Awareness and Screening for Type 2 Diabetes in High Risk Younger Adult Populations - CNR Seminar Augusta University College of Nursing June 11 ...
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Awareness and Screening
for Type 2 Diabetes in
High Risk Younger Adult
Populations
CNR Seminar
Augusta University
College of Nursing
June 11, 2021
Lynn E. Glenn PhD, APRN-C
Learning Objectives At the end of this presentation, participants will be able to: 1. Identify younger adult populations who are at high risk for developing Type 2 Diabetes 2. Identify facilitators and barriers to diabetes screening 3. Identify racial and geographical disparities of awareness and diagnosis of diabetes in high-risk, younger adult populations
Incidence and Prevalence of Type 2
Diabetes in Younger Adults
• Younger Adults defined as 18 to 44 years old
• Type 2 Diabetes = T2DM
• Incidence = 4 per 1,000 (2018 U.S. average)
9.7 (45-64 yrs.); 8.6 (65-79 yrs.)
• Prevalence = 3.3 % (2018 U.S. average); approx. 9-10% (
2018 age-adjusted rate)
• U.S. Diabetes Surveillance System – USDSS (Division of
Diabetes Translation, CDC)
• National Health Interview Survey (NHIS)
Classification of Type 2 Diabetes Fasting Blood Glucose > 126 OR 2 hr Plasma Glucose 75 g OGTT > 200 OR HgA1C > 6.5% OR Random Plasma Glucose > 200
Age at Diagnosis of Diabetes, Total, Adults with Diabetes Aged 18+ years, Crude Percentage, National
Percentage ( Total )
Source: www.cdc.gov/diabetes/data
Disclaimer: This is a user-generated report. The findings and conclusions are those of the user and do not necessarily represent the views of the CDC.
National Center for Chronic Disease Prevention and Health Promotion
Division of Diabetes TranslationDiagnosed Diabetes, Age, Adults Aged 18+ Years, Percentage, National
U.S.
Average =
3.3%
18- 44 yrs.;
9.8% all
ages
Source: www.cdc.gov/diabetes/data
Disclaimer: This is a user-generated report. The findings and conclusions are those of the user and do not necessarily represent the views of the CDC.
National Center for Chronic Disease Prevention and Health Promotion
Division of Diabetes TranslationDiagnosed Diabetes, Age, Adults Aged 18+ Years, Percentage, Georgia
GA = 3.2 %
MS = 4.8 %
AR = 4.8%
NM = 4.3%
OR = 5%
Source: www.cdc.gov/diabetes/data
Disclaimer: This is a user-generated report. The findings and conclusions are those of the user and do not necessarily represent the views of the CDC.
National Center for Chronic Disease Prevention and Health Promotion
Division of Diabetes TranslationHigh Risk Younger Adult Populations • History of gestational diabetes • Family history of diabetes • Obesity • Sedentary lifestyle • Race/ethnicity • History of HTN (co-existing) • Metabolic syndrome, Prediabetes or Glucose Intolerance • HIV positive
Diabetes Awareness • There is a lack of diabetes awareness in younger adult, high- risk populations with an estimated 1.5 million adults with asymptomatic, undiagnosed diabetes, ages 18-44 years old • Low levels of engagement in preventive care among younger adult, high risk populations • Inadequate levels of diabetes screening by providers
Preventive Care Behaviors – Young
Adults
• Lower rates of preventive health care behaviors in younger
adults (flu vaccine, diabetes preventive care, etc.)
• Health care avoidance in rural populations
• Czeisler et al. (2020) - Impact of COVID pandemic
• delay in care more likely among younger adults, persons
with 2 or more health conditions, persons with
disabilities, Blacks and Hispanics (more than 50% ages
18-24 years old reported forgone care)
• Higher rates of uninsured or underinsuredScreening for Diabetes • Facilitators – Patient – Provider • Barriers – Patient – Provider • Alternatives to health care setting In home testing kits Retail clinics Employer-based health screenings
ADA Standards of Care - Glucose
Testing
• Screening should be yearly for high risk/prediabetes
• If low risk or no prediabetes, screening should occur every 3 years or begin at
45 years of age
• Women with history of gestational diabetes should have lifelong testing AT
LEAST every 3 years
• Youth (age 10 or onset of puberty) testing should be considered if overweight
> 85 percentile/obesity >95 percentile, and have at least one additional risk
factor, at least very 3 years
– Maternal history of DM or gestational DM
– Family history of DM
– High Risk Racial/Ethnic groups
– Insulin resistancePrediabetes Awareness of prediabetes is low, but improving (NHANES 2005-2016) • 6.5 13.3% • Lower rates of awareness in men, younger adults, Asians and Hispanics Classification • Impaired Fasting Glucose (fasting 100-125 mg/dl) • Impaired Glucose Tolerance (75 g OGTT 2 hr PG 140-199 mg/dl) • HgA1C 5.7-6.4% • Scoring a 5 or higher on “Prediabetes Risk Test” Risks Prediabetes is associated with CVD and at best, 50% of persons with prediabetes can be reversed to NORMAL GLUCOSE regulation with lifestyle interventions or Diabetes Prevention Program
ADA – diabetes.org/risk-test
Racial Disparities in Undiagnosed Diabetes Cohort of 6.774 non-pregnant women with high rate of undiagnosed diabetes and prediabetes Undiagnosed 75.6% Non-Hispanic Blacks 48.1% Hispanics 22.8% Non-Hispanic Whites 11.4 % Asians Prediabetes 38.5 % Non-Hispanic Blacks 27.8% Hispanics 25.1% Asians 20.3% Native Americans 16.6% Non-Hispanic Whites Britton, L. E., Hussey, J. M., Crandell, J. L., Berry, D. C., Brooks, J. L., & Bryant, A. G. (2018). Racial/Ethnic Disparities in Diabetes Diagnosis and Glycemic Control Among Women of Reproductive Age. J Womens Health (Larchmt), 27(10), 1271-1277. https://doi.org/10.1089/jwh.2017.6845
Gestational Diabetes – Screening and
Prevalence
• One Step Strategy 75 g OGTT, 24 to 28 weeks {IADPSG criteria}, 1 or more criteria**
glucose threshold (mg/dl)
Fasting 92
Prevalence ~ 8.6 per 100 (2016);
3 – 14%
1 hour 180
2 hour 153
• Two Step Strategy 50 gm non-fasting glucose load test, 24 to 28 weeks {Carpenter-Coustan criteria}***
– If > 130, 135, or 140 at 1 hour, proceed to 100 g OGTT
– 2 or more criteria; ACOG one value exceed threshold for diagnosis of GDM
glucose threshold (mg/dl)
Fasting 95
1 hour 180
2 hour 155
3 hour 140Postpartum Glucose Screening – Women with Gestational Diabetes Current ADA recommendations: • OGTT 75 gm 4-12 weeks postpartum • HgA1C not recommended (persistently lower because of increased RBC turnover in pregnancy or blood loss at delivery) • Some pilot studies support immediate postpartum testing (esp. for early detection of overt T2DM) • Testing should be repeated every 1 to 3 years thereafter if normal, more frequently if prediabetes dx
Postpartum Glucose Screening
Adherence –
Women with Gestational Diabetes
• Adherence is LOW
Herrick et al. (2019) cohort of low income, minority women
– ~ 10% within 12 weeks and ~ 19% within 1 year
– ~ 85% had postpartum visit
Bernstein et al. (2017) cohort of primarily white, privately insured women
– ~ 6% within 12 weeks and ~ 20% within 1 year
– ~ 40% had postpartum visit
• Subsequent risk of developing T2DM is HIGH - 7 fold risk
• Postpartum diagnosis of overt diabetes is 5-14% for women with GDM
• Inadequate transition from postpartum care to primary care
– < 15% reported a visit with a primary care provider within the first year
following pregnancyAssociated Risks of Gestational
Diabetes
• Recurrent Gestational Diabetes (30-60%)
• Increased Risk of Maternal Mortality and Morbidity
– Elevated preconception A1C is associated with a higher risk of SMM or
death among women without known diabetes, and below thresholds
commonly used to diagnose DM
– Relative risk of SMM or death was 1.16 per 0.5% increase in A1C. For A1C
> 6.4%, the adjusted relative risk of SMM or death was 3.25.
• Increased vascular dysfunction, hyperlipidemia, & cardiovascular risk at earlier
age
Gunderson et al. (2021) - CARDIA Study
– Regardless of levels of glucose tolerance, 2 fold higher risk of CAC
– Midlife atherosclerotic CVD risk among women with previous GDM is NOT
diminished by attaining normo-glycemiaSubsequent risk of Prediabetes,
Glucose Intolerance & T2DM
Progression to GDM to T2DM increases over time (~ 7 fold risk)
Vounzoulaki et 9% 1 to 5 12% 5 to 10 16% > 10
al., (2020) years years years
Song et al., 2018Postpartum Glucose Adherence
Rates – Chart Review
• Augusta University Medical Center Chart Review
– IRB approved 11/15/2020
– Women with ICD diagnosis of gestational diabetes, 18 years or older
– 1/2015 to 10/2020
– Excluded if previously diagnosed with T2DM, NO prenatal care or
postpartum care at AU
– Data collection - dates of service, # prenatal and postnatal visits, #
prenatal and postpartum glucose testing up to 12 mos. postpartum,
infant birthweight, maternal/pregnancy complications, rural
residence/FIPS code, demographics, number of visits to CDE or diabetes
education, medications (diabetes related medications in antepartum
and postpartum)Postpartum Glucose Adherence
Rates – Chart Review
• Approximately 490 charts retrieved via i2B2 / Joy Hayman
• Estimated minimum sample size needed for data analysis =
152
• Preliminary analysis = 52 women with GDM
N = 52 Urban Rural
Race (Black/White) 15, 10 15, 6 (4 Hispanic)
Age 31.88 30.42
Birthweight (gm) 2910.60 3240.96
County 13 (County = RICHMOND) 23 (County = JEFFERSON)Maternal Complications C-SEC, pre-eclampsia, elevated troponins post delivery; NSTEMI, PP wound, shoulder dystocia, placenta previa/percreta; PP hemorrhage, hysterectomy, PROM, Chorioamnionitis, IUGR, Post Op ILEUS, PP Pulm EMB/DVT, placenta previa, Post op Acute Hypoxia/Resp. Failure/Aspiration Pneumonia, Breech, Post op infection, stillborn, delivery in EMS, poor fetal growth, atrial fib/cardioversion, active herpes
Racial and Geographical Health
Disparities
Urban Rural
# Prenatal Visits Mean = 11.41 Mean = 13.42
# Postpartum Visits Mean = 2.16 Mean = 1.35
# Postpartum Glucose 12/23 (52%) 8/25 (32%)
Testing = 1 or more
Mean = 0.87 Mean = 0.32
Herrick et al. (2020) postpartum screening rates higher among Hispanic, Asian women (up to 50%)
and lower among Black, White women (up to 35%)Rural Classification - RUCA
RUCA = Rural Urban Commuting Areas
– Based on Census tracts, urbanization, population density
and daily commuting
– Primary Codes 1-10, 21 Secondary Codes
– Most frequent RUCA code = 7 (11/26) and 10 (13/26)
– Overall sample mean = 5.06, rural mean = 8.62Code Classification Description
1 Metropolitan area core: Primary flow within an urbanized area (UA)
2 Metropolitan area high commuting: Primary flow 30% or more to a UA
3 Metropolitan area low commuting: Primary flow 10% to 30% to a UA
4 Micropolitan area core: Primary flow within an urban cluster of 10,000 to
49,999 (Large UC)
5 Micropolitan high commuting: Primary flow 30% or more to a large UC
6 Micropolitan low commuting: Primary flow 10% to 30% to a large UC
7 Small town core: Primary flow within an urban cluster of 2.500 to 9,999
(Small UC)
8 Small town high commuting: Primary flow 30% or more to a small UC
9 Small town low commuting: Primary flow 10% to 30% to a small UC
10 Rural areas: Primary flow to a tract outside a UA or UC
99 Not coded: Census tract has zero population and no rural-urban identifier
informationTransition to Primary Care and Long-Term Follow up of High Risk Younger Adults Ideas? Evidence-based Practice? Community-Engaged Approach?
Short-term Research Objectives 1. Strengthen existing community partnerships to address the needs of younger adult women (18-44 yrs.) in the rural areas of SC and GA who are at high risk for developing T2 DM 2. Promote the knowledge and application of PCOR and CBPR engagement principles in a shared learning community to address and prioritize the health needs of the priority population 3. Develop a pilot study intervention to facilitate timely glucose screening and engagement in care among high risk, younger adult, rural populations
Long-term Research Objectives The overall aim is to establish earlier recognition of diabetes and reduce diabetes-related complications 1. Examine the impact of population screening for type 2 diabetes on long-term health outcomes and mortality in high- risk, younger adults (unknown) Simmons et al. (2011) – 10 year follow up of cohort in UK; avg. age 50 2. To develop effective community-based and workplace-based interventions that facilitate engagement in preventive care and enhance health outcomes in younger (< 45 yr), rural dwelling adults at high risk for diabetes
Potential Funding Opportunities • Patient Centered Outcomes Research Institute (PCORI) Engagement Awards and Comparative Effectiveness Research/CER • Office of Minority Health /DHHS “Family-Centered Approaches to Improving Type 2 Diabetes Control and Prevention” • American Diabetes Association (ADA) Health Disparities and Diabetes Research Junior Faculty Award • Private Foundation Grants – Healthcare Georgia Foundation
References
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Centers for Disease Control and Prevention. National Diabetes Statistics Report, 2020. Atlanta, GA:
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Czeisler, M., Marynak, K., Clarke, K. E. N., Salah, Z., Shakya, I., Thierry, J. M., Ali, N., McMillan, H., Wiley, J.
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https://doi.org/10.1136/bmj.m1361You can also read
