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.

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.

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.

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.

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.

"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.

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.

Novel Challenges in Aging with Type 1 Diabetes.

PURPOSE OF REVIEW: Due to treatment advancements, individuals with type 1 diabetes (T1D) are living longer, presenting a unique understudied population with advanced complex needs. This article is a review of the aging literature in T1D and identifies existing gaps while serving as a call to the research community. RECENT FINDINGS: Recent studies have identified an association between cognitive impairment and glycemic variability, as well as increased risk and frequency of hypoglycemia in older adults with T1D. However, limited research exists about additional physical and mental health conditions and barrier to successful treatment in this population. Older adults may experience both age- and diabetes-related barriers to diabetes management. Due to the scarcity of aging T1D research, current treatment guidelines for this age group are based on type 2 diabetes research. There is a critical need to further investigate the physical and mental effects of T1D and aging as well as public health policy; insurance challenges; and needs for support and interventions for older adults with T1D.

"I Live in Constant Fear of Highs," the Daily Impact of Type 1 Diabetes.

Limited research exists regarding the burdens associated with type 1 diabetes (T1D). The study's objective was to understand the impact of T1D from people with T1D and caregivers of minors with T1D. Six focus groups were conducted, with a total of 31 participants. Participants included people with T1D, ages 23 to 72 (n = 17) and caregivers ages 34 to 55 (n = 14). Participants were recruited from T1D Exchange Glu. People with T1D reported time spent managing diabetes had greatest impact, while caregivers reported financial and employment sacrifices as most impactful. Our findings provide insight into the real-world daily impact of diabetes.

Impact of Medicare Continuous Subcutaneous Insulin Infusion Policies in Patients With Type 1 Diabetes.

BACKGROUND: The Centers for Medicare and Medicaid Services (CMS) has numerous requirements for coverage of continuous subcutaneous insulin infusion (CSII; insulin pump). Due to recent improvements in diabetes treatment, people with type 1 diabetes are living longer, resulting in an increase in the number of individuals who are eligible for Medicare and are impacted by CMS policies regarding CSII. METHODS: Two hundred forty-one adults with type 1 diabetes who had been on CSII with CMS coverage for at least 6 months were surveyed. Median age was 67 years, mean A1c was 7.0%, 64% were women, 93% were white, and the median type 1 diabetes duration was 42 years. Participants reported median CSII use of 15 years and 82% were on CSII before starting CMS. RESULTS: Of those starting CSII while on CMS, challenges included cost of supplies (29%) or the insulin pump (24%). The majority (57.5%) reported issues with obtaining supplies, the most common problems being delays in release of supplies (29%), difficulty getting paperwork completed (23.5%), and seeing a health care provider every 90 days (18%). Participants reported changing their CSII behaviors because of supply delays (39%) including leaving site in place >3 days (64%), and reusing pump supplies (34%). Consequently, participants reported adverse outcomes including more erratic (48%) or higher (42%) blood glucose and pain or irritation at sites (34%). CONCLUSION: This study concluded that current CMS CSII policies promote adverse CSII behaviors and outcomes in type 1 diabetes and thus call for changes in the CMS CSII policies.

Crossing event boundaries changes prospective perceptions of temporal length and proximity.

We conducted two experiments to investigate how crossing a single naturalistic event boundary impacted two different types of temporal estimation involving the same target duration - one where participants directly compared marked temporal durations and another where they judged the temporal proximity of stimuli. In Experiment 1, participants judged whether time intervals presented during movies of everyday events were shorter or longer than a previously encoded 5-s reference interval. We examined how the presence of a transition between events (event boundary) in the movie influenced people's judgments about the length of the comparison interval. Comparison intervals presented during a portion of the movie containing an event boundary were judged as shorter than the reference interval more often than comparison intervals that contained no boundary. Working-memory updating at the event boundary may have directed attention away from the concurrent timing task. In Experiment 2, participants judged whether the second of three tones presented during everyday movies was closer to the first or the third tone presented. Tones separated by an event boundary were judged as farther apart than tones contained within the same event. When judging temporal proximity, attention directed to processing information at an event boundary between two stimuli may disrupt the formation of temporal associations between those stimuli. Overall, these results demonstrate that crossing a single event boundary can impact people's prospective perceptions of the temporal characteristics of their experience and suggest that the episodic memory updating that occurs during an event boundary both captures timing-relevant attentional resources and plays a role in the temporal binding of information.