In This Issue of Diabetes Care

Health insurance coverage among U.S. adults with diabetes has significantly increased as a result of the introduction of the Affordable Care Act (ACA), according to Casagrande et al. (p. 956). Additionally, the amount of money spent on medical costs has been reduced, particularly in lower income families. The conclusions come from a cross-sectional analysis of data from the 2009 and 2016 National Health Interview Surveys and cover adults age ≥18 years with a previous diagnosis of diabetes and self-report of their health insurance coverage. According to the authors, health insurance coverage increased between 2009 and 2016 from 84.7 to 90.1% among adults age 18–64 years (ACA mandated coverage was largely introduced in 2014). For adults age ≥65 years, coverage remained virtually universal at 99.5%. The authors then looked at subgroups and found that coverage increased in many of the predefined groups. The groups included men, non-Hispanic whites and blacks, Hispanics, married couples, those with lower than high school education or higher than high school education, or a low family income (<$35,000). Specifically referring to Hispanics and those with a lower income and education level, the authors say the large increases in coverage are important because these groups are disproportionately affected by diabetes. They also point out that the increase in coverage among those with a new diagnosis of diabetes increases the chances that they will receive early care and hence reduce the risk of future complications. Commenting more widely on the study, author Sarah S. Casagrande told Diabetes Care: “Given the national economic burden that diabetes imposes, especially as the U.S. population ages, we hope that this study will be used to inform legislation related to the ACA. Health insurance coverage is critically important for persons with diabetes, and this study underscores how national policy can have significant and positive impacts on those who need insurance for regular medical care.”

Casagrande et al. Changes in health insurance coverage under the Affordable Care Act: a national sample of U.S. adults with diabetes, 2009 and 2016. Diabetes Care 2018;41:956–962

Diabetes is likely to have a significant effect on economic productivity according to an analysis by Magliano et al. (p. 979). They state that the elimination of diabetes should result in prolonged years of life lived at a population level and increased productivity. Consequently, they call on employers and governments to recognize that having diabetes likely affects productivity and to implement prevention programs to reduce the impact of diabetes. Using a novel index of productivity called “productivity-adjusted life years” (PALYs) and life table modeling, the authors provide estimates of years of life and PALYs lost to diabetes in adults (age 20–65 years) in Australia. They then repeat the analysis with the assumption that the cohort did not have diabetes, and they use the different outcomes to estimate the economic impact of diabetes. According to their analysis, diabetes reduced the cohort’s number of years lived by just over 190,000 years (a 3% reduction) and reduced PALYs by 11.6% and 10.5% among men and women, respectively. Then, stratifying by age, they found that diabetes had the lowest impact on productivity in the oldest participants (age 65–69 years) with the most impact on the youngest (age 20–24 years). According to author Dianna J. Magliano: “The intent of these analyses was to highlight that diabetes imposes a large, previously unmeasured burden on work productivity. Burden of disease is often expressed in terms of impact on years of life lost and quality-adjusted life years (QALYs) lost, but rarely in terms of productivity. Our work devises a novel metric for measuring the impact of disease on productivity in the same manner as QALYs. PALYs provide an additional economic viewpoint of the impact of diabetes, upon which stronger arguments for preventing diabetes can be made. This is especially relevant for low- and middle-income countries that can ill afford the rising epidemic of diabetes.”

Magliano et al. The productivity burden of diabetes at a population level. Diabetes Care 2018;41:979–984

According to Billings et al. (p. 1009), a fixed-ratio combination of insulin degludec and the glucagon-like peptide 1 receptor agonist (GLP-1RA) liraglutide (IDegLira) is noninferior to basal-bolus insulin for reducing HbA_1c in patients with poorly controlled type 2 diabetes. In addition, the IDegLira combination had lower rates of hypoglycemia and improved weight loss in comparison to weight gain with the insulin combination. The conclusions come from the phase 3b DUAL (Dual Action of Liraglutide and Insulin Degludec in Type 2 Diabetes) VII trial that compared the IDegLira combination with basal-bolus insulin for HbA_1c reductions as the primary outcome. Approximately 250 patients with type 2 diabetes were enrolled in each group, and the treatment period was 26 weeks. Additional secondary outcomes included hypoglycemia events and changes in body weight, total daily insulin dose, and fasting plasma glucose. According to the authors, HbA_1c decreased from 8.2% at baseline to 6.7% after 26 weeks in both groups, confirming the noninferiority of the IDegLira combination versus the insulin combination. In addition, 20% of patients on IDegLira experienced hypoglycemia, while just over 50% experienced it with basal-bolus insulin. For body weight, patients in the IDegLira group experienced a decrease of 0.9 kg over 26 weeks, but in the basal-bolus insulin group, weight increased by 2.6 kg. Author Liana K. Billings said: “The DUAL VII trial demonstrated that blood glucose control for patients—even those with relatively long-standing diabetes—does not have to come at the cost of undesirable outcomes. Only one injection and only one self-monitored plasma glucose measurement in the IDegLira arm provided noninferior lowering of HbA_1c compared with the basal-bolus arm, which had up to five injections per day and at least four glucose measurements. As we aim to improve glucose control, individualize therapy, and consider factors beyond HbA_1c control, it is exciting to know there is now a desirable option with IDegLira that clearly demonstrated efficacy, safety, and tolerability for therapy without adding significant treatment burden.”

Billings et al. Efficacy and safety of IDegLira versus basal-bolus insulin therapy in patients with type 2 diabetes uncontrolled on metformin and basal insulin: the DUAL VII randomized clinical trial. Diabetes Care 2018;41:1009–1016

Obesity has again been tied to increased risk of developing diabetes, with long-term weight changes potentially modifying risk, according to Stokes et al. (p. 1025). As a result, the authors say the study underscores the importance of population-level approaches to preventing and treating obesity. Using data from the National Health and Nutrition Examination Survey (NHANES), the authors categorized individuals into four weight-change categories over a transition period from early adulthood (age 25 years) to midlife and their association with subsequent incidence of diabetes. The groups included nonobese, individuals who moved from obese to nonobese, individuals who moved from nonobese to obese, and individuals who remained obese over the entire period. Diabetes status was then established through self-report. While a rare event in the cohort, individuals who were obese but lost weight reportedly had a significantly lower risk of diabetes than those who remained obese. Those who remained nonobese and even individuals who became obese had a lower risk of diabetes in comparison to those that remained obese. Overall, those who remained nonobese had the least risk for diabetes. Using a modeling approach, the authors go on to show that if individuals who were obese had managed to become nonobese during the study period, they estimate that 9.1% of observed cases of diabetes might have been averted. Extending the scenario still further, they suggest that if the entire cohort had maintained a weight in the normal BMI range of 18.5–25 kg/m² for the study period, 64.2% of diabetes cases might have been averted. According to author Andrew Stokes: “Our findings suggest that population-based obesity prevention and treatment strategies may lead to large reductions in new cases of diabetes. For those with obesity in early adulthood, losing weight by midlife may lead to meaningful reductions in the risk of developing diabetes.” Coauthor Robin F. Scamuffa added: “This work underscores the importance of providing those with obesity in early adulthood with access to programs and interventions for successful weight loss sooner rather than later in their disease progression.”

Stokes et al. Obesity progression between young adulthood and midlife and incident diabetes: a retrospective cohort study of U.S. adults. Diabetes Care 2018;41:1025–1031