosis. Insulin requirements temporarily decrease; maintain insulin therapy."},
    {head:"Sick Day Rules", body:"Never stop insulin in T1DM. Increase monitoring, hydration. Check ketones if glucose >250 mg/dL."},
    {head:"Hypoglycemia Management", body:"15–15 rule: 15g fast carbs → recheck in 15 min. Severe: glucagon IM/SC/intranasal or IV dextrose."},
  ];

  principles.forEach((p,i)=>{
    const yP=1.45+i*0.7;
    s.addShape(pres.shapes.RECTANGLE, {
      x:5.15, y:yP, w:4.6, h:0.66,
      fill:{color:i%2===0?C.white:"EDF2F7"}, line:{color:C.rule, pt:1}
    });
    s.addShape(pres.shapes.RECTANGLE, {
      x:5.15, y:yP, w:0.1, h:0.66,
      fill:{color:i<2?C.teal:i<3?C.gold:C.blue}, line:{color:C.rule}
    });
    s.addText(p.head, {x:5.3, y:yP+0.04, w:4.4, h:0.25, fontSize:10.5, bold:true, color:C.mid, valign:"top", margin:0});
    s.addText(p.body, {x:5.3, y:yP+0.3, w:4.35, h:0.32, fontSize:9.5, color:C.sub, valign:"top", margin:0});
  });

  // Vertical divider
  s.addShape(pres.shapes.RECTANGLE, {x:5.05,y:1.12,w:0.08,h:4.1,fill:{color:C.rule},line:{color:C.rule}});

  footer(s);
}

// ══════════════════════════════════════════════════════
// SLIDE 9 ── CGM & AID TECHNOLOGY (ADA 2026)
// ══════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  bg(s);
  hdr(s, "Diabetes Technology: CGM & AID Systems", "ADA 2026 — Technology is now standard of care");

  // CGM section
  s.addShape(pres.shapes.RECTANGLE, {
    x:0.2, y:1.1, w:4.55, h:0.36,
    fill:{color:C.teal}, line:{color:C.teal}
  });
  s.addText("CONTINUOUS GLUCOSE MONITORING (CGM)", {
    x:0.2, y:1.1, w:4.55, h:0.36,
    fontSize:10, bold:true, color:C.white, align:"center", valign:"middle", margin:0, charSpacing:1
  });
  s.addShape(pres.shapes.RECTANGLE, {
    x:0.2, y:1.46, w:4.55, h:3.7,
    fill:{color:C.white}, line:{color:C.rule, pt:1}
  });

  const cgm = [
    "Recommended at/shortly after diagnosis (ADA 2026)",
    "Indicated for ALL adults on insulin",
    "Also for any noninsulin therapy with hypoglycemia risk",
    "CGM Metrics:",
    "  • Time-in-Range (TIR) 70–180: target >70% (T1DM)",
    "  • TIR >50% minimum; Time Below Range (<70): <4%",
    "  • CV (glucose variability) < 36%",
    "Real-time vs. flash/intermittent CGM — both acceptable",
    "Strongly recommended for older adults (↓ hypoglycemia)",
    "Gestational DM: updated CGM guidance 2026",
    "Reduce fingerstick testing burden",
    "Systems: Dexcom G7, Libre 3, Medtronic Guardian",
  ];
  s.addText(cgm.map((p,i)=>({
    text:p,
    options:{bullet:!p.startsWith("  "), color:p.startsWith("  ")?C.blue:C.text, fontSize:10, breakLine:i<cgm.length-1}
  })), {x:0.3, y:1.52, w:4.35, h:3.56, valign:"top", margin:[3,3,3,6]});

  // AID section
  s.addShape(pres.shapes.RECTANGLE, {
    x:5.2, y:1.1, w:4.55, h:0.36,
    fill:{color:C.mid}, line:{color:C.mid}
  });
  s.addText("AUTOMATED INSULIN DELIVERY (AID)", {
    x:5.2, y:1.1, w:4.55, h:0.36,
    fontSize:10, bold:true, color:C.white, align:"center", valign:"middle", margin:0, charSpacing:1
  });
  s.addShape(pres.shapes.RECTANGLE, {
    x:5.2, y:1.46, w:4.55, h:3.7,
    fill:{color:C.white}, line:{color:C.rule, pt:1}
  });

  const aid = [
    "AID = CGM sensor + insulin pump + control algorithm",
    "ADA 2026 — PREFERRED insulin delivery for:",
    "  • ALL adults with Type 1 DM",
    "  • Children & adolescents with T1DM",
    "  • Adults with T2DM on insulin (NEW 2026)",
    "Open-source AID systems explicitly supported (NEW 2026)",
    "Systems: MiniMed 780G, Omnipod 5, Tandem Control-IQ",
    "DIY: OpenAPS, Loop, AndroidAPS (open-source)",
    "Hybrid closed-loop: automates basal + some bolus",
    "Fully closed-loop: under development/trial",
    "Reduces: HbA1c, hypoglycemia, glycemic variability",
    "Improves: sleep, quality of life, caregiver burden",
  ];
  s.addText(aid.map((p,i)=>({
    text:p,
    options:{bullet:!p.startsWith("  "), color:p.startsWith("  ")?C.teal:C.text, fontSize:10, breakLine:i<aid.length-1}
  })), {x:5.3, y:1.52, w:4.35, h:3.56, valign:"top", margin:[3,3,3,6]});

  s.addShape(pres.shapes.RECTANGLE, {x:5.1,y:1.1,w:0.08,h:4.1,fill:{color:C.rule},line:{color:C.rule}});

  footer(s, "ADA 2026: CGM and AID are no longer optional add-ons — they are recommended standard of care for insulin-using patients");
}

// ══════════════════════════════════════════════════════
// SLIDE 10 ── ADA 2026 MAJOR NEW RECOMMENDATIONS
// ══════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  bg(s);
  hdr(s, "ADA 2026 — Major New Recommendations at a Glance", "What changed this year — practice-changing updates");

  const updates = [
    {icon:"🆕", label:"T1DM + Obesity", text:"GLP-1 RAs recommended for T1DM with obesity — FIRST TIME in ADA history. Mandatory DKA/hypoglycemia education.", color:C.red},
    {icon:"🤖", label:"AID Expanded", text:"AID systems now the PREFERRED insulin delivery for all T1DM AND insulin-using T2DM. Open-source AID supported.", color:C.teal},
    {icon:"📊", label:"CGM Universal", text:"CGM recommended at diabetes onset for any patient on insulin or hypoglycemia-risk therapy. Not just T1DM.", color:C.mid},
    {icon:"🫘", label:"CKD Simultaneous Tx", text:"For CKD: start SGLT2i + finerenone (nsAMRA) + RAS inhibitor SIMULTANEOUSLY — not sequentially.", color:C.blue},
    {icon:"❤️", label:"HFpEF Treatment", text:"Tirzepatide (GIP/GLP-1) or GLP-1 RA recommended for T2DM + symptomatic HFpEF to reduce HF events.", color:"8E44AD"},
    {icon:"🔪", label:"Perioperative (NEW)", text:"HbA1c ≤ 8% before surgery. Glucose 100–180 mg/dL perioperatively. Discontinue GLP-1s before elective surgery.", color:"E67E22"},
    {icon:"🤰", label:"Pregnancy", text:"Stop GLP-1s before conception. BP threshold 140/90 for treatment in pregnancy. Updated CGM data for GDM.", color:"E91E8C"},
    {icon:"🧬", label:"Cancer/Immunotherapy", text:"Screen checkpoint inhibitor patients for T1DM/DKA risk. Metformin first-line for mTOR/PI3K inhibitor hyperglycemia.", color:"6A4C9C"},
    {icon:"🫀", label:"Liver (MASH)", text:"GLP-1 RAs now recommended for metabolic-associated steatohepatitis (MASH/NASH) in T2DM.", color:C.green},
    {icon:"🍽️", label:"Diet Prevention", text:"Mediterranean and low-carbohydrate eating patterns highlighted as strongest evidence for T2DM prevention.", color:C.teal},
  ];

  updates.forEach((u,i)=>{
    const col=i<5?0:1;
    const row=i<5?i:i-5;
    const x=col===0?0.2:5.1;
    const y=1.12+row*0.87;
    s.addShape(pres.shapes.RECTANGLE, {
      x, y, w:4.72, h:0.82,
      fill:{color:i%2===0?C.white:"EDF2F7"}, line:{color:C.rule, pt:1}
    });
    s.addShape(pres.shapes.RECTANGLE, {
      x, y, w:0.12, h:0.82, fill:{color:u.color}, line:{color:u.color}
    });
    s.addText(`${u.icon} ${u.label}`, {
      x:x+0.18, y:y+0.05, w:4.4, h:0.28,
      fontSize:11.5, bold:true, color:C.mid, valign:"top", margin:0
    });
    s.addText(u.text, {
      x:x+0.18, y:y+0.33, w:4.45, h:0.44,
      fontSize:10, color:C.text, valign:"top", margin:0
    });
  });

  // Center divider
  s.addShape(pres.shapes.RECTANGLE, {x:5.0,y:1.12,w:0.08,h:4.4,fill:{color:C.rule},line:{color:C.rule}});

  footer(s, "Source: ADA Standards of Care in Diabetes — 2026 | Diabetes Care 49(Suppl 1) January 2026 | doi:10.2337/dc26-SREV");
}

// ══════════════════════════════════════════════════════
// SLIDE 11 ── CV & RENAL PROTECTION
// ══════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  bg(s);
  hdr(s, "Cardiovascular & Renal Protection in Diabetes", "Evidence-based organ-protective strategies — ADA 2026");

  // 4 key evidence-based domains
  const domains2 = [
    {
      title:"ASCVD PREVENTION", color:C.red, x:0.2, y:1.12, w:4.6,
      items:[
        "High-intensity statin for age ≥40 with diabetes + CV risk factors",
        "LDL target: <70 mg/dL with ASCVD; <100 without",
        "Aspirin 75–162 mg: only for established CVD (not primary prevention)",
        "BP <130/80 for most; ACE-i/ARB preferred if albuminuria",
        "GLP-1 RA or SGLT2i: proven CV mortality reduction",
        "Evidence: EMPA-REG, LEADER, DECLARE-TIMI 58, REWIND"
      ]
    },
    {
      title:"HEART FAILURE MANAGEMENT", color:"8E44AD", x:5.15, y:1.12, w:4.6,
      items:[
        "SGLT2i (empagliflozin/dapagliflozin): ↓ HF hospitalization, all EF types",
        "For HFpEF + T2DM: Tirzepatide or GLP-1 RA — NEW ADA 2026",
        "Avoid TZDs (worsen fluid retention), saxagliptin (HF signal)",
        "Diuretics for symptom relief; RAAS inhibitor + beta-blocker for HFrEF",
        "Evidence: EMPEROR-Reduced, DAPA-HF, EMPEROR-Preserved, SURMOUNT-4"
      ]
    },
  ];
  domains2.forEach(d=>{
    s.addShape(pres.shapes.RECTANGLE, {x:d.x,y:d.y,w:d.w,h:0.36,fill:{color:d.color},line:{color:d.color}});
    s.addText(d.title,{x:d.x,y:d.y,w:d.w,h:0.36,fontSize:11,bold:true,color:C.white,align:"center",valign:"middle",margin:0,charSpacing:1});
    s.addShape(pres.shapes.RECTANGLE,{x:d.x,y:d.y+0.36,w:d.w,h:1.6,fill:{color:C.white},line:{color:C.rule,pt:1}});
    s.addText(d.items.map((p,i)=>({
      text:p,options:{bullet:true,color:p.startsWith("Evidence")?C.blue:C.text,fontSize:10,italic:p.startsWith("Evidence"),breakLine:i<d.items.length-1}
    })),{x:d.x+0.1,y:d.y+0.4,w:d.w-0.2,h:1.5,valign:"top",margin:[3,3,3,6]});
  });

  // CKD row
  s.addShape(pres.shapes.RECTANGLE, {
    x:0.2, y:3.2, w:9.55, h:0.36,
    fill:{color:C.blue}, line:{color:C.blue}
  });
  s.addText("CHRONIC KIDNEY DISEASE (CKD) — ADA 2026 MAJOR UPDATE", {
    x:0.3, y:3.2, w:9.35, h:0.36,
    fontSize:12, bold:true, color:C.white, valign:"middle", margin:0
  });
  s.addShape(pres.shapes.RECTANGLE, {
    x:0.2, y:3.56, w:9.55, h:1.68,
    fill:{color:C.white}, line:{color:C.rule, pt:1}
  });

  const ckdItems = [
    {l:"Triple Simultaneous Therapy (NEW):", r:"Start SGLT2i + finerenone (nsAMRA) + RAS inhibitor (ACE-i or ARB) SIMULTANEOUSLY — not step-up therapy"},
    {l:"SGLT2 inhibitors:", r:"Reduce eGFR decline and ESKD risk; approved regardless of HbA1c; safe in advanced CKD (eGFR ≥20)"},
    {l:"GLP-1 Receptor Agonists:", r:"Explicitly recommended for T2DM + advanced CKD; reno-protective independent of glucose (FLOW trial — semaglutide)"},
    {l:"Finerenone (nsAMRA):", r:"Reduces CKD progression and CV events in T2DM+CKD (FIDELIO-DKD, FIGARO-DKD); add alongside SGLT2i"},
    {l:"Monitoring:", r:"uACR + eGFR at least annually; more frequent if CKD G3+; optimize BP <130/80"},
  ];
  ckdItems.forEach((row,ri)=>{
    const yR=3.6+ri*0.32;
    s.addText([
      {text:row.l+" ", options:{bold:true, color:C.blue}},
      {text:row.r, options:{color:C.text}},
    ],{x:0.35, y:yR, w:9.25, h:0.3, fontSize:10.2, valign:"middle", margin:0});
  });

  footer(s, "Evidence: EMPA-REG, LEADER, CREDENCE, FIDELIO-DKD, FIGARO-DKD, FLOW (semaglutide+CKD), EMPEROR trials");
}

// ══════════════════════════════════════════════════════
// SLIDE 12 ── COMPLICATIONS
// ══════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  bg(s);
  hdr(s, "Diabetes Complications — Monitoring & Management", "Systematic surveillance prevents morbidity and mortality");

  const comps = [
    {title:"RETINOPATHY",color:C.teal,x:0.2,y:1.12,w:3.1,h:2.1,items:[
      "Screen: T2DM at diagnosis; T1DM after 5 years",
      "Annual dilated fundus exam",
      "Strict HbA1c + BP control: prevents progression",
      "Treat: Anti-VEGF injections for PDR/DME",
      "Laser photocoagulation: proliferative DR"
    ]},
    {title:"NEPHROPATHY",color:C.blue,x:3.42,y:1.12,w:3.1,h:2.1,items:[
      "Annual: uACR + eGFR",
      "ACE-i/ARB: first-line if albuminuria",
      "SGLT2i + nsAMRA + RAS: simultaneously (2026)",
      "BP target: <130/80 mmHg",
      "Avoid nephrotoxic drugs & IV contrast carefully"
    ]},
    {title:"NEUROPATHY",color:"6A4C9C",x:6.64,y:1.12,w:3.1,h:2.1,items:[
      "Annual: 10-g monofilament + vibration sense",
      "Foot exam at EVERY clinic visit",
      "Painful DPN: duloxetine, pregabalin, gabapentin",
      "Autonomic neuropathy: gastroparesis, orthostasis",
      "Refer to podiatry for high-risk feet"
    ]},
    {title:"DIABETIC FOOT",color:C.red,x:0.2,y:3.3,w:3.1,h:2.1,items:[
      "Risk classification: low → high risk",
      "Inspect both feet every visit",
      "Footwear assessment; therapeutic shoes if needed",
      "Wound care: debridement, offloading, antibiotics",
      "Refer: vascular surgery if ischemia present"
    ]},
    {title:"HYPOGLYCEMIA",color:"E67E22",x:3.42,y:3.3,w:3.1,h:2.1,items:[
      "Level 1: 54–70 mg/dL (alert value)",
      "Level 2: <54 mg/dL (clinically significant)",
      "Level 3: severe — requires assistance",
      "Treatment: 15g fast carbs; repeat if needed",
      "Severe: glucagon IM/SC/nasal; IV dextrose (hospital)"
    ]},
    {title:"DKA & HHS",color:C.mid,x:6.64,y:3.3,w:3.1,h:2.1,items:[
      "DKA: glucose >250, ketones+, acidosis (T1DM mainly)",
      "HHS: glucose >600, hyperosmolar, no significant ketosis",
      "IV fluids → insulin infusion → K+ replacement",
      "Monitor: glucose q1h, electrolytes q2–4h",
      "ADA 2026: clearer DKA/HHS recognition + protocols"
    ]},
  ];

  comps.forEach(c=>{
    s.addShape(pres.shapes.RECTANGLE, {
      x:c.x, y:c.y, w:c.w, h:c.h,
      fill:{color:C.white}, line:{color:C.rule, pt:1},
      shadow:{type:"outer",color:"000000",blur:4,offset:2,angle:135,opacity:0.1}
    });
    s.addShape(pres.shapes.RECTANGLE, {
      x:c.x, y:c.y, w:c.w, h:0.32, fill:{color:c.color}, line:{color:c.color}
    });
    s.addText(c.title, {x:c.x, y:c.y, w:c.w, h:0.32, fontSize:11, bold:true, color:C.white, align:"center", valign:"middle", margin:0});
    s.addText(c.items.map((p,i)=>({
      text:p, options:{bullet:true, color:C.text, fontSize:9.5, breakLine:i<c.items.length-1}
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  });

  footer(s);
}

// ══════════════════════════════════════════════════════
// SLIDE 13 ── SPECIAL POPULATIONS
// ══════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  bg(s);
  hdr(s, "Special Populations — Individualized Care", "ADA 2026 specific guidance");

  const pops2 = [
    {title:"PREGNANCY & GDM", color:C.red, x:0.2, items:[
      "Stop GLP-1 RAs before conception (ADA 2026)",
      "GDM screen: all at 24–28 wks; high risk: earlier",
      "Insulin is drug of choice in pregnancy",
      "Metformin: second-line only if insulin declined",
      "BP threshold: 140/90 mmHg to start antihypertensives (2026)",
      "Updated CGM guidance for GDM (2026)",
    ]},
    {title:"OLDER ADULTS (≥65)", color:"8E44AD", x:3.42, items:[
      "HbA1c 7–8% (individualize based on health status)",
      "BP <130/80 if tolerated; relax to <140/90 if frail",
      "CGM recommended to ↓ hypoglycemia burden",
      "Protein ≥ 0.8 g/kg/day minimum (NEW 2026)",
      "Avoid complex regimens; prefer low-hypo-risk agents",
      "Screen for polypharmacy, falls, cognitive impairment",
    ]},
    {title:"CHILDREN & ADOLESCENTS", color:C.teal, x:6.64, items:[
      "T1DM: AID is preferred insulin delivery",
      "Screen T2DM: BMI ≥85th %ile + risk factors ≥ age 10",
      "Metformin first-line for pediatric T2DM",
      "Psychosocial screen from age 7–8 (ADA 2026)",
      "Screen for eating disorders in adolescents",
      "Intensify care at transition to adult services",
    ]},
  ];

  pops2.forEach(p=>{
    s.addShape(pres.shapes.RECTANGLE, {x:p.x, y:1.12, w:3.1, h:0.38, fill:{color:p.color}, line:{color:p.color}});
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    s.addShape(pres.shapes.RECTANGLE, {x:p.x, y:1.5, w:3.1, h:2.05, fill:{color:C.white}, line:{color:C.rule, pt:1}});
    s.addText(p.items.map((pt,i)=>({
      text:pt, options:{bullet:true, color:C.text, fontSize:10, breakLine:i<p.items.length-1}
    })), {x:p.x+0.1, y:1.54, w:2.9, h:1.95, valign:"top", margin:[3,3,3,6]});
  });

  // Bottom row
  const pops3 = [
    {title:"DIABETES + OBESITY", color:C.green, x:0.2, items:[
      "Tirzepatide: best weight loss in T2DM (>20%)",
      "Semaglutide 2.4 mg: also approved for weight",
      "Most effective dose ≠ highest dose (NEW 2026)",
      "Bariatric surgery: BMI ≥35 with T2DM",
    ]},
    {title:"INPATIENT / SURGICAL", color:"E67E22", x:3.42, items:[
      "Glucose target: 140–180 mg/dL (non-ICU)",
      "ICU: 140–180 mg/dL with IV insulin protocol",
      "Pre-op HbA1c ≤8%; periop 100–180 (NEW 2026)",
      "Hold metformin; hold GLP-1s before surgery",
    ]},
    {title:"CANCER / IMMUNOTHERAPY", color:"6A4C9C", x:6.64, items:[
      "Checkpoint inhibitors: monitor for T1DM/DKA",
      "mTOR/PI3K inhibitors: metformin first-line",
      "Steroids: correctional + NPH dosing strategy",
      "Individualize targets based on prognosis",
    ]},
  ];

  pops3.forEach(p=>{
    s.addShape(pres.shapes.RECTANGLE, {x:p.x, y:3.65, w:3.1, h:0.32, fill:{color:p.color}, line:{color:p.color}});
    s.addText(p.title, {x:p.x, y:3.65, w:3.1, h:0.32, fontSize:10.5, bold:true, color:C.white, align:"center", valign:"middle", margin:0});
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    s.addText(p.items.map((pt,i)=>({
      text:pt, options:{bullet:true, color:C.text, fontSize:10, breakLine:i<p.items.length-1}
    })), {x:p.x+0.1, y:4.0, w:2.9, h:1.34, valign:"top", margin:[2,2,2,6]});
  });

  footer(s);
}

// ══════════════════════════════════════════════════════
// SLIDE 14 ── MONITORING & FOLLOW-UP
// ══════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  bg(s);
  hdr(s, "Diabetes Monitoring & Follow-up Schedule", "Comprehensive care — at every visit and annually");

  const schedule = [
    {freq:"EVERY VISIT", color:C.red, items:[
      "Blood pressure measurement",
      "Weight and BMI",
      "Foot inspection (visual)",
      "Review of medications and adherence",
      "Hypoglycemia episodes review",
      "Mental health / diabetes distress screen",
      "Review glucose log / CGM data",
    ]},
    {freq:"QUARTERLY", color:C.mid, items:[
      "HbA1c (every 3 months if not at target)",
      "HbA1c every 6 months if stable at goal",
      "Medication adjustments as needed",
      "Weight management review",
      "DSMES reinforcement",
    ]},
    {freq:"ANNUALLY", color:C.teal, items:[
      "HbA1c (if stable at goal)",
      "Urine albumin-to-creatinine ratio (uACR)",
      "Serum creatinine + eGFR",
      "Fasting lipid panel",
      "Comprehensive foot exam (10-g monofilament + vibration)",
      "Dilated eye exam (retinopathy screening)",
      "Dental exam referral",
      "Influenza vaccine; review pneumococcal, COVID vaccines",
    ]},
    {freq:"AS INDICATED", color:C.blue, items:[
      "Thyroid function (T1DM: regularly)",
      "Vitamin B12 if on metformin long-term",
      "Bone density (high-risk patients)",
      "Coronary artery disease assessment if ASCVD risk high",
      "Sleep apnea screening (obesity + T2DM)",
      "Celiac disease screen (T1DM)",
    ]},
  ];

  schedule.forEach((sec,i)=>{
    const col=i<2?0:1;
    const row=i<2?i:i-2;
    const x=col===0?0.2:5.15;
    const y=1.12+row*2.2;
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    s.addText(sec.freq, {x:x+0.1, y, w:4.5, h:0.36, fontSize:12, bold:true, color:C.white, valign:"middle", margin:0, charSpacing:2});
    s.addShape(pres.shapes.RECTANGLE, {x, y:y+0.36, w:4.7, h:1.78, fill:{color:C.white}, line:{color:C.rule, pt:1}});
    s.addText(sec.items.map((pt,ii)=>({
      text:pt, options:{bullet:true, color:C.text, fontSize:10, breakLine:ii<sec.items.length-1}
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  });

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  footer(s);
}

// ══════════════════════════════════════════════════════
// SLIDE 15 ── KEY TAKEAWAYS
// ══════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  darkBg(s);

  // Red top accent bar
  s.addShape(pres.shapes.RECTANGLE, {
    x:0, y:0, w:10, h:0.18, fill:{color:C.red}, line:{color:C.red}
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    x:0, y:5.44, w:10, h:0.185, fill:{color:C.gold}, line:{color:C.gold}
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    x:7.35, y:0.18, w:2.65, h:5.26, fill:{color:C.mid}, line:{color:C.mid}
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    x:0.4, y:0.3, w:6.7, h:0.65,
    fontSize:30, bold:true, color:C.white, charSpacing:3, margin:0
  });
  s.addText("ADA Standards of Care in Diabetes — 2026", {
    x:0.4, y:1.0, w:6.7, h:0.35,
    fontSize:13, color:C.teal, italic:true, margin:0
  });

  const takes = [
    {icon:"✅", text:"Diabetes care is COMORBIDITY-DRIVEN — organ protection, not just HbA1c"},
    {icon:"✅", text:"CGM at/near diagnosis + AID for all insulin users is 2026 standard"},
    {icon:"✅", text:"GLP-1 RAs in T1DM with obesity — historic first recommendation"},
    {icon:"✅", text:"CKD: triple therapy simultaneously (SGLT2i + finerenone + RAS)"},
    {icon:"✅", text:"Tirzepatide/GLP-1 RA for HFpEF; SGLT2i for all HF types"},
    {icon:"✅", text:"New perioperative protocol: HbA1c ≤8%, periop glucose 100–180"},
    {icon:"✅", text:"Stop GLP-1s before conception and elective surgery"},
    {icon:"✅", text:"Mediterranean/low-carb diets: best evidence for T2DM prevention"},
    {icon:"✅", text:"Shared decision-making + SDOH remain the foundation of all care"},
  ];

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    const yT=1.48+i*0.43;
    s.addShape(pres.shapes.RECTANGLE, {
      x:0.4, y:yT, w:6.7, h:0.38,
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    s.addText(`${t.icon}  ${t.text}`, {
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      fontSize:11.5, color:i<3?C.white:"9BB8D0", valign:"middle", margin:0
    });
  });

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    x:7.5, y:0.4, w:2.3, h:0.35,
    fontSize:13, bold:true, color:C.gold, margin:0, charSpacing:2
  });
  const srcs = [
    "ADA Standards of Care\nin Diabetes — 2026\nDiabetes Care 49(S1)\nJanuary 2026",
    "Harrison's Principles of\nInternal Medicine 22E\n(McGraw-Hill, 2025)",
    "BMJ Living Clinical\nPractice Guideline\nT2DM Therapeutics\nAug 2025 [PMID:40813129]",
    "ADA CV Disease\nStandards 2026\n[PMID:41358899]",
  ];
  srcs.forEach((src,i)=>{
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      x:7.45, y:0.82+i*1.13, w:2.3, h:1.05,
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      fontSize:8.5, color:"7AACC8", valign:"middle", margin:0
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  });
}

// ══════════════════════════════════════════════════════
// WRITE
// ══════════════════════════════════════════════════════
pres.writeFile({ fileName: "/home/daytona/workspace/diabetes-ppt/Diabetes_Management_Treatment_ADA2026.pptx" })
  .then(()=>console.log("✅ Done!"))
  .catch(e=>console.error("❌",e));