Improving health among people living in poverty often transcends narrowly focused illness care. Meaningful success is unlikely without confronting the complex social origins of illness. We describe an emerging community of solution to improve health outcomes for a population of 6000 San Antonio, Texas, residents enrolled in a county health care program. The community of solution comprises a county health system, a family medicine residency program, a metropolitan public health department, and local nonprofit organizations and businesses. Community-based activities responding to the needs of individuals and their neighborhoods are driven by a cohort of promotores (community health workers) whose mission encompasses change at both the individual and community levels.

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Recently, cluster analysis has been proposed to classify adult onset diabetes which can better predict diabetes associated complications. Individuals with primarily insulin resistant phenotype have been associated with increased incidence of nephropathy while those with insulin deficient phenotype are associated with retinopathy. We evaluated the application of this classification in a VA diabetes clinic. Ninety patients who had C-peptide and anti-GADab, and detailed clinical follow-up, were included in the analysis. Additionally we defined patients with severe insulin resistance as those who required > 200 units of insulin a day and those with insulin doses < 0.5 U/kg/day were categorized as mild insulin resistance. Six subjects belonged to the Severe Autoimmune Diabetes (SAID) cohort, with average GADab 713±301IU; 66% of the cohort had nephropathy, 33% had retinopathy. The Severe Insulin Deficiency (SIDD) cohort had 9 patients, of which 4 had retinopathy, 3 had nephropathy. Thirty subjects had severe insulin resistance (n=30, M/F=29/1 age 61±2 yr), duration of diabetes 18.3±0.3 yr, HbA1c -8.4±0.2%, total daily insulin dose (TDD) 301±31U) and 32 had mild insulin resistance (N=32, M/F: 28/2, age 61±2 yr, BMI 30±1 kg/m2, duration of diabetes 12±1.2 yr, HbA1c 7.2±0.2%, TDD 17±2U). Insulin resistant subjects had a higher BMI, (41 ± 2 vs. 30 ±1 kg/m2, p<0.05), and higher plasma triglyceride (325±0.3 vs. 202±0.3 mg/dl, p=0.04). Prevalence of nephropathy was higher in the insulin resistant group vs. the mild insulin resistant group (76% vs. 43%, p<0.05). There was no difference in prevalence of retinopathy (p=0.09) or CAD (p=0.6) between the groups. Our results support the higher prevalence of diabetic nephropathy in patients with severe insulin resistance. Long-term follow up of these patients may provide insight into the underlying mechanisms of these complications. Disclosure J. Trejo: None. S. Pinkson: None. L. Gondin: None. L. Esteve: None. X. Chen: None. D. Tripathy: None.

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