In This Issue of Diabetes Care

Adults with type 1 diabetes who were also Black used continuous glucose monitoring (CGM) and insulin pumps much less than equivalent non-Black individuals, according to Kanbour et al. (p. 56). The retrospective but real-world study points to lower levels of provider–patient discussions about the technologies, lower levels of prescribing of the technologies, and consequently lower levels of use among Black individuals with type 1 diabetes. However, why that is the case is unclear. The authors point to numerous socioeconomic issues as potentially contributing factors, and on that basis, they call for prospective studies to look at the reasons why such disparities continue to exist and potentially how solutions to the issue might help. The retrospective electronic medical record–based study included 1,528 adults with type 1 diabetes who were then characterized according to Black or non-Black racial background. According to the authors, baseline use of CGM by Black individuals was 7.9% and use of pumps was 18.7%. This compared to 30.3% and 49.6%, respectively, among non-Black individuals. Prevalent technology use, which combines baseline and incident use, saw just under half of Black individuals use CGM during the 7-year study period. This compared to threequarters of non-Black individuals who used the technology at any time. Around one-third of Black individuals used insulin pump technologies compared to about two-thirds of non-Black individuals. Odds of Black patients having discussions about the technologies and/or receiving a prescription for them were consistently reduced. The authors cite local neighborhood conditions, a lack of adequate insurance, marital and employment status, and the state of medical care as potential additional factors that might explain the disparities in use. However, they also caution that numerous other factors may have an influence, including “implicit racial bias” in care providers. “Prospective studies should assess the impact of provider type, training, and experience, racial concordance of provider and patient, quantity/quality of provider–patient discussions, patient sustained use of technologies, and ethnic disparities on technology use,” they write.

Incident early-onset type 2 diabetes appears to be associated with increased risks for early-onset cancers, including diabetes- and obesity-related cancers, according to Zhang et al. (p. 120). This was especially the case when individuals had higher BMI at 18 years of age and suggests that early-onset type 2 diabetes has an outsized impact on cancer risk compared to later onset of type 2 diabetes. Accordingly, the authors suggest there is an urgent need for initiatives in the space of prevention and screening for cancers in the context of type 2 diabetes. They specifically call for attention to individuals with early-onset type 2 diabetes and their risks for diabetes/obesity-related cancers. This includes endometrium, kidney, colorectal, pancreas, thyroid, and bladder cancers. The findings come from further prospective analysis of the Nurses’ Health Studies and included just over 228,000 individuals and follow-up for up to 38 years. According to the authors, they identified just under 18,300 cases of incident type 2 diabetes, just over 6,500 cases of early-onset cancer (i.e., <50 years), and just under 37,000 cases of later-onset diabetes. After fully adjusting for a long list of potential confounders, hazard ratios for early-onset diabetes were all strongly elevated for total diabetes- and obesityrelated cancer and particularly so when BMI at age 18 years was equal to or greater than 21 kg/m2. Early-onset diabetes was also associated with elevated risks for later-onset cancers, although the relationship was weaker. The authors note that exact mechanisms driving an early-onset diabetes–cancer link remain to be determined. Nevertheless, they explain there are potential direct and indirect candidate links between the two conditions. “Cancer prevention efforts tailored for early-onset type 2 diabetes patients may need to focus on those with higher adolescent or emerging adulthood BMI,” they write. “The impact of early-onset type 2 diabetes on cancer risk may be inherently stronger than that of later-onset type 2 diabetes.”

There is high cardiovascular- and diabetes-related mortality following a first-ever myocardial infarction in the context of type 1 diabetes, further analysis from the Finnish Diabetic Nephropathy (FinnDiane) study suggests. According to Smidtslund et al. (p. 197), poor kidney function and chronic kidney disease pose a particularly high risk for earlier mortality and risks for secondary events. Consequently, the authors suggest that prevention of chronic kidney disease in type 1 diabetes is crucial both prior to and after myocardial infarction to improve prognosis. Out of just over 4,200 individuals with type 1 diabetes, the authors identified 253 individual cases of myocardial infarction between 1997 and 2012. Nearly three-quarters of these individuals died during roughly 3 years of follow-up, on average. Indeed, after myocardial infarction, the 30-day mortality rate was 29%, and only a quarter of individuals were alive at the end of follow-up. Falling levels of kidney filtration function, prior heart disease diagnosis, and older age when the myocardial infarction happened were all independent risk factors for mortality. Conversely, acute and subacute revascularization were associated with lower risk of mortality. Evident issues with the competing risk of death in the study population prompted the authors to use modelling to look at factors associated with poor outcomes. According to that analysis, there was a very high risk of recurrent myocardial infarction, heart failure, and coronary revascularization associated with kidney failure. While the study design could not give definitive answers on the kidney disease–heart failure relationship, the authors suggest it might be due to “complex neurohumoral damages resulting in hemodynamic changes and reduced kidney perfusion.” In their conclusion, they suggest that in the context of type 1 diabetes, mortality is high following first-ever myocardial infarction and that chronic kidney disease is the strongest explanatory factor. “Prevention of chronic kidney disease is consequently crucial to improve the prognosis for individuals with type 1 diabetes, both before and after a [myocardial infarction],” they write.

Large-scale changes are needed in the preventive care and screening for diabetic foot ulcers (DFU), a review by McDermott et al. concludes (p. 209). In particular, efforts should be made to focus on groups that are disproportionately affected by the condition, with race, ethnicity, socioeconomic factors, and geography being particularly powerful modifiers of risk. They also call out the relative lack of funding that research activities receive despite the complication being common and having considerable morbidity among diabetes patients. The wide-ranging review initially focuses on the presentation and characteristics of DFU and looks at how peripheral neuropathy and peripheral artery disease contribute to the development of DFU. The authors then look at the epidemiology of DFU and the various (and varying) estimates of incidence and prevalence. In terms of incidence, some studies suggest it is lower than 0.1%, while others suggest it is as high as 11%. In terms of prevalence, it may be ∼6% globally or 15% in certain populations, with much depending on factors that are, or are not, accounted for. While large-scale epidemiological studies are evidently warranted to accurately estimate rates and risk factors more fully, in the latter case there are known clinical and demographic risk factors, which the authors review. They also look at aspects of morbidity and mortality, the economic burden, and finally primary/secondary prevention of DFU. Drawing it all together, the authors conclude that DFU are common and increasing in diabetes, with serious outcomes likely for patients if not treated adequately. They also suggest that major efforts are needed to improve care, with funding directed towards research that would lead to such improvements. “Significantly more public and institutional funding for DFU research and care initiatives is warranted to correct the imbalance between current resource allocation and the enormous burden of DFU,” they write. “Ultimately, a paradigm shift towards DFU prevention and health equity is required to produce meaningful reductions in DFU, major lower-extremity amputation, and mortality.”