Racial and Ethnic Disparities in the Incidence, Treatment, and Outcomes of Youth with Type 1 Diabetes

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.

Technology and health inequities in diabetes care: How do we widen access to underserved populations and utilize technology to improve outcomes for all?

Digital health technologies are being utilized increasingly in the modern management of diabetes. These include tools such as continuous glucose monitoring systems, connected blood glucose monitoring devices, hybrid closed-loop systems, smart insulin pens, telehealth, and smartphone applications (apps). Although many of these technologies have a solid evidence base, from the perspective of a person living with diabetes, there remain multiple barriers preventing their optimal use, creating a digital divide. In this article, we describe many of the origins of these barriers and offer recommendations on widening access to digital health technologies for underserved populations living with diabetes to improve their health outcomes.

Addressing disparities in technology use among patients with type 1 diabetes: a review

PURPOSE OF REVIEW

The benefits of continuous glucose monitors (CGMs) and insulin pumps in the management of type 1 diabetes (T1D) are widely recognized. However, glaring disparities in access exist, particularly in marginalized and economically disadvantaged groups that stand to benefit significantly from diabetes technology use. We will review recent data describing drivers of these disparities and approaches to address the disparities.

RECENT FINDINGS

Several qualitative studies were published in recent years that have investigated the drivers of disparities reported over the past decades. These studies report that in addition to typical barriers seen in the diabetes technology, marginalized patients have unique challenges that make insulin pumps and CGMs less accessible.

SUMMARY

Barriers to technology use in these groups include stigmatization, lack of support, financial constraints, provider biases, stringent insurance policies, and clinic infrastructure. To address inequities, multifaceted strategies across community, healthcare, and provider sectors are essential. Key initiatives include enhancing public awareness, refining health policies, ensuring access to high-quality care, and emphasizing patient-centered approaches. The equitable use of technology can narrow the gap in T1D outcomes. The social and economic implications of suboptimal T1D management further underscore the urgency of these efforts for both improved health outcomes and cost-efficient care.

Interventions Across the Translational Research Spectrum: Addressing Disparities Among Racial and Ethnic Minoritized Youth with Type 1 Diabetes

Racial and ethnic minoritized youth with type 1 diabetes (T1D) are at elevated risk for health disparities. Few intervention studies have been conducted for these youth and evidence to support best practices to address their needs is lacking. Existing evidence supports the use of brief trials of diabetes technology with structured support from clinic staff, culturally tailored interventions such as language-congruent clinical care, and use of community health workers as promising directions to improve health outcomes. Clinicians and researchers should work collaboratively with community members to improve the quality of T1D intervention science for racial and ethnic minoritized youth.

Narrowing the Divide: The Role of Telehealth in Type 1 Diabetes Care for Marginalized Communities

Widespread uptake of telehealth in response to the COVID-19 pandemic has highlighted geographic, demographic, and economic disparities in access to virtual care. However, research studies and clinical programs that predate the pandemic demonstrate the potential for telehealth-based interventions to improve access to and outcomes of type 1 diabetes (T1D) care for individuals in geographically or socially marginalized communities. In this expert commentary, we discuss telehealth-based care models that have been successful in improving care for marginalized T1D populations. We also outline the policy changes needed to expand access to such interventions to reduce established disparities in T1D care and promote better health equity among people living with T1D.

The Insulin-Only Bionic Pancreas Improves Glycemic Control in Non-Hispanic White and Minority Adults and Children With Type 1 Diabetes

OBJECTIVE

We evaluated the performance of the iLet bionic pancreas (BP) in non-Hispanic White individuals (here referred to as "Whites") and in Black, Hispanic, and other individuals (here collectively referred to as "Minorities").

RESEARCH DESIGN AND METHODS

A multicenter, randomized controlled trial evaluated glycemic management with the BP versus standard of care (SC) in 161 adult and 165 pediatric participants with type 1 diabetes over 13 weeks.

RESULTS

In Whites (n = 240), the mean baseline-adjusted difference in 13-week HbA1c between the BP and SC groups was -0.45% (95% CI -0.61 to -0.29 [-4.9 mmol/mol; -6.6 to -3.1]; P < 0.001), while this difference among Minorities (n = 84) was -0.53% (-0.83 to -0.24 [-6.0 mmol/mol; -9.2 to -2.8]; P < 0.001). In Whites, the mean baseline-adjusted difference in time in range between the BP and SC groups was 10% (95% CI 7-12; P < 0.001) and in Minorities was 14% (10-18; P < 0.001).

CONCLUSIONS

The BP improves glycemic control in both Whites and Minorities and offers promise in decreasing health care disparities.

Emerging Diabetes Technologies: Continuous Glucose Monitors/Artificial Pancreases

Over the past decade there have been many advances in diabetes technologies, such as continuous glucose monitors (CGM s), insulin-delivery devices, and hybrid closed loop systems . Now most CGMs (Medtronic-Guardian, Dexcom-G6, and Abbott-Libre-2) have MARD values of < 10%, in contrast to two decades ago when the MARD used to be > 20%. In addition, the majority of the new CGMs do not require calibrations, and the latest CGMs last for 10-14 days. An implantable 6-months CGM by Eversense-3 is now approved in the USA and Europe. Recently, the FDA approved Libre 3 which provides real-time glucose values every minute. Even though it is approved as an iCGM it is not interoperable with automatic-insulin-delivery (AID) systems. The newer CGMs that are likely to be launched in the next few months in the USA include the 10-11 days Dexcom G7 (60% smaller than the existing G6), and the 7-days Medtronic Guardian 4. Most of the newer CGM have several features like automatic initialization, easy insertion, predictive alarms, and alerts. It has also been noticed that an arm insertion site might have better accuracy than abdomen or other sites, like the buttock for kids. Lag time between YSI and different sensors have been reported differently, sometimes it is down to 2-3 min; however, in many instances, it is still 15-20 min, especially when the rate of change of glucose is > 2 mg/min. We believe that in the next decade there will be a significant increase in the number of people who use CGM for their day-to-day diabetes care.

Support Provided by Caregivers for Community-Dwelling Diabetic Hispanic Adults with Intellectual Disabilities and Comorbid Conditions

Diabetes is an age-related chronic health condition and a major public health concern. Diabetes is one of the significant causes of morbidity and mortality and a major contributing factor to dementia. Recent research reveals that Hispanic Americans are at an increased risk of chronic conditions such as diabetes, dementia, and obesity. Recent research also revealed that diabetes develops at least ten years earlier in Hispanics and Latinos than in neighboring non-Hispanic whites. Furthermore, the management of diabetes and providing necessary/timely support is a challenging task for healthcare professionals. Caregiver support is an emerging area of research for people with diabetes, mainly family caregiver support work for Hispanic and Native Americans. Our article discusses several aspects of diabetes, factors associated with diabetes among Hispanics, its management, and how caregivers can support individuals with diabetes.

A Longitudinal View of Disparities in Insulin Pump Use Among Youth with Type 1 Diabetes: The SEARCH for Diabetes in Youth Study

Objective: To evaluate changes in insulin pump use over two decades in a national U.S. sample. Research Design and Methods: We used data from the SEARCH for Diabetes in Youth study to perform a serial cross-sectional analysis to evaluate changes in insulin pump use in participants <20 years old with type 1 diabetes by race/ethnicity and markers of socioeconomic status across four time periods between 2001 and 2019. Multivariable generalized estimating equations were used to assess insulin pump use. Temporal changes by subgroup were assessed through interactions. Results: Insulin pump use increased from 31.7% to 58.8%, but the disparities seen in pump use persisted and were unchanged across subgroups over time. Odds ratio for insulin pump use in Hispanic (0.57, confidence interval [95% CI] 0.45-0.73), Black (0.28, 95% CI 0.22-0.37), and Other race (0.49, 95% CI 0.32-0.76) participants were significantly lower than White participants. Those with ≤high school degree (0.39, 95% CI 0.31-0.47) and some college (0.68, 95% CI 0.58-0.79) had lower use compared to those with ≥bachelor's degree. Those with public insurance (0.84, 95% CI 0.70-1.00) had lower use than those with private insurance. Those with an annual household income <$25K (0.43, 95% CI 0.35-0.53), $25K-$49K (0.52, 95% CI 0.43-0.63), and $50K-$74K (0.79, 95% CI 0.66-0.94) had lower use compared to those with income ≥$75,000. Conclusion: Over the past two decades, there was no improvement in the racial, ethnic, and socioeconomic inequities in insulin pump use, despite an overall increase in use. Studies that evaluate barriers or test interventions to improve technology access are needed to address these persistent inequities.

Racial Disparities in Access and Use of Diabetes Technology Among Adult Patients With Type 1 Diabetes in a U.S. Academic Medical Center

OBJECTIVE

Recent studies highlight racial disparities in insulin pump (PUMP) and continuous glucose monitor (CGM) use in children and adolescents with type 1 diabetes (T1D). This study explored racial disparities in diabetes technology among adult patients with T1D.

RESEARCH DESIGN AND METHODS

This was a retrospective clinic-based cohort study of adult patients with T1D seen consecutively from April 2013 to January 2020. Race was categorized into non-Black (reference group) and Black. The primary outcomes were baseline and prevalent technology use, rates of diabetes technology discussions (CGMdiscn, PUMPdiscn), and prescribing (CGMrx, PUMPrx). Multivariable logistic regression analysis evaluated the association of technology discussions and prescribing with race, adjusting for social determinants of health and diabetes outcomes.

RESULTS

Among 1,258 adults with T1D, baseline technology use was significantly lower for Black compared with non-Black patients (7.9% vs. 30.3% for CGM; 18.7% vs. 49.6% for PUMP), as was prevalent use (43.6% vs. 72.1% for CGM; 30.7% vs. 64.2% for PUMP). Black patients had adjusted odds ratios (aORs) of 0.51 (95% CI 0.29, 0.90) for CGMdiscn and 0.61 (95% CI 0.41, 0.93) for CGMrx. Black patients had aORs of 0.74 (95% CI 0.44, 1.25) for PUMPdiscn and 0.40 (95% CI, 0.22, 0.70) for PUMPrx. Neighborhood context, insurance, marital and employment status, and number of clinic visits were also associated with the outcomes.

CONCLUSIONS

Significant racial disparities were observed in discussions, prescribing, and use of diabetes technology. Further research is needed to identify the causes behind these disparities and develop and evaluate strategies to reduce them.

Transition From Pediatric to Adult Care for Individuals With Type 1 Diabetes: Opportunities and Challenges

OBJECTIVES

Type 1 diabetes (T1D) is a chronic disease with patients across the age spectrum that has high potential for morbidity and mortality. Unfortunately, patients transitioning from pediatric to adult care continue to demonstrate worsened glycemic control in part due to lack of understanding of transition of care best practices.

METHODS

This review highlights the impact of existing transition of care interventions, assessment tools, and other recently published strategies for providers to consider to improve care of adolescent and young adult (AYA) patients with T1D in both hospital- and clinic-based settings.

RESULTS

Many barriers impact patients with T1D during the transition period and disparities by race, sex, insurance status, and comorbid illness persist. As diabetic care continues to evolve and the prevalence of adolescents and young adults living with T1D increases, an intentional approach to transition of care is more pressing than ever. While current literature on transition of care models is limited, many show promise in improving clinic attendance and decreasing hospitalization. There are critical discussions that providers should lead with AYA patients to improve their outcomes and increase diabetes self-management, such as re-addressing carbohydrate counseling, sleep hygiene, and reproductive planning.

CONCLUSION

While further research on transition of care is needed, many care models offer the promise of improved T1D outcomes, enhancements in our approach to care, and increased value for our health care system at large.

A centennial review of discoveries and advances in diabetes: Children and youth

Diabetes is an increasingly common chronic metabolic disorder in children worldwide. The discovery of insulin in 1921 resulted in unprecedented advancements that improved the lives of children and youth with diabetes. The purpose of this article is to review the history of diabetes in children and youth over the last century and its implications for future developments in the field. We identified 68 relevant events between 1921 and 2021 through literature review and survey of pediatric endocrinologists. Basic research milestones led to the discovery of insulin and other regulatory hormones, established the normal physiology of carbohydrate metabolism and pathophysiology of diabetes, and provided insight into strategies for diabetes prevention. While landmark clinical studies were initially focused on adult diabetes populations, later studies assessed etiologic factors in birth cohort studies, evaluated technology use among children with diabetes, and investigated pharmacologic management of youth type 2 diabetes. Technological innovations culminated in the introduction of continuous glucose monitoring that enabled semi-automated insulin delivery systems. Finally, professional organizations collaborated with patient groups to advocate for the needs of children with diabetes and their families. Together, these advances transformed type 1 diabetes from a terminal illness to a manageable disease with near-normal life expectancy and increased our knowledge of type 2 diabetes and other forms of diabetes in the pediatric population. However, disparities in access to insulin, diabetes technology, education, and care support remain and disproportionately impact minority youth and communities with less resources. The overarching goal of diabetes management remains promoting a high quality of life and improving glycemic management without undermining the psychological health of children and youth living with diabetes.

Childhood diabetes and sleep

Sleep modulates glucose metabolism, both in healthy states and in disease. Alterations in sleep duration (insufficient and excessive) and obstructive sleep apnea may have reciprocal ties with obesity, insulin resistance and Type 2 diabetes, as demonstrated by emerging evidence in children and adolescents. Type 1 diabetes is also associated with sleep disturbances due to the influence of wide glycemic fluctuations upon sleep architecture, the need to treat nocturnal hypoglycemia, and the need for glucose monitoring and insulin delivery technologies. In this article, we provide an extensive and critical review on published pediatric literature regarding these topics, reviewing both epidemiologic and qualitative data, and provide an overview of the pathophysiology linking sleep with disorders of glucose homeostasis.

Inequity in Adoption of Advanced Diabetes Technologies Among Medicare Fee-for-service Beneficiaries

CONTEXT

Health inequity is often associated with race-ethnicity.

OBJECTIVE

To determine the prevalence of insulin pump therapy and continuous glucose monitoring (CGM) among Medicare beneficiaries with type 1 diabetes (T1D) by race-ethnicity, and to compare diabetes-related technology users with nonusers.

DESIGN

The prevalence of technology use (pump, CGM) was determined by race-ethnicity for enrollees in coverage years (CY) 2017-2019 in the Medicare fee-for-service database. Using CY2019 data, technology users were compared with nonusers by race-ethnicity, sex, average age, Medicare eligibility criteria, and visit to an endocrinologist.

SETTING

Community.

PATIENTS OR OTHER PARTICIPANTS

Beneficiaries with T1D and at least 1 inpatient or 2 outpatient claims in a CY.

INTERVENTION(S)

Pump or CGM therapy, visit to an endocrinologist.

MAIN OUTCOME MEASURE(S)

Diabetes-related technology use by race-ethnicity groups.

RESULTS

Between 2017 and 2019, CGM and insulin pump use increased among all groups. Prevalence of insulin pump use was < 5% for Black and Other beneficiaries yet increased from 14% to 18% among White beneficiaries. In CY2019, 57% of White patients used a pump compared with 33.1% of Black and 30.3% of Other patients (P < 0.001). Black patients were more likely than White patients to be eligible because of disability/end-stage renal disease or to be Medicare/Medicaid eligible (both P < 0.001), whether using technology or not. Significant race-ethnicity differences (P < 0.001) existed between technology users and nonusers for all evaluated factors except visiting an endocrinologist.

CONCLUSIONS

Significant race-ethnicity associated differences existed in T1D management. The gap in diabetic technology adoption between Black and White beneficiaries grew between 2017 and 2019.

Technology Utilization in Black Adolescents with Type 1 Diabetes: Exploring the Decision-Making Process

Background: Significant disparities in diabetes device (DD) use exist for Black adolescents with type 1 diabetes (T1D), meriting further exploration. We sought to describe how Black adolescents with T1D and their parents make decisions about using DDs and understand personal, familial, and cultural beliefs that may influence use. Materials and Methods: Nineteen Black adolescents with T1D and 17 parents participated in individual qualitative semistructured interviews. Adolescents were purposively sampled for a range of socioeconomic and clinical demographics. Interview data were recorded, transcribed, and coded for thematic analysis, analyzed separately for parents and adolescents, and then compared across groups. Data collection continued until thematic saturation was achieved. Results: Adolescents and parents reported similar themes related to the (1) intersectionality of multiple identities: T1D experience of Black adolescents; (2) decision to use DDs: complexities of T1D management and easing the burden; and (3) reasons for differential uptake of DDs in Black adolescents. Adolescents reported lacking peers with T1D "who look like me," leading to stigmatization, exacerbated by device visibility and alarms. Cultural and familial traditions as well as individual factors were described as both facilitators and barriers in DD use. Lack of familiarity with T1D, limited exposure to DDs, and mistrust of the medical community, both historically and currently, were brought up as reasons for inequities in DD use. Conclusions: Understanding the decision-making process surrounding DDs in one sample of Black adolescents and their parents is critical to guide further research to improve equity in DD use and glycemic outcomes.

Improvement in Mean CGM Glucose in Young People with Type 1 Diabetes During 1 Year of the COVID-19 Pandemic

The coronavirus disease 2019 (COVID-19) pandemic likely affected youth with type 1 diabetes (T1D). We used electronic health record-extracted data to compare continuous glucose monitoring (CGM) metrics during 1 year of the pandemic with those of the previous year. The sample comprised CGM users, aged 1 to <18 years, with T1D duration ≥6 months (age <6 years) or ≥1 year (age ≥6 years). The prepandemic sample comprised 641 youth (52% female, aged 12.3 ± 3.5, T1D duration 6.0 ± 3.5 years). The pandemic sample comprised 648 youth (52% female, age 13.3 ± 3.5, duration 6.7 ± 3.8 years), with care delivered primarily through telemedicine. Mean CGM glucose was 6.3 mg/dL lower during the pandemic (187.3 ± 35.6) versus prepandemic (193.6 ± 33.0) (P < 0.001). A higher percentage of youth achieved glucose management indicator <7% during the pandemic than the prior year (P < 0.001). Lower CGM glucose values were observed during the COVID-19 pandemic. Future studies are needed to assess how changes in health care delivery, including telemedicine, and lifestyle during this time may have supported this improvement.

Identifying and addressing disparities in the evaluation and treatment of children with growth hormone deficiency

Health disparities are a significant cause of concern globally and in the United States. Disparities have been additionally highlighted throughout the ongoing COVID-19 pandemic during which populations of color have been the most affected by the disease. Social determinants of health, race, ethnicity, and gender have all contributed to disparate outcomes and disparities spanning all age groups. Multiple socio-ecological factors contribute to disparities and different strategies have been proposed. The purpose of this paper is to provide an overview of disparities in pediatric treatment and outcomes, with a focus on children with endocrine disorders.

Influence of social determinants of health barriers to family management of type 1 diabetes in Black single parent families: A mixed methods study

OBJECTIVE

US disparities in pediatric type 1 diabetes treatment and outcomes are increasing disproportionately among Black youth and compounded for youth from single parent homes. Despite worsened outcomes, Black youth from single parent homes and their caregivers are underrepresented in pediatric type 1 diabetes research. The purpose of this study was to understand the social determinants of health (SDOH) barriers that may contribute to health disparities and family management in Black youth with type 1 diabetes from single parent homes.

RESEARCH DESIGN AND METHODS

A three-phase mixed methods study with self-identified Black single parents of youth with type 1 diabetes from an urban US pediatric diabetes center was conducted. Focus groups and interviews informed development of a parent-generated survey of SDOH barriers to diabetes management. Survey results are presented.

RESULTS

A resulting 71 item parent-generated survey was administered to 105 parents. Among all items, most problematic SDOH barriers included lack of social support, managing parent/child diabetes-related stress, difficulties accessing diabetes supplies, pain management, cost of food and diabetes camp, need to take time off from work, lack of skilled school staff, school absences and unsafe neighborhoods. Structural racism related to child welfare reporting, and police targeting were also notable concerns.

CONCLUSIONS

There is a critical need for clinical, community, and policy-related research and interventions, designed to reduce type 1 diabetes racial health disparities by addressing the impacts of SDOH as drivers of family management outcomes among Black youth from single parent families.

Hispanic Caregivers' experience of pediatric type 1 diabetes: A qualitative study

OBJECTIVE

It is widely recognized that Type 1 Diabetes (T1D) outcomes are worse among Hispanic children; however, little is published about the perspectives of these patients and their caregivers. Our intent was to characterize the lived experience of Hispanic caregivers of children with T1D, focusing on the role of language and culture and their perspectives on current medical care and alternative care models. We studied Hispanic caregivers of patients (age 2-17 years) with T1D of greater than 6 months' duration.

RESEARCH DESIGN AND METHODS

We completed semi-structured interviews and focus-groups of a purposive sample of 20 members of our population of interest. We developed a codebook and completed multidisciplinary consensus coding, then conducted iterative thematic analysis using qualitative software and discussion to generate themes.

RESULTS

We gathered data from 20 Hispanic caregivers of T1D patients (11.37 ± 3.00 years old, 4.80 ± 2.84 years since diagnosis). 85% of caregivers were female, 80% preferred Spanish, and 15% were college-educated. Our analysis yielded 4 themes across the participants: (1) Culturally-based nutrition challenges, (2) Social isolation and lack of support for T1D care, (3) Hesitancy to fully embrace diabetes technology, and (4) Deferential views of care experience and providers. Overarching all of these themes was support for Hispanic group-based models of care tailored to address these concerns.

CONCLUSIONS

The unique concerns among Hispanic caregivers of children with T1D suggest the importance of culturally tailored interventions to improve care. With successful implementation, such interventions could diminish widening disparities in healthcare outcomes.

Racism and pediatric health outcomes

Racism- a system operating at the intrapersonal, interpersonal, institutional, and structural levels- is a serious threat to the health and wellbeing of children and adolescents. This narrative review highlights racism as a social determinant of health, and describes how racism breeds disparate pediatric health outcomes in infant health, asthma, Type 1 diabetes, mental health, and pediatric surgical conditions. Key examples include the association of residential racial segregation and the alarming infant mortality rate among Black infants as well as the role of redlining and discriminatory housing practices on asthma morbidity among Black children and adolescents. Furthermore, inequitable care practices such as (1) racial and ethnic disparities in insulin pump usage in patients with Type 1 diabetes, (2) lower rates pharmacotherapy initiation in racialized children with mental health disorders, and (3) decreased pain medication management and confirmatory imaging in Black children with acute appendicitis, highlight the role of interpersonal racism in propagating poor health outcomes. An urgent call to action is needed to address pediatric health inequities and ensure all children can live healthy lives. Key strategies must tackle racism at the individual, institutional, and structural levels and include building a diverse workforce, prioritizing research to describe the impact of racism on pediatric health outcomes, initiating improvement efforts to close equity gaps, building community partnerships, co-designing solutions alongside patients and families, and advocating for policy change to address the social conditions that impact children and adolescents of color.

Can Innovative Technologies Overcome HbA1c Disparity for African-American Youth with Type 1 Diabetes?

Achieving normal or near-normal glycemic control as reflected by HbA1c levels in patients with type 1 diabetes (T1D) is important for preventing the development and progression of chronic complications. Despite delineation and dissemination of HbA1c management targets and advances in insulin pharmacology, insulin delivery systems, and glucose monitoring, the majority of children with T1D do not achieve HbA1c goals. In particular, African Americans are more likely not to reach HbA1c goals and have persistently higher HbA1c than Non-Hispanic Whites. Availability of pumps and other technology has not eliminated the disparity in HbA1c. Multiple factors play a role in the persisting racial disparity in HbA1c outcome. The carefully designed application and deployment of new technology to help the patient/family and facilitate the supportive role of the diabetes management team may be able to overcome racial disparity in glycemic outcome and improve patient quality of life.

Racial Disparities in Diabetes Technology Use and Outcomes in Type 1 Diabetes in a Safety-Net Hospital

BACKGROUND

Limited data exist regarding diabetes technology use among adults with type 1 diabetes (T1D) in urban racially/ethnically diverse safety-net hospitals. We examined racial/ethnic differences in the use of continuous glucose monitor (CGM) and continuous subcutaneous insulin infusion (CSII) in this setting.

METHODS

A retrospective review of 227 patients ≥ 18 years of age with T1D seen in an urban, safety-net endocrinology clinic during 2016-2017 was completed (mean age: 39; 80% English-speaking; 50% had public insurance). Diabetes technology use, defined as either CGM or CSII or both CGM and CSII, and clinical outcomes were examined by race/ethnicity.

RESULTS

Overall, 30% used CGM and 26% used CSII. After adjusting for age, language, insurance, and annual income, diabetes technology use in non-White patients was significantly lower than in White patients, predominantly lower in Black (aOR 0.25 [95% CI 0.11-0.56]) and patients identified as other race/ethnicity (aOR 0.30 [95% CI 0.11-0.77]). At the highest household income level (≥$75,000/y), Black and Hispanic individuals were significantly less likely than White individuals to use diabetes technology (P < .0007). Mean hemoglobin A1c (HbA1c) was lower in patients using any diabetes technology compared with patients using no technology (P < .0001). Use of CGM and CSII together was associated with the lowest HbA1c across all racial/ethnic groups.

CONCLUSIONS

Racial/ethnic disparities in diabetes technology use and glycemic control were observed even after adjusting for sociodemographic factors. Further research should explore barriers to accessing diabetes technology in non-White populations.

Inequities in Health Outcomes in Children and Adults With Type 1 Diabetes: Data From the T1D Exchange Quality Improvement Collaborative

Health care inequities among racial and ethnic groups remain prevalent. For people with type 1 diabetes who require increased medical access and care, disparities are seen in access to care and health outcomes. This article reports on a study by the T1D Exchange Quality Improvement Collaborative evaluating differences in A1C, diabetic ketoacidosis (DKA), severe hypoglycemia, and technology use among racial and ethnic groups. In a diverse cohort of nearly 20,000 children and adults with type 1 diabetes, A1C was found to differ significantly among racial and ethnic groups. Non-Hispanic Blacks had higher rates of DKA and severe hypoglycemia and the lowest rate of technology use. These results underscore the crucial need to study and overcome the barriers that lead to inequities in the care and outcomes of people with type 1 diabetes.

Pediatric Medicaid Patients With Type 1 Diabetes Benefit From Continuous Glucose Monitor Technology

BACKGROUND

We determined the uptake rate of continuous glucose monitors (CGMs) and examined associations of clinical and demographic characteristics with CGM use among patients with type 1 diabetes covered by Colorado Medicaid during the first two years of CGM coverage with no out-of-pocket cost.

METHOD

We retrospectively reviewed data from 892 patients with type 1 diabetes insured by Colorado Medicaid (Colorado Health Program [CHP] and CHP+, Colorado Medicaid expansion). Demographics, insulin pump usage, CGM usage, and hemoglobin A1c (A1c) were extracted from the medical record. Data downloaded into CGM software at clinic appointments were reviewed to determine 30-day use prior to appointments. Subjects with some exposure to CGM were compared to subjects never exposed to CGM, and we examined the effect of CGM use on glycemic control.

RESULTS

Twenty percent of subjects had some exposure to CGM with a median of 22 [interquartile range 8, 29] days wear. Sixty one percent of CGM users had >85% sensor wear. Subjects using CGM were more likely to be younger (P < .001), have shorter diabetes duration (P < .001), and be non-Hispanic White (P < .001) than nonusers. After adjusting for age and diabetes duration, combined pump and CGM users had a lower A1c than those using neither technology (P = .006). Lower A1c was associated with greater CGM use (P = .002) and increased percent time in range (P < .001).

CONCLUSION

Pediatric Medicaid patients successfully utilized CGM. Expansion of Medicaid coverage for CGM may help improve glycemic control and lessen disparities in clinical outcomes within this population.

The Evolution of Hemoglobin A1c Targets for Youth With Type 1 Diabetes: Rationale and Supporting Evidence

The American Diabetes Association 2020 Standards of Medical Care in Diabetes (Standards of Care) recommends a hemoglobin A1c (A1C) of <7% (53 mmol/mol) for many children with type 1 diabetes (T1D), with an emphasis on target personalization. A higher A1C target of <7.5% may be more suitable for youth who cannot articulate symptoms of hypoglycemia or have hypoglycemia unawareness and for those who do not have access to analog insulins or advanced diabetes technologies or who cannot monitor blood glucose regularly. Even less stringent A1C targets (e.g., <8%) may be warranted for children with a history of severe hypoglycemia, severe morbidities, or short life expectancy. During the "honeymoon" period and in situations where lower mean glycemia is achievable without excessive hypoglycemia or reduced quality of life, an A1C <6.5% may be safe and effective. Here, we provide a historical perspective of A1C targets in pediatrics and highlight evidence demonstrating detrimental effects of hyperglycemia in children and adolescents, including increased likelihood of brain structure and neurocognitive abnormalities, microvascular and macrovascular complications, long-term effects, and increased mortality. We also review data supporting a decrease over time in overall severe hypoglycemia risk for youth with T1D, partly associated with the use of newer insulins and devices, and weakened association between lower A1C and severe hypoglycemia risk. We present common barriers to achieving glycemic targets in pediatric diabetes and discuss some strategies to address them. We aim to raise awareness within the community on Standards of Care updates that impact this crucial goal in pediatric diabetes management.

Insulin Pump Use in Children with Type 1 Diabetes: Over a Decade of Disparities

PURPOSE

Racial disparities have been shown in outcomes and treatment of children with type 1 diabetes (T1D). The purpose of this study was to examine temporal trends in insulin pump use among non-Hispanic white (NHW), non-Hispanic black (NHB) and Hispanic children attending a large urban diabetes center. . This study was a retrospective chart review of insulin pump usage by race (NHW/ NHB) in 2005, and race/ethnicity (NHW/NHB/Hispanic) in 2011-2019. Demographic data (age, sex, diabetes duration, SES) and most recent hemoglobin A1c were also abstracted in 2011-2019.

RESULTS

In 2005, NHW children were twice as likely to use an insulin pump as NHB children. From 2011 to 2019, the odds ratio increased to 2.5 for NHW compared to NHB children. The odds of Hispanic children using insulin pumps were also higher than NHB. Insurance status (government versus private), a surrogate for SES, had very little influence on these trends, with NHW children consistently more likely than NHB children to be treated with insulin pumps in 2011, 2013, 2017, 2019 (p < 0.001).

CONCLUSIONS

We have demonstrated that racial disparities in insulin pump use have persisted over the past 15 years, and are not determined by SES. This inequity in diabetes treatment may be playing a role in the poorer glycemic control and higher rates of diabetes complications in NHB children.

PRACTICE IMPLICATIONS

Healthcare providers should be cognizant of racial and ethnic disparities in the treatment of children with T1D. Standardized treatment protocols may reduce unconscious bias in prescribing.

Effectiveness of social media (Facebook), targeted mailing, and in-person solicitation for the recruitment of young adult in a diabetes self-management clinical trial

BACKGROUND/AIMS

Research is needed to identify promising recruitment strategies to reach and engage diverse young adults in diabetes clinical research. The aim of this study was to examine the relative strengths and weaknesses of three recruitment strategies used in a diabetes self-management clinical trial: social media advertising (Facebook), targeted mailing, and in-person solicitation of clinic patients.

METHODS

Strategies were compared in terms of (1) cost-effectiveness (i.e. cost of recruitment/number of enrolled participants), (2) ability to yield participants who would not otherwise be reached by alternative strategies, and (3) likelihood of participants recruited through each strategy to adhere to study procedures. We further explored the appeal (overall and among age and gender subgroups) of social media advertisement features.

RESULTS

In-person recruitment of clinic patients was overall the most cost-effective strategy. However, differences in demographic, clinical, and psychosocial characteristics of participants recruited via different strategies suggest that the combination of these approaches yielded a more diverse sample than would any one strategy alone. Once successfully enrolled, there was no difference in study completion and intervention adherence between individuals recruited by the three recruitment strategies.

CONCLUSIONS

Ultimately, the utility of a recruitment strategy is defined by its ability to effectively attract people representative of the target population who are willing to enroll in and complete the study. Leveraging a variety of recruitment strategies appears to produce a more representative sample of young adults, including those who are less engaged in diabetes care.

Smoking Status and Well-Being of Underserved African American Older Adults

Purpose: This study investigated the association between current and past cigarette smoking, with four domains of well-being, namely, physical quality of life, mental quality of life, depressive symptoms, and self-rated health status (SRH), among older African American adults who lived in economically impoverished areas of South Los Angles. Methods: This community-based cross-sectional study included a convenience sample of economically-disadvantaged African Americans adults (n = 740) who were 55 years old and older residing in South Los Angeles. We conducted in-depth face-to-face interviews to collect data on the socioeconomic status (level of education and fiscal pressures), demographic factors (age and gender), physical health (number of chronic medical conditions), smoking (never smokers (reference group), past smokers, and current smokers), and well-being (quality of life, depressive symptoms, and self-rated health). Linear regressions were used to analyze the data. Results: Over 21% reported that they are current smokers, compared with 31% who identified as former smokers. Almost 40% perceived the quality of their health status to be fair or poor. Compared with non-smokers, current cigarette smokers reported a worse physical quality of life, depressive symptoms, and self-rated health. Current smokers also reported a marginally worse mental quality of life. Past smoker status was inconsistently associated with worse well-being in some, but not all, indicators. The association between smoking status and worse well-being was independent of gender, socioeconomic status, and physical health status. Conclusion: Current smoking is associated with worse well-being of older African American adults in economically constrained urban settings. As the same pattern could not be found for former smokers, quitting smoking may be a strategy for economically-disadvantaged African American individuals to enhance their well-being. This provides additional support for programs that help African American individuals who are smokers to quit smoking, particularly in economically-disadvantaged urban areas.

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.

Association Between Parental Educational Attainment and Youth Outcomes and Role of Race/Ethnicity

Importance

The concept of minorities' diminished returns refers to the smaller protective effects of educational attainment for racial and ethnic minority groups compared with those for majority groups.

Objective

To explore racial and ethnic differences in the associations between parental educational attainment and youth outcomes among US adolescents.

Design, Setting, and Participants

A cross-sectional study was performed of 10 619 youth aged 12 to 17 years who were participants at wave 1 of the Population Assessment of Tobacco and Health (PATH) study, a nationally representative survey, in 2013. Data analysis was performed from August to October 2019.

Main Outcomes and Measures

The dependent variables were youth tobacco dependence, aggression, school performance, psychological distress, and chronic medical conditions. The independent variable was parental educational attainment. Age and sex of the adolescents and marital status of the parents were the covariates. Race and ethnicity were the moderating variables. Logistic regression was used for data analysis.

Results

Among the participants, 5412 (51.0%) were aged 12 to 15 years, and 5207 (49.0%) were aged 16 to 17 years; 5480 (51.7%) were male. For non-Hispanic white youth, as parental educational attainment increased, there were stepwise reductions in the prevalence of tobacco dependence (13.2% vs 6.9% vs 2.7%), aggression (37.9% vs 34.8% vs 26.1%), low grade point average (84.2% vs 75.6% vs 53.3%), and chronic medical conditions (51.7% vs 50.8% vs 43.9%), but there was not such a trend for psychological distress (43.7% vs 48.6% vs 41.0%). Interactions were significant between Hispanic ethnicity and parental education on tobacco dependence (OR, 3.37 [95% CI, 2.00-5.69] for high school graduation; OR, 5.40 [95% CI, 2.52-11.56] for college graduation; P < .001 for both), aggression (OR, 1.41 [95% CI, 1.09-1.81]; P = .008 for high school graduation; OR, 1.59 [95% CI, 1.14-2.21]; P = .006 for college graduation), and psychological distress (OR, 1.50 [95% CI, 1.05-2.13]; P = .03). Black race showed an interaction with college graduation on poor school performance (OR, 2.00 [95% CI, 1.26-3.17]; P = .003) and chronic medical conditions (OR, 1.56 [95% CI, 1.14-2.14]; P = .005). All these findings suggest that the protective associations between high parental educational attainment and youth development might be systemically smaller for Hispanic and black youth than for non-Hispanic youth.

Conclusions and Relevance

Although high parental educational attainment is associated with better outcomes for youth, this association is systemically less significant for Hispanic and black than non-Hispanic white youth. The result is an increased health risk in youth from middle class black and Hispanic families. Given the systemic pattern for outcomes across domains, the diminishing returns of parental educational attainment may be due to upstream social processes that hinder ethnic minority families from translating their capital and human resources into health outcomes.

Parental Educational Attainment and Chronic Medical Conditions among American Youth; Minorities' Diminished Returns

Background: Parental educational attainment is protective against chronic medical conditions (CMCs). According to the minorities’ diminished returns (MDRs) theory, however, the health effects of socioeconomic status (SES) indicators are smaller for socially marginalized groups such as racial and ethnic minorities rather than Whites. Aims: To explore racial and ethnic differences in the effect of parental educational attainment on CMCs in a nationally representative sample of American youth. Methods: In this cross-sectional study, we used baseline data of 10,701 12–17 years old youth in the Population Assessment of Tobacco and Health (PATH; 2013). Parental educational attainment was the independent variable. The dependent variable was the number of CMCs in youth. Age, gender, and family structure were covariates. Race and ethnicity were the focal moderators. Linear and multinomial regression were applied to analyze the data. Results: Overall, higher parental educational attainment was associated with a lower number of CMCs. Race and ethnicity, however, showed significant interactions with parental educational attainment on a number of CMCs as well as 2+ CMCs, suggesting that the effect of parenting educational attainment on CMCs is significantly smaller for Black and Hispanic than White youth. Conclusions: In the United States, race and ethnicity alter the health gains that are expected to follow parental educational attainment. While White youth who are from highly educated families are most healthy, Black and Hispanic youth from highly educated families remain at higher risk for CMCs. That means, while the most socially privileged group, Whites, gain the most health from their parental education, Blacks and Hispanics, the least privileged groups, gain the least. The result is a disproportionately high number of CMCs in middle-class Blacks and Hispanics. Economic, social, public, and health policy makers should be aware that health disparities are not all due to lower SES of the disadvantaged group but also diminished returns of SES resources for them. Youth physical health disparities due to race and ethnicity exist across all SES levels.

The association between socio-economic status and diabetes care and outcome in children with diabetes type 1 in Germany: The DIAS study (diabetes and social disparities)

OBJECTIVE

To evaluate the association between socioeconomic status (SES) and diabetes outcomes in German children and adolescents.

METHODS

A total of 1829 subjects <18 years old with type 1 diabetes mellitus from 13 German diabetes centers were included from June 2013 until June 2014. Data were collected within the multicenter DPV (Diabetes Prospective Follow-up) registry. SES was measured with a composite index. Multivariable regression models were applied to analyze the association of SES and outcomes adjusted for age, sex, diabetes duration, and migration status.

RESULTS

Low SES was significantly associated with worse diabetes outcomes: higher hemoglobin A1C (HbA1c) (64.3 mmol/mol), lower proportion of insulin pump therapy (43.6%), fewer daily self-monitored blood glucose (SMBG) measurements (5.7), more inpatient days per patient-year (5.8) compared to patients with medium/high SES (HbA1c: 61.3 mmol/mol, P < 0.001/59.8 mmol/mol, P < 0.0001; proportion of pump therapy: 54.5%, P < 0.01/ 54.9%, P < 0.01; SMBG: 6.0, P < 0.01/ 6.1, P < 0.01; inpatient days: 4.5, P < 0.0001/3.4, P < 0.0001). The inclusion of migration status in the models resulted in only minor changes in the outcomes.

CONCLUSION

Despite free health care, low SES is associated with unfavorable diabetes outcomes in Germany. The poorer diabetes outcomes of children with diabetes have been attributed to their migration status and may be partly explained by low SES. Both factors must become part of targeted diabetes care in children and adolescents with type 1 diabetes.

Systematic review of sociodemographic representation and cultural responsiveness in psychosocial and behavioral interventions with adolescents with type 1 diabetes

BACKGROUND

The increasing incidence of type 1 diabetes (T1D) in youth aged less than 20 years in the USA is a mounting public health concern. Specific sociodemographic characteristics-racial/ethnic minority, low socioeconomic status (SES), single-parent home and underinsured-have been associated with increased risk for poor glycemic control and poor self-management in adolescents with T1D.

METHODS

Sample demographic and cultural responsiveness methods in psychosocial and behavioral interventions focused on improving self-management and glycemic control in adolescents with T1D were systematically evaluated, to identify if studies were targeting these high-risk groups. Keyword searches of PsychInfo, PubMed and CINAHL identified 259 studies published between 2006 and 2016, of adolescents (13-18 years old) with T1D; 28 studies met inclusion criteria.

RESULTS

Samples focused predominantly on White adolescents with fair glycemic control, from middle-high income, two-parent households with private insurance. The majority of studies scored poorly in cultural responsiveness and moderately in culturally responsive reporting. Studies lacked descriptions of culturally inclusive recruitment and sampling methods, and use of culturally responsive assessments for diverse groups. The majority of studies recruited and enrolled homogeneous adolescent samples from the lowest risk groups.

CONCLUSION

T1D intervention researchers must increase targeted recruitment and sampling methods to include more high-risk pediatric T1D groups, expand sociodemographic reporting, and increase the use of culturally responsive recruitment and sampling methods, such as those used in community-based participatory research. Such efforts have the potential to reduce T1D disparities by making interventions more relevant to the unique needs, goals and priorities of highest risk groups.

Prevalence of celiac disease in a large cohort of young patients with type 1 diabetes

BACKGROUND

Serological screening for celiac disease (CD) allows the identification of individuals genetically predisposed, as type 1 diabetes mellitus (T1DM). However, the diagnosis is confirmed by intestinal biopsy. The aim was to determine the prevalence of immunoglobulin-A anti-tissue transglutaminase antibodies (IgA-tTG) and CD in a large cohort of young T1DM patients.

METHODS

Screening for CD was randomly conducted in 881 T1DM by IgA-tTG and total IgA. Individuals with positive antibodies were referred to endoscopy/duodenal biopsy.

RESULTS

The age of the cohort at the screening was 14.3 ± 5.9 years and at T1DM onset was 7.9 ± 4.4 years. The prevalence of positive serology was 7.7%. Median IgA-tTG levels were 117.7 U/mL (interquartile range [IQR] 35.7-131.5 U/mL). Of the 62 duodenal biopsy, CD was diagnosed in 79.0%, yielding an overall prevalence of 5.6%. The mean age of CD patients was 15.6 ± 6.5 years and, at T1DM onset was 6.3 years (4.0-9.9 years). The modified Marsh-Oberhuber histological classification was 22.5% (3a), 36.7% (3b), and 40.8% (3c). In the biopsy-proven patients, T1DM onset occurred at slightly younger ages (6.3 vs 9.7 years, P = 0.1947), gastrointestinal (GI) manifestations, predominantly abdominal pain and distension, were more prevalent (71.4% vs 38.5%, P = 0.027) and higher IgA-tTG titers (128.0 vs 26.3 U/mL, P = 0.0003) were found than in those with negative-biopsies.

CONCLUSION

Our results demonstrate the prevalence of 7.7% of IgA-tTG and 5.6% of CD in T1DM patients in South Brazil and, emphasize the importance of the screening in high-risk individuals. Furthermore, the presence of GI manifestations and higher IgA-tTG titers strongly suggest the diagnosis of CD.

Disparities in Insulin Pump Therapy Persist in Youth With Type 1 Diabetes Despite Rising Overall Pump Use Rates

PURPOSE

This study sought to determine if disparities in insulin pump therapy among youth with type 1 diabetes (T1DM) persist despite recent increases in overall pump use rates.

DESIGN AND METHODS

All patients aged 6 months-17 years, diagnosed with T1DM, and completed 4+ outpatient diabetes visits at an academically-affiliated pediatric health care center from 2011 to 2016 were identified (n = 2131). Data were collected from existing electronic medical records and a multivariable logistic regression model was used to identify factors associated with insulin pump therapy.

RESULTS

Findings revealed one novel factor (patients/families whose primary language is Spanish [OR 0.47, p = 0.038] or other non-English languages [OR 0.47, p = 0.028]) and confirmed several previously known factors associated with lower insulin pump use: patients who were older (10-14 years OR 0.38, p < 0.0001; 15+ years OR 0.15, p < 0.0001), male (OR 0.80, p = 0.021), non-Hispanic black (OR 0.59, p = 0.009), American Indian/Alaska Native (OR 0.19, p = 0.023), had either government (OR 0.42, p < 0.0001) or no insurance (OR 0.52, p = 0.004) and poor glycemic control (at least one HbA1c ≥ 8.5%; OR 0.54, p < 0.0001).

CONCLUSION

Significant disparities in insulin pump use in youth with T1DM persist despite known benefits associated with pump therapy and underlying causes remain unclear.

PRACTICE IMPLICATIONS

Health care providers should explore barriers to insulin pump therapy, including limited English language proficiency.

Ethnic inequalities in child and adolescent health in the Scandinavian welfare states: The role of parental socioeconomic status - a systematic review

Aims: Adult non-Western immigrants in Scandinavia tend to be worse off in terms of health than native-born populations, which cannot be fully ascribed to their often lower socioeconomic status (SES). This review examines if differences in health status are also present between non-Western immigrant and majority children in Denmark, Norway and Sweden, and if SES explains the differences. Methods: Following PRISMA guidelines, relevant Scandinavian peer-reviewed quantitative publications since 1990 were identified through a systematic search of PubMed, EMBASE, Scopus, Web of Science and SveMed. Of 1197 identified publications, 27 remained relevant after applying inclusion criteria: 3 Danish, 6 Norwegian and 18 Swedish studies. Results: Non-western immigrant children had overall poorer outcomes compared with ethnic majority children in Denmark, Norway and Sweden in health issues covered by the included studies: diabetes, obesity, oral and mental health, and well-being. However, in diabetes, obesity and mental health, non-Western immigrant children from certain countries and regions, and descendants of non-Western immigrants had similar/more favourable outcomes than majority children. In mental health and well-being, ethnic inequalities were strongly associated with SES, while for diabetes, obesity and oral health, differences remained significant after adjusting for SES. Conclusions: Overall poorer health outcomes in non-Western immigrant compared with majority children in Scandinavia cannot be fully explained by SES. Evidence points to additional mechanisms at individual, household, societal or policy levels, including reasons for migration, culture and societal discrimination. Finally, methodological issues may influence study outcomes, e.g. heterogeneity of populations studied and socioeconomic variables included.

High rates of ocular complications in a cohort of Haitian children and adolescents with diabetes

BACKGROUND

Ophthalmic complications of pediatric diabetes are rare, and rates are unknown in Haitian youth.

OBJECTIVES

To determine the prevalence and predictors of diabetic retinopathy (DR) and cataracts in a cohort of Haitian youth with insulin-treated diabetes.

METHODS

We performed a cross-sectional retrospective review of pediatric patients with diabetes from a pediatric chronic disease center in Haiti, from December 1, 2012 to November 1, 2016. Data collection included demographic and anthropometric information, total daily insulin dose and result of eye examination by a local ophthalmologist.

RESULTS

Of 67 patients (54% female, mean age at diagnosis 14.6 ± 3.9 years, mean diabetes duration 3.3 ± 3.0 years, mean HbA1c 84 ± 22 mmol/mol (9.8% ± 2.0%), mean current insulin requirement 0.49 ± 0.28 IU/kg/day), DR was diagnosed in 10/57 (18%) and cataracts in 10/62 (16%), at a mean age of 19.0 ± 4.3 and 19.1 ± 3.3 years, respectively. Diabetes duration was 4.9 ± 5.4 and 3.0 ± 1.5 years at the time of diagnosis of DR and cataracts, respectively. Age at complication, insulin requirement, sex, body mass index, family history, mean HbA1c and diabetes duration were not significant predictors of an ocular complication.

CONCLUSIONS

In this cohort of Haitian youth, DR and cataracts occur prematurely. Low-insulin requirements years after diagnosis, possibly allowing for prolonged undetected hyperglycemia prediagnosis, may explain complication risk. The phenotypes of diabetes in pediatric populations of African ancestry may be distinct. Ophthalmologic evaluation should possibly start at diagnosis, and screening guidelines may need to be adapted.

Occupational Therapy Intervention Improves Glycemic Control and Quality of Life Among Young Adults With Diabetes: the Resilient, Empowered, Active Living with Diabetes (REAL Diabetes) Randomized Controlled Trial

OBJECTIVE

To assess the efficacy of a manualized occupational therapy (OT) intervention (Resilient, Empowered, Active Living with Diabetes [REAL Diabetes]) to improve glycemic control and psychosocial well-being among ethnically diverse young adults with low socioeconomic status (SES) who have type 1 or type 2 diabetes.

RESEARCH DESIGN AND METHODS

Eighty-one young adults (age 22.6 ± 3.5 years; hemoglobin A_1c [HbA_1c] = 10.8%/95 mmol/mol ± 1.9%/20.8 mmol/mol) were randomly assigned to the REAL Diabetes intervention group (IG) or an attention control group (CG) over 6 months. IG participants received biweekly sessions guided by a manual composed of seven content modules; CG participants received standardized educational materials and biweekly phone calls. Blinded assessors collected data at baseline and 6 months. The primary outcome was HbA_1c; secondary outcomes included diabetes self-care, diabetes-related quality of life (QOL), diabetes distress, depressive symptoms, and life satisfaction. Change scores were analyzed using Wilcoxon rank sum tests.

RESULTS

Intent-to-treat analyses showed that IG participants showed significant improvement in HbA_1c (-0.57%/6.2 mmol/mol vs. +0.36%/3.9 mmol/mol, P = 0.01), diabetes-related QOL (+0.7 vs. +0.15, P = 0.04), and habit strength for checking blood glucose (+3.9 vs. +1.7, P = 0.05) as compared with CG participants. There was no statistically significant effect modification by sex, ethnicity, diabetes type, recruitment site, or SES. No study-related serious adverse events were reported.

CONCLUSIONS

The REAL Diabetes intervention improved blood glucose control and diabetes-related QOL among a typically hard-to-reach population, thus providing evidence that a structured OT intervention may be beneficial in improving both clinical and psychosocial outcomes among individuals with diabetes.

Considering Culture: A Review of Pediatric Behavioral Intervention Research in Type 1 Diabetes

PURPOSE OF REVIEW

Type 1 diabetes (T1D) incidence in youth is growing across all racial/ethnic backgrounds, with the most marked increase in African-American youth under 5. Underrepresented racial/ethnic minorities are at an increased risk for health complications. This review focuses on the reported disparities, demographics of samples in behavioral interventions, and study design considerations.

RECENT FINDINGS

Recruitment data from two ongoing behavioral intervention trials for young children with T1D are presented to compare enrolled/non-enrolled individuals and to discuss culturally appropriate study design considerations. Data were compared to the demographics of children (ages 1-6) with T1D in the clinic populations from the recruitment sites. Enrolling a representative sample and designing culturally appropriate behavioral interventions are important for generalizability, yet there is a gap between the individuals participating in T1D research and those who are most negatively affected by T1D. Suggestions are offered for ways to expand inclusion of diverse samples in behavioral intervention research in T1D.

Sociodemographic Characteristics, Health Literacy, and Care Compliance in Families With Spina Bifida

Children with spina bifida experience varying rates of disease complications and health system overutilization. Data on sociodemographics, urinary tract infection, clean intermittent catheterization, and health system utilization were collected from caregiver-patient dyads. Newest Vital Sign (NVS) and Brief Health Literacy Screen (BRIEF) were administered to evaluate health literacy (HL). In total, 105 dyads completed enrolment with 24.8% versus 12.4% of caregivers scoring poor/marginal on the NVS and BRIEF, respectively. Nearly half on clean intermittent catheterization missed a catheterization over the previous week. Medicaid insurance, parental education, and household income predicted HL (P < .01). Over the preceding 5 years, 68.5% visited our hospital's emergency department. Eighteen (25%) visited the emergency department >6 times and 12 incurred charges over $50 000. Caregivers of children who missed ≥4 catheterizations per week had lower NVS scores (P = .03). Children with spina bifida represent high utilizers, and consideration of sociodemographic and HL differences is necessary when tailoring care plans.