Social Determinants and Health Disparities Pertaining to Diabetes in Appalachia.

CONTEXT: Diabetes poses a significant threat to public health in the United States, with an estimated total prevalence of 37.3 million individuals in 2019, of which 28.7 million were diagnosed and 8.5 million remained undiagnosed. The high prevalence of diabetes imposes a considerable economic burden on the U.S. healthcare system. Appalachian Ohio is disproportionately impacted with southeastern Ohio exhibiting a diabetes prevalence that exceeds the national average by more than twofold and a critical shortage of healthcare providers. OBJECTIVE: To quantify the associations between diabetes prevalence and incidence in Ohio counties, considering various factors that impact health and quality-of-life outcomes. METHODS: The data used in this study were obtained from the United States Diabetes Surveillance System (USDSS) on the 88 counties in Ohio. Pearson correlation tests were employed to investigate the relationship between diabetes (prevalence and incidence) and social determinants of health. A t-test and multivariate analysis of variance (MANOVA) test were performed to analyze the disparities in diabetes and social determinants between Appalachian and non-Appalachian counties. RESULTS: The results of this study demonstrate notable disparities in diabetes prevalence between Appalachian and non-Appalachian counties (P < .001, α = .05). Furthermore, the MANOVA test revealed significant differences between these 2 groups regarding social determinants of health (P < .05). CONCLUSION: These findings suggest that Appalachian counties may face a disproportionate impact from health-related factors and experience limited access to healthcare services. The data highlight the need for focused efforts to address the specific challenges faced by Appalachian counties. Improving access to healthcare services in the Appalachian region is paramount to ensure equitable healthcare and enhance the overall health outcomes of affected communities.

Availability of Evidence-Based Diabetes Programs in U.S. Children's Hospitals.

Diabetes affects Americans across the lifespan requiring individual and community-level interventions for prevention and management. Nonprofit hospitals are required to address community health needs under current tax law. The study objective was to assess what strategies children's hospitals implemented in prevention and care of diabetes and determine how many hospitals used evidence-based strategies. We identified the most recent Children's Hospital Needs Assessments and implementation strategies for each hospital. Data were thematically coded. Twenty-nine of the 233 U.S. children's hospitals addressed diabetes in their community benefit investments. Of the 130 hospital programs, 48 (37%) aligned with the DSMES framework. Programs focused on prevention (32%), healthy eating (18%), education (15%), physical activity (12%), quality improvement (11%), and self-management (5%). Most children's hospital interventions (85%) did not state a focus on reducing health disparities and none addressed problem solving or diabetes technology. Minimal hospitals are using evidence-based programming for diabetes management and are not targeting health disparities which undercuts their efforts. Hospitals are not adopting structural evidence-based approaches, missing key opportunities to implement strategies shown to reduce diabetes prevalence and lower A1c. This study suggests that children's hospitals need improvement in their diabetes programming to better serve their communities.

Severe Hypoglycemia and the Use of Glucagon Rescue Agents: An Observational Survey in Adults With Type 1 Diabetes.

Severe hypoglycemia (SH) is the most frequent and potentially serious complication affecting individuals with type 1 diabetes and can have major clinical and psychosocial consequences. Glucagon is the only approved treatment for SH that can be administered by non-health care professionals (HCPs); however, reports on the experiences and emotions of people with type 1 diabetes associated with SH and glucagon rescue use are limited. This survey study demonstrated that an increasing number of individuals with type 1 diabetes have current and filled prescriptions for glucagon and have been educated about glucagon rescue use by an HCP. Despite this positive trend, challenges with SH remain, including a high level of health care resource utilization, considerable out-of-pocket expenses for glucagon kits, a high prevalence of hypoglycemia unawareness, and a negative emotional impact on individuals with diabetes. Nocturnal and exercise-related hypoglycemia were concerns for most survey participants.

Development and validation of fear of hypoglycemia screener: results from the T1D exchange registry.

BACKGROUND: Fear of Hypoglycemia (FoH) in people with diabetes has a significant impact on their quality of life, psychological well-being, and self-management of disease. There are a few questionnaires assessing FoH in people living with diabetes, but they are more often used in research than clinical practice. This study aimed to develop and validate a short and actionable FoH screener for adults living with type 1 diabetes (T1D) for use in routine clinical practice. METHODS: We developed an initial screener based on literature review and, interviews with healthcare providers (HCPs) and people with T1D. We developed a cross-sectional web-based survey, which was then conducted to examine the reliability and validity of the screener. Adults (aged ≥ 18 years) with diagnosis of T1D for ≥ 1 year were recruited from the T1D Exchange Registry (August-September 2020). The validation analyses were conducted using exploratory factor analyses, correlation, and multivariable regression models for predicting cut-off scores for the final screener. RESULTS: The final FoH screener comprised nine items assessing two domains, "worry" (6-items) and "avoidance behavior" (three items), in 592 participants. The FoH screener showed good internal consistency (Cronbach's α = 0.88). The screener also demonstrated high correlations (r = 0.71-0.75) with the Hypoglycemia Fear Survey and moderate correlations with depression, anxiety, and diabetes distress scales (r = 0.44-0.66). Multivariable regression analysis showed that higher FoH screener scores were significantly associated with higher glycated hemoglobin (HbA1c) (b = 0.04) and number of comorbidities (b = 0.03). CONCLUSIONS: This short FoH screener demonstrated good reliability and validity. Further research is planned to assess clinical usability to identify patients with FoH and assist effective HCP-patient conversations.

Examination of Health Care Providers' Use of Language in Diabetes Care: A Secondary Qualitative Data Analysis.

The purpose of this secondary qualitative data analysis was to assess the frequency and context of stigmatizing language used by health care providers (HCPs). The authors conducted content and thematic analysis of in-depth face-to-face and telephone interviews with HCPs in southeastern Ohio. Participants frequently used labeling language, such as "diabetic" and "noncompliant," as well as language with negative connotations, such as "control," "testing," and "regimen." These findings offer a real-world glimpse of how HCPs communicate about people with diabetes in this region of the country.

Professional Competencies for Diabetes Technology Use in the Care Setting.

PURPOSE: The integration of diabetes technology into diabetes care and self-management is evolving so rapidly that providing sufficient support has become an obstacle for many health care professionals (HCPs) in practice. Diabetes technology requires HCPs to stay current with treatment goals and practice guidelines. Diabetes care and education specialists (DCESs) are well positioned to take on this challenge by seizing opportunities to apply their skills, knowledge, and experience to contribute to a technology-enabled practice environment. Diabetes technology includes devices, hardware, and software utilized to manage all aspects of diabetes care, including lifestyle management, glucose monitoring, and insulin delivery. The complexities of caring for persons with diabetes (PWD) who utilize diabetes technology is best accomplished in partnership with other members of the care team and support staff to cover all aspects of technology including prior authorizations, onboarding PWD, downloading and interpreting data, and supporting ongoing utilization. The purpose of this article is to introduce a comprehensive set of role-based competencies for HCPs, DCESs, and staff for the selection, implementation, and sustainability of diabetes technology when providing diabetes care, education, and support. The role-based competencies described in this article are intended to support the initiation, continuation, and optimal use of diabetes technology in practice through ongoing education and guidance of care team members. CONCLUSION: This article describes the diabetes technology competencies essential for all levels of the care team and support staff in various care settings to deliver comprehensive diabetes management and support to PWD utilizing diabetes technology in their self-care regimen.

Building the 2022 Diabetes Technology Practice Competencies Using Modified Delphi Methodology.

PURPOSE: The purpose of this study was to construct professional competencies for diabetes technology use in various care settings reflecting the mission of the Association of Diabetes Care & Education Specialists (ADCES). METHOD: ADCES convened a core team of nationally representative diabetes technology experts to develop professional competencies specifically related to diabetes technology use. A modified Delphi methodology, which comprised 4 rounds, was used for consensus development among these experts. First, experts developed and arrived at a consensus on the initial draft of competencies. They also identified health care professionals and staff essential for effective technology integration in various diabetes care settings. A survey was completed by diabetes technology experts that are members of ADCES. Next, a multidisciplinary focus group was conducted to gain feedback. Finally, the edited competencies were distributed via survey for feedback by diabetes technology experts from various disciplines. RESULTS: One hundred four diabetes technology experts in the United States participated in the final survey, representing various health care professions and clinical settings. A final set of 94 competencies across 7 domains was determined. CONCLUSION: Modified Delphi methodology is an effective way to utilize multidisciplinary expertise to develop diabetes technology-related competencies for diabetes care professionals and staff in a variety of settings. These competencies align with the mission of ADCES to empower diabetes care and education specialists to expand the horizons of innovative education, management, and support.

Emergency Glucagon: a Focused Review of Psychosocial Experiences of Rescue Drugs for Type 1 Diabetes.

PURPOSE OF REVIEW: The purpose of this paper is to describe rescue glucagon types, safety, efficacy, and preferences, as well as to review articles regarding emergency glucagon usage, severe hypoglycemia, and the emotions of both phenomena. We conducted a review of current literature on glucagon usage and the emotional impact of severe hypoglycemia on people with diabetes (PwD) and the caregivers of people with type 1 diabetes (T1D). RECENT FINDINGS: Minimal research exists pertaining to glucagon and severe hypoglycemic experiences in PwD, which is troubling considering the severity of risks and possible side effects. Recent articles described negative emotions such as fear, anxiety, stress, helplessness, shame, embarrassment, loneliness, frustration, hopefulness, and uncertainty surrounding glucagon usage. There is scarce research regarding PwD's emotions surrounding severe hypoglycemia and rescue glucagon use. Additional research is needed to investigate the emotions and feelings people with T1D and their caregivers' experience pertaining to severe hypoglycemia and emergency glucagon use.

A New Taxonomy for Technology-Enabled Diabetes Self-Management Interventions: Results of an Umbrella Review.

BACKGROUND: A 2017 umbrella review defined the technology-enabled self-management (TES) feedback loop associated with a significant reduction in A1C. The purpose of this 2021 review was to develop a taxonomy of intervention attributes in technology-enabled interventions; review recent, high-quality systematic reviews and meta-analyses to determine if the TES framework was described and if elements contribute to improved diabetes outcomes; and to identify gaps in the literature. METHODS: We identified key technology attributes needed to describe the active ingredients of TES interventions. We searched multiple databases for English language reviews published between April 2017 and April 2020, focused on PwD (population) receiving diabetes care and education (intervention) using technology-enabled self-management (comparator) in a randomized controlled trial, that impact glycemic, behavioral/psychosocial, and other diabetes self-management outcomes. AMSTAR-2 guidelines were used to assess 50 studies for methodological quality including risk of bias. RESULTS: The TES Taxonomy was developed to standardize the description of technology-enabled interventions; and ensure research uses the taxonomy for replication and evaluation. Of the 26 included reviews, most evaluated smartphones, mobile applications, texting, internet, and telehealth. Twenty-one meta-analyses with the TES feedback loop significantly lowered A1C. CONCLUSIONS: Technology-enabled diabetes self-management interventions continue to be associated with improved clinical outcomes. The ongoing rapid adoption and engagement of technology makes it important to focus on uniform measures for behavioral/psychosocial outcomes to highlight healthy coping. Using the TES Taxonomy as a standard approach to describe technology-enabled interventions will support understanding of the impact technology has on diabetes outcomes.

An Exploratory Mixed Methods Study of Diabetes self-management in Blind Americans.

This study used mixed methods to investigate the experiences of 33 participants who are blind (PWB) and have diabetes in managing their diabetes, support (or lack thereof) from their health care providers, and diabetes distress as PWB. Participants most frequently reported barriers to check blood glucose (55%), maintaining a healthy diet (45%), and distress due to their intersectional status of having blindness and diabetes. Those who mentioned intersectional distress of managing diabetes as a PWB tended to be Braille illiterate and less likely to use mobility tools that are symbolic of blindness (e.g., white cane, guide dog). These results illuminate heterogenous characteristics of PWB with diabetes, an understudied population of public health significance, to be considered when setting priorities for diabetes self-management support and health care coverage policy.

"It's embarrassing. I get angry. I get frustrated.": Understanding severe hypoglycemia and glucagon usage from the perspectives of people with type 1 diabetes.

Introduction: This study characterized the emotional impact of severe hypoglycemia, views of glucagon, and barriers to glucagon use from the perspective of adults with type 1 diabetes (T1D). Methods: Participants included individuals recruited from the T1D Exchange online community. The current study conducted 7 focus groups consisting of adults with T1D (N = 38, average age 49.4, SD = 16.11 years). Average duration of diabetes was 34.4 years (SD = 17.3) and average self-reported A1c was 6.8 % (SD = 0.7). Focus group interviews were recorded, transcribed, and thematically analyzed. Results: A range of emotions was expressed about severe hypoglycemia including fear, anxiety, stress, frustration, shame, and embarrassment. Participants frequently identified prescription cost and insurance deductibles as barriers to glucagon use. Participants were also concerned about ease of administration-how difficult it is to prepare the glucagon in an emergency. Many participants expressed a preference for auto-injectables over nasal administration. Timing of glucagon action and time to recovery were high priorities. Some participants, while they had not self-administered glucagon, were interested in a mini-dose glucagon they could self-administer. They also identified desirable characteristics of glucagon treatment including reduced cost, long shelf-life, and quick activation. Conclusions: These results highlight the attitudes about severe hypoglycemia and emergency treatment with glucagon. Healthcare professionals should assess glucagon training needs and knowledge when they meet with their patients with diabetes.

Engaging Social Media Influencers to Recruit Hard-to-Reach Populations.

BACKGROUND: Though clinical researchers have begun to use social media platforms to recruit participants, social media influencers are innovative community connectors to further expand recruitment reach, especially in hard-to-reach populations. OBJECTIVES: The purpose of this methods article is to provide a step-by-step guide for engaging social media influencers for virtual participant recruitment. METHODS: There are multiple steps for researchers to follow, including preplanning, institutional review board approval, engaging with influencers, the pitch, the post, and results dissemination. DISCUSSION: Engaging social media influencers to recruit for clinical research demonstrates great potential to increase access to hard-to-reach populations. Several methodological considerations remain, and this article shares both opportunities and challenges to guide researchers in this technique.

Metabolics of PH - an update.

PURPOSE OF REVIEW: While there has been a longstanding interest in metabolic disease in pulmonary hypertension, publications in the last several years have translated basic science findings to human disease and even led to recently published studies of metabolic therapy in pulmonary arterial hypertension that are discussed here. RECENT FINDINGS: Progress has been made in four key areas including mechanisms of insulin resistance in pulmonary arterial hypertension, the role of obesity in pulmonary vascular disease, novel clinical trials targeting metabolism in pulmonary hypertension, and the role of metabolism in chronic thromboembolic pulmonary hypertension. SUMMARY: : Insulin resistance in pulmonary arterial hypertension is primarily in the lipid axis. There are systemic manifestations of insulin resistance including right ventricular lipotoxicity. Obesity is associated with elevation of right ventricular systolic pressure even in a healthy population and therapies in pulmonary arterial hypertension that target metabolism hold promise for improving exercise, right ventricular function, and visceral adiposity. Finally, there are emerging data that chronic thromboembolic pulmonary hypertension is similarly characterized by metabolic alterations, though the specific metabolites may be different from pulmonary arterial hypertension.

"I've Had an Alarm Set for 3:00 a.m. for Decades": The Impact of Type 1 Diabetes on Sleep.

There is a dearth of research characterizing the impact on a caregiver's sleep when caring for a minor with type 1 diabetes. This study used focus groups of people with type 1 diabetes and caregivers of minors with type 1 diabetes to explore the experience of how diabetes affects sleep. The occurrence of both unanticipated and planned sleep disruptions led to the majority of participants reporting that their sleep was considerably affected by diabetes. Despite the improvement in blood glucose management that diabetes technology devices can provide, people with type 1 diabetes and their caregivers still report sleep disruption and sleep loss resulting from overnight diabetes management.

Seeking Health Information and Social Support in the Diabetes Online Community.

Purpose: People with type 1 diabetes (T1D) search for health information online in the Diabetes Online Community (DOC), where individuals with diabetes, researchers and caregivers post and respond to health questions. The aims of this study were 1) to understand how people with T1D are seeking health information and engaging in health behaviors in the DOC, and 2) develop a measure of online health information seeking in adults with T1D. Research Method: Ninety-five adults with T1D completed qualitative prompts online. Results: Themes that emerged in this study included sense of community, and multiple types of social support that are necessary in disease management. Conclusions: This study used qualitative methods to develop a valid scale tailored for adults with T1D. Future research should seek to collect additional data to bolster validity and reliability.

Patient perspectives on the use of half-unit insulin pens by people with type 1 diabetes: a cross-sectional observational study.

BACKGROUND: Half-unit pens offer the ability to dose insulin more precisely. Information about half-unit pen use and evidence of their benefits and drawbacks is limited. This study aims to characterize people with type 1 diabetes (T1D) who have used (current/former = EVER) vs. those who have never used half-unit pens (NEVER users) and to understand their perspective. METHODS: An observational cross-sectional online survey was administered through T1D Exchange's online patient community, myGlu.org, to understand the use of half-unit insulin pens. RESULTS: The 278 adult participants (156 EVER, 122 NEVER) had a mean age of 41.8 ± 12.7 years, body mass index of 26.0 ± 3.8 kg/m2, glycated hemoglobin of 6.3% ± 1.0%, and 55% were male. EVER users had T1D for a shorter duration than NEVER users (p < .001). EVER users were less likely to use continuous subcutaneous insulin infusion (p < .001) and more likely to start correcting high blood glucose at a lower level (p < .001) and low blood glucose at a higher level (p < .001). The highest ranked benefits of half-unit pen reported by its current users (N = 131) included prevention of hyperglycemia (40.5%), less anxiety or worry (23.7%), and prevention of hypoglycemia (16.8%). CONCLUSIONS: Half-unit insulin pen is perceived as an insulin device that may help people with T1D to avoid hypo- and hyperglycemic events and decrease their level of disease worry and anxiety. This study highlights the need for patients and health care providers to understand the benefits of half-unit pens while considering options for individualized diabetes management.

Perspectives of Interactions with Healthcare Providers Among Patients Who Are Blind.

Healthcare providers' (HCPs) stereotypes about the incompetence of blind and low-vision patients may lead them to patronize blind patients, over-focus on impairments, and neglect the presenting problem. The content of perceived HCP stereotypes about blind patients in the clinical setting was examined from the patient perspective with seven focus groups, including a total of 42 individual participants. Most participants reported an interaction when their HCPs treated them as if they were incompetent, and discussed how perceived evaluations of their warmth and competence impacted whether their HCPs trusted and respected them. Participants also discussed their evaluations of their HCPs' warmth and competence, and how these evaluations impacted their trust and respect for the HCP. These results provide insight into blind patients' experiences interacting with their HCPs and can inform interventions to 1) help HCPs avoid stereotypic attitudes and 2) improve HCPs' comfort and abilities when working with patient with disabilities.

Factors associated with fear of hypoglycaemia among the T1D Exchange Glu population in a cross-sectional online survey.

OBJECTIVES: Fear of hypoglycaemia (FoH) has been associated with suboptimal diabetes management and health outcomes. This study investigated factors associated with behavioural and emotional aspects of FoH among adults living with type 1 diabetes (T1D) mellitus. DESIGN: Cross-sectional study. SETTING: Online survey hosted on T1D Exchange Glu, an online community for patients living with T1D mellitus. MEASURES: The Hypoglycaemia Fear Survey II-short form and the Hypoglycaemic Attitudes and Behaviour Scale were used to assess FoH. Multivariable regressions were performed on assessment scores. RESULTS: The study included 494 participants (mean±SD age 43.9±12.2 years, duration of T1D mellitus 16.6±16.8 years, self-reported glycosylated hemoglobin (HbA1c) 6.9%±0.8% (52±9 mmol/mol)), 63% men, 89% on insulin pump, 25% experienced a severe hypoglycaemic event in the last 6 months. Multivariable regression analyses showed higher anxiety, depression severity and diabetes distress were independently associated with FoH (all p<0.01). Longer diabetes duration was associated with lower FoH (p<0.01). Past experience with severe hypoglycaemia was associated with higher worry of hypoglycaemia (p<0.01) but not avoidance behaviour (ns). CONCLUSIONS: These results highlighted the multifaceted nature of FoH, which warrants further discussion between providers and patients to uncover drivers of and actions required to reduce FoH and improve patient care and outcomes.