Click to view more from Federal Health Care Data Trends 2024.

Click to view more from Federal Health Care Data Trends 2024.

Click to view more from Federal Health Care Data Trends 2024.

Poorer physical function, not poorer bone mineral density (BMD), could be the principal reason for the increased fracture risk in older women with type 2 diabetes (T2D), according to a Swedish prospective observational study in JAMA Network Open.

The study was conducted in more than 3000 Swedish women by Mattias Lorentzon, MD, a professor of geriatric medicine at Gothenburg University, and chief physician at the Osteoporosis Clinic at Sahlgrenska University Hospital in Mölndal, and colleagues.

Study Details

A fractures study was performed in the Gothenburg area from March 2013 to May 2016 with follow-up of incident fracture data completed in March 2023. Data were collected from questionnaires and through examination of anthropometrics, physical function, and bone measurements using dual-energy x-ray absorptiometry and high-resolution peripheral computed tomography. A subsample underwent bone microindentation to assess BMSi.

Among the cohort’s 3008 women, ages 75-80 (mean, 77.8), 294 patients with T2D were compared with 2714 same-age unaffected women.

During a median follow-up of 7.3 years, 1071 incident fractures, 853 major osteoporotic fractures, and 232 hip fractures occurred. In models adjusted for age, BMI, clinical risk factors, and femoral neck BMD, T2D was associated with an increased risk of any fracture: hazard ratio (HR), 1.26; (95% CI, 1.04-1.54), and major osteoporotic fracture (HR, 1.25; 95% CI, 1.00-1.56).

Most fractures were due to falls, with the most common affected sites being the forearm, upper arm, spine, and hip, Dr. Lorentzon said.

Among the findings:

• In bone microarchitecture, women with T2D had higher BMD at all sites: total hip, 4.4% higher; femoral neck, 4.9% higher; and lumbar spine, 5.2% higher.
• At the tibia, the T2D group had 7.4% greater cortical area and 1.3% greater density, as well as 8.7% higher trabecular bone volume fraction.

“Our findings regarding BMD are consistent with previous publications showing higher BMD in individuals with T2D compared with those without diabetes,” Dr. Lorentzon said. A 2012 meta-analysis, for example, showed higher BMD levels in T2D patients. “Some smaller studies, however, have found worse bone microstructure and lower bone material strength in contrast to the results from our study,” Dr. Lorentzon said.

• There was no difference in BMSi, with a mean of 78 in both groups.
• The T2D group had lower performance on all physical function tests: a 9.7% lower grip strength, 9.9% slower gait speed, and 13.9% slower timed up-and-go time than women without diabetes.

“We found all parameters regarding physical function, such as muscle strength, balance, and performance, were much worse in women with diabetes than in those without,” Dr. Lorentzon said. “Dizziness could also be a contributor to the increased risk of falls, but this factor was not investigated in our study.”

Commenting on the study but not involved in it, Anthony J. Pick, MD, an endocrinologist at Northwestern Medicine Lake Forest Hospital in Lake Forest, Illinois, said sarcopenia is a common and often under-recognized problem in older adults and is especially prevalent in T2D, obesity, and heart failure. “I believe that ‘exercise is medicine’ is a key concept for metabolic and osteoporosis patients — and wellness and longevity in general — and I certainly hope studies like this drive awareness of the importance of engaging in strengthening exercises.”

Poorer physical function, not poorer bone mineral density (BMD), could be the principal reason for the increased fracture risk in older women with type 2 diabetes (T2D), according to a Swedish prospective observational study in JAMA Network Open.

The study was conducted in more than 3000 Swedish women by Mattias Lorentzon, MD, a professor of geriatric medicine at Gothenburg University, and chief physician at the Osteoporosis Clinic at Sahlgrenska University Hospital in Mölndal, and colleagues.

Study Details

A fractures study was performed in the Gothenburg area from March 2013 to May 2016 with follow-up of incident fracture data completed in March 2023. Data were collected from questionnaires and through examination of anthropometrics, physical function, and bone measurements using dual-energy x-ray absorptiometry and high-resolution peripheral computed tomography. A subsample underwent bone microindentation to assess BMSi.

Among the cohort’s 3008 women, ages 75-80 (mean, 77.8), 294 patients with T2D were compared with 2714 same-age unaffected women.

During a median follow-up of 7.3 years, 1071 incident fractures, 853 major osteoporotic fractures, and 232 hip fractures occurred. In models adjusted for age, BMI, clinical risk factors, and femoral neck BMD, T2D was associated with an increased risk of any fracture: hazard ratio (HR), 1.26; (95% CI, 1.04-1.54), and major osteoporotic fracture (HR, 1.25; 95% CI, 1.00-1.56).

Most fractures were due to falls, with the most common affected sites being the forearm, upper arm, spine, and hip, Dr. Lorentzon said.

Among the findings:

• In bone microarchitecture, women with T2D had higher BMD at all sites: total hip, 4.4% higher; femoral neck, 4.9% higher; and lumbar spine, 5.2% higher.
• At the tibia, the T2D group had 7.4% greater cortical area and 1.3% greater density, as well as 8.7% higher trabecular bone volume fraction.

“Our findings regarding BMD are consistent with previous publications showing higher BMD in individuals with T2D compared with those without diabetes,” Dr. Lorentzon said. A 2012 meta-analysis, for example, showed higher BMD levels in T2D patients. “Some smaller studies, however, have found worse bone microstructure and lower bone material strength in contrast to the results from our study,” Dr. Lorentzon said.

• There was no difference in BMSi, with a mean of 78 in both groups.
• The T2D group had lower performance on all physical function tests: a 9.7% lower grip strength, 9.9% slower gait speed, and 13.9% slower timed up-and-go time than women without diabetes.

“We found all parameters regarding physical function, such as muscle strength, balance, and performance, were much worse in women with diabetes than in those without,” Dr. Lorentzon said. “Dizziness could also be a contributor to the increased risk of falls, but this factor was not investigated in our study.”

Commenting on the study but not involved in it, Anthony J. Pick, MD, an endocrinologist at Northwestern Medicine Lake Forest Hospital in Lake Forest, Illinois, said sarcopenia is a common and often under-recognized problem in older adults and is especially prevalent in T2D, obesity, and heart failure. “I believe that ‘exercise is medicine’ is a key concept for metabolic and osteoporosis patients — and wellness and longevity in general — and I certainly hope studies like this drive awareness of the importance of engaging in strengthening exercises.”

Poorer physical function, not poorer bone mineral density (BMD), could be the principal reason for the increased fracture risk in older women with type 2 diabetes (T2D), according to a Swedish prospective observational study in JAMA Network Open.

The study was conducted in more than 3000 Swedish women by Mattias Lorentzon, MD, a professor of geriatric medicine at Gothenburg University, and chief physician at the Osteoporosis Clinic at Sahlgrenska University Hospital in Mölndal, and colleagues.

Study Details

A fractures study was performed in the Gothenburg area from March 2013 to May 2016 with follow-up of incident fracture data completed in March 2023. Data were collected from questionnaires and through examination of anthropometrics, physical function, and bone measurements using dual-energy x-ray absorptiometry and high-resolution peripheral computed tomography. A subsample underwent bone microindentation to assess BMSi.

Among the cohort’s 3008 women, ages 75-80 (mean, 77.8), 294 patients with T2D were compared with 2714 same-age unaffected women.

During a median follow-up of 7.3 years, 1071 incident fractures, 853 major osteoporotic fractures, and 232 hip fractures occurred. In models adjusted for age, BMI, clinical risk factors, and femoral neck BMD, T2D was associated with an increased risk of any fracture: hazard ratio (HR), 1.26; (95% CI, 1.04-1.54), and major osteoporotic fracture (HR, 1.25; 95% CI, 1.00-1.56).

Most fractures were due to falls, with the most common affected sites being the forearm, upper arm, spine, and hip, Dr. Lorentzon said.

Among the findings:

• In bone microarchitecture, women with T2D had higher BMD at all sites: total hip, 4.4% higher; femoral neck, 4.9% higher; and lumbar spine, 5.2% higher.
• At the tibia, the T2D group had 7.4% greater cortical area and 1.3% greater density, as well as 8.7% higher trabecular bone volume fraction.

“Our findings regarding BMD are consistent with previous publications showing higher BMD in individuals with T2D compared with those without diabetes,” Dr. Lorentzon said. A 2012 meta-analysis, for example, showed higher BMD levels in T2D patients. “Some smaller studies, however, have found worse bone microstructure and lower bone material strength in contrast to the results from our study,” Dr. Lorentzon said.

• There was no difference in BMSi, with a mean of 78 in both groups.
• The T2D group had lower performance on all physical function tests: a 9.7% lower grip strength, 9.9% slower gait speed, and 13.9% slower timed up-and-go time than women without diabetes.

“We found all parameters regarding physical function, such as muscle strength, balance, and performance, were much worse in women with diabetes than in those without,” Dr. Lorentzon said. “Dizziness could also be a contributor to the increased risk of falls, but this factor was not investigated in our study.”

Commenting on the study but not involved in it, Anthony J. Pick, MD, an endocrinologist at Northwestern Medicine Lake Forest Hospital in Lake Forest, Illinois, said sarcopenia is a common and often under-recognized problem in older adults and is especially prevalent in T2D, obesity, and heart failure. “I believe that ‘exercise is medicine’ is a key concept for metabolic and osteoporosis patients — and wellness and longevity in general — and I certainly hope studies like this drive awareness of the importance of engaging in strengthening exercises.”

As pediatric providers we are dedicated to helping children have optimal health. And what could be more basic to health than having enough food? Yet, even in one of the richest countries on the planet, as much as 25% of US families are reported to have “food insecurity.”

What does this mean? The US Department of Agriculture (USDA), the agency tracking and addressing food issues, defines food security as “marginal” when there are one or two indications, typically anxiety over food sufficiency or shortage of food even with little or no alteration of diet or intake. “Low” includes reduced quality, variety, or desirability of the diet but little or no reduced intake. When eating patterns are disrupted and intake is reduced, this is considered “very low food security.” “Hunger” refers to an individual’s physiological state when prolonged, involuntary lack of food results in discomfort, illness, weakness, or pain beyond the usual uneasy sensation. Pediatric researchers include in the definition lack of access to enough food for an active and healthy life. I will use the common term “food insecurity” here.

Food insecurity has serious consequences for children’s health. Children under 3 years old in homes with food insecurity have been found to be sick more often, recover more slowly from illness, and be hospitalized more frequently. Deficiencies in nutrition vary by age, with children under 6 having low vegetable intake and low iron, ages 6-11 excess sugary food intake and lower bone density in boys, and adolescents, although harder to measure, had low iron.
 

Physical and Mental Effects of Food Insecurity

Associated with food insecurity in the home are more developmental delays in children 4-36 months old. Beyond that, children of all ages have lower cognitive indicators, dysregulated behavior, and emotional distress than those in homes with secure food access. These are persisting deficits: kindergarten children with food insecurity have lower math and reading abilities over at least 4 years.

Mental health is also affected by food insecurity. Reviews of multiple studies of children from preschool through adolescence show more child hyperactivity, emotional dysregulation, anxiety, depression, and stress beyond those attributable to their mother’s depression and anxiety. Food insecurity in the early years is associated with mental health issues even into adolescence. School aged children and youth are well aware of the family’s struggle with food access, even when their parents do not realize this. In addition to the anxiety and depression, they may feel shame or be socially ostracized. They may eat less, or choose low-quality foods to cope. Adolescents experiencing food insecurity report greater dysthymia and suicidal ideation. It is unknown whether these mental health difficulties are due to the stress, shame, or decreased intake of macronutrients important to emotional regulation or all of these. One implication is that pediatric providers should also screen for food insecurity as well as other social drivers of health (SDOH) when addressing developmental, behavioral, or mental health issues, not just at well visits.

While we worry about effects for the child, impact of food insecurity on caregivers is significant for parenting as well as adult well-being beginning prenatally. First trimester food insecurity is associated with increased maternal stress at 2 months postpartum and lower bonding scores at 6 months, although this is moderated by social support. The stress of food insecurity and other SDoH present are associated with parental depression, anxiety, and toxic stress, making optimal parenting difficult. Caregivers experiencing insecure food access worry most about their children and may reduce their own eating and food quality to spare the child. More than 30% of families indicated that they had to choose between paying for food and paying for medicine or medical care, jeopardizing their health, making this an important point of discussion for us as well.
 

Quality Versus Quantity

The total amount of food is not the only factor in adequate child nutrition. Healthy foods usually cost more and also may not be conveniently available. There are so called “food deserts,” areas with few/no full-service grocery stores, and also “food swamps” where unhealthy foods (eg fast food) are more available than healthy options. Life stress, higher in low-income populations, increases the impulse to consume sweet or high-fat “comfort foods” (we all know this!) due to the rush of calories and quick satiety. Children may be influenced in their food choices by media messages about non-nutritious foods. All of these may explain the association of food insecurity with obesity in both children and adults. It also sets them up for lifetime health problems of diabetes, hyperlipidemia, and cardiovascular conditions, especially in racial and ethnic minority groups and the poor.

The Larger Picture

Obvious to us all, low income is the main reason for inadequate access to enough or good quality food. Over 60% of families with food insecurity had incomes below the poverty threshold in 2013. Households without children are half as likely to be food insecure. But as 30% of food-insecure households have incomes above the eligibility cut offs for food programs — typically 130% of poverty for Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) or 185% for Supplemental Nutrition Assistance Program (SNAP) — it is clear the problem is not related solely to poverty. Even small changes in income or expenses, such as a car breaking down, or heating or medical bills, can quickly result in inability to afford food, especially in areas of high food costs. This is particularly true for immigrant, large, and single-parent families and those with less education. Federal food programs do not cover all food needs for every family.

But we can’t tell if a child lives in a family with food insecurity by whether the child is thin, dropping growth percentiles, or receiving Medicaid insurance. Parents, and even youth, may be reluctant to tell us that they do not have enough to eat out of pride, fear, of prejudice, being reported to a contentious ex, being detected as an illegal immigrant, or even reported for neglect and having their child removed. Because of the suffering and impacts of food insecurity on child well-being, the American Academy of Pediatrics (AAP) published a Policy Statement in 2015, reaffirmed in 2021, recommending screening for food insecurity at all well visits and a toolkit to help. The USDA 18-item Household Food Security Scale (HFSS) has been the gold-standard screen, but affirmative answers to either of the 2-item Hunger Vital Sign (HVS) questionnaire identifies food insecurity with a sensitivity of 97% and a specificity of 83% compared with the HFSS. The questions ask how often the following were true in the past year: 1) “We worried whether our food would run out before we got money to buy more” and 2) “The food we bought just didn’t last and we didn’t have money to buy more.” This brief screen is now recommended and practical.
 

Screening for Food Insecurity

All set to manage food insecurity in your practice, then? Not exactly. Screening is only useful if it results in access to food. A study in a majority low-income clinic found that parents reported food insecurity 7% of the time when the clinician asked the HVS questions versus 45% when they self-reported on paper. Parent focus groups revealed reasons for the discrepant underreporting to the clinician: shame, concerns about stigma, and fear of the child being taken away. They felt more comfortable reporting about their child than about their own family situation. When asked what the clinician did that helped them disclose food insecurity, the caregivers cited strong interpersonal skills, open body language, and empathy. They also requested being given resources for other social issues, not just food insecurity. Clinic staff found paper screening inconvenient and recommended using tablet devices (such as with CHADIS that also scores and provides interviewing help, education, and local resource listings). Clinicians found the need for a follow-up conversation time consuming. Clinic staff thought screening could be facilitated by clinician’s initiating conversations, taking care about children present, and normalizing the screen as applying to all. Caregivers wanted know the use and privacy of the information. This same clinic referred the caregivers to a Benefits Data Trust with a goal of enrolling them in food programs. Of the food insecure, 55% were referred but only one third could be reached by phone with three attempts by the benefits group. Subsequent enrollment of those reached had barriers of verification requirements, wait times, and perceived mistreatment. The program concluded that this difficult two-step process of screening and referral would be improved by an integrated system of screening and enrollment in public benefits. Provision of information about free local food resources is also important, as 84% of those already receiving SNAP benefits remained food insecure.

Offering Assistance

To assist families where food insecurity is found, we need to understand the options of services both for referrals and advocacy. The AAP toolkit is designed to help. For pregnant and postpartum women and children 0-5 years in families with income less than 130% of the poverty level, the WIC program provides electronic cards to purchase approved categories of healthy food from participating vendors. For families with incomes less than 185% of the poverty level, the SNAP program, formerly called food stamps, provides benefits. There are other programs including free and reduced cost National School Breakfast and/or Lunch programs (best when open to all), Child and Adult Care Food Program for institutions (which may include medical offices), and Summer Food Service Programs providing lunch at community sites. Since not all food-insecure families are eligible for the above services, it is important that we are ready to provide information about local food banks, pantries, and low- or no-cost produce programs (see Healthy Food Bank Hub, Feeding America, 2-1-1, or FindHelp.org).

As pediatric providers we have a special opportunity and responsibility to expand our capabilities for sensitively addressing and advocating for help for food insecurity to improve the outlook for the families under our care.

Dr. Howard is assistant professor of pediatrics at The Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS. She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. E-mail her at [email protected].

As pediatric providers we are dedicated to helping children have optimal health. And what could be more basic to health than having enough food? Yet, even in one of the richest countries on the planet, as much as 25% of US families are reported to have “food insecurity.”

What does this mean? The US Department of Agriculture (USDA), the agency tracking and addressing food issues, defines food security as “marginal” when there are one or two indications, typically anxiety over food sufficiency or shortage of food even with little or no alteration of diet or intake. “Low” includes reduced quality, variety, or desirability of the diet but little or no reduced intake. When eating patterns are disrupted and intake is reduced, this is considered “very low food security.” “Hunger” refers to an individual’s physiological state when prolonged, involuntary lack of food results in discomfort, illness, weakness, or pain beyond the usual uneasy sensation. Pediatric researchers include in the definition lack of access to enough food for an active and healthy life. I will use the common term “food insecurity” here.

Food insecurity has serious consequences for children’s health. Children under 3 years old in homes with food insecurity have been found to be sick more often, recover more slowly from illness, and be hospitalized more frequently. Deficiencies in nutrition vary by age, with children under 6 having low vegetable intake and low iron, ages 6-11 excess sugary food intake and lower bone density in boys, and adolescents, although harder to measure, had low iron.
 

Physical and Mental Effects of Food Insecurity

Associated with food insecurity in the home are more developmental delays in children 4-36 months old. Beyond that, children of all ages have lower cognitive indicators, dysregulated behavior, and emotional distress than those in homes with secure food access. These are persisting deficits: kindergarten children with food insecurity have lower math and reading abilities over at least 4 years.

Mental health is also affected by food insecurity. Reviews of multiple studies of children from preschool through adolescence show more child hyperactivity, emotional dysregulation, anxiety, depression, and stress beyond those attributable to their mother’s depression and anxiety. Food insecurity in the early years is associated with mental health issues even into adolescence. School aged children and youth are well aware of the family’s struggle with food access, even when their parents do not realize this. In addition to the anxiety and depression, they may feel shame or be socially ostracized. They may eat less, or choose low-quality foods to cope. Adolescents experiencing food insecurity report greater dysthymia and suicidal ideation. It is unknown whether these mental health difficulties are due to the stress, shame, or decreased intake of macronutrients important to emotional regulation or all of these. One implication is that pediatric providers should also screen for food insecurity as well as other social drivers of health (SDOH) when addressing developmental, behavioral, or mental health issues, not just at well visits.

While we worry about effects for the child, impact of food insecurity on caregivers is significant for parenting as well as adult well-being beginning prenatally. First trimester food insecurity is associated with increased maternal stress at 2 months postpartum and lower bonding scores at 6 months, although this is moderated by social support. The stress of food insecurity and other SDoH present are associated with parental depression, anxiety, and toxic stress, making optimal parenting difficult. Caregivers experiencing insecure food access worry most about their children and may reduce their own eating and food quality to spare the child. More than 30% of families indicated that they had to choose between paying for food and paying for medicine or medical care, jeopardizing their health, making this an important point of discussion for us as well.
 

Quality Versus Quantity

The total amount of food is not the only factor in adequate child nutrition. Healthy foods usually cost more and also may not be conveniently available. There are so called “food deserts,” areas with few/no full-service grocery stores, and also “food swamps” where unhealthy foods (eg fast food) are more available than healthy options. Life stress, higher in low-income populations, increases the impulse to consume sweet or high-fat “comfort foods” (we all know this!) due to the rush of calories and quick satiety. Children may be influenced in their food choices by media messages about non-nutritious foods. All of these may explain the association of food insecurity with obesity in both children and adults. It also sets them up for lifetime health problems of diabetes, hyperlipidemia, and cardiovascular conditions, especially in racial and ethnic minority groups and the poor.

The Larger Picture

Obvious to us all, low income is the main reason for inadequate access to enough or good quality food. Over 60% of families with food insecurity had incomes below the poverty threshold in 2013. Households without children are half as likely to be food insecure. But as 30% of food-insecure households have incomes above the eligibility cut offs for food programs — typically 130% of poverty for Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) or 185% for Supplemental Nutrition Assistance Program (SNAP) — it is clear the problem is not related solely to poverty. Even small changes in income or expenses, such as a car breaking down, or heating or medical bills, can quickly result in inability to afford food, especially in areas of high food costs. This is particularly true for immigrant, large, and single-parent families and those with less education. Federal food programs do not cover all food needs for every family.

But we can’t tell if a child lives in a family with food insecurity by whether the child is thin, dropping growth percentiles, or receiving Medicaid insurance. Parents, and even youth, may be reluctant to tell us that they do not have enough to eat out of pride, fear, of prejudice, being reported to a contentious ex, being detected as an illegal immigrant, or even reported for neglect and having their child removed. Because of the suffering and impacts of food insecurity on child well-being, the American Academy of Pediatrics (AAP) published a Policy Statement in 2015, reaffirmed in 2021, recommending screening for food insecurity at all well visits and a toolkit to help. The USDA 18-item Household Food Security Scale (HFSS) has been the gold-standard screen, but affirmative answers to either of the 2-item Hunger Vital Sign (HVS) questionnaire identifies food insecurity with a sensitivity of 97% and a specificity of 83% compared with the HFSS. The questions ask how often the following were true in the past year: 1) “We worried whether our food would run out before we got money to buy more” and 2) “The food we bought just didn’t last and we didn’t have money to buy more.” This brief screen is now recommended and practical.
 

Screening for Food Insecurity

All set to manage food insecurity in your practice, then? Not exactly. Screening is only useful if it results in access to food. A study in a majority low-income clinic found that parents reported food insecurity 7% of the time when the clinician asked the HVS questions versus 45% when they self-reported on paper. Parent focus groups revealed reasons for the discrepant underreporting to the clinician: shame, concerns about stigma, and fear of the child being taken away. They felt more comfortable reporting about their child than about their own family situation. When asked what the clinician did that helped them disclose food insecurity, the caregivers cited strong interpersonal skills, open body language, and empathy. They also requested being given resources for other social issues, not just food insecurity. Clinic staff found paper screening inconvenient and recommended using tablet devices (such as with CHADIS that also scores and provides interviewing help, education, and local resource listings). Clinicians found the need for a follow-up conversation time consuming. Clinic staff thought screening could be facilitated by clinician’s initiating conversations, taking care about children present, and normalizing the screen as applying to all. Caregivers wanted know the use and privacy of the information. This same clinic referred the caregivers to a Benefits Data Trust with a goal of enrolling them in food programs. Of the food insecure, 55% were referred but only one third could be reached by phone with three attempts by the benefits group. Subsequent enrollment of those reached had barriers of verification requirements, wait times, and perceived mistreatment. The program concluded that this difficult two-step process of screening and referral would be improved by an integrated system of screening and enrollment in public benefits. Provision of information about free local food resources is also important, as 84% of those already receiving SNAP benefits remained food insecure.

Offering Assistance

To assist families where food insecurity is found, we need to understand the options of services both for referrals and advocacy. The AAP toolkit is designed to help. For pregnant and postpartum women and children 0-5 years in families with income less than 130% of the poverty level, the WIC program provides electronic cards to purchase approved categories of healthy food from participating vendors. For families with incomes less than 185% of the poverty level, the SNAP program, formerly called food stamps, provides benefits. There are other programs including free and reduced cost National School Breakfast and/or Lunch programs (best when open to all), Child and Adult Care Food Program for institutions (which may include medical offices), and Summer Food Service Programs providing lunch at community sites. Since not all food-insecure families are eligible for the above services, it is important that we are ready to provide information about local food banks, pantries, and low- or no-cost produce programs (see Healthy Food Bank Hub, Feeding America, 2-1-1, or FindHelp.org).

As pediatric providers we have a special opportunity and responsibility to expand our capabilities for sensitively addressing and advocating for help for food insecurity to improve the outlook for the families under our care.

Dr. Howard is assistant professor of pediatrics at The Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS. She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. E-mail her at [email protected].

As pediatric providers we are dedicated to helping children have optimal health. And what could be more basic to health than having enough food? Yet, even in one of the richest countries on the planet, as much as 25% of US families are reported to have “food insecurity.”

What does this mean? The US Department of Agriculture (USDA), the agency tracking and addressing food issues, defines food security as “marginal” when there are one or two indications, typically anxiety over food sufficiency or shortage of food even with little or no alteration of diet or intake. “Low” includes reduced quality, variety, or desirability of the diet but little or no reduced intake. When eating patterns are disrupted and intake is reduced, this is considered “very low food security.” “Hunger” refers to an individual’s physiological state when prolonged, involuntary lack of food results in discomfort, illness, weakness, or pain beyond the usual uneasy sensation. Pediatric researchers include in the definition lack of access to enough food for an active and healthy life. I will use the common term “food insecurity” here.

Food insecurity has serious consequences for children’s health. Children under 3 years old in homes with food insecurity have been found to be sick more often, recover more slowly from illness, and be hospitalized more frequently. Deficiencies in nutrition vary by age, with children under 6 having low vegetable intake and low iron, ages 6-11 excess sugary food intake and lower bone density in boys, and adolescents, although harder to measure, had low iron.
 

Physical and Mental Effects of Food Insecurity

Associated with food insecurity in the home are more developmental delays in children 4-36 months old. Beyond that, children of all ages have lower cognitive indicators, dysregulated behavior, and emotional distress than those in homes with secure food access. These are persisting deficits: kindergarten children with food insecurity have lower math and reading abilities over at least 4 years.

Mental health is also affected by food insecurity. Reviews of multiple studies of children from preschool through adolescence show more child hyperactivity, emotional dysregulation, anxiety, depression, and stress beyond those attributable to their mother’s depression and anxiety. Food insecurity in the early years is associated with mental health issues even into adolescence. School aged children and youth are well aware of the family’s struggle with food access, even when their parents do not realize this. In addition to the anxiety and depression, they may feel shame or be socially ostracized. They may eat less, or choose low-quality foods to cope. Adolescents experiencing food insecurity report greater dysthymia and suicidal ideation. It is unknown whether these mental health difficulties are due to the stress, shame, or decreased intake of macronutrients important to emotional regulation or all of these. One implication is that pediatric providers should also screen for food insecurity as well as other social drivers of health (SDOH) when addressing developmental, behavioral, or mental health issues, not just at well visits.

While we worry about effects for the child, impact of food insecurity on caregivers is significant for parenting as well as adult well-being beginning prenatally. First trimester food insecurity is associated with increased maternal stress at 2 months postpartum and lower bonding scores at 6 months, although this is moderated by social support. The stress of food insecurity and other SDoH present are associated with parental depression, anxiety, and toxic stress, making optimal parenting difficult. Caregivers experiencing insecure food access worry most about their children and may reduce their own eating and food quality to spare the child. More than 30% of families indicated that they had to choose between paying for food and paying for medicine or medical care, jeopardizing their health, making this an important point of discussion for us as well.
 

Quality Versus Quantity

The total amount of food is not the only factor in adequate child nutrition. Healthy foods usually cost more and also may not be conveniently available. There are so called “food deserts,” areas with few/no full-service grocery stores, and also “food swamps” where unhealthy foods (eg fast food) are more available than healthy options. Life stress, higher in low-income populations, increases the impulse to consume sweet or high-fat “comfort foods” (we all know this!) due to the rush of calories and quick satiety. Children may be influenced in their food choices by media messages about non-nutritious foods. All of these may explain the association of food insecurity with obesity in both children and adults. It also sets them up for lifetime health problems of diabetes, hyperlipidemia, and cardiovascular conditions, especially in racial and ethnic minority groups and the poor.

The Larger Picture

Obvious to us all, low income is the main reason for inadequate access to enough or good quality food. Over 60% of families with food insecurity had incomes below the poverty threshold in 2013. Households without children are half as likely to be food insecure. But as 30% of food-insecure households have incomes above the eligibility cut offs for food programs — typically 130% of poverty for Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) or 185% for Supplemental Nutrition Assistance Program (SNAP) — it is clear the problem is not related solely to poverty. Even small changes in income or expenses, such as a car breaking down, or heating or medical bills, can quickly result in inability to afford food, especially in areas of high food costs. This is particularly true for immigrant, large, and single-parent families and those with less education. Federal food programs do not cover all food needs for every family.

But we can’t tell if a child lives in a family with food insecurity by whether the child is thin, dropping growth percentiles, or receiving Medicaid insurance. Parents, and even youth, may be reluctant to tell us that they do not have enough to eat out of pride, fear, of prejudice, being reported to a contentious ex, being detected as an illegal immigrant, or even reported for neglect and having their child removed. Because of the suffering and impacts of food insecurity on child well-being, the American Academy of Pediatrics (AAP) published a Policy Statement in 2015, reaffirmed in 2021, recommending screening for food insecurity at all well visits and a toolkit to help. The USDA 18-item Household Food Security Scale (HFSS) has been the gold-standard screen, but affirmative answers to either of the 2-item Hunger Vital Sign (HVS) questionnaire identifies food insecurity with a sensitivity of 97% and a specificity of 83% compared with the HFSS. The questions ask how often the following were true in the past year: 1) “We worried whether our food would run out before we got money to buy more” and 2) “The food we bought just didn’t last and we didn’t have money to buy more.” This brief screen is now recommended and practical.
 

Screening for Food Insecurity

All set to manage food insecurity in your practice, then? Not exactly. Screening is only useful if it results in access to food. A study in a majority low-income clinic found that parents reported food insecurity 7% of the time when the clinician asked the HVS questions versus 45% when they self-reported on paper. Parent focus groups revealed reasons for the discrepant underreporting to the clinician: shame, concerns about stigma, and fear of the child being taken away. They felt more comfortable reporting about their child than about their own family situation. When asked what the clinician did that helped them disclose food insecurity, the caregivers cited strong interpersonal skills, open body language, and empathy. They also requested being given resources for other social issues, not just food insecurity. Clinic staff found paper screening inconvenient and recommended using tablet devices (such as with CHADIS that also scores and provides interviewing help, education, and local resource listings). Clinicians found the need for a follow-up conversation time consuming. Clinic staff thought screening could be facilitated by clinician’s initiating conversations, taking care about children present, and normalizing the screen as applying to all. Caregivers wanted know the use and privacy of the information. This same clinic referred the caregivers to a Benefits Data Trust with a goal of enrolling them in food programs. Of the food insecure, 55% were referred but only one third could be reached by phone with three attempts by the benefits group. Subsequent enrollment of those reached had barriers of verification requirements, wait times, and perceived mistreatment. The program concluded that this difficult two-step process of screening and referral would be improved by an integrated system of screening and enrollment in public benefits. Provision of information about free local food resources is also important, as 84% of those already receiving SNAP benefits remained food insecure.

Offering Assistance

To assist families where food insecurity is found, we need to understand the options of services both for referrals and advocacy. The AAP toolkit is designed to help. For pregnant and postpartum women and children 0-5 years in families with income less than 130% of the poverty level, the WIC program provides electronic cards to purchase approved categories of healthy food from participating vendors. For families with incomes less than 185% of the poverty level, the SNAP program, formerly called food stamps, provides benefits. There are other programs including free and reduced cost National School Breakfast and/or Lunch programs (best when open to all), Child and Adult Care Food Program for institutions (which may include medical offices), and Summer Food Service Programs providing lunch at community sites. Since not all food-insecure families are eligible for the above services, it is important that we are ready to provide information about local food banks, pantries, and low- or no-cost produce programs (see Healthy Food Bank Hub, Feeding America, 2-1-1, or FindHelp.org).

As pediatric providers we have a special opportunity and responsibility to expand our capabilities for sensitively addressing and advocating for help for food insecurity to improve the outlook for the families under our care.

Dr. Howard is assistant professor of pediatrics at The Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS. She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. E-mail her at [email protected].

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ORLANDO, FLORIDA — As increasing data show benefit for continuous glucose monitoring (CGM) devices beyond just insulin-treated diabetes, efforts are being made to optimize the use of CGM in primary care settings.

Currently, Medicare and most private insurers cover CGM for people with diabetes who use insulin, regardless of the type of diabetes or the type of insulin, and for those with a history of severe hypoglycemia. Data are increasingly showing benefit for people who don’t use insulin. As of now, with the exception of some state Medicaid beneficiaries, the majority must pay out of pocket.

Such use is expected to grow with the upcoming availability of two new over-the-counter CGMs, Dexcom’s Stelo and Abbott’s Libre Rio, both made for people with diabetes who don’t use insulin. (Abbott will also launch the Lingo, a wellness CGM for people without diabetes.)

This means that CGM will become increasingly prevalent in primary care, where there is currently a great deal of variability in the capacity to manage and use the data generated by the devices to improve diabetes management, experts said during an oral abstract session at the recent American Diabetes Association (ADA) 84th Scientific Sessions and in interviews with this news organization.

“It’s picking up steam, and there’s a lot more visibility of CGM in primary care and a lot more people prescribing it,” Thomas W. Martens, MD, medical director of the International Diabetes Center at HealthPartners Institute, Minneapolis, told this news organization. He noted that the recent switch in many cases of CGM from billing as durable medical equipment to pharmacy has made prescribing easier, while television advertising has increased demand.

But still unclear, he noted, is how the CGM data are being used. “The question is, are prescriptions just being sent out and people using it like a finger-stick blood glucose monitor, or is primary care really using the data to move diabetes forward? I think that’s where a lot of the work on dissemination and implementation is going. How do we really make this a useful tool for optimizing diabetes care?”
 

Informing Food Choice, Treatment Intensification

At the ADA meeting, Dr. Martens presented topline data from a randomized multicenter controlled trial funded by Abbott, examining the effect of CGM use on guiding food choices and other behaviors in 72 adults with type 2 diabetes who were not using insulin but who were using other glucose-lowering medications.

At 3 months, with no medication changes, there was a significant overall 26% reduction in time spent above 180 mg/dL (P < .0001), which didn›t differ significantly between those randomized to CGM alone or in conjunction with a food logging app. Both groups also experienced a significant 1.1% reduction in A1c (P < .0001) and about a 4-lb weight loss (P = .014 for CGM alone, P = .0032 for CGM + app).

“The win for people not on insulin is you can see the impact of food choices really quickly with a CGM ... and then perhaps modify that to improve postprandial hyperglycemia,” Dr. Martens said.

And for the clinician, “not everybody with type 2 diabetes not on insulin can get where they need to be just by changing their diets. The CGM is a pretty good tool for knowing when you need to advance therapy.”
 

Diabetes Care and Education Specialists (DCESs) Assist CGM Use

Another speaker at the ADA meeting, Sean M. Oser, MD, director of the Practice Innovation Program and associated director of the Primary Care Diabetes Lab at the University of Colorado Anschutz Medical Campus, Aurora, Colorado, noted that 90% of adults with type 2 diabetes and 50% with type 1 diabetes receive their diabetes care in primary care settings.

“CGM is increasingly becoming standard of care in diabetes ... But [primary care providers] remain relatively untrained about CGM ... What I’m concerned about is the disparity disparities in who has access and who does not. We really need to bring our primary care colleagues along,” he said.

Dr. Oser described tools he and his wife, Tamara K. Oser, MD, professor in the Department of Family Medicine at the same institution, developed in conjunction with the American Academy of Family Physicians (AAFP), including the Transformation in Practice series (TIPS).

The PREPARE 4 CGM study examined the use of three different strategies for incorporating CGM into primary care settings: Either use of AAFP TIPS alone, TIPS plus practice facilitation services by coaches who assist the practice in implementing new workflows, or referral to a virtual CGM initiation service (virCIS) with a virtual CGM workshop that Dr. Oser and Dr. Oser also developed.

Of the 76 Colorado primary care practices participating (out of 60 planned), the 46 who chose AAFP TIPS were randomized to either the AAFP TIPS alone or to TIPS + practice facilitation. The other 30 chose virCIS with the onetime CGM basics webinar. The fact that more practices than anticipated were recruited for the study suggests that “primary care interest in CGM is very high. They want to learn,” Dr. Oser noted.

Of the 51 practice characteristics investigated, only one, the presence of a DCES, in the practice, was significantly associated with the choice of CGM implementation strategy. Of the 16 practices with access to a DCES, all of them chose self-initiation with CGM using TIPS. But of the 60 practices without a DCES, half chose the virCIS.

“We know that 36% of primary care practices have access to a DCES within the clinic, part-time or full-time, and that’s not enough, I would argue,” Dr. Oser said.

Indeed, Dr. Martens told this news organization that those professionals, formerly called “diabetes educators,” often aren’t available in primary care settings, especially in rural areas. “Unfortunately, they are not well reimbursed. A lot of care systems don’t employ as many as they ideally should because it tends not to be a moneymaker ... Something’s got to change with reimbursement for the cognitive aspects of diabetes management.”

Dr. Oser said his team’s next steps include completion of the virCIS operations, analysis of the effectiveness of the three implantation strategies in practice- and patient-level outcomes, a cost analysis of the three strategies, and further development of toolkits to assist in these efforts.

“One of our goals is to keep people at their primary care home, where they want to be ... Diabetes knows no borders. People should have access wherever they are,” Dr. Oser concluded in his ADA talk.
 

What Predicts Primary Care CGM Prescribing?

Further clues about effective strategies to improve CGM prescribing in primary care were provided in a study presented by Jovan Milosavljevic, MD, a second-year endocrinology fellow at the Fleischer Institute for Diabetes and Metabolism, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York.

He began by noting that there are currently 61.5 million diabetes visits annually in primary care compared with 32.0 million in specialty care and that there is a shortage of endocrinologists in the face of the rising number of people diagnosed with diabetes. “Primary care will continue to be the only point of care for most people with diabetes. So, standard-of-care treatment such as CGM must enter routine primary care practice to impact population-level health outcomes.”

Electronic health record data were examined for 39,710 patients with type 2 diabetes seen at 13 primary care sites affiliated with Montefiore Medical Center, a large safety net hospital in New York, where CGM is widely covered by public insurance. Between July 31, 2020, and July 31, 2023, a total of 3503, or just 8.8%, were prescribed CGM by a primary care provider.

Those with CGM prescribed were younger than those without (59.7 vs 62.7 years), about 40% of both groups were Hispanic or Black, and a majority were English-speaking: 84.5% of those prescribed CGM spoke English, while only 13.1% spoke Spanish. Over half (59.1%) of those prescribed CGM had commercial insurance, while only 11.2% had Medicaid and 29.7% had Medicare.

More patients with CGM prescribed had providers with more than 10 years in practice: 72.5% vs 64.5% with no CGM.

Not surprisingly, those with CGM prescribed were more likely on insulin — 21% using just basal and 35% on multiple daily injections. Those prescribed CGM had higher A1c levels before CGM prescription: 9.2% vs 7.2% for those not prescribed CGM.

No racial or ethnic bias was found in the relationships between CGM use and insulin use, provider experience, engagement with care, and A1c. However, there were differences by age, sex, and spoken language.

For example, the Hispanic group aged 65 years and older was less likely than those younger to be prescribed CGM, but this wasn’t seen in other ethnic groups. In fact, older White people were slightly more likely to have CGM prescribed. Spanish-speaking patients were about 43% less likely to have CGM prescribed than were English-speaking patients.

These findings suggest a dual approach might work best for improving CGM prescribing in primary care. “We can leverage the knowledge that some of these factors are independent of bias and promote clinical and evidence-based guidelines for CGM. Additionally, we should focus on physicians in training,” Dr. Milosavljevic said.

At the same time, “we need to tackle systemic inequity in prescription processes,” with measures such as improving prescription workflows, supporting prior authorization, and using patient hands-on support for older adults and Spanish-speaking individuals, he said.

In a message to this news organization, Tamara K. Oser, MD, wrote, “Disparities in CGM and other diabetes technology are prevalent and multifactorial. In addition to insurance barriers, implicit bias also plays a large role. Shared decision-making should always be used when deciding to prescribe diabetes technologies.”

The PREPARE 4 CGM study is evaluating willingness to pay for CGM, she noted.

“Even patients without insurance might want to purchase one sensor every few months to empower them to learn more about how food and exercise affect their glucose or to help assess the need for [adjusting] diabetes medications. It is an exciting time for people living with diabetes. Primary care, endocrinology, device manufacturers, and insurers should all do their part to assure increased access to these evidence-based technologies.”

Dr. Martens’ employer has received funds on his behalf for research and speaking support from Dexcom, Abbott Diabetes Care, Medtronic, Insulet, Tandem, Sanofi, Eli Lilly and Company, and Novo Nordisk, and for consulting from Sanofi and Eli Lilly and Company. He is employed by the nonprofit HealthPartners Institute dba International Diabetes Center and received no personal income from these activities.

The Osers have received advisory board consulting fees (through the University of Colorado) from Dexcom, Medscape Medical News, Ascensia, and Blue Circle Health and research grants (through the University of Colorado) from National Institute of Nursing Research, National Institute of Diabetes and Digestive and Kidney Diseases, the Helmsley Charitable Trust, Abbott Diabetes, Dexcom, and Insulet. They do not own stocks in any device or pharmaceutical company.

Dr. Milosavljevic’s work was supported by the National Institutes of Health/National Center for Advancing Translational Science and Einstein-Montefiore Clinical and Translational Science Awards. He had no further disclosures.
 

A version of this article first appeared on Medscape.com.

ORLANDO, FLORIDA — As increasing data show benefit for continuous glucose monitoring (CGM) devices beyond just insulin-treated diabetes, efforts are being made to optimize the use of CGM in primary care settings.

Currently, Medicare and most private insurers cover CGM for people with diabetes who use insulin, regardless of the type of diabetes or the type of insulin, and for those with a history of severe hypoglycemia. Data are increasingly showing benefit for people who don’t use insulin. As of now, with the exception of some state Medicaid beneficiaries, the majority must pay out of pocket.

Such use is expected to grow with the upcoming availability of two new over-the-counter CGMs, Dexcom’s Stelo and Abbott’s Libre Rio, both made for people with diabetes who don’t use insulin. (Abbott will also launch the Lingo, a wellness CGM for people without diabetes.)

This means that CGM will become increasingly prevalent in primary care, where there is currently a great deal of variability in the capacity to manage and use the data generated by the devices to improve diabetes management, experts said during an oral abstract session at the recent American Diabetes Association (ADA) 84th Scientific Sessions and in interviews with this news organization.

“It’s picking up steam, and there’s a lot more visibility of CGM in primary care and a lot more people prescribing it,” Thomas W. Martens, MD, medical director of the International Diabetes Center at HealthPartners Institute, Minneapolis, told this news organization. He noted that the recent switch in many cases of CGM from billing as durable medical equipment to pharmacy has made prescribing easier, while television advertising has increased demand.

But still unclear, he noted, is how the CGM data are being used. “The question is, are prescriptions just being sent out and people using it like a finger-stick blood glucose monitor, or is primary care really using the data to move diabetes forward? I think that’s where a lot of the work on dissemination and implementation is going. How do we really make this a useful tool for optimizing diabetes care?”
 

Informing Food Choice, Treatment Intensification

At the ADA meeting, Dr. Martens presented topline data from a randomized multicenter controlled trial funded by Abbott, examining the effect of CGM use on guiding food choices and other behaviors in 72 adults with type 2 diabetes who were not using insulin but who were using other glucose-lowering medications.

At 3 months, with no medication changes, there was a significant overall 26% reduction in time spent above 180 mg/dL (P < .0001), which didn›t differ significantly between those randomized to CGM alone or in conjunction with a food logging app. Both groups also experienced a significant 1.1% reduction in A1c (P < .0001) and about a 4-lb weight loss (P = .014 for CGM alone, P = .0032 for CGM + app).

“The win for people not on insulin is you can see the impact of food choices really quickly with a CGM ... and then perhaps modify that to improve postprandial hyperglycemia,” Dr. Martens said.

And for the clinician, “not everybody with type 2 diabetes not on insulin can get where they need to be just by changing their diets. The CGM is a pretty good tool for knowing when you need to advance therapy.”
 

Diabetes Care and Education Specialists (DCESs) Assist CGM Use

Another speaker at the ADA meeting, Sean M. Oser, MD, director of the Practice Innovation Program and associated director of the Primary Care Diabetes Lab at the University of Colorado Anschutz Medical Campus, Aurora, Colorado, noted that 90% of adults with type 2 diabetes and 50% with type 1 diabetes receive their diabetes care in primary care settings.

“CGM is increasingly becoming standard of care in diabetes ... But [primary care providers] remain relatively untrained about CGM ... What I’m concerned about is the disparity disparities in who has access and who does not. We really need to bring our primary care colleagues along,” he said.

Dr. Oser described tools he and his wife, Tamara K. Oser, MD, professor in the Department of Family Medicine at the same institution, developed in conjunction with the American Academy of Family Physicians (AAFP), including the Transformation in Practice series (TIPS).

The PREPARE 4 CGM study examined the use of three different strategies for incorporating CGM into primary care settings: Either use of AAFP TIPS alone, TIPS plus practice facilitation services by coaches who assist the practice in implementing new workflows, or referral to a virtual CGM initiation service (virCIS) with a virtual CGM workshop that Dr. Oser and Dr. Oser also developed.

Of the 76 Colorado primary care practices participating (out of 60 planned), the 46 who chose AAFP TIPS were randomized to either the AAFP TIPS alone or to TIPS + practice facilitation. The other 30 chose virCIS with the onetime CGM basics webinar. The fact that more practices than anticipated were recruited for the study suggests that “primary care interest in CGM is very high. They want to learn,” Dr. Oser noted.

Of the 51 practice characteristics investigated, only one, the presence of a DCES, in the practice, was significantly associated with the choice of CGM implementation strategy. Of the 16 practices with access to a DCES, all of them chose self-initiation with CGM using TIPS. But of the 60 practices without a DCES, half chose the virCIS.

“We know that 36% of primary care practices have access to a DCES within the clinic, part-time or full-time, and that’s not enough, I would argue,” Dr. Oser said.

Indeed, Dr. Martens told this news organization that those professionals, formerly called “diabetes educators,” often aren’t available in primary care settings, especially in rural areas. “Unfortunately, they are not well reimbursed. A lot of care systems don’t employ as many as they ideally should because it tends not to be a moneymaker ... Something’s got to change with reimbursement for the cognitive aspects of diabetes management.”

Dr. Oser said his team’s next steps include completion of the virCIS operations, analysis of the effectiveness of the three implantation strategies in practice- and patient-level outcomes, a cost analysis of the three strategies, and further development of toolkits to assist in these efforts.

“One of our goals is to keep people at their primary care home, where they want to be ... Diabetes knows no borders. People should have access wherever they are,” Dr. Oser concluded in his ADA talk.
 

What Predicts Primary Care CGM Prescribing?

Further clues about effective strategies to improve CGM prescribing in primary care were provided in a study presented by Jovan Milosavljevic, MD, a second-year endocrinology fellow at the Fleischer Institute for Diabetes and Metabolism, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York.

He began by noting that there are currently 61.5 million diabetes visits annually in primary care compared with 32.0 million in specialty care and that there is a shortage of endocrinologists in the face of the rising number of people diagnosed with diabetes. “Primary care will continue to be the only point of care for most people with diabetes. So, standard-of-care treatment such as CGM must enter routine primary care practice to impact population-level health outcomes.”

Electronic health record data were examined for 39,710 patients with type 2 diabetes seen at 13 primary care sites affiliated with Montefiore Medical Center, a large safety net hospital in New York, where CGM is widely covered by public insurance. Between July 31, 2020, and July 31, 2023, a total of 3503, or just 8.8%, were prescribed CGM by a primary care provider.

Those with CGM prescribed were younger than those without (59.7 vs 62.7 years), about 40% of both groups were Hispanic or Black, and a majority were English-speaking: 84.5% of those prescribed CGM spoke English, while only 13.1% spoke Spanish. Over half (59.1%) of those prescribed CGM had commercial insurance, while only 11.2% had Medicaid and 29.7% had Medicare.

More patients with CGM prescribed had providers with more than 10 years in practice: 72.5% vs 64.5% with no CGM.

Not surprisingly, those with CGM prescribed were more likely on insulin — 21% using just basal and 35% on multiple daily injections. Those prescribed CGM had higher A1c levels before CGM prescription: 9.2% vs 7.2% for those not prescribed CGM.

No racial or ethnic bias was found in the relationships between CGM use and insulin use, provider experience, engagement with care, and A1c. However, there were differences by age, sex, and spoken language.

For example, the Hispanic group aged 65 years and older was less likely than those younger to be prescribed CGM, but this wasn’t seen in other ethnic groups. In fact, older White people were slightly more likely to have CGM prescribed. Spanish-speaking patients were about 43% less likely to have CGM prescribed than were English-speaking patients.

These findings suggest a dual approach might work best for improving CGM prescribing in primary care. “We can leverage the knowledge that some of these factors are independent of bias and promote clinical and evidence-based guidelines for CGM. Additionally, we should focus on physicians in training,” Dr. Milosavljevic said.

At the same time, “we need to tackle systemic inequity in prescription processes,” with measures such as improving prescription workflows, supporting prior authorization, and using patient hands-on support for older adults and Spanish-speaking individuals, he said.

In a message to this news organization, Tamara K. Oser, MD, wrote, “Disparities in CGM and other diabetes technology are prevalent and multifactorial. In addition to insurance barriers, implicit bias also plays a large role. Shared decision-making should always be used when deciding to prescribe diabetes technologies.”

The PREPARE 4 CGM study is evaluating willingness to pay for CGM, she noted.

“Even patients without insurance might want to purchase one sensor every few months to empower them to learn more about how food and exercise affect their glucose or to help assess the need for [adjusting] diabetes medications. It is an exciting time for people living with diabetes. Primary care, endocrinology, device manufacturers, and insurers should all do their part to assure increased access to these evidence-based technologies.”

Dr. Martens’ employer has received funds on his behalf for research and speaking support from Dexcom, Abbott Diabetes Care, Medtronic, Insulet, Tandem, Sanofi, Eli Lilly and Company, and Novo Nordisk, and for consulting from Sanofi and Eli Lilly and Company. He is employed by the nonprofit HealthPartners Institute dba International Diabetes Center and received no personal income from these activities.

The Osers have received advisory board consulting fees (through the University of Colorado) from Dexcom, Medscape Medical News, Ascensia, and Blue Circle Health and research grants (through the University of Colorado) from National Institute of Nursing Research, National Institute of Diabetes and Digestive and Kidney Diseases, the Helmsley Charitable Trust, Abbott Diabetes, Dexcom, and Insulet. They do not own stocks in any device or pharmaceutical company.

Dr. Milosavljevic’s work was supported by the National Institutes of Health/National Center for Advancing Translational Science and Einstein-Montefiore Clinical and Translational Science Awards. He had no further disclosures.
 

A version of this article first appeared on Medscape.com.

ORLANDO, FLORIDA — As increasing data show benefit for continuous glucose monitoring (CGM) devices beyond just insulin-treated diabetes, efforts are being made to optimize the use of CGM in primary care settings.

Currently, Medicare and most private insurers cover CGM for people with diabetes who use insulin, regardless of the type of diabetes or the type of insulin, and for those with a history of severe hypoglycemia. Data are increasingly showing benefit for people who don’t use insulin. As of now, with the exception of some state Medicaid beneficiaries, the majority must pay out of pocket.

Such use is expected to grow with the upcoming availability of two new over-the-counter CGMs, Dexcom’s Stelo and Abbott’s Libre Rio, both made for people with diabetes who don’t use insulin. (Abbott will also launch the Lingo, a wellness CGM for people without diabetes.)

This means that CGM will become increasingly prevalent in primary care, where there is currently a great deal of variability in the capacity to manage and use the data generated by the devices to improve diabetes management, experts said during an oral abstract session at the recent American Diabetes Association (ADA) 84th Scientific Sessions and in interviews with this news organization.

“It’s picking up steam, and there’s a lot more visibility of CGM in primary care and a lot more people prescribing it,” Thomas W. Martens, MD, medical director of the International Diabetes Center at HealthPartners Institute, Minneapolis, told this news organization. He noted that the recent switch in many cases of CGM from billing as durable medical equipment to pharmacy has made prescribing easier, while television advertising has increased demand.

But still unclear, he noted, is how the CGM data are being used. “The question is, are prescriptions just being sent out and people using it like a finger-stick blood glucose monitor, or is primary care really using the data to move diabetes forward? I think that’s where a lot of the work on dissemination and implementation is going. How do we really make this a useful tool for optimizing diabetes care?”
 

Informing Food Choice, Treatment Intensification

At the ADA meeting, Dr. Martens presented topline data from a randomized multicenter controlled trial funded by Abbott, examining the effect of CGM use on guiding food choices and other behaviors in 72 adults with type 2 diabetes who were not using insulin but who were using other glucose-lowering medications.

At 3 months, with no medication changes, there was a significant overall 26% reduction in time spent above 180 mg/dL (P < .0001), which didn›t differ significantly between those randomized to CGM alone or in conjunction with a food logging app. Both groups also experienced a significant 1.1% reduction in A1c (P < .0001) and about a 4-lb weight loss (P = .014 for CGM alone, P = .0032 for CGM + app).

“The win for people not on insulin is you can see the impact of food choices really quickly with a CGM ... and then perhaps modify that to improve postprandial hyperglycemia,” Dr. Martens said.

And for the clinician, “not everybody with type 2 diabetes not on insulin can get where they need to be just by changing their diets. The CGM is a pretty good tool for knowing when you need to advance therapy.”
 

Diabetes Care and Education Specialists (DCESs) Assist CGM Use

Another speaker at the ADA meeting, Sean M. Oser, MD, director of the Practice Innovation Program and associated director of the Primary Care Diabetes Lab at the University of Colorado Anschutz Medical Campus, Aurora, Colorado, noted that 90% of adults with type 2 diabetes and 50% with type 1 diabetes receive their diabetes care in primary care settings.

“CGM is increasingly becoming standard of care in diabetes ... But [primary care providers] remain relatively untrained about CGM ... What I’m concerned about is the disparity disparities in who has access and who does not. We really need to bring our primary care colleagues along,” he said.

Dr. Oser described tools he and his wife, Tamara K. Oser, MD, professor in the Department of Family Medicine at the same institution, developed in conjunction with the American Academy of Family Physicians (AAFP), including the Transformation in Practice series (TIPS).

The PREPARE 4 CGM study examined the use of three different strategies for incorporating CGM into primary care settings: Either use of AAFP TIPS alone, TIPS plus practice facilitation services by coaches who assist the practice in implementing new workflows, or referral to a virtual CGM initiation service (virCIS) with a virtual CGM workshop that Dr. Oser and Dr. Oser also developed.

Of the 76 Colorado primary care practices participating (out of 60 planned), the 46 who chose AAFP TIPS were randomized to either the AAFP TIPS alone or to TIPS + practice facilitation. The other 30 chose virCIS with the onetime CGM basics webinar. The fact that more practices than anticipated were recruited for the study suggests that “primary care interest in CGM is very high. They want to learn,” Dr. Oser noted.

Of the 51 practice characteristics investigated, only one, the presence of a DCES, in the practice, was significantly associated with the choice of CGM implementation strategy. Of the 16 practices with access to a DCES, all of them chose self-initiation with CGM using TIPS. But of the 60 practices without a DCES, half chose the virCIS.

“We know that 36% of primary care practices have access to a DCES within the clinic, part-time or full-time, and that’s not enough, I would argue,” Dr. Oser said.

Indeed, Dr. Martens told this news organization that those professionals, formerly called “diabetes educators,” often aren’t available in primary care settings, especially in rural areas. “Unfortunately, they are not well reimbursed. A lot of care systems don’t employ as many as they ideally should because it tends not to be a moneymaker ... Something’s got to change with reimbursement for the cognitive aspects of diabetes management.”

Dr. Oser said his team’s next steps include completion of the virCIS operations, analysis of the effectiveness of the three implantation strategies in practice- and patient-level outcomes, a cost analysis of the three strategies, and further development of toolkits to assist in these efforts.

“One of our goals is to keep people at their primary care home, where they want to be ... Diabetes knows no borders. People should have access wherever they are,” Dr. Oser concluded in his ADA talk.
 

What Predicts Primary Care CGM Prescribing?

Further clues about effective strategies to improve CGM prescribing in primary care were provided in a study presented by Jovan Milosavljevic, MD, a second-year endocrinology fellow at the Fleischer Institute for Diabetes and Metabolism, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York.

He began by noting that there are currently 61.5 million diabetes visits annually in primary care compared with 32.0 million in specialty care and that there is a shortage of endocrinologists in the face of the rising number of people diagnosed with diabetes. “Primary care will continue to be the only point of care for most people with diabetes. So, standard-of-care treatment such as CGM must enter routine primary care practice to impact population-level health outcomes.”

Electronic health record data were examined for 39,710 patients with type 2 diabetes seen at 13 primary care sites affiliated with Montefiore Medical Center, a large safety net hospital in New York, where CGM is widely covered by public insurance. Between July 31, 2020, and July 31, 2023, a total of 3503, or just 8.8%, were prescribed CGM by a primary care provider.

Those with CGM prescribed were younger than those without (59.7 vs 62.7 years), about 40% of both groups were Hispanic or Black, and a majority were English-speaking: 84.5% of those prescribed CGM spoke English, while only 13.1% spoke Spanish. Over half (59.1%) of those prescribed CGM had commercial insurance, while only 11.2% had Medicaid and 29.7% had Medicare.

More patients with CGM prescribed had providers with more than 10 years in practice: 72.5% vs 64.5% with no CGM.

Not surprisingly, those with CGM prescribed were more likely on insulin — 21% using just basal and 35% on multiple daily injections. Those prescribed CGM had higher A1c levels before CGM prescription: 9.2% vs 7.2% for those not prescribed CGM.

No racial or ethnic bias was found in the relationships between CGM use and insulin use, provider experience, engagement with care, and A1c. However, there were differences by age, sex, and spoken language.

For example, the Hispanic group aged 65 years and older was less likely than those younger to be prescribed CGM, but this wasn’t seen in other ethnic groups. In fact, older White people were slightly more likely to have CGM prescribed. Spanish-speaking patients were about 43% less likely to have CGM prescribed than were English-speaking patients.

These findings suggest a dual approach might work best for improving CGM prescribing in primary care. “We can leverage the knowledge that some of these factors are independent of bias and promote clinical and evidence-based guidelines for CGM. Additionally, we should focus on physicians in training,” Dr. Milosavljevic said.

At the same time, “we need to tackle systemic inequity in prescription processes,” with measures such as improving prescription workflows, supporting prior authorization, and using patient hands-on support for older adults and Spanish-speaking individuals, he said.

In a message to this news organization, Tamara K. Oser, MD, wrote, “Disparities in CGM and other diabetes technology are prevalent and multifactorial. In addition to insurance barriers, implicit bias also plays a large role. Shared decision-making should always be used when deciding to prescribe diabetes technologies.”

The PREPARE 4 CGM study is evaluating willingness to pay for CGM, she noted.

“Even patients without insurance might want to purchase one sensor every few months to empower them to learn more about how food and exercise affect their glucose or to help assess the need for [adjusting] diabetes medications. It is an exciting time for people living with diabetes. Primary care, endocrinology, device manufacturers, and insurers should all do their part to assure increased access to these evidence-based technologies.”

Dr. Martens’ employer has received funds on his behalf for research and speaking support from Dexcom, Abbott Diabetes Care, Medtronic, Insulet, Tandem, Sanofi, Eli Lilly and Company, and Novo Nordisk, and for consulting from Sanofi and Eli Lilly and Company. He is employed by the nonprofit HealthPartners Institute dba International Diabetes Center and received no personal income from these activities.

The Osers have received advisory board consulting fees (through the University of Colorado) from Dexcom, Medscape Medical News, Ascensia, and Blue Circle Health and research grants (through the University of Colorado) from National Institute of Nursing Research, National Institute of Diabetes and Digestive and Kidney Diseases, the Helmsley Charitable Trust, Abbott Diabetes, Dexcom, and Insulet. They do not own stocks in any device or pharmaceutical company.

Dr. Milosavljevic’s work was supported by the National Institutes of Health/National Center for Advancing Translational Science and Einstein-Montefiore Clinical and Translational Science Awards. He had no further disclosures.
 

A version of this article first appeared on Medscape.com.

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