The role of structural racism and geographical inequity in diabetes outcomes.

Diabetes is pervasive, exponentially growing in prevalence, and outpacing most diseases globally. In this Series paper, we use new theoretical frameworks and a narrative review of existing literature to show how structural inequity (structural racism and geographical inequity) has accelerated rates of diabetes disease, morbidity, and mortality globally. We discuss how structural inequity leads to large, fixed differences in key, upstream social determinants of health, which influence downstream social determinants of health and resultant diabetes outcomes in a cascade of widening inequity. We review categories of social determinants of health with known effects on diabetes outcomes, including public awareness and policy, economic development, access to high-quality care, innovations in diabetes management, and sociocultural norms. We also provide regional perspectives, grounded in our theoretical framework, to highlight prominent, real-world challenges.

Interventions to address global inequity in diabetes: international progress.

Diabetes is a serious chronic disease with high associated burden and disproportionate costs to communities based on socioeconomic, gender, racial, and ethnic status. Addressing the complex challenges of global inequity in diabetes will require intentional efforts to focus on broader social contexts and systems that supersede individual-level interventions. We codify and highlight best practice approaches to achieve equity in diabetes care and outcomes on a global scale. We outline action plans to target diabetes equity on the basis of the recommendations established by The Lancet Commission on Diabetes, organising interventions by their effect on changing the ecosystem, building capacity, or improving the clinical practice environment. We present international examples of how to address diabetes inequity in the real world to show that approaches addressing the individual within a larger social context, in addition to addressing structural inequity, hold the greatest promise for creating sustainable and equitable change that curbs the global diabetes crisis.

Understanding the relationship between social risk factors and functional limitation among stroke survivors in the US.

BACKGROUND: Stroke is the fifth leading cause of death and disability in the United States. Social risk factors contribute to recovery from stroke, however the relationship between social risk factors and functional limitation among stroke survivors remains unknown. METHODS: Data on 2,888 adults with stroke from the National Health Interview Survey from 2016-2018 was analyzed. The primary independent variables included six social risk factors: economic instability, lack of community, educational deficit, food insecurity, social isolation, and inadequate access to care. The outcome measure was functional limitation count. Negative binomial regression models were run to test the relationship between the independent and dependent variables adjusting for covariates. RESULTS: Overall, 56% of the study participants were aged 65+, 70% were Non-Hispanic White, and 95% had at least one comorbidity. The mean functional limitation count was 1.8. In the unadjusted model, each social risk factor was significantly associated with functional limitation. In the fully adjusted model, significant association with functional limitation was found in individuals reporting economic instability (Incidence rate ratio [IRR] 1.65, 95% CI 1.33, 2.06), food insecurity (IRR 1.28, 95% CI 1.15, 1.42), and social isolation (IRR 1.64, 95% CI 1.48, 1.82). CONCLUSIONS: Social risk factors such as economic instability, food insecurity and social isolation are significantly associated with functional limitation in adults with stroke. Interventions designed to address both social and medical needs have the potential to improve physical functioning and other clinical outcomes in stroke survivors.

Historic Residential Redlining and Present-Day Social Determinants of Health, Home Evictions, and Food Insecurity within US Neighborhoods.

OBJECTIVE: Examine the association between historic residential redlining and present-day racial/ethnic composition of neighborhoods, racial/ethnic differences in social determinant of health domains, and risk of home evictions and food insecurity. RESEARCH DESIGN AND METHODS: We examined data on 12,334 (for eviction sample), and 8996 (for food insecurity sample), census tracts in 213 counties across 37 states in the USA with data on exposure to historic redlining. First, we examined relationships between Home Owners' Loan Corporation (HOLC) redlining grades (A="Best", B="Still Desirable", C="Definitely Declining", D="Hazardous") and present-day racial/ethnic composition and racial/ethnic differences in social determinant of health domains of neighborhoods. Second, we examined whether historic redlining is associated with present-day home eviction rates (measured across eviction filings rates, and eviction judgment rates for 12,334 census tracts in 2018) and food insecurity (measured across low supermarket access, low supermarket access and income, low supermarket access and low car ownership for 8996 census tracts in 2019). Multivariable regression models were adjusted for census tract population, urban/rural designation, and county level fixed effects. RESULTS: Relative to areas with a historic HOLC grading of "A (Best)", areas with a "D (Hazardous)" grading had a 2.59 (95%CI=1.99-3.19; p-value<0.01) higher rate of eviction filings, and a 1.03 (95%CI=0.80-1.27; p-value<0.01) higher rate of eviction judgments. Compared to areas with a historic HOLC grading of "A (Best)", areas rated with a "D (Hazardous)" had a 16.20 (95%CI=15.02-17.79; p-value<0.01) higher rate of food insecurity based on supermarket access and income, and a 6.15 (95%CI =5.53-6.76; p-value<0.01) higher rate of food insecurity based on supermarket access and car ownership. CONCLUSIONS: Historic residential redlining is significantly associated with present-day home evictions and food insecurity, highlighting persistent associations between structural racism and present-day social determinants of health.

Modern Day Consequences of Historic Redlining: Finding a Path Forward.

There is emerging evidence that structural racism is a major contributor to poor health outcomes for ethnic minorities. Structural racism captures upstream historic racist events (such as slavery, black code, and Jim Crow laws) and more recent state-sanctioned racist laws in the form of redlining. Redlining refers to the practice of systematically denying various services (e.g., credit access) to residents of specific neighborhoods, often based on race/ethnicity and primarily within urban communities. Historical redlining is linked to increased risk of diabetes, hypertension, and early mortality due to heart disease with evidence suggesting it impacts health through suppressing economic opportunity and human capital, or the knowledge, skills, and value one contributes to society. Addressing structural racism has been a rallying call for change in recent years-drawing attention to the racialized impact of historical policies in the USA. Unfortunately, the enormous scope of work has also left people feeling incapable of effecting the very change they seek. This paper highlights a path forward by briefly discussing the origins of historical redlining, highlighting the modern-day consequences both on health and at the societal level, and suggest promising initiatives to address the impact.

Relationship between mental health diagnoses and COVID-19 test positivity, hospitalization, and mortality in Southeast Wisconsin.

BACKGROUND: There is a paucity of literature on the relationship between pre-existing mental health conditions and coronavirus disease-2019 (COVID-19) outcomes. The aim was to examine the association between pre-existing mental health diagnosis and COVID-19 outcomes (positive screen, hospitalization, mortality). METHODS: Electronic medical record data for 30 976 adults tested for COVID-19 between March 2020 and 10th July 2020 was analyzed. COVID-19 outcomes included positive screen, hospitalization among screened positive, and mortality among screened positive and hospitalized. Primary independent variable, mental health disorders, was based on ICD-10 codes categorized as bipolar, internalizing, externalizing, and psychoses. Descriptive statistics were calculated, unadjusted and adjusted logistic regression and Cox proportional hazard models were used to investigate the relationship between each mental health disorder and COVID-19 outcomes. RESULTS: Adults with externalizing (odds ratio (OR) 0.67, 95%CI 0.57-0.79) and internalizing disorders (OR 0.78, 95% CI 0.70-0.88) had lower odds of having a positive COVID-19 test in fully adjusted models. Adults with bipolar disorder had significantly higher odds of hospitalization in fully adjusted models (OR 4.27, 95% CI 2.06-8.86), and odds of hospitalization were significantly higher among those with externalizing disorders after adjusting for demographics (OR 1.71, 95% CI 1.23-2.38). Mortality was significantly higher in the fully adjusted model for patients with bipolar disorder (hazard ratio 2.67, 95% CI 1.07-6.67). CONCLUSIONS: Adults with mental health disorders, while less likely to test positive for COVID-19, were more likely to be hospitalized and to die in the hospital. Study results suggest the importance of developing interventions that incorporate elements designed to address smoking cessation, nutrition and physical activity counseling and other needs specific to this population to improve COVID-19 outcomes.

Dose response relationship between food insecurity and quality of life in United States adults: 2016-2017.

BACKGROUND: Food insecurity is associated with worse general health rating, but little research exists investigating whether there is a dose response relationship across levels of food security and mental and physical health domains at the population level. METHODS: Data from the Medical Expenditure Panel Survey (2016-2017) with US adults aged 18 years and older was used. The physical component score (PCS) and mental component score (MCS) of Quality of Life, served as the outcome measures. Four categories of food insecurity (high, marginal, low, very low food security) served as the primary independent variable. Linear regression was used to run unadjusted followed by adjusted models. Separate models were run for PCS and MCS. RESULTS: In a sample of US adults, 16.1% reported some degree of food insecurity. For PCS, marginal (ß = - 2.54 (p < 0.001), low (ß = - 3.41, (p < 0.001), and very low (ß = - 5.62, (p < 0.001) food security was associated with worse PCS scores, compared to adults with high food security. For MCS, marginal (ß = - 3.90 (p < 0.001), low (ß = - 4.79, (p < 0.001), and very low (ß = - 9.72, (p < 0.001) food security was associated with worse MCS scores, compared to adults with high food security. CONCLUSION: Increasing levels of food insecurity were associated with decreased physical and mental health quality of life scores. This relationship was not explained by demographic factors, socioeconomic factors, insurance, or comorbidity burden. This study suggests work is needed to mitigate the impact of social risk, such as food insecurity, on quality of life in adults, and understand pathways and mechanisms for this relationship.

Racial/ethnic differences in social determinants of health and health outcomes among adolescents and youth ages 10-24 years old: a scoping review.

INTRODUCTION: With the recent emergence of the Healthy People 2030 goals there is a need to understand the role of SDOH on health inequalities from an upstream perspective. This review summarizes the recent body of evidence on the impact of SDOH across adolescence and youth health outcomes by race/ethnicity using the Health People 2030 Framework. METHODS: A systematic, reproducible search was performed using PubMed, Academic Search Premier, PsychInfo, and ERIC. A total of 2078 articles were screened for inclusion. A total of 263 articles met inclusion criteria, resulting in 29 articles included for final synthesis. RESULTS: Across the 29 articles, 11 were cross-sectional, 16 were cohort, and 2 were experimental. Across SDOH categories (economic stability, education access and quality, health care access and quality, neighborhood and built environment, and social and community context), 1 study examined self-efficacy, 6 educational attainment, 10 behavior, 5 smoking, 11 alcohol use, 10 substance use, and 1 quality of life. The majority of outcomes represented in this search included health behaviors such as health risk behavior, smoking, alcohol use, and substance use. Across the 29 articles identified, significant differences existed across outcomes by race/ethnicity across SDOH factors, however magnitude of differences varied by SDOH category. DISCUSSION: SDOH differentially affect adolescents and youth across race/ethnicity. The lived adverse experiences, along with structural racism, increase the likelihood of adolescents and youth engaging in risky health behaviors and negatively influencing health outcomes during adolescence and youth. Research, public health initiatives, and policies integrating SDOH into interventions at early stage of life are needed to effectively reduce social and health inequalities at a population level.

Identification of "Digital Sarcopenia" Can Aid the Detection of Pancreatic Exocrine Insufficiency and Malnutrition Assessment in Patients with Suspected Pancreatic Pathology.

BACKGROUND: Pancreatic exocrine insufficiency (PEI) and subsequent malnutrition can be difficult to diagnose but lead to sarcopenia and increased mortality and morbidity even in benign disease. Digital skeletal muscle analysis has been increasingly recognised as a tool to diagnose sarcopenia. OBJECTIVE: The aim of the study was to assess the prevalence of sarcopenia in patients with PEI secondary to benign disease using novel skeletal muscle recognition software. METHODS: Prospective recruitment of patients referred for endoscopic ultrasound (EUS) with suspected pancreatic pathology. Patients with suspected pancreatic cancer on initial computed tomography (CT) were excluded. The diagnosis of chronic pancreatitis (CP) was based on CT and EUS findings. PEI was assessed with faecal elastase-1. Digital measurement of skeletal muscle mass identified sarcopenia, with demographic and comorbidity data also collected. RESULTS: PEI was identified in 45.1% (46/102) of patients recruited, and 29.4% (30/102) had changes of CP. Sarcopenia was significantly more prevalent in PEI 67.4% (31/46) than no-PEI 37.5% (21/56) (37.5%), regardless of CP changes (p < 0.003). The prevalence of sarcopenia (67% vs. 35%; p = 0.02) and sarcopenic obesity (68.4% vs. 25%; p = 0.003) was significantly higher when PEI was present without a radiological diagnosis of CP. Multivariate analysis identified sarcopenia and diabetes to be independently associated with PEI (odds ratio 4.8 and 13.8, respectively, p < 0.05). CONCLUSION: Sarcopenia was strongly associated with PEI in patients undergoing assessment for suspected benign pancreatic pathology. Digital skeletal muscle assessment can be used as a tool to aid identification of sarcopenia in patients undergoing CT scan for pancreatic symptoms.

Explanatory role of sociodemographic, clinical, behavioral, and social factors on cognitive decline in older adults with diabetes.

BACKGROUND: The aim of the study was to examine the explanatory role of sociodemographic, clinical, behavioral, and social factors on racial/ethnic differences in cognitive decline among adults with diabetes. METHODS: Adults aged 50+ years with diabetes from the Health and Retirement Survey were assessed for cognitive function (normal, mild cognitive impairment [MCI], and dementia). Generalized estimating equation (GEE) logistic regression models were used to account for repeating measures over time. Models were adjusted for sociodemographic (gender, age, education, household income and assets), behavioral (smoking), clinical (ie. comorbidities, body mass index), and social (social support, loneliness, social participation, perceived constraints and perceived mastery on personal control) factors. RESULTS: Unadjusted models showed non-Hispanic Blacks (NHB) and Hispanics were significantly more likely to progress from normal cognition to dementia (NHB OR: 2.99, 95%CI 2.35-3.81; Hispanic OR: 3.55, 95%CI 2.77-4.56), and normal cognition to MCI (NHB OR = 2.45, 95%CI 2.14-2.82; Hispanic OR = 2.49, 95%CI 2.13-2.90) compared to non-Hispanic Whites (NHW). Unadjusted models for the transition from mild cognitive decline to dementia showed Hispanics were more likely than NHW to progress (OR = 1.43, 95%CI 1.11-1.84). After adjusting for sociodemographic, clinical/behavioral, and social measures, NHB were 3.75 times more likely (95%CI 2.52-5.56) than NHW to reach dementia from normal cognition. NHB were 2.87 times more likely (95%CI 2.37-3.48) than NHW to reach MCI from normal. Hispanics were 1.72 times more likely (95%CI 1.17-2.52) than NHW to reach dementia from MCI. CONCLUSION: Clinical/behavioral and social factors did not explain racial/ethnic disparities. Racial/ethnic disparities are less evident from MCI to dementia, emphasizing preventative measures/interventions before cognitive impairment onset are important.

Differences in the relationship between social capital and hypertension in emerging vs. established economies in Sub-Saharan Africa.

BACKGROUND: The global burden of hypertension is growing, particularly in low- and middle-income countries. This study aimed to investigate differences in the relationship between social capital and hypertension between regions in Sub-Saharan Africa (West vs. South Africa) and within regions (rural vs. urban residence within each country). METHODS: Data for 9,800 adults were analyzed from the Study on Global Ageing and Adult Health (SAGE) 2007-2010 for Ghana (West African emerging economy) and South Africa (South African established economy). Outcomes were self-reported and measured hypertension. The primary independent variable was social capital, dichotomized into low vs. medium/high. Interaction terms were tested between social capital and rural/urban residence status for each outcome by country. Linear and logistic regression models were run separately for both countries and each outcome. RESULTS: Those with low social capital in the emerging economy of Ghana were more likely to have hypertension based on measurement (OR=1.35, 95% CI=1.18,1.55), but the relationship with self-reported hypertension lost significance after adjustment. There was no significant relationship in the relationship between social capital and hypertension in the established economy of South Africa after adjustment. No significant interactions existed by rural/urban residence status in either country. CONCLUSION: Low social capital was associated with worse hypertension outcomes, however, the relationship differed between South Africa and Ghana. Further investigation is needed to understand differences between and within countries to guide development of programs targeted at leveraging and promoting social capital as a positive component of overall health.

Relationship between housing insecurity, diabetes processes of care, and self-care behaviors.

BACKGROUND: The aim of this analysis was to examine the influence of housing insecurity on diabetes processes of care and self-care behaviors and determine if that relationship varied by employment status or race/ethnicity. METHODS: Using nationally representative data from the Behavioral Risk Factor Surveillance System (2014-2015), 16,091 individuals were analyzed for the cross-sectional study. Housing insecurity was defined as how often respondents reported being worried or stressed about having enough money to pay rent/mortgage. Following unadjusted logistic models testing interactions between housing insecurity and either employment or race/ethnicity on diabetes processes of care and self-care behaviors, stratified models were adjusted for demographics, socioeconomic status, health insurance status, and comorbidity count. RESULTS: 38.1% of adults with diabetes reported housing insecurity. Those reporting housing insecurity who were employed were less likely to have a physicians visit (0.58, 95%CI 0.37,0.92), A1c check (0.45, 95%CI 0.26,0.78), and eye exam (0.61, 95%CI 0.44,0.83), while unemployed individuals were less likely to have a flu vaccine (0.84, 95%CI 0.70,0.99). Housing insecure White adults were less likely to receive an eye exam (0.67, 95%CI 0.54,0.83), flu vaccine (0.84, 95%CI 0.71,0.99) or engage in physical activity (0.82, 95%CI 0.69,0.96), while housing insecure Non-Hispanic Black adults were less likely to have a physicians visit (0.56, 95%CI 0.32,0.99). CONCLUSIONS: Housing insecurity had an influence on diabetes processes of care and self-care behaviors, and this relationship varied by employment status and race/ethnicity. Diabetes interventions should incorporate discussion surrounding housing insecurity and consider differences in the impact by demographic factors on diabetes care.

Cross-Sector Collaborations Between Health Care Systems and Community Partners That Target Health Equity/Disparities in Diabetes Care.

Evidence shows that social determinants of health (SDOH) are key drivers of diabetes outcomes and disparities in diabetes care. Targeting SDOH at the individual, organizational, and policy levels is an essential step in improving health equity for individuals living with diabetes. In addition, there is increasing recognition of the need to build collaboration across the health care system and the communities experiencing inequities to improve health equity. As a result, partnerships between health and nonhealth sectors have emerged as a crucial component for increasing health equity in diabetes care and achieving health equity. The purpose of this article is to discuss cross-sector collaborations between health care systems and nonhealth partners that target health equity in diabetes care.

Team Science, Population Health, and COVID-19: Lessons Learned Adapting a Population Health Research Team to COVID-19.

Our multidisciplinary research team is composed of 6 faculty with expertise in internal medicine, nephrology, maternal/fetal medicine, health services research, statistics, and community-based research, and 36 program staff including biostatisticians, nurses, program coordinators, program assistants, and medical assistants/phlebotomists. With the emergence of the COVID-19 pandemic and the impact it was having on our community, especially the ethnic minority population in inner-city Milwaukee, we felt it was critical to stay engaged and figure out how to ask meaningful research questions that are important to the community, are relevant to the times, and will lead to lasting change. While navigating this unprecedented challenge, our research team made difficult decisions but were able to engage our staff and respond to community needs. We organized our lessons learned to serve as a perspective on how to effectively remain committed to vision and serve our communities, while collecting evidence that can inform policy in difficult times.

Prevalence of food insecurity and association with mental health in an indigenous population in Panamá.

OBJECTIVE: Understanding food insecurity and its health consequences is important for identifying strategies to best target support for individuals and communities. Given the limited information that exists for indigenous groups in Latin America, this study aimed to understand the association between food insecurity and mental health in an indigenous population in Panama. DESIGN: Cross-sectional data were collected using a survey conducted with Kuna Indians residing off the coast of Panama. Data sources included measures from the Panamanian prevalence of risk factors associated with CVD survey, and validated measures for psychosocial factors and standardised health outcome measures. Regression models with each of the mental health outcomes (depression, serious psychological distress, perceived stress) were used to examine the association between food insecurity and mental health outcomes. SETTING: Indigenous Kuna community residing on the San Blas Islands of Panama. PARTICIPANTS: Two-hundred nine adults. RESULTS: Food insecurity was reported by 83 % of the participants. Across demographic categories, the only significant difference was by age with higher prevalence in younger ages. After adjusting for demographics, higher food insecurity was significantly associated with higher number of depressive symptoms and more serious psychological distress, but not with levels of perceived stress. CONCLUSIONS: Based on these findings, treatment for mental health in the Kuna community may need to account for social determinants of health and be tailored to meet the needs of younger age groups in this population. In addition, interventions designed to decrease food insecurity should be considered as a possible means for improving mental health.

HIV and cardiovascular disease in sub-Saharan Africa: Demographic and Health Survey data for 4 countries.

BACKGROUND: Investigate the relationship between two common cardiovascular diseases and HIV in adults living in sub-Saharan Africa using population data provided through the Demographic and Health Survey. METHODS: Data for four sub-Saharan countries were used. All adults asked questions regarding diagnosis of HIV, diabetes, and hypertension were included in the sample totaling 5356 in Lesotho, 3294 in Namibia, 9917 in Senegal, and 1051 in South Africa. Logistic models were run for each country separately, with self-reported diabetes as the first outcome and self-reported hypertension as the second outcome and HIV status as the primary independent variable. Models were adjusted for age, gender, rural/urban residence and BMI. Complex survey design allowed weighting to the population. RESULTS: Prevalence of self-reported diabetes ranged from 3.8% in Namibia to 0.5% in Senegal. Prevalence of self-reported hypertension ranged from 22.9% in Namibia to 0.6% in Senegal. In unadjusted models, individuals with HIV in Lesotho were 2 times more likely to have self-reported diabetes (OR = 2.01, 95% CI 1.08-3.73), however the relationship lost significance after adjustment. Individuals with HIV were less likely to have self-reported diabetes after adjustment in Namibia (OR = 0.29, 95% CI 0.12-0.72) and less likely to have self-reported hypertension after adjustment in Lesotho (OR = 0.63, 95% CI 0.47-0.83). Relationships were not significant for Senegal or South Africa. DISCUSSION: HIV did not serve as a risk factor for self-reported cardiovascular disease in sub-Saharan Africa during the years included in this study. However, given the growing prevalence of diabetes and hypertension in the region, and the high prevalence of undiagnosed cardiovascular disease, it will be important to continue to track and monitor cardiovascular disease at the population level and in individuals with and without HIV. CONCLUSIONS: The odds of self-reported diabetes in individuals with HIV was high in Lesotho and low in Namibia, while the odds of self-reported hypertension in individuals with HIV was low across all 4 countries included in this study. Programs are needed to target individuals that need to manage multiple diseases at once and should consider increasing access to cardiovascular disease management programs for older adults, individuals with high BMI, women, and those living in urban settings.

Financial incentives to improve glycemic control in African American adults with type 2 diabetes: a pilot randomized controlled trial.

BACKGROUND: Financial incentives is emerging as a viable strategy for improving clinical outcomes for adults with type 2 diabetes. However, there is limited data on optimal structure for financial incentives and whether financial incentives are effective in African Americans with type 2 diabetes. This pilot study evaluated impact of three financial incentive structures on glycemic control in this population. METHODS: Sixty adults with type 2 diabetes were randomized to one of three financial incentive structures: 1) single incentive (Group 1) at 3 months for Hemoglobin A1c (HbA1c) reduction, 2) two-part equal incentive (Group 2) for home testing of glucose and HbA1c reduction at 3 months, and 3) three-part equal incentive (Group 3) for home testing, attendance of weekly telephone education classes and HbA1c reduction at 3 months. The primary outcome was HbA1c reduction within each group at 3 months post-randomization. Paired t-tests were used to test differences between baseline and 3-month HbA1c within each group. RESULTS: The mean age for the sample was 57.9 years and 71.9% were women. Each incentive structure led to significant reductions in HbA1c at 3 months with the greatest reduction from baseline in the group with incentives for multiple components: Group 1 mean reduction = 1.25, Group 2 mean reduction = 1.73, Group 3 mean reduction = 1.74. CONCLUSION: Financial incentives led to significant reductions in HbA1c from baseline within each group. Incentives for multiple components led to the greatest reductions from baseline. Structured financial incentives that reward home monitoring, attendance of telephone education sessions, and lifestyle modification to lower HbA1c are viable options for glycemic control in African Americans with type 2 diabetes. TRIAL REGISTRATION: Trial registration: NCT02722499 . Registered 23 March 2016, url.

The influence of daily stress on glycemic control and mortality in adults with diabetes.

There is mixed evidence regarding the relationship between different types of stress and outcomes in adults with diabetes. The aim of this study was to understand the relationship between daily stress and glycemic control (HbA1c), and to examine whether multiple daily stressors is associated with early mortality among individuals with diabetes. This was a cross-sectional analysis of national Midlife Development in the United States (MIDUS) study data. A total of 141 adults with diabetes completed the National Study of Daily Experiences (NSDE) project during the initial phase of the study, which was summarized through a series of measures about daily stress frequency, type and impact. General linear models investigated the relationship between daily stress and HbA1c. Kaplan-Meier curves based on national death index information linked to MIDUS were investigated for individuals reporting no/one stressor per week versus multiple stressors per week. On average, this population of adults with diabetes reported 3.1 days with a stressor and 2.45 stressor types per week. No significant relationships existed between glycemic control and frequency of daily stress. Higher stress from work was associated with higher HbA1c (ß = 0.65, 95% CI 0.08, 1.22) and higher perceived risk of stress influencing physical health was associated with higher HbA1c (ß = 0.60, 95% CI 0.01, 1.20). In conclusion, while many ways of measuring daily stress were shown not to have a significant influence on glycemic control, daily stress related to work and the perceived risk of stress influencing one's physical health may influence outcomes for adults with diabetes. Interventions incorporating stress management, and in particular coping with the risk that stress has on health may help adults with diabetes better manage glycemic control over time.

Differential Impact of Food Insecurity, Distress, and Stress on Self-care Behaviors and Glycemic Control Using Path Analysis.

BACKGROUND: The aim of this study was to investigate the direct and indirect pathways through which food insecurity influences glycemic control and self-care behaviors. METHODS: Using data collected from 615 adults with type 2 diabetes, we investigated pathways between food insecurity and diabetes outcomes using path analysis. We included measures of perceived stress, diabetes distress, diabetes fatalism, and depression as psychosocial factors in the pathway. Self-care behaviors included general diet, specific diet, exercise, blood sugar testing, foot care, and medication adherence. Analyses were conducted using Stata v14, to include both direct and indirect effects, with standardized estimates to allow comparison of paths. RESULTS: Food insecurity was directly associated with stress (r = 0.43, p < 0.001), depression (r = 0.34, p < 0.001), fatalism (r = 0.09, p = 0.03), and distress (r = 0.36, p < 0.001). The type of stress, however, was differentially associated with outcomes, with distress associated with HbA1c (r = 0.25, p < 0.001), general and specific diet (r = - 0.28 and - 0.17, respectively, p = 0.001), and medication adherence (r = - 0.26, p < 0.001), while stress was associated with specific diet (r = - 0.14, p = 0.005) and medication adherence (r = - 0.15, p < 0.001) and depression was associated with exercise (r = - 0.06, p = 0.007). Food insecurity was indirectly associated with HbA1c (r = 0.08, p = 0.001), and four self-care behaviors (general diet, specific diet, exercise, and medication adherence). CONCLUSIONS: Food insecurity influences self-care behaviors indirectly via multiple psychosocial factors, and glycemic control indirectly through diabetes distress, supporting the hypothesis that stress is an important mechanism. Programs to improve access to resources and manage psychosocial concerns should be combined with food-based programs for food insecure populations with diabetes.

Diagnostic yield of magnetically assisted capsule endoscopy versus gastroscopy in recurrent and refractory iron deficiency anemia.

BACKGROUND: Small-bowel capsule endoscopy is advocated and repeat upper gastrointestinal (GI) endoscopy should be considered for evaluation of recurrent or refractory iron deficiency anemia (IDA). A new device that allows magnetic steering of the capsule around the stomach (magnetically assisted capsule endoscopy [MACE]), followed by passive small-bowel examination might satisfy both requirements in a single procedure. METHODS: In this prospective cohort study, MACE and esophagogastroduodenoscopy (EGD) were performed in patients with recurrent or refractory IDA. Comparisons of total (upper GI and small bowel) and upper GI diagnostic yields, gastric mucosal visibility, and patient comfort scores were the primary end points. RESULTS: 49 patients were recruited (median age 64 years; 39 % male). Combined upper and small-bowel examination using the new capsule yielded more pathology than EGD alone (113 vs. 52; P < 0.001). In upper GI examination (proximal to the second part of the duodenum, D2), MACE identified more total lesions than EGD (88 vs. 52; P < 0.001). There was also a difference if only IDA-associated lesions (esophagitis, altered/fresh blood, angioectasia, ulcers, and villous atrophy) were included (20 vs. 10; P = 0.04). Pathology distal to D2 was identified in 17 patients (34.7 %). Median scores (0 - 10 for none - extreme) for pain (0 vs. 2), discomfort (0 vs. 3), and distress (0 vs. 4) were lower for MACE than for EGD (P < 0.001). CONCLUSION: Combined examination of the upper GI tract and small bowel using the MACE capsule detected more pathology than EGD alone in patients with recurrent or refractory IDA. MACE also had a higher diagnostic yield than EGD in the upper GI tract and was better tolerated by patients.