Rates of Downstream Procedures and Complications Associated With Lung Cancer Screening in Routine Clinical Practice : A Retrospective Cohort Study.

BACKGROUND: Lung cancer screening (LCS) using low-dose computed tomography (LDCT) reduces lung cancer mortality but can lead to downstream procedures, complications, and other potential harms. Estimates of these events outside NLST (National Lung Screening Trial) have been variable and lacked evaluation by screening result, which allows more direct comparison with trials. OBJECTIVE: To identify rates of downstream procedures and complications associated with LCS. DESIGN: Retrospective cohort study. SETTING: 5 U.S. health care systems. PATIENTS: Individuals who completed a baseline LDCT scan for LCS between 2014 and 2018. MEASUREMENTS: Outcomes included downstream imaging, invasive diagnostic procedures, and procedural complications. For each, absolute rates were calculated overall and stratified by screening result and by lung cancer detection, and positive and negative predictive values were calculated. RESULTS: Among the 9266 screened patients, 1472 (15.9%) had a baseline LDCT scan showing abnormalities, of whom 140 (9.5%) were diagnosed with lung cancer within 12 months (positive predictive value, 9.5% [95% CI, 8.0% to 11.0%]; negative predictive value, 99.8% [CI, 99.7% to 99.9%]; sensitivity, 92.7% [CI, 88.6% to 96.9%]; specificity, 84.4% [CI, 83.7% to 85.2%]). Absolute rates of downstream imaging and invasive procedures in screened patients were 31.9% and 2.8%, respectively. In patients undergoing invasive procedures after abnormal findings, complication rates were substantially higher than those in NLST (30.6% vs. 17.7% for any complication; 20.6% vs. 9.4% for major complications). LIMITATION: Assessment of outcomes was retrospective and was based on procedural coding. CONCLUSION: The results indicate substantially higher rates of downstream procedures and complications associated with LCS in practice than observed in NLST. Diagnostic management likely needs to be assessed and improved to ensure that screening benefits outweigh potential harms. PRIMARY FUNDING SOURCE: National Cancer Institute and Gordon and Betty Moore Foundation.

A Pragmatic, Randomized Clinical Trial of Gestational Diabetes Screening.

BACKGROUND: Gestational diabetes mellitus is common and is associated with an increased risk of adverse maternal and perinatal outcomes. Although experts recommend universal screening for gestational diabetes, consensus is lacking about which of two recommended screening approaches should be used. METHODS: We performed a pragmatic, randomized trial comparing one-step screening (i.e., a glucose-tolerance test in which the blood glucose level was obtained after the oral administration of a 75-g glucose load in the fasting state) with two-step screening (a glucose challenge test in which the blood glucose level was obtained after the oral administration of a 50-g glucose load in the nonfasting state, followed, if positive, by an oral glucose-tolerance test with a 100-g glucose load in the fasting state) in all pregnant women who received care in two health systems. Guidelines for the treatment of gestational diabetes were consistent with the two screening approaches. The primary outcomes were a diagnosis of gestational diabetes, large-for-gestational-age infants, a perinatal composite outcome (stillbirth, neonatal death, shoulder dystocia, bone fracture, or any arm or hand nerve palsy related to birth injury), gestational hypertension or preeclampsia, and primary cesarean section. RESULTS: A total of 23,792 women underwent randomization; women with more than one pregnancy during the trial could have been assigned to more than one type of screening. A total of 66% of the women in the one-step group and 92% of those in the two-step group adhered to the assigned screening. Gestational diabetes was diagnosed in 16.5% of the women assigned to the one-step approach and in 8.5% of those assigned to the two-step approach (unadjusted relative risk, 1.94; 97.5% confidence interval [CI], 1.79 to 2.11). In intention-to-treat analyses, the respective incidences of the other primary outcomes were as follows: large-for-gestational-age infants, 8.9% and 9.2% (relative risk, 0.95; 97.5% CI, 0.87 to 1.05); perinatal composite outcome, 3.1% and 3.0% (relative risk, 1.04; 97.5% CI, 0.88 to 1.23); gestational hypertension or preeclampsia, 13.6% and 13.5% (relative risk, 1.00; 97.5% CI, 0.93 to 1.08); and primary cesarean section, 24.0% and 24.6% (relative risk, 0.98; 97.5% CI, 0.93 to 1.02). The results were materially unchanged in intention-to-treat analyses with inverse probability weighting to account for differential adherence to the screening approaches. CONCLUSIONS: Despite more diagnoses of gestational diabetes with the one-step approach than with the two-step approach, there were no significant between-group differences in the risks of the primary outcomes relating to perinatal and maternal complications. (Funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development; ScreenR2GDM ClinicalTrials.gov number, NCT02266758.).

Uptake of Lung Cancer Screening CT After a Provider Order for Screening in the PROSPR-Lung Consortium.

BACKGROUND: Uptake of lung cancer screening (LCS) has been slow with less than 20% of eligible people who currently or formerly smoked reported to have undergone a screening CT. OBJECTIVE: To determine individual-, health system-, and neighborhood-level factors associated with LCS uptake after a provider order for screening. DESIGN AND SUBJECTS: We conducted an observational cohort study of screening-eligible patients within the Population-based Research to Optimize the Screening Process (PROSPR)-Lung Consortium who received a radiology referral/order for a baseline low-dose screening CT (LDCT) from a healthcare provider between January 1, 2015, and June 30, 2019. MAIN MEASURES: The primary outcome is screening uptake, defined as LCS-LDCT completion within 90 days of the screening order date. KEY RESULTS: During the study period, 18,294 patients received their first order for LCS-LDCT. Orders more than doubled from the beginning to the end of the study period. Overall, 60% of patients completed screening after receiving their first LCS-LDCT order. Across health systems, uptake varied from 41 to 87%. In both univariate and multivariable analyses, older age, male sex, former smoking status, COPD, and receiving care in a centralized LCS program were positively associated with completing LCS-LDCT. Unknown insurance status, other or unknown race, and lower neighborhood socioeconomic status, as measured by the Yost Index, were negatively associated with screening uptake. CONCLUSIONS: Overall, 40% of patients referred for LCS did not complete a LDCT within 90 days, highlighting a substantial gap in the lung screening care pathway, particularly in decentralized screening programs.

Individuals Eligible for Lung Cancer Screening Less Likely to Receive Screening When Enrolled in Health Plans With Deductibles.

BACKGROUND: In 2015, the Centers for Medicare & Medicaid Services and commercial insurance plans began covering lung cancer screening (LCS) without patient cost-sharing for all plans. We explore the impact of enrolling into a deductible plan on the utilization of LCS services despite having no out-of-pocket cost requirement. METHODS: This retrospective study analyzed data from the Population-based Research to Optimize the Screening Process Lung Consortium. Our cohort included non-Medicare LCS-eligible individuals enrolled in managed care organizations between February 5, 2015, and February 28, 2019. We estimate a series of sequential logistic regression models examining utilization across the sequence of events required for baseline LCS. We report the marginal effects of enrollment into deductible plans compared with enrollment in no-deductible plans. RESULTS: The total effect of deductible plan enrollment was a 1.8 percentage-point (PP) decrease in baseline LCS. Sequential logistic regression results that explore each transition separately indicate deductible plan enrollment was associated with a 4.3 PP decrease in receipt of clinician visit, a 1.7 PP decrease in receipt of LCS order, and a 7.0 PP decrease in receipt of baseline LCS. Reductions persisted across all observable races and ethnicities. CONCLUSIONS: These findings suggest individuals enrolled in deductible plans are more likely to forgo preventive LCS services despite requiring no out-of-pocket costs. This result may indicate that increased cost-sharing is associated with suboptimal choices to forgo recommended LCS. Alternatively, this effect may indicate individuals enrolling into deductible plans prefer less health care utilization. Patient outreach interventions at the health plan level may improve LCS.

Vitamin D deficiency and insufficiency in Hawaii: Levels and sources of serum vitamin D in older adults.

OBJECTIVE: To examine the major sources of vitamin D [25-hydroxyvitamin D (25(OH)D)] and evaluate their collective role on rates of vitamin D deficiency/insufficiency among older adults. METHODS: Cross-sectional analysis of the relationship between serum 25(OH)D levels and sources of vitamin D (self-reported and objectively validated sun exposure, supplementation, food including fortified sources). Study subjects were part of the Hawaii Longitudinal Study of Personality and Health who completed a clinic visit between 55 and 65 years (M = 59.6) and food frequency questionnaire, and provided serum to assay 25(OH)D (n = 223). RESULTS: Although mean serum 25(OH)D levels were overall sufficient (34.3 ng/ml, [SD = 10.9]), over one-third of participants (38%) had vitamin D deficiency/insufficiency (<30 ng/ml). Asians were the most likely to be insufficient and Filipinos were the least likely (43% vs. 11%, respectively). Overall, supplement use and sun exposure were both associated with higher 25(OH)D levels and lower risk of vitamin D deficiency/insufficiency. Moreover, Vitamin D sources varied by race/ethnic groups. In multivariate models, higher body mass index, being Asian or Native Hawaiian/Pacific Islander, low supplement use, and low sun exposure were associated with higher risk for vitamin D deficiency/insufficiency (<30 ng/ml). CONCLUSIONS: Over 1/3 of the older adult sample was vitamin D deficient/insufficient, despite most of the participants living in a tropical climate with year-round access to sun as a vitamin D source. Sun exposure and supplement use, but not food intake, explained differences in vitamin D deficiency/insufficiency in this population.

Impact of earlier gestational diabetes screening for pregnant people with obesity on maternal and perinatal outcomes.

OBJECTIVES: Gestational diabetes (GDM) screening at 24-28 weeks' gestation reduces risk of adverse maternal and perinatal outcomes. While experts recommend first-trimester screening for high-risk patients, including those with obesity, data supporting this recommendation is limited. METHODS: We implemented a systematic population intervention to encourage first-trimester GDM screening by oral glucose tolerance testing in a cohort of pregnant people with obesity in two integrated health systems from 2009 to 2013, and compared outcomes to the same population pre-intervention (2006-2009). Up to five years of postpartum glucose testing results (through 2018) were assessed among GDM cases in the post-intervention group. Primary outcomes were large-for-gestational-age birthweight (LGA); macrosomia; a perinatal composite outcome; gestational hypertension/preeclampsia; cesarean delivery; and medication treatment of GDM. RESULTS: A total of 40,206 patients (9,156 with obesity) were screened for GDM; 2,672 (6.6%) were diagnosed with GDM. Overall, multivariate adjusted risk for LGA and cesarean delivery were lower following the intervention (LGA: aOR 0.89 [0.82, 0.96]; cesarean delivery: 0.89 [0.85, 0.93]). This difference was more pronounced in patients diagnosed with GDM (LGA: aOR 0.52 [0.39, 0.70]; cesarean delivery 0.78 [0.65, 0.94]); insulin/oral hypoglycemic treatment rates for GDM were also higher post-intervention than pre-intervention (22 vs. 29%; p<0.0001). There were no differences for the other primary outcomes. Only 20% of patients diagnosed with GDM early in pregnancy who had postpartum testing had results in the overt diabetes range, suggesting a spectrum of diabetes detected early in pregnancy. CONCLUSIONS: First trimester GDM screening for pregnant people with obesity may improve GDM-associated outcomes.

Weight changes according to treatment in a diverse cohort of breast cancer patients.

BACKGROUND: Weight changes are common among breast cancer patients. The majority of studies to date have focused on weight gain after a breast cancer diagnosis and its implications on health in survivors. Fewer studies have examined weight loss and its related characteristics. Weight changes have been reported to be influenced by several factors such as age, treatment, stage and pre-diagnostic weight. We evaluated weight changes during key treatment time points in early stage breast cancer patients. METHODS: We characterized 389 female patients diagnosed in Hawaii with early stage breast cancer from 2003 to 2017 in the Multiethnic Cohort (MEC) linked with Kaiser Permanente Hawaii electronic medical record data. We evaluated weight changes from surgery to 4 years post-diagnosis with six time points along a patient's treatment trajectory (chemotherapy, radiation, endocrine, or surgery alone) and annually thereafter, adjusting for age, race/ethnicity and initial body mass index (BMI). RESULTS: We found key time points of significant weight change for breast cancer patients according to their adjuvant treatment. In patients who had surgery alone (S), surgery-radiation (SR), or surgery-endocrine therapy (SE), the majority of patients had stable weight, although this consistently decreased over time. However, the percentages of patients with weight loss and weight gain during this time steadily increased up to 4 years after initial surgery. Weight loss was more common than weight gain by about 2 fold in these treatment groups. For patients with surgery-chemotherapy (SC), there was significant weight loss seen within the first 3 months after surgery, during the time when patients receive chemotherapy. And this weight loss persisted until year 4. Weight gain was less commonly seen in this treatment group. CONCLUSIONS: We identified key time points during breast cancer treatment that may provide a therapeutic window to positively influence outcomes. Tailored weight management interventions should be utilized to promote overall health and long term survivorship.

Impact of Maternal Glucose and Gestational Weight Gain on Child Obesity over the First Decade of Life in Normal Birth Weight Infants.

Objective To determine, among children with normal birth weight, if maternal hyperglycemia and weight gain independently increase childhood obesity risk in a very large diverse population. Methods Study population was 24,141 individuals (mothers and their normal birth weight offspring, born 1995-2003) among a diverse population with universal GDM screening [50-g glucose-challenge test (GCT); 3 h. 100 g oral glucose tolerance test (OGTT) if GCT+]. Among the 13,037 full-term offspring with normal birth weight (2500-4000 g), annual measured height/weight was ascertained between ages 2 and 10 years to calculate gender-specific BMI-for-age percentiles using USA norms (1960-1995 standard). Results Among children who began life with normal birth weight, we found a significant trend for developing both childhood overweight (>85 %ile) and obesity (>95 %ile) during the first decade of life with both maternal hyperglycemia (normal GCT, GCT+ but no GDM, GDM) and excessive gestational weight gain [>40 pounds (18.1 kg)]; p < 0.0001 for both trends. These maternal glucose and/or weight gain effects to imprint for childhood obesity in the first decade remained after adjustment for potential confounders including maternal age, parity, as well as pre-pregnancy BMI. The attributable risk (%) for childhood obesity was 28.5 % (95 % CI 15.9-41.1) for GDM and 16.4 % (95 % CI 9.4-23.2) for excessive gestational weight gain. Conclusions for Practice Both maternal hyperglycemia and excessive weight gain have independent effects to increase childhood obesity risk. Future research should focus on prevention efforts during pregnancy as a potential window of opportunity to reduce childhood obesity.

Race and ethnicity and pharmacy dispensing of SGLT2 inhibitors and GLP-1 receptor agonists in type 2 diabetes.

Background: Sodium-Glucose Cotransporter 2 Inhibitors (SGLT2i) and Glucagon-Like Peptide-1 Receptor Agonists (GLP-1 RA) improve cardiorenal outcomes in patients with type 2 diabetes. Equitable use of SGLT2i and GLP-1 RA has the potential to reduce racial and ethnic health disparities. We evaluated trends in pharmacy dispensing of SGLT2i and GLP-1 RA by race and ethnicity. Methods: Retrospective cohort study of patients (≥18 years) with type 2 diabetes using 2014-2022 electronic health record data from six US care delivery systems. Entry was at earliest pharmacy dispensing of any type 2 diabetes medication. We used multivariable logistic regression to evaluate the association between pharmacy dispensing of SGLT2i and GLP1-RA and race and ethnicity. Findings: Our cohort included 687,165 patients (median 6 years of dispensing data; median 60 years; 0.3% American Indian/Alaska Native (AI/AN), 16.6% Asian, 10.5% Black, 1.4% Hawaiian or Pacific Islander (HPI), 31.1% Hispanic, 3.8% Other, and 36.3% White). SGLT2i was lower for AI/AN (OR 0.80, 95% confidence interval 0.68-0.94), Black (0.89, 0.86-0.92) and Hispanic (0.87, 0.85-0.89) compared to White patients. GLP-1 RA was lower for AI/AN (0.78, 0.63-0.97), Asian (0.50, 0.48-0.53), Black (0.86, 0.83-0.90), HPI (0.52, 0.46-0.57), Hispanic (0.69, 0.66-0.71), and Other (0.78, 0.73-0.83) compared to White patients. Interpretation: Dispensing of SGLT2is, and GLP-1 RAs was lower in minority group patients. There is a need to evaluate approaches to increase use of these cardiorenal protective drugs in patients from racial and ethnic minority groups with type 2 diabetes to reduce adverse cardiorenal outcomes and improve health equity. Funding: Patient-Centered Outcomes Research Institute and National Institutes of Health.

Incidence and Survival for Patients Diagnosed With Breast, Colorectal, and Lung Cancer in an Integrated System.

INTRODUCTION: Documenting trends in cancer incidence and survival is a national priority. This study estimated age- and sex-adjusted incidence and 5-year relative survival among patients with cancer diagnosed within Kaiser Permanente compared to Surveillance, Epidemiology, and End Results (SEER) estimates. METHODS: The cohort included Kaiser Permanente health plan members diagnosed with breast (BC), colorectal (CRC), or lung cancer (LC) between January 1, 1999 and December 31, 2018. Incidence was computed as age-adjusted rates per 100,000 member-years. SEER*Stat was used to compute 5-year relative survival. RESULTS: Kaiser Permanente BC incidence rates were persistently higher than SEER from 2004 (126.5 [95% confidence interval (CI) = 123.2-129.9] vs 122.6 [95% CI = 121.3-123.2]) through 2013 (132.06 [95% CI = 129.5-135.7] vs 126.7 [95% CI = 125.9-127.5]). Kaiser Permanente CRC and LC incidence rates were lower than SEER for all years except 2008, showing a spike in CRC incidence (51.5 [95% CI = 49.9-53.0] vs 46.1 [95% CI = 45.7-46.4]). Kaiser Permanente BC, CRC, and LC survival estimates for all stages were higher than SEER. CONCLUSIONS: Incidence rates for all-stage and localized-stage BC were consistently higher for Kaiser Permanente than for SEER. CRC and LC rates were lower. Kaiser Permanente survival rates were consistently higher than for SEER. The strengths of these findings are associated with the ability to capture "gold-standard" cancer registry data on defined Kaiser Permanente populations. However, findings should be interpreted cautiously given differences in the underlying populations and secular and regional differences between Kaiser Permanente and SEER. The Kaiser Permanente population is younger and more racially diverse than SEER aggregate populations, and Kaiser Permanente members are insured with access to preventive care (eg, smoking cessation programs, cancer screening).

First year infant weight trajectories predict overweight/obesity at age 2 in a diverse population.

BACKGROUND: Obesity is emerging as early as two years of age and risk may be elucidated by differences in infant growth trajectories. We examined infant weight gain in the first year of life and association with overweight/obesity at age two. METHODS: In a diverse, population-based cohort study we conducted growth curve analysis using Health Maintenance Organization electronic medical record data from January 1, 2012 through December 31, 2013. RESULTS: Among 930 infants, there was a linear relationship with birth weight and initial weight gain from birth and increased odds of developing overweight/obesity at age two [Odds Ratio OR = 1.001; (95% CI: 1.000-1.002), p = 0.0274] and [OR = 1.009; (1.006-1.01), p = 0.0001) respectively. The odds of becoming overweight/obese at age 2 increased in infants who had slower weight deceleration rates (OR third quartile = 2.78, fourth quartile = 4.3) compared to the first quartile. Other factors associated with overweight/obesity risk at age two included female sex and Native Hawaiian race/ethnicity. CONCLUSIONS: Rate of weight gain in the first year may be an important risk factor for early childhood obesity. A deeper dive into first year growth patterns and related sociocultural and nutritional factors is needed to inform targetable points for intervention.

Lung Cancer Screening by Race and Ethnicity in an Integrated Health System in Hawaii.

Importance: Racial and ethnic differences in lung cancer screening (LCS) completion and follow-up may be associated with lung cancer incidence and mortality rates among high-risk populations. Aggregation of Asian American, Native Hawaiian, and Pacific Islander racial and ethnic groups may mask the true underlying disparities in screening uptake and diagnostic follow-up, creating barriers for targeted, preventive health care. Objective: To examine racial and ethnic differences in LCS completion and follow-up rates in a multiethnic population. Design, Setting, and Participants: This population-based cohort study was conducted at a health maintenance organization in Hawaii. LCS program participants were identified using electronic medical records from January 1, 2015, to December 31, 2019. Study eligibility requirements included being aged 55 to 79 years, a 30 pack-year smoking history, a current smoker or having quit within the past 15 years, at least 5 years past any lung cancer diagnosis and treatment, and cancer free. Data analysis was performed from June 2019 to October 2020. Exposure: Eligible for LCS. Main Outcomes and Measures: Screening rates were analyzed by self-reported race and ethnicity and completion of a low-dose computed tomography (LDCT) test. Diagnostic follow-up results were based on the Lung Imaging Reporting and Data System (Lung-RADS) staging system. Results: A total of 1030 eligible LCS program members had an order placed; their mean (SD) age was 65.5 (5.8) years, and 633 (61%) were men. The largest racial and ethnic groups were non-Hispanic White (381 participants [37.0%]), Native Hawaiian or part Native Hawaiian (186 participants [18.1%]), and Japanese (146 participants [14.2%]). Men and Filipino, Chinese, Japanese, and non-Hispanic White individuals had a higher proportion of screen orders for LDCT compared with women and individuals of the other racial and ethnic groups. The overall LCS completion rate was 81% (838 participants). There was a 14% to 15% screening completion rate gap among groups. Asian individuals had the highest screening completion rate (266 participants [86%]) followed by Native Hawaiian (149 participants [80%]) and non-Hispanic White individuals (305 participants [80%]), Pacific Islander (50 participants [79%]) individuals, and individuals of other racial and ethnic groups (68 participants [77%]). Within Asian subgroups, Korean (31 participants [94%]) and Japanese (129 participants [88%]) individuals had the highest completion rates followed by Chinese individuals (28 participants [82%]) and Filipino individuals (78 participants [79%]). Of the 54 participants with Lung-RADS stage 3 disease, 93% (50 participants) completed a 6-month surveillance LDCT test; of 37 individuals with Lung-RADS stage 4 disease, 35 (97%) were followed-up for additional procedures. Conclusions and Relevance: This cohort study found racial and ethnic disparities in LCS completion rates after disaggregation of Native Hawaiian, Pacific Islander, and Asian individuals and their subgroups. These findings suggest that future research is needed to understand factors that may be associated with LCS completion and follow-up behaviors among these racial and ethnic groups.

Perceptions of middle school educators in Hawai'i about school-based gardening and child health.

BACKGROUND: Childhood obesity prevention is a national priority. School-based gardening has been proposed as an innovative obesity prevention intervention. Little is known about the perceptions of educators about school-based gardening for child health. As the success of a school-based intervention depends on the support of educators, we investigated perceptions of educators about the benefits of gardening programs to child health. METHODS: Semi-structured interviews of 9 middle school educators at a school with a garden program in rural Hawai'i were conducted. Data were analyzed using a grounded theory approach. RESULTS: Perceived benefits of school-based gardening included improving children's diet, engaging children in physical activity, creating a link to local tradition, mitigating hunger, and improving social skills. Poverty was cited as a barrier to adoption of healthy eating habits. Opinions about obesity were contradictory; obesity was considered both a health risk, as well as a cultural standard of beauty and strength. Few respondents framed benefits of gardening in terms of health. CONCLUSIONS: In order to be effective at obesity prevention, school-based gardening programs in Hawai'i should be framed as improving diet, addressing hunger, and teaching local tradition. Explicit messages about obesity prevention are likely to alienate the population, as these are in conflict with local standards of beauty. Health researchers and advocates need to further inform educators regarding the potential connections between gardening and health.

Characteristics of adults with overweight and obesity who have not attempted weight loss in the prior 12 months.

OBJECTIVE: To determine weight-related characteristics of adults with overweight or obesity who had not attempted weight loss in the prior 12 months. METHODS: Adults from the obesity cohort of the PORTAL clinical data research network were randomly selected to complete a survey in 2015. It included topics of experiences with health care providers, weight history, and health-promoting behaviors. RESULTS: A total of 2811 adults completed the survey, of whom 24% reported not attempting weight loss in the previous 12 months. Controlling for sociodemographic characteristics and body mass index, respondents who reported that their health care provider never talked about weight were more likely to not attempt weight loss in the previous 12 months compared with respondents who reported providers frequently brought up weight (OR: 0.45; 95% CI: 0.24, 0.66). Respondents who perceived themselves as normal weight or underweight were 4.22 times more likely (95% CI: 3.53, 5.05) to not attempt weight loss compared with respondents who perceived themselves as overweight. Respondents who reported that they never tried to lose at least 10 lbs, ate 0-2 servings of fruits and vegetables daily, or engaged in 0-29 min of physical activity weekly were less likely to attempt weight loss. CONCLUSIONS: Receiving advice on weight loss from health care providers to improve awareness of overweight and obesity status may be important factors for a person's weight management. Provider discussions about weight may be a strategy to motivate weight loss attempts.

Timing of Gestational Diabetes Diagnosis by Maternal Obesity Status: Impact on Gestational Weight Gain in a Diverse Population.

Background: We hypothesized that earlier gestational diabetes mellitus (GDM) diagnosis and treatment of high-risk women would reduce gestational weight gain (GWG) in the first trimester and overall. Materials and Methods: We evaluated timing of GDM diagnosis among 5,391 pregnant women who delivered singleton births 2010-2013 in a large diverse health maintenance organization (HMO). All GDM screening was by the same oral glucose tolerance testing protocol; GDM treatment protocols were also consistent irrespective of timing of diagnosis. Women without risk factors were universally screened at 24-28 weeks gestation (Usual). Early screening was recommended in obese and other high-risk women at the first prenatal visit; those who screened negative Early were rescreened at 24-28 weeks (Early+Usual). Results: Average GWG for all women was 12.8 kg; 10.7% of women were diagnosed with GDM. Average GWG for all women diagnosed with GDM was 10.7 kg, adjusted for gestational age. Women with EarlyGDM averaged 2.4 kg less GWG than women diagnosed with UsualGDM (p < 0.0001). Among obese women, only women diagnosed with EarlyGDM averaged overall GWG within Institute of Medicine (IOM) weight guidelines (mean 8.1 kg) and were weight neutral in the first trimester (-0.2 kg). Overall, 43% of all pregnant women exceeded IOM GWG guidelines (gained more total weight than recommended); 60% of obese women exceeded guidelines. Obese women diagnosed with GDM were less likely to exceed IOM guidelines if diagnosed earlier in pregnancy (35% EarlyGDM vs. 59% UsualGDM exceeded guidelines, p < 0.0001). Conclusion: Our results suggest that EarlyGDM diagnosis (and thus treatment) in high-risk women is beneficial for optimizing GWG.

Behavioural and psychosocial factors associated with 5-year weight trajectories within the PORTAL Overweight/Obesity Cohort.

OBJECTIVE: The purpose of this study was to model weight trajectories over a 5-year time period (2012-2016) and their association with behavioural and psychosocial characteristics and health care-related experiences using data from the Patient Outcomes Research to Advance Learning (PORTAL) overweight/obesity cohort. METHODS: Weight trajectories for each eligible patient in the PORTAL overweight/obesity cohort (n = 2864) were identified first using growth modelling; trajectories were then grouped using a hierarchical cluster analysis. Weight trajectory clusters that emerged were compared on demographics, and predictors of cluster membership were examined. Clusters were also compared on responses to a survey assessing health behaviours, quality of life, and health care experience completed in 2015 by 49% of the total sample (n = 1391). RESULTS: Seven distinct weight trajectory clusters were identified: (a) significant weight loss then maintenance; (b) higher stable weight; (c) moderate stable weight; (d) steady weight loss then relapse; (e) weight gain then weight loss; (f) steady weight gain then maintenance; and (g) lower stable weight. Age, sex, race/ethnicity, and body mass index at baseline predicted patient's weight trajectory (P < .001). Over two thirds of patients maintained their weight over the 5-year period. Significant weight loss then maintenance, weight gain then weight loss, and higher stable weight patients were more likely to report receiving weight counselling from their provider. Patients in the significant weight loss then maintenance and lower stable weight clusters were more likely to be physically active than the other clusters. CONCLUSION: Findings suggest variability in patterns of weight change among adults with overweight or obesity who have access to health care and that these patterns differ on demographic, behavioural and psychosocial factors, and health care experience.

Evaluating Lung Cancer Screening Across Diverse Healthcare Systems: A Process Model from the Lung PROSPR Consortium.

Numerous organizations, including the United States Preventive Services Task Force, recommend annual lung cancer screening (LCS) with low-dose CT for high risk adults who meet specific criteria. Despite recommendations and national coverage for screening eligible adults through the Centers for Medicare and Medicaid Services, LCS uptake in the United States remains low (<4%). In recognition of the need to improve and understand LCS across the population, as part of the larger Population-based Research to Optimize the Screening PRocess (PROSPR) consortium, the NCI (Bethesda, MD) funded the Lung PROSPR Research Consortium consisting of five diverse healthcare systems in Colorado, Hawaii, Michigan, Pennsylvania, and Wisconsin. Using various methods and data sources, the center aims to examine utilization and outcomes of LCS across diverse populations, and assess how variations in the implementation of LCS programs shape outcomes across the screening process. This commentary presents the PROSPR LCS process model, which outlines the interrelated steps needed to complete the screening process from risk assessment to treatment. In addition to guiding planned projects within the Lung PROSPR Research Consortium, this model provides insights on the complex steps needed to implement, evaluate, and improve LCS outcomes in community practice.

A randomized pragmatic clinical trial of gestational diabetes screening (ScreenR2GDM): Study design, baseline characteristics, and protocol adherence.

BACKGROUND: ScreenR2GDM is a pragmatic randomized clinical trial designed to investigate if one of two gestational diabetes (GDM) screening and treatment protocols results in improved outcomes in the context of standard clinical care. METHODS: Pregnant women are randomized to one of two GDM screening strategies: 1-step: 2-h, 75 g, oral glucose tolerance test (OGTT) or 2-step: 1-h, 50 g glucose challenge test (GCT) followed by 3-h, 100 g OGTT if GCT-positive. Providers are prompted within the electronic medical record to order the assigned test but were given the option to order the alternate test. Collected data include maternal and pregnancy characteristics, GDM testing, and outcomes for mother and newborn. We describe the study design and baseline characteristics and evaluate characteristics associated with adhering to the randomized protocol. RESULTS: Baseline characteristics of the 23,792 randomized pregnancies were comparable between the two groups. Adherence to assigned test differed between the two strategies: 66.1% for 1-step and 91.7% for 2-step (p < .0001). 27% of the women randomized to receive the 1-step completed the 2-step test vs 2% randomized to the 2-step who completed the 1-step (p < .0001). Patient characteristics related to adherence included obesity, age, prior GDM, Medicaid insurance, race and nulliparity. Clinician characteristics related to adherence included provider type, age and gender. CONCLUSIONS: Both patient and provider characteristics were related to adherence to the randomized GDM screening protocol. Analytical techniques that incorporate these findings into the formal evaluation of the two protocols on GDM-associated outcomes will be necessary to account for potential biases introduced by non-adherence.

Racial/Ethnic Disparities in the Prevalence of Diabetes and Prediabetes by BMI: Patient Outcomes Research To Advance Learning (PORTAL) Multisite Cohort of Adults in the U.S.

OBJECTIVE: To examine racial/ethnic disparities in the prevalence of diabetes and prediabetes by BMI category. RESEARCH DESIGN AND METHODS: In a consortium of three U.S. integrated health care systems, 4,906,238 individuals aged ≥20 years during 2012-2013 were included. Diabetes and prediabetes were ascertained by diagnosis and laboratory results; antihyperglycemic medications were also included for diabetes ascertainment. RESULTS: The age-standardized diabetes and prediabetes prevalence estimates were 15.9% and 33.4%, respectively. Diabetes but not prediabetes prevalence increased across BMI categories among all racial/ethnic groups (P for trend < 0.001). Racial/ethnic minorities reached a given diabetes prevalence at lower BMIs than whites; Hawaiians/Pacific Islanders and Asians had a diabetes prevalence of 24.6% (95% CI 24.1-25.2%) in overweight and 26.5% (26.3-26.8%) in obese class 1, whereas whites had a prevalence of 23.7% (23.5-23.8%) in obese class 2. The age-standardized prediabetes prevalence estimates in overweight among Hispanics (35.6% [35.4-35.7%]), Asians (38.1% [38.0-38.3%]), and Hawaiians/Pacific Islanders (37.5% [36.9-38.2%]) were similar to those in obese class 4 among whites (35.3% [34.5-36.0%]), blacks (36.8% [35.5-38.2%]), and American Indians/Alaskan Natives (34.2% [29.6-38.8%]). In adjusted models, the strength of association between BMI and diabetes was highest among whites (relative risk comparing obese class 4 with normal weight 7.64 [95% CI 7.50-7.79]) and lowest among blacks (3.16 [3.05-3.27]). The association between BMI and prediabetes was less pronounced. CONCLUSIONS: Racial/ethnic minorities had a higher burden of diabetes and prediabetes at lower BMIs than whites, suggesting the role of factors other than obesity in racial/ethnic disparities in diabetes and prediabetes risk and highlighting the need for tailored screening and prevention strategies.