Objective. Screening for type 1 diabetes provides an opportunity to identify those with pre-symptomatic, early-stage disease, enabling increased monitoring to prevent diabetic ketoacidosis and facilitating access to emerging therapies. Given potential benefits, discussions about population-wide type 1 diabetes screening are ongoing. Routine primary care visits could offer a scalable approach to such screening. We used mixed methods to explore multilevel barriers to and facilitators of type 1 diabetes autoantibody screening at well-child visits and, more broadly, the acceptability, appropriateness, and feasibility of such a screening approach. Research Design and Methods. Semi-structured interviews were completed with parents, clinicians, and health insurers. Transcripts were double coded using an iteratively adapted a priori codebook. A survey leveraging the validated Acceptability of Implementation, Intervention Appropriateness, and Feasibility of Intervention Measures instruments was deployed to assess pediatric primary care clinician perspectives. Results. A total of 26 parents, 10 clinicians (endocrinologists and pediatricians), and two health insurers participated in interviews, and 15 pediatricians participated in the survey. Most parents interviewed and clinicians surveyed found type 1 diabetes screening acceptable and appropriate. Parents noted lack of education, need for a blood draw, costs, difficulty scheduling, and fear of results as barriers. Clinicians reflected barriers including parental views on blood draws and clinician time. Insurers described lack of insurance coverage as a barrier. Facilitators across constituents included education, reduced costs, convenient screening, guidelines supporting screening, and institutional support. Conclusion. If population screening for type 1 diabetes is pursued, models that integrate primary care will be needed. Screening for type 1 diabetes through primary care well-child visits could enable high adoption if implementation strategies adequately address described barriers and promote facilitators. Key Points · Early childhood screening for type 1 diabetes provides an opportunity to identify individuals with presymptomatic, early-stage disease and intervene to prevent diabetic ketoacidosis. · Mixed methods were used to explore multilevel barriers and facilitators to type 1 diabetes autoantibody screening in pediatric well-child visits, and, more broadly, the implementation outcomes of acceptability, appropriateness, and feasibility. · Most parents and clinicians who participated in this study found type 1 diabetes screening during pediatric well-child visits to be acceptable and appropriate. Implementation barriers (e.g., costs) and facilitators (e.g., education) were identified. · Screening for type 1 diabetes within pediatric well-child visits could be a viable strategy if implementation strategies address identified barriers and promote facilitators.
In the United States, >2 million people are projected to be diagnosed with cancer in 2025, and ~20% of these patients will have a diabetes diagnosis (1–3). Hyperglycemia and cancer have a bidirectional relationship, and managing blood glucose in patients with cancer is complex because hyperglycemia may result from the underlying cancer or from anticancer or supportive care therapies that are administered intermittently (2). Hyperglycemia can worsen survival and increase risks of cancer recurrence, infection, hospitalization, toxicity, and morbidity (2). Allogeneic hematopoietic cell transplant (HCT) recipients are especially vulnerable because of insulin resistance and the use of immunosuppressants such as calcineurin inhibitors and corticosteroids for the prophylaxis and treatment of graft-versus-host disease (GVHD) (4,5). Additionally, 20–60% of patients with cancer experience treatment-induced hyperglycemia from agents such as immune checkpoint inhibitors, mammalian target of rapamycin inhibitors, phosphoinositide 3‐kinase inhibitors, and epidermal growth factor inhibitors (2).
Type 1 diabetes is a risk factor for developing mental health disorders, particularly disordered eating. Female adolescents are vulnerable to abnormal eating behaviors when transitioning from childhood to adult diabetes management. The challenge of achieving glycemic stability while navigating developmental changes during adolescence can lead females to unhealthy eating patterns as a coping mechanism. Disordered eating behavior is a term that encompasses a variety of patterns that do not meet the criteria for a formal eating disorder diagnosis. Such behaviors include dietary restriction, binge eating, and purging methods, including self-induced vomiting, excessive exercise, and medication misuse. The intentional omission of insulin is a purging method specific to diabetes, and especially type 1 diabetes. Without insulin, the body is unable to take up glucose from the bloodstream, resulting in hyperglycemia. A prolonged state of hyperglycemia can lead to serious complications, including diabetic ketoacidosis. A persistently elevated A1C is one of the few objective findings of disordered eating in patients with type 1 diabetes. Disordered eating instruments, including the SCOFF and Diabetes Eating Problem Survey–Revised questionnaires, have been adjusted to inquire about insulin misuse. Positive screening results and clinical findings of sustained hyperglycemia are pathognomonic of disordered eating behavior. Treatment of the concurrent conditions includes cognitive behavioral therapy with a multidisciplinary approach to regain glycemic stability. Health care providers must maintain a high index of suspicion for signs of psychosocial distress in female adolescents with type 1 diabetes to ensure that appropriate interventions are made before long-term complications arise.
Endogenous hypercortisolism (Cushing syndrome) is a multisystemic disease characterized by a wide range of clinical signs and symptoms. Its heterogeneous presentation can cause significant diagnostic delays, and prolonged exposure to excess cortisol activity can contribute to cardiometabolic abnormalities such as diabetes. When diabetes remains unresponsive or only partially responsive to standard-of-care treatment, clinicians should consider hypercortisolism as a potential underlying driver. Despite the risks associated with hypercortisolism, guidance on identifying and managing it in patients with diabetes remains limited. This article presents a case series of 10 patients from a single practice who were screened for hypercortisolism because of difficult-to-manage diabetes and additional comorbidities. All patients were treated for hypercortisolism with mifepristone, resulting in significant clinical improvements including weight loss, improved glycemic control, and reduced medication needs. This real-world case series highlights the importance of recognizing hypercortisolism as a differential diagnosis and a potential contributing factor to difficult-to-manage diabetes despite standard-of-care therapies. Addressing hypercortisolism with mifepristone can result in substantial clinical benefits.
Globally, >10% of adults aged 20–79 years (537 million people) are living with diabetes, and the burden is predicted to rise to 643 million (11.3%) by 2030 and to 783 million (12.2%) by 2045. An additional 240 million are estimated to live with undiagnosed diabetes (1). Diabetes was the sixth leading driver of disability in the world in 2015 (2). It is further estimated that ~90% of people with undiagnosed diabetes live in low-income countries (LICs), especially in Africa, Southeast Asia, and the Western Pacific (1). In LICs, the prevalence of diabetes is projected to increase from 5.5% in 2021 to 6.1% in 2045 (3), which will further widen the health equity gap. For example, across sub-Saharan Africa, type 2 diabetes accounts for 90% of diabetes cases (4), and the cases of diabetes in Africa are projected to increase from 23.6 million in 2021 to 54.9 million (132%) by 2045 (3).
Objective. Hypoglycemia is a serious complication in people with diabetes. Risk factors include increased age, certain comorbidities, and certain glucose-lowering medications. Although the American Diabetes Association recommends prescribing glucagon to individuals at high risk for hypoglycemia for use in emergent episodes, glucagon use remains low. This is particularly concerning in federally qualified health centers (FQHCs), where patients face socioeconomic barriers that may exacerbate this gap in care. This study evaluated glucagon prescribing rates among high-risk patients with diabetes in a FQHC. Methods. A retrospective chart review was conducted of patients with diabetes seen between March 2022 and March 2023 who were prescribed a high-risk medication and/or had a history of hypoglycemia. Demographics and clinical characteristics such as history of hypoglycemia, high-risk medications, and active glucagon prescriptions were analyzed using descriptive statistics and comparative tests to determine characteristics associated with glucagon prescriptions. Results. Of the 7,304 patients, 95% had type 2 diabetes, and 61.5% were prescribed insulin, but only 4.4% had an active glucagon prescription. Among 65 individuals with documented hypoglycemia, 80% were prescribed a high-risk medication, yet only 13.8% were prescribed glucagon. Patients with type 1 diabetes were more likely to have glucagon prescribed (P = 0.002). Conclusion. Glucagon was significantly under-prescribed in this high-risk population, highlighting gaps in applying clinical guidelines to practice as well as gaps in access to preventive care. These findings will inform provider education and interventions to improve glucagon prescribing practices.
OBJECTIVE:Multiple states have passed legislation limiting out-of-pocket insulin costs for individuals on private insurance, including Colorado in 2020. Because disruptions in insulin access are life-threatening for people with type 1 diabetes, this study examined the real-world impact of Colorado's law on patient/parent-reported outcomes. RESEARCH DESIGN AND METHODS:Patient/parent-reported frequency of insulin insecurity (insulin rationing, running out early, or finding alternative sources of insulin), cost concerns, and most recent insulin out-of-pocket cost were assessed by a clinic-developed survey. Demographics, A1C, and glycemic time in range (TIR; 70-180 mg/dL) were obtained from medical record review. Linear regression models were fit to compare out-of-pocket costs, A1C, and TIR, adjusting for sex, diabetes duration, race/ethnicity, insurance, and age. RESULTS:Of 184 enrolled participants, 149 responded to insulin insecurity questions, with 34% reporting at least one insulin insecurity behavior. Insulin insecurity was associated with higher monthly insulin costs ($77.60 vs. $19.30, P = 0.004) and A1C (+0.69 ± 0.23%, P = 0.003) and lower TIR (-9.78 ± 4.03%, P = 0.02) compared with insulin security. Similar rates of insecurity were seen in emerging adults (46%, n = 18/39) and those publicly insured (43.5%, n = 10/23). There was no difference in mean copayments between those on public versus private insurance ($39.40 vs. $38.00). CONCLUSION:Despite costs falling below the out-of-pocket cap, insulin insecurity remains common among emerging adults and families of youth with type 1 diabetes and is associated with worse glycemia. Further research into root causes of insecurity, such as limitations on early refills, is required.
Pregnant people with type 1 diabetes often experience considerable emotional distress when striving for tight glucose management, managing the changes in insulin sensitivity over the three trimesters, adjusting to the real risks of hypoglycemia, and dealing with a myriad of frightening feelings and pregnancy-related experiences. Thus, pregnancy-related emotional distress during the perinatal period can have profound implications for maternal and child health and well-being over time. This article provides a comprehensive description of the subjective experience of pregnancy-related emotional distress reported by many women with type 1 diabetes, reviews options for its practical assessment in clinical care, and outlines strategies for intervention.
OBJECTIVE. Patients with type 2 diabetes are at an elevated risk for metabolic dysfunction-associated steatotic liver disease and advanced liver fibrosis. Multiple professional societies recommend initiating screening with a fibrosis-4 (FIB-4) index score calculation. This study aimed to evaluate the frequency of laboratory assessments necessary for FIB-4 score calculation in patients with type 2 diabetes. RESEARCH DESIGN AND METHODS. A retrospective analysis of de-identified electronic medical records from 337,094 patients aged 40–75 years with type 2 diabetes was conducted to evaluate the completion rate of FIB-4 scoring and adherence to other recommended measurements and medications, including urinary albumin measurement and statin use. RESULTS. Only 33% of patients with type 2 diabetes had all necessary components for FIB-4 score calculation, although this rate increased significantly over time (odds ratio 2.51, 95% CI 2.44–2.58) in the period from 2020 to April 2024 compared with 2010–2014. Urinary albumin measurements also increased but remained low at 13% during the period from 2020 to April 2024. Prescriptions for statin and newer antihyperglycemic medications significantly increased. CONCLUSION. Our findings indicate that, although testing frequency for liver health in patients with type 2 diabetes is gradually increasing, substantial gaps in clinical practice persist.
OBJECTIVE:Negative social determinants of health (SDOH) are associated with greater kidney disease incidence and progression, partly because of suboptimal management. We studied the association of demographic, clinical, and individual- and contextual-level SDOH factors with sodium-glucose cotransporter 2 (SGLT2) inhibitor and glucagon-like peptide 1 (GLP-1) receptor agonist initiation in patients with type 2 diabetes and whether these associations were modified by the Kidney Coordinated HeAlth Management Partnership (K-CHAMP) population health management (PHM) program. RESEARCH DESIGN AND METHODS:Using data from the K-CHAMP trial, which cluster-randomized 101 primary care offices to a control arm or the PHM intervention (including nephology electronic consultation, chronic kidney disease education, and pharmacist medication review), we explored associations between SGLT2 inhibitor and GLP-1 receptor agonist initiation with a priori patient factors using adjusted Poisson regression. Enrolled patients with type 2 diabetes who were not prescribed an SGLT2 inhibitor or a GLP-1 receptor agonist at baseline were included. Effect modification by K-CHAMP was assessed using interaction terms. RESULTS:The cohort had 891 patients (402 receiving the PHM intervention and 489 in the control group). Of the participants, 55% were female and 89% were White; the cohort had a mean age of 73 ± 9 years, mean BMI of 33 ± 7 kg/m2, mean A1C of 7.3 ± 1.5%, and mean estimated glomerular filtration rate of 37.4 ± 8.3 mL/min/1.73 m2; and 24% were rural living. Over a median follow-up of 17.7 months (interquartile range [IQR] 12.4-23.8 months), 238 (26.7%) initiated an SGLT2 inhibitor or GLP-1 receptor agonist. In adjusted analysis, age (incidence rate ratio [IRR] 0.92, 95% CI 0.85-0.99) and A1C (IRR 1.15, 95% CI 1.07-1.24) were significantly associated with SGLT2 inhibitor or GLP-1 receptor agonist initiation. The K-CHAMP PHM intervention did not significantly modify association of any factors. CONCLUSION:Younger age and higher A1C were associated with increased likelihood of initiating an SGLT2 inhibitor or GLP-1 receptor agonist. Other demographic, clinical, and SDOH factors were not significantly associated with medication initiation. The K-CHAMP PHM intervention did not moderate the association of patient-level or SDOH factors with initiation of an SGLT2 inhibitor or GLP-1 receptor agonist.
OBJECTIVE:Taking into account the potential link between oral hygiene and glycemic management in individuals with type 2 diabetes, this study aimed to investigate the relationship between oral hygiene practices, namely, tooth brushing, interdental cleaning, dental visits, and remaining teeth, and glycemic variability measured by continuous glucose monitoring (CGM) in people with type 2 diabetes, with a particular focus on the role of inflammation. RESEARCH DESIGN AND METHODS:This cross-sectional study included 104 adults with type 2 diabetes visiting an internal medicine clinic. Questionnaires were used to collect data on oral hygiene practices, dental visit frequency, and the number of remaining teeth. Blood and urine samples were obtained, and CGM was performed for 2 weeks. The relationship between oral hygiene practices and diabetes management indicators, as well as inflammation markers, was analyzed. RESULTS:The frequency of tooth brushing was negatively correlated with BMI, inflammation-related markers such as high-sensitivity C-reactive protein and tumor necrosis factor-α, and urine albumin-to-creatinine ratio. Interdental cleaning three or more times per week compared with less frequent cleaning was associated with lower fasting blood glucose, lower A1C, and improve CGM-related metrics, including greater time in range (TIR), lower glucose management indicator (GMI), and lower time above range. In logistic regression analysis, interdental cleaning showed associations with achieving TIR and GMI goals, even after adjusting for background factors and inflammatory markers. CONCLUSION:This study highlights the crucial role of oral hygiene practices in type 2 diabetes. Regular dental visits and effective oral self-care are paramount for promoting optimal oral health and managing diabetes.
OBJECTIVE:Preconception planning can reduce complications in pregnancy with type 1 diabetes. However, high periconception A1C is not uncommon and increases maternal and fetal risks. Because of limited data regarding preconception counseling, questions about education and contraception use were added to the 2022 T1D Exchange Quality Improvement Collaborative (T1DX-QI) survey. RESEARCH DESIGN AND METHODS:The annual T1DX-QI survey was conducted in August and September 2022 with a center response rate of 94% of 50 centers, including 33 pediatric centers (66%) and 17 adult centers (34%). Representatives from each center answered questions relating to center resources and practices. The study includes females of reproductive age (13-50 years) diagnosed with type 1 diabetes who had at least one A1C value in 2022 in the T1DX-QI database. RESULTS:Most centers report discussing contraception (74%) and pregnancy planning (72%) at least once per year. Among pediatric centers, 42% report always asking about menstruation history, compared with 6% of adult centers. Only 12% of adult centers and 6% of pediatric centers have a formal preconception counseling protocol. Only 12% of adult centers and 9% of pediatric centers estimated that >80% of their patients of childbearing potential were using contraception. Of females aged 13-50 years of age with type 1 diabetes, 15% at pediatric centers and 24.4% at adult centers had an A1C <6.5% at the time of the survey. CONCLUSION:Although most centers reported discussing contraception and pregnancy planning, estimated rates of formal preconception counseling programs, contraception use, and attaining goal A1C remain low. Quality improvement efforts are needed to determine rates of preconception counseling and implement best practices to improve pregnancy outcomes.
Few studies have examined associations of social support with blood glucose control in American Indians (AIs), a population with a high burden of type 2 diabetes and related complications. This study examined the association of perceived social support with A1C among AIs in the Strong Heart Study. This cross-sectional study included 431 AI participants. Social support was measured using questions adapted from the National Comorbidity Survey and validated for use in AIs. A1C was measured using high-performance liquid chromatography. Generalized estimating equations were used to examine the association of social support with A1C. Participants who reported greater levels of social support had lower A1C levels. After adjustment for potential confounders, for every 1-SD increase in social support (6.8 points), A1C was 0.21% lower (β = -0.21%, 95% CI -0.40 to -0.01, P = 0.04). These data suggest that higher levels of social support are associated with better control of blood glucose. Further studies are needed to determine the mechanism by which perceived social support affects A1C.
Breastfeeding presents distinct physiological and practical challenges in individuals with type 1 or type 2 diabetes. This review examines the barriers to successful lactation in this population, evaluates evidence-based interventions to address these obstacles, provides clinical recommendations regarding medication and nutritional management, and delineates the impact of diabetes on lactation physiology.
OBJECTIVE:We aimed to explore sex differences in type 1 diabetes management and investigate the perceived need for improved diabetes technology to mitigate the effect of the menstrual cycle on glycemic control in females with type 1 diabetes. RESEARCH DESIGN AND METHODS:A REDCap survey was designed to ask adults with type 1 diabetes about demographics, medical history, diabetes management, and, when applicable, the impact of the menstrual cycle on glycemic control and the extent to which currently available diabetes technology is successful at regulating blood glucose levels across cycle phases. RESULTS:A total of 299 respondents completed the survey. Of these, 218 (72.9%) reported being female. No significant sex differences were detected in reported A1C, glycemic time in range, or diabetes technology used (χ2 tests, all P >0.3). One hundred and thirty-six female respondents reported actively menstruating. Of these, 97 (71.3%) indicated the luteal phase of the menstrual cycle to be the cycle phase that most affected their glycemic control, and 102 (75.0%) reported increased exposure to hyperglycemia during this phase. When asked about technology satisfaction, 68 respondents (50.0%) reported that their diabetes technology was not successful at regulating blood glucose levels across the menstrual cycle, and 88 (64.7%) indicated that the technology they used could be better at mitigating cycle-related metabolic variability. CONCLUSION:Most investigated type 1 diabetes management outcomes showed no significant sex differences. Importantly, 65% of female respondents who were actively menstruating indicated the need for improved diabetes technology to stabilize glycemic control across the menstrual cycle.
OBJECTIVE:Despite their documented significance in type 2 diabetes management, social determinants of health (SDOH), including material needs security and quality of life (QoL), are understudied in the Middle East and North Africa (MENA) region. Material needs security refers to the consistent availability of essential material resources required to sustain health and manage diseases. This study aimed to assess the relation between material needs security and QoL in Lebanese adults with type 2 diabetes. RESEARCH DESIGN AND METHODS:Using convenience sampling, 300 participants with type 2 diabetes were recruited. Demographic and material need variables were self-reported, and QoL was assessed using the abbreviated World Health Organization Quality of Life Scale (WHOQOL-BREF). WHOQOL-BREF score was the outcome variable used. Regression models were used to examine associations between material needs security and WHOQOL-BREF score, controlling for relevant confounding variables. RESULTS:Most of the participants were men and married and had lower education levels. Multivariate analyses revealed that having material needs security was associated with physical health (β = 0.32, 95% CI 0.14-0.51), psychological health (β = 0.33, 95% CI 0.15-0.50), social relationships (β = 0.29, 95% CI 0.08-0.50), environment (β = 0.53, 95% CI 0.39-0.67), and overall perception of QoL (β = 0.09, 95% CI 0.04-0.14) after controlling for all relevant confounding variables. Other significant correlates of good QoL included lower age, higher education, higher income, and being employed. CONCLUSION:This study highlights the important influence of material needs security on QoL in adults with type 2 diabetes in the MENA region. Further research is needed to understand potential pathways and mechanisms, as well as options for effective interventions.
OBJECTIVE:We sought to examine barriers to diabetes technology use in underserved non-Hispanic Black and Hispanic youth with type 1 diabetes from the caregivers' perspectives and to co-create solutions to overcome barriers. RESEARCH DESIGN AND METHODS:Using user-centered design methodology, we held virtual workshops with caregivers to identify barriers and solutions associated with diabetes technology use. Three independent coders analyzed workshop recordings using an inductive coding approach. RESULTS:Twenty-three caregivers of non-Hispanic Black and Hispanic youth with type 1 diabetes participated. The majority of participants were mothers (n = 21), were publicly insured (n = 18), and had social needs (n = 13). We uncovered novel barriers to diabetes technology use, including 1) health-related social needs specific to diabetes technology use, 2) insufficient diabetes technology support at school, 3) disjointed care integration, and 4) the need for personalized diabetes device education. Proposed solutions included resources for social needs, more technology education for schools, enhanced care coordination, and a nonmedical person to deliver tailored device education. CONCLUSION:This study revealed new approaches to support caregivers of non-Hispanic Black and Hispanic youth with type 1 diabetes with persistent barriers to device use. Integrating interventions that align with caregivers' needs will facilitate the adoption and sustained use of diabetes technology by non-Hispanic Black and Hispanic youth with type 1 diabetes.
