Connor Leadley1
Ananta Addala2,3Juliet Berkeley4
Hamish Crocket5
Elizabeth A. Davis6,7,8Niranjala Hewapathirana4,9
Sufyan Hussain10,11,12Rayhan Lal2,3,13
Kate Lomax6,7
Thomas Wilkinson1
Martin de Bock1
Marie-Anne Burckhardt14,15*- 1Department of Pediatrics, University of Otago, Christchurch, New Zealand
- 2Division of Endocrinology, Department of Pediatrics, Stanford University, Stanford, United States
- 3Stanford Diabetes Research Center, Stanford University, Stanford, United States
- 4Department of Diabetes and Endocrinology, Te Whatu Ora Waitaha, Christchurch, New Zealand
- 5Te Huataki Waiora School of Health, University of Waikato, Hamilton, New Zealand
- 6Department of Endocrinology and Diabetes, Perth Children’s Hospital, Perth, WA, Australia
- 7Children’s Diabetes Centre, Telethon Kids Institute, The University of Western Australia, Perth, WA, Australia
- 8Division of Pediatrics within the Medical School, The University of Western Australia, Perth, WA, Australia
- 9Department of Medicine, University of Otago, Christchurch, New Zealand
- 10Department of Diabetes and Endocrinology, Guy’s & St Thomas’ National Health Service (NHS) Foundation Trust, London, United Kingdom
- 11Department of Diabetes, School of Cardiovascular, Metabolic Medicine and Sciences, King's College London, London, United Kingdom
- 12Institute of Diabetes, Endocrinology and Obesity, King’s Health Partners, London, United Kingdom
- 13Division of Endocrinology, Department of Medicine, Stanford University, Stanford, United States
- 14Pediatric Endocrinology and Diabetology, University Children’s Hospital, Basel, Switzerland
- 15Department of Clinical Research, University of Basel, Basel, Switzerland
While advancements in the treatment of diabetes continue to rapidly evolve, many of the newer technologies have financial barriers to care, opposing the egalitarian ethos of Banting who sold his patent on insulin for a nominal cost to allow it to be made widely available. Inequity in access to new therapies drives disparity in diabetes burden with potential for these gaps to widen in the future. The 2023 International Conference on Advanced Technologies and Treatments of Diabetes (ATTD) presented ground-breaking and current research in diabetes technology. Oral presentations of the ATTD conference 2023 were analyzed to describe what percentage of speakers discussed equity in their talks. Overall, less than a quarter of presenters discussed equity, though there was regional variation. To ensure that diabetes technologies reduce disparity and improve outcomes, we encourage future speakers at diabetes (technology) conferences to consider equity of diabetes care and incorporate this into their presentations.
1 Introduction
The 100-year anniversary of the discovery of insulin is a timely reminder that altruism is central to the ethos of diabetes management. Indeed, Banting felt it was unethical for a doctor to profit from a discovery that would save lives, leading to the insulin patent being sold to the University of Toronto for a mere $1 (1). However, in recent times, with lifesaving and burden reducing technological innovations for the management of diabetes, it is a sad indictment that profiteering from health has ensued, with a resultant health equity gap that is both intra and inter geographical (2–5).
Diabetes conferences where expert clinicians, scientists, and industry come together are a great opportunity to highlight equity, or lack of, for people living with diabetes and encourage robust discussion on how this can be addressed. Access to new diabetes technologies has been shown to improve outcomes and yet enormous disparity exists within many countries and between countries (3, 4). The International Conference on Advanced Technologies and Treatments of Diabetes (ATTD) is an annual conference where ground-breaking research in diabetes technology is shared and discussed. As one of the premier technology advancing conferences, ATTD is an excellent setting to assess how consistently equity is discussed. Hence, the aim of this study was to assess how many presentations discuss equity in diabetes technology and therapeutics.
2 Methods
All presentations (plenaries, parallel sessions, oral presentations, industry symposia presentations) at ATTD 2023 were assessed, either on the virtual platform, or in person by the reviewers. E-Posters were excluded.
The group of reviewers comprised nine people, five females and four males. Country of residence of most of the reviewers was in Oceania (n=8). All reviewers were given a link to a shared document containing the sessions, presentation and speaker names and country of origin of the speakers. They were asked to confirm the country of origin of the speaker, to note gender and whether the talk discussed equity or not (yes/no). They were asked to record in real-time while listening to the presentations. Equity was defined as mentioning themes around socioeconomic, access, gender and health system disparities in diabetes technology.
While it was not possible to check ethnicity of presenters, their countries as recorded from their affiliations were grouped into the following regions: North America, Western Europe, Eastern Europe, Asia, Africa, Middle East and Oceania. Session introductions by moderators were excluded from the analysis. If a single presenter gave multiple different talks, each talk was individually included in analysis. Simple descriptive statistics such as frequency and percentages were used to present data.
3 Results
A total of 229 speakers were included in this analysis, who contributed to a total of 266 presentations: 23 plenary presentations, 109 parallel session presentations, 103 oral presentations and 31 industry symposia presentations. For each presentation, the demographics of the speaker are presented in Table 1. Almost two thirds (64%) of the presentations had a male presenter, and the vast majority of speakers (86.8%) were from institutions in North America (40.6%), and Europe (46.2%).
Table 1 Demographics of speakers for each presentation and whether they discussed equity in their talks at the 2023 International Conference on Advanced Technologies and Treatments of Diabetes (ATTD).
Table 1 also shows the percentage of presenters that discussed equity. Overall, just under a quarter (23.7%) of presentations discussed equity in some form throughout their talk. Equity was considered by a greater percentage of presenters from institutions in Asia (63.6%), Oceania (75%) and Africa (100%), however individuals from these areas only made up 6% of presenters at ATTD 2023.
Split by presentation type, 43.5% (10/23) speakers of plenary session presentations and 33% (36/109) speakers of parallel session presentations discussed equity in their talks. In contrast only 12.6% (13/103) of the speakers of oral presentations and 12.9% (4/31) of the speakers of industry session presentations spoke of equity in their presentation.
4 Discussion
Fewer than a quarter of all presentations at ATTD 2023 discussed equity. Of note, presenters from institutions outside of Western Europe and North America seemed more likely to mention equity. Furthermore, speakers of plenary and parallel sessions were more likely to mention equity in their talks. However formal statistical comparisons were not performed. One has to acknowledge that presenters of short oral presentations - in contrast to presenters in industry sessions - have limited time to present their data and often need to focus of a few aspects of their research.
A further limitation of the data presented in this perspective may be that what is presented reflects primarily what the conference planning committee accepted for presentation and is not a comprehensive representation of the work being done around diabetes technology and health equity. However, new technologies have shown the greatest benefit in those from the lowest socio-economic backgrounds, and therefore have the potential to reduce disparities if equitable access is promoted (4, 6, 7). It is therefore important that all new frontiers with respect to managing diabetes strongly consider equity in their mandates. In addition, it is important to promote equitable access to diabetes therapeutics and technology by funding research through public as well as industry sectors, given that technology and insulin manufacturing companies have high annual net incomes (8–13).
If certain subsets of the population continue to miss out on new therapeutics due to financial, socio-economic or health system barriers, not only will disparities increase, but the burden of disease and subsequent complications will lead to preventable costs and strain on stressed healthcare systems worldwide (14). It is in the best interest of individuals living with diabetes, healthcare systems, and populations as a whole to reduce inequity, and the first step is to consider this in new developments. Thus, future speakers and supporters of diabetes conferences such as ATTD should be supported to consider the precedent that Banting set 100 years ago, recalling that everyone with diabetes should benefit from new innovations.
Data availability statement
The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.
Ethics statement
Ethical approval was not required for the study involving humans in accordance with the local legislation and institutional requirements. Written informed consent to participate in this study was not required from the participants or the participants’ legal guardians/next of kin in accordance with the national legislation and the institutional requirements.
Author contributions
CL: Data curation, Formal Analysis, Investigation, Visualization, Writing – original draft. AA: Conceptualization, Methodology, Supervision, Writing – review & editing. JB: Investigation, Writing – review & editing. HC: Investigation, Writing – review & editing. ED: Investigation, Writing – review & editing. NH: Investigation, Writing – review & editing. SH: Investigation, Writing – review & editing. RL: Investigation, Writing – review & editing. KL: Investigation, Writing – review & editing. TW: Investigation, Writing – review & editing. MD: Conceptualization, Data curation, Formal Analysis, Investigation, Methodology, Supervision, Writing – original draft, Writing – review & editing. M-AB: Conceptualization, Data curation, Formal Analysis, Investigation, Supervision, Visualization, Writing – review & editing, Methodology.
Funding
The author(s) declare financial support was received for the research, authorship, and/or publication of this article.
Conflict of interest
MD declares receiving speaker fees from Medtronic, Dexcom, Boerhinger Ingelheim, research support from Dexcom, Medtronic, Novonordisk, Pfizer, SOOIL, and has served as advisory board membership for Dexcom. RL receives consulting fees from Abbott DIabetes Care, Gluroo, PhysioLogic Devices, Provention Bio and is chief medical advisor for Tidepool. He receives research support from NIDDK 1K23DK122017 and P30 DK116074, JDRF, Abbott, Insulet, Medtronic and Tandem. ED declares receiving speaker fees from Lilly, and being part of speaker’s bureau for Dexcom.
The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Publisher’s note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.
References
1. Palme RD. Insulin Patent Sold for $1. London, United Kingdom: Banting House NHSC (2018). Available at: https://bantinghousenhs.ca/2018/12/14/insulin-patent-sold-for-1/.
2. Garcia JF, Peters AL, Raymond JK, Fogel J, Orrange S. Equity in Medical care for people living with diabetes. Diabetes Spectr (2022) 35(3):266–75. doi: 10.2337/dsi22-0003
3. Lipman TH, Hawkes CP. Racial and socioeconomic disparities in pediatric type 1 diabetes: time for a paradigm shift in approach. Diabetes Care (2020) 44(1):14–6. doi: 10.2337/dci20-0048
4. Burnside MJ, Williman JA, Davies HM, Jefferies CA, Paul RG, Wheeler BJ, et al. Inequity in access to continuous glucose monitoring and health outcomes in paediatric diabetes, a case for national continuous glucose monitoring funding: A cross-sectional population study of children with type 1 diabetes in New Zealand. Lancet Regional Health-Western Pacific (2023) 31:100644. doi: 10.1016/j.lanwpc.2022.100644
5. McKergow E, Parkin L, Barson DJ, Sharples KJ, Wheeler BJ. Demographic and regional disparities in insulin pump utilization in a setting of universal funding: a New Zealand nationwide study. Acta diabetologica (2017) 54(1):63–71. doi: 10.1007/s00592-016-0912-7
6. Agarwal S, Kanapka LG, Raymond JK, Walker A, Gerard-Gonzalez A, Kruger D, et al. Racial-ethnic inequity in young adults with type 1 diabetes. J Clin Endocrinol Metab (2020) 105(8):e2960–e9. doi: 10.1210/clinem/dgaa236
7. Addala A, Auzanneau M, Miller K, Maier W, Foster N, Kapellen T, et al. A decade of disparities in diabetes technology use and hbA1c in pediatric type 1 diabetes: A transatlantic comparison. Diabetes Care (2020) 44(1):133–40. doi: 10.2337/dc20-0257
8. Eli Lilly and Company 2022 Annual Report on Form 10-K. Indianapolis, Indiana, United State: Eli Lilly and Company (2023). Available at: https://investor.lilly.com/static-files/2f9b7bb1-f955-448d-baa2-c4343d39ee62.
9. Novo-Nordisk Annual Report 2022: Novo-Nordisk. Bagsværd, Denmark: Novo-Nordisk (2022). Available at: https://www.novonordisk.com/content/dam/nncorp/global/en/investors/irmaterial/annual_report/2023/novo-nordisk-annual-report-2022.pdf.
10. Sanofi Fourth quarter and full year 2022 results. Gentilly, France: Sanofi (2023). Available at: https://www.sanofi.com/en/investors/financial-results-and-events/financial-results/Q4-results-2022.
11. Abbott reports fourth-quarter and full-year 2022 results; Issues 2023 Financial Outlook. Illinois, United States: Abbott Laboratories (2023). Available at: https://abbott.mediaroom.com/2023-01-25-Abbott-Reports-Fourth-Quarter-and-Full-Year-2022-Results-Issues-2023-Financial-Outlook.
12. Dexcom Reports Fourth Quarter and Fiscal Year 2022 Financial Results. San Diego, California, United States: Dexcom (2023). Available at: https://investors.dexcom.com/news/news-details/2023/Dexcom-Reports-Fourth-Quarter-and-Fiscal-Year-2022-Financial-Results/.
13. Medtronic reports full year and fourth quarter fiscal year 2022 financial results; announces 8% dividend increase. Minneapolis, Minnesota, United States: Medtronic (2022). Available at: https://news.medtronic.com/2022-05-26-Medtronic-reports-full-year-and-fourth-quarter-fiscal-year-2022-financial-results-announces-8-dividend-increase#assets_all.
Keywords: equity, type 1 diabetes, type 2 diabetes, diabetes technology, conference
Citation: Leadley C, Addala A, Berkeley J, Crocket H, Davis EA, Hewapathirana N, Hussain S, Lal R, Lomax K, Wilkinson T, de Bock M and Burckhardt M-A (2023) Following in Banting’s footsteps or straying from the path? Observations from contemporary diabetes innovation. Front. Endocrinol. 14:1270517. doi: 10.3389/fendo.2023.1270517
Received: 31 July 2023; Accepted: 20 October 2023;
Published: 14 November 2023.
Edited by:
Christian Göbl, Medical University of Vienna, AustriaReviewed by:
Latife Bozkurt, Hietzing Clinic, AustriaCopyright © 2023 Leadley, Addala, Berkeley, Crocket, Davis, Hewapathirana, Hussain, Lal, Lomax, Wilkinson, de Bock and Burckhardt. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Marie-Anne Burckhardt, bWFyaWUtYW5uZS5idXJja2hhcmR0QHVrYmIuY2g=