Socioeconomic inequalities and type 2 diabetes complications: A systematic review

A Scoping Review of Possible Solutions for Decreasing Socioeconomic Inequalities in Type 2 Diabetes Mellitus

Background

As socioeconomic inequalities are key factors in access and utilization of type 2 diabetes (T2D) services, the purpose of this scoping review was to identify solutions for decreasing socioeconomic inequalities in T2D.

Methods

A scoping review of scientific articles from 2000 and later was conducted using PubMed, Web of Science (WOS), Scopus, Embase, and ProQuest databases. Using the Arksey and O'Malley framework for scoping review, articles were extracted, meticulously read, and thematically analyzed.

Results

A total of 7204 articles were identified from the reviewed databases. After removing duplicate and nonrelevant articles, 117 articles were finally included and analyzed. A number of solutions and passways were extracted from the final articles. Solutions for decreasing socioeconomic inequalities in T2D were categorized into 12 main solutions and 63 passways.

Conclusions

Applying identified solutions in diabetes policies and interventions would be recommended for decreasing socioeconomic inequalities in T2D. Also, the passways could be addressed as entry points to help better implementation of diabetic policies.

Impact of two COVID-19 lockdowns on HbA1c levels in patients with type 2 diabetes and associations with patient characteristics: a multicentre, observational cohort study over three years

Introduction

Glycemic effects of COVID-19 lockdowns on patients with type 2 diabetes (T2D) are controversial. In this long-term observation, we aimed (1) to analyze changes in HbA1c levels during lockdowns in Germany, and (2) to investigate whether diabetes medication, comorbidities, and sociodemographic data influenced these changes.

Materials and methods

This cohort study observed 1,089 patients aged ≥18 years over the years 2019 to 2021. Patients were recruited from 14 physicians specialized on diabetes. As dependent variable, 7,987 HbA1c values were analyzed by multivariable linear regression adjusted for random effects of physicians and patients.

Results

Patients had a median age of 68 (60/76) years and 623 (57.2%) were male. Before the pandemic, median HbA1c level (in %) was 6.9 (6.3/7.7). Average HbA1c level increased during first lockdown (0.21,0.11/0.31,p < 0.001), after first lockdown (0.23,0.18/0.28,p < 0.001), during second lockdown (0.40,0.33/0.47,p < 0.001) and after second lockdown (0.27,0.18/0.36,p < 0.001). The increase of HbA1c levels was more pronounced in male patients (0.08,0.01/0.15,p = 0.019), if patients did not have German as native language (0.12,0.01/0.23,p = 0.041) and if they were widowed (0.19,0.05/0.32,p = 0.008). End organ damages (0.12,0.01/0.23,p = 0.039), atherosclerotic cardiovascular disease (ASCVD; 0.23,0.10/0.36,p = 0.001) and cardiovascular events (0.25,0.10/0.40,p = 0.001) as well as oral medication (0.09,0.03/0.15,p = 0.002), intermediate- or long-acting insulins (0.24,0.16/0.32,p < 0.001), and fast-acting or mixed insulins (0.30,0.23/0.36,p < 0.001) were also related to a greater increase in HbA1c levels.

Conclusion

Both lockdowns resulted in a significant increase in HbA1c levels. In particular, patients with ASCVD, cardiovascular events, and insulin therapy appear to be at risk for worsening glycemic control in crisis and thus require special medical attention.

Clinical Trial Registration

ClinicalTrials.gov (NCT04821921).

Socioeconomic inequalities in health-related functioning among people with type 2 Diabetes: longitudinal analyses in the Maastricht Study

BACKGROUND

Type 2 diabetes mellitus (T2DM) is a common chronic disease that disproportionally affects disadvantaged groups. People with a low socioeconomic position (SEP) have increased risk of T2DM and people with a low SEP and T2DM have higher HbA1c-levels compared to people with T2DM and high SEP. The aim of this study is to analyze longitudinal socioeconomic differences in health-related functioning in people with T2DM.

METHODS

Longitudinal data from 1,537 participants of The Maastricht Study with T2DM were used (32.6% female, mean (SD) age 62.9 (7.7) years). SEP was determined by baseline measures of education, occupation and income. Health-related functioning (physical, mental and social) was measured with the Short-Form Health Survey and the Impact on Participation and Autonomy survey (all scored from 0 to 100). Associations of SEP and health-related functioning were studied annually over a 10-year period (median (IQR) 7.0 (5.0) years, baseline 2010-2018) using linear mixed methods adjusting for demographics, HbA1c-levels and lifestyle factors.

RESULTS

Participants with a low SEP had significantly worse health-related functioning compared to those with a high SEP. For example, participants with low income had lower scores for physical (-4.49[CI -5.77;-3.21]), mental (-2.61[-3.78,-1.44]) and social functioning (-9.76[-12.30;-7.23]) compared to participants with high income on a scale from 0 to 100. In addition, participants with a low education significantly declined more over time in mental (score for interaction education with time - 0.23[-0.37;-0.09]) and social functioning (-0.44[-0.77;-0.11]) compared to participants with high education. Participants with low and intermediate incomes significantly declined more over time in physical functioning (-0.17 [-0.34, -0.01 and - 0.18 [-0.36, 0.00]) compared to participants with high income.

CONCLUSIONS

Among people with T2DM, those with a lower SEP had worse health-related functioning in general than people with a higher SEP. Additionally, people with T2DM and low education developed poorer mental and social functioning over time compared to people with T2DM and high education. People with T2DM and low or intermediate income declined more in physical functioning over time than those with high incomes. In addition to HbA1c-levels and lifestyle patterns, more attention is needed for socioeconomic differences in health-related functioning for people living with T2DM.

Reported recommendations to address cardiovascular risk factors differ by socio-economic status in Brazil. Results from the Brazilian National Health Survey 2019

Background

Management of cardiovascular risk factors (high cholesterol, diabetes, and hypertension) should start by implementing a healthy lifestyle. Whereas lifestyle recommendations are provided irrespective of the patient's socio-economic status has not been recently assessed in the Brazilian population.

Aims

To assess the preventive measures against cardiovascular risk factors according to educational level and income in the Brazilian population.

Methods

Survey data of the 2019 Brazilian National Health Survey (PNS). The PNS is a nationwide household-based survey carried out by the Brazilian Ministry of Health. The PNS included face-to-face interviews and collected information on lifestyle management of high cholesterol, diabetes, and hypertension by a healthy diet, an adequate weight, exercise, and quitting smoking. The participant's educational level and income (in multiples of the basic salary per capita) was collected.

Results

Of the 88,052 participants included, 13,151 (14.9%), 6,986 (7.9%) and 22,516 (25.6%) reported being diagnosed with high cholesterol, diabetes, or hypertension, respectively. Dietary recommendations were the most frequently provided (94.5%, 94.6% and 88.1% for high cholesterol diabetes, and hypertension, respectively), while recommendations to quit smoking to current smokers were the least frequently provided (74.9%, 85.8% and 81.1% for high cholesterol, diabetes, and hypertension, respectively). After multivariable adjustment, participants with a higher educational level or a higher income had a higher likelihood of reporting receipt lifestyle recommendations for high cholesterol or hypertension, while no associations were found for most recommendations for diabetes.

Conclusion

Better-educated, wealthier Brazilians report receiving more lifestyle recommendations regarding high cholesterol and hypertension management more frequently than lower-educated or with low-income.

Bridging ethics and epidemiology: Modelling ethical standards of health equity

Health inequities are differences in health that are 'unjust'. Yet, despite competing ethical views about what counts as an 'unjust difference in health', theoretical insights from ethics have not been systematically integrated into epidemiological research. Using diabetes as an example, we explore the impact of adopting different ethical standards of health equity on population health outcomes. Specifically, we explore how the implementation of population-level weight-loss interventions using different ethical standards of equity impacts the intervention's implementation and resultant population health outcomes. We conducted a risk prediction modelling study using the nationally representative 2015-16 Canadian Community Health Survey (n = 75,044, 54% women). We used the Diabetes Population Risk Tool (DPoRT) to calculate individual-level 10-year diabetes risk. Hypothetical weight-loss interventions were modelled in individuals with overweight or obesity based on each ethical standard: 1) health sufficiency (reduce DPoRT risk below a high-risk threshold (16.5%); 2) health equality (equalize DPoRT risk to the low risk group (5%)); 3) social-health sufficiency (reduce DPoRT risk <16.5 in individuals with lower education); 4) social-health equality (equalize DPoRT risk to the level of individuals with high education). For each scenario, we calculated intervention impacts, diabetes cases prevented or delayed, and relative and absolute educational inequities in diabetes. Overall, we estimated that achieving health sufficiency (i.e., all individuals below the diabetes risk threshold) was more feasible than achieving health equality (i.e., diabetes risk equalized for all individuals), requiring smaller initial investments and fewer interventions; however, fewer diabetes cases were prevented or delayed. Further, targeting only diabetes inequalities related to education reduced the target population size and number of interventions required, but consequently resulted in even fewer diabetes cases prevented or delayed. Using diabetes as an example, we found that an explicit, ethically-informed definition of health equity is essential to guide population-level interventions that aim to reduce health inequities.

Influence of social deprivation on morbidity and all-cause mortality of cardiometabolic multi-morbidity: a cohort analysis of the UK Biobank cohort

BACKGROUND

The relation of social deprivation with single cardiometabolic disease (CMD) was widely investigated, whereas the association with cardiometabolic multi-morbidity (CMM), defined as experiencing more than two CMDs during the lifetime, is poorly understood.

METHODS

We analyzed 345,417 UK Biobank participants without any CMDs at recruitment to study the relation between social deprivation and four CMDs including type II diabetes (T2D), coronary artery disease (CAD), stroke and hypertension. Social deprivation was measured by Townsend deprivation index (TDI), and CMM was defined as occurrence of two or more of the above four diseases. Multivariable Cox models were performed to estimate hazard ratios (HRs) per one standard deviation (SD) change and in quartile (Q1-Q4, with Q1 as reference), as well as 95% confidence intervals (95% CIs).

RESULTS

During the follow up, 68,338 participants developed at least one CMD (median follow up of 13.2 years), 16,225 further developed CMM (median follow up of 13.4 years), and 18,876 ultimately died from all causes (median follow up of 13.4 years). Compared to Q1 of TDI (lowest deprivation), the multivariable adjusted HR (95%CIs) of Q4 (highest deprivation) among participants free of any CMDs was 1.23 (1.20 ~ 1.26) for developing one CMD, 1.42 (1.35 ~ 1.48) for developing CMM, and 1.34 (1.27 ~ 1.41) for all-cause mortality. Among participants with one CMD, the adjusted HR (95%CIs) of Q4 was 1.30 (1.27 ~ 1.33) for developing CMM and 1.34 (1.27 ~ 1.41) for all-cause mortality, with HR (95%CIs) = 1.11 (1.06 ~ 1.16) for T2D patients, 1.07 (1.03 ~ 1.11) for CAD patients, 1.07 (1.00 ~ 1.15) for stroke patients, and 1.24 (1.21 ~ 1.28) for hypertension patients. Among participants with CMM, TDI was also related to the risk of all-cause mortality (HR of Q4 = 1.35, 95%CIs 1.28 ~ 1.43).

CONCLUSIONS

We revealed that people living with high deprived conditions would suffer from higher hazard of CMD, CMM and all-cause mortality.

Temporal Patterns of Diabetes: Analyzing Disease Burden Among Adults Over 18 (2000-2021) Using the U.S. Diabetes Surveillance System (USDDS) Database

Background This study investigates the temporal patterns of diagnosed diabetes cases among adults aged 18 and above in the United States from 2000 to 2021, using data from the U.S. Diabetes Surveillance System (USDDS) database. The study analyzed variations in diagnosed diabetes cases based on gender, age, education, location, and race to provide insights into the changing disease burden over two decades. Methods A retrospective observational design was employed in analyzing data from the USDDS database. The study population comprised adults aged 18 and above with diagnosed diabetes. Descriptive statistical analysis and subgroup comparisons were performed to identify temporal trends and disparities in diagnosed diabetes cases among different demographic groups. Results The study uncovered significant temporal patterns in diagnosed diabetes cases among US adults. Males consistently reported higher diabetes cases (8.44%) than females (7.45%). Variations existed among age groups, with the 65-74 age group having the highest cases (19.69%) and the 18-44 age group having the lowest cases (2.34%). Disparities by race/ethnicity were evident, with non-Hispanic black individuals (11.80%) and Hispanics (11.07%) having the highest percentages, while Asians (7.84%) and whites (6.81%) had lower rates. Distinct temporal patterns emerged based on education levels, with the less than high school education group having the highest cases (11.77%), followed by those with a high school education (8.50%), and the lowest among those with higher than a high school education (6.60%). Conclusion The study has revealed a complex and evolving landscape of this chronic disease. Over these two decades, we observed significant fluctuations, with an overall upward trend in diagnosed diabetes cases. These findings underscore the need for a multifaceted approach to tackle diabetes effectively. Tailored interventions that consider age, gender, education, and geographic location are crucial to addressing the observed disparities in diabetes prevalence.

The interplay between the impact of household's and children's education on the risk of type 2 diabetes and death among older adults: a Danish register-based cohort study

OBJECTIVES

This study aims to assess the association of household's and children's education on the risk of type 2 diabetes (T2D) and subsequent death.

STUDY DESIGN

Danish register-based cohort study.

METHODS

In total, 1,021,557 adults were included at their 65th birthday between 2000 and 2018. A multistate survival model was performed to estimate the association of household's and children's education on the transition between the three states: 1) 65th birthday; 2) diagnosis of T2D; and 3) all-cause death.

RESULTS

The incidence rates per 1000 person-years were 9.1 for T2D, 18.4 for death without T2D, and 45.0 for death with T2D. Compared to long household's education and children's education, long household's education combined with either short-medium children's education or no children were associated with a 1.49- (95% confidence interval [CI]: 1.44; 1.54] and 1.69-times (95% CI: 1.61;1.78) higher hazard of T2D, respectively. Short-medium household's education combined with either long children's education or no children were associated with 0.64- (95% CI: 0.62; 0.66) and 0.77-times (95% CI: 0.74; 0.79) lower hazard of T2D, respectively. Compared to long household's education and children's education, any other combination of household's and children's education was associated with higher hazards of death both without and with T2D.

CONCLUSION

Older adults living in households with long education with no children or children with short-medium education had higher hazards of T2D. Households with short-medium education and no children or children with long education were associated with lower hazards of T2D. Both household's and children's education were associated with higher hazard of death without and with T2D.

The worldwide prevalence of latent autoimmune diabetes of adults among adult-onset diabetic individuals: a systematic review and meta-analysis

PURPOSE

The actual global burden of Latent Autoimmune Diabetes of Adults (LADA) remains unknown even though its prevalence is almost equal to the type 1 form of diabetes. Hence the present systematic review and meta-analysis were performed to estimate the prevalence of LADA among diabetic individuals using the studies published at global levels.

METHODS

A comprehensive literature revival was performed to identify articles on the prevalence of LADA published till 2023. The prevalence estimates were calculated using DerSimonian and Laird random-effects models with a heterogeneity measure by Cochrane Q and I2 statistics. Publication bias was assessed by the Doi plot and Luis Furuya-Kanamori asymmetry index (LFKindex). P < 0.05 was considered statistically significant.

RESULTS

The overall pooled prevalence of LADA obtained from a total of 51,725 diabetic individuals was found to be 8.9% (95%CI 7.5-10.4, P < 0.001) with a prevalence range of 2.3% in to 18.9% in United Arab Emirates and Bahrain respectively. Subgroup analysis of LADA in the context of the IDF geographic regions showed a higher prevalence in North America (13.5%), 9.5% in Middle East and North Africa, 9.4% in Africa, 9.2% in South East Asia, 8.3% in Western Pacific and the lowest prevalence of 7.0% in Europe.

CONCLUSION

The Meta-analysis revealed a worldwide prevalence of LADA as 8.9%, with the highest prevalence in Bahrain and the lowest in United Arab Emirates. Further, the higher prevalence in some IDF regions and the inconsistent association between socioeconomic status and LADA recommend more research in the future.

Linking Sepsis with chronic arterial hypertension, diabetes mellitus, and socioeconomic factors in the United States: A scoping review

RATIONALE

Sepsis is a syndrome of life-threatening organ dysfunction caused by a dysregulated host immune response to infection. Social risk factors including location and poverty are associated with sepsis-related disparities. Understanding the social and biological phenotypes linked with the incidence of sepsis is warranted to identify the most at-risk populations. We aim to examine how factors in disadvantage influence health disparities related to sepsis.

METHODS

A scoping review was performed for English-language articles published in the United States from 1990 to 2022 on PubMed, Web of Science, and Scopus. Of the 2064 articles found, 139 met eligibility criteria and were included for review.

RESULTS

There is consistency across the literature of disproportionately higher rates of sepsis incidence, mortality, readmissions, and associated complications, in neighborhoods with socioeconomic disadvantage and significant poverty. Chronic arterial hypertension and diabetes mellitus also occur more frequently in the same geographic distribution as sepsis, suggesting a potential shared pathophysiology.

CONCLUSIONS

The distribution of chronic arterial hypertension, diabetes mellitus, social risk factors associated with socioeconomic disadvantage, and sepsis incidence, are clustered in specific geographical areas and linked by endothelial dysfunction. Such population factors can be utilized to create equitable interventions aimed at mitigating sepsis incidence and sepsis-related disparities.

A Multi-Method Study of Patient Reach and Attendance in a Pragmatic Trial of Diabetes Shared Medical Appointments

Shared medical appointments (SMAs) are an evidence-based approach to diabetes care in primary care settings, yet practices can struggle to ensure participation, especially among racial and ethnic minority and low-income patients. We conducted a multimethod evaluation of reach and attendance in the Invested in Diabetes study of the comparative effectiveness of two SMA delivery models (standardized and patient-driven) in two practice settings (federally qualified health centers [FQHCs] and clinics serving more commercially insured patients). Through this study, 22 practices reached 6.2% of patients with diabetes through SMAs over 3 years, with good attendance for both practice types and both SMA delivery models. FQHCs were especially successful at enrolling underserved populations and improved attendance with virtual SMAs.

Overview of Social Determinants of Health in the Development of Diabetes

To guide effective planning and decision-making regarding strategies to address adverse social determinants of health (SDOH) in diabetes, an understanding of upstream drivers and root causes is imperative. The World Health Organization SDOH framework includes socioeconomic and political systems and racism as upstream drivers of SDOH. These factors are not currently included in the Healthy People 2030 framework or other commonly used U.S. SDOH frameworks. This review gives an overview of the socioeconomic status SDOH and race and ethnicity in diabetes prevalence and incidence, discusses socioeconomic and political contexts and racism as upstream drivers and root causes of SDOH that necessitate attention in the U.S., illustrates the role of these drivers in the entrenched nature of SDOH within racial and ethnic minoritized and marginalized populations, and examines current and emerging actions within and beyond the health care sector to mitigate adverse SDOH. The incorporation of socioeconomic and political systems and racism as root causes and current drivers of adverse SDOH into U.S. SDOH frameworks enables an emphasis shift from primary individual- and neighborhood-level time-limited solutions to multisector and all-of-government initiatives that bring requisite policy change and permanent structural change.

Global, regional, and national burden of diabetes from 1990 to 2021, with projections of prevalence to 2050: a systematic analysis for the Global Burden of Disease Study 2021

BACKGROUND

Diabetes is one of the leading causes of death and disability worldwide, and affects people regardless of country, age group, or sex. Using the most recent evidentiary and analytical framework from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD), we produced location-specific, age-specific, and sex-specific estimates of diabetes prevalence and burden from 1990 to 2021, the proportion of type 1 and type 2 diabetes in 2021, the proportion of the type 2 diabetes burden attributable to selected risk factors, and projections of diabetes prevalence through 2050.

METHODS

Estimates of diabetes prevalence and burden were computed in 204 countries and territories, across 25 age groups, for males and females separately and combined; these estimates comprised lost years of healthy life, measured in disability-adjusted life-years (DALYs; defined as the sum of years of life lost [YLLs] and years lived with disability [YLDs]). We used the Cause of Death Ensemble model (CODEm) approach to estimate deaths due to diabetes, incorporating 25 666 location-years of data from vital registration and verbal autopsy reports in separate total (including both type 1 and type 2 diabetes) and type-specific models. Other forms of diabetes, including gestational and monogenic diabetes, were not explicitly modelled. Total and type 1 diabetes prevalence was estimated by use of a Bayesian meta-regression modelling tool, DisMod-MR 2.1, to analyse 1527 location-years of data from the scientific literature, survey microdata, and insurance claims; type 2 diabetes estimates were computed by subtracting type 1 diabetes from total estimates. Mortality and prevalence estimates, along with standard life expectancy and disability weights, were used to calculate YLLs, YLDs, and DALYs. When appropriate, we extrapolated estimates to a hypothetical population with a standardised age structure to allow comparison in populations with different age structures. We used the comparative risk assessment framework to estimate the risk-attributable type 2 diabetes burden for 16 risk factors falling under risk categories including environmental and occupational factors, tobacco use, high alcohol use, high body-mass index (BMI), dietary factors, and low physical activity. Using a regression framework, we forecast type 1 and type 2 diabetes prevalence through 2050 with Socio-demographic Index (SDI) and high BMI as predictors, respectively.

FINDINGS

In 2021, there were 529 million (95% uncertainty interval [UI] 500-564) people living with diabetes worldwide, and the global age-standardised total diabetes prevalence was 6·1% (5·8-6·5). At the super-region level, the highest age-standardised rates were observed in north Africa and the Middle East (9·3% [8·7-9·9]) and, at the regional level, in Oceania (12·3% [11·5-13·0]). Nationally, Qatar had the world's highest age-specific prevalence of diabetes, at 76·1% (73·1-79·5) in individuals aged 75-79 years. Total diabetes prevalence-especially among older adults-primarily reflects type 2 diabetes, which in 2021 accounted for 96·0% (95·1-96·8) of diabetes cases and 95·4% (94·9-95·9) of diabetes DALYs worldwide. In 2021, 52·2% (25·5-71·8) of global type 2 diabetes DALYs were attributable to high BMI. The contribution of high BMI to type 2 diabetes DALYs rose by 24·3% (18·5-30·4) worldwide between 1990 and 2021. By 2050, more than 1·31 billion (1·22-1·39) people are projected to have diabetes, with expected age-standardised total diabetes prevalence rates greater than 10% in two super-regions: 16·8% (16·1-17·6) in north Africa and the Middle East and 11·3% (10·8-11·9) in Latin America and Caribbean. By 2050, 89 (43·6%) of 204 countries and territories will have an age-standardised rate greater than 10%.

INTERPRETATION

Diabetes remains a substantial public health issue. Type 2 diabetes, which makes up the bulk of diabetes cases, is largely preventable and, in some cases, potentially reversible if identified and managed early in the disease course. However, all evidence indicates that diabetes prevalence is increasing worldwide, primarily due to a rise in obesity caused by multiple factors. Preventing and controlling type 2 diabetes remains an ongoing challenge. It is essential to better understand disparities in risk factor profiles and diabetes burden across populations, to inform strategies to successfully control diabetes risk factors within the context of multiple and complex drivers.

FUNDING

Bill & Melinda Gates Foundation.

Socioeconomic inequalities in type 2 diabetes comorbidities in different population subgroups: trend analyses using German health insurance data

While socioeconomic inequalities in the prevalence and management of type 2 diabetes (T2D) are well established, little is known about whether inequalities exist in the prevalence and the temporal development of T2D comorbidities. Previous research points towards expansion of morbidity in T2D as depicted mainly by a rising trend of T2D comorbidities. Against this background, and using German claims data, this study aims to examine whether socioeconomic status (SES) inequalities exist in the rates and the temporal development of T2D comorbidities. Since previous research indicates varying risk levels for T2D prevalence in the population subgroups: working individuals, nonworking spouses and pensioners, the analyses are stratified by these three population subgroups. The study is done on a large population of statutory insured individuals with T2D in three time-periods between 2005 and 2017. Predicted probabilities of three comorbidity groups and the number of comorbidities were estimated using logistic and ordinal regression analyses among different income, education and occupation groups. Interaction analyses were applied to examine whether potential SES inequalities changed over time. The study showed that neither the cross-sectional existence, nor the temporal development of T2D comorbidities differed significantly among SES groups, ruling out SES inequalities in the prevalence and the temporal development of T2D comorbidities in Germany. In men and women of all examined population subgroups, predicted probabilities for less severe cardiovascular (CVD) comorbidities, other vascular diseases and the number of comorbidities per individual rose significantly over time regardless of SES, but little if any change took place for more severe CVD comorbidities. Another important finding is that the population subgroup of nonworking spouses had markedly higher predicted probabilities for most of the examined outcomes compared to working individuals. The study indicates that the expansion of morbidity in T2D in Germany does not appear to be SES-dependent, and applies equally to different population subgroups. Yet, the study highlights that nonworking spouses are a susceptible population subgroup that needs to be focused upon when planning and implementing T2D management interventions.

Targeting Diabetes Prevention to More Disadvantaged Groups Improves Cost-Effectiveness: Implications of Inequality in Type 2 Diabetes From Theoretical Interventions

OBJECTIVES

To determine the effect of socioeconomic status on efficacy and cost thresholds at which theoretical diabetes prevention policies become cost-effective.

METHODS

We designed a life table model using real-world data that captured diabetes incidence and all-cause mortality in people with and without diabetes by socioeconomic disadvantage. The model used data from the Australian diabetes registry for people with diabetes and the Australian Institute of Health and Welfare for the general population. We simulated theoretical diabetes prevention policies and estimated the threshold at which they would be cost-effective and cost saving, overall, and by socioeconomic disadvantage, from the public healthcare perspective.

RESULTS

From 2020 to 2029, 653 980 people were projected to develop type 2 diabetes, 101 583 in the least disadvantaged quintile and 166 744 in the most. Theoretical diabetes prevention policies that reduce diabetes incidence by 10% and 25% would be cost-effective in the total population at a maximum per person cost of Australian dollar (AU$) 74 (95% uncertainty interval: 53-99) and AU$187 (133-249) and cost saving at AU$26 (20-33) and AU$65 (50-84). Theoretical diabetes prevention policies remained cost-effective at a higher cost in the most versus least disadvantaged quintile (eg, a policy that reduces type 2 diabetes incidence by 25% would be cost-effective at AU$238 [169-319] per person in the most disadvantaged quintile vs AU$144 [103-192] in the least).

CONCLUSIONS

Policies targeted at more disadvantaged populations will likely be cost-effective at higher costs and lower efficacy compared to untargeted policies. Future health economic models should incorporate measures of socioeconomic disadvantage to improve targeting of interventions.

Health Care Disparities in Outpatient Diabetes Management During the Coronavirus Disease 2019 Pandemic: Where Do We Stand Now?

OBJECTIVE

We examined diabetes outpatient management during the first 2 years of the Coronavirus Disease 2019 pandemic in an endocrinology practice with a focus on health care disparities in outcomes.

METHODS

We conducted a retrospective cohort study examining adults with diabetes during 3 time periods: T1 (March 2019-February 2020), T2 (March 2020-February 2021), and T3 (March 2021-February 2022). Clinical outcomes included body mass index (BMI), systolic blood pressure (SBP), Hemoglobin A1c (HgbA1c), low-density lipoprotein cholesterol (LDL), and urine albumin:creatinine ratio. Appointment types (virtual vs in-person) were also collected.

RESULTS

Frequencies of HgbA1c, BMI, and SBP measurements reduced by 36.0%, 46.3%, and 48.5% in T2, respectively, and remaining 8.7% (HgbA1c), 13.4% (BMI), and 15.2% (SBP) lower at the end of the study period (P < .001) compared to prepandemic levels. However, the average HgbA1c and LDL slightly improved. Clinic appointments per patient increased during the pandemic, fueled by telehealth utilization. Women had fewer in-person visits during T2, those older than 65 had better HgbA1c, and the most socioeconomically deprived group had the worst HgbA1c during every time period. In addition, black patients had worse HgbA1c, LDL, and SBP values throughout the study, which did not worsen over the pandemic.

CONCLUSION

While the frequency of health measurements had not fully recovered 2 years into the pandemic, this did not translate to worse diabetes management or a widening of pre-existing disparities. Our study emphasizes the role of equitable health care in minimizing inequalities in diabetes, particularly during times of crisis.

The application of nanomedicine in clinical settings

As nanotechnology develops in the fields of mechanical engineering, electrical engineering, information and communication, and medical care, it has shown great promises. In recent years, medical nanorobots have made significant progress in terms of the selection of materials, fabrication methods, driving force sources, and clinical applications, such as nanomedicine. It involves bypassing biological tissues and delivering drugs directly to lesions and target cells using nanorobots, thus increasing concentration. It has also proved useful for monitoring disease progression, complementary diagnosis, and minimally invasive surgery. Also, we examine the development of nanomedicine and its applications in medicine, focusing on the use of nanomedicine in the treatment of various major diseases, including how they are generalized and how they are modified. The purpose of this review is to provide a summary and discussion of current research for the future development in nanomedicine.

Risk Factors Associated with Diabetes among Mexican-Origin Adults in Southern Arizona

Diabetes is the seventh leading cause of death in the United States, and it is particularly problematic among the Latine population. This study employed multivariable logistic regression models to examine how hypertension, depression, and sociodemographics were associated with diabetes in a cross-sectional sample of Mexican-origin adults living in three counties of Southern Arizona. The overall prevalence of diabetes from this primary care sample was 39.4%. Holding covariates at fixed values, individuals having hypertension were 2.36 (95% CI: 1.15, 4.83) times more likely to have diabetes, when compared to individuals not having hypertension. The odds of having diabetes for individuals with ≥12 years of educational attainment were 0.29 (95% CI: 0.14, 0.61) times the corresponding odds of individuals with <12 years of educational attainment. For individuals with depression, the odds of having diabetes for those who were born in Mexico and had <30 years living in the US were 0.04 (95% CI: 0, 0.42) times the corresponding odds of individuals without depression and who were born in the US. Findings suggest clinical and public health systems should be aware of the potential increased risk of diabetes among Mexican-origin adults with hypertension and lower educational attainment.

Perceptions of multiple chronic conditions and coping strategies among migrants from Sub-Saharan Africa living in France with diabetes mellitus and HIV: An interview-based qualitative study

Although diabetes is common among people living with HIV/AIDS (PLWHA), few data exists on how migrants from Sub-Saharan Africa (SSA) experience living with these two coexisting conditions in France. The objective of this study was to analyze perception of polypathology among PLWHA from SSA with type 2 diabetes and identify barriers and facilitators to their self-management. A qualitative study was conducted using semi-structured interviews from November 2019 to April 2020 with participants selected from a cohort of PLWHA and diabetes at Avicenne University Hospital. A total of 12 semi-structured interviews were conducted and analyzed using thematic analysis with inductive approach. Stigma remained a major issue in self-managing HIV, and some participants did not consider themselves as having a polypathology, as HIV has always been considered as a distinct condition. In general, emotion-based resources (e.g spirituality, trust in the medical discourse) and social support were mobilized more than problem-solving resources (e.g perception of medication as life-saving). Participants used the same main resource in self-management of HIV and diabetes, and resources used differed from participant to participant. This study highlighted challenges in self-management of diabetes and HIV in this population and complexity related to the socioeconomic and cultural specificities. Self-management could be more successful if patients and carers move in the same direction, having identified the individual coping resources to reach objectives.

Enhancing the utilization of healthy living interventions among cancer survivors in historically underserved populations and communities

PURPOSE

This study aimed to describe the clinical characteristics and wellness programming preferences of cancer survivors from Acres Homes, a historically Black neighborhood in Houston, Texas, with areas of persistent poverty. The goal of this study was to identify opportunities to increase cancer survivor utilization of healthy eating and active living interventions aligned to cancer center community outreach and engagement efforts.

METHODS

This multiple methods study included a retrospective review of electronic health record data (n = 413) and qualitative interviews with cancer survivors (n = 31) immediately preceding initiation of healthy eating, active living programming in Acres Homes.

RESULTS

This study found Acres Homes survivors have high rates of co-occurrent cardiometabolic disease including obesity (45.0%), diabetes (30.8%), and other related risk factors as well as treatment-related symptoms. Four major concepts emerged from interviews: (1) Factors that influence survivors' ability to eat well and exercise, (2) Current usage of community resources, (3) Interest in relevant programming, and (4) Specific programming preferences. Opportunities for current and future health promotion programming for cancer survivors were explored.

CONCLUSION

Strategically tailoring community resources for cancer survivors can provide a more robust network of support to promote healthy eating and active living in this population. This work informed community implementation of evidence-based health interventions in Acres Homes and may support future projects aiming to enhance community-led cancer prevention efforts in historically underserved communities.

Are social determinants of health associated with the development of early complications among young adults with type 2 diabetes? A population based study using linked databases

AIMS

To quantify the impact of social determinants of health (SDOH) on top of medical determinants on the development of diabetes-related complications in young adults with type 2 diabetes.

METHODS

In this observational population-based study, SDOH (income and origin) were linked to routine primary care data. Young adults (18-45 years) with incident type 2 diabetes between 2007 and 2013 were included. The main outcome, the development of the first micro- or macrovascular complication, was analyzed by multivariate Cox regression. Medical determinants included antidiabetic treatment, HbA1c in the year after diagnosis, body mass index, comorbidity and smoking.

RESULTS

Of 761 young adults (median age: 39 years (IQR 33-42), men: 49%, Western origin: 36%, low income: 48%), 154 developed at least one complication (median follow-up 99 months (IQR 73-123)). Young men of non-Western origin were more likely to develop a complication (HR 1.98 (1.19-3.30)), as were young adults with HbA1c > 7% (>53 mmol/mol) (HR: 1.72 95% CI: 1.15-2.57). No associations were found with income. Being women was protective.

CONCLUSION

In this multi-ethnic population, non-Western origin was associated with the development of complications, but only in men. Low income was not associated with developing complications. The importance of adequate HbA1c regulation was re-emphasized by this study.

Incidence of the first diabetic foot ulcer: A systematic review and meta-analysis

AIM

Investigate the incidence of the first diabetic foot ulcer.

METHOD

This is a systematic review with meta-analysis of cohort studies following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and using RevMan software. A systematic search of Medline databases via PubMed, Embase, Lilacs, Scopus databases, and Web of Science was performed until July 2021. In addition to investigating the incidence of the first diabetic foot ulcer, the influence of the variables of the Human Development Index (HDI), glycated hemoglobin, and follow-up time of the participants on the incidence of the first diabetic foot ulcer (DFU) was analyzed through meta-regression. For the meta-analysis of cumulative incidence and possible variable associations, RevMan software was used in the Metaprop data package with 95% confidence interval (CI).

RESULTS

A total of 9,772 articles were identified out of which 87 were selected and 12 studies ultimately included in the systematic review and meta-analysis. The meta-analysis of cumulative incidence was 5.65% (95% CI: 4.20; 7.57). By meta-regression, a significant inverse association was identified between DFU incidence and HDI (estimate - 2.38; 95% CI - 4.10--0.67; p = 0.01).

CONCLUSION

The study presents the cumulative incidence for the first DFU, an inexistent datum in the national and international literature, and the HDI was inversely associated with the incidence of DFU.

Disparities in limb preservation and associated socioeconomic burden among patients with diabetes and/or peripheral artery disease in the United States

Racial, ethnic, socioeconomic, and geographic disparities in limb preservation and nontraumatic lower extremity amputation (LEA) are consistently demonstrated in populations with diabetes and peripheral artery disease (PAD). Higher rates of major LEA in disadvantaged groups are associated with increased health care utilization and higher costs of care. Functional decline that often follows major LEA confers substantial risk of disability and premature mortality, and the burden of these outcomes is more prevalent in racial and ethnic minority groups, people with low socioeconomic status, and people in geographic regions where limited resources or distance from specialty care are barriers to access. We present a narrative review of the existing literature on estimated costs of diabetic foot disease and PAD, inequalities in care that contribute to excess costs, and disparities in outcomes that lead to a disproportionate burden of diabetes- and PAD-related LEA on systematically disadvantaged populations.

Impact of a social prescribing intervention in North East England on adults with type 2 diabetes: the SPRING_NE multimethod study

Background

Link worker social prescribing enables health-care professionals to address patients’ non-medical needs by linking patients into various services. Evidence for its effectiveness and how it is experienced by link workers and clients is lacking.

Objectives

To evaluate the impact and costs of a link worker social prescribing intervention on health and health-care costs and utilisation and to observe link worker delivery and patient engagement.

Data sources

Quality Outcomes Framework and Secondary Services Use data.

Design

Multimethods comprising (1) quasi-experimental evaluation of effects of social prescribing on health and health-care use, (2) cost-effectiveness analysis, (3) ethnographic methods to explore intervention delivery and receipt, and (4) a supplementary interview study examining intervention impact during the first UK COVID-19 lockdown (April–July 2020).

Study population and setting

Community-dwelling adults aged 40–74 years with type 2 diabetes and link workers in a socioeconomically deprived locality of North East England, UK.

Intervention

Link worker social prescribing to improve health and well-being-related outcomes among people with long-term conditions.

Participants

(1) Health outcomes study, approximately n = 8400 patients; EuroQol-5 Dimensions, five-level version (EQ-5D-5L), study, n = 694 (baseline) and n = 474 (follow-up); (2) ethnography, n = 20 link workers and n = 19 clients; and COVID-19 interviews, n = 14 staff and n = 44 clients.

Main outcome measures

The main outcome measures were glycated haemoglobin level (HbA1c; primary outcome), body mass index, blood pressure, cholesterol level, smoking status, health-care costs and utilisation, and EQ-5D-5L score.

Results

Intention-to-treat analysis of approximately 8400 patients in 13 intervention and 11 control general practices demonstrated a statistically significant, although not clinically significant, difference in HbA1c level (–1.11 mmol/mol) and a non-statistically significant 1.5-percentage-point reduction in the probability of having high blood pressure, but no statistically significant effects on other outcomes. Health-care cost estimates ranged from £18.22 (individuals with one extra comorbidity) to –£50.35 (individuals with no extra comorbidity). A statistically non-significant shift from unplanned (non-elective and accident and emergency admissions) to planned care (elective and outpatient care) was observed. Subgroup analysis showed more benefit for individuals living in more deprived areas, for the ethnically white and those with fewer comorbidities. The mean cost of the intervention itself was £1345 per participant; the incremental mean health gain was 0.004 quality-adjusted life-years (95% confidence interval –0.022 to 0.029 quality-adjusted life-years); and the incremental cost-effectiveness ratio was £327,250 per quality-adjusted life-year gained. Ethnographic data showed that successfully embedded, holistic social prescribing providing supported linking to navigate social determinants of health was challenging to deliver, but could offer opportunities for improving health and well-being. However, the intervention was heterogeneous and was shaped in unanticipated ways by the delivery context. Pressures to generate referrals and meet targets detracted from face-to-face contact and capacity to address setbacks among those with complex health and social problems.

Limitations

The limitations of the study include (1) a reduced sample size because of non-participation of seven general practices; (2) incompleteness and unreliability of some of the Quality and Outcomes Framework data; (3) unavailability of accurate data on intervention intensity and patient comorbidity; (4) reliance on an exploratory analysis with significant sensitivity analysis; and (5) limited perspectives from voluntary, community and social enterprise.

Conclusions

This social prescribing model resulted in a small improvement in glycaemic control. Outcome effects varied across different groups and the experience of social prescribing differed depending on client circumstances.

Future work

To examine how the NHS Primary Care Network social prescribing is being operationalised; its impact on health outcomes, service use and costs; and its tailoring to different contexts.

Trial registration

This trial is registered as ISRCTN13880272.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme, Community Groups and Health Promotion (grant no. 16/122/33) and will be published in full in Public Health Research; Vol. 11, No. 2. See the NIHR Journals Library website for further project information.

Factors Associated With Initiation of Antidepressant Medication in Adults With Type 1 and Type 2 Diabetes: A Primary Care Retrospective Cohort Study in Ontario, Canada

OBJECTIVES

Depression in patients with diabetes mellitus is common and associated with poorer outcomes. This study aims to identify demographic, socioeconomic and medical factors associated with the initiation of antidepressant medication after a diagnosis of diabetes in adult patients without a previous prescription for antidepressants. We also examined frequency of primary care visits in the year after antidepressant initiation compared with the year before treatment began.

METHODS

This was a retrospective cohort study using routinely collected electronic medical record data spanning January 2011 to December 2019 from the University of Toronto Practice-based Research Network (UTOPIAN) Data Safe Haven. Our primary outcome was a first prescription for an antidepressant in patients with diabetes. We used a mixed-effects logistic regression model to identify sociodemographic and medical factors associated with this event.

RESULTS

Among 22,750 patients with diabetes mellitus, 3,055 patients (13.4%) began taking an antidepressant medication. Increased odds of antidepressant initiation were observed in younger patients (odds ratio [OR], 1.77; 95% confidence interval [CI], 1.39 to 2.26), females (OR, 1.60; 95% CI, 1.46 to 1.7), those receiving insulin treatment (OR, 1.59; 95% CI, 1.43 to 1.78) and cases of polypharmacy (OR, 3.67; 95% CI, 3.29 to 4.11). There was an increase in the mean number of primary care visits from 4.6 to 5.9 per year after antidepressant initiation.

CONCLUSIONS

In patients with diabetes, age, sex and medical characteristics were associated with the initiation of antidepressants. These patients accessed primary care more frequently. Screening and prevention of depression, particularly in these subgroups, could reduce its personal and systemic burdens.

Prevalence and incidence of cardiovascular and renal diseases in type 1 compared with type 2 diabetes: A nationwide French observational study of hospitalized patients

BACKGROUND

Type 1 diabetes mellitus (T1DM) and type 2 diabetes mellitus (T2DM) increase risks of cardiovascular (CV) and renal disease compared with diabetes-free populations. There are only a few studies comparing T1DM and T2DM for the relative risk of these clinical events.

METHODS

All adult patients hospitalized in French hospitals in 2013 with at least 5 years of follow-up were identified and categorized by their diabetes status. A total of 50,623 patients with T1DM (age 61.4 ± 18.6, 53% male) and 425,207 patients with T2DM (age 68.6 ± 14.3, 55% male) were followed over a median period of 5.3 years (interquartile range: 2.8 - 5.8 years). Prevalence and event rates of myocardial infarction (MI), heart failure (HF), ischemic stroke, chronic kidney disease (CKD), all-cause death and CV death were assessed with age stratification of 10-year intervals. For clinical events during follow-up, we report hazard ratios (HRs) in T1DM relative to T2DM.

RESULTS

The age and sex-adjusted prevalence of CV diseases was higher in T2DM for ages above 40 years whereas the prevalence of CKD was more common in T1DM between ages 18 and 70 years. During 2,033,239 person-years of follow-up, age and sex-adjusted HR event rates comparing T1DM, versus T2DM as reference, showed that MI and HF relative risks were increased above 60 years (1.2 and 1.4 -fold). HR of ischemic stroke did not markedly differ between T1DM and T2DM. Risk of incident CKD was 2.4-fold higher in T1DM above 60 years. All-cause death HR risk was 1.1-fold higher in T1DM after 60 years and the CV death risk was 1.15-fold higher in T1DM between 60 and 69 years compared to T2DM.

CONCLUSIONS

Although the crude prevalent burden of CV diseases may be lower in T1DM than in T2DM, patients with T1DM may have a higher risk of incident MI, HF, all-cause death and CV death above 60 years of age, highlighting the need for improved prevention in this population.

Understanding Insulin in the Age of Precision Medicine and Big Data: Under-Explored Nature of Genomics

Insulin is amongst the human genome's most well-studied genes/proteins due to its connection to metabolic health. Within this article, we review literature and data to build a knowledge base of Insulin (INS) genetics that influence transcription, transcript processing, translation, hormone maturation, secretion, receptor binding, and metabolism while highlighting the future needs of insulin research. The INS gene region has 2076 unique variants from population genetics. Several variants are found near the transcriptional start site, enhancers, and following the INS transcripts that might influence the readthrough fusion transcript INS-IGF2. This INS-IGF2 transcript splice site was confirmed within hundreds of pancreatic RNAseq samples, lacks drift based on human genome sequencing, and has possible elevated expression due to viral regulation within the liver. Moreover, a rare, poorly characterized African population-enriched variant of INS-IGF2 results in a loss of the stop codon. INS transcript UTR variants rs689 and rs3842753, associated with type 1 diabetes, are found in many pancreatic RNAseq datasets with an elevation of the 3'UTR alternatively spliced INS transcript. Finally, by combining literature, evolutionary profiling, and structural biology, we map rare missense variants that influence preproinsulin translation, proinsulin processing, dimer/hexamer secretory storage, receptor activation, and C-peptide detection for quasi-insulin blood measurements.

Socio-economic gradients in diagnosed and undiagnosed Type 2 diabetes and its related health complications

BACKGROUND AND AIMS

Diagnosed and undiagnosed Type 2 Diabetes (T2D) remains a challenge in high-income countries. In addition, the presence of T2D can cause further disease burden because of its high susceptibility to complications. Nevertheless, there is limited evidence of socio-economic gradients in undiagnosed T2D and its complications in a large population cohort. We investigated this using the Dutch Lifelines Cohort Study (Lifelines).

METHODS AND RESULTS

Within Lifelines, baseline data of 102 163 adults aged 30 and above were collected from 2007 to 2013. The associations of Socio-Economic Status (SES), indicated by monthly household income, with the prevalence of T2D status and the number of T2D complications were assessed using multinomial Poisson and linear regressions with adjustments for age and sex. The prevalence of diagnosed and undiagnosed T2D was, respectively, 3.0% and 3.0% in the low SES group compared to 1.1% and 1.8% in the high SES group. Individuals with lower SES were at higher risk of having undiagnosed T2D (relative risk ratio (rrr) [95% CI]: 1.63 [1.47-1.81] for low SES and 1.16 [1.05-1.29] for middle SES) and diagnosed T2D, compared with those with high SES. Lower SES was positively associated with the number of T2D complications (low SES vs. high SES (ref); B [95% CI]: 0.15 [0.13-0.16]).

CONCLUSION

Complementing the known socio-economic gradients in diagnosed T2D, we document socio-economic gradients in undiagnosed T2D and T2D complications in a single, large general representative population. Furthermore, individuals with low SES with diagnosed or undiagnosed T2D were more susceptible to T2D complications.

Etiology, Epidemiology, and Disparities in the Burden of Diabetic Foot Ulcers

Diabetic foot ulcers (DFU) are a major source of preventable morbidity in adults with diabetes. Consequences of foot ulcers include decline in functional status, infection, hospitalization, lower-extremity amputation, and death. The lifetime risk of foot ulcer is 19% to 34%, and this number is rising with increased longevity and medical complexity of people with diabetes. Morbidity following incident ulceration is high, with recurrence rates of 65% at 3-5 years, lifetime lower-extremity amputation incidence of 20%, and 5-year mortality of 50-70%. New data suggest overall amputation incidence has increased by as much as 50% in some regions over the past several years after a long period of decline, especially in young and racial and ethnic minority populations. DFU are a common and highly morbid complication of diabetes. The pathway to ulceration, involving loss of sensation, ischemia, and minor trauma, is well established. Amputation and mortality after DFU represent late-stage complications and are strongly linked to poor diabetes management. Current efforts to improve care of patients with DFU have not resulted in consistently lower amputation rates, with evidence of widening disparities and implications for equity in diabetes care. Prevention and early detection of DFU through guideline-directed multidisciplinary care is critical to decrease the morbidity and disparities associated with DFU. This review describes the epidemiology, presentation, and sequelae of DFU, summarizes current evidence-based recommendations for screening and prevention, and highlights disparities in care and outcomes.

Sustained Low Income, Income Changes, and Risk of All-Cause Mortality in Individuals With Type 2 Diabetes: A Nationwide Population-Based Cohort Study

OBJECTIVE

There is limited evidence on the association of sustained low-income status, income changes, and all-cause mortality risk in individuals with type 2 diabetes (T2D).

RESEARCH DESIGN AND METHODS

Using the Korean Health Insurance Service database, we studied 1,923,854 adults with T2D (aged ≥30 years) without cardiovascular disease and cancer, who were enrolled from 2009 through 2012 and followed to the end of 2020 (median 10.8 years of follow-up). We defined income levels based on the amount of health insurance premiums and categorized them into quartiles, the first being the low-income group, and assessed the income status annually in the preceding 5 years. Cox proportional hazards models were used to quantify the association of low-income status and income changes with mortality, with adjustment for sociodemographic factors, comorbidities, and diabetes duration and treatment.

RESULTS

Participants who consecutively had low income showed a higher risk of mortality (hazard ratio [HR] 1.19; 95% CI 1.16-1.22), compared with those who had never been in the low-income group. This association was much stronger for consecutive recipients of Medical Aid, reflecting very-low-income status (HR 2.26; 95% CI 2.16-2.36), compared with those who had never been Medical Aid beneficiaries. Sustained low- and very-low-income status was associated with increased risk of mortality, specifically for younger adults (aged <40 years) and males. Those who experienced declines in income between the first (preceding 5 years) and the last (baseline) time points had an increased risk of mortality, regardless of baseline income status.

CONCLUSIONS

Among Korean adults with T2D, sustained low-income status and declines in income were associated with increased risk of mortality.

Adverse Clinical Outcomes Attributable to Socioeconomic and Ethnic Disparities Among People with Type 2 Diabetes in New Zealand Between 1994-2018: A Multiple Linked Cohort Study

Purpose

The study aimed to examine the separate population-level contributions of the ethnic and socioeconomic disparities among people with type 2 diabetes mellitus (T2DM) and residence in New Zealand (NZ).

Patients and Methods

A prospective cohort enrolled T2DM patients from 01/01/1994 into the Diabetes Care Support Service, a primary care audit program in Auckland, NZ. The cohort was linked to national registry databases (socioeconomic status, pharmaceutical claim, hospitalization, and death registration). Each cohort member was followed up till death or the study end time (31/12/2019), whichever came first. Incident clinical events (stroke, myocardial infarction (MI), heart failure (HF), end-stage renal disease (ESRD), and premature mortality (PM)) were used as outcomes. The attributable fractions (AFs) were estimated for the whole population and for specific population with NZ Europeans (NZE) and/or least deprived population as reference, both unadjusted and with adjustment for covariables by Cox Regression models.

Results

Among 36,267 patients, adjusted population AFs indicated 6.6(-30.8-33.3)% of PM, 17.1(5.8-27.0)% of MI, 35.3(22.6-46.0)% of stroke, 14.3(3.2-24.2)% of HF, and 15.9(6.7-24.2)% of ESRD could be attributed to deprivation; while 14.3(3.3-25.4)% of PM, -3.3(-8.3-1.5)% of MI, -0.5(-6.7-5.3)% of stroke, 4.7(0.3-8.8)% of HF, 13.3(9.9-16.6)% of ESRD could be attributed to ethnicity. Deprivation contributed a significant AF to stroke, while ethnicity was important for ESRD. Gradient of AF for deprivation indicated NZE and Asians were most affected by deprivation across outcomes. Conversely, Māori, with the highest AFs for ethnicity of PM and ESRD, were unaffected by deprivation. At same deprivations, the AFs of MI and stroke were greatest among NZE compared with other ethnic groups; the AF of ESRD was greatest among Māori and Pasifika.

Conclusion

Both socioeconomic deprivation and ethnicity are strongly associated with outcomes in patients with T2DM in NZ, although the extent of the deprivation gradient is greatest among NZE and Asians, and least among Māori.

Descriptive phenomenology study of the reasons for the low uptake of free health service package among type II diabetic patients

BACKGROUND

Although several diabetes management and control programs are introduced in Iran, rate of using such cares in patients with Type II Diabetic in Ahvaz is low and they show no tendency for receiving free diabetes service package. The aim of this study was to identify reasons behind low uptake of free health service package among T2DM patients in Ahvaz, Iran.

METHODS

This descriptive phenomenology study based on semi-structured guided interviews of patients with Type II Diabetic in Ahvaz, was carried out in the year 2021. Through purposeful sampling, 495 patients with diabetics who not received health services package more than 6 months were interviewed until the data saturation. The gathered data were analyzed through conventional content analysis.

RESULTS

Reasons were categorized into three themes which include 13 subthemes and 57 codes. Themes included individual, accessibility, and structural factors. Besides, subthemes were lack of awareness, poor health literacy, adverse patients experience, difficulties to use services, verbal miscommunication cultural barriers, low trust, geographic barriers, time barriers, financial difficulties, lack of human resources, poor service delivery, and organizational factors were as barriers to participation.

CONCLUSION

Regarding individual level, there is a need for further training of diabetic patients. Besides, for accessibility and structural factors Iranian healthcare system needs a comprehensive integrated care for the management of diabetes, this underlines the collaboration for improving patients' uptake of free health service package.

Malus toringoides (Rehd.) Hughes Ameliorates Nonalcoholic Fatty Liver Disease with Diabetes via Downregulation of SREBP-1c and the NF-κB Pathway In Vivo and In Vitro

Diabetic patients are more prone to developing nonalcoholic fatty liver disease (NAFLD) compared with healthy people. As a plant homologous to both medicine and food, Malus toringoides (Rehd.) Hughes has been used as an intervention for both NAFLD and diabetes. However, the effect and mechanism of M. toringoides on NAFLD on type 2 diabetes mellitus (T2DM) is unclear. The current investigation was designed to evaluate the ameliorative effects and mechanism of M. toringoides ethanol extract (CBTM-E375) on T2DM, and to identify the compounds in these extracts. The effects of CBTM-E375 on T2DM were verified using a high-fat diet-/streptozotocin-induced diabetic rat and free fatty acid (0.5 mM)-induced human hepatocellular carcinoma cell (HepG2) models. The components of CBTM-E375 were identified by high performance liquid chromatography-mass spectrometry/mass spectrometry. Our results demonstrate that CBTM-E375 ameliorated lipid accumulation (total cholesterol, triglyceride), oxidative stress (superoxide dismutase, catalase, malondialdehyde, glutathione peroxidase), and inflammation (tumor necrosis factor-α [TNF-α], interleukin [IL]-1β, IL-6, C-reactive protein [CRP]) in vivo and in vitro, these effects were associated with a CBTM-E375-mediated downregulation of SREBP-1c (sterol regulatory element binding protein 1c) and the NF-κB (nuclear factor κB) signaling pathway. A total of 20 chemical compounds were identified in CBTM-E375, including phlorizin, isoquercitrin, chlorogenic acid, quercetin, naringenin, and trigonelline, which have been reported to have positive effects on diabetes or on NAFLD.

Associations of polysocial risk score, lifestyle and genetic factors with incident type 2 diabetes: a prospective cohort study

AIM/HYPOTHESIS

We aimed to investigate the association between polysocial risk score (PsRS), an estimator of individual-level exposure to cumulative social risks, and incident type 2 diabetes in the UK Biobank study.

METHODS

This study includes 319,832 participants who were free of diabetes, cardiovascular disease and cancer at baseline in the UK Biobank study. The PsRS was calculated by counting the 12 social determinants of health from three social risk domains (namely socioeconomic status, psychosocial factors, and neighbourhood and living environment) that had a statistically significant association with incident type 2 diabetes after Bonferroni correction. A healthy lifestyle score was calculated using information on smoking status, alcohol intake, physical activity, diet quality and sleep quality. A genetic risk score was calculated using 403 SNPs that showed significant genome-wide associations with type 2 diabetes in people of European descent. The Cox proportional hazards model was used to analyse the association between the PsRS and incident type 2 diabetes.

RESULTS

During a median follow-up period of 8.7 years, 4427 participants were diagnosed with type 2 diabetes. After adjustment for major confounders, an intermediate PsRS (4-6) and high PsRS (≥7) was associated with higher risks of developing type 2 diabetes with the HRs being 1.38 (95% CI 1.26, 1.52) and 2.02 (95% CI 1.83, 2.22), respectively, compared with those with a low PsRS (≤3). In addition, an intermediate to high PsRS accounted for approximately 34% (95% CI 29, 39) of new-onset type 2 diabetes cases. A healthy lifestyle slightly, but significantly, mitigated PsRS-related risks of type 2 diabetes (p_interaction=0.030). In addition, the additive interactions between PsRS and genetic predisposition led to 15% (95% CI 13, 17; p<0.001) of new-onset type 2 diabetes cases (p_interaction<0.001).

CONCLUSIONS/INTERPRETATION

A higher PsRS was related to increased risks of type 2 diabetes. Adherence to a healthy lifestyle may attenuate elevated diabetes risks due to social vulnerability. Genetic susceptibility and disadvantaged social status may act synergistically, resulting in additional risks for type 2 diabetes.

Does crime trigger genetic risk for type 2 diabetes in young adults? A G x E interaction study using national data

BACKGROUND

Living in neighborhoods perceived as disordered exacerbates genetic risk for type 2 diabetes (T2D) among older adults. It is unknown whether this gene-neighborhood interaction extends to younger adults. The present study aims to investigate whether crime, an objectively measured indicator of neighborhood disorder, triggers genetic risk for T2D among younger adults, and whether this hypothesized triggering occurs through exposure to obesity.

METHODS

Data were from the Wave I (2008) National Longitudinal Study of Adolescent to Adult Health. A standardized T2D polygenic score was created using 2014 GWAS meta-analysis results. Weighted mediation analyses using generalized structural equation models were conducted in a final sample of 7606 adults (age range: 25-34) to test the overall association of T2D polygenic scores with T2D, and the mediating path through obesity exposure in low, moderate, and high county crime-rate groups. Age, sex, ancestry, educational degree, household income, five genetic principal components, and county-level concentrated advantage and population density were adjusted.

RESULTS

The overall association between T2D polygenic score and T2D was not significant in low-crime areas (p = 0.453), marginally significant in moderate-crime areas (p = 0.064), and statistically significant in high-crime areas (p = 0.007). The mediating path through obesity was not significant in low or moderate crime areas (ps = 0.560 and 0.261, respectively), but was statistically significant in high-crime areas (p = 0.023). The indirect path through obesity accounted for 12% of the overall association in high-crime area.

CONCLUSION

A gene-crime interaction in T2D was observed among younger adults, and this association was partially explained by exposure to obesity.

Oral Health Knowledge, Attitudes and Practices of People Living with Diabetes in South Asia: A Scoping Review

Diabetes increases the risk of oral health complications. This review aimed to synthesise the current evidence on the oral health knowledge, attitudes and practices of people living with diabetes in South Asian countries and provide recommendations on possible strategies for addressing the gaps in oral health care in this population, including the role of non-dental professionals. Using a scoping review framework, six electronic databases (Ovid Medline, CINAHL, ProQuest Central, Scopus, Web of Science and Embase) were searched to identify the relevant literature published between January 2000 and December 2021. The data were extracted into three main categories based on the review's aims, and further refined into sub-categories. A total of 23 studies were included. The review identified that while people with diabetes living in South Asian countries had some level of awareness about oral health and limited care practices to maintain good oral health, there were gaps in knowledge, and there were areas where their oral health practices and attitudes could be improved. The findings suggest a need for developing targeted oral health policies as well as implementing integrated oral health care interventions involving non-dental professionals to improve the oral health outcomes of people with diabetes.

Prevalence of prediabetes, diabetes, diabetes awareness, treatment, and its socioeconomic inequality in west of Iran

We aim to estimate the prevalence of prediabetes, and diabetes mellitus (DM). We estimated awareness, treatment, plasma glucose control, and associated factors in diabetes, as well as, socioeconomic-related inequality in the prevalence of diabetes and prediabetes. Data for adults aged 35-70 years were obtained from the baseline phase of the Dehgolan prospective cohort study (DehPCS). Diabetes status was determined as fasting plasma glucose (FPG) of ≥ 126 mg/dl and/or taking glucose lowering medication confirmed by a medical practitioner. Prediabetes was considered as 100 ≤ FPG ≤ 125 mg/dl. The relative concentration index (RCI) was used to exhibit socioeconomic inequality in the prevalence of prediabetes and DM. Prevalence of prediabetes and DM, diabetes awareness and treatment, and glycemic control of DM 18.22%, 10.00%, 78.50%, 68.91% and, 28.50%, respectively. Increasing age (p < 0.001), Increasing body mass index (BMI) (p < 0.05), ex-smoker (p < 0.01), family history of diabetes (FHD) (p < 0.001), and comorbidity (p < 0.001) were independent risk factors for DM. Age group of 46-60 (p < 0.05), ex-smoker (p < 0.05), FHD (p < 0.05) were increased chance of awareness. Current smokers (p < 0.05), and higher education increase the chance of glycemic control in DM. Both DM (RCI =  - 0.234) and prediabetes (RCI =  - 0.122) were concentrated significantly among less-educated participants. DM was concentrated significantly among poor (RCI =  - 0.094) people. A significant proportion of DM awareness and treatment can be due to the integration of diabetes into the primary health care system. The high prevalence of prediabetes and diabetes, which is affected by socioeconomic inequality and combined with low levels of glycemic control may place a greater burden on the health system. Therefore, awareness, receiving treatment, and glycemic control in people with diabetes, and the socioeconomic status of people have become increasingly important in the near future.

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.

Socioeconomic Inequalities in the Prevalence of Diabetes in Argentina: A Repeated Cross-Sectional Study in Urban Women and Men

This study measured the socioeconomic inequalities in the prevalence of diabetes between 2005 and 2018 in an urban Argentinian population. Data were obtained from the repeated cross-sectional surveys “National Survey of Risk Factors” (ENFR is its acronym in Spanish). From 2005 to 2018, four rounds of ENFR were administered to men and women over 18 years of age. Concentration curves (CC) and the Erreygers concentration index (ECI) were used to describe the socioeconomic inequalities in diabetes’ prevalence. A decomposition analysis was performed to determine the contribution of each variable to inequality in diabetes’ prevalence. Data from 41,219 (2005), 34,583 (2009), 32,232 (2013), and 29,094 (2018) individuals were analyzed. Women reported a greater prevalence of diabetes compared with men for all the years included. According to the CC and ECI, we found no evidence of inequality in men throughout all study years. For women, throughout all years, the CCs were above the line of equity, and the ECIs during all the years were negative and different from zero (p < 0.01). For women, we found no evidence of a reduction in inequalities between 2005 and 2018 (p = 0.475). The socioeconomic inequality for women was largely driven by public insurance, primary and secondary education, and employment. Diabetes’ prevalence was not associated with socioeconomic status in men, while the prevalence of diabetes in women was more concentrated among poorer women. During the 13 years, there was no evidence of a reduction of inequality in women, noting that interventions must prioritize and should focus on the main contribution of inequalities, such as education and employment.

Poor Self-Care Practices and Being Urban Resident Strongly Predict Chronic Complications Among Patients with Type 2 Diabetes in Eastern Ethiopia: A Hospital-Based Cross-Sectional Study

Background

Diabetes, together with its complications, has a considerable negative influence on people's quality of life and healthcare delivery and raises diabetic mortality. However, there is limited information about the diabetes-associated chronic complications in the study setting. Therefore, this study aimed to determine the burden and factors related to the chronic complications among patients with type 2 diabetes (T2D) in Eastern Ethiopia.

Methods

A hospital-based cross-sectional study was conducted among 879 patients with T2D at two public hospitals in Harar. The data were collected through interviews using a structured questionnaire. Data related to the diagnosis of chronic complications and biochemical tests were extracted from medical records. The outcome variable was the number of chronic complications that happened to the patients. A generalized Poisson regression model with robust variance estimation was used to investigate the association of independent variables with chronic complications. An adjusted prevalence ratio with a 95% CI was reported to show an association using a p-value ≤0.05.

Results

One or more chronic complications were presented in 43% of T2D (95% CI: 39.65, 46.19). Macrovascular and microvascular complications were found in 27.6% and 23.5% of patients, respectively. Urban residence (APR = 2.64; 95% CI: 1.54, 4.54), low wealth status (APR = 1.80; 95% CI: 1.17, 2.76), diabetes duration ≥5 years (APR = 1.46; 95% CI: 1.05, 2.01), hypertriglyceridemia (APR = 1.48; 95% CI: 1.07, 2.09) and poor self-care practices (APR = 1.62; 95% CI: 1.18, 2.23) were factors significantly associated with the chronic complications.

Conclusion

The burden of chronic complications was high, with nearly half of T2D patients experiencing one or more chronic complications. Almost one in ten patients suffered from multiple chronic complications. The complications were mainly influenced by being urban resident, low wealth status, and poor self-care practices. Therefore, health care providers need to educate patients and promote self-care practices and healthy lifestyles to achieve treatment goals and lower the risk of chronic complications.

Prediction models of diabetes complications: a scoping review

BACKGROUND

Diabetes often places a large burden on people with diabetes (hereafter 'patients') and the society, that is, in part attributable to its complications. However, evidence from models predicting diabetes complications in patients remains unclear. With the collaboration of patient partners, we aimed to describe existing prediction models of physical and mental health complications of diabetes.

METHODS

Building on existing frameworks, we systematically searched for studies in Ovid-Medline and Embase. We included studies describing prognostic prediction models that used data from patients with pre-diabetes or any type of diabetes, published between 2000 and 2020. Independent reviewers screened articles, extracted data and narratively synthesised findings using established reporting standards.

RESULTS

Overall, 78 studies reported 260 risk prediction models of cardiovascular complications (n=42 studies), mortality (n=16), kidney complications (n=14), eye complications (n=10), hypoglycaemia (n=8), nerve complications (n=3), cancer (n=2), fracture (n=2) and dementia (n=1). Prevalent complications deemed important by patients such as amputation and mental health were poorly or not at all represented. Studies primarily analysed data from older people with type 2 diabetes (n=54), with little focus on pre-diabetes (n=0), type 1 diabetes (n=8), younger (n=1) and racialised people (n=10). Per complication, predictors vary substantially between models. Studies with details of calibration and discrimination mostly exhibited good model performance.

CONCLUSION

This rigorous knowledge synthesis provides evidence of gaps in the landscape of diabetes complication prediction models. Future studies should address unmet needs for analyses of complications n> and among patient groups currently under-represented in the literature and should consistently report relevant statistics. SCOPING REVIEW REGISTRATION: https://osf.io/fjubt/.

Prevalence of SGLT2i and GLP1RA use among US adults with type 2 diabetes

AIMS

To determine national prevalence of sodium-glucose contransporter-2 inhibitor (SGLT2i) and glucagon-like peptide-1 receptor agonist (GLP1RA) use among adults with type 2 diabetes mellitus (T2DM).

METHODS

We studied adults with T2DM and eGFR ≥ 30 mL/min/1.73 m² who participated in the cross-sectional National Health and Nutrition Examination Survey (NHANES), focusing on the 2017-2020 examination cycle, a key time period prior to widespread dissemination of pivotal trial results and corresponding clinical practice guidelines. We tested prevalence of SGLT2i and GLP1RA use among subgroups based on demographic variables and relevant comorbidities, including chronic kidney disease (CKD), congestive heart failure (CHF), and atherosclerotic cardiovascular disease (ASCVD). We compared use of SGLT2i and GLP1RA to other glucose-lowering medications and assessed trends from prior NHANES cycles.

RESULTS

Among 1375 participants studied in 2017-2020, mean age was 60 years, 46% were women, 13% self-identified as non-Hispanic Black, 10% self-identified as Mexican American, 37% had CKD, 8.5% had CHF, and 23% had ASCVD. The prevalence of SGLT2i and GLP1RA use was 5.8% and 4.4%, respectively. Among adults with CKD, CHF, or ASCVD, SGLT2i were used by 7.7% and GLP1RA were used by 3.5%. Differences in SGLT2i or GLP1RA use were observed by age, race, ethnicity, health insurance status, body mass index, and by whether a single healthcare provider was identified as responsible for diabetes management. Biguanides, sulfonylureas, DPP-4 inhibitors, and insulin were used more frequently than SGLT2i or GLP1RA. Prevalence of SGLT2i but not GLP1RA use increased significantly from 2013-2014 to 2017-2020.

CONCLUSIONS

SGLT2i and GLP1RA use is low among adults with T2DM, including among those with strong indications. Enhanced implementation of these agents is crucial to improving kidney and cardiovascular outcomes and mitigating health disparities in T2DM.

Social Aspects of Diabetic Foot: A Scoping Review

Diabetic foot ulcer (DFU) is a severe complication of diabetes mellitus (DM). Patients with DFU have increased mortality and morbidity as well as decreased quality of life (QoL). The present scoping review aims to study the social issues of diabetic foot. Following PRISMA guidelines, the review was conducted in two databases (Scopus and Pubmed) with the use of the following keywords: “social aspects and diabetic foot”, “social characteristics and diabetic foot”, “social issues and diabetic foot”, “demographic profiles and diabetic foot”, “social determinants and diabetic foot”, “social capital and diabetic foot”, “social characteristics and gender and diabetic foot”, “social profiles and diabetic foot”, “social relationships and diabetic foot” and “social risk and diabetic foot”, from July to August 2021. Predetermined exclusion and inclusion criteria were selected. Forty-five studies (quantitative and qualitative) were eligible for inclusion in this review. Gender problems, socioeconomic status, social capital, and medical problems were the most important negative variables for diabetic foot. All the included variables reveal that the social impact of diabetic foot is the most important factor for management and prevention, in terms of aggravation and more, of the diabetic foot.

Improvements in physical activity and some dietary behaviors in a community health worker-led diabetes self-management intervention for adults with low incomes: results from a randomized controlled trial

People with low incomes have a disproportionate prevalence of diabetes and its complications and experience many barriers to self-management, which community health workers (CHWs) may help address. We sought to examine the effects of an in-home CHW-led intervention for adults with diabetes and incomes <250% of the federal poverty line on self-management behaviors and test mediators and moderators. From 2010 to 2013, we randomized participants from three Washington State health systems with type 2 diabetes and hemoglobin A1c (HbA1c) ≥ 8% to the CHW intervention (N = 145) or usual care control (N = 142) arms. We examined effects on 12-month self-management: physical activity, dietary behaviors, medication taking, blood glucose monitoring, foot care, and tobacco use. For behaviors with significant intervention-control group differences, we tested mediation by self-efficacy and social support. We also investigated whether intervention-associated changes in behaviors varied by race/ethnicity, gender, and baseline values of HbA1c, diabetes distress, depression, and food insecurity (moderators). Compared to controls, intervention participants engaged in more physical activity and reported better dietary behaviors for some measures (general diet, frequency of skipping meals, and frequency of eating out) at 12-months, but there was no evidence of mediation by self-efficacy or social support. Evidence of moderation was limited: improvements in the frequency of skipping meals were restricted to participants with baseline HbA1c < 10%. Study findings suggest CHWs could be integrated into diabetes care to effectively support lifestyle changes around physical activity and some eating behaviors among adults with low incomes. More research is needed to understand mechanisms of change.

Type 2 Diabetes Mellitus and Clinicopathological Tumor Characteristics in Women Diagnosed with Breast Cancer: A Systematic Review and Meta-Analysis

Poor prognosis caused by type 2 diabetes mellitus (T2DM) in women with breast cancer is conferred, while the association between T2DM and breast tumor aggressiveness is still a matter of debate. This study aimed to clarify the differences in breast cancer characteristics, including stage, size, lymph node status, grade, estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor (Her2), between patients with and without pre-existing T2DM. PubMed, Embase, and Web of Science were searched for studies from 1 January 2010 to 2 July 2021. Adjusted odds ratios (ORs) with 95% confidence intervals (CIs) were pooled by using a random effects model. T2DM was significantly associated with tumor stages III/IV versus cancers in situ and stages I/II (pooled ORs (pOR), 95% CI: 1.19; 1.04-1.36, p = 0.012), tumor size >20 versus ≤20 mm (pOR, 95% CI: 1.18; 1.04-1.35, p = 0.013), and lymph node invasion versus no involvement (pOR, 95% CI: 1.26; 1.05-1.51, p = 0.013). These findings suggest that women with T2DM are at a higher risk of late-stage tumors, large tumor sizes, and invasive lymph nodes at breast cancer diagnosis.

Evaluation of a Community Health Worker Social Prescribing Program Among UK Patients With Type 2 Diabetes

IMPORTANCE

Despite lacking robust evidence of effectiveness, health care systems in developed countries are funding holistic community health worker (CHW) social prescribing programs that address social needs and health behaviors as adjuncts to clinical care.

OBJECTIVE

To determine whether a UK National Health Service (NHS) CHW social prescribing program was associated with improved hemoglobin A1c (HbA1c) levels among patients with type 2 diabetes.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study with difference-in-differences analysis was conducted among 8086 patients (4752 in the referral program, 3334 in the control group) in 24 NHS primary care practices in a city in North East England. Patients aged 40 to 74 years with a diagnosis of type 2 diabetes were observed for 8 years, from 2011 through 2019. The statistical analysis was conducted between June 1, 2019, and January 31, 2021.

INTERVENTIONS

A social prescribing program, launched in April 2015, enabling primary care staff to refer patients to CHW support to identify condition management and social needs goals and access voluntary and community sector support to address these goals. Intervention referral was only available in primary care practices in the city's west. The control group included patients in the city's east where referral was unavailable.

MAIN OUTCOMES AND MEASURES

HbA1c level, a marker of glycemic control.

RESULTS

A total of 8086 patients were included in the analysis (mean [SD] age, 57.8 [8.78] years; 3477 women [43%]; 6631 White patients [82%]). Mean (SD) baseline HbA1c levels were 7.56% (1.47%) in the referral program group and 7.44% (1.43%) in the control group. Following introduction of the social prescribing referral program, the referral group experienced an HbA1c reduction of -0.10 percentage points (95% CI, -0.17 to -0.03 percentage points) compared with the control group. The association increased over time: after 3 years the estimated association was -0.14 percentage points (95% CI, -0.24 to -0.03 percentage points). The association was stronger for White patients compared with non-White patients (-0.15 percentage points [95% CI, -0.26 to -0.04 percentage points] after 3 years), those with fewer additional comorbidities (-0.16 percentage points [95% CI, -0.29 to -0.04 percentage points] after 3 years), and those living in the most socioeconomically deprived areas (-0.19 percentage points [95% CI, -0.32 to -0.07 percentage points] after 3 years).

CONCLUSIONS AND RELEVANCE

In this study of UK adults with type 2 diabetes, a social prescribing program with referral to CHWs targeting patients' social needs and health behaviors was associated with improved HbA1c levels, suggesting that holistic CHW interventions may help to reduce the public health burden of type 2 diabetes.

Factors associated with treatment in primary versus specialist care: A population-based study of people with type 2 and type 1 diabetes

AIMS

The objectives of this study are to identify the proportion and characteristics of people with type 1 and 2 diabetes treated in primary, specialist and shared care and to identify the proportion of persons with type 2 diabetes reaching HbA_1c treatment targets and the clinical risk factors and general practitioner and practice characteristics associated with treatment in specialist care.

METHODS

Population-based cross-sectional study including all adults ≥18 years diagnosed with diabetes in primary and specialist care in Salten, Norway. We used multivariable mixed-effects logistic regression models with level of care as outcome variable and population, general practitioner, and practice characteristics as exposure variables.

RESULTS

Of 2704 people with type 2 diabetes, 13.5% were treated in shared care and 2.1% in specialist care only. Of 305 people with type 1 diabetes, 14.4% received treatment in primary care only. The HbA_1c treatment target of 53 mmol/mol (7.0%) was reached by 67.3% of people with type 2 diabetes in primary care versus 30.4% in specialist care. HbA_1c , use of insulin, coronary heart disease, retinopathy and urban practice location were positively associated with treatment in specialist care. General practitioners' use of a structured form and a diabetes nurse were negatively associated with specialist care.

CONCLUSIONS

Of people with type 2 diabetes, 16% were treated in specialist care. They had higher HbA_1c and more vascular complications, as expected from priority guidelines. The use of a structured diabetes form and diabetes nurses seem to support type 2 diabetes follow-up in primary care.