Socioeconomic inequalities and type 2 diabetes complications: A systematic review

Socioeconomic inequalities and diabetes complications: an analysis of administrative data from Hungary

Diabetes complications are associated with increased healthcare costs and worsened patient outcomes. In this paper, we analyse how individual-level demographic and territorial-level socioeconomic and healthcare variables influence the presence and severity of diabetes complications and their relationship with mortality. Our study utilizes anonymized administrative healthcare data on all diabetes patients of Hungary between 2010 and 2017. We construct settlement-year level and individual-year level panel datasets to analyse diabetes prevalence, incidence and complications, employing Poisson and logit models to explore associations between complications and the explanatory variables. The adapted Diabetes Complications Severity Index (aDCSI) is employed to quantitatively evaluate the severity of complications by aggregating individual complication scores from ICD-10 diagnosis codes. We find that diabetes prevalence and incidence are higher in settlements with above-median unemployment rates, where patients exhibit more severe complications, as shown by higher average aDCSI scores. Among socioeconomic factors, unemployment rate is particularly associated with increased aDCSI scores, while better healthcare access is associated with lower aDCSI scores in unadjusted but with higher scores in adjusted models. The presence and severity of complications, especially renal, cardiovascular and peripheral vascular ones, substantially increase 5-year inpatient mortality. Most of the mortality difference by settlement-level unemployment rate disappears when complications are accounted for. We conclude that socioeconomic inequalities, particularly higher unemployment rates, are strongly linked to diabetes complications and associated mortality risk. Addressing these disparities through improved healthcare accessibility and targeted public health strategies could play a crucial role in reducing the burden of diabetes-related complications and improving patient outcomes.

Particulate matter, socioeconomic status, and cognitive function among older adults in China

BACKGROUND

Both air pollution and low socioeconomic status (SES) are associated with worse cognitive function. The extent to which low SES may compound the adverse effect of air pollution on cognitive function remains unclear.

METHODS

7,087 older adults aged 65 and above were included from the Chinese Longitudinal Healthy Longevity Survey (CLHLS) and followed up in 4 waves during 2008-2018. Cognitive function was measured repeatedly at each wave using the modified Chinese Mini-Mental State Examination (MMSE). Concentrations of particulate matter (PM1, PM2.5, and PM10) were evaluated using satellite-based spatiotemporal models. SES was measured based on five components and categorized into three levels (low, middle, and high). Generalized estimating equation models were used to estimate the association of PM and SES with cognitive function. Stratified analyses and effect modification by SES levels were further conducted.

RESULTS

Each 10 µg/m3 increase in PM1, PM2.5, and PM10 was associated with a 0.43 (95 % CI: -0.58, -0.27), 0.29 (95% CI: -0.37, -0.20), and 0.17 (95 % CI: -0.22, -0.13) unit decrease in MMSE scores, respectively. Lower SES was associated with worse cognitive function. Significant effect modifications were observed by SES, with the corresponding association of PM exposure being more pronounced among participants with a lower SES (p-interaction = 0.006, 0.001, and 0.006 for PM1, PM2.5, and PM10, respectively).

CONCLUSIONS

SES is an important effect modifier, and lower SES may compound the detrimental effect of PM on cognitive health. This finding may have implications for identifying vulnerable populations and targeted interventions against air pollution.

Diabetes disparities in diabetes health care access and outcomes during the COVID-19 pandemic in the United States

OBJECTIVES

To investigate the impact of COVID-19 on hospitalization and consequent diabetes-related complications in patients with type 2 diabetes mellitus (diabetes).

METHODS

We conducted a retrospective cohort study of patients with diabetes. Interrupted time series analysis (ITS) was used to analyze the monthly trends in diabetes-related hospitalization rates, including short- and long-term complications, 1-year before and after onset of COVID-19.

RESULTS

Persons with diabetes experienced a significant (p < 0.001) rapid drop in monthly hospital admission rates at onset of COVID-19, then rose significantly (p = 0.003) to higher than pre-COVID-19 levels. Older age, lower education, and income levels were associated with higher base-level monthly hospital admission rates and a greater rate reduction at COVID-19 onset. ITS analysis showed monthly hospital admission rates from short-term complications surged to higher level 6 months after COVID-19 onset. Hospital admissions due to long-term complications decreased immediately post-COVID-19, but rose significantly (p < 0.001) to higher than pre-COVID levels, with patients experiencing higher nephropathy, angiography, and dermatological complications post-COVID-19.

CONCLUSION

COVID-19 had a negative impact on diabetes-related hospitalization access, resulting in increased short- and long-term complications. Long-term effects of deferred care due to COVID-19 on diabetes-related complications may persist, emphasizing the need for continued education toward improved diabetes self-management.

Real world initiation of newly funded empagliflozin and dulaglutide under special authority for patients with type 2 diabetes in New Zealand

BACKGROUND

Type 2 diabetes (T2D) is sub-optimally managed for many in Aotearoa New Zealand, and disproportionately affects Māori and Pacific peoples. In February 2021, SGLT2i/GLP1RA agents were funded for use for the first time with prioritisation for Māori, Pacific and those with cardiovascular and/or renal disease or risk (CVRD). This study evaluates the impact of health system factors on initiation of SGLT2i/GLP1RA therapy.

METHODS

Primary care data was collected for patients with T2D aged 18-75 years from four primary care organisations (302 general practices) in the Auckland / Waikato region of New Zealand (Feb 2021 - July 2022). Initiation of SGLT2i/GLP1RA therapy was reviewed by patient (age, gender, ethnicity, CVRD status) and health system variables (funding, provider type, staffing, patient numbers, rurality, after-hours access). Logistic regression was used to estimate the odds ratio of a patient being dispensed SGLT2i/GLP1RA.

RESULTS

Of 57,743 patients with T2D, 22,331 were eligible for funded SGLT2i/GLP1RA access and 10,272 of those (46.0%) were prescribed. Initiation of therapy was highest in Māori (50.8%) and Pacific (48.8%) patients (vs. 36·2-40·7% of other ethnic groups; P < 0.001), but was comparable in those with and without CVRD (47·1% vs. 48·9%; P = 0.2). Prescribing was highest in practices with higher doctor/patient numbers, low-cost fees, Māori health providers and clinics without after-hours access.

CONCLUSION

Prioritised access for SGLT2i/GLP1RA appears to be associated with a reduced health equity gap for Māori and Pacific patients with T2D in NZ, but work is required to improve prescribing for patients with CVRD.

Association between estimated glucose disposal rate and metabolic syndrome: a cross-sectional analysis of the National Health and Nutrition Examination Survey

Metabolic syndrome (MS) is a complex metabolic disorder that is often closely associated with the development of chronic diseases such as cardiovascular disease and diabetes. This study aimed to explore the relationship between estimated glucose metabolic rate (eGDR) and MS. The correlation between eGDR levels and the prevalence of metabolic syndrome was analyzed here based on data from the National Health and Nutrition Examination Survey from 2005 to 2020. The study sample consisted of 63,131 adult participants, and the results showed that lower eGDR levels were significantly associated with a higher prevalence of metabolic syndrome. Further regression analyses showed that eGDR acted as a protective factor and that the risk of MS significantly decreased as its level increased. Subgroup analyses showed that this trend held across gender, age, and BMI categories, and that the protective effect of eGDR was weaker in the higher BMI group. Based on the nonlinear relationship between subjects' eGDR levels and MS prevalence, RCS analyses further confirmed a significant correlation between lower eGDR levels and increased risk of MS. In conclusion, the present study suggests that eGDR levels could serve as a potential biomarker for predicting metabolic syndrome, providing new perspectives for early screening and intervention of MS.

Health literacy among individuals with type 2 diabetes in France: greater social inequalities among women; the Entred 3 study

AIM

The aim of this study was to describe and explore the health literacy in people living with type 2 diabetes in mainland France and its association with socioeconomic factors.

METHODS

ENTRED 3 is a nationally representative French diabetes population-based survey conducted in 2019. Health literacy was measured using two scales from the Health Literacy Questionnaire: ability to actively engage with healthcare providers (HLQ6) and sufficient understanding of health information to know what to do (HLQ9). Gender-stratified analyses and multivariate linear regressions were conducted to study health literacy according to education level and country of birth, adjusting for age and antidiabetic treatment. These analyses were weighted to account for the study's complex sampling design and non-response bias.

RESULTS

Two thousand seven hundred fourteen people living with type 2 diabetes responded to the ENTRED 3 questionnaire. The mean scores for respectively HLQ6 and HLQ9 were significantly higher among men (4.03 (sd 0.02); 4.16 (sd 0.03)) than among women (3.87 (sd 0.01); 3.98 (sd 0.05)). At comparable age and antidiabetic treatment: i) education level were positively associated with HLQ6 and HLQ9 among men; ii) women born in North Africa had lower HLQ6 and faced more pronounced educational inequalities with regards to HLQ9 than women born in France.

CONCLUSION

This study provides a reference for health literacy in persons living with type 2 diabetes in France and identifies a link between health literacy and socioeconomic factors. Its results represent a significant step in the understanding of the mechanisms of social inequalities in health in France.

From inequalities to solutions: an explanatory sequential study on type 2 diabetes health services utilization

BACKGROUND

Health inequities are a significant issue. This study aimed to measure and decompose socioeconomic inequality in the utilization of type 2 diabetes (T2D) services and propose solutions to mitigate these inequalities.

METHODS

This explanatory sequential mixed-method study was conducted in two phases: quantitative and qualitative. A total of 2000 T2D patients from health centers, hospitals, and diabetes clinics in Isfahan and Khuzestan provinces, Iran, were selected. In the quantitative phase, the existence of inequality in the utilization of T2D services was examined using the Concentration Index (CI) approach. To determine the contribution of each explanatory variable to T2D inequality, we used concentration index decomposition analysis. In the qualitative phase, based on the main contributors identified in the quantitative phase, we conducted semi-structured interviews with purposefully selected key experts to identify solutions for reducing inequality in the utilization of T2D services.

RESULTS

The sample consisted of 65.3% men, with 40% of T2D patients being over 60 years old. The CI values were 0.31 (p < 0.05) for outpatient services, -0.10 (p > 0.05) for inpatient services, and 0.11 (p < 0.05) for pharmaceutical services. This indicates an inequality in the utilization of outpatient and pharmaceutical services among T2D patients, while the inequality in inpatient services was not significant. The main variables contributing to inequality in outpatient services were health status (33.54%), basic insurance (27.43%), and socioeconomic status (24.08%). For pharmaceutical services, the contributing variables were health status (22.20%), basic insurance (13.63%), and socioeconomic status (34.35%). Experts' solutions to reduce socioeconomic inequalities in Iran were classified into three main themes: socioeconomic status, health status, and basic insurance, with 29 sub-themes.

CONCLUSION

The results suggest that targeted health interventions for poor T2D patients are recommended. Efforts towards universal coverage in outpatient care and commonly used pharmaceutical items, such as: Antidiabetic Drugs, Triglyceride Control Drugs, Cardiovascular Drugs, Neuropathy Drugs, and Nephropathy Drugs, should be considered.

Cardiovascular Complications, Kidney Failure, and Mortality in Young-Onset Type 1 and Type 2 Diabetes: Data From the Korean National Health Insurance Service

OBJECTIVE

To explore all-cause mortality and the incidence of cardiovascular and renal complications among patients with young-onset diabetes in South Korea using a nationwide registry database.

RESEARCH DESIGN AND METHODS

Data were collected from the Korean National Health Insurance Service-National Sample Cohort database from 2006 to 2019 for patients aged ≤30 years with type 1 diabetes (T1D) or type 2 diabetes (T2D). The incidence rates of cardiovascular complications (myocardial infarction [MI] and stroke) and kidney failure, as well as all-cause mortality, were compared with those in the general population.

RESULTS

This study included 513,633 participants, comprising 413 with T1D, 1,250 with T2D, and 511,970 control individuals. After adjusting for sex, age, family income, hypertension, and dyslipidemia, the hazard ratio (HR) for MI was 6.76 (95% CI 2.44-18.72) and 5.07 (95% CI 2.48-10.36) for T1D and T2D, respectively. The HR for stroke was 4.65 (95% CI 1.70-12.71) and 3.30 (95% CI 1.67-6.53) for T1D and T2D, respectively. The HR for kidney failure was 20.92 (95% CI 11.40-38.39) and 2.78 (95% CI 1.37-5.64) for T1D and T2D, respectively. The mortality risk was significantly higher in patients with T1D (3.69; 95% CI 1.95-6.98) and T2D (3.06; 95% CI 2.02-4.63) than in the control group. The mortality risk was highest in the T2D subgroup of participants aged <20 years at enrollment (10.70; 95% CI 4.41-25.94).

CONCLUSIONS

In South Korea, patients with young-onset diabetes are at high risk of cardiovascular complications, kidney failure, and death.

Unveiling inequalities: Racial, ethnic, and socioeconomic disparities in diabetes: Findings from the 2007-2020 NHANES data among U.S. adults

Objective

Despite persistent disparities in diabetes prevalence among racial and ethnic minorities, there remains a significant lack of understanding regarding the intersectionality of racial and ethnic groups and socioeconomic status (SES) with diabetes.

Methods

The data came from the National Health and Nutrition Examination Survey (NHANES; N = 30,754, mean age = 47.4) using cross-sectional survey cycles from 2007 to 2008 through 2017-2020. Diabetes status was self-reported by physician diagnosis. Sociodemographic factors included racial and ethnic groups and SES. Weighted Poisson models were used to examine the association of racial and ethnic groups and SES with diabetes, stratified by age groups (20-44, 45-64, 65-79), sex, and racial and ethnic groups for SES, separately.

Results

Non-Hispanic Black, Hispanic, and other adults had a 47 %, 31 %, and 76 % higher prevalence of diabetes than non-Hispanic White adults, while adults from low and middle SES compared to high SES had a 37 % and 22 % higher prevalence of diabetes. Non-Hispanic Black, Hispanic, and other adults aged 45-64 years had a 45 %, 34 %, and 78 % higher prevalence of diabetes, and low and middle SES had a 57 % and 32 % higher prevalence of diabetes. Similar patterns were observed for adults aged 65-79. Males among non-Hispanic Black, Hispanic, and other adults and females from low and middle-SES families had a higher prevalence of diabetes.

Conclusion

Minority groups, middle and older-aged adults, males from minority groups, and females from low SES had a greater prevalence of diabetes. Effective interventions should prioritize tailoring efforts to specific minoritized and low SES groups to address diabetes disparities.

Burden of type 2 diabetes and its relationship with human development index in Asian countries: Global Burden of Disease Study in 2019

BACKGROUND

The mounting burden of type 2 diabetes is a major concern in healthcare systems worldwide. The purpose of this study is to investigate Burden of type 2 diabetes and its relationship with human development index in Asian countries.

METHODS

All accessible data from the 2019 Global Burden of Disease study were used to estimate the diabetes mellitus type 2 prevalence, mortality and disability-adjusted life years and diabetes mellitus type 2 in Asia from 1990 to 2019. We estimated all-cause and cause-specific mortality, years of life lost (YLLs), years lived with disability (YLDs), disability-adjusted life-years (DALYs) and attributable risk.

RESULTS

The results indicated that the human development index (HID) was positively and significantly correlated with the incidence of type 2 diabetes in men (r = 0.481, P < 0.05) and women (r = 0.414, P < 0.05, but the correlation between death and the HDI was not significant in men and women (P > 0.05). The highest share of DALY risk factors in men (12093.2 per 100000) and in women (7122.4 per 100000) was related to behavioral factors. According to the results, air pollution, high fasting plasma glucose, and dietary risks are the main risk factors associated with the burden of type 2 diabetes in women and men, respectively.

CONCLUSION

Given that the burden of type 2 diabetes is escalating in Asia and the burden of disease can be largely controlled by managing its risk factors, the disease management program in different countries, especially in countries with high prevalence and high burden could be reduced by making policies.

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.

Global, regional, and national burdens of type 1 and type 2 diabetes mellitus in adolescents from 1990 to 2021, with forecasts to 2030: a systematic analysis of the global burden of disease study 2021

BACKGROUND

Adolescent diabetes is one of the major public health problems worldwide. This study aims to estimate the burden of type 1 diabetes mellitus (T1DM) and type 2 diabetes mellitus (T2DM) in adolescents from 1990 to 2021, and to predict diabetes prevalence through 2030.

METHODS

We extracted epidemiologic data from the Global Burden of Disease (GBD) on T1DM and T2DM among adolescents aged 10-24 years in 204 countries and territories worldwide. This study calculated the age-standardized prevalence rate (ASPR) and age-standardized DALY rate (ASDR) in adolescents based on the world standard population for cross-country comparisons. Average annual percentage changes (AAPC) in age-standardized rate were calculated by linkage point regression. Correlation analyses were used to identify the relationship between age-standardized rate and sociodemographic index (SDI). The Bayesian age-period-cohort (BAPC) model was used to predict changes in the diabetes prevalence among adolescents from 2022 to 2030.

RESULTS

In 2021, 3.4 million adolescents were living with T1DM, with an ASPR of 180.96 (95% CI 180.77-181.15), and 14.6 million were living with T2DM, with ASPR of 1190.73 (1190.13-1191.34). As national and territory SDI levels rise, the prevalence rate of T1DM increases (r = 0.44, p < 0.01), and the prevalence rate of T2DM decreases (r = - 0.18, p < 0.01). Compared with males, females had a greater age-standardized prevalence of T1DM (185.49 [185.21-185.76] vs. 176.66 [176.39-176.92]), whereas males had a greater ASPR of T2DM than females did (1241.45 [1240.58-1242.31] vs. 1138.24 [1137.40-1139.09]). This study found a negative correlation between the SDI and the ASDR for both T1DM (r = - 0.51, p < 0.01) and T2DM (r = - 0.62, p < 0.01) in adolescents. For T2DM patients, 32.84% of DALYs were attributed to high BMI, which increased by 40.78% during the study period. By 2030, 3.7 million people are projected to have T1DM, and 14.6 million are projected to have T2DM.

CONCLUSIONS

Among adolescents, the burden of T1DM and T2DM is increasing and varies by region, sex, and SDI. Therefore, targeted interventions based on regional features are needed to prevent and control adolescent diabetes. Moreover, more efforts are needed to control climate change and obesity to reduce the adolescent diabetes burden.

Navigating diabetes care inequities: an observational study linking chronic care model's structural elements to process and outcomes of type 2 diabetes care in Belgium

BACKGROUND

Although the Chronic Care Model (CCM) provides the essential structural components of practice organisation to deliver high-quality type 2 diabetes (T2D) care, little is known about which of its elements are most important, and the extent to which it may reduce social inequities in the quality of T2D care. This study aims to assess the association between the implementation of CCM's structural elements and the quality of T2D care processes and outcomes in Flanders (Belgium), paying specific attention to differences by patients' socioeconomic vulnerability.

METHODS

We developed a longitudinal database combining information on primary care practices' CCM implementation, with individual-level health insurance and medical lab data. Our sample included 7,593 T2D patients aged 40 years and above from 58 primary care practices in Flanders, followed up from 2017 to 2019. Medical lab data were available for a subsample of 4,549 patients. By estimating a series of hierarchical mixed-effects models, we assessed the association between primary care practices' CCM implementation and two process and two outcome indicators of T2D care. In addition, we explored cross-level interactions with patients' socioeconomic vulnerability.

RESULTS

Patients were more likely to have their HbA1c tested twice a year and LDL cholesterol tested yearly in practices with a higher overall CCM implementation. Regarding the different CCM elements, the clinical information system and linkages to the community were significantly associated with higher odds of being up-to-date with HbA1c testing, whereas stronger community linkages was the only dimension significantly associated with yearly LDL cholesterol testing. While socioeconomic vulnerable patients were less likely to have their HbA1c tested twice yearly, this difference disappeared in the highest-scoring practices. Regarding the outcome indicators, only a negligible proportion of variation in HbA1c and LDL cholesterol levels was due to systematic differences between practices, and hence, no clinically relevant associations with the CCM elements were found.

CONCLUSION

Our pioneering findings support the social capital pathway, as CCM implementation is associated with a reduction in the healthcare inequity gap in the T2D care process. This suggests that promoting CCM implementation may improve healthcare equity, particularly in regions with significant socioeconomic disparities or high concentrations of deprived individuals.

Association of socioeconomic status with diabetic microvascular complications: a UK Biobank prospective cohort study

BACKGROUND

Prior studies on the link between socioeconomic status (SES) and diabetic microvascular complications have been inconclusive. This study aimed to explore whether SES is associated with the risk of diabetic retinopathy (DR), nephropathy (DN) and diabetic peripheral neuropathy (DPN) using large prospective cohort.

METHODS

SES was evaluated using education attainment (individual level), household income (household level), and Townsend deprivation index (TDI, neighborhood level). This study included 28,339 participants without DR, 29,951 without DN and 29,762 without DPN at baseline from the UK Biobank. Weighted Cox proportional hazard models were used to investigate the relationship between SES and the risk of diabetic microvascular complications.

RESULTS

The median follow-ups of the DR, DN and DPN cohorts were 12.95, 12.89 and 13.02 years, respectively. In total, 3,177 (11.2%) participants developed DR, 4,418 (14.8%) developed DN and 1,604 (5.4%) developed DPN. After adjusting for confounders, higher education levels (DN: hazard ratios [HR] = 0.85; 95% CI, 0.82-0.89; P < 0.001; DPN: HR = 0.93; 95% CI, 0.87-1.00; P = 0.040), higher household income (DN: HR = 0.80; 95% CI, 0.75-0.85; P < 0.001; DPN: HR = 0.80; 95% CI, 0.73-0.89; P < 0.001), and lower TDI (DN: HR = 1.19; 95% CI, 1.14-1.23; P < 0.001; DPN: HR = 1.27; 95% CI, 1.19-1.36; P < 0.001) were associated with a lower risk of DN and DPN. In contrast, a lower risk of DR was only related to higher household income (HR = 0.92; 95% CI, 0.87-0.97; P = 0.004) and lower TDI (HR = 1.08; 95% CI, 1.02-1.13; P = 0.004).

CONCLUSIONS

Low SES increases the risk of diabetic microvascular complications, emphasizing the need for equitable medical resource allocation to reduce diabetes-related inequity.

The diabetes mellitus comorbidity index in European Union member states based on the 2019 European Health Interview Survey

Multiple chronic conditions reduce the quality of life and increase healthcare needs for people with diabetes mellitus (DM). This study aims to describe the prevalence of comorbidities associated with DM in the European Union (EU) at national and sub-national levels and to assess the utility of a comorbidity burden index. The study was carried out using microdata from European Health Interview Survey 2019 including adults aged 25 and older with DM from 26 EU member states (n = 20,042). The comorbidity index was calculated for 9 chronic conditions using the self-rated general health of individuals and disability weights obtained from the Global Burden of Disease 2019. Beta regression analysis was performed to evaluate the association between the comorbidity index and several determinants. A higher comorbidity index was found in sub-populations exhibiting lower education, unemployment or other labour status, lower income, rural residence, and poor health behaviours including obesity, physical inactivity, and poor diet. A higher comorbidity burden was observed in Eastern and Southern European countries and specific subregions within each country. The comorbidity index has the potential to identify regions and subpopulations with the highest disability burden and to help develop interventions to improve the quality of life of people with DM.

Racial and ethnic disparities in the uptake of SGLT2is and GLP-1RAs among Medicare beneficiaries with type 2 diabetes and heart failure, atherosclerotic cardiovascular disease and chronic kidney disease, 2013-2019

AIMS/HYPOTHESIS

The aim of this study was to investigate racial and ethnic disparities in the use of sodium-glucose cotransporter 2 inhibitors (SGLT2is) and glucagon-like peptide-1 receptor antagonists (GLP-1RAs) among older adults with type 2 diabetes and cardiorenal conditions.

METHODS

Using Medicare fee-for-service data (2013-2019), this retrospective cohort study identified older adults (≥65 years) with type 2 diabetes initiating second-line therapies (SGLT2is, GLP1-RAs, dipeptidyl peptidase-4 inhibitors [DPP4is] and sulfonylureas [SUs]) with (1) heart failure (HF), (2) atherosclerotic cardiovascular disease (ASCVD), (3) chronic kidney disease (CKD) and (4) no recorded cardiorenal conditions. Participants were classified as non-Hispanic White, non-Hispanic Black and Hispanic. Multinomial regressions, adjusting for sociodemographic, clinical and county-level characteristics, were used to model the odds of initiating SGLT2is or GLP-1RAs within each cohort.

RESULTS

Black participants with HF, ASCVD, CKD or no recorded cardiorenal conditions had 35% (adjusted OR 0.65 [95% CI 0.61, 0.68]), 33% (0.67 [0.64, 0.69]), 32% (0.68 [0.64, 0.72]) and 24% (0.76 [0.74, 0.79]) lower odds of initiating SGLT2is, respectively, than White participants. Disparities ameliorated from 50-60% lower odds in 2013 to 17-18% in 2019. Similar patterns were observed for GLP-1RA uptake among Black participants. By contrast, Hispanic participants had similar odds of SGLT2i initiation in the HF and CKD cohorts as White participants, but 6% (0.94 [0.91, 0.98]) lower odds in the ASCVD cohort. Notable disparities for Hispanic participants compared with White participants were observed for GLP-1RA uptake in the HF, ASCVD, CKD and no cardiorenal conditions cohorts: 11% (0.89 [0.84, 0.94]), 16% (0.84 [0.81, 0.87]), 16% (0.84 [0.80, 0.89]) and 25% (0.75 [0.72, 0.78]) lower odds, respectively. Participants had greater odds than White participants of initiating DPP4is, which confer no cardiorenal benefits, across all cohorts (HF 1.25 [1.19, 1.31]; ASCVD 1.36 [1.32, 1.40]; CKD 1.32 [1.26, 1.38). Adjustment for social determinants of health did not meaningfully change the study findings.

CONCLUSIONS/INTERPRETATION

Compared with White participants, disparities in the uptake of SGLT2is were evident for Black participants, and in the uptake of GLP-1RAs for both Black and Hispanic participants. This study highlights how type 2 diabetes management is evolving, while underscoring historical imbalances that have shown signs of abatement.

The differences of metabolic profiles, socioeconomic status and diabetic retinopathy in U.S. working-age and elderly adults with diabetes: results from NHANES 1999-2018

AIMS

Controlled metabolic factors and socioeconomic status (SES) was crucial for prevention of diabetic retinopathy (DR). The study aims to assess the metabolic factors control and SES among working-age adults (18-64 years) with diabetes compared to older adults (65 years and older).

METHODS

Totals of 6738 participants with self-reported diagnosed diabetes from National Health and Nutrition Examination Survey were included, of whom 3482 were working-age and 3256 were elderly. The prevalence of DR, metabolic factors control, and the impact of SES and diabetic duration on DR was estimated. Subgroup analysis among working-age adults was employed across different diabetic duration and SES level.

RESULTS

The prevalence of DR was 20.8% among working-age adults and 20.6% in elderly adults. Further, working-age adults possessed suboptimal control on glycemia (median HbA1c: 7.0% vs. 6.8%, p < 0.001) and lipids (Low-density lipoprotein < 100 mg/dL: 46.4% vs. 63.5%, p < 0.001), but better blood pressure control (< 130/80 mmHg: 53.5% vs. 37.5%, p < 0.001) compared to the elderly, judging based on age-specific control targets. Prolonged diabetic duration didn't improve glycemic and composite factors control. SES like education and income impacted metabolic factors control and adults with higher SES were more likely to control well. Diabetic duration was a significant risk factor (OR = 4.006, 95%CI= (2.752,5.832), p < 0.001) while higher income (OR = 0.590, 95%CI= (0.421,0.826), p = 0.002) and educational level (OR = 0.637, 95%CI= (0.457,0.889), p = 0.008) were protective against DR.

CONCLUSIONS

Working-age adults with diabetes demonstrate suboptimal metabolic profile control, especially glycemia and lipids. Additional efforts are needed to improve metabolic factor control and reduce DR risk, particularly for those with longer diabetes duration, less education, and lower incomes.

The Landscape of Products for Diabetic Peripheral Neuropathy: A Scientific and Patent Systematic Review

BACKGROUND

Diabetic peripheral neuropathy (DPN) is a complication of diabetes that occurs in 40 - 60 million individuals worldwide and is associated with other chronic diseases. However, there are no review studies that present the state-of- the- art and technologies developed to circumvent this important health problem.

MATERIALS AND METHODS

This review was conducted based on scientific papers and patents. The papers were retrieved from Lilacs, PubMed, and Web of Science databases, and the patents from INPI, ESPACENET, WIPO, and GOOGLE PATENTS. Thus, a sample consisting of 14 scientific articles and 667 patents was analyzed.

RESULTS

From the analysis of the data, we drew an overview of the development of biomedical technologies for DPN and detected the pioneering spirit of China, the USA, and Japan in the area, with a focus on the treatment of DPN. Based on this, we carried out a SWOT analysis to help direct future efforts in the area, which should focus primarily on developing technologies for prevention, early diagnosis, and, above all, cure of the disease to reduce the important impact of this disease in various sectors of society.

CONCLUSION

This study finds a concentration of diabetic peripheral neuropathy products, especially therapeutic drugs, in high-income countries. It highlights the need for global collaboration and strategic focus on therapeutic adherence and preventive strategies to effectively manage DPN.

Differential impact of lifestyle factors on 2-hour glucose values in individuals with type 2 diabetes: potential for more personalized interventions

INTRODUCTION

Lifestyle determinants of 2-hour glucose concentration in people with type 2 diabetes and interindividual differences need to be identified.

RESEARCH DESIGN AND METHODS

38 participants with type 2 diabetes, treated with lifestyle advice and/or metformin, tracked their physical activity, sleep and dietary intake, while continuously monitoring interstitial glucose concentrations for 11 periods of four consecutive days each. A linear mixed-effects model was used to quantify the effect of sleep, stress, current glucose, carbohydrate intake and exercise on glucose levels 2 hours later.

RESULTS

The final model identified carbohydrate intake (grams) in the past 5 min as well as in the past 30 min, sleep duration during the previous night (hours) and physical activity (metabolic equivalents) over the past 12 hours as significant fixed effects that influenced glucose concentrations 2 hours later. In addition, carbohydrate intake in the past 5 and past 30 min, and physical activity in the past and future 30 min were included as random or individualized effects. Although carbohydrate intake led to increased glucose concentrations in 2 hours in all individuals, the magnitude of this effect varied between individuals. The physical activity on glucose concentrations in 2 hours varied among individuals as well, in terms of magnitude and in terms of direction (showing either increase or decline).

CONCLUSIONS

Carbohydrate intake, sleep and physical activity at specific points in time have both fixed as well as individualized effects on glucose concentrations 2 hours later in individuals with type 2 diabetes. Interindividual differences in glycemic response to lifestyle components call for personalized advice in the management of type 2 diabetes.

Availability and affordability of diabetes healthcare services associated with the frequency of diabetes-related complications

AIMS

Understanding the healthcare access challenges facing diabetic patients in low- and middle-income countries is very important. The present study investigated the association between availability (physical access) and affordability (economic access) to diabetes healthcare services and the frequency of diabetes-related complications.

METHODS

A cross-sectional survey study was conducted between February and May 2023 in Qazvin, Iran. Using convenience sampling, 373 type 2 diabetic patients (mean age = 57.99 years; SD = 11.71) referred to diabetic specialists' clinics were surveyed. Demographic characteristics, physical access to diabetes healthcare services, economic access to diabetes healthcare services, and frequency of diabetes-related complications (FDRCs) were assessed. Data were assessed using linear regression analysis.

RESULTS

The mean total access score to healthcare services was 17.71 (out of 30; SD ± 4.21; range 6-30). Patients who had more access to healthcare services had less diabetes-related complications (p < 0.005). There was a significant negative correlation (p < 0.01) between FDRCs and (i) physical access to diabetes-related healthcare services (r = -0.166) and (ii) economic access to diabetes-related healthcare services (r = -0.153). Linear regression analysis showed that with each unit increase in participants' economic, physical and total access to diabetes-related healthcare services, the FDRCs among participants decreased by 8.7%, 13.5%, and 8.8% respectively.

CONCLUSION

The results indicate that increased physical accessibility (availability) and economic accessibility (affordability) of healthcare services are associated with fewer diabetes-related complications. Therefore, policymakers and healthcare managers need to reduce diabetes-related complications by implementing schemes to increase patient access to diabetes treatment services.

Characteristics of Children, Youth, and Young Adults With Diabetes: A Cross-Sectional Study in New Zealand Aotearoa

Background: The prevalence of diabetes mellitus among children, youth, and young adults is increasing, yet limited information is known about the characteristics and management of these groups with Type 1 (T1D) and Type 2 (T2D) diabetes in primary care. The aim of the study is to explore the characteristics of people with T1D and T2D aged < 25 years across the Auckland and Waikato regions of New Zealand. Methods: Sociodemographic and clinical data were collected from electronic primary care records (February 2021-July 2022) of four primary healthcare organisations, with medication data sourced from the National Pharmaceutical dataset. Associations between sociodemographic and clinical data were conducted using chi-square and nonparametric ANOVA. Results: Of 1198 patients, 72% had T1D and 28% had T2D. People with T1D were evenly distributed by gender but more commonly of European descent (66.7%) compared to other ethnic groups. A higher proportion of T2D was observed in females (58.2%) compared to males (41.6%) and among Māori (38.2% vs. 20.3% European; p < 0.001). Over 95% of individuals with T2D were overweight/obese. Overall, 9.5% and 23.9% of individuals with T1D and T2D, respectively, were at target for HbA1c, though median HbA1c was higher for Māori and Pasifika compared to other ethnicities (p < 0.001). In T1D, 94.7% of individuals were dispensed insulin and 7.5% and 4.4% were dispensed angiotensin-converting enzyme (ACE) inhibitors and statins, respectively. In T2D, medication use included metformin (84.9%), insulin (76.1%), and SGLT2i/GLP1RA (59.5%). Conclusions: The increasing burden of diabetes among young individuals in New Zealand underscores the urgent need for comprehensive strategies to address obesity and socioeconomic disparities, especially among marginalised communities. Addressing socioeconomic factors such as affordable housing, living wages, and healthcare access may be important for improving diabetes outcomes, as these factors significantly influence overall childhood health and well-being.

Glycemic Control With Layperson-Delivered Telephone Calls vs Usual Care for Patients With Diabetes: A Randomized Clinical Trial

Importance

Diabetes is associated with emotional distress and poor mental health, especially for individuals with low income, hindering patients' ability to manage their condition. The health care system's workforce constraints limit its capacity to holistically support patients.

Objective

To assess the effectiveness of layperson-delivered empathetic engagement over the telephone in helping improve glycemic management for patients with diabetes.

Design, Setting, and Participants

This parallel-arm randomized clinical trial with blinded outcome assessment was conducted from February 12, 2022, to April 15, 2023, with final measurements on November 18, 2023, among 260 patients with uncontrolled diabetes from a federally qualified health center in Austin, Texas, engaging telephonically from home.

Intervention

Patients assigned to the intervention group received empathy-oriented telephone calls by community-hired laypeople for 6 months, while those assigned to the control group received usual care. Patients were stratified by baseline score (≥5 vs <5) on the depressive symptom scale of the 9-item Patient Health Questionnaire (PHQ-9).

Main Outcomes and Measures

The primary outcome was hemoglobin A1c level at baseline, 3 months, and 6 months, assessed for interaction between time and trial arm. Secondary outcomes were self-perceptions of managing diabetes, diabetes-related behaviors and distress, and mental health symptoms (measured via surveys). Analysis was performed on an intention-to-treat basis.

Results

Of 260 participants (mean [SD] age, 49.5 [10.1] years; 163 of 259 women [62.9%]; 176 of 203 [86.7%] with annual income <$40 000) enrolled, 6 withdrew. At 6 months, 204 of 254 (80.3%; intervention, 109 of 127 [85.8%] and control, 95 of 127 [74.8%]) returned for measurements. Participants in the intervention group had statistically significant mean (SD) decreases in hemoglobin A1c level at 6 months (from 10.0% [1.9%] to 9.3% [2.0%]) compared with those in the control group (from 9.8% [1.6%] to 9.7% [2.3%]) (P = .004). The within-person change in hemoglobin A1c level was -0.7% (95% CI, -1.0% to -0.4%) for the intervention group and 0.02% (95% CI, -0.4% to 0.4%) for the control group. For the subgroup with a PHQ-9 score of 5 or more at baseline (38.1% [99 of 260]), the within-person change in hemoglobin A1c was -1.1% (95% CI, -1.8% to -0.5%) for the intervention group and 0.1% (95% CI, -0.7% to 0.8%; P = .004) for the control group. For the subgroup with a PHQ-9 score less than 5, the within-person change in hemoglobin A1c was -0.4% (95% CI, -0.8% to -0.1%) for the intervention group and -0.02% (95% CI, -0.5% to 0.5%; P = .21) for the control group. At 6 months, 91.7% of the participants (99 of 108) responded that the program was very or extremely beneficial.

Conclusions and Relevance

In this randomized clinical trial of telephone-based layperson-delivered empathetic engagement, patients with diabetes and low income achieved clinically meaningful improvements in glycemic control. With workforce constraints, layperson-delivered programs for diabetes show promise.

Trial Registration

ClinicalTrials.gov Identifier: NCT05173675.

Proactive total diet replacement referral for type 2 diabetes: A service evaluation

AIMS

Type 2 Diabetes Mellitus morbidity disproportionally effects the most socioeconomically deprived 20 % of England. Total Diet Replacement (TDR) is a high impact intervention currently commissioned by Integrated Care Boards (ICB). Finding and referring eligible, motivated patients is a significant challenge. This study evaluates a 12-month population health management, proactive referral intervention commissioned by Nottingham and Nottinghamshire ICB during a 2-year TDR pilot designed to supplement referrals from primary care.

METHODS

A Diabetes specialist nurse clinically reviewed a list of potentially eligible patients found by searching routinely collected health care data from 16 primary care centres in 3 PCNs.

RESULTS

19.7 % (50/254) of potential patients were referred during the intervention period. 19.3 % (49/254) were uncontactable. 39.8 % (101/254) declined referral. 17.7 % (45/254) were ineligible after clinical review. An interrupted time series analysis suggests monthly referrals increased during the study period due to the intervetion (F (1,22) = 5.19 p=0.0345). Searching for patients from more socioeconomically deprived areas (index of multiple deprivation deciles 1-3) did not meaningfully alter the referral yield (19.6 %, 19/97).

CONCLUSIONS

Proactive care interventions could be used to facilitate referrals to the TDR or other high impact interventions by healthcare commissioning bodies.

Socioeconomic inequalities in the prevalence, non-awareness, non-treatment, and non-control of diabetes among South Korean adults in 2021

The purpose of this study was to investigate socioeconomic inequalities in diabetes prevalence, non-awareness, non-treatment, and non-control among South Korean adults in 2021. This cross-sectional study used data from the 2021 Korean National Health and Nutrition Examination Survey. Relative concentration indices (RCIs) and relative concentration curves stratified by sex and age were used to investigate socioeconomic inequalities in the prevalence, non-awareness, non-treatment, and non-control of diabetes. The prevalence, non-awareness, lack of treatment, and non-control rates in adults aged 30 years and older in 2021 were 15.9%, 29.5%, 33.3%, and 76.1%, respectively. Diabetes was more prevalent in participants under the age of 65 years than those aged 65 years and older for both men (RCI: -0.081, RCI: -0.158, respectively) and women (RCI: -0.203, RCI: -0.292, respectively). The larger the absolute value of the RCI in non-awareness and non-treatment of diabetes in women, the greater the level of socioeconomic inequalities (RCI: 0.182, RCI: 0.154). Socioeconomic inequalities existed in the prevalence of diabetes among both men and women aged under 65 years. In women, socioeconomic inequalities of non-awareness and non-treatment of diabetes were greater than those in men. Thus, preventive care and monitoring are required, particularly among women and individuals under the age of 65 years.

The Social Determinants of Health in a Cohort of Romanian Patients with Diabetic and Nondiabetic Neuropathy

Background/Objectives: The importance of the social determinants of health (SODHs) in diabetic and nondiabetic neuropathy has recently gained more attention. This retrospective study examined the correlation of incident diabetic neuropathy and neuropathy of other etiologies with SODH in Romania. Methods: All cases with the primary or secondary discharge diagnosis codes of neuropathy reported across Romania in 2019 were analyzed. The crude incidence rate was calculated per 100,000 persons for the whole population resident in Romania on the 1 July 2019. As SODHs sex, gross domestic product (GDP) per capita, unemployment rate, and the number of physicians/1000 persons were evaluated. Results: In total, 207,026 hospitalizations with a discharge diagnosis of neuropathy were recorded. Of these, 80,480 had a discharge diagnosis of diabetic neuropathy, with an incidence rate of 414.97 cases/100,000 persons. The incidence rate of diabetic neuropathy by county was correlated with the corresponding GDP (p = 0.013) and unemployment rate (p = 0.001). By sex, the correlation with GDP remained significant only for women (p = 0.010), while the correlation with unemployment rate remained significant in both sexes. No correlation was observed with the number of physicians/1000 persons/county. The incidence rate of neuropathy of other etiology was 652.49 cases/100,000 persons. No correlation between the incidence rate of neuropathy of other etiology by county and the corresponding GDP, unemployment rate or number of physicians/1000 persons was observed neither in the total sample nor by sex. Conclusions: Lower socioeconomic status was correlated with a higher incidence rate of hospitalized diabetic neuropathy and not with neuropathies of other etiologies.

Early life socioeconomic inequalities and type 2 diabetes incidence: Longitudinal analyses in the Maastricht study

AIM

Type 2 diabetes (T2D) is a common chronic disease that disproportionally affects groups with a low socioeconomic position (SEP). This study aimed to examine associations between childhood SEP and incident T2D, independent of adult SEP.

METHODS

Longitudinal data from The Maastricht Study were used (N=6,727, 55.2 % female, mean (SD) age 58.7(8.7) years). Childhood SEP was determined by asking for the highest completed educational level for the father and mother and childhood income inadequacy. Adult SEP was determined by highest completed educational level, equivalent household income, and occupational position. Incident T2D was self-reported yearly (up to 12 years of follow-up). Associations were studied with Cox regression analyses.

RESULTS

In participants without T2D at baseline, 3.7% reported incident T2D over 8.2 (median) years of follow-up. Incident T2D was most common in people with low childhood and adult SEP and lowest in those with high childhood and adult SEP (1.7 vs. 7.5 per 1,000 person years). The association between childhood SEP and incident T2D was mainly explained by adult SEP, except for childhood income inadequacy which was independently associated with incident T2D.

CONCLUSION

Socioeconomic inequalities in childhood and adulthood are risk factors for incident T2D. More attention is needed to reduce childhood poverty and improve adult SEP to reduce the T2D risk.

Patients with type 2 diabetes and surgical foot wounds: Overtrust in primary care physicians, isolation, and difficulties contemplating the future

AIMS

In Europe, 27 % of patients with a podiatric complication of diabetes are referred to a specialized structure for surgery after more than 3 months' disease progression. Our study aimed to analyze access to healthcare and future self-projection in patients with severe diabetic foot conditions.

METHODS

We performed a qualitative study with semi-structured interviews in patients hospitalized with diabetic foot conditions requiring surgical treatment. We collected quantitative data on the diabetes characteristics, levels of social precariousness, anxiety and depression.

RESULTS

We conducted 13 interviews with 2 females and 11 males; mean age 62.7 years. Five had undergone surgical debridement, six toe amputation, and two mid-tarsal amputation. Most were socioeconomically deprived and/or isolated. Three discourse themes emerged: 1) heterogeneity in the care pathway, with systemic barriers, negligence or overtrust 2) relationship between social support and the ability to project oneself into the future, 3) poverty of speech.

CONCLUSIONS

Education should emphasize the importance of prompt referral to a specialized structure after the onset of a wound. The lack of support from loved ones and social support appeared to be associated with patients' failure to plan for their future. We advocate for a psychological evaluation and support for all these patients.

The impact of COVID-19 on the care of diabetic foot ulcers: A scoping review

AIM

The aims and objectives of this scoping review were to conduct a systematic search of the literature to identify the nature and extent of the research evidence to which the COVID-19 pandemic impacted and disrupted the care of Diabetic Foot Ulcers (DFU) and the subsequent impact on patient outcomes. Secondly, to identify transformation in models of care and service delivery, adoption of innovative technologies and new models of service innovations, including modalities such as telehealth that were adopted during the pandemic.

METHODS

This systematic scoping review was conducted in accordance with the Joanna Briggs Institute methodology for scoping reviews and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping reviews (PRISMA-ScR).

RESULTS

Nineteen papers were included. These studies explored aspects of care for DFUs during the COVID-19 pandemic. The focus of these studies ranged from exploring new modalities of care such as telehealth, reporting of clinical outcomes, development of triage systems and patient behaviors during COVID-19.

CONCLUSION

Ten of twelve studies reported on DFU outcomes and reported a worsening of outcomes compared to pre-pandemic times. Reduced DFU presentations, alongside an increase in urgent hospitalisations and amputation, were key themes that emerged from this review. More high-quality evidence is needed to establish any longer-lasting effects of the Covid-19 pandemic on people living with DFU. Further, there is a lack of evidence relating to the feasibility and success of telemedicine and limited data on changes to service delivery, including triage systems in this patient cohort.

Latent classes of learners in people with type 2 diabetes, stratified by educational status: A cross-sectional study

OBJECTIVE

Research suggests that people with type 2 diabetes (PWT2D) exhibit different approaches to learning about disease-management. This study's aims to identify distinct learner groups among PWT2D and stratify them by educational status (ES).

METHODS

Cross-sectional data from 227 PWT2D, collected through 46 Likert-scale questions on learning behaviors, preferences, and attitudes, were analyzed using latent class analysis, to identify learner groups. Participants were recruited via healthcare practices in central Germany and a countrywide online survey. Group membership was displayed according to low, medium, and high ES, defined by years of schooling.

RESULTS

Four learner groups were identified: casual, versatile, insecure, and theorist learners. Insecure learners accounted for almost half of all respondents in the low ES group (46 %), casual learners were most prevalent among PWT2D with a medium (27 %), versatile (34 %) and theorist (29 %) learners among those with a high ES.

CONCLUSION

This study sheds light on learner groups among PWT2D, which differ by ES, suggesting social disparities in diabetes care. Further research is needed to validate these findings.

PRACTICE IMPLICATIONS

Understanding individual learning preferences and motivations is crucial for developing effective diabetes self-management trainings, which may involve providing additional background material for theorists and practical applications for insecure learners.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Continuous glucose monitoring for self-management of diabetes in people living with type 2 diabetes mellitus on basal insulin therapy: A microsimulation model and cost-effectiveness analysis from a US perspective with relevance to Medicaid

BACKGROUND

Reducing the risks of complications is a primary goal of diabetes management, with effective glycemic control a key factor. Glucose monitoring using continuous glucose monitoring (CGM) technology is an important part of diabetes self-management, helping patients reach and maintain targeted glucose and glycated hemoglobin (HbA1c) levels. Although clinical guidelines recommended CGM use, coverage by Medicaid is limited, likely because of cost concerns.

OBJECTIVE

To assess the cost-effectiveness of FreeStyle Libre CGM systems, compared with capillary-based self-monitoring of blood glucose (SMBG), in US individuals with type 2 diabetes mellitus using basal insulin.

METHODS

A patient-level microsimulation model was used to compare CGM with SMBG for a population of 10,000 patients. A 10-year horizon was used, with an annual discount rate of 3.0% for costs and utilities. Model population characteristics were based on US national epidemiology data. Patient outcomes were based on published clinical trials and real-world studies. Annual costs, reflective of 2023 values, included CGM and SMBG acquisition costs and the costs of treating diabetic ketoacidosis, severe hypoglycemia, and diabetes complications. The effect of CGM was modeled as a persistent 1.1% reduction in HbA1c relative to SMBG based on US real-world evidence. Disutilities were based on published clinical trials and other relevant literature. The primary outcome was cost per quality-adjusted life-year (QALY) gained. Sensitivity analyses were performed to test the validity of the model results when accounting for a plausible variation of inputs.

RESULTS

In the base case analysis, CGM was dominant to SMBG, providing more QALYs (6.18 vs 5.97) at a lower cost ($70,137 vs $71,809) over the 10-year time horizon. A $10,456 increase in glucose monitoring costs was offset by a $12,127 reduction in treatment costs. Cost savings reflected avoidance of acute diabetic events (savings owing to reductions in severe hypoglycemia and diabetic ketoacidosis were $271 and $2,159, respectively) and a reduced cumulative incidence of diabetes complications, particularly renal failure (saving $5,292), myocardial infarction (saving $1,996), and congestive heart failure (saving $1,061). Scenario analyses were consistent with the base case results, and the incremental cost-effectiveness ratio for CGM vs SMBG ranged from dominant to cost-effective. In probabilistic analysis, CGM was 100% likely to be cost-effective at a willingness-to-pay threshold of $50,000/QALY.

CONCLUSIONS

CGM is cost-effective compared with SMBG for US patients with type 2 diabetes mellitus receiving basal insulin therapy. This suggests that state Medicaid programs could benefit from broader coverage of CGM.

Patient, family and caregiver engagement in diabetes care: a scoping review protocol

INTRODUCTION

New treatments and technologies have advanced diabetes care; however, diabetes continues to have a major impact on the daily lives of affected individuals, especially among equity-deserving groups. Evidence from patient engagement literature suggests that involving diverse patients in healthcare can create cost-effective improvements and enhanced efficiency in care that has high patient acceptability and numerous health benefits, as well as improved provider satisfaction. A scoping review will be conducted to provide a cohesive and comprehensive understanding of patient engagement practices and the resulting outcomes.

METHODS AND ANALYSIS

The review will follow the recommendations for the conduct of scoping reviews developed by the Joanna Briggs Institute (JBI) Scoping Review Methodology Group. The review will include English-language literature published between 1 January 1990 and the present, searched through MEDLINE (Ovid), Embase (Ovid), CINAHL (EBSCOhost), PsycINFO (Ovid), International Bibliography of the Social Sciences (IBSS), Sociological Abstracts, Applied Social Sciences Index and Abstracts (ASSIA), Scopus, Social Sciences Citation Index and Campbell Collaboration; hand searches; and grey literature. Literature that describes conceptualisations of engagement, methods/strategies for engagement and/or evaluations of engagement across different levels of diabetes care, including direct care, organisational design and governance and policymaking will be included. The review will encompass quantitative, qualitative and mixed-methods studies. Research that is secondary, published in languages other than English, or not specifically focused on patient engagement will be excluded. Screening and extraction will be completed by two independent reviewers and conflicts will be resolved by discussion or a third reviewer, with piloting at each step. Studies will be analysed through descriptive numerical summary and content analysis.

ETHICS AND DISSEMINATION

No ethical or safety considerations are pertinent to this work. The results will be disseminated to patients/patient advocacy groups, diabetes organisations, clinicians, researchers, decision-makers and policymakers by way of summary documents, infographics, meeting presentations and through peer-reviewed publications.

TRIAL REGISTRATION NUMBER

The protocol has been registered with Open Science Framework: https://doi.org/10.17605/OSF.IO/KCD7Z.

Purification and Identification of Novel Dipeptidyl Peptidase IV Inhibitory Peptides Derived from Bighead Carp (Hypophthalmichthys nobilis)

Dipeptidyl peptidase IV (DPP-IV) inhibitors are widely used in treating type 2 diabetes due to their ability to lower blood glucose levels. However, synthetic versions often lead to gastrointestinal side effects. This study explores DPP-IV inhibitory properties in peptides from bighead carp skin. Collagen was prepared, hydrolyzed into collagen peptides, and then fractionated for DPP-IV inhibitory activity examination. The most effective fractions were identified, and their peptide sequences were determined. Molecular docking analysis identified nine peptides with potential inhibitory activity, four of which (VYP, FVA, PPGF, PGLVG) were synthesized and tested in vitro. PPGF exhibited the highest potency with an IC50 of 4.63 nM, competitively binding to key DPP-IV sites, including ARG125, VAL711, TYR666, and TYR662. Other peptides showed varying effectiveness, with IC50 values of 398.87 nM (VYP), 402.02 nM (FVA), and 110.20 nM (PGLVG). These findings highlight bighead carp skin peptides as potent DPP-IV inhibitors with hypoglycemic potential, suggesting a novel avenue for diabetes management using natural peptides. Moreover, this research underscores the utilization of bighead carp by-products, contributing to environmental sustainability.

Self-Reported Diabetes in Older Adults: A Comparison of Prevalence and Related Factors in the Mexican Health and Aging Study (2015, 2018, and 2021)

Aim: To estimate the prevalence and factors associated with diabetes among older adults and compare the prevalence rate of a three-round national survey of the Mexican Health and Aging Study (MHAS). Methods: A cross-sectional study was conducted with data obtained from MHAS 2015 (n = 8167), 2018 (n = 7854), and 2021 (n = 8060), which comprised a nationally representative sample of older adults in Mexico. The measures included sociodemographic characteristics and health. A binary logistic regression model was used to identify the association between independent variables and self-reported diabetes. Results: The prevalence of diabetes was 26.3%, 27.7%, and 28.1% in 2015, 2018, and 2021, respectively. This prevalence decreased with age and was higher for female, urban older adults, those with multimorbidity, a lower level of education, and without social security coverage for the three years. Age was associated with a lower possibility of presenting diabetes ([OR = 0.79[0.71-0.89]] and [OR = 0.41[0.33-0.52]] in groups aged 75-84 years and ≥85 years, respectively). Females continue to be more likely to present diabetes than males (OR = 1.39 [95% CI 1.25-1.55]). Older adults living in rural areas are 20% less likely to present diabetes than those living in urban areas (OR = 0.80 [95% CI 0.69-0.93]). Uninsured older adults (OR = 1.35 [95% CI 1.20-1.53]), those who wear glasses (OR = 1.23 [95% CI 1.16-1.30]), those with multimorbidity (OR = 1.13 [95% CI 1.01-1.27]), and those who currently drink alcohol (OR = 1.12 [95% CI 1.00-1.25]) were significantly more likely to have diabetes. Conclusion: An elevated prevalence of diabetes was found in older adults in Mexico, while not having access to social security was associated with a higher possibility of presenting diabetes and living in a rural area was associated with a lower possibility of presenting diabetes. Detection, prevention, and control programs should be implemented to reduce the incidence and severity of the disease in older adults and, thus, prevent its associated complications.

The impact of social deprivation on development and progression of diabetic kidney disease

Introduction

Diabetes is one of the leading causes of chronic kidney disease. Social deprivation is recognised as a risk factor for complications of diabetes, including diabetic kidney disease. The effect of deprivation on rate of decline in renal function has not been explored in the Irish Health System to date. The objective of this study is to explore the association between social deprivation and the development/progression of diabetic kidney disease in a cohort of adults living with diabetes in Ireland.

Methods

This is a retrospective cohort study using an existing dataset of people living with diabetes who attended the diabetes centre at University Hospital Galway from 2012 to 2016. The variables included in this dataset include demographic variables, type and duration of diabetes, clinical variables such as medication use, blood pressure and BMI and laboratory data including creatinine, urine albumin to creatinine to ratio, haemoglobin A1c and lipids. This dataset will be updated with laboratory data until January 2023. Individual's addresses will be used to calculate deprivation indices using the Pobal Haase Pratschke (HP) deprivation index. Rate of renal function decline will be calculated using linear mixed-effect models. The relationship between deprivation and renal function will be assessed using linear regression (absolute and relative rate of renal function decline based on eGFR) and logistic regression models (rapid vs. non-rapid decline).

Type 2 diabetes mellitus in patients with ischemic stroke - A nationwide study

AIMS

Type 2 diabetes (T2D) is a risk factor for ischemic stroke (IS) and associated with an adverse prognosis. Both stroke and diabetes care has evolved substantially during the last decade. This study aimed to determine the prevalence of T2D among IS patients along with time trends in the risk profile, use of glucose-lowering medications, quality-of-care and clinical outcomes, including stroke severity; length-of-stay; mortality, readmission and recurrent stroke in a large national cohort.

METHODS

Registry-based cohort study including all IS events in Denmark from 2004 to 2020. IS with co-morbid T2D were compared to IS without diabetes while adjusting for age, sex, stroke severity, co-morbidity and socio-economic factors.

RESULTS

The study included 169,262 IS events; 24,479 with co-morbid T2D. The prevalence of T2D in IS increased from 12.0% (2004-2006) to 17.0% (2019-2020). The adjusted absolute 30-day mortality risk in IS with T2D decreased from 9.9% (2004-2006) to 7.8% (2019-2020). The corresponding adjusted risk ratios (aRR) were 1.22 95% confidence interval (1.09-1.37) and 1.29 (1.11-1.50), respectively. The aRR of 365-day mortality was in 2004-2006: 1.20 (1.12-1.29) and in 2019-2020: 1.34 (1.22-1.47). The 30- and 365-day readmissions rates were also consistently higher in IS with T2D.

CONCLUSIONS

The prevalence of T2D in IS increased over time. The 30- and 365-day mortality rates decreased over the time-period but were consistently higher in IS with co-morbid T2D. Readmissions were also higher in IS with T2D. This highlights an urgent need for strategies to further improve the prognosis in IS patients with co-morbid T2D.

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.

Associations of social determinants of health with life expectancy and future health risks among individuals with type 2 diabetes: two nationwide cohort studies in the UK and USA

BACKGROUND

Social determinants of health (SDHs) are the primary drivers of preventable health inequities, and the associations between SDHs and health outcomes among individuals with type 2 diabetes remain unclear. This study aimed to estimate the associations of combined SDHs with life expectancy and future health risks among adults with type 2 diabetes from the UK and USA.

METHODS

In an analysis of two nationwide cohort studies, adults with type 2 diabetes were identified from the UK Biobank from March 13, 2006, to Oct 1, 2010 (adults aged 37-73 years) and the US National Health and Nutrition Examination Survey (NHANES) from 1999 to 2018 (adults aged ≥20 years). Participants with type 2 diabetes at baseline were included in our analysis. Participants without information on SDHs or follow-up were excluded. The UK Biobank assessed 17 SDHs and the US NHANES assessed ten SDHs, with each SDH dichotomised into advantaged and disadvantaged levels. The combined score of SDHs were calculated as the sum of the weighted scores for each SDH. Participants were then categorised into tertiles (favourable, medium, and unfavourable SDH groups). Primary outcomes were life expectancy and mortality in both cohorts, and incidences of cardiovascular disease, diabetes-related microvascular disease, dementia, and cancer in the UK Biobank. Outcomes were obtained from disease registries up until Dec 31, 2021, in the UK Biobank and Dec 31, 2019, in the US NHANES cohorts.

FINDINGS

We included 17 321 participants from the UK Biobank cohort (median age 61·0 years [IQR 56·0-65·0]; 6028 [34·8%] women and 11 293 [65·2%] men) and 7885 participants from the NHANES cohort (mean age 59·2 years [95% CI 58·7-59·6]; 3835 [49·1%, weighted] women and 4050 [50·9%, weighted] men) in our analysis. In the UK Biobank, 3235 deaths (median follow-up 12·3 years [IQR 11·5-13·2]), 3010 incident cardiovascular disease (12·1 years [10·8-13·0]), 1997 diabetes-related microvascular disease (8·0 years [7·1-8·9]), 773 dementia (12·6 years [11·8-13·5]), and 2259 cancer cases (11·3 years [10·4-12·2]) were documented; and the US NHANES documented 2278 deaths during a median follow-up of 7·0 years (3·7-11·2). After multivariable adjustment, compared with the favourable SDH group, the hazard ratio was 1·33 (95% CI 1·21-1·46) in the medium SDH group and 1·89 (1·72-2·07) in the unfavourable SDH group in the UK Biobank cohort; 1·51 (1·34-1·70) in the medium SDH group and 2·02 (1·75-2·33) in the unfavourable SDH group in the US NHANES cohort for all-cause mortality; 1·13 (1·04-1·24) in the medium SDH group and 1·40 (1·27-1·53) in the unfavourable SDH group for incident cardiovascular disease; 1·13 (1·01-1·27) in the medium SDH group and 1·41 (1·26-1·59) in the unfavourable SDH group for incident diabetes-related microvascular disease; 1·35 (1·11-1·64) in the medium SDH group and 1·76 (1·46-2·13) in the unfavourable SDH group for incident dementia; and 1·02 (0·92-1·13) in the medium SDH group and 1·17 (1·05-1·30) in the unfavourable SDH group for incident cancer in the UK Biobank cohort (ptrend<0·010 for each category). At the age of 45 years, the mean life expectancy of participants was 1·6 years (0·6-2·3) shorter in the medium SDH group and 4·4 years (3·3-5·4) shorter in the unfavourable SDH group than in the favourable SDH group in the UK Biobank. In the US NHAHES cohort, the life expectancy was 1·7 years (0·6-2·7) shorter in the medium SDH group and 3·0 years (1·8-4·3) shorter in the unfavourable SDH group, compared with the favourable group.

INTERPRETATION

Combined unfavourable SDHs were associated with a greater loss of life expectancy and higher risks of developing future adverse health outcomes among adults with type 2 diabetes. These associations were similar across two nationwide cohorts from varied social contexts, and were largely consistent across populations with different demographic, lifestyle, and clinical features. Thus, assessing the combined SDHs of individuals with type 2 diabetes might be a promising approach to incorporate into diabetes care to identify socially vulnerable groups and reduce disease burden.

FUNDING

The National Natural Science Foundation of China, the National Key R&D Program of China, and the Fundamental Research Funds for the Central Universities.

Correlates of Self-Reported Executive Function Impairment Among Medicaid Beneficiaries With Type 2 Diabetes

Aims

Executive function (EF) impairment is associated with poorer outcomes for individuals with type 2 diabetes. Previous research has identified risk factors for EF impairment, but many of these are also associated with type 2 diabetes. To address this issue, this study identified relevant variables from the literature and compared their association with EF in a sample of people with type 2 diabetes.

Methods

Adult members of a Medicaid health plan diagnosed with type 2 diabetes were enrolled in a social needs intervention trial. Using baseline data from the trial, bivariate and multivariable regression analyses examined associations between EF and demographic, health, and psychosocial factors.

Results

When controlling for other factors, we identified six significant correlates of EF impairment: age (β = 0.10), education (college vs. no college; β = -0.38), depression symptoms (β = 0.18), comorbidity burden (β = 0.21), diabetes-related distress (β = 0.14), and future time orientation (β = -0.13).

Conclusion

Our analysis identified several factors associated with greater EF impairment, which may interfere with diabetes self-management. Providers should consider these factors when prescribing treatments and determine whether additional resources or accommodations are warranted.

Characteristics associated with perceived level of confidence managing diabetes among United States adults with diabetes: A retrospective cross-sectional study

Objectives

Identifying characteristics associated with patients' confidence managing diabetes may aid the primary care provider in offering diabetes self-management education and support to patients. This analysis assessed the relationship between demographic, health, economic, access to care, satisfaction with care, and healthcare utilization characteristics with patients' confidence managing diabetes.

Methods

United States adults with diabetes in the 2020 Medical Expenditure Panel Survey were included in this retrospective cross-sectional analysis. Characteristics related statistically to patients' confidence managing diabetes in multivariable logistic regression analysis were reported.

Results

Among the 1,516 eligible individuals, 76.3% stated they were very confident/confident with their diabetes management. Adults who perceived their health positively (odds ratio 2.3, 95% confidence interval [CI] 1.3-3.9), completed ≥30 min moderate/vigorous exercise five times weekly (odds ratio 1.6, 95% CI 1.0-2.6), had at least one inpatient discharge in 2020 (odds ratio 3.5, 95% CI 1.5-8.1), said it was not difficult to telephone their usual provider (odds ratio 3.3, 95% CI 1.4-7.8), and had no emergency room visits in 2020 (odds ratio 2, 95% CI 1.1-3.3) had higher odds of stating they were very confident or confident with their diabetes management.

Conclusion

The characteristics associated with being very confident/confident managing diabetes should be considered by primary healthcare physicians and other healthcare professionals when helping patients manage diabetes.

Income variability and incident cardiovascular disease in diabetes: a population-based cohort study

BACKGROUND AND AIMS

Longitudinal change in income is crucial in explaining cardiovascular health inequalities. However, there is limited evidence for cardiovascular disease (CVD) risk associated with income dynamics over time among individuals with type 2 diabetes (T2D).

METHODS

Using a nationally representative sample from the Korean National Health Insurance Service database, 1 528 108 adults aged 30-64 with T2D and no history of CVD were included from 2009 to 2012 (mean follow-up of 7.3 years). Using monthly health insurance premium information, income levels were assessed annually for the baseline year and the four preceding years. Income variability was defined as the intraindividual standard deviation of the percent change in income over 5 years. The primary outcome was a composite event of incident fatal and nonfatal CVD (myocardial infarction, heart failure, and stroke) using insurance claims. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated after adjusting for potential confounders.

RESULTS

High-income variability was associated with increased CVD risk (HRhighest vs. lowest quartile 1.25, 95% CI 1.22-1.27; Ptrend < .001). Individuals who experienced an income decline (4 years ago vs. baseline) had increased CVD risk, which was particularly notable when the income decreased to the lowest level (i.e. Medical Aid beneficiaries), regardless of their initial income status. Sustained low income (i.e. lowest income quartile) over 5 years was associated with increased CVD risk (HRn = 5 years vs. n = 0 years 1.38, 95% CI 1.35-1.41; Ptrend < .0001), whereas sustained high income (i.e. highest income quartile) was associated with decreased CVD risk (HRn = 5 years vs. n = 0 years 0.71, 95% CI 0.70-0.72; Ptrend < .0001). Sensitivity analyses, exploring potential mediators, such as lifestyle-related factors and obesity, supported the main results.

CONCLUSIONS

Higher income variability, income declines, and sustained low income were associated with increased CVD risk. Our findings highlight the need to better understand the mechanisms by which income dynamics impact CVD risk among individuals with T2D.

Diabetes mellitus as a cause of premature death in small areas of Spain by socioeconomic level from 2016 to 2020: A multiple-cause approach

OBJECTIVE

This study aimed to assess premature mortality due to Diabetes in small areas of Spain between 2016 and 2020, and its relationship with socioeconomic level and the immediate cause of death. As a secondary objective, we evaluated the effect of the Covid 19 pandemic.

METHODS

This was an ecological study of premature mortality due to Diabetes from 2016 to 2020, with a focus on small areas. All deaths in people under 75 years of age due to Diabetes as the underlying cause were included RESULTS: The final sample comprised 7382 premature deaths in 5967 census tracts. Women living in census tracts with an high level of deprivation(RR=2.40) were at a significantly higher risk. Mortality from Diabetes increased with deprivation, especially people aged 0-54(RR=2.40). People with an immediate cause of death related to a circulatory disease, living in census tracts with an high level of deprivation(RR=3.86) was associated with a significantly greater risk of death with underlying Diabetes. When a disease of the circulatory system was recorded as the immediate cause of death, being 65-74 years (RR=71.01) was associated with a significantly higher risk of premature mortality.

CONCLUSIONS

Living in geographic areas with higher levels of socioeconomic deprivation is associated with a higher risk of premature death from Diabetes in Spain. This relationship has a greater impact on women, people under 54 years, and people at risk of death caused directly by diseases of the circulatory system. Premature mortality due to diabetes saw a modest increase in 2020.

Preferred sources of information on diabetes prevention programmes: a population-based cross-sectional study in Poland

OBJECTIVE

This study aimed to analyse preferred sources of information on diabetes prevention programmes and to identify sociodemographic determinants influencing these preferences among adults in Poland.

DESIGN

A cross-sectional survey was carried out between 15 and 18 September 2023 using a computer-assisted web interview. A self-prepared questionnaire included 10 questions on sources of information on type 2 diabetes prevention.

PARTICIPANTS

Data were obtained from 1046 adults (18-82 years); 53.4% were females.

RESULTS

Most respondents preferred email communication (46.4%), followed by a doctor or nurse (33.5%), and a letter or leaflet directly delivered to the mailbox (25.8%) for type 2 diabetes mellitus (DM2) prevention information. Younger respondents were more likely to indicate mass media (OR=1.81, 95% CI=1.12 to 2.95, p=0.01) and digital media (OR=1.65, 95% CI=1.02 to 2.67, p=0.04) as a source of information on DM2 prevention. Those who had higher education (OR=1.51, 95% CI=1.16 to 1.96, p=0.002), as well as those with chronic diseases (OR=1.50, 95% CI=1.14 to 1.97, p=0.004), were more likely to indicate digital media. Out of 10 different variables analysed in this study, passive occupational status (OR=1.43, 95% CI=1.04 to 1.96, p=0.03) as well as having chronic diseases (OR=1.51, 95% CI=1.16 to 1.96, p=0.002) were associated with higher odds of indicating healthcare workers as a preferred source of information. Marital status, having children, place of residence, household characteristics and financial status do not significantly decide communication preferences.

CONCLUSION

Communication on DM2 prevention should be adjusted to public preferences and expectations. Tailoring interventions to different demographic groups can enhance outreach and engagement. Email emerged as a popular choice, suggesting the potential of digital communication in preventive health programmes.

Social deprivation and diabetic kidney disease: A European view

There is a large body of literature demonstrating a social gradient in health and increasing evidence of an association between social deprivation and diabetes complications. Diabetic kidney disease (DKD) increases mortality in people with diabetes. Socioeconomic deprivation is increasingly recognized as a modifier of risk factors for kidney disease but also an independent risk factor itself for kidney disease. This may not be truly appreciated by clinicians and warrants further attention and exploration. In this review we explore the literature to date from Europe on the relationship between social deprivation and DKD. The majority of the studies showed at least an association with microalbuminuria, an early marker of DKD, while many showed an association with overt nephropathy. This was seen across many countries in Europe using a variety of different measures of deprivation. We reviewed and considered the mechanisms by which deprivation may lead to DKD. Health related behaviors such as smoking and suboptimal control of risk factors such as hypertension, hyperglycemia and elevated body mass index (BMI) accounts for some but not all of the association. Poorer access to healthcare, health literacy, and stress are also discussed as potential mediators of the association. Addressing deprivation is difficult but starting points include targeted interventions for people living in deprived circumstances, equitable roll out of diabetes technology, and flexible outpatient clinic arrangements including virtual and community-based care.

Diagnosis rates, therapeutic characteristics, lifestyle, and cancer screening habits of patients with diabetes mellitus in a highly deprived region in Hungary: a cross-sectional analysis

Introduction

Low socioeconomic status affects not only diagnosis rates and therapy of patients with diabetes mellitus but also their health behavior. Our primary goal was to examine diagnosis rates and therapy of individuals with diabetes living in Ormánság, one of the most deprived areas in Hungary and Europe. Our secondary goal was to examine the differences in lifestyle factors and cancer screening participation of patients with diagnosed and undiagnosed diabetes compared to healthy participants.

Methods

Our study is a cross-sectional analysis using data from the "Ormánság Health Program". The "Ormánság Health Program" was launched to improve the health of individuals in a deprived region of Hungary. Participants in the program were coded as diagnosed diabetes based on diagnosis by a physician as a part of the program, self-reported diabetes status, and self-reported prescription of antidiabetic medication. Undiagnosed diabetes was defined as elevated blood glucose levels without self-reported diabetes and antidiabetic prescription. Diagnosis and therapeutic characteristics were presented descriptively. To examine lifestyle factors and screening participation, patients with diagnosed and undiagnosed diabetes were compared to healthy participants using linear regression or multinomial logistic regression models adjusted for sex and age.

Results

Our study population consisted of 246 individuals, and 17.9% had either diagnosed (n=33) or undiagnosed (n=11) diabetes. Metformin was prescribed in 75.8% (n=25) of diagnosed cases and sodium-glucose cotransporter-2 inhibitors (SGLT-2) in 12.1% (n=4) of diagnosed patients. After adjustment, participants with diagnosed diabetes had more comorbidities (adjusted [aOR]: 3.50, 95% confidence interval [95% CI]: 1.34-9.18, p<0.05), consumed vegetables more often (aOR: 2.49, 95% CI: 1.07-5.78, p<0.05), but desserts less often (aOR: 0.33, 95% CI: 0.15-0.75, p<0.01) than healthy individuals. Patients with undiagnosed diabetes were not different in this regard from healthy participants. No significant differences were observed for cancer screening participation between groups.

Conclusions

To increase recognition of diabetes, targeted screening tests should be implemented in deprived regions, even among individuals without any comorbidities. Our study also indicates that diagnosis of diabetes is not only important for the timely initiation of therapy, but it can also motivate individuals in deprived areas to lead a healthier lifestyle.

Racial Disparities in Selected Complications and Comorbidities among People with Type 2 Diabetes

Type 2 diabetes (T2D) is a growing public health concern, disproportionately impacting racial and ethnic minorities. Assessing disparities is the first step towards achieving the translation goal to reduce disparities in diabetes outcomes, according to the Centers for Disease Control and Prevention (CDC)'s Division of Diabetes. We analyzed the data of patients (18+ years) diagnosed with T2D between 1 January 2012 and 31 March 2017, using the electronic health records of the University of Texas Medical Branch at Galveston. We compared the crude rate and age-standardized rate (using direct method) of selected micro- and macrovascular complication rates, associated obesity, and insulin dependence among racial and ethnic groups. Our sample included 20,680 patients who made 394,106 visits (9922 non-Hispanic White patients, 4698 non-Hispanic Black patients, and 6060 Hispanic patients). Our results suggest a higher risk of acquiring macrovascular (hypertension, ischemic disease, and stroke) and microvascular (renal, ophthalmic, and neurological) complications in Black patients compared to non-Hispanic White and Hispanic patients. The rates of stage I or II obesity were higher in Black patients compared with White and Hispanic patients. The rates of insulin use rather than oral hypoglycemics were also higher in Black patients than White and Hispanic patients. The disparities in terms of the higher susceptibility to complications among Black patients are possibly linked to the socioeconomic disadvantages of this population, leading to poorer management. Prevention strategies are warranted to reduce the incidence of T2D complications in racial minorities.

Assessment of diabetic foot ulcers: back to basics

Diabetic foot ulceration affects up to 34% of the global diabetic population as a result of poor glycaemic control. Complications resulting from diabetic foot ulceration can be complex, expensive and challenging. It is important for risk factors to be recognised early and for regular assessment to take place. Streamlining a coordinated approach that enhances communication and guides treatment approaches can help to improve wound outcomes.

Understanding the Burden of Nonalcoholic Fatty Liver Disease: Time for Action

The prevalence of nonalcoholic fatty liver disease (NAFLD) in the United States is 38%, having increased by 50% within the past 3 decades. The estimated NAFLD prevalence among people with type 2 diabetes is 55-70%. The presence of type 2 diabetes is associated with a higher likelihood of progression of NAFLD to fibrosis development, liver transplant, and death. Cardiovascular disease is the main cause of mortality among people with NAFLD, and the risk of death is significantly higher in people with both NAFLD and type 2 diabetes. NAFLD carries high patient and economic burdens but low awareness among both the general public and health care providers. This article reviews the epidemiology of NAFLD and discusses the need for appropriate risk stratification, referral for specialty care, management of cardiometabolic risk factors, and treatment of the disease. The authors present a call to action to raise awareness of NAFLD and address its increasing burden in a systematic and efficient manner.

Overadjustment bias in systematic reviews and meta-analyses of socio-economic inequalities in health: a meta-research scoping review

BACKGROUND

Overadjustment bias occurs when researchers adjust for an explanatory variable on the causal pathway from exposure to outcome, which leads to biased estimates of the causal effect of the exposure. This meta-research review aimed to examine how previous systematic reviews and meta-analyses of socio-economic inequalities in health have managed overadjustment bias.

METHODS

We searched Medline and Embase until 16 April 2021 for systematic reviews and meta-analyses of observational studies on associations between individual-level socio-economic position and health outcomes in any population. A set of criteria were developed to examine methodological approaches to overadjustment bias adopted by included reviews (rated Yes/No/Somewhat/Unclear).

RESULTS

Eighty-four reviews were eligible (47 systematic reviews, 37 meta-analyses). Regarding approaches to overadjustment, whereas 73% of the 84 reviews were rated as Yes for clearly defining exposures and outcomes, all other approaches were rated as Yes for <55% of reviews; for instance, 5% clearly defined confounders and mediators, 2% constructed causal diagrams and 35% reported adjusted variables for included studies. Whereas only 2% included overadjustment in risk of bias assessment, 54% included confounding. Of the 37 meta-analyses, 16% conducted sensitivity analyses related to overadjustment.

CONCLUSIONS

Our findings suggest that overadjustment bias has received insufficient consideration in systematic reviews and meta-analyses of socio-economic inequalities in health. This is a critical issue given that overadjustment bias is likely to result in biased estimates of health inequalities and accurate estimates are needed to inform public health interventions. There is a need to highlight overadjustment bias in review guidelines.