Timely News and Notes for Primary Care Providers from the American Diabetes Association

Mortality due to diabetes in areas of Seattle, WA, that were subject to the 1930s practice of redlining was nearly 54% higher in 2014 in areas historically rated “hazardous” or “D” compared to those rated “best” or “A.”

Redlining was a practice of the long-gone Home Owners’ Loan Corporation (HOLC), which systematically discriminated against Black communities for the purposes of mortgage approvals and other financial arrangements in the 1930s and ’40s. Until it was outlawed in the late 1960s, the practice was a hallmark of housing inequality and discrimination and, according to an analysis by Linde et al. (Diabetes Care, doi.org/h6m9), its effects are still being felt, particularly in terms of diabetes health outcomes.

Linde et al. report that HOLC redlining in Seattle explains 45–56% of the variation in diabetes mortality between the years 1990 and 2014. Over the same period, the policy also explained 51–60% of the variation in years of lost life due to diabetes. HOLC originally graded residential areas of Seattle from A to D, with D rating typically given to communities with a majority Black population. According to the authors, in 2014, a 1-unit higher A–D historic HOLC score was associated nearly 54% higher diabetes mortality rates and nearly 67% higher years of lost life.

“While significant attention has been brought to the issue of social determinants and social risk factors as drivers of poor health outcomes for diabetes, there is limited appreciation of the fact that structural racism and/or structural inequalities are antecedent to social determinants of health,” author Leonard Egede said. “Therefore, this study provides strong evidence for the ongoing impact of structural racism and historic redlining on health outcomes for diabetes. Next steps are large population-based studies that elucidate the mechanisms and pathways that explain this effect as a starting point for designing interventions to address the problem.”

In a wider analysis of the decades-long effects of neighborhood redlining, Motairek et al. (Journal of the American College of Cardiology, doi.org/h6nb) detail how the practice is still affecting cardiovascular health across the United States.

“We already know historic redlining has been linked with modern-day health inequities in major urban areas, including asthma, certain types of cancer, preterm birth, mental health, and other chronic disease,” senior author Sadeer Al-Kindi said. “While ours is the first study to examine the national relationship between redlined neighborhoods and cardiovascular diseases, it’s logical that many of the socioeconomic, environmental, and social impacts of redlining on other areas of residents’ health outcomes would also be seen in heart disease.”

Using methods similar to those of the previously mentioned study by Linde et al., the authors mapped current census tracts to historic HOLC gradings and then looked at current rates of various cardiovascular-related outcomes.

“We found neighborhoods with so-called better HOLC grades had higher cholesterol screening and routine health visits when compared to neighborhoods with worse HOLC grades. And the prevalence of adults 18–64 years old without health insurance nearly doubled from A- through D-graded areas,” lead author Issam Motairek said. “In each stepwise increase across the HOLC grading spectrum, from A to D, we also observed an overall increase in rates of diabetes, obesity, hypertension, and smoking.”

According to the authors, the influence of historic redlining practices may be seen in numerous contemporary heart risk factors, including lower access to public transport, health insurance, and healthy foods and environmental factors such as pollution, lack of green spaces, and toxins. Similar to Linde et al., they point to redlining as a byword for deprivation and discrimination.

A mapped view of historic redlining in the United States is available from bit.ly/3oNbjNH.

The enrollment of Black, indigenous, and other people of color in U.S. and European randomized controlled trials focusing on diabetes has not improved over the past two decades, according to Zhang et al. (Diabetes Care, doi.org/h6nc).

The review included 42 eligible trials following an extensive literature search of the Cochrane Library, Medline/Pubmed, and EMBASE databases. Rates stood at 27.4% in trials based in the United States, while in Europe, enrollment was just 2.9% of study populations. There was also no discernible change in rates through the years.

According to the authors, this persistent problem raises concerns about health equities and about the generalizability of such trials. Based on their findings, the authors point to potential biases of researchers, but also potential reluctance on the part of people of color to enroll in medical trials. They call for “culturally competent measures and strategies” to encourage Black, indigenous, and other people of color to participate in such trials. They also suggest that research journals require data collection and detailed reporting on the race/ethnicity of study populations in research articles.

About 1.2 million or about 1 in 7 insulin users in the United States face “catastrophic” levels of spending, according to Bakkila et al. (Health Affairs, doi.org/10.1377/hlthaff.2021.01788). By catastrophic, they mean having to spend >40% of their disposable income (i.e., income remaining after paying for food and housing) on insulin.

Using data from the most recent Medical Expenditures Panel Survey covering 2017 and 2018, the authors found that about two-thirds of those experiencing such spending levels were Medicare beneficiaries. Overall, individuals with private insurance or no insurance paid the most, followed by those with Medicare coverage. Medicaid beneficiaries paid the least. These patterns suggest, according to the authors, that factors other than income, such as insurance status, may influence whether individuals experience such extreme spending levels. They suggest that policy reform is needed to curb such out-of-pocket spending.

Meanwhile, a survey from CharityRx (bit.ly/3bduSMk) suggests that as many as 79% of respondents said insulin had caused them financial difficulties. A similar proportion said they had taken on credit card debt to pay for insulin, with average amounts of ∼$9,000. As a consequence of insulin-related financial difficulties, many reported difficulties with various other living expenses. Many also reported feeling pressured to sell possessions, take unwarranted risks, or sell prescriptions or illegal drugs to be able to afford insulin. About two-thirds also reported rationing their insulin to curb spending. While various pieces of federal and state legislation to cap insulin costs make progress (and class-action lawsuits try to force down prices), there are hints of movement toward more affordable prices. Civica announced in March 2022 that it will manufacture and distribute three biologic insulins corresponding to brand-name products Lantus, Humalog, and Novolog, with consumer prices capped at $30 per vial and $55 for a box of five pen cartridges. The launch of these products is penciled in for 2024, but an analysis in the New England Journal of Medicine (doi.org/h6ng) suggests their pathway to market could be tricky given the market incumbents and financial incentives built into the current system.

With much the same ambition for disruption as Civica, the State of California wants to manufacture its own insulin and sell it at below-market prices. Governor Gavin Newsom used Twitter (bit.ly/3zivw2P) to announce the initiative, tweeting, “California is going to make its own insulin. It’s simple. People should not get into debt to get life-saving medication.”

Meanwhile, Sanofi in June announced (bit.ly/3blzsYD) it will cap its insulin pricing at $35 for a 30-day supply, perhaps in anticipation of impending legislation that could soon force such an action anyway.

Walking up to ∼10,000 steps per day may be optimal for lowering the risk of all-cause mortality in adults with prediabetes and diabetes, according to del Pozo-Cruz et al. (Diabetes Care, doi.org/h7qg). The dose-response relationship between steps and all-cause mortality risk also appears to be L-shaped, suggesting that any increase in steps taken above a minimum-level may carry benefits.

Although suggesting that 10,000 steps may be an optimal target, the authors acknowledge that specific recommendations for individuals with prediabetes or diabetes should probably be tailored. This could be particularly true for individuals who “accumulate their physical activity in an unstructured manner” and for individuals who find it challenging to know whether they are sufficiently active, the authors noted.

The findings come from a prospective analysis of the National Health and Nutrition Examination Survey using data from ∼1,200 individuals with prediabetes and just under 500 individuals with diabetes. Specifically, the authors looked for individuals with available accelerometer-step data. Mortality (if any) was then determined via the National Death Index, with follow- up over ∼9 years.

The authors found that 200 adults with prediabetes and 138 with diabetes died during the study period and that there was a nonlinear, L-shaped relationship with steps per day (i.e., as steps increased, mortality risks dropped to a nadir at ∼10,000 steps, after which risks rose, but only slightly). This pattern held for both prediabetes and diabetes after adjustment for multiple confounding factors.

The implementation of telemedicine and wider adoption of continuous glucose monitoring helped to minimize the effects of the coronavirus disease 2019 pandemic lockdowns on children with type 1 diabetes, according to Choudhary et al. (BMC Pediatrics, doi.org/gp8kdb). However, the success was not universal, with minority groups often having poorer outcomes.

“Our diabetes team implemented telemedicine visits within weeks of the shutdown, allowing us to provide care to our patients in an efficient and timely manner,” author Abha Choudhary said. “Our team was also able to utilize continuous glucose monitoring [CGM] for a growing number of patients, which may have helped to mitigate some of the challenges brought on by the pandemic.”

The single-center study used data from Children’s Medical Center Dallas to determine how management of type 1 diabetes might have changed, comparing 2019 to 2020, when the pandemic started. They found that the number of office visits declined during 2020, but there were no differences in patients’ overall glucose control or number of hospitalizations between the years. Notably, however, patients of minority and low-income demographic groups had worse glucose control and more hospitalizations than those who were White, non-Hispanic, and insured.

They also found that CGM use was higher among insured patients but that there was a significant increase in the numbers of uninsured patients using the approach, likely because it became available to Medicaid recipients at the start of the pandemic.

“For all the progress we have made, significant disparities remain with regard to access to some of the tools we think made the biggest differences during the early months of the pandemic,” Choudhary said. “From broadband access to the hardware and software that’s so central to diabetes care these days, we’ve only begun to scratch the surface when it comes to addressing disparities in technology and remote patient monitoring.”

The American Diabetes Association (ADA) recently published a comprehensive guide to eye care as part of Focus on Diabetes, the multi year initiative that brings together the ADA and partners from leading organizations in vision care to increase awareness about diabetes and eye health. The guide aims to improve outcomes for people with diabetes related retinal disease.

The authors identify key data eye care professionals need to receive from diabetes health care providers and vice versa to ensure the eye health of their shared patients. They also provide helpful suggestions for reducing patient apprehension by explaining what to expect from retinal screenings and therapeutic procedures. In addition, the authors emphasize the need to address social determinants of health and ensure equity in the provision of eye care services.

Online access to this compendium is free, supported by unrestricted education grants from VSP Vision Care and Regeneron. To access this and all ADA published compendia, visit https://diabetesjournals.org/compendia.

New resources are available from the ADA’s Overcoming Therapeutic Inertia (OTI) initiative. The following materials can be downloaded for free from the OTI website (therapeuticinertia.diabetes.org).

• An infographic highlighting best practices, based on the initiative s 2021 meta analysis, that can be applied at the practice, health care professional, and patient levels

• An advocacy presentation that can be shared with hospital or health system executives and summarizes the business case for implementing system level changes in diabetes care to improve health outcomes and efficiencies

• An implementation guide that can be shared in grand rounds and team trainings to help you and your team explore best practices and develop strategies to overcome therapeutic inertia in your organization

The ADA’s Focus on Diabetes initiative is offering a free series of continuing education (CE) modules titled Diabetes & Eye Health: A Guide for Primary Care Clinicians. The course includes:

• Module 1: Overview of Diabetes and Eye Health

• Module 2: Ocular Manifestations of Diabetes

• Module 3: Supporting Patients and Fostering Collaborative Care

Professionals who complete all three modules will be eligible to receive 1 CE credit. To register, visit the Association’s Professional Education Portal at bit.ly/3bf5iXh.

American Diabetes Association’s 82nd Scientific Sessions The 82nd Scientific Sessions of the American Diabetes Association were held 3–7 June 2022 in New Orleans, LA, with a packed program covering everything diabetes. Sessions focused on a wide range of topics, including detecting gestational diabetes with metabolomics, continuous glucose monitoring and time in range for glucose control, automated insulin delivery, barriers to insulin access, diabetes technology use in various age-groups, strategies for weight management, novel therapeutics, and more. Highlights of the meeting are available at adameetingnews.org.

To pick just one highlight, however, we look at the progress of islet stem cell transplants that aim to reverse type 1 diabetes. The treatment, called VX-880, is an investigational stem cell– derived, fully differentiated pancreatic islet cell replacement therapy and is being developed by Vertex Pharmaceuticals. Previously, the company provided updates on the program of the first type 1 diabetes patients (literally Patient 1 and Patient 2) in a phase 1/2 trial of the therapy. The update at the Scientific Sessions focused on glycemic time in range (TIR). Researchers reported that Patient 1, who had a baseline TIR of 40.1%, saw TIR increase to 99.9% at day 270 and was free of any insulin requirement. Patient 2, with a baseline TIR of 35.9%, saw TIR increase to 51.9% at day 150, with a 30% reduction in insulin use. The treatment is reportedly well tolerated so far, with only mild or moderate adverse events detected.

“The potential impact of this treatment on patients cannot be overstated,” said researcher James Markmann, who led the treatment of Patient 1. “This study shows a significant leap forward in the potential treatment of patients with type 1 diabetes.”

The study continues with further enrollment. Three patients so far have received the treatment. The presentation abstract is available at bit.ly/3DYqGvz, and further details are available in a Vertex press release (bit.ly/3POvTcq).