Glucose control in diabetes: the impact of racial differences on monitoring and outcomes

Improving Diabetes Control in a Medicaid Managed Care Population With Complex Needs

INTRODUCTION

People enrolled in Medicaid managed care who struggle with diabetes control often have complex medical, behavioral, and social needs. Here the authors report the results of a program designed to partner with primary care teams to address those needs.

METHODS

A nonprofit organization partnered with a Medicaid managed care plan and a Federally Qualified Health Center in California to enroll people with A1cs >9% in a 12-month program. The program team included a community health worker, certified diabetes care and education specialist/registered dietitian, behavioral health counselor, and registered nurse. They developed patient-led action plans, connected patients to community resources, and supported behavior changes to improve diabetes control. Baseline assessments of behavioral health conditions and social needs were collected. Monthly A1c values were tracked for participants and a comparison group.

RESULTS

Of the 51 people enrolled, 83% had at least 1 behavioral health condition. More than 90% reported at least 1 unmet social need. The average monthly A1c among program participants was 0.699 lower than the comparison group post-enrollment (P = .0008), and the disparity in A1c between Hispanic and non-Hispanic White participants at enrollment declined.

DISCUSSION

Participants had high levels of unmet medical, behavioral, and social needs. Addressing these needs resulted in a rapid and sustained improvement in A1c control compared to non-enrollees and a reduction in disparity of control among Hispanic participants.

CONCLUSION

By partnering with a primary care team, a program external to Federally Qualified Health Center primary care can improve clinical outcomes for people with complex needs living with diabetes.

Process evaluation of Dulce Digital-Me: an adaptive mobile health (mHealth) intervention for underserved Hispanics with diabetes

Type 2 diabetes disproportionately impacts ethnic minorities and individuals from low socioeconomic status. Diabetes self-management education and support has been shown to improve clinical outcomes in these populations, and mobile health (mHealth) interventions can reduce barriers to access. Dulce Digital-Me (DD-Me) was developed to integrate adaptive mHealth technologies to enhance self-management and reduce disparities in the high-risk, underserved Hispanic population. The objective of the present study was to evaluate reach, adoption, and implementation of an mHealth diabetes self-management education and support intervention in this underrepresented population. The present analysis is a multimethod process evaluation using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. The study was effective in reaching a sample that was representative of the intended population; only modest but significant differences were observed in sex and age. The DD-Me health coach (HC) cited several important facilitators of intervention adoption, including outreach frequency and personalization, and the automated HC report. Implementation fidelity was high, with participants receiving >90% of intended interventions. Participants who received DD-Me with support from a HC were most engaged, suggesting utility and acceptability of integrating HCs with mHealth interventions. Perceptions of implementation among study participants were positive and consistent across study arms. This evaluation revealed the target population was successfully reached and engaged in the digital health interventions, which was implemented with high fidelity. Further studies should evaluate the efficacy and maintenance of the study following the RE-AIM model to determine whether this intervention warrants expansion to additional settings and populations.

Current evidence for designing self-management support for underserved populations: an integrative review using the example of diabetes

AIMS

With numerous and continuing attempts at adapting diabetes self-management support programmes to better account for underserved populations, its important that the lessons being learned are understood and shared. The work we present here reviews the latest evidence and best practice in designing and embedding culturally and socially sensitive, self-management support programmes.

METHODS

We explored the literature with regard to four key design considerations of diabetes self-management support programmes: Composition - the design and content of written materials and digital tools and interfaces; Structure - the combination of individual and group sessions, their frequency, and the overall duration of programmes; Facilitators - the combination of individuals used to deliver the programme; and Context - the influence and mitigation of a range of individual, socio-cultural, and environmental factors.

RESULTS

We found useful and recent examples of design innovation within a variety of countries and models of health care delivery including Brazil, Mexico, Netherlands, Spain, United Kingdom, and United States of America. Within Composition we confirmed the importance of retaining best practice in creating readily understood written information and intuitive digital interfaces; Structure the need to offer group, individual, and remote learning options in programmes of flexible duration and frequency; Facilitators where the benefits of using culturally concordant peers and community-based providers were described; and finally in Context the need to integrate self-management support programmes within existing health systems, and tailor their various constituent elements according to the language, resources, and beliefs of individuals and their communities.

CONCLUSIONS

A number of design principles across the four design considerations were identified that together offer a promising means of creating the next generation of self-management support programme more readily accessible for underserved communities. Ultimately, we recommend that the precise configuration should be co-produced by all relevant service and patient stakeholders and its delivery embedded in local health systems.

SMS texting for uncontrolled diabetes among persons experiencing homelessness: Study protocol for a randomized trial

BACKGROUND

Diabetes mellitus (DM) is common among persons experiencing homelessness (PEH), often inadequately managed, and carries significant costs. mHealth strategies including short messaging service (SMS) texting have been feasible and acceptable, and improved control of chronic diseases including DM. SMS strategies for DM have not been tested among PEH despite the accessibility of mobile phones. We propose an SMS strategy could offer better communication, education, and information management; improve outreach; facilitate care coordination; explore barriers to care; and support behavior changes.

METHODS AND ANALYSIS

This mixed-methods (RCT and qualitative) study will be implemented in shelter-clinics in New York City in collaboration with community organizations, allowing for sustainability and scalability. Aim 1 will evaluate the efficacy of a 6-month SMS program for DM management versus an attention control on changes in HbA1c and adherence to DM self-care activities, medications, and appointments at 9 months in adult PEH with uncontrolled DM (n = 100). Outcomes will be measured at 0, 3, 6, &9 months. AIM 2 will assess patients' and providers' attitudes, acceptability, and experience of the program through semi-structured interviews with PEH (n = 20) and providers (n = 10).

DISCUSSION

DM is not well-addressed among PEH. SMS strategies for DM have never been tested in PEH despite evidence of their effectiveness and access to mobile phones among PEH. Results from this study will provide important empirical data to inform evidence-based strategies to avert personal suffering and significant costs. It will have broader policy implications in control of DM and other chronic diseases.

Precision Medicine in Diabetes

Tailoring treatment or management to groups of individuals based on specific clinical, molecular, and genomic features is the concept of precision medicine. Diabetes is highly heterogenous with respect to clinical manifestations, disease progression, development of complications, and drug response. The current practice for drug treatment is largely based on evidence from clinical trials that report average effects. However, around half of patients with type 2 diabetes do not achieve glycaemic targets despite having a high level of adherence and there are substantial differences in the incidence of adverse outcomes. Therefore, there is a need to identify predictive markers that can inform differential drug responses at the point of prescribing. Recent advances in molecular genetics and increased availability of real-world and randomised trial data have started to increase our understanding of disease heterogeneity and its impact on potential treatments for specific groups. Leveraging information from simple clinical features (age, sex, BMI, ethnicity, and co-prescribed medications) and genomic markers has a potential to identify sub-groups who are likely to benefit from a given drug with minimal adverse effects. In this chapter, we will discuss the state of current evidence in the discovery of clinical and genetic markers that have the potential to optimise drug treatment in type 2 diabetes.

Racial Differences and Social Determinants of Health in Achieving Hypertension Control

OBJECTIVE

To investigate whether specific social determinants of health could be a "health barrier" toward achieving blood pressure (BP) control and to further evaluate any differences between Black patients and White patients.

PATIENTS AND METHODS

We conducted a retrospective cohort study of 3305 patients with elevated BP who were enrolled in a hypertension digital medicine program for at least 60 days and followed up for up to 1 year. Patients were managed virtually by a dedicated hypertension team who provided guideline-based medication management and lifestyle support to achieve goal BP.

RESULTS

Compared with individuals without any health barriers, the addition of 1 barrier was associated with lower probability of control at 1 year from 0.73 to 0.60 and to 0.55 in those with 2 or more barriers. Health barriers were more prevalent in Black patients than in those who were White (44.6% [482 of 1081] vs 31.3% [674 of 2150]; P<.001). There was no difference at all in BP control between Black individuals and those who were White if 2 or more barriers were present.

CONCLUSION

Patient-related health barriers are associated with BP control. Black patients with poorly controlled hypertension have a higher prevalence of health barriers than their White counterparts. When 2 or more health barriers were present, there was no differences in BP control between White and Black individuals.

Efficacy of a language-concordant health coaching intervention for latinx with diabetes

OBJECTIVE

To describe the effect of a language-concordant health coaching intervention for Spanish-speaking patients with limited English proficiency (LEP) and uncontrolled Type 2 Diabetes (T2D) on glycemic control, anxiety, depression, and diabetes self-efficacy.

METHODS

64 patients with T2D were randomly assigned to a control or intervention group. Outcomes were assessed by blood work and surveys pre and post intervention.

RESULTS

The mean sample age was 47.8 years (SD=11.3) and 81% were female. HbA1c was not significantly different between groups at baseline. The intervention group's HbA1c was significantly lower at times 2 and 3 than in the control arm (p < .01 and p < .001). There were significant reductions in the intervention group's mean HbA1c levels from baseline 10.37 to midpoint 9.20, p < .001; and from baseline 10.42 to study end 8.14, p < .001. Depression and anxiety scores significantly decreased (p < .05 and p < .001), and diabetes self-efficacy significantly increased (p < .001).

CONCLUSION

Health coaching led to statistically significant and clinically meaningful decreases in HbA1c, depression, and anxiety scores among LEP Latinx adults with uncontrolled T2D.

PRACTICE IMPLICATIONS

Heath coaching can be conducted in primary care clinics by nurses or advanced practice nurses. The short-term intervention tested here could be adapted to the clinical setting.

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.

Dulce Digital-Me: protocol for a randomized controlled trial of an adaptive mHealth intervention for underserved Hispanics with diabetes

BACKGROUND

By 2034, the number of US individuals with diabetes is predicted to increase from 23.7 to 44.1 million, and annual diabetes-related spending is expected to grow from $113 to $336 billion. Up to 55% of US Hispanics born in the year 2000 are expected to develop diabetes during their lifetime. Poor healthcare access and cultural barriers prevent optimal care, adherence, and clinical benefit, placing Hispanics at disproportionate risk for costly diabetes complications. Mobile technology is increasingly prevalent in all populations and can circumvent such barriers. Our group developed Dulce Digital, an educational text messaging program that improved glycemic control relative to usual care. Dulce Digital-Me (DD-Me) has been tailored to a participant's individual needs with a greater focus on health behavior change.

METHODS

This is a three-arm, parallel group, randomized trial with equal allocation ratio enrolling Hispanic adults with low income and poorly managed type 2 diabetes (N = 414) from a San Diego County Federally Qualified Health Center. Participants are randomized to receive Dulce Digital, Dulce Digital-Me-Automated, or Dulce Digital-Me-Telephonic. The DD-Me groups include Dulce Digital components plus personalized goal-setting and feedback delivered via algorithm-driven automated text messaging (DD-Me-Automated) or by the care team health coach (DD-Me-Telephonic) over a 12-month follow-up period. The study will examine the comparative effectiveness of the three groups in improving diabetes clinical control [HbA1c, primary outcome; low-density lipoprotein cholesterol (LDL-C), and systolic blood pressure (SBP)] and patient-provider communication and patient adherence (i.e., medication, self-management tasks) over 12 months and will examine cost-effectiveness of the three interventions.

DISCUSSION

Our comparative evaluation of three mHealth approaches will elucidate how technology can be integrated most effectively and efficiently within primary care-based chronic care model approaches to reduce diabetes disparities in Hispanics and will assess two modes of personalized messaging delivery (i.e., automated messaging vs. telephonic by health coach) to inform cost and acceptability.

TRIAL REGISTRATION

NCT03130699-All items from the WHO Trial Registration data set are available in https://clinicaltrials.gov/ct2/show/study/NCT03130699 .

Assessment of Glycemic Control at St. Luke's Free Medical Clinic: Retrospective Chart Review

Background

A free clinic is a health care delivery model that provides primary care and pharmaceutical services exclusively to uninsured patients. With a multidisciplinary volunteer clinical staff, which includes physicians, social workers, dieticians, and osteopathic medical students, St. Luke’s Free Medical Clinic (SLFMC) cares for over 1700 patients annually in Spartanburg, South Carolina.

Objective

This study aims to measure the change, over time, in patient hemoglobin A_1c measurements at the SLFMC to quantify the success of the clinic’s diabetes treatment program.

Methods

A prospective-retrospective chart review of patients (n=140) enrolled at the SLFMC between January 1, 2018, and January 1, 2021, was performed. Patients were stratified as having controlled (hemoglobin A_1c<7.0, n=53) or uncontrolled (hemoglobin A_1c≥7.0, n=87) diabetes relative to a therapeutic hemoglobin A_1c target of 7.0, which is recommended by the American Diabetes Association. For both controlled and uncontrolled groups, baseline hemoglobin A_1c values were compared to subsequent readings using a Wilcoxon matched-pairs signed rank test. Results from the SLFMC population were compared to the published literature on hemoglobin A_1c from other free clinics.

Results

Patients with uncontrolled diabetes experienced significant reductions in median hemoglobin A_1c at both 6 months (P=.006) and 1 year (P=.002) from baseline. Patients with controlled diabetes showed no significant changes. Black and Hispanic patients with uncontrolled diabetes experienced a 1.0% mean improvement in hemoglobin A_1c over the study window. The SLFMC’s wholly uninsured patient population showed a population rate of controlled diabetes (42%), which was similar to recent nationwide averages for adults with diabetes (51% to 56%), as reported by the National Health and Nutrition Examination Survey. The clinic’s Hispanic population (n=47) showed the greatest average improvement in hemoglobin A_1c of any ethnic group from baseline. Additionally, 61% of the SLFMC’s Black population (n=33) achieved a hemoglobin A_1c of <7.0 by the end of the study window, which surpassed the nationwide averages for glycemic control.

Conclusions

We present free clinic hemoglobin A_1c outcomes obtained through a retrospective chart review. Uninsured patients treated for diabetes at the SLFMC show a reduction in hemoglobin A_1c, which is comparable to nationwide standards, although average hemoglobin A_1c levels in this study were higher than nationwide averages. Black and Hispanic patients with uncontrolled diabetes showed a mean 1% improvement in hemoglobin A_1c levels. These results represent some of the first in the literature emerging from a free clinic that is not affiliated with a major medical school.

Type 2 diabetes mellitus screening rates in racial and ethnic minority groups

BACKGROUND

More than 7 million Americans aged 18 years and older have undiagnosed diabetes. As primary health care moves toward preventative medicine, it is important that diabetes screening deficits are addressed.

PURPOSE

The purpose of this study was to identify current screening rates among racial and ethnic minorities who are considered at high risk of developing type 2 diabetes mellitus (T2DM).

METHODOLOGY

Data were collected through an IRB-approved i2b2 database from previously consented patients who had been treated at a large academic health center and outpatient facilities. Patients who were included in this study were those seen in outpatient settings between June 2011 and June 2019, aged 18-39 years at high risk for developing T2DM, defined as those of a racial and ethnic minority background, obese, and with a family history of T2DM.

RESULTS

Approximately 1,476 ± 3 individuals were identified as high risk, and of those, only 106 ± 3 (13.9%) were screened for T2DM between June 2011 and June 2019. Following the American Diabetes Association guidelines of including body mass index ≥25 kg/m2, approximately 1,263 ± 3 of the original 1,476 patients were identified as overweight with high risk, and of those patients, only 90 ± 3 (13.8%) were screened.

CONCLUSIONS

Findings indicate that less than 14% of patients at high risk for developing T2DM in their lifetime are being screened.

IMPLEMENTATIONS

Screening strategies need to be developed and implemented to better identify individuals at high risk of developing T2DM, which may lead to earlier diagnosis, treatment, and decreased disease burden.

Self-reported cultural competency measures among patients with diabetes: A nationwide cross-sectional study in the United States

Background

Culturally tailored interventions may reduce disparities in diabetes care. We conducted a nationally representative assessment of self-reported cultural competency measures of care among patients with diabetes in the United States.

Methods

The 2017 National Health Interview Survey was queried for adults with self-reported diabetes. Sample weight-adjusted multivariable logistic regressions defined adjusted odds ratios and 95% confidence intervals of a positive response to each of the cultural competency measures while controlling for relevant sociodemographic variables.

Findings

2,448 adults were included in the analyses. Black, Latinx, and Asian respondents had greater odds of and individuals with the highest income level had lower odds of placing greater importance in sharing cultures with their provider. Black and Latinx individuals had lower odds of reporting encountering providers who shared or understood their cultures. Asians had lower odds of and respondents aged 40-64 and 65 years and older had greater odds of reporting frequently being treated with respect by their providers. Non-English speakers had lower odds of and individuals from higher income brackets had greater odds of reporting frequently receiving easy-to-understand information about their care. Blacks and respondents not part of the workforce had greater odds of reporting frequently being asked about their opinions or beliefs in care.

Interpretation

Disparities in self-reported provider cultural competency measures exist among cultural minorities in the United States. Our findings may inform efforts to reduce disparities and improve care among minorities with diabetes.

Funding

No funding was used in the preparation of this work.

Improvements in physical activity and some dietary behaviors in a community health worker-led diabetes self-management intervention for adults with low incomes: results from a randomized controlled trial

People with low incomes have a disproportionate prevalence of diabetes and its complications and experience many barriers to self-management, which community health workers (CHWs) may help address. We sought to examine the effects of an in-home CHW-led intervention for adults with diabetes and incomes <250% of the federal poverty line on self-management behaviors and test mediators and moderators. From 2010 to 2013, we randomized participants from three Washington State health systems with type 2 diabetes and hemoglobin A1c (HbA1c) ≥ 8% to the CHW intervention (N = 145) or usual care control (N = 142) arms. We examined effects on 12-month self-management: physical activity, dietary behaviors, medication taking, blood glucose monitoring, foot care, and tobacco use. For behaviors with significant intervention-control group differences, we tested mediation by self-efficacy and social support. We also investigated whether intervention-associated changes in behaviors varied by race/ethnicity, gender, and baseline values of HbA1c, diabetes distress, depression, and food insecurity (moderators). Compared to controls, intervention participants engaged in more physical activity and reported better dietary behaviors for some measures (general diet, frequency of skipping meals, and frequency of eating out) at 12-months, but there was no evidence of mediation by self-efficacy or social support. Evidence of moderation was limited: improvements in the frequency of skipping meals were restricted to participants with baseline HbA1c < 10%. Study findings suggest CHWs could be integrated into diabetes care to effectively support lifestyle changes around physical activity and some eating behaviors among adults with low incomes. More research is needed to understand mechanisms of change.

Barriers to Type 2 Diabetes Management Among Older Adult Haitian Immigrants

PURPOSE

The purpose of this study was to describe the experiences of older adult Haitian immigrants in managing type 2 diabetes mellitus (T2DM).

METHODS

A descriptive qualitative approach using semistructured interviews was conducted with 20 older adult Haitian immigrants with T2DM. Interviews were transcribed verbatim and categorized using NVivo. An iterative descriptive data analysis method was used to examine the data, compare codes, challenge interpretations, and develop themes inductively.

RESULTS

Older adult Haitian immigrants reported that T2DM affected every aspect of their lives. Financial hardship and social isolation were described as the major barriers to T2DM management, which forced them to choose between basic needs and health care, and at times, they had to forgo medications or avoid seeking medical care. They recognized that creating and maintaining good community support was the key to self-management of T2DM.

CONCLUSIONS

Financial hardship and social isolation have a tremendous impact on the ability of older Haitian immigrants to manage T2DM effectively. It is challenging to modify these barriers through individual efforts, and clinical, research, and public efforts may be necessary to address these concerns.

Mechanisms of socioeconomic differences in COVID-19 screening and hospitalizations

Background

Social and ecological differences in early SARS-CoV-2 pandemic screening and outcomes have been documented, but the means by which these differences have arisen are not well understood.

Objective

To characterize socioeconomic and chronic disease-related mechanisms underlying these differences.

Design

Observational cohort study.

Setting

Outpatient and emergency care.

Patients

12900 Cleveland Clinic Health System patients referred for SARS-CoV-2 testing between March 17 and April 15, 2020.

Interventions

Nasopharyngeal PCR test for SARS-CoV-2 infection.

Measurements

Test location (emergency department, ED, vs. outpatient care), COVID-19 symptoms, test positivity and hospitalization among positive cases.

Results

We identified six classes of symptoms, ranging in test positivity from 3.4% to 23%. Non-Hispanic Black race/ethnicity was disproportionately represented in the group with highest positivity rates. Non-Hispanic Black patients ranged from 1.81 [95% confidence interval: 0.91–3.59] times (at age 20) to 2.37 [1.54–3.65] times (at age 80) more likely to test positive for the SARS-CoV-2 virus than non-Hispanic White patients, while test positivity was not significantly different across the neighborhood income spectrum. Testing in the emergency department (OR: 5.4 [3.9, 7.5]) and cardiovascular disease (OR: 2.5 [1.7, 3.8]) were related to increased risk of hospitalization among the 1247 patients who tested positive.

Limitations

Constraints on availability of test kits forced providers to selectively test for SARS-Cov-2.

Conclusion

Non-Hispanic Black patients and patients from low-income neighborhoods tended toward more severe and prolonged symptom profiles and increased comorbidity burden. These factors were associated with higher rates of testing in the ED. Non-Hispanic Black patients also had higher test positivity rates.

Influences of Demographic, Social Determinants, Clinical, Knowledge, and Self-Care Factors on Quality of Life in Adults With Type 2 Diabetes: Black-White Differences

BACKGROUND

This study evaluated racial differences in the contribution of demographic, social determinants, clinical, and self-care factors on quality of life (QOL) in adults with type 2 diabetes mellitus (T2DM).

METHODS

A total of 615 adults with T2DM in Southeastern United States were recruited. Linear regression models were used to assess the contribution of demographic, social determinants, clinical, and self-care factors on the mental (MCS) and physical components (PCS) of QOL, after stratifying by race.

RESULTS

For the entire sample, there were significant relationships between PCS and psychological distress (β = 0.02, p < 0.01), neighborhood aesthetics (β = 0.05, p < 0.01), neighborhood walking environment (β = -0.02, p < 0.05), access to healthy food (β = 0.01, p < 0.05), neighborhood crime (β = -0.15, p < 0.05), and neighborhood comparison (β = 0.13, p < 0.05); and MCS and depression (β = -0.06, p < 0.05), psychological distress (β = -0.09, p < 0.001), perceived stress (β = -0.12, p < 0.01), and perceived health status (β = -0.33, p < 0.01). In the regression models stratified by race, notable differences existed in the association between PCS, MCS, and demographic, psychosocial, built environment, and clinical factors among Whites and Blacks, respectively.

CONCLUSION

In this sample, there were racial differences in demographic, social determinants, built environment, and clinical factors associated with PCS and MCS components of QOL. Interventions may need to be tailored by race or ethnicity to improve quality of life in adults with T2DM.

Feasibility and Acceptability of a Language Concordant Health Coaching Intervention Delivered by Nurses for Latinx With Type 2 Diabetes

BACKGROUND

Latinx immigrants have high rates of type 2 diabetes (T2D), exhibit out-of-range glycemic control, and have higher rates of diabetes-related complications than non-Latinx whites, with limited English proficiency (LEP) being a major barrier to care.

AIMS

We tested the feasibility and acceptability of a language concordant (provider that is proficient in the patient's preferred language) health coaching intervention delivered by nurse and nurse practitioner students in a pilot study of Latinx immigrants with T2D and LEP.

METHODS

A sample of 17 Latinx immigrants with T2D and LEP were split into intervention and control groups. The control group received basic diabetes care and written educational materials on diabetes self-management in Spanish. Individuals in the intervention group received the standard diabetes care offered by the clinic and six biweekly health coaching sessions (intervention) with a trained language concordant health coach.

RESULTS

The language concordant health coaching intervention was both feasible (delivery) and acceptable (satisfactory) to Latinx immigrants with T2D and LEP and resulted in clinically meaningful differences in key diabetes-related outcomes.

LINKING EVIDENCE TO ACTION

Our findings suggest that lack of language concordance between provider and patient has an important and meaningful impact on the ability of an LEP Latinx patient to receive, and perhaps act upon, adequate education for T2D management. Receiving biweekly coaching calls could have offered further emotional support for participants to discuss living with T2D, which may have helped to alleviate symptoms of depression and anxiety that individuals with T2D frequently endure.

Quantifying the Influence of Individual, Community, and Health System Factors on Quality of Life Among Inner-City African Americans With Type 2 Diabetes

PURPOSE

The purpose of this study is to examine the association of individual, community, and health system factors on quality of life among inner-city African Americans with type 2 diabetes.

METHODS

Primary data from a cross-sectional study with a community sample of 241 inner-city African Americans with type 2 diabetes were analyzed. Paper-based surveys were administered in which the SF-12 was used to capture the physical component (PCS) and mental component (MCS) of quality of life. Four regression approaches (sequential, stepwise with backward and forward selection, and all possible subsets regression) were used to examine the influence of individual, community, and health system factors on PCS and MCS after adjusting for relevant covariates using a conceptual framework.

RESULTS

In fully adjusted models, having less than a high school education and having major depression were associated with lower quality-of-life scores for MCS across all 4 regression approaches. Being employed was positively associated with better quality-of-life scores for PCS across all 4 regression approaches. PCS was higher across all 4 regression approaches for those reporting a history of trauma. At the health systems level, usual source of care was associated with better PCS across 3 regression approaches.

CONCLUSIONS

These results highlight key factors that influence quality of life among inner-city African Americans with type 2 diabetes that could be targets for interventions in this population. However, additional research is needed to understand existing pathways that may be driving many of these relationships.

Lowering the impact of food insecurity in African American adults with type 2 diabetes mellitus (LIFT-DM) - Study protocol for a randomized controlled trial

BACKGROUND

There is strong evidence that disparities in the burden of diabetes exist by both race and poverty. Food insecurity, or an inability to or limitation in accessing nutritionally adequate food, is an important modifiable social determinant of health, particularly in adults with chronic disease. African Americans are more likely to be diagnosed with diabetes and more likely than whites to be food insecure.

METHODS

We describe a 4-year ongoing randomized controlled trial, which will test the separate and combined efficacy of monthly food vouchers and monthly food stock boxes layered upon diabetes education in improving glycemic control in low income, food insecure, African Americans with type 2 diabetes mellitus using a 2 × 2 factorial design. Three hundred African American adults with clinical diagnosis of diabetes and HbA1c ≥ 8% will be randomized into one of four groups: 1) diabetes education alone; 2) diabetes education plus food vouchers; 3) diabetes education plus stock boxes; and 4) diabetes education plus combined food vouchers and stock boxes. Our primary hypothesis is: among low-income, food insecure, African Americans with type 2 diabetes, those receiving diabetes education enhanced with food supplementation (food vouchers alone, stock boxes alone, or combination) will have significantly greater reduction in HbA1c at 12 months compared to those receiving diabetes education only.

DISCUSSION

Results from this study will yield valuable insight currently lacking on how best to design and deliver diabetes interventions to low-income, food insecure, African Americans with diabetes that takes into account both clinical and social determinants of health.

TRIAL REGISTRATION

This study was registered on November 29, 2019 with the United States National Institutes of Health Clinical Trials Registry (ClinicalTrials.gov identifier# NCT04181424).

Impact of a Culturally Tailored Diabetes Education and Empowerment Program in a Mexican American Population Along the US/Mexico Border: A Pragmatic Study

Background

The study purpose was to deliver a diabetes education program under real world conditions and evaluate its effect on diabetes-related clinical, self-management and psychosocial outcomes among Mexican Americans residing along the US/Mexico border.

Methods

A pragmatic study was conducted among adult patients with diabetes in three primary care clinics located along the US/Mexico border. A bilingual culturally tailored diabetes education program incorporating hands-on participatory techniques was delivered in 4 - 8 weekly group sessions. Clinical, self-management and psychosocial outcomes were evaluated pre- and post-intervention with surveys and medical record review.

Results

A total of 209 participants were enrolled; mean age was 58.9 years (range 23 - 94, standard deviation: 11.2); 68.4% were female; 91.1% were Hispanic. Significant improvements were observed in glycated hemoglobin (-1.1%, P < 0.001, n = 79), total cholesterol (-17.2 mg/dL, P = 0.041, n = 63), glucose self-monitoring (+1.3 times a week, P = 0.021, n = 115), exercise less than once a week (-18.2%, P < 0.001, n = 129), nutritional behavior (+2.23, P < 0.001, n = 115), knowledge (+1. 83, P < 0.001, n = 141) and diabetes-related emotional distress (-7.32, P = 0.002, n = 111). Benefits were observed with attendance rates as low as 50%.

Conclusion

A clinic-based culturally competent diabetes education/self-management program resulted in significant improvements in outcomes among Hispanic participants. Experimentally tested culturally appropriate interventions adapted for real world situations can benefit Mexican American diabetic patients even when attendance is imperfect.

The Probability of A1C Goal Attainment in Patients With Uncontrolled Type 2 Diabetes in a Large Integrated Delivery System: A Prediction Model

OBJECTIVE

To assess patient characteristics and treatment factors associated with uncontrolled type 2 diabetes (T2D) and the probability of hemoglobin A_1c (A1C) goal attainment.

RESEARCH DESIGN AND METHODS

This was a retrospective cohort study using the electronic health record at Cleveland Clinic. Patients with uncontrolled T2D (A1C >9%) were identified on the index date of 31 December 2016 (n = 6,973) and grouped by attainment (n = 1,653 [23.7%]) or nonattainment (n = 5,320 [76.3%]) of A1C <8% by 31 December 2017, and subgroups were compared on a number of demographic and clinical variables. On the basis of these variables, a nomogram was created for predicting probability of A1C goal attainment.

RESULTS

For the entire population, median age at index date was 57.7 years (53.3% male), and the majority were white (67.2%). Median A1C was 10.2%. Obesity (50.6%), cardiovascular disease (46.9%), and psychiatric disease (61.1%) were the most common comorbidities. Metformin (62.7%) and sulfonylureas (38.7%) were the most common antidiabetes medications. Only 1,653 (23.7%) patients achieved an A1C <8%. Predictors of increased probability of A1C goal attainment were older age, white/non-Hispanic race/ethnicity, Medicare health insurance, lower baseline A1C, higher frequency of endocrinology/primary care visits, dipeptidyl peptidase 4 inhibitor use, thiazolidinedione use, metformin use, glucagon-like peptide 1 receptor agonist use, and fewer classes of antidiabetes drugs. Factors associated with lower probability included insulin use and longer time in the T2D database (both presumed as likely surrogates for duration of T2D).

CONCLUSIONS

A minority of patients with an A1C >9% achieved an A1C <8% at 1 year. While most identified predictive factors are nonmodifiable by the clinician, pursuit of frequent patient engagement and tailored drug regimens may help to improve A1C goal attainment.

Sociodemographic disparities in the management of type 2 diabetes in the United States

Objective: To examine the potential sociodemographic disparities in type 2 diabetes (T2D) management and care among US adult individuals, after controlling for clinical and behavioral factors.Methods: This was a retrospective cohort study of individuals with T2D (N = 4552) from a linked database of the National Health and Wellness Survey and a large US ambulatory electronic health record (EHR) database. This study period was between 1 January 2015 and 31 December 2018 and individuals were followed up for at least 6 months through EHR after the completion of the survey. The sociodemographic characteristics included gender, race, ethnicity, marital status, education, employment status, household income, insurance status, and geographic region. The independent variables included testing and control of HbA1c, blood pressure (BP), and low-density lipoprotein-cholesterol (LDL-C); hypoglycemia, emergency room (ER) visits, and all-cause hospitalization. Multivariable analyses were conducted using generalized linear models.Results: The percentage of uncontrolled HbA1c was 38.6%. With clinical and behavioral characteristics adjusted, individuals living in the Northeast region had 30% higher odds of having HbA1c testing than those who lived in the South. Blacks and Asians were less likely to have HbA1c control than Whites. Uninsured individuals had a lower likelihood of receiving HbA1c, BP, or LDL-C testing compared with commercial insurers. Individuals with low income were more likely to have higher ER visits and hospitalizations.Conclusion: Potential sociodemographic disparities exist in T2D management and care in the US, indicating the needs for improvement in healthcare access, educational and behavioral programs, as well as disease and treatment management in these subgroups.

Insurance Status and Biological and Psychosocial Determinants of Cardiometabolic Risk Among Mexican-Origin U.S. Hispanic/Latino Adults with Type 2 Diabetes

Purpose: Hispanics/Latinos in the United States bear higher burden of type 2 diabetes (T2D) and associated complications compared with the general population. Health insurance coverage is also lower in this population. We examined the association of health insurance with biological and psychosocial determinants of cardiometabolic risk among U.S. Mexican-origin Hispanic/Latino adults with T2D.

Methods: Participants were self-reported Hispanic/Latino adults with T2D diagnosis. Trained bilingual community health workers collected cross-sectional information on biological and psychosocial factors using clinical examinations, laboratory tests, validated questionnaires, and wearable activity monitors.

Results: One hundred and seven Hispanic/Latino adults (54±12 years, 65% female, 36% prescribed insulin, 60% uninsured) with T2D were enrolled. While 93% had low language-based acculturation, 88% had high health literacy in Spanish. Forty percent were food insecure and 47% expressed at least one social need. Overall, 35% had an HbA_1c <7.0% (indicating good control) and 31% had an HbA_1c >9.0%. Sixty-three percent had blood pressure within target (<130/80 mmHg), and overall participants were moderately physically active. However, 53% were obese (body mass index ≥30 kg/m²) and 76% had a waist measurement defined as high risk (>88 cm for women and >102 cm for men). Participants without health insurance were younger (51.9±10.4 vs. 58.8±10.5 years mean±standard deviation, p=0.0008) but had higher HbA_1c (8.4±2.2% vs. 7.6±1.6, p=0.031) and fasting glucose (184.9±86.5 vs. 148.6±61.2 mg/dl, p=0.008) levels.

Conclusions: Health insurance status appears to influence achieved glycemic control for U.S. Hispanic/Latino adults with T2D. However, various psychosocial factors potentially influencing cardiometabolic risk independently of health insurance status may also be implicated in the inequitable burden of T2D. ClinicalTrials.gov Identifier: NCT03736486.

Racial and Regional Disparities in Outcomes Among Veterans Initially Adherent to Oral Antidiabetic Therapies: an Observational Cohort Study

BACKGROUND

Adherence to prescribed medications is connected with, but is not a guarantee of, improved disease management and health outcomes. It remains unclear whether underlying health disparities exist among patients adherent to therapy and whether differences in outcomes vary by race and residential areas of the country.

OBJECTIVE

To determine the extent of racial and regional variation in outcomes within 5 years of oral antidiabetic drug initiation among veterans adherent to therapy.

DESIGN

Retrospective cohort study of 83,265 US Veterans Health Administration data, 2002-2014 PATIENTS: US veterans with uncomplicated diabetes and taking oral antidiabetic agents MAIN MEASURES: Veterans initially adherent to oral antidiabetic therapy were followed for up to 5 years, and comparisons focused on differences between non-Hispanic White and non-Hispanic Black veterans across geographic region and residential type (urban or rural). Outcomes included composite cardiovascular events, composite cerebrovascular events, or all-cause mortality using Poisson and adjusted Cox proportional hazards models.

KEY RESULTS

Cardiovascular event and all-cause mortality rates differed by race and region, while urban/rural differences were evident for cerebrovascular events and all-cause mortality. For non-Hispanic Blacks, the mortality rate was half that compared to non-Hispanic Whites (6.5 [95% CI 5.8-7.2] versus 13.3 [95% CI 12.9-13.8], p < 0.0001). Compared to the Northeast, all other regions had higher adjusted hazards for cardiovascular or cerebrovascular events (with a single exception), but no regional differences in all-cause mortality were observed. Models with interactions demonstrated that racial differences in cardiovascular events and all-cause mortality were isolated to the Midwest (HR 1.99 [95% CI 1.301-3.06; HR 1.64 [95% CI 1.210-2.215]) and South (HR 1.69 [85% CI 1.347-2.131]; HR 1.27 [95% CI 1.095-1.470]).

CONCLUSIONS

Despite adherence to therapy, differences in outcomes are likely among veterans with diabetes based on race and geography. Localized analyses may uncover specific social determinants contributing to differences in outcomes.

Racial/Ethnic Differences in Glycemic Control in Older Adults with Type 2 Diabetes: United States 2003-2014

The aim of this study was to determine whether racial differences in HbA1c persist in older adults (≥65 years) living with type 2 diabetes. Data from The National Health and Nutrition Examination Survey (NHANES) 2003–2014 were used to examine the association between HbA1c and older adults (≥65 years) over time. Compared to non-Hispanic Whites, Mexican Americans had the greatest difference in average HbA1c among minority groups, followed by those with unspecified/mixed ethnicities and non-Hispanic Blacks. In the adjusted linear model, racial minorities had a statistically significant relationship with HbA1c. There was no relationship between HbA1c and older age and insulin use. Trends in mean HbA1c over time increased for non-Hispanic Blacks and Mexican Americans and decreased for non-Hispanic Whites. The findings suggest that racial differences in HbA1c persist into older age and compared to non-Hispanic Whites, non-Hispanic Blacks and Mexican Americans are at an increased risk of morbidity, mortality, and disability due to high HbA1c. Furthermore, alternate measures of glycemic control may be needed to screen and manage T2DM in racial minorities.

Long-Acting Injectable GLP-1 Receptor Agonists for the Treatment of Adults with Type 2 Diabetes: Perspectives from Clinical Practice

Randomized controlled trials (RCTs) have consistently shown glycemic and extra-glycemic benefits of long-acting injectable glucagon-like-peptide-1 receptor agonists (GLP-1RAs, liraglutide, albiglutide, exenatide once-weekly, dulaglutide, and semaglutide) in terms of reduction in the rates of cardiovascular events and mortality among patients with type 2 diabetes. Recently, the analyses of large datasets collecting routinely-accumulated data from clinical practice (ie, real-world studies, RWS) have provided new opportunities to complement the information obtained from RCTs. In this narrative review, we addressed clinically relevant questions that might be answered by well-conducted RWS: are subjects treated with GLP-1RAs in the "real-world" similar to those included in RCTs? Is the performance of GLP-1RA observed in the RWS (effectiveness) similar to that described in RCTs (efficacy)? Is the effectiveness similar in population of patients generally under-represented in RCTs? Are the cardiovascular benefits of GLP-1RAs confirmed in RWS? We also describe a few comparisons currently un-explored by specific RCTs, such as direct comparison between different administration strategies (eg, fixed- versus flexible-combination with basal-insulin) or between GLP-1RAs versus dipeptidyl-peptidase-4 inhibitor (DDP4i) or versus sodium/glucose cotransporter-2 inhibitors (SGLT-2i) on hard cardio-renal outcomes. Altogether, RWS provide highly informative information on treatment with GLP-1RAs. On the one side, RWS showed different clinical characteristics between subjects enrolled in RCTs versus those attending real-world clinics and receiving a GLP-1RA. On the other hand, RWS showed that GLP-1RA effectiveness is overall consistent in subgroups of patients less represented in RCTs. In addition, RWS allowed the identification of modifiable factors (eg, titration or adherence) that might guide physicians towards better GLP-1RAs use. Finally, multiple RWS reported better cardio-renal outcomes with GLP-1RAs than with DPP-4i, while initial findings from RWS described a weaker cardiovascular protection compared to SGLT-2i. Therefore, there is the need for further RWS and RCTs comparing these different classes of glucose lowering medications.

Development and Evaluation of a Blood Glucose Monitoring YouTube Video for Marshallese Patients Using a Community-Based Participatory Research Approach

The purpose of this study was to (a) describe the development of a culturally appropriate glucose monitoring video using a community-based participatory research approach and (b) assess the cultural appropriateness and effectiveness of the video. The topic of the video-using a glucometer and the importance of performing blood glucose checks-was chosen by Marshallese community stakeholders. The video was produced in Marshallese with English subtitles and disseminated through YouTube. Participants were recruited from August 16, 2016 to September 12, 2016 in a diabetes clinic that serves Marshallese patients in northwest Arkansas. Fifty participants completed a survey at pre- and postintervention, with questions capturing demographic information and questions on glucose monitoring self-efficacy using an adapted version of the Stanford Patient Education Research Center's Diabetes Self-Efficacy Scale. Twenty of those participants who completed the survey also completed semistructured interviews that assessed cultural appropriateness and effectiveness of the video. Participants reported significant increases in self-efficacy related to glucometer use and the importance of performing blood glucose checks (p < .001) and a 1.45% reduction in A1C between preintervention and 12 weeks postintervention (p = .006). Qualitative results indicated the video was both culturally appropriate and effective. The findings of this study were consistent with evidence in the literature, which shows health education videos can be effective at improving health behaviors. Using a community-based participatory research approach to prioritize video topics, and including members of the community in the creation and dissemination of the videos, could aid in ensuring the videos are effective and culturally appropriate.

Hospital admissions for hyperglycemic emergencies in young adults at an inner-city hospital

AIMS

There is limited information characterizing young adults (18-35 years) (YA) with diabetes, especially those admitted for hyperglycemic emergencies. The study aims were to examine associations of patient-level characteristics with hyperglycemic emergency hospitalization and to identify variations based on diabetes type and glycemic control.

METHODS

We conducted retrospective analysis of 273 YA admitted to an inner-city hospital with diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic nonketotic syndrome (HHS). T-tests, Chi-Square tests, and ANOVA identified differences in demographics, diabetes history, clinical indicators, complications/comorbidities, and hospital admission stratified separately by diabetes type (1 vs 2) and admission HbA1c < 9% (75 mmol/mol), ≥9% to 12% (108 mmol/mol), ≥12%).

RESULTS

Mean admission HbA1c was 12.4% (112 mmol/ml). HbA1c was ≥9.0% for 90.5%. The main DKA/HHS trigger was medication nonadherence (57.9%), with 35.6% presenting with new-onset type 2 diabetes. Only 3.7% utilized outpatient diabetes clinics, 38.8% were re-hospitalized within the year, and 69% lacked insurance. Diabetes complications (44.7%) and psychiatric co-morbidities (35.5%) were common. Significantly more YA with type 1 diabetes had insurance, whereas YA with type 2 diabetes had higher admission HbA1c. YA with HbA1c ≥12% were more likely to be Black and lack insurance.

CONCLUSIONS

YA hospitalized for DKA/HHS in an inner-city hospital tended to have severely uncontrolled diabetes. Many already had comorbidities and diabetes complications, high use of acute care services and low use of diabetes specialty services. YA characteristics varied by diabetes type and HbA1c. Overall, a substantial percentage lacked insurance, potentially impacting healthcare utilization patterns and medication adherence, and leading to DKA/HHS admissions.

Making Inroads in Addressing Population Health in Underserved Communities With Type 2 Diabetes

IN BRIEF Diabetes continues to represent a substantial individual and societal burden for those affected by the disease and its complications in the United States, and especially for racial/ethnic minorities, the socioeconomically disadvantaged, and the underinsured. Although tools and strategies are now available to manage the condition and its associated comorbidities at the patient level, we continue to struggle to gain control of this health burden at the population health level. Most patients are not achieving desired clinical goals and thus continue to be exposed to preventable risks and complications. As the U.S. health system moves toward a more value-based system of reimbursement, there are opportunities to rethink our approaches to patient and population health management and to harness the available tools and technologies to better understand the disease burden, stratify our patient populations by risk, redirect finite resources to high-impact initiatives, and facilitate better diabetes care management for patients and providers alike.

Association Between Metformin Initiation and Incident Dementia Among African American and White Veterans Health Administration Patients

PURPOSE

African American patients are more likely to experience cognitive decline after type 2 diabetes mellitus onset than white patients. Metformin use has been associated with a lower risk of dementia compared with sulfonylureas. Evidence for whether this association differs by race is sparse.

METHODS

Veterans Health Administration (VHA) medical record data were obtained for 73,761 African American and white patients aged ≥50 years who used the VHA from fiscal years 2000 to 2015. Patients were free of dementia and diabetes medications during fiscal years 2000 and 2001 and subsequently initiated metformin or sulfonylurea monotherapy. For race and age subgroups, Cox proportional hazards models using propensity scores and inverse probability of treatment weighting to control for confounding were computed to measure the association between metformin vs sulfonylurea initiation and incident dementia.

RESULTS

After controlling for confounding, among patients aged ≥50 years, metformin vs sulfonylurea use was associated with a significantly lower risk of dementia in African American patients (hazard ratio [HR] = 0.73; 95% CI, 0.6-0.89) but not white patients (HR = 0.96; 95% CI, 0.9-1.03). The strongest magnitude of association between metformin and dementia was observed among African American patients aged 50 to 64 years (HR = 0.6; 95% CI, 0.45-0.81). Among those aged 65 to 74 years, metformin was significantly associated with lower risk of dementia in both races. Metformin was not associated with dementia in patients aged ≥75 years.

CONCLUSIONS

Metformin vs sulfonylurea initiation was associated with a substantially lower risk of dementia among younger African American patients. These results may point to a novel approach for reducing the risk of dementia in African Americans with type 2 diabetes mellitus.

Diabetes and the Built Environment: Evidence and Policies

PURPOSE OF REVIEW

To explore the relationship between the built environment and type 2 diabetes, considering both risk factors and policies to reduce risk. The built environment refers to the physical characteristics of the areas in which people live including buildings, streets, open spaces, and infrastructure.

RECENT FINDINGS

A review of current literature suggests an association between the built environment and type 2 diabetes, likely driven by two key pathways-physical activity and the food environment. Other hypothesized mechanisms linking the built environment and type 2 diabetes include housing policy, but evidence in these areas is underdeveloped. Policies designed to enhance the built environment for diabetes risk reduction are mechanistically plausible, but as of yet, little direct evidence supports their effectiveness in reducing in type 2 diabetes risk. Future work should rigorously evaluate policies meant to reduce type 2 diabetes via the built environment.

Racial and Ethnic Differences in Out-of-Pocket Expenses among Adults with Diabetes

BACKGROUND

Racial and ethnic minority groups have a higher prevalence of diabetes, increased risk for adverse complications, and worse health outcomes compared to Non-Hispanic Whites. Evidence suggests they also have higher healthcare expenses associated with diabetes care. Therefore, the objective of this study was to assess racial and ethnic differences in out-of-pocket (OOP) costs among a nationally representative sample of adults with diabetes.

METHODS

Cross-sectional study of 17,702 adults (aged ≥18 years) with diabetes from years 2002-2011 in the Medical Expenditure Panel Survey Household Component. The outcome was OOP expenditures, and the primary predictor was race/ethnicity. Descriptive statistics summarized the sample population. Unadjusted mean values were computed to compare OOP expenses over time. A two-part model was used to estimate adjusted incremental OOP expenses.

RESULTS

For the overall sample, OOP expenditures decreased significantly over time. In addition, compared to NHWs, racial and ethnic minority groups had significantly lower OOP costs per year when adjusted for sociodemographic characteristics, comorbid conditions, and time. NHBs paid $481 less than NHWs; Hispanics paid $591 less than NHWs; and individuals in the 'Other' racial/ethnic category paid nearly $645 less compared to NHWs (p < 0.001).

CONCLUSIONS

Racial/ethnic minority patients with diabetes had significantly less OOP expenses compared to NHWs, possibly due to differences in healthcare utilization. OOP expenses decreased significantly over time for all racial and ethnic groups. Additional research is needed to understand the factors associated with differences in OOP expenditures among racial groups.

Race in Older but Not Younger Patients Associated With Greater Glycemic Burden in Primary Care Patients

PURPOSE

The purpose of this study is to determine if race disparities in glycemic control differ in young vs older white and African American patients with diabetes.

METHODS

Electronic medical record data were gathered from 1431 primary care patients ≥18 years old, diagnosed with type 2 diabetes, who had ≥2 A1C measurements between July 1, 2008, and June 30, 2015. A1C values were used to compute the average monthly glycemic burden (AMGB). AMGB is the average monthly cumulative amount of A1C >7.5. Age-stratified (18-50 vs >50 years old) linear regression models were computed to measure the association between race and AMGB before and after adjusting for covariates.

RESULTS

Younger compared to older patients had significantly greater AMGB. In younger patients, AMGB was not significantly different in African American vs white patients. In older patients, African Americans had significantly greater AMGB compared to whites, and this association remained significant after adjusting for all covariates in a linear regression model.

CONCLUSIONS

Results narrow the known race disparity in glycemic control to older African American patients. Substantial AMGB in white and African American younger patients warrants aggressive clinical and public health interventions that could help patients manage their diabetes and reduce their risk for diabetes-related health conditions.

Structural social support and cardiovascular disease risk factors in Hispanic/Latino adults with diabetes: results from the Hispanic Community Health Study/Study of Latinos (HCHS/SOL)

OBJECTIVE(S)

Cross-sectional and longitudinal studies have yielded inconsistent findings on the associations of social support networks with cardiovascular health in Hispanic/Latino adults with diabetes. We examined the cross-sectional associations of structural social support and traditional cardiovascular disease (CVD) risk factors in a diverse sample of Hispanic/Latino adults with diabetes.

RESEARCH DESIGN AND METHODS

This analysis included 2994 adult participants ages 18-74 with diabetes from the Hispanic Community Health Study/Study of Latinos (HCHS/SOL - 2008-2011). Select items from the Social Network Inventory (SNI) were used to assess indices of structural social support, i.e. network size (number of children, parents, and in-laws) and frequency of familial contact. Standardized methods were used to measure abdominal obesity, BMI, hypertension, hypercholesterolemia, and smoking status. Multivariate regression was used to examine associations of structural support with individual CVD risk factors with demographics, acculturation, physical health, and psychological ill-being (depressive symptoms and anxiety) included as covariates.

RESULTS

There were no significant cross-sectional associations of structural support indices with abdominal obesity, hypertension, hypercholesterolemia, or smoking status. There was a marginally significant (OR: 1.05; 95%CI 0.99-1.11) trend toward higher odds of obesity in participants reporting a larger family unit (including children, parents, and in-laws) and those with closer ties with extended family relatives (OR: 1.04; 95%CI 0.99-1.09).

CONCLUSIONS

Structural social support was marginally associated with higher odds of obesity in Hispanic/Latino adults with diabetes. Alternate forms of social support (e.g. healthcare professionals, friends, peers) should be further explored as potential markers of cardiac risk in Hispanics/Latinos with diabetes.

A risk score including body mass index, glycated haemoglobin and triglycerides predicts future glycaemic control in people with type 2 diabetes

AIM

To identify, predict and validate distinct glycaemic trajectories among patients with newly diagnosed type 2 diabetes treated in primary care, as a first step towards more effective patient-centred care.

METHODS

We conducted a retrospective study in two cohorts, using routinely collected individual patient data from primary care practices obtained from two large Dutch diabetes patient registries. Participants included adult patients newly diagnosed with type 2 diabetes between January 2006 and December 2014 (development cohort, n = 10 528; validation cohort, n = 3777). Latent growth mixture modelling identified distinct glycaemic 5-year trajectories. Machine learning models were built to predict the trajectories using easily obtainable patient characteristics in daily clinical practice.

RESULTS

Three different glycaemic trajectories were identified: (1) stable, adequate glycaemic control (76.5% of patients); (2) improved glycaemic control (21.3% of patients); and (3) deteriorated glycaemic control (2.2% of patients). Similar trajectories could be discerned in the validation cohort. Body mass index and glycated haemoglobin and triglyceride levels were the most important predictors of trajectory membership. The predictive model, trained on the development cohort, had a receiver-operating characteristic area under the curve of 0.96 in the validation cohort, indicating excellent accuracy.

CONCLUSIONS

The developed model can effectively explain heterogeneity in future glycaemic response of patients with type 2 diabetes. It can therefore be used in clinical practice as a quick and easy tool to provide tailored diabetes care.

Racial differences in spatial patterns for poor glycemic control in the Southeastern United States

PURPOSE

Evidence consistently shows poor outcomes in racial minorities, but there is limited understanding of differences that are explained by spatial variation. The goal of this analysis was to examine contribution of spatial patterns on disparities in diabetes outcomes in the Southeastern United States.

METHODS

Data on 64,022 non-Hispanic black (NHB) and non-Hispanic white (NHW) veterans with diabetes living in Georgia, Alabama, and South Carolina were analyzed for 2014. Hemoglobin A1c (HbA1c) was categorized as controlled (less than 8%) and uncontrolled (greater than or equal to 8%). Logistic regression was used to understand the additional explanatory capability of spatial random effects over covariates such as demographics, service connectedness, and comorbidities. Data aggregated at the county level were used to identify hotspots in distribution of uncontrolled HbA1c and tested using local Moran's I test.

RESULTS

Overall percent uncontrolled HbA1c was 36.5% (40.8% in NHB and 33.4% in NHW). In unadjusted analyses, NHB had 37% higher odds of uncontrolled HbA1c (odds ratio [OR]: 1.37, 95% confidence interval, 1.32, 1.41). After adjusting for demographics and comorbidities, the OR decreased to 1.09 but remained significant (95% confidence interval, 1.05, 1.13). The OR further decreased after incorporating spatial effects (OR: 1.07, 95% confidence interval, 1.03, 1.11) but remained statistically significant. Hotspots of high HbA1c were detected, and spatial patterns differed across racial groups.

CONCLUSIONS

Differences in spatial patterns in glycemic control exists between NHB and NHW veterans with type 2 diabetes. Incorporating spatial effects helps explain more of the disparity in uncontrolled HbA1c than adjusting only for demographics and comorbidities, but significant differences in uncontrolled HbA1c remained.

Albiglutide efficacy and safety in the Latino/Hispanic subpopulation for the integrated phase III program

OBJECTIVE

to evaluate the efficacy and safety of albiglutide compared with placebo and active comparators from an integrated trial subpopulation of Latino/Hispanic patients whose type 2 diabetes mellitus (T2DM) was inadequately controlled on their current regimen of diet and exercise, with or without oral antidiabetic drugs (OADs) and/or insulin.

METHODS

Latino/Hispanic patient subpopulations (N = 1204) across 7 phase III albiglutide studies (N = 4400) were evaluated post-hoc for efficacy and safety. Comparators were placebo, sulfonylureas, insulin, thiazolidinediones, and dipeptidyl peptidase-4 inhibitors. Glycatedhemoglobin (HbA_1c) change from baseline to the time of the primary endpoint assessment (from 26 to 104 weeks) was evaluated in patients on diet and exercise and/or OADs, with or without insulin. Patients were allowed to continue in the study if hyperglycemic rescue was required, according to a prespecified algorithm and at the discretion of the investigator.

RESULTS

At baseline in the Latino/Hispanic subpopulation, the mean HbA_1c was 8.3%, mean age was 53 years, mean body mass index was 32 kg/m², and mean duration of T2DM was 8.0 years. The primary endpoint of mean HbA_1c difference (albiglutide - placebo) was -0.94% for the Latino/Hispanic subpopulation and -0.86% (p < 0.001) for the overall phase III population. Changes in fasting plasma glucose mirrored those of HbA_1c. Weight loss with albiglutide was numerically greater than with OADs and insulin in both populations, but it was smaller than with liraglutide. Within the Latino/Hispanic subpopulation, more injection-site reactions were reported with albiglutide vs all comparators, while gastrointestinal and hypoglycemic adverse events were comparable between the two groups, and the latter was uncommon when used without insulin and/or a sulfonylurea.

CONCLUSIONS

In the Latino/Hispanic population, albiglutide resulted in effective lowering of glucose and modest weight loss, and it was generally well tolerated.

Dulce Digital: An mHealth SMS-Based Intervention Improves Glycemic Control in Hispanics With Type 2 Diabetes

OBJECTIVE

Type 2 diabetes is growing in epidemic proportions and disproportionately affects lower-income, diverse communities. Text messaging may provide one of the most rapid methods to overcome the "digital divide" to improve care.

RESEARCH DESIGN AND METHODS

A randomized, nonblinded, parallel-groups clinical trial design allocated N = 126 low-income, Hispanic participants with poorly controlled type 2 diabetes to receive the Dulce Digital intervention or usual care (UC). Dulce Digital participants received up to three motivational, educational, and/or call-to-action text messages per day over 6 months. The primary outcome was HbA_1c; lipids, blood pressure, and BMI were secondary outcomes. Satisfaction and acceptability were evaluated via focus groups and self-report survey items.

RESULTS

The majority of patients were middle-aged (mean age 48.43 years, SD 9.80), female (75%), born in Mexico (91%), and uninsured (75%) and reported less than a ninth-grade education level (73%) and mean baseline HbA_1c 9.5% (80 mmol/mol), SD 1.3, and fasting plasma glucose 187.17 mg/dL, SD 64.75. A statistically significant time-by-group interaction effect indicated that the Dulce Digital group achieved a significantly greater reduction in HbA_1c over time compared with UC (P = 0.03). No statistically significant effects were observed for secondary clinical indicators. The number of blood glucose values texted in by participants was a statistically significant predictor of month 6 HbA_1c (P < 0.05). Satisfaction and acceptability ratings for the Dulce Digital intervention were high.

CONCLUSIONS

Use of a simple, low-cost text messaging program was found to be highly acceptable in this sample of high-risk, Hispanic individuals with type 2 diabetes and resulted in greater improvement in glycemic control compared with UC.

Defining the Association between Diabetes and Plastic Surgery Outcomes: An Analysis of Nearly 40,000 Patients

Background:

Diabetes is an increasingly prevalent comorbidity in patients presenting for surgery, impacting nearly 14% of adults in the United States. Although it is known that diabetic patients are at an increased risk for postoperative complications, there is a paucity of literature on the specific ramifications of diabetes on different surgical procedures.

Methods:

Using the American College of Surgeons National Surgical Quality Improvement Program dataset, demographics, outcomes, and length of in-patient hospitalization were examined for patients who underwent plastic surgery between 2007 and 2012. Adjusted multivariable logistic regression models were used to assess the relationship between diabetes status and a spectrum of medical and surgical postoperative outcomes.

Results:

Thirty-nine thousand four hundred seventy-five plastic surgery patients were identified, including 1,222 (3.10%) with insulin-dependent diabetes mellitus (IDDM) and 1,915 (4.75%) with non–insulin-dependent diabetes mellitus (NIDDM), who had undergone breast, hand/upper and lower extremity, abdominal, or craniofacial procedures. Logistic regression analyses showed that only insulin-dependent diabetics had a higher likelihood of surgical complications (IDDM: P value < 0.0001; NIDDM: P value < 0.103), whereas patients with both IDDM and NIDDM had increased likelihoods of medical complications (IDDM: P value < 0.001; NIDDM: P value = 0.0093) compared with nondiabetics. Average hospital stay for diabetics was also longer than for nondiabetics.

Conclusions:

Diabetes is associated with an increase in a multitude of postoperative complications and in hospital length of stay, in patients undergoing plastic surgery. Diabetes status should thus be evaluated and addressed when counseling patients preoperatively. Risks may be further stratified based on IDDM versus NIDDM status.

Impact of primary care on hospital admission rates for diabetes patients: A systematic review

High-quality primary care for diabetes patients may be related to lowered hospital admissions. A systematic search was performed to assess the impact of structure, process, and outcome of primary diabetes care on hospital admission rates, considering patient characteristics. Studies on diabetes patients in primary care with hospitalisation rates as outcomes published between January 1996 and December 2015 were included. Indicators of quality of care (access, continuity and structure of care, process, and outcome indicators) and patient characteristics (age, gender, ethnicity, insurance, socio-economic status, diabetes characteristics, co-morbidity, and health-related lifestyle) were extracted. After assessment of the strength of evidence, characteristics of care and diabetes patients were presented in relation to the likelihood of hospitalisation. Thirty-one studies were identified. A regular source of primary care and a well-controlled HbA1c level decreased the likelihood of hospitalisation. Other aspects of care were less consistent. Patients' age, co-morbidity, and socio-economic status were related to higher hospitalisation. Gender and health-related lifestyle showed no relationship. Studies were heterogeneous in design, sample, and healthcare system. Different definitions of diabetes and unscheduled admissions limited comparisons. In healthcare systems where diabetes patients have a regular source of primary care, hospital admission rates cannot be meaningfully related to primary care characteristics.

Influence of Race, Ethnicity and Social Determinants of Health on Diabetes Outcomes

BACKGROUND

There is strong evidence that race, ethnicity and social determinants of health significantly influence outcomes for patients with diabetes. A better understanding of the mechanisms of these relationships or associations would improve development of cost-effective, culturally tailored programs for patients with diabetes.

METHODS

This article reviews the current state of the literature on the influence of race and ethnicity and social determinants of health on process of care, quality of care and outcomes for diabetes, with particular emphasis on the rural South to give an overview of the state of the literature.

RESULTS

The literature review shows that racial or ethnic differences in the clinical outcomes for diabetes, including glycemic, blood pressure (BP) and lipid control, continue to persist. In addition, the literature review shows that the role of social determinants of health on outcomes, and the possible role these determinants play in disparities have largely been ignored. Psychosocial factors, such as self-efficacy, depression, social support and perceived stress, show consistent associations with self-care, quality of life and glycemic control. Neighborhood factors, such as food insecurity, social cohesion and neighborhood esthetics have been associated with glycemic control. Perceived discrimination has also been associated with self-care and the psychological component of quality of life.

CONCLUSION

Healthcare professionals need to be skilled in assessing social determinants of health and taking them into consideration in clinical care. In addition, more research is needed to identify the separate and combined influence of race and ethnicity and social determinants of health on process of care, quality of care and outcomes in diabetes, especially in the South, where the burden of disease is particularly high.

Efficacy and Safety of Linagliptin in Black/African American Patients with Type 2 Diabetes: A 6-month, Randomized, Double-blind, Placebo-controlled Study

OBJECTIVE

Although black/African American individuals are disproportionately affected by type 2 diabetes, there is scant clinical trial information available on antidiabetes therapies in this group. We compared linagliptin with placebo in black/African American adults who were treatment-naïve or receiving one oral antidiabetes drug.

METHODS

Of 226 patients randomized to 24 weeks' linagliptin 5 mg/day or placebo, 208 had baseline and at least one on-treatment glycated hemoglobin (HbA1c) measurement. Mean baseline HbA1c was 8.6% in the linagliptin group (n = 98) and 8.68% in the placebo group (n = 110). The primary outcome was change in HbA1c from baseline to week 24.

RESULTS

By week 24, mean HbA1c changes were -0.84% with linagliptin and -0.25% with placebo (treatment difference, -0.58%; P<.001), and more patients in the linagliptin group achieved HbA1c <7.0% (26.8% vs. 8.3%; P = .001) or an HbA1c reduction ≥0.5% (54.1% vs. 30.0%; P<.001). Mean weight loss was -1.1 kg in both groups. During the treatment period, 8 of 98 linagliptin-group patients and 17 of 110 placebo-group patients required rescue therapy (odds ratio, 0.5; P = .14). For postprandial glucose, values were available for few patients (11 placebo, 10 linagliptin), and thus the between-group difference was associated with wide confidence intervals (CIs) (difference, -1.97 mg/dL; 95% CI, -53.80 to 49.86; P = .94). In the overall study population, a similar proportion of patients in both groups had adverse events (58.5% vs. 61.7%); most events were mild or moderate and considered unrelated to study drug. Investigator-defined hypoglycemia was rare (3 linagliptin-group patients and 1 placebo-group patient), with no severe events (requiring external assistance).

CONCLUSION

This study confirms that linagliptin is efficacious and well tolerated in black/African American patients with type 2 diabetes.

The Impact of a Home-Based Diabetes Prevention and Management Program on High-Risk American Indian Youth

PURPOSE

The purpose of this study was to examine the impact of a home-based diabetes prevention and management program on high-risk American Indian youth.

METHODS

Together on Diabetes (TOD) was designed via a participatory approach with 4 tribal communities in the southwestern United States. A multisite pre- and postevaluation design was used to evaluate the efficacy of the TOD intervention on improving youth's psychosocial, knowledge, behavioral, and physiological outcomes at 4 time points from baseline to 12 months postenrollment.

RESULTS

A total of 256 youth and 225 support persons were enrolled in the TOD program. At 12 months postenrollment, improvements were observed in youth's quality of life (P < .001), depressive symptoms (P < .001), knowledge related to TOD content (P < .001), standardized body mass index scores (P = .004), and hypertension (P = .026). Improvements in mean A1C were observed among diabetic youth with baseline A1C >6.5% (P = .036).

CONCLUSIONS

The TOD program was feasible, acceptable, and effective in lowering diabetes risk among reservation-based American Indian youth. It is the first efficacious youth-focused diabetes prevention and management program developed and implemented in partnership with tribal communities.

A Cross-sectional Study of Depressive Symptoms and Diabetes Self-care in African Americans and Hispanics/Latinos With Diabetes: The Role of Self-efficacy

PURPOSE

The purpose of this study is to examine the relationship between depressive symptoms and diabetes self-care in African American and Hispanic/Latino patients with type 2 diabetes and whether the association, if any, is mediated by diabetes-related self-efficacy.

METHODS

The sample included self-report baseline data of African American and Hispanic/Latino patients with type 2 diabetes who were aged ≥18 years and enrolled in a diabetes self-management intervention study. Depressive symptoms were assessed with the 9-item Patient Health Questionnaire. The Summary of Diabetes Self-care Activities measured engagement in healthy eating, physical activity, blood glucose checking, foot care, and smoking. The Diabetes Empowerment Scale-Short Form assessed diabetes-related psychosocial self-efficacy. Indirect effects were examined with the Baron and Kenny regression technique and Sobel testing.

RESULTS

Sample characteristics (n = 250) were as follows: mean age of 53 years, 68% women, 54% African American, and 74% with income <$20 000. Depressive symptoms showed a significant inverse association with the self-care domains of general diet, specific diet, physical activity, and glucose monitoring in the African American group. In Hispanics/Latinos, depression was inversely associated with specific diet. Self-efficacy served a significant mediational role in the relation between depression and foot care among African Americans.

CONCLUSIONS

Self-efficacy mediated the relationship between depression and foot care in the African American group but was not found to be a mediator of any self-care areas within the Hispanic/Latino group. In clinical practice, alleviation of depressive symptoms may improve self-care behavior adherence. Diabetes education may consider inclusion of components to build self-efficacy related to diabetes self-care, especially among African American patients.

Utilizing health ambassadors to improve type 2 diabetes and cardiovascular disease outcomes in Gadsden County, Florida

Minority racial and ethnic groups are at higher risk for developing type 2 diabetes. These groups also experience more severe complications from diabetes and have higher mortality rates as a result of the disease, such as cardiovascular disease, amputation and kidney failure. Underserved rural ethnically disparate populations benefit from health education outreach efforts that are conveyed and translated by specially-trained community health ambassadors. Project H.I.G.H. (Helping Individuals Get Healthy) was developed to target the priority areas of type 2 diabetes and cardiovascular disease. Utilizing trained community health ambassadors, CDC's The Road to Health Toolkit as well as New Beginnings: A Discussion Guide for Living Well with Diabetes was used as a model for a community-based educational program. The overall goal of Project H.I.G.H was to implement and evaluate: (1) a coordinated, behavior-focused, family-centered, community-based educational program and; (2) a client service coordination effort resulting in improved health outcomes (BMI, Glucose Levels, BP) for individuals with type 2 diabetes and cardiovascular disease in Gadsden County, Florida. Overall, Project H.I.G.H. was very successful in its first year at motivating participants to delay or prevent diabetes and/or cardiovascular disease or at the very least to start taking better care of their health.

Conceptualizing type 2 diabetes and its management

Type 2 diabetes is growing worldwide due to population growth, increased rates of obesity, unhealthy diet, and physical inactivity. Risk assessment methods can effectively evaluate the risk of diabetes, and a healthy lifestyle can significantly reduce risk or prevent complications of type 2 diabetes. However, risk assessment alone has not significantly improved poor adherence to recommended medical interventions and lifestyle changes. This paper focuses on the challenge of nonadherence and posits that improving adherence requires tailoring interventions that explicitly consider the social determinants of health.