The Longitudinal Influence of Social Determinants of Health on Glycemic Control in Elderly Adults With Diabetes

Independent Correlates of Glycemic Control among Adults with Diabetes in South Africa

BACKGROUND

Globally, the prevalence of diabetes is increasing, especially in low- and middle-income countries (LMICs), including those in the sub-Saharan African region. However, the independent socioeconomic correlates of glycemic control as measured by hemoglobin A1C have yet to be identified. Therefore, the aim of this analysis was to understand the independent correlates of glycemic control in South Africa.

METHODS

Data from the 2016 South Africa Demographic and Health Survey on adults with diabetes were used for this analysis. The dependent variable, glycemic control, was defined using hemoglobin A1c (HbA1c). Independent variables included: age, gender, ethnicity, marital status, region, urban/rural residence, ability to read, education, insurance, wealth, occupation, and employment in the last year. Analysis of variance was used to test for differences in mean HbA1c for each category of all independent variables, and a fully adjusted linear regression model was used to identify independent correlates of glycemic control (HbA1c).

RESULTS

Among the 772 people included in this analysis, there were significant differences in mean HbA1c by age (p < 0.001), ethnicity (p < 0.001), place of residence (p = 0.024), wealth index (p = 0.001), and employment in the last year (p = 0.008). Independent correlates of HbA1c included age, ethnicity, and wealth index.

CONCLUSIONS

This study used data from a large diverse population with a high prevalence of diabetes in sub-Saharan Africa and provides new evidence on the correlates of glycemic control and potential targets for interventions designed to lower HbA1c and improve diabetes-related health outcomes of adults in South Africa.

Identifying Individuals with Highest Social Risk in Adults with Type 2 Diabetes Using Item Response Theory

OBJECTIVE

The aim of this analysis was to create a parsimonious tool to screen for high social risk using item response theory to discriminate across social risk factors in adults with type 2 diabetes.

METHODS

Cross-sectional data of 615 adults with diabetes recruited from two primary care clinics were used. Participants completed assessments including validated scales on economic instability (financial hardship), neighborhood and built environment (crime, violence, neighborhood rating), education (highest education, health literacy), food environment (food insecurity), social and community context (social isolation), and psychological risk factors (perceived stress, depression, serious psychological distress, diabetes distress). Item response theory (IRT) models were used to understand the association between a participant's underlying level of a particular social risk factor and the probability of that response. A two-parameter logistic IRT model was used with each of the 12 social determinant factors being added as a separate parameter in the model. Higher values in item discrimination indicate better ability of a specific social risk factor in differentiating participants from each other.

RESULTS

Rate of crime reported in a neighborhood (discrimination 3.13, SE 0.50; item difficulty - 0.68, SE 0.07) and neighborhood rating (discrimination 4.02, SE 0.87; item difficulty - 1.04, SE 0.08) had the highest discrimination.

CONCLUSIONS

Based on these findings, crime and neighborhood rating discriminate best between individuals with type 2 diabetes who have high social risk and those with low social risk. These two questions can be used as a parsimonious social risk screening tool to identify high social risk.

Combining zip code-based population data and pharmacy administrative claims data to create measures of social determinants of health

BACKGROUND

Social determinants of health (SDoH) are key factors that impact health outcomes. However, there are many barriers to collecting SDoH data (eg, cost of data collection, technological barriers, and lack of standardized measures). Population data may provide an accessible alternative to collecting SDoH data for patients.

OBJECTIVE

To explain how population data can be leveraged to create SDoH measures, assess the association of population SDoH measures with diabetic medication adherence, and discuss how understanding a patient's SDoH can inform care plans and patient engagement.

METHODS

A nationally representative commercial sample of patients who were aged 18 years and older and met Pharmacy Quality Alliance inclusion criteria for diabetes mellitus were analyzed (N = 37,789). US Census and North American Industry Classification System data were combined with pharmacy administrative claims data to create SDoH measures. Derived measures represent 2 SDoH domains: (1) economic stability (housing density, housing relocation, jobs per resident, and average salary) and (2) health care access and quality (urban/rural classification, distance traveled to prescriber and pharmacy, use of a primary care provider [PCP], and residents per PCP). The association of population SDoH measures with diabetic medication adherence (proportion of days covered) was assessed via logistic regression, which included covariates (eg, sex, age, comorbidities, and prescription plan attributes).

RESULTS

As housing density (houses per resident) increased, so did the likelihood of adherence (odds ratio = 1.54, 95% CI = 1.21-1.97, P = 0.001). Relative to patients who did not move, patients who moved once had 0.87 (95% CI = 0.81-0.93, P < 0.001) the odds of being adherent, and patients who moved 2 or more times had 0.82 (95% CI = 0.71-0.95, P = 0.008) the odds of being adherent. Compared with areas with fewer jobs per resident, patients living within a zip code with 0.16 to 0.26 jobs per resident were 1.12 (95% CI = 1.04-1.20, P = 0.002) times more likely to be adherent. Patients who lived in an urban cluster were 1.11 (95% CI = 1.01-1.22, P = 0.037) times more likely to be adherent than patients living in a rural area. Patients who travel at least 25 miles to their prescriber had 0.82 (95% CI = 0.77-0.86, P < 0.001) the odds of being adherent. Community pharmacy users had 0.65 (95% CI = 0.59-0.71, P < 0.001) the odds of being adherent compared with mail order pharmacy users. Patients who had a PCP were 1.26 (95% CI = 1.18-1.34, P < 0.001) times more likely to be adherent to their medication.

CONCLUSIONS

Leveraging publicly available population data to create SDoH measures is an accessible option to overcome barriers to SDoH data collection. Derived measures can be used to increase equity in care received by identifying patients who could benefit from assistance with medication adherence.

Role of Insulin Use and Social Determinants of Health on Non-melanoma Skin Cancer: Results From the Behavioral Risk Factor Surveillance System

BACKGROUND

Non-melanoma skin cancer (NMSC) is a frequent type of malignancy with a steadily increasing incidence rate worldwide. Although NMSC was shown to be associated with diabetes, no studies have addressed the extent to which insulin use influences the risk of NMSC in light of social determinants of health (SDOH). We conducted a quantitative study that examined the interplay between insulin use, SDOH, additional covariates, and NMSC among individuals with diabetes.

METHODS

We based our analysis on the 2020 Behavioral Risk Factor Surveillance System (BRFSS), a national survey conducted yearly in the US. We performed weighted chi-squared test, logistic regression, and survival analyses on 8685 eligible participants with diabetes enrolled in the BRFSS.

RESULTS

Kaplan Meier survival curves showed higher probability of NMSC event-free survival for participants with diabetes using insulin compared to participants with diabetes not using insulin (log-rank test P < .001). Significant associations were detected between insulin use and reduced odds of NMSC (OR .56; 95% CI: .38-.82), and decreased hazard (HR .36; 95% CI: .21-.62), along with indices of SDOH.

CONCLUSIONS

Our findings suggest that socioeconomic differences related to the healthcare system and behavioral patterns are linked to discrepancies in the use of insulin and the development of NMSC.

The role of neighborhood inequalities on diabetes prevention care: a mini-review

An emerging research niche has focused on the link between social determinants of health and diabetes mellitus, one of the most prevalent non-communicable diseases in modern society. The aim of the present mini-review is to explore and summarize current findings in this field targeting high-income countries. In the presence of disadvantaged neighborhood factors (including socioeconomic status, food environment, walkability and neighborhood aesthetics), diabetes prevention and care are affected at a multidimensional level. The vast majority of the included studies suggest that, besides individual risk factors, aggregated neighborhood inequalities should be tackled to implement effective evidence-based policies for diabetes mellitus.

A narrative review of clinic-community food provision interventions aimed at improving diabetes outcomes among food-insecure adults: examining the role of nutrition education

BACKGROUND

Food provision interventions (eg, produce/food prescriptions, food pharmacies, food voucher programs) that bridge clinic and community settings for improved nutritional health outcomes of at-risk patients have gained momentum. Little is known about the role of nutrition education and potential augmented impact on patient outcomes.

OBJECTIVE

To describe intervention designs and outcomes of direct food provision clinic-community programs aimed at improving diabetes-related outcomes (glycated hemoglobin [HbA1c] levels) among patients with type 2 diabetes (T2DM) or prediabetes and food insecurity, and to compare nutrition education components across interventions.

METHODS

The PubMed and Academic Search Complete databases were systematically searched for original peer-reviewed articles (published during 2011-2022) that described the impact of clinic-community food provision programs (ie, produce/food prescriptions, food pharmacies, and food voucher programs) onHbA1c values among adults diagnosed with T2DM or prediabetes and who screened positive for food insecurity or low income. Study designs, intervention approaches, program implementation, and intervention outcomes were described.

RESULTS

Ten studies representing 8 distinct programs were identified. There was a high degree of variation in the studies' design, implementation, and evaluation. Across the 8 programs, 6 included nutrition education; of these, 1 used a theoretical framework, and 3 incorporated goal setting. Nutrition education covered multiple topical contents, including general nutrition knowledge, fruit and vegetable consumption, and accessing resources (eg, enrolling in the Supplemental Nutrition Assistance Program). Furthermore, the education was delivered through various formats (from 1-on-1 to group-based sessions), educators (community health workers, registered dietitians, physicians), and durations (from a single session to biweekly). All programs with a nutrition education component reported reduced participant HbA1c, and 4 demonstrated an increase in fruit and vegetable purchases or improved dietary quality. The remaining 2 programs that did not include nutrition education yielded mixed results.

CONCLUSION

The majority of programs included a nutrition education component; however, there was a high degree of heterogeneity in terms of content, educator, and duration. Patients who participated in programs that included nutrition education had consistent reductions in HbA1c. These observational trends warrant further exploration to conclusively determine the impact of nutrition education on patient outcomes participating in clinic-community food provision programs.

Effects of turmeric (Curcuma longa) supplementation on glucose metabolism in diabetes mellitus and metabolic syndrome: An umbrella review and updated meta-analysis

AIMS

This study aims to comprehensively review the existing evidence and conduct analysis of updated randomized controlled trials (RCTs) of turmeric (Curcuma longa, CL) and its related bioactive compounds on glycemic and metabolic parameters in patients with type 2 diabetes (T2DM), prediabetes, and metabolic syndrome (MetS) together with a sub-group analysis of different CL preparation forms.

METHODS

An umbrella review (UR) and updated systematic reviews and meta-analyses (SRMAs) were conducted to evaluate the effects of CL compared with a placebo/standard treatment in adult T2DM, prediabetes, and MetS. The MEDLINE, Embase, The Cochrane Central Register of Control Trials, and Scopus databases were searched from inception to September 2022. The primary efficacy outcomes were hemoglobin A1C (HbA1C) and fasting blood glucose (FBG). The corrected covered area (CCA) was used to assess overlap. Mean differences were pooled across individual RCTs using a random-effects model. Subgroup and sensitivity analyses were performed for various CL preparation forms.

RESULTS

Fourteen SRMAs of 61 individual RCTs were included in the UR. The updated SRMA included 28 studies. The CCA was 11.54%, indicating high overlap across SRMAs. The updated SRMA revealed significant reduction in FBG and HbA1C with CL supplementation, obtaining a mean difference (95% confidence interval [CI]) of -8.129 (-12.175, -4.084) mg/dL and -0.134 (-0.304, -0.037) %, respectively. FBG and HbA1C levels decreased with all CL preparation forms as did other metabolic parameters levels. The results of the sensitivity and subgroup analyses were consistent with those of the main analysis.

CONCLUSION

CL supplementation can significantly reduce FBG and HbA1C levels and other metabolic parameters in T2DM and mitigate related conditions, including prediabetes and MetS.

TRIAL REGISTRATION

PROSPERO (CRD42016042131).

Trends and Self-Management Predictors of Glycemic Control During Pregnancy in Women With Preexisting Type 1 or Type 2 Diabetes: A Cohort Study

Background

Because much of diabetes management during pregnancy occurs at home, self-management factors such as self-efficacy, self-care activities, and care satisfaction may affect glycemia. Our objective was to explore trends in glycemic control during pregnancy in women with type 1 or type 2 diabetes; assess self-efficacy, self-care, and care satisfaction; and examine these factors as predictors of glycemic control.

Methods

We conducted a cohort study from April 2014 to November 2019 at a tertiary center in Ontario, Canada. Self-efficacy, self-care, care satisfaction, and A1C were measured three times during pregnancy (T1, T2, and T3). Linear mixed-effects modeling explored trends in A1C and examined self-efficacy, self-care, and care satisfaction as predictors of A1C.

Results

We recruited 111 women (55 with type 1 diabetes and 56 with type 2 diabetes). Mean A1C significantly decreased by 1.09% (95% CI -1.38 to -0.79) from T1 to T2 and by 1.14% (95% CI -1.43 to -0.86) from T1 to T3. Self-efficacy significantly predicted glycemic control for women with type 2 diabetes and was associated with a mean change in A1C of -0.22% (95% CI -0.42 to -0.02) per unit increase in scale. The exercise subscore of self-care significantly predicted glycemic control for women with type 1 diabetes and was associated with a mean change in A1C of -0.11% (95% CI -0.22 to -0.01) per unit increase in scale.

Conclusion

Self-efficacy significantly predicted A1C during pregnancy in a cohort of women with preexisting diabetes in Ontario, Canada. Future research will continue to explore the self-management needs and challenges in women with preexisting diabetes in pregnancy.

Association Between Social Determinants of Health and Glycemic Control Among African American People with Type 2 diabetes: The Jackson Heart Study

BACKGROUND

Social determinants of health have a significant impact on health outcomes. However, the complexity and interaction of multiple factors influencing glycemic control remain understudied.

PURPOSE

This study examined associations of socioeconomic position (income, education, and occupation), environmental (physical activity facilities, neighborhood social cohesion, neighborhood problem, and violence), behavioral (physical activity, nutrition, and smoking), and psychological factors (depressive symptoms, stress, and discrimination) with glycemic control (hemoglobin A1c [A1c]) using the World Health Organization Social Determinants of Health framework in African American adults with type 2 diabetes.

METHODS

A secondary data analysis was conducted using a longitudinal cohort of 1,240 African American adults with type 2 diabetes who participated in the community-based Jackson Heart Study. Socioeconomic position, environmental, behavioral, and psychological factors were measured using validated instruments in the Jackson Heart Study. Longitudinal structural equation modeling was used with glycemic control (A1c) collected over time (Exams 1-3) as the study outcome.

RESULTS

Our study presents the complex interplay of socioeconomic determinants of health and glycemic control over time. Higher socioeconomic position (higher income, higher level of education, and professional occupation) was directly associated with improvement in glycemic control over time. An association of socioeconomic position on glycemic control mediated through health behavior factors was also observed.

CONCLUSIONS

In this analysis, socioeconomic position components were determinants of glycemic control in African American adults with type 2 diabetes. Future studies aimed at reducing health disparities and achieving equality of outcomes in this population will benefit from embedding socioeconomic position components into their design.

Glycemic control and its influencing factors in type 2 diabetes patients in Anhui, China

Objective

To investigate the status of glycemic control and analyze its influencing factors in patients with type 2 diabetes (T2D) in Anhui, China.

Methods

1,715 T2D patients aged 18-75 years old were selected from 4 counties or districts in Anhui Province in 2018, using a convenience sampling method. All patients have undergone a questionnaire survey, physical examination, and a glycosylated hemoglobin (HbA1c) test. According to the 2022 American Diabetes Association criteria, HbA1c was used to evaluate the glycemic control status of patients, and HbA1c < 7.0% was defined as good glycemic control. The influencing factors of glycemic control were analyzed by multivariate unconditional logistic regression.

Results

The prevalence of good glycemic control among people with T2D in the Anhui Province was low (22.97%). On univariate analysis, gender, education level, occupation, region, smoking, drinking, waist circumference and disease duration (all P < 0.05) were significantly associated with glycemic control. The factors associated with pool glycemic control were female gender [OR = 0.67, 95%CI (0.52, 0.86), P = 0.001], higher level of education [OR = 0.47, 95%CI (0.27, 0.83), P = 0.001], living in rural areas [OR = 1.77, 95%CI (1.39, 2.26), P < 0.001], central obesity [OR = 1.58, 95%CI (1.19, 2.09), P = 0.001] and longer duration of disease [OR = 2.66, 95%CI (1.91, 3.69), P < 0.001].

Conclusions

The prevalence of good glycemic control in people with T2D in Anhui Province was relatively low, and gender, region, education level, central obesity and course of the disease were influencing factors. The publicity and education on the importance of glycemic control should be further strengthened in T2D patients, and targeted intervention measures should be carried out for risk groups.

Association of Social Risk Domains With Poor Cardiovascular Risk Factor Control in US Adults With Diabetes, From 2006 to 2016

IMPORTANCE

Few studies have examined the association between social risk factors and poor control of cardiovascular disease (CVD) risk factors.

OBJECTIVE

To examine the sequential association between social risk domains and CVD risk control over time in older adults with diabetes.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study analyzed core interviews from 4877 US adults with diabetes who were participating in the Health and Retirement Study, a national longitudinal survey of US adults. Participants were older than 50 years, completed the social risk domain questions, and had data on CVD risk factor measures from January 2006 to December 2016. Data were analyzed from June to July 2022.

EXPOSURES

Five social risk domains were created: (1) economic stability, (2) neighborhood or built environment, (3) education access, (4) health care access, and (5) social or community context.

MAIN OUTCOMES AND MEASURES

The 4 primary outcomes were (1) poor glycemic control (hemoglobin A1c [HbA1c] level ≥8.0%), (2) poor blood pressure (BP) control (systolic BP≥140 mm Hg and diastolic BP ≥90 mm Hg), (3) poor cholesterol control (total cholesterol/high-density lipoprotein ratio ≥5), and (4) a composite of poor CVD risk control (≥2 poorly controlled glucose level, BP, or cholesterol level).

RESULTS

Among this cohort of 4877 older adults with diabetes (mean [SD] age, 68.6 [9.8] years; 2715 women [55.7%]), 890 participants (18.3%) had an HbA1c level of 8% or higher, 774 (15.9%) had systolic BP of 140 mm Hg or higher and diastolic BP of 90 mm Hg or higher, 962 (19.7%) had total cholesterol/high-density lipoprotein ratio of 5 or higher, and 437 (9.0%) had at least 2 poorly controlled CVD risk factors. Neighborhood or built environment (ie, adverse social support) was independently associated with poor glycemic control (odds ratio [OR], 1.31; 95% CI, 1.06-1.63), whereas economic stability (ie, medication cost-related nonadherence) (OR, 1.40; 95% CI, 1.04-1.87) and health care access (ie, lack of health insurance) (OR, 1.58; 95% CI, 1.20-2.09) were independently associated with poor BP control after full adjustment. Education access (ie, lack of education) (OR, 1.24; 95% CI, 1.01-1.52) and health care access (ie, lack of health insurance) (OR, 1.31; 95% CI, 1.02-1.68) were independently associated with poor cholesterol control. Health care access (ie, lack of health insurance) was the only social risk domain that was independently associated with having at least 2 poorly controlled CVD risk factors (OR, 1.72; 95% CI, 1.26-2.37).

CONCLUSIONS AND RELEVANCE

Results of this study suggest that certain social risk domains are associated with control of CVD risk factors over time. Interventions targeting domains, such as neighborhood or built environment, economic stability, and education access, may be beneficial to controlling CVD risk factors in older adults with diabetes.

Complications in Diabetes Mellitus: Social Determinants and Trends

Conditions that impact an individual's health are referred to as social determinants of health. Through a retrospective study (January 2017-February 2022) and statistical analysis, researchers looked at the relationship between social demands and type 2 diabetes mellitus (T2DM) diagnosis. All social demands, with the exception of childcare, were more typically documented in patients with T2DM. Prescription expense, conveyance, and health literacy were the domains with the greatest relationships. These results might help health systems and social service providers develop collaborations to help in certain areas.

Prevalence Trends of Diabetes Subgroups in the United States: A Data-driven Analysis Spanning Three Decades From NHANES (1988-2018)

CONTEXT

Data-driven diabetes subgroups were proposed as an alternative to address diabetes heterogeneity. However, changes in trends for these subgroups have not been reported.

OBJECTIVE

Here, we analyzed trends of diabetes subgroups, stratified by sex, race, education level, age categories, and time since diabetes diagnosis in the United States.

METHODS

We used data from consecutive NHANES cycles spanning the 1988-2018 period. Diabetes subgroups (mild obesity-related [MOD], severe insulin-deficient [SIDD], severe insulin-resistant [SIRD], and mild age-related diabetes [MARD]) were classified using validated self-normalizing neural networks. Severe autoimmune diabetes (SAID) was assessed for NHANES-III. Prevalence was estimated using examination sample weights considering bicyclic changes (BCs) to evaluate trends and changes over time.

RESULTS

Diabetes prevalence in the United States increased from 7.5% (95% CI 7.1-7.9) in 1988-1989 to 13.9% (95% CI 13.4-14.4) in 2016-2018 (BC 1.09%, 95% CI 0.98-1.31, P < .001). Non-Hispanic Black people had the highest prevalence. Overall, MOD, MARD, and SIDD had an increase during the studied period. Particularly, non-Hispanic Black people had sharp increases in MARD and SIDD, Mexican Americans in SIDD, and non-Hispanic White people in MARD. Males, subjects with secondary/high school, and adults aged 40-64 years had the highest increase in MOD prevalence. Trends in diabetes subgroups sustained after stratifying time since diabetes diagnosis.

CONCLUSION

Prevalence of diabetes and its subgroups in the United States has increased from 1988 to 2018. These trends were different across sex, ethnicities, education, and age categories, indicating significant heterogeneity in diabetes within the US obesity burden, population aging, socioeconomic disparities, and lifestyle aspects could be implicated in the increasing trends of diabetes in the United States.

Impact of the COVID-19 Pandemic on Diabetes Care Among a North Carolina Patient Population

In this study, researchers reviewed electronic health record data to assess whether the coronavirus disease 2019 pandemic was associated with disruptions in diabetes care processes of A1C testing, retinal screening, and nephropathy evaluation among patients receiving care with Wake Forest Baptist Health in North Carolina. Compared with the pre-pandemic period, they found an increase of 13-21 percentage points in the proportion of patients delaying diabetes care for each measure during the pandemic. Alarmingly, delays in A1C testing were greatest for individuals with the most severe disease and may portend an increase in diabetes complications.

Socioeconomic Factors Associated With Glycemic Measurement and Poor HbA1c Control in People With Type 2 Diabetes: The Global DISCOVER Study

DISCOVER is a 3-year observational study program of 15,983 people with type 2 diabetes initiating second-line glucose-lowering therapy in 38 countries. We investigated the association between socioeconomic status and both the availability of a baseline glycated hemoglobin (HbA1c) measurement and poor glycemic control (HbA1c level ≥ 9.0%) in participants enrolled in DISCOVER. Factors associated with a lack of baseline HbA1c measurement or an HbA1c level ≥ 9.0% were assessed using three-level hierarchical logistic models. Overall, 19.1% of participants did not have a baseline HbA1c measurement recorded. Lower-middle country income (vs. high) and primary/no formal education (vs. university education) were independently associated with a reduced likelihood of having a baseline HbA1c measurement (odds ratio [95% confidence interval]: 0.11 [0.03-0.49] and 0.81 [0.66-0.98], respectively. Of the participants with an available HbA1c measurement, 26.9% had an HbA1c level ≥ 9.0%; 68.7% of these individuals were from lower- or upper-middle-income countries. Factors associated with an increased likelihood of poor glycemic control included low country income, treatment at a site with public and/or governmental funding (vs. private funding) and having public or no health insurance (vs. private). A substantial proportion of DISCOVER participants did not have an HbA1c measurement; more than one-quarter of these participants had poorly controlled type 2 diabetes. Both individual- and country-level socioeconomic factors are associated with the quality of care regarding glycemic control. Awareness of these factors could help improve the management of patients with type 2 diabetes.

The management of type 1 diabetes in adults. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD)

The American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) convened a writing group to develop a consensus statement on the management of type 1 diabetes in adults. The writing group has considered the rapid development of new treatments and technologies and addressed the following topics: diagnosis, aims of management, schedule of care, diabetes self-management education and support, glucose monitoring, insulin therapy, hypoglycaemia, behavioural considerations, psychosocial care, diabetic ketoacidosis, pancreas and islet transplantation, adjunctive therapies, special populations, inpatient management and future perspectives. Although we discuss the schedule for follow-up examinations and testing, we have not included the evaluation and treatment of the chronic microvascular and macrovascular complications of diabetes as these are well-reviewed and discussed elsewhere. The writing group was aware of both national and international guidance on type 1 diabetes and did not seek to replicate this but rather aimed to highlight the major areas that healthcare professionals should consider when managing adults with type 1 diabetes. Though evidence-based where possible, the recommendations in the report represent the consensus opinion of the authors. Graphical abstract.

The Management of Type 1 Diabetes in Adults. A Consensus Report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD)

The American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) convened a writing group to develop a consensus statement on the management of type 1 diabetes in adults. The writing group has considered the rapid development of new treatments and technologies and addressed the following topics: diagnosis, aims of management, schedule of care, diabetes self-management education and support, glucose monitoring, insulin therapy, hypoglycemia, behavioral considerations, psychosocial care, diabetic ketoacidosis, pancreas and islet transplantation, adjunctive therapies, special populations, inpatient management, and future perspectives. Although we discuss the schedule for follow-up examinations and testing, we have not included the evaluation and treatment of the chronic microvascular and macrovascular complications of diabetes as these are well-reviewed and discussed elsewhere. The writing group was aware of both national and international guidance on type 1 diabetes and did not seek to replicate this but rather aimed to highlight the major areas that health care professionals should consider when managing adults with type 1 diabetes. Though evidence-based where possible, the recommendations in the report represent the consensus opinion of the authors.

Residential Street Block Disorder and Biological Markers of Aging in Older Adults: The National Health and Aging Trends Study

BACKGROUND

Residential environments are associated with older adult health, but underlying physiologic causal mechanisms are not well understood. As adults age, street blocks are likely more relevant to their health than the larger neighborhood environment. This study examined the effects of adverse street block conditions on aging biomarkers among older adults.

METHODS

We included community-dwelling Medicare beneficiaries aged 67 and older with 2017 biomarker data from the nationally representative National Health and Aging Trends Study (n=4,357). Street block disorder in 2016 was measured using interviewer report of any trash/glass/litter, graffiti, or vacant buildings on participants' blocks. Propensity score models were used to create balanced groups with regard to multiple 2015 participant characteristics, including demographic, socioeconomic, residence, and early life characteristics. Linear regressions modeled street block disorder as a predictor of four aging biomarkers, hemoglobin A1C, high-sensitivity C-reactive protein, interleukin-6, and cytomegalovirus antibodies, before and after applying propensity score weighting.

RESULTS

Adjusting for participant sociodemographic characteristics and applying propensity score weights, living on a block with any disorder was associated with 2% higher mean hemoglobin A1C levels (95% CI: 0.002-0.03), 13% higher C-reactive protein (95% CI: 0.03-0.23), 10% higher interleukin-6 (95% CI: 0.02-0.19), and 19% more cytomegalovirus antibodies (95% CI: 0.09-0.29) compared to living on a block with no disorder.

CONCLUSIONS

Street block disorder predicted subsequent aging biomarkers after applying a propensity score approach to account for confounding among a national sample of older adults. Targeting street-level residential contexts for intervention may reduce risk for poor health in older adults.

The relationship between financial hardship and incident diabetic kidney disease in older US adults - a longitudinal study

Background

Financial hardship is associated with poor health, however the association of financial hardship and incident diabetic kidney disease (DKD) is unknown. This study aimed to examine the longitudinal relationship between financial hardship and incident DKD among older adults with diabetes.

Methods

Analyses were conducted in 2735 adults age 50 or older with diabetes and no DKD using four waves of data (2006–2012) from the Health and Retirement Study, a national longitudinal cohort. The primary outcome was incident DKD. Financial hardship was based on three measures: 1) difficulty paying bills; 2) food insecurity; and 3) cost-related medication non-adherence using validated surveys. A dichotomous financial hardship variable (0 vs 1 or more) was constructed based on all three measures. Cox regression models were used to estimate the association between financial hardship, change in financial hardship experience and incident DKD adjusting for demographics, socioeconomic status, and comorbidities.

Results

During the median follow-up period of 4.1 years, incident DKD rate was higher in individuals with versus without financial hardship (41.2 versus 27/1000 person years). After adjustment, individuals with financial hardship (HR 1.32, 95% CI 1.04–1.68) had significantly increased likelihood of developing DKD compared to individuals without financial hardship. Persistent financial hardship (adjusted HR 1.52 95% CI 1.06–2.18) and negative financial hardship (adjusted HR 1.54 95% CI 1.02–2.33) were associated with incident DKD compared with no financial hardship experience. However, positive financial hardship was not statistically significant in unadjusted and adjusted (adjusted HR 0.89 95% CI 0.55–1.46) models. Cost-related medication non-adherence (adjusted HR 1.43 95% CI 1.07–1.93) was associated with incident DKD independent of other financial hardship measures.

Conclusions

Financial hardship experience is associated with a higher likelihood of incident DKD in older adults with diabetes. Future studies investigating factors that explain the relationship between financial hardship and incident DKD are needed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12882-021-02373-3.

Toward Understanding Social Needs Among Primary Care Patients With Uncontrolled Diabetes

Introduction/Objectives:

Uncontrolled diabetes can lead to major health complications, and significantly contributes to diabetes-related morbidity, mortality, and healthcare costs. Few studies have examined the relationship between unmet social needs and diabetes control among predominantly Black and Hispanic patient populations.

Methods:

In a large urban hospital system in the Bronx, NY, 5846 unique patients with diabetes seen at a primary care visit between April 2018 and December 2019 completed a social needs screener. Measures included diabetes control (categorized as Hemoglobin (Hb) A1c <9.0 as controlled and Hb A1C ≥9.0 as uncontrolled), social needs (10-item screen), and demographic covariates, including age, sex, race/ethnicity, insurance status, percentage of block-group poverty, patient’s preferred language, and the Elixhauser Comorbidity Index.

Results:

Twenty-two percent (22%) of the patient sample had at least 1 unmet social need, and the most prevalent unmet social needs were housing issues (including housing quality and insecurity), food insecurity, and lack of healthcare transportation. Logistic regression analysis showed a significant relationship between social needs and uncontrolled diabetes, with more social needs indicating a greater likelihood of uncontrolled diabetes (Adjusted Odds Ratio (AOR) for ≥3 needs: 1.59, 95% CI: 1.26, 2.00). Of the patients with most frequently occurring unmet social needs, lack of healthcare transportation (AOR: 1.54, 95% CI: 1.22, 1.95) and food insecurity (AOR: 1.50, 95% CI: 1.19, 1.89) had the greatest likelihood of having uncontrolled diabetes, after adjusting for covariates.

Conclusion:

Unmet social needs appear to be linked to a greater likelihood of uncontrolled diabetes. Implications for healthcare systems to screen and address social needs for patients with diabetes are discussed.

Exploring Culture, Religiosity and Spirituality Influence on Antihypertensive Medication Adherence Among Specialised Population: A Qualitative Ethnographic Approach

BACKGROUND

Hypertension is one of the major risk factors of stroke and leading risk factors for global death. Inadequate control of blood pressure due to medication non-adherence remains a challenge and identifying the underlying causes will provide useful information to formulate suitable interventions.

PURPOSE

This study aimed to explore the roles of culture, religiosity, and spirituality on adherence to anti-hypertensive medications.

METHODOLOGY

A semi-structured qualitative interview was used to explore promoters and barriers to medication adherence among hypertensive individuals residing in urban and rural areas of Perak State, West Malaysia. Study participants were individuals who are able to comprehend either in Malay or English, above 18 years old and on antihypertensive medications. Interview transcriptions from 23 participants were coded inductively and analyzed thematically. Codes generated were verified by three co-investigators who were not involved in transcribing process. The codes were matched with quotations and categorized using three levels of themes named as organizing, classifying and general themes.

RESULTS

Cultural aspects categorized as societal and communication norms were related to non-adherence. The societal norms related to ignorance, belief in testimony and anything "natural is safe" affected medication adherence negatively. Communication norms manifested as superficiality, indirectness and non-confrontational were also linked to medication non-adherence. Internal and organizational religiosity was linked to increased motivation to take medication. In contrast, religious misconception about healing and treatment contributed towards medication non-adherence. The role of spirituality remains unclear and seemed to be understood as related to religiosity.

CONCLUSION

Culture and religiosity (C/R) are highly regarded in many societies and shaped people's health belief and behaviour. Identifying the elements and mechanism through which C/R impacted adherence would be useful to provide essential information for linking adherence assessment to the interventions that specifically address causes of medication non-adherence.

Race/Ethnicity and County-Level Social Vulnerability Impact Hospice Utilization Among Patients Undergoing Cancer Surgery

BACKGROUND

Integration of palliative care services into the surgical treatment plan is important for holistic patient care. We sought to examine the association between patient race/ethnicity and county-level vulnerability relative to patterns of hospice utilization.

PATIENTS AND METHODS

Medicare Standard Analytic Files were used to identify patients undergoing lung, esophageal, pancreatic, colon, or rectal cancer surgery between 2013 and 2017. Data were merged with the Centers for Disease Control and Prevention's social vulnerability index (SVI). Logistic regression was utilized to identify factors associated with overall hospice utilization among deceased individuals.

RESULTS

A total of 54,256 Medicare beneficiaries underwent lung (n = 16,645, 30.7%), esophageal (n = 1427, 2.6%), pancreatic (n = 6183, 11.4%), colon (n = 26,827, 49.4%), or rectal (n = 3174, 5.9%) cancer resection. Median patient age was 76 years (IQR 71-82 years), and 28,887 patients (53.2%) were male; the majority of individuals were White (91.1%, n = 49,443), while a smaller subset was Black or Latino (racial/ethnic minority: n = 4813, 8.9%). Overall, 35,416 (65.3%) patients utilized hospice services prior to death. Median SVI was 52.8 [interquartile range (IQR) 30.3-71.2]. White patients were more likely to utilize hospice care compared with minority patients (OR 1.24, 95% CI 1.17-1.31, p < 0.001). Unlike White patients, there was reduced odds of hospice utilization (OR 0.97, 95% CI 0.96-0.99) and early hospice initiation (OR 0.94, 95% CI 0.91-0.97) as SVI increased among minority patients.

CONCLUSIONS

Patients residing in counties with high social vulnerability were less likely to be enrolled in hospice care at the time of death, as well as be less likely to initiate hospice care early. The effects of increasing social vulnerability on hospice utilization were more profound among minority patients.