A socioeconomic and behavioral survey of patients with difficult-to-control type 2 diabetes mellitus reveals an association between diabetic retinopathy and educational attainment

Socioeconomic Status, Modifiable Factors, and Risk of Microvascular Complications in Individuals With Type 2 Diabetes: A Cohort Study From the UK Biobank

BACKGROUND

To investigate whether lower socioeconomic status (SES) was associated with an increased risk of diabetic microvascular complications and to analyze the potential mediating role of several modifiable factors.

METHODS

The study included 11 309 patients with type 2 diabetes at baseline from the UK Biobank cohort. SES was grouped based on income, education, and employment status by using latent class analysis. Microvascular complications of diabetes were identified through electronic health records. Cox regression models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for microvascular complications across SES groups. Mediation analysis was applied to explore potential mediators in these associations.

RESULTS

During a median follow-up of 12.2 years, 262, 764, and 1017 participants in the high, medium, and low SES groups were diagnosed with microvascular complications. Compared to participants with high SES, those with low SES had a HR of 1.75 (95% CI: 1.53, 2.01) for total microvascular complications, a HR of 2.11 (95% CI: 1.74, 2.55) for nephropathy, a HR of 1.40 (95% CI: 1.14, 1.72) for retinopathy, and a HR of 1.79 (95% CI: 1.32, 2.43) for neuropathy. Mediation analysis indicated that alcohol consumption, body mass index, triglycerides, high density lipoprotein cholesterol, and glycated hemoglobin mediated the association between SES and microvascular complications, with mediation percentages of 1.3%, 12.2%, 4.4%, 10.9%, and 10.8%, respectively.

CONCLUSIONS

Lower SES may be associated with a higher risk of diabetic microvascular complications, and obesity-related indicators and glycated hemoglobin may play important mediating roles in the association.

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 Prevalence and Progression of Microvascular Complications and the Interaction With Ethnicity and Socioeconomic Status in People With Type 2 Diabetes: A Systematic Review and Meta-Analysis

Introduction: Diabetic nephropathy (DN) and diabetic retinopathy (DR) are serious complications of type 2 diabetes mellitus (T2DM). The reported estimates of prevalence and progression of DN and DR vary widely across studies. We undertook a systematic review and meta-analysis to determine the extent to which these variations in prevalence and progression of DN and DR may relate to different ethnic groups and socioeconomic status (SES). Methods: We searched the databases Ovid MEDLINE, Global Health, APA Psych Info, Embase, and PubMed for publications from 2005 to September 2023, based on T2DM and DN or DR, which included patient's ethnicities and SES. Prevalence estimates were summarized by meta-analysis using random effects models for each microvascular complication, stratified by ethnicity and SES. Data on progression was summarized narratively. Results: Twenty-seven studies were included. The overall prevalence of DN was 18% (95% CI: 14%, 22%) with no differences noted by ethnic group. Low economic status and low education levels were associated with a 4% increased risk of DN compared to higher levels. Higher prevalence of DR was noted among the Afro-Caribbeans, 28% (95% CI: 11%, 46%), compared to the White/Caucasian 19% (95% CI: 11%, 27%), and Asian/Indo Asians 25% (95% CI: 9%, 41%). Low-SES populations have a higher prevalence of DR than high-SES populations. The average prevalence was 16% (95% CI: 11%, 22%) among the high economic status group, compared to 25% (95% CI:20%, 30%) for the low economic status. Our study showed that Black ethnicity was associated with a higher risk of progression to end-stage renal disease (ESRD) and diabetic maculopathy compared to other ethnicities. People with high SES had a lower rate of DR progression than those with low SES, odds ratio (OR) (0.63, 95% CI: 53%, 74%). Conclusion: Ethnicity and SES may be associated with differential risk of development and progression of DN and DR. The available evidence was limited by the number of studies and small samples for certain ethnic/socioeconomic groups.

Diabetic Retinopathy Disease Burden in Patients With Lower Household Incomes vs Higher Household Incomes

Purpose: To assess the differences in measures of diabetic retinopathy (DR) disease burden between patients in high-income vs low-income ZIP codes when presenting to retina specialists. Methods: This retrospective cohort study comprised patients who presented to a retina specialist at Duke Eye Center between 2014 and 2023 for the management of DR. The quartile of patients with the highest income was compared with the quartile with the lowest income. Demographic data included age, sex, and race. Clinical data included glycosylated hemoglobin A1c (HbA1c), visual acuity (VA), DR diagnostic stage, presence of diabetic macular edema (DME) or vitreous hemorrhage, and whether treatment was indicated. Measures of DR disease burden included HbA1c, VA, presence of DME or vitreous hemorrhage, severity of DR, and need for intervention. Results: The analysis included 430 eyes of 215 patients. After controlling for age, sex, race, and glycemic control, it was found that patients in the low-income group were more likely to have DME at presentation (P < .01), to have more severe DR at presentation (P < .001), and to require an intervention for DR (P < .001). The VA was worse in the low-income group than in the high-income group (20/50 vs 20/32; P < .10); however, this did not reach statistical significance. Conclusions: Patients living in low-income ZIP codes have greater DR severity, prevalence of DME, and need for treatment than their high-income counterparts when first presenting to a retina specialist. These findings suggest that patients from low-income backgrounds may face additional barriers before being evaluated by a retina specialist, resulting in more clinically advanced stages of DR at presentation.

Narrative review of comprehensive management strategies for diabetic retinopathy: interdisciplinary approaches and future perspectives

This review examines the epidemiological trends, pathophysiologic mechanisms, and current and future therapeutic strategies for diabetic retinopathy (DR), focusing on innovative management countermeasures in the face of this global public health challenge. As the number of patients with diabetes continues to increase, DR, as one of its major complications, poses a significant threat to global visual health. This review not only summarises the latest advances in personalised treatment and emerging therapeutic modalities (such as anti-vascular endothelial growth factor therapy, laser treatment, surgical procedures and cutting-edge gene and stem cell therapies) but also emphasises the revolutionary potential of telemedicine technologies and digital health platforms to improve DR screening and adherence among people with diabetes. We show how these technological innovations, especially in resource-limited settings, can achieve early diagnosis and effective treatment, thereby significantly reducing the public health burden of DR. In addition, this article highlights the critical role of interdisciplinary teamwork in optimising the comprehensive management of DR, involving close collaboration among physicians, researchers, patient education specialists and policy-makers, as well as the importance of implementing these innovative solutions through societal engagement and policy support. By highlighting these innovative strategies and their specific impact on improving public health practices, this review offers new perspectives and strategies for the future management of DR, with the goal of promoting the prevention, diagnosis and treatment of DR worldwide, improving patient prognosis and enhancing quality of life.

No relationship between socioeconomic status, education level and development and progression of diabetic retinopathy in type 2 diabetes: a FIELD trial substudy

In 6002 Australian adults with type 2 diabetes and a median 5-year follow-up in the FIELD (Fenofibrate Intervention and Event Lowering in Diabetes) trial, baseline socioeconomic status (SES) and self-reported education level were not related to development of on-trial sight-threatening diabetic retinopathy. Similarly, in a retinal photography substudy (n = 549), two-step diabetic retinopathy progression was not related to SES or education.

Time and risk preferences and the perceived effectiveness of incentives to comply with diabetic retinopathy screening among older adults with type 2 diabetes

Behavioral economics has the potential to inform the design of incentives to improve disease screening programs by accounting for various behavioral biases. We investigate the association between multiple behavioral economics concepts and the perceived effectiveness of incentive strategies for behavioral change among older patients with a chronic disease. This association is examined by focusing on diabetic retinopathy screening, which is recommended but very variably followed by persons living with diabetes. Five time and risk preference concepts (i.e., utility curvature, probability weighting, loss aversion, discount rate, and present-bias) are estimated simultaneously in a structural econometric framework, based on a series of deliberately-designed economic experiments offering real money. We find that higher discount rates and loss aversion and lower probability weighting are significantly associated with lower perceived effectiveness of intervention strategies whereas present-bias and utility curvature have an insignificant association with it. Finally, we also observe strong urban vs. rural heterogeneity in the association between our behavioral economic concepts and the perceived effectiveness of intervention strategies.

Prevalence and factors associated with Diabetes retinopathy among type 2 diabetic patients at Northwest Amhara Comprehensive Specialized Hospitals, Northwest Ethiopia 2021

INTRODUCTION

The worldwide prevalence of Diabetic Retinopathy was recently estimated to be 34.6%. The prevalence of diabetic retinopathy in developed nations has been thoroughly investigated, and risk factors are well understood. However, there is a shortage of information in the study areas about the prevalence and contributing factors of diabetic retinopathy among type two diabetes patients.

OBJECTIVE

The aim of this study was to assess the prevalence of diabetic retinopathy and associated factor among type 2 diabetic patients who were on follow up services at northwest Amhara comprehensive specialized hospitals diabetic care units.

METHOD

An institutional based cross-sectional study was conducted at northwest Amhara comprehensive specialized hospitals from October 15 to November 15, 2021, among 496 diabetes patients. Systematic random sampling technique was used. Data were collected by utilizing a semi-structured questionnaire and a direct Topcon retinal camera inspection. Then data were coded, entered, and exported to SPSS version 23 from EPI-Data version 4.6. All variables with P-value < 0.25 in the binary logistic regression analyses were included in the multivariable regression analysis. The degree of association was interpreted by using the adjusted odds ratio with 95% confidence intervals, and the significance level was declared at P-value < 0.05. The Hosmer-Lemeshow test was used to check the fitness of the model.

RESULT

The prevalence of diabetic retinopathy among type two diabetes patients was 36.3%. Sex [AOR = 3.25, 95% CI (1.80, 6.68)], visiting health institution [AOR = 0.027, 95% CI (0.003, 0.253)], educational level [AOR = 4.23, 95% CI (1.09, 16.47)], glycemic control [AOR = 0.099, 95% CI (0.02, 0.49)], hypertension status (AOR = 2.56, 95% CI (1.01, 6.45)] were significantly associated with diabetic retinopathy.

CONCLUSION

In this study less than half of diabetic patients had diabetic retinopathy. Sex, visiting health institution, educational level, glycemic control, and hypertension status were significantly associated with diabetic retinopathy.

Single-Field Fundus Photography for Screening of Diabetic Retinopathy: The Prevalence and Associated Factors in a Population-Based Study

INTRODUCTION

We aimed to determine the prevalence and risk factors for diabetic retinopathy (DR) in a multi-primary healthcare facilities-based DR screening project by analyzing single-field fundus photographs among patients with diabetes in Rafsanjan City, Iran, based on the Rafsanjan Cohort Study, as a part of the prospective epidemiological research studies in IrAN (PERSIAN).

METHODS

Of all participants in the Rafsanjan Cohort Study (performed in four primary healthcare facilities across Rafsanjan City from August 2015 to December 2017), patients with diabetes were recruited in this study. All participants underwent a standardized interview and clinical and paraclinical examinations for demographic characteristics, and medical conditions according to the PERSIAN's protocols. In addition, digital fovea-centered and single-field fundus photography was performed for DR identification and grading. For assessment of agreement, a subgroup of participants underwent fundus examination, randomly. DR was graded as nonproliferative (NPDR) or proliferative (PDR).

RESULTS

Of 8414 screened participants, 1889 had diabetes. The total prevalence of DR was 6.93% [131 individuals including 110 (5.82%) with NPDR, and 21 (1.11%) with PDR] based on single-field fundus photographs, with almost perfect agreement with fundus examinations (κ = 0.82). On adjusted multivariate analysis, duration of diabetes (OR 1.16, 95% CI 1.13-1.19), positive family history for diabetes (OR 1.73, 95% CI 1.09-2.75), fasting plasma glucose (FPG) ≥ 126 mg/dL (OR 1.98, 95% CI 1.16-3.39), and serum creatinine level (OR 1.79, 95% CI 1.08-2.98) were associated with DR. Factors including age, education level, physical activity, body mass index, hypertension, and cardiovascular and renal diseases did not have association with DR on adjusted multivariate analysis.

CONCLUSIONS

Single-field fundus photography can be used for screening of DR in primary healthcare facilities. In individuals with diabetes, duration of diabetes, positive family history for diabetes, FPG ≥ 126 mg/dL, and serum creatinine level may be associated with DR.

Physical Activity Reduces the Risk of Developing Diabetes and Diabetes Medication Use

Diabetes is a global public health challenge, exerting a large socioeconomic burden on healthcare systems. This study aimed to explore Diabetes prevalence and Diabetes medication use in diabetics regarding sex, age group, Physical Activity Level (PAL) and Body Mass Index (BMI) by studying possible differences and calculating the risks of developing Diabetes and Diabetes medication use in the population according to their PAL. A cross-sectional study was conducted using data extracted from the Spanish National Health Survey (ENSE2017). The sample was finally composed of 17,710 participants. A descriptive analysis was performed to characterise Diabetes prevalence and Diabetes medication use (Chi-square test and a z-test for independent proportions). Odds Ratios (OR) and 95% Confidence Intervals (CI) were calculated for Diabetes prevalence and Diabetes medication use according to the participants’ PAL. Both the Diabetes and Diabetes medication use was higher in men than in women, increasing with age and BMI, and decreasing with increasing PAL (p < 0.001). Higher prevalence levels were observed in the inactive group versus very active or active people (p < 0.001). Inactive people had a higher risk of Diabetes and use of Diabetes medication risk compared to the very active and active groups. Prevalence decreased the higher the PAL both in men and women.

Socioeconomic disparity in global vision loss burden due to diabetic retinopathy: an analysis on time trends from 1990 to 2017

PURPOSE

To describe the trends of socioeconomic disparity in global vision loss burden associated with diabetic retinopathy (DR) based on prevalence and years lived with disability (YLDs).

METHODS

In the Global Burden of Disease (GBD) 2017 study, we extracted global, regional, national, and World Bank categorical epidemiological data in vision impairment by time and age. We searched the Human development index (HDI) from the Human Development Report. Pearson correlation, linear regression, and Kruskal-Wallis test were conducted to analyze the correlation between YLD rates and HDI. We used the Gini coefficient and concentration index to evaluate the socioeconomic inequality trendency.

RESULTS

The global and World Bank categorical prevalence and YLDs increased from 1990 to 2017, and rose with ageing. The age-standardized prevalence and YLD rates varied geographically and highest in the Eastern Mediterranean countries. Higher vision loss burden of DR was concentrated in countries with medium level of socioeconomic development, including lower/upper middle-income and medium/high-HDI countries. The Gini coefficient decreased from 0.572 in 1990 to 0.542 in 2017, showing the decreasing between-country inequality. The concentration index decreased from 0.153 in 2000 to 0.061 in 2017, showing the reducing socioeconomic-associated disparity.

CONCLUSION

The vision loss burden of DR increased in the past few decades, with a notable declining socioeconomic disparity since 2000. Our results highlight the necessity to provide more services to reduce the vision loss burden.

Risk Preferences, Rationality of Choices, and Willingness to Pay for Preventive Medicine in Patients with Graves' Thyrotoxicosis

PURPOSE

Patients with thyrotoxicosis show neuropsychological changes, and these may damage the quality of informed consent in clinical practice. Therefore, we examined patients' real-life preferences to assess whether change in risk preferences was dependent on thyroid function state.

PATIENTS AND METHODS

The participants were 86 patients who were newly diagnosed with Graves' thyrotoxicosis between 1 January and 31 December 2018 (group A), and an additional 33 euthyroid patients diagnosed before 2018 (group B). In a survey conducted via a questionnaire based on the concept of behavioral economics, we sought to determine risk preferences, rationality of choices, and other relevant factors. An identical second survey was completed 6-12 months later by 36 patients in group A after their thyroid functions had been normalized by treatment, and by 11 euthyroid patients in group B. We performed paired analysis of the first and second surveys in 32 patients of group A and single regression analysis of a total of 140 surveys obtained from 119 patients by combining the first and second surveys of groups A and B with serum level of FT3 as an independent variable.

RESULTS

The paired analysis indicated that there was no significant difference in any survey item. The single regression analysis revealed that willingness-to-pay (WTP) for preventive medicine and monthly average out-of-pocket (OOP) expenditure on medical care were both significantly positively associated with serum level of FT3. Patients in the hyperthyroid state tend to have high WTP for preventive medicine, which may be accelerated by the anchoring effect of OOP expenditure.

CONCLUSION

Almost all risk preferences of patients with Graves' disease are constant, rational, and reproducible in the hyperthyroid and euthyroid states. However, medical professionals should be aware that the willingness of patients with thyrotoxicosis to pay for medical costs may change after the normalization of thyroid function.

Determinants of diabetic retinopathy in Southwest Ethiopia: a facility-based case-control study

Background

Diabetic Retinopathy is one of the serious complications patients’ diabetic patients suffer from. Little is known about which risk factors are associated with this complication. The aim of this study was therefore to identify determinants of Diabetic Retinopathy in Jimma University Medical Center.

Methods

A facility-based case-control study was conducted. Cases were Diabetic patients with diabetic retinopathy and who were on follow up at the Jimma University Medical Center while controls were Diabetic patients but free of diabetic retinopathy and who were on follow up at the Jimma University Medical Center. Cases and controls were identified and 311 of them were recruited using systematic random sampling. Data were entered into the Epi-Data version 4.1 and analyzed using SPSS Version 20. Binary Logistic regression analysis was conducted to identify determinants of diabetic retinopathy.

Result

A total of 106 cases and 205 controls diabetic participated in the study. Being ≥60 years of age (AOR = 5.04,95%CI: 1.83,13.87),being illiterate (AOR = 7.17, 95% CI: 2.61,19.7), poor adherence to medication (AOR =3: 95% CI: 1.29,6.95),having high systolic blood pressure (AOR = 3.38:95% CI: 1.26,9.05), having family history of Diabetes Mellitus (AOR = 3.95: 95% CI: 1.64,9.54), having other micro vascular complications (AOR = 3.76,95% CI: 1.33,10.66), poor glycemic control (AOR = 9.08, 95%CI: 3.7,22.29), poor cholesterol control (AOR = 0.21, 95%CI: 0.08,0.51) and being anaemic (AOR = 2.8, 95%CI: 1.05,7.47) were the independent determinants of diabetic retinopathy.

Conclusion

This study found that poor adherence to medication, being at the age of 60 years and above, being illiterate patients, having high systolic blood pressure, having a family history of Diabetes Mellitus, having other micro vascular complication, poor glycemic control, poor cholesterol control and being anemic patient were the independent determinants of diabetic retinopathy. Therefore, more attention should be given to older age and illiterate patients. Giving more emphasis for patients poorly adhered to anti-diabetic medications and giving advice for diabetic patients with high systolic blood pressure to follow their blood pressure regularly are also vital. Diabetic patients should also control their Blood sugar and blood cholesterol levels to prevent diabetic retinopathy or reduce its further complications.

Irrational Responses to Risk Preference Questionnaires by Patients with Diabetes with or without Retinopathy and Comparison with Those without Diabetes

PURPOSE

The risk preferences of patients with diabetes have profound effects on the progression of complications. The present study aimed to clarify whether the preferences of patients with diabetes and retinopathy are deliberately risk-seeking or irrational and whether this propensity is specific to those with retinopathy or is also found in patients without retinopathy compared with those without diabetes.

PATIENTS AND METHODS

A total of 394 patients with diabetes (264 without retinopathy and 130 with retinopathy) and 198 patients without diabetes agreed to participate in this survey. The questions were modified versions of those from the Japan Household Survey on Consumer Preferences and Satisfaction, which sought to determine the participants' personal socioeconomic status and risk preferences. In the questionnaires, responses were analyzed by determining the participants' willingness to pay for a lottery ticket and for an insurance policy. Irrational responses were defined as violations of two axioms of the Expected Utility Theory: completeness and transitivity.

RESULTS

The incidence of irrational responses increased with age and was associated with educational level. The incidence of irrational responses was significantly higher in patients with retinopathy than in those without retinopathy after adjusting for age and educational level. There was no significant difference in the incidence of irrational responses between patients with diabetes but without retinopathy and those without diabetes.

CONCLUSION

The risk-seeking behavior of patients with diabetes and retinopathy was not deliberate but was irrational under uncertainty. Medical professionals should be aware of their patients' propensity to make irrational decisions, which is an important risk factor for the progression of retinopathy in patients with diabetes regardless of age and educational level.

Socioeconomic inequalities and type 2 diabetes complications: A systematic review

BACKGROUND AND OBJECTIVES

A socioeconomic gradient related to type 2 diabetes (T2D) prevalence has been demonstrated in high-income countries. However, there is no evidence of such a socioeconomic gradient regarding diabetes complications. Thus, the aim of this systematic review was to collect data on risk of complications according to socioeconomic status in patients with T2D.

METHODS

PubMed and EMBASE were searched for English-language observational studies evaluating the prevalence or incidence of micro- and macrovascular complications according to individual and geographical socioeconomic status (SES). Observational studies reporting the prevalence and risk of micro- and macrovascular diabetes complications, according to an individual or geographical index of deprivation, were selected, and estimated crude and adjusted risks for each complication were reported.

RESULTS

Among the 28 included studies, most described a clear relationship between SES and diabetes complications, especially retinopathy (in 9 of 14 studies) and cardiopathy (in 8 of 9 studies). Both individual and area-based low SES was associated with an increased risk of complications. However, very few studies adjusted their analyses according to HbA_1c level.

CONCLUSION

Evaluation of SES is necessary for every T2D patient, as it appears to be a risk factor for diabetes complications. However, the available studies are insufficient for gradation of the impact of low socioeconomic level on each of these complications. Regardless, strategies for the improved screening, follow-up and care of high-risk patients should now be implemented.

Utilization patterns of insulin for patients with type 2 diabetes from national health insurance claims data in South Korea

Type 2 diabetes mellitus (T2DM) is a chronic disease that requires long-term therapy and regular check-ups to prevent complications. In this study, insurance claim data from the National Health Insurance Service (NHIS) of Korea were used to investigate insulin use in T2DM patients according to the economic status of patients and their access to primary physicians, operationally defined as the frequently used medical care providers at the time of T2DM diagnosis. A total of 91,810 participants were included from the NHIS claims database for the period between 2002 and 2013. The utilization pattern of insulin was set as the dependent variable and classified as one of the following: non-use of antidiabetic drugs, use of oral antidiabetic drugs only, or use of insulin with or without oral antidiabetic drugs. The main independent variables of interest were level of income and access to a frequently-visited physician. Multivariate Cox proportional hazards analysis was performed. Insulin was used by 9,281 patients during the study period, while use was 2.874 times more frequent in the Medical-aid group than in the highest premium group [hazard ratio (HR): 2.874, 95% confidence interval (CI): 2.588-3.192]. Insulin was also used ~50% more often in the patients managed by a frequently-visited physician than in those managed by other healthcare professionals (HR: 1.549, 95% CI: 1.434-1.624). The lag time to starting insulin was shorter when the patients had a low income and no frequently-visited physicians. Patients with a low level of income were more likely to use insulin and to have a shorter lag time from diagnosis to starting insulin. The likelihood of insulin being used was higher when the patients had a frequently-visited physician, particularly if they also had a low level of income. Therefore, the economic statuses of patients should be considered to ensure effective management of T2DM. Utilizing frequently-visited physicians might improve the management of T2DM, particularly for patients with a low income.

Socioeconomic status and time in glucose target range in people with type 2 diabetes: a baseline analysis of the GP-OSMOTIC study

BACKGROUND

Optimal glycaemia, reflected by glycated haemoglobin (HbA1c) levels, is key in reducing type 2 diabetes (T2D) complications. However, most people with T2D have suboptimal recall and understanding of HbA1c. Continuous glucose monitoring (CGM) measures glucose levels every 5 to 15-min over days and may be more readily understood. Given that T2D is more common in lower socioeconomic settings, we aim to study relationships between socioeconomic status (SES) and percentage time in glucose target range (TIR) which is a key metric calculated from CGM.

METHODS

Analysis of baseline data from the General Practice Optimising Structured MOnitoring To Improve Clinical outcomes (GP-OSMOTIC) randomised controlled trial (October 2016 - November 2017) of 300 people with T2D from 25 Victorian General Practices. FreeStyle Libre Pro® sensor patch was used for this study. SES was defined by the Index of Relative Socio-economic Disadvantage (IRSD) and educational attainment. Univariable and multivariable mixed-effects linear regression analyses controlling for age, BMI, diet, exercise and study arm were performed.

RESULTS

One hundred and sixty-seven (60.1%) participants were male, the mean (SD) participant age was 61.0 (9.7) years, and the mean (SD) duration of CGM use was 12.3 (2.5) days. The 10th IRSD decile (least disadvantaged) was associated with a 15% higher TIR vs. the 1st decile (most disadvantaged) (95% CI 5, 25; p = 0.003) and a 0.6% lower HbA1c (95% CI 0.1, 1; p = 0.03). There was no evidence of an association between educational attainment and TIR/HbA1c.

CONCLUSION

Higher SES measured at an area level is associated with better achievement of glycaemic target using complementary measures of HbA1c and TIR in the GP-OSMOTIC cohort. Given that TIR may be more easily used in patient education and self-management support compared to HbA1c values, the social gradient identified in TIR provides an opportunity for clinicians and policy makers to address health inequities in T2D.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry Trial ACTRN12616001372471 , prospective, Date registered 4/10/2016.

Basal-Bolus Insulin Therapy with Gla-300 During Hospitalization Reduces Nocturnal Hypoglycemia in Patients with Type 2 Diabetes Mellitus: A Randomized Controlled Study

INTRODUCTION

Although reduction in the incidence of nocturnal hypoglycemia, as estimated by symptom or self-monitored plasma glucose, was shown to be more pronounced with 300 units/mL insulin glargine (Gla-300) than with 100 units/mL insulin glargine (Gla-100) in type 2 diabetes patients, the exact frequency of nocturnal hypoglycemia estimated with continuous glucose monitoring (CGM) has not been reported.

METHODS

Forty patients with type 2 diabetes who were admitted for glycemic control with basal-bolus insulin therapy (BBT) were randomized into the Gla-100 and Gla-300 groups. Insulin doses were adjusted to maintain blood glucose levels within 100-120 mg/dL at each meal. Plasma glucose and C-peptide profiles were estimated serially after admission and before discharge. Daily CGM was also performed before discharge.

RESULTS

In the Gla-100 and Gla-300 groups, the mean duration of hospitalization was 15 ± 2 and 15 ± 1 days, respectively, and the mean basal insulin dose before discharge was 13 ± 7 and 15 ± 10 units, respectively. The dose of meal-time insulin was not different between the two groups. Compared with the Gla-300 group, the Gla-100 group had significantly lower nocturnal profiles of plasma glucose and C-peptide, but significantly higher frequency of CGM-estimated nocturnal hypoglycemia (10.7% ± 18.4% versus 1.2% ± 3.6%, P = 0.033).

CONCLUSION

In type 2 diabetic patients, reduction in the incidence of CGM-estimated nocturnal hypoglycemia by BBT under tightly controlled diet therapy was higher with Gla-300 than with Gla-100.

TRIAL REGISTRATION

UMIN clinical trials registry (UMIN000023360).