Understanding the social factors that contribute to diabetes: a means to informing health care and social policies for the chronically ill

Diabetes Disparities in the United States: Trends by Educational Attainment from 2001 to 2020

INTRODUCTION

Tracking changes in socioeconomic disparities in diabetes in the U.S. is important to evaluate progress in health equity and guide prevention efforts. Disparities in diabetes prevalence by educational attainment from 2001 to 2020 were investigated.

METHODS

Using a serial cross-sectional design, data from 33,220 adults aged 30-79 assessed in nine rounds of the National Health and Nutrition Examination Surveys between 2001 and 2020 were analyzed in 2023-2024. Diabetes was defined as self-reported prior diagnosis, elevated glycated hemoglobin (HbA1c≥6.5%), or use of diabetes medications. Marginalized age- and covariate-adjusted prevalence differences (PD) and prevalence ratios (PR) of diabetes by educational attainment (less than high school graduation, high school graduation, some college education or associate degree, or college graduation [reference]) by calendar period (2001-2004, 2005-2008, 2009-2012, 2013-2016, 2017-2020) were derived from logistic regression models.

RESULTS

From 2001 to 2020, age-adjusted diabetes prevalence was consistently higher among adults without a college degree. Adults without a high school diploma exhibited the largest disparities in both 2001-2004 (PD 8.0%; 95%CI 5.6-10.5 and PR 2.1; 95%CI 1.5-2.6) and 2017-20 (PD 11.0%; 95%CI 6.7-15.2 and PR 2.1; 95%CI 1.5-2.7). Between 2001-2004 and 2017-2020, the absolute disparity in diabetes changed only among adults with a high school diploma (increase from PD 1.7%; 95%CI -0.5- 3.9 to PD 8.8% 95%CI 4.1-13.4, respectively), while the PR did not change in any group. Education-related disparities in diabetes were attenuated after accounting for socio-demographic factors and BMI.

CONCLUSIONS

From 2001 to 2020, national education-related disparities in diabetes prevalence have shown no signs of narrowing.

Determinants of Diabetes Awareness Among Hispanic/Latino Adults in the U.S., 2005-2018

OBJECTIVE

Despite improvements in screening, Hispanic/Latino individuals bear a disproportionate burden of undiagnosed diabetes in the U.S. Identifying who is at risk within this large and diverse population is important for targeting interventions. In this study, we sought to characterize risk factors for undiagnosed diabetes among Hispanic/Latino adults. We also investigated determinants among insured adults to explore barriers for those with access to care.

RESEARCH DESIGN AND METHODS

We used data from 1,883 Hispanic/Latino adults aged ≥20 years from the National Health and Nutrition Examination Surveys (2005-2018). Sequential multivariable logistic regression models were used to examine a range of social, health care, and individual-level determinants of undiagnosed diabetes (defined as having elevated fasting plasma glucose ≥126 mg/dL or HbA1c ≥6.5% [48 mmol/mol] in participants self-reporting as not having diabetes) in the overall sample and among those with health insurance (n = 1,401).

RESULTS

Younger age (20-44 years), male sex, and having immigrated (compared with being U.S. born), but not socioeconomic factors, were significantly associated with a higher odds of undiagnosed diabetes compared with being diagnosed. These estimates were attenuated after adjusting for health care utilization variables. In fully adjusted models, having no health care visits in the past year, reporting no family history of diabetes, and having better self-reported health were the predominant risk factors for undiagnosed diabetes in the overall sample and among insured Hispanic/Latino adults.

CONCLUSIONS

Our findings highlight the importance of reaching younger, male, and immigrant Hispanic/Latino adults and addressing barriers to health care utilization, even among insured adults, to improve diabetes awareness.

The Impact of Social Support on Health Outcomes of Diabetic Patients: A Systematic Review

Type 2 diabetes mellitus (T2DM) is a common chronic disease worldwide. The prevalence of T2DM has consistently increased over the past few decades. Factors affecting patient management of diabetes are important in preventing diabetic complications. Social support has been cited as one of the most important aspects of managing chronic conditions. This systematic review aims to consolidate the existing literature discussing the impact of social support on managing type 1 diabetes mellitus (T1DM) and T2DM. To begin our review, the Ovid MEDLINE (Medical Literature Analysis and Retrieval System Online) database was searched for all current literature on social support and diabetes health outcomes. Articles were then included and removed according to specific inclusion and exclusion criteria, and a systematic review was performed on the remaining articles. Twenty-two papers that met the inclusion and exclusion criteria were selected, and after data collection, a significant correlation was found between social support and health outcomes of diabetic patients and most articles reported that social support improves the health outcomes of diabetic patients. Studies show that there is some correlation between social support and improved health outcomes for diabetic patients. Further studies should be done to determine the exact correlations between social support and T2DM management and to explore the long-term impacts of social support on health outcomes for diabetic patients.

Screening for adverse social conditions in child healthcare settings: protocol for a systematic review

INTRODUCTION

Adverse social conditions affect children's development and health outcomes from preconception throughout their life course. Early identification of adverse conditions is essential for early support of children and their families. Healthcare contacts with children provide a unique opportunity to screen for adverse social conditions and to take preventive action to identify and address emerging, potentially harmful or accumulating social problems. The aim of our study is to identify and describe available screening tools in outpatient and inpatient healthcare settings that capture social conditions that may affect children's development, health or well-being.

METHODS AND ANALYSIS

We will conduct a systematic review and will report the results following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidance. A systematic search of three databases (PubMed (Ovid), PsycInfo (EBSCOhost) and Web of Science Core Collection (Clarivate)) for English-language and German-language articles from 2014 to date will be conducted. We will include peer-reviewed articles that develop, describe, test or use an instrument to screen children for multiple social conditions in paediatric clinics or other outpatient or inpatient child healthcare settings. Key study characteristics and information on screening tools will be extracted and presented in structured tables to summarise the available evidence. We will assess the methodological quality of the instruments with the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist.

ETHICS AND DISSEMINATION

Ethical approval is not required for this study as we will not be collecting any personal data. Dissemination will consist of publications, presentations, and other knowledge translation activities.

Oxidant-induced disruption of vascular K+ channel function: implications for diabetic vasculopathy

Diabetes in humans a chronic metabolic disorder characterised by hyperglycaemia, it is associated with an increased risk of cardiovascular disease, disruptions to metabolism and vascular functions. It is also linked to oxidative stress and its complications. Its role in vascular dysfunctions is generally reported without detailed impact on the molecular mechanisms. Potassium ion channel (K+ channels) are key regulators of vascular tone, and as membrane proteins, are modifiable by oxidant stress associated with diabetes. This review manuscript examined the impact of oxidant stress on vascular K+ channel functions in diabetes, its implication in vascular complications and metabolic and cardiovascular diseases.

Intersectoral health interventions to improve the well-being of people living with type 2 diabetes: a scoping review protocol

INTRODUCTION

Intersectoral collaboration is a collaborative approach between the health sectors and other sectors to address the interdependent nature of the social determinants of health associated with chronic diseases such as diabetes. This scoping review aims to identify intersectoral health interventions implemented in primary care and community settings to improve the well-being and health of people living with type 2 diabetes.

METHODS AND ANALYSIS

This protocol is developed by the Arksey and O'Malley (2005) framework for scoping reviews and the Levac et al methodological enhancement. MEDLINE, Embase, CINAHL, grey literature and the reference list of key studies will be searched to identify any study, published between 2000 and 2023, related to the concepts of intersectorality, diabetes and primary/community care. Two reviewers will independently screen all titles/abstracts, full-text studies and grey literature for inclusion and extract data. Eligible interventions will be classified by sector of action proposed by the Social Determinants of Health Map and the conceptual framework for people-centred and integrated health services and further sorted according to the actors involved. This work started in September 2023 and will take approximately 10 months to be completed.

ETHICS AND DISSEMINATION

This review does not require ethical approval. The results will be disseminated through a peer-reviewed publication and presentations to stakeholders.

Cultural Influences on Making Nutritional Adjustments in Type 2 Diabetes in Pakistan: The Perspectives of People Living With Diabetes and Their Family Members

In Pakistan, type 2 diabetes is widespread, and although dietary recommendations from healthcare professionals are critical to its treatment, cultural norms can have a great influence on the dietary habits of people living with diabetes (PLwD). Understanding the social aspects of the lives of PLwD is crucial when examining the effectiveness of nutritional recommendations and adjustments. This study investigated (1) how PLwD and their family members adjust their nutrition to the recommendations of healthcare professionals to manage type 2 diabetes mellitus (T2DM) and (2) what do PLwD and their family members perceive as enablers and barriers to the necessary nutritional adjustments for managing T2DM. Prime consideration was given to experiences of living in Pakistan as the cultural context. Semi-structured interviews were conducted with 30 PLwD and 17 family members; the data were analysed thematically. Three themes emerged: (i) 'Influence of family system, gender, and age on meals prepared at home': family hierarchy and opinions based on gender and age can enable or hinder nutritional adjustment in meals prepared at home; (ii) 'Temptations of "unhealthy" foods, festivals, cultural interactions, and social etiquette': family/social interactions at home, gatherings, or festivities can affect PLwD's ability to resist temptations to eat foods prohibited by healthcare professionals; and (iii) 'Folk knowledge, folk remedy, and the balance between culture and Western medicine': PLwD and their family members in Pakistan hold strong beliefs concerning foods' medicinal properties. Power dynamics within families need to be considered when making nutritional recommendations. Medical guidelines should acknowledge personal agency and cultural beliefs.

Associations of dietary inflammatory index with low estimated glomerular filtration rate, albuminuria and chronic kidney disease in U.S adults: Results from the NHANES 2011-2018

BACKGROUND AND AIMS

Chronic Kidney Disease (CKD) is characterized by a high inflammation status with ever-increasing prevalence, and defined as low estimated glomerular filtration rate (eGFR) or albuminuria. Both low eGFR and albuminuria can have independent effects on the body. The dietary inflammatory index (DII) is a validated tool used to assess the inflammatory potential of the diet. We aim to explore not only the association between DII and CKD, but also the associations of DII with low eGFR and albuminuria, respectively. In addition, their associations in different subgroups remain to be explored.

METHODS AND RESULTS

18,070 participants from the 2011-2018 NHANES with complete data of dietary intake and laboratory data were involved in our study. The data of 24-hour dietary recall interview was used to calculate DII, CKD could be reflected by laboratory data of creatinine and albumin. Then weighted multivariate logistic regression models and subgroup analyses were performed. The prevalence of low eGFR, albuminuria and CKD were 6.8%, 9.8% and 14.5%, respectively. A positive association between DII and low eGFR was observed (OR=1.12, 95%CI: 1.05-1.21), Q2, Q3 and Q4 are positively associated with a significant 39%, 65% and 71% increased risk of low eGFR compared with Q1 (P for trend<0.05). DII was also associated with CKD (OR=1.06, 95%CI: 1.01-1.11).

CONCLUSION

Significant positive associations of DII with CKD and low eGFR were observed. But we didn't find such association between DII and albuminuria.

Knowledge about type 2 diabetes: its impact for future management

Diabetes can cause several long-term complications. Knowledge about this disease can play an important role in reducing diabetes-related complications. In addition, the lack of awareness leads to misconceptions, which joined with inadequate knowledge, are relevant barriers to proper diabetes management. In this study, we aimed to assess the diabetes knowledge of a type 2 diabetes (T2D) population and identify major knowledge gaps, in order to prevent complications and to increase quality of life. In a cross-sectional, observational study in a convenience sample, we identified individuals diagnosed with T2D attending ambulatory visits from five health settings, older than 18 years, with a time diagnosis of at least 1 year, and attending multidisciplinary visits for at least 3 months. To assess the knowledge of T2D individuals, we applied the Portuguese version of the Diabetes Knowledge Test. The sample included a total of 1,200 persons, of whom almost half were female. The age range of the participants varied from 24 to 94 years old, and the mean age was 65.6 ± 11.4 years. Most of the sample had a level of education under secondary and lived with someone. In our sample, 479 (39.9%) were insulin-treated. The percentage of correct answers was 51.8% for non-insulin vs. 58.7% for insulin treated (p < 0.05). There were three items with a percentage of correct answers lower than 15%; the item with the lower value of correct answers was the one related to the identification of signs of ketoacidosis with only 4.4% of correct answers, the errors presented a random pattern; the item related to the identification of which food should not be used to treat low blood glucose with 11.9%, where 56.9% of the sample's participants considered that one cup of skim milk would be the correct answer (53.1% in non-insulin patients and 62.6% in insulin treated patients; p < 0.001). The item regarding the knowledge of free food presented a 13.3% of correct answers (10.8% non-insulin group vs. 17.1% insulin group; p < 0.01). Two of the three items with lower value of correct answers were related to glycemic control and health status monitoring, the other was related to diet and food.

Beyond the Body: Using Photovoice to Explore Social Determinants of Diabetes With South Asian Adolescents in the Peel Region of Ontario, Canada

OBJECTIVES

The higher prevalence of diabetes in the South Asian (SA) population living in Canada spans across generations and is often associated with individual risk factors while undermining the social determinants of health (SDOH). There is a scarcity of studies on the perspectives of SA adolescents with a family history of type 2 diabetes mellitus (T2DM). Learning directly from these adolescents can fill a major gap by providing insight on how the SDOH contribute to disproportionate rates of T2DM in SA immigrant communities.

METHODS

In this study, we used Photovoice, which is a community-based participatory research (CBPR) method that involves the use of photography to visually capture the challenges of diabetes prevention from the perspective of those with lived experiences. A group of 15 SA youth were recruited from an adolescent diabetes education program in the Peel Region of Ontario. The youth discussed their images and accompanied written narratives during focus groups.

RESULTS

Four themes emerged from the thematic analysis of the photographs and participant narratives that influence the manifestation of T2DM in SA communities: 1) immigration and resettlement stressors; 2) food insecurity; 3) unhealthy school environments; and 4) academic pressures.

CONCLUSIONS

Findings suggest the need to address T2DM as a response to unjust conditions and environments rather than as an epidemic entrenched in genetic predisposition, culture, and poor lifestyle choices.

Association between prevalence and severity of chronic kidney disease and employment status: a nationwide study in Korea

BACKGROUND

The prevalence of chronic kidney disease (CKD) is increasing globally, and understanding the association between CKD and employment status is crucial. This cross-sectional study aimed to investigate the association of CKD with employment and occupation type among patients with CKD.

METHODS

We analyzed data from 36,732 Korean adults aged ≥ 30 years, who participated in the Korean National Health and Nutrition Examination Survey between 2014 and 2021. CKD was detected based on the estimated glomerular filtration rate, and the employment status of the participants was classified into distinct categories: full-time permanent employment, unemployment, self-employment, and precarious employment. We analyzed the data using multiple logistic regression.

RESULTS

We observed a significant association between CKD and a higher likelihood of unemployment compared to that in individuals without CKD (odds ratio, 1.70; 95% confidence interval, 1.47-1.96). This association was more prominent in patients with severe CKD. In the multivariable logistic analysis, patients with CKD had a higher likelihood for precarious employment (odds ratio, 1.29; 95% confidence interval, 0.92-1.88), self-employment (odds ratio, 1.3; 95% confidence interval, 0.90-1.88), and unemployment (odds ratio, 2.10; 95% confidence interval, 1.51-2.92) compared to individuals without CKD.

CONCLUSIONS

Our study demonstrated that CKD is associated with a higher likelihood of unemployment and engagement in precarious employment. These findings highlight the challenges faced by patients with CKD in obtaining stable employment and emphasize the need for interventions to improve the employment outcomes of individuals with CKD.

A Fair Individualized Polysocial Risk Score for Identifying Increased Social Risk in Type 2 Diabetes

Background

Racial and ethnic minority groups and individuals facing social disadvantages, which often stem from their social determinants of health (SDoH), bear a disproportionate burden of type 2 diabetes (T2D) and its complications. It is crucial to implement effective social risk management strategies at the point of care.

Objective

To develop an electronic health records (EHR)-based machine learning (ML) analytical pipeline to address unmet social needs associated with hospitalization risk in patients with T2D.

Methods

We identified real-world patients with T2D from the EHR data from University of Florida (UF) Health Integrated Data Repository (IDR), incorporating both contextual SDoH (e.g., neighborhood deprivation) and individual-level SDoH (e.g., housing instability). The 2015-2020 data were used for training and validation and 2021-2022 data for independent testing. We developed a machine learning analytic pipeline, namely individualized polysocial risk score (iPsRS), to identify high social risk associated with hospitalizations in T2D patients, along with explainable AI (XAI) and fairness optimization.

Results

The study cohort included 10,192 real-world patients with T2D, with a mean age of 59 years and 58% female. Of the cohort, 50% were non-Hispanic White, 39% were non-Hispanic Black, 6% were Hispanic, and 5% were other races/ethnicities. Our iPsRS, including both contextual and individual-level SDoH as input factors, achieved a C statistic of 0.72 in predicting 1-year hospitalization after fairness optimization across racial and ethnic groups. The iPsRS showed excellent utility for capturing individuals at high hospitalization risk because of SDoH, that is, the actual 1-year hospitalization rate in the top 5% of iPsRS was 28.1%, ~13 times as high as the bottom decile (2.2% for 1-year hospitalization rate).

Conclusion

Our ML pipeline iPsRS can fairly and accurately screen for patients who have increased social risk leading to hospitalization in real word patients with T2D.

Exploring the association between primary care efficiency and health system characteristics across European countries: a two-stage data envelopment analysis

BACKGROUND

Primary care is widely seen as a core component of resilient and sustainable health systems, yet its efficiency is not well understood and there is a lack of evidence about how primary care efficiency is associated with health system characteristics. We examine this issue through the lens of diabetes care, which has a well-established evidence base for effective treatment and has previously been used as a tracer condition to measure health system performance.

METHODS

We developed a conceptual framework to guide the analysis of primary care efficiency. Using data on 18 European countries during 2010-2016 from several international databases, we applied a two-stage data envelopment analysis to estimate (i) technical efficiency of primary care and (ii) the association between efficiency and health system characteristics.

RESULTS

Countries varied widely in terms of primary care efficiency, with efficiency scores depending on the range of population characteristics adjusted for. Higher efficiency was associated with bonus payments for the prevention and management of chronic conditions, nurse-led follow-up, and a financial incentive or requirement for patients to obtain a referral to specialist care. Conversely, lower efficiency was associated with higher rates of curative care beds and financial incentives for patients to register with a primary care provider.

CONCLUSIONS

Our results underline the importance of considering differences in population characteristics when comparing country performance on primary care efficiency. We highlight several policies that could enhance the efficiency of primary care. Improvements in data collection would enable more comprehensive assessments of primary care efficiency across countries, which in turn could more effectively inform policymaking.

Which diabetes specific patient reported outcomes should be measured in routine care? A systematic review to inform a core outcome set for adults with Type 1 and 2 diabetes mellitus: The European Health Outcomes Observatory (H2O) programme

OBJECTIVES

The objective was to identify candidate patient reported outcomes with potential to inform individual patient care and service development for inclusion in a digital outcome set to be collected in routine care, as part of an international project to enhance care outcomes for people with diabetes.

METHODS

PubMed, COSMIN and COMET databases were searched. Published studies were included if they recommended patient reported outcomes that were clinically useful and/or important to people with diabetes. To aid selection decisions, recommended outcomes were considered in terms of the evidence endorsing them and their importance to people with diabetes.

RESULTS

Twenty-seven studies recommending 53 diabetes specific outcomes, and patient reported outcome measures, were included. The outcomes reflected the experience of living with diabetes (e.g. psychological well-being, symptom experience, health beliefs and stigma) and behaviours (e.g. self-management). Diabetes distress and self-management behaviours were most endorsed by the evidence.

CONCLUSIONS

The review provides a comprehensive list of candidate outcomes endorsed by international evidence and informed by existing outcome sets, and suggestions for measures.

PRACTICE IMPLICATIONS

The review offers evidence to guide clinical application. Integrated measurement of these outcomes in care settings holds enormous potential to improve provision of care and outcomes in diabetes.

Racial and Ethnic Disparities in Glycemic Control Among Insured US Adults

Importance

Poor access to care and lack of health insurance are important contributors to disparities in glycemic control. However expanding health insurance coverage may not be enough to fully address the high burden of poor glycemic control for some groups.

Objective

To characterize racial and ethnic disparities in glycemic control among adults with private and public insurance in the US over a 15-year timeframe and to evaluate whether social, health care, and behavioral or health status factors attenuate estimates of disparities.

Design, Setting, and Participants

This cross-sectional study used data from the National Health and Nutrition Examination Survey from 2003 to 2018. Participants included Hispanic or Latino, non-Hispanic Black, and non-Hispanic White adults aged 25 to 80 years with self-reported diabetes and health insurance. Data were analyzed from January 15 to August 23, 2023.

Exposure

Participants self-identified as Hispanic or Latino, non-Hispanic Black, or non-Hispanic White.

Main Outcomes and Measures

The main outcome, poor glycemic control, was defined as glycated hemoglobin A1c (HbA1c) of 7.0% or greater. Information about social (education, food security, and nativity), health care (insurance type, routine place for health care, insurance gap in past year, and use of diabetes medications), and behavioral or health status (years with diabetes, waist circumference, and smoking) factors were collected via questionnaires.

Results

A total of 4070 individuals (weighted mean [SE] age, 61.4 [0.27] years; 1970 [weighted proportion, 49.3%] were women) were included, representing 16 337 362 US adults, including 1146 Hispanic or Latino individuals (weighted proportion, 13.2%), 1196 non-Hispanic Black individuals (weighted proportion, 15.7%), and 1728 non-Hispanic White individuals (weighted proportion, 71.1%). In models adjusted for age, sex, and survey year, Hispanic or Latino and non-Hispanic Black individuals had significantly higher odds of poor glycemic control than non-Hispanic White individuals (Hispanic or Latino: odds ratio [OR], 1.46; 95% CI, 1.16-1.83; Black: OR, 1.28; 95% CI, 1.04-1.57). There was some attenuation after adjustment for social factors, especially food security (Hispanic or Latino: OR, 1.39; 95% CI, 1.08-1.81); Black: OR, 1.39; 95% CI, 1.08-1.81). However, accounting for health care and behavioral or health status factors increased disparities, especially for Hispanic or Latino individuals (OR, 1.63; 95% CI, 1.24-2.16), with racial and ethnic disparities persisting even among those with private insurance (OR, 1.66; 95% CI, 1.10-2.52).

Conclusions and Relevance

In this cross-sectional study of insured adults with diabetes in the US, disparities in poor glycemic control persisted despite adjustment for social, health care, and behavioral factors. Research is needed to identify the barriers contributing to poor control even in populations with access to care.

Market competition influences practice patterns in management of patients with intermittent claudication in the vascular quality initiative

OBJECTIVE

The Society for Vascular Surgery (SVS) clinical practice guidelines recommend best medical therapy (BMT) as first-line therapy before offering revascularization to patients with intermittent claudication (IC). Notably, atherectomy and tibial-level interventions are generally discouraged for management of IC; however, high regional market competition may incentivize physicians to treat patients outside the scope of guideline-directed therapy. Therefore, we sought to determine the association between regional market competition and endovascular treatment of patients with IC.

METHODS

We examined patients with IC undergoing index endovascular peripheral vascular interventions (PVI) in the SVS Vascular Quality Initiative from 2010 to 2022. We assigned the Herfindahl-Hirschman Index as a measure of regional market competition and stratified centers into very high competition (VHC), high competition, moderate competition, and low competition cohorts. We defined BMT as preoperative documentation of being on antiplatelet medication, statin, nonsmoking status, and a recorded ankle-brachial index. We used logistic regression to evaluate the association of market competition with patient and procedural characteristics. A sensitivity analysis was performed in patients with isolated femoropopliteal disease matched by the TransAtlantic InterSociety classification of disease severity.

RESULTS

There were 24,669 PVIs that met the inclusion criteria. Patients with IC undergoing PVI were more likely to be on BMT when treated in higher market competition centers (odds ratio [OR], 1.07 per increase in competition quartile; 95% confidence interval [CI], 1.04-1.11; P < .0001). The probability of undergoing aortoiliac interventions decreased with increasing competition (OR, 0.84; 95% CI, 0.81-0.87; P < .0001), but there were higher odds of receiving tibial (OR, 1.40; 95% CI, 1.30-1.50; P < .0001) and multilevel interventions in VHC vs low competition centers (femoral + tibial OR, 1.10; 95% CI, 1.03-1.14; P = .001). Stenting decreased as competition increased (OR, 0.89; 95% CI, 0.87-0.92; P < .0001), whereas exposure to atherectomy increased with higher market competition (OR, 1.15; 95% CI, 1.11-1.19; P < .0001). When assessing patients undergoing single-artery femoropopliteal intervention for TransAtlantic InterSociety A or B lesions to account for disease severity, the odds of undergoing either balloon angioplasty (OR, 0.72; 95% CI, 0.625-0.840; P < .0001) or stenting only (OR, 0.84; 95% CI, 0.727-0.966; P < .0001) were lower in VHC centers. Similarly, the likelihood of receiving atherectomy remained significantly higher in VHC centers (OR, 1.6; 95% CI, 1.36-1.84; P < .0001).

CONCLUSIONS

High market competition was associated with more procedures among patients with claudication that are not consistent with guideline-directed therapy per the SVS clinical practice guidelines, including atherectomy and tibial-level interventions. This analysis demonstrates the susceptibility of care delivery to regional market competition and signifies a novel and undefined driver of PVI variation among patients with claudication.

Uncovering heterogeneous cardiometabolic risk profiles in US adults: the role of social and behavioral determinants of health

INTRODUCTION

Social and behavioral determinants of health (SBDH) have been linked to diabetes risk, but their role in explaining variations in cardiometabolic risk across race/ethnicity in US adults is unclear. This study aimed to classify adults into distinct cardiometabolic risk subgroups using SBDH and clinically measured metabolic risk factors, while comparing their associations with undiagnosed diabetes and pre-diabetes by race/ethnicity.

RESEARCH DESIGN AND METHODS

We analyzed data from 38,476 US adults without prior diabetes diagnosis from the National Health and Nutrition Examination Survey (NHANES) 1999-2018. The k-prototypes clustering algorithm was used to identify subgroups based on 16 SBDH and 13 metabolic risk factors. Each participant was classified as having no diabetes, pre-diabetes or undiagnosed diabetes using contemporaneous laboratory data. Logistic regression was used to assess associations between subgroups and diabetes status, focusing on differences by race/ethnicity.

RESULTS

Three subgroups were identified: cluster 1, primarily middle-aged adults with high rates of smoking, alcohol use, short sleep duration, and low diet quality; cluster 2, mostly young non-white adults with low income, low health insurance coverage, and limited healthcare access; and cluster 3, mostly older males who were the least physically active, but with high insurance coverage and healthcare access. Compared with cluster 2, adjusted ORs (95% CI) for undiagnosed diabetes were 14.9 (10.9, 20.2) in cluster 3 and 3.7 (2.8, 4.8) in cluster 1. Clusters 1 and 3 (vs cluster 2) had high odds of pre-diabetes, with ORs of 1.8 (1.6, 1.9) and 2.1 (1.8, 2.4), respectively. Race/ethnicity was found to modify the relationship between identified subgroups and pre-diabetes risk.

CONCLUSIONS

Self-reported SBDH combined with metabolic factors can be used to classify adults into subgroups with distinct cardiometabolic risk profiles. This approach may help identify individuals who would benefit from screening for diabetes and pre-diabetes and potentially suggest effective prevention strategies.

Social Determinants of Health Documentation in Structured and Unstructured Clinical Data of Patients With Diabetes: Comparative Analysis

Background

Electronic health records (EHRs) have yet to fully capture social determinants of health (SDOH) due to challenges such as nonexistent or inconsistent data capture tools across clinics, lack of time, and the burden of extra steps for the clinician. However, patient clinical notes (unstructured data) may be a better source of patient-related SDOH information.

Objective

It is unclear how accurately EHR data reflect patients' lived experience of SDOH. The manual process of retrieving SDOH information from clinical notes is time-consuming and not feasible. We leveraged two high-throughput tools to identify SDOH mappings to structured and unstructured patient data: PatientExploreR and Electronic Medical Record Search Engine (EMERSE).

Methods

We included adult patients (≥18 years of age) receiving primary care for their diabetes at the University of California, San Francisco (UCSF), from January 1, 2018, to December 31, 2019. We used expert raters to develop a corpus using SDOH in the compendium as a knowledge base as targets for the natural language processing (NLP) text string mapping to find string stems, roots, and syntactic similarities in the clinical notes of patients with diabetes. We applied advanced built-in EMERSE NLP query parsers implemented with JavaCC.

Results

We included 4283 adult patients receiving primary care for diabetes at UCSF. Our study revealed that SDOH may be more significant in the lives of patients with diabetes than is evident from structured data recorded on EHRs. With the application of EMERSE NLP rules, we uncovered additional information from patient clinical notes on problems related to social connectionsisolation, employment, financial insecurity, housing insecurity, food insecurity, education, and stress.

Conclusions

We discovered more patient information related to SDOH in unstructured data than in structured data. The application of this technique and further investment in similar user-friendly tools and infrastructure to extract SDOH information from unstructured data may help to identify the range of social conditions that influence patients' disease experiences and inform clinical decision-making.

Main drivers of diabetes pharmaceuticals expenditures: evidence from OECD countries and Iran

Purpose

This study aimed to identify the impact of prominent drivers on drug expenditure for diabetes.

Method

Following the examination of previous studies, this study identified possible factors contributing to diabetes pharmaceutical expenditures. The explanatory variables for the study were the median population age, access to innovative drugs, GDP per capita, prevalence, price, and consumption of diabetes drugs. Then, to estimate the per capita expenditure among diabetic patients, this study developed the panel data model and two time-series regression models for OECD countries and Iran, respectively.

Results

In the panel data regression model, R2 was 0.43. The influence of the age, prevalence, consumption volume and GDP per capita coefficients were + 1.79, + 0.704, + 3.86057, + 0.00054, respectively. Also, the probability level of all variables was less than 0.05. In Iran's comparative time-series regression model, R2 was 0.9, and the only significant influence coefficient was the age (β=+0.91). In the another model for Iran, R2 was 0.99, the influence coefficient of age was + 0.249, the prevalence was + 0.131, innovation was + 0.029, and the price was + 0.00054; all the probability levels were less than 0.05.

Conclusion

Pharmaceutical per capita expenditure is affected by several factors. These factors are not the same in various counties. Passing a judgment on drug utilization only based on pharmaceutical per capita expenditure cannot be perfect. Also, judging whether the per capita drug expenditure in one country is desirable without attention to the affecting factors and only relying on the value of utilized medicines is defective.

Protocol for a scoping review of health equity frameworks and models applied in empirical studies of chronic disease prevention and control

BACKGROUND

Chronic diseases, such as cancers and cardiovascular diseases, present the greatest burden of morbidity and mortality worldwide. This burden disproportionately affects historically marginalized populations. Health equity is rapidly gaining increased attention in public health, health services, and implementation research, though many health inequities persist. Health equity frameworks and models (FM) have been called upon to guide equity-focused chronic disease and implementation research. However, there is no clear synthesis of the health equity FM used in chronic disease research or how these are applied in empirical studies. This scoping review seeks to fill this gap by identifying and characterizing health equity FM applied in empirical studies along the chronic disease prevention and control continuum, describing how these FM are used, and exploring potential applications to the field of implementation science.

METHODS

We follow established guidance for conducting scoping reviews, which includes six stages: (1) identify the research question; (2) identify relevant studies; (3) select studies for inclusion; (4) data extraction; (5) collating, summarizing, and reporting the results; and (6) consultation. This protocol presents the iterative, collaborative approach taken to conceptualize this study and develop the search strategy. We describe the criteria for inclusion in this review, methods for conducting two phases of screening (title and abstract, full text), data extraction procedures, and quality assurance approaches taken throughout the project.

DISCUSSION

The findings from this review will inform health-equity focused chronic disease prevention and control research. FM identified through this review will be added to an existing website summarizing dissemination and implementation science frameworks, and we will offer case examples and recommendations for utilizing a health equity FM in empirical studies. Our search strategy and review methodology may serve as an example for scholars seeking to conduct reviews of health equity FM in other health disciplines.

SYSTEMATIC REVIEW REGISTRATION

Open Science Framework Registration https://doi.org/10.17605/OSF.IO/SFVE6.

Epidemiology of type 2 diabetes mellitus and treatment utilization patterns among the elderly from the first wave of Longitudinal Aging study in India (2017-18)using a Heckman selection model

INTRODUCTION

Unmanaged Type 2 diabetes mellitus (T2DM) substantially contributes to the multi-morbidity of the elderly. Fewer research has concentrated on understanding the determinants of treatment utilization among older people, with even lesser concerns about missing data in outcome variables leading to biased estimates. The present study intends to evaluate the epidemiology of T2DM in the elderly in India and explore the socioeconomic and behavioral risk factors determining the treatment utilization among the elderly > 60 years in India by addressing the missing data to generate robust estimates.

METHODS

The secondary analysis used data from the Longitudinal Ageing Study in India. The key dependent variables were the presence or absence of T2DM and treatment utilization. Descriptive statistics were used to understand the differences in the prevalence of diabetes and the utilization of treatment across various socio-demographic characteristics. Heckman's statistical technique evaluated the predictors of T2DM and treatment utilization. Analysis was done using STATA software version 14.0.

RESULTS

Almost 14% elderly reported to be living with T2DM. The odds of living with T2DM increased with non-working status, a sedentary lifestyle, and a higher BMI. A higher proportion of the elderly was on oral drugs than insulin and had been practicing lifestyle modifications to control their disease. The probability of developing T2DM was lower among females than males, but females had better odds for treatment utilization of health medication than males. Lastly, treatment utilization was significantly affected by socio-demographic characteristics like education and monthly per capita expenditure.

CONCLUSIONS

Treatment utilization by the elderly living with T2DM is significantly affected by socio-demographic characteristics. Keeping in mind the increasing proportion of the geriatric population in our country, it is pertinent to tailor-made counseling sessions for the elderly to improve medication utilization and adherence and realize our goals concerning non-communicable diseases.

Socio-economic inequalities in undiagnosed, untreated, and uncontrolled diabetes mellitus in Bangladesh: is there a gender difference?

OBJECTIVES

We aimed to determine: (1) the prevalence and socio-economic distribution of undiagnosed, untreated, and uncontrolled diabetes mellitus (DM); (2) the relationship between socio-economic status (SES) and undiagnosed, untreated, and uncontrolled DM; and (3) if this relationship is mediated by gender.

STUDY DESIGN

Cross-sectional nationally representative household-based survey.

METHODS

We used data from the Bangladesh Demographic Health Survey from 2017 to 18. Our findings were based on the responses of 12,144 individuals aged 18 years and older. As a measure of SES, we focused on standard of living (hereinafter referred to as wealth). The study's outcome variables were prevalence of total (diagnosed + undiagnosed), undiagnosed, untreated, and uncontrolled DM. We used three regression-based approaches-adjusted odds ratio, relative inequality index, and slope inequality index-to assess different aspects of SES differences in the prevalence of total, undiagnosed, untreated, and uncontrolled DM. We used logistic regression analysis to look at the adjusted association between SES and the outcomes after gender stratification to see whether gender status moderates the association between SES and the targeted outcomes.

RESULTS

In our sample analysis, the age-adjusted prevalence of total, undiagnosed, untreated, and uncontrolled DM was 9.1%, 61.4%, 64.7%, and 72.1%, respectively. Females had a higher prevalence of DM and undiagnosed, untreated, and uncontrolled DM than males. When compared to people in the poor SES group, people in the rich and middle SES groups had 2.60 times (95% confidence interval [CI] 2.05-3.29) and 1.47 times (95% CI 1.18-1.83) higher chance of developing DM. When compared to individuals in the poor SES group, those in the rich SES groups were 0.50 (95% CI 0.33-0.77) and 0.55 times (95% CI 0.36-0.85) less likely to have undiagnosed and untreated DM.

CONCLUSIONS

In Bangladesh, rich SES groups were more likely than poor SES groups to have DM, whereas poor SES groups with DM were less likely than rich SES groups to be aware of their disease and obtain treatment. The government and other concerned parties are urged by this study to pay more attention to developing suitable policy measures to reduce the risk of DM, particularly among rich SES groups, as well as targeted efforts to screen for and diagnose DM in socio-economically disadvantaged groups.

Evaluation of an Integrated Intervention to Address Clinical Care and Social Needs Among Patients with Type 2 Diabetes

BACKGROUND

The Providence Diabetes Collective Impact Initiative (DCII) was designed to address the clinical challenges of type 2 diabetes and the social determinants of health (SDoH) challenges that exacerbate disease impact.

OBJECTIVE

We assessed the impact of the DCII, a multifaceted intervention approach to diabetes treatment that employed both clinical and SDoH strategies, on access to medical and social services.

DESIGN

The evaluation employed a cohort design and used an adjusted difference-in-difference model to compare treatment and control groups.

PARTICIPANTS

Our study population consisted of 1220 people (740 treatment, 480 control), aged 18-65 years old with a pre-existing type 2 diabetes diagnosis who visited one of the seven Providence clinics (three treatment and four control) in the tri-county area of Portland, Oregon, between August 2019 and November 2020.

INTERVENTIONS

The DCII threaded together clinical approaches such as outreach, standardized protocols, and diabetes self-management education and SDoH strategies including social needs screening, referral to a community resource desk, and social needs support (e.g., transportation) to create a comprehensive, multi-sector intervention.

MAIN MEASURES

Outcome measures included SDoH screens, diabetes education participation, HbA1c, blood pressure, and virtual and in-person primary care utilization, as well as inpatient and emergency department hospitalization.

KEY RESULTS

Compared to patients at the control clinics, patients at DCII clinics saw an increase in diabetes education (15.5%, p<0.001), were modestly more likely to receive SDoH screening (4.4%, p<0.087), and had an increase in the average number of virtual primary care visits of 0.35 per member, per year (p<0.001). No differences in HbA1c, blood pressure, or hospitalization were observed.

CONCLUSIONS

DCII participation was associated with improvements in diabetes education use, SDoH screening, and some measures of care utilization.

Risk of progression from pre-diabetes to type 2 diabetes in a large UK adult cohort

AIMS

People with pre-diabetes are at high risk of progressing to type 2 diabetes. This progression is not well characterised by ethnicity, deprivation and age, which we describe in a large cohort of individuals with pre-diabetes.

METHODS

A retrospective cohort study with The Health Improvement Network (THIN) database was conducted. Patients aged 18 years and over and diagnosed with pre-diabetes [HbA1c 42 mmol/mol (6.0%) to 48 mmol/mol (6.5%) were included]. Cox proportional hazards regression was used to calculate adjusted hazard rate ratios (aHR) for the risk of progression from pre-diabetes to type 2 diabetes for each of the exposure categories [ethnicity, deprivation (Townsend), age and body mass index (BMI)] separately.

RESULTS

Of the baseline population with pre-diabetes (n = 397,853), South Asian (aHR 1.31; 95% CI 1.26-1.37) or Mixed-Race individuals (aHR 1.22; 95% CI 1.11-1.33) had an increased risk of progression to type 2 diabetes compared with those of white European ethnicity. Likewise, deprivation (aHR 1.17; 95% CI 1.14-1.20; most vs. least deprived) was associated with an increased risk of progression. Both younger (aHR 0.63; 95% CI 0.58-0.69; 18 to <30 years) and older individuals (aHR 0.85; 95% CI 0.84-0.87; ≥65 years) had a slower risk of progression from pre-diabetes to type 2 diabetes, than middle-aged (40 to <65 years) individuals.

CONCLUSIONS

South Asian or Mixed-Race individuals and people with social deprivation had an increased risk of progression from pre-diabetes to type 2 diabetes. Clinicians need to recognise the differing risk across their patient populations to implement appropriate prevention strategies.

Youth-Onset Type 2 Diabetes: The Epidemiology of an Awakening Epidemic

In this narrative review, we describe the epidemiology (prevalence, incidence, temporal trends, and projections) of type 2 diabetes among children and adolescents (<20 years), focusing on data from the U.S. and reporting global estimates where available. Secondarily, we discuss the clinical course of youth-onset type 2 diabetes, from prediabetes to complications and comorbidities, drawing comparisons with youth type 1 diabetes to highlight the aggressive course of this condition, which, only recently, has become recognized as a pediatric disease by health care providers. Finally, we end with an overview of emerging topics in type 2 diabetes research that have potential to inform strategies for effective preventive action at the community and individual levels.

Global Prevalence of Diabetic Retinopathy in Pediatric Type 2 Diabetes: A Systematic Review and Meta-analysis

IMPORTANCE

Type 2 diabetes (T2D) is increasing globally. Diabetic retinopathy (DR) is a leading cause of blindness in adults with T2D; however, the global burden of DR in pediatric T2D is unknown. This knowledge can inform retinopathy screening and treatments to preserve vision in this population.

OBJECTIVE

To estimate the global prevalence of DR in pediatric T2D.

DATA SOURCES

MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Cochrane Library, the Web of Science, and the gray literature (ie, literature containing information that is not available through traditional publishing and distribution channels) were searched for relevant records from the date of database inception to April 4, 2021, with updated searches conducted on May 17, 2022. Searches were limited to human studies. No language restrictions were applied. Search terms included diabetic retinopathy; diabetes mellitus, type 2; prevalence studies; and child, adolescent, teenage, youth, and pediatric.

STUDY SELECTION

Three teams, each with 2 reviewers, independently screened for observational studies with 10 or more participants that reported the prevalence of DR. Among 1989 screened articles, 27 studies met the inclusion criteria for the pooled analysis.

DATA EXTRACTION AND SYNTHESIS

This systematic review and meta-analysis followed the Meta-analysis of Observational Studies in Epidemiology (MOOSE) and the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines for systematic reviews and meta-analyses. Two independent reviewers performed the risk of bias and level of evidence analyses. The results were pooled using a random-effects model, and heterogeneity was reported using χ2 and I2 statistics.

MAIN OUTCOMES AND MEASURES

The main outcome was the estimated pooled global prevalence of DR in pediatric T2D. Other outcomes included DR severity and current DR assessment methods. The association of diabetes duration, sex, race, age, and obesity with DR prevalence was also assessed.

RESULTS

Among the 27 studies included in the pooled analysis (5924 unique patients; age range at T2D diagnosis, 6.5-21.0 years), the global prevalence of DR in pediatric T2D was 6.99% (95% CI, 3.75%-11.00%; I2 = 95%; 615 patients). Fundoscopy was less sensitive than 7-field stereoscopic fundus photography in detecting retinopathy (0.47% [95% CI, 0%-3.30%; I2 = 0%] vs 13.55% [95% CI, 5.43%-24.29%; I2 = 92%]). The prevalence of DR increased over time and was 1.11% (95% CI, 0.04%-3.06%; I2 = 5%) at less than 2.5 years after T2D diagnosis, 9.04% (95% CI, 2.24%-19.55%; I2 = 88%) at 2.5 to 5.0 years after T2D diagnosis, and 28.14% (95% CI, 12.84%-46.45%; I2 = 96%) at more than 5 years after T2D diagnosis. The prevalence of DR increased with age, and no differences were noted based on sex, race, or obesity. Heterogeneity was high among studies.

CONCLUSIONS AND RELEVANCE

In this study, DR prevalence in pediatric T2D increased significantly at more than 5 years after diagnosis. These findings suggest that retinal microvasculature is an early target of T2D in children and adolescents, and annual screening with fundus photography beginning at diagnosis offers the best assessment method for early detection of DR in pediatric patients.

Epidemiology and health impact of diabetes in France

OBJECTIVES

Diabetes is a growing health concern. An update on epidemiology and health outcomes is mandatory to devise strategies to alleviate the burden of diabetes. The objective of this study was to assess the prevalence of diabetes and associated complications in France in 2017.

METHODS

Demographics and healthcare data from a representative permanent secondary database were analyzed. Patients with at least 2 national health insurance payments for anti-diabetic drugs in 2017 were selected, with the index date set to the last payment date. Patients were grouped as diabetes treated with insulin only (DTi), diabetes treated with anti-diabetic drugs other than only insulin (DT2) or gestational diabetes. Comorbidities, diabetes-related complications and hospital admissions, healthcare consumption and medical follow-up were extracted for a 5- or 2-year period prior to the index date and summarized using descriptive statistics.

RESULTS

Overal, 29,288 patients were included in the study population: 1964 (6.7%) were categorized as DTi and 27,243 (93.0%) as DT2. Patients with gestational diabetes (81 [0.3%]) are not further described here. Prevalence was estimated at 4.9%. For DT2, marked geographic disparities were observed, with prevalence being highest in the northeast France. Diabetes-related complications were more frequent in DTi than in DT2 over a 5-year period (52.2% vs 34.7%). Diabetes-related admissions were also more common in DTi than in DT2 over a 2-year period (29.8% vs 16.9%). In the DT2 category, another antidiabetic drug was added during the 3 months prior to the index date in 16.5% of cases overall and in 25% of patients with recent hospital admission or diabetes-related complications. Although more than 80% of patients in the DTi and DT2 categories had at least 1 healthcare consultation during 2 years prior to the index date, only 10% to 20% of patients complied with guidelines for all 5 recommended examinations.

CONCLUSIONS

Prevalence of diabetes is high in the French population, while compliance with recommended healthcare consultations falls short of the 80% goal set by regulations. New strategies are mandatory in order to reduce the burden of diabetes-related complications and admissions, focusing on patient and physician information and education in order to increase proactive treatment adjustment and reduce therapeutic inertia.

The adoption of social determinants of health documentation in clinical settings

OBJECTIVE

To understand the frequency of social determinants of health (SDOH) diagnosis codes (Z-codes) within the electronic health record (EHR) for patients with prediabetes and diabetes and examine factors influencing the adoption of SDOH documentation in clinical care.

DATA SOURCES

EHR data and qualitative interviews with health care providers and stakeholders.

STUDY DESIGN

An explanatory sequential mixed methods design first examined the use of Z-codes within the EHR and qualitatively examined barriers to documenting SDOH. Data were integrated and interpreted using a joint display. This research was informed by the Framework for Dissemination and Utilization of Research for Health Care Policy and Practice.

DATA COLLECTION/EXTRACTION METHODS

We queried EHR data for patients with a hemoglobin A1c > 5.7 between October 1, 2015 and September 1, 2020 (n = 118,215) to examine the use of Z-codes and demographics and outcomes for patients with and without social needs. Semi-structured interviews were conducted with 23 participants (n = 15 health care providers; n = 7 billing and compliance stakeholders). The interview questions sought to understand how factors at the innovation-, individual-, organizational-, and environmental-level influence SDOH documentation. We used thematic analysis to analyze interview data.

PRINCIPAL FINDINGS

Patients with social needs were disproportionately older, female, Black, uninsured, living in low-income and high unemployment neighborhoods, and had a higher number of hospitalizations, obesity, prediabetes, and type 2 diabetes than those without a Z-code. Z-codes were not frequently used in the EHR (<1% of patients), and there was an overall lack of congruence between quantitative and qualitative results related to the prevalence of social needs. Providers faced barriers at multiple levels (e.g., individual-level: discomfort discussing social needs; organizational-level: limited time, competing priorities) for documenting SDOH and identified strategies to improve documentation.

CONCLUSIONS

Providers recognized the impact of SDOH on patient health and had positive perceptions of screening for and documenting social needs. Implementation strategies are needed to improve systematic documentation.

The association of body mass index and odds of type 2 diabetes mellitus varies by race/ethnicity

OBJECTIVE

This study aimed to examine the association between body mass index (BMI; weight [kilogram]/height² [meter]) and type 2 diabetes mellitus (T2DM) among the largest three largest racial/ethnic groups in the United States.

METHODS

We compiled 10 waves of the continuous National Health and Nutrition Examination Survey from 1999-2000 through 2017-2018. Participants (N = 45,514) were those who had data on BMI, HbA_1c, and demographics. We estimated associations between BMI and prediabetes/T2DM odds for Black, Latine, and White participants.

RESULTS

BMI was associated with 10% higher odds of prediabetes/T2DM vs. having normal HbA_1c levels (odds ratio = 1.10, 95% confidence interval = 1.10-1.11) for Latine and White individuals. However, the association between BMI and prediabetes/T2DM was significantly weaker among Black individuals. When focusing on T2DM prevalence, the association with BMI for Black participants was even weaker (odds ratio = 0.97, 95% confidence interval = 0.95-0.98).

CONCLUSIONS

The unstable associations between BMI and T2DM across race indicate that BMI has received unwarranted focus as a prime predictor of T2DM. Relying on BMI introduces bias in T2DM risk estimations especially in Black individuals. Focusing on BMI places the onus on individuals to change and increases weight stigma, which can worsen health outcomes. Instead, policymakers should focus on social determinants of T2DM and its concomitant racial/ethnic disparities.

"The potential of social media in health promotion beyond creating awareness: an integrative review"

BACKGROUND

Developing strategies to change health behaviour is one of the biggest challenges of health promotion programs. Social media, as a popular and innovative communication and education tool, offers opportunities to modify health behaviour. While literature on using social media for health promotion campaigns is growing, there is a need to evaluate the approaches used to change health behaviour, rather than only creating awareness.

OBJECTIVE

The paper reviewed the literature on application of social media in health promotion campaigns with a particular focus on the methodologies used in assessing the outcome of the programs for behaviour change. This fills the void in collating evidence to extend health promotion campaigns to effect sustainable behavioural change.

METHOD

Peer-reviewed articles were identified through multiple science databases. A systematic electronic search was conducted to retrieve review and original papers published between January 2010 and April 2022. The titles and abstracts of the articles were screened according to inclusion and exclusion criteria. All authors independently read the full texts and discussed them to reach a consensus about the themes. Concept mapping was used to present results from analysis of the included papers.

RESULTS

Of the 674 citations, 28 (4.1%) studies were included in this review. The methodology approaches of 18 (2.7%) papers, that aimed to evaluate the impact of social media in health promotion campaigns towards behaviour change, were analysed further using concept mapping. The results showed that 10 studies (55.5%) adopted quantitative methods and five studies (27.7%) used mixed methods and three studies (16.6%) used qualitative methods. Facebook and YouTube were used more for intervention purposes to change health behaviour. Twitter and Instagram were used more to observe the trend of changes in health behaviour. Six studies (33.3%) adopted Social Cognitive Theory and one study (5.5%) applied the Transtheoretical Model as the framework to evaluate the outcome. Overall, the results show that though social media has potential in promoting behaviour change, the estimation of this change in long-term lies outside the scope of social media health campaigns. This is also reflected in the methodologies used in existing studies to assess such sustainable changes. The employed measures usually target immediate behaviour or social media engagement rather than addressing the change on a behavioural level.

CONCLUSION

Evaluating the performance of social media campaigns to promote health behaviours towards a sustainable outcome is a complex process. Emerging research is focused on evaluating the potential of social media as an opportunity to create awareness. Such measures require less effort in quantifying and isolating the effect. The design of the campaigns is required to be aligned in relation to stages of the behaviour change. The study provides suggestions on how this can be achieved.

Pharmacogenetics of CYP2C19*17: Functional and Clinical Implications of CYP2C19*17 - rs12248560 (c.-806C>T) in the Development of Type 2 Diabetes

The prevalence of diabetes mellitus (DM) is increasing worldwide including Saudi Arabia. DM increases mortality rate, morbidity and vascular complications, accompanied by poor general health status and low quality of life. CYP2C19*17 polymorphism in CYP2C19 gene is associated with the clinical outcome of drugs that are substrates of CYP2C19. CYP2C19*17 confers reduced susceptibility to certain illnesses. This research was conducted to develop a robust method to genotype the rs12248560 single nucleotide variation (SNV). We enrolled 206 subjects: 100 subjects were clinically confirmed cases of type 2 diabetes (T2D), and 106 subjects were healthy controls in this study. Samples from all subjects were screened for the CYP2C19 rs12248560 (c.-806C>T) by the amplification-refractory mutation system PCR (ARMS-PCR). The frequencies of CYP2C19*17 TT, CT, CC genotypes in T2D cases were 12%, 21%, and 67%, respectively whereas those in healthy controls were 70.75%, 26.41%, and 2.83%, respectively. The difference was significant (p < 0.035). T allele (fT) prevalence was found to be substantially greater in T2D cases compared to healthy controls (0.22 vs. 0.16). Results indicated that the CYP2C19*17 - TT genotype is associated with increased susceptibility to T2D with OR = 4.47, RR = 2.64, (p < 0.024). Moreover, the ARMS-based assay proved to be an easy method for the determination of CYP2C19*17 genotypes with reduced cost and good accuracy. In addition, this result helps in the detection and stratification of the individuals who are at risk for the development of T2D. Nevertheless, this finding needs to be validated in molecular genetic studies with increased specimen size and in different ethnicities.

Level of education is associated with coronary heart disease and chronic kidney disease in individuals with type 2 diabetes: a population-based study

INTRODUCTION

To study the relationship between education level and vascular complications in individuals with type 2 diabetes in Norway.

RESEARCH DESIGN AND METHODS

Multiregional population-based cross-sectional study of individuals with type 2 diabetes in primary care. Data were extracted from electronic medical records in the period 2012-2014. Information on education level was obtained from Statistics Norway. Using multivariable multilevel regression analyses on imputed data we analyzed the association between education level and vascular complications. We adjusted for age, sex, HbA1c, low-density lipoprotein cholesterol, systolic blood pressure, smoking and diabetes duration. Results are presented as ORs and 95% CIs.

RESULTS

Of 8192 individuals with type 2 diabetes included, 34.0% had completed compulsory education, 49.0% upper secondary education and 16.9% higher education. The prevalence of vascular complications in the three education groups was: coronary heart disease 25.9%, 23.0% and 16.9%; stroke 9.6%, 7.4% and 6.6%; chronic kidney disease (estimated glomerular filtration rate <60 mL/min/1.73 m²) 23.9%, 16.8% and 12.6%; and retinopathy 13.9%, 11.5% and 11.7%, respectively. Higher education was associated with lower odds for coronary heart disease (OR 0.59; 95% CI 0.49 to 0.71) and chronic kidney disease (OR 0.75; 95% CI 0.60 to 0.93) compared with compulsory education when adjusting for age, sex, HbA1c, low-density lipoprotein cholesterol, systolic blood pressure, smoking and diabetes duration.

CONCLUSIONS

In a country with equal access to healthcare, high education level was associated with lower odds for coronary heart disease and chronic kidney disease in individuals with type 2 diabetes.

Is Sociodemographic Status Associated with Empathic Communication and Decision Quality in Diabetes Care?

OBJECTIVE

To assess the relationship between empathic communication, shared decision-making, and patient sociodemographic factors of income, education, and ethnicity in patients with diabetes.

RESEARCH DESIGN AND METHODS

This was a cross-sectional study from five primary care practices in the Greater Toronto Area, Ontario, Canada, participating in a randomized controlled trial of a diabetes goal setting and shared decision-making plan. Participants included 30 patients with diabetes and 23 clinicians (physicians, nurses, dietitians, and pharmacists), with a sample size of 48 clinical encounters. Clinical encounter audiotapes were coded using the Empathic Communication Coding System (ECCS) and Decision Support Analysis Tool (DSAT-10).

RESULTS

The most frequent empathic responses among encounters were "acknowledgement with pursuit" (28.9%) and "confirmation" (30.0%). The most frequently assessed DSAT components were "stage" (86%) and knowledge of options (82.0%). ECCS varied by education (p=0.030) and ethnicity (p=0.03), but not income. Patients with only a college degree received more empathic communication than patients with bachelor's degrees or more, and South Asian patients received less empathic communication than Asian patients. DSAT varied with ethnicity (p=0.07) but not education or income. White patients experienced more shared decision-making than those in the "other" category.

CONCLUSIONS

We identified a new relationship between ECCS, education and ethnicity, as well as DSAT and ethnicity. Limitations include sample size, heterogeneity of encounters, and predominant white ethnicity. These associations may be evidence of systemic biases in healthcare, with hidden roots in medical education.

Food Insecurity and Type 2 Diabetes Among Latinos: Examining Neighborhood Cohesion as a Protective Factor

Qualitative work has found that Latino food pantry recipients share food and reciprocally provide social support to their food-insecure neighbors. These findings suggest that neighborhood cohesion (NC) may serve as an important community-level resource that Latinos utilize as a coping mechanism when food-insecure. High levels of NC may be a proxy for instrumental support outside the household and act as a buffer against the adverse health effects of food insecurity including type 2 diabetes (T2D), which is highly sensitive to food insecurity. The purpose of this study was to quantitatively test this theory by examining whether NC moderated the association between T2D and food security (FS) status among Latino adults nationwide. We used data from the 2013-2018 National Health Interview Survey (n = 23,478). We found that FS status was associated with T2D prevalence, with Latino adults having a higher odds of T2D if they had low FS or very low FS compared to their FS counterparts. We also found Latinos adults who reported high NC had a lower odds of T2D compared to those who reported low NC. However, we did not find there was significant interaction between FS status and NC on T2D. NC may instead be a precursor to FS status, rather than a buffer of food insecurity on T2D. Low NC may lead to less instrumental support and tangible benefits that determine FS. Additionally, perceived NC might not align with objective NC and T2D may be too distal of a health outcome to test the protective effect of NC.

Incorporating social determinants of health into individual care—a multidisciplinary perspective of health professionals who work with people who have type 2 diabetes

Social determinants of health (SDoH) and type 2 diabetes mellitus (T2DM) are interrelated. The prevalence of T2DM is increased amongst those with suboptimal SDoH. Poor SDoH can also negatively impact T2DM self-management. Social determinants of health are mostly considered at population and community levels, rather than individually or clinically. This qualitative study combines the perspectives of a multidisciplinary cohort of health professionals to identify and explore the impact of social determinants on self-management, and ways they could be incorporated into individual clinical care. Purposively selected participants chose to partake in an in-depth, semi-structured, one-on-one interview or focus group. Data were analysed, and themes identified using a combination of deductive and inductive thematic analysis. Fifty-one health professionals volunteered for the study. Two small focus groups (n = 3 and n = 4) and 44 one-on-one interviews were conducted. The identified themes were: 1) Support for incorporating SDoH into T2DM care, 2) Effect of SDoH on T2DM self-management, 3) Identifying and addressing social need, 4) Requirements for incorporating SDoH into T2DM individual clinical care. Health professionals reported that poor social determinants negatively affect an individual’s ability to self manage their T2DM. Person-centred care could be enhanced, and people with T2DM may be more likely to achieve self-management goals if SDoH were included in individual clinical care. To achieve successful and sustained self-management for people with T2DM, health professionals require a thorough understanding of T2DM and the effect of social determinants, respect for client privacy, client trust and rapport, effective communication skills, validated tools for assessing SDoH, team champions, teamwork, ongoing education and training, adequate resources, guiding policies and procedures, and management support. Incorporating SDoH into individual, clinical care for people with T2DM was strongly supported by health professionals. If embraced, this addition to care for individuals with T2DM could improve self-management capacity and enhance person-centred care.

Food insecurity, diabetes, and perceived diabetes self-management among Latinos in California: Differences by nativity and duration of residence

We examined associations between food security (FS) status and type 2 diabetes (T2D) prevalence and perceived T2D self-management by nativity and US duration of residence among Latinos living in California. We used the California Health Interview Survey (2012-2017) and included Latinos who lived below 200% of the federal poverty line (n = 16,254) and for our management outcome, those with T2D (n = 2284). Latinos with low FS (OR = 1.44, 95% CI 1.14-1.83) or very low FS (OR = 1.87, 95% CI 1.33-2.61) had a higher odds of T2D compared to their food-secure counterparts. When stratified by nativity/duration in the US, US-born Latinos and Latino immigrants with >10 years duration had a higher odds of T2D if they reported low FS (US-born: OR = 1.60, 95% CI 1.02-2.52; >10 yrs: OR = 1.48, 95% CI 1.12-1.97) or very low FS (US-born: OR = 2.37, 95% CI 1.45-3.86; >10 yrs: OR = 1.78, 95% CI 1.15-2.76) compared to their food-secure counterparts. There was no association among immigrants with <10 years duration. For perceived T2D self-management, those with low or very low FS had lower odds of reporting proper management (OR = 0.56, 95% CI 0.36-0.86; OR = 0.46, 95% CI 0.26-0.83) compared to their food-secure counterparts. When stratified by nativity, the US-born did not differ in their perceived self-management by FS status, while immigrants with low or very FS had lower odds of perceived self-management (OR = 0.54, 95% CI 0.34-0.86; OR = 0.36, 95% CI 0.17-0.74), compared to their food-secure counterparts. Food insecurity may be an important contributor to T2D prevalence and perceived T2D self-management for Latino immigrants.

Transcultural Lifestyle Medicine in Type 2 Diabetes Care: Narrative Review of the Literature

Disparities in type 2 diabetes (T2D) care is a global problem across diverse cultures. The Dysglycemia-Based Chronic Disease (DBCD) model promotes early and sustainable interventions along the insulin resistance (stage 1), prediabetes (stage 2), T2D (stage 3), and complications (stage 4) spectrum. In this model, lifestyle medicine is the cornerstone of preventive care to reduce DBCD progression and the socioeconomic/biological burden of disease. A comprehensive literature review, spanning 2000 to 2021, was performed and 55 studies were included examining the effects of lifestyle medicine and their cultural adaptions with different prevention modalities. In stage 1, primordial prevention targets modifiable primary drivers (behavior and environment), unhealthy lifestyles, abnormal adiposity, and insulin resistance with educational and motivational health promotion activities at individual, group, community, and population-based scales. Primary, secondary, and tertiary prevention targets individuals with mild hyperglycemia, severe hyperglycemia, and complications, respectively, using programs that incorporate structured lifestyle interventions. Culturally adapted lifestyle change in primary and secondary prevention improved quality of life and biomarkers, but with a limited impact of tertiary prevention on cardiovascular events. In conclusion, lifestyle medicine with cultural adaptations is an integral part of preventive care in patients with T2D. However, considerable research gaps exist, especially for tertiary prevention.

Patient education for people living with diabetes in the Philippines: A scoping review of information needs, diabetes knowledge and effectiveness of educational interventions

BACKGROUND AND AIMS

Despite the growing burden of diabetes in the Philippines, available evidence indicates that its care and control are far from optimal, including patient education. The aim of this scoping review was to synthesize information in the available literature to describe the state of science of patient education for people living with diabetes in the Philippines, specific to educational needs, diabetes knowledge, and effectiveness of educational interventions.

METHODS

Medline, Embase, Emcare, CINAHL, Pubmed and American Psychological Association PsycInfo were searched from data inception through July 2021. Studies of any methodology (qualitative/quantitative/mixed methods), sample size, and language were eligible for inclusion.

RESULTS

Of 2021 initial citations, 7 studies were included, with all being quantitative in design and with a median Critical Appraisal Skills Program score of 8/12. Information needs were described by one study and related to self-care abilities. Diabetes knowledge was measured in 6 studies and improved significantly after educational interventions. Overall, studies showed that educational interventions significantly impacted self-efficacy, anthropometric measures, hemoglobin A1c levels, utilization of care and routine programme and attitudes regarding their health.

CONCLUSIONS

The findings highlight the importance of a comprehensive and culturally appropriate educational intervention for this population. Further research is needed to develop such intervention and assess its effectiveness to change behaviour, such as increasing physical activity.

Prevalence of overweight and obesity amongst patients with diabetes and their non-diabetic family members in Senwabarwana, Limpopo province, South Africa

Background

Diabetes remains a public health concern and the second cause of mortality in South Africa. Family history of diabetes increases risk of developing diabetes. Obesity amongst patients is associated with comorbidity, whilst amongst non-diabetic family members it is associated with developing diabetes. This study aimed at determining prevalence of overweight and obesity amongst patients with diabetes and non-diabetic family members.

Methods

A quantitative, cross-sectional descriptive study was conducted on 200 patients and 200 non-diabetic family members were selected using systematic random sampling from rural clinics of Senwabarwana. Data were collected using close-ended questionnaires and anthropometric measurements. Body mass index (BMI) and waist circumference were measured and interpreted according to World Health Organization guidelines. Data were analysed using Statistical Package for Social Sciences, using both descriptive and inferential statistics. Chi-square test was used to calculate associations at 95% confidence interval where a p-value of < 0.05 was considered statistically significant.

Results

Most patients (75.5%) had comorbidities and hypertension was most prevalent (89.0%). Over half of the patients (57.0%) and 38.0% of family members were obese. Most patients (75.0%) and 58.0% of family members had abdominal obesity.

Conclusion

Patients with diabetes suffer from comorbidities are overweight and obese whilst evidence from various studies suggest that non-diabetic family members are at added risk of developing diabetes because of higher BMI and abdominal obesity. There is an urgent need to create a conducive environment that discourages sedentary behaviours through lifestyle modifications using the family centred approach, and involve family members in the care of patients.

Factors That Contribute to hIAPP Amyloidosis in Type 2 Diabetes Mellitus

Cases of Type 2 Diabetes Mellitus (T2DM) are increasing at an alarming rate due to the rise in obesity, sedentary lifestyles, glucose-rich diets and other factors. Numerous studies have increasingly illustrated the pivotal role that human islet amyloid polypeptide (hIAPP) plays in the pathology of T2DM through damage and subsequent loss of pancreatic β-cell mass. HIAPP can misfold and form amyloid fibrils which are preceded by pre-fibrillar oligomers and monomers, all of which have been linked, to a certain extent, to β-cell cytotoxicity through a range of proposed mechanisms. This review provides an up-to-date summary of recent progress in the field, highlighting factors that contribute to hIAPP misfolding and aggregation such as hIAPP protein concentration, cell stress, molecular chaperones, the immune system response and cross-seeding with other amyloidogenic proteins. Understanding the structure of hIAPP and how these factors affect amyloid formation will help us better understand how hIAPP misfolds and aggregates and, importantly, help identify potential therapeutic targets for inhibiting amyloidosis so alternate and more effective treatments for T2DM can be developed.

Socioeconomic and Behavioral Disparities Among Diabetics in Saudi Arabia: A Nation-Wide Descriptive Study

PURPOSE

This study aims to explore sociodemographic, behavioral and clinical factors in adult participants with Diabetes in Saudi Arabia.

METHODS

A population-based cross-sectional study of 20492 potential participants conducted in quarters 1 and 2 in 2021 from all 13 administrative regions of Saudi Arabia. A backward maximum likelihood logistic regression model, including all variables, was used to identify variables associated with participants living with Diabetes.

RESULTS

A total of 14007 participants, aged ≥18 years, completed the interview, with a response rate of 68.3% and successful quota sampling. Fifty percent were male, the mean age was 36.7 (SD 13.7; range: 18-90). Of the total sample, 1633, 11.7% had Diabetes. Seven percent only of diabetic patients (124 participants) had an acceptable level of fruit and vegetable intake. In addition, only (274, 16.8%) had an acceptable level of physical activity, compared to (2389, 19.3%) in the non-diabetic group. Daily smokers were slightly higher in the diabetic group compared to the non-diabetic group (13.2% vs 11.7%). Hypertension was reported mostly by the diabetic group (45.1% vs 8%). Overweight and Obesity were more prevalent in patients with Diabetes (72.50% vs 51.62%). The results of the logistic regression have shown that several sociodemographic, behavioral and intermediate risk factors were significantly associated with Diabetes.

CONCLUSION

The study found that the prevalence of Diabetes in Saudi Arabia is around 12%, which is lower than the previously reported prevalence of Diabetes in Saudi Arabia. Moreover, Diabetes was found to be associated with lower educational level, smoking, obesity and overweight, hypercholesterolemia and hypertension. These factors are essential to be identified and screened in the community at regular interval; furthermore, controlling these factors may improve their disease management and quality of life. Additionally, knowing these factors will assist policymakers to shape an effective practical approach to combat diabetes widespread.

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.

Adverse childhood experiences in relation to comorbid cardiovascular diseases and diabetes among middle-aged and old adults in China

AIM

To examine whether various aspects of adverse childhood experiences (ACEs) are associated with comorbid cardiovascular diseases (CVDs) and diabetes among middle-aged and old adults in China.

METHODS

Using the 2018 China Health and Retirement Longitudinal Study survey and the 2014 Life History survey, in total, 17 115 respondents aged ≥45 years were included. Logistic regressions were applied to estimate the relationship between aspects of ACEs and diagnosis of both CVDs and diabetes while adjusting for adulthood demographics, health and health behaviors.

RESULTS

Childhood hunger (OR = 1.75, P < 0.01), childhood socioeconomic status (OR = 1.45, P < 0.05) and abuse from father (OR = 1.50, P < 0.05) were significantly associated with greater odds of comorbid CVDs and diabetes above and beyond adulthood characteristics. In addition, the effects of these ACEs on comorbidity were stronger than their effects on the single chronic condition.

CONCLUSIONS

Our findings suggest that, for middle-aged and old Chinese adults, ACEs could have long-lasting impacts on multiple chronic conditions in later life. Public health interventions should focus on the early life stage as the protective childhood conditions might help in warning of later clustering chronic diseases. Geriatr Gerontol Int ••; ••: ••-•• Geriatr Gerontol Int 2021; ••: ••-••.

Implementation of a multi-level community-clinical linkage intervention to improve glycemic control among south Asian patients with uncontrolled diabetes: study protocol of the DREAM initiative

BACKGROUND

A number of studies have identified patient-, provider-, and community-level barriers to effective diabetes management among South Asian Americans, who have a high prevalence of type 2 diabetes. However, no multi-level, integrated community health worker (CHW) models leveraging health information technology (HIT) have been developed to mitigate disease among this population. This paper describes the protocol for a multi-level, community-clinical linkage intervention to improve glycemic control among South Asians with uncontrolled diabetes.

METHODS

The study includes three components: 1) building the capacity of primary care practices (PCPs) to utilize electronic health record (EHR) registries to identify patients with uncontrolled diabetes; 2) delivery of a culturally- and linguistically-adapted CHW intervention to improve diabetes self-management; and 3) HIT-enabled linkage to culturally-relevant community resources. The CHW intervention component includes a randomized controlled trial consisting of group education sessions on diabetes management, physical activity, and diet/nutrition. South Asian individuals with type 2 diabetes are recruited from 20 PCPs throughout NYC and randomized at the individual level within each PCP site. A total of 886 individuals will be randomized into treatment or control groups; EHR data collection occurs at screening, 6-, 12-, and 18-month. We hypothesize that individuals receiving the multi-level diabetes management intervention will be 15% more likely than the control group to achieve ≥0.5% point reduction in hemoglobin A1c (HbA1c) at 6-months. Secondary outcomes include change in weight, body mass index, and LDL cholesterol; the increased use of community and social services; and increased health self-efficacy. Additionally, a cost-effectiveness analysis will focus on implementation and healthcare utilization costs to determine the incremental cost per person achieving an HbA1c change of ≥0.5%.

DISCUSSION

Final outcomes will provide evidence regarding the effectiveness of a multi-level, integrated EHR-CHW intervention, implemented in small PCP settings to promote diabetes control among an underserved South Asian population. The study leverages multisectoral partnerships, including the local health department, a healthcare payer, and EHR vendors. Study findings will have important implications for the translation of integrated evidence-based strategies to other minority communities and in under-resourced primary care settings.

TRIAL REGISTRATION

This study was registered with clinicaltrials.gov: NCT03333044 on November 6, 2017.

The role of Sociodemographic factors on goal achievement in a community-based diabetes prevention program behavioral lifestyle intervention

BACKGROUND

The Diabetes Prevention Program (DPP) behavioral lifestyle intervention was effective among a diverse sample of adults with prediabetes. Demonstrated effectiveness in translated versions of the DPP lifestyle intervention (such as Group Lifestyle Balance, DPP-GLB) led to widescale usage with national program oversight and reimbursement. However, little is known about the success of these DPP-translation programs across subgroups of sociodemographic factors. This current effort investigated potential disparities in DPP-translation program primary goal achievement (physical activity and weight) by key sociodemographic factors.

METHODS

Data were combined from two 12-month community-based DPP-GLB trials among overweight/obese individuals with prediabetes and/or metabolic syndrome. We evaluated change in weight (kilograms and percent) and activity (MET-hrs/week) and goal achievement (yes/no; ≥5% weight loss and 150 min per week activity) after 6 and 12 months of intervention within and across subgroups of race/ethnicity (non-Hispanic white, non-Hispanic black), employment status, education, income, and gender.

RESULTS

Among 240 participants (85%) with complete data, most sociodemographic subgroups demonstrated significant weight loss. However, non-Hispanic white lost more weight at both 6 and 12 months compared to non-Hispanic black participants [median weight loss (IQR), 6 months: 5.7% (2.7-9.0) vs. 1.5% (1.2-7.5) p = .01 and 12 months: 4.8% (1.1-9.6) vs. 1.1% (- 2.0-3.7) p = .01, respectively]. In addition, a larger percentage of non-Hispanic white demonstrated a 5% weight loss at 6 and 12 months. Employment was significantly related to 12-month weight loss, with retired participants being the most successful. Men, participants with graduate degrees, and those with higher income were most likely to meet the activity goal at baseline and 12 months. Differences in physical activity goal achievement across gender, education, and income groups were significant at baseline, attenuated after 6 months, then re-emerged at 12 months.

CONCLUSIONS

The DPP-GLB was effective in promoting weight loss and helped to alleviate disparities in physical activity levels after 6 months. Despite overall program success, differences in weight loss achievement by race/ethnicity were found and disparities in activity re-emerged after 12 months of intervention. These results support the need for intervention modification providing more tailored approaches to marginalized groups to maximize the achievement and maintenance of DPP-GLB behavioral goals.

TRIAL REGISTRATION

NCT01050205 , NCT02467881 .

When Scarcity Meets Disparity: "Resources Allocation and COVID-19 Patients with Diabetes"

The COVID-19 pandemic raised distinct challenges in the field of scarce resource allocation, a long-standing area of inquiry in the field of bioethics. Policymakers and states developed crisis guidelines for ventilator triage that incorporated such factors as immediate prognosis, long-term life expectancy, and current stage of life. Often these depend upon existing risk factors for severe illness, including diabetes. However, these algorithms generally failed to account for the underlying structural biases, including systematic racism and economic disparity, that rendered some patients more vulnerable to these conditions. This paper discusses this unique ethical challenge in resource allocation through the lens of care for patients with severe COVID-19 and diabetes.