Trends In HbA1c Research Articles

Trend of body mass index and its impact on glycemic control in Finnish patients with type 2 diabetes

Abstract Background Obesity prevalence has increased in Finland and is prevalent in patients with type 2 diabetes (T2D). Understanding the trend in body mass index (BMI) and its impact on glycemic control helps in the assessment of treatment strategies for T2D. We aimed to investigate the current trend in BMI among Finnish patients with T2D and the glycated hemoglobin (HbA1c) control across different BMI categories. Methods Regional data on electronic health records (EHRs) covering all public health care in North Karelia, Finland, were used. Patients with T2D (ICD-10 code E11) in 2012-2022 were identified from EHRs. In each study year, patients with ≥1 measurement of BMI and HbA1c were included in data analysis. Generalized estimating equations regression analyses were performed to evaluate the trends. Results The annual number of patients in the analyses ranged from 5149 to 10216 in 2012-2022. The unadjusted mean BMI remained stable. However, an increasing trend in BMI was observed in the age-adjusted model and remained unchanged with further adjustment for sex, duration of diabetes, and antidiabetic medication use, reflecting the aging of the patient population and lower BMI in aged patients. Patients with higher BMI had higher HbA1c levels in 2012-2022. The increasing trends in HbA1c over time were observed across different BMI categories (except for the obsess class III) accounting for age, sex, and duration of diabetes. However, a decreasing trend in HbA1c was found in the obese class III category with further adjustment for antidiabetic medication use, along with the highest usage rates of the new antidiabetic medications during the follow-up. Conclusions Our findings suggest that weight management requires increased attention in Finnish patients with T2D and is also important for better glycemic control. Multimodal treatment, including effective lifestyle counseling, self-care support, and medication management, is needed. Key messages • More attention and resources are needed to achieve optimal weight control. • Weight management could aid in better glycemic control.

Assessment of Glucose and HbA1c Monitoring in a Pancreatic Cancer Surveillance Program for High-Risk Individuals.

Several studies suggest that new-onset diabetes mellitus is an early manifestation of pancreatic ductal adenocarcinoma (PDAC). Therefore, the International Cancer of the Pancreas Screening Consortium recommends glucose and hemoglobin A1c (HbA1c) monitoring in high-risk individuals (HRIs) undergoing surveillance. However, evidence that such monitoring improves PDAC detection is lacking. Our aim was to investigate the association between serum glucose and HbA1c values and the development of PDAC in HRIs undergoing surveillance. Participants were recruited from the familial pancreatic cancer surveillance cohort, which follows hereditary predisposed HRIs yearly by magnetic resonance imaging and/or endoscopic ultrasound and blood sampling. Those who underwent fasting glucose and/or HbA1c monitoring at least once were eligible candidates. Four hundred four HRIs met the inclusion criteria. During a median follow-up of 41 months (range 14-120), 9 individuals developed PDAC and 4 (without PDAC) were diagnosed with new-onset diabetes mellitus. Glucose levels ranged from 3.4 to 10.7 mmol/L (mean 5.6 ± 0.7) and HbA1c levels from 25 to 68 mmol/mol (mean 37.7 ± 4.1). The mean values did not differ significantly between PDAC cases and controls. The percentage of individuals with at least one elevated value were comparable between PDAC cases and controls for glucose (33% and 27%, P = 0.707) and HbA1c (22% and 14%, P = 0.623). No consistent glucose or HbA1c trends over time suggested a correlation with PDAC development. In this HRI surveillance cohort, measuring glucose and HbA1c values did not contribute to PDAC detection. Larger and longer-term studies are needed to determine the final role of glucose and HbA1c monitoring in PDAC surveillance.

SAT671 SGLT2 Inhibition Decreases Adipose Tissue And Global Inflammaging Profile Of Older Obese Adults With Pre-Diabetes

Abstract Disclosure: J. Nie: None. M.K. Semwal: None. F.M. Acosta: None. A.R. Stepanenko: None. M. Brown: None. A.J. Moody: None. N. Sanchez: None. T.M. Cortes: None. Y. Qin: None. C. Triplitt: None. G. Clarke: None. S.E. Espinoza: None. N. Musi: None. C. Solis-Herrera: None. Sodium-glucose co-transporter-2 inhibitors (SGLT2i) are drugs for treating T2D. Through their glucosuric effect, you see a reduced HbA1c, weight loss, and improved insulin sensitivity/ β-cell function. Beyond their glycemic properties, SGLT2i provide substantial cardio-renal benefits. Given their multiple therapeutic advantages and established safety profile, there is the presupposition that SGLT2i may have various beneficial possibilities in medical practice. An area of interest for SGLT2i is their use as agents for late-aging and longevity. SGLT2i are known to promote a calorie restriction (CR) state by promoting glucosuria and fatty acid-oxidation/ketogenesis and reducing insulin levels. CR activates a myriad of anti-aging-related pathways, including senescence-associated “inflammaging,” which can be triggered by obesity and states of overnutrition. However, clinical research in this area remains largely unexplored. A single-center, open-label, randomized-controlled clinical trial was designed to determine the effect of SGLT2i on the aging-related processes of global and adipose tissue inflammation and senescence. Twenty older, obese, pre-diabetic subjects (Age=70±1.5, BMI=33.7±0.6, A1c=5.9±0.03) were randomized dapagliflozin 10mg/day (SGLT2i) vs. nutritional counseling for weight loss (control) in a 1:1 fashion for 12 weeks. Healthspan and clinical evaluation were performed at baseline and weeks 10-12 of the study. The SGLT2i group showed a significant decrease (-5.4±1.7, p=0.01) in weight loss, downward trend in HbA1c (-0.02±0.06 vs. +0.06±0.04), and significant loss in %Fat vs. control (-1%, p=0.05 vs. -0.5%, p=0.1). Given adiposity changes observed with SGLT2i, in a subset of subjects (n=10), subcutaneous fat biopsies were performed, and single nuclei (sn)RNA-seq done to map changes in adipose cellular populations (mature adipocytes, immune, endothelial, and adipogenic progenitor cells) and molecular profiling. Notably, with SGLT2i, the mature adipocyte, immune, and adipogenic progenitor cells, saw a significant (p≤0.05) decrease in senescent score. Globally, plasma-measured inflammaging-associated factors in the IL8 and TNFα families, also saw a significant decrease (p≤0.05) with SGLT2i.Aging and metabolic homeostasis are bidirectional processes. As you age, adiposity tends to increase, associated with an upsurge in the development of metabolic syndrome-related diseases in older adults. Here we demonstrate that in the high-risk population of older obese adults with pre-diabetes, SGLT2i targets multiple points in the spectrum that delay the aging process. In particular, we show evidence that SGLT2i treatment improves the global and adipose senescent and inflammatory profile, alongside glycemic and weight control. These findings support the notion that SGLT2i may contribute to the increase of both healthspan and lifespan. Presentation: Saturday, June 17, 2023

SAT152 Retrospective Analysis Of HbA1c In Patients Diagnosed With Pancreatic Insulinoma Prior To- And After Surgical Excision

Abstract Disclosure: S.J. Lawless: None. A. McGrath: None. R. Campbell: None. D. O'Keeffe: None. M.J. Bell: None. Insulinomas are rare pancreatic tumours characterised by episodes of hyperinsulinaemic hypoglycaemia. Patients may develop secondary diabetes following surgical intervention for insulinoma. Glycated haemoglobin (HbA1c) is a reliable bio-marker for the diagnosis and prognosis of diabetes. HbA1c is a useful surrogate marker for insulinoma (1). A retrospective analysis of patients diagnosed with insulinoma and attending our service in Galway University Hospital (GUH) was performed. Data was collected using the electronic patient correspondence system to gather information from clinic letters, hospital and GP laboratory results were accessed on the Evolve laboratory system. Diagnostic criteria employed a 72-hour fast with plasma glucose levels of ≤2.2 mmol/L, with a corresponding insulin level ≥18 pmol/L and a c-peptide of <200 pmol/l. We analysed their HbA1c at initial presentation and longitudinally following treatment. There are currently six patients carrying a diagnosis of insulinoma attending our service. All of these patients have had surgical intervention. At diagnosis four of the six patients had a HbA1c taken. One patient was diagnosed prior to HbA1c being routinely available and another patient had initial investigations and management elsewhere. The average HbA1c at time of diagnosis was 27.75 mmol/mol (n=4) (reference range 20 to 42 mmol/mol). All insulinoma patients have their HbA1c monitored yearly as part of ongoing follow-up. HbA1c trends upwards with an average HbA1c 18-24 months post surgical excision of 36.25 mmol/mol (n=4). There is a tendency of increased HbA1c post-operatively with a mean increase in HbA1c of 8.5 mmol/mol over 18-24 months. Three of our six patients have developed diabetes on extended follow-up. The average time to diagnosis post-surgical resection was 5.5 years (n=3). HbA1c is a useful tool for monitoring for secondary diabetes post pancreatic surgery. While admitting our number of patients is low, it is interesting to observe the difference in HbA1c pre- and post-operatively in patients with insulinoma. 1.Vaidakis, Dennis, et al. "Pancreatic insulinoma: current issues and trends." Hepatobiliary & pancreatic diseases international: HBPD INT 9.3 (2010): 234-241. Presentation: Saturday, June 17, 2023

Longitudinal Trends in Glycemic Outcomes and Technology Use for Over 48,000 People with Type 1 Diabetes (2016-2022) from the T1D Exchange Quality Improvement Collaborative.

Previous studies revealed that HbA1c increased overall in the U.S. in the past decade. Additionally, health inequities in type 1 diabetes (T1D) outcomes by race-ethnicity and insurance type persist. This study examines the trends in HbA1c from 2016 to 2022 stratified by race-ethnicity and insurance in a large multicenter national database. We analyzed glycemic outcomes and diabetes device use trends for over 48,000 people living with type 1 diabetes (PwT1D) from three adult and twelve pediatric centers in the T1D Exchange Quality Improvement Collaborative (T1DX-QI), comparing data from 2016-2017 with data from 2021-2022. The mean HbA1c in 2021-2022 was lower at 8.4% compared to the mean HbA1c in 2016-2017 of 8.7% (0.3% improvement; p<0.01). Over the same period, the percentage of PwT1D using a continuous glucose monitor (CGM), insulin pump, or hybrid closed-loop system increased (45%, 12%, and 33%, respectively). However, these improvements were not equitably demonstrated across racial-ethnic groups or insurance types. Racial-ethnic and insurance-based inequities persisted over all seven years across all outcomes; comparing non-Hispanic White and non-Hispanic Black PwT1D, disparate gaps in HbA1c (1.2-1.6%), CGM (30%), pump (25-35%), and HCLS (up to 20%) are illuminated. Population-level data on outcomes, including hemoglobin A1c (HbA1c), can provide trends and insights into strategies to improve health for PwT1D. The T1DX-QI cohort showed a significant improvement in HbA1c from 2016-2022. Improvements in diabetes device use are also demonstrated. However, these increases were inconsistent across all racial-ethnic groups or insurance types, an important focus for future T1D population health improvement work.

Gaps Remain for Achieving HbA1c Targets for People with Type 1 or Type 2 Diabetes Using Insulin: Results from NHANES 2009-2020.

Glycated hemoglobin A1c (HbA1c) is an important measure to assess glycemic control and predict diabetes complications. However, there is limited information on trends in HbA1c among people with diabetes (PwDs) who use insulin. The aim of this study was to describe trends in HbA1c among PwDs who use insulin by diabetes type and insulin regimen. A retrospective analysis was conducted using data from the National Health and Nutrition Examination Survey (NHANES, 2009-2020). PwDs were classified into three cohorts: type 1 diabetes mellitus (T1DM), type 2 diabetes mellitus using mealtime insulin (T2DM-MTI), and type 2 diabetes mellitus (T2DM) using basal-only insulin (T2DM basal-only). Trends in HbA1c over time were assessed using regression analysis after adjusting for age, gender, and race/ethnicity. Mean HbA1c values aggregated over 2009-2020 were 8.0% (T1DM), 8.6% (T2DM-MTI), and 8.6% (T2DM basal-only). The American Diabetes Association-recommended target of HbA1c of < 7% was achieved by 25.2% of people in the T1DM and T2DM-MTI groups each and by 12.3% of people in the T2DM basal-only group. Over time, an upward trend was observed in the percentage of people achieving HbA1c < 7% in the T2DM basal-only group. The percentage of PwDs achieving individualized HbA1c targets was 27.0%, 12.4%, and 16.1% for the T1DM, T2DM-MTI, and T2DM basal-only groups, respectively. Our study using NHANES data suggests that approximately 25% of PwDs achieve glycemic targets. This study highlights the need for improved therapies to better manage glycemic targets in PwDs.

Diabetes Technology and Therapy in the Pediatric Age Group.

Diabetes Technology and Therapy in the Pediatric Age Group.

Glycosylated haemoglobin as an indicator of diabetes control in pregnancy: A 10-year review of the relationship between HbA1c trends and delivery outcome in type I and type II diabetes

BackgroundPregestational diabetes mellitus (PGDM) confers an increased risk of adverse maternal and neonatal outcomes [1,2]. Glycaemic control in the medium and long term is commonly evaluated by examining glycosylated haemoglobin (HbA1c) levels. However, the value of HbA1c in pregnancy may be diminished by increased level of red cell turnover characteristic of pregnancy [3,4]. We sought to examine the impact of HbA1c in the first trimester and pre-delivery, and the within-patient change throughout gestation on mode of delivery and birthweight in pregnancies complicated by a pre-pregnancy diagnosis of type I or type II diabetes. MethodsA 10-year consecutive cohort of pregnancies complicated by PGDM, from Jan 2010 until Dec 2019, was examined for HbA1c data in the first trimester and within 6 weeks of delivery. Perinatal outcome data, including gestational age at delivery, mode of delivery and birthweight centile, were obtained from hospital records. The Spearman Rank correlation was used to correlate HcA1c levels in the first trimester with birthweight centiles. Non-parametric summaries and rank-based tests, Signed-rank test and Kruskal-Wallis test, were used to compare Hba1c levels. ResultsDuring the 10-year study period, a consecutive cohort of 396 pregnancies that attained a viable gestational age (>24 weeks’ gestation) and complicated by pregestational diabetes was identified; representing 81 % of the population of pregestational diabetic pregnancies managed by this service during the study period. The median [IQR] HbA1c levels (mmol/mol) in the first trimester, pre-delivery and the differential across gestation were 51 [19] mmol/mol, 43 [11] mmol/mol and −8 [13] mmol/mol, respectively. A statistically significant reduction in HbA1c levels throughout gestation was observed (p < 0.001). The median [IQR] birthweight centile was 69 [50 – 96]. The distributions in HbA1c levels and birthweight centiles were heavily skewed. No correlation was identified between HbA1c levels and mode of delivery. ConclusionNeither baseline HbA1c levels, pre-delivery values, nor trends across gestation appear to impact birthweight centile or mode of delivery in PGDM. While optimising glycaemic control can affect the long term health of the mother, these indices cannot be relied upon to reflect the impact of glycaemic control on fetal growth aberrations that influence mode of delivery.

Abstract 10732: Independent Evaluation of Effects of a Virtual Employer-Sponsored Type 2 Diabetes Management Program on Blood Glucose

Objective: To evaluate the effect of an employer-sponsored T2D management virtual program (Onduo) on blood glucose changes, via an independent data source, within the first year of participation. Methods: This retrospective pre-post study included participants with T2D who engaged in Onduo Dec 2020-Sept 2021. Participants had to have completed an employer-sponsored wellness program (independent of Onduo) with year-end biometric screening in 2019, 2020 and 2021, which included HbA1c, fasting glucose (FG), lipids, and other biometric measurements (Table). Year-to-year changes pre-intervention (2019 vs 2020 wellness screening, before Onduo) and post-intervention (2020 vs 2021) were compared using paired t-tests (significant at P ≤.05). We also assessed year-to-year changes based on use of specific Onduo telehealth tools (mobile app, blood glucose meter [BGM], health coach consultations, continuous glucose monitor [CGM], and telemedicine visits). Results: All 578 participants included (Table) used a mobile app, 84% used personalized coaching, 69% BGM, 13% telehealth visits, and 10% CGM. Seventy (12.1%) participants had HbA1c ≥9% in 2019, 79 (13.7%) in 2020, and 57 (9.9%) in 2021 (2019 vs 2020: P =.3; 2020 vs 2021: P =.01; Χ 2 tests). Within the first year of intervention, year-to-year changes in HbA1c, FG, HDL, and LDL significantly improved compared to pre-intervention changes (Table). The largest glycemic improvements post-intervention were in participants with baseline HbA1c ≥9% ( P &lt;.001; ANOVA) or baseline FG ≥126 mg/dL ( P &lt;.001; 2-sample t-test). Participants who used a CGM or telemedicine visits (n=81) had greater post-intervention drops (2020 vs 2021) in HbA1c than did others (-0.7 vs -0.2%, P &lt;.01; 2-sample t-test). Conclusions: Participation in Onduo improved year-to-year trends in HbA1c, FG, HDL, and LDL. Improvements in glycemia were greater in participants with the highest baseline glycemic indices and those who used a CGM or telemedicine visits.

Temporal Changes in Hemoglobin A1c and Diabetes Technology Use in DPV, NPDA, and T1DX Pediatric Cohorts from 2010 to 2018.

Objective: The German/Austrian Diabetes Patient Follow-up Registry (Diabetes-Patienten-Verlaufsdokumentation or DPV), England/Wales National Pediatric Diabetes Audit (NPDA), and Type 1 Diabetes Exchange (T1DX) in the United States investigated changes in hemoglobin A1c (HbA1c) and diabetes technology use from 2010 to 2018. Methods: Registry/audit data from 2010 to 2018 were analyzed in annual cohorts using linear regression for those <18 years of age with type 1 diabetes diagnosed at age >6 months. Time trends in HbA1c, pump, and continuous glucose monitoring (CGM) use were studied using repeated measurements linear and logistic regression models with an autoregressive covariance structure and with year and data source as independent variables. Results: A total of 1,172,980 visits among 114,264 (54,119 DPV, 43,550 NPDA, 16,595 T1DX) patients were identified. HbA1c remained clinically stable in DPV (7.7% [61 mmol/mol] to 7.6% [60 mmol/mol]), decreased in the NPDA (8.7% [72 mmol/mol] to 7.9% [63 mmol/mol]), and increased in T1DX (8.0% [64 mmol/mol] to 8.5% [69 mmol/mol] from 2010 to 2018). In all registries/audits, insulin pump and CGM use increased over time with greatest pump use in T1DX and lowest uptake reported in NPDA. Conclusions: These data reveal three different longitudinal patterns of change in registry/audit HbA1c from 2010 to 2018. Diabetes technology use increased throughout, at different rates. Quality improvement (QI) programs in DPV have been ongoing for 25 years, began in NPDA in 2009 and T1DX in 2016. We speculate that in England/Wales, development of networks, peer review, and implementation of QI measures contributed to reductions in population HbA1c. Many of these interventions had been implemented in DPV before 2010. Further efforts to understand this improvement, including the role of QI, and continued success within standardized documentation and benchmarking could inform T1DX programs to reduce HbA1c.

658-P: Gaps Remain for Achieving Guideline-Recommended and Individualized HbA1c Targets for People with Type 1 and Type 2 Diabetes Using Mealtime Insulin or Basal-Only Insulin

Background: HbA1c is a primary measure of glycemic control and managing HbA1c may help reduce the risk of complications. This study aimed to describe trends in HbA1c by insulin regimen. Methods: This was a retrospective analysis of cross-sectional surveys collected from the National Health and Nutrition Examination Survey between 2009-2018. Mean HbA1c and proportion achieving guideline- and HCP-recommended (i.e. personalized) HbA1c targets were evaluated in aggregate and over time in adults (18-64 years) with type 1 (T1DM) or type 2 (T2DM) diabetes using mealtime insulin (MTI) or basal insulin only. Trends over time between 2009-2018 were evaluated after adjusting for age, gender, race/ethnicity. The analysis included the strata, clusters, and weighting of the complex survey design. Results: From 2009-2018, 26.1% of people with T1DM (weighted n=891,194; mean HbA1c [SE] 7.9% [0.2]) , 24.8% with T2DM MTI (weighted n=1,591,183; mean HbA1c [SE] 8.6% [0.2]) , and 11.2% with T2DM basal only (weighted n=1,087,895; mean HbA1c [SE] 8.6% [0.2]) achieved the ADA recommended HbA1c goal of &amp;lt;7%. Among those who reported personalized HbA1c goals, 28.7% (T1DM) , 9.5% (T2DM MTI) , and 17.1% (T2DM basal only) achieved their goals. After adjustment, the proportion of people achieving HbA1c &amp;lt;7% in the basal only group increased significantly over time (2009-2018; p=0.04) , driven by an increase in 2017-2018. Adjusted mean HbA1c for T2DM MTI significantly decreased during the 2009-2018 timeframe (p=0.003) , whereas no significant differences were seen in the other subgroups. Conclusions: Across all insulin regimens based off the most recent NHANES data, ∼75-90% of individuals are not achieving ADA-recommended or personalized HbA1c goals. Emerging treatment tools (e.g. new technologies, advanced insulins, and time in range metrics) may facilitate improved diabetes outcomes. Disclosure E.R.Hankosky: Employee; Eli Lilly and Company, Stock/Shareholder; Eli Lilly and Company. D.Schapiro: Employee; Eli Lilly and Company. K.B.Gunn: Employee; Eli Lilly and Company. E.Lubelczyk: Employee; Eli Lilly and Company. J.Mitroi: None. D.R.Nelson: Employee; Eli Lilly and Company. Funding Eli Lilly and Company

Less Timely Initiation of Glucose-Lowering Medication Among Younger and Male Patients With Diabetes and Similar Initiation of Blood Pressure-Lowering Medication Across Age and Sex: Trends Between 2015 and 2020.

Aims: We aimed to assess trends in glycosylated hemoglobin A1c (HbA1c) and systolic blood pressure (SBP) thresholds at initiation of glucose- and blood pressure-lowering medication among patients with type 2 diabetes and assess the influence of age and sex on these trends. Materials and Methods: We used the Groningen Initiative to ANalyze Type 2 diabetes Treatment (GIANTT) primary care database. Patients initiating a first non-insulin glucose-lowering or any blood pressure-lowering medication between 2015 and 2020 with an HbA1c or SBP measurement in the 120 days before initiation were included. We used multilevel regression analyses adjusted for potential confounders to assess the influence of calendar year, age or sex, and the interaction between calendar year and age or sex on trends in HbA1c and SBP thresholds at initiation of medication. Results: We included 2,671 and 2,128 patients in the analyses of HbA1c and SBP thresholds, respectively. The overall mean HbA1c threshold at initiation of glucose-lowering medication significantly increased from 7.4% in 2015 to 8.0% in 2020 (p < 0.001), and particularly in the younger age groups. Compared to patients ≥80 years, patients aged 60–69 years initiated medication at lower levels mainly in the early years. Patients <60 years and between 70–79 years initiated medication at similar levels as patients ≥80 years. Females initiated medication at lower levels than males throughout the study period (p < 0.001). The mean SBP threshold at initiation of blood pressure-lowering medication varied from 145 to 149 mmHg without a clear trend (p = 0.676). There were no differences in SBP thresholds between patients of different ages or sex. Conclusion: The rising trend in the HbA1c threshold for initiating glucose-lowering medication in the lower age groups was unexpected and requires further investigation. Males appear to receive less timely initiation of glucose-lowering medication than females. The lack of higher thresholds for the oldest age group or lower thresholds for the youngest age group in recent years is not in line with the age-related recommendations for personalized diabetes care and calls for health systems interventions.

Effect of Preablation Glycemic Control on Outcomes of Atrial Fibrillation Patients With Diabetes Mellitus Following Valvular Surgery Combined With the Cox-Maze IV Procedure.

BackgroundThis study was performed to assess the effect of preablation glycemic control on atrial fibrillation recurrence rates after heart valve surgery concomitant with Cox-Maze IV ablation.MethodsTwelve-month preablation trends in glycemic control were studied. Recurrence and clinical outcome data were obtained during a mean follow-up period of 36.7 ± 23.3 months postablation.ResultsHigher glycated hemoglobin (HbA1c) at the time of ablation was associated with higher postablation recurrence rates. The cumulative atrial fibrillation recurrence-free survival of patients with HbA1c ≥7.5% at the time of operation at 12, 24, 36 and 48 months was 97.1, 78.3, 54.2, and 36.3%, respectively (P < 0.001), and 100, 84.9, 37.2, and 16.2% for patients who preoperatively had an upward trend in HbA1c, respectively (P < 0.001).ConclusionMaintaining a downward trend in HbA1c during the 12-month period before the operation and an HbA1c value < 7.5% at the time of the operation reduced the recurrence of AF among patients who underwent heart valve surgery concomitant with the Cox-Maze IV procedure.

Introduction of publicly funded pharmacare and socioeconomic disparities in glycemic management in children and youth with type 1 diabetes in Ontario, Canada: a population-based trend analysis.

Background:We evaluated the impact of publicly funded pharmacare (Ontario Health Insurance Plan [OHIP]+), which was introduced in Ontario on Jan. 1, 2018, for youth less than 25 years of age, on temporal trends in hemoglobin A1c (HbA1c, a measure of glycemic management) and the differential effect on the change in temporal trends in HbA1c according to socioeconomic status (SES).Methods:We conducted a trend analysis using administrative data sets. We included youth aged 21 years, 9 months or younger, residing in Ontario on Jan. 1, 2016, with diabetes diagnosed before age 15 years and before Jan. 1, 2015. We used claims for insulin to measure pharmacare use. We evaluated the change in HbA1c (%) per 90 days before (Jan. 1, 2016, to Dec. 31, 2017) the introduction of and during (Apr. 1, 2018, to Mar. 31, 2019) OHIP+ coverage, and the difference in the change in HbA1c according to SES, using segmented regression analysis.Results:Of 9641 patients, 7041 (73.0%) made an insulin claim. We found a negligible difference in the temporal change in HbA1c during compared with before OHIP+ coverage that was not statistically significant (β estimate −0.0002, 95% confidence interval [CI] −0.0004 to 0.0000). The size of the effect was slightly greater in those individuals with the lowest SES than in those with the highest SES (β estimate −0.0008, 95% CI −0.0015 to −0.0001).Interpretation:We found that the effect of OHIP+ on the change in HbA1c was slightly greater for youth in the lowest SES than for those in the highest SES. Our findings suggest that publicly funded pharmacare may be an effective policy tool to combat worsening socioeconomic disparities in diabetes care and outcomes.

Abstract P165: Glycemic Response To Initial Treatment In Data-driven Diabetes Clusters In A Real-world Sample Of Adults With Newly Diagnosed Diabetes

Diabetes patient heterogeneity is well recognized. Statistical clustering methods are gaining popularity as a precision medicine tool for identifying diabetes subgroups. We evaluated data-driven clusters among individuals with newly diagnosed diabetes and examined associations with glycemic response to initial treatment in real-world care. We studied individuals in the US Veterans Affairs Health Care System with newly diagnosed diabetes based on diagnosis codes and medications who were initially treated with a single diabetes medication from 2005-2013. We performed k -means clustering as previously described based on age, body mass index (BMI), and hemoglobin A1c (HbA1c) at the time of diabetes diagnosis. We compared 5-year glycemic response by initial medication class (metformin, sulfonylurea, or insulin) in each cluster using linear mixed effects models, adjusted for age, race, sex, BMI, glomerular filtration rate, and HbA1c, and including a medication*time term to assess medication-specific HbA1c trends. Four clusters best fit the data for the 325,250 individuals studied (mean age 63.5 years, BMI 32.7 kg/m 2 , HbA1c 7.5%). Clusters corresponded to those identified previously in other studies with three characterized by extreme values of clustering variables: Cluster 1 with mean HbA1c 11.3% (N=35,071), Cluster 2 with mean BMI 41.1 kg/m 2 (N=70,909), Cluster 3 with mean age 76.8 years (N=92,363), and Cluster 4 with intermediate values for all the three variables (N=126,907). HbA1c trends differed by medication class in all four clusters (p&lt;0.0001 for all). However, differences in HbA1c trends by medication class were clinically small in all 4 clusters (Figure). Mean HbA1c trend was lowest among metformin users, intermediate among sulfonylurea users, and highest among insulin users in all clusters. Conclusion: Data-driven clustering of individuals with newly diagnosed diabetes using routinely collected clinical variables may not help guide initial diabetes treatment choice with regard to glycemic control.

Diabetes Status After Lateral Pancreaticojejunostomy and Frey's Procedure in Chronic Calcific Pancreatitis: An Observational Study.

IntroductionDiabetes secondary to pancreatic diseases is commonly referred to as pancreatogenic diabetes or type 3c diabetes mellitus. This study was conducted to determine the status of diabetes mellitus after Frey’s procedure and lateral pancreaticojejunostomy (LPJ) in diabetic and nondiabetic patients with chronic calcific pancreatitis (CCP) and to discuss the clinicopathological course as well as diabetes in CCP.Materials and methodsThis study was designed as a retrospective observational study consisting of 27 patients with CCP who were surgically treated either with the pancreatic head coring Frey’s procedure or with LPJ. Surgeries were performed in a tertiary care hospital of Eastern India by a team of surgeons following the same surgical principle. The diagnosis of CCP was made by clinical and radiological evaluations. Visual Analog Scale (VAS) scoring was used perioperatively to assess pain. Postoperatively, all the patients were monitored clinically; pain scoring and relevant investigations were done depending upon subjective and objective indications. Special attention was paid to diabetic patients through frequent follow-ups and tight glycemic control. All 27 patients were followed up with at least two outpatient follow-ups.ResultsThe trends in fasting blood sugar values in the LPJ group showed a small spike in the early postoperative period (two weeks) with a p-value of >0.05, and later on, it improved over 18 months of follow-up, reaching below the preoperative values (mean 109.38). On the contrary, the fasting blood glucose levels in Frey’s procedure revealed a significant spike in the early postoperative period (two weeks) with a mean sugar value of 148 mg/dl and a p-value of 0.01. The levels stayed well above the preoperative values over 18 months of follow-up. The trends in HbA1c showed marginal improvement in the LPJ group in a six-month follow-up period (p-value 0.008) from the preoperative levels. In Frey’s procedure group, postoperative HbA1c levels at three months revealed an increase, which can be attributed to the minor but significant loss of pancreatic tissue from the head, which continued to be on the higher side at the six-month follow-up. Trends in mean insulin dosage showed a significant spike in the early postoperative period (two weeks) both in the LPJ (p-value 0.01) and Frey’s procedure group (0.01); however, in the LPJ group, the insulin dose showed a reduction over the 18-month follow-up, reaching below the mean preoperative insulin dose. While in the Frey’s procedure group, the postoperative insulin dose remained higher throughout the 18-month follow-up period (p-value <0.05).ConclusionsLPJ has got a little effect on the diabetic status of nondiabetic patients. Frey’s procedure leads to marginal deterioration of the diabetic status and increases in insulin dosage in both diabetic and nondiabetic patients.

Adherence to the American Diabetes Association's Glycemic Goals in the Treatment of Diabetes Among Older Americans, 2001-2018.

To assess trends in HbA1c and appropriateness of diabetes medication use by patient health status. We conducted cross-sectional analysis of 2001-2018 National Health and Nutrition Examination Survey (NHANES). We included older adults age ≥65 years who had ever been told they had diabetes, had HbA1c >6.4%, or had fasting plasma glucose >125 mg/dL. Health status was categorized as good, intermediate, or poor. Being below goal was defined as taking medication despite having HbA1c ≥1% below the glycemic goals of the American Diabetes Association (ADA), which varied by patient health status and time period. Drugs associated with hypoglycemia included sulfonylureas, insulin, and meglitinides. We included 3,539 patients. Mean HbA1c increased over time and did not differ by health status. Medication use increased from 59% to 74% with metformin being the most common drug in patients with good or intermediate health and sulfonylureas and insulin most often prescribed to patients with poor health. Among patients taking medications, prevalence of patients below goal increased while prevalence of those above goal decreased from 2001 to 2018. One-half of patients with poor health and taking medications had below-goal HbA1c; two-thirds received drugs associated with hypoglycemia. Patients with poor health who were below goal had 4.9 (95% CI 2.3-10.4) times the adjusted odds of receiving drugs associated with hypoglycemia than healthy patients. In accordance with ADA's newer Standards of Medical Care in Diabetes, HbA1c goals were relaxed but did not differ by health status. Below-goal HbA1c was common among patients with poor health; many were prescribed medications associated with a higher risk of hypoglycemia.

Sex differences over time for glycemic control, pump use and insulin dose in patients aged 10–40 years with type 1 diabetes: a diabetes registry study

IntroductionTo evaluate sex differences in people with type 1 diabetes concerning changes in glycemic control and trends in insulin pump use and insulin dose over two decades in adolescents and...

Changes in HbA1c Between 2011 and 2017 in Germany/Austria, Sweden, and the United States: A Lifespan Perspective.

Aims: This study assessed hemoglobin A1c (HbA1c) across the lifespan in people with type 1 diabetes (T1D) in Germany/Austria, Sweden, and the United States between 2011 and 2017 to ascertain temporal and age-related trends. Methods: Data from the Diabetes-Patienten-Verlaufsdokumentation (DPV) (n = 25,651 in 2011, n = 29,442 in 2017); Swedish Pediatric Diabetes Quality Registry (SWEDIABKIDS)/National Diabetes Register (NDR), (n = 44,474 in 2011, n = 53,690 in 2017); and T1D Exchange (n = 16,198 in 2011, n = 17,087 in 2017) registries were analyzed by linear regression to compare mean HbA1c overall and by age group. Results: Controlling for age, sex, and T1D duration, HbA1c increased in the United States between 2011 and 2017, decreased in Sweden, and did not change in Germany/Austria. Controlling for sex and T1D duration, mean HbA1c decreased between 2011 and 2017 in all age cohorts in Sweden (P < 0.001). In the United States, HbA1c stayed the same for participants <6 years and 45 to <65 years and increased in all other age groups (P < 0.05). In Germany/Austria, HbA1c stayed the same for participants <6 to <13 years and 18 to <25 years; decreased for participants ages 13 to <18 years (P < 0.01); and increased for participants ≥25 years (P < 0.05). Conclusions: The comparison of international trends in HbA1c makes it possible to identify differences, explore underlying causes, and share quality improvement processes. National quality improvement initiatives are well accepted in Europe but have yet to be implemented systematically in the United States. However, disparities created by the lack of universal access to health care coverage, unequal access to diabetes technologies (e.g., continuous glucose monitoring) regardless of insurance status, and high out-of-pocket cost for the underinsured ultimately limit the potential of quality improvement initiatives.

Identifying HbA1c trajectories and modifiable risk factors of trajectories in 5- to 9-year-olds with recent-onset type 1 diabetes from the United States.

To explore glycated haemoglobin (HbA1c) patterns in 5- to 9-year-olds in the recent-onset period of type 1 diabetes and identify parent psychosocial factors that may predict children's HbA1c trajectory using a prospective, longitudinal design. We measured family demographics and parent psychosocial factors at baseline. We collected HbA1c levels from children every 3months for up to 30months. Deriving several features around HbA1c trends, we used k-means clustering to group trajectories and linear and logistic regressions to identify parent psychosocial predictors of children's HbA1c trajectories. The final cohort included 106 families (48 boys, mean child age 7.50±1.35years and mean diabetes duration 4.71±3.19months). We identified four unique HbA1c trajectories in children: high increasing, high stable, intermediate increasing and low stable. Compared to a low stable trajectory, increasing parent-reported hypoglycaemia fear total score was associated with decreased odds of having a high stable or intermediate increasing trajectory. Increasing parent-reported diabetes-specific family conflict total score was associated with increased odds of having a high stable or intermediate increasing trajectory. We are the first to identify distinct HbA1c trajectories in 5- to 9-year-olds with recent-onset type 1 diabetes as well as parent psychosocial factors that may predict high stable or increasing trajectories and could represent future treatment targets.