Relationship between health care insurance status, social determinants and prevalence of diabetes-related microvascular complications in patients with type 1 diabetes: a nationwide survey in Brazil

Prevalence of overweight/obesity and its relationship with metabolic syndrome and fatty liver index in adult patients with type 1 diabetes. A Brazilian multicenter study

AIMS

To determine the prevalence of overweight/obesity and its relationship with metabolic syndrome (MS), fatty liver index (FLI), cardiovascular risk factors (CVRF), and diabetes-related chronic complications (DRCC) in adult patients with type 1 diabetes (T1D).

METHODS

This study was conducted in 14 Brazilian public clinics in ten cities, with 1,390 patients: 802 females (57.7%), 779 (56.0%) Caucasians, aged 33.6 ± 10.8 years, age at diagnosis, 16.2 ± 9.2 years, diabetes duration, 17.4 ± 9.2 years, and HbA1c 8.8 ± 2.0%.

RESULTS

Overall, 825 patients (59.4%) had normal weight, and 565 had overweight/obesity; ( 429 (30.9%) presented overweight and 136 (9.8%) presented obesity). After adjustments, overweight/obesity was associated with age, family history of overweight/obesity, total daily insulin dose, hypertension, adherence to diet, type of health care insurance, use of metformin, levels of C-reactive protein, triglycerides, uric acid and HDL-cholesterol. These patients also presented a higher prevalence of MS, FLI ≥ 60, and CVRF than patients without overweight/obesity. Overweight/obesity was not associated with DRCC and with HbA1c levels.

CONCLUSIONS

Patients with T1D with overweight/obesity presented traditional risk factors for DRCC, cardiovascular diseases, MS, and non-alcoholic fatty liver disease; most of these risk factors are modifiable and can be avoided with interventions that prevent overweight/obesity.

Bias and Non-Diversity of Big Data in Artificial Intelligence: Focus on Retinal Diseases

Artificial intelligence (AI) applications in healthcare will have a potentially far-reaching impact on patient care, however issues regarding algorithmic bias and fairness have recently surfaced. There is a recognized lack of diversity in the available ophthalmic datasets, with 45% of the global population having no readily accessible representative images, leading to potential misrepresentations of their unique anatomic features and ocular pathology. AI applications in retinal disease may show less accuracy with underrepresented populations that may further widen the gap of health inequality if left unaddressed. Beyond disease symptomatology, social determinants of health must be integrated into our current paradigms of disease understanding, with the goal of more personalized care. AI has the potential to decrease global healthcare inequality, but it will need to be based on a more diverse, transparent and responsible use of healthcare data.

Comparison of three insulin bolus calculators to increase time in range of glycemia in a group of poorly controlled adults Type 1 diabetes in a Brazilian public health service

BACKGROUND

A main factor contributing to insufficient glycemic control, during basal/bolus insulin therapy, is poor self-management bolus. Insulin bolus administration frequency is strongly associated with glycated hemoglobin (A1c) in Type 1 Diabetes (T1D). In the present study, we analyzed the performance of two-bolus calculator's software that could be accessible to T1D patients from a Public Health Service to improve glycemic time in range (TIR) and A1c.

METHODS

This prospective, controlled, randomized, parallel intervention clinical trial was carried out with 111 T1D participants on basal/bolus therapy [multiple daily insulin injections (MDI) or subcutaneous infusion pump (CSII)] with basal A1c ≥ 8.5% for 24 weeks. Patients were divided into 3 groups: 2 interventions: COMBO^® (bolus calculator) and GLIC (mobile application) and 1 control (CSII group). Anthropometrics and metabolic variables were assessed on basal, 3 and 6 months of follow-up.

RESULTS

TIR was increased in 9.42% in COMBO group (29 ± 12% to 38.9 ± 12.7%; p < 0.001) in 8.39% in the GLIC® group (28 ± 15% to 36.6 ± 15.1%; p < 0.001) while remained stable in CSII group (40 ± 11% to 39.3 ± 10.3%). A1c decrease in 1.08% (p < 0.001), 0.64% (p < 0.001) and 0.38% (p = 0.01) at 6 months in relation to basal in the COMBO, GLIC and CSII respectively. Daily basal insulin dose was reduced by 8.8% (p = 0.01) in the COMBO group.

CONCLUSION

The COMBO and a mobile applicative (GLIC) bolus calculator had a similar and a good performance to optimize the intensive insulin treatment of T1D in the public health system with increase in the TIR and reduction in A1C without increase hypoglycemia prevalence.

A randomized pharmacokinetic and pharmacodynamic trial of two regular human insulins demonstrates bioequivalence in type 1 diabetes and availability of biosimilar insulin may improve access to this medication

AIMS

To compare the pharmacokinetic (PK) and pharmacodynamic (PD) effects and safety of therapeutic dosages of a regular insulin (experimental drug) produced by Bioton S.A. (Warsaw, Poland) versus Humulin® R, a regular insulin (reference drug) produced by Eli Lilly (Indianapolis, Indiana).

MATERIALS AND METHODS

In a single-centre, randomized, double-blinded phase 1 crossover study, we used the manual euglycaemic clamp technique to compare PK and PD profiles between single subcutaneous doses (0.3 units/kg) of the two regular insulins in participants with type 1 diabetes (T1DM) with a washout period of 14 (± 7) days between tests.

RESULTS

We evaluated 56 participants. The mean participant age and body mass index were 32.9 years and 22.9 kg/m² , respectively. The ratios (experimental/reference) of the geometric means of maximum plasma insulin concentration and for plasma insulin area under the curve (AUC) were 0.909 (90% confidence interval [CI] 0.822-1.01) and 0.993 (90% CI 0.944-1.04), respectively. The ratios of the geometric means of maximum glucose infusion rate (GIR) and for GIR AUC were 0.999 (95% CI 0.912-1.09) and 1.04 (95% CI 0.962-1.12), respectively.

CONCLUSIONS

The experimental product regular human insulin and comparator Humulin® R are bioequivalent in patients with T1DM. Wider entry to the pharmaceutical market of affordable, biosimilar regular insulins may substantially improve access to insulin for many socioeconomically disadvantaged patients with diabetes.

Relationship among health-related quality of life and global ancestry, clinical and socioeconomic factors in type 1 diabetes in an admixed Brazilian population

We aimed to evaluate the Health-related quality of life (HRQoL) of Type 1 diabetes mellitus (T1D) patients in an admixed Brazilian population. This is a cross-sectional study with 152 T1D patients. HRQoL information was obtained from two self-completed questionnaires: Short Form-6 dimensions and EuroQol-5 dimensions with visual analog scale. For inference of global ancestry, the panel of 46 autosomal informational insertion/deletion ancestry markers was used. Demographic and socioeconomic data, presence of chronic complications, glycemic control level, and type of treatment were obtained. Patients with good HRQoL were: male, under 18 years old, had health insurance, less than 5 years of diagnosis, practiced physical activity, without hypoglycemia in the last 30 days, absence of retinopathy and nephropathy, a participant in educational activities, used analogous insulin, monitoring blood glucose, observed maximum adherence to treatment and came from the secondary service. Global ancestry and self-reported color/race did not influence HRQoL indexes. Our study is the first to measure HRQoL, global ancestry and recognize the impact of T1D on the lives of patients in the State of Maranhão, Brazil. The results validate the need to provide T1D patients with continuous training on self-management and self-monitoring, aiming for better results in metabolic control and, subsequently, in the prevention of acute and chronic complications, in order to generate positive impacts on the quality of life of this population. We understand that global ancestry in a highly mixed population such as ours did not influence the HRQoL of these patients.

Determinants of ultra-processed food consumption in Brazilian children and adolescents with type 1 diabetes mellitus: a cross-sectional study

OBJECTIVES

To analyze the determinants of UPP consumption among children and adolescents with type 1 diabetes mellitus.

METHODS

Cross-sectional study at a reference hospital for the treatment of diabetes in Rio de Janeiro, Brazil. The sociodemographic, anthropometric, dietary, and clinical factors associated with the percentage of total energy intake (TEI) consumed in the form of UPP were investigated. Food consumption was assessed by 24 h recall and the foods were classified according to the degree of processing as described in the NOVA classification, after which the TEI of each food group was calculated. Multiple linear regression was adopted in the analysis, and associations with p<0.05 were considered significant.

RESULTS

The study included 120 children and adolescents with a mean age of 11.74 ± 2.88 years, 53.3% female. Body mass index z-score was 0.65 (± 0.89) and 31.7% (n=38) were overweight. The average total energy consumption was 1,756.38 kcal (± 518.38). The mean percentage of TEI from UPP was 24.2% ± 17.9, meaning that 425.59 kcal (± 380.15) of all calories ingested came from such foods. The independent variables associated with the percentage of ultra-processed foods (UPP) in TEI were: per capita household income up to one the minimum wage (β: -22.03; CI 95% -35.24 to -8.82); and parents/guardians schooling of the up to nine years in formal education (β: 19.86; CI 95% 8.27-31.45).

CONCLUSIONS

Lower household income and fewer years in formal education seem to determine a preference for UPP over fresh and minimally processed foods.

The Association between Social Determinants of Health and Self-Reported Diabetic Retinopathy: An Exploratory Analysis

One-third of Americans with diabetes will develop diabetic retinopathy (DR), the leading cause of blindness in working-age Americans. Social determinants of health (SDOHs) are conditions in a person’s environment that may impact health. The objective of this study was to determine whether there is an association between SDOHs and DR in patients with type II diabetes. This cross-section study used data from the 2018 Behavioral Risk Factor Surveillance System (BRFSS). This study included people with self-reported diabetes in the US in 2018 (n = 60,703). Exposure variables included homeownership, marital status, income, health care coverage, completed level of education, and urban vs. rural environment. The outcome variable was DR. Logistic regression analysis were applied to calculate odds ratios (ORs) and 95% confidence intervals (CIs). Alaskan Native/Native American (OR 2.11; 95% CI: 1.14–3.90), out of work (OR 2.82; 95% CI: 1.62–4.92), unable to work (OR 2.14; 95% CI: 1.57–2.91), did not graduate high school (OR 1.91; 95% CI: 1.30–2.79), only graduated high school (OR 1.43; 95% CI 1.08–1.97), or only attended college or technical school without graduating (OR 1.42; 95% CI: 1.09–1.86) were SDOHs associated with DR in patients with diabetes. Health care providers should identify these possible SDOHs affecting their diabetic patients.

Therapeutic play to teach children with type 1 diabetes insulin self-injection: A pilot trial in a developing country

PURPOSE

Child participation in type 1 diabetes (T1D) self-care is needed in developing countries due to a lack of resources, especially during the school day. This pilot study evaluated the feasibility of a therapeutic play intervention (ITP) versus standard education (SE) on the ability of children with T1D to correctly perform insulin injection technique.

DESIGN AND METHODS

Children with T1D (7-12 years) were recruited at two diabetes clinics in Brazil and randomized to ITP or SE. Registered nurses received protocol training to deliver the intervention and perform data collection. ITP group received an education that included a story about a child with T1D who self-injects insulin at school; SE group received routine clinic-based education. Preintervention, children were video-recorded giving insulin injections to a doll; postintervention, children were rerecorded giving the doll an injection. The research team reviewed the videos and assessed the injection technique using validated checklists. Parents reported children's self-injection practices at baseline and 30 days.

RESULTS

Children (N = 20, 40% male) were 9.6 ± 1.3 years old and had T1D for 3.6 ± 2.3 years; HbA1c was 9.1 ± 2.0%; 20% of ITP and 50% of SE children used syringes (vs. pens) for injections. At baseline, 80% of both groups knew how to self-inject; most were taught by a parent/relative. Injection technique scores were low in both groups; ITP group increased their scores significantly postintervention. Practices of self-injection did not change in either group after 30 days.

PRACTICE IMPLICATIONS

The play-based intervention appeared to improve the injection technique in the short-term. Pilot findings support the development of a larger trial to evaluate the effectiveness of ITP on educating children on insulin injections.

Genomic ancestry and glycemic control in adolescents with type 1 diabetes: A multicenter study in Brazil

OBJECTIVE

To determine the influence of genomic ancestry (GA) and self-reportedcolor-race (SRCR) on glycemic control in adolescents with type 1 diabetes (T1D) in an admixed population.

RESEARCH DESIGN AND METHODS

This multicenter nationwide study was conducted in 14 public clinics in 10 Brazilian cities. We estimated global and individual African, European, and Native Amerindian GA proportions using a panel of 46 AIM-INDEL markers. From 1760 patients, 367 were adolescents (20.9%): 184 female (50.1%), aged 16.4 ± 1.9 years, age at diagnosis 8.9 ± 4.3 years, duration of diabetes 8.1 ± 4.3 years, years of study 10.9 ± 2.5 and HbA1c of 9.6 ± 2.4%.

RESULTS

Patients SRCR as White: 176 (48.0%), Brown: 159 (43.3%), Black: 19(5.2%), Asians: 5 (1.4%) and Amerindians: 8 (2.2%). The percentage of European GA prevailed in all groups: White (71.1), Brown (58.8), Black (49.6), Amerindians (46.1), and Asians (60.5). Univariate correlation was noted between A1c and African GA, r = 0.11, P = .03; years of study, r = -0.12 P = .010, and having both private and public health care insurance (r = -0.20, P < .001). After adjustments, the multivariate logistic analysis showed that SRCR or GA did not influence glycemic control.

CONCLUSIONS

A high percentage of European GA was noted in our patients, even in those who self-reported as non-White, confirming the highly admixed ethnicity of the Brazilian population. Better glycemic control was associated with having both types of health care; however, there was no association between glycemic control with GA or SRCR. Future prospective studies with other admixed populations are necessary to confirm our findings.