Place matters: neighborhood deprivation and cardiometabolic risk factors in the Diabetes Study of Northern California (DISTANCE)

Food Insecurity and Hypoglycemia among Older Patients with Type 2 Diabetes Treated with Insulin or Sulfonylureas: The Diabetes & Aging Study

BACKGROUND

Severe hypoglycemia is a serious adverse drug event associated with hypoglycemia-prone medications; older patients with diabetes are particularly at high risk. Economic food insecurity (food insecurity due to financial limitations) is a known risk factor for hypoglycemia; however, less is known about physical food insecurity (due to difficulty cooking or shopping for food), which may increase with age, and its association with hypoglycemia.

OBJECTIVE

Study associations between food insecurity and severe hypoglycemia.

DESIGN

Survey based cross-sectional study.

PARTICIPANTS

Survey responses were collected in 2019 from 1,164 older (≥ 65 years) patients with type 2 diabetes treated with insulin or sulfonylureas.

MAIN MEASURES

Risk ratios (RR) for economic and physical food insecurity associated with self-reported severe hypoglycemia (low blood glucose requiring assistance) adjusted for age, financial strain, HbA1c, Charlson comorbidity score and frailty. Self-reported reasons for hypoglycemia endorsed by respondents.

KEY RESULTS

Food insecurity was reported by 12.3% of the respondents; of whom 38.4% reported economic food insecurity only, 21.1% physical food insecurity only and 40.5% both. Economic food insecurity and physical food insecurity were strongly associated with severe hypoglycemia (RR = 4.3; p = 0.02 and RR = 4.4; p = 0.002, respectively). Missed meals ("skipped meals, not eating enough or waiting too long to eat") was the dominant reason (77.5%) given for hypoglycemia.

CONCLUSIONS

Hypoglycemia prevention efforts among older patients with diabetes using hypoglycemia-prone medications should address food insecurity. Standard food insecurity questions, which are used to identify economic food insecurity, will fail to identify patients who have physical food insecurity only.

Willingness to take less medication for type 2 diabetes among older patients: The Diabetes & Aging Study

BACKGROUND

To examine the willingness of older patients to take less diabetes medication (de-intensify) and to identify characteristics associated with willingness to de-intensify treatment.

METHODS

Survey conducted in 2019 in an age-stratified, random sample of older (65-100 years) adults with diabetes on glucose-lowering medications in the Kaiser Permanente Northern California Diabetes Registry. We classified survey responses to the question: "I would be willing to take less medication for my diabetes" as willing, neutral, or unwilling to de-intensify. Willingness to de-intensify treatment was examined by several clinical characteristics, including American Diabetes Association (ADA) health status categories used for individualizing glycemic targets. Analyses were weighted to account for over-sampling of older individuals.

RESULTS

A total of 1337 older adults on glucose-lowering medication(s) were included (age 74.2 ± 6.0 years, 44% female, 54.4% non-Hispanic white). The proportions of participants willing, neutral, or unwilling to take less medication were 51.2%, 27.3%, and 21.5%, respectively. Proportions of willing to take less medication varied by age (65-74 years: 54.2% vs. 85+ years: 38.5%) and duration of diabetes (0-4 years: 61.0% vs. 15+ years: 44.2%), both p < 0.001. Patients on 1-2 medications were more willing to take less medication(s) compared with patients on 10+ medications (62.1% vs. 46.6%, p = 0.03). Similar proportions of willingness to take less medications were seen across ADA health status, and HbA1c. Willingness to take less medication(s) was similar across survey responses to questions about patient-clinician relationships.

CONCLUSIONS

Clinical guidelines suggest considering treatment de-intensification in older patients with longer duration of diabetes, yet patients with these characteristics are less likely to be willing to take less medication(s).

Neighborhood Disadvantage and Risk of Heart Failure: The Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study

BACKGROUND

Heart failure (HF) affects >6 million US adults, with recent increases in HF hospitalizations. We aimed to investigate the association between neighborhood disadvantage and incident HF events and potential differences by diabetes status.

METHODS

We included 23 645 participants from the REGARDS study (Reasons for Geographic and Racial Differences in Stroke), a prospective cohort of Black and White adults aged ≥45 years living in the continental United States (baseline 2005-2007). Neighborhood disadvantage was assessed using a Z score of 6 census tract variables (2000 US Census) and categorized as quartiles. Incident HF hospitalizations or HF-related deaths through 2017 were adjudicated. Multivariable-adjusted Cox regression was used to examine the association between neighborhood disadvantage and incident HF. Heterogeneity by diabetes was assessed using an interaction term.

RESULTS

The mean age was 64.4 years, 39.5% were Black adults, 54.9% females, and 18.8% had diabetes. During a median follow-up of 10.7 years, there were 1125 incident HF events with an incidence rate of 3.3 (quartile 1), 4.7 (quartile 2), 5.2 (quartile 3), and 6.0 (quartile 4) per 1000 person-years. Compared to adults living in the most advantaged neighborhoods (quartile 1), those living in neighborhoods in quartiles 2, 3, and 4 (most disadvantaged) had 1.30 (95% CI, 1.06-1.60), 1.36 (95% CI, 1.11-1.66), and 1.45 (95% CI, 1.18-1.79) times greater hazard of incident HF even after accounting for known confounders. This association did not significantly differ by diabetes status (interaction P=0.59). For adults with diabetes, the adjusted incident HF hazards comparing those in quartile 4 versus quartile 1 was 1.34 (95% CI, 0.92-1.96), and it was 1.50 (95% CI, 1.16-1.94) for adults without diabetes.

CONCLUSIONS

In this large contemporaneous prospective cohort, neighborhood disadvantage was associated with an increased risk of incident HF events. This increase in HF risk did not differ by diabetes status. Addressing social, economic, and structural factors at the neighborhood level may impact HF prevention.

Telehealth Collaborative Care Led by Clinical Pharmacists for People With Psychosis or Bipolar Disorder: A Propensity Weighted Comparison With Usual Psychiatric Care

Objective: People with psychosis or bipolar disorder (severe and persistent mental illness [SPMI]) are at high risk for poor psychiatric and chronic illness outcomes, which could be ameliorated through improved health care quality. This study assessed whether a telehealth, collaborative care program managed by psychiatric clinical pharmacists (SPMI Population Care) was associated with improved health care quality for adults with SPMI in a large California health system.

Methods: This retrospective cohort study used electronic health record data to compare 968 program enrollees at 6 demonstration sites (Population Care) to 8,339 contemporaneous patients with SPMI at 6 non-program sites (Usual Care). SPMI diagnoses were based on ICD-10-CM diagnostic codes. Primary outcomes were optimal psychotropic medication adherence, guideline-recommended glycemic screening, annual psychiatrist visit, and emergency department use. Difference-in-difference analyses assessed change in outcomes from 12 months pre- to 12 months post-enrollment using overlap weighting with high dimensional propensity scores to balance participant characteristics across groups. Participant data were collected from January 1, 2020, to June 30, 2022.

Results: From pre- to post-enrollment, Population Care was associated with greater achievement of psychotropic medication adherence and glycemic screening (+6 and +9 percentage points), but unexpectedly with a decrease in annual psychiatrist visits (-6 percentage points) and no significant change in emergency department use, relative to Usual Care. More than 75% of Population Care participants attended an intake and ≥ 1 follow-up visits. Participants with psychosis (26% of sample) had similar results as those with bipolar disorder.

Conclusions: Clinical pharmacist-led telehealth collaborative care has potential to improve psychopharmacologic treatment adherence and recommended disease preventive screening for people with psychosis or bipolar disorder.

Predictors of lack of glycemic control in persons with type 2 diabetes

BACKGROUND

Professional guidelines recommend an HbA1c < 7% for most people with diabetes and < 8.5% for those with relaxed glycemic goals. However, many people with type 2 diabetes mellitus (T2DM) are unable to achieve the desired HbA1c goal. This study evaluated factors associated with lack of improvement in HbA1c over 3 years.

METHODS

All patients with T2DM treated within a major academic healthcare system during 2015-2020, who had at least one HbA1c value > 8.5% within 3 years from their last HbA1c were included in analysis. Patients were grouped as improved glycemic control (last HbA1c ≤ 8.5%) or lack of improvement (last HbA1c > 8.5%). Multivariate logistic regression analysis was performed to assess independent predictors of lack of improvement in glycemic control.

RESULTS

Out of 2,232 patients who met the inclusion criteria, 1,383 had an improvement in HbA1c while 849 did not. In the fully adjusted model, independent predictors of lack of improvement included: younger age (odds ratio, 0.89 per 1-SD [12 years]; 95% CI, 0.79-1.00), female gender (1.30, 1.08-1.56), presence of hypertension (1.29, 1.08-1.55), belonging to Black race (1.32, 1.04-1.68, White as reference), living in low income area (1.86,1.28-2.68, high income area as reference), and insurance coverage other than Medicare (1.32, 1.05-1.66). Presence of current smoking was associated with a paradoxical improvement in HbA1c (0.69, 0.47-0.99). In a subgroup analysis, comparing those with all subsequent HbA1c values > 8.5% (N = 444) to those with all subsequent HbA1c values < 8.5% (N = 341), similar factors were associated with lack of improvement, but smoking was no longer significant.

CONCLUSION

We conclude that socioeconomic factors like race, type of insurance coverage and living in low-income areas are associated with lack of improvement in HbA1c over a period of 3-years in people with T2DM. Intervention strategies focused on low-income neighborhoods need to be designed to improve diabetes management.

Structural Racism, Mass Incarceration, and Racial and Ethnic Disparities in Severe Maternal Morbidity

Importance

Racial and ethnic inequities in the criminal-legal system are an important manifestation of structural racism. However, how these inequities may influence the risk of severe maternal morbidity (SMM) and its persistent racial and ethnic disparities remains underinvestigated.

Objective

To examine the association between county-level inequity in jail incarceration rates comparing Black and White individuals and SMM risk in California.

Design, Setting, and Participants

This population-based cross-sectional study used state-wide data from California on all live hospital births at 20 weeks of gestation or later from January 1, 1997, to December 31, 2018. Data were obtained from hospital discharge and vital statistics records, which were linked with publicly available county-level data. Data analysis was performed from January 2022 to February 2023.

Exposure

Jail incarceration inequity was determined from the ratio of jail incarceration rates of Black individuals to those of White individuals and was categorized as tertile 1 (low), tertile 2 (moderate), tertile 3 (high), with mean cutoffs across all years of 0 to 2.99, 3.00 to 5.22, and greater than 5.22, respectively.

Main Outcome and Measures

This study used race- and ethnicity-stratified mixed-effects logistic regression models with birthing people nested within counties and adjusted for individual- and county-level characteristics to estimate the odds of non-blood transfusion SMM (NT SMM) and SMM including blood transfusion-only cases (SMM; as defined by the Centers for Disease Control and Prevention SMM index) associated with tertiles of incarceration inequity.

Results

This study included 10 200 692 births (0.4% American Indian or Alaska Native, 13.4% Asian or Pacific Islander, 5.8% Black, 50.8% Hispanic or Latinx, 29.6% White, and 0.1% multiracial or other [individuals who self-identified with ≥2 racial groups and those who self-identified as "other" race or ethnicity]). In fully adjusted models, residing in counties with high jail incarceration inequity (tertile 3) was associated with higher odds of SMM for Black (odds ratio [OR], 1.14; 95% CI, 1.01-1.29 for NT SMM; OR, 1.20, 95% CI, 1.01-1.42 for SMM), Hispanic or Latinx (OR, 1.24; 95% CI, 1.14-1.34 for NT SMM; OR, 1.20; 95% CI, 1.14-1.27 for SMM), and White (OR, 1.02; 95% CI, 0.93-1.12 for NT SMM; OR, 1.09; 95% CI, 1.02-1.17 for SMM) birthing people, compared with residing in counties with low inequity (tertile 1).

Conclusions and Relevance

The findings of this study highlight the adverse maternal health consequences of structural racism manifesting via the criminal-legal system and underscore the need for community-based alternatives to inequitable punitive practices.

Glycemic control and diabetes complications across health status categories in older adults treated with insulin or insulin secretagogues: The Diabetes & Aging Study

BACKGROUND

For older adults with type 2 diabetes (T2D) treated with insulin or sulfonylureas, Endocrine Society guideline recommends HbA1c between 7% to <7.5% for those in good health, 7.5% to <8% for those in intermediate health, and 8% to <8.5% for those in poor health. Our aim was to examine associations between attained HbA1c below, within (reference), or above recommended target range and risk of complication or mortality.

METHODS

Retrospective cohort study of adults ≥65 years old with T2D treated with insulin or sulfonylureas from an integrated healthcare delivery system. Cox proportional hazards models of complications during 2019 were adjusted for sociodemographic and clinical variables. Primary outcome was a combined outcome of any microvascular or macrovascular event, severe hypoglycemia, or mortality during 12-month follow-up.

RESULTS

Among 63,429 patients (mean age: 74.2 years, 46.8% women), 8773 (13.8%) experienced a complication. Complication risk was significantly elevated for patients in good health (n = 16,895) whose HbA1c was above (HR 1.97, 95% CI 1.62-2.41) or below (HR 1.29, 95% CI 1.02-1.63) compared to within recommended range. Among those in intermediate health (n = 30,129), complication risk was increased for those whose HbA1c was above (HR 1.45, 95% CI 1.30-1.60) but not those below the recommended range (HR 0.99, 95% CI 0.89-1.09). Among those in poor health (n = 16,405), complication risk was not significantly different for those whose HbA1c was below (HR 0.98, 95% CI 0.89-1.09) or above (HR 0.96, 95% CI 0.88-1.06) recommended range.

CONCLUSIONS

For older adults with T2D in good health, HbA1c below or above the recommended range was associated with significantly elevated complication risk. However, for those in poor health, achieving specific HbA1c levels may not be helpful in reducing the risk of complications.

Race- and Gender-Specific Associations between Neighborhood-Level Socioeconomic Status and Body Mass Index: Evidence from the Southern Community Cohort Study

Obesity and a low socioeconomic status (SES), measured at the neighborhood level, are more common among Americans of Black race and with a low individual-level SES. We examined the association between the neighborhood SES and body mass index (BMI) using data from 80,970 participants in the Southern Community Cohort Study, a cohort that oversamples Black and low-SES participants. BMI (kg/m2) was examined both continuously and categorically using cut points defined by the CDC. Neighborhood SES was measured using a neighborhood deprivation index composed of census-tract variables in the domains of education, employment, occupation, housing, and poverty. Generally, the participants in lower-SES neighborhoods were more likely to have a higher BMI and to be considered obese. We found effect modification by race and sex, where the neighborhood-BMI association was most apparent in White female participants in all the quintiles of the neighborhood SES (ORQ2 = 1.55, 95%CI = 1.34, 1.78; ORQ3 = 1.71, 95%CI = 1.48, 1.98; ORQ4 = 1.76, 95%CI = 1.52, 2.03; ORQ5 = 1.64, 95%SE = 1.39, 1.93). Conversely, the neighborhood-BMI association was mostly null in Black male participants (ORQ2 = 0.91, 95%CI = 0.72, 1.15; ORQ3 = 1.05, 95%CI = 0.84, 1.31; βQ4 = 1.00, 95%CI = 0.81, 1.23; ORQ5 = 0.76, 95%CI = 0.63, 0.93). Within all the subgroups, the associations were attenuated or null in participants residing in the lowest-SES neighborhoods. These findings suggest that the associations between the neighborhood SES and BMI vary, and that other factors aside from the neighborhood SES may better predict the BMI in Black and low-SES groups.

A narrative review of exercise participation among adults with prediabetes or type 2 diabetes: barriers and solutions

Type 2 diabetes (T2D) has been rising in prevalence over the past few decades in the US and worldwide. T2D contributes to significant morbidity and premature mortality, primarily due to cardiovascular disease (CVD). Exercise is a major cornerstone of therapy for T2D as a result of its positive effects on glycemic control, blood pressure, weight loss and cardiovascular risk as well as other measures of health. However, studies show that a majority of people with T2D do not exercise regularly. The reasons given as to why exercise goals are not met are varied and include physiological, psychological, social, cultural and environmental barriers to exercise. One potential cause of inactivity in people with T2D is impaired cardiorespiratory fitness, even in the absence of clinically evident complications. The exercise impairment, although present in both sexes, is greater in women than men with T2D. Women with T2D also experience greater perceived exertion with exercise than their counterparts without diabetes. These physiological barriers are in addition to constructed societal barriers including cultural expectations of bearing the burden of childrearing for women and in some cultures, having limited access to exercise because of additional cultural expectations. People at risk for and with diabetes more commonly experience unfavorable social determinants of health (SDOH) than people without diabetes, represented by neighborhood deprivation. Neighborhood deprivation measures lack of resources in an area influencing socioeconomic status including many SDOH such as income, housing conditions, living environment, education and employment. Higher indices of neighborhood deprivation have been associated with increased risk of all-cause, cardiovascular and cancer related mortality. Unfavorable SDOH is also associated with obesity and lower levels of physical activity. Ideally regular physical activity should be incorporated into all communities as part of a productive and healthy lifestyle. One potential solution to improve access to physical activity is designing and building environments with increased walkability, greenspace and safe recreational areas. Other potential solutions include the use of continuous glucose monitors as real-time feedback tools aimed to increase motivation for physical activity, counseling aimed at improving self-efficacy towards exercise and even acquiring a dog to increase walking time. In this narrative review, we aim to examine some traditional and novel barriers to exercise, as well as present evidence on novel interventions or solutions to overcome barriers to increase exercise and physical activity in all people with prediabetes and T2D.

Neighborhood disadvantage is associated with decreased ovarian reserve in women with overweight and obesity

OBJECTIVE(S)

To evaluate the association between neighborhood disadvantage and ovarian reserve stratified by body mass index (BMI).

DESIGN

Cross-sectional cohort study.

SETTING

Single academic medical center.

PATIENT(S)

A total of 193 healthy reproductive-age women with regular menstrual cycles in the St. Louis, Missouri metropolitan area.

INTERVENTION(S)

Residence in a disadvantaged neighborhood.

MAIN OUTCOME MEASURE(S)

Ovarian reserve as assessed by ovarian antral follicle count (AFC) and serum anti-Müllerian hormone (AMH) concentration.

RESULT(S)

Women (n = 193) ranged from 20 to 44 years. The majority had overweight or obesity (59%, n = 117) with mean BMI of 28±7 kg/m2. Forty-eight women lived in the most disadvantaged neighborhood quartile, of which 75% had overweight or obesity, compared with 54% of the 145 women living in the 3 less disadvantaged neighborhood quartiles. When controlling for age, race, and smoking status, women with overweight or obesity living in the most disadvantaged neighborhoods had significantly lower AMH compared with those living in the less disadvantaged neighborhoods. Antral follicle count did not differ among women with overweight or obesity by neighborhood of residence. Neighborhood disadvantage was not associated with ovarian reserve by AFC or AMH in women with normal weight or underweight status.

CONCLUSION(S)

Living in a socioeconomically deprived area is associated with lower markers of ovarian reserve among women with an elevated BMI.

Supermarket Proximity and Risk of Hypertension, Diabetes, and CKD: A Retrospective Cohort Study

RATIONALE & OBJECTIVE

Living in environments with low access to food may increase the risk of chronic diseases. We investigated the association of household distance to the nearest supermarket (as a measure of food access) with the incidence of hypertension, diabetes, and chronic kidney disease (CKD) in a metropolitan area of the United States.

STUDY DESIGN

Retrospective cohort study.

SETTING & PARTICIPANTS

777,994 individuals without hypertension, diabetes, or CKD at baseline within the HealthLNK Data Repository, which contains electronic health records from 7 health care institutions in Chicago, Illinois.

EXPOSURE

Zip code-level average distance between households and nearest supermarket.

OUTCOME

Incidence of hypertension, diabetes, and CKD based on presence of ICD-9 code and/or blood pressure≥140/90mm Hg, hemoglobin A1c≥6.5%, and eGFR<60mL/min/1.73m², respectively.

ANALYTICAL APPROACH

Average distance to nearest supermarket was aggregated from street-level metrics for 56 Chicagoland zip codes. The cumulative incidence of hypertension, diabetes, and CKD from 2007-2012 was calculated for each zip code in patients free of these diseases in 2006. Spatial analysis of food access and disease incidence was performed using bivariate local indicator of spatial association (BiLISA) maps and bivariate local Moran I statistics. The relationship between supermarket access and outcomes was analyzed using logistic regression.

RESULTS

Of 777,994 participants, 408,608 developed hypertension, 51,380 developed diabetes, and 56,365 developed CKD. There was significant spatial overlap between average distance to supermarket and incidence of hypertension and diabetes but not CKD. Zip codes with large average supermarket distances and high incidence of hypertension and diabetes were clustered in southern and western neighborhoods. Models adjusted only for neighborhood factors (zip code-level racial composition, access to vehicles, median income) revealed significant associations between zip code-level average distance to supermarket and chronic disease incidence. Relative to tertile 1 (shortest distance), ORs in tertiles 2 and 3, respectively, were 1.27 (95% CI, 1.23-1.30) and 1.38 (95% CI, 1.33-1.43) for diabetes, 1.03 (95% CI, 1.02-1.05) and 1.04 (95% CI, 1.02-1.06) for hypertension, and 1.18 (95% CI, 1.15-1.21) and 1.33 (95% CI, 1.29-1.37) for CKD. Models adjusted for demographic factors and health insurance showed significant and positive association with greater odds of incident diabetes (tertile 2: 1.29 [95% CI, 1.26-1.33]; tertile 3: 1.35 [95% CI, 1.31-1.39]) but lesser odds of hypertension (tertile 2: 0.95 [95% CI, 0.94-0.97]; tertile 3: 0.91 [95% CI, 0.89-0.92]) and CKD (tertile 2: 0.80 [95% CI, 0.78-0.82]; tertile 3: 0.73 [95% CI, 0.72-0.76]). After adjusting for both neighborhood and individual covariates, supermarket distance remained significantly associated with greater odds of diabetes and lesser odds of hypertension, but there was no significant association with CKD.

LIMITATIONS

Unmeasured neighborhood and social confounding variables, zip code-level analysis, and limited individual-level information.

CONCLUSIONS

There are significant disparities in supermarket proximity and incidence of hypertension, diabetes, and CKD in Chicago, Illinois. The relationship between supermarket access and chronic disease is largely explained by individual- and neighborhood-level factors.

Association of Area Deprivation Index and hypertension, diabetes, dyslipidemia, and Obesity: A Cross-Sectional Study of the HABS-HD Cohort

Objective: This study aims to investigate the association between neighborhood deprivation and the prevalence of major cardiovascular disease (CVD) risk factors (hypertension, diabetes, dyslipidemia, and obesity) in a Mexican American (MA) population compared to NonHispanic Whites (NHW). Method: A cross-sectional analysis was conducted to include 1,867 subjects (971 MA and 896 NHW). Participants underwent a clinical interview, neuropsychological exam battery, functional examination, MRI of the head, amyloid PET scan, and blood draw for clinical and biomarker analysis. We use the Area Deprivation Index (ADI) Model to assign an ADI score to participants based on their neighborhoods. Descriptive, Cochran-Armitage test for trend, and odds ratio statistical analysis were applied. Results: Our results suggest that NHW had higher odds of having HTN, DM, and obesity in the most deprived neighborhoods, while MA showed no increased odds. The study also found that neighborhood deprivation contributed to diabetes in both MA and NHW and was associated with obesity in NHW. Conclusions: These findings highlighted the importance of addressing both individual and societal factors in efforts to reduce cardiovascular risk. Future research should explore the relationship between socio-economic status and cardiovascular risk in more detail to inform the development of targeted interventions.

Assessing racial bias in type 2 diabetes risk prediction algorithms

Risk prediction models for type 2 diabetes can be useful for the early detection of individuals at high risk. However, models may also bias clinical decision-making processes, for instance by differential risk miscalibration across racial groups. We investigated whether the Prediabetes Risk Test (PRT) issued by the National Diabetes Prevention Program, and two prognostic models, the Framingham Offspring Risk Score, and the ARIC Model, demonstrate racial bias between non-Hispanic Whites and non-Hispanic Blacks. We used National Health and Nutrition Examination Survey (NHANES) data, sampled in six independent two-year batches between 1999 and 2010. A total of 9,987 adults without a prior diagnosis of diabetes and with fasting blood samples available were included. We calculated race- and year-specific average predicted risks of type 2 diabetes according to the risk models. We compared the predicted risks with observed ones extracted from the US Diabetes Surveillance System across racial groups (summary calibration). All investigated models were found to be miscalibrated with regard to race, consistently across the survey years. The Framingham Offspring Risk Score overestimated type 2 diabetes risk for non-Hispanic Whites and underestimated risk for non-Hispanic Blacks. The PRT and the ARIC models overestimated risk for both races, but more so for non-Hispanic Whites. These landmark models overestimated the risk of type 2 diabetes for non-Hispanic Whites more severely than for non-Hispanic Blacks. This may result in a larger proportion of non-Hispanic Whites being prioritized for preventive interventions, but it also increases the risk of overdiagnosis and overtreatment in this group. On the other hand, a larger proportion of non-Hispanic Blacks may be potentially underprioritized and undertreated.

Neighborhood deprivation and morbid obesity: Insights from the Houston Methodist Cardiovascular Disease Health System Learning Registry

This study examined the relationship between a validated measure of socioeconomic deprivation, such as the Area Deprivation Index (ADI), and morbid obesity. We used cross-sectional data on adult patients (≥18 years) in the Houston Methodist Cardiovascular Disease Health System Learning Registry (located in Houston, Texas, USA) between June 2016 and July 2021. Each patient was grouped by quintiles of ADI, with higher quintiles signaling greater deprivation. BMI was calculated using measured height and weight with morbid obesity defined as ≥ 40 kg/m². Multivariable logistic regression models were used to examine the association between ADI and morbid obesity adjusting for demographic (age, sex, and race/ethnicity) factors. Out of the 751,174 adults with an ADI ranking included in the analysis, 6.9 % had morbid obesity (n = 51,609). Patients in the highest ADI quintile had a higher age-adjusted prevalence (10.9 % vs 3.3 %), and about 4-fold odds (aOR, 3.8; 95 % CI = 3.6, 3.9) of morbid obesity compared to the lowest ADI quintile. We tested for and found interaction effects between ADI and each demographic factor, with stronger ADI-morbid obesity association observed for patients that were female, Hispanic, non-Hispanic White and 40-65 years old. The highest ADI quintile also had a high prevalence (44 %) of any obesity (aOR, 2.2; 95 % CI = 2.1, 2.2). In geospatial mapping, areas with higher ADI were more likely to have higher proportion of patients with morbid obesity. Census-based measures, like the ADI, may be informative for area-level obesity reduction strategies as it can help identify neighborhoods at high odds of having patients with morbid obesity.

Review article: the epidemiologic burden of non-alcoholic fatty liver disease across the world

BACKGROUND

The prevalence of non-alcoholic fatty liver disease (NAFLD) is increasing in parallel with obesity and type 2 diabetes.

AIM

To review the global epidemiology of NAFLD METHODS: We retrieved articles from PubMed using search terms of NAFLD, epidemiology, prevalence, incidence, and comorbidities.

RESULTS

Over 250 articles were reviewed. In 2016, the global NAFLD prevalence was 25%; this increased to >30% in 2019. Prevalence in Asia, Latin America and Middle East-North Africa (MENA) was 30.8%, 34.5% and 42.6%, respectively. Prevalence increased with age. Although prevalence was higher in men, prevalence in post-menopausal women was similar. NAFLD prevalence was higher in certain subpopulations, especially among the obese and those with metabolic syndrome (MS). However, the prevalence of lean NAFLD was 11.2%. The global prevalence of non-alcoholic steatohepatitis (NASH) is estimated between 2% and 6% in the general population. Approximately 7% of patients with NAFLD have advanced fibrosis; rates were between 21% and 50% among patients with NASH. Overall mortality related to NAFLD was 15-20 per 1000 person-years, and increased substantially in patients with NASH, especially in those with components of MS. Recent data suggest mortality/morbidity from NAFLD is increasing globally but NAFLD awareness remains low among patients and healthcare providers.

CONCLUSIONS

NAFLD poses a global public health problem with a very high disease burden in Asia, MENA and Latin America. Research is needed to better quantify the full impact of NAFLD and to develop strategies to improve awareness and risk stratification.

Neighborhood deprivation and Medicare expenditures for common surgical procedures

INTRODUCTION

The Center of Medicare and Medicaid Services valued based payments for inpatient surgical hospitalizations are adjusted for clinical but not social risk factors. While research has shown that social risk is associated with worse surgical patient outcomes, it is unknown if inpatient surgical episode Medicare payments are affected by social risk factors.

METHODS

Retrospective review of Medicare beneficiaries, age 65-99, undergoing appendectomy, colectomy, hernia repair, or cholecystectomy between 2014 and 2018. Neighborhood deprivation measured by Area Deprivation Index for beneficiary census tract. We evaluated Medicare payments for a total episode of surgical care comprised of index hospitalization, physician fees, post-acute care, and readmission by beneficiary neighborhood deprivation.

RESULTS

A total of 809,059 patients (Women, 56.0%) and mean (SD) age of 75.7 (7.4 years were included. A total of 145,351 beneficiaries lived in the least deprived neighborhoods and 134,188 who lived in the most deprived neighborhoods. Total surgical episode spending was $2654 higher among beneficiaries from the most deprived neighborhoods compared to those from the least after risk adjustment for clinical and hospital factors. These differences were driven in part by higher rates of readmissions (12.9% vs 10.8%, P < 0.001) and post-acute care (67.8% vs. 61.2%, P < 0.001) among beneficiaries living in the most deprived neighborhoods.

CONCLUSION

These findings suggest that value-based payment models with inclusion of social risk adjustment may be needed for surgical cohorts. Moreover, efforts focused on investing in deprived communities may be aligned with surgical quality improvement.

Assuring Healthy Populations During the COVID-19 Pandemic: Recognizing Women's Contributions in Addressing Syndemic Interactions

A syndemic framework examines disease interactions and the contributions of structural, social, economic, and environmental factors that synergistically interact to contribute to adverse health outcomes. Populations residing in environments with structural susceptibilities experience health disparities and syndemics to a greater extent than their less vulnerable counterparts. The interactions among the social determinants of health (SDoH) and the COVID-19 pandemic have had different results for marginalized populations and have worsened health outcomes for many in this synergistic pandemic. Also, the exposome, the exposure measures for an individual over their lifetime and how those exposures relate to the individual's health, may help to explain why some populations experience more serious cases of COVID-19 compared to other groups. The purpose of this perspective is to: (1) examine the relationship between the syndemic model and the SDoH-exposome; (2) highlight, via specific examples, the contributions of female health professionals to SDoH and the COVID-19 syndemic in response to the Women in Science Research Topic, and (3) propose health policy to address syndemic-exposome interactions to help mitigate or prevent public health challenges. By investing in policies that assure health for all populations, the investments could pay dividends in the form of a less severe syndemic next time since we are starting from a place of health and not disease. Lastly, due to the magnification of underlying societal inequities laid bare during the COVID-19 syndemic, we support the expansion of the disease-focused syndemic model to include societal syndemics, such as systemic racism.

Continuous Glucose Monitor Use Prevents Glycemic Deterioration in Insulin-Treated Patients with Type 2 Diabetes

Continuous glucose monitoring (CGM) is indicated in poorly controlled insulin-treated patients with type 2 diabetes (T2D) to improve glycemic control and reduce the risk of hypoglycemia, but the benefits of CGM for lower risk patients have not been well studied. Among 17,422 insulin-treated patients with T2D with hemoglobin A1c (HbA1c) <8% and no recent severe hypoglycemia (based on emergency room visits or hospitalizations), CGM initiation occurred in 149 patients (17,273 noninitiators served as reference). Changes in HbA1c and severe hypoglycemia rates for the 12 months before and after CGM initiation were calculated. CGM initiation was associated with decreased HbA1c (-0.06%), whereas noninitiation was associated with increased HbA1c (+0.32%); a weighted adjusted difference-in-difference model of change in HbA1c yielded a net benefit of -0.30%; 95% CI -0.50%, -0.10%; P = 0.004). No significant differences were observed for severe hypoglycemia. CGM may be useful in preventing glycemic deterioration in well-controlled patients with insulin-treated T2D.

Differentiating distinct and converging neural correlates of types of systemic environmental exposures

Systemic environmental disadvantage relates to a host of health and functional outcomes. Specific structural factors have seldom been linked to neural structure, however, clouding understanding of putative mechanisms. Examining relations during childhood/preadolescence, a dynamic period of neurodevelopment, could aid bridge this gap. A total of 10,213 youth were recruited from the Adolescent Brain and Cognitive Development study. Self-report and objective measures (Census and Federal bureau of investigation metrics extracted using geocoding) of environmental exposures were used, including stimulation indexing lack of safety and high attentional demands, discrepancy indexing social exclusion/lack of belonging, and deprivation indexing lack of environmental enrichment. Environmental measures were related to cortical thickness, surface area, and subcortical volume regions, controlling for other environmental exposures and accounting for other brain regions. Self-report (|β| = .04-.09) and objective (|β| = .02-.06) environmental domains related to area/thickness in overlapping (e.g., insula, caudal anterior cingulate), and unique regions (e.g., for discrepancy, rostral anterior and isthmus cingulate, implicated in socioemotional functions; for stimulation, precuneus, critical for cue reactivity and integration of environmental cues; and for deprivation, superior frontal, integral to executive functioning). For stimulation and discrepancy exposures, self-report and objective measures showed similarities in correlate regions, while deprivation exposures evidenced distinct correlates for self-report and objective measures. Results represent a necessary step toward broader work aimed at establishing mechanisms and correlates of structural disadvantage, highlighting the relevance of going beyond aggregate models by considering types of environmental factors, and the need to incorporate both subjective and objective measurements in these efforts.

Incorporating community-level risk factors into traumatic stress research: Adopting a public health lens

Infusing community-level risk factors into traumatic stress research can broaden intervention targets. The Neighborhood Deprivation Index (NDI) and the Index of Concentration at the Extremes (ICE) are two common community-level risk factors derived from U.S. census data. We provide R scripts facilitating the computation of these risk factors and demonstrate their relationship with PTSD symptomatology in 74 injury survivors assessed at 2-weeks, 6-weeks, and 3-months post-injury. The NDI and the ICE were computed using the Census Data Application Programming Interface, then matched to participants' census tracts using their residential addresses. Results indicated that after controlling for person-level characteristics, both risk factors were associated with PTSD symptom severity at follow up time points (Cohen's f² =0.011,.14). This study provides an easy method for computing the NDI and ICE, demonstrates the increased mental health risk that they convey in the aftermath of injury, and highlights their value in intervention efforts.

Area-based inequalities and distribution of healthcare resources for managing diabetes in South Korea: a cross-sectional multilevel analysis

OBJECTIVES

We aimed to identify area-based socioeconomic inequalities in diabetes management and to examine whether the distribution of healthcare resources could explain area-based inequalities in diabetes management.

DESIGN

Cross-sectional multilevel analysis from national survey data.

SETTING AND PARTICIPANTS

Data were derived from the 2018 Korean Community Health Survey. Study subjects included 23 760 participants aged 30 years or older with diabetes diagnosed by a doctor.

MAIN OUTCOME MEASURES

The dependent variables were self-reported good glycaemic control, haemoglobin A1c (HbA1c) testing, recognition of the term HbA1c, and diabetic complications testing. Area Deprivation Index was used as an area-based measure of socioeconomic position. Factors related to regional healthcare resources-the coefficient of variation (CV) value of clinics and the number of physicians per 1000-were considered as potential mediating variables in explaining the association between diabetes management and area deprivation. A multilevel logistic regression analysis was used.

RESULTS

Compared with the least deprived quintile, the likelihoods of not taking HbA1c tests, not recognising the term HbA1c, and not taking diabetic complication tests in the most deprived quintile were approximately 1.5 times (95% CI 1.25 to 1.80), 2.6 times (95% CI 1.97 to 3.45) and two times (95% CI 1.67 to 2.48) higher, respectively. In the most deprived quintile, CV value of clinics was the highest and the number of doctors was the lowest. Regional healthcare resource factors explained inequalities in managing diabetes by 14%-18%, especially in the most deprived quintile.

CONCLUSIONS

The results in this study suggest that socioeconomic inequalities in diabetes management may be explained by regional healthcare resource disparities. Policy interventions for a more even distribution of healthcare resources would likely reduce the magnitude of regional socioeconomic inequalities in diabetes management.

Retail food outlets and metabolic syndrome: a systematic review of longitudinal studies

CONTEXT

The community food environment covers the type, quantity, density, location, and access to retail food outlets, and its influence on eating behavior, obesity, and metabolic syndrome has been investigated.

OBJECTIVE

To evaluate the evidence on longitudinal associations between objectively measured retail food outlets and metabolic syndrome components in children, adolescents, and adults.

DATA EXTRACTION

This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Study quality and risk of bias were assessed with the Newcastle-Ottawa Scale.

DATA SOURCES

The Scopus, Embase, Web of Science, Scielo, PubMed, MEDLINE, and Lilacs databases were searched without any restriction on publication dates.

DATA ANALYSIS

Of the 18 longitudinal studies included, significant associations were reported in 9 between retail food outlets and metabolic syndrome components in adults (6 positive associations, 2 negative, and 1 both positive and negative), and in 3 studies of children and adolescents (2 negative associations and 1 both positive and negative). Six studies with adults found no association.

CONCLUSION

Limited evidence was found for longitudinal associations between retail food outlets and metabolic syndrome components. In future studies, researchers should consider the use of standardized retail food outlet measurements and accurate analysis to better understand the influence of the community food environment on metabolic syndrome.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no: CRD42020177137.

Health-Related Social Needs Facing Youth with NonAlcoholic Fatty Liver Disease

Background

The objective of this study was to identify the prevalence of health-related social needs among youth with nonalcoholic fatty liver disease (NAFLD).

Methods

Retrospective review of prospectively administered health-related social needs questionnaires from Steatohepatitis Clinics.

Results

Patients with NAFLD (n=271) were predominantly male (72%), and non-Hispanic (68%). The most common unmet need was food insecurity (13%, n=36). Families who endorsed food insecurity at the first visit were 27-fold more likely to have unmet health-related social needs persist at subsequent visits than those who were food-secure at their first visit (95% CI: 6.7-111).

Conclusion

Screening for social, economic, and environmental needs may identify previously unrecognized family challenges and may enhance intervention delivery, inform resource allocation, and improve outcomes.

Regional living conditions and the prevalence, awareness, treatment, control of hypertension at the individual level in Russia

Background

The objective of our study was to investigate the associations of characteristics inherent in large Russian Federation (RF) regions with prevalence, awareness, treatment and control of hypertension at the individual level.

Methods

Regional characteristics were obtained from the official website of the Federal State Statistics Service of the RF. We employed principal component analysis to reduce the dimensionality of data, which allowed defining five integral regional indices. Prevalence, awareness, treatment and control of hypertension were assessed from the data of the cross-sectional stage of ESSE-RF study conducted in 2013–2014. The final sample included 19,791 patients from 12 RF regions. Generalized estimating equations were used to identify the associations of regional indices with prevalence, awareness, treatment and control of hypertension at the individual level, taking into consideration nested data structures (study subjects in the regions).

Results

The index characterizing deterioration of social living conditions and societal marginalization exhibited positive associations with the prevalence of hypertension among men (OR = 1.18; 95% CI: 1.05–1.32) and elderly people (OR = 1.16; 95% CI: 1.02–1.32). Moreover, deterioration in the social environment was associated with a reduction in treatment (OR = 0.76; 95% CI: 0.64–0.90) and control of hypertension (OR = 0.79; 95% CI: 0.69–0.90). Hypertension awareness was directly connected with demographic crisis (OR = 1.13; 95% CI: 1.02–1.25) and augmented industrial development (OR = 1.15; 95% CI: 1.01–1.33) in the regions. The association of regional living conditions with the prevalence of hypertension is relatively weak, compared to predictors at the individual level, but this influence is important for awareness, treatment and control of hypertension.

Conclusion

The study contributed to evaluating the associations of the vital characteristics inherent in population of large RF regions with arterial hypertension prevalence, as well as with awareness, treatment and control of this disease. Our results provided original insights from the standpoint of cardiovascular disease epidemiology in the RF, as well as in the context of investigating the impact of living conditions on population health.

Diabetes control is associated with environmental quality in the USA

Environmental parameters, including built and sociodemographic environments, can impact diabetes control (DC). Epidemiological studies have associated specific environmental factors with DC; however, the impact of multidimensional environmental status has not been assessed. The Environmental Quality Index (EQI), a comprehensive quantitative metric capturing five environmental domains, was considered as an exposure. Age-adjusted rates of DC prevalence for each county in the United States were used as an outcome. DC was defined as the proportion of adults aged 20+ years with a previous diabetes diagnosis who currently do not have high fasting blood glucose (≥126 mg/dL) or elevated HbA1c (≥6.5). We conducted county-level analyses of DC prevalence rates for the years 2004-2012 in association with EQI for 2006-2010 and domain-specific indices using random intercept multilevel linear regression models clustered by state and controlled for county-level rates of obesity and physical inactivity. Analyses were stratified by rural-urban strata, and results are reported as prevalence rate differences (PRD) with 95% CIs comparing highest quintile/worst environmental quality to lowest quintile/best environmental quality. The association of DC with cumulative environmental quality was negative after control for all counties (PRD -0.32, 95% CI: -0.38, -0.27); suggesting that rates of DC worsen as environmental quality declines. While overall environmental quality exerts effects on DC that vary across the rural-urban spectrum, poor sociodemographic, and built environmental factors are associated with decreased DC nationally. These data suggest improvements in environmental quality mediated by larger-scale policy and practice interventions may improve glycemic control and reduce the morbidity and mortality arising from hyperglycemia.

Association of Real-time Continuous Glucose Monitoring With Glycemic Control and Acute Metabolic Events Among Patients With Insulin-Treated Diabetes

IMPORTANCE

Continuous glucose monitoring (CGM) is recommended for patients with type 1 diabetes; observational evidence for CGM in patients with insulin-treated type 2 diabetes is lacking.

OBJECTIVE

To estimate clinical outcomes of real-time CGM initiation.

DESIGN, SETTING, AND PARTICIPANTS

Exploratory retrospective cohort study of changes in outcomes associated with real-time CGM initiation, estimated using a difference-in-differences analysis. A total of 41 753 participants with insulin-treated diabetes (5673 type 1; 36 080 type 2) receiving care from a Northern California integrated health care delivery system (2014-2019), being treated with insulin, self-monitoring their blood glucose levels, and having no prior CGM use were included.

EXPOSURES

Initiation vs noninitiation of real-time CGM (reference group).

MAIN OUTCOMES AND MEASURES

Ten end points measured during the 12 months before and 12 months after baseline: hemoglobin A1c (HbA1c); hypoglycemia (emergency department or hospital utilization); hyperglycemia (emergency department or hospital utilization); HbA1c levels lower than 7%, lower than 8%, and higher than 9%; 1 emergency department encounter or more for any reason; 1 hospitalization or more for any reason; and number of outpatient visits and telephone visits.

RESULTS

The real-time CGM initiators included 3806 patients (mean age, 42.4 years [SD, 19.9 years]; 51% female; 91% type 1, 9% type 2); the noninitiators included 37 947 patients (mean age, 63.4 years [SD, 13.4 years]; 49% female; 6% type 1, 94% type 2). The prebaseline mean HbA1c was lower among real-time CGM initiators than among noninitiators, but real-time CGM initiators had higher prebaseline rates of hypoglycemia and hyperglycemia. Mean HbA1c declined among real-time CGM initiators from 8.17% to 7.76% and from 8.28% to 8.19% among noninitiators (adjusted difference-in-differences estimate, -0.40%; 95% CI, -0.48% to -0.32%; P < .001). Hypoglycemia rates declined among real-time CGM initiators from 5.1% to 3.0% and increased among noninitiators from 1.9% to 2.3% (difference-in-differences estimate, -2.7%; 95% CI, -4.4% to -1.1%; P = .001). There were also statistically significant differences in the adjusted net changes in the proportion of patients with HbA1c lower than 7% (adjusted difference-in-differences estimate, 9.6%; 95% CI, 7.1% to 12.2%; P < .001), lower than 8% (adjusted difference-in-differences estimate, 13.1%; 95% CI, 10.2% to 16.1%; P < .001), and higher than 9% (adjusted difference-in-differences estimate, -7.1%; 95% CI, -9.5% to -4.6%; P < .001) and in the number of outpatient visits (adjusted difference-in-differences estimate, -0.4; 95% CI, -0.6 to -0.2; P < .001) and telephone visits (adjusted difference-in-differences estimate, 1.1; 95% CI, 0.8 to 1.4; P < .001). Initiation of real-time CGM was not associated with statistically significant changes in rates of hyperglycemia, emergency department visits for any reason, or hospitalizations for any reason.

CONCLUSIONS AND RELEVANCE

In this retrospective cohort study, insulin-treated patients with diabetes selected by physicians for real-time continuous glucose monitoring compared with noninitiators had significant improvements in hemoglobin A1c and reductions in emergency department visits and hospitalizations for hypoglycemia, but no significant change in emergency department visits or hospitalizations for hyperglycemia or for any reason. Because of the observational study design, findings may have been susceptible to selection bias.

An external exposome-wide association study of COVID-19 mortality in the United States

The risk factors for severe COVID-19 beyond older age and certain underlying health conditions are largely unknown. Recent studies suggested that long-term environmental exposures may be important determinants of severe COVID-19. However, very few environmental factors have been studied, often separately, without considering the totality of the external environment (i.e., the external exposome). We conducted an external exposome-wide association study (ExWAS) using the nationwide county-level COVID-19 mortality data in the contiguous US. A total of 337 variables characterizing the external exposome from 8 data sources were integrated, harmonized, and spatiotemporally linked to each county. A two-phase procedure was used: (1) in Phase 1, a random 50:50 split divided the data into a discovery set and a replication set, and associations between COVID-19 mortality and individual factors were examined using mixed-effect negative binomial regression models, with multiple comparisons addressed, and (2) in Phase 2, a multivariable regression model including all variables that are significant from both the discovery and replication sets in Phase 1 was fitted. A total of 13 and 22 variables were significant in the discovery and replication sets in Phase 1, respectively. All the 4 variables that were significant in both sets in Phase 1 remained statistically significant in Phase 2, including two air toxicants (i.e., nitrogen dioxide or NO₂, and benzidine), one vacant land measure, and one food environment measure. This is the first external exposome study of COVID-19 mortality. It confirmed some of the previously reported environmental factors associated with COVID-19 mortality, but also generated unexpected predictors that may warrant more focused evaluation.

Influence of the urban context on the relationship between neighbourhood deprivation and obesity

BACKGROUND

In middle- and high-income countries, obesity is positively associated with neighbourhood deprivation. However, the moderating effect of the broader urban residential context on this relationship remains poorly understood.

METHODS

In this study, we have examined the nonlinear and geographically varying relationship between neighbourhood deprivation and the likelihood of being a person with overweight among participants of the French NutriNet-Santé adult cohort study (n = 68,698), adjusted for age, gender and educational level. Ten urban residential contexts (e.g., suburbs, peri-urban or rural areas) were defined. We used a multilevel generalised additive modelling framework for analyses.

RESULTS

We found that the relationship between neighbourhood deprivation and overweight differed according to urban context, in terms of both linearity and intensity. Overall, the deprivation-overweight relationship was strongly positive (with a higher prevalence of overweight in deprived neighbourhoods) in suburban areas of Paris and of other large French cities, while weak or null in small towns and rural areas, and intermediate in inner cities. In addition, we observed in suburbs of Paris and in peri-urban belts of large cities that beyond a certain level of neighbourhood deprivation, the relationship with overweight plateaued.

DISCUSSION

In a French population from a high-income country, suburbs, as well as moderately deprived neighbourhoods of peri-urban areas of large cities, are potential targets for public health and urban planning policies aiming at preventing obesity. Our results emphasize the value of local analyses to better capture the complexity and contextual variations of socioeconomic determinants of non-communicable diseases such as obesity.

The Neighborhood Deprivation Index and Provider Geocoding Identify Critical Catchment Areas for Diabetes Outreach

PURPOSE

In designing a Project ECHO™ type 1 diabetes (T1D) program in Florida and California, the Neighborhood Deprivation Index (NDI) was used in conjunction with geocoding of primary care providers (PCPs) and endocrinologists in each state to concurrently identify areas with low endocrinology provider density and high health risk/poverty areas. The NDI measures many aspects of poverty proven to be critical indicators of health outcomes.

METHODS

The data from the 2013-2017 American Community Survey (ACS) 5-year estimates were used to create NDI maps for California and Florida. In addition, geocoding and 30-minute drive-time buffers were performed using publicly available provider directories for PCPs and endocrinologists in both states by Google Geocoding API and the TravelTime Search Application Programming Interface (API).

RESULTS

Based on these findings, we defined high-need catchment areas as areas with (1) more than a 30-minute drive to the nearest endocrinologist but within a 30-minute drive to the nearest PCP; (2) an NDI in the highest quartile; and (3) a population above the median (5199 for census tracts, and 1394 for census block groups). Out of the 12 181 census tracts and 34 490 census block groups in California and Florida, we identified 57 tracts and 215 block groups meeting these criteria as high-need catchment areas.

CONCLUSION

Geospatial analysis provides an important initial methodologic step to effectively focus outreach efforts in diabetes program development. The integration of the NDI with geocoded provider directories enables more cost-effective and targeted interventions to reach the most vulnerable populations living with T1D.

A geospatial analysis of Type 2 Diabetes Mellitus and the food environment in urban New Zealand

The aim of this research is to analyse the spatial epidemiology of Type 2 Diabetes Mellitus (T2DM) and investigate associations with the built environment in urban New Zealand. Data on T2DM was sourced from the New Zealand Virtual Diabetes Register (2016), and data on environmental variables sourced from the Ministry for Primary Industries and Territorial Authorities (2013-2016). Novel measures of the built environment using an enhanced two-step floating catchment area model were established using data on fast food outlets, takeaways, dairy/convenience stores, supermarkets and fruit/vegetable stores. Rates of T2DM per 1000 population and standardised morbidity ratios were computed and visualised for all urban areas. Getis Ord was used to assess spatial clustering, and Bayesian modelling was used to understand associations between T2DM and environmental variables. Results indicate that T2DM is influenced by demographic factors, spatially clustered and associated with accessibility to environmental exposures. Health-promoting resources, such as fruit/vegetable stores, were shown to have a consistently protective effect on T2DM while those considered detrimental to health showed varying, and largely insignificant, associations. This is the first study in New Zealand to spatially quantify the effects of multiple environmental exposures on population level T2DM for all urban areas using a geospatial approach. It has implications for both policy and future research efforts as a deeper knowledge of local environments forms a basis on which to better understand spatial associations between the built environment and health, as well as formulate policy directed toward environmental influences on chronic health conditions.

Muscle Mass Is Linked to Liver Disease Severity in Pediatric Nonalcoholic Fatty Liver Disease

OBJECTIVE

To investigate the association between muscle mass and liver disease severity in pediatric patients with non-alcoholic fatty liver disease (NAFLD).

STUDY DESIGN

This was a retrospective study of patients aged <20 years followed from 2009 to 2018. Muscle mass was estimated in all patients by measuring magnetic resonance imaging-based total psoas muscle surface area (tPMSA) and correcting for height (tPMSA index = tPMSA/height²). Two cohorts were studied, one with histological confirmation of NAFLD (n = 100) and the other with magnetic resonance imaging (MRI) evidence of hepatic steatosis (n = 236). Histology was scored using Nonalcoholic Steatohepatitis Clinical Research Network (NASH CRN) criteria. MRI-measured proton density fat fraction (PDFF) and liver stiffness were collected. Demographic, clinical, and socioeconomic status (using a validated Community Deprivation Index [CDI]) were assessed as covariates. Univariate regression analyses, followed by multivariable regression analyses, were used to determine the relationships between tPMSA index and NAS, MRI-PDFF, and liver stiffness, adjusting for clinical, demographic, and CDI variables.

RESULTS

In the multivariable regression analyses, higher steatosis score was associated with a lower tPMSA index (OR, 0.73; 95% CI, 0.56-0.96) and younger age (OR, 0.84; 95% CI, 0.73-0.97). Liver PDFF was also significantly associated with the tPMSA index (P = .029), sex (P = .019), and CDI (P = .005). In contrast, liver stiffness was not associated with tPMSA in multivariable analyses.

CONCLUSIONS

tPMSA index was independently associated with both imaging and histological features of hepatic steatosis severity in children. Future studies should directly explore the presence and directionality of causative links between muscle mass and steatosis, as well as whether interventions that enhance muscle mass can reduce disease severity in children with NAFLD.

Geographic variation in cardiometabolic risk factor prevalence explained by area-level disadvantage in the Illawarra-Shoalhaven region of the NSW, Australia

Cardiometabolic risk factors (CMRFs) demonstrate significant geographic variation in their distribution. The study aims to quantify the general contextual effect of the areas on CMRFs; and the geographic variation explained by area-level socioeconomic disadvantage. A cross sectional design and multilevel logistic regression methods were adopted. Data included objectively measured routine pathology test data between years 2012 and 2017 on: fasting blood sugar level; glycated haemoglobin; total cholesterol; high density lipoprotein; urinary albumin creatinine ratio; estimated glomerular filtration rate; and body mass index. The 2011 Australian census based Index of Relative Socioeconomic Disadvantage (IRSD) were the area-level study variables, analysed at its smallest geographic unit of reporting. A total of 1,132,029 CMRF test results from 256,525 individuals were analysed. After adjusting for individual-level covariates, all CMRFs significantly associated with IRSD and the probability of higher risk CMRFs increases with greater area-level disadvantage. Though the specific contribution of IRSD in the geographic variation of CMRF ranged between 57.8 and 14.71%, the general contextual effect of areas were found minimal (ICCs 0.6-3.4%). The results support universal interventions proportional to the need and disadvantage level of populations for the prevention and control of CMRFs, rather than any area specific interventions as the contextual effects were found minimal in the study region.

Neighborhood Poverty and Control of HIV, Hypertension, and Diabetes in the Women's Interagency HIV Study

Neighborhoods with high poverty rates have limited resources to support residents' health. Using census data, we calculated the proportion of each Women's Interagency HIV Study participant's census tract (neighborhood) living below the poverty line. We assessed associations between neighborhood poverty and (1) unsuppressed viral load [VL] in HIV-seropositive women, (2) uncontrolled blood pressure among HIV-seropositive and HIV-seronegative hypertensive women, and (3) uncontrolled diabetes among HIV-seropositive and HIV-seronegative diabetic women using modified Poisson regression models. Neighborhood poverty was associated with unsuppressed VL in HIV-seropositive women (> 40% versus ≤ 20% poverty adjusted prevalence ratio (PR), 1.42; 95% confidence interval (CI) 1.04-1.92). In HIV-seronegative diabetic women, moderate neighborhood poverty was associated with uncontrolled diabetes (20-40% versus ≤ 20% poverty adjusted PR, 1.75; 95% CI 1.02-2.98). Neighborhood poverty was associated with neither uncontrolled diabetes among HIV-seropositive diabetic women, nor uncontrolled hypertension in hypertensive women, regardless of HIV status. Women living in areas with concentrated poverty may need additional resources to control health conditions effectively.

Neighborhood deprivation, prefrontal morphology and neurocognition in late childhood to early adolescence

Background:

Neighborhood deprivation adversely effects neurodevelopment and cognitive function; however, mechanisms remain unexplored. Neighborhood deprivation could be particularly impactful in late childhood/early adolescence, in neural regions with protracted developmental trajectories, e.g., prefrontal cortex (PFC).

Methods:

The Adolescent Brain Cognitive Development (ABCD) study recruited 10,205 youth. Geocoded residential history was used to extract individual neighborhood characteristics. A general cognitive ability index and MRI scans were completed. Associations with neurocognition were examined. The relation of PFC surface area and cortical thickness to neighborhood deprivation was tested. PFC subregions and asymmetry, with putative differential environmental susceptibility during key developmental periods, were explored. Analyses tested PFC area as a possible mediating mechanism.

Results:

Neighborhood deprivation predicted neurocognitive performance (β = −0.11), even after accounting for parental education and household income (β = −0.07). Higher neighborhood deprivation related to greater overall PFC surface area (η²_p = 0.003), and differences in leftward asymmetry were observed for area (η²_p = 0.001), and thickness (η²_p = 0.003). Subregion analyses highlighted differences among critical areas that are actively developing in late childhood/early adolescence and are essential to modulating high order cognitive function. These included orbitofrontal, superior frontal, rostral middle frontal, and frontal pole regions (Cohen’s d = 0.03–0.09). PFC surface area partially mediated the relation between neighborhood deprivation and neurocognition.

Discussion:

Neighborhood deprivation related to cognitive function (a foundational skill tied to a range of lifetime outcomes) and PFC morphology, with evidence found for partial mediation of PFC on neurocognitive function. Results inform public health conceptualizations of development and environmental vulnerability.

The Area Deprivation Index: A novel tool for harmonizable risk assessment in Alzheimer's disease research

INTRODUCTION

Residence in a disadvantaged neighborhood associates with adverse health exposures and outcomes, and may increase risk for cognitive impairment and dementia. Utilization of a publicly available, geocoded disadvantage metric could facilitate efficient integration of social determinants of health into models of cognitive aging.

METHODS

Using the validated Area Deprivation Index and two cognitive aging cohorts, we quantified Census block-level poverty, education, housing, and employment characteristics for the neighborhoods of 2119 older adults. We assessed relationships between neighborhood disadvantage and cognitive performance in domains sensitive to age-related change.

RESULTS

Participants in the most disadvantaged neighborhoods (n = 156) were younger, more often female, and less often college-educated or white than those in less disadvantaged neighborhoods (n = 1963). Disadvantaged neighborhood residence associated with poorer performance on tests of executive function, verbal learning, and memory.

DISCUSSION

This geospatial metric of neighborhood disadvantage may be valuable for exploring socially rooted risk mechanisms, and prioritizing high-risk communities for research recruitment and intervention.

Diabetes management at community health centers: Examining associations with patient and regional characteristics, efficiency, and staffing patterns

A major source of primary health care for millions of Americans, community health centers (CHCs) act as a key point of access for diabetes care. The ability of a CHC to deliver high quality care, that supports patients' management of their diabetes, may be impacted by the unique set of resources and constraints it faces, both in terms of characteristics of its patient population and aspects of operations. This study examines how patient and regional characteristics, staffing patterns, and efficiency were associated with diabetes management at CHCs (percentage of patients with uncontrolled diabetes, HbA1C > 9%). Data on a sample of 1229 CHCs came from multiple sources. CHC-level information was obtained from the Uniform Data System and regional-level information from the Behavioral Risk Factor Surveillance System and the US Census American Community Survey. A clustering methodology, latent class analysis, identified seven underlying staffing patterns at CHCs. Data envelopment analysis was performed to evaluate the efficiency of CHCs, relative to centers with similar staffing patterns. Finally, generalized linear models were used to examine the association between staffing patterns, efficiency, and patient and regional-level characteristics. Findings from this study have sociological, practical, and methodological implications. Findings highlight that the intersection of patient racial composition with regional racial composition is significant; diabetes control appears to be worse at CHCs serving racial minorities living in predominantly White areas. Findings suggest that CHCs that incorporate more behavioral health care into their staffing mix have lower rates of uncontrolled diabetes among their patients. Finally, greater efficiency in CHC operations is associated with better diabetes control among patients. By identifying sociodemographic and operational characteristics associated with better hemoglobin control among diabetes patients, the current study contributes to our understanding of both health care operations and health inequalities.

Residential mobility and chronic disease among World Trade Center Health Registry enrollees, 2004-2016

Residential mobility is hypothesized to impact health through changes to the built environment and disruptions in social networks, and may vary by neighborhood deprivation exposure. However, there are few longitudinal investigations of residential mobility in relation to health outcomes. This study examined enrollees from the World Trade Center Health Registry, a longitudinal cohort of first responders and community members in lower Manhattan on September 11, 2001. Enrollees who completed ≥2 health surveys between 2004 and 2016 and did not have diabetes (N = 44,089) or hypertension (N = 35,065) at baseline (i.e., 2004) were included. Using geocoded annual home addresses, residential mobility was examined using two indicators: moving frequency and displacement. Moving frequency was defined as the number of times someone was recorded as living in a different neighborhood; displacement as any moving to a more disadvantaged neighborhood. We fit adjusted Cox proportional hazards models with time-dependent exposures (moving frequency and displacement) and covariates to evaluate associations with incident diabetes and hypertension. From 2004 to 2016, the majority of enrollees never moved (54.5%); 6.5% moved ≥3 times. Those who moved ≥3 times had a similar hazard of diabetes (hazard ratio (HR) = 0.78; 95% Confidence Interval (CI): 0.40, 1.53) and hypertension (HR = 0.99; 95% CI: 0.68, 1.43) compared with those who never moved. Similarly, displacement was not associated with diabetes or hypertension. Residential mobility was not associated with diabetes or hypertension among a cohort of primarily urban-dwelling adults.

Living in Food Deserts and Adverse Cardiovascular Outcomes in Patients With Cardiovascular Disease

Background

Food deserts (FDs), defined as low‐income communities with limited access to healthy food, are a growing public health concern. We evaluated the impact of living in FDs on incident cardiovascular events.

Methods and Results

We recruited 4944 subjects (age 64±12, 64% male) undergoing cardiac catheterization into the Emory Cardiovascular Biobank. Using the US Department of Agriculture definition of FD, we determined whether their residential addresses had (1) poor access to healthy food, (2) low income, or (3) both (=FD). Subjects were prospectively followed for a median of 3.2 years for myocardial infarction (MI) and death. Fine and Gray's subdistribution hazard models for MI and Cox proportional hazard models for death/MI were used to examine the association between area characteristics (FD, poor access, and low income) and the rates of adverse events after adjusting for traditional risk factors. A total of 981 (20%) lived in FDs and had a higher adjusted risk of MI (subdistribution hazard ratio, 1.44 [95% CI, 1.06–1.95]) than those living in non‐FDs. In a multivariate analysis including both food access and area income, only living in a low‐income area was associated with a higher adjusted risk of MI (subdistribution hazard ratio, 1.40 [1.06–1.85]) and death/MI (hazard ratio, 1.18 [1.02–1.35]) while living in a poor‐access area was not significantly associated with either (subdistribution hazard ratio, 1.05 [0.80–1.38] and hazard ratio, 0.99 [0.87–1.14], respectively).

Conclusions

Living in an FD is associated with a higher risk of adverse cardiovascular events in those with coronary artery disease. Specifically, low area income of FDs, not poor access to food, was significantly associated with worse outcomes.

Community Socioeconomic Deprivation and Nonalcoholic Fatty Liver Disease Severity

BACKGROUND AND OBJECTIVES

Nonalcoholic fatty liver disease (NAFLD) is linked to obesity. Obesity is associated with lower socioeconomic status (SES). An independent link between pediatric NAFLD and SES has not been elucidated. The objective of this study was to evaluate the distribution of socioeconomic deprivation, measured using an area-level proxy, in pediatric patients with known NAFLD and to determine whether deprivation is associated with liver disease severity.

METHODS

Retrospective study of patients <21 years with NAFLD, followed from 2009 to 2018. The patients' addresses were mapped to census tracts, which were then linked to the community deprivation index (CDI; range 0--1, higher values indicating higher deprivation, calculated from six SES-related variables available publicly in US Census databases).

RESULTS

Two cohorts were evaluated; 1 with MRI (magnetic resonance imaging) and/or MRE (magnetic resonance elastography) findings indicative of NAFLD (n = 334), and another with biopsy-confirmed NAFLD (n = 245). In the MRI and histology cohorts, the majority were boys (66%), non-Hispanic (77%-78%), severely obese (79%-80%), and publicly insured (55%-56%, respectively). The median CDI for both groups was 0.36 (range 0.15-0.85). In both cohorts, patients living above the median CDI were more likely to be younger at initial presentation, time of MRI, and time of liver biopsy. MRI-measured fat fraction and liver stiffness, as well as histologic characteristics were not different between the high- and low-deprivation groups.

CONCLUSIONS

Children with NAFLD were found across the spectrum of deprivation. Although children from more deprived neighborhoods present at a younger age, they exhibit the same degree of NAFLD severity as their peers from less deprived areas.

Neighbourhood socioeconomic status and overweight/obesity: a systematic review and meta-analysis of epidemiological studies

OBJECTIVE

Low neighbourhood socioeconomic status (NSES) has been linked to a higher risk of overweight/obesity, irrespective of the individual's own socioeconomic status. No meta-analysis study has been done on the association. Thus, this study was done to synthesise the existing evidence on the association of NSES with overweight, obesity and body mass index (BMI).

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

PubMed, Embase, Scopus, Cochrane Library, Web of Sciences and Google Scholar databases were searched for articles published until 25 September 2019.

ELIGIBILITY CRITERIA

Epidemiological studies, both longitudinal and cross-sectional ones, which examined the link of NSES to overweight, obesity or BMI, were included.

DATA EXTRACTION AND SYNTHESIS

Data extraction was done by two reviewers, working independently. The methodological quality of included studies was assessed using the Newcastle-Ottawa Scale for the observational studies. The summary estimates of the relationships of NSES with overweight, obesity and BMI statuses were calculated with random-effects meta-analysis models. Heterogeneity was assessed by Cochran's Q and I² statistics. Subgroup analyses were done by age categories, continents, study designs and NSES measures. Publication bias was assessed by visual inspection of funnel plots and Egger's regression test.

RESULT

A total of 21 observational studies, covering 1 244 438 individuals, were included in this meta-analysis. Low NSES, compared with high NSES, was found to be associated with a 31% higher odds of overweight (pooled OR 1.31, 95% CI 1.16 to 1.47, p<0.001), a 45% higher odds of obesity (pooled OR 1.45, 95% CI 1.21 to 1.74, p<0.001) and a 1.09 kg/m² increase in mean BMI (pooled beta=1.09, 95% CI 0.67 to 1.50, p<0.001).

CONCLUSION

NSES disparity might be contributing to the burden of overweight/obesity. Further studies are warranted, including whether addressing NSES disparity could reduce the risk of overweight/obesity.

PROSPERO REGISTRATION NUMBER

CRD42017063889.

Nutrition and Health Improvements After Participation in an Urban Home Garden Program

OBJECTIVE

To elucidate the perceived health benefits of an urban home gardening and nutritional education program in a population at high cardiometabolic risk.

DESIGN

Qualitative data collected via in-depth, semistructured interviews in Spanish or English.

SETTING

Community-based program offering supported urban home gardening together with nutrition education in Santa Clara County, CA.

PARTICIPANTS

A total of 32 purposively sampled low-income participants in an urban home gardening program. Participants were primarily female (n = 24) and Latino/a (n = 22).

PHENOMENON OF INTEREST

Perceptions of the nutrition and health benefits of education-enhanced urban home gardening.

ANALYSIS

Bilingual researchers coded transcripts using a hybrid inductive and deductive approach. Two coders double coded at intervals, independently reviewed coding reports, organized content into key themes, and selected exemplary quotations.

RESULTS

The most salient perceived impacts were greater food access, increased consumption of fresh produce, a shift toward home cooking, and decreased fast food consumption. Participants attributed these changes to greater affordability, freshness, flavor, and convenience of their garden produce; increased health motivation owing to pride in their gardens; and improved nutritional knowledge. Participants also reported improved physical activity, mental health, and stress management; some reported improved weight and adherence to diabetes-healthy diets.

CONCLUSIONS AND IMPLICATIONS

Education-enhanced urban home gardening may facilitate multidimensional nutrition and health improvements in marginalized populations at high cardiometabolic risk.

Randomized Trial of a Lifestyle Intervention for Urban Low-Income African Americans with Type 2 Diabetes

BACKGROUND

African Americans suffer more than non-Hispanic whites from type 2 diabetes, but diabetes self-management education (DSME) has been less effective at improving glycemic control for African Americans. Our objective was to determine whether a novel, culturally tailored DSME intervention would result in sustained improvements in glycemic control in low-income African-American patients of public hospital clinics.

RESEARCH DESIGN AND METHODS

This randomized controlled trial (n = 211) compared changes in hemoglobin A1c (A1c) at 6, 12, and 18 months between two arms: (1) Lifestyle Improvement through Food and Exercise (LIFE), a culturally tailored, 28-session community-based intervention, focused on diet and physical activity, and (2) a standard of care comparison group receiving two group DSME classes. Cluster-adjusted ANCOVA modeling was used to assess A1c changes from baseline to 6, 12, and 18 months, respectively, between arms.

RESULTS

At 6 months, A1c decreased significantly more in the intervention group than the control group (- 0.76 vs - 0.21%, p = 0.03). However, by 12 and 18 months, the difference was no longer significant (12 months - 0.63 intervention vs - 0.45 control, p = 0.52). There was a decrease in A1c over 18 months in both the intervention (β = - 0.026, p = 0.003) and the comparison arm (β = - 0.018, p = 0.048) but no difference in trend (p = 0.472) between arms. The intervention group had greater improvements in nutrition knowledge (11.1 vs 6.0 point change, p = 0.002) and diet quality (4.0 vs - 0.5 point change, p = 0.018) while the comparison group had more participants with improved medication adherence (24% vs 10%, p < 0.05) at 12 months.

CONCLUSIONS

The LIFE intervention resulted in improved nutrition knowledge and diet quality and the comparison intervention resulted in improved medication adherence. LIFE participants showed greater A1c reduction than standard of care at 6 months but the difference between groups was no longer significant at 12 and 18 months.

NIH TRIAL REGISTRY NUMBER

NCT01901952.

Diabetes and the Built Environment: Evidence and Policies

PURPOSE OF REVIEW

To explore the relationship between the built environment and type 2 diabetes, considering both risk factors and policies to reduce risk. The built environment refers to the physical characteristics of the areas in which people live including buildings, streets, open spaces, and infrastructure.

RECENT FINDINGS

A review of current literature suggests an association between the built environment and type 2 diabetes, likely driven by two key pathways-physical activity and the food environment. Other hypothesized mechanisms linking the built environment and type 2 diabetes include housing policy, but evidence in these areas is underdeveloped. Policies designed to enhance the built environment for diabetes risk reduction are mechanistically plausible, but as of yet, little direct evidence supports their effectiveness in reducing in type 2 diabetes risk. Future work should rigorously evaluate policies meant to reduce type 2 diabetes via the built environment.

Understanding Risk Environments in Permanent Supportive Housing for Formerly Homeless Adults

In this study, we used ethnographic methods and a risk environment framework to consider how contextual factors produce or reduce risk for substance use with a sample of 27 adults who recently moved into permanent supportive housing (PSH). Most apparent was how the social and physical environments interacted, because most participants focused on how having an apartment had dramatically changed their lives and how they interact with others. Specific themes that emerged that also involved economic and policy environments included the following: isolation versus social engagement; becoming one's own caseworker; and engaging in identity work. This study underscores the scarcity yet importance of research that examines the multiple types of environment in which PSH is situated, and suggests that a better understanding of how these environments interact to produce or reduce risk is needed to develop optimal interventions and support services.

Association between neighborhood-level socioeconomic deprivation and incident hypertension: A longitudinal analysis of data from the Dallas heart study

BACKGROUND

Cardiovascular disease is a leading economic and medical burden in the United States (US). As an important risk factor for cardiovascular disease, hypertension represents a critical point of intervention. Less is known about longitudinal effects of neighborhood deprivation on blood pressure outcomes, especially in light of new hypertension guidelines.

METHODS

Longitudinal data from the Dallas Heart Study facilitated multilevel regression analysis of the relationship between neighborhood deprivation, blood pressure change, and incident hypertension over a 9-year period. Factor analysis explored neighborhood perception, which was controlled for in all analyses. Neighborhood deprivation was derived from US Census data and divided into tertiles for analysis. Hypertension status was compared using pre-2017 and 2017 hypertension guidelines.

RESULTS

After adjusting for covariates, including moving status and residential self-selection, we observed significant associations between residing in the more deprived neighborhoods and 1) increasing blood pressure over time and 2) incident hypertension. In the fully adjusted model of continuous blood pressure change, significant relationships were seen for both medium (SBP: β = 4.81, SE = 1.39, P = .0005; DBP: β = 2.61, SE = 0.71, P = .0003) and high deprivation (SBP: β = 7.64, SE = 1.55, P < .0001; DBP: β = 4.64, SE = 0.78, P < .0001). In the fully adjusted model of incident hypertension, participants in areas of high deprivation had 1.69 higher odds of developing HTN (OR 1.69; 95% CI 1.02, 2.82), as defined by 2017 hypertension guidelines. Results varied based on definition of hypertension used (pre-2017 vs. 2017 guidelines).

CONCLUSION

These findings highlight the potential impact of adverse neighborhood conditions on cardiometabolic outcomes, such as hypertension.

Socio-economic status and HbA1c in type 2 diabetes: A systematic review and meta-analysis

Up until now, differences in HbA_1c levels by socio-economic status (SES) have been identified, but not yet quantified in people with type 2 diabetes. The aim of this study was therefore to assess the difference in HbA_1c levels between people with type 2 diabetes of different SES in a systematic review and meta-analysis. A systematic literature search was conducted in MEDLINE, Embase, Ebsco, and the Cochrane Library until January 14, 2018. Included studies described adults with type 2 diabetes in whom the association between SES and HbA_1c levels was studied. Studies were rated for methodological quality and data were synthesized quantitatively (meta-analysis) and qualitatively (levels of evidence), stratified for type of SES variable, i.e., education, income, deprivation, and employment. Fifty-one studies were included: 15 high, 27 moderate, and 9 of low methodological quality. Strong evidence was provided that people of low SES have higher HbA_1c levels than people of high SES, for deprivation, education, and employment status. The pooled mean difference in HbA_1c levels between people of low and high SES was 0.26% (95% CI, 0.09-0.43) or 3.12 mmol/mol (95% CI, 1.21-5.04) for education and 0.20% (95% CI, -0.05 to 0.46) or 2.36 mmol/mol (95%CI, -0.61 to 5.33) for income. In conclusion, our systematic review and meta-analysis showed that there was an inverse association between SES and HbA_1c levels in people with type 2 diabetes. Future research should focus on finding SES-sensitive strategies to reduce HbA_1c levels in people with type 2 diabetes.

Socioeconomic status and time in glucose target range in people with type 2 diabetes: a baseline analysis of the GP-OSMOTIC study

BACKGROUND

Optimal glycaemia, reflected by glycated haemoglobin (HbA1c) levels, is key in reducing type 2 diabetes (T2D) complications. However, most people with T2D have suboptimal recall and understanding of HbA1c. Continuous glucose monitoring (CGM) measures glucose levels every 5 to 15-min over days and may be more readily understood. Given that T2D is more common in lower socioeconomic settings, we aim to study relationships between socioeconomic status (SES) and percentage time in glucose target range (TIR) which is a key metric calculated from CGM.

METHODS

Analysis of baseline data from the General Practice Optimising Structured MOnitoring To Improve Clinical outcomes (GP-OSMOTIC) randomised controlled trial (October 2016 - November 2017) of 300 people with T2D from 25 Victorian General Practices. FreeStyle Libre Pro® sensor patch was used for this study. SES was defined by the Index of Relative Socio-economic Disadvantage (IRSD) and educational attainment. Univariable and multivariable mixed-effects linear regression analyses controlling for age, BMI, diet, exercise and study arm were performed.

RESULTS

One hundred and sixty-seven (60.1%) participants were male, the mean (SD) participant age was 61.0 (9.7) years, and the mean (SD) duration of CGM use was 12.3 (2.5) days. The 10th IRSD decile (least disadvantaged) was associated with a 15% higher TIR vs. the 1st decile (most disadvantaged) (95% CI 5, 25; p = 0.003) and a 0.6% lower HbA1c (95% CI 0.1, 1; p = 0.03). There was no evidence of an association between educational attainment and TIR/HbA1c.

CONCLUSION

Higher SES measured at an area level is associated with better achievement of glycaemic target using complementary measures of HbA1c and TIR in the GP-OSMOTIC cohort. Given that TIR may be more easily used in patient education and self-management support compared to HbA1c values, the social gradient identified in TIR provides an opportunity for clinicians and policy makers to address health inequities in T2D.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry Trial ACTRN12616001372471 , prospective, Date registered 4/10/2016.

Association of Initiation of Basal Insulin Analogs vs Neutral Protamine Hagedorn Insulin With Hypoglycemia-Related Emergency Department Visits or Hospital Admissions and With Glycemic Control in Patients With Type 2 Diabetes

IMPORTANCE

In clinical trials of patients with type 2 diabetes, long-acting insulin analogs modestly reduced the risk of nocturnal hypoglycemia compared with human neutral protamine Hagedorn (NPH) insulin, but cost 2 to 10 times more. Outcomes in clinical practice may differ from trial results.

OBJECTIVE

To compare the rates of hypoglycemia-related emergency department (ED) visits or hospital admissions associated with initiation of long-acting insulin analogs vs human NPH insulin in patients with type 2 diabetes.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective observational study using data from Kaiser Permanente of Northern California from January 1, 2006, through September 30, 2015. Patients with type 2 diabetes who initiated a long-acting insulin analog or NPH insulin were included and censored at death, loss of health plan coverage, change in insulin treatment, or study end on September 30, 2015.

EXPOSURE

Initiation of basal insulin analogs (glargine or detemir) vs NPH insulin.

MAIN OUTCOMES AND MEASURES

The primary outcome was the time to a hypoglycemia-related ED visit or hospital admission and the secondary outcome was the change in hemoglobin A1c level within 1 year of insulin initiation.

RESULTS

There were 25 489 patients with type 2 diabetes who initiated basal insulin therapy (mean age, 60.2 [SD, 11.8] years; 51.9% white; 46.8% female). During a mean follow-up of 1.7 years, there were 39 hypoglycemia-related ED visits or hospital admissions among 1928 patients who initiated insulin analogs (11.9 events [95% CI, 8.1 to 15.6] per 1000 person-years) compared with 354 hypoglycemia-related ED visits or hospital admissions among 23 561 patients who initiated NPH insulin (8.8 events [95% CI, 7.9 to 9.8] per 1000 person-years) (between-group difference, 3.1 events [95% CI, -1.5 to 7.7] per 1000 person-years; P = .07). Among 4428 patients matched by propensity score, the adjusted hazard ratio was 1.16 (95% CI, 0.71 to 1.78) for hypoglycemia-related ED visits or hospital admissions associated with insulin analog use. Within 1 year of insulin initiation, hemoglobin A1c level decreased from 9.4% (95% CI, 9.3% to 9.5%) to 8.2% (95% CI, 8.1% to 8.2%) after initiation of insulin analogs and from 9.4% (95% CI, 9.3% to 9.5%) to 7.9% (95% CI, 7.9% to 8.0%) after initiation of NPH insulin (adjusted difference-in-differences for glycemic control, -0.22% [95% CI, -0.09% to -0.37%]).

CONCLUSIONS AND RELEVANCE

Among patients with type 2 diabetes, initiation of a basal insulin analog compared with NPH insulin was not associated with a reduced risk of hypoglycemia-related ED visits or hospital admissions or with improved glycemic control. These findings suggest that the use of basal insulin analogs in usual practice settings may not be associated with clinical advantages for these outcomes.

Outcomes of Secondary Prevention among Coronary Heart Disease Patients in a High-Risk Region in Finland

Despite comprehensive national treatment guidelines, goals for secondary prevention of coronary heart disease (CHD) have not been sufficiently met everywhere in Finland. We investigated the recorded risk factor rates of CHD and their spatial differences in North Karelia Hospital District, which has a very high cardiovascular burden, in order to form a general view of the state of secondary prevention in a high-risk region. Appropriate disease codes of CHD-diagnoses and coding for percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) were used to identify from the electronic patient records the patient group eligible for secondary prevention. The cumulative incidence rate of new patients (n = 2556) during 2011–2014 varied from 1.9% to 3.5% between municipalities. The success in secondary prevention of CHD was assessed using achievement of treatment targets as defined in national guidelines. Health centres are administrated by municipalities whereupon the main reporting units were municipalities, together with composed classification of patients by age, gender and dwelling location. Health disparities between municipalities, settlement types and patient groups were found and are interpreted. Moreover, spatial high-risk and low-risk clusters of acute CHD were detected. The proportion of patients achieving the treatment targets of low-density lipoprotein cholesterol (LDL-C) varied from 21% to 38% between municipalities. Variation was also observed in the follow-up of patients; e.g., the rate of follow-up measurements of LDL-C in municipalities varied from 72% to 86%. Spatial variation in patients’ sociodemographic and neighbourhood characteristics and morbidity burden partly explain the differences in outcomes, but there are also very likely differences in the care process between municipalities which requires a study in its own right.