A picture is worth a thousand words: A culturally-tailored video-based approach to diabetes education in Somali families of children with type 1 diabetes

Objectives

Type 1 diabetes (T1D) is highly prevalent in Somali immigrant children and hemoglobin A1c (HbA1c) levels are elevated in this population compared to non-Hispanic Whites. Current self-management diabetes education has not been tailored to this population. We aimed to improve delivery of T1D education to Somali immigrants by developing and testing a culturally-appropriate video-based curriculum.

Methods

This cross-sectional study involved Somali youth ≤ 19 years with T1D followed at two pediatric tertiary centers in Minnesota. Ten Somali-language T1D education videos were developed (∼60 min for total program) based on core ADA curriculum and tailored to address cultural concerns and misconceptions. A diabetes knowledge questionnaire was administered to parents of all participants and to children aged ≥12 years. Pre- and post-educational session questionnaire mean scores were compared using a paired t-test to assess knowledge improvement immediately post-video education (primary endpoint) and retention at 3 months (secondary endpoint). HbA1c was measured pre- and 6 months post education (exploratory endpoint).

Results

Twenty-two Somali parents of 22 children participated (mean age 12.3 ± 4 years; 36 % female), 12 children ≥12 years. Diabetes knowledge scores significantly improved immediately post-video education compared to baseline (p = 0.012). This improvement persisted 3 months later (p = 0.0008). There was no significant change in mean HbA1c from baseline at 6 months post education (9.0 ± 1.5 % vs 9.3 ± 1.9; p = 0.6).

Conclusion

Culturally and linguistically tailoring diabetes education materials to African immigrants and delivering it audio-visually could improve effectiveness of diabetes education and increase knowledge and retention compared to simply translating standard diabetes education materials. The effect on HbA1c needs further study with a larger sample size.

Utilizing clinical pharmacists and a medication assistance program to improve medication access for indigent and underserved patients in primary care

Background

Medication Assistance Programs (MAP) provide needed medications to uninsured and underinsured patients. In 2019, 24% of adults had difficulty affording their medications. Literature has shown enrollment in MAP decreased emergency department (ED) visits, hospital admission, and total hospital cost.

Objectives

Primary objective described cost savings of MAP in patients identified by pharmacists. Secondary objectives included comparing rates one year before and after MAP utilization for hospitalization, ED visits, and combined hospitalization and ED visits. The purpose of the study was to evaluate the effect of pharmacists in improving medication access.

Methods

A retrospective observational cohort was conducted in primary care and family medicine resident clinics. Inclusion criteria included one or more visits with a pharmacist and MAP application between January 1, 2019 through December 31, 2019. The primary objective and demographics were analyzed using descriptive statistics. Secondary objectives were analyzed using paired t-test.

Results

In total, 18 patients saved $187,789, with an average of $10,432 per patient, for 35 medications. There were no statistically significant differences in average hospitalizations, ED visits, and combined hospitalizations and ED visits.

Conclusions

Pharmacists utilizing MAP resulted in cost savings and increased patient access to medications. The study did not find differences in hospital visits, ED visits, or combined hospital and ED visits.

Evolution of Mineralocorticoid Receptor Antagonists in the Treatment of Chronic Kidney Disease Associated with Type 2 Diabetes Mellitus

Chronic kidney disease (CKD) is one of the most frequent complications associated with type 2 diabetes mellitus (T2DM) and is also an independent risk factor for cardiovascular disease. The mineralocorticoid receptor (MR) is a nuclear receptor expressed in many tissue types, including kidney and heart. Aberrant and long-term activation of MR by aldosterone in patients with T2DM triggers detrimental effects (eg, inflammation and fibrosis) in these tissues. The suppression of aldosterone at the early stage of T2DM has been a therapeutic strategy for patients with T2DM-associated CKD. Although patients have been treated with renin-angiotensin system (RAS) blockers for decades, RAS blockers alone are not sufficient to prevent CKD progression. Steroidal MR antagonists (MRAs) have been used in combination with RAS blockers; however, undesired adverse effects have restricted their usage, prompting the development of nonsteroidal MRAs with better target specificity and safety profiles. Recently conducted studies, Finerenone in Reducing Kidney Failure and Disease Progression in Diabetic Kidney Disease (FIDELIO-DKD) and Finerenone in Reducing Cardiovascular Mortality and Morbidity in Diabetic Kidney Disease (FIGARO-DKD), have reported that finerenone, a nonsteroidal MRA, improves both renal and cardiovascular outcomes compared with placebo. In this article, we review the history of MRA development and discuss the possibility of its combination with other treatment options, such as sodium-glucose cotransporter 2 inhibitors, glucagon-like peptide-1 receptor agonists, and potassium binders for patients with T2DM-associated CKD.

An Approach to the Management of Diabetes Mellitus in Cirrhosis: A Primer for the Hepatologist

The management of diabetes in cirrhosis and liver transplantation can be challenging. There is difficulty in diagnosis and monitoring of diabetes as fasting blood sugar values are low and glycosylated hemoglobin may not be a reliable marker. The challenges in the management of diabetes in cirrhosis include the likelihood of cognitive impairment, risk of hypoglycemia, altered drug metabolism, frequent renal dysfunction, risk of lactic acidosis, and associated malnutrition and sarcopenia. Moreover, calorie restriction and an attempt to lose weight in obese diabetics may be associated with a worsening of sarcopenia. Many commonly used antidiabetic drugs may be unsafe or be associated with a high risk of hypoglycemia in cirrhotics. Post-transplant diabetes is common and may be contributed by immunosuppressive medication. There is inadequate clinical data on the use of antidiabetic drugs in cirrhosis, and the management of diabetes in cirrhosis is hampered by the lack of guidelines focusing on this issue. The current review aims at addressing the practical management of diabetes by a hepatologist.

Prediabetes screening: Questionable benefits in the golden years

Irrespective of the definition and diagnostic criteria used, the term prediabetes denotes a state of dysmetabolism with a high risk of progression to diabetes mellitus. Although diabetes-related complications may already be evident among individuals with prediabetes, interventions at this stage primarily aim to hinder the development of overt hyperglycemia rather than to prevent complications. Current recommendations for prediabetes testing are common across all adult age categories. Recent evidence arising from the prospective investigation of the natural course of prediabetes among elderly individuals pose questions regarding the benefits of meticulous prediabetes screening in this age group. In view of this and due to the lack of sufficient data to concretely support a positive impact of further preventive strategies among older individuals, screening recommendations should be reevaluated to target selected elderly individuals who are most likely to benefit in terms of quality of life and prognosis. Further therapeutic measures should be tailored to the inherent features of this frail age group, in order to exert a meaningful effect on overall health status.

NASH-related increases in plasma bile acid levels depend on insulin resistance

Background & Aims

Plasma bile acids (BAs) have been extensively studied as pathophysiological actors in non-alcoholic steatohepatitis (NASH). However, results from clinical studies are often complicated by the association of NASH with type 2 diabetes (T2D), obesity, and insulin resistance (IR). Here, we sought to dissect the relationship between NASH, T2D, and plasma BA levels in a large patient cohort.

Methods

Four groups of patients from the Biological Atlas of Severe Obesity (ABOS) cohort (Clinical Trials number NCT01129297) were included based on the presence or absence of histologically evaluated NASH with or without coincident T2D. Patients were matched for BMI, homeostatic model assessment 2 (HOMA2)-assessed IR, glycated haemoglobin, age, and gender. To study the effect of IR and BMI on the association of plasma BA and NASH, patients from the HEPADIP study were included. In both cohorts, fasting plasma BA concentrations were measured.

Results

Plasma BA concentrations were higher in NASH compared with No-NASH patients both in T2D and NoT2D patients from the ABOS cohort. As we previously reported that plasma BA levels were unaltered in NASH patients of the HEPADIP cohort, we assessed the impact of BMI and IR on the association of NASH and BA on the combined BA datasets. Our results revealed that NASH-associated increases in plasma total cholic acid (CA) concentrations depend on the degree of HOMA2-assessed systemic IR, but not on β-cell function nor on BMI.

Conclusions

Plasma BA concentrations are elevated only in those NASH patients exhibiting pronounced IR.

Lay summary

Non-alcoholic steatohepatitis (NASH) is a progressive liver disease that frequently occurs in patients with obesity and type 2 diabetes. Reliable markers for the diagnosis of NASH are needed. Plasma bile acids have been proposed as NASH biomarkers. Herein, we found that plasma bile acids are only elevated in patients with NASH when significant insulin resistance is present, limiting their utility as NASH markers.

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Bile acids have been studied as pathophysiological actors and biomarkers in NASH.

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Plasma BAs have been reported to be higher in NASH vs. No-NASH patients.

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Plasma BAs are altered in patients with T2D, IR, and obesity, risk factors for NASH.

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Thus, the independent association between plasma BA increases and NASH is unclear.

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NASH-associated increases in plasma BA depend on the degree of insulin sensitivity.

Patient Preparation for Outpatient Blood Work and the Impact of Surreptitious Fasting on Diagnoses of Diabetes and Prediabetes

Objective

To describe patient preparation for routine outpatient blood work and examine the implications of surreptitious fasting on interpretation of glucose results.

Patients and Methods

We designed a survey and administered it between September 1, 2016, and April 30, 2017, to assess fasting behaviors in a convenience sample of 526 adults presenting for outpatient blood work in 2 health systems between 7 am and 12 pm. We reviewed the electronic health records to extract glucose results. We describe the frequency of clinician-directed fasting and surreptitious fasting. In those surreptitiously fasting, we describe the frequency of missed diagnoses of prediabetes and diabetes.

Results

Of 526 participants, 330 (62.7%) self-identified as fasting, and 304 (92.1%) of those fasting met American Diabetes Association fasting criteria. Only 131 (24.9%) of those fasting were told to fast by their health care team. Almost 50% (257 of 526) believed it was important to fast for every blood test. Of the 64 patients with diabetes who were taking insulin, 37 (57.8%) fasted and took their insulin as prescribed. Among the 89 patients without diabetes who fasted without knowledge of their health care team and had glucose tested, 2 (2.2%) had a missed diagnosis of diabetes and 18 (20.2%) had a missed diagnosis of prediabetes.

Conclusion

Fasting for outpatient blood work is common, and patients frequently fast without awareness of their health care team. Failure to capture fasting status at the time of glucose testing is a missed opportunity to identify undiagnosed cases of diabetes and prediabetes.

Implementation of a food insecurity screening and referral program in student-run free clinics in San Diego, California

Food insecurity is associated with many poor health outcomes yet is not routinely addressed in clinical settings. The purpose of this study was to implement a food insecurity screening and referral program in Student-run Free Clinics (SRFC) and to document the prevalence of food insecurity screening in this low-income patient population. All patients seen in three SRFC sites affiliated with one institution in San Diego, California were screened for food insecurity using the 6-item United States Department of Agriculture (USDA) Food Security Survey between January and July 2015 and referred to appropriate resources. The percentage of patients who were food insecure was calculated. The screening rate was 92.5% (430/463 patients), 74.0% (318/430) were food insecure, including 30.7% (132/430) with very low food security. A food insecurity registry and referral tracking system revealed that by January 2016, 201 participants were receiving monthly boxes of food onsite, 66 used an off-site food pantry, and 64 were enrolled in the Supplemental Nutrition Assistance Program (SNAP). It is possible to implement a food insecurity screening and referral program into SRFCs. The prevalence of food insecurity in this population was remarkably high yet remained largely unknown until this program was implemented. Other health care settings, particularly those with underserved patient populations, should consider implementing food insecurity screening and referral programs.

Utilization of angiotensin converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB) in patients diagnosed with diabetes: Analysis from the National Ambulatory Medical Care Survey

Objective

The objective of this study was to determine if a difference exists in the proportion of visits for the prescribing of angiotensin converting enzyme inhibitors (ACEI), or angiotensin receptor blockers (ARBs) in diabetic patients during 2007–2010.

Methods

This retrospective, cross-sectional, observational study included adults diagnosed with diabetes mellitus from the National Ambulatory Medical Care Survey (NAMCS) during 2007–2010. Weighted chi-square tests and a multivariable logistic regression model were used to analyze associations between ACEI/ARB prescriptions and predictors of interest. Odds ratios and 95% confidence intervals were reported.

Results

An unweighted total of 13,590 outpatient ambulatory care visits were identified for adult patients with diabetes without contraindications to ACEIs or ARBs in the NAMCS for the years studied. No statistically significant increase in the proportion of visits with an ACEI/ARB prescription was identified for years 2007–2010 (28.1% in 2007 to 32.2% in 2010). Females (OR 0.78, 95% CI 0.69- 0.89), patients 18–39 years old (OR 0.56, 95% CI 0.43- 0.75), and Medicare users (OR 0.81, 95% CI 0.70- 0.94) were significantly less likely to receive an ACEI/ARB prescription. Patients with hypertension (OR 2.80, 95% CI 2.39-3.29), hyperlipidemia (OR 1.42, 95% CI 1.22-1.65), and ischemic heart disease (OR 1.36, 95% CI 1.10-1.70) were significantly more likely to receive an ACEI/ARB prescription.

Conclusions

Despite extensive evidence showing the benefits of ACEI/ARB medications in diabetic patients, disparities of treatment remain evident.

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Assessed ACEI/ARB prescriptions in diabetic patients for ADA guideline adherence

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A low percentage of patients prescribed an ACEI/ARB (28.1% in 2007–32.2% in 2010)

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Females, age 18–39, and Medicare users less likely to receive ACEI/ARB prescription

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Hypertension, hyperlipidemia and IHD: more likely to receive ACEI/ARB prescription

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Disparities in ACEI/ARB prescriptions remain evident

No detectable association of IGF2BP2 and SLC30A8 genes with type 2 diabetes in the population of Hyderabad, India

Genome-wide association studies identified novel genes associated with T2DM which have been replicated in different populations. We try to examine here if certain frequently replicated SNPs of Insulin growth factor 2 m-RNA binding protein 2 (IGF2BP2) (rs4402960, rs1470579) and Solute Carrier family 30 member 8 (SLC30A8) (rs13266634) genes, known to be implicated in insulin pathway, are associated with T2DM in the population of Hyderabad, which is considered to be a diabetic capital of India. Genotyping of the 1379 samples, 758 cases and 621 controls, for the SNPs was performed on sequenom massarray platform. The logistic regression analysis was done using SPSS software and the post-hoc power of the study was estimated using G power. The allele and genotype frequencies were similar between cases and controls, both for SNPs of IGF2BP2 and SLC30A8 genes. Logistic regression did not reveal significant allelic or genotypic association of any of the three SNPs with T2DM. Despite large sample size and adequate power, we could not replicate the association of IGF2BP2 and SLC30A8 SNPs with T2DM in our sample from Hyderabad (A.P.), India, albeit another study based on much larger sample but from heterogeneous populations from the northern parts of India showed significant association of two of the above 3 SNPs, suggesting variable nature of susceptibility of these genes in different ethnic groups. Although the IGF2BP2 and SLC30A8 genes are important in the functional pathway of Insulin secretion, it appears that these genes do not play a significant role in the susceptibility to T2DM in this population.

C-reactive protein + 1059 G>C polymorphism in type 2 diabetes and coronary artery disease patients

Human C-reactive protein (CRP) is an acute phase reactant involved in chronic and acute inflammation. CRP is associated with metabolic syndrome, obesity, atherosclerosis, unstable angina, insulin resistance and diabetes. The present study evaluates the association of + 1059 G>C silent polymorphism in exon 2 of CRP gene in 581 cases [CAD (206), T2D (266), T2D with CAD (109)] and 235 controls in the population of Punjab (North-West India). The frequency of + 1059 G allele is highest in CAD (98.3%) followed by T2D (98.1%), T2D + CAD cases (97.7%) and controls (94.7%). G-allele is associated with increased risk of T2D [P = 0.003, OR = 2.93 (1.39–6.17)] and CAD [P = 0.004, OR = 3.25 (1.39–7.60)] in comparison to controls. Recessive model shows that GG genotype increases the risk of CAD by 4 fold (P = 0.003, OR = 4.19, 1.62–10.80), T2D by 3 fold (P = 0.008, OR = 3.23, 1.36–7.60) and T2D + CAD by 3.5 fold (P = 0.029, OR = 3.64, 1.14–11.66). Factor analyses show that BMI, WC, and WHR are core predictors for CAD and T2D, whereas CHO, TG and VLDL for T2D + CAD. The present study concludes that GG genotype of CRP + 1059 G>C polymorphism and clustering of obesity and dyslipidemia underlie the risk towards CAD, T2D and T2D + CAD in the North-West Indian population of Punjab.

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CRP + 1059 G>C SNP analyzed in 266 T2D, 109 T2D with CAD, 206 CAD, and 235 controls

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GG genotype increases the risk towards T2D, CAD, and T2D + CAD in population of Punjab.

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GC genotype provides protection towards T2D, CAD, and T2D + CAD in population of Punjab.

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Clustering of obesity and dyslipidemia underlies the risk towards T2D, CAD, and T2D + CAD.