Racial differences in all-cause mortality and future complications among people with diabetes: a systematic review and meta-analysis of data from more than 2.4 million individuals

Ethnic Disparities in the Risk Factors, Morbidity, and Mortality of Cardiovascular Disease in People With Diabetes

Cardiovascular disease (CVD) is the leading cause of death in people with diabetes. Compared with European Americans, African Americans have more favorable lipid profiles, as indicated by higher high-density lipoprotein cholesterol, lower triglycerides, and less dense low-density lipoprotein particles. The less atherogenic lipid profile translates to lower incidence and prevalence of CVD in African Americans with diabetes, despite higher rates of hypertension and obesity. However, African Americans with CVD experience worse clinical outcomes, including higher mortality, compared with European Americans. This mini-review summarizes the epidemiology, pathophysiology, mechanisms, and management of CVD in people with diabetes, focusing on possible factors underlying the "African American CVD paradox" (lower CVD incidence/prevalence but worse outcomes). Although the reasons for the disparities in CVD outcomes remain to be fully elucidated, we present a critical appraisal of the roles of suboptimal control of risk factors, inequities in care delivery, several biological factors, and psychosocial stress. We identify gaps in current knowledge and propose areas for future investigation.

Bringing an end to diabetes stigma and discrimination: an international consensus statement on evidence and recommendations

People with diabetes often encounter stigma (ie, negative social judgments, stereotypes, prejudice), which can adversely affect emotional, mental, and physical health; self-care, access to optimal health care; and social and professional opportunities. To accelerate an end to diabetes stigma and discrimination, an international multidisciplinary expert panel (n=51 members, from 18 countries) conducted rapid reviews and participated in a three-round Delphi survey process. We achieved consensus on 25 statements of evidence and 24 statements of recommendations. The consensus is that diabetes stigma is driven primarily by blame, perceptions of burden or sickness, invisibility, and fear or disgust. On average, four in five adults with diabetes experience diabetes stigma and one in five experience discrimination (ie, unfair and prejudicial treatment) due to diabetes, such as in health care, education, and employment. Diabetes stigma and discrimination are harmful, unacceptable, unethical, and counterproductive. Collective leadership is needed to proactively challenge, and bring an end to, diabetes stigma and discrimination. Consequently, we achieved unanimous consensus on a pledge to end diabetes stigma and discrimination.

Race and Ethnicity Disparities in Cardiovascular and Cancer Mortality: the Role of Socioeconomic Status-a Systematic Review and Meta-analysis

To clarify the role of socioeconomic status (SES) in cardiovascular and cancer mortality disparities observed between Black, Hispanic, and Asian compared to White adults, we conducted a meta-analysis of the longitudinal research in the USA. A PubMed, Ovid Medline, Web of Science, and EBSCO search was performed from January 1995 to May 2023. Two authors independently screened the studies and conducted risk assessments, with conflicts resolved via consensus. Studies were required to analyze mortality data using Cox proportional hazard regression. Random-effects models were used to pool hazard ratios (HR) and reporting followed PRISMA guidelines. Twenty-two studies with cardiovascular mortality (White and Black (n = 22), Hispanic (n = 7), and Asian (n = 3) adults) and twenty-three with cancer mortality endpoints (White and Black (n = 23), Hispanic (n = 11), and Asian (n = 10) adults) were included. The meta-analytic sample for cardiovascular mortality endpoints was 6,199,049 adults (White = 4,891,735; Black = 935,002; Hispanic = 295,623; Asian = 76,689), while for cancer-specific mortality endpoints was 7,745,180 adults (White = 5,988,392; Black= 1,070,447; Hispanic= 484,848; Asian = 201,493). Median follow-up was 10 and 11 years in cohorts with cardiovascular and cancer mortality endpoints, respectively. Adjustments for SES attenuated the higher risk for cardiovascular (HR, 1.46; 95% CI, 1.30-1.64) and cancer mortality (HR, 1.35; 95% CI, 1.32-1.38) of Black compared to White adults by 25% (HR, 1.21; 95% CI, 1.15-1.28) and 19% (HR, 1.16; 95% CI, 1.13-1.18), respectively. However, the Hispanic cardiovascular (HR, 0.79; 95% CI, 0.73-0.85) and Asian cancer mortality (HR, 0.81; 95% CI, 0.76-0.86) advantage were independent of SES. These findings emphasize the need to develop strategies focused on SES to reduce cardiovascular and cancer mortality in Black adults.

Underlying mechanisms of diabetes knowledge influencing diabetes self-management behaviors among patients with type II diabetes in rural China: Based on health belief model

OBJECTIVE

To investigate the association between diabetes knowledge and diabetes self-management (DSM) behaviors and to explore the influence mechanism between them among patients with type 2 diabetes mellitus (T2DM) based on health belief model in rural China.

METHODS

This cross-sectional study included 483 participants with T2DM from 8 villages of 3 townships in Jiangsu Province. All participants completed a structured questionnaire, including demographic information, diabetes knowledge, DSM behaviors, health beliefs, and cognitive function. Multiple linear regression and mediation analysis were performed to analyze the association between diabetes knowledge and DSM behaviors, furthermore the mechanism between them.

RESULTS

Diabetes knowledge and self-efficacy positively influenced DSM behaviors. Health beliefs multiply mediated the association between diabetes knowledge and DSM behaviors. Perceived behavioral barriers mediated the relationship between diabetes knowledge and DSM behaviors, where a suppression effect existed. A chain-mediated effect was found: diabetes knowledge affected perceived benefits, followed by self-efficacy, and finally DSM behaviors.

CONCLUSION

Diabetes knowledge acquisition played an important role in improving DSM behaviors, and health beliefs multiply mediated the relationship between them.

PRACTICE IMPLICATIONS

When designing interventions, health systems and health providers should refocus on diabetes knowledge, emphasize the benefits of self-management, and consider the barriers that patients may encounter.

Use of herbal medicines for the management of type 2 diabetes: A systematic review of qualitative studies

BACKGROUND

Many people with Type 2 Diabetes Mellitus (T2DM) use herbal medicines, some of which can improve glycaemic control. Providing evidence-based advice on herbal medicines could be an effective intervention to improve control of diabetes, if it is designed to address key needs and concerns of T2DM patients.

AIM

To understand the views and experiences of patients and health professionals on herbal treatments for self-management of T2DM.

METHOD

MEDLINE, EMBASE, CINAHL, SOCIOFILE and Google Scholar were searched for qualitative studies in T2DM patients about their views on herbal medicines. Included papers were analysed using thematic synthesis.

RESULTS

Thirty-one papers (about 30 studies) were included: 20 from low-and-middle income countries, 10 from high income countries, and 1 internet-based study. Almost all studies from high income countries focussed on ethnic minorities. Many people with T2DM wanted a "cure", and often took advice from friends and family, but also traditional healers and mass media. However, they were reluctant to discuss herbal medicines with health professionals, whom they perceived as "closed-minded". They based their treatment decisions on personal experience (from "trial-and-error"), availability, cost and convenience of both herbal and conventional medicines. Most health professionals were reluctant to discuss herbal medicines, or recommended against their use, because of lack of knowledge and concerns about their quality, efficacy and potential interactions.

CONCLUSION

Evidence-based information could help to overcome the current lack of communication about herbal medicines between people with T2DM and health professionals.

The role of structural racism and geographical inequity in diabetes outcomes

Diabetes is pervasive, exponentially growing in prevalence, and outpacing most diseases globally. In this Series paper, we use new theoretical frameworks and a narrative review of existing literature to show how structural inequity (structural racism and geographical inequity) has accelerated rates of diabetes disease, morbidity, and mortality globally. We discuss how structural inequity leads to large, fixed differences in key, upstream social determinants of health, which influence downstream social determinants of health and resultant diabetes outcomes in a cascade of widening inequity. We review categories of social determinants of health with known effects on diabetes outcomes, including public awareness and policy, economic development, access to high-quality care, innovations in diabetes management, and sociocultural norms. We also provide regional perspectives, grounded in our theoretical framework, to highlight prominent, real-world challenges.

Subgroups of adult-onset diabetes: a data-driven cluster analysis in a Ghanaian population

Adult-onset diabetes mellitus (here: aDM) is not a uniform disease entity. In European populations, five diabetes subgroups have been identified by cluster analysis using simple clinical variables; these may elucidate diabetes aetiology and disease prognosis. We aimed at reproducing these subgroups among Ghanaians with aDM, and establishing their importance for diabetic complications in different health system contexts. We used data of 541 Ghanaians with aDM (age: 25-70 years; male sex: 44%) from the multi-center, cross-sectional Research on Obesity and Diabetes among African Migrants (RODAM) Study. Adult-onset DM was defined as fasting plasma glucose (FPG) ≥ 7.0 mmol/L, documented use of glucose-lowering medication or self-reported diabetes, and age of onset ≥ 18 years. We derived subgroups by cluster analysis using (i) a previously published set of variables: age at diabetes onset, HbA1c, body mass index, HOMA-beta, HOMA-IR, positivity of glutamic acid decarboxylase autoantibodies (GAD65Ab), and (ii) Ghana-specific variables: age at onset, waist circumference, FPG, and fasting insulin. For each subgroup, we calculated the clinical, treatment-related and morphometric characteristics, and the proportions of objectively measured and self-reported diabetic complications. We reproduced the five subgroups: cluster 1 (obesity-related, 73%) and cluster 5 (insulin-resistant, 5%) with no dominant diabetic complication patterns; cluster 2 (age-related, 10%) characterized by the highest proportions of coronary artery disease (CAD, 18%) and stroke (13%); cluster 3 (autoimmune-related, 5%) showing the highest proportions of kidney dysfunction (40%) and peripheral artery disease (PAD, 14%); and cluster 4 (insulin-deficient, 7%) characterized by the highest proportion of retinopathy (14%). The second approach yielded four subgroups: obesity- and age-related (68%) characterized by the highest proportion of CAD (9%); body fat-related and insulin-resistant (18%) showing the highest proportions of PAD (6%) and stroke (5%); malnutrition-related (8%) exhibiting the lowest mean waist circumference and the highest proportion of retinopathy (20%); and ketosis-prone (6%) with the highest proportion of kidney dysfunction (30%) and urinary ketones (6%). With the same set of clinical variables, the previously published aDM subgroups can largely be reproduced by cluster analysis in this Ghanaian population. This method may generate in-depth understanding of the aetiology and prognosis of aDM, particularly when choosing variables that are clinically relevant for the target population.

Disparities in diabetes prevalence and management by race and ethnicity in the USA: defining a path forward

Type 2 diabetes disparities in the USA persist in both the prevalence of disease and diabetes-related complications. We conducted a literature review related to diabetes prevention, management, and complications across racial and ethnic groups in the USA. The objective of this review is to summarise the current understanding of diabetes disparities by examining differences between and within racial and ethnic groups and among young people (aged <18 years). We also examine the pathophysiology of diabetes as it relates to race and ethnic differences. We use a conceptual framework built on the socioecological model to categorise the causes of diabetes disparities across the lifespan looking at factors in five domains of health behaviours and social norms, public awareness, structural racism, economic development, and access to high-quality care. The range of disparities in diabetes prevalence and management in the USA calls for a community-engaged and multidisciplinary approach that must involve community partners, researchers, practitioners, health system administrators, and policy makers. We offer recommendations for each of these groups to help to promote equity in diabetes prevention and care in the USA.

Global estimates of diabetes-related amputations incidence in 2010-2020: A systematic review and meta-analysis

AIMS/HYPOTHESIS

This study sought to provide up-to-date pooled global estimates of diabetes-related amputation incidence from 2010 to 2020.

METHODS

Embase and Medline databases were searched for studies reporting the incidence rate (IR) of diabetes-related amputations from 2010 to 2020. IR estimates of diabetes-related amputations with associated 95% confidence interval (CI) per 100,000 individuals with diabetes were calculated.

RESULTS

23 studies were included, reporting 505,390 diabetes-related lower extremity amputations. IR of minor amputations was 139.97 (95% CI 88.18-222.16) per 100,000 individuals with diabetes, among patients with type 1 diabetes was 148.59 (95% CI 65.00-339.68) and in type 2 diabetes was 75.53 (95% CI 29.94-190.54). IR of major amputations was 94.82 (95% CI 56.62-158.80) per 100,000 individuals with diabetes, among patients with type 1 diabetes was 100.76 (95% CI 53.71-189.01) and among type 2 diabetes was 40.58 (95% CI 11.03-149.28). There were 83.84 annual amputations (95% CI 41.67-168.65) per 100,000 women with diabetes and 178.04 (95% CI 81.16-390.55) per 100,000 men.

CONCLUSIONS

Globally, annual incidence of diabetes-related amputations from 2010 to 2020 has shown to disproportionately affect men and individuals with type 1 diabetes mellitus, although its incidence is not uniform across countries.

Adverse Clinical Outcomes Attributable to Socioeconomic and Ethnic Disparities Among People with Type 2 Diabetes in New Zealand Between 1994-2018: A Multiple Linked Cohort Study

Purpose

The study aimed to examine the separate population-level contributions of the ethnic and socioeconomic disparities among people with type 2 diabetes mellitus (T2DM) and residence in New Zealand (NZ).

Patients and Methods

A prospective cohort enrolled T2DM patients from 01/01/1994 into the Diabetes Care Support Service, a primary care audit program in Auckland, NZ. The cohort was linked to national registry databases (socioeconomic status, pharmaceutical claim, hospitalization, and death registration). Each cohort member was followed up till death or the study end time (31/12/2019), whichever came first. Incident clinical events (stroke, myocardial infarction (MI), heart failure (HF), end-stage renal disease (ESRD), and premature mortality (PM)) were used as outcomes. The attributable fractions (AFs) were estimated for the whole population and for specific population with NZ Europeans (NZE) and/or least deprived population as reference, both unadjusted and with adjustment for covariables by Cox Regression models.

Results

Among 36,267 patients, adjusted population AFs indicated 6.6(-30.8-33.3)% of PM, 17.1(5.8-27.0)% of MI, 35.3(22.6-46.0)% of stroke, 14.3(3.2-24.2)% of HF, and 15.9(6.7-24.2)% of ESRD could be attributed to deprivation; while 14.3(3.3-25.4)% of PM, -3.3(-8.3-1.5)% of MI, -0.5(-6.7-5.3)% of stroke, 4.7(0.3-8.8)% of HF, 13.3(9.9-16.6)% of ESRD could be attributed to ethnicity. Deprivation contributed a significant AF to stroke, while ethnicity was important for ESRD. Gradient of AF for deprivation indicated NZE and Asians were most affected by deprivation across outcomes. Conversely, Māori, with the highest AFs for ethnicity of PM and ESRD, were unaffected by deprivation. At same deprivations, the AFs of MI and stroke were greatest among NZE compared with other ethnic groups; the AF of ESRD was greatest among Māori and Pasifika.

Conclusion

Both socioeconomic deprivation and ethnicity are strongly associated with outcomes in patients with T2DM in NZ, although the extent of the deprivation gradient is greatest among NZE and Asians, and least among Māori.

Prevalence of diabetes in the USA from the perspective of demographic characteristics, physical indicators and living habits based on NHANES 2009-2018

OBJECTIVE

To determine differences in DM in the U.S. population according to demographic characteristics, physical indicators and living habits.

METHODS

23 546 participants in the 2009 to 2018 National Health and Nutrition Examination Survey (NHANES) who were 20 year of age or older and not pregnant. All analyses used weighted samples and considered the stratification and clustering of the design. Specific indicators include length of leg (cm), BMI (kg/cm²), TCHOL (mg/dL), fasting plasma glucose (mg/dL) and comparison of means and the proportion of participants with DM.

RESULTS

The prevalence of DM in the USA has been rising modestly in the past decade, and were consistent and robust for the observed differences in age, sex, and ethnicity. Compared with white participants, black participants and Mexican-American were both more likely (P<0.001) to have diabetes: 14.6% (CI, 13.6% to 15.6%) among black participants, 10.6% (CI, 9.9% to 11.3%) among white participants, and 13.5% (CI, 11.9% to 15.2%) among Mexican-American participants. The prevalence of diabetes is increasing with age, males peaked around the 60s, and women around the 70s. The overall mean leg length and TCHOL was lower in diabetics than in non-diabetics (1.07 cm, 18.67 mg/dL, respectively), while mean BMI were higher in diabetics than in non-diabetics (4.27 kg/cm2). DM had the greatest effect on decline of TCHOL in white participants (23.6 mg/dL), less of an effect in black participants (9.67 mg/dL), and the least effect in Mexican-American participants (8.25 mg/dL). Notably, smoking had great effect on percent increment of DM in whites (0.2%), and have little effect on black and Mexican-Americans.

CONCLUSIONS

DM is more common in the general population than might be clinically recognized, and the prevalence of DM was associated to varying degrees with many indicators of demographic characteristics, physical indicators, and living habits. These indicators should be linked with medical resource allocation and scientific treatment methods to comprehensively implement the treatment of DM.

Comparing Patient Perspectives on Diabetes Management to the Deficit-Based Literature in an Ethnic Minority Population: A Mixed-Methods Study

Marginalized racial/ethnic minorities have disproportionately high rates of type 2 diabetes prevalence, complications and mortality. Researchers and policymakers have typically addressed these disparities using a deficit-based discourse focused on individual/cultural deficiencies or failure. A mixed-methods study was used to compare the deficit discourse to the perspectives of adults with diabetes in the Arab minority in Israel, using data from 10 focus groups (5 men's, 5 women's) and 296 quantitative in-person surveys. Both qualitative and quantitative data were triangulated. In addition, multivariable regression models tested associations between diabetes management perspectives and participant characteristics. Contrary to the deficit-based characterizations of patients as fatalistic and unknowledgeable, participants viewed diabetes as a chronic disease with serious complications. They expressed more support for patient responsibility in diabetes management than for passive fatalism, and were less fatalistic as educational level and adequacy of diabetes self-care training increased. The impact of social/environmental barriers and changing cultural norms on lifestyle behaviors was highlighted. Over 95% used prescription medications for diabetes management, although 35% reported economic barriers. The deficit discourse is not well-aligned with Arab patients' evolving perceptions and needs, and has deflected attention from the socioeconomic/structural determinants of health, and the healthcare system's responsibility to provide effective, culturally-relevant diabetes services.

Racial discrimination and adverse pregnancy outcomes: a systematic review and meta-analysis

Introduction

Racial discrimination has been consistently linked to various health outcomes and health disparities, including studies associating racial discrimination with patterns of racial disparities in adverse pregnancy outcomes. To expand our knowledge, this systematic review and meta-analysis assesses all available evidence on the association between self-reported racial discrimination and adverse pregnancy outcomes.

Methods

Eight electronic databases were searched without language or time restrictions, through January 2022. Data were extracted using a pre-piloted extraction tool. Quality assessment was conducted using the Newcastle–Ottawa Scale (NOS), and across all included studies using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Random effects meta-analyses were performed on preterm birth and small for gestational age. Heterogenicity was assessed using Cochran’s χ² test and I² statistic.

Results

Of 13 597 retrieved records, 24 articles were included. Studies included cohort, case–control and cross-sectional designs and were predominantly conducted in the USA (n=20). Across all outcomes, significant positive associations (between experiencing racial discrimination and an adverse pregnancy event) and non-significant associations (trending towards positive) were reported, with no studies reporting significant negative associations. The overall pooled odds ratio (OR) for preterm birth was 1.40 (95% CI 1.17 to 1.68; 13 studies) and for small for gestational age it was 1.23 (95% CI 0.76 to 1.99; 3 studies). When excluding low-quality studies, the preterm birth OR attenuated to 1.31 (95% CI 1.08 to 1.59; 10 studies). Similar results were obtained across sensitivity and subgroup analyses, indicating a significant positive association.

Conclusion

These results suggest that racial discrimination has adverse impacts on pregnancy outcomes. This is supported by the broader literature on racial discrimination as a risk factor for adverse health outcomes. To further explore this association and underlying mechanisms, including mediating and moderating factors, higher quality evidence from large ethnographically diverse cohorts is needed.

Diabetes mellitus and diabetic foot ulcer: Etiology, biochemical and molecular based treatment strategies via gene and nanotherapy

Diabetes mellitus (DM) is a collection of metabolic and pathophysiological disorders manifested with high glucose levels in the blood due to the inability of β-pancreatic cells to secrete an adequate amount of insulin or insensitivity of insulin towards receptor to oxidize blood glucose. Nevertheless, the preceding definition is only applicable to people who do not have inherited or metabolic disorders. Suppose a person who has been diagnosed with Type 1 or Type 2DM sustains an injury and the treatment of the damage is complicated and prolonged. In that case, the injury is referred to as a diabetic foot ulcer (DFU). In the presence of many proliferating macrophages in the injury site for an extended period causes the damage to worsen and become a diabetic wound. In this review, the scientific information and therapeutic management of DM/DFU with nanomedicine, and other related data were collected (Web of Science and PubMed) from January 2000 to January 2022. Most of the articles revealed that standard drugs are usually prescribed along with hypoglycaemic medications. Conversely, such drugs stabilize the glucose transporters and homeostasis for a limited period, resulting in side effects such as kidney damage/failure, absorption/gastrointestinal problems, and hypoglycemic issues. In this paper, we review the current basic and clinical evidence about the potential of medicinal plants, gene therapy, chemical/green synthesized nanoparticles to improving the metabolic profile, and facilitating the DM and DFU associated complications. Preclinical studies also reported lower plasma glucose with molecular targets in DM and DFU. Research is underway to explore chemical/green synthesized nanoparticle-based medications to avoid such side effects. Hence, the present review is intended to address the current challenges, recently recognized factors responsible for DM and DFU, their pathophysiology, insulin receptors associated with DM, medications in trend, and related complications.

Modeling Chronic Kidney Disease in Type 2 Diabetes Mellitus: A Systematic Literature Review of Models, Data Sources, and Derivation Cohorts

INTRODUCTION

As novel therapies for chronic kidney disease (CKD) in type 2 diabetes mellitus (T2DM) become available, their long-term benefits should be evaluated using CKD progression models. Existing models offer different modeling approaches that could be reused, but it may be challenging for modelers to assess commonalities and differences between the many available models. Additionally, the data and underlying population characteristics informing model parameters may not always be evident. Therefore, this study reviewed and summarized existing modeling approaches and data sources for CKD in T2DM, as a reference for future model development.

METHODS

This systematic literature review included computer simulation models of CKD in T2DM populations. Searches were implemented in PubMed (including MEDLINE), Embase, and the Cochrane Library, up to October 2021. Models were classified as cohort state-transition models (cSTM) or individual patient simulation (IPS) models. Information was extracted on modeled kidney disease states, risk equations for CKD, data sources, and baseline characteristics of derivation cohorts in primary data sources.

RESULTS

The review identified 49 models (21 IPS, 28 cSTM). A five-state structure was standard among state-transition models, comprising one kidney disease-free state, three kidney disease states [frequently including albuminuria and end-stage kidney disease (ESKD)], and one death state. Five models captured CKD regression and three included cardiovascular disease (CVD). Risk equations most commonly predicted albuminuria and ESKD incidence, while the most predicted CKD sequelae were mortality and CVD. Most data sources were well-established registries, cohort studies, and clinical trials often initiated decades ago in predominantly White populations in high-income countries. Some recent models were developed from country-specific data, particularly for Asian countries, or from clinical outcomes trials.

CONCLUSION

Modeling CKD in T2DM is an active research area, with a trend towards IPS models developed from non-Western data and single data sources, primarily recent outcomes trials of novel renoprotective treatments.

Continuous Glucose Monitoring Initiation Within First Year of Type 1 Diabetes Diagnosis Is Associated With Improved Glycemic Outcomes: 7-Year Follow-Up Study

OBJECTIVE

To evaluate long-term glycemic outcomes of continuous glucose monitoring (CGM) initiation within the first year of type 1 diabetes diagnosis.

RESEARCH DESIGN AND METHODS

Patients with type 1 diabetes (N = 396) were divided into three groups: 1) CGM (CGM use within 1 year of diabetes diagnosis and continued through the study), 2) no-CGM (no CGM use throughout the study), and 3) new-CGM (CGM use after 3 years since diabetes diagnosis). Patients were followed up to 7 years.

RESULTS

A1c was significantly lower in the CGM compared with the no-CGM group throughout 7 years of follow-up (least squares mean A1c values: 6 months, 7.3% vs. 8.1%; 1 year, 7.4% vs. 8.6%; 2 years, 7.7% vs. 9.1%; 3 years, 7.6% vs. 9.3%; 4 years, 7.4% vs. 9.6%; 5 years, 7.6% vs. 9.7%; 6 years, 7.5% vs. 10.0%; and 7 years, 7.6% vs. 9.8%; for all, P < 0.001) adjusting for age at diagnosis, sex, and insulin delivery method.

CONCLUSIONS

CGM initiation within first year of type 1 diabetes diagnosis results in long-term improvement in A1c.