Associations between socioeconomic status and major complications in type 1 diabetes: the Pittsburgh epidemiology of diabetes complication (EDC) Study

Are Nutrition Literacy and Sustainable Dietary Habits Associated with Cardiovascular Disease and Diabetes Developmental Risks?

OBJECTIVE

This study aimed to examine the association of nutritional literacy levels and sustainable nutritional behaviors with the risk of developing cardiovascular diseases and diabetes in the Turkish adult population.

METHODS

Sociodemographic information, disease history, nutritional habits, and physical activity levels of 3146 volunteer individuals (male = 1590, female = 1556) between the ages of 40-75 were collected using a questionnaire form and face-to-face interviews. The sustainable nutritional behaviors of the participants were evaluated using Turkish validated scales for Sustainable and Healthy Eating Behavior (SHE) and nutritional literacy levels with the Evaluation Instrument of Nutrition Literacy on Adults (EINLA). Cardiovascular disease risks of the participants were assessed with the Atherosclerotic Cardiovascular Disease (ASCVD) Risk Estimator program and the Heart Score (SCORE) scale and type-2 diabetes risk with the Finnish Diabetes Risk Score (FINDRISC). Each participant's 24-h food consumption record was obtained using the retrospective recall method.

RESULTS

It was determined that ASCVD and SCORE levels were significantly higher in males compared to females. It was observed that individuals with lower cardiovascular and diabetes risk scores had higher educational levels, and the risks increased significantly with age (p < 0.05). Anthropometric measurements such as body mass index, and waist hip circumference were significantly higher in those with higher cardiovascular and diabetes risk scores. Furthermore, in individuals with higher SCORE and FINDRISC levels, SHE and EINLA scores were significantly lower (p < 0.05). It was also observed that SCORE and diabetes risk scores increased with higher energy and macronutrient intakes.

CONCLUSION

The risk of developing cardiovascular disease and diabetes was associated with sustainable nutritional behaviors and nutritional literacy. It may be suggested that increasing nutritional literacy and encouraging sustainable nutritional behaviors may be effective strategies in the management and reduction of the prevalence of certain chronic diseases. KEY TEACHING POINTSCardiovascular diseases and diabetes are two major chronic conditions that can be managed and treated through proper nutrition.Increased nutritional literacy levels and sustainable dietary habits may result in reduced risk of cardiovascular diseases and diabetes.Nutritionists should assess the patients' nutrition literacy levels and implement sustainable, health-focused nutrition education programs to enhance their understanding of nutrition.

Exploring the intersection of income and race in an age diverse sample of people with Type 1 diabetes

Prior literature suggests that the social gradient in health is racialised such that Black individuals receive fewer health benefits from socioeconomic status than White individuals, yet scarce research studies examine whether this relationship persists in the context of Type 1 diabetes (T1D). Further, most research studies on racial health disparities in T1D outcomes focus on health during early life. We used data from the 2017-2018 wave of the T1D Exchange Registry (N = 11,963) and examined the relationship between household income, race and HbA1c in an age diverse sample of people with T1D. Results revealed that the inverse association between income and HbA1c is stronger for Black T1Ds compared to White T1Ds. Despite this, Black T1Ds with an income of $100,000 or more had higher HbA1c values compared to White individuals with an income of less than $25,000. Further, Black adolescents with T1D had particularly high HbA1c values. There is an urgent need for more research on the interpersonal and structural barriers associated with suboptimal glycaemic control among Black individuals.

Higher fibre and lower carbohydrate intake are associated with favourable CGM metrics in a cross-sectional cohort of 470 individuals with type 1 diabetes

AIMS/HYPOTHESIS

The aim of this work was to investigate the association between macronutrient intakes and continuous glucose monitoring (CGM) metrics in individuals with type 1 diabetes.

METHODS

In 470 individuals with type 1 diabetes of the GUTDM1 cohort (65% female, median age 40 [IQR 28-53] years, median diabetes duration 15 [IQR 6-29] years), we used logistic regression to establish associations between macronutrient intakes and the CGM metrics time in range (TIR, time spent between 3.9-10.0 mmol/l blood glucose, optimally set at ≥70%) and time below range (TBR, <3.9 mmol/l blood glucose, optimally set at <4%). ORs were expressed per 1 SD intake of nutrient and were adjusted for other macronutrient intakes, age, sex, socioeconomic status, BMI, duration of type 1 diabetes, pump use, insulin dose and alcohol intake.

RESULTS

The median (IQR) TIR was 67 (51-80)% and TBR was 2 (1-4)%; the mean ± SD energy intake was 6879±2001 kJ, fat intake 75±31 g, carbohydrate intake 162±63 g, fibre intake 20±9 g and protein intake 70±24 g. A higher fibre intake and a lower carbohydrate intake were associated with higher odds of having a TIR≥70% (OR [95% CI] 1.64 [1.22, 2.24] and 0.67 [0.51, 0.87], respectively), whereas solely a higher carbohydrate intake was associated with TBR<4% (OR 1.34 [95% CI 1.02, 1.78]).

CONCLUSIONS/INTERPRETATION

A higher fibre intake is independently associated with a higher TIR. A higher carbohydrate intake is associated with less time spent in hypoglycaemia, a lower TIR and a higher time above range. These findings warrant confirmatory (interventional) investigations and may impact current nutritional guidelines for type 1 diabetes.

Increase Access, Reduce Disparities: Recommendations for Modifying Medicaid CGM Coverage Eligibility Criteria

Numerous studies have demonstrated the clinical value of continuous glucose monitoring (CGM) in type 1 diabetes (T1D) and type 2 diabetes (T2D) populations. However, the eligibility criteria for CGM coverage required by the Centers for Medicare & Medicaid Services (CMS) ignore the conclusive evidence that supports CGM use in various diabetes populations that are currently deemed ineligible. In an earlier article, we discussed the limitations and inconsistencies of the agency's CGM eligibility criteria relative to current scientific evidence and proposed practice solutions to address this issue and improve the safety and care of Medicare beneficiaries with diabetes. Although Medicaid is administered through CMS, there is no consistent Medicaid policy for CGM coverage in the United States. This article presents a rationale for modifying and standardizing Medicaid CGM coverage eligibility across the United States.

Investigation of geographic disparities of diabetes-related hospitalizations in Florida using flexible spatial scan statistics: An ecological study

BACKGROUND

Hospitalizations due to diabetes complications are potentially preventable with effective management of the condition in the outpatient setting. Diabetes-related hospitalization (DRH) rates can provide valuable information about access, utilization, and efficacy of healthcare services. However, little is known about the local geographic distribution of DRH rates in Florida. Therefore, the objectives of this study were to investigate the geographic distribution of DRH rates at the ZIP code tabulation area (ZCTA) level in Florida, identify significant local clusters of high hospitalization rates, and describe characteristics of ZCTAs within the observed spatial clusters.

METHODS

Hospital discharge data from 2016 to 2019 were obtained from the Florida Agency for Health Care Administration through a Data Use Agreement with the Florida Department of Health. Raw and spatial empirical Bayes smoothed DRH rates were computed at the ZCTA level. High-rate DRH clusters were identified using Tango's flexible spatial scan statistic. Choropleth maps were used to display smoothed DRH rates and significant high-rate spatial clusters. Demographic, socioeconomic, and healthcare-related characteristics of cluster and non-cluster ZCTAs were compared using the Wilcoxon rank sum test for continuous variables and Chi-square test for categorical variables.

RESULTS

There was a total of 554,133 diabetes-related hospitalizations during the study period. The statewide DRH rate was 8.5 per 1,000 person-years, but smoothed rates at the ZCTA level ranged from 0 to 101.9. A total of 24 significant high-rate spatial clusters were identified. High-rate clusters had a higher percentage of rural ZCTAs (60.9%) than non-cluster ZCTAs (41.8%). The median percent of non-Hispanic Black residents was significantly (p < 0.0001) higher in cluster ZCTAs than in non-cluster ZCTAs. Populations of cluster ZCTAs also had significantly (p < 0.0001) lower median income and educational attainment, and higher levels of unemployment and poverty compared to the rest of the state. In addition, median percent of the population with health insurance coverage and number of primary care physicians per capita were significantly (p < 0.0001) lower in cluster ZCTAs than in non-cluster ZCTAs.

CONCLUSIONS

This study identified geographic disparities of DRH rates at the ZCTA level in Florida. The identification of high-rate DRH clusters provides useful information to guide resource allocation such that communities with the highest burdens are prioritized to reduce the observed disparities. Future research will investigate determinants of hospitalization rates to inform public health planning, resource allocation and interventions.

Association of HbA1C and comfort with diabetes self-management among adolescents and young adults with type 1 diabetes

Introduction

Adolescents and young adults (AYA) living with type 1 diabetes (T1D) are a vulnerable demographic at risk for sub-optimal glycemic outcomes at a time when they are taking over their diabetes management. The purposes of this study were to examine levels of self-reported comfort with diabetes management tasks among AYA living with T1D and to describe the relationships among comfort levels, sociodemographic factors, and HbA1c.

Methods

During a routine diabetes care visit, AYA aged 15-23 years old living with T1D received a transition survey to self-assess their comfort level with different diabetesmanagement tasks.

Results

Among 161 participants who completed the survey (median age 17 years, median diabetes duration 7 years, 82.3% White, 40.9% female, 66.5% with private insurance, and median HbA1c 8.8%), comfort with diabetes management tasks was generally rated highly (median overall comfort level of 4.5 out of 5), irrespective of race or insurance type. Regression analysis revealed that higher self-reported comfort level with diabetes management tasks was associated with a higher HbA1c (p = 0.006), after controlling for age, sex, race, insurance type, and diabetes duration.

Discussion

These findings suggest that self-reported comfort with independently managing T1D may not be a sufficient metric in assessing AYA patients' need for further intervention to optimize glycemic outcomes as they transition from pediatric to adult diabetes care, and highlights the importance of continuity of care to support diabetes management during this transitional period.

Association Between Psychosocial Acuity and Glycemic Control in a Pediatric Type 1 Diabetes Clinic

PURPOSE

The purpose of this study was to describe the frequency of psychosocial risk and its associations with glycemic levels in youth with type 1 diabetes (T1D) seen by social work staff during regular clinical care.

METHODS

A retrospective longitudinal analysis of observational clinical data was conducted. Individuals (1-26 years) with known T1D who were seen at a pediatric diabetes clinic in a US academic medical center between 2014 and 2021 were included. Variables included psychosocial acuity, A1C, and demographic characteristics. Chi-square tests, Wilcoxon rank sum tests, and mixed linear regressions were used to examine associations between demographic variables, psychosocial acuity, and A1C.

RESULTS

Of 966 patients, 513 (53.1%) were male, 76 (7.9%) were non-Hispanic Black, and 804 (83.2%) were non-Hispanic White. There was a mean of 6.9 annual social work encounters per patient, with 3 psychosocial domains measured at each visit. Results showed that as psychosocial acuity level increased, glycemic control decreased. There were significant differences in A1C according to race/ethnicity, insurance, age, and psychosocial acuity.

CONCLUSIONS

In a real-world clinical population, psychosocial acuity was associated with glycemic control. Presenting for psychosocial issues in their diabetes clinic was associated with reduced glycemic control among youth with T1D. There is an opportunity to connect pediatric patients with appropriate mental health services and psychosocial supports.

Factors Associated With Attainment of Glycemic Targets Among Adults With Type 1 and Type 2 Diabetes in Canada: A Cross-sectional Study Using Primary and Specialty Care Electronic Medical Record Data

OBJECTIVE

Using a new database combining primary and specialty care electronic medical record (EMR) data in Canada, we determined attainment of glycemic targets and associated predictors among adults with diabetes.

METHODS

We conducted a cross-sectional observational study combining primary and specialty care EMR data in Canada. Adults with diabetes whose primary care provider contributed to the National Diabetes Repository or who were assessed at a diabetes specialty clinic (LMC Diabetes and Endocrinology) between July 3, 2015, and June 30, 2019, were included. Diabetes type was categorized as type 2 diabetes (T2D) not prescribed insulin, T2D prescribed insulin, and type 1 diabetes (T1D). Covariates were age, sex, income quintile, province, rural/urban location, estimated glomerular filtration rate, medications, and insulin pump use. Associations between predictors and the outcome (glycated hemoglobin [A1C] of ≤7.0%) were assessed by multivariable logistic regressions.

RESULTS

Among 122,106 adults, consisting of 91,366 with T2D not prescribed insulin, 25,131 with T2D prescribed insulin, and 5,609 with T1D, attainment of an A1C of ≤7.0% was 60%, 25%, and 23%, respectively. Proportions with an A1C of ≤7.5% and ≤8.0% were 75% and 84% for those with T2D not prescribed insulin, 41% and 57% for those with T2D prescribed insulin, and 37% and 53% for those with T1D. Highest vs lowest income quintile was associated with greater odds of meeting the A1C target (adjusted odds ratio [95% confidence interval] for each diabetes category: 1.15 [1.10 to 1.21], 1.21 [1.10 to 1.33], and 1.29 [1.04 to 1.60], respectively). Individuals in Alberta and Manitoba had less antihyperglycemic medication use and attainment of A1C target than other provinces.

CONCLUSIONS

Attainment of glycemic targets among adults with diabetes was poor and differed by income and geographic location, which must be addressed in national diabetes strategies.

Parent Perspectives on Electronic Health Record-Based Social Needs Screening and Documentation: A Qualitative Study

OBJECTIVE

Social needs interventions in clinical settings can improve child health outcomes; however, they are not routinely delivered in routine pediatric care. The electronic health record (EHR) can support these interventions, but parent engagement in the development of EHR-based social needs interventions is lacking. The aim of this study was to assess parent perspectives on EHR-based social needs screening and documentation and identify family-centered approaches for screening design and implementation.

METHODS

We enrolled 20 parents from four pediatric primary care clinics. Parents completed a social risk questionnaire from an existing EHR module and participated in qualitative interviews. Parents were asked about the acceptability of EHR-based social needs screening and documentation and preferences for screening administration. A hybrid deductive-inductive approach was used to analyze qualitative data.

RESULTS

Parents identified the benefits of social needs screening and documentation but expressed concerns related to privacy, fear of negative outcomes, and use of outdated documentation. Some felt self-administered electronic questionnaires would mitigate parent discomfort and encourage disclosure of social needs, while others felt face-to-face screening would be more effective. Parents stressed the importance of transparency on the purpose of social needs screening and the use of data.

CONCLUSIONS

This work can inform the design and implementation of EHR-based social needs interventions that are acceptable and feasible for parents. Findings suggest strategies such as clear communication and multi-modal delivery methods may enhance intervention uptake. Future work should integrate feedback from multiple stakeholders to design and evaluate interventions that are family-centered and feasible to implement in clinical settings.

Socioeconomic disparities in diabetes-concordant comorbidity: national health interview survey, 1997-2018

OBJECTIVE

Although social disparities in morbidity and mortality are well-documented, little is known how socioeconomic status (SES) shapes diabetes-concordant comorbidity (DCC). This study examines socioeconomic inequalities in DCC among adults with diabetes in the United States.

STUDY DESIGN

The study incorporated a cross-sectional nationally representative household health survey.

METHODS

This study used data from the National Health Interview Survey, 1997-2018. The analysis included 56,192 adults aged 30 or above with diabetes. Multinomial logistic regression was used to obtain relative risk ratios in gender-stratified models after adjusting for sociodemographic covariates.

RESULTS

The multivariable-adjusted analyses suggest that across all SES indicators and in both men and women, individuals with lower SES had greater odds of DCC than individuals with higher SES. The associations of SES indicators with DCC were larger in magnitude among women than in men. For example, compared to individuals with a college or higher degree, men with less than a high school degree were 2.06 times (95% confidence interval = 1.76-2.41) and women with less than a high school degree were 3.19 times (95% confidence interval = 2.67-3.82) more likely to have 3 or more DCCs. Similar associations were observed for other indicators of SES.

CONCLUSION

Study findings suggest strong social status and gender-based patterns in DCC. Identifying population groups with poor social status may be useful for informing interventions aiming to improve healthcare services of diabetes-related complications.

Challenges in the Management of Type 1 Diabetes Mellitus (T1DM) in a Pediatric Patient Due to Social Determinants of Health: A Case Report

Type 1 diabetes mellitus is a rare pediatric condition that is complex to treat and requires careful life-long management. This report outlines a case of a pediatric patient who recently immigrated to the United States without financial resources or health insurance. The social determinants of health play a prominent role in this case as they have created barriers for the patient in obtaining insulin and maintaining adequate glycemic control. Pediatricians should be aware of how social determinants of health influence glucose management and be prepared to help their patients overcome barriers to parental education and treatment.

Proceedings from the 2021 SAEM Consensus Conference: Research Priorities for Interventions to Address Social Risks and Needs Identified in Emergency Department Patients

INTRODUCTION

Emergency departments (ED) function as a health and social safety net, regularly taking care of patients with high social risk and need. Few studies have examined ED-based interventions for social risk and need.

METHODS

Focusing on ED-based interventions, we identified initial research gaps and priorities in the ED using a literature review, topic expert feedback, and consensus-building. Research gaps and priorities were further refined based on moderated, scripted discussions and survey feedback during the 2021 SAEM Consensus Conference. Using these methods, we derived six priorities based on three identified gaps in ED-based social risks and needs interventions: 1) assessment of ED-based interventions; 2) intervention implementation in the ED environment; and 3) intercommunication between patients, EDs, and medical and social systems.

RESULTS

Using these methods, we derived six priorities based on three identified gaps in ED-based social risks and needs interventions: 1) assessment of ED-based interventions, 2) intervention implementation in the ED environment, and 3) intercommunication between patients, EDs, and medical and social systems. Assessing intervention effectiveness through patient-centered outcome and risk reduction measures should be high priorities in the future. Also noted was the need to study methods of integrating interventions into the ED environment and to increase collaboration between EDs and their larger health systems, community partners, social services, and local government.

CONCLUSION

The identified research gaps and priorities offer guidance for future work to establish effective interventions and build relationships with community health and social systems to address social risks and needs, thereby improving the health of our patients.

Prevalence and incidence of cardiovascular and renal diseases in type 1 compared with type 2 diabetes: A nationwide French observational study of hospitalized patients

BACKGROUND

Type 1 diabetes mellitus (T1DM) and type 2 diabetes mellitus (T2DM) increase risks of cardiovascular (CV) and renal disease compared with diabetes-free populations. There are only a few studies comparing T1DM and T2DM for the relative risk of these clinical events.

METHODS

All adult patients hospitalized in French hospitals in 2013 with at least 5 years of follow-up were identified and categorized by their diabetes status. A total of 50,623 patients with T1DM (age 61.4 ± 18.6, 53% male) and 425,207 patients with T2DM (age 68.6 ± 14.3, 55% male) were followed over a median period of 5.3 years (interquartile range: 2.8 - 5.8 years). Prevalence and event rates of myocardial infarction (MI), heart failure (HF), ischemic stroke, chronic kidney disease (CKD), all-cause death and CV death were assessed with age stratification of 10-year intervals. For clinical events during follow-up, we report hazard ratios (HRs) in T1DM relative to T2DM.

RESULTS

The age and sex-adjusted prevalence of CV diseases was higher in T2DM for ages above 40 years whereas the prevalence of CKD was more common in T1DM between ages 18 and 70 years. During 2,033,239 person-years of follow-up, age and sex-adjusted HR event rates comparing T1DM, versus T2DM as reference, showed that MI and HF relative risks were increased above 60 years (1.2 and 1.4 -fold). HR of ischemic stroke did not markedly differ between T1DM and T2DM. Risk of incident CKD was 2.4-fold higher in T1DM above 60 years. All-cause death HR risk was 1.1-fold higher in T1DM after 60 years and the CV death risk was 1.15-fold higher in T1DM between 60 and 69 years compared to T2DM.

CONCLUSIONS

Although the crude prevalent burden of CV diseases may be lower in T1DM than in T2DM, patients with T1DM may have a higher risk of incident MI, HF, all-cause death and CV death above 60 years of age, highlighting the need for improved prevention in this population.

Diabetes Mellitus: An Overview in Relationship to Charcot Neuroarthropathy

Diabetes mellitus with the lack of glycemic control increases risks for developing comorbidities affecting organ systems responsible for critical function. The development of diabetic neuropathy predisposes patients to the onset of Charcot neuroarthropathy (CN). There is significant complexity with treatment of diabetic-induced CN, which can have an often delayed or missed diagnosis. Supervision and treatment from trained specialists are required to provide care for this multifaceted disease process. It is essential for patients to partner with glucose control, comorbidity prevention and care, as well as lower extremity management. Ultimately, CN can result in significant lower extremity deformity placing patients at risk of limb and life.

The Association of Personality Traits and Parameters of Glycemic Regulation in Type 1 Diabetes Mellitus Patients Using isCGM

This study aimed to examine the impact of personality on glycemic regulation in adult patients with type 1 diabetes mellitus (T1DM). The study group consisted of subjects with T1DM, who were ≥ 18 years of age. The study was conducted in two phases: At baseline, subjects completed the Croatian version of the International Personality Item Pool scale (IPIP50s) and a questionnaire designed to gather socioeconomic data, duration of diabetes, presence of chronic complications, presence of cardiovascular risk factors, frequency, and type of pre-existing hypoglycemic episodes per week. Blood and urine samples were collected and body mass index (BMI) was calculated. Each participant was provided with the intermittently scanned glucose monitoring system (isCGM) Freestyle Libre. During the second visit (3 months from the start of the trial), glycemic parameters were collected from the reports generated from the Freestyle Libre system. Estimated glycated hemoglobin (HbA1c) values were significantly lower after three months compared to baseline HbA1c (Wilcoxon test, p < 0.001). An inverse correlation between the number of daily scans and degree of extraversion among subjects was observed, e.g., higher degrees of extraversion resulted in lower numbers of daily scans, while lower degrees of extraversion, i.e., introvertedness, resulted in higher numbers of daily scans (Rho = −0.238 p = 0.009). There was a positive correlation between emotional stability and time spent in hypoglycemia (Rho = 0.214; p = 0.02). In addition, a shorter duration of diabetes was associated with higher percentages of TIR and vice versa (p = 0.02). Investigating personality traits can be a useful tool for identifying patients predisposed to hypoglycemia and lower scanning frequency. Patients with a longer history of T1DM require closer follow-up and should be re-educated when necessary.

Incident cardiovascular disease by clustering of favourable risk factors in type 1 diabetes: the EURODIAB Prospective Complications Study

AIMS

The aim of this prospective study was to examine CVD risk reduction in type 1 diabetes (1) for people with favourable cardiovascular health metrics and (2) by clustering of these metrics.

METHODS

Data from 2313 participants from the EURODIAB Prospective Complications Study were analysed. All had type 1 diabetes (51% men, mean ± SD age 32 ± 9 years). Seven cardiovascular health metrics were studied-smoking, BMI, physical activity, a diet score, total cholesterol/HDL-cholesterol ratio, combined systolic and diastolic BP and HbA_1c-divided into favourable/less favourable categories. Cox proportional hazards models were used to calculate HRs (95% CIs) of incident CVD for each metric. Clusters were made by scoring each individual by the number of favourable metrics.

RESULTS

A total of 163 people developed incident CVD during a mean ± SD follow-up of 7.2 ± 1.3 years. Participants with more favourable HbA_1c levels of <57 mmol/mol (<7.4%) had a 37% significantly lower CVD risk than those with a less favourable HbA_1c (HR [95% CI] 0.63 [0.44, 0.91]), and participants with a more favourable BP (systolic BP <112 mmHg and diastolic BP <70 mmHg) had a 44% significantly lower CVD risk than participants in the less favourable BP group (HR [95% CI] 0.56 [0.34, 0.92]). There was a dose-response relation with a lower HR observed with greater clustering of more favourable metrics: people with four or more favourable metrics had an HR of 0.37 (95% CI 0.18, 0.76), adjusted for sex and age at diabetes diagnosis, compared with those with no favourable metrics.

CONCLUSIONS/INTERPRETATION

Low HbA_1c and low BP were protective cardiovascular health metrics in our study of people with type 1 diabetes. Targeting all cardiovascular health metrics could be more effective in preventing CVD than targeting single metrics.

Nine-fold higher risk of acute myocardial infarction in subjects with type 1 diabetes compared to controls in Norway 1973-2017

BACKGROUND

We aimed to study the cumulative incidence and risk factors (sex, age, calendar year of diabetes onset, country of origin and educational level) of acute myocardial infarction (AMI) in subjects with type 1 diabetes and matched controls.

METHODS

A nationwide cohort of subjects with type 1 diabetes diagnosed at age < 15 years in Norway during 1973-2000 was followed until the first AMI event, emigration, death or 31st of December 2017. The Norwegian Childhood Diabetes Registry was linked to five nationwide registries, and up to ten sex- and age-matched controls per case were included.

RESULTS

Among 7086 subjects with type 1 diabetes, 170 (2.4%) were identified with incident AMI, compared to 193 (0.3%) of 69,356 controls. Mean age and diabetes duration at first AMI was 40.8 years and 30.6 years, respectively. The probability of AMI after 40 years of follow-up was 8.0% in subjects with type 1 diabetes and 1.1% in controls, aHR 9.05 (95% CI 7.18-11.41). In type 1 diabetes, male sex (aHR 1.45), higher age at onset of diabetes and lower education (higher compared to lower, aHR 0.38) were significantly associated with higher risk of AMI. There was no significant time trend in AMI by calendar year of diabetes onset.

CONCLUSIONS

We found nine-fold excess risk of AMI in subjects with type 1 diabetes, and three-fold higher risk in subjects with low versus high education. These results highlight a strengthened focus on prevention of cardiovascular disease, and diabetes education tailored to the subjects' educational background.

Occupations associated with diabetes complications: A nationwide-multicenter hospital-based case-control study

AIM

Investigating the risks of diabetes complications among inpatients with diabetes associated with longest-held and current occupations.

METHOD

Using a Japanese nationwide, multicenter, hospital inpatient dataset (2005-2015), a matched case-control study with 39,550 inpatients with diabetes was conducted. We considered both the longest-held and current occupations of the study subjects.

RESULT

Diabetes complications such as retinopathy, nephropathy, neuropathy, and peripheral vascular complications occur more often in managers, sales workers, service workers, transportation workers, construction and mining workers and carrying, cleaning and packing workers. Among these occupations, particularly the service workers indicated consistently significant increased risks (OR = 1.36 (1.23-1.51)) in developing all the considered subtypes of diabetes complications, and the performed sensitivity analysis confirmed this conclusion. Moreover, among service workers, cooks, waiters, building service staff and other service workers were identified as having the highest risks in developing diabetes complications (ORs = 1.30 (1.12-1.51), 1.63 (1.36-1.95), 1.79 (1.21-2.67), and 2.05 (1.30-3.22), respectively).

CONCLUSIONS

Our study's potential translational impact should lead to subsequent investigations on the causes connected to certain occupations of various diabetes complications and particularly to more carefully dealing with patients with diabetes who work in the identified occupational areas and their health risks.

Comparison of cognitive function in older adults with type 1 diabetes, type 2 diabetes, and no diabetes: results from the Study of Longevity in Diabetes (SOLID)

INTRODUCTION

The incidence of both type 1 diabetes (T1D) and type 2 diabetes (T2D) is increasing. Life expectancy is improving in T1D, resulting in a growing population of elderly adults with diabetes. While it is well established that older adults with T2D are at increased risk of cognitive impairment, little is known regarding cognitive aging in T1D and how their cognitive profiles may differ from T2D.

RESEARCH DESIGN AND METHODS

We compared baseline cognitive function and low cognitive function by diabetes status (n=734 T1D, n=232 T2D, n=247 without diabetes) among individuals from the Study of Longevity in Diabetes (mean age=68). We used factor analysis to group cognition into five domains and a composite measure of total cognition. Using linear and logistic regression models, we examined the associations between diabetes type and cognitive function, adjusting for demographics, comorbidities, depression, and sleep quality.

RESULTS

T1D was associated with lower scores on total cognition, language, executive function/psychomotor processing speed, and verbal episodic memory, and greater odds of low executive function/psychomotor processing speed (OR=2.99, 95% CI 1.66 to 5.37) and verbal episodic memory (OR=1.92, 95% CI 1.07 to 3.46), compared with those without diabetes. T2D was associated with lower scores on visual episodic memory. Compared with T2D, T1D was associated with lower scores on verbal episodic memory and executive function/psychomotor processing speed and greater odds of low executive function/psychomotor processing speed (OR=1.74, 95% CI 1.03 to 2.92).

CONCLUSIONS

Older adults with T1D had significantly poorer cognition compared with those with T2D and those without diabetes even after accounting for a range of comorbidities. Future studies should delineate how to reduce risk in this vulnerable population who are newly surviving to old age.

Impact of Socioeconomic Factors and Gender on Refill Adherence and Persistence to Lipid-Lowering Therapy in Type 1 Diabetes

INTRODUCTION

Lipid-lowering therapy (LLT) reduces the risk of cardiovascular disease (CVD) in patients with type 1 diabetes (T1D). However, socioeconomic factors and gender may have an impact on the adherence to and non-persistence with LLT.

METHODS

This was a nationwide register-based cohort study that included 6192 individuals with T1D aged ≥ 18 years who were registered in the Swedish National Diabetes Register and had initiated novel use of LLT. Information on socioeconomic parameters (source: Statistics Sweden) and comorbidity (source: National Patient Register) was collected. The individuals were followed for 36 months, and adherence to LLT was analyzed according to age, socioeconomics and gender. The medication possession ratio (MPR; categorized into ≤ 80% and > 80%) and non-persistence (discontinuation) with medication was calculated after 18 and 36 months.

RESULTS

Individuals older than 53 years were more adherent to LLT (MPR > 80%) than those younger than 36 years (odds ratio [(OR] 1.30, p < 0.0001) at 36 months. Women were more adherent and less prone to discontinue LLT at 18 months (OR 1.05, p = 0.0005 and OR 0.95, p = 0.0004, respectively), but not at 36 months. Divorced individuals were less adherent than married ones (OR 0.93, p = 0.0005) and discontinued LLT more often than the latter (OR 1.06, p = 0.003). Education had no impact on adherence, but individuals with higher incomes discontinued LLT less frequently than those with lower incomes. Individuals with a country of origin other than Sweden discontinued LLT more often.

CONCLUSION

Lower adherence to LLT in individuals with T1D was associated with male gender, younger age, marital status and country of birth. These factors should be considered when evaluating adherence to LLT in clinical practice, with the aim to help patients achieve full cardioprotective treatment.

Racial/Ethnic and Educational Disparities in the Impact of Diabetes on Population Health among the US-Born Population

OBJECTIVES

This study examines total life expectancies (TLE) for both healthy and diabetic US-born populations and two measures capturing quality of life: 1) the proportion of remaining life to be spent without either other chronic conditions or ADL disabilities (ADLs), and 2) the proportion of remaining life to be spent with ADLs for US-born diabetic populations by race/ethnicity and educational attainment.

METHODS

Using the 1998-2014 waves of the Health and Retirement Study (n=16,983), we apply a Bayesian multistate life table method to calculate these quantities from the constructed life tables.

RESULTS

TLE at age 50 is shorter for diabetic individuals than healthy individuals, for non-Hispanic Blacks than members of other racial/ethnic groups, and for less-educated individuals. Gaps in TLE at age 50 between healthy and diabetic populations range from 6.3 to 8.8 years across sex-race combinations, and 5.6 to 9.2 years across sex-education combinations. Among the diabetic population, those with at least a college degree on average have a higher proportion of remaining life to be spent without either other chronic conditions or ADLs. Hispanics and those without a college degree have a particularly high proportion of remaining life to be spent with ADLs. Although diabetic women on average live longer than men, their quality of life tends to be lower.

DISCUSSION

The impact of diabetes on population health varies across racial/ethnic and educational groups. The findings support targeted interventions for vulnerable groups, such as people of color, women, and less-educated individuals.

Democratizing type 1 diabetes specialty care in the primary care setting to reduce health disparities: project extension for community healthcare outcomes (ECHO) T1D

INTRODUCTION

Project ECHO (Extension for Community Healthcare Outcomes) is a tele-education outreach model that seeks to democratize specialty knowledge to reduce disparities and improve health outcomes. Limited utilization of endocrinologists forces many primary care providers (PCPs) to care for patients with type 1 diabetes (T1D) without specialty support. Accordingly, an ECHO T1D program was developed and piloted in Florida and California. Our goal was to demonstrate the feasibility of an ECHO program focused on T1D and improve PCPs' abilities to manage patients with T1D.

RESEARCH DESIGN AND METHODS

Health centers (ie, spokes) were recruited into the ECHO T1D pilot through an innovative approach, focusing on Federally Qualified Health Centers and through identification of high-need catchment areas using the Neighborhood Deprivation Index and provider geocoding. Participating spokes received weekly tele-education provided by the University of Florida and Stanford University hub specialty team through virtual ECHO clinics, real-time support with complex T1D medical decision-making, access to a diabetes support coach, and access to an online repository of diabetes care resources. Participating PCPs completed pre/post-tests assessing diabetes knowledge and confidence and an exit survey gleaning feedback about overall ECHO T1D program experiences.

RESULTS

In Florida, 12 spoke sites enrolled with 67 clinics serving >1000 patients with T1D. In California, 11 spoke sites enrolled with 37 clinics serving >900 patients with T1D. During the 6-month intervention, 27 tele-education clinics were offered and n=70 PCPs (22 from Florida, 48 from California) from participating spoke sites completed pre/post-test surveys assessing diabetes care knowledge and confidence in diabetes care. There was statistically significant improvement in diabetes knowledge (p≤0.01) as well as in diabetes confidence (p≤0.01).

CONCLUSIONS

The ECHO T1D pilot demonstrated proof of concept for a T1D-specific ECHO program and represents a viable model to reach medically underserved communities which do not use specialists.

Barriers to Technology Use and Endocrinology Care for Underserved Communities With Type 1 Diabetes

OBJECTIVE

Disparities in type 1 diabetes related to use of technologies like continuous glucose monitors (CGMs) and utilization of diabetes care are pronounced based on socioeconomic status (SES), race, and ethnicity. However, systematic reports of perspectives from patients in vulnerable communities regarding barriers are limited.

RESEARCH DESIGN AND METHODS

To better understand barriers, focus groups were conducted in Florida and California with adults ≥18 years old with type 1 diabetes with selection criteria including hospitalization for diabetic ketoacidosis, HbA_1c >9%, and/or receiving care at a Federally Qualified Health Center. Sixteen focus groups were conducted in English or Spanish with 86 adults (mean age 42 ± 16.2 years). Transcript themes and pre-focus group demographic survey data were analyzed. In order of frequency, barriers to diabetes technology and endocrinology care included 1) provider level (negative provider encounters), 2) system level (financial coverage), and 3) individual level (preferences).

RESULTS

Over 50% of participants had not seen an endocrinologist in the past year or were only seen once including during hospital visits. In Florida, there was less technology use overall (38% used CGMs in FL and 63% in CA; 43% used pumps in FL and 69% in CA) and significant differences in pump use by SES (P = 0.02 in FL; P = 0.08 in CA) and race/ethnicity (P = 0.01 in FL; P = 0.80 in CA). In California, there were significant differences in CGM use by race/ethnicity (P = 0.05 in CA; P = 0.56 in FL) and education level (P = 0.02 in CA; P = 0.90 in FL).

CONCLUSIONS

These findings provide novel insights into the experiences of vulnerable communities and demonstrate the need for multilevel interventions aimed at offsetting disparities in diabetes.

Effect of Covid-19 quarantine on diabetes Care in Children

BACKGROUND

With the onset of the COVID-19 pandemic and state-mandated school closures in the spring of 2020, the management of type 1 diabetes in children underwent significant changes. The aim of our study was to assess the effect of stay-at-home orders on glycemic control in children.

METHODS

We conducted a retrospective review of 238 children with type 1 and type 2 diabetes who were seen in the Pediatric Endocrinology Clinic at the University of South Alabama. Average Hemoglobin A1c (A1c) levels in the year prior to stay-at home orders (May 2019-April 2020) were compared with A1c values during the quarantine period (May 2020-July 2020) using a paired t-test. We also analyzed the change of A1c level with respect to sex, race, type of diabetes, type of insurance, and mode of insulin administration, using a 2-sample t-test.

RESULTS

The average A1c significantly increased from 9.2% during the previous year to 9.5% during the quarantine period (p = 0.0097). The increase of A1c was significantly higher in public insurance patients (0.49% increase) compared to private insurance patients (0.03% increase), (p = 0.0137). We also observed a significant association between the direction of change and type of insurance. Forty-eight percent of public insurance patients had an A1c increase of > 0.5% while 54% of private insurance patients had no change or decrease in A1c (p = 0.0079).

CONCLUSIONS

The COVID-19 pandemic resulted in worsening glycemic control in children with type 1 diabetes, with those on public insurance affected in greater proportion than those with private insurance.

Development and Validation of a Machine Learning Model Using Administrative Health Data to Predict Onset of Type 2 Diabetes

Importance

Systems-level barriers to diabetes care could be improved with population health planning tools that accurately discriminate between high- and low-risk groups to guide investments and targeted interventions.

Objective

To develop and validate a population-level machine learning model for predicting type 2 diabetes 5 years before diabetes onset using administrative health data.

Design, Setting, and Participants

This decision analytical model study used linked administrative health data from the diverse, single-payer health system in Ontario, Canada, between January 1, 2006, and December 31, 2016. A gradient boosting decision tree model was trained on data from 1 657 395 patients, validated on 243 442 patients, and tested on 236 506 patients. Costs associated with each patient were estimated using a validated costing algorithm. Data were analyzed from January 1, 2006, to December 31, 2016.

Exposures

A random sample of 2 137 343 residents of Ontario without type 2 diabetes was obtained at study start time. More than 300 features from data sets capturing demographic information, laboratory measurements, drug benefits, health care system interactions, social determinants of health, and ambulatory care and hospitalization records were compiled over 2-year patient medical histories to generate quarterly predictions.

Main Outcomes and Measures

Discrimination was assessed using the area under the receiver operating characteristic curve statistic, and calibration was assessed visually using calibration plots. Feature contribution was assessed with Shapley values. Costs were estimated in 2020 US dollars.

Results

This study trained a gradient boosting decision tree model on data from 1 657 395 patients (12 900 257 instances; 6 666 662 women [51.7%]). The developed model achieved a test area under the curve of 80.26 (range, 80.21-80.29), demonstrated good calibration, and was robust to sex, immigration status, area-level marginalization with regard to material deprivation and race/ethnicity, and low contact with the health care system. The top 5% of patients predicted as high risk by the model represented 26% of the total annual diabetes cost in Ontario.

Conclusions and Relevance

In this decision analytical model study, a machine learning model approach accurately predicted the incidence of diabetes in the population using routinely collected health administrative data. These results suggest that the model could be used to inform decision-making for population health planning and diabetes prevention.

Cardiovascular and Renal Disease Burden in Type 1 Compared With Type 2 Diabetes: A Two-Country Nationwide Observational Study

OBJECTIVE

Type 1 diabetes (T1D) and type 2 diabetes (T2D) increase risks of cardiovascular (CV) and renal disease (CVRD) compared with diabetes-free populations. Direct comparisons between T1D and T2D are scarce. We examined this by pooling full-population cohorts in Sweden and Norway.

RESEARCH DESIGN AND METHODS

A total of 59,331 patients with T1D and 484,241 patients with T2D, aged 18-84 years, were followed over a mean period of 2.6 years from 31 December 2013. Patients were identified in nationwide prescribed drug and hospital registries in Norway and Sweden. Prevalence and event rates of myocardial infarction (MI), heart failure (HF), stroke, chronic kidney disease (CKD), all-cause death, and CV death were assessed following age stratification in 5-year intervals. Cox regression analyses were used to estimate risk.

RESULTS

The prevalence of CV disease was similar in T1D and T2D across age strata, whereas CKD was more common in T1D. Age-adjusted event rates comparing T1D versus T2D showed that HF risk was increased between ages 65 and 79 years, MI between 55 and 79 years, and stroke between 40 and 54 years (1.3-1.4-fold, 1.3-1.8-fold, and 1.4-1.7-fold, respectively). CKD risk was 1.4-3.0-fold higher in T1D at all ages. The all-cause death risk was 1.2-1.5-fold higher in T1D at age >50 years, with a similar trend for CV death.

CONCLUSIONS

Adult patients with T1D compared with those with T2D had an overall greater risk of cardiorenal disease (HF and CKD) across ages, MI and all-cause death at middle-older ages, and stroke at younger ages. The total age-adjusted CVRD burden and risks were greater among patients with T1D compared with those with T2D, highlighting their need for improved prevention strategies.

Availability and service provision of multidisciplinary diabetes foot units in Australia: a cross-sectional survey

BACKGROUND

With growing global prevalence of diabetes mellitus, diabetes-related foot disease (DFD) is contributing significantly to disease burden. As more healthcare resources are being dedicated to the management of DFD, service design and delivery is being scrutinised. Through a national survey, this study aimed to investigate the current characteristics of services which treat patients with DFD in Australia.

METHODS

An online survey was distributed to all 195 Australian members of the Australian and New Zealand Society for Vascular Surgery investigating aspects of DFD management in each member's institution.

RESULTS

From the survey, 52 responses were received (26.7%). A multidisciplinary diabetes foot unit (MDFU) was available in more than half of respondent's institutions, most of which were tertiary hospitals. The common components of MDFU were identified as podiatrists, endocrinologists, vascular surgeons and infectious disease physicians. Many respondents identified vascular surgery as being the primary admitting specialty for DFD patients that require hospitalisation (33/52, 63.5%). This finding was consistent even in centres with MDFU clinics. Less than one third of MDFUs had independent admission rights.

CONCLUSIONS

The present study suggests that many tertiary centres in Australia provide their diabetic foot service in a multidisciplinary environment however their composition and function remain heterogeneous. These findings provide an opportunity to evaluate current practice and, to initiate strategies aimed to improve outcomes of patients with DFD.

Social Determinants of Health, Goals and Outcomes in High-Risk Children With Type 1 Diabetes

OBJECTIVES

Despite advances in technology and type 1 diabetes (T1D) care, children from low-income families continue to have suboptimal outcomes and increased health-care utilization. In this study, we describe social determinants of health (SDOH) in high-risk children with T1D, as well as their SDOH-related priority goals, and assess the correlation between SDOH, glycemic control and health-care utilization.

METHODS

Caregivers of children aged 4 to 18 years with a diagnosis of T1D of >1 year, poor glycemic control (glycated hemoglobin [A1C] ≥9.5%) or high health-care utilization (≥2 diabetes-related hospitalizations, emergency department attendances or missed outpatient appointments in the previous year) were included. Primary caregiver health-related quality of life (HRQOL), self-efficacy (Maternal Self-Efficacy in Diabetes [MSED] scale) and SDOH were assessed. Goals were identified after assessment by a community health worker.

RESULTS

Fifty-three families were included, most (n=48, 91%) of whom had government insurance. Children had a median age of 13.4 (interquartile range [IQR], 12 to 15.3) years and a median A1C of 11.1% (IQR, 10% to 13%). Almost half of the families (n=24, 45%) reported at least 1 adverse SDOH. One or more adverse SDOH was associated with significantly lower total HRQOL scores (56.6 [IQR, 38.5 to 70.7] vs 77.8 [IQR, 60.8 to 92.4], p=0.004), but not associated with A1C (p=0.3), emergency department visits (p=0.9) or MSED (p=0.5).

CONCLUSIONS

Screening for adverse SDOH and addressing these barriers to glycemic control is not part of routine T1D care. In children with poorly controlled T1D and high health-care utilization, we have demonstrated a high prevalence of adverse SDOH, which may represent a modifiable factor to improve outcomes in this patient population.

Predicting adverse outcomes due to diabetes complications with machine learning using administrative health data

Across jurisdictions, government and health insurance providers hold a large amount of data from patient interactions with the healthcare system. We aimed to develop a machine learning-based model for predicting adverse outcomes due to diabetes complications using administrative health data from the single-payer health system in Ontario, Canada. A Gradient Boosting Decision Tree model was trained on data from 1,029,366 patients, validated on 272,864 patients, and tested on 265,406 patients. Discrimination was assessed using the AUC statistic and calibration was assessed visually using calibration plots overall and across population subgroups. Our model predicting three-year risk of adverse outcomes due to diabetes complications (hyper/hypoglycemia, tissue infection, retinopathy, cardiovascular events, amputation) included 700 features from multiple diverse data sources and had strong discrimination (average test AUC = 77.7, range 77.7-77.9). Through the design and validation of a high-performance model to predict diabetes complications adverse outcomes at the population level, we demonstrate the potential of machine learning and administrative health data to inform health planning and healthcare resource allocation for diabetes management.

Telehealth in type 1 diabetes

PURPOSE OF REVIEW

The role of telehealth in the care of people with type 1 diabetes (T1D) has expanded dramatically during the coronavirus pandemic, and is expected to remain a major care delivery modality going forward. This review explores the landscape of recent evidence for telehealth in T1D care.

RECENT FINDINGS

Telemedicine for routine T1D care has shown equivalence to standard in-person care, with respect to glycemic control, while also increasing access, convenience, and satisfaction. Telehealth use promotes increased engagement of adolescents with T1D. Telehealth platforms have successfully been used in the care of microvascular complications and to support mental health related to diabetes. Machine learning and advanced decision support will increasingly be used to augment T1D care, as recent evidence suggests increasing capabilities to improve glycemic control. A spectrum of digital connected care services are emerging to support people with diabetes with daily management of diabetes. Finally, policy and systems are required that promote data interoperability, telemedicine provision, and reimbursement to support the ongoing growth of telehealth in T1D.

SUMMARY

A developing field of evidence supports use of telehealth in T1D. As this care modality scales, it has the potential to increase access to high-quality diabetes care for many people with T1D.

Socioeconomic position is associated with glycemic control in youth and young adults with type 1 diabetes

OBJECTIVE

Health inequities persist in youth and young adults (YYA) with type 1diabetes in achieving optimal glycemic control. The purpose of this study was to assess the contribution of multiple indicators of social need to these inequities.

RESEARCH DESIGN AND METHODS

Two hundred and twenty two YYA withtype 1 diabetes enrolled in the SEARCH Food Insecurity Study in South Carolina and Washington between the years 2013 and 2015 were included. Latent class analysis was used to identify socioeconomic profiles based on household income, parental education, health insurance, household food insecurity, and food assistance. Profiles were evaluated in relation to glycemic control using multivariable linear and logistic regression, with HbA1c > 9%(75 mmol/mol) defined as high-risk glycemic control.

RESULTS

Two profiles were identified: a lower socioeconomic profile included YYA whose parents had lower income and/or education, and were more likely to be uninsured, receive food assistance, and be food insecure. A higher socioeconomic profile included YYA whose circumstances were opposite to those in the lower socioeconomic profile. Those with a lower socioeconomic profile were more likely to have high-risk glycemic control relative to those with a higher socioeconomic profile (OR = 2.24, 95%CI = 1.16-4.33).

CONCLUSIONS

Lower socioeconomic profiles are associated with high-risk glycemic control among YYA with type 1 diabetes. This supports recommendations that care providers of YYA with type 1 diabetes assess individual social needs in tailoring diabetes management plans to the social context of the patient.

The Relationship Between Estimated Median Household Income and Critical Care Length of Stay in Children With Diabetic Ketoacidosis

Diabetic ketoacidosis (DKA) is an important diagnosis in the pediatric intensive care unit (PICU) and is associated with significant morbidity. We hypothesized children with DKA living in poorer communities would have unfavorable outcomes while critically ill. This single-center retrospective study included children with DKA admitted to a PICU over a 27-month period. Patients were classified as low-income if they lived in a ZIP code where the median household income was estimated to be less than 200% of the federal poverty threshold, or $48 016 for a family of 4. In this study, living in a low-income ZIP code was not associated with increased severity of illness, longer PICU length of stay (LOS), or readmission.

The Neighborhood Deprivation Index and Provider Geocoding Identify Critical Catchment Areas for Diabetes Outreach

PURPOSE

In designing a Project ECHO™ type 1 diabetes (T1D) program in Florida and California, the Neighborhood Deprivation Index (NDI) was used in conjunction with geocoding of primary care providers (PCPs) and endocrinologists in each state to concurrently identify areas with low endocrinology provider density and high health risk/poverty areas. The NDI measures many aspects of poverty proven to be critical indicators of health outcomes.

METHODS

The data from the 2013-2017 American Community Survey (ACS) 5-year estimates were used to create NDI maps for California and Florida. In addition, geocoding and 30-minute drive-time buffers were performed using publicly available provider directories for PCPs and endocrinologists in both states by Google Geocoding API and the TravelTime Search Application Programming Interface (API).

RESULTS

Based on these findings, we defined high-need catchment areas as areas with (1) more than a 30-minute drive to the nearest endocrinologist but within a 30-minute drive to the nearest PCP; (2) an NDI in the highest quartile; and (3) a population above the median (5199 for census tracts, and 1394 for census block groups). Out of the 12 181 census tracts and 34 490 census block groups in California and Florida, we identified 57 tracts and 215 block groups meeting these criteria as high-need catchment areas.

CONCLUSION

Geospatial analysis provides an important initial methodologic step to effectively focus outreach efforts in diabetes program development. The integration of the NDI with geocoded provider directories enables more cost-effective and targeted interventions to reach the most vulnerable populations living with T1D.

Neighborhood disadvantage, parent-adolescent relationship quality, and type 1 diabetes in late adolescents transitioning to early emerging adulthood

OBJECTIVE

We examined whether neighborhood disadvantage predicted subsequent levels, and longitudinal trajectories, of type 1 diabetes (T1D) outcomes among late adolescents transitioning into early emerging adulthood. We also examined whether such associations occur indirectly through parent-adolescent relationship quality.

RESEARCH DESIGN & METHODS

Seniors in high school with T1D (N = 236; mean age 17.76 ± 0.39 years; 61% female; 73.7% non-Latino White) completed selfreport measures of relationship quality with mothers and fathers, and adherence to their diabetes regimen; glycemic control was measured using HbA1c assay kits. Both T1D outcomes (i.e. adherence, HbA1c) were assessed annually across three time points (two years). Census tract indicators of neighborhood disadvantage (e.g., % unemployed) were culled from participant addresses at baseline linked to American Community Survey data. Structural Equation Modeling was used to estimate direct and indirect links between neighborhood disadvantage, relationship quality, and both subsequent levels (i.e., intercepts centered at Time 2), and trajectories of T1D outcomes (i.e., slopes across three time points).

RESULTS

All models showed excellent fit to the data. Greater neighborhood disadvantage associated with lower relationship quality with both parents. Lower relationship quality with fathers (but not with mothers) measured at Time 1 predicted poorer levels of adherence and HbA1c at Time 2, and formed an indirect path linking neighborhood disadvantage to each Time 2 outcome. Neighborhood disadvantage and parent-adolescent relationship quality during high school did not predict longitudinal trajectories of T1D outcomes across all three time points.

CONCLUSIONS

Parent-adolescent relationship quality (especially with fathers) remains important for T1D outcomes among late adolescents on the cusp of emerging adulthood, but may be at risk among those living within a socioeconomically-disadvantaged neighborhood.

Factors associated with glycemic control in type 1 diabetes patients in China: A cross-sectional study

Aims/Introduction

Glycemic control in type 1 diabetes can be challenging, and is influenced by many factors. This study aimed to investigate glycemic control and its associated factors in Chinese people with type 1 diabetes.

Materials and Methods

This cross‐sectional study included 779 participants with type 1 diabetes selected from hospital records review, outpatient clinics and inpatient wards. Data were collected through face‐to‐face interviews, medical records and venous blood samples. Multiple logistic regression analysis was carried out to determine factors associated with glycemic control.

Results

Among 779 participants, 49.2% were male. The median age was 24 years (interquartile range 14–36 years). The median age at diagnosis of diabetes was 17 years (interquartile range 10–28 years) and the median duration of diabetes was 4 years (interquartile range 1–8 years). The mean ± standard deviation hemoglobin A1c was 9.1 ± 2.5%. Nearly 80% of participants had inadequate glycemic control (hemoglobin A1c ≥7.0%). Multivariable analysis showed that age at diagnosis of diabetes ≤20 years, living in a rural location, low household income, low intake of fruit and vegetables, low level of physical activity, low adherence to insulin, and low utilization of insulin pump were independent risk factors for poor glycemic control (hemoglobin A1c ≥9.0%).

Conclusions

Inadequate glycaemic control is common among people with type 1 diabetes in China. Efforts should be made to control the modifiable risk factors, which include low intake of fruit and vegetables, low level of physical activity, and low adherence to insulin for the improvement of glycemic control. Appropriate use of insulin pump among type 1 diabetes should be encouraged.

Diabetes Mellitus and Stroke - A cross Sectional Study of 2.5 Million Adults in the United States

Objectives: The main purpose of this work is to study diabetes mellitus and stroke in the United States during the years 2007-2017 and to find not only statistically significant predictors for diabetes, but also a possible association between diabetes and stroke. Methods: Chi-square test and One-way analysis of variance (ANOVA) were the statistical methods used to derive the results of this work in order to check the statistical significance of diabetes mellitus in relation to patients' socioeconomic factors. In addition, a multivariate logistic regression analysis was used to obtain odds ratio and find statistically significant prognostic factors for both diabetes and stroke. Results: According to multiple logistic regression analysis, the risk for diabetes mellitus is four times higher in widowed men and two times higher in unemployed male subjects who had previously worked. In addition, marital status and employment have been shown to be prognostic risks for stroke. Conclusion: The results describe for the first time the importance of deprivation (of work and partner) as a primary prognostic risk factor for diabetes. Moreover, the same factor was proved to be the primary prognostic risk factor for both stroke and diabetes, which implies a nexus between diabetes mellitus and stroke.

Risk factors differ by first manifestation of cardiovascular disease in type 1 diabetes

AIMS

We compared risk factors for three CVD manifestations and a composite outcome over 25 years' follow-up in the Pittsburgh Epidemiology of Diabetes Complications (EDC) prospective cohort study of childhood-onset (<17 years) type 1 diabetes (n = 658).

METHODS

First CVD manifestations examined were: (1) major atherosclerotic cardiovascular event (MACE, i.e. CVD death, myocardial infarction, stroke), (2) coronary revascularization, (3) soft coronary artery disease (CAD, i.e. ischemia ECG, angina), and a (4) composite (MACE + revascularization) outcome. Baseline and time-varying mean and current risk factors, including medication use, were assessed, in diabetes duration-adjusted models.

RESULTS

MACE (n = 107) was predicted by ln(albumin excretion rate) (AER, HR = 1.3, p < 0.0001), systolic BP (SBP, HR = 1.03, p < 0.0001), white blood cell count (WBC, HR = 1.2, p < 0.0001), HbA1c (HR = 1.2p = 0.03), LDLc (HR = 1.01, p = 0.03). Soft CAD (n = 91) was predicted by ln(AER) (HR = 1.2, p = 0.004), SBP (HR = 1.03, p = 0.0002), WBC (HR = 1.2, p = 0.0003), HbA1c (HR = 1.2, p = 0.005). Revascularization (n = 38) was predicted by LDLc (HR = 1.03, p < 0.0001), eGFR (HR = 0.98, p = 0.002), HbA1c (HR = 1.3, p = 0.03). Adding revascularization to MACE enhanced the role of LDLc, while diminishing that of HbA1c, compared to MACE alone.

CONCLUSIONS

Important risk factor associations may be affected by examining composite CVD outcomes. More research is needed to determine how to best incorporate revascularization into composite CVD definitions.

Towards implementation of AI in New Zealand national diabetic screening program: Cloud-based, robust, and bespoke

Convolutional Neural Networks (CNNs) have become a prominent method of AI implementation in medical classification tasks. Grading Diabetic Retinopathy (DR) has been at the forefront of the development of AI for ophthalmology. However, major obstacles remain in the generalization of these CNNs onto real-world DR screening programs. We believe these difficulties are due to use of 1) small training datasets (<5,000 images), 2) private and 'curated' repositories, 3) locally implemented CNN implementation methods, while 4) relying on measured Area Under the Curve (AUC) as the sole measure of CNN performance. To address these issues, the public EyePACS Kaggle Diabetic Retinopathy dataset was uploaded onto Microsoft Azure™ cloud platform. Two CNNs were trained; 1 a "Quality Assurance", and 2. a "Classifier". The Diabetic Retinopathy classifier CNN (DRCNN) performance was then tested both on 'un-curated' as well as the 'curated' test set created by the "Quality Assessment" CNN model. Finally, the sensitivity of the DRCNNs was boosted using two post-training techniques. Our DRCNN proved to be robust, as its performance was similar on 'curated' and 'un-curated' test sets. The implementation of 'cascading thresholds' and 'max margin' techniques led to significant improvements in the DRCNN's sensitivity, while also enhancing the specificity of other grades.

Primary Care Providers in California and Florida Report Low Confidence in Providing Type 1 Diabetes Care

People with type 1 diabetes may receive a significant portion of their care from primary care providers (PCPs). To understand the involvement of PCPs in delivering type 1 diabetes care, we performed surveys in California and Florida, two of the most populous and diverse states in the United States. PCPs fill insulin prescriptions but report low confidence in providing type 1 diabetes care and difficulty accessing specialty referrals to endocrinologists.

Glycaemic control across the lifespan in a cohort of New Zealand patients with type 1 diabetes mellitus

BACKGROUND

It is well known that tight glycaemic control reduces all-cause mortality and the development of microvascular complications in patients with type 1 diabetes mellitus (T1D), but that effective glycaemic control is difficult to achieve in different age groups. Currently, the state of glycaemic control across the lifespan in patients with T1D in New Zealand is not known.

AIM

To determine the differences in glycaemic control with age, gender, rurality and ethnicity in patients with T1D in the Waikato region of New Zealand.

METHODS

Retrospective review of clinical records of all patients with T1D on the Waikato Regional Diabetes Database in December 2017 (n = 1303). Glycaemic control was determined by the most recent HbA1c in the past 2 years.

RESULTS

Median (25%, 75%) HbA1c was 67 (59, 81) mmol/mol (8.3%) and highest in those aged 15-29 years. Values exceeded clinical recommendations in 85.3% of all patients. Median HbA1c was lower in patients on insulin pump therapy than on multiple daily injections (63 (7.9%) versus 69 mmol/mol (8.5%); P < 0.001), though insulin pumps were significantly less likely to be used by Māori (P = 0.003) and men (P < 0.0001). Worsening glycaemic control was associated with increasing social deprivation (P < 0.001) but was not influenced by rural/urban living.

CONCLUSIONS

Poor glycaemic control in Waikato patients with T1D is likely due to inequities in health care, including reduced access to insulin pump therapy, particularly in Māori and socially deprived populations.

Effects of In-Person Assistance vs Personalized Written Resources About Social Services on Household Social Risks and Child and Caregiver Health: A Randomized Clinical Trial

IMPORTANCE

Social and economic contexts shape children's short- and long-term health. Efforts to address contextual risk factors are increasingly incorporated into pediatric health care.

OBJECTIVE

To compare the effectiveness of 2 social risk-related interventions.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial included English- and/or Spanish-speaking caregiver-child dyads recruited from a pediatric urgent care clinic nested in a large, urban, safety-net hospital. Study recruitment, enrollment, and follow-up were conducted from July 18, 2016, to March 8, 2019. Data analysis was conducted from January 1, 2019, to January 20, 2020.

INTERVENTIONS

Following standardized social risk assessment, caregivers were randomly assigned to receive either written information regarding relevant government and community social services resources or comparable written information plus in-person assistance and follow-up focused on service access.

MAIN OUTCOMES AND MEASURES

Caregiver-reported number of social risk factors and child health 6 months after enrollment.

RESULTS

Among 611 caregiver-child dyads enrolled in the study, 302 dyads were randomized to the written resources group and 309 dyads were randomized to the written resources plus in-person assistance group. The mean (SD) age of children was 6.1 (5.0) years; 483 children (79.1%) were Hispanic; and 315 children (51.6%) were girls. There were no significant differences between groups in the effects of the interventions. In post hoc secondary analyses, the number of reported social risks decreased from baseline to 6-month follow-up in both groups: caregivers who received written resources alone reported a mean (SE) of 1.28 (0.19) fewer risks at follow-up, while those receiving written resources plus in-person assistance reported 1.74 (0.21) fewer risks at follow-up (both P < .001). In both groups, there were small but statistically significant improvements from baseline to follow-up in child health (mean [SE] change: written resources, 0.37 [0.07]; written resources plus in-person assistance, 0.24 [0.07]; both P < .001).

CONCLUSIONS AND RELEVANCE

This randomized clinical trial compared 2 approaches to addressing social risks in a pediatric urgent care setting and found no statistically significant differences in the social risk and child and caregiver health effects of providing written resources at the point of care with vs without in-person longitudinal navigation services. Caregivers in both groups reported fewer social risks and improved child and caregiver health 6 months after the intervention. These findings deepen understanding of effective doses of social risk-related interventions.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02746393.

Addressing health disparities in type 1 diabetes through peer mentorship

Pronounced health disparities exist in type 1 diabetes (T1D) based on socioeconomic status (SES) yet there are a lack of programs designed to promote health equity for vulnerable communities. The All for ONE (Outreach, Networks, and Education) mentoring program was piloted pairing college students and publicly insured teenagers with T1D to assess feasibility as a possible intervention. There were 22 mentors recruited (mean age 20 ± 2 years; 17 [77%] females; mean HbA1c 8.4 ± 1.5%) and matched with mentees based on gender. There were 42 teens randomized to treatment and control groups including 22 teens in the treatment group (age 14 ± 2 years; 17 [77%] females; HbA1c 9.8 ± 2.3%) and 20 teens in the control group (age 14 ± 2 years; 15 [75%] females; HbA1c 8.9 ± 2.0%) followed over 9 months. Outcome measures included HbA1c and the Children's Hope Scale. The intervention included automated text reminders for blood glucose monitoring, text exchanges, social events with education, and clinic visits with mentors/mentees. Mean change in HbA1c for teens was +0.09% in the intervention group, compared with +0.28% in the control group (P = .61); college students had a reduction in HbA1c of -0.22% (P = .38). Treatment group teens had marked improvement in their hope for the future compared to control group teens (P = .04) and were more likely to attend clinic visits (P = .02). This program established feasibility for a model that could be replicated and modified for other types of settings. Additional research is warranted to study the potential long-term benefits of participating in the All for ONE mentoring program.

Muscle and bone parameters in underprivileged Indian children and adolescents with T1DM

BACKGROUND

The incidence of Type 1 diabetes mellitus (T1DM) is increasing and sarcopenia and osteoporosis have been reported to be associated with long standing diabetes. There is scarcity of data on bone health status of children with T1DM. Our aim was to assess bone health parameters [by Dual energy X-ray absorptiometry (DXA) and peripheral quantitative computed tomography (pQCT)] and muscle strength (by hand grip) in underprivileged Indian children with T1DM.

MATERIAL AND METHODS

A cross sectional, observational study was conducted in underprivileged children with diabetes attending the out patient clinic for T1DM at a tertiary care hospital. Children with T1DM with disease duration more than 1 year were included in the study. Age and gender matched controls were also enrolled. Data on age, gender, disease duration, anthropometric parameters and HbA1c were collected. Bone mineral density (BMD) was assessed by dual energy X-ray absorptiometry (Lunar iDXA) and peripheral quantitative computed tomography (pQCT, Stratec XCT 2000) and muscle strength by handgrip. Data were analysed using SPSS 25.0.

RESULTS

251 children with T1DM and 250 age gender matched controls were studied. Mean age of T1DM children was 10.8 ± 4.3yrs (controls 10.3 ± 3.6). Mean HbA1C was 9.7 ± 2.1%. The total body less head areal BMD (TBLH aBMD) and lumbar spine bone mineral apparent density (LSBMAD) Z-scores were significantly lower in children with T1DM (-1.5 ± 1.3, -1.3 ± 1.6 respectively) as compared to controls (-0.5 ± 1.3, -0.64 ± 1.5 respectively) (p < 0.05 for both). Z-scores for trabecular and total density (vBMD) were significantly lower in patients with T1DM (-0.7 ± 1.0, -0.7 ± 1.0 respectively) than controls (-0.15 ± 1.2, -0.31 ± 1.1), (p <  0.05) and trabecular density was lower at distal radius with increasing disease duration. Hand-grip strength Z-score was lower in children with T1DM (-3.0 ± 0.5) as compared to controls (-2.8 ± 0.5). Trabecular density and HbA1C concentrations were negatively correlated (R = -0.18, p < 0.05) as was muscle area and HbA1C concentrations (R = -0.17, p < 0.05,).

CONCLUSION

Bone and muscle health were affected in children with poorly controlled T1DM. With increasing disease duration, attention is required for optimising musculoskeletal health.

Incidences of Severe Hypoglycemia and Diabetic Ketoacidosis and Prevalence of Microvascular Complications Stratified by Age and Glycemic Control in U.S. Adult Patients With Type 1 Diabetes: A Real-World Study

OBJECTIVE

To assess the burden of disease for adults with type 1 diabetes in a U.S. electronic health record database by evaluating acute and microvascular complications stratified by age and glycemic control.

RESEARCH DESIGN AND METHODS

This is a retrospective observational study of adults with type 1 diabetes (1 July 2014-30 June 2016) classified using a validated algorithm, with disease duration ≥24 months and, during a 12-month baseline period, not pregnant and having one or more insulin prescriptions and one or more HbA_1c measurements. Demographic characteristics, acute complications (severe hypoglycemia [SH], diabetic ketoacidosis [DKA]), and microvascular complications (neuropathy, nephropathy, retinopathy) were stratified by age (18-25, 26-49, 50-64, ≥65 years) and glycemic control (HbA_1c <7%, 7% to <9%, ≥9%).

RESULTS

Of 31,430 patients, ∼20% had HbA_1c <7%. Older patients had lower HbA_1c values than younger patients (P < 0.001). Patients with poor glycemic control had the highest annual incidence of SH (4.2%, 4.0%, and 8.3%) and DKA (1.3%, 2.8%, and 15.8%) for HbA_1c <7%, 7% to <9%, and ≥9% cohorts, respectively (both P < 0.001), and a higher prevalence of neuropathy and nephropathy (both P < 0.001).

CONCLUSIONS

For adults with type 1 diabetes, glycemic control appears worse than previously estimated. Rates of all complications increased with increasing HbA_1c. Compared with HbA_1c <7%, HbA_1c ≥9% was associated with twofold and 12-fold higher incidences of SH and DKA, respectively. Younger adults had more pronounced higher risks of SH and DKA associated with poor glycemic control than older adults.

Income Relates to Adherence in Youth with Type 1 Diabetes Through Parenting Constructs

OBJECTIVE

Informed by the family stress and family investment models, this study investigated whether income is indirectly related to adherence and glycemic control through parenting constructs among youth with type 1 diabetes (TID).

METHODS

Youth and their families (n = 390) from 4 geographically dispersed pediatric endocrinology clinics in the United States were participants in a multisite clinical trial from 2006 to 2009 examining the efficacy of a clinic-integrated behavioral intervention targeting family disease management for youth with TID. Baseline data were collected from youth aged 9 to 14 years and their parents. Parents reported family income and completed a semistructured interview assessing diabetes management adherence. Parents and children reported diabetes-specific parent-child conflict. Children completed measures of collaborative parent involvement and authoritative parenting. Hemoglobin A1c (HbA1c), a biomarker of glycemic control, was analyzed centrally at a reference laboratory. The relations of income, parenting variables, regimen, adherence, and HbA1c were examined using structural equation modeling.

RESULTS

Lower family income was associated with greater parent-child conflict and a less authoritative parenting style. Authoritative parenting was associated with more collaborative parent involvement and less parent-child conflict, both of which were associated with greater adherence, which was associated with more optimal glycemic control (p < 0.05 all associations). Indirect effects of family income on adherence and glycemic control through parenting constructs were significant (p < 0.001).

CONCLUSION

Findings lend support for the family stress and family investment models, suggesting that lower family income may negatively impact parent-child constructs, with adverse effects on diabetes management.

Biologic and social factors predict incident kidney disease in type 1 diabetes: Results from the T1D exchange clinic network

AIMS

Diabetic kidney disease (DKD) is a major complication of type 1 diabetes (T1D). To better understand the development of DKD in modern clinical practice, we evaluated risk factors in participants from the T1D Exchange Registry who completed 5-years of longitudinal follow-up.

METHODS

Participants had T1D duration ≥ 1 year, age ≥ 10 years, eGFR ≥ 60 ml/min and no albuminuria at enrollment, and at least two serum creatinine and urine albumin measurements recorded during follow-up. Adverse kidney outcomes were defined as eGFR ≪ 60 ml/min and/or albuminuria (ALB) defined by as two consecutive albumin/creatinine ratios or two out of the past three measurements ≫ 30 μg/mg at any follow-up data collection. Associations of baseline characteristics with adverse kidney outcomes were assessed.

RESULTS

Among 3940 participants (mean age 41 ± 15 yrs, T1D duration 21 ± 13 yrs), 653 (16.6%) experienced an adverse kidney outcome: 268 (6.8%) experienced incident ALB only, 322 (8.2%) had eGFR decline to ≪60 ml/min without ALB, and 63 (1.6%) experienced eGFR ≪ 60 ml/min with ALB. In a multivariable analysis, higher HbA1c, higher SBP, lower DBP, older age and lower education level were associated with the development of adverse kidney outcomes (all p values ≤ 0.03).

CONCLUSIONS

Improving modifiable risk factors, including glucose and blood pressure control, remain important to reduce the risk of DKD in T1D.

Prevalence of Type 1 and Type 2 Diabetes-Related Complications and Their Association With Determinants Identified in Canada's Survey on Living With Chronic Diseases-Diabetes Component

OBJECTIVES

In this study, we estimated the prevalence of diabetes-related complications and the factors associated with them in Canadian patients with diabetes.

METHODS

Data from the 2011 Survey on Living with Chronic Diseases in Canada---Diabetes Component (SLCDC-DM-2011) were used to calculate the weighted prevalence of 16 diabetes-related complications. A multivariable, sex-stratified logistic regression model was used to examine the association between each diabetes-related complication and select determinants.

RESULTS

Among Canadian patients who self-reported having diabetes, 80.26% reported having at least 1 type of diabetes-related complication. The most frequently reported complications were high blood pressure (54.65%), cataracts (29.52%) and poor circulation (21.68%). Male patients were more associated to have at least 1 complication if they had an inappropriate body mass index (odds ratio [OR], 2.94; 95% confidence interval [CI], 1.39 to 6.23) and had a high level of glycated hemoglobin (OR, 2.32; 95% CI, 1.05 to 5.13), were older (OR, 6.92; 95% CI, 1.82 to 24.74) and had diabetes for a longer period of time (OR, 3.42; 95% CI, 1.71 to 6.85). Among the female patients, a longer duration diabetes was found to have a significant association with complications (OR, 2.00; 95% CI, 1.05 to 3.81).

CONCLUSIONS

Our findings suggest that socioeconomic factors, including marital status, income and education, have a significant association with most types of complications. Our findings also confirm that low levels of physical activity and high levels of glycated hemoglobin were major determinants in many diabetes-related complications.