Comparison of Oral Semaglutide w/ Placebo- Treatment for Latino Adults w/T2 Diabetes Receiving Enhanced Lifestyle Care

Oral Semaglutide is the first oral formulation of a glucagon-like peptide-1 (GLP-1) receptor agonist developed for the treatment of type 2 diabetes (T2D). Monotherapy with once-daily oral Semaglutide has been shown to provide superior and dose-dependent decreases in HbA1c compared with placebo, and superior decreases in bodyweight in patients with T2D whose glycaemia was insufficiently controlled on diet and exercise. Recently, in patients with T2D and chronic kidney disease, Semaglutide was also effective in improving glycemic control and bodyweight with a low risk of hypoglycemia compared to placebo. Oral Semaglutide has also been shown to be superior to Sitagliptin. Results from the PIONEER 6 trial showed that no increased risk for major cardiovascular events was observed with oral Semaglutide in patients with T2D at high cardiovascular (CV) risk. In that study, Semaglutide reduced CV death and all- cause mortality by nearly 50% versus placebo after a median follow-up of 15.9 months. Therefore based on the evidence from the PIONEER trials, oral Semaglutide is likely to offer significant benefits for adults with T2D. However in the United States (US), members of racial and ethnic minority groups are disproportionally affected by T2D and there is a paucity of information on what the potential impact of novel therapies such as oral Semaglutide might be for these populations. For example, the prevalence of both diagnosed and undiagnosed T2D is nearly twice as high among Mexican- origin Hispanic/Latino (hereafter Latino) adults compared to non-Latino whites. Likewise, rates of diabetes-related complications (including premature death from diabetes, acute stroke and end- stage renal disease) are also higher among Latino adults compared to their non-Latino white counterparts. For Latinos and other US minorities, beyond genetics and biological factors, it is recognized that sociocultural influences are also important factors in determining an individual's response to a therapy. In addition, self-identified race correlates with ancestry, which determines genomic variation, but this does not necessarily predict the response to a particular drug, nor can it be assumed that responses are similar between different races. As a corollary, being uninsured or a Medicaid recipient presents formidable challenges to improving cost-effective outcomes for people with diabetes. Currently, in the US, more than 29 million people are uninsured, with substantial inequalities in access to health care along economic, gender, racial, and ethnic lines. Racial and ethnic minority groups in the US also receive lower quality of health care compared with their white counterparts and disparities exist in the burden and cost of diabetes care for Medicare recipients. Identifying sub-groups with especially high risk of complications early in the course of T2D will also help clinicians to offer more cost-effective therapies. In addition, regulatory and policy decisions are increasingly based on a continuum of data from intensively monitored randomized clinical trials (RCTs) to real-world evidence (RWE), i.e., from tightly controlled, homogeneous populations to broader ones seen in usual clinical practice. US minorities commonly live in "poorer" neighborhood environments with respect to access to healthy food sources, places to exercise or safety from crime. Plant-based dietary foods have the potential to help manage several major chronic diseases, including T2D. For underserved populations with T2D, food insecurity and low socioeconomic status are frequent barriers to nutrition-based self-management. As a consequence, Sansum Diabetes Research Institute (SDRI) has recently created Farming for Life, which provides medically prescribed produce to Latino adults with non-insulin treated T2D. Farming for Life uses prescriptions of predominantly organic vegetable produce, as studies have shown that organic crops have higher concentrations of antioxidants and a lower incidence of pesticide residues than non-organic crops. There is growing evidence of an association between pesticide exposure and T2D risk.