Diabetes in African American youth: prevalence, incidence, and clinical characteristics: the SEARCH for Diabetes in Youth Study

A Systematic Review of the Effects of Provider Bias on Health in Youth and Young Adults with Type 1 Diabetes

PURPOSE OF REVIEW

Although pervasive inequities in the health outcomes of youth and young adults with type 1 diabetes (T1D) exist, the role of provider bias in these inequities is not well-understood. The purpose of this review is to synthesize evidence from existing studies on the associations between patient characteristics, provider bias, and patient health.

RECENT FINDINGS

Fourteen articles were included. Determining the extent of the effects of provider bias on patient health is limited by a lack of consensus on its definition. Experiences of provider bias (e.g., shaming, criticism) negatively affects self-esteem, relationships with medical providers, and depressive symptoms. Provider bias also impacts diabetes technology recommendations, insulin regimen intensity, and risk for life-threatening T1D complications. Future studies are needed to develop questionnaires and interviews that better account for diverse experiences and interpretations of bias in T1D healthcare. More research is also needed to investigate mitigating factors to reduce provider bias as a way to improve psychological and physical health in individuals with T1D.

Hemoglobin A1c and Type 2 Diabetes Incidence Among Adolescents With Overweight and Obesity

Importance

With the increase in prediabetes among adolescents with overweight and obesity, identifying those at highest risk for type 2 diabetes (T2D) can support prevention strategies.

Objective

To assess T2D risk by hemoglobin A1c (HbA1c) levels among adolescents with overweight and obesity.

Design, Setting, and Participants

This retrospective cohort study was conducted using data for January 1, 2010, to December 31, 2019, from a large California health care system. The study population comprised adolescents aged 10 to 17 years who had a body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) at or above the 85th percentile, had HbA1c measured during 2010 to 2018, and did not have preexisting diabetes. Data abstraction and analyses were conducted from January 1, 2020, to November 16, 2023.

Exposures

Baseline HbA1c, with covariates including BMI category (overweight: 85th to <95th percentile; moderate obesity: 100% to <120% of 95th percentile; or severe obesity: ≥120% of 95th percentile), age, sex, race and ethnicity, and Neighborhood Deprivation Index score.

Main Outcomes and Measures

The main outcome was incident T2D during follow-up through 2019, including cumulative incidence and multivariable hazard ratios (HRs) with 95% CIs using Cox proportional hazard regression analyses.

Results

This study included 74 552 adolescents with a mean (SD) age of 13.4 (2.3) years. More than half (50.6%) were female; 26.9% of individuals had overweight, 42.3% had moderate obesity, and 30.8% had severe obesity. Individuals identified as Asian or Pacific Islander (17.6%), Black (11.1%), Hispanic (43.6%), White (21.6%), and other or unknown race or ethnicity (6.1%). During follow-up, 698 adolescents (0.9%) developed diabetes, and 626 (89.7%) had T2D; 72 individuals (10.3%) who had type 1, secondary, or other diabetes were censored. The overall T2D incidence was 2.1 (95% CI, 1.9-2.3) per 1000 person-years, with a 5-year cumulative incidence of 1.0% (95% CI, 0.9%-1.1%). Higher baseline HbA1c (from <5.5% to 5.5%-5.6%, 5.7%-5.8%, 5.9%-6.0%, 6.1%-6.2%, and 6.3-6.4%) was associated with higher 5-year cumulative T2D incidence (from 0.3% [95% CI, 0.2%-0.4%] to 0.5% [0.4%-0.7%], 1.1% [0.8%-1.3%], 3.8% [3.2%-4.7%], 11.0% [8.9%-13.7%], and 28.5% [21.9%-36.5%], respectively). In addition, higher baseline HbA1c was associated with greater T2D risk (reference [HbA1c <5.5%]: HR, 1.7 [95% CI, 1.3-2.2], 2.8 [2.1-3.6], 9.3 [7.2-12.1], 23.3 [17.4-31.3], and 71.9 [51.1-101.1], respectively). Higher BMI category, older age, female sex, and Asian or Pacific Islander race (HR, 1.7 [95% CI, 1.3-2.2]), but not Black race or Hispanic ethnicity (compared with White race), were also independent indicators of T2D. In stratified analyses, incremental risk associated with higher HbA1c was greater for Asian or Pacific Islander and White adolescents than for Black and Hispanic adolescents.

Conclusions and Relevance

In this cohort study of adolescents with overweight and obesity, T2D risk increased substantially with baseline HbA1c above 6.0%. Risk varied by BMI, age, sex, and race and ethnicity. These findings suggest that diabetes surveillance in adolescents should be tailored to optimize identification among high-risk subgroups.

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.

Small Business Support Is Associated with the Quantity, Quality, and Usage of Youth Physical Activity Opportunities in Urban, Low-Income, African American Neighborhoods

Evidence suggests small businesses could play a significant role in bringing quality youth physical activity opportunities (YPAOs) to urban areas. Knowing more about their involvement with YPAOs in African American neighborhoods would be of significant value given the relatively low PA rates of African American youth. The current study examined associations between small businesses and YPAOs in low-income, African American urban neighborhoods. Surveys were conducted with 46.4% (n = 223) of eligible small business owners/managers and 44.2% (n = 38) of eligible YPAO providers in 20 low-income, African American urban neighborhoods to ascertain business and YPAO characteristics. Audits were conducted at the YPAOs and parks (n = 28) in the study areas to obtain counts of users and data on amenities/incivilities. Analyses included multiple linear regression. Only 33.6% of all businesses were currently supporting YPAOs. The percentage of businesses supporting only local YPAOs (YPAOs near the business) was significantly associated with the number of YPAOs in the area, number of YPAO amenities, youth participants, teams, amenity quality, and the severity of incivilities after controlling for neighborhood demographics. Businesses supporting only local YPAOs were at their location longer, and their owners were more likely to have a sports background, children, and believe small businesses should support YPAOs than business not supporting local YPAOs. This study provides evidence that YPAOs in low-income, African American urban neighborhoods are improved by support from small businesses. Efforts to enhance PA among African American youth living in low-income urban neighborhoods could benefit from involving small businesses.

Epidemiology of Type 1 Diabetes

PURPOSE OF REVIEW

Epidemiological research on type 1 diabetes (T1D) has traditionally focussed on the paediatric age group, but recent data in adults has confirmed it to be a disease of all ages with a wide clinical spectrum. We review the epidemiology and clinical features of T1D across the lifespan.

RECENT FINDINGS

While the peak incidence of T1D is still in early adolescence, T1D is now diagnosed more commonly in adulthood than childhood due to increasing recognition of adult-onset T1D and the length of the adult lifespan. It still follows the known geographic variations in incidence, being highest in Northern Europe and lowest in Asia. The onset of T1D in adulthood is usually less acute than in childhood and confers a lower, although still substantial, risk of complications and early mortality. Interventions to delay T1D onset are emerging and screening for those at risk at birth is increasingly available. Type 1 diabetes can develop at any age and may not present with ketosis or an immediate insulin requirement in adults. Macro- and microvascular complications are the greatest cause of excess morbidity and mortality in this population.

Utility of Diabetes Type-Specific Genetic Risk Scores for the Classification of Diabetes Type Among Multiethnic Youth

OBJECTIVE

Genetic risk scores (GRS) aid classification of diabetes type in White European adult populations. We aimed to assess the utility of GRS in the classification of diabetes type among racially/ethnically diverse youth in the U.S.

RESEARCH DESIGN AND METHODS

We generated type 1 diabetes (T1D)- and type 2 diabetes (T2D)-specific GRS in 2,045 individuals from the SEARCH for Diabetes in Youth study. We assessed the distribution of genetic risk stratified by diabetes autoantibody positive or negative (DAA+/-) and insulin sensitivity (IS) or insulin resistance (IR) and self-reported race/ethnicity (White, Black, Hispanic, and other).

RESULTS

T1D and T2D GRS were strong independent predictors of etiologic type. The T1D GRS was highest in the DAA+/IS group and lowest in the DAA-/IR group, with the inverse relationship observed with the T2D GRS. Discrimination was similar across all racial/ethnic groups but showed differences in score distribution. Clustering by combined genetic risk showed DAA+/IR and DAA-/IS individuals had a greater probability of T1D than T2D. In DAA- individuals, genetic probability of T1D identified individuals most likely to progress to absolute insulin deficiency.

CONCLUSIONS

Diabetes type-specific GRS are consistent predictors of diabetes type across racial/ethnic groups in a U.S. youth cohort, but future work needs to account for differences in GRS distribution by ancestry. T1D and T2D GRS may have particular utility for classification of DAA- children.

Improved genetic risk scoring algorithm for type 1 diabetes prediction

BACKGROUND

Precise risk prediction of type 1 diabetes (T1D) facilitates early intervention and identification of risk factors prior to irreversible beta-islet cell destruction, and can significantly improve T1D prevention and clinical care. Sharp et al. developed a genetic risk scoring (GRS) system for T1D (T1D-GRS2) capable of predicting T1D risk in children of European ancestry. The T1D-GRS2 was developed on the basis of causal genetic variants, thus may be applicable to minor populations, while a trans-ethnic GRS for T1D may avoid the exacerbation of health disparities due to the lack of genomic information in minorities.

METHODS

Here, we describe a T1D-GRS2 calculator validated in two independent cohorts, including African American children and European American children. Participants were recruited by the Center for Applied Genomics at the Children's Hospital of Philadelphia.

RESULTS

It demonstrates that GRS2 is applicable to the T1D risk prediction in the AA cohort, while population-specific thresholds are needed for different populations.

CONCLUSIONS

The study highlights the potential to further improve T1D-GRS2 performance with the inclusion of additional genetic markers.

Metformin therapy in pediatric type 2 diabetes mellitus and its comorbidities: A review

Type 2 diabetes (T2D) rates in children and adolescents are rising globally. T2D is a complex and aggressive disease in children with several comorbidities, high treatment failure rates, and insulin needs within a few years from diagnosis. While myriads of pharmacotherapies are licensed to treat adults with T2D, treatments accessible to children and adolescents have been limited until recently. Metformin is an old drug with multiple beneficial metabolic health effects beyond glycemic control. This review discusses Metformin's origins, its mechanisms of action, and evidence for its use in the pediatric population to treat and prevent T2D. We also explore the evidence for its use as an obesity therapy, which is the primary driver of T2D, and T2D-driven comorbidities. While emerging therapies create new horizons for managing pediatric T2D, Metformin remains an inexpensive and safe part of the treatment plans of many T2D children globally for its beneficial metabolic effects.

Twenty years of pediatric diabetes surveillance: what do we know and why it matters

SEARCH for Diabetes in Youth (SEARCH) was initiated in 2000 as a multicenter study to address major gaps in the understanding of childhood diabetes in the United States. An active registry of youth diagnosed with diabetes at age <20 years since 2002 assessed prevalence, annual incidence, and trends by age, race/ethnicity, sex, and diabetes type. An observational cohort nested within the population-based registry was established to assess the natural history and risk factors for acute and chronic diabetes-related complications, as well as the quality of care and quality of life of children and adolescents with diabetes from diagnosis into young adulthood. SEARCH findings have contributed to a better understanding of the complex and heterogeneous nature of youth-onset diabetes. Continued surveillance of the burden and risk of type 1 and type 2 diabetes is important to track and monitor incidence and prevalence within the population. SEARCH reported evidence of early diabetes complications highlighting that continuing the long-term follow-up of youth with diabetes is necessary to further our understanding of its natural history and to develop the most appropriate approaches to primary, secondary, and tertiary prevention of diabetes and its complications. This review summarizes two decades of research and suggests avenues for further work.

Type 2 diabetes in children and adolescents across Australia and New Zealand: A 6-year audit from The Australasian Diabetes Data Network (ADDN)

OBJECTIVES

To assess the clinical and demographic characteristics of children and adolescents across Australia and New Zealand (NZ) with type 2 diabetes.

METHODS

We performed a descriptive audit of data prospectively reported to the Australasian Diabetes Data Network (ADDN) registry. Data were collected from six tertiary pediatric diabetes centers across Australia (New South Wales, Queensland, South Australia, Western Australia, and Victoria) and NZ (Auckland). Children and adolescents diagnosed with type 2 diabetes aged ≤ 18 years with data reported to ADDN between 2012 and 2017 were included. Age, sex, ethnicity, HbA1c, blood pressure, BMI, waist circumference and lipid profile at first visit were assessed.

RESULTS

There were 269 cases of type 2 diabetes in youth reported to ADDN between 2012 and 2017. The most common ethnicities were Indigenous Australian in 56/243 (23%) and NZ Maori or Pacifica in 47 (19%). Median age at diagnosis was 13.7 years and 94% of participants were overweight or obese. Indigenous Australian and Maori/Pacifica children were younger at diagnosis compared with nonindigenous children: median 13.3 years (indigenous Australian); 13.1 years (Maori/Pacifica); 14.1 years (nonindigenous), p = 0.005. HbA1c was higher in indigenous Australian (9.4%) and Maori/Pacifica youth (7.8%) compared with nonindigenous (6.7%) p < 0.001. BMI-SDS was higher in Maori/Pacifica youth (2.3) compared with indigenous Australian (2.1) and nonindigenous (2.2) p = 0.011.

CONCLUSIONS

Indigenous Australian and Maori/Pacifica youth in ADDN were younger and had worse glycaemic control at diagnosis of type 2 diabetes. Our findings underscore the need to consider targeted and earlier screening in these "high-risk" populations.

Prevalence of Hypertension and Albuminuria in Pediatric Type 2 Diabetes: A Systematic Review and Meta-analysis

Importance

Hypertension and albuminuria are markers of diabetes-related nephropathy and important factors associated with kidney outcomes in pediatric type 2 diabetes. However, their prevalence in these patients is unknown.

Objective

To measure the prevalence of hypertension and albuminuria in pediatric patients with type 2 diabetes and to evaluate the association of sex and race/ethnicity with these conditions.

Data Sources

MEDLINE, Embase, CINAHL, Cochrane Library, Web of Science, the gray literature, and references of the screened articles were searched for human studies from date of database inception to February 20, 2020.

Study Selection

Observational studies with at least 10 participants reporting the prevalence of hypertension and/or albuminuria in pediatric patients with type 2 diabetes were included. Three teams of 2 independent reviewers screened 7614 papers, of which 60 fulfilled the eligibility criteria.

Data Extraction and Synthesis

Three teams of 2 independent reviewers performed data extraction, risk of bias analysis, and level of evidence analyses. The meta-analysis was conducted using a random-effects model and followed the Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines.

Main Outcomes and Measures

The primary outcomes included the pooled prevalence rates (percentages with 95% CI) for hypertension and albuminuria. The secondary outcomes assessed pooled prevalence rates by sex and racial/ethnic group.

Results

Sixty studies were included in the systematic review. Diabetes duration varied from inclusion at diagnosis to 15.0 years after diagnosis, and the reported mean age at diagnosis ranged from 6.5 to 21.0 years. Hypertension prevalence among 3463 participants was 25.33% (95% CI, 19.57%-31.53%). Male participants had higher hypertension risk than female participants (odds ratio [OR], 1.42 [95% CI, 1.10-1.83]), with Pacific Islander and Indigenous youth having the highest prevalence of all racial/ethnic groups (Pacific Islander youth: 26.71% [95% CI, 14.54%-40.72%]; Indigenous youth: 26.48% [95% CI, 17.34%-36.74%]; White youth: 20.95% [95% CI, 12.65%-30.57%]; African American youth: 19.04% [95% CI, 12.01%-27.23%]; Hispanic/Latino youth: 15.11% [95% CI, 6.56%-26.30%]; Asian youth: 18.37% [95% CI, 9.49%-29.23%]). Albuminuria prevalence among 2250 participants was 22.17% (95% CI, 17.34%-27.38%). Pacific Islander youth, Indigenous youth, and Asian youth had higher prevalence rates than White youth (Pacific Islander youth: 31.84% [95% CI, 11.90%-55.47%]; Indigenous youth: 24.27% [95% CI, 14.39%-35.73%]; Asian youth: 23.00% [95% CI, 18.85%-27.41%]; White youth: 12.59% [95% CI, 7.75%-18.33%]), with no sex differences (OR for male vs female participants, 0.68 [95% CI, 0.46-1.01]). Heterogeneity was high among studies, with a low to moderate risk of bias.

Conclusions and Relevance

In this study, markers of diabetes-related nephropathy were commonly detected in pediatric patients with type 2 diabetes, with a disproportionate burden noted among Pacific Islander and Indigenous youth. Personalized management strategies to target kidney outcomes are urgently needed in pediatric patients with type 2 diabetes to alleviate the burden of this condition on the kidneys.

Diabetes Type 1 Negatively Influences Leydig Cell Function in Rats, Which is Partially Reversible By Insulin Treatment

Type 1 diabetes mellitus (T1DM) is associated with impaired spermatogenesis and lower testosterone levels and epididymal weight. However, the underlying processes in the testis are unknown and remain to be elucidated. Therefore, the present study focused on the effects of T1DM on testicular function in a spontaneously diabetic rat model. BB/OKL rats after diabetes manifestation were divided into 3 groups: those without insulin treatment and insulin treatment for a duration of 2 and of 6 weeks. Anthropometrical data, circulating levels of gonadotrophins, testosterone, and inhibin B were measured. Intratesticular testosterone, oxidative stress, inflammation, and apoptosis were analyzed. Key enzymes of steroidogenesis were evaluated in the testis. Untreated diabetic rats had significantly lower serum follicle-stimulating hormone and luteinizing hormone levels. Serum and intratesticular testosterone levels significantly decreased in untreated diabetic rats compared to healthy controls. Key markers of Leydig cell function were significantly downregulated at the RNA level: insulin-like factor 3 (Insl3) by 53% (P = .006), Star by 51% (P = .004), Cyp11A1 by 80% (P = .003), 3Beta-Hsd2 by 61% (P = .005), and Pbr by 52% (P = .002). In the insulin-treated group, only Cyp11A1 and 3Beta-Hsd2 transcripts were significantly lower. Interestingly, the long-term insulin-treated group showed significant upregulation of most steroidogenic enzymes without affecting testosterone levels. Tumor necrosis factor α and apoptosis were significantly increased in the long-term insulin-treated rats. In conclusion T1DM, with a severe lack of insulin, has an adverse action on Leydig cell function. This is partially reversible with well-compensated blood glucose control. Long-term T1DM adversely affects Leydig cell function because of the process of inflammation and apoptosis.

2017 National Standards for Diabetes Self-Management Education and Support

PURPOSE

The purpose of this study is to review the literature for Diabetes Self-Management Education and Support (DSMES) to ensure the National Standards for DSMES (Standards) align with current evidence-based practices and utilization trends.

METHODS

The 10 Standards were divided among 20 interdisciplinary workgroup members. Members searched the current research for diabetes education and support, behavioral health, clinical, health care environment, technical, reimbursement, and business practice for the strongest evidence that guided the Standards revision.

RESULTS

Diabetes Self-Management Education and Support facilitates the knowledge, skills, and ability necessary for diabetes self-care as well as activities that assist a person in implementing and sustaining the behaviors needed to manage their condition on an ongoing basis. The evidence indicates that health care providers and people affected by diabetes are embracing technology, and this is having a positive impact of DSMES access, utilization, and outcomes.

CONCLUSION

Quality DSMES continues to be a critical element of care for all people with diabetes. The DSMES services must be individualized and guided by the concerns, preferences, and needs of the person affected by diabetes. Even with the abundance of evidence supporting the benefits of DSMES, it continues to be underutilized, but as with other health care services, technology is changing the way DSMES is delivered and utilized with positive outcomes.

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.

Prevalence of Overweight and Obesity Among African American Children and Adolescents: Risk Factors, Health Outcomes, and Prevention/Intervention Strategies

This paper examines the biological, psychosocial, cultural, and obesogenic environmental factors that might account for the high prevalence rates of overweight and obesity among African American young children (aged 2-11) and adolescents (aged 12-19). Research findings are discussed on the practices associated with the development of childhood obesity including maternal overweight and obesity, physiological predisposition, infant feeding practices, breastfeeding, rapid infant weight gain, sleep disruption, low nutrition diets, physical inactivity, and sedentary behavior. The psychological correlates of overweight and obesity are discussed. Consistent with the obesogenic arguments, this paper examines the development of childhood obesity as a function of socioeconomic disadvantages, social inequities, urban environmental contingencies, and media food product messages. The potential deleterious health consequences of overweight and obesity are discussed. There is an examination of the structural-level and individual-level prevention/intervention strategies necessary for sustainable declines in childhood overweight and obesity.

Temporal patterns of hospitalizations for diabetic ketoacidosis in children and adolescents

Objectives

To examine the temporal patterns of hospitalizations with diabetic ketoacidosis (DKA) in the pediatric population and their associated fiscal impact.

Methods

The Texas Inpatient Public Use Data File was used to identify hospitalizations of state residents aged 1month-19 years with a primary diagnosis of DKA during 2005–2014. Temporal changes of population-adjusted hospitalization rates and hospitalization volumes were examined for the whole cohort and on stratified analyses of sociodemographic attributes. Changes in the aggregate and per-hospitalization charges were assessed overall and on stratified analyses.

Results

There were 24,072 DKA hospitalizations during the study period. The population-adjusted hospitalization rate for the whole cohort increased from 31.3 to 35.9 per 100,000 between 2005–2006 and 2013–2014. Hospitalization volume increased by 30.2% over the same period, driven mainly by males, ethnic minorities, those with Medicaid insurance and uninsured patients. The aggregate hospital charges increased from approximately $69 million to $130 million between 2005–2006 and 2013–2014, with 66% of the rise being due to increased per-hospitalization charges.

Conclusions

There was progressive rise in pediatric DKA hospitalizations over the last decade, with concurrent near-doubling of the associated fiscal footprint. Marked disparities were noted in the increasing hospitalization burden of DKA, born predominantly by racial and ethnic minorities, as well as by the underinsured and the uninsured. Further studies are needed to identify scalable preventive measures to achieve an equitable reduction of pediatric DKA events.

Country-Specific Prevalence and Incidence of Youth-Onset Type 2 Diabetes: A Narrative Literature Review

BACKGROUND

With increased awareness of type 2 diabetes (T2D) in children and adolescents, an overview of country-specific differences in epidemiology data is needed to develop a global picture of the disease development.

SUMMARY

This study examined country-specific prevalence and incidence data of youth-onset T2D published between 2008 and 2019, and searched for national guidelines to expand the understanding of country-specific similarities and differences. Of the 1,190 articles and 17 congress abstracts identified, 58 were included in this review. Our search found the highest reported prevalence rates of youth-onset T2D in China (520 cases/100,000 people) and the USA (212 cases/100,000) and lowest in Denmark (0.6 cases/100,000) and Ireland (1.2 cases/100,000). However, the highest incidence rates were reported in Taiwan (63 cases/100,000) and the UK (33.2 cases/100,000), with the lowest in Fiji (0.43 cases/100,000) and Austria (0.6 cases/100,000). These differences in epidemiology data may be partly explained by variations in the diagnostic criteria used within studies, screening recommendations within national guidelines and race/ethnicity within countries. Key Messages: Our study suggests that published country-specific epidemiology data for youth-onset T2D are varied and scant, and often with reporting inconsistencies. Finding optimal diagnostic criteria and screening strategies for this disease should be of high interest to every country.

TRIAL REGISTRATION

Not applicable.

Concordance and Discordance in the Geographic Distribution of Childhood Obesity and Pediatric Type 2 Diabetes in New York City

OBJECTIVE

As rates of childhood obesity and pediatric type 2 diabetes (T2D) increase, a better understanding is needed of how these 2 conditions relate and which subgroups of children are more likely to develop diabetes with and without obesity.

METHODS

To compare hotspots of childhood obesity and pediatric T2D in New York City, we performed geospatial clustering analyses on obesity estimates obtained from surveys of school-aged children and diabetes estimates obtained from health care claims data, from 2009 to 2013. Analyses were performed at the Census tract level. We then used multivariable regression analysis to identify sociodemographic and environmental factors associated with these hotspots.

RESULTS

We identified obesity hotspots in Census tracts with a higher proportion of Black or Hispanic residents, with low median household income, or located in a food swamp. Total 51.1% of pediatric T2D hotspots overlapped with obesity hotspots. For pediatric T2D, hotspots were identified in Census tracts with a higher proportion of Black residents and a lower proportion of Hispanic residents.

CONCLUSIONS

Non-Hispanic Black neighborhoods had a higher probability of being hotspots of both childhood obesity and pediatric T2D. However, we identified a discordance between hotspots of childhood obesity and pediatric diabetes in Hispanic neighborhoods, suggesting either under-detection or under-diagnosis of diabetes, or that obesity may influence diabetes risk differently in these 2 populations. These findings warrant further investigation of the relationship between childhood obesity and pediatric diabetes among different racial and ethnic groups, and may help guide pediatric public health interventions to specific neighborhoods.

Young-onset type 2 diabetes mellitus - implications for morbidity and mortality

Accumulating data suggest that type 2 diabetes mellitus (T2DM) in younger people (aged <40 years), referred to as young-onset T2DM, has a more rapid deterioration of β-cell function than is seen in later-onset T2DM. Furthermore, individuals with young-onset T2DM seem to have a higher risk of complications than those with type 1 diabetes mellitus. As the number of younger adults with T2DM increases, young-onset T2DM is predicted to become a more frequent feature of the broader diabetes mellitus population in both developing and developed nations, particularly in certain ethnicities. However, the magnitude of excess risk of premature death and incident complications remains incompletely understood; likewise, the potential reasons for this excess risk are unclear. Here, we review the evidence pertaining to young-onset T2DM and its current and future burden of disease in terms of incidence and prevalence in both developed and developing nations. In addition, we highlight the associations of young-onset T2DM with premature mortality and morbidity.

Prevalence and incidence of type 1 diabetes in the world: a systematic review and meta-analysis

Background: Diabetes is referred to a group of diseases characterized by high glucose levels in blood. It is caused by a deficiency in the production or function of insulin or both, which can occur because of different reasons, resulting in protein and lipid metabolic disorders. The aim of this study was to systematically review the prevalence and incidence of type 1 diabetes in the world. Methods: A systematic search of resources was conducted to investigate the prevalence and incidence of type 1 diabetes in the world. The databases of Medline (via PubMed and Ovid),ProQuest, Scopus, and Web of Science from January 1980 to September 2019 were searched to locate English articles. The located articles were screened in multiple levels of title, abstract,and full-text and final studies that met the inclusion criteria were retrieved and included in the study. Results: From 1202 located articles, 193 studies were included in this systematic review. The results of meta-analysis showed that the incidence of type 1 diabetes was 15 per 100,000 people and the prevalence was 9.5% (95% CI: 0.07 to 0.12) in the world, which was statistically significant. Conclusion: According to the results, the incidence and prevalence of type 1 diabetes are increasing in the world. As a result, insulin will be difficult to access and afford, especially in underdeveloped and developing countries.

2017 National Standards for Diabetes Self-Management Education and Support

PURPOSE

The purpose of this study is to review the literature for Diabetes Self-Management Education and Support (DSMES) to ensure the National Standards for DSMES (Standards) align with current evidence-based practices and utilization trends.

METHODS

The 10 Standards were divided among 20 interdisciplinary workgroup members. Members searched the current research for diabetes education and support, behavioral health, clinical, health care environment, technical, reimbursement, and business practice for the strongest evidence that guided the Standards revision.

RESULTS

Diabetes Self-Management Education and Support facilitates the knowledge, skills, and ability necessary for diabetes self-care as well as activities that assist a person in implementing and sustaining the behaviors needed to manage their condition on an ongoing basis. The evidence indicates that health care providers and people affected by diabetes are embracing technology, and this is having a positive impact of DSMES access, utilization, and outcomes.

CONCLUSION

Quality DSMES continues to be a critical element of care for all people with diabetes. The DSMES services must be individualized and guided by the concerns, preferences, and needs of the person affected by diabetes. Even with the abundance of evidence supporting the benefits of DSMES, it continues to be underutilized, but as with other health care services, technology is changing the way DSMES is delivered and utilized with positive outcomes.

Community Violence Exposure, Sleep Disruption, and Insulin Resistance in Low-Income Urban Adolescents

BACKGROUND

Exposure to violence, which is experienced at disproportionally higher levels by black versus white youth, is associated with disruptions in sleep and elevated cardiovascular risk. Further, poor sleep hygiene is associated with insulin resistance. However, research to date examining disruptions in sleep and cardiovascular risk in African-American adolescents has not taken the impact of exposure to violence into account, nor considered how gender might affect patterns of association. The present study addressed this gap by testing a path model linking exposure to community violence, sleep disruption, and insulin resistance in a sample of African-American adolescents and evaluating model fit across gender.

METHOD

African-American adolescents (N = 107; 56% female; M_age = 14.29, SD = 1.17) completed structured interviews at home and provided a blood sample after fasting overnight.

RESULTS

The model fit connecting exposure to violence with sleep disruption and insulin resistance, adjusting for depressive symptoms and body mass index z score, was excellent. Multiple group analysis indicated gender differences in model fit. Path analysis revealed significant positive associations between exposure to violence and sleep disruption and sleep disruption and insulin resistance for females but not males.

CONCLUSION

These data indicate that low-income, urban African-American female adolescents who witness violence and experience sleep disruptions may already be at elevated risk for health problems compared with their male counterparts. Additional research should attempt to replicate and explicate the underlying reasons for the gender differences observed here, with the goal of improving health and disrupting the path leading to health disparities.

Racial/ethnic differences in the burden of type 2 diabetes over the life course: a focus on the USA and India

Type 2 diabetes is a common disease worldwide, but its prevalence varies widely by geographical region and by race/ethnicity. This review summarises differences in the frequencies of type 2 diabetes according to race, ethnicity, socioeconomic position, area of residence and environmental toxins. Type 2 diabetes susceptibility often begins early in life, starting with genetic susceptibility at conception and continuing in later life, via in utero, childhood and adult exposures. Early-life factors may lead to overt type 2 diabetes in childhood or in later life, supporting the concept of developmental origins of health and disease. The causes of the racial/ethnic differences in incidence of type 2 diabetes are not well understood. Specifically, the relative contributions of genetic and environmental factors to such differences are largely unknown. With a few exceptions in isolated populations, there is little evidence that differences in frequencies of known type 2 diabetes susceptibility genetic alleles account for racial/ethnic differences, although the search for genetic susceptibility has not been uniform among the world's racial/ethnic groups. In the USA, race/ethnicity is associated with many other risk factors for type 2 diabetes, including being overweight/obese, diet and socioeconomic status. Some studies suggest that some of these factors may account for the race/ethnic differences in prevalence of type 2 diabetes, although there is inadequate research in this area. A better understanding of the impact of these factors on type 2 diabetes risk should lead to more effective prevention and treatment of this disease. This has not yet been achieved but should be a goal for future research.

Prevalence of type 1 and type 2 diabetes among US pediatric population in the MarketScan Multi-State Database, 2002 to 2016

OBJECTIVES

To estimate the prevalence of type 1 (T1DM) and type 2 diabetes mellitus (T2DM) among U.S. Medicaid pediatric population aged <18 years 2002 to 2016 by age, sex, and race/ethnicity.

METHODS

Participants aged <18 years old from 2002 to 2016 were identified from the MarketScan Multi-State Medicaid Database. Diabetes was defined as having (a) ≥1 claims for an outpatient or inpatient diabetes diagnosis and ≥2 prescriptions for any anti-diabetes medications or (b) records of ≥2 claims for an outpatient or inpatient diabetes diagnosis that were at least 30 days apart. Annual prevalence of diabetes and 95% confidence intervals (CIs) were calculated. Age-, sex-, and race-stratified prevalence were also assessed.

RESULTS

The annual prevalence of T1DM increased from 1.29 to 2.34/1000 pediatric persons from 2002 to 2016. The prevalence of T2DM rose from 0.70 in 2002 to 2.76/1000 in 2011, but then dropped to 2.12/1000 pediatric persons in 2016 in the Medicaid population. Prevalence of both T1DM and T2DM increased with age. While the prevalence of T1DM was similar in both sexes, and was most prevalent in Whites, prevalence of T2DM was higher in girls and was most prevalent in Blacks.

CONCLUSIONS

While the annual prevalence of T1DM in pediatric persons enrolled in Medicaid increased continuously from 2002 to 2016, the annual prevalence of T2DM increased from 2002 to 2011, with a subsequent decrease in 2016, possibly because of the increase of relatively healthier participants with the expanded eligibility through the ACA between 2011 and 2016.

Promoting Small Business Support of Youth Physical Activity in Low-Income, Minority Neighborhoods: Protocol for a Randomized Controlled Trial

Background

An unacceptably high percentage of our nation’s low-income, minority youth (age<18 years) are not regularly physically active. One reason for this could be their lack of access to quality youth physical activity opportunities (YPAOs). Our previous research found that small businesses (<500 employees), which represent over 99.64% (27.9/28.0 million businesses in United States) of all employers, are powerful resources for creating and improving YPAOs. In accordance with the socioecological model and established philanthropic principles, we developed an alpha version of an intervention (alpha-i) for increasing small businesses’ involvement with YPAOs.

Objective

The aims of this proposed study are to (1) create a beta version (beta-i) of the intervention and (2) conduct a pilot study of its impact on small business support for YPAOs and YPAO utilization by the youth in low-income, minority neighborhoods.

Methods

The alpha-i will be refined using information from focus groups and surveys conducted with small business owners and managers, YPAO providers, and parents and guardians of the youths from low-income, predominantly minority neighborhoods. A cluster randomized controlled trial will then be conducted for 1 year to examine the effects of the refined intervention (beta-i) on small business support for YPAOs in 10 low-income, minority neighborhoods. The control group of neighborhoods (n=10) will be provided with a standard practice intervention. The primary outcome for aim 2 will be the percentage of small businesses not supporting YPAOs at baseline that subsequently provide support for YPAOs at follow-up. We also will consider the US dollar equivalent of all types of support (monetary, goods/services, and time) donated for YPAOs by small businesses. In addition, we will examine the impact of the increased small business support for YPAOs on YPAO utilization by the youth.

Results

As of May 1, 2019, all YPAOs and small businesses in the study neighborhoods have been identified, and surveys have begun with these groups. In addition, 9 focus groups were completed, and the data have been transcribed. We anticipate that manuscripts regarding these aspects of the study will be submitted in fall 2019.

Conclusions

The proposed study is significant because it will provide evidence that an easily replicated approach can be used to increase small business support for YPAOs and that this support results in greater use of the YPAOs by youth. A logical next step will be to determine if YPAO changes resulting from increased small business support positively influence youth physical activity levels.

ClinicalTrial

ClinicalTrials.gov NCT03936582; https://clinicaltrials.gov/ct2/show/NCT03936582.

International Registered Report Identifier (IRRID)

DERR1-10.2196/13141

Racial and ethnic differences in cardiovascular disease and outcome in type 1 diabetes patients

INTRODUCTION

Type 1 diabetes mellitus (T1DM) has increased dramatically over the last two decades with global variation greater than 350-fold difference reflecting the ethnic, racial, and geographical variation. Diabetic patients remain at a higher risk of cardiovascular mortality than those without diabetes. Therefore, it is vital for clinicians to have in-depth knowledge of T1DM statistics and their impact on people health and health resources.

AREAS COVERED

This review will cover the epidemiologic characteristics of T1DM and the influence of race, ethnicity, and geographical variation on the incidence and the outcome. The minority populations health disparities in the clinical presentation and outcomes among youth with T1DM, the long-term glycemic control patterns in racially and ethnically diverse youth, and the long-term influence of these factors on cardiovascular outcomes will be elucidated. The PubMed database was searched using the terms: T1DM ± incidence, Race, ethnicity, and Genetic.

EXPERT OPINION

Understanding the epidemiological characteristics of T1DM including race, ethnicity and the genetic predisposition will help to develop guidelines target these higher risk patients of an unfavorable outcome. Further research and interventional strategies to identify infants at genetic risk of T1DM may help to prevent, stop or retard the destructive autoimmune process leading to T1DM.

Black Immigrants from Africa and the Caribbean Have Similar Rates of Diabetes but Africans Are Less Obese: the New York City Community Health Survey 2009-2013

OBJECTIVE

This study was designed to determine (a) whether the prevalence and odds of either obesity or diabetes differed in foreign-born black Africans and Caribbeans living in New York City (NYC) and (b) whether time in the United States (US) affected odds of either outcome.

METHODS

Data were obtained from NYC Community Health Survey 2009-13 for 380 African-born blacks and 2689 Caribbean-born blacks. Weighted logistic regression estimated odds of obesity and diabetes, adjusting for age, sex, education, income, marital status, children < 18, BMI (diabetes models only), and time in the US.

RESULTS

Obesity prevalence in Africans (60.2%, male; age, 46.0 ± 13.5 years, (mean ± SD); BMI, 27.3 ± 5.6 kg/m2) was 16.7 and 30.2% in Caribbeans (39.3%, male; age, 49.7 ± 14.7 years; BMI, 28.0 ± 5.8 kg/m2). Prevalence of diabetes was 10.5% in Africans and 14.7% in Caribbeans. Africans had lower adjusted odds of obesity (aOR = 0.60 (95% CI, 0.40-0.90); P = 0.015), but there was no difference in diabetes odds between groups. Obesity odds were higher in African (aOR = 2.35 (95% CI, 1.16-4.78); P = 0.018) and Caribbean women (aOR = 2.20 (95% CI, 1.63-2.98); P < 0.001) than their male counterparts. Odds of diabetes did not differ between sexes in either group. Time in the US did not affect odds of either obesity or diabetes.

CONCLUSIONS

Africans living in NYC are less obese than Caribbeans, but odds of diabetes do not differ. Time in the US does not affect odds of either obesity or diabetes. Hence, BMI and diabetes risk profiles in blacks differ by region of origin and combining foreign-born blacks into one group masks important differences.

The Continuing Evolution of Precision Health in Type 2 Diabetes: Achievements and Challenges

PURPOSE OF REVIEW

The purpose of this review was to summarize recent advances in the genomics of type 2 diabetes (T2D) and to highlight current initiatives to advance precision health.

RECENT FINDINGS

Generation of multi-omic data to measure each of the "biologic layers," developments in describing genomic function and annotation in T2D relevant tissue, along with the increasing recognition that T2D is a heterogeneous disease, and large-scale collaborations have all contributed to advancing our understanding of the molecular basis of T2D. Substantial advances have been made in understanding the molecular basis of T2D pathogenesis, such that precision health diabetes is increasingly becoming a reality. For precision diabetes to become a routine in clinical and public health, additional large-scale multi-omic initiatives are needed along with better assessment of our environment to delineate an individual's diabetes subtype for improved detection and management.

2017 National Standards for Diabetes Self-Management Education and Support

PURPOSE

The purpose of this study is to review the literature for Diabetes Self-Management Education and Support (DSMES) to ensure the National Standards for DSMES (Standards) align with current evidence-based practices and utilization trends.

METHODS

The 10 Standards were divided among 20 interdisciplinary workgroup members. Members searched the current research for diabetes education and support, behavioral health, clinical, health care environment, technical, reimbursement, and business practice for the strongest evidence that guided the Standards revision.

RESULTS

Diabetes Self-Management Education and Support facilitates the knowledge, skills, and ability necessary for diabetes self-care as well as activities that assist a person in implementing and sustaining the behaviors needed to manage their condition on an ongoing basis. The evidence indicates that health care providers and people affected by diabetes are embracing technology, and this is having a positive impact of DSMES access, utilization, and outcomes.

CONCLUSION

Quality DSMES continues to be a critical element of care for all people with diabetes. The DSMES services must be individualized and guided by the concerns, preferences, and needs of the person affected by diabetes. Even with the abundance of evidence supporting the benefits of DSMES, it continues to be underutilized, but as with other health care services, technology is changing the way DSMES is delivered and utilized with positive outcomes.

Blood-based bioenergetic profiling is related to differences in brain morphology in African Americans with Type 2 diabetes

Blood-based bioenergetic profiling has promising applications as a minimally invasive biomarker of systemic bioenergetic capacity. In the present study, we examined peripheral blood mononuclear cell (PBMC) mitochondrial function and brain morphology in a cohort of African Americans with long-standing Type 2 diabetes. Key parameters of PBMC respiration were correlated with white matter, gray matter, and total intracranial volumes. Our analyses indicate that these relationships are primarily driven by the relationship of systemic bioenergetic capacity with total intracranial volume, suggesting that systemic differences in mitochondrial function may play a role in overall brain morphology.

Association of Race and Ethnicity With Glycemic Control and Hemoglobin A1c Levels in Youth With Type 1 Diabetes

IMPORTANCE

Health disparities in the clinical presentation and outcomes among youth with type 1 diabetes exist. Long-term glycemic control patterns in racially/ethnically diverse youth are not well described.

OBJECTIVES

To model common trajectories of hemoglobin A1c (HbA1c) among youth with type 1 diabetes and test how trajectory group membership varies by race/ethnicity.

DESIGN SETTING AND PARTICIPANTS

Longitudinal cohort study conducted in 5 US locations. The analysis included data from 1313 youths (aged <20 years) newly diagnosed in 2002 through 2005 with type 1 diabetes in the SEARCH for Diabetes in Youth study (mean [SD] age at diabetes onset, 8.9 [4.2] years) who had 3 or more HbA1c study measures during 6.1 to 13.3 years of follow-up. Data were analyzed in 2017.

EXPOSURES

Self-reported race/ethnicity.

MAIN OUTCOMES AND MEASURES

Hemoglobin A1c trajectories identified through group-based trajectory modeling over a mean (SD) of 9.0 (1.4) years of diabetes duration. Multinomial models studied the association of race/ethnicity with HbA1c trajectory group membership, adjusting for demographic characteristics, clinical factors, and socioeconomic position.

RESULTS

The final study sample of 1313 patients was 49.3% female (647 patients) with mean (SD) age 9.7 (4.3) years and mean (SD) disease duration of 9.2 (6.3) months at baseline. The racial/ethnic composition was 77.0% non-Hispanic white (1011 patients), 10.7% Hispanic (140 patients), 9.8% non-Hispanic black (128 patients), and 2.6% other race/ethnicity (34 patients). Three HbA1c trajectories were identified: group 1, low baseline and mild increases (50.7% [666 patients]); group 2, moderate baseline and moderate increases (41.7% [548 patients]); and group 3, moderate baseline and major increases (7.5% [99 patients]). Group 3 was composed of 47.5% nonwhite youths (47 patients). Non-Hispanic black youth had 7.98 higher unadjusted odds (95% CI, 4.42-14.38) than non-Hispanic white youth of being in the highest HbA1c trajectory group relative to the lowest HbA1c trajectory group; the association remained significant after full adjustment (adjusted odds ratio of non-Hispanic black race in group 3 vs group 1, 4.54; 95% CI, 2.08-9.89). Hispanic youth had 3.29 higher unadjusted odds (95% CI, 1.78-6.08) than non-Hispanic white youth of being in the highest HbA1c trajectory group relative to the lowest HbA1c trajectory group; the association remained significant after adjustment (adjusted odds ratio of Hispanic ethnicity in group 3 vs group 1, 2.24; 95% CI, 1.02-4.92). In stratified analyses, the adjusted odds of nonwhite membership in the highest HbA1c trajectory remained significant among male patients and youth diagnosed at age 9 years or younger, but not female patients and youth who were older than 9 years when they were diagnosed (P for interaction = .04 [sex] and .02 [age at diagnosis]).

CONCLUSIONS AND RELEVANCE

There are racial/ethnic differences in long-term glycemic control among youth with type 1 diabetes, particularly among nonwhite male patients and nonwhite youth diagnosed earlier in life.

Role of Social Factors in Glycemic Control Among African American Children and Adolescents with Type 1 Diabetes

OBJECTIVE

With the rising incidence of Type 1 diabetes (T1DM), it is important to recognize deficiencies in care and areas of improvement to provide better access to resources and education for T1DM patients. The objective of this study was to recognize social factors and compliance barriers affecting glycated hemoglobin (A1c) level in T1D patients among the minority population.

METHODS

A total of 84 T1DM patients, ages 3 to 21 years, 49% males, 87% African American participated in the study. Study questionnaires assessing patient knowledge and other variables were distributed and patient charts were reviewed retrospectively to obtain relevant clinical data. T-tests, one-way ANOVA and spearman correlation were used for analysis.

RESULTS

Mean A1c in our study was 10.5% and mean knowledge score was 10.1 out of 14. There was no significant correlation (r = 0.12, p = 0.26) between A1c and patients' knowledge scores. Patients with more frequent blood sugar (BS) monitoring (3-4 times/day) had 2 points lower A1c (9.6 vs 11.6 %, 95% CI 0.2-3.7, p = 0.03) than those with 2 or less times/day. No significant difference in A1c between 3-4 checks/day vs >4 checks/day BS checks. Most patients reported 'forgetfulness' (19%) followed by 'too time consuming' (17.9%) as barriers to daily BS monitoring. There was no significant difference in A1c between pen or pump users (10.5 vs 10.2 %, p = 0.55). Surprisingly, those with home supervision had higher A1c than those without (10.7 vs 9.6 %, p = 0.04) while there was no significant difference between those with or without nurse supervision at school (10.6 vs 9.8 %, p = 0.33). Those reporting happy mood interestingly had higher A1c than those with sad/depressed mood (10.7 vs 9.4 %, p = 0.04). On multiple linear regression analysis, frequency of BS checks, home supervision and mood were the most significant predictors of A1c and altogether explained 20% of the variability in A1c.

CONCLUSION

Frequent BS monitoring is associated with lower A1c. Supervision at home and school did not improve A1c, but it was self-reported information. Mood did not affect A1c contrary to that reported in other studies.

Mortality in youth-onset type 1 and type 2 diabetes: The SEARCH for Diabetes in Youth study

AIMS

To estimate short-term mortality rates for individuals with type 1 or type 2 diabetes diagnosed before age 20 years from the SEARCH for Diabetes in Youth study.

METHODS

We included 8358 individuals newly-diagnosed with type 1 (n = 6840) or type 2 (n = 1518) diabetes from 1/1/2002-12/31/2008. We searched the National Death Index through 12/31/2010. We calculated standardized mortality ratios (SMRs) based on age, sex, and race for the comparable US population in the geographic areas of the SEARCH study.

RESULTS

During 44,893 person-years (PY) of observation (median follow-up = 5.3 years), 41 individuals died (91.3 deaths/100,000 PY); 26 with type 1 (70.6 deaths/100,000 PY) and 15 with type 2 (185.6 deaths/100,000 PY) diabetes. The expected mortality rate was 70.9 deaths/100,000 PY. The overall SMR (95% CI) was 1.3 (1.0, 1.8) and was high among individuals with type 2 diabetes 2.4 (1.3, 3.9), females 2.2 (1.3, 3.3), 15-19 year olds 2.7 (1.7,4.0), and non-Hispanic blacks 2.1 (1.2, 3.4).

CONCLUSIONS

Compared to the state populations of similar age, sex, and race, our results show excess mortality in individuals with type 2 diabetes, females, older youth, and non-Hispanic blacks. We did not observe excess short-term mortality in individuals with type 1 diabetes.

Racial/Ethnic Minority Youth With Recent-Onset Type 1 Diabetes Have Poor Prognostic Factors

OBJECTIVE

To compare races/ethnicities for characteristics, at type 1 diabetes diagnosis and during the first 3 years postdiagnosis, known to influence long-term health outcomes.

RESEARCH DESIGN AND METHODS

We analyzed 927 Pediatric Diabetes Consortium (PDC) participants <19 years old (631 non-Hispanic white [NHW], 216 Hispanic, and 80 African American [AA]) diagnosed with type 1 diabetes and followed for a median of 3.0 years (interquartile range 2.2-3.6). Demographic and clinical data were collected from medical records and patient/parent interviews. Partial remission period or "honeymoon" was defined as insulin dose-adjusted hemoglobin A_1c (IDAA1c) ≤9.0%. We used logistic, linear, and multinomial regression models, as well as repeated-measures logistic and linear regression models. Models were adjusted for known confounders.

RESULTS

AA subjects, compared with NHW, at diagnosis, were in a higher age- and sex-adjusted BMI percentile (BMI%), had more advanced pubertal development, and had higher frequency of presentation in diabetic ketoacidosis, largely explained by socioeconomic factors. During the first 3 years, AA subjects were more likely to have hypertension and severe hypoglycemia events; had trajectories with higher hemoglobin A_1c, BMI%, insulin doses, and IDAA1c; and were less likely to enter the partial remission period. Hispanics, compared with NHWs, had higher BMI% at diagnosis and over the three subsequent years. During the 3 years postdiagnosis, Hispanics had higher prevalence of dyslipidemia and maintained trajectories of higher insulin doses and IDAA1c.

CONCLUSIONS

Youth of minority race/ethnicity have increased markers of poor prognosis of type 1 diabetes at diagnosis and 3 years postdiagnosis, possibly contributing to higher risk of long-term diabetes complications compared with NHWs.

Identifying Geographic Disparities in Diabetes Prevalence Among Adults and Children Using Emergency Claims Data

Geographic surveillance can identify hotspots of disease and reveal associations between health and the environment. Our study used emergency department surveillance to investigate geographic disparities in type 1 and type 2 diabetes prevalence among adults and children. Using all-payer emergency claims data from 2009 to 2013, we identified unique New York City residents with diabetes and geocoded their location using home addresses. Geospatial analysis was performed to estimate diabetes prevalence by New York City Census tract. We also used multivariable regression to identify neighborhood-level factors associated with higher diabetes prevalence. We estimated type 1 and type 2 diabetes prevalence at 0.23% and 10.5%, respectively, among adults and 0.20% and 0.11%, respectively, among children in New York City. Pediatric type 1 diabetes was associated with higher income (P = 0.001), whereas adult type 2 diabetes was associated with lower income (P < 0.001). Areas with a higher proportion of nearby restaurants categorized as fast food had a higher prevalence of all types of diabetes (P < 0.001) except for pediatric type 2 diabetes. Type 2 diabetes among children was only higher in neighborhoods with higher proportions of African American residents (P < 0.001). Our findings identify geographic disparities in diabetes prevalence that may require special attention to address the specific needs of adults and children living in these areas. Our results suggest that the food environment may be associated with higher type 1 diabetes prevalence. However, our analysis did not find a robust association with the food environment and pediatric type 2 diabetes, which was predominantly focused in African American neighborhoods.

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.

2017 National Standards for Diabetes Self-Management Education and Support

Purpose

The purpose of this study is to review the literature for Diabetes Self-Management Education and Support (DSMES) to ensure the National Standards for DSMES (Standards) align with current evidence-based practices and utilization trends.

Methods

The 10 Standards were divided among 20 interdisciplinary workgroup members. Members searched the current research for diabetes education and support, behavioral health, clinical, health care environment, technical, reimbursement, and business practice for the strongest evidence that guided the Standards revision.

Results

Diabetes Self-Management Education and Support facilitates the knowledge, skills, and ability necessary for diabetes self-care as well as activities that assist a person in implementing and sustaining the behaviors needed to manage their condition on an ongoing basis. The evidence indicates that health care providers and people affected by diabetes are embracing technology, and this is having a positive impact of DSMES access, utilization, and outcomes.

Conclusion

Quality DSMES continues to be a critical element of care for all people with diabetes. The DSMES services must be individualized and guided by the concerns, preferences, and needs of the person affected by diabetes. Even with the abundance of evidence supporting the benefits of DSMES, it continues to be underutilized, but as with other health care services, technology is changing the way DSMES is delivered and utilized with positive outcomes.

Resveratrol attenuates testicular apoptosis in type 1 diabetic mice: Role of Akt-mediated Nrf2 activation and p62-dependent Keap1 degradation

Infertility is a common complication in diabetic men, mainly due to the loss of germ cells by apoptotic cell death. However, effective and safe approaches to prevent diabetic induction of testicular apoptosis for diabetic patients have not been available. Resveratrol (RSV), a group of compounds called polyphenols from plants, has been indicated its promising used clinically for cancers and cardiovascular diseases. Therefore, the present study aimed determining whether RSV attenuates type 1 diabetes (T1D)-induced testicular apoptotic cell death in a mouse model. We found that testicular apoptosis and oxidative stress levels were significantly higher in T1D mice than control mice. In addition, the phosphorylation level of metabolism-related Akt and GSK-3β was downregulated and Akt negative regulators PTEN, PTP1B and TRB3 were upregulated in the T1D group. These effects were partially prevented by RSV treatment. Nrf2 and its downstream genes, such as NQO-1, HO-1, SOD, catalase and metallothionein were significantly upregulated by RSV treatment. In addition, RSV-induced Nrf2 activation was found due to Keap1 degradation, mainly reliant on p62 that functions as an adaptor protein during autophagy. These results indicate that the attenuation of T1D-induced testicular oxidative stress and apoptosis by RSV treatment was mainly related to Akt-mediated Nrf2 activation via p62-dependent Keap1 degradation.

•

First evidence for the resveratrol (RSV) protection from T1D-induced male germ cell apoptosis.

•

Nrf2 up-regulation and activation plays important role in RSV testis protection from diabetes.

•

RVS activation of Nrf2 may be due to p62-dependent autophagic degradation of Keap1.

2017 National Standards for Diabetes Self-Management Education and Support

This article was copublished in Diabetes Care 2017;40:1409-1419 and The Diabetes Educator 2017;43:449-464 and is reprinted with permission. The previous version of this article, also copublished in Diabetes Care and The Diabetes Educator, can be found at Diabetes Care 2012;35:2393-2401 (https://doi.org/10.2337/dc12-1707).

Racial and ethnic differences among children with new-onset autoimmune Type 1 diabetes

AIM

To compare demographic and clinical characteristics among children from ethnic minorities and non-Hispanic white children with new-onset autoimmune Type 1 diabetes.

METHODS

We analysed a single-centre series of 712 children with new-onset autoimmune Type 1 diabetes between January 2008 and March 2011. The median (range) age was 9.7 (0.3-18.1) years, the mean (sd) BMI percentile was 69.7 (25.4) and 48.3% of the cohort were girls. The cohort comprised 57.3% non-Hispanic white, 20.5% Hispanic and 14.8% African-American children, and 7.4% were of other, mixed or unknown race.

RESULTS

The Hispanic subgroup, compared with non-Hispanic white subgroup, had a higher mean (sd) C-peptide level [0.82 (1.62) vs 0.55 (0.47) ng/ml; P=0.004), and a greater proportion of children with elevated BMI (overweight or obesity; 49.6% vs 32.5%; P<0.001) and diabetic ketoacidosis (51.8% vs 38.2%; P=0.006). The African-American group had a higher mean (sd) glucose level [24.4 (12.8) vs 21.4 (10.7) mmol/l; P=0.017], a greater proportion of children with ketoacidosis (56.7% vs 38.2%; P=0.001), a greater proportion with elevated BMI (52.9% vs 32.5%; P<0.001), and a lower proportion of children at pre-pubertal stage (49.0% vs 61.6%; P=0.01), and tended to have higher C-peptide levels [0.65 (0.59) vs 0.55 [0.47] ng/ml; P=0.079) compared with the non-Hispanic white children. The differences in C-peptide levels compared with non-Hispanic white children persisted for Hispanic (P=0.01) but not African-American children (P=0.29) after adjustment for age, sex, BMI, ketoacidosis, glucose, Tanner stage and autoantibody number.

CONCLUSION

At the onset of paediatric autoimmune Type 1 diabetes, Hispanic, but not African-American children had higher C-peptide levels, after adjustment for potential confounders, compared with non-Hispanic white children. These findings suggest that ethnicity may contribute to the heterogeneity of Type 1 diabetes pathogenesis, with possible implications for intervention.

A Comprehensive Survey of the Roles of Highly Disordered Proteins in Type 2 Diabetes

Type 2 diabetes mellitus (T2DM) is a chronic and progressive disease that is strongly associated with hyperglycemia (high blood sugar) related to either insulin resistance or insufficient insulin production. Among the various molecular events and players implicated in the manifestation and development of diabetes mellitus, proteins play several important roles. The Kyoto Encyclopedia of Genes and Genomes (KEGG) database has information on 34 human proteins experimentally shown to be related to the T2DM pathogenesis. It is known that many proteins associated with different human maladies are intrinsically disordered as a whole, or contain intrinsically disordered regions. The presented study shows that T2DM is not an exception to this rule, and many proteins known to be associated with pathogenesis of this malady are intrinsically disordered. The multiparametric bioinformatics analysis utilizing several computational tools for the intrinsic disorder characterization revealed that IRS1, IRS2, IRS4, MAFA, PDX1, ADIPO, PIK3R2, PIK3R5, SoCS1, and SoCS3 are expected to be highly disordered, whereas VDCC, SoCS2, SoCS4, JNK9, PRKCZ, PRKCE, insulin, GCK, JNK8, JNK10, PYK, INSR, TNF-α, MAPK3, and Kir6.2 are classified as moderately disordered proteins, and GLUT2, GLUT4, mTOR, SUR1, MAPK1, IKKA, PRKCD, PIK3CB, and PIK3CA are predicted as mostly ordered. More focused computational analyses and intensive literature mining were conducted for a set of highly disordered proteins related to T2DM. The resulting work represents a comprehensive survey describing the major biological functions of these proteins and functional roles of their intrinsically disordered regions, which are frequently engaged in protein–protein interactions, and contain sites of various posttranslational modifications (PTMs). It is also shown that intrinsic disorder-associated PTMs may play important roles in controlling the functions of these proteins. Consideration of the T2DM proteins from the perspective of intrinsic disorder provides useful information that can potentially lead to future experimental studies that may uncover latent and novel pathways associated with the disease.

Comparative analyses of population-scale phenomic data in electronic medical records reveal race-specific disease networks

Motivation: Underrepresentation of racial groups represents an important challenge and major gap in phenomics research. Most of the current human phenomics research is based primarily on European populations; hence it is an important challenge to expand it to consider other population groups. One approach is to utilize data from EMR databases that contain patient data from diverse demographics and ancestries. The implications of this racial underrepresentation of data can be profound regarding effects on the healthcare delivery and actionability. To the best of our knowledge, our work is the first attempt to perform comparative, population-scale analyses of disease networks across three different populations, namely Caucasian (EA), African American (AA) and Hispanic/Latino (HL).

Results: We compared susceptibility profiles and temporal connectivity patterns for 1988 diseases and 37 282 disease pairs represented in a clinical population of 1 025 573 patients. Accordingly, we revealed appreciable differences in disease susceptibility, temporal patterns, network structure and underlying disease connections between EA, AA and HL populations. We found 2158 significantly comorbid diseases for the EA cohort, 3265 for AA and 672 for HL. We further outlined key disease pair associations unique to each population as well as categorical enrichments of these pairs. Finally, we identified 51 key ‘hub’ diseases that are the focal points in the race-centric networks and of particular clinical importance. Incorporating race-specific disease comorbidity patterns will produce a more accurate and complete picture of the disease landscape overall and could support more precise understanding of disease relationships and patient management towards improved clinical outcomes.

Contacts: rong.chen@mssm.edu or joel.dudley@mssm.edu

Supplementary information:Supplementary data are available at Bioinformatics online.

2017 National Standards for Diabetes Self-Management Education and Support

Purpose The purpose of this study is to review the literature for Diabetes Self-Management Education and Support (DSMES) to ensure the National Standards for DSMES (Standards) align with current evidence-based practices and utilization trends. Methods The 10 Standards were divided among 20 interdisciplinary workgroup members. Members searched the current research for diabetes education and support, behavioral health, clinical, health care environment, technical, reimbursement, and business practice for the strongest evidence that guided the Standards revision. Results Diabetes Self-Management Education and Support facilitates the knowledge, skills, and ability necessary for diabetes self-care as well as activities that assist a person in implementing and sustaining the behaviors needed to manage their condition on an ongoing basis. The evidence indicates that health care providers and people affected by diabetes are embracing technology, and this is having a positive impact of DSMES access, utilization, and outcomes. Conclusion Quality DSMES continues to be a critical element of care for all people with diabetes. The DSMES services must be individualized and guided by the concerns, preferences, and needs of the person affected by diabetes. Even with the abundance of evidence supporting the benefits of DSMES, it continues to be underutilized, but as with other health care services, technology is changing the way DSMES is delivered and utilized with positive outcomes.

Treating Mental Illness Among Diabetic Black Male Adolescents: A Review

OBJECTIVE

To examine randomized controlled trials (RCTs) for treatment evidence for Black male adolescents suffering from comorbid mental illness and diabetes mellitus.

METHOD

A review of the studies published in English-language journals was conducted.

RESULTS

We found no RCT focused on Black males with diabetes mellitus Type 2 (DMT2). However, we found RCT inclusive of Black male adolescents with diabetes mellitus Type 1 (DMT1). Multisystemic therapy appears to be the best supported overall treatment for DMT1 management and psychosocial functioning followed by an enhanced form of behavioral family systems therapy for diabetics. Metformin was the only treatment in this review noted for use within DMT2. Metformin and a nursing-based telephone case management intervention realized utility as secondary services.

CONCLUSIONS

There are gaps present for what effectively treats comorbid mental illness and DMT2 in Black male adolescents. For comorbid mental illness and DMT1, there are gaps in additional efficacious treatments, effectiveness across conditions, and effect duration beyond 24 months.

Correlates of Medication Adherence in the TODAY Cohort of Youth With Type 2 Diabetes

OBJECTIVE

To identify factors that predict medication adherence and to examine relationships among adherence, glycemic control, and indices of insulin action in TODAY (Treatment Options for Type 2 Diabetes in Adolescents and Youth).

RESEARCH DESIGN AND METHODS

A total of 699 youth 10-17 years old with recent-onset type 2 diabetes and ≥80% adherence to metformin therapy for ≥8 weeks during a run-in period were randomized to receive one of three treatments. Participants took two study pills twice daily. Adherence was calculated by pill count from blister packs returned at visits. High adherence was defined as taking ≥80% of medication; low adherence was defined as taking <80% of medication. Depressive symptoms, insulin sensitivity (1/fasting insulin), insulinogenic index, and oral disposition index (oDI) were measured. Survival analysis examined the relationship between medication adherence and loss of glycemic control. Generalized linear mixed models analyzed trends in adherence over time.

RESULTS

In this low socioeconomic cohort, high and low adherence did not differ by sex, age, family income, parental education, or treatment group. Adherence declined over time (72% high adherence at 2 months, 56% adherence at 48 months, P < 0.0001). A greater percentage of participants with low adherence had clinically significant depressive symptoms at baseline (18% vs. 12%, P = 0.0415). No adherence threshold predicted the loss of glycemic control. Longitudinally, participants with high adherence had significantly greater insulin sensitivity and oDI than those with low adherence.

CONCLUSIONS

In the cohort, the presence of baseline clinically significant depressive symptoms was associated with subsequent lower adherence. Medication adherence was positively associated with insulin sensitivity and oDI, but, because of disease progression, adherence did not predict long-term treatment success.

Prescribing Patterns for Outpatient Treatment of Constipation, Irritable Bowel Syndrome-Related Constipation, and Opioid-Induced Constipation: A Retrospective Cross-Sectional Study

BACKGROUND

Despite national recommendations for treatment of constipation, prescribing patterns for treatment are inconsistent, and health care utilization has increased.

OBJECTIVE

To identify patterns in pharmacologic and nonpharmacologic treatment of constipation and associations between treatment and other variables across age groups.

METHODS

This was a retrospective cross-sectional study that used the National Ambulatory Medical Care Survey (NAMCS) to compare prescribing from 2000 to 2004 and from 2005 to 2009. Treatment patterns for constipation, irritable bowel syndrome-related constipation (IBS-C), and opioid-induced constipation were considered.

RESULTS

From 2000 to 2009, there were 89.6 million office visits related to constipation: 63.4 million for constipation alone, 28.2 million for IBS-C alone, and 3.7 million for opioid-induced constipation. For constipation, there was an overall decrease in the prescription of combination therapy (17% vs. 11%, P  less than  0.05); an increase in the prescription of medication monotherapy (21% vs. 29%, P  less than  0.05); decreases in the use of lubricants (9% vs. 2%, P  less than  0.05) and saline (7% vs. 1%, P  less than   0.001) among patients aged less than  18 years; a decrease in combination therapy (31% vs. 17%, P  less than  0.05); and age group differences in the prescription of specific medications. For IBS-C and opioid-induced constipation, there were no changes in major treatment category or specific medication. Age, gender, race, ethnicity, payer source, physician specialty, and region were all found to be associated with treatment choice.

CONCLUSIONS

Health care utilization for constipation increased, and prescribing patterns shifted significantly from 2000 to 2009 for constipation and IBS-C. Patterns in treatment were significantly influenced by many factors, including age, gender, and race. Changes in treatment categories over time included a decrease in combination therapy for patients aged less than  18 years and an increase in medication monotherapy for all ages, which are in contrast to national recommendations.