Welcome to the ATTD 2024 Interactive Program

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Despite major improvements over the last decade, significant disparities in healthcare access and clinical outcomes exist in individuals with T1D in low compared to high income countries. Using the blinded FreeStyle Libre Pro system, we performed a pilot study to obtain baseline data in 68 Ugandan and Kenyan youth age 4-26 with T1D who were treated and educated by trained pediatric endocrinologists, performed self-monitoring of blood glucose (SMBG) an average of 2.1 times per day, and had access to sufficient quantities of insulin. With this degree of care, the average HbA1c level was 11%. Glucose percent time-in-range (TIR, 3.9-10 mmol/L) was only 30% by blinded CGM. Patients demonstrated extremes of both hyper- and hypoglycemia: more than 40% of the time glucose levels were >13.9 mmol/L, and levels were <3.1 mmol/L 7%, of the time. More than 80% of subjects spent an average of 2 hours a day with blood glucose levels <3.1 mmol/L. The pilot study also demonstrated poor correlation between HbA1c levels and average glucose levels obtained by CGM. Acknowledging that current practices are failing these children, we launched two studies in August 2023, using the pilot data for power analysis and to help inform study design.

Abbott Diabetes funded a project to further explore the relation between HbA1c and average glucose in Ugandan youth. Sixty-four people with T1D age 4-26 years were studied for three consecutive sensor wears with HbA1c measurement before and after each. Comparisons were made between the Glucose Management Indicator (GMI), the Hemoglobin Glycation Index (HGI) and the Personal Glycation Ratio (PGR). Clinical conditions that might impact HbA1c levels were also assessed (e.g. iron deficiency, sickle cell trait, G6PD deficiency, malaria). These data will be presented for the first time at this meeting.

The primary objective of the second study, a five year randomized clinical trial funded by an NIH R01 grant (PI Moran), is to determine if patient ability to continuously observe plasma glucose levels for 6 months using an intermittently scanned CGM improves glucose TIR compared to baseline. Half of patients (n=90) will be given an unblinded FreeStyle Libre 2 CGM for the entire 12 months. They and their providers will be able to see their glucose levels in real time. Half (n=90) will be given sufficient test strips for 3x daily SMBG while wearing blinded CGM for 6 months (control group). They will switch to unblinded CGM months 6-12. All subjects will receive monthly diabetes self-management education. The first cohort of ~50 individuals has completed the study and a second cohort has begun.

This project also has education objectives. It provides an opportunity for the experienced University of Minnesota diabetes research team to mentor the Ugandan pediatric diabetes research team, thus increasing local research capacity. Workshops are also planned for local physicians not involved in the study, trainees, families of children with diabetes, and school personnel.

Modern diabetes care is expensive. Organizations supporting individuals with T1D in low resource nations have argued for a “minimum acceptable level of care”, including sufficient quantities of insulin, ≥2x/d SMBG, and diabetes education for patients and health care workers. Now that this standard has largely been reached in many settings, the adequacy of this approach requires reassessment since HbA1c levels are still distressingly high and hypoglycemia is common. Newer diabetes therapies are expensive in the short term, but if they significantly improve diabetes control in patients from low income regions, it could be argued that 1) long term personal and societal costs will be less, and 2) as with HIV/AIDS drugs, a way will have to be found to make effective therapies affordable in low income settings. Data from well-designed randomized clinical trials are necessary to make these decisions.

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THE TECHNOLOGY PERSPECTIVE IN LOW INCOME COUNTRIES

UGANDA’S REALITIES
In Uganda, children with T1D are at high risk suboptimal health outcomes due to a variety of reasons including low T1D capacity, prohibitive costs of essential medicines and the failure to address the Social Determinants of Health (SDoH) such as:

- Poverty
- Psychosocial barriers
- Food insecurity
- Literacy ad Education

ADVOCATES REALITIES
- Type one diabetes is not a commonly well understood condition from societies
- Having two meals a day is not a guarantee!
- Our food requires a different approach to carb counting in order to achieve good sugar levels

BARRIERS TO TECHNOLOGY
- Abject poverty
- Illiteracy
- Access to electricity
- Access to the internet
- Access to Healthcare facilities

FACES OF T1D AFRICA
Warrior X

Amolatar, Uganda
- 14 years old, diagnosed December 2017
- Born to single mother that earns up to 5,000 UGX (1.5 USD)/day selling tomatoes
- Father is deceased
- 6 children in the family, all under the age of 15
- 2 nights/week are meal-less
- Anxious about resentment from siblings as mother prioritizes his food needs
- Fear of sleeping and dying of hypoglycemia
- A1c: 12.3%

Warrior Y

Andankwame, Kumasi, Ghana
- Diagnosed December, 2017
- Born to a polio-afflicted cobbler and a petty trader earning a combined income of approximately US$2.75/day
- Frequent hospitalization & prohibitive T1D costs forced the family of 5 into bankruptcy and homelessness.
- In June 2019, Warrior Z enlisted at an Orphanage
- Ousted from school due to T1D. Currently not in school

MY LIVED EXPERIENCE
- Misdiagnosed in 2005 with Malaria and Sickle Cell Anemia and went into DKA coma
- Subjected to herbal remedies in search for a cure, however well intentioned
- Struggled with loneliness and depression
- By the age of 17yrs, I was out of school as my family had exhausted their financial resources

I was fortunate enough to be part of a CGM study in Uganda in 2022 which greatly improved my glycemic control however:
- I needed to go to the clinic in order to access the data
- I had to hide it for fear of it getting stolen
- Once my participation in the study was over I could not afford to continue with it

THE FUTURE
- Improvements in Infrastructure for example, electricity and internet access
- Low cost technology for example, technology that is compatible with basic feature phones
- Enabling government regulatory environments
- Subsidization of costs of medical technology
- An empowered T1D community

TOGETHER WE CAN