Body mass index changes and their association with SARS-CoV-2 infection: a real-world analysis.

Objective: To study body mass index (BMI) changes among individuals aged 18-99 years with and without SARS-CoV-2 infection. Subjects/Methods: Using real-world data from the OneFlorida+ Clinical Research Network of the National Patient-Centered Clinical Research Network, we compared changes over time in BMI in an Exposed cohort (positive SARS-CoV-2 test between March 2020 - January 2022), to a contemporary Unexposed cohort (negative SARS-CoV-2 tests), and an age/sex-matched Historical control cohort (March 2018 - January 2020). Body mass index (kg/m2) was retrieved from objective measures of height and weight in electronic health records. We used target trial approaches to estimate BMI at baseline and change per 100 days of follow-up for Unexposed and Historical cohorts relative to the Exposed cohort by categories of sex, race-ethnicity, age, and hospitalization status. Results: The study sample consisted of 44,436 (Exposed cohort), 164,118 (Unexposed cohort), and 41,189 (Historical cohort). Cumulatively, 62% were women, 21.5% Non-Hispanic Black, 21.4% Hispanic and 5.6% Non-Hispanic Other. Patients had an average age of 51.9 years (SD: 18.9). At baseline, relative to the Exposed cohort (mean BMI: 29.3 kg/m2 [95%CI: 29.0, 29.7]), the Unexposed (-0.07 kg/m2 [95%CI; -0.12, -0.01]) and Historical controls (-0.27 kg/m2 [95%CI; -0.34, -0.20]) had lower BMI. Relative to no change in the Exposed over 100 days (0.00 kg/m2 [95%CI; -0.03,0.03]), the BMI of those Unexposed decreased (-0.04 kg/m2 [95%CI; -0.06, -0.01]) while the Historical cohort's BMI increased (+0.03 kg/m2 [95%CI;0.00,0.06]). BMI changes were consistent between Exposed and Unexposed cohorts for most population groups, except at start of follow-up period among Males and those 65 years or older, and in changes over 100 days among Males and Hispanics. Conclusions: In a diverse real-world cohort of adults, mean BMI of those with and without SARS-CoV2 infection varied in their trajectories. The mechanisms and implications of weight retention following SARS-CoV-2 infection remain unclear.

Test and Treat for Prediabetes: A Review of the Health Effects of Prediabetes and the Role of Screening and Prevention.

The term prediabetes describes blood glucose levels above the normal range but below the threshold to diagnose type 2 diabetes. Several population health initiatives encourage a test and treat approach for prediabetes. In this approach, screening and identification of individuals with prediabetes should be followed by prompt referral to structured lifestyle modification programs or pharmacologic interventions that have been shown to prevent or delay the progression to type 2 diabetes in clinical trials. Here we provide a critical review of evidence for this test and treat approach by examining health outcomes associated with prediabetes and the availability and effectiveness of lifestyle modification approaches that target prediabetes. We also describe current limitations to the reach and uptake of evidence-based treatment options for prediabetes. Finally, we highlight lessons learned from identifying and labeling other preconditions to consider challenges and opportunities that may arise with increasing awareness of prediabetes as part of routine preventive care.

Food is medicine intervention shows promise for engaging patients attending a safety-net hospital in the Southeast United States.

Public health organizations, including the Academy of Nutrition and Dietetics and the American Hospital Association, recognize the importance of achieving food and nutrition security to improve health outcomes, reduce healthcare costs, and advance health equity. In response, federal, state, and private agencies are increasingly seeking to fund healthcare-based interventions to address food insecurity among patients. Simultaneously, nutrition-based interventions targeting chronic diseases have grown across the United States as part of the broader "Food is Medicine" movement. Few studies have examined the successes, challenges, and limitations of such efforts. As Food is Medicine programs continue to expand, identifying common approaches, metrics, and outcomes will be imperative for ensuring program success, replicability, and sustainability. Beginning in 2020, the Food as Medicine (FAM) program, a multipronged, collaborative intervention at Grady Health System has sought to combat food insecurity and improve patient health by leveraging community resources, expertise, and existing partnerships. Using this program as a case study, we (1) outline the collaborative development of the FAM program; (2) describe and characterize patient engagement in the initial 2 years; and (3) summarize strengths and lessons learned for future hospital-based food and nutrition programming. As this case study illustrates, the Food as Medicine program provides a novel model for building health equity through food within healthcare organizations.

The Diabetes Prevention Gap And Opportunities To Increase Participation In Effective Interventions.

To understand the current state of prediabetes burden and treatment in the US, we examined recent trends in prediabetes prevalence, testing, and access to preventive resources. We estimated 13.5 percent prevalence of diagnosed prediabetes in the overall US adult population, using national survey data. Although prediabetes prevalence increased by 4.8 percentage points from 2010 to 2020, access to preventive resources remained low. The most effective intervention for diabetes prevention, known as the National Diabetes Prevention Program, remained woefully undersupplied and underused. There are only 2,098 National Diabetes Prevention Program-recognized providers nationally, and only 3 percent of adults with prediabetes have participated in the program. We suggest three actions to augment prevention efforts: increase payment for prevention interventions to avoid supply distortions, improve data integration and patient follow-up, and extend coverage and broaden access for preventive interventions. These actions, which would require policy-level changes, could lower the barriers to prevention.

Diabetes medication regimens and patient clinical characteristics in the national patient-centered clinical research network, PCORnet.

We used electronic medical record (EMR) data in the National Patient-Centered Clinical Research Network (PCORnet) to characterize "real-world" prescription patterns of Type 2 diabetes (T2D) medications. We identified a retrospective cohort of 613,203 adult patients with T2D from 33 datamarts (median patient number: 12,711) from 2012 through 2017 using a validated computable phenotype. We characterized outpatient T2D prescriptions for each patient in the 90 days before and after cohort entry, as well as demographics, comorbidities, non-T2D prescriptions, and clinical and laboratory variables in the 730 days prior to cohort entry. Approximately half of the individuals in the cohort were females and 20% Black. Hypertension (60.3%) and hyperlipidemia (50.5%) were highly prevalent. Most patients were prescribed either a single T2D drug class (42.2%) or had no evidence of a T2D prescription in the EMR (42.4%). A smaller percentage was prescribed multiple T2D drug types (15.4%). Among patients prescribed a single T2D drug type, metformin was the most common (42.6%), followed by insulin (18.2%) and sulfonylureas (13.9%). Newer classes represented approximately 13% of single T2D drug type prescriptions (dipeptidyl peptidase-4 inhibitors [6.6%], glucagon-like peptide-1 receptor agonists [2.5%], thiazolidinediones [2.0%], and sodium-glucose cotransporter-2 inhibitors [1.6%]). Among patients prescribed multiple T2D drug types, the most common combination was metformin and sulfonylureas (63.5%). Metformin-based regimens were highly prevalent in PCORnet's T2D population, whereas newer agents were prescribed less frequently. PCORnet is a novel source for the potential conduct of observational studies among patients with T2D.

Putting the National Diabetes Prevention Program to Work: Predictors of Achieving Weight-Loss Goals in an Employee Population.

INTRODUCTION: Differences in eligibility criteria and intervention characteristics have limited the generalizability of findings from studies of worksite translations of the National Diabetes Prevention Program (DPP). The objective of our study was to identify factors associated with achievement of the DPP's 5% weight-loss goal in the Vanderbilt University Medical Center (VUMC) Faculty and Staff Health and Wellness DPP from 2014 to 2017. METHODS: We analyzed data from a DPP worksite translation that adhered to national standards for program quality and intervention fidelity. We compared baseline characteristics and program metrics for participants who did and did not achieve the program's 5% weight-loss goal, and we developed a multivariable logistic regression model to identify independent predictors of achieving this goal. RESULTS: Of the 165 employees enrolled in the DPP from 2014 to 2017, 43.6% (n = 72) met the 5% weight-loss goal. Mean (standard deviation) percentage weight loss for the program was 5.2% (6.0%), or 4.8 (6.0) kg. The median (interquartile range) body mass index at baseline was lower among participants who achieved the 5% weight-loss goal than among those who did not (31.6 [29.4-37.4] vs 34.7 [31.5-39.2], P = .009), and participants who achieved the goal reported more physical activity minutes per week (166.0 [135.2-223.0] min vs 128.5 [83.2-169.8] min, P < .001). Session attendance was greater for participants achieving the 5% weight-loss goal (23 [21-25]) sessions vs 18 [12-21] sessions, P < .001). In the adjusted analysis, physical activity and session attendance remained significant predictors of achieving the 5% weight-loss goal. CONCLUSION: Session attendance and physical activity independently predicted achievement of the 5% weight-loss goal in this worksite translation of the DPP. Strategies designed to improve these metrics may increase DPP success rates.

Performance of a computable phenotype for identification of patients with diabetes within PCORnet: The Patient-Centered Clinical Research Network.

PURPOSE: PCORnet, the National Patient-Centered Clinical Research Network, represents an innovative system for the conduct of observational and pragmatic studies. We describe the identification and validation of a retrospective cohort of patients with type 2 diabetes (T2DM) from four PCORnet sites. METHODS: We adapted existing computable phenotypes (CP) for the identification of patients with T2DM and evaluated their performance across four PCORnet sites (2012-2016). Patients entered the cohort on the earliest date they met one of three CP categories: (CP1) coded T2DM diagnosis (ICD-9/ICD-10) and an antidiabetic prescription, (CP2) diagnosis and glycosylated hemoglobin (HbA1c) ≥6.5%, or (CP3) an antidiabetic prescription and HbA1c ≥6.5%. We required evidence of health care utilization in each of the 2 prior years for each patient, as we also developed an incident T2DM CP to identify the subset of patients without documentation of T2DM in the 365 days before t0 . Among a systematic sample of patients, we calculated the positive predictive value (PPV) for the T2DM CP and incident-T2DM CP using electronic health record (EHR) review as reference. RESULTS: The CP identified 50 657 patients with T2DM. The PPV of patients randomly selected for validation was 96.2% (n = 1572; CI:95.1-97.0) and was consistently high across sites. The PPV for the incident-T2DM CP was 5.8% (CI:4.5-7.5). CONCLUSIONS: The T2DM CP accurately and efficiently identified patients with T2DM across multiple sites that participate in PCORnet, although the incident T2DM CP requires further study. PCORnet is a valuable data source for future epidemiological and comparative effectiveness research among patients with T2DM.

Gestational Diabetes and Maternal Weight Management During and After Pregnancy.

Background: Women diagnosed with gestational diabetes mellitus (GDM) substantially modify their diets during pregnancy to control hyperglycemia. These changes could also affect maternal weight management. Materials and Methods: From July 2014 to December 2015 we enrolled women with and without GDM in a prospective cohort study to compare their mean rates of (1) weight gain before GDM screening, (2) weight gain after GDM screening, and (3) postpartum weight loss. All GDM-affected women were referred to Medical Nutrition Therapy and asked to self-monitor blood glucose until delivery. Rate comparisons were conducted separately for each interval using weighted t-tests and inverse probability of treatment weighting (IPTW) to account for age and prepregnancy body mass index (BMI). Linear regression models were developed to characterize the association of GDM status and rate of weight change. Results: The study included 40 women with GDM and 49 women without GDM. The IPTW analysis found that (1) women with and without GDM had similar mean rates of gestational weight gain before GDM screening (0.41 ± 0.26 kg/week vs. 0.45 ± 0.35 kg/week, respectively, p = 0.86), (2) women with GDM gained weight at a significantly lower mean rate than women without GDM following GDM screening (0.30 ± 0.28 kg/week vs. 0.53 ± 0.28 kg/week, respectively, p = 0.001), and (3) women with and without GDM had similar mean rates of postpartum weight loss (-1.37 ± 0.58 kg/week vs. -1.28 ± 0.46 kg/week, respectively, p = 0.73). The linear regression model (adjusted for age and prepregnancy BMI) demonstrated that women with GDM gained 0.19 kg/week less than women without GDM (p = 0.004) during pregnancy after GDM screening. Conclusions: In the postpartum period, women with GDM lose weight at similar rates to women without GDM despite gaining weight at significantly lower rates following GDM screening. Diagnosis and treatment of GDM may improve maternal weight management, but this benefit is limited to late pregnancy.

Hospitalization Rates for Acute Myocardial Infarction Among Asian-American Subgroups: Have We Been Underestimating the Problem?

Concerns about the quality of race/ethnicity data collected by hospitals have limited our understanding of healthcare disparities affecting ethnic minorities in the United States. Using data from the New Jersey State Inpatient Databases and the American Community Survey, we calculated age-adjusted AMI hospitalization rates for Asian-American subgroups before (2005-2006) and after (2008-2009) New Jersey hospitals implemented standardized practices to collect more accurate granular race/ethnicity data from patients. Rates were reported per 100,000 persons for Asian Indian, Chinese, Filipino, Japanese, Korean, and Vietnamese subgroups. AMI hospitalization rates increased for all subgroups except Vietnamese following implementation of the New Jersey program; increases were statistically significant for Asian Indian, Chinese, and Korean subgroups. Rates of hospitalization for AMI increased significantly for multiple Asian-American subgroups following implementation of the New Jersey program. National population health metrics for Asian-American subgroups may be prone to significant underestimation without widespread utilization of similar practices.

Socioeconomic Status and Care Metrics for Women Diagnosed With Gestational Diabetes Mellitus.

IN BRIEF Appropriate management of hyperglycemia can significantly attenuate perinatal risks associated with a diagnosis of gestational diabetes mellitus (GDM). This article reports on a study evaluating the independent associations of maternal income and education with select measures of GDM management. This exploratory study demonstrates notable socioeconomic differences in select measures of GDM management. Additional studies are needed to determine the reasons for these differences and whether they exist in broader populations.

Validating Health Literacy and Numeracy Measures in Minority Groups.

BACKGROUND: Validation studies of existing health literacy or numeracy tools among racial/ethnic minorities are limited. OBJECTIVE: This study assessed the validity of the Subjective Numeracy Scale (SNS), the Diabetes Numeracy Test (DNT-5), the Brief Health Literacy Screen (BHLS), and the Short Test of Functional Health Literacy in Adults (S-TOFHLA) by trait (health literacy or numeracy) and by method (subjective or objective) among non-Hispanic white (NHW), non-Hispanic black (NHB), and Hispanic patients with type 2 diabetes mellitus (T2DM). METHODS: We conducted a secondary analysis of baseline data from the Partnering to Improve Diabetes Education (PRIDE) study, a clustered randomized controlled trial testing the efficacy of a health communication intervention on T2DM outcomes at state Department of Health clinics in middle Tennessee. PRIDE participants with race/ethnicity data available (n = 398) were included in this study. Most patients identified as NHW (59%), 18% identified as NHB, and 23% identified as Hispanic. Pearson correlations among the 4 measures were compared for each racial/ethnic group by trait and method. The convergent validity of each measure with education was also assessed using Pearson correlation analyses. KEY RESULTS: Significant correlations were observed across all 3 subgroups for the numeracy measures (SNS and DNT-5) and the objective measures (DNT-5 and S-TOFHLA). Nonsignificant correlations were observed among Hispanic participants for the health literacy measures (BHLS and S-TOFHLA, correlation coefficient = 0.13) and among NHB and Hispanic participants for the subjective measures (SNS and BHLS, correlations coefficients = 0.15 and 0.09, respectively). A significant positive correlation was noted between education and each measure across all 3 subgroups. CONCLUSIONS: Subjective and health literacy measures demonstrate weaker correlations than objective and numeracy measures, respectively, among minority patients in this study. Our findings highlight the need to further evaluate the appropriateness of these tools for use with minority populations, particularly the BHLS for Hispanic patients.

Self-Care Disparities Among Adults with Type 2 Diabetes in the USA.

Suboptimal glycemic control is more common among non-Hispanic Blacks (NHBs) and Hispanics than non-Hispanic Whites (NHWs). Disparities in the performance of self-care behaviors may contribute to this. To synthesize knowledge on current self-care disparities, we reviewed studies from January 2011-March 2016 that included NHWs, NHBs, and Hispanics with type 2 diabetes in the USA. Self-care behaviors included diet, exercise, medications, self-monitoring of blood glucose (SMBG), self-foot exams, and not smoking. Of 1241 articles identified in PubMed, 25 met our inclusion criteria. These studies report consistent disparities in medication adherence. Surprisingly, we found consistent evidence of no disparities in exercise and some evidence of reverse disparities: compared to NHWs, Hispanics had healthier diets and NHBs had more regular SMBG. Consistent use of validated measures could further inform disparities in diet and exercise. Additional research is needed to test for disparities in self-foot exams, not smoking, and diabetes-specific problem solving and coping.

Perceptions of Provider Communication Among Vulnerable Patients With Diabetes: Influences of Medical Mistrust and Health Literacy.

Patient-provider communication is modifiable and is linked to diabetes outcomes. The association of communication quality with medical mistrust is unknown. We examined these factors within the context of a low-literacy/numeracy-focused intervention to improve diabetes care, using baseline data from diverse patients enrolled in a randomized trial of a health communication intervention. Demographics, measures of health communication (Communication Assessment Tool [CAT], Interpersonal Processes of Care survey [IPC-18]), health literacy (Short Test of Functional Health Literacy in Adults), depression, medical mistrust, and glycemic control were ascertained. Adjusted proportional odds models were used to test the association of mistrust with patient-reported communication quality. The interaction effect of health literacy on mistrust and communication quality was also assessed. A total of 410 patients were analyzed. High levels of mistrust were observed. In multivariable modeling, patients with higher mistrust had lower adjusted odds of reporting a higher CAT score (adjusted odds ratio [AOR] = 0.67, 95% confidence interval [CI] [0.52, 0.86], p = .003) and higher scores on the Communication (AOR = 0.69, 95% CI [0.55, 0.88], p = .008), Decided Together (AOR = 0.74, 95% CI [0.59, 0.93], p = .02), and Interpersonal Style (AOR = 0.69, 95% CI [0.53, 0.90], p = .015) subscales of the IPC-18. We observed evidence of an interaction effect of health literacy for the association between mistrust and the Decided Together subscale of the IPC-18 such that patients with higher mistrust and lower literacy perceived worse communication relative to mistrustful patients with higher literacy. In conclusion, medical mistrust was associated with poorer communication with providers in this public health setting. Patients' health literacy level may vary the effect of mistrust on interactional aspects of communication. Providers should consider the impact of mistrust on communication with vulnerable diabetes populations and focus efforts on mitigating its influence.

Standardized data collection practices and the racial/ethnic distribution of hospitalized patients.

BACKGROUND: Although frequently used to track health care disparities, patient race/ethnicity data collected by hospitals can be unreliable, particularly for smaller minority groups. We sought to determine whether the racial/ethnic distribution of hospitalized patients shifted after implementation of a statewide initiative to standardize data collection practices. METHODS: We conducted a difference-in-differences analysis of the State Inpatient Databases to estimate changes in the proportion of patients identified as non-Hispanic white, non-Hispanic black, Hispanic, Asian/Pacific Islander, and "other," before (2005-2006) and after (2008-2009) standardized practices were implemented in New Jersey relative to New York, a state with similar demographics but no changes to data collection. RESULTS: Among 12,552,702 hospital discharges, modest relative changes were noted in the proportion of patients identified as non-Hispanic white [+1.1%; 95% confidence interval (CI): +0.9 to +1.2] and non-Hispanic black (+1.6%; 95% CI: +1.1 to +2.1) in New Jersey that were attributed to its use of standardized data collection practices as compared with New York. Larger relative changes were noted in the proportion of patients identified as Hispanic (-7.1%; 95% CI: -7.8 to -6.4), Asian/Pacific Islander (+26.5%; 95% CI: +25.1 to +27.9), and "other" (-24.6%; 95% CI: -26.4 to -22.8). This pattern was largely consistent in analyses stratified by sex, age, and Major Diagnostic Category. CONCLUSIONS: Measurement of health care disparities fundamentally depends on the racial/ethnic categorization of individuals. By redistributing substantial proportions of patients across smaller minority groups, standardized data collection could lead to shifts in estimates of health care disparities for these rapidly growing populations.

Variation in the relationship between gestational diabetes diagnosis and total gestational weight gain by race/ethnicity.

Prior research suggests that women diagnosed and treated for gestational diabetes mellitus (GDM) gain less total gestational weight than normoglycemic women. Our study finds that race/ethnicity modifies this association. Relative to normoglycemic women, non-Hispanic white women with GDM gain less weight but non-Hispanic black and Hispanic women gain more weight.

Implementing clinical guidelines in low-income settings: a review of literature.

The use of clinical guidelines has been shown to confer benefits for care delivery in high-income settings, but little is known about their implementation in low-income settings. We conducted a systematic literature review on the implementation of World Health Organisation (WHO) clinical guidelines for hospital care in low-income settings. We searched Medline, Global Health and Scopus for articles describing the implementation of clinical guidelines issued by the WHO for hospitals in low-income countries. Each article in the final sample was reviewed independently by two reviewers who harmonised their findings to identify key factors affecting the implementation process, which were grouped into thematic categories through negotiated consensus among project team members. Seventeen studies met the inclusion criteria. Factors affecting the guideline implementation process in low-income countries were (1) degree of support from facility management and Ministry of Health, (2) credibility and acceptability of clinical guidelines from the perspective of health care providers, (3) efforts to adapt clinical guidelines to local circumstances and (4) use of guides and checklists for implementation. These four factors consistently emerged in our review and should be considered when designing future strategies to implement clinical guidelines in low-income countries.

Does patient gender impact resident physicians' approach to the cardiac exam?

BACKGROUND: Physical examination remains an important part of the initial evaluation of patients presenting with chest pain but little is known about the effect of patient gender on physician performance of the cardiovascular exam. OBJECTIVE: To determine if resident physicians are less likely to perform five key components of the cardiovascular exam on female versus male standardized patients (SPs) presenting with acute chest pain. DESIGN: Videotape review of SP encounters during Objective Structured Clinical Examinations (OSCEs) administered by the Emory University Internal Medicine Residency Program in 2006 and 2007. Encounters were reviewed to assess residents' performance of five cardiac exam skills: auscultation of the aortic, pulmonic, tricuspid, and mitral valve areas and palpation for the apical impulse. PARTICIPANTS: One hundred forty-nine incoming residents. MAIN MEASURES: Residents' performance for each skill was classified as correct, incorrect, or unknown. KEY RESULTS: One hundred ten of 149 (74 %) of encounters were available for review. Residents were less likely to correctly perform each of the five skills on female versus male SPs. This difference was statistically significant for auscultation of the tricuspid (p = 0.004, RR = 0.62, 95 % CI 0.46-0.83) and mitral (p = 0.007, RR = 0.58, 95 % CI = 0.41-0.83) valve regions and palpation for the apical impulse (p < 0.001, RR = 0.27, 95 % CI = 0.16-0.47). Male residents were less likely than female residents to correctly perform each maneuver on female versus male SPs. The interaction of SP gender and resident gender was statistically significant for auscultation of the mitral valve region (p = 0.006) and palpation for the apical impulse (p = 0.01). CONCLUSIONS: We observed significant differences in the performance of key elements of the cardiac exam for female versus male SPs presenting with chest pain. This observation represents a previously unidentified but potentially important source of gender bias in the evaluation of patients presenting with cardiovascular complaints.

Preventing diabetes among Fair Haven families: a community-based approach to quality improvement.

In this paper, we describe our efforts to integrate the Diabetes Prevention Program and the Bright Bodies program into a coordinated intensive lifestyle intervention program for families living in Fair Haven, an underserved Hispanic neighborhood in New Haven, Connecticut with high rates of obesity and prediabetes in adults and children.