International Diabetes Federation Position Statement on the 1-hour post-load plasma glucose for the diagnosis of intermediate hyperglycaemia and type 2 diabetes

Many individuals with intermediate hyperglycaemia (IH), including impaired fasting glycaemia (IFG) and impaired glucose tolerance (IGT), as presently defined, will progress to type 2 diabetes (T2D). There is confirmatory evidence that T2D can be prevented by lifestyle modification and/or medications, in people with IGT diagnosed by 2-h plasma glucose (PG) during a 75-gram oral glucose tolerance test (OGTT). Over the last 40 years, a wealth of epidemiological data has confirmed the superior value of 1-h plasma glucose (PG) over fasting PG (FPG), glycated haemoglobin (HbA1c) and 2-h PG in populations of different ethnicity, sex and age in predicting diabetes and associated complications including death. Given the relentlessly rising prevalence of diabetes, a more sensitive, practical method is needed to detect people with IH and T2D for early prevention or treatment in the often lengthy trajectory to T2D and its complications. The International Diabetes Federation (IDF) Position Statement reviews findings that the 1-h post-load PG ≥ 155 mg/dL (8.6 mmol/L) in people with normal glucose tolerance (NGT) during an OGTT is highly predictive for detecting progression to T2D, micro- and macrovascular complications, obstructive sleep apnoea, cystic fibrosis-related diabetes mellitus, metabolic dysfunction-associated steatotic liver disease, and mortality in individuals with risk factors. The 1-h PG of 209 mg/dL (11.6 mmol/L) is also diagnostic of T2D. Importantly, the 1-h PG cut points for diagnosing IH and T2D can be detected earlier than the recommended 2-h PG thresholds. Taken together, the 1-h PG provides an opportunity to avoid misclassification of glycaemic status if FPG or HbA1c alone are used. The 1-h PG also allows early detection of high-risk people for intervention to prevent progression to T2D which will benefit the sizeable and growing population of individuals at increased risk of T2D. Using a 1-h OGTT, subsequent to screening with a non-laboratory diabetes risk tool, and intervening early will favourably impact the global diabetes epidemic. Health services should consider developing a policy for screening for IH based on local human and technical resources. People with a 1-h PG ≥ 155 mg/dL (8.6 mmol/L) are considered to have IH and should be prescribed lifestyle intervention and referred to a diabetes prevention program. People with a 1-h PG ≥ 209 mg/dL (11.6 mmol/L) are considered to have T2D and should have a repeat test to confirm the diagnosis of T2D and then referred for further evaluation and treatment. The substantive data presented in the Position Statement provides strong evidence for redefining current diagnostic criteria for IH and T2D by adding the 1-h PG.

Large-Scale, Primary Care-Based Hepatitis C Treatment in an Urban, Medically Underserved Patient Population

Hepatitis C virus (HCV) infection is a critical public health concern in the United States. HCV is highly curable, but access to care is limited for many patients. Primary care models can expand access to HCV care. The Grady Liver Clinic (GLC) is a primary care-based HCV clinic founded in 2002. During 20 years, using a multidisciplinary team, the GLC expanded its operations in response to advances in HCV screening and treatment. We describe the clinic model, patient population, and treatment outcomes of the clinic from 2015 through 2019. During this period, 2689 patients were seen in the GLC, and 77% (n = 2083) initiated treatment. Eighty-five percent (1779 of 2083) of patients who started treatment completed treatment and were tested for cure, and 1723 (83% of the total treated cohort, 97% of those tested for cure) were cured. Building on a successful primary care-based treatment model, the GLC dynamically responded to the changes in HCV screening and treatment guidelines, continually increasing access to HCV care. The GLC serves as a model of primary care-based HCV care that aims to achieve HCV microelimination in a safety-net health system. Our findings support the notion that for the United States to achieve elimination of HCV by 2030, generalists can and should provide HCV care, particularly in medically underserved patient populations.

Effect of home-based lifestyle interventions on cognition in older adults with mild cognitive impairment: a systematic review

BACKGROUND

Mild Cognitive Impairment (MCI) is frequently a precursor to dementia, affecting aspects of cognition such as language, thinking, or memory. Lifestyle interventions are increasingly studied as potential means to slow the progression from MCI to dementia.

OBJECTIVE

A systematic review was conducted to investigate the effectiveness of home-based lifestyle interventions in reducing cognitive decline in older adults with MCI.

METHODS

A systematic review of randomized controlled trials (RCTs) was conducted to identify home-based lifestyle interventions for individuals with MCI from 1980 to 2023. These interventions were either single-component or multi-component and included diet, physical activity, stress-reduction, or cognitive stimulation treatments to assess their impact on cognition. We performed a comprehensive search in the PubMed, Web of Science, Google Scholar, Embase, and MEDLINE databases.

RESULTS

From 320 abstracts, 20 (6.25%) studies met the criteria for inclusion, with five multi-component and fifteen single-component studies. Eighteen home-based lifestyle interventions for MCI patients were focused on physical activity, diet, and/or cognitive training, while two studies were identified that incorporated stress reduction training as a method to improve cognitive function. Nineteen studies reported significant improvements in cognitive performance between the experimental and control groups post-intervention for at least one aspect of cognition. Four studies reported nonsignificant improvements in cognitive function between the two groups for at least one area of cognition.

CONCLUSIONS

Home-based lifestyle interventions have the potential to improve cognition in elderly patients with MCI. However, future RCTs with larger sample sizes and longer intervention durations are needed to confirm these findings.

Racial Disparities in COVID-19 Severity Are Partially Mediated by Chronic Stress-Evidence from a Large Integrated Healthcare System

BACKGROUND

Racial and ethnic minorities have experienced a disproportionate burden of severe COVID-19. Whether chronic stress, also disproportionately experienced by racial and ethnic minorities, explains this excess risk is unknown.

METHODS

We identified 9577 adults (≥ 18 years) diagnosed with COVID-19 from January 1, 2020, through September 30, 2021, enrolled in Kaiser Permanente Georgia (KPGA) with complete biomarker data. Self-reported race (Black or White) was defined from electronic medical records. Chronic stress, defined as allostatic load (AL), a composite score (scale 0-7) based on seven cardio-metabolic biomarkers, was categorized as below (low AL) or above (high AL) the median. Severe COVID-19 was defined as hospitalization or mortality within 30 days of COVID-19 diagnosis. The association between race, AL, and severe COVID-19 was assessed using multivariable Poisson regression. The mediating effect of AL was assessed using the Valeri and VanderWeele method. All results were expressed as risk ratios (RRs) with 95% confidence intervals.

RESULTS

Overall, Black (vs. White) KPGA members had an 18% excess risk of AL (RR: 1.18, 95%CI: 1.14-1.23) and a 24% excess risk of severe COVID-19 (RR: 1.24, 95%CI: 1.12, 1.37). AL explained 23% of the Black-White disparities in severe COVID-19.

CONCLUSIONS

In our study, chronic stress, characterized by AL, partially mediated Black-White disparities in severe COVID-19 outcomes.

The Association Between Black vs. White Race and 30-Day Hospitalization Among People Diagnosed with COVID-19 Within an Integrated Care Setting: a Cohort Study

BACKGROUND

Black Americans are more likely to experience hospitalization from COVID-19 compared with White Americans. Whether this excess risk differs by age, sex, obesity, or diabetes, key risk factors for COVID hospitalization, among an integrated population with uniform healthcare access, are less clear.

METHODS

We identified all adult members (≥ 18 years) of Kaiser Permanente Georgia (KPGA) diagnosed with COVID-19 between January 1, 2020, and September 30, 2021 (N = 24,564). We restricted the analysis to members of Black or White race identified from electronic medical records. Our primary outcome was first hospitalization within 30 days of COVID-19 diagnosis. To assess the association between race and 30-day hospitalization, we performed multivariable logistic regression adjusting for several member and neighborhood-level characteristics, and tested for interactions of race with age, sex, diabetes, and obesity. A regression-based decomposition method was then used to estimate how much of the observed race disparity in 30-day hospitalization could be explained by member and neighborhood-level factors.

RESULTS

Overall, 11.27% of Black KPGA members were hospitalized within 30 days of a COVID diagnosis, as compared with 9.44% of White KPGA members. Black (vs. White) KPGA members had a 34% (aOR: 1.32 [95% CI: 1.19-1.47]) higher odds of 30-day hospitalization following COVID-19 after accounting for clinical differences. The odds of 30-day hospitalization in Black vs. White KPGA members did not differ significantly by sex (men: 1.46 [1.25-1.70]; women: 1.24 [1.07-1.43]), by age (18-29 years: 1.33 [0. 841-2.10]; 30-49 years: 1.26 [1.02-1.56]; ≥ 50 years: 1.24 [1.10-1.41]); by diabetes status (with diabetes: 1.38 [1.16-1.66]; without diabetes: 1.26 [1.11-1.44]), or by obesity (with obesity: 1.31 [1.15-1.50]; without obesity: 1.28 [1.06-1.53]). Factors that, if Black and White KPGA members had the same level of exposure, would be most likely to reduce the Black-White disparity in 30-day hospitalization from COVID-19 were obesity, history of flu vaccine, and neighborhood-level income and social vulnerability.

CONCLUSIONS

Early in the pandemic, Black (vs. White) members of an integrated health system had higher odds of being hospitalized within 30 days of COVID-19 diagnosis and this excess risk was similar by sex, age, and comorbidities. Factors that explained the largest proportions of race-based disparities were obesity, receipt of flu vaccine, and neighborhood-level social determinants of health. These findings suggest that social determinants of health, or other unmeasured factors, may be drivers of racial disparities in COVID-19 outcomes.

Fructosamine is Not a Reliable Test for the Detection of Hyperglycemia: Insight from the Africans in America Study

Objective

To improve detection of abnormal glucose tolerance (Abnl-GT), attention has moved beyond the oral glucose tolerance test (OGTT), to non-fasting markers of glycemia, specifically, HbA1c, fructosamine (FA) and glycated albumin (GA). Emerging data suggest that in African descent populations, the combination of HbA1c and GA is superior to the combination of HbA1c and FA. However, the diagnosis of Abnl-GT is usually based on tests which are performed only once. As reproducibility of Abnl-GT diagnosis by HbA1c, fructosamine (FA) and glycated albumin (GA) is unknown, reproducibility of Abnl-GT diagnosis by HbA1c, FA and GA were assessed in 209 African-born Blacks living in America.

Methods

At Visits 1 and 2 (9 ± 4 days apart), samples were obtained for HbA1c, FA and GA levels. Glucose tolerance status was determined at Visit 1 by OGTT. Reproducibility was based on the К-statistic and paired t-tests. Thresholds for the diagnosis of Abnl-GT by FA and GA which corresponded to an HbA1c of 5.7% were 235umol/L and 14.6%, respectively.

Results

Abnl-GT occurred in 38% (80/209). Diagnostic reproducibility was excellent for HbA1c (К≥0.86) and GA (К≥0.89), but only moderate for FA (К=0.59). Neither HbA1c nor GA levels varied between visits (both P≥0.3). In contrast, FA was significantly lower at Visit 2 than Visit 1(P<0.01).

Conclusion

As HbA1c and GA provided similar diagnostic results on different days and FA did not, HbA1C and GA are superior to FA in both clinical care settings and epidemiologic studies.

One-hour glucose is an earlier marker of dysglycemia than two-hour glucose

AIMS

The timing of increase in 1-hour PG and its utility as an earlier predictor of both prediabetes (PreDM) and type 2 diabetes (T2D) compared to 2-hour PG (2 h-PG) are unknown. To evaluate the timing of crossing of the 1 h-PG ≥ 155 mg/dl (8.6 mmol/L) for PreDM and 209 mg/dl (11.6 mmol/L) for T2D and respective current 2 h-PG thresholds of 140 mg/dl (7.8 mmol/L) and 200 mg/dl (11.1 mmol/L).

METHODS

Secondary analysis of 201 Southwest Native Americans who were followed longitudinally for 6-10 years and had at least 3 OGTTs.

RESULTS

We identified a subset of 43 individuals who first developed PreDM by both 1 h-PG and 2 h-PG criteria during the study. For most (32/43,74%), 1 h-PG ≥ 155 mg/dl was observed before 2 h-PG reached 140 mg/dl (median [IQR]: 1.7 [-0.25, 4.59] y; mean ± SEM: 5.3 ± 1.9 y). We also identified a subset of 33 individuals who first developed T2D during the study. For most (25/33, 75%), 1 h-PG reached 209 mg/dl earlier (median 1.0 [-0.56, 2.02] y; mean ± SEM: 1.6 ± 0.8 y) than 2 h-PG reached 200 mg/dl, diagnostic of T2D.

CONCLUSIONS

1 h-PG ≥ 155 mg/dl is an earlier marker of elevated risk for PreDM and T2D than 2 h-PG ≥ 140 mg/dl.

Abstract P352: A Review of Trials Designed to Achieve Diabetes Remission With Lifestyle Intervention Alone: Implications for Sub-Saharan Africa

Introduction: As the prevalence of type 2 diabetes (T2D) in sub-Saharan Africa rises and pharmacological hypoglycemics are often unavailable or prohibitively expensive, the ability to induce T2D remission through medication-free lifestyle interventions (LSI) needs urgent assessment.

Objective: This scoping review evaluated trials designed to induce T2D remission by LSI without hypoglycemic medications.

Methods: Using a combination of controlled vocabulary terms and key words specific to each database, PubMed, Embase, Cochrane, and CINAHL databases were searched for trials designed induce diabetes remission through LSI alone and were published before September 16, 2021. Of the 928 identified, 63 duplicates were removed. After title and abstract review, 727 irrelevant articles were excluded. After full-text review 112 inappropriate articles were removed. The remaining 26 articles described 16 trials. So each trial would be represented by one article, the latest publication from each trial was included. Of the 16 trials, 7 trials were on newly-diagnosed, treatment-naïve T2D and 9 trials were on established T2D with LSI initiated after discontinuation of medications.

Results: The 16 trials were published between 1984 and 2021. They were conducted in 10 different countries. None were conducted in Sub-Saharan Africa. Median number of participants was 180 and 20 for the newly-diagnosed and established T2D respectively. Median duration was 5 years for newly-diagnosed T2D and 5 months for established T2D. For newly-diagnosed T2D, LSI involved dietary counseling with or without calorie restriction (~1500 kcal/d) and exercise. For established T2D trial the main focus was dietary intervention most often divided into 3 phases; Phase 1: low-calorie meal replacement; Phase 2: food re-introduction; and Phase 3: weight maintenance. Median remission rate for the 16 trials was 55%. The consensus across trials was with or without exercise, T2D remission requires diet modification and weight loss. Predictors of remission were: higher BMI and lower A1C at enrollment, shorter T2D at enrolment, and a 10% loss of baseline weight. Nonglycemic benefits of LSI included improved blood pressure, renal function and lipid profile as well as enhanced quality of life.

Conclusions: LSI without medications can induce remission in both newly-diagnosed and established T2D. In sub-Saharan Africa, LSI as the initial therapeutic option needs exploration.

Abstract P560: Pilot Study Reveals Excellent Agreement in the Diagnosis of Diabetes Between the Newly Developed Pastry Sugar Tolerance Test and the OGTT: Africans in America Study

Introduction: Sub-Saharan Africa has the highest percentage of people in the world living with diabetes who are undiagnosed. To avoid end-organ damage, identification of undiagnosed diabetes needs prioritization. Glucola (75g glucose) used for the oral glucose tolerance test (OGTT) is expensive and rarely available in sub-Saharan Africa. Due to hemoglobinopathies, G6PD deficiency, and challenges associated with fasting, both A1C and fasting plasma glucose (FPG) may be diagnostically unreliable. As an alternative to the OGTT, we developed the Pastry Sugar Tolerance Test (PSTT). For the PSTT, pastry sugar (75g glucose powder) is dissolved in hot water. Pastry sugar is more widely available in sub-Saharan Africa and nine times less expensive than Glucola.

Objective: Our goals were to determine the diagnostic agreement for the detection of diabetes between the OGTT and: (1) PSTT, (2) A1C and (3) FPG.

Methods: The participants were 36 African-born Blacks enrolled in the Africans in America study (male: 67%; age: 42±10y (mean±SD); BMI: 28.5±5.2 kg/m2). At Visit 1, each enrollee had an OGTT, A1C and FPG. At Visit 2, which occurred 8±3 days after Visit 1, a PSTT was performed. Glucose tolerance status was based on glucose results from the OGTT. The kappa-statistic was used to determine the diagnostic agreement between the OGTT and each of the following: PSTT, A1C and FPG.

Results: Based on the OGTT, diabetes, prediabetes and normal glucose tolerance occurred in 11%(4/36), 33%(12/36) and 56%(20/36) resp. For diabetes, diagnostic agreement between the OGTT and PSTT was excellent (κ=0.99) but much lower for the OGTT and A1C (κ=0.64) and the OGTT and FPG (κ=0.38) (Figure).

Conclusions: This pilot study has revealed that for diabetes screening, the PSTT has excellent diagnostic agreement with the OGTT, is less expensive than the OGTT, and is more accurate than A1C or FPG.

Abstract P562: Body Size Dissatisfaction is High in African Immigrants With Obesity: Insight From the Africans in America Cohort

Background: In African populations, attitudes towards both optimal body size and healthful weights are evolving. Due to the adverse effect of obesity on health, larger body sizes are beginning to be seen as less ideal. Our goal was to determine body size satisfaction in African immigrants who were obese.

Methods: The participants were 326 African-born Blacks enrolled in the Africans in America cohort and living in metropolitan Washington DC (female: 39%, age 40±11y (mean±SD). The African region of origin of the participants were: West: 49% (161/326), Central 12% (39/326) and East: 39% (126/326). Twenty-seven percent (89/326) of the countries of origin were francophone. Enrollees were asked to rank their current body size and ideal body size according to the Stunkard Figure Rating Scale. Body size satisfaction was determined by the difference between perceived and wish body size.

Results: BMI was higher in women than men (29.1±4.9 vs. 27.0±3.9 kg/m 2 , P<0.001). The overall prevalence of obesity was 27% (88/326) and higher in women than men (38% vs 20%, P=0.001). Among participants with obesity, there was no difference by sex in degree of dissatisfaction due to high body size (OR 2.14, 95% CI: 0.48, 9.58, P=0.32). Attitudes towards body size in participants with obesity were: 1% (1/88) considered themselves too small, 8% (7/88) just right and 91% (80/88) too large (Figure). These results did not vary by African region of origin or francophone status.

Conclusions: The majority of African immigrants with obesity were dissatisfied with their high BMI. To optimize health, risk factors associated with weight gain and body size dissatisfaction should be addressed.

A Scoping Review of Trials Designed to Achieve Remission of Type 2 Diabetes with Lifestyle Intervention Alone: Implications for Sub-Saharan Africa

According to the International Diabetes Federation, sub-Saharan Africa is experiencing the highest anticipate increase in the prevalence of type 2 diabetes (T2D) in the world and has the highest percent of people living with T2D who are undiagnosed. Therefore, diagnosis and treatment need prioritization. However, pharmacological hypoglycemics are often unavailable and bariatric surgery is not an option. Therefore, the ability to induce T2D remission through lifestyle intervention alone (LSI-alone) needs assessment. This scoping review evaluated trials designed to induce T2D remission by LSI-alone. PubMed, Embase, Cochrane, and CINAHL databases were searched for trials designed to induce T2D remission through LSI-alone. Of the 928 identified, 63 duplicates were removed. With abstract review, 727 irrelevant articles were excluded. After full-text review, 112 inappropriate articles were removed. The remaining 26 articles described 16 trials. These trials were published between 1984 and 2021 and were conducted in 10 countries, none of which were in Africa. Remission rates varied across trials. Predictors of remission were 10% weight loss and higher BMI, lower A1C and shorter T2D duration at enrollment. However, LSI-alone regimens for newly diagnosed and established T2D were very different. In newly diagnosed T2D, LSI-alone were relatively low-cost and focused on exercise and dietary counseling with or without calorie restriction (~1500 kcal/d). Presumably due to differences in cost, LSI-alone trials in newly diagnosed T2D had higher enrollments and longer duration. For established T2D trials, the focus was on arduous phased dietary interventions; phase 1: low-calorie meal replacement (<1000 kcal/day); phase 2: food re-introduction; phase 3: weight maintenance. In short, LSI-alone can induce remission in both newly diagnosed and established T2D. To demonstrate efficacy in Africa, initial trials could focus on newly diagnosed T2D. Insight gained could provide proof of concept and a foundation in Africa on which successful studies of LSI-alone in established T2D could be built.

An Evaluation of Alternative Technology-Supported Counseling Approaches to Promote Multiple Lifestyle Behavior Changes in Patients With Type 2 Diabetes and Chronic Kidney Disease

OBJECTIVES

Although technology-supported interventions are effective for reducing chronic disease risk, little is known about the relative and combined efficacy of mobile health strategies aimed at multiple lifestyle factors. The purpose of this clinical trial is to evaluate the efficacy of technology-supported behavioral intervention strategies for managing multiple lifestyle-related health outcomes in overweight adults with type 2 diabetes (T2D) and chronic kidney disease (CKD).

DESIGN AND METHODS

Using a 2 × 2 factorial design, adults with excess body weight (body mass index ≥27 kg/m2, age ≥40 years), T2D, and CKD stages 2-4 were randomized to an advice control group, or remotely delivered programs consisting of synchronous group-based education (all groups), plus (1) Social Cognitive Theory-based behavioral counseling and/or (2) mobile self-monitoring of diet and physical activity. All programs targeted weight loss, greater physical activity, and lower intakes of sodium and phosphorus-containing food additives.

RESULTS

Of 256 randomized participants, 186 (73%) completed 6-month assessments. Compared to the ADVICE group, mHealth interventions did not result in significant changes in weight loss, or urinary sodium and phosphorus excretion. In aggregate analyses, groups receiving mobile self-monitoring had greater weight loss at 3 months (P = .02), but between 3 and 6 months, weight losses plateaued, and by 6 months, the differences were no longer statistically significant.

CONCLUSIONS

When engaging patients with T2D and CKD in multiple behavior changes, self-monitoring diet and physical activity demonstrated significantly larger short-term weight losses. Theory-based behavioral counseling alone was no better than baseline advice and demonstrated no interaction effect with self-monitoring.

Estimated glomerular filtration rate trajectories in south Asians: Findings from the cardiometabolic risk reduction in south Asia study

Background

Few longitudinal data characterize kidney function decline among South Asians, one of the world's largest population groups. We aimed to identify estimated glomerular filtration rate (eGFR) trajectories in a population-based cohort from India and assess predictors of rapid kidney function decline.

Methods

We used 6-year longitudinal data from participants of a population-representative study from Delhi and Chennai, India who had at least two serum creatinine measures and baseline CKD-EPI eGFR> 60 ml/min/1.73m² (n=7779). We used latent class trajectory modeling to identify patterns of kidney function trajectory (CKD-EPI eGFR) over time. In models accounting for age, sex, education, and city, we tested the association between 15 hypothesized risk factors and rapid kidney function decline.

Findings

Baseline mean eGFR was 108 (SD 16); median eGFR was 110 [IQR: 99-119] ml/min/1.73m². Latent class trajectory modeling and functional characterization identified three distinct patterns of eGFR: class-1 (no decline; 58%) annual eGFR change 0.2 [0.1, 0.3]; class-2 (slow decline; 40%) annual eGFR change -0.2 [-0.4, -0.1], and class-3 (rapid decline; 2%) annual eGFR change -2.7 [-3.4, -2.0] ml/min/1.73m². Albuminuria (>30 mg/g) was associated with rapid eGFR decline (OR for class-3 vs class-1: 5.1 [95% CI: 3.2; 7.9]; class-3 vs. class-2: 4.3 [95% CI:2.7; 6.6]). Other risk factors including self-reported diabetes, cardiovascular disease, peripheral arterial disease, and metabolic biomarkers such as HbA1c and systolic blood pressure were associated with rapid eGFR decline phenotype but potential 'non-traditional' risk factors such as manual labor or household water sources were not.

Interpretation

Although mean and median eGFRs in our population-based cohort were higher than those reported in European cohorts, we found that a sizeable number of adults residing in urban India are experiencing rapid kidney function decline. Early and aggressive risk modification among persons with albuminuria could improve kidney health among South Asians.

Funding

The CARRS study has been funded with federal funds from the National Heart, Lung, and Blood Institute, National Institutes of Health, under Contract No. HHSN2682009900026C and P01HL154996. Dr. Anand was supported by NIDDK K23DK101826 and R01DK127138.

Study Protocol: A Mixed-Methods Study for Understanding Racial Disparities in COVID-19-Related Complications

Background

In the United States, the COVID-19 pandemic has magnified the disproportionate and long-standing health disparities experienced by Black communities. Although it is acknowledged that social determinants of health (SDOH) rather than biological factors likely contribute to this disparity, few studies using rigorous analytic approaches in large, information-rich community-based data sets are dedicated to understanding the underlying drivers of these racial disparities.

Objective

The overall aim of our study is to elucidate the mechanisms by which racial disparities in severe COVID-19 outcomes arise, using both quantitative and qualitative methods.

Methods

In this protocol, we outline a convergent parallel mixed methods approach to identifying, quantifying, and contextualizing factors that contribute to the dramatic disparity in COVID-19 severity (ie, hospitalization, mortality) in Black versus white COVID-19 patients within the integrated health care system of Kaiser Permanente Georgia (KPGA). Toward this end, we will generate two quantitative cohorts of KPGA members with a confirmed COVID-19 diagnosis between January 1, 2020, and September 30, 2021: (1) an electronic medical record (EMR) cohort including routinely captured data on diagnoses, medications, and laboratory values, and a subset of patients hospitalized at Emory Healthcare to capture additional in-hospital data; and (2) a survey cohort, where participants will answer a range of questions related to demographics (eg, race, education), usual health behaviors (eg, physical activity, smoking), impact of COVID-19 (eg, job loss, caregiving responsibilities), and medical mistrust. Key outcomes of interest for these two cohorts include hospitalization, mortality, intensive care unit admission, hospital readmission, and long COVID-19. Finally, we will conduct qualitative semistructured interviews to capture perceptions of and experiences of being hospitalized with COVID-19 as well as related interactions with KPGA health care providers. We will analyze and interpret the quantitative and qualitative data separately, and then integrate the qualitative and quantitative findings using a triangulation design approach.

Results

This study has been funded by a Woodruff Health Sciences grant from December 2020 to December 2022. As of August 31, 2022, 31,500 KPGA members diagnosed with COVID-19 have been included in the EMR cohort, including 3028 who were hospitalized at Emory Healthcare, and 482 KPGA members completed the survey. In addition, 20 KPGA members (10 Black and 10 white) have been interviewed about their experiences navigating care with COVID-19. Quantitative and qualitative data cleaning and coding have been completed. Data analysis is underway with results anticipated to be published in December 2022.

Conclusions

Results from this mixed methods pilot study in a diverse integrated care setting in the southeastern United States will provide insights into the mechanisms underpinning racial disparities in COVID-19 complications. The quantitative and qualitative data will provide important context to generate hypotheses around the mechanisms for racial disparities in COVID-19, and may help to inform the development of multilevel strategies to reduce the burden of racial disparities in COVID-19 and its ongoing sequelae. Incorporating contextual information, elucidated from qualitative interviews, will increase the efficacy, adoption, and sustainability of such strategies.

International Registered Report Identifier (IRRID)

RR1-10.2196/38914

One-hour post-load glucose is associated with severity of hepatic fibrosis risk

AIM

Individuals with high 1-hour post-load glucose (1-h PG > 155 mg/dl; 8.6 mmol/l) during an oral glucose tolerance test are at increased risk of type 2 diabetes (T2D) and cardiovascular complications, hepatic steatosis, and mortality. However,the clinical relevance of 1-h PG for the severity of hepatic fibrosis risk remains undefined.

METHODS

Cross-sectional data of the CATAMERI study (n = 2335) were analyzed. Participants underwent anthropometric measurements, liver enzyme determinations, cardiometabolic profiling, and a75-gram oral glucose tolerance test, including fasting, 1-h and 2-h PG determinations and measurement of FIB-4 score to assess degree of hepatic fibrosis. Multivariable logistic regression analysis was performed to evaluate risk of advanced hepatic fibrosis with worsening glycemic status.

RESULTS

We stratifiedthe study group into 6 categories based on glycemic status: normal glucose tolerance (NGT) 1h-PG Low, NGT 1h-PG High, iIFG 1h-PG Low, iIFG 1h-PG High, IGT, and newly detected T2D. Anthropometric and cardiometabolic profiles worsened gradually with glycemic status. Moreover, compared to NGT-1h-PG Low group, worsening glycemic status was significantly associated with the severity of fibrosis, independent of other significant clinical risk factors.

CONCLUSIONS

1-PG is a valuable tool for stratifying subjects with NGT or IFG at heightened risk of hepatic fibrosis requiring further evaluation with elastography.

Association of Obesity, Diabetes, and Alcohol Use With Liver Fibrosis Among US Adults With Hepatitis C Virus Infection

This cross-sectional study examines the association of obesity, diabetes, and alcohol use with liver fibrosis among treatment-naive US adults with hepatitis C virus infection seen at a safety-net hospital in Atlanta, Georgia.

Sleep and Economic Status Are Linked to Daily Life Stress in African-Born Blacks Living in America

To identify determinants of daily life stress in Africans in America, 156 African-born Blacks (Age: 40 ± 10 years (mean ± SD), range 22–65 years) who came to the United States as adults (age ≥ 18 years) were asked about stress, sleep, behavior and socioeconomic status. Daily life stress and sleep quality were assessed with the Perceived Stress Scale (PSS) and Pittsburgh Sleep Quality Index (PSQI), respectively. High-stress was defined by the threshold of the upper quartile of population distribution of PSS (≥16) and low-stress as PSS < 16. Poor sleep quality required PSQI > 5. Low income was defined as <40 k yearly. In the high and low-stress groups, PSS were: 21 ± 4 versus 9 ± 4, p < 0.001 and PSQI were: 6 ± 3 versus 4 ± 3, p < 0.001, respectively. PSS and PSQI were correlated (r = 0.38, p < 0.001). The odds of high-stress were higher among those with poor sleep quality (OR 5.11, 95% CI: 2.07, 12.62), low income (OR 5.03, 95% CI: 1.75, 14.47), and no health insurance (OR 3.01, 95% CI: 1.19, 8.56). Overall, in African-born Blacks living in America, daily life stress appears to be linked to poor quality sleep and exacerbated by low income and lack of health insurance.

1-h Glucose During Oral Glucose Tolerance Test Predicts Hyperglycemia Relapse-Free Survival in Obese Black Patients With Hyperglycemic Crises

OBJECTIVE

Approximately 50% of obese Black patients with unprovoked diabetic ketoacidosis (DKA) or severe hyperglycemia (SH) at new-onset diabetes achieve near-normoglycemia remission with intensive insulin treatment. Despite the initial near-normoglycemia remission, most DKA/SH individuals develop hyperglycemia relapse after insulin discontinuation. Traditional biomarkers such as normal glucose tolerance at the time of remission were not predictive of hyperglycemia relapse. We tested whether 1-h plasma glucose (1-h PG) at remission predicts hyperglycemia relapse in Black patients with DKA/SH.

METHODS

Secondary analysis was performed of two prospective randomized controlled trials in 73 patients with DKA/SH at the safety net hospital with a median follow-up of 408 days. Patients with DKA/SH underwent a 5-point, 2-h 75-g oral glucose tolerance test after hyperglycemia remission. Hyperglycemia relapse is defined by fasting blood glucose (FBG) > 130 mg/dl, random blood glucose (BG) >180 mg/dl, or HbA1c > 7%.

RESULTS

During the median 408 (interquartile range: 110-602) days of follow-up, hyperglycemia relapse occurred in 28 (38.4%) participants. One-hour PG value ≥199 mg/dl discriminates hyperglycemia relapse (sensitivity: 64%; specificity: 71%). Elevated levels of 1-h PG (≥199 mg/dl) were independently associated with hyperglycemia relapse (adjusted hazard ratio: 2.40 [95% CI: 1.04, 5.56]). In a multivariable model with FBG, adding 1-h PG level enhanced the prediction of hyperglycemia relapse, with significant improvements in C-index (Δ: +0.05; p = 0.04), net reclassification improvement (NRI: 48.7%; p = 0.04), and integrated discrimination improvement (IDI: 7.8%; p = 0.02) as compared with the addition of 2-h PG (NRI: 20.2%; p = 0.42; IDI: 1.32%; p = 0.41) or HbA1c (NRI: 35.2%; p = 0.143; IDI: 5.8%; p = 0.04).

CONCLUSION

One-hour PG at the time of remission is a better predictor of hyperglycemia relapse than traditional glycemic markers among obese Black patients presenting with DKA/SH. Testing 1-h PG at insulin discontinuation identifies individuals at high risk of developing hyperglycemia relapse.

Defining the Value of Analgesia for Total Knee Arthroplasty Using Time-Driven Activity-Based Costing: A Novel Approach to Clinical Practice Transformation

Objective

To compare the relative value of 3 analgesic pathways for total knee arthroplasty (TKA).

Patients and Methods

Time-driven activity-based costing analyses were performed on 3 common analgesic pathways for patients undergoing TKA: periarticular infiltration (PAI) only, PAI and single-injection adductor canal blockade (SACB), and PAI and continuous adductor canal blockade (CACB). Additionally, adult patients who underwent elective primary TKA from November 1, 2017, to May 1, 2018, were retrospectively identified to analyze analgesic (pain score, opiate use) and hospital outcomes (distance walked, length of stay) after TKA based on analgesic pathway.

Results

There was no difference in patient demographic characteristics, specifically complexity (American Society of Anesthesiologists score) or preoperative opiate use, between groups. Compared with PAI, total cost (labor and material) was 1.4-times greater for PAI plus SACB and 2.3-times greater for PAI plus CACB. The addition of SACB to PAI resulted in lower average and maximum pain scores and opiate use on the day of operation compared with PAI alone. Average and maximum pain scores and opiate use between SACB and CACB were not significantly different. Walking distance and hospital length of stay were not significantly different between groups.

Conclusion

Perioperative care teams should consider the cost and relative value of pain management when selecting the optimal analgesic strategy for TKA. Despite slightly higher relative cost, the combination of SACB with PAI may offer short-term analgesic benefit compared with PAI alone, which could enhance its relative value in TKA.

Trends in inpatient admissions and emergency department visits for heart failure in adults with versus without diabetes in the USA, 2006-2017

INTRODUCTION

Heart failure (HF) is a major contributor to cardiovascular morbidity and mortality in people with diabetes. In this study, we estimated trends in the incidence of HF inpatient admissions and emergency department (ED) visits by diabetes status.

RESEARCH DESIGN AND METHODS

Population-based age-standardized HF rates in adults with and without diabetes were estimated from the 2006-2017 National Inpatient Sample, Nationwide ED Sample and year-matched National Health Interview Survey, and stratified by age and sex. Trends were assessed using Joinpoint.

RESULTS

HF inpatient admissions did not change in adults with diabetes between 2006 and 2013 (from 53.9 to 50.4 per 1000 persons; annual percent change (APC): -0.3 (95% CI -2.5 to 1.9) but increased from 50.4 to 62.3 between 2013 and 2017 (APC: 4.8 (95% CI 0.3 to 9.6)). In adults without diabetes, inpatient admissions initially declined (from 14.8 in 2006 to 12.9 in 2014; APC -2.3 (95% CI -3.2 to -1.2)) and then plateaued. Patterns were similar in men and women, but relative increases were greatest in young adults with diabetes. HF-related ED visits increased overall, in men and women, and in all age groups, but increases were greater in adults with (vs without) diabetes.

CONCLUSIONS

Causes of increased HF rates in hospital settings are unknown, and more detailed data are needed to investigate the aetiology and determine prevention strategies, particularly among adults with diabetes and especially young adults with diabetes.

Clinical Trials of COVID-19 Therapies Should Account for Diabetes and Hyperglycemia

Complications of Coronavirus Disease 2019 (COVID-19) occur with increased frequency in people admitted to the hospital with diabetes or hyperglycemia. The increased risk for COVID-19 infections in the presence of these metabolic conditions is in part due to overlapping pathophysiologic features of COVID-19, diabetes, and glucose control. Various antiviral treatments are being tested in COVID-19 patients. We believe that in these trials, it will be useful to evaluate treatment effect differences in patients stratified according to whether they have diabetes or hyperglycemia. In this way, it will be possible to better facilitate development of antiviral treatments that are most specifically beneficial for the large subset of COVID-19 patients who have diabetes or hyperglycemia.

The effects of shoulder arthroscopy on ultrasound image quality of the interscalene brachial plexus: a pre-procedure vs post-procedure comparative study

BACKGROUND

Fluid extravasation from the shoulder compartment and subsequent absorption into adjacent soft tissue is a well-documented phenomenon in arthroscopic shoulder surgery. We aimed to determine if a qualitative difference in ultrasound imaging of the interscalene brachial plexus exists in relation to the timing of performing an interscalene nerve block (preoperative or postoperative).

METHODS

This single-center, prospective observational study compared pre- and postoperative interscalene brachial plexus ultrasound images of 29 patients undergoing shoulder arthroscopy using a pretest-posttest methodology where individual patients served as their own controls. Three fellowship-trained regional anesthesiologists evaluated image quality and confidence in performing a block for each ultrasound scan using a five-point Likert scale. The association of image quality with age, gender, BMI, duration of surgery, obstructive sleep apnea, and volume of arthroscopic irrigation fluid were analyzed as secondary outcomes.

RESULTS

Aggregate preoperative mean scores in quality of ultrasound visualization were higher than postoperative scores (preoperative 4.5 vs postoperative 3.8; p < .001), as was confidence in performing blockade based upon the imaging (preoperative 4.8 vs postoperative 4.2; p < .001). Larger BMI negatively affected visualization of the brachial plexus in the preoperative period (p < 0.05 for both weight categories). Patients with intermediate-high risk or confirmed obstructive sleep apnea had lower aggregate postoperative mean scores compared to the low-risk group for both ultrasound visualization (3.4 vs 4.0; p < .05) and confidence in block performance (3.8 vs 4.4; p < .05).

CONCLUSION

Due to the potential reduction of ultrasound visualization of the interscalene brachial plexus after shoulder arthroscopy, we advocate for a preoperative interscalene nerve block when feasible.

TRIAL REGISTRATION

ClinicalTrials.gov ( NCT03657173 ; September 4, 2018).

Lifestyle Interventions for Diabetes Prevention in South Asians: Current Evidence and Opportunities

PURPOSE OF REVIEW

This review summarizes the burden of diabetes in South Asian populations and reviews recent evidence for diabetes prevention through lifestyle modification among South Asians worldwide. We indicate important gaps in the current literature and point to opportunities for additional research in this area.

RECENT FINDINGS

Randomized, controlled, efficacy studies and implementation research show that lifestyle intervention can be an effective, cost-effective, and feasible method for reducing diabetes risk, improving cardiometabolic health, and improving lifestyle behaviors in South Asian populations, a population at high diabetes risk and elevated rates of diabetes risk factors. Additional research is needed to address diabetes risk reduction in normal-weight South Asians and individuals with impaired fasting glucose; improve community-level implementation, individual uptake, and dissemination of proven programs; and assess long-term outcomes of interventions.

Association Between APOL1 Genotype and Kidney Diseases and Annual Kidney Function Change: A Systematic Review and Meta-Analysis of the Prospective Studies

Background

Two coding risk variants in the Apo L1 gene (APOL1) underlie most of the excess risk for kidney diseases in recent African ancestry patients. Strength and consistency of the relationship between APOL1 high-risk genotypes and the risk of chronic kidney diseases (CKD) and end-stage renal disease (ESRD) are not uniform.

Objective

To conduct a systematic review and meta-analysis of prospective studies assessing the association of APOL1 genotypes and the risk of developing CKD, ESRD, and CKD to ESRD in adults.

Methods

Systematic search of MEDLINE, EMBASE, and Google Scholar was performed for prospective studies assessing the associations between APOL1 genotypes and CKD, ESRD, and progression from CKD to ESRD. Secondary analyses were to evaluate the annual kidney function change by APOL1 gene status. Random effects models were used to estimate pooled risk ratios (RRs) and weighted mean differences for outcomes of interest.

Results

The search yield 10 prospective during a follow-up period ranging from 4.4 to 25 years. The high-risk APOL1 genotype was associated with the incidence of CKD (RR:1.41[95% CI: 1.14–1.75]), the progression from CKD to ESRD (RR: 1.70[95% CI:1.44; 2.01]) compared with the low-risk APOL1 genotype. There was no appreciable association between high-risk APOL1 genotype with the incidence of ESRD. Furthermore, high-risk APOL1 genotype was associated with a marginal decrement in the annual eGFR decline (−0.55[95% CI: −0.94 to −0.16]) mL/min/1.73m² compared with low-risk APOL1 genotype status.

Conclusion

In summary, African Americans carrying APOL1 high-risk genotypes are at increased risk of developing CKD and ESRD. Given that the APOL1 risk alleles are common among individuals with African ancestry, with ~18% of African Americans carrying high-risk alleles, these findings highlight the potential identification of subgroups of patients who may benefit from APOL1 screening and developing culturally-appropriate interventions.

Association between varying cut-points of intermediate hyperglycemia and risk of mortality, cardiovascular events and chronic kidney disease: a systematic review and meta-analysis

INTRODUCTION

We conducted a systematic review and meta-analysis to evaluate the updated evidence regarding prediabetes for predicting mortality, macrovascular and microvascular outcomes.

RESEARCH DESIGN AND METHODS

We identified English language studies from MEDLINE, PubMed, OVID and Cochrane database indexed from inception to January 31, 2020. Paired reviewers independently identified 106 prospective studies, comprising nearly 1.85 million people, from 27 countries. Primary outcomes were all-cause mortality (ACM), cardiovascular mortality (CVDM), cardiovascular disease (CVD), coronary heart disease (CHD) and stroke. Secondary outcomes were heart failure, chronic kidney disease (CKD) and retinopathy.

RESULTS

Impaired glucose tolerance was associated with ACM; HR 1.19, 95% CI (1.15 to 1.24), CVDM; HR 1.21, 95% CI (1.10 to 1.32), CVD; HR 1.18, 95% CI (1.11 to 1.26), CHD; HR; 1.13, 95% CI (1.05 to 1.21) and stroke; HR 1.24, 95% CI (1.06 to 1.45). Impaired fasting glucose (IFG) 110-125 mg/dL was associated with ACM; HR 1.17, 95% CI (1.13 to 1.22), CVDM; HR 1.20, 95% CI (1.09 to 1.33), CVD; HR 1.21, 95% CI (1.09 to 1.33), CHD; HR; 1.14, 95% CI (1.06 to 1.22) and stroke; HR 1.22, 95% CI (1.07 to 1.40). IFG 100-125 mg/dL was associated with ACM; HR 1.11, 95% CI (1.04 to 1.19), CVDM; HR 1.14, 95% CI (1.03 to 1.25), CVD; HR 1.15, 95% CI (1.05 to 1.25), CHD HR; 1.10, 95% CI (1.02 to 1.19) and CKD; HR; 1.09, 95% CI (1.01 to 1.18). Glycosylated hemoglobin A1c (HbA1c) 6.0%-6.4% was associated with ACM; HR 1.30, 95% CI (1.03 to 1.66), CVD; HR 1.32, 95% CI (1.00 to 1.73) and CKD; HR 1.50, 95% CI (1.32 to 1.70). HbA1c 5.7%-6.4% was associated with CVD HR 1.15, 95% CI (1.02 to 1.30), CHD; HR 1.28, 95% CI (1.13 to 1.46), stroke; HR 1.23, 95% CI (1.04 to 1.46) and CKD; HR 1.32, 95% CI (1.16 to 1.50).

CONCLUSION

Prediabetes is an elevated risk state for macrovascular and microvascular outcomes. The prevention and management of prediabetes should be considered.

The OGTT is highly reproducible in Africans for the diagnosis of diabetes: Implications for treatment and protocol design

Whether an OGTT reproducibly detects either type 2 diabetes (T2D) or prediabetes in Africans in unknown. Therefore, 131 Africans had two OGTT. Diagnostic reproducibility for T2D was excellent (κ = 0.84), but only moderate for prediabetes (κ = 0.51). A single OGTT positive for T2D may be sufficient to guide clinical care and inform epidemiologic study design. ClinicalTrials.gov Identifier: NCT00001853.

The Oral Glucose Tolerance Test: 100 Years Later

For over 100 years, the oral glucose tolerance test (OGTT) has been the cornerstone for detecting prediabetes and type 2 diabetes (T2DM). In recent decades, controversies have arisen identifying internationally acceptable cut points using fasting plasma glucose (FPG), 2-h post-load glucose (2-h PG), and/or HbA1c for defining intermediate hyperglycemia (prediabetes). Despite this, there has been a steadfast global consensus of the 2-h PG for defining dysglycemic states during the OGTT. This article reviews the history of the OGTT and recent advances in its application, including the glucose challenge test and mathematical modeling for determining the shape of the glucose curve. Pitfalls of the FPG, 2-h PG during the OGTT, and HbA1c are considered as well. Finally, the associations between the 30-minute and 1-hour plasma glucose (1-h PG) levels derived from the OGTT and incidence of diabetes and its complications will be reviewed. The considerable evidence base supports modifying current screening and diagnostic recommendations with the use of the 1-h PG. Measurement of the 1-h PG level could increase the likelihood of identifying high-risk individuals when the pancreatic ß-cell function is substantially more intact with the added practical advantage of potentially replacing the conventional 2-h OGTT making it more acceptable in the clinical setting.

Manhattan Veterans Affairs Medical Center Diabetes Prevention Clinic

Quality Improvement Success Stories are published by the American Diabetes Association in collaboration with the American College of Physicians, Inc., and the National Diabetes Education Program. This series is intended to highlight best practices and strategies from programs and clinics that have successfully improved the quality of care for people with diabetes or related conditions. Each article in the series is reviewed and follows a standard format developed by the editors of Clinical Diabetes. The following article describes the establishment of a Diabetes Prevention Clinic for veterans with prediabetes.

Review of methods for detecting glycemic disorders

Prediabetes (intermediate hyperglycemia) consists of two abnormalities, impaired fasting glucose (IFG) and impaired glucose tolerance (IGT) detected by a standardized 75-gram oral glucose tolerance test (OGTT). Individuals with isolated IGT or combined IFG and IGT have increased risk for developing type 2 diabetes (T2D) and cardiovascular disease (CVD). Diagnosing prediabetes early and accurately is critical in order to refer high-risk individuals for intensive lifestyle modification. However, there is currently no international consensus for diagnosing prediabetes with HbA1c or glucose measurements based upon American Diabetes Association (ADA) and the World Health Organization (WHO) criteria that identify different populations at risk for progressing to diabetes. Various caveats affecting the accuracy of interpreting the HbA1c including genetics complicate this further. This review describes established methods for detecting glucose disorders based upon glucose and HbA1c parameters as well as novel approaches including the 1-hour plasma glucose (1-h PG), glucose challenge test (GCT), shape of the glucose curve, genetics, continuous glucose monitoring (CGM), measures of insulin secretion and sensitivity, metabolomics, and ancillary tools such as fructosamine, glycated albumin (GA), 1,5- anhydroglucitol (1,5-AG). Of the approaches considered, the 1-h PG has considerable potential as a biomarker for detecting glucose disorders if confirmed by additional data including health economic analysis. Whether the 1-h OGTT is superior to genetics and omics in providing greater precision for individualized treatment requires further investigation. These methods will need to demonstrate substantially superiority to simpler tools for detecting glucose disorders to justify their cost and complexity.

Nexus of COVID-19 and diabetes pandemics: Global public health lessons

Individuals with non-communicable diseases (NCDs) such as diabetes are susceptible to communicable diseases (CDs) as the current COVID-19 pandemic illustrates. The co-occurrence of diabetes as well as other co-morbid conditions with COVID-19 augurs greater risk for severe outcomes and mortality. Hence, NCD and CD pandemics are closely linked and require global efforts to thwart and disrupt their nexus before the next viral outbreaks occurs. This will require steadfast dedication and resolve to address NCDs previously committed to by the global community.

Fibroblast Growth Factor-23 and a Vegetarian Diet

OBJECTIVE

Sparse data exist on population distributions of serum fibroblast growth factor-23 (FGF23) levels from developing, middle-income economies. FGF23 levels may differ substantially across regions based on differences in diet and urbanization. In a population-based study from North India, we tested the hypothesis that urinary phosphate excretion and FGF23 levels are lower among rural compared with urban participants, and among vegetarian compared with nonvegetarian participants.

METHODS

We measured 24-hour urinary phosphate, and serum parathyroid hormone and FGF23 in a subsample of the population-based Cardiometabolic Risk Reduction in South Asia and Indian Council of Medical Research Coronary Heart Disease surveys. We categorized participants according to diet and residence: urban nonvegetarians (n = 70), urban vegetarians (n = 564), and rural vegetarians (n = 558). Using least square means, we compared the groups' 24-hour urinary phosphate (with urban vegetarians as reference) and FGF23 levels after accounting for age, sex, diabetes, and body mass index.

RESULTS

Among 1,192 study participants, mean FGF23 was 41 ± 18 pg/mL, median parathyroid hormone was 44 (interquartile range [IQR] 31-60) pg/mL, and median 24-hour urinary phosphate excretion was 419 (IQR: 47-622) mg/day. Urinary phosphate was significantly higher in rural compared with urban vegetarians (median, 503; IQR, 334-543 versus 365; IQR, 199-399 mg/day), but adjusted mean FGF23 levels did not differ across study groups.

CONCLUSION

In rural and urban India, urinary phosphate excretion was low, but FGF23 levels did not differ by residence or dietary preference. Homogenously low dietary phosphate intake across different settings and diets may partly explain the lack of differences in FGF23.

Clinical utility of 30-min plasma glucose for prediction of type 2 diabetes among people with prediabetes: Ancillary analysis of the diabetes community lifestyle improvement program

AIMS

To examine the clinical utility of 30-min plasma glucose (30-min-PG) measurement during an oral glucose tolerance (OGTT) in predicting type 2 diabetes (T2DM).

RESEARCH DESIGN AND METHODS

Data from a 3-year, randomized, controlled, primary prevention trial among 548 Asian Indians with prediabetes were analyzed. Participants underwent OGTT with PG measurements at fasting, 30-min, and 2-h at baseline and annually until the end of the study. Multivariable Cox regression models were constructed to calculate the risk of developing diabetes based on 30-min-PG levels. Improvement in prediction performance gained by adding an elevated level of 30-min-PG over prediabetic categories was calculated using the area-under-curve (AUC), net-reclassification (NRI), and integrated discrimination improvement (IDI) statistics.

RESULTS

At the end of follow-up, 30.4% of individuals had been diagnosed with T2DM by ADA criteria. Based on the maximally selected log-rank statistics, the optimal 30-min-PG cut point for predicting incident T2DM was >182 mg/dl. Multivariable-adjusted Cox regression models showed an independent association between elevated 30-min-PG (>182 mg/dl) and incident diabetes (hazard ratio (95% CI): 1.85 [1.32, 2.59]; D_xy = 0.353, c-statistic = 0.676). The addition of an elevated 30-min-PG (>182 mg/dl) model significantly improved the prediction of diabetes (Δdeviance: -15.4; ΔAUC: 0.11; NRI_continuous: 0.51; IDI: 0.08) compared with IFG model alone) in individuals with prediabetes.

CONCLUSION

In prediabetic individuals, baseline 30-min-PG independently predicted T2DM and significantly improved reclassification and discrimination. Therefore, 30-min-PG should be considered as part of the routine testing in addition to FPG and 2-h-PG for better risk stratification.

Global Updates on Cardiovascular Disease Mortality Trends and Attribution of Traditional Risk Factors

PURPOSE OF REVIEW

The last 2-3 decades have witnessed a decline in age-standardized cardiovascular mortality rates in high-income regions, whereas this has only slightly decreased or even increased in most of the low- and middle-income countries. A systematic comparison of global CVD mortality by regions attributable to various modifiable risk factors such as diabetes, obesity, hypertension, poor diet, and physical inactivity is not available.

RECENT FINDINGS

We present a summary of time trends and heterogeneity in the distribution of global CVD mortality and the attribution of risk factors between 1990 and 2017 using the Global Burden of Disease (GBD) 2017 study. Globally, an estimated ~ 17.8 million (233.1 per 100,000) people died of CVD in 2017. The rate of CVD death was decreased in high-income countries (1990: 271.8 (95% UI (uncertainty interval), 270.9-273.5); 2017: 128.5 (95% UI, 126.4-130.7) per 100,000)) whereas it remained the same in lower- and middle-income countries (1990: 368.2 (95% UI, 335.6-383.3); 2017: 316.9 (95% UI, 307.0-325.5) per 100,000). Among the various traditional risk factors, high systolic blood pressure, unhealthy diet, high fasting plasma glucose, and high low-density lipoprotein levels were attributed to most of the CVD death and disability-adjusted life year lost. We also observed gender variations in tobacco and increased alcohol consumption. In addition to the traditional risk factors, poor air quality is associated with increased CVD burden in developing countries. Surveillance, country-specific guidelines, evidence-based policies, reinforcement of multisectoral health systems, and innovative solutions are urgently needed in resource-challenged settings to curb CVD risk factors and overall burden.

Intermittent bolus versus continuous infusion techniques for local anesthetic delivery in peripheral and truncal nerve analgesia: the current state of evidence

Manually delivered intermittent bolus (MIB) and programmable intermittent bolus (PIB), alternatives to continuous infusion (CI), involve administering a set volume of solution at a set interval of time. The benefits of intermittent bolus techniques in truncal and peripheral nerve blockade (TPNB) are unclear, and studies have largely demonstrated conflicting results. Using MEDLINE, Embase, Google Scholar, and the Cochrane Library, we conducted an evidenced-based review of published randomized controlled trials comparing intermittent bolus and CI methods in TPNB. In total, 13 randomized controlled trials were identified and evaluated. Outcomes data addressed in these studies included assessments of pain, opioid and local anesthetic consumption, patient satisfaction, adverse events, and physical therapy metrics. The overall quality of current evidence was found to be low given the small sample sizes, heterogeneity of data, and the variations in intermittent bolus techniques between studies. At this time, we found limited supportive data to endorse MIB or PIB over CI in TPNB. While unable to provide data-driven conclusions for local anesthetic delivery methods at this time, we propose that future studies and quantitative analysis between techniques should be on an anatomic, site-specific basis, with greater focus on evaluation of opioid use, adverse events, patient satisfaction, and rehabilitative metrics.

Petition to replace current OGTT criteria for diagnosing prediabetes with the 1-hour post-load plasma glucose ≥ 155 mg/dl (8.6 mmol/L)

Many individuals with prediabetes, as presently defined, will progress to diabetes (T2D) despite the considerable benefit of lifestyle modification. Therefore, it is paramount to screen individuals at increased risk with a more sensitive method capable of identifying prediabetes at an even earlier time point in the lengthy trajectory to T2D. This petition reviews findings demonstrating that the 1-hour (1-h) postload plasma glucose (PG) ≥ 155 mg/dl (8.6 mmol/L) in those with normal glucose tolerance (NGT) during an oral glucose tolerance test (OGTT) is highly predictive for detecting progression to T2D, micro- and macrovascular complications and mortality in individuals at increased risk. Furthermore, the STOP DIABETES Study documented effective interventions that reduce the future risk of T2D in those with NGT and a 1-h PG ≥ 155 mg/dl (8·6 mmol/L). The 1-h OGTT represents a valuable opportunity to extend the proven benefit of diabetes prevention to the sizeable and growing population of individuals at increased risk of progression to T2D. The substantial evidence provided in this petition strongly supports redefining current diagnostic criteria for prediabetes with the elevated 1-h PG level. The authors therefore advocate a 1-h OGTT to detect prediabetes and hence, thwart the global diabetes epidemic.

Physical activity promotion for patients transitioning to dialysis using the "Exercise is Medicine" framework: a multi-center randomized pragmatic trial (EIM-CKD trial) protocol

BACKGROUND

Patients on dialysis are physically inactive, with most reporting activity levels below the fifth percentile of healthy age-matched groups. Several small studies have reported efficacy of diverse exercise interventions among persons with CKD and those on dialysis. However, no single intervention has been widely adopted in real-world practice, despite a clear need in this vulnerable population with high rates of mortality, frailty, and skilled nursing hospitalizations.

METHODS/DESIGN

We describe a pragmatic clinical trial for an exercise intervention among patients transitioning to dialysis. We will use an existing framework - Exercise is Medicine (EIM) - developed by the American College of Sports Medicine. After undertaking formative qualitative research to tailor the EIM framework to the advanced CKD population (eGFR < 30 ml/min/1.73m2), we will randomize 96 patients from two regions-Atlanta and Bay Area-in two intervention arms with incremental levels of clinical-community integration: physical activity assessment during Nephrology clinical visit, brief counseling at pre-dialysis education, and physical activity wearable (group 1) versus group 1 intervention components plus a referral to a free, EIM practitioner-led group exercise program over 16 weeks (group 2; 8 week core intervention; 8-week follow up). We will assess efficacy by comparing between group differences in minutes/week of objectively measured moderate intensity physical activity. To evaluate implementation, we will use questionnaires for assessing barriers to referral, participation and retention along the path of the intervention. Further we will have a plan for dissemination of the intervention by partnering with relevant stakeholders.

DISCUSSION

The overall goal is to inform the development of a practical, cost-conscious intervention "package" that addresses barriers and challenges to physical activity commonly faced by patients with advanced CKD and can be disseminated amongst interested practices.

TRIAL REGISTRATION

ClinicalTrials.gov identifier (Dated:10/17/2017): NCT03311763 .

Sleep Duration and Physical Activity Profiles Associated With Self-Reported Stroke in the United States: Application of Bayesian Belief Network Modeling Techniques

Introduction: Physical activity (PA) and sleep are associated with cerebrovascular disease and events like stroke. Though the interrelationships between PA, sleep, and other stroke risk factors have been studied, we are unclear about the associations of different types, frequency and duration of PA, sleep behavioral patterns (short, average and long sleep durations), within the context of stroke-related clinical, behavioral, and socio-demographic risk factors. The current study utilized Bayesian Belief Network analysis (BBN), a type of machine learning analysis, to develop profiles of physical activity (duration, intensity, and frequency) and sleep duration associated with or no history of stroke, given the influence of multiple stroke predictors and correlates. Such a model allowed us to develop a predictive classification model of stroke which can be used in post-stroke risk stratification and developing targeted stroke rehabilitation care based on an individual's profile. Method: Analysis was based on the 2004-2013 National Health Interview Survey (n = 288,888). Bayesian BBN was used to model the omnidirectional relationships of sleep duration and physical activity to history of stroke. Demographic, behavioral, health/medical, and psychosocial factors were considered as well as sleep duration [defined as short < 7 h. and long ≥ 9 h, referenced to healthy sleep (7-8 h)], and intensity (moderate and vigorous) and frequency (times/week) of physical activity. Results: Of the sample, 48.1% were ≤ 45 years; 55.7% female; 77.4% were White; 15.9%, Black/African American; and 45.3% reported an annual income < $35 K. Overall, the model had a precision index of 95.84%. We found that adults who reported 31-60 min of vigorous physical activity six times for the week and average sleep duration (7-8 h) had the lowest stroke prevalence. Of the 36 sleep (short, average, and long sleep) and physical activity profiles we tested, 30 profiles had a self-reported stroke prevalence lower than the US national average of approximately 3.07%. Women, compared to men with the same sleep and physical activity profile, appeared to have higher self-reported stroke prevalence. We also report age differences across three groups 18-45, 46-65, and 66+. Conclusion: Our findings indicate that several profiles of sleep duration and physical activity are associated with low prevalence of self-reported stroke and that there may be sex differences. Overall, our findings indicate that more than 10 min of moderate or vigorous physical activity, about 5-6 times per week and 7-8 h of sleep is associated with lower self-reported stroke prevalence. Results from the current study could lead to more tailored and personalized behavioral secondary stroke prevention strategies.

Lessons learned from the 1-hour post-load glucose level during OGTT: Current screening recommendations for dysglycaemia should be revised

This perspective covers a novel area of research describing the inadequacies of current approaches for diagnosing dysglycaemia and proposes that the 1-hour post-load glucose level during the 75-g oral glucose tolerance test may serve as a novel biomarker to detect dysglycaemia earlier than currently recommended screening criteria for glucose disorders. Considerable evidence suggests that a 1-hour post-load plasma glucose value ≥155 mg/dl (8.6 mmol/L) may identify individuals with reduced β-cell function prior to progressing to prediabetes and diabetes and is highly predictive of those likely to progress to diabetes more than the HbA_1c or 2-hour post-load glucose values. An elevated 1-hour post-load glucose level was a better predictor of type 2 diabetes than isolated 2-hour post-load levels in Indian, Japanese, and Israeli and Nordic populations. Furthermore, epidemiological studies have shown that a 1-hour PG ≥155 mg/dl (8.6 mmol/L) predicted progression to diabetes as well as increased risk for microvascular disease and mortality when the 2-hour level was <140 mg/dl (7.8 mmol/L). The risk of myocardial infarction or fatal ischemic heart disease was also greater among subjects with elevated 1-hour glucose levels as were risks of retinopathy and peripheral vascular complications in a Swedish cohort. The authors believe that the considerable evidence base supports redefining current screening and diagnostic recommendations with the 1-hour post-load level. Measurement of the 1-hour PG level would increase the likelihood of identifying a larger, high-risk group with the additional practical advantage of potentially replacing the conventional 2-hour oral glucose tolerance test making it more acceptable in a clinical setting.

The 1-h post-load plasma glucose as a novel biomarker for diagnosing dysglycemia

Identifying the earliest moment for intervention to avert progression to prediabetes and diabetes in high-risk individuals is a substantial challenge. As β-cell function is already compromised in prediabetes, attention should therefore be focused on identifying high-risk individuals earlier in the so-called pre-prediabetes stage. Biomarkers to monitor progression and identify the time point at which β-cell dysfunction occurs are therefore critically needed. Large-scale population studies have consistently shown that the 1-h plasma glucose (1-h PG) ≥ 155 mg/dl (8.6 mmol/l) during the oral glucose tolerance test detected incident type 2 diabetes and associated complications earlier than fasting plasma glucose or 2-h plasma glucose levels. An elevated 1-h PG level appears to be a better alternative to HbA1c [5.7-6.4% (37-47 mmol/mol)] or traditional glucose criteria for identifying high-risk individuals at a stage when ß-cell function is substantially more intact than in prediabetes. Diagnosing high-risk individuals earlier proffers the opportunity for potentially reducing progression to diabetes, development of microvascular complications and mortality, thereby advancing benefit beyond that which has been demonstrated in global diabetes prevention programs.

Enhanced Predictive Capability of a 1-Hour Oral Glucose Tolerance Test: A Prospective Population-Based Cohort Study

OBJECTIVE

To examine whether the 1-h blood glucose measurement would be a more suitable screening tool for assessing the risk of diabetes and its complications than the 2-h measurement.

RESEARCH DESIGN AND METHODS

We conducted a prospective population-based cohort study of 4,867 men, randomly selected from prespecified birth cohorts between 1921 and 1949, who underwent an oral glucose tolerance test with blood glucose measurements at 0, 1, and 2 h. Subjects were followed for up to 39 years, with registry-based recording of events. Discriminative abilities of elevated 1-h (≥8.6 mmol/L) versus 2-h (≥7.8 mmol/L) glucose for predicting incident type 2 diabetes, vascular complications, and mortality were compared using Kaplan-Meier analysis, Cox proportional hazards regression, and net reclassification improvement.

RESULTS

Median age was 48 years (interquartile range [IQR] 48-49). During follow-up (median 33 years [IQR 24-37]), 636 (13%) developed type 2 diabetes. Elevated 1-h glucose was associated with incident diabetes (hazard ratio 3.40 [95% CI 2.90-3.98], P < 0.001) and provided better risk assessment than impaired glucose tolerance (Harrell concordance index 0.637 vs. 0.511, P < 0.001). Addition of a 1-h measurement in subjects stratified by fasting glucose provided greater net reclassification improvement than the addition of a 2-h measurement (0.214 vs. 0.016, respectively). Finally, the 1-h glucose was significantly associated with vascular complications and mortality.

CONCLUSIONS

The 1-h blood glucose level is a stronger predictor of future type 2 diabetes than the 2-h level and is associated with diabetes complications and mortality.

Health App Use Among US Mobile Phone Users: Analysis of Trends by Chronic Disease Status

Background

Mobile apps hold promise for serving as a lifestyle intervention in public health to promote wellness and attenuate chronic conditions, yet little is known about how individuals with chronic illness use or perceive mobile apps.

Objective

The objective of this study was to explore behaviors and perceptions about mobile phone–based apps for health among individuals with chronic conditions.

Methods

Data were collected from a national cross-sectional survey of 1604 mobile phone users in the United States that assessed mHealth use, beliefs, and preferences. This study examined health app use, reason for download, and perceived efficacy by chronic condition.

Results

Among participants, having between 1 and 5 apps was reported by 38.9% (314/807) of respondents without a condition and by 6.6% (24/364) of respondents with hypertension. Use of health apps was reported 2 times or more per day by 21.3% (172/807) of respondents without a condition, 2.7% (10/364) with hypertension, 13.1% (26/198) with obesity, 12.3% (20/163) with diabetes, 12.0% (32/267) with depression, and 16.6% (53/319) with high cholesterol. Results of the logistic regression did not indicate a significant difference in health app download between individuals with and without chronic conditions (P>.05). Compared with individuals with poor health, health app download was more likely among those with self-reported very good health (odds ratio [OR] 3.80, 95% CI 2.38-6.09, P<.001) and excellent health (OR 4.77, 95% CI 2.70-8.42, P<.001). Similarly, compared with individuals who report never or rarely engaging in physical activity, health app download was more likely among those who report exercise 1 day per week (OR 2.47, 95% CI 1.6-3.83, P<.001), 2 days per week (OR 4.77, 95% CI 3.27-6.94, P<.001), 3 to 4 days per week (OR 5.00, 95% CI 3.52-7.10, P<.001), and 5 to 7 days per week (OR 4.64, 95% CI 3.11-6.92, P<.001). All logistic regression results controlled for age, sex, and race or ethnicity.

Conclusions

Results from this study suggest that individuals with poor self-reported health and low rates of physical activity, arguably those who stand to benefit most from health apps, were least likely to report download and use these health tools.

Urbanization and kidney function decline in low and middle income countries

Urbanization is expected to increase in low and middle-income countries (LMICs), and might contribute to the increased disease burden. The association between urbanization and CKD is incompletely understood among LMICs. Recently, Inoue et al., explored the association of urbanization on renal function from the China Health and Nutrition Survey. The study found that individuals living in an urban environment had a higher odds of reduced renal function independent of behavioral and cardiometabolic measures, and this effect increased in a dose dependent manner. In this commentary, we discuss the results of these findings and explain the need for more surveillance studies among LMICs.