Race/ethnic difference in diabetes and diabetic complications

Examining Medical and Demographic Associations With the Diabetes Management Questionnaire Among Racially Minoritized Youth With Type 1 Diabetes

PurposeThe purpose of this study was to examine demographic and diabetes-related factors with the Diabetes Management Questionnaire (DMQ) among racially minoritized youth with type 1 diabetes.MethodsA descriptive correlational study was employed. Youth and their caregivers were enrolled in a behavioral intervention to promote optimal continuous glucose monitoring (CGM) use along with completing the DMQ at baseline.ResultsParticipants included 60 youth ages 10 to 15 years (53% Black, 27% Hispanic/Latino/a/x, 12% another minoritized identity, 8% White; mean A1C = 10.6% ± 2.0%). Only child age was significantly associated with caregiver DMQ scores. No other demographic or medical variables, including A1C, were significantly related to DMQ scores. Mean youth DMQ scores significantly differed between samples, with the current sample reporting stronger adherence to diabetes management regimens despite higher overall A1C.ConclusionsThe lack of associations between the DMQ and demographic or medical variables in this sample compared to that of the validation sample suggest that the DMQ may have weaker psychometric properties among racially minoritized families. It is crucial that existing questionnaires like the DMQ be reexamined in a larger, more racially diverse population, where structural factors, beyond individual management behaviors, also influence A1C.

Developing and Validating Models to Predict Suboptimal Early Glycemic Control Among Individuals With Younger Onset Type 2 Diabetes

OBJECTIVE

Younger age at the time of type 2 diabetes onset increases individuals' future complication risk. Proactively identifying younger-onset individuals at increased risk of not achieving early glycemic goals can support targeted initial care.

DESIGN AND METHODS

Individuals (ages 21-44) newly diagnosed with type 2 diabetes were identified and randomly assigned to training (70%) and validation (30%) datasets. Least absolute shrinkage and selection operator regression models were specified to identify key predictors (assessed at diagnosis) of suboptimal glycemic control (HbA1c≥8%) within 1 year after diagnosis using the training dataset. The full model included 48 candidate predictors. We also developed additional more streamlined models using more widely available predictors (transferable model), a smaller number of available predictors (simplified transferable model), and a bivariate model with HbA1c as the sole predictor (HbA1c-only model). Model-based predicted risk scores were used to stratify individuals in the validation dataset.

RESULTS

The cohort included 10,879 individuals. All of the models, including the HbA1c-only model, performed comparably. All had good discrimination (C-statistics ranging from 0.71 to 0.73) in the validation dataset.

CONCLUSIONS

When predicting the risk of not achieving glycemic goals, the HbA1c-only model had comparable performance to the more complex prediction models. This simple risk stratification requires no computation and could be implemented simply by looking at the diagnosis HbA1c value. This practical approach can be used to identify newly diagnosed younger adults who may need extra attention during the critical early period after diagnosis.

Comorbidity Prevalence in Prediabetes and Type 2 Diabetes: A Cross-Sectional Study in a Predominantly Hispanic U.S.-Mexico Border Population

Type 2 diabetes and prediabetes are associated with a higher risk of several health conditions. We conducted a cross-sectional study to compare the prevalence of comorbidities among 88,724 adults with prediabetes and 12,071 adults with type 2 diabetes in El Paso, Texas, using data from the Paso del Norte Health Information Exchange (PHIX) from 1 January 2021, to 31 January 2023. We estimated prevalence ratios (aPR) adjusted for age decade, gender, and Hispanic ethnicity. Individuals with prediabetes, compared to type 2 diabetes, had lower adjusted prevalence of circulatory (59.1% vs. 80.4%; aPR = 0.82 [95% CI: 0.81-0.84]), genitourinary (44.9% vs. 50.5%; aPR = 0.97 [0.96-0.99]), respiratory (32.0% vs. 35.7%; aPR = 0.94 [0.92-0.97]), neurological (27.4% vs. 32.8%; aPR = 0.91 [0.88-0.94]), blood (21.2% vs. 30.5%; aPR = 0.77 [0.75-0.80]), mental (19.5% vs. 26.1%; aPR = 0.72 [0.69-0.75]), infectious (12.8% vs. 21.5%; aPR = 0.63 [0.60-0.66]), skin (12.2% vs. 14.8%; aPR = 0.82 [0.78-0.86]), and COVID-19 (10.2% vs. 11.9%; aPR = 0.86 [0.81-0.91]) diseases/conditions. Adjusted prevalence was higher among those with prediabetes for musculoskeletal (53.8% vs. 47.0%; aPR = 1.19 [1.17, 1.21]), ear (18.4% vs. 12.9%; aPR = 1.54 [1.47-1.60]), eye (11.1% vs. 7.8%; aPR = 1.52 [1.43, 1.61]), digestive (44.0% vs. 44.0%; aPR = 1.02 [1.00-1.05]), and neoplastic (14.4% vs. 14.5%; aPR = 1.12 [1.06-1.17]) diseases/conditions. People with prediabetes in El Paso, Texas, had a lower prevalence of most comorbidities than those with type 2 diabetes, suggesting that preventing prediabetes from progressing to type 2 diabetes could have a beneficial impact on comorbid disease burden.

The Burden of Diabetes Mortality by County, Race, and Ethnicity in the U.S., 2000-2019

OBJECTIVE

Diabetes is a leading cause of death in the U.S. Previous studies have found substantial racial, ethnic, and geographical disparities in diabetes mortality; however, research considering racial, ethnic, and geographical disparities simultaneously has been limited. To fill this gap, we estimated trends in diabetes mortality rates from 2000 to 2019 at the county level for five racial and ethnic populations.

RESEARCH DESIGN AND METHODS

We applied small-area estimation methods to death registration data from the U.S. National Vital Statistics System and population data from the U.S. National Center for Health Statistics and corrected for misclassification of race and ethnicity on death certificates.

RESULTS

Age-standardized diabetes mortality rates decreased in the U.S. from 28.1 deaths per 100,000 (95% uncertainty interval 27.9-28.2) in 2000 to 19.1 deaths per 100,000 (19.0-19.2) in 2019. In 2019, national-level rates were highest for the American Indian or Alaska Native (AIAN) population (35.6 [32.1-39.4]), followed by the Black (31.9 [31.5-32.3]), Latino (19.7 [19.3-20.2]), White (17.6 [17.5-17.8]), and Asian (12.6 [12.1-13.1]) populations. There was substantial heterogeneity in diabetes mortality rates across counties within each racial and ethnic population, with the AIAN population experiencing the greatest heterogeneity in 2019 (interquartile range 18.7-50.3 [median 31.9]). For each racial and ethnic population, mortality rates declined in most counties from 2000 to 2019.

CONCLUSIONS

Since 2000, progress has been made in reducing diabetes mortality rates. Nonetheless, diabetes mortality remains too high for many Americans. Interventions focusing on communities at highest risk are vital to resolving persistent health inequities.

Racial Disparities of Type 2 Diabetes Through Exercise: The Multi-Ethnic Study of Atherosclerosis

INTRODUCTION

Persistent racial and ethnic disparities exist for Type 2 diabetes in the U.S. Racial and ethnic minorities have a higher risk of Type 2 diabetes, and studies suggest that they engage in less exercise than White population. This study examined whether and to what degree racial differences in Type 2 diabetes were explained by exercise.

METHODS

Adults aged 45-84 years without Type 2 diabetes at baseline (2000-2002) were included from the Multi-Ethnic Study of Atherosclerosis cohort and followed through 2020. Associations between race and Type 2 diabetes were examined using multivariable Cox proportional hazard regression. The effects of exercise were assessed using natural mediation effects. Analyses were conducted in 2023.

RESULTS

Controlling for confounders, Hispanic (adjusted hazard ratio [95% CI]=2.02 [1.74, 2.34]), Chinese (1.50 [1.24, 1.82]), and Black (1.66 [1.44, 1.93]) participants had higher Type 2 diabetes risks than White participants. Hispanic (β [SE]= -0.29 [0.04] square root of MET-hour/day, p<0.001) and Chinese (-0.25 [0.04], p<0.001) participants had lower habitual intentional exercise than White participants; this was not true for Black participants (-0.01 [0.03], p=0.85). Habitual intentional exercise explained Type 2 diabetes excess risk by 13.6% for Hispanic and 13.2% for Chinese participants but not for Black participants, compared with that for White participants.

CONCLUSIONS

Habitual intentional exercise accounted for one tenth of the racial differences in Type 2 diabetes when comparing Hispanic or Chinese populations with White populations. Interventions promoting exercise are crucial to decrease Type 2 diabetes risk for all racial groups but may also narrow disparities in Type 2 diabetes among Hispanic and Chinese populations.

Abnormal Glucose Metabolism and Body Composition Changes in Childhood Acute Lymphoblastic Leukemia Survivors During Their Adolescence

Childhood acute lymphoblastic leukemia survivors (ALL-S) face an increased risk of abnormal glucose metabolism (AGM). This study aimed to assess glucose metabolism in 141 ALL-S. All underwent an oral glucose tolerance test (OGTT) and were classified into AGM and normal glucose tolerance (NGT) groups. Insulin sensitivity and secretion indices were calculated from plasma glucose and serum insulin derived from the OGTT. Fat mass index (FMI) was derived from body composition analysis. Sixty-seven of 141 (48%) ALL-S had AGM. AGM was demonstrated in 33 of 98 nonobese ALL-S. ALL-S with AGM had a greater waist circumference percentile and FMI SD score than those with NGT. In addition, ALL-S with AGM had lower insulin sensitivity (greater homeostasis model assessment of insulin resistance: 2.3 [1.4, 3.3] vs. 1.0 [0.5, 1.4], P <0.001 and lower whole-body insulin sensitivity index: 3.5 [2.3, 4.1] vs. 7.9 [5.3, 10.9], P <0.001) and lower insulin secretion relative to insulin sensitivity (disposition index: 5.8 [4.2, 10.2] vs. 10.0 [6.1, 14.6], P <0.001) than those with NGT. Therefore, ALL-S could develop AGM regardless of their body mass index status. AGM in ALL-S stemmed from both insulin resistance and impaired insulin secretion.

Multilevel Intervention to Increase Patient Portal Use in Adults With Type 2 Diabetes Who Access Health Care at Community Health Centers: Single Arm, Pre-Post Pilot Study

BACKGROUND

Diabetes self-management education and support (DSMS) delivered via patient portals significantly improves glycemic control. Yet, disparities in patient portal use persist. Community health centers (CHCs) deliver care to anyone who needs it, regardless of income or insurance status.

OBJECTIVE

This study aimed to evaluate the feasibility, acceptability, and preliminary efficacy of a multilevel intervention to increase access and use of portals (MAP) among people with type 2 diabetes (T2D) receiving health care at CHCs.

METHODS

A within-subjects, pre-post design was used. Adults with T2D who were portal naive were recruited from 2 CHCs. After informed consent, participants met with a community health worker for referrals for social determinants of health, provision of a tablet with cell service, and individualized training on use of the tablet and portal. Next, a nurse met individually with participants to develop a DSMS plan and then communicated with patients via the portal at least twice weekly during the first 3 months and weekly for the latter 3 months. Data were collected at baseline, 3 months and 6 months. The primary outcome was patient activation and engagement with the portal. Secondary outcomes included technology attitudes, digital health literacy, health-related outcomes and psychosocial function.

RESULTS

In total, 26 patients were eligible, 23 received the intervention, and one was lost to follow up. The sample was predominately Latino or Hispanic (17/22, 77%) and reported low income (19/22, 86%< US $40,000/year), low education (13/22, 59%

CONCLUSIONS

MAP shows promise for improving health equity in portal use for T2D. Larger, controlled studies are needed to determine how best to implement MAP in complex clinical settings and to evaluate efficacy over time.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05180721; https://clinicaltrials.gov/study/NCT05180721.

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Key Words

• CHCs
• DM
• T2D
• Type 2 diabetes
• adults
• community health center
• community health centers
• diabetes
• diabetes mellitus
• diabetic
• digital health
• digital health literacy
• efficacy
• feasibility
• glycemic control
• health technologies
• health technology
• mobile phone
• patient portal
• patient portals
• pilot study
• primary outcome
• psychosocial
• self-management
• social determinants of health

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MESH Headings

• Humans
• Diabetes Mellitus, Type 2/therapy
• Diabetes Mellitus, Type 2/psychology
• Male
• Female
• Patient Portals/statistics & numerical data
• Middle Aged
• Pilot Projects
• Community Health Centers/statistics & numerical data
• Health Services Accessibility/statistics & numerical data
• Aged
• Adult
• Patient Education as Topic/methods
• Self-Management/education
• Feasibility Studies

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Grants

• R21 MD016949 NIMHD NIH HHS

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Affiliation(s)

Robin Whittemore School of Nursing, Yale University, Orange, CT, United States
Sangchoon Jeon School of Nursing, Yale University, Orange, CT, United States
Samuel Akyirem School of Nursing, Yale University, Orange, CT, United States
Helen N C Chen Department of Epidemiology, Richard M. Fairbanks School of Public Health, Indiana University, Indianapolis, IN, United States
Joanna Lipson School of Nursing, Yale University, Orange, CT, United States
Maritza Minchala School of Public Health, Yale University, New Haven, CT, United States
Julie Wagner Department of Behavioral Sciences and Community Health, University of Connecticut School of Dental Medicine, Farmington, CT, United States

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Collaborators Collapse

Insulin resistance and cancer: molecular links and clinical perspectives

The association between insulin resistance (IR), type 2 diabetes mellitus (T2DM), and cancer is increasingly recognized and poses an escalating global health challenge, as the incidence of these conditions continues to rise. Studies indicate that individuals with T2DM have a 10-20% increased risk of developing various solid tumors, including colorectal, breast, pancreatic, and liver cancers. The relative risk (RR) varies depending on cancer type, with pancreatic and liver cancers showing a particularly strong association (RR 2.0-2.5), while colorectal and breast cancers demonstrate a moderate increase (RR 1.2-1.5). Understanding these epidemiological trends is crucial for developing integrated management strategies. Given the global rise in T2DM and cancer cases, exploring the complex relationship between these conditions is critical. IR contributes to hyperglycemia, chronic inflammation, and altered lipid metabolism. Together, these factors create a pro-tumorigenic environment conducive to cancer development and progression. In individuals with IR, hyperinsulinemia triggers the insulin-insulin-like growth factor (IGF1R) signaling pathway, activating cancer-associated pathways such as mitogen-activated protein kinase (MAPK) and phosphatidylinositol 3-kinase (PIK3CA), which promote cell proliferation and survival, thereby supporting tumor growth. Both IR and T2DM are linked to increased morbidity and mortality in patients with cancer. By providing an in-depth analysis of the molecular links between insulin resistance and cancer, this review offers valuable insights into the role of metabolic dysfunction in tumor progression. Addressing insulin resistance as a co-morbidity may open new avenues for risk assessment, early intervention, and the development of integrated treatment strategies to improve patient outcomes.

External validity of randomized clinical trials in vascular surgery: systematic review of demographic factors of patients recruited to randomized clinical trials with comparison to the National Vascular Registry

BACKGROUND

Evidence-based medicine relies on randomized clinical trials, which should represent the patients encountered in clinical practice. Characteristics of patients recruited to randomized clinical trials involving vascular index operations (carotid endarterectomy, abdominal aortic aneurysm repair, infrainguinal bypass and major lower limb amputations) were compared with those recorded in the National Vascular Registry across England and Wales.

METHODS

MEDLINE, Embase, Web of Science, CENTRAL, clinicaltrials.gov and World Health Organization International Trials Registry Platform (CRD42021247905) were searched for randomized clinical trials involving the index operations. Demographic (age, sex, ethnicity) and clinical (co-morbidities, medications, body mass index, smoking, alcohol, cognition) data were extracted, by operation. Characteristics of operated on patients were extracted from publicly available National Vascular Registry reports (2014-2020). All findings are reported according to PRISMA guidelines. Rayyan.AI, Excel and GraphPad Prism were used for screening and analysis.

RESULTS

A total of 307 randomized clinical trials (66 449 patients) were included and compared with National Vascular Registry data for 119 019 patients. Randomized clinical trial patients were younger across all operations; for carotid endarterectomy, bypass and major lower limb amputation randomized clinical trials, there were differences in female patient representation. Further comparisons were limited by the insufficient baseline data reporting across randomized clinical trials, though reporting improved over decades. National Vascular Registry reports lacked information on patient factors such as patient ethnicity or body mass index.

CONCLUSIONS

There are significant differences in demographic and clinical factors between patients recruited to vascular surgery randomized clinical trials and the real-world National Vascular Registry vascular surgery patient population. Minimum reporting standards for baseline data should be defined to allow future randomized clinical trials to represent real-world patient populations and ensure the external validity of their results.

Family history of type 2 diabetes and the risk of type 2 diabetes among young and middle-aged adults

Background

The prevalence of type 2 diabetes has been growing among younger and middle-aged adults in the United States. A portion of this increase for this age group may be attributable to shared type 2 diabetes risks with family members. How family history of type 2 diabetes history is associated with type 2 diabetes risk among younger and middle-aged adults is not well understood.

Methods

This population-based retrospective cohort study uses administrative, genealogical, and electronic medical records from the Utah Population Database. The study population comprises offspring born between 1970 and 1990 and living in the four urban Utah counties in the United States between 1990 and 2015. The sample comprises 360,907 individuals without a type 2 diabetes diagnosis and 14,817 with a diagnosis. Using multivariate logistic regressions, we estimate the relative risk (RR) of type 2 diabetes associated with the number of affected first- (FDRs), second- (SDRs), and third-degree (first cousin) relatives for the full sample and for Hispanic-specific and sex-specific subsets.

Results

Individuals with 2+ FDRs with type 2 diabetes have a significant risk of type 2 diabetes in relation to those with no affected FDRs (RR = 3.31 [3.16, 3.48]). Individuals with 2+ versus no SDRs with type 2 diabetes have significant but lower risks (RR = 1.32 [1.25, 1.39]). Those with 2+ versus no affected first cousins have a similarly low risk (RR = 1.28 [1.21, 1.35]). Larger RRs are experienced by males (2+ vs. 0 FDRs, RR = 3.55) than females (2+ vs. 0 FDRs, RR = 3.18) (p < 0.05 for the interaction). These familial associations are partly mediated by the individual's own obesity.

Conclusions

The risks of type 2 diabetes are significantly associated with having affected first-, second-, and third-degree relatives, especially for men. One of the forces contributing to the rising patterns of type 2 diabetes among young and middle-aged adults is their connection to affected, often older, kin.

Effectiveness of school-based programs for type 2 diabetes mellitus prevention for school children and adolescents: a systematic review protocol

OBJECTIVE

The objective of this review will be to synthesize the effectiveness of school-based programs for type 2 diabetes mellitus (T2DM) prevention for school children and adolescents.

INTRODUCTION

Schools function as a fundamental platform for communicating health-related knowledge, such as information on preventing chronic diseases such as diabetes. However, the effectiveness of school-based programs for preventing T2DM in children and adolescents remains unclear.

INCLUSION CRITERIA

This review will consider both experimental and quasi-experimental study designs, including randomized controlled trials, cluster randomized controlled trials, non-randomized controlled trials, before and after studies, and interrupted time-series studies. School children and adolescents aged 6 to 18 years (in Grades 1 to 12) of any ethnicity will be considered. This review will consider studies on T2DM prevention and education programs in school settings. Comparators will include no treatment, standard care, or waitlist controls, with outcomes covering diabetes risk factors, knowledge, health literacy, insulin sensitivity, fasting blood glucose, and glycated hemoglobin. These parameters will be assessed using validated instruments.

METHODS

This review will follow the JBI methodology for systematic reviews of effectiveness. The databases to be searched will include MEDLINE, CINAHL, Embase, PsycINFO, and Scopus. Two independent reviewers will select studies, critically appraise them using the standard JBI critical appraisal instruments, and extract data. Studies will be pooled in a meta-analysis or presented narratively. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach will be used to grade the certainty of the evidence.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42024499998.

The association between age at diagnosis of diabetes and development of diabetic retinopathy and assessment of healthcare access as an effect modifier

AIMS

To examine if healthcare access modifies the association between age at diagnosis of diabetes and the prevalence of retinopathy.

METHODS

BRFSS 2020 survey data was obtained from 12,198 adults. Participants with missing information in the variables "retinopathy" (N = 569) and "insurance-cost barrier" (N = 75) were excluded. The final sample included 11,556 participants. Age at diagnosis of diabetes was the main exposure and retinopathy was the main outcome. We tested if the main association was different among the insurance-cost barrier variable. Binary logistic regression models were used to calculate odds ratios (OR) and 95 % confidence intervals (CI).

RESULTS

The odds of retinopathy decreased by 22 % in patients 46-64 years-of-age (OR 0.78; 95 CI 0.6-1.0) and 57 % in those 65+ (OR 0.43; 95 CI 0.28-0.65). The odds decreased by 39 % if female (OR 0.61; 95 CI 0.48-0.77). An increase in odds by 86 % (OR 1.86; 95 CI 1.07-3.21) occurred in other non-Hispanics, 50 % (OR 1.50; 95 CI 1.13-1.99) in black non-Hispanics and 70 % (OR 1.70; 95 CI 1.17-2.46) in Hispanics. There was no evidence that age at diagnosis of diabetes and presence of retinopathy varied by insurance cost (p > 0.05).

CONCLUSION

Health professionals may utilize these results to advocate for early disease intervention.

Disparities in Diabetes Distress and Nutrition Management Among Black and Hispanic Adults: A Mixed Methods Exploration of Social Determinants

PURPOSE

The purpose of this study was to explore self-reported diabetes management strategies, social determinants of health (SDOH), and barriers to care among people with diabetes receiving care in a safety-net setting to identify factors contributing to disparities in outcomes for Black and Hispanic adults and inform future interventions.

METHODS

Sequential, explanatory, mixed methods study comprised a survey of adults with diabetes seen in primary care at a safety-net hospital in New England, followed by qualitative semistructured interviews with a subset of the Black and Hispanic respondents. Descriptive statistics, chi-square and t tests were used to analyze quantitative data. The health equity implementation framework was used to guide qualitative data collection and directed content analysis.

RESULTS

A total of 496 respondents completed the survey; 48 Black and Hispanic adults participated in interviews. Diabetes-related distress was significantly higher among Black and Hispanic participants compared to White participants. Nutrition management use was significantly lower among Black and Hispanic participants. Qualitative findings suggest that SDOH and lack of education and support, specifically, nutrition and access to self-management resources, contributed to diabetes-related distress and prevented optimal self-management.

CONCLUSIONS

High rates of diabetes-related distress and low rates of nutrition management were identified in Black and Hispanic adults in a safety-net setting. Qualitative interviews demonstrated a relationship between adverse SDOH and lack of nutrition education with diabetes distress and challenges to self-management, potentially contributing to disparities in outcomes. Findings suggest that increased uptake of nutrition therapy and self-management education and support may be critical for improving diabetes outcomes and promoting health equity.

Disparities in Cardiovascular Disease Prevalence by Race and Ethnicity, Socioeconomic Status, Urbanicity, and Social Determinants of Health Among Medicare Beneficiaries With Diabetes

Introduction

The association between various disparity factors and cardiovascular disease (CVD) prevalence among older US adults with diabetes has not been comprehensively explored. We examined disparities in CVD prevalence among Medicare beneficiaries with diabetes.

Methods

Data were from the 2015-2019 Medicare Current Beneficiary Survey. Diabetes and CVD conditions - myocardial infarction (MI), stroke, and heart failure - were self-reported. We estimated the adjusted prevalence ratios (APRs) of CVD by race and ethnicity, education, income-to-poverty ratio (IPR), urbanicity, food insecurity, and social vulnerability using logistic regressions that controlled for these factors as well as age and sex.

Results

Annually, an estimated 9.2 million Medicare beneficiaries aged 65 years or older had diabetes. Among them, 16.7% had MI, 13.7% had stroke, and 12.5% had heart failure. Beneficiaries who were food insecure, socially vulnerable, with an IPR less than or equal to 135%, and residing in rural areas had a higher crude CVD prevalence. After controlling for other factors, low IPR and food insecurity were linked to a higher prevalence of CVD. Hispanic beneficiaries had lower stroke and heart failure prevalence than non-Hispanic (NH) White and NH Black beneficiaries. NH Black beneficiaries had lower MI prevalence but higher heart failure prevalence compared with NH White beneficiaries. Female respondents with an IPR less than or equal to 135% had higher MI and stroke prevalence; this was not seen in male respondents.

Conclusion

Low IPR and food insecurity were associated with higher MI, stroke, and heart failure prevalence among Medicare beneficiaries with diabetes. Our findings can inform targeted interventions to reduce CVD disparities in these populations.

Data-driven Cluster Analysis Reveals Increased Risk for Severe Insulin-deficient Diabetes in Black/African Americans

CONTEXT

Diabetes is a heterogenic disease and distinct clusters have emerged, but the implications for diverse populations have remained understudied.

OBJECTIVE

Apply cluster analysis to a diverse diabetes cohort in the US Deep South.

DESIGN

Retrospective hierarchical cluster analysis of electronic health records from 89 875 patients diagnosed with diabetes between January 1, 2010, and December 31, 2019, at the Kirklin Clinic of the University of Alabama at Birmingham, an ambulatory referral center.

PATIENTS

Adult patients with International Classification of Diseases diabetes codes were selected based on available data for 6 established clustering parameters (glutamic acid decarboxylase autoantibody; hemoglobin A1c; body mass index; diagnosis age; HOMA2-B; HOMA2-IR); ∼42% were Black/African American.

MAIN OUTCOME MEASURE(S)

Diabetes subtypes and their associated characteristics in a diverse adult population based on clustering analysis. We hypothesized that racial background would affect the distribution of subtypes. Outcome and hypothesis were formulated prior to data collection.

RESULTS

Diabetes cluster distribution was significantly different in Black/African Americans compared to Whites (P < .001). Black/African Americans were more likely to have severe insulin-deficient diabetes (OR, 1.83; 95% CI, 1.36-2.45; P < .001), associated with more serious metabolic perturbations and a higher risk for complications (OR, 1.42; 95% CI, 1.06-1.90; P = .020). Surprisingly, Black/African Americans specifically had more severe impairment of β-cell function (homoeostatic model assessment 2 estimates of β-cell function, C-peptide) (P < .001) but not being more obese or insulin resistant.

CONCLUSION

Racial background greatly influences diabetes cluster distribution and Black/African Americans are more frequently and more severely affected by severe insulin-deficient diabetes. This may further help explain the disparity in outcomes and have implications for treatment choice.

Comparison of mortality in people with type 2 diabetes between different ethnic groups: Systematic review and meta-analysis of longitudinal studies

AIMS

Type 2 diabetes (T2D) is more common in certain ethnic groups. This systematic review compares mortality risk between people with T2D from different ethnic groups and includes recent larger studies.

METHODS

We searched nine databases using PRISMA guidelines (PROSPERO CRD42022372542). We included community-based prospective studies among adults with T2D from at least two different ethnicities. Two independent reviewers undertook screening, data extraction and quality assessment using the Newcastle-Ottawa Scale. The primary outcome compared all-cause mortality rates between ethnic groups (hazard ratio (HR) with 95% confidence intervals).

RESULTS

From 30,825 searched records, we included 13 studies (7 meta-analysed), incorporating 573,173 T2D participants; 12 were good quality. Mortality risk was lower amongst people with T2D from South Asian [HR 0.68 (0.65-0.72)], Black [HR 0.82 (0.77-0.87)] and Chinese [HR 0.57 (0.46-0.70)] ethnicity compared to people of White ethnicity. Narrative synthesis corroborated these findings but demonstrated that people of indigenous Māori ethnicity had greater mortality risk compared to European ethnicity.

CONCLUSIONS

People with T2D of South Asian, Black and Chinese ethnicity have lower all-cause mortality risk than White ethnicity, with Māori ethnicity having higher mortality risk. Factors explaining mortality differences require further study, including understanding complication risk by ethnicity, to improve diabetes outcomes.

A Prescription Produce Program integrating lifestyle behavior counseling and health education: A program description and evaluation

Prescription Produce Programs (PPPs) are increasingly being used to address food insecurity and healthy diets. Yet, limited evidence exists on the effectiveness of integrating lifestyle counseling within a PPP to promote dietary and health behaviors. To describe the implementation of a 6- or 12-week PPP integrating lifestyle counseling to low-income adults. The PPP was implemented as part of a wellness and care coordination program and included: (i) a screening for social needs, (ii) PPP health education and lifestyle counseling visits, and (iii) distribution of produce. We conducted a pre- and post-descriptive analysis. We also reported a case study illustrating the PPP implementation and a Strengths/Weaknesses/Opportunities/Threats analysis. Fifty-three participants (85% Black American, 64% female, mean age: 66 years) completed the PPP. Food insecurity scores significantly decreased between pre- and post-enrollment in the PPP (P = .002). Compared with pre-enrollment, participants who completed the PPP reported an increase in the frequency of fruits and vegetables intake (χ2 = 12.6, P = .006). A majority of the participants (77%) reported setting and achieving at least one health-related goal by the end of the program. A strength of the PPP included the long-standing relationship with community partners. Weaknesses included the survey burden, the need for additional personnel, and the need for a sustained funding source. Integrating lifestyle counseling within a PPP can promote food security and a healthy diet. Future research is warranted using rigorous research methods, including randomization and a comparison group.

Diabetic Heart Disease: An Intricate Interplay of a Widespread Metabolic Disorder with the Cardiovascular System

Diabetes is a chronic medical condition that causes high glycaemic levels, leading to damage to vital organs over time. It is a common disease worldwide, affecting around 422 million individuals living in middle- and low-income countries, which make up most of the population. Unfortunately, diabetes results in 1.5 million deaths annually. Diabetic patients are at a higher risk for developing cardiovascular conditions. Diabetic heart disease constitutes multiple genres, including diabetic cardiomyopathy, coronary artery disease, and heart failure. Hypoglycaemic agents aim to prevent these metabolic issues however some of these are cardiotoxic in nature. In contrast, other hypoglycaemic agents work beyond controlling glycaemic levels with their cardioprotective properties. Given that there is an alarming increase in diabetic heart disease cases universally, we have attempted to review the existing data on the topic and the effects of hypoglycaemic drugs on heart diseases.

Simulating Realistic Continuous Glucose Monitor Time Series By Data Augmentation

BACKGROUND

Simulated data are a powerful tool for research, enabling benchmarking of blood glucose (BG) forecasting and control algorithms. However, expert created models provide an unrealistic view of real-world performance, as they lack the features that make real data challenging, while black-box approaches such as generative adversarial networks do not enable systematic tests to diagnose model performance.

METHODS

To address this, we propose a method that learns missingness and error properties of continuous glucose monitor (CGM) data collected from people with type 1 diabetes (OpenAPS, OhioT1DM, RCT, and Racial-Disparity), and then augments simulated BG data with these properties. On the task of BG forecasting, we test how well our method brings performance closer to that of real CGM data compared with current simulation practices for missing data (random dropout) and error (Gaussian noise, CGM error model).

RESULTS

Our methods had the smallest performance difference versus real data compared with random dropout and Gaussian noise when individually testing the effects of missing data and error on simulated BG in most cases. When combined, our approach was significantly better than Gaussian noise and random dropout for all data sets except OhioT1DM. Our error model significantly improved results on diverse data sets.

CONCLUSIONS

We find a significant gap between BG forecasting performance on simulated and real data, and our method can be used to close this gap. This will enable researchers to rigorously test algorithms and provide realistic estimates of real-world performance without overfitting to real data or at the expense of data collection.

International Society for Pediatric and Adolescent Diabetes Clinical Practice Consensus Guidelines 2024: Glycemic Targets

The International Society for Pediatric and Adolescent Diabetes (ISPAD) guidelines represent a rich repository that serves as the only comprehensive set of clinical recommendations for children, adolescents, and young adults living with diabetes worldwide. This chapter builds on the 2022 ISPAD guidelines, and updates recommendations on the glycemic targets for children and adolescents living with diabetes. A new target for hemoglobin A1c (HbA1c) of ≤6.5% (48 mmol/mol) is recommended for those who have access to advanced diabetes technologies like continuous glucose monitoring and automated insulin delivery. This target should be encouraged for all children and adolescents living with diabetes when safely achievable. In other settings, the HbA1c target is ≤7.0% (53 mmol/mol). The International Society for Pediatric and Adolescent Diabetes (ISPAD) guidelines represent a rich repository that serves as the only comprehensive set of clinical recommendations for children, adolescents, and young adults living with diabetes worldwide. This chapter builds on the 2022 ISPAD guidelines, and updates recommendations on the glycemic targets for children and adolescents living with diabetes. A new target for hemoglobin A1c (HbA1c) of ≤6.5% (48 mmol/mol) is recommended for those who have access to advanced diabetes technologies like continuous glucose monitoring and automated insulin delivery. This target should be encouraged for all children and adolescents living with diabetes when safely achievable. In other settings, the HbA1c target is ≤7.0% (53 mmol/mol).

Mitigation of AI adoption bias through an improved autonomous AI system for diabetic retinal disease

Where adopted, Autonomous artificial Intelligence (AI) for Diabetic Retinal Disease (DRD) resolves longstanding racial, ethnic, and socioeconomic disparities, but AI adoption bias persists. This preregistered trial determined sensitivity and specificity of a previously FDA authorized AI, improved to compensate for lower contrast and smaller imaged area of a widely adopted, lower cost, handheld fundus camera (RetinaVue700, Baxter Healthcare, Deerfield, IL) to identify DRD in participants with diabetes without known DRD, in primary care. In 626 participants (1252 eyes) 50.8% male, 45.7% Hispanic, 17.3% Black, DRD prevalence was 29.0%, all prespecified non-inferiority endpoints were met and no racial, ethnic or sex bias was identified, against a Wisconsin Reading Center level I prognostic standard using widefield stereoscopic photography and macular Optical Coherence Tomography. Results suggest this improved autonomous AI system can mitigate AI adoption bias, while preserving safety and efficacy, potentially contributing to rapid scaling of health access equity. ClinicalTrials.gov NCT05808699 (3/29/2023).

Coping with Type 2 diabetes: Commonly used strategies associated with mental wellbeing and treatment engagement

Type 2 diabetes (T2D) is a common, chronic condition. People with T2D often report poor mental wellbeing and treatment engagement, especially when stressed. Coping mechanisms may help manage stress, but it is crucial to identify which strategies are most common and (mal)adaptive. Using a psychometrically-informed approach and a series of pilot studies (n = 570) to develop and test the structural validity of a final item pool of coping strategies, a final study recruited 503 people with T2D through Prolific. Participants reported on coping, mental wellbeing (stress, anxiety and depressive symptoms), and treatment engagement (adherence, self-efficacy, A1C). All seven coping strategies (humor, self-blame, avoidance, support-seeking, positive mindset, religion/spirituality, and accessing resources) were psychometrically distinct and were associated with at least one indicator of treatment engagement, but fewer with wellbeing. After controlling for other variables, self-blame, avoidance, and positive mindset were the most robust predictors of both wellbeing and treatment engagement.

Association among diabetes, cardiovascular disease and mortality in patients hospitalised for COVID-19: an analysis of the American Heart Association COVID-19 CVD Registry

OBJECTIVE

To examine inpatient COVID-19-related outcomes among patients with and without diabetes alone or with a history of established heart failure (HF) or established atherosclerotic cardiovascular disease (ASCVD).

DESIGN

Observational study; longitudinal analysis of registry data.

SETTING

Hospitals in the USA reporting to the American Heart Association (AHA) COVID-19 Registry from January 2020 to May 2021.

PARTICIPANTS

20 796 individuals with diabetes (11 244 men; mean age 64.2) and 30 798 without diabetes (15 980 men; mean age 59.0) hospitalised for COVID-19 in the USA.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcome measures were all-cause mortality, inpatient major adverse cardiovascular events (MACE) and/or inpatient mechanical ventilation. Secondary outcome measures included the association with diabetes and these outcomes among those with and without pre-existing ASCVD and HF and the association with insulin use and these outcomes in patients hospitalised for COVID-19.

RESULTS

After adjustment for relevant covariates diabetes increased the risk of mortality (HR 1.12, 95% CI: 1.03 to 1.21), MACE (HR 1.32, 95% CI: 1.17 to 1.48) and mechanical ventilation (HR 1.33, 95% CI: 1.26 to 1.42). Among patients with established ASCVD or HF, diabetes did not modify the risk of adverse outcomes. There was a significant difference in the risk of mortality between patients taking insulin compared with those who were not (HR 1.32, 95% CI: 1.01 to 1.26); however, there was no difference in the risk of MACE or mechanical ventilation.

CONCLUSIONS

Diabetes was associated with a higher risk of in-hospital all-cause mortality, MACE and need for mechanical ventilation in patients hospitalised for COVID-19. Diabetes was independently associated with adverse outcomes, particularly among those without pre-existing cardiovascular disease.

Eye Axial Length: Is There a Protective Link to Diabetic Retinopathy?

Diabetic retinopathy (DR) is a leading cause of vision impairment and blindness globally, particularly among working-age adults. As the prevalence of diabetes continues to rise, understanding factors that influence DR development and progression is increasingly important. Recent studies suggest a protective association between a longer axial length (AL) of the eye and the risk of DR, particularly in myopic individuals. This review explores the potential mechanisms underlying this relationship, including reduced retinal vascular density, altered retinal blood flow, and ocular biomechanics, which may collectively reduce the susceptibility of retinal tissues to hyperglycemic damage. However, limitations such as confounding factors, ethnic and genetic differences, and methodological challenges highlight the need for further research. This review aims to explore the relationship between AL and DR, examining the biological mechanisms that may underpin this association, summarizing the epidemiological evidence, discussing the clinical implications, and identifying directions for future research. Understanding the protective role of AL could have significant clinical suggestions, including more tailored screening intervals and personalized treatment approaches for DR. Future studies should focus on longitudinal analyses, mechanistic insights, and diverse populations to establish a clearer understanding of this relationship and its potential for novel therapeutic strategies.

Does interaction occur between risk factors for revision total knee arthroplasty?

INTRODUCTION

Several risk factors for revision TKA have previously been identified, but interactions between risk factors may occur and affect risk of revision. To our knowledge, such interactions have not been previously studied. As patients often exhibit multiple risk factors for revision, knowledge of these interactions can help improve risk stratification and patient education prior to TKA.

MATERIALS AND METHODS

The State Inpatient Databases (SID), part of the Healthcare Cost and Utilization Project (HCUP), were queried to identify patients who underwent TKA between January 1, 2006 and December 31, 2015. Risk factors for revision TKA were identified, and interactions between indication for TKA and other risk factors were analyzed.

RESULTS

Of 958,944 patients who underwent TKA, 33,550 (3.5%) underwent revision. Age, sex, race, length of stay, Elixhauser readmission score, urban/rural designation, and indication for TKA were significantly associated with revision (p < 0.05). Age was the strongest predictor (p  < 0.0001), with younger patients exhibiting higher revision risk. Risks associated with age were modified by an interaction with indication for TKA (p < 0.0001). There was no significant interaction between sex and indication for TKA (p = 0.535) or race and indication for TKA (p = 0.187).

CONCLUSIONS

Age, sex, race, length of stay, Elixhauser readmission score, urban/rural designation, and indication for TKA are significantly associated with revision TKA. Interaction occurs between age and indication.

The impact of ethnicity and its definition on diabetes prevalence: A national Australian whole-of-population study

AIMS

We assessed the extent to which using large geographic regions to group ethnicities (ancestries or countries-of-birth) masked intra-regional variation in diabetes risk.

METHODS

We performed a cross-sectional analysis of the 2021 Australian National Census, which included self-reported health data. Ethnicity-specific diabetes prevalence was age/sex-standardised to a reference population of all census respondents 20 years and above.

RESULTS

There were 17.5 million adults included in this study. Within four geographical regions, there wastwo-four-fold intra-regional variation in diabetes risk. Diabetes prevalence among people reporting a single East Asianancestry ranged from less than the Australian prevalence (Japanese 4.2%, Thai 6.1%) to twice the Australian prevalence (Filipino 12.6%). Among peoplereporting a single South/Central Asianancestry, diabetes prevalence ranged from 7.3% (Armenian) to 18.4% (Bangladeshi). Among people reporting a single Middle Eastern/North African ancestry, diabetes prevalence values rangedfrom 5.4% (Jewish) to 12.3% (Iraqi). In Oceania, the diabetes prevalence in people of Australian Aboriginal, Fijian, Maori, Samoan and Tongan ancestry was greater than the Australian prevalence(17.5%, 12.3%, 10.0%, 16.3% and 17.4%, respectively versus 6.3%).

CONCLUSIONS

There wastwo-four-fold variation in diabetes prevalence between populations within four geographical regions. Aggregating ethnicity into large geographic regional groups may incorrectly estimate diabetes risk.

Access to Chronic Pain Services for Adults from Minority Ethnic Groups in the United Kingdom (UK): a Scoping Review

BACKGROUND

Chronic pain services in the UK are required to provide services which meet the diverse needs of patients, but little is known about the access and use of these services by minority ethnic groups.

OBJECTIVE

To assess the available evidence regarding the ethnic profile of adults who access secondary and tertiary chronic pain services in the UK.

METHODS

A scoping review was conducted (August 2021-October 2021), comprising comprehensive literature searches using Embase, Medline and CINAHL databases and the grey literature. Studies were included if they reported on (i) access to chronic pain services in secondary and/or tertiary care in the UK, (ii) adults and (iii) stated the ethnicity of the involved participants. Studies were included if published between 2004 and 2021, as demographic data during this period would be broadly representative of the UK population, as per the 2021 UK census. A descriptive synthesis of the extracted data was performed.

RESULTS

The search yielded 124 records after duplicates were removed. Following title and abstract screening, 44 full texts were screened, ten of which were included in the review.

CONCLUSIONS

This is the first review to explore access to chronic pain services for adults from minority ethnic groups in the UK. Given the limited number of studies that met the inclusion criteria, the review highlights the need for routine collection of ethnicity data using consistent ethnic categories within UK chronic pain services and increased involvement of minority ethnic groups within chronic pain research. Findings should inform future research that aims to improve access to UK chronic pain services for adults from minority ethnic groups.

Effects of daily almond consumption on glycaemia in adults with elevated risk for diabetes: a randomised controlled trial

The purpose of this study was to examine the potential for sustained almond consumption to reduce HbA1c concentrations among individuals with elevated values. A 16-week randomised, parallel-arm, controlled trial was conducted. Eighty-one adults with elevated HbA1c concentrations (> 5·7 %) were randomly assigned to incorporate 2 oz of raw almonds (A: n 39) or energy-matched snacks (C: n 42) into their daily diets. Body weight, body composition, plasma lipids, HbA1c, plasma vitamin E, glycaemia (by meal tolerance test and continuous glucose monitoring), dietary intake and hedonic responses to test foods were measured at stipulated time points. Participants consuming almonds ingested 253 kcal/d more than participants in the control group (P = 0·02), but this did not result in a significant difference in body weight. No statistically significant differences were observed in HbA1c concentrations, blood chemistries, body composition or glycaemia over time or between groups. However, Healthy Eating Index scores improved within the almond group as compared with the control group (P < 0·001). Additionally, the hedonic rating of almonds within the almond group did not decline as markedly as the control group's reduced liking of the pretzel snack. Alpha-tocopherol increased significantly, and gamma tocopherol tended to decrease in the almond group, indicating compliance with the dietary intervention. Overall, daily ingestion of 2 oz of raw almonds in a self-selected diet for 16 weeks did not alter short-term or longer-term glycaemia or HbA1c concentrations in adults with elevated HbA1c concentrations, but they were well-tolerated hedonically and improved diet quality without promoting weight gain.

Anti-Black racism in Canadian health care: a qualitative study of diverse perceptions of racism and racial discrimination among Black adults in Montreal, Quebec

BACKGROUND

Racism has been shown to impact the health of Black persons through its influence on health care, including its expression through implicit biases in provider training, attitudes, and behaviours. Less is known about the experiences of racism in contexts outside of the USA, and how race and racism interact with other social locations and systems of discrimination to shape Black patients' experiences of racism in health care encounters. To help address this gap, this study examined diverse Black individuals' perceived experiences of, and attitudes towards, anti-Black racism and racial discrimination in Canadian health care, specifically in Montreal, Quebec.

METHODS

This descriptive qualitative study adopted a social constructionist approach. Employing purposive maximal variation and snowball sampling strategies, eligible study participants were: self-identified Black persons aged 18 years and older who lived in Montreal during the COVID-19 pandemic, who could speak English or French, and who were registered with the Quebec medical insurance program. In-depth interviews were conducted, and a Framework Analysis approach guided the systematic exploration and interpretation of data using an intersectionality lens.

RESULTS

We interviewed 32 participants, the majority of whom were women (59%), university educated (69%), and modestly comfortable financially (41%), but diverse in terms of age (22 to 79 years), country of origin, and self-defined ethnicity. We identified five major themes demonstrating substantial variations in perceived racism in health care that are influenced by unique social locations such as gender identity, age, and immigration history: (1) no perceptions of racism in health care, (2) ambiguous perceptions of racism in health care, (3) perceptions of overt interpersonal racism in health care, (4) perceptions of covert interpersonal racism in health care (including the downplaying of health concerns, stereotyping, and racial microaggressions), and (5) perceptions of systemic racism in health care.

CONCLUSIONS

Perceptions of anti-Black racism and racial discrimination in Canadian health care are complex and may include intra-racial group differences. This study begins to address the dearth of empirical research documenting experiences of anti-Black racism in health care in Quebec, highlighting a continued need for serious consideration of the ways in which racism may manifest in the province, as well as a need for anti-racist advocacy. Advancing racial health equity requires greater sensitivity from providers and decision makers to variations in Black patients' health care experiences, towards ensuring that they have access to high quality and equitable health care services.

Baseline Characteristics and Clinical Outcomes of Patients Seen Through the Free Diabetes Screening (FDS) Program

Purpose

To characterize the baseline characteristics and clinical outcomes of patients seen through the Free Diabetic Screening (FDS) program, a free diabetic retinopathy screening program for uninsured patients, in the ophthalmology resident clinic at the Wilmer Eye Institute.

Patients and Methods

This retrospective longitudinal cohort study included uninsured patients ≥18 years with diabetes mellitus seen through the FDS clinic from 2013 to 2023. Data extraction was performed using manual chart review of the first FDS visit, and automated extraction of the data warehouse related to all other office visits. Patient demographic and clinical characteristics at presentation, treatments, and follow-ups were collected.

Results

A total of 422 patients were included in this study (mean age 52 years; 59% female; 47% Hispanic; 49% Spanish as primary language). One-third of patients had some form of diabetic retinopathy or diabetic macular edema, and 12% had vision-threatening diabetic retinopathy at presentation. In all, nearly 10% of patients were referred for further specialty care, and 71% of these patients completed at least one follow-up visit. The majority of patients (55%) returned for care as recommended and were followed for a mean length of 200 weeks and 10 office visits.

Conclusion

The FDS clinic provided much needed diabetic retinopathy screening and treatment for uninsured patients in Baltimore City and surrounding areas. This study highlights the need for strong integration between initial screening and downstream services, as nearly 10% of patients require further sub-specialty intervention or care.

Type 2 diabetes complications in ethnic minority compared with European host populations: a systematic review and meta-analysis

This systematic review and meta-analysis aimed to quantify differences in type 2 diabetes (T2D) complications between ethnic minority populations and European host populations, in both cross-sectional and prospective studies. Following Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines, we searched multiple databases for studies (until July 1, 2024) with T2D complications as outcome. Studies were included if they compared ethnic minority populations to the host population and were conducted in Europe. T2D complications included mortality, macrovascular and microvascular complications and mental disorders. Risk of bias was assessed with the assessment tool for observational cohort and cross-sectional studies. Risk estimates were pooled using random effects models. From a total of 2901 references, 58 studies were included, comprising 805 to 1 230 410 individuals for the meta-analyzed complications. Compared with the host population, ethnic minority populations generally had a lower risk of all-cause mortality (RR 0.70 (95% CI 0.63; 0.77); I2=87%)) and macrovascular complications (RR 0.72 (95% CI 0.58; 0.88); I2=88%). South Asians, however, showed comparable risks for most macrovascular complications and a slighthly higher risk of major adverse cardiovascular events. Increased risks for microvascular complications, nephropathy and retinopathy were observed (eg, in prospective studies RR 1.50 (95% CI 1.14; 1.96); I2=86% for nephropathy). No ethnic differences were observed for mental disorders. Ethnic minority populations with T2D in Europe are generally at reduced risk of all-cause mortality and macrovascular complications, but at higher risk of nephropathy and retinopathy. Our findings may help to further identify high-risk populations and to develop guidelines and future interventions. PROSPERO registration number:PROSPERO 2022 CRD42022366854.

Partnerships with primary care providers: Opportunities to prevent eating disorders and mitigate their progression in young people

Epidemiologic research has identified numerous interpersonal and individual risk factors for and warning signs of emerging eating disorders in adolescents. These findings have informed public health prevention and treatment strategies, including translation of findings to clinical recommendations for primary care providers (PCPs). A next step in this translational work could include a comprehensive approach where PCPs are seen as partners in efforts to improve population health outcomes. PCPs have great potential to implement high-yield interventions that prevent or attenuate the course of adolescent eating disorders. To illustrate this potential, we present a case that highlights missed opportunities for a PCP to prevent, detect, and intervene during a patient's developing eating disorder. We then relate the case to two emerging research programs that utilize PCP partnerships: one trains PCPs in Strengths-Based Adolescent Healthcare to improve eating disorder prevention; the other adapts Family-Based Treatment for primary care to improve early access to evidence-based treatment. In addition to these promising areas of research, efforts are needed to widen requirements for eating disorder curricula in medical training programs and to address weight stigma in primary care. Together these efforts will help PCPs become effective partners in the prevention and treatment of eating disorders.

Renal Disease and Kidney Transplantation in Hispanic American Persons

The Hispanic population of the United States is the second largest racial or ethnic group, comprising 18.7% of the population. However, this population is incredibly heterogeneous differing in genetic traits, cultural upbringing, educational backgrounds, and financial status. The impact of this heterogeneity on the prevalence and outcomes of renal disease and kidney transplantation is understudied compared with non-Hispanic White and Black populations. What is known appears to be underrecognized. This review aims to critically assess current medical literature on Hispanic individuals, focusing on etiological factors, disease progression, and outcomes related to CKD and kidney transplantation. By doing so, we aim to underscore key areas for further in-depth investigation.

Energy-Adjusted Dietary Inflammatory Index and Diabetes Risk in Postmenopausal Hispanic Women

BACKGROUND

Type 2 diabetes is a major public health concern in the United States and worldwide. The dietary inflammatory index (DII) and the energy-adjusted DII (E-DII) are tools that assess dietary inflammation. Previous evidence suggests that obesity can modify the association between inflammation and disease.

OBJECTIVE

The aim of this study was to evaluate the association between the DII/E-DII and incident diabetes in self-identified Hispanic women from the Women's Health Initiative (WHI). The secondary aim was to evaluate whether obesity modifies the association between the DII/E-DII scores and incident diabetes.

DESIGN

Participants were from the WHI Observational Study and the Clinical Trial Components (except women from the treatment arm in the Dietary Modification Trial) conducted among postmenopausal women in the United States. DII/E-DII scores were calculated from a self-administered food frequency questionnaire at baseline that included 122 food items, of which 12 are representative of Hispanic eating patterns.

PARTICIPANTS/SETTINGS

Participants included 3,849 postmenopausal women who self-identified as Hispanic that were recruited for the WHI from 1993 to 1998 at 40 US clinical centers.

MAIN OUTCOME MEASURES

The outcome was incident diabetes.

STATISTICAL ANALYSIS PERFORMED

Cox regression models were used to assess the association between DII/E-DII and incident diabetes. Models were adjusted for age at baseline, lifestyle-related risk factors, known type 2 diabetes mellitus (T2DM) risk factors, and neighborhood socioeconomic status. Interaction was tested between the DII/E-DII scores and obesity.

RESULTS

The incidence of diabetes was 13.1% after a median follow-up of 13 years. Higher E-DII scores were associated with a higher risk of incident diabetes (hazard ratio [HR], 1.09; 95% confidence interval [CI], 1.04-1.14). There was no interaction between E-DII scores and obesity (P = 0.73).

CONCLUSIONS

Pro-inflammatory diets, as measured by higher E-DII scores, were associated with a higher risk of incident diabetes. Future research is needed for understanding how the inflammatory potential of diets can be decreased.

Health Catch-UP!: a realist evaluation of an innovative multi-disease screening and vaccination tool in UK primary care for at-risk migrant patients

BACKGROUND

Migrants to the UK face disproportionate risk of infections, non-communicable diseases, and under-immunisation compounded by healthcare access barriers. Current UK migrant screening strategies are unstandardised with poor implementation and low uptake. Health Catch-UP! is a collaboratively produced digital clinical decision support system that applies current guidelines (UKHSA and NICE) to provide primary care professionals with individualised multi-disease screening (7 infectious diseases/blood-borne viruses, 3 chronic parasitic infections, 3 non-communicable disease or risk factors) and catch-up vaccination prompts for migrant patients.

METHODS

We carried out a mixed-methods process evaluation of Health Catch-UP! in two urban primary healthcare practices to integrate Health Catch-UP! into the electronic health record system of primary care, using the Medical Research Council framework for complex intervention evaluation. We collected quantitative data (demographics, patients screened, disease detection and catch-up vaccination rates) and qualitative participant interviews to explore acceptability and feasibility.

RESULTS

Ninety-nine migrants were assessed by Health Catch-UP! across two sites (S1, S2). 96.0% (n = 97) had complete demographics coding with Asia 31.3% (n = 31) and Africa 25.2% (n = 25), the most common continents of birth (S1 n = 92 [48.9% female (n = 44); mean age 60.6 years (SD 14.26)]; and S2 n = 7 [85.7% male (n = 6); mean age 39.4 years (SD16.97)]. 61.6% (n = 61) of participants were eligible for screening for at least one condition and uptake of screening was high 86.9% (n = 53). Twelve new conditions were identified (12.1% of study population) including hepatitis C (n = 1), hypercholesteraemia (n = 6), pre-diabetes (n = 4), and diabetes (n = 1). Health Catch-UP! identified that 100% (n = 99) of patients had no immunisations recorded; however, subsequent catch-up vaccination uptake was poor (2.0%, n = 1). Qualitative data supported acceptability and feasibility of Health Catch-UP! from staff and patient perspectives, and recommended Health Catch-UP! integration into routine care (e.g. NHS health checks) with an implementation package including staff and patient support materials, standardised care pathways (screening and catch-up vaccination, laboratory, and management), and financial incentivisation.

CONCLUSIONS

Clinical Decision Support Systems like Health Catch-UP! can improve disease detection and implementation of screening guidance for migrant patients but require robust testing, resourcing, and an effective implementation package to support both patients and staff.

A fair individualized polysocial risk score for identifying increased social risk in type 2 diabetes

Racial and ethnic minorities bear a disproportionate burden of type 2 diabetes (T2D) and its complications, with social determinants of health (SDoH) recognized as key drivers of these disparities. Implementing efficient and effective social needs management strategies is crucial. We propose a machine learning analytic pipeline to calculate the individualized polysocial risk score (iPsRS), which can identify T2D patients at high social risk for hospitalization, incorporating explainable AI techniques and algorithmic fairness optimization. We use electronic health records (EHR) data from T2D patients in the University of Florida Health Integrated Data Repository, incorporating both contextual SDoH (e.g., neighborhood deprivation) and person-level SDoH (e.g., housing instability). After fairness optimization across racial and ethnic groups, the iPsRS achieved a C statistic of 0.71 in predicting 1-year hospitalization. Our iPsRS can fairly and accurately screen patients with T2D who are at increased social risk for hospitalization.

Racial and Ethnic Disparities in Dietary Intake and Quality Among United States Veterans

Background

Dietary quality plays an important role in disease development and prognosis, and diet is also a key contributor to disparities in many chronic diseases and health conditions.

Objectives

This study aimed to assess racial and ethnic disparities experienced by veterans; we examined food intake and dietary quality across different racial and ethnic groups of United States veterans.

Methods

The study included 420,730 males and females aged 19-107 y (91.2% males) enrolled in the Veterans Affairs Million Veteran Program with plausible dietary intake measured by food frequency questionnaire. Dietary quality was evaluated with dietary approaches to stop hypertension (DASH) score. Dietary intakes of various race and ethnicity groups were standardized to the age distribution of non-Hispanic White participants, separately for males and females. Differences across race and ethnicity groups were compared using general linear regression models after adjustment for socioeconomic and lifestyle factors as well as military service.

Results

Compared to non-Hispanic White males, non-Hispanic Black males had a relatively lower DASH score, higher red and processed meats, higher sugar-sweetened beverages (SSBs), and lower low-fat dairy intakes. Non-Hispanic Asian males had a relatively higher DASH score as compared to non-Hispanic White males with relatively higher intakes of fruits and vegetables and relatively lower intakes of sodium, red meat and SSBs. Age-standardized DASH scores of Hispanic males and "Other" race/ethnicity groups were not statistically different from non-Hispanic White males. Similar race and ethnicity dietary patterns were found in females, although not all reached a statistically significant level.

Conclusions

A modest difference in overall dietary quality (i.e., DASH score) was observed, but unique differences in food preferences across the different racial/ethnic groups were identified. Findings from our study may provide insight for the potential development of specific interventions to help address nutritional disparities experienced among veterans.

Comparison of race- and ethnicity-specific BMI cutoffs for categorizing obesity severity: a multicountry prospective cohort study

OBJECTIVE

The objective of this study was to compare race- and ethnicity-specific BMI cutoffs for the three classes of obesity based on equivalent risk of type 2 diabetes (T2D).

METHODS

Participants without T2D were included from the UK Biobank, the China Health and Nutrition Survey, and the Singapore Chinese Health Study. Poisson regressions with restricted cubic splines were applied to determine BMI cutoffs for each non-White race and ethnicity for equivalent incidence rates of T2D at BMI values of 30.0, 35.0, and 40.0 kg/m2 in White adults.

RESULTS

During a median follow-up of 13.8 years among 507,763 individuals, 5.2% developed T2D. In women, BMI cutoffs for an equivalent incidence rate of T2D as observed at 40.0 kg/m2 in White adults were 31.6 kg/m2 in Black, 29.2 kg/m2 in British Chinese, 27.3 kg/m2 in South Asian, 26.9 kg/m2 in Native Chinese, and 25.1 kg/m2 in Singapore Chinese adults. In men, the corresponding BMI cutoffs were 31.9 kg/m2 in Black, 30.6 kg/m2 in British Chinese, 29.0 kg/m2 in South Asian, 29.6 kg/m2 in Native Chinese, and 27.6 kg/m2 in Singapore Chinese adults. The race and ethnicity order was consistent when equivalent BMI cutoffs were estimated for class I and II obesity.

CONCLUSIONS

Establishing a race- and ethnicity-tailored classification of the three classes of obesity is urgently needed.

Discontinuation of blood pressure-lowering, glucose-lowering, and lipid-lowering medications after bariatric surgery in patients with morbid obesity: a nationwide cohort study in South Korea

BACKGROUND

Limited evidence exists on the patterns of medication use for hypertension, diabetes mellitus (DM), and dyslipidemia after bariatric surgery among Asian patients.

OBJECTIVES

To investigate the patterns in the use of blood pressure-lowering, glucose-lowering, and lipid-lowering medications following BS in Korean patients with morbid obesity.

SETTING

This study is a retrospective cohort study using the Health Insurance Review and Assignment claims database of South Korea (from 2019 to 2021).

METHODS

We included patients who underwent BS between 2019 and 2020 in South Korea. We evaluated the treatment patterns of blood pressure-lowering, glucose-lowering, and lipid-lowering medications at 3-month intervals for 1-year following BS, including medication use, individual medication classes, and the number of medications prescribed. Furthermore, we estimated remission rates for each disorder based on patient characteristics by defining patients who discontinued their medications for at least 2 consecutive quarters as remission.

RESULTS

A total of 3810 patients were included in this study. For 1-year following BS, a marked decrease in the number of patients using blood pressure-lowering, glucose-lowering, and lipid-lowering medications was observed. The most remarkable decrease occurred in glucose-lowering medications, which decreased by approximately -75.1% compared with that at baseline. This tendency was consistently observed when analyzing both the number of medications prescribed and the specific medication classes. Regarding remission rates, patients who were female, younger, and received the biliopancreatic diversion-duodenal switch as their BS showed a relatively higher incidence of remission than other groups.

CONCLUSIONS

BS was associated with a decrease in the use of medications for hypertension, diabetes mellitus (DM), and dyslipidemia.

Racial and Ethnic Disparities in Diabetes Prevention Outcomes: Insights from the Prediabetes Informed Decisions and Education Study

Background

To achieve health equity, interventions should yield similar effectiveness across all patient subgroups. However, the adoption of diabetes prevention strategies and successful weight loss in "real-world" Diabetes Prevention Program (DPP) translational studies have varied by race and ethnicity. We examined racial and ethnic differences in diabetes prevention outcomes among study participants from the Prediabetes Informed Decisions and Education (PRIDE) Study.

Methods

In a retrospective analysis of data from the PRIDE cluster randomized trial across a large health system, we examined (1) percent weight change and (2) uptake of DPP and/or metformin among overweight/obese participants with prediabetes 12 months after participating in a pharmacist-led shared decision-making (SDM) intervention. We stratified the outcomes by race and ethnicity using a generalized linear mixed-effects model.

Results

The study participants (n = 515) had an average age of 56 years (standard deviation [SD] = 11.0), hemoglobin A1c of 6.0% (SD = 0.20), and body mass index of 30.3 (SD = 5.2). Black/African American and Latino study participants lost significantly less weight at the 12-month follow-up compared with White/Caucasian participants (-1.0% and -1.2%, respectively, vs. -3.3%, p < 0.01 for both comparisons). There was no significant difference in the adoption of diabetes prevention strategies between racial and ethnic groups after completing an educational SDM intervention.

Conclusion

To better promote health equity, future studies should investigate the potential causal factors for these differences in weight loss, such as variations in socioeconomic status, physical activity, cultural influences, and neighborhood characteristics.

Dual Use of Cannabis with Tobacco Is Associated with Increased Sugary Food and Drink Intake in Young People

Rates of cannabis initiation among teenagers and young adults are increasing. Further, the use of various forms of cannabis (smoked or vaped) with nicotine (dual use) is increasingly common among young people. The health effects of dual use are lesser known, particularly in the context of high-potency cannabis products and across different routes of administration, which is ominous in terms of predicting future health outcomes. There is a long history of cannabis use being associated with decreased activity and increased snacking, both of which could portend an increased risk of metabolic and cardiovascular disease, particularly when these habits begin during formative years. However, modern forms of cannabis may not have these same effects. Here, we assess whether cannabis use alone and dual use of cannabis with nicotine impact dietary and exercise habits in young people. An anonymous, social media-based survey was designed based on the UC San Diego Inhalant Questionnaire and published diet and exercise questionnaires. A total of 457 surveys were completed. Young sole cannabis users represented 29% of responders, 16% were dual users of cannabis and nicotine, and 55% were non-users of either drug. Although the sole use of cannabis was not associated with dietary or activity differences relative to non-users, dual users of cannabis and nicotine reported higher consumption of unhealthy sugars. This novel finding of dual use being associated with increased sugar intake in young people raises concerns for an increased risk of metabolic syndrome and cardiovascular disease in this population.

Race and Ethnicity Independently Predict Adverse Outcomes Following Head and Neck Autograft Surgery

OBJECTIVE

There is growing attention toward the implications of race and ethnicity on health disparities within otolaryngology. While race is an established predictor of adverse head and neck oncologic outcomes, there is paucity in the literature on studies employing national, multi-institutional data to assess the impact of race and ethnicity on head and neck autograft surgery.

METHODS

Using the National Surgical Quality Improvement Program (NSQIP) database, trends in 30 days outcomes were assessed. Patients with ICD-10 codes for malignant head and neck neoplasms were isolated. Autograft surgeries were selected using Current Procedural Terminology (CPT) codes for free flap and pedicled flap reconstruction. Primary outcomes included surgical complications, reoperation, readmission, extended length of stay and operation time. Each binary categorical variable was compared to racial/ethnic identity via binary logistic regression.

RESULTS

The study cohort consisted of 2447 patients who underwent head and neck autograft surgery (80.71% free flap reconstruction and 19.39% pedicled flap reconstruction). Black patients had significantly higher odds of overall surgical complications (odds ratio [OR] 1.583, 95% confidence interval [CI] 1.091, 2.298, p = 0.016) with much higher odds of perioperative blood transfusions (OR 2.291, 95% CI 1.532, 3.426, p = <.001). Hispanic patients were more likely to undergo reoperation within 30 days after surgery and were more likely to be hospitalized for more than 30 days post-operatively (OR 1.566, 95% CI 1.015, 2.418, p = 0.043 and OR 12.224, 95% CI 2.698, 55.377, p = 0.001, respectively).

CONCLUSIONS

Race and ethnicity serve as independent predictors of complications in the post-operative period following head and neck autograft surgery.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:3595-3603, 2024.

Current state of inclusion and diversity in pediatric urology fellowship programs

BACKGROUND

Increased racial/ethnic diversity of the physician workforce can improve health outcomes for marginalized populations. Currently, the pediatric urology workforce is less racially/ethnically diverse than the pediatric population it serves.

OBJECTIVE

We aimed to assess current recruitment efforts and barriers to recruitment of underrepresented in medicine (URM) fellows in pediatric urology fellowship programs.

METHODS

A 20-question REDCap survey was created and distributed to 27 pediatric urology fellowship program directors (PDs). The survey consisted of 4 sections of questions focused on PD demographics, program characteristics, recruitment efforts, and perceptions of barriers to recruitment.

RESULTS

A total of 20 PDs responded to the survey (74 %), including 3 incomplete responses. A majority of participants identified as Caucasian/white (79 %), male (68 %), over 40 years of age (89 %), and had served as PD for 5 years or more (68 %). Most PDs (70 %) identified their program having 5-10 full-time pediatric urologists. Many PDs (75 %, 15/20) identified their program as less diverse than the patient population served, and 53 % (9/17) reported having no methods in place for diversity recruitment. Of those who reported a recruitment method, mentorship was the most common (35 %, 6/17). When asked about recruitment barriers, 59 % (10/17) reported that no barriers existed, while those who identified a barrier most commonly cited an overall limited applicant pool (18 %, 3/17).

DISCUSSION

Pediatric urology fellowship programs are less diverse than the patient populations served; while PDs value program diversity, most PDs report that there are no mechanisms in place to recruit racially/ethnically diverse trainees. To address this, we recommend active and intentional efforts to increase URM recruitment in pediatric urology. By taking an active role in existing recruitment efforts, pediatric urologists can increase their visibility, broadcast their commitment to diversity, form relationships with trainees earlier in training and increase opportunities for mentorship and early exposure to the field.

CONCLUSION

Intentional recruitment efforts are needed to recruit URM trainees to pediatric urology fellowship programs and ensure the diversity of the pediatric urology workforce can better reflect patients served.

The moderating role of diabetes distress on the effect of a randomized eHealth intervention on glycemic control in Black adolescents with type 1 diabetes

OBJECTIVE

Due to systemic inequities, Black adolescents with type 1 diabetes are more likely to have suboptimal glycemic control and high rates of diabetes distress, but tailored interventions for this population are lacking. In primary outcomes of a randomized clinical trial, a family-based eHealth intervention improved glycemic control in Black adolescents with type 1 diabetes and elevated depressive symptoms. The present study is a secondary analysis of these clinical trial data examining the moderating effect of diabetes distress on the efficacy of the intervention.

METHODS

Using secondary data from a multicenter randomized clinical trial (Clinicaltrials.gov [NCT03168867]), caregiver-adolescent dyads were randomly assigned to either up to three sessions of an eHealth parenting intervention (n = 75) or a standard medical care control group (n = 74). Black adolescents (10 years, 0 months to 14 years, 11 months old) with type 1 diabetes and a caregiver willing to participate were eligible. Adolescents reported their diabetes distress at baseline, and hemoglobin A1c (HbA1c) data were collected at baseline, 6-, 13-, and 18-month follow-up.

RESULTS

No between-group contrasts emerged in a linear mixed-effects regression (p's > .09). Within-group contrasts emerged such that adolescents assigned to the intervention who reported high diabetes distress had lower HbA1c at the 18-month follow-up relative to baseline (p = .004); the 18-month decrease in HbA1c was -1.03%.

CONCLUSIONS

Black adolescents with type 1 diabetes and high levels of diabetes distress showed significant decreases in HbA1c following a family-based eHealth intervention, suggesting diabetes distress may be a key moderator of intervention efficacy within this population.

Epidemiology of fractures in adults of African ancestry with diabetes mellitus: A systematic review and meta-analysis

Diabetes mellitus (DM) is associated with increased fracture risk in White adults. However, the impact of DM on fractures in Black adults is unknown. This systematic review and meta-analysis investigated the association between DM and fractures in adults of African ancestry. MEDLINE, Scopus, CINAHL and Embase databases were searched from their inception up to November 2023 for all studies in the English language investigating the epidemiology of fractures (prevalence, incidence, or risk) in Black men and women (age ≥ 18 years) with type 1 or type 2 DM. Effect sizes for prevalence of previous fractures (%) and incident fracture risk (hazard ratio [HR]) were calculated using a random-effects model on Stata (version 18.0). There were 13 eligible studies, of which 12 were conducted in Black adults from the United States, while one was conducted in adults of West African ancestry from Trinidad and Tobago. We found no fracture data in Black adults with DM living in Africa. Five studies were included in a meta-analysis of incident fracture risk, reporting data from 2926 Black and 6531 White adults with DM. There was increased risk of fractures in Black adults with DM compared to non-DM (HR = 1.65; 95 % confidence interval [CI]: 1.14, 2.39). The risk of fractures was also higher in White adults with DM compared to non-DM (HR = 1.31; 95 % CI: 1.06, 1.61) among these studies. Five studies were included in a meta-analysis of fracture prevalence, of which three also reported fracture prevalence in White adults. There were 175 previous fractures among 993 Black adults with DM and 384 previous fractures among 1467 White adults with DM, with a pooled prevalence of 17.5 % (95 % CI: 15.4, 19.6) and 25.8 % (95 % CI: 4.8, 46.8), respectively. Our results indicate a high burden of fractures in Black adults with DM.

Diabetes and Financial Well-Being: Differential Hardship Among Vulnerable Populations

PURPOSE

The purpose of the study was to examine financial well-being among a diverse population of individuals with and without diabetes.

METHODS

Data from the Understanding America Survey, a nationally representative, longitudinal panel, were utilized to identify adults with self-reported diabetes diagnoses between 2014 and 2020. We used longitudinal mixed effects regression models to assess the association between diabetes and financial well-being score (FWBS) among racial and ethnic population subgroups. Models included sex, age, marital status, household size, income, education, race/ethnicity, insurance, body mass index, employment, and health insurance, incorporating individual- and household-level fixed effects. Racial and ethnic differentials were captured using group-condition interactions.

RESULTS

Black participants (17.06%) had the highest prevalence of diabetes, followed by White participants (12.2%), "other" racial groups (10.7%), and Hispanic participants (10.0%). In contrast, White participants (M = 67.66, SD = 22.63) and other racial groups (M = 67.99, SD = 18.45) had the highest FWBSs, followed by Hispanic participants (M = 59.31, SD = 22.78) and Black participants (M = 55.86, SD = 25.67). Compared to White participants, Black participants (β = -5.49, SE = 0.71) and Hispanic participants (β = -2.06, SE = 0.63) have significantly lower FWBSs. Compared to males, females (β = -3.25, SE = 0.41) had lower FWBSs among individuals with diabetes. FWBSs of individuals with diabetes was 2.71 points lower (SE = 0.52), on average, than those without diabetes. Education, household size, age, marital status, and income were also significantly associated with FWBSs.

CONCLUSIONS

Findings suggest potential disparities in the financial ramifications of diabetes among socially marginalized populations.

Racial, ethnic and regional differences in the effect of sodium-glucose co-transporter 2 inhibitors and glucagon-like peptide 1 receptor agonists on cardiovascular and renal outcomes: a systematic review and meta-analysis of cardiovascular outcome trials

OBJECTIVES

The cardiorenal protective effects of sodium-glucose co-transporter 2 inhibitors (SGLT2-Is) and glucagon-like peptide 1 receptor agonists (GLP1-RAs) across racial and ethnic groups are not well defined. By conducting a systematic review and meta-analysis of all randomised, placebo-controlled, cardiovascular disease (CVD) outcomes trials (CVOTs), we aimed to compare racial/ethnic as well as regional patterns in the effects of SGLT2-Is and GLP1-RAs on cardiovascular and renal outcomes in patients with type 2 diabetes (T2D).

DESIGN

Trials were identified from MEDLINE, Embase, the Cochrane Library, and search of bibliographies to 7 July 2023. Setting North America, South/Central America, Europe (Eastern and Western), Asia, Australia-New Zealand (Pacific), Asia/Pacific, and Africa.

SETTING

North America, South/Central America, Europe (Eastern and Western), Asia, Australia-New Zealand (Pacific), Asia/Pacific, and Africa.

PARTICIPANTS

people with type 2 diabetes enrolled in cardiovascular outcome trials of SGLT2-Is and GLP1-RAs.

MAIN OUTCOME MEASURES

Outcomes were (i) major adverse cardiovascular events (MACE), (ii) composite CVD death/heart failure (HF) hospitalization; (iii) composite renal outcome; and (iv) their components. Study-specific hazard ratios (HRs) with 95% confidence intervals (CIs) were pooled.

RESULTS

In total, 14 unique CVOTs (7 comparing SGLT2-Is vs placebo and 7 comparing GLP1-RAs vs placebo) were eligible. The proportion of participants enrolled in the trials ranged from 66.6-93.2% for White populations, 1.2-21.6% for Asian populations, 2.4-8.3% for Black populations and 0.9-23.1% for Other populations. The HR (95% CI) for MACE comparing SGLT2-Is vs placebo was 0.92 (0.86-0.98), 0.69 (0.53-0.92) and 0.70 (0.54-0.91) for White, Asian and Hispanic/Latino populations, respectively. Comparing GLP1-RAs vs placebo, the corresponding HR (95% CI) was 0.88 (0.80-0.97), 0.76 (0.63-0.93) and 0.82 (0.70-0.95), respectively. SGLT2-Is reduced the risk of all other cardiorenal outcomes in White and Asian populations, except for HF hospitalizations in Asians. No effects were observed in Black populations except for a reduced risk of HF hospitalizations by SGLT2-I. SGLT1-Is reduced the risk of composite CVD death/HF hospitalization in North America and Europe, whereas GLP1-RAs reduced the risk of MACE in Europe. GRADE certainty of evidence ranged from moderate to high.

CONCLUSIONS

There appears to be substantial racial/ethnic differences in the cardiorenal effects of SGLT2-Is and GLP1-RAs in patients with T2D, with consistent benefits observed among White and Asian populations and consistent lack of benefits in Black populations. Whether the differences are due to issues with under-representation of Black populations and low statistical power or racial/ethnic variations in the pharmacokinetics, pharmacodynamics and safety of SGLT2-Is and GLP1-RAs need further investigation.PROSPERO Registration: CRD42023401734.

Prediction of proliferative diabetic retinopathy using machine learning in Latino and non-Hispanic black cohorts with routine blood and urine testing

PURPOSE

The objective was to predict proliferative diabetic retinopathy (PDR) in non-Hispanic Black (NHB) and Latino (LA) patients by applying machine learning algorithms to routinely collected blood and urine laboratory results.

METHODS

Electronic medical records of 1124 type 2 diabetes patients treated at the Bronxcare Hospital eye clinic between January and December 2019 were analysed. Data collected included demographic information (ethnicity, age and sex), blood (fasting glucose, haemoglobin A1C [HbA1c] high-density lipoprotein [HDL], low-density lipoprotein [LDL], serum creatinine and estimated glomerular filtration rate [eGFR]) and urine (albumin-to-creatinine ratio [ACR]) test results and the outcome measure of retinopathy status. The efficacy of different machine learning models was assessed and compared. SHapley Additive exPlanations (SHAP) analysis was employed to evaluate the contribution of each feature to the model's predictions.

RESULTS

The balanced random forest model surpassed other models in predicting PDR for both NHB and LA cohorts, achieving an AUC (area under the curve) of 83%. Regarding sex, the model exhibited remarkable performance for the female LA demographic, with an AUC of 87%. The SHAP analysis revealed that PDR-related factors influenced NHB and LA patients differently, with more pronounced disparity between sexes. Furthermore, the optimal cut-off values for these factors showed variations based on sex and ethnicity.

CONCLUSIONS

This study demonstrates the potential of machine learning in identifying individuals at higher risk for PDR by leveraging routine blood and urine test results. It allows clinicians to prioritise at-risk individuals for timely evaluations. Furthermore, the findings emphasise the importance of accounting for both ethnicity and sex when analysing risk factors for PDR in type 2 diabetes individuals.

Strategic use of resources to enhance colorectal cancer screening for patients with diabetes (SURE: CRC4D) in federally qualified health centers: a protocol for hybrid type ii effectiveness-implementation trial

BACKGROUND

Persons with diabetes have 27% elevated risk of developing colorectal cancer (CRC) and are disproportionately from priority health disparities populations. Federally qualified health centers (FQHCs) struggle to implement CRC screening programs for average risk patients. Strategies to effectively prioritize and optimize CRC screening for patients with diabetes in the primary care safety-net are needed.

METHODS

Guided by the Exploration, Preparation, Implementation and Sustainment Framework, we conducted a stakeholder-engaged process to identify multi-level change objectives for implementing optimized CRC screening for patients with diabetes in FQHCs. To identify change objectives, an implementation planning group of stakeholders from FQHCs, safety-net screening programs, and policy implementers were assembled and met over a 7-month period. Depth interviews (n = 18-20) with key implementation actors were conducted to identify and refine the materials, methods and strategies needed to support an implementation plan across different FQHC contexts. The planning group endorsed the following multi-component implementation strategies: identifying clinic champions, development/distribution of patient educational materials, developing and implementing quality monitoring systems, and convening clinical meetings. To support clinic champions during the initial implementation phase, two learning collaboratives and bi-weekly virtual facilitation will be provided. In single group, hybrid type 2 effectiveness-implementation trial, we will implement and evaluate these strategies in a in six safety net clinics (n = 30 patients with diabetes per site). The primary clinical outcomes are: (1) clinic-level colonoscopy uptake and (2) overall CRC screening rates for patients with diabetes assessed at baseline and 12-months post-implementation. Implementation outcomes include provider and staff fidelity to the implementation plan, patient acceptability, and feasibility will be assessed at baseline and 12-months post-implementation.

DISCUSSION

Study findings are poised to inform development of evidence-based implementation strategies to be tested for scalability and sustainability in a future hybrid 2 effectiveness-implementation clinical trial. The research protocol can be adapted as a model to investigate the development of targeted cancer prevention strategies in additional chronically ill priority populations.

TRIAL REGISTRATION

This study was registered in ClinicalTrials.gov (NCT05785780) on March 27, 2023 (last updated October 21, 2023).