Health Care Spending on Diabetes in the U.S., 1996-2013

Impact of bodyweight loss on type 2 diabetes remission: a systematic review and meta-regression analysis of randomised controlled trials

BACKGROUND

Bodyweight loss is associated with type 2 diabetes remission; however, the quantitative relationship between the degree of bodyweight loss and the likelihood of remission, after controlling for confounding factors, remains unknown. We aimed to analyse the relationship between the degree of bodyweight loss and diabetes remission after controlling for various confounding factors, and to provide estimates for the effect sizes of these factors on diabetes remission.

METHODS

This systematic review and meta-regression analysis followed Cochrane and PRISMA guidelines to systematically review, synthesise, and report global evidence from randomised controlled trials done in individuals with type 2 diabetes and overweight or obesity. The outcome was the proportion of participants with complete diabetes remission (HbA1c <6·0% [42 mmol/mol] or fasting plasma glucose [FPG] <100 mg/dL [5·6 mmol/L], or both, with no use of glucose-lowering drugs) or partial diabetes remission (HbA1c <6·5% [48 mmol/mol] or FPG <126 mg/dL [7·0 mmol/L], or both, with no use of glucose-lowering drugs) at least 1 year after a bodyweight loss intervention. We searched PubMed, Embase, and trial registries from database inception up to July 30, 2024. Data were extracted from published reports. Meta-analyses and meta-regressions were performed to analyse the data. The study protocol is registered with PROSPERO (CRD42024497878).

FINDINGS

We identified 22 relevant publications, encompassing 29 outcome measures of complete diabetes remission and 33 outcome measures of partial remission. The pooled mean proportion of participants with complete remission 1 year after the intervention was 0·7% (95% CI 0·1-4·6) in those with bodyweight loss less than 10%, 49·6% (40·4-58·9) in those with bodyweight loss of 20-29%, and 79·1% (68·6-88·1) in those with bodyweight loss of 30% or greater; no studies reported on complete remission with 10-19% bodyweight loss. The pooled mean proportion of participants with partial remission 1 year after the intervention was 5·4% (95% CI 2·9-8·4) in those with bodyweight loss less than 10%, 48·4% (36·1-60·8) in those with 10-19% bodyweight loss, 69·3% (55·8-81·3) in those with bodyweight loss of 20-29%, and 89·5% (80·0-96·6) in those with bodyweight loss of 30% or greater. There was a strong positive association between bodyweight loss and remission. For every 1 percentage point decrease in bodyweight, the probability of reaching complete remission increased by 2·17 percentage points (95% CI 1·94-2·40) and the probability of reaching partial remission increased by 2·74 percentage points (2·48-3·00). No significant or appreciable associations were observed between age, sex, race, diabetes duration, baseline BMI, HbA1c, insulin use, or type of bodyweight loss intervention and remission. Overall, data were derived from randomised controlled trials with a low risk of bias in all quality domains.

INTERPRETATION

A robust dose-response relationship between bodyweight loss and diabetes remission was observed, independent of age, diabetes duration, HbA1c, BMI, and type of intervention. These findings highlight the crucial role of bodyweight loss in managing type 2 diabetes and reducing the risk of diabetes-related complications.

FUNDING

Biomedical Research Program at Weill Cornell Medicine-Qatar and the Qatar National Research Fund (a member of Qatar Foundation).

In-patient expenditure between 2011 and 2021 for patients with type 2 diabetes mellitus: a hospital-based multicenter retrospective study in southwest China

Background

Type 2 diabetes mellitus (T2DM) is a chronic non-infectious disease that seriously endangers human health. This study aimed to determine the main factors influencing the medical expenditure of T2DM patients and provide guidance for the allocation and control of medical expenditure.

Methods

The homepage data of patients with T2DM were retrospectively collected from six tertiary hospitals in southwest China from January 2011 to December 2021. A multiple linear regression model was constructed to examine the factors associated with medical expenses per patient. Furthermore, the trends of medical expenditure according to other important measures and patient subgroups were described, and a proportional breakdown of medical expenditure was generated. All expenditure data were reported in Chinese Yuan (CNY), based on the 2021 value, and adjusted using the year-specific healthcare consumer price index.

Results

A total of 45,237 patients with T2DM were analyzed in this study. Multiple linear regression showed that age, marital status, insurance type, length of stay, number of clinical visits, number of comorbidities, history of disease, history of surgery, smoking history, and the age-adjusted Charlson comorbidity index score were influencing factors of medical expenditure in patients with T2DM. Considering the overall average medical expenditure, diagnosis cost accounted for the largest proportion and was never <25% since 2011, showing a decreasing trend year by year. Among the types of comorbidity, hypertension was the most prevalent, followed by kidney disease and hyperlipidemia. In terms of the combination of comorbidities, medical expenditure was the highest for pulmonary infection+hypertension (24,360 CNY), followed by coronary heart disease+heart failure+hypertension (22,029 CNY).

Conclusions

Identifying the main factors influencing the medical expenditure of patients with T2DM can provide a reference for the medical security department to formulate reasonable compensation plans and for medical institutions to optimize treatment plans. Ultimately, this might reduce the financial burden of patients and relieve the pressure of medical insurance funds.

Economic burden of Type 2 diabetes in Iran in 2022

BACKGROUND

Diabetes mellitus, particularly Type 2 diabetes (T2D), represents a significant global health challenge, with its prevalence steadily rising over the past few decades. This study was conducted with the aim of estimating the economic burden of T2D in Iran.

METHODS

This study employed a prevalence-based approach to estimate the economic burden of T2D and its attributable complications in adults above 20 years old in Iran for 2022. Both direct medical costs and indirect costs were considered in our analysis. Direct medical costs included inpatient and outpatient costs attributable to T2D and its complications, while indirect costs encompassed absenteeism, presenteeism, inability to work, and premature mortality costs due to the disease.

RESULTS

The findings showed that a total of 5,702,547 people, equivalent to 14.2% of Iranian adults, had T2D. The estimated total direct medical cost of T2D and its attributable complications in Iran in 2022 was 1,879.2 million US dollars (US$-PPP 6,676.9 million). Chronic kidney disease accounted for the largest proportion, followed by ischemic heart disease (IHD), and T2D itself. The total economic burden of T2D and its attributable complications in Iran in 2022, was estimated to be $2,905.7 million US dollars (US$-PPP 10,324.2 million). The direct medical cost constituted the majority of the economic burden (64.7%), while the inability to work due to these health conditions also contributes significantly (28.6%). Absenteeism (2.9%), presenteeism (1.7%), and premature mortality (2.2%) make up smaller proportions of the overall economic impact of T2D and its complications in Iran during that year.

CONCLUSION

Our study highlights the significant and diverse economic impact of T2D and its complications in Iran. This burden encompasses not only healthcare-related expenses but also negative impacts on society and productivity, as well as the occurrence of early death. To successfully address this burden, a comprehensive strategy is needed, which includes programs to prevent diabetes, better access to healthcare services, and increased social support for individuals with this long-term condition.

Long-term effect of short-term exercise instructions in Japanese patients with type 2 diabetes: observation study after randomized controlled study

Aims

To clarify the long-term effects of short-term exercise instructions by physical therapists in Japanese people with type 2 diabetes (T2D).

Methods

This was a follow-up study of 2 years after randomized controlled study of short-term exercise instructions included 18 patients (5 in the non-intervention and 13 in the intervention groups). Motor skills, including 6 min walk test scores, and transtheoretical model was evaluated at baseline (week 0), the end of the study of the previous study (week 8), and 2 years after (2 years).

Results

In the intervention group, changes in 6 min walk distance, which was significant at 8 weeks (from 445 (420-480) m to 490 (450-520) m, p = 0.01)), were maintained at 2 years (496 (420-540) m, p = 0.05), whereas in the non-intervention group, there were no changes in 6 min walk distance at 8 weeks (from 460 (458-493) m to 464 (460-485) m, p = 0.86) and 2 years (490 (480-506) m, p = 0.63). Furthermore, the changes in transtheoretical model, which was significant at 8 weeks (p = 0.008), were maintained at 2 years (p = 0.02), whereas in the non-intervention group, there were no changes in 6 min walk distance at 8 weeks and 2 years. On the other hand, the other markers were not significantly different between week 8 and 2 years compared to baseline in both groups.

Conclusions

Short-term outpatient exercise instruction by physical therapists may lead to long-term improvement effect on walking ability in people with T2D.

Relationship between indices of insulin resistance and incident type 2 diabetes mellitus in Chinese adults

BACKGROUND

Insulin resistance (IR) is a pivotal pathogenesis characteristic of type 2 diabetes mellitus (T2DM). The current study aimed to explore the association between triglyceride/high-density lipoprotein cholesterol ratio (TG/HDL-c), triglyceride-glucose (TyG), and triglyceride glucose-body mass index (TyG-BMI), and T2DM incidence.

METHODS

A total of 116,855 Chinese adults aged over 20 without diabetes were included. Multivariate Cox regression analysis and restricted cubic spine were utilized to investigate the association between IR indicators and T2DM. The T2DM risk across different quartiles of IR parameters was compared using Kaplan-Meier curves. The receiver operating characteristic analysis was used to investigate the predictive potential of each IR indicator for future T2DM.

RESULTS

A total of 2685 participants developed T2DM during a median follow-up of 2.98 years. The adjusted hazard ratios (HR) of incident T2DM were 1.177, 2.766, and 1.1018 for TG/HDL-c, TyG, and TyG-BMI, respectively. There were significant increasing trends of T2DM across the quartiles of TG/HDL-c, TyG, and TyG-BMI. The HRs of new-onset T2DM in the highest quartiles versus the lowest quartile of TG/HDL-c, TyG, and TyG-BMI were 3.298, 8.402, and 8.468. RCS revealed the nonlinear relationship between IR and T2DM risk. The correlations between IR and T2DM were more pronounced in subjects aged <40. TyG-BMI had the highest predictive value for incident T2DM (AUC = 0.774), with a cut-off value of 213.289.

CONCLUSION

TG/HDL-c, TyG, and TyG-BMI index were all significantly positively associated with higher risk for future T2DM. Baseline TyG-BMI level had high predictive value for the identification of T2DM.

Once-weekly insulin icodec versus once-daily long-acting insulins for type 2 diabetes mellitus: Systematic review and meta-analysis

Background

Insulin icodec is a novel, long-acting, once-weekly basal insulin analog. Its comparative efficacy and safety with basal once-daily insulins in type 2 diabetes mellittus is uncertain.

Objective

Evaluate potential efficacy, benefits and risks associated with icodec compared to once-daily basal insulin analogs (degludec or glargine).

Methods

We systematically searched PubMed, Cochrane, and Embase for randomized controlled trials (RCTs) published until June 2023 comparing icodec versus long-acting insulin analogs (degludec and glargine) in type 2 diabetes mellitus (T2DM) with at least 12 weeks of follow-up. Binary endpoints were assessed with risk ratios (RRs) and continuous endpoints were compared using mean differences (MDs), with 95% confidence intervals (CIs). The protocol was registered in PROSPERO (CRD42023452468).

Results

A total of seven RCTs and 3286 patients with T2DM were included, of whom 1509 (60.6%) received icodec treatment. The follow-up period ranged from 16 to 78 weeks. Compared with once-daily basal insulin analogs, icodec led to a greater improvement in HbA1c (MD -0.15%; 95% CI -0.21, -0.10; p < 0.0001; I2 = 0%) and time in range (TIR) (MD 2.83%; 95%CI 0.94; 4.71; p = 0.003; I2 = 22%). Body weight was increased with icodec treatment (MD 0.78 Kg; 95%CI 0.42, 1.15; p < 0.01; I2 = 86%). There was also a higher rate of injection site reactions (RR 1.89; 95%CI 1.12, 3.18; p = 0.016; I2 = 0%) and nasopharyngitis (RR 1.94; 95%CI 1.11, 3.38; p = 0.020; I2 = 0%) in the icodec group, compared with once-daily regimens. There was no significant difference between groups in fasting plasma glucose.

Conclusions

In this meta-analysis of RCTs, insulin icodec led to better control of HbA1c and TIR as compared with once-daily insulin regimens, albeit with increased weight gain and a higher rate of injection site reaction in the Icodec group.

Arsenic and adipose tissue: an unexplored pathway for toxicity and metabolic dysfunction

Arsenic-contaminated drinking water can induce various disorders by disrupting lipid and glucose metabolism in adipose tissue, leading to insulin resistance. It inhibits adipocyte development and exacerbates insulin resistance, though the precise impact on lipid synthesis and lipolysis remains unclear. This review aims to explore the processes and pathways involved in adipogenesis and lipolysis within adipose tissue concerning arsenic-induced diabetes. Although arsenic exposure is linked to type 2 diabetes, the specific role of adipose tissue in its pathogenesis remains uncertain. The review delves into arsenic's effects on adipose tissue and related signaling pathways, such as SIRT3-FOXO3a, Ras-MAP-AP-1, PI(3)-K-Akt, endoplasmic reticulum stress proteins, CHOP10, and GPCR pathways, emphasizing the role of adipokines. This analysis relies on existing literature, striving to offer a comprehensive understanding of different adipokine categories contributing to arsenic-induced diabetes. The findings reveal that arsenic detrimentally impacts white adipose tissue (WAT) by reducing adipogenesis and promoting lipolysis. Epidemiological studies have hinted at a potential link between arsenic exposure and obesity development, with limited research suggesting a connection to lipodystrophy. Further investigations are needed to elucidate the mechanistic association between arsenic exposure and impaired adipose tissue function, ultimately leading to insulin resistance.

Low-Density Neutrophils Contribute to Subclinical Inflammation in Patients with Type 2 Diabetes

Type 2 diabetes (T2D) is characterized by low-grade inflammation. Low-density neutrophils (LDNs) represent normally less than 2% of total neutrophils but increase in multiple pathologies, releasing inflammatory cytokines and neutrophil extracellular traps (NETs). We assessed the count and role of high-density neutrophils (HDNs), LDNs, and NET-related activities in patients with T2D. HDNs and LDNs were purified by fluorescence-activated cell sorting (FACS) and counted by flow cytometry. Circulating inflammatory and NETs biomarkers were measured by ELISA (Enzyme Linked Immunosorbent Assay). NET formation was quantified by confocal microscopy. Neutrophil adhesion onto a human extracellular matrix (hECM) was assessed by optical microscopy. We recruited 22 healthy volunteers (HVs) and 18 patients with T2D. LDN counts in patients with diabetes were significantly higher (160%), along with circulating NETs biomarkers (citrullinated H3 histone (H3Cit), myeloperoxidase (MPO), and MPO-DNA (137%, 175%, and 69%, respectively) versus HV. Circulating interleukins (IL-6 and IL-8) and C-Reactive Protein (CRP) were significantly increased by 117%, 171%, and 79%, respectively, in patients compared to HVs. Isolated LDNs from patients expressed more H3Cit, MPO, and NETs, formed more NETs, and adhered more on hECM compared to LDNs from HVs. Patients with T2D present higher levels of circulating LDN- and NET-related biomarkers and associated pro-inflammatory activities.

Economic Costs of Diabetes in the U.S. in 2022

OBJECTIVE

This study updates previous estimates of the economic burden of diagnosed diabetes, with calculation of the health resource use and indirect costs attributable to diabetes in 2022.

RESEARCH DESIGN AND METHODS

We combine the demographics of the U.S. population in 2022 with diabetes prevalence, from national survey data, epidemiological data, health care cost data, and economic data, into a Cost of Diabetes Economic Model to estimate the economic burden at the population and per capita levels. Health resource use and associated medical costs are analyzed by age, sex, race/ethnicity, comorbid condition, and health service category. Data sources include national surveys (2015-2020 or most recent available), Medicare standard analytic files (2020), and administrative claims data from 2018 to 2021 for a large commercially insured population in the U.S.

RESULTS

The total estimated cost of diagnosed diabetes in the U.S. in 2022 is $412.9 billion, including $306.6 billion in direct medical costs and $106.3 billion in indirect costs attributable to diabetes. For cost categories analyzed, care for people diagnosed with diabetes accounts for 1 in 4 health care dollars in the U.S., 61% of which are attributable to diabetes. On average people with diabetes incur annual medical expenditures of $19,736, of which approximately $12,022 is attributable to diabetes. People diagnosed with diabetes, on average, have medical expenditures 2.6 times higher than what would be expected without diabetes. Glucose-lowering medications and diabetes supplies account for ∼17% of the total direct medical costs attributable to diabetes. Major contributors to indirect costs are reduced employment due to disability ($28.3 billion), presenteeism ($35.8 billion), and lost productivity due to 338,526 premature deaths ($32.4 billion).

CONCLUSIONS

The inflation-adjusted direct medical costs of diabetes are estimated to rise 7% from 2017 and 35% from 2012 calculations (stated in 2022 dollars). Following decades of steadily increasing prevalence of diabetes, the overall estimated prevalence in 2022 remains relatively stable in comparison to 2017. However, the absolute number of people with diabetes has grown and contributes to increased health care expenditures, particularly per capita spending on inpatient hospital stays and prescription medications. The enormous economic toll of diabetes continues to burden society through direct medical and indirect costs.

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

BACKGROUND

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

METHODS

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

FINDINGS

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

INTERPRETATION

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

FUNDING

Bill & Melinda Gates Foundation.

Administration of Jerusalem artichoke reduces the postprandial plasma glucose and glucose-dependent insulinotropic polypeptide (GIP) concentrations in humans

Background

The consumption of Jerusalem artichoke has multiple beneficial effects against diabetes and obesity.

Objective

The aim of this study was to determine the effect of a single administration of Jerusalem artichoke tubers on postprandial glycemia and the concentrations of incretin hormones in humans.

Method

Grated Jerusalem artichoke was administered prior to a meal (Trial 1; white rice for prediabetic participants, n = 10). Dose-dependent effect of Jerusalem artichoke (Trial 2; white rice for prediabetic participants, n = 4) and effect prior to the fat-rich meal were also investigated (Trial 3; healthy participants, n = 5) in this pilot study. Circulating glucose, insulin, triglyceride, glucagon, active glucagon-like peptide-1 (GLP-1), and active glucose-dependent insulinotropic polypeptide (GIP) concentrations were subsequently measured in all the trials.

Results

Jerusalem artichoke significantly reduced the glucose and GIP concentrations after the consumption of either meal in Trial 1 and Trial 3, whereas there were no differences in the insulin, glucagon, and active GLP-1 concentrations. Also, there was no significant difference in the triglyceride concentration after the ingestion of the fat-rich meal in Trial 3. The glucose and GIP-lowering effects were dose-dependent, and the consumption of at least 100 g of Jerusalem artichoke was required to have these effects in Trial 2.

Conclusion

This study demonstrates that a single administration of Jerusalem artichoke tubers reduces postprandial glucose and active GIP concentrations in prediabetic and healthy individuals.

Assessment of simple strategies for identifying undiagnosed diabetes and prediabetes in the general population

BACKGROUND AND AIMS

The rising tide of diabetes mellitus (DM) and prediabetes (PDM) is urgently calling for strategies easily applicable to anticipate diagnosis. We assessed the effectiveness of random capillary blood glucose (RCBG), administration of a validated DM risk questionnaire, or the combination of both.

MATERIALS AND METHODS

RCBG measurement and/or questionnaire administration were offered to all individuals presenting at gazebos organized during the World Diabetes Day or similar public initiatives on diabetes awareness. Subjects with suspicious DM or PDM were invited to the Diabetes Center (DC) for laboratory confirmation (fasting plasma glucose and HbA1c).

RESULTS

Among 8563 individuals without known diabetes undergoing RCBG measurement, 341 (4%) had suspicious values. Diagnosis of DM was confirmed in 36 (41.9%) of the 86 subjects who came to the DC and PDM was found in 40 (46.5%). Among 3351 subjects to whom the questionnaire was administered, 480 (14.3%) had suspicious scores. Diagnosis of DM was confirmed in 40 (10.1%) of the 397 who came to the DC and PDM was found in 214 (53.9%). These 3351 subjects also had RCBG measurement and 30 out of them had both tests positive. Among them, 27 subjects came to DC and DM was diagnosed in 17 (63.0%) and PDM was found in 9 (33.3%).

CONCLUSIONS

These data suggest that RCBG definitely outperforms the questionnaire to identify unknown DM and PDM. RCBG measurement, with questionnaire as an adjunctive tool, appears to be a simple, fast, and feasible opportunistic strategy in detecting undiagnosed DM and PDM.

Outcomes after surgery in patients with diabetes who used metformin: a retrospective cohort study based on a real-world database

INTRODUCTION

Limited information was available regarding the perioperative outcomes in patients with and without use of metformin. This study aims to evaluate the complications and mortality after major surgery in patients with diabetes who use metformin.

RESEARCH DESIGN AND METHODS

Using a real-world database of Taiwan's National Health Insurance from 2008 to 2013, we conducted a matched cohort study of 91 356 patients with diabetes aged >20 years who used metformin and later underwent major surgery. Using a propensity score-matching technique adjusted for sociodemographic characteristics, medical condition, surgery type, and anesthesia type, 91 356 controls who underwent surgery but did not use metformin were selected. Logistic regression was used to calculate the ORs with 95% CIs for postoperative complications and 30-day mortality associated with metformin use.

RESULTS

Patients who used metformin had a lower risk of postoperative septicemia (OR 0.94, 95% CI 0.90 to 0.98), acute renal failure (OR 0.87, 95% CI 0.79 to 0.96), and 30-day mortality (OR 0.79, 95% CI 0.71 to 0.88) compared with patients who did not use metformin, in both sexes and in every age group. Metformin users who underwent surgery also had a decreased risk of postoperative intensive care unit admission (OR 0.60, 95% CI 0.59 to 0.62) and lower medical expenditures (p<0.0001) than non-use controls.

CONCLUSIONS

Among patients with diabetes, those who used metformin and underwent major surgery had a lower risk of complications and mortality compared with non-users. Further randomized clinical trials are needed to show direct evidence of how metformin improves perioperative outcomes.

Managing the multifaceted nature of type 2 diabetes using once-weekly injectable GLP-1 receptor agonist therapy

WHAT IS KNOWN AND OBJECTIVE

As a highly prevalent chronic condition associated with complications and high mortality rates, it is important for pharmacists to have a comprehensive understanding of the impact of type 2 diabetes (T2D) and available treatment options. The use of injectable glucagon-like peptide 1 receptor agonists (GLP-1 RAs) is recommended as an effective and convenient treatment regimen for improving glycaemic control in individuals with T2D, with a good safety profile; however, the wider extent of its potential benefits often are unknown to clinical pharmacists. The objective of this article is to provide an overview of the impact of T2D on individuals and to discuss the multifaceted role of once-weekly (QW) GLP-1 RAs in addressing these challenges.

METHODS

This is a narrative review of the published literature regarding the use of injectable GLP-1 RAs in managing health complications in people with T2D.

RESULTS AND DISCUSSION

Recent findings reveal additional benefits of GLP-1 RAs in managing T2D complications, including atherosclerotic cardiovascular (CV) disease, retinopathy, neuropathy, and nephropathy. Dulaglutide and semaglutide have been shown to provide additional CV benefit in patients at high risk of CV events compared with standard of care/placebo and may offer renal protection in patients with chronic kidney disease. Cost-effectiveness studies, taking into consideration these different complications, have shown that QW GLP-1 RAs were cost-effective compared with other therapies. GLP-1 RAs may also help to improve overall health-related quality of life, reducing the risk of depression and 'diabetes distress', and limiting the risk of hypoglycaemia.

WHAT IS NEW AND CONCLUSION

From the literature, this appears to be the first review of the evidence supporting the multifaceted role of QW GLP-1 RAs in T2D, with particular emphasis on their use in comorbid conditions, as well as associated potential financial and well-being benefits. The results suggest that QW GLP-1 RAs may be an attractive treatment option for improving glycaemic control in T2D, especially in individuals with (or at risk of) additional comorbidities or health complications.

Regional differences in the management of cardiovascular risk factors among adults with diabetes: An evaluation of the Diabetes Collaborative Registry

AIMS

To compare cardiovascular risk factor control in adults with diabetes participating in a national diabetes registry to those in the general population and to ascertain regional differences in diabetes care.

METHODS

Adults with diagnosed diabetes in the Diabetes Collaborative Registry (DCR) were compared with those in the National Health and Nutrition Examination Survey (NHANES) from 2015 to 2016; standardized mean difference (SMD) > 0.2 defined significance. Regional differences were assessed in the DCR cohort; p < .05 defined significance.

RESULTS

The DCR cohort was older (61 vs. 57 years, SMD = 0.38), more insured (99.7% vs. 91.0%, SMD = 0.42), and less ethnically diverse (83% non-Hispanic white vs. 76%, SMD = 0.30) compared with NHANES. The proportion of overweight/obesity, A1c < 7% (<53 mmol/mol), and BP < 140/90 were similar, but DCR participants had higher proportion with LDL < 2.59 mmol/L (61% vs. 41%, SMD = 0.39) and fewer tobacco users (17% vs. 32%, SMD = 0.35). Regionally, obesity, lack of glycaemic control, and tobacco use were highest in the Midwest, BP control was the lowest in the South, and LDL control was lowest in the Northeast.

CONCLUSIONS

Significant regional differences in diabetes care delivery and outcomes were identified using a national diabetes registry. Serial analyses of the DCR may supplement national evaluations to deepen our understanding of diabetes care in the US.

Prevention and management of cardiovascular disease in patients with diabetes: current challenges and opportunities

More than 100 million people in the USA have diabetes or prediabetes and are at high risk for developing cardiovascular disease. Current evidence-based guidelines support a multifactorial approach in patients with diabetes, including lifestyle intervention and pharmacological treatment of hyperglycemia, hypertension, and dyslipidemia. In addition, recent cardiovascular outcome trials demonstrated that sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide 1 receptor agonists improve cardiovascular outcomes in patients with diabetes. Albeit this evidence, over 80% of patients with diabetes do not achieve the recommended treatment goals. Considering the rising burden of cardiovascular complications, there is need to improve the quality of care in patients with diabetes. In this review, we discuss the current quality of health care in patients with diabetes in the USA, identify barriers to achieve guideline-recommended treatment goals and outline opportunities for the improvement in caring for patients with diabetes.

Enrichment of Tc1 cells and T cell resistance to suppression are associated with dysglycemia in the visceral fat in human obesity

OBJECTIVE

Insulin resistance, defined as tissue inflammation leading to type 2 diabetes, is a feature of obesity. The immune system has been implicated in its pathogenesis, but the role of adaptive immunity in humans remains uncertain. Here, we aim to determine whether specific phenotypic and functional properties of visceral adipose tissue (VAT)-derived CD4 conventional T cells (Tconv) and CD8 T cells are associated with dysglycemia in human obesity.

RESEARCH DESIGN AND METHODS

Peripheral blood and the stromal vascular fraction of obese patients without dysglycemia (n=23), with impaired fasting glucose or type 2 diabetes (n=17), and non-diabetic lean controls (n=11) were studied. Characterization of memory, activation profile, cytokine production, proliferative capacity, cytotoxic potential and transforming growth factor-β-mediated suppression of CD4 Tconv and CD8 T cells was performed. Correlation between anthropometric/metabolic parameters and VAT-derived T cell subsets was determined.

RESULTS

In the VAT of the overall obese population, reduced frequency of interferon-γ-producing or tumor necrosis factor-α-producing CD4 (ie, T helper 1, Th1) and CD8 (ie, cytotoxic type 1, Tc1) T cells, as well as interleukin-17-producing CD8 T cells (ie, Tc17), was evident when compared with lean controls. However, enrichment of Tc1 cells, together with the impaired ability of CD4 and CD8 T cells to be suppressed, distinguished the visceral fat of obese patients with dysglycemia from the one of non-diabetic obese patients. Moreover, accumulation of Th1 and Tc1 cells in the VAT correlated with anthropometric and metabolic parameters.

CONCLUSIONS

Here, we define the VAT-specific characteristics of T cells in human obesity, showing that accumulation of Tc1 cells and T cell resistance to suppression can be harmful to the development of obesity-induced diabetes. These findings open new directions to investigate immunological targets in the obesity setting.

US Health Care Spending by Payer and Health Condition, 1996-2016

IMPORTANCE

US health care spending has continued to increase and now accounts for 18% of the US economy, although little is known about how spending on each health condition varies by payer, and how these amounts have changed over time.

OBJECTIVE

To estimate US spending on health care according to 3 types of payers (public insurance [including Medicare, Medicaid, and other government programs], private insurance, or out-of-pocket payments) and by health condition, age group, sex, and type of care for 1996 through 2016.

DESIGN AND SETTING

Government budgets, insurance claims, facility records, household surveys, and official US records from 1996 through 2016 were collected to estimate spending for 154 health conditions. Spending growth rates (standardized by population size and age group) were calculated for each type of payer and health condition.

EXPOSURES

Ambulatory care, inpatient care, nursing care facility stay, emergency department care, dental care, and purchase of prescribed pharmaceuticals in a retail setting.

MAIN OUTCOMES AND MEASURES

National spending estimates stratified by health condition, age group, sex, type of care, and type of payer and modeled for each year from 1996 through 2016.

RESULTS

Total health care spending increased from an estimated $1.4 trillion in 1996 (13.3% of gross domestic product [GDP]; $5259 per person) to an estimated $3.1 trillion in 2016 (17.9% of GDP; $9655 per person); 85.2% of that spending was included in this study. In 2016, an estimated 48.0% (95% CI, 48.0%-48.0%) of health care spending was paid by private insurance, 42.6% (95% CI, 42.5%-42.6%) by public insurance, and 9.4% (95% CI, 9.4%-9.4%) by out-of-pocket payments. In 2016, among the 154 conditions, low back and neck pain had the highest amount of health care spending with an estimated $134.5 billion (95% CI, $122.4-$146.9 billion) in spending, of which 57.2% (95% CI, 52.2%-61.2%) was paid by private insurance, 33.7% (95% CI, 30.0%-38.4%) by public insurance, and 9.2% (95% CI, 8.3%-10.4%) by out-of-pocket payments. Other musculoskeletal disorders accounted for the second highest amount of health care spending (estimated at $129.8 billion [95% CI, $116.3-$149.7 billion]) and most had private insurance (56.4% [95% CI, 52.6%-59.3%]). Diabetes accounted for the third highest amount of the health care spending (estimated at $111.2 billion [95% CI, $105.7-$115.9 billion]) and most had public insurance (49.8% [95% CI, 44.4%-56.0%]). Other conditions estimated to have substantial health care spending in 2016 were ischemic heart disease ($89.3 billion [95% CI, $81.1-$95.5 billion]), falls ($87.4 billion [95% CI, $75.0-$100.1 billion]), urinary diseases ($86.0 billion [95% CI, $76.3-$95.9 billion]), skin and subcutaneous diseases ($85.0 billion [95% CI, $80.5-$90.2 billion]), osteoarthritis ($80.0 billion [95% CI, $72.2-$86.1 billion]), dementias ($79.2 billion [95% CI, $67.6-$90.8 billion]), and hypertension ($79.0 billion [95% CI, $72.6-$86.8 billion]). The conditions with the highest spending varied by type of payer, age, sex, type of care, and year. After adjusting for changes in inflation, population size, and age groups, public insurance spending was estimated to have increased at an annualized rate of 2.9% (95% CI, 2.9%-2.9%); private insurance, 2.6% (95% CI, 2.6%-2.6%); and out-of-pocket payments, 1.1% (95% CI, 1.0%-1.1%).

CONCLUSIONS AND RELEVANCE

Estimates of US spending on health care showed substantial increases from 1996 through 2016, with the highest increases in population-adjusted spending by public insurance. Although spending on low back and neck pain, other musculoskeletal disorders, and diabetes accounted for the highest amounts of spending, the payers and the rates of change in annual spending growth rates varied considerably.

Burden and Consequences of Financial Hardship From Medical Bills Among Nonelderly Adults With Diabetes Mellitus in the United States

Background:

The trend of increasing total and out-of-pocket expenditure among patients with diabetes mellitus represents a risk of financial hardship for Americans and a threat to medical and nonmedical needs. We aimed to describe the national scope and associated tradeoffs of financial hardship from medical bills among nonelderly individuals with diabetes mellitus.

Methods and Results:

We used the National Health Interview Survey data from 2013 to 2017, including adults ≤64 years old with a self-reported diagnosis of diabetes mellitus. Among 164 696 surveyed individuals, 8967 adults ≤64 years old reported having diabetes mellitus, representing 13.1 million individuals annually across the United States. The mean age was 51.6 years (SD 10.3), and 49.1% were female. A total of 41.1% were part of families that reported having financial hardship from medical bills, with 15.6% reporting an inability to pay medical bills at all. In multivariate analyses, individuals who lacked insurance, were non-Hispanic black, had low income, or had high-comorbidity burden were at higher odds of being in families with financial hardship from medical bills. When comparing the graded categories of financial hardship, there was a stepwise increase in the prevalence of high financial distress, food insecurity, cost-related nonadherence, and foregone/delayed medical care, reaching 70.5%, 49.4%, 49.5%, and 74% among those unable to pay bills, respectively. Compared with those without diabetes mellitus, individuals with diabetes mellitus had higher odds of financial hardship from medical bills (adjusted odds ratio [aOR], 1.27 [95% CI, 1.18–1.36]) or any of its consequences, including high financial distress (aOR, 1.14 [95% CI, 1.05–1.24]), food insecurity (aOR, 1.27 [95% CI, 1.16–1.40]), cost-related medication nonadherence (aOR, 1.43 [95% CI, 1.30–1.57]), and foregone/delayed medical care (aOR, 1.30 [95% CI, 1.20–1.40]).

Conclusions:

Nonelderly patients with diabetes mellitus have a high prevalence of financial hardship from medical bills, with deleterious consequences.

The Cardiometabolic Risk Profile of Young Adults With Diabetes in the U.S

OBJECTIVE

We examined young adults with and young adults without diabetes by using demographic data and cardiometabolic risk profiles and compared the risk profiles of younger versus older (aged ≥45 years) adults with diabetes.

RESEARCH DESIGN AND METHODS

Data were obtained from the National Health and Nutrition Examination Survey (NHANES) 2007-2016. Diabetes was defined by self-report of health care provider diagnosis or by A1C levels of 6.5% or higher among those without a self-reported diagnosis. The cardiometabolic risk profile included adiposity, blood pressure, serum lipids, healthy eating, physical activity (PA), and exposure to tobacco smoke. Adjusted difference in difference was calculated as the difference among younger adults with and younger adults without diabetes minus the difference among older adults with and older adults without diabetes.

RESULTS

Adults with diabetes in both age-groups had higher levels of adiposity, hypertension, and cholesterol and lower levels of healthy eating and leisure-time PA. However, the differences in high cholesterol and adiposity by diabetes status were greater among young adults compared with older adults after adjustment for demographics and health insurance status. Elevated lipids were 9.6 percentage points higher (95% CI 4.6, 14.5) and obesity was 37.3 percentage points higher (95% CI 31.8, 42.7) among young adults with diabetes compared with those without diabetes than among older adults with diabetes compared with those without diabetes.

CONCLUSIONS

Young adults with diabetes have high rates of cardiometabolic risk factors, which can lead to an increased disease prevalence and mortality rate among these individuals as they age.

Environmental neglect: endocrine disruptors as underappreciated but potentially modifiable diabetes risk factors

Type 2 diabetes prevalence is increasing dramatically across the globe, imposing a tremendous toll on individuals and healthcare systems. Reversing these trends requires comprehensive approaches to address both classical and emerging diabetes risk factors. Recently, environmental toxicants acting as endocrine-disrupting chemicals (EDCs) have emerged as novel metabolic disease risk factors. EDCs implicated in diabetes pathogenesis include various inorganic and organic molecules of both natural and synthetic origin, including arsenic, bisphenol A, phthalates, polychlorinated biphenyls and organochlorine pesticides. Indeed, evidence implicates EDC exposures across the lifespan in metabolic dysfunction; moreover, specific developmental windows exhibit enhanced sensitivity to EDC-induced metabolic disruption, with potential impacts across generations. Importantly, differential exposures to diabetogenic EDCs likely also contribute to racial/ethnic and economic disparities. Despite these emerging links, clinical practice guidelines fail to address this underappreciated diabetes risk factor. Comprehensive approaches to stem the tide of diabetes must include efforts to address its environmental drivers.

Description of a pharmacist-led diabetes prevention service within an employer-based wellness program

OBJECTIVES

To describe a pharmacist-led diabetes prevention service piloted within an employer-based wellness program.

PRACTICE DESCRIPTION

A pharmacist-led ambulatory care clinic within a school of pharmacy that provides wellness services to university employees.

PRACTICE INNOVATION

Implementation of a diabetes prevention service using opportunistic A1C screening within a biometric screening program. Patients with a prediabetes-level A1C from July 2016 to March 2019 were invited to participate in the National Diabetes Prevention Program (NDPP).

EVALUATION

Comparison of baseline characteristics of participants with normal and elevated A1C. Evaluation of participation in the NDPP and changes in clinical values at the subsequent biometric screening appointment for individuals with a prediabetes-level AlC.

RESULTS

A1C testing of 740 individuals identified 69 participants (9.3%) with a prediabetes-level A1C and 7 (1.0%) with a diabetes-level A1C. Compared with those with a normal A1C (< 5.7%), participants with an elevated A1C were more likely to be older, nonwhite, obese, and physically inactive, to have a sibling with diabetes, higher random blood sugar (RBS), lower high-density lipoprotein (HDL), and more likely to have hypertension. Twelve patients participated in the NDPP, although most attended only 1 session. Attenders had a significantly lower baseline weight and body mass index (BMI). There were no significant differences in the changes in A1C, BMI, weight, RBS, or HDL between attenders and nonattenders approximately 1 year later.

CONCLUSION

This pilot demonstrated that opportunistic A1C testing could be incorporated into an ambulatory care clinic within a pharmacist-led employer-based wellness program. Uptake and retention of the NDPP were poor. Barriers to NDPP participation need to be investigated and addressed to improve service impact.

A perspective on global access to insulin: a descriptive study of the market, trade flows and prices

AIM

To describe the global insulin market.

METHODS

Market intelligence data, United Nations Commodity Trade Statistics for insulin trade, the International Medical Products Price Guide for prices of human insulin and additional web searches were used as data sources. These sources were combined to gain further insight into possible links among market, trade flows and prices. Descriptive statistics and Spearman's rank order correlation were used for the analysis.

RESULTS

A total of 34 insulin manufacturers were identified. Most countries and territories are reliant on a limited number of supplying countries. The overall median (interquartile range) government procurement price for a 10-ml, 100-IU/ml vial during the period 1996-2013 equivalent was US$4.3 (US$ 3.8-4.8), with median prices in Africa (US$ 4.7) and low- (US$ 6.9) and low- to middle- (US$ 4.7) income countries being higher over this period. The relationships between price and quantity of insulin (Spearman's r=0.046; P>0.1) and number of import links (Spearman's r=0.032; P>0.1) were weak. The links between price and percentage of total insulin from a country where a 'big three' manufacturer produces insulin (Spearman's r=0.294; P<0.05) and total insulin from the main import link (Spearman's r=-0.392; P<0.05) were stronger.

CONCLUSIONS

This research shows the high variability of insulin prices and the reliance on a few sources, both companies and countries, for global supply. In addressing access to insulin, countries need to use existing price data to negotiate prices, and mechanisms need to be developed to foster competition and security of supply of insulin, given the limited number of truly global producers.

Global, Regional, National, and Subnational Big Data to Inform Health Equity Research: Perspectives from the Global Burden of Disease Study 2017

Objectives

Everyone deserves a long and healthy life, but in reality, health outcomes differ across populations. We use results from the Global Burden of Disease Study 2017 (GBD 2017) to report patterns in the burden of diseases, injuries, and risks at the global, regional, national, and subnational level, and by sociodemographic index (SDI), from 1990 to 2017.

Design

GBD 2017 undertook a systematic analysis of published studies and available data providing information on prevalence, incidence, remission, and excess mortality. We computed prevalence, incidence, mortality, life expectancy, healthy life expectancy, years of life lost due to premature mortality, years lived with disability, and disability-adjusted life years with 95% uncertainty intervals for 23 age groups, both sexes, and 918 locations, including 195 countries and territories and subnational locations for 16 countries from 1990 to 2017. We also computed SDI, a summary indicator combining measures of income, education, and fertility.

Results

There were wide disparities in the burden of disease by SDI, with smaller burdens in affluent countries and in specific regions within countries. Select diseases and risks, such as drug use disorders, high blood pressure, high body mass index, diet, high fasting plasma glucose, smoking, and alcohol use disorders warrant increased global attention and indicate a need for greater investment in prevention and treatment across the life course.

Conclusions

Policymakers need a comprehensive picture of what risks and causes result in disability and death. The GBD provides the means to quantify health loss: these findings can be used to examine root causes of disparities and develop programs to improve health and health equity.