American Diabetes Association Research Articles

The Michigan Collaborative for Type 2 Diabetes (MCT2D): Development and implementation of a statewide collaborative quality initiative

BackgroundType 2 diabetes (T2D) is one of the most prevalent chronic diseases worldwide and a leading cause of cardiorenal disease and mortality. Only one-third of individuals with T2D receive care as recommended by the American Diabetes Association’s clinical practice guidelines. Effective strategies are needed to accelerate the implementation of guideline concordant T2D care.MethodsThe Michigan Collaborative for Type 2 Diabetes (MCT2D) is a statewide population health collaborative quality initiative (CQI) developed to improve the care of all people with T2D in Michigan. MCT2D has developed a learning health system with physician organizations and their constituent practices to support quality improvement initiatives focused on (1) improving use of guideline-directed pharmacotherapy to improve cardiorenal outcomes, (2) increasing evidence-based use of continuous glucose monitoring, and (3) supporting use of lower carbohydrate eating patterns.ResultsBetween 2021 and 2022, MCT2D recruited 28 of the 40 Michigan-based physician organizations participating in Blue Cross’ Physician Group Incentive Program with 336 constituent practices and 1357 physicians in primary care (304), endocrinology (21) and nephrology (11). In January 2022, baseline data included a sample of 96,140 unique individuals with T2D. The baseline HbA1c was ≤ 7.0% for 66.3% of patients (n = 32,787), while 14.9% of patients had a most recent HbA1c ≥ 8.0% (n = 7,393). The most recent body mass index (BMI) was ≥ 30.0 for 64.8% of patients (n = 38,516).DiscussionMCT2D has organized a statewide collaborative to recruit and engage a diverse and large set of physician organizations and their constituent practices. This is a promising opportunity to accelerate adoption of guideline-concordant care for people with T2D and may be a model for other state or regional collaboratives. Future directions include specific evidence-based interventions targeted at reducing diabetes-linked comorbidities and associated healthcare costs as well as strategies focused on T2D prevention among at-risk populations.

Prediabetes and Associated Risk Factors among Undergraduate Medical Students in Bangladesh

Background: Early detection and timely intervention of prediabetes is an important first step in preventing the disease. Objectives: To assess the prediabetes and associated risk factors in medical students of Bangladesh. Materials and Methods: A cross-sectional study was done among 252 medical students of Shaheed Ziaur Rahman Medical College, Bogura. Data related to demography with some behavioral factors, anthropometry, blood pressure, fasting plasma glucose, family history of hypertension (HTN) and diabetes mellitus (DM) were collected. Prediabetes was assessed by the American Diabetes Association (ADA) and World Health Organization (WHO) criteria. Results: The proportion of prediabetes was 13% according to ADA and 1.6% according to WHO respectively. Students with a positive family history of hypertension (HTN) had more prediabetes compared to those who didn’t have. None of the demographic factors, family history of DM or HTN, exercise and obesity were related between prediabetic and normal students, though prediabetic students had more proportion of family history of HTN. Conclusion: Prediabetes is proportionately high among students with positive family history of HTN. We recommend a regular checking of fasting plasma glucose of medical students with special attention to those who have a strong positive family history of DM and HTN. KYAMC Journal Volume: 15, No: 01, April 2024: 20-24.

Standardizing Hypoglycemic Critical Values Across United States Hospitals

Abstract Introduction/Objective While previous diabetes studies have defined severe hypoglycemia as glucose < 50 mg/dL, the American Diabetes Association (ADA) classified glucose < 54 mg/dL as requiring immediate action in 2019. In response, some laboratories implemented 54 mg/dL as their hypoglycemia critical value. However, there is no standardization across the medical community. Methods/Case Report To investigate the variability of hypoglycemia critical values across hospitals in the United States, hypoglycemia critical value thresholds were collected from the top 50 hospitals from the Newsweek’s World’s Best Hospitals 2020 United States list via hospital websites or representatives from the clinical laboratory. To evaluate the potential burden to providers and laboratory staff of raising the hypoglycemia critical value at our institution, we retrospectively reviewed deidentified glucose laboratory data for inpatient and outpatient core laboratories and determined the volume of critical value alerts sent to ordering providers per month under different hypoglycemia critical value thresholds. Results (if a Case Study enter NA) Across the 45 hospitals included, median hypoglycemia critical value was 50 mg/dL (Range: 40-60 mg/dL). The hypoglycemia critical value was set at 40 mg/dL at 12 hospitals and 50 mg/dL at 21 hospitals. 22% of institutions set the hypoglycemia critical value at or above the ADA recommendation of 54 mg/dL. Increasing the hypoglycemia critical alert to 50 mg/dL at our institution would increase the average monthly alerts by 122 for inpatient and 41 for outpatient core laboratories, corresponding to 163 additional total core laboratory alerts per month. Increasing the critical alert to 55 mg/dL, would increase average monthly alerts by 243 for inpatient and 99 for outpatient core laboratories, corresponding to 342 total additional alerts per month. Conclusion Our analysis suggests standardizing 50 mg/dL as the hypoglycemia critical value across institutions to improve patient safety by reducing the risk of severe acute symptoms and long-term complications without adding excessive burden to laboratory staff and providers.

Association of Low Vitamin D Status With Adiponectin and Fibroblast Growth Factor-21 in Newly Diagnosed Type 2 Diabetes Mellitus Patients.

Adiponectin and fibroblast growth factor-21 (FGF-21) have important roles in metabolic regulation and insulin sensitivity. Vitamin D is linked to metabolic dysregulation, inflammation, and oxidative stress in chronic type 2 diabetes mellitus (T2DM). The present study aimed to assessthe relationship of vitamin D levels with adiponectin and FGF-21 in newly diagnosed T2DM. A descriptive study was conducted on 47 patients with newly diagnosed T2DM recruited based on the American Diabetes Association criteria. Fasting plasma glucose and insulin were measured, and the homeostatic model assessment for insulin resistance was calculated. The serum levels of metabolic regulators such as vitamin D, adiponectin, and FGF-21; inflammatory markers such as interleukin-6 (IL-6), tumor necrosis factor-α, and high-sensitivity C-reactive protein; and oxidative stress markers such as malondialdehyde (MDA) and total antioxidant status were measured. The mean serum vitamin D concentration was 17.49±7.10 ng/ml, and all patients had low vitamin D levels (<30 ng/ml). Vitamin D was positively correlated with adiponectin (r=0.331, p=0.023), and it was negatively correlated with FGF-21 (r=-0.356, p=0.014), IL-6 (r=-0.411, p=0.004), and MDA (r=-0.515, p<0.001). There was a reduction in vitamin D concentration in all subjects. Vitamin D showed a positive association with adiponectin and a negative association with FGF-21 and inflammatory and oxidative stress markers. Vitamin D deficiency might increase the risk of progression of T2DM in these subjects.

Indirect estimation of the prevalence of type 2 diabetes mellitus in the sub-population of Tehran: using non-laboratory risk-score models in Iran

BackgroundThe prevalence of type 2 diabetes mellitus (T2DM) in the population covered by the Tehran University of Medical Sciences is unclear but crucial for healthcare programs. This study aims to validate four non-laboratory risk-score models, the American Diabetes Association (ADA) Risk Score, Australian Type 2 Diabetes Risk Assessment Tool (AUSDRISK), Finnish Diabetes Risk Score (FINDRISC), and TOPICS Diabetes Screening Score, for identifying undiagnosed diabetes and indirectly estimate the prevalence of T2DM in a subset of the Tehranian population using the selected model.MethodsThis research consisted of two main parts. In the first part, non-laboratory risk-score models to identify undiagnosed T2DM were validated using Iranian data from STEPs 2016 survey. The model performance was evaluated through the Area Under the Curve (AUC) and calibration via the observed-to-expected (O/E) ratio. Additional independent data from STEPs 2011 survey in Iran were utilized to test the model results by comparing indirect prevalence estimates with observed estimates. In the second part, the prevalence of T2DM was estimated indirectly by applying the selected model to a representative random sample from a Tehranian population telephone survey conducted in 2023.ResultsAmong the different models used, AUSDRISK showed the best performance in both discrimination (AUC (95% confidence interval (CI)): 0.80 (0.78, 0.81)) and calibration (O/E ratio = 1.01). After updating the original model, there was no change in the AUC value or calibration. Additionally, our findings indicate that the indirect estimates are nearly identical to the observed values in STEPs 2011 survey. In the second part of the study, by applying the recalibrated model to a subsample, the indirect prevalence of undiagnosed diabetes and T2DM (95% CI) were estimated at 4.18% (3.87, 4.49) and 11.1% (9.34, 13.1), respectively.ConclusionGiven the strong performance of the model, it appears that indirect method can provide a cost-effective and simple approach to assess disease prevalence and intervention effectiveness.Graphical

Recommendations for early identification of heart failure in patients with diabetes: Consensus statement of the Swiss Society of Endocrinology and Diabetology and the Heart Failure Working Group of the Swiss Society of Cardiology.

Diabetes is a well-recognised risk factor for the development of heart failure, with a prevalence higher than 30% in patients with diabetes aged over 60 years. Heart failure often emerges as the primary cardiovascular manifestation in patients with type 2 diabetes and appears to be even more prevalent in type 1 diabetes. In Switzerland, there are approximately 500,000 individuals with diabetes, and the number of affected people has been steadily rising in recent years. Therefore, the consequences of heart failure will affect an increasing number of patients, further straining the Swiss healthcare system. Early lifestyle modification and initiation of appropriate treatment can prevent or at least significantly delay the onset of symptomatic heart failure by several years. These facts underscore the urgent need for early detection of individuals with subclinical heart failure, which often remains undiagnosed until the first episode of acute heart failure requiring hospital admission occurs. To address this issue, the European Society of Cardiology, the American Diabetes Association (ADA) and other international professional societies have published recommendations on heart failure screening, diagnosis and management. To address this issue in Switzerland, experts from the Swiss Society of Endocrinology and Diabetology, the Swiss Society of Cardiology and the General Internal Medicine specialty met and prepared a consensus report including a simple diagnostic algorithm for use in everyday practice.

Type 3c diabetes mellitus: what are we dealing with? Review

The authors presented updated data on the term «type 3 diabetes mellitus», its modern classification, pathophysiological mechanisms of development and features of treatment, its definitions, epidemiology and modern classification based on the recommendations of the American Diabetes Association. Definitions and epidemiological features of acute pancreatitis and its most frequent complications, including 3c type diabetes have been described. Statistical data were presented on the risk of developing complications of acute pancreatitis in the form of carbohydrate metabolism disorders. Historical prerequisites of fatal complications of acute pancreatitis in the form of hyperglycemic states were also described. The pathophysiological mechanisms of the development of type 3c diabetes, namely local and systemic inflammation, loss of islet tissue of the pancreas, dysregulation of the insulin­­incretin axis, autoimmune destruction of β­cells of the pancreas, etc. were highlighted in detail. The role of genetic factors in the development of diabetes against the background of acute pancreatitis is described. Currently there are no standardized unified criteria of type 3c diabetes, thus the main and additional diagnostic criteria according to the different authors have been analyzed in detail. The differential characteristics and features of the diagnosis of diabetes mellitus by type and peculiarities of the diagnosis of type 1, 2 and 3c diabetes mellitus have been presented. The discussion on the glycemic target goals for patients with type 3c diabetes and the need for screening and prevention of carbohydrate metabolism disorders in patients with acute pancreatitis has been outlined. The authors provided current recommendations for the treatment of type 3c diabetes and discussed the possibilities of the use of insulin in the basis/bolus mode to achieve compensation of carbohydrate metabolism. The necessity to compensate pancreas exocrine insufficiency to improve the assimilation of fats and fat‑soluble vitamins has been emphasized.

8707 Are We Adequately Prescribing Sodium-Glucose Cotransporter 2 Inhibitors (SGLT2i) Or Glucagon-Like Peptide 1 Receptor Agonist (GLP-1 RA) In Patients With Type 2 Diabetes Mellitus (T2DM) And Established Atherosclerotic Cardiovascular Disease (ASCVD) Or Chronic Kidney Disease (CKD) In An Outpatient Setting: A Community Center Experience

Abstract Disclosure: R.K. Maan: None. A. Sawhney: None. A. Hayat: None. S. Kc: None. A. Madan: None. S. K c: None. L. Williams: None. A. Zweben: None. A. Rana: None. Introduction: The American Diabetes Association (ADA) recommends prescribing Sodium-Glucose Cotransporter 2 inhibitors (SGLT2i) or Glucagon-Like Peptide 1 Receptor Agonist (GLP-1 RA) in patients with Type 2 Diabetes Mellitus (T2DM) and established Atherosclerotic Cardiovascular Disease (ASCVD) or Chronic Kidney Disease (CKD) for its cardiovascular benefits. Methods: Our retrospective study analyzed data from 511 T2DM patients who visited the outpatient clinic between 7/1/22 to 6/30/23. Using Microsoft Excel, we assessed adherence to ADA guidelines by collecting data for SGLT2i, GLP-1 RA and statin prescriptions, urine microalbumin creatinine ratio measurements, and appropriate management of albuminuria. The study also investigated patients on dipeptidyl peptidase-4 inhibitors (DPP-4i) who were eligible for SGLT2i or GLP-1 RA. Results: Out of the 511 patients, 478 were eligible for SGLT2i or GLP-1 RA, and only 60% were prescribed these medications. Out of 479 patients eligible for statin prescription, only 85% were on it. Albuminuria was appropriately managed in 76% of eligible patients with Angiotensin-Converting Enzyme Inhibitors (ACEI) or Angiotensin II Receptor Blockers (ARBs). Additionally, 8 out of 11 patients on DPP-4i were eligible for SGLT2i or GLP-1 RA. Conclusion: We concluded that 60% of the patients eligible for SGLT2i or GLP-1 RA were prescribed the medication in our outpatient settings. The barriers identified were issues with insurance prior authorization and knowledge gaps. We aim to improve adherence to guidelines through multifaceted education strategies combined with audits and feedback.

6635 A Call for High-Value Diabetic Retinopathy Screening and the Introduction of a Novel Predictive Model

Abstract Disclosure: P.J. Williams: None. C. Kim: None. K. Ziadeh: None. E. White: None. C.S. Chen-Milhone: None. L.D. Lugo: None. K.B. Ellis: None. M.S. Juzych: None. Introduction: Diabetic retinopathy (DR) remains one of the leading causes of preventable blindness in middle-aged and older populations. Late-stage DR is often visually symptomatic; however, early DR is generally asymptomatic and requires screening. For type 2 diabetes mellitus (T2DM), the American Diabetes Association and the National Institute of Diabetes and Digestive and Kidney Diseases recommend an initial dilated eye exam with follow-up every 1-3 years, or annually if diabetic retinopathy is detected. Despite these guidelines, providers and insurers in the United States routinely recommend annual screening regardless of other factors. Methods: A cross-sectional analysis with prospective data verification was done for new diabetic eye exam referrals from August 2021 through July 2022 to address screening discrepancies. Established patients and referrals unrelated to hyperglycemia were excluded. Data collection included duration of diabetes, last hemoglobin A1c (HbA1c), maximum HbA1c, age, race, gender, BMI, relevant medication use, and imaging, as well as the presence of hypertension, hypercholesterolemia, diabetic peripheral neuropathy (DPN), diabetic nephropathy, diabetic amputation, and DR and data was verified against objective records up to 2 years later. Logistical multivariate analysis was conducted by a trained statistician. Results: 474 consecutive patients were referred over 1 year. Among all referrals, 2.11% (10/474) of patients were prediabetic. Among the patients with diabetes, 5.39% (25/464) were type 1 and 94.6% (439/464) were type 2. Among patients with T2DM, the average age was 57.64±11.52 (range = 25-98) and females made up 52.16% (229/439). The average diabetes duration among T2DM patients with DR was 19.39±8.45 years (range = 11-51) compared to 6.12±5.77 years (range = 0-31 years) without DR. Maximum lifetime HbA1c (p=0.0016), duration of diabetes (p&amp;lt;0.0001), and presence of DPN (p = 0.0047) were the strongest predictors of DR in patients with T2DM. A predictive model for DR was created utilizing these variables and hypercholesterolemia (p=0.048) with a predictive accuracy of 89.5% (chi-squared value (4)=121.451, p&amp;lt;0.001, Nagelkerke R2=57%). Sensitivity and specificity measured 92.31% and 87.99% respectively. The area under the ROC curve measured 0.952 (CI 0.925 to 0.972, p&amp;lt;0.0001). Conclusion: Duration of diabetes, maximum HbA1c, and DPN are strongly associated with DR among patients with T2DM and should be tracked to guide screening. Among T2DM patients with a well-documented recent onset of diabetes, maximum HbA1c less than 8, and benign initial eye exam, annual diabetic eye exams are unlikely to reveal DR in the first 10 years after onset. Based on our data, annual diabetic screening exams are unnecessary for many patients, and upper limits of screening intervals should be considered in low-risk patients to increase high-value care. Presentation: 6/2/2024

5040 Leveraging Continuous Glucose Monitoring Data as an Additional Source for Glucagon Prescription Behavior

Abstract Disclosure: J. Ambalavanan: None. J. Rusticelli: None. D. Isaacs: Consulting Fee; Self; Medtronic Diabetes, Lilly USA, LLC, Novo Nordisk, Insulet Corporation, Abbott Laboratories, Dexcom. H. Xiao: None. J. Bena: None. Z. Jin: None. C. Babiuch: None. M. Lansang: Consulting Fee; Self; Glooko. Research Investigator; Self; Abbott Laboratories, Dexcom, Xeris. Background: Hypoglycemia is a major source of anxiety in, and can be life-threatening for, patients with diabetes (DM). Even though the American Diabetes Association (ADA) recommends glucagon be made available to all individuals taking insulin or at high risk for hypoglycemia (level E evidence), few patients have access to this life-saving medication. Given the rapid adoption of continuous glucose monitoring (CGM) in the management of DM, we aimed to 1) evaluate glucagon prescription by identifying patients with hypoglycemia on CGM reports, and 2) deliver an educational letter to the providers. Methods: Our study had a retrospective chart review and a quality improvement (QI) component. From Mar-Oct 2023, we identified adult patients in the Cleveland Clinic Ohio health system with type 1 or type 2 DM on insulin (including insulin pumps), sulfonylurea, or meglitinide, and hypoglycemia defined as time below range (TBR) ≥4% on CGM reports. We evaluated the percentages of pre-existing and incident glucagon prescription among those patients. For the QI component, we contacted providers individually via letter if the patients did not have a glucagon prescription and shared with them the ADA Standards of Care on hypoglycemia along with information about various forms of glucagon. Whether to prescribe glucagon was left to the clinical judgement of the providers. Information was collected 4 weeks later to see whether there was any change in the prescription practice. Results: Patients numbered 1543, with170 patients having TBR ≥4%. Among patients with hypoglycemia, 37% had pre-existing prescription and 14% incident glucagon prescription, compared with patients without hypoglycemia (p&amp;lt;0.001). Significant (p&amp;lt;0.001) risk factors for hypoglycemia included type 1 DM, insulin-only therapy, use of conventional insulin pumps, and lower A1c. Among patients with TBR ≥4%, 66 (39%) had level 1 hypoglycemia (54 to &amp;lt;70 mg/dl), 88 (52%) had level 2, and 16 (9%) had level 3 (hospitalization or ER admission for hypoglycemia). Pre-existing or incident glucagon prescription was seen in 28% without hypoglycemia, 38% with level 1 hypoglycemia, 49% with level 2, and 63% with level 3 (p&amp;lt;0.001 level 1 vs level 3; level 2 vs no hypoglycemia; level 3 vs no hypoglycemia). Among 70 patients whose providers received education letters, 27 (39%) prescribed glucagon after education. Glucagon emergency kit, glucagon autoinjector, and inhaled glucagon were the top prescription choices. A greater proportion of advanced practice providers responded to our education than physicians (p=0.021). Conclusion: Glucagon prescription remains suboptimal though better than in other studies even among patients with documented hypoglycemia on CGM reports. Effective provider education and communication can increase glucagon prescription. Provider and patient factors should be studied next to determine steps for further improvement. Presentation: 6/1/2024

7252 Difference between interstitial and blood glucose during glucose loading is associated with the degree of insulin resistance in subjects with prediabetes and type 2 diabetes

Abstract Disclosure: D. Kim: None. S. Ryang: None. M. Im: None. J. Kim: None. Y. Kim: None. Y. kim: None. J. ha: None. J. Kim: None. S. Kim: None. Background and Aims: This study investigated the main factors responsible for the differences between blood glucose (BG) and interstitial fluid glucose (ISF) during glucose loading. Methods: A total of 204 Korean subjects without history of type 2 diabetes were enrolled. The subjects were categorized into three groups according to diabetes criteria by American Diabetes Association; NGT (normal glucose tolerance, n=36), PreDM (prediabetes, n=130) and T2D (undiagnosed type 2 diabetes, n=38). For glucose monitoring, a CGM (continuous glucose monitoring) system (Dexcom G6, Dexcom, San Diego, USA) was attached for 10 days. 75g oral glucose tolerance test (OGTT) was performed during applying CGM with stabilization (after wear of 3 days). Blood sample collected at t=0, 30, 60, 90 and 120 min for glucose and insulin concentration. Two parameters [insulin sensitivity (mIS) and beta-cell function (mBCF)] were derived novel mathematical model. Results: Among NGT, PreDM and T2D, there are heterogeneity in the difference and pattern between BG and ISF in this study. We identified the probability density function of BG - ISF across glucose tolerance, there is a trend that the means of BG - ISF with G60, 90, and 120 move to the right, as glucose tolerance status changes NGT to PreDM and DM. BG - ISF is significantly associated with insulin resistance (R=0.32, p&amp;lt;0.001), not diminished beta cell function. Conclusions: Because individuals vary in their degree of insulin resistance as a primary pathophysiology of type 2 diabetes, the caution should be needed in interpreting the glycemic response of CGM after a glucose load. Presentation: 6/3/2024

8473 Prediabetes As A Risk Factor For All-Cause And Cause-Specific Mortality In 117,227 Diabetes-Free Adults In Mexico City

Abstract Disclosure: C.A. Fermin-Martinez: None. O.Y. Bello-Chavolla: None. N.E. Antonio-Villa: None. D. Ramirez Garcia: None. J.A. Seiglie: None. Background: Prediabetes has been consistently linked to high risk of diabetes progression, cardiovascular disease, and all-cause mortality. However, no large-scale studies have been conducted in Mexico or Latin America examining these associations despite the growing prevalence of this condition in low- and middle-income countries. Methods: We analyzed data from 117,227 adults without diabetes aged ≥35 years who participated in the Mexico City Prospective Study (1998-2004). Individuals with self-reported chronic comorbidities at baseline were excluded to mitigate reverse causation. Participants were followed-up until January 1st, 2021 for cause-specific mortality. We defined prediabetes according to the American Diabetes Association (ADA, HbA1c ≥5.7%) and the International Expert Committee (IEC, HbA1c ≥6.0%) definitions. Cox regressions were used to estimate prediabetes-related risk for all-cause and cause-specific mortality, stratified by sex and age-at-risk and adjusted for municipality of residence, education level, physical activity, smoking, alcohol consumption, and adiposity markers. Results: Compared to individuals with normoglycemia, participants with IEC-defined prediabetes had a higher risk of all-cause (HR 1.16, 95%CI 1.05-1.27), cardiac (HR 1.29, 95%CI 1.05-1.59), renal (HR 1.59, 95%CI 1.14-2.23), and acute diabetes-related (HR 2.60, 95%CI 1.52-4.43) mortality at ages 40-74 years compared to normoglycemic participants. HRs were attenuated at older ages. Results were broadly similar irrespective of the definition of prediabetes except for cardiac deaths, in which the risk was non-significant using the ADA cutoff (HR 1.14, 95%CI 0.99-1.31). Long-term effects of prediabetes (IEC-defined) accounted for ∼37% of renal deaths and ∼61% of acute diabetes-related deaths in Mexican adults without diabetes at baseline. Conclusion: Prediabetes is an important risk factor that accounts for a significant fraction of all-cause, cardiac, renal, and acute diabetes-related deaths among Mexican adults, particularly when using the higher threshold of IEC-defined prediabetes. Endpoint-driven definitions of prediabetes should be considered for widespread implementation of screening and preventive strategies that minimize overdiagnosis and improve cardiometabolic outcomes in this population. Presentation: 6/1/2024

8765 Assessment of the Social Vulnerability Index of a 10-Year Retrospective Cohort of Youth with Prediabetes

Abstract Disclosure: D. Somerville: None. R.H. Kolagani, MHS: None. C.E. McCrory: None. S. Budakoti: None. V.M. Chinchilli, PhD: None. J. Joseph: None. D.E. Hale: None. N. Raja-Khan: None. L.P. Huerta Saenz: None. Background: The incidence of prediabetes (preD) is rising among youth in the US. While there are known metabolic risk factors linked to preD development, we were interested in exploring the role of social determinants of health (SDoH) in the development of pediatric preD. The social vulnerability index (SVI) is a tool developed by the CDC to stratify SDoH risk for communities based on 14 factors such socioeconomic status (SES), household composition, race and transportation access. By understanding the role of SVI in the development of preD in youth, we may be able to plan interventions to prevent progression to Type 2 Diabetes (T2D). Objective: Our study goal was to determine the relationship between SVI and preD in youth receiving care at our institution, a large pediatric referral center in Central Pennsylvania. Methods: We conducted a 10-year retrospective chart review of electronic medical records (EMRs) to identify children/youth aged 6-17 years old diagnosed with preD at our pediatric health system between 01/2010 and 01/2020. We used the American Diabetes Association definitions of preD (one or more sub-type): 1) Impaired fasting glucose (IFG), 2) Impaired glucose tolerance (IGT), and 3) Elevated hemoglobin A1c (HA1C). ICD10 codes were used for initial chart identification (R73.01, R73.02, R73.03 and R73.09). The second phase of identification of youth with preD included the review of biological measures of glycemia of the initial identified charts to support the reported ICD10 diagnosis (either isolated subtypes or combinations). Social, demographic characteristics, and residence setting (urban vs. rural) were also investigated. SVI was assessed on a 0-1 scale, with high SVI (0.5-1) indicating greater social vulnerability and low SVI (0-0.49) indicating lower social vulnerability. Rurality was determined per the Health Resources and Services Administration Tool (HRSA). SAS frequencies were calculated. Fisher’s exact tests were applied to compare the frequencies of the aforementioned groups with respect to IFG, IGT, and HA1C. Results: We identified 2700 charts of youth with preD per ICD10 codes search, but only 552 had confirmed preD diagnosis supported by biological data registered in EMRs. The most common preD isolated subtype was HA1C (87.3%), while 12% and 4% had isolated IFG and IGT, respectively. Most youth had high SVI (66.9%) and only 5.8% were rural (p &amp;gt; 0.05). Neither SVI or rurality were associated with isolated preD subtypes, but 8.2% of low-SVI youth had composite [IFG +HA1C] subtypes compared to 3.5% of high-SVI youth (p=0.02). Conclusions: SVI was not significantly associated with any isolated preD subtype. However, youth with the combined preD subtypes [IFG + HA1C] had lower SVI. As T2D is more prevalent in youth from low SES, addressing SDoH at earlier stages of T2D (preD phase) is needed in the effort to prevent the progression of the disease. Presentation: 6/1/2024

9253 Prediabetes As A Risk Factor For All-Cause And Cause-Specific Mortality In 117,227 Diabetes-Free Adults In Mexico City

Abstract Disclosure: C.A. Fermin-Martinez: None. O.Y. Bello-Chavolla: None. N.E. Antonio-Villa: None. D. Ramirez Garcia: None. J.A. Seiglie: None. Background: Prediabetes has been consistently linked to high risk of diabetes progression, cardiovascular disease, and all-cause mortality. However, no large-scale studies have been conducted in Mexico or Latin America examining these associations despite the growing prevalence of this condition in low- and middle-income countries. Methods: We analyzed data from 117,227 adults without diabetes aged ≥35 years who participated in the Mexico City Prospective Study (1998-2004). Individuals with self-reported chronic comorbidities at baseline were excluded to mitigate reverse causation. Participants were followed-up until January 1st, 2021 for cause-specific mortality. We defined prediabetes according to the American Diabetes Association (ADA, HbA1c ≥5.7%) and the International Expert Committee (IEC, HbA1c ≥6.0%) definitions. Cox regressions were used to estimate prediabetes-related risk for all-cause and cause-specific mortality, stratified by sex and age-at-risk and adjusted for municipality of residence, education level, physical activity, smoking, alcohol consumption, and adiposity markers. Results: Compared to individuals with normoglycemia, participants with IEC-defined prediabetes had a higher risk of all-cause (HR 1.16, 95%CI 1.05-1.27), cardiac (HR 1.29, 95%CI 1.05-1.59), renal (HR 1.59, 95%CI 1.14-2.23), and acute diabetes-related (HR 2.60, 95%CI 1.52-4.43) mortality at ages 40-74 years compared to normoglycemic participants. HRs were attenuated at older ages. Results were broadly similar irrespective of the definition of prediabetes except for cardiac deaths, in which the risk was non-significant using the ADA cutoff (HR 1.14, 95%CI 0.99-1.31). Long-term effects of prediabetes (IEC-defined) accounted for ∼37% of renal deaths and ∼61% of acute diabetes-related deaths in Mexican adults without diabetes at baseline. Conclusion: Prediabetes is an important risk factor that accounts for a significant fraction of all-cause, cardiac, renal, and acute diabetes-related deaths among Mexican adults, particularly when using the higher threshold of IEC-defined prediabetes. Endpoint-driven definitions of prediabetes should be considered for widespread implementation of screening and preventive strategies that minimize overdiagnosis and improve cardiometabolic outcomes in this population. Presentation: 6/1/2024

6741 Serum Urate-Lowering Effects Of Sodium-Glucose Transport Protein 2 Inhibitors Compared To Dipeptidyl Peptidase-4 Inhibitors In Gout Patients With Type 2 Diabetes Mellitus: A Population-Based Cohort Study

Abstract Disclosure: R.K. Shariff: None. C. Chung: None. P. Huang: None. S. Mon: None. K. Ma: None. Background/Purpose: Effective management of gout in patients requiring long-term urate-lowering therapy involves maintaining serum rate levels within specific ranges. Hyperuricemia and gout have been associated with an increased risk of Type 2 Diabetes Mellitus (T2DM), with a reported prevalence of 16% in gout patients. Pharmacological approaches to glycemic control, including Sodium-glucose Transport Protein 2 Inhibitors inhibitor (SGLT2i) and Dipeptidyl Peptidase-4 Inhibitors (DPP-4i), have showed potential serum urate lowering effects. However, a direct comparison of these effects in patients with gout and concomitant T2DM is lacking. This study aims to evaluate the serum urate-lowering effects of SGLT2i compared to DPP-4i in this patient population. Methods: This was a population-based cohort study of patients with gout diagnosed following the 2015 Gout classification criteria in the American College of Rheumatology/European League Against Rheumatism collaborative initiative and T2DM diagnosed following the American Diabetes Association criteria, respectively. Subjects treated between 2008 and 2023 at 92 United States hospitals were screened. Propensity score matching was used to balance the baseline differences in age of gout onset, sex, comorbidities, and past medical history between the two groups. The primary predictor variable was the use of therapies of SGLT2i and DPP-4i. The primary outcome of interest was the serum urate more than 6 mg/dL during the follow-up period. Kaplan-Meier analysis and log-rank tests were utilized to compare if the numbers of serum urate were higher than 6 mg/dL in both arms. A Cox proportional hazards model was utilized to estimate the association between the use of SGLT2i versus DPP-4i and the numbers of serum urate higher than 6 mg/dL. Inclusion criteria include patients with gout and concomitant T2DM, age over 18, and must have serum uric acid level data available. Results: Of the 11,495 gout patients, including 3,593 users of SGLT2i users, were propensity score-matched to 3593 DPP-4i users. Among gout patients with T2DM on SGLT2i, 598 experienced serum urate levels exceeding than 6 mg/dL, while in the DPP-4i group, 920 patients had serum urate higher than 6 mg/dL. The use of SGLT2i was associated with significantly lower odds of serum uric acid exceeding 6 mg/dl compared to DPP-4i. (OR: 0.580 [0.517-0.651]). Conclusion: Our study suggests that SGLT2i may offer a more effective means of managing serum uric acid levels in gout patients with concomitant T2DM compared to DPP-4i. Clinical trials are required to validate the findings. For clinical practice, the dosage for SGLT2i to cause the urate-lowering effect needs to be investigated. With further studies and clinical trials, the rationale of choosing SGLT2i over DPP-4i may be incorporated into the management of T2DM in gout patients with T2DM. Presentation: 6/1/2024

Prevalence of Hypertension in Type 2 Diabetes Mellitus in the Working Area of Jatibaru Community Health Center in 2023

The World Health Organization (WHO) predicts an increase in the number of diabetes mellitus sufferers in Indonesia from 8.4 million people in 2000 to around 21.3 million people in 2030. The prevalence of type 2 diabetes increases with age and changes in unhealthy lifestyles. Several studies show that the incidence of hyperglycemia in diabetes is closely related to hypertension. According to the American Diabetes Association (ADA) 2017, two out of three people with diabetes have high blood pressure. At the Jatibaru Community Health Center, based on 2023 data, it is known that hypertension and diabetes are always included in the data on the 10 most common diseases every month. Based on this background and related to the incidence of Hypertension and type 2 diabetes mellitus is still relatively high, so researchers are interested to knowing the picture hypertension in type 2 diabetes mellitus in the Jatibaru. This research is a descriptive study with a cross-sectional approach using secondary data taken from Non-Communicable Disease data. The population in this study were all adult and elderly respondents registered in the non-communicable disease program register, who based on anamnesis, physical and laboratory examination, were diagnosed with type 2 diabetes mellitus and hypertension. The sample was taken by purposive sampling. In this research, it was found that people with hypertension and diabetes mellitus were found in all adult and elderly age categories. The distribution of hypertension and type 2 diabetes mellitus patients continues to increase with increasing age, the prevalence of sufferers being more female than male. As many as 65% of the total type 2 diabetes mellitus sufferers also experience hypertension.

Paucity of Published Data and Protocols for Hypoglycemia Management in Long-term Care.

Background: Older people with diabetes are at high risk for hypoglycemia. Implementing a hypoglycemia treatment protocol in long-term care (LTC) settings may positively affect patient-related outcomes and health care resource utilization and costs. Anecdotal experience indicates little has been studied and published regarding this clinical practice. Objective: To identify hypoglycemia treatment protocols established for LTC settings and assess their effects on patient-related outcomes and health care resource use. Data Sources: The authors performed a systematic literature search of English-language articles and abstracts published between January 1, 2003 (PubMed), or 2018 (Google Scholar) and May 10, 2023. Search terms were "hypoglycemia," "diabetes mellitus," "longterm care," "nursing facilities," "assisted living facilities," "geriatrics," "elderly," "aged," "disabled," "disease management," "evidence-based medicine," "clinical protocols," "guideline," "glucagon," and/or "blood glucose." Included were publications with hypoglycemia treatment and management protocols or hypoglycemia-specific recommendations for LTC settings. DATA SYNTHESIS: The authors identified 405 articles and abstracts, removed 36 duplicates, screened 369 titles/ abstracts, and analyzed the full text for 93. Five met the inclusion criteria. Two originated from the American Diabetes Association: 2016 position statement regarding the management of diabetes in LTC and skilled nursing facilities, and 2023 standard-of-care guideline for managing older people with diabetes. One included the results after implementing an overall diabetes clinical care management algorithm in LTC facilities. A 2020 abstract and 2019 article were the only 2 publications involving specific hypoglycemia treatment protocols in LTC settings. Conclusion: This systematic literature search identified lack of published hypoglycemia treatment protocols in LTC settings and their effects on patient outcomes.

Evaluating Physician Knowledge, Attitudes, and Practices in Screening and Supplementation for Vitamin B12 Deficiency in Type 2 Diabetes Patients Treated with Metformin.

Long-term metformin use in Type 2 Diabetes Mellitus (T2DM) patients is associated with Vitamin B12 deficiency. This study aims to evaluate physicians' knowledge, attitudes, and practices regarding Vitamin B12 screening and supplementation in this context. A survey was administered to physicians across various specialties in government hospitals and primary care centers in Riyadh, Saudi Arabia, from January 2019 to January 2020. The survey assessed their knowledge, attitudes, and practices concerning Vitamin B12 deficiency screening and supplementation. Of the 402 participating physicians, 94.0% (378 respondents) demonstrated sufficient knowledge about Vitamin B12 deficiency. However, 26.1% believed that Vitamin B12 supplementation does not necessitate screening. 55.7% did not prescribe Vitamin B12 prophylactically, 41.5% omitted neurological examinations in patients presenting with neuropathy, and 22.4% were unaware of the recommended Vitamin B12 supplement dose. Only 49.8% routinely screened for Vitamin B12 deficiency in symptomatic patients. Physicians with more extended years of experience showed significantly better knowledge about Vitamin B12 screening and supplementation (p<0.001). While most physicians were knowledgeable about Vitamin B12 deficiency and supplementation, a substantial gap in translating this knowledge into practice was observed. There is a critical need for institutional oversight to ensure adherence to American Diabetes Association (ADA) guidelines for Vitamin B12 screening and supplementation in T2DM patients on long-term metformin therapy.

Associations between periodontal disease severity and selected cardiometabolic risk factors.

To explore associations between periodontal disease (PD) severity and cardiometabolic risk factors, including body mass index (BMI), age, Type 2 Diabetes Mellitus (T2DM) risk, sex, and hypertension (HTN) in patients at an urban dental school clinic. A cross-sectional study design was used to analyze electronic health record data, including periodontal status, demographic characteristics, cardiometabolic risk factors and the American Diabetes Association Diabetes Risk Test (DRT) Score. Chi-square tests and ordinal logistic regression were conducted using SAS 9.4. Of those with available data (n&#61;6,778), 44% were male, 70.2% were overweight/obese, and the mean age was 50.9 (SD&#61;16.6) years. Associations between PD severity and BMI, sex, age, DRT score, and HTN were statistically significant (all p<0.0001) in bivariate analyses. Using logistic regression, HTN (p&#61;0.0006), sex (p<0.0001), and age (p<0.0001) were significant predictors of severe PD which was most common in those with HTN (35.9%), males (31.7%), those >60 years (36.6%). The odds of having severe PD for those with HTN were 1.2 times that of those without HTN. Males were 1.7 times more likely to have severe PD than females. Those aged 40-49 years, 50-59 years, and >60 years were 2.9, 4.2, and 4.3 times more likely to have severe PD than those who were 18-39 years, respectively. All cardiometabolic risk factors were associated with PD severity in bivariate analyses. In the logistic regression model, being older, male, and having HTN were significant predictors of PD severity. Future research is needed with a more diverse sample.

Understanding primary care provider’s knowledge and perceptions of diabetes self-management education and support

ObjectiveThe American Diabetes Association Standards of Care recommends that individuals with diabetes receive self-management education, but the utilization of these services remains low. This study explores primary care providers’ knowledge and perceptions of diabetes self-management education and support (DSMES). Study designA convergent mixed methods study design grounded in the Theoretical Domains Framework was conducted with an initial provider survey, followed by semi-structured interview of a purposeful sub-sample of providers. The survey was distributed via REDCap and interviews were recorded and transcribed verbatim. ResultsA total of 140 PCP’s responded to the survey (response rate 37.63 %) and 17 participated in interviews. The average knowledge score of the correct selection of DSMES referral time points was 70.35 %. Five themes emerged in provider interviews: procedural knowledge, ability, beliefs, reinforcement, and cultural norms. Providers wanted bidirectional communication with the DSMES program and were more likely to refer if they had a cultural norm of referring. ConclusionProviders have limited knowledge of the appropriate time to refer to DSMES but expressed a willingness to refer. They emphasized the importance of providing their patients with appropriate self-management education and support.