Analysis & commentary: Global prevention and control of type 2 diabetes will require paradigm shifts in policies within and among countries

The international and domestic politics of type 2 diabetes policy reform in Brazil

Introduction

Understanding the international and domestic political factors influencing the evolution of type 2 diabetes policies and primary care institutions is a new area of scholarly research. This article contributes to this area of inquiry by illustrating how a government’s shifting foreign policy aspirations, that is, to establish the government’s reputation as an internationally recognised leader in type 2 diabetes policy, and presidential electoral incentives provide alternative insights into the evolution of type 2 diabetes treatment policies and primary care institutional reforms.

Methods

I conduct a single-case study analysis with the usage of qualitative data; quantitative statistical data on epidemiological trends and government policy spending is also provided as supportive evidence.

Results

The case of Brazil illustrates how a reduction in foreign policy commitment to international reputation building in health as well as presidential electoral incentives to use diabetes policy as an electoral strategy account for a decline in sustaining policy and primary care institutional innovations in response to type 2 diabetes.

Conclusion

Future scholars interested in understanding the lack of sustainability and effectiveness in type 2 diabetes programmes should consider investigating the complex international and domestic political factors influencing political interests, incentives and commitment to reform.

Identifying diabetes management opportunity areas in the USA

Using adherence to diabetes management guidelines as a case study, this paper applied a novel geospatial hot-spot and cold-spot methodology to identify priority counties to target interventions. Data for this study were obtained from the Dartmouth Atlas of Healthcare, the United States Census Bureau’s American Community Survey and the University of Wisconsin County Health Rankings. A geospatial approach was used to identify four tiers of priority counties for diabetes preventive and management services: diabetes management cold-spots, clusters of counties with low rates of adherence to diabetes preventive and management services (Tier D); Medicare spending hot-spots, clusters of counties with high rates of spending and were diabetes management cold-spots (Tier C); preventable hospitalisation hot-spots, clusters of counties with high rates of spending and are diabetes management cold-spots (Tier B); and counties that were located in a diabetes management cold-spot cluster, preventable hospitalisation hot-spot cluster and Medicare spending hot-spot cluster (Tier A). The four tiers of priority counties were geographically concentrated in Texas and Oklahoma, the Southeast and central Appalachia. Of these tiers, there were 62 Tier A counties. Rates of preventable hospitalisations and Medicare spending were higher in Tier A counties compared with national averages. These same counties had much lower rates of adherence to diabetes preventive and management services. The novel geospatial mapping approach used in this study may allow practitioners and policy makers to target interventions in areas that have the highest need. Further refinement of this approach is necessary before making policy recommendations.

Political party ambitions and type-2 diabetes policy in Brazil and Mexico

In the Americas, next to the United States, Brazil and Mexico have the highest prevalence of type-2 diabetes. In contrast to most studies, this article compares and analyzes the politics behind the implementation of type-2 diabetes self-care management programs (DSM), which is a new area of scholarly research. This article claims that Brazil outpaced Mexico with respect to the implementation of effective DSM programs, the product of positive policy spillover effects associated with the president and governing political party's popular anti-poverty programs, and the enduring legacy of centralized ministry of health financial and human resource assistance to primary care programs in a context of decentralization. Brazil also benefited from having a strong partnership with international health agencies. None of these factors was present in Mexico. Findings suggest that more research needs to go into understanding the complex political and inter-governmental contexts facilitating DSM program implementation, which is a neglected area of research.

Fitting a square peg into a round hole: Perceptions of Appalachian physicians on the incorporation of chronic disease prevention into their practice

This study used a focus group in August 2017 (n = 9) to explore the perceptions of rural physicians to a state request to incorporate diabetes prevention screening into their West Virginia medical practice. Analysis of the data revealed that the participants did not think private physicians were equipped to incorporate diabetes prevention programming into their practice. Three categories emerged from the data analysis to explain the reasoning of the health practitioners on the incorporation of pre-diabetes screening and management into their practice.⁎

The practice of medicine

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Prevention is a mismatch

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Social determinants of health

In the end, the study revealed that a request for physicians to identify and refer at risk patients to a diabetes prevention program is problematic due to conceptual and structural issues. Based on the findings it does not appear at this time that private physicians in rural settings can incorporate diabetes prevention into their existing practice. To address conceptual and structural barriers the invitation to rural physicians must: 1) present evidence on how physicians may be effective in a diabetes management team; 2) include a model that demonstrates a limited, specific role and duties for the physician within a team setting; and last, 3) integrate physicians into an existing community-based network of social and human service providers set up to provide diabetes prevention services.

Evolving Trends in the Epidemiology, Risk Factors, and Prevention of Type 2 Diabetes: A Review

Currently, the global prevalence of diabetes is 8.8%. This figure is expected to increase worldwide, with the largest changes projected to occur in low- and middle-income countries. The aging of the world's population and substantial increases in obesity have contributed to the rise in diabetes. Global shifts in lifestyles have led to the adoption of unhealthy behaviours such as physical inactivity and poorer-quality diets. Correspondingly, diabetes is a rapidly-increasing problem in higher- as well as lower-income countries. In Canada, the prevalence of diabetes increased approximately 70% in the past decade. Although diabetes-related mortality rates have decreased in Canada, the number of people affected by diabetes has continued to grow because of a surge in the number of new diabetes cases. Non-European ethnic groups and individuals of lower socioeconomic status have been disproportionately affected by diabetes and its risk factors. Clinical trials have proven efficacy in reducing the onset of diabetes in high-risk populations through diet and physical activity interventions. However, these findings have not been broadly implemented into the Canadian health care context. In this article we review the evolving epidemiology of type 2 diabetes, with regard to trends in occurrence rates and prevalence; the role of risk factors including those related to ethnicity, obesity, diet, physical activity, socioeconomic status, prediabetes, and pregnancy; and the identification of critical windows for lifestyle intervention. Identifying high-risk populations and addressing the upstream determinants and risk factors of diabetes might prove to be effective diabetes prevention strategies to curb the current diabetes epidemic.

Chronic Disease and Mobile Technology: An Innovative Tool for Clinicians

Chronic disease is common, costly and the epidemic of the 21st century. Primary care providers seek new and innovative approaches to prevent chronic illness. Since the majority of chronic illness management occurs outside a physician's office, providers must use different techniques to support daily self-management of any chronic illness. Assisting the individual to develop life skills to support self-management is one way to improve patient outcomes. Technology, that is easily accessed, may provide an additional method to develop and individual's self-management skills to prevent diabetes.

Reducing major risk factors for chronic kidney disease

Chronic kidney disease (CKD) is a global public health concern and a key determinant of poor health outcomes. While the burden of CKD is reasonably well defined in developed countries, increasing evidence indicates that the CKD burden may be even greater in developing countries. Diabetes, hypertension, and obesity are major contributors to the global burden of the disease and are important traditional CKD risk factors; however, nontraditional CKD risk factors such as nephrotoxin exposure, kidney stones, fetal and maternal factors, infections, environmental factors, and acute kidney injury are also increasingly being recognized as major threats to global kidney health. A broad approach to CKD prevention begins with the identification of CKD risk factors in the population, followed by the development of appropriate mitigation strategies. Effective prevention policies rely on an accurate understanding of the incidence and prevalence of CKD in a given setting, as well as the distribution and burden of risk factors. Populations or individuals at CKD risk must be screened and treated early to prevent the onset of and delay the progression of the kidney disease. Systematically collected data should be analyzed at country, province, and district levels to identify regional disparities and CKD hotspots and develop targeted prevention strategies. Race-ethnicity, genetics, sex, socioeconomic status, and geography are likely modifiers of CKD risk. A comprehensive, informed approach to prevention that takes into account all of these factors is therefore required to successfully tackle the global CKD epidemic.

Impact of a type 2 diabetes diagnosis on mental health, quality of life, and social contacts: a longitudinal study

AIMS

The aim was to examine whether a type 2 diabetes mellitus (T2DM) diagnosis increases the odds of psychological distress, a worsening in overall quality of life, and a potential reduction in social contacts.

METHOD

Longitudinal data were obtained from the 45 and Up Study (baseline 2006-2008; 3.4±0.95 years follow-up time). Fixed effects logistic and negative binomial regression models were fitted on a complete case on outcome sample that did not report T2DM at baseline (N=26 344), adjusted for time-varying confounders. The key exposure was doctor-diagnosed T2DM at follow-up. Outcome variables examined included the Kessler Psychological Distress Scale, self-rated quality of life, and four indicators of social contacts.

RESULTS

A modest increase in the odds of psychological distress associated with T2DM diagnosis (OR=1.30) was not statistically significant (95% CI 0.75 to 2.25). A T2DM diagnosis was associated with a fivefold increase in the odds of a participant reporting that their quality of life had become significantly poorer (OR 5.49, 95% CI 1.26 to 23.88). T2DM diagnosis was also associated with a reduction in times spent with friends and family (RR 0.88, 95% CI 0.82 to 0.95), contacts by telephone (RR 0.95, 95% CI 0.87 to 1.02), attendance at social clubs or religious groups (RR 0.82, 95% CI 0.73 to 0.91), and the number of people nearby but outside the home that participants felt they could rely on (RR 0.92, 95% CI 0.86 to 0.98).

CONCLUSIONS

A T2DM diagnosis can have important impacts on quality of life and on social contacts, which may have negative impacts on mental health and T2DM management in the longer term.

Prevalence, Risk Factors, and Complications of Diabetes in the Kilimanjaro Region: A Population-Based Study from Tanzania

BACKGROUND

In sub-Saharan Africa, diabetes is a growing burden, yet little is known about its prevalence, risk factors, and complications. To address these gaps and help inform public health efforts aimed at prevention and treatment, we conducted a community-based study assessing diabetes epidemiology.

METHODS AND FINDINGS

We conducted a stratified, cluster-designed, serial cross-sectional household study from 2014-2015 in the Kilimanjaro Region, Tanzania. We used a three-stage cluster probability sampling method to randomly select individuals. To estimate prevalence, we screened individuals for glucose impairment, including diabetes, using hemoglobin A1C. We also screened for hypertension and obesity, and to assess for potential complications, individuals with diabetes were assessed for retinopathy, neuropathy, and nephropathy. We enrolled 481 adults from 346 urban and rural households. The prevalence of glucose impairment was 21.7% (95% CI 15.2-29.8), which included diabetes (5.7%; 95% CI 3.37-9.47) and glucose impairment with increased risk for diabetes (16.0%; 95% CI 10.2-24.0). Overweight or obesity status had an independent prevalence risk ratio for glucose impairment (2.16; 95% CI 1.39-3.36). Diabetes awareness was low (35.6%), and few individuals with diabetes were receiving biomedical treatment (33.3%). Diabetes-associated complications were common (50.2%; 95% CI 33.7-66.7), including renal (12.0%; 95% CI 4.7-27.3), ophthalmic (49.6%; 95% CI 28.6-70.7), and neurological (28.8%; 95% CI 8.0-65.1) abnormalities.

CONCLUSIONS

In a northern region of Tanzania, diabetes is an under-recognized health condition, despite the fact that many people either have diabetes or are at increased risk for developing diabetes. Most individuals were undiagnosed or untreated, and the prevalence of diabetes-associated complications was high. Public health efforts in this region will need to focus on reducing modifiable risk factors, which appear to include obesity, as well as early detection that includes increasing awareness. These findings highlight a growing urgency of diabetes prevention in this region as well as the need for treatment, including management of complications.

Does area of residence influence weight loss following a diagnosis of type 2 diabetes? Fixed effects longitudinal analysis of 54,707 middle-to-older aged Australians

Reductions in body mass index and reduced overweight/obesity risk among participants in the 45 and Up Study diagnosed with type 2 diabetes mellitus (T2DM) were relatively large in rural areas compared to those in urban environs. Further research is needed to explain why where people reside influences optimal management of T2DM.

Worldwide trends in diabetes since 1980: a pooled analysis of 751 population-based studies with 4.4 million participants

BACKGROUND

One of the global targets for non-communicable diseases is to halt, by 2025, the rise in the age-standardised adult prevalence of diabetes at its 2010 levels. We aimed to estimate worldwide trends in diabetes, how likely it is for countries to achieve the global target, and how changes in prevalence, together with population growth and ageing, are affecting the number of adults with diabetes.

METHODS

We pooled data from population-based studies that had collected data on diabetes through measurement of its biomarkers. We used a Bayesian hierarchical model to estimate trends in diabetes prevalence-defined as fasting plasma glucose of 7.0 mmol/L or higher, or history of diagnosis with diabetes, or use of insulin or oral hypoglycaemic drugs-in 200 countries and territories in 21 regions, by sex and from 1980 to 2014. We also calculated the posterior probability of meeting the global diabetes target if post-2000 trends continue.

FINDINGS

We used data from 751 studies including 4,372,000 adults from 146 of the 200 countries we make estimates for. Global age-standardised diabetes prevalence increased from 4.3% (95% credible interval 2.4-7.0) in 1980 to 9.0% (7.2-11.1) in 2014 in men, and from 5.0% (2.9-7.9) to 7.9% (6.4-9.7) in women. The number of adults with diabetes in the world increased from 108 million in 1980 to 422 million in 2014 (28.5% due to the rise in prevalence, 39.7% due to population growth and ageing, and 31.8% due to interaction of these two factors). Age-standardised adult diabetes prevalence in 2014 was lowest in northwestern Europe, and highest in Polynesia and Micronesia, at nearly 25%, followed by Melanesia and the Middle East and north Africa. Between 1980 and 2014 there was little change in age-standardised diabetes prevalence in adult women in continental western Europe, although crude prevalence rose because of ageing of the population. By contrast, age-standardised adult prevalence rose by 15 percentage points in men and women in Polynesia and Micronesia. In 2014, American Samoa had the highest national prevalence of diabetes (>30% in both sexes), with age-standardised adult prevalence also higher than 25% in some other islands in Polynesia and Micronesia. If post-2000 trends continue, the probability of meeting the global target of halting the rise in the prevalence of diabetes by 2025 at the 2010 level worldwide is lower than 1% for men and is 1% for women. Only nine countries for men and 29 countries for women, mostly in western Europe, have a 50% or higher probability of meeting the global target.

INTERPRETATION

Since 1980, age-standardised diabetes prevalence in adults has increased, or at best remained unchanged, in every country. Together with population growth and ageing, this rise has led to a near quadrupling of the number of adults with diabetes worldwide. The burden of diabetes, both in terms of prevalence and number of adults affected, has increased faster in low-income and middle-income countries than in high-income countries.

FUNDING

Wellcome Trust.

The health system and population health implications of large-scale diabetes screening in India: a microsimulation model of alternative approaches

BACKGROUND

Like a growing number of rapidly developing countries, India has begun to develop a system for large-scale community-based screening for diabetes. We sought to identify the implications of using alternative screening instruments to detect people with undiagnosed type 2 diabetes among diverse populations across India.

METHODS AND FINDINGS

We developed and validated a microsimulation model that incorporated data from 58 studies from across the country into a nationally representative sample of Indians aged 25-65 y old. We estimated the diagnostic and health system implications of three major survey-based screening instruments and random glucometer-based screening. Of the 567 million Indians eligible for screening, depending on which of four screening approaches is utilized, between 158 and 306 million would be expected to screen as "high risk" for type 2 diabetes, and be referred for confirmatory testing. Between 26 million and 37 million of these people would be expected to meet international diagnostic criteria for diabetes, but between 126 million and 273 million would be "false positives." The ratio of false positives to true positives varied from 3.9 (when using random glucose screening) to 8.2 (when using a survey-based screening instrument) in our model. The cost per case found would be expected to be from US$5.28 (when using random glucose screening) to US$17.06 (when using a survey-based screening instrument), presenting a total cost of between US$169 and US$567 million. The major limitation of our analysis is its dependence on published cohort studies that are unlikely fully to capture the poorest and most rural areas of the country. Because these areas are thought to have the lowest diabetes prevalence, this may result in overestimation of the efficacy and health benefits of screening.

CONCLUSIONS

Large-scale community-based screening is anticipated to produce a large number of false-positive results, particularly if using currently available survey-based screening instruments. Resource allocators should consider the health system burden of screening and confirmatory testing when instituting large-scale community-based screening for diabetes.

Value of lifestyle intervention to prevent diabetes and sequelae

BACKGROUND

The Community Preventive Services Task Force recommends combined diet and physical activity promotion programs for people at increased risk of type 2 diabetes, as evidence continues to show that intensive lifestyle interventions are effective for overweight individuals with prediabetes.

PURPOSE

To illustrate the potential clinical and economic benefits of treating prediabetes with lifestyle intervention to prevent or delay onset of type 2 diabetes and sequelae.

METHODS

This 2014 analysis used a Markov model to simulate disease onset, medical expenditures, economic outcomes, mortality, and quality of life for a nationally representative sample with prediabetes from the 2003-2010 National Health and Nutrition Examination Survey. Modeled scenarios used 10-year follow-up results from the lifestyle arm of the Diabetes Prevention Program and Outcomes Study versus simulated natural history of disease.

RESULTS

Over 10 years, estimated average cumulative gross economic benefits of treating patients who met diabetes screening criteria recommended by the ADA ($26,800) or USPSTF ($24,700) exceeded average benefits from treating the entire prediabetes population ($17,800). Estimated cumulative, gross medical savings for these three populations averaged $10,400, $11,200, and $6,300, respectively. Published estimates suggest that opportunistic screening for prediabetes is inexpensive, and lifestyle intervention similar to the Diabetes Prevention Program can be achieved for ≤$2,300 over 10 years.

CONCLUSIONS

Lifestyle intervention among people with prediabetes produces long-term societal benefits that exceed anticipated intervention costs, especially among prediabetes patients that meet the ADA and USPSTF screening guidelines.

Management of NCD in low- and middle-income countries

Noncommunicable disease (NCD), comprising cardiovascular disease, stroke, diabetes, and chronic obstructive pulmonary disease, are increasing in incidence rapidly in low- and middle-income countries (LMICs). Some patients have access to the same treatments available in high-income countries, but most do not, and different strategies are needed. Most research on noncommunicable diseases has been conducted in high-income countries, but the need for research in LMICs has been recognized. LMICs can learn from high-income countries, but they need to devise their own systems that emphasize primary care, the use of community health workers, and sometimes the use of mobile technology. The World Health Organization has identified "best buys" it advocates as interventions in LMICs. Non-laboratory-based risk scores can be used to identify those at high risk. Targeting interventions to those at high risk for developing diabetes has been shown to work in LMICs. Indoor cooking with biomass fuels is an important cause of chronic obstructive pulmonary disease in LMICs, and improved cookstoves with chimneys may be effective in the prevention of chronic diseases.

A simplified indication of metabolic syndrome to recognize subjects with a moderate risk to develop type 2 diabetes mellitus in a large Italian sample

To propose a simplified tool to recognize subjects with a moderate risk to develop type 2 diabetes mellitus (Type 2 DM): this method would take into account only variables from metabolic syndrome definitions which are cheaply assessable. A total of 3,003 employees without diabetes in Italy who attended one annual health examination between 2009 and 2012 were enrolled in this cross-sectional study. A questionnaire was administered along with the annual health examination to record personal and familiar anamnesis. To identify Type 2 DM-prone individuals, the diabetes predictive model by Stern MP et al. was used. Then a multiple logistic regression model was developed using the predicted probability 20%+ of developing Type 2 DM as the outcome variable and a panel of easily measurable continuous baseline characteristics as explanatory variables (waist circumference, WC; body mass index, BMI; and systolic blood pressure, SBP). The optimism-adjusted area under the curve of the proposed model receiver-operating characteristic (ROC) is 0.90. The effects of the explanatory variables on the presumed Type 2 DM risk are summarized by the following adjusted odds ratio values: 2.65 for SBP (P < 0.001), 2.01 for WC (P = 0.04) and 4.64 for BMI (P < 0.001). The satisfactory ROC of the proposed model suggests the importance of simple assessments in the prognostic information on Type 2 DM risk. Such ease of use may be particularly relevant in populations facing the transition from traditional to industrial food who do not have a sophisticated health service yet.

Inadequacies of current approaches to prediabetes and diabetes prevention

In view of the global shift from communicable to chronic, non-communicable diseases including obesity, prediabetes, and type 2 diabetes mellitus, the increasing prevalence of the latter creates a considerable challenge to the clinician and public health infrastructure. Despite the substantial research efforts in the last 10-15 years highlighting the considerable benefit of lifestyle modification in thwarting the insidious progression to diabetes and its complications, many individuals will ineluctably progress even when initially responsive. Furthermore, the vast majority of individuals with prediabetes remain undiagnosed and untreated. Therefore, the responsibilities of the medical and public health communities involve identifying new methods for screening and identifying those at risk as well as refining therapeutic approaches availing as many high-risk individuals as possible to novel treatment modalities.

Physical activity, smoking, and alcohol consumption in association with incidence of type 2 diabetes among middle-aged and elderly Chinese men

BACKGROUND

Type 2 diabetes mellitus (T2DM) is a prevalent chronic disease worldwide. The prevalence of T2DM is increasing rapidly in China. Understanding the contribution of modifiable lifestyle factors on T2DM risk is imperative to prevent the development of T2DM in China.

METHODS

We examined associations between lifestyle factors including physical activity, smoking and alcohol consumption with incidence of T2DM among middle-aged and elderly men in urban Shanghai. Information on socio-demographics, lifestyle habits, dietary habits, and disease history was collected via in-person interviews. Anthropometric measurements were taken. A total of 51 464 Chinese men aged 40-74 years free of T2DM, coronary heart disease (CHD), and stroke at baseline were included in the current study. Incident T2DM was identified through follow-up surveys conducted every 2-3 years. Cox proportional hazard analyses were conducted to evaluate associations between lifestyle risk factors and incidence of T2DM.

RESULTS

We documented 1304 new cases of T2DM during 276 929 person-years of follow-up (average: 5.4 years). Physical activity was inversely associated with T2DM risk. Daily living, commuting, and total physical activity METs had inverse negative dose-response relationships with T2DM (P-trend = 0.0033, 0.0022, and <0.0001, respectively). Regular participation in exercise or sports reduced T2DM risk (HR = 0.86, 95%CI: 0.76-0.98). Moderate alcohol intake (1-3 drinks/day) was inversely related to T2DM risk (HR = 0.80, 95%CI: 0.67-0.94). Cigarette smoking, on the other hand, was associated with increased T2DM risk; HRs were 1.25 (95%CI: 1.00-1.56) for smoking more than 20 cigarettes per day and 1.28 (95%CI: 1.04-1.57) for smoking more than 40 pack-years.

CONCLUSIONS

Physical activity and moderate alcohol intake are inversely associated with T2DM risk, whereas smoking was positively associated with T2DM risk among middle-age and elderly Chinese men. Preventive measures should be developed to focus on these modifiable lifestyle habits to reduce the upward trend of T2DM.

Diabetes prevention: perspectives and actions of one company

Diabetes, particularly type 2 diabetes mellitus (T2DM), has reached epidemic proportions in the U.S. and globally, highlighting the need for major improvements in treatment strategies for detecting, preventing, and slowing disease progression. Despite escalating treatment costs, diabetes care remains largely substandard, with hospitalizations for late-stage complications in particular placing a major burden on the healthcare system. Although considerable advances have been made in identifying the risk factors of diabetes and developing treatments, goals targeting prevention have remained elusive. Although there is currently no consensus regarding terminology among public health practitioners, the concept of prevention in terms of diabetes care runs the gamut from interventions used to avoid disease in individuals without risk factors (primordial prevention) to prevention of the consequences of established complications (quaternary prevention). Given the worldwide prevalence of diabetes, it is crucial to improve the quality of care for those diagnosed with overt diabetes, as well as those who have been identified as at risk for developing the disease. Earlier screening enables undiagnosed, asymptomatic individuals with diabetes to be identified sooner, managed more effectively, and where necessary, treated with the appropriate pharmacotherapeutic options in a timely manner. All stakeholders (including government, industry, professional, and patient groups) must partner in concert to address these vital issues so that treatment goals ultimately may be realized.

Rationale and design of the multinational observational study assessing insulin use: the MOSAIc study

BACKGROUND

Although consensus guidelines recommend insulin progression among patients with type 2 diabetes (T2DM) who fail to meet glycemic targets over time, many fewer patients are progressed than may benefit. We describe the rationale and design of the MOSAIc (Multinational Observational Study Assessing Insulin use) study, a multinational observational cohort study to identify patient-, physician, and health care environment-based factors associated with insulin progression for patients with T2DM in real-world practice.

METHODS/DESIGN

We will enroll 4,500 patients with T2DM taking initial insulin therapy for ≥3 months across 175 physician practice sites in 18 countries. Extensive demographic, clinical, and psychosocial data at the patient and physician level and practice site characteristics will be collected at baseline and regular intervals during a 24-month follow-up period. We will use a multivariable logistic regression model to identify predictors of insulin progression and highlight potential opportunities for health behavior intervention to improve insulin progression rates. Secondary outcomes include evaluating factors associated with glycemic control, hypoglycemia, and treatment adherence among patients who do and do not progress beyond their initial insulin therapy and exploring geographic heterogeneity in treatment.

DISCUSSION

Practice site and patient recruitment began in 2011 and baseline data will be available in late 2012. The MOSAIC study's longitudinal observational design as well as the breadth and depth of data will be used to explore and quantify predictors of insulin progression and to identify potential opportunities for health behavior intervention in order to improve T2DM treatment and clinical outcomes.