Uncovering heterogeneous cardiometabolic risk profiles in US adults: the role of social and behavioral determinants of health.

INTRODUCTION: Social and behavioral determinants of health (SBDH) have been linked to diabetes risk, but their role in explaining variations in cardiometabolic risk across race/ethnicity in US adults is unclear. This study aimed to classify adults into distinct cardiometabolic risk subgroups using SBDH and clinically measured metabolic risk factors, while comparing their associations with undiagnosed diabetes and pre-diabetes by race/ethnicity. RESEARCH DESIGN AND METHODS: We analyzed data from 38,476 US adults without prior diabetes diagnosis from the National Health and Nutrition Examination Survey (NHANES) 1999-2018. The k-prototypes clustering algorithm was used to identify subgroups based on 16 SBDH and 13 metabolic risk factors. Each participant was classified as having no diabetes, pre-diabetes or undiagnosed diabetes using contemporaneous laboratory data. Logistic regression was used to assess associations between subgroups and diabetes status, focusing on differences by race/ethnicity. RESULTS: Three subgroups were identified: cluster 1, primarily middle-aged adults with high rates of smoking, alcohol use, short sleep duration, and low diet quality; cluster 2, mostly young non-white adults with low income, low health insurance coverage, and limited healthcare access; and cluster 3, mostly older males who were the least physically active, but with high insurance coverage and healthcare access. Compared with cluster 2, adjusted ORs (95% CI) for undiagnosed diabetes were 14.9 (10.9, 20.2) in cluster 3 and 3.7 (2.8, 4.8) in cluster 1. Clusters 1 and 3 (vs cluster 2) had high odds of pre-diabetes, with ORs of 1.8 (1.6, 1.9) and 2.1 (1.8, 2.4), respectively. Race/ethnicity was found to modify the relationship between identified subgroups and pre-diabetes risk. CONCLUSIONS: Self-reported SBDH combined with metabolic factors can be used to classify adults into subgroups with distinct cardiometabolic risk profiles. This approach may help identify individuals who would benefit from screening for diabetes and pre-diabetes and potentially suggest effective prevention strategies.

"We are a family with diabetes": Parent perspectives on siblings of youth with type 1 diabetes.

Having a child with type 1 diabetes (T1D) impacts the entire family system. Parental distress and burden have been well studied, but other family members, including siblings, have received little attention. Based on research about family life and sibling experiences in other chronic condition populations (e.g., autism, cancer), we expected parents of youth with T1D would report that siblings participated in T1D management and that T1D had a psychological impact on siblings. As part of a larger qualitative study, parents of youth with T1D age 5-17 (M = 10.8 ± 3.6 years) participated in semistructured interviews about T1D-specific health-related quality of life. For this study, we conducted secondary analyses on transcripts from 20 parents (95% mothers) from households with at least 1 sibling of the child with T1D. Three themes emerged: (a) siblings share the workload and help with T1D management, (b) T1D takes an emotional toll on siblings, and (c) parents feel guilty about prioritizing T1D over siblings' needs and desires. Parents recognized siblings have impactful roles in T1D management and family functioning. Future research into these themes can guide clinical and research efforts to develop sibling-inclusive resources and interventions for families with T1D. Enhancing family-focused interventions to recognize and support the needs of siblings may ultimately improve family T1D-related quality of life. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Health promotion interventions for African Americans delivered in U.S. barbershops and hair salons- a systematic review.

BACKGROUND: African American adults suffer disproportionately from obesity-related chronic diseases, particularly at younger ages. In order to close the gap in these health disparities, efforts to develop and test culturally appropriate interventions are critical. METHODS: A PRISMA-guided systematic review was conducted to identify and critically evaluate health promotion interventions for African Americans delivered in barbershops and hair salons. Subject headings and keywords used to search for synonyms of 'barbershops,' 'hair salons,' and 'African Americans' identified all relevant articles (from inception onwards) from six databases: Academic Search Ultimate, Cumulative Index of Nursing and Allied Health Literature (CINAHL), Embase, PsycINFO, PubMed, Web of Science (Science Citation Index and Social Sciences Citation Index). Experimental and quasi-experimental studies for adult (> 18 years) African Americans delivered in barbershops and hair salons that evaluated interventions focused on risk reduction/management of obesity-related chronic disease: cardiovascular disease, cancer, and type 2 diabetes were included. Analyses were conducted in 2020. RESULTS: Fourteen studies met criteria for inclusion. Ten studies hosted interventions in a barbershop setting while four took place in hair salons. There was substantial variability among interventions and outcomes with cancer the most commonly studied disease state (n = 7; 50%), followed by hypertension (n = 5; 35.7%). Most reported outcomes were focused on behavior change (n = 10) with only four studies reporting clinical outcomes. CONCLUSIONS: Health promotion interventions delivered in barbershops/hair salons show promise for meeting cancer screening recommendations and managing hypertension in African Americans. More studies are needed that focus on diabetes and obesity and utilize the hair salon as a site for intervention delivery. TRIAL REGISTRATION: PROSPERO CRD42020159050 .

Protocol for a systematic review of health promotion interventions for African Americans delivered in US barbershops and hair salons.

INTRODUCTION: African American adults are disproportionately burdened by chronic diseases, particularly at younger ages. Developing culturally appropriate interventions is paramount to closing the gap in these health inequities. The purpose of this systematic review is to critically evaluate health promotion interventions for African Americans delivered in two environments that are frequented by this population: barbershops and hair salons. Characteristics of effective interventions will be identified and evidence for the effectiveness of these interventions will be provided. Results of this review will inform future health promotion efforts for African Americans particularly focused on the leading health inequities in obesity-related chronic diseases: cardiovascular disease, cancer and type 2 diabetes. METHODS AND ANALYSIS: Subject headings and keywords will be used to search for synonyms of 'barbershops,' 'hair salons' and 'African Americans' to identify all relevant articles (from inception onwards) in the following databases: Academic Search Ultimate, Cumulative Index of Nursing and Allied Health Literature, Embase, PsycINFO, PubMed, Web of Science (Science Citation Index and Social Sciences Citation Index) and ProQuest Dissertations. Experimental and quasi-experimental studies for adult (>18 years) African Americans delivered in barbershops and hair salons will be included. Eligible interventions will include risk reduction/management of obesity-related chronic disease: cardiovascular disease, cancer and type 2 diabetes. Two reviewers will independently screen, select and extract data and a third will mediate disagreements. The methodological quality (or risk of bias) of individual studies will be appraised using the Effective Public Health Practice Project Quality Assessment Tool. Quality and content of the evidence will be narratively synthesised. ETHICS AND DISSEMINATION: Since this is a protocol for a systematic review, ethical approval is not required. Findings from the review will be widely disseminated through conference presentations, peer-reviewed publications and traditional and social media outlets.

Comparison of Commercial and Self-Initiated Weight Loss Programs in People With Prediabetes: A Randomized Control Trial.

OBJECTIVES: To determine if a widely available weight-management program (Weight Watchers) could achieve sufficient weight loss in persons with prediabetes compared with a Diabetes Prevention Program-based individual counseling program supported by National Diabetes Education Program materials. METHODS: We conducted an individual, randomized intervention trial in Indianapolis, Indiana, in 2013 to 2014, in 225 persons with prediabetes. We compared the Weight Watchers weight-management program (n = 112) with Your Game Plan to Prevent Type 2 Diabetes, a program developed by the National Diabetes Education Program. Outcomes were weight and metabolic markers measured at baseline, 6 months, and 12 months. RESULTS: Intervention participants lost significantly more weight than controls at 6 months (5.5% vs 0.8%) and 12 months (5.5% vs 0.2%; both P < .001). The intervention group also had significantly greater improvements in hemoglobin A1c and high-density lipoprotein cholesterol level than did controls. CONCLUSIONS: A large weight-management program is effective for achieving lifestyle changes associated with diabetes prevention. Such programs could significantly increase the availability of diabetes prevention programs worldwide making an immediate and significant public health impact.

A Randomized Controlled Trial Translating the Diabetes Prevention Program to a University Worksite, Ohio, 2012-2014.

INTRODUCTION: Working adults spend much time at the workplace, an ideal setting for wellness programs targeting weight loss and disease prevention. Few randomized trials have evaluated the efficacy of worksite diabetes prevention programs. This study evaluated the efficacy of a worksite lifestyle intervention on metabolic and behavioral risk factors compared with usual care. METHODS: A pretest-posttest control group design with 3-month follow-up was used. Participants with prediabetes were recruited from a university worksite and randomized to receive a 16-week lifestyle intervention (n = 35) or usual care (n = 34). Participants were evaluated at baseline, postintervention, and 3-month follow-up. Dietary intake was measured by a food frequency questionnaire and level of physical activity by accelerometers. Repeated measures analysis of variance compared the change in outcomes between and within groups. RESULTS: Mean (standard error [SE]) weight loss was greater in the intervention (-5.5% [0.6%]) than in the control (-0.4% [0.5%]) group (P < .001) postintervention and was sustained at 3-month follow-up (P < .001). Mean (SE) reductions in fasting glucose were greater in the intervention (-8.6 [1.6] mg/dL) than in the control (-3.7 [1.6] mg/dL) group (P = .02) postintervention; both groups had significant glucose reductions at 3-month follow-up (P < .001). In the intervention group, the intake of total energy and the percentage of energy from all fats, saturated fats, and trans fats decreased, and the intake of dietary fiber increased (all P < .01) postintervention. CONCLUSION: The worksite intervention improved metabolic and behavioral risk factors among employees with prediabetes. The long-term impact on diabetes prevention and program sustainability warrant further investigation.

Impact of lifestyle intervention and metformin on health-related quality of life: the diabetes prevention program randomized trial.

BACKGROUND: Adults at high risk for diabetes may have reduced health-related quality of life (HRQoL). OBJECTIVE: To assess changes in HRQoL after interventions aimed at diabetes risk reduction. DESIGN, SETTING, AND PARTICIPANTS: A randomized clinical trial, the Diabetes Prevention Program, was conducted in 27 centers in the United States, in 3,234 non-diabetic persons with elevated fasting and post-load plasma glucose, mean age 51 years, mean BMI 34 Kg/m(2); 68 % women, and 45 % members of minority groups. INTERVENTIONS: Intensive lifestyle (ILS) program with the goals of at least 7 % weight loss and 150 min of physical activity per week, metformin (MET) 850 mg twice daily, or placebo (PLB). MEASUREMENTS: HRQoL using the 36-Item Short-Form (SF-36) health survey to evaluate health utility index (SF-6D), physical component summaries (PCS) and mental component summaries (MCS). A minimally important difference (MID) was met when the mean of HRQoL scores between groups differed by at least 3 %. RESULTS: After a mean follow-up of 3.2 years, there were significant improvements in the SF-6D (+0.008, p=0.04) and PCS (+1.57, p<0.0001) scores in ILS but not in MET participants (+0.002 and +0.15, respectively, p=0.6) compared to the PLB group. ILS participants showed improvements in general health (+3.2, p<0.001), physical function (+3.6, p<0.001), bodily pain (+1.9, p=0.01), and vitality (+2.1, p=0.01) domain scores. Treatment effects remained significant after adjusting sequentially for baseline demographic factors, and for medical and psychological comorbidities. Increased physical activity and weight reduction mediated these ILS treatment effects. Participants who experienced weight gain had significant worsening on the same HRQoL specific domains when compared to those that had treatment-related (ILS or MET) weight loss. No benefits with ILS or MET were observed in the MCS score. CONCLUSION: Overweight/obese adults at high risk for diabetes show small improvement in most physical HRQoL and vitality scores through the weight loss and increased physical activity achieved with an ILS intervention.

Predictors of mortality over 8 years in type 2 diabetic patients: Translating Research Into Action for Diabetes (TRIAD).

OBJECTIVE: To examine demographic, socioeconomic, and biological risk factors for all-cause, cardiovascular, and noncardiovascular mortality in patients with type 2 diabetes over 8 years and to construct mortality prediction equations. RESEARCH DESIGN AND METHODS: Beginning in 2000, survey and medical record information was obtained from 8,334 participants in Translating Research Into Action for Diabetes (TRIAD), a multicenter prospective observational study of diabetes care in managed care. The National Death Index was searched annually to obtain data on deaths over an 8-year follow-up period (2000-2007). Predictors examined included age, sex, race, education, income, smoking, age at diagnosis of diabetes, duration and treatment of diabetes, BMI, complications, comorbidities, and medication use. RESULTS: There were 1,616 (19%) deaths over the 8-year period. In the most parsimonious equation, the predictors of all-cause mortality included older age, male sex, white race, lower income, smoking, insulin treatment, nephropathy, history of dyslipidemia, higher LDL cholesterol, angina/myocardial infarction/other coronary disease/coronary angioplasty/bypass, congestive heart failure, aspirin, ß-blocker, and diuretic use, and higher Charlson Index. CONCLUSIONS: Risk of death can be predicted in people with type 2 diabetes using simple demographic, socioeconomic, and biological risk factors with fair reliability. Such prediction equations are essential for computer simulation models of diabetes progression and may, with further validation, be useful for patient management.

Race and medication adherence and glycemic control: findings from an operational health information exchange.

The Central Indiana Beacon Community leads efforts for improving adherence to oral hypoglycemic agents (OHA) to achieve improvements in glycemic control for patients with type 2 diabetes. In this study, we explored how OHA adherence affected hemoglobin A1C (HbA1c) level in different racial groups. OHA adherence was measured by 6-month proportion of days covered (PDC). Of 3,976 eligible subjects, 12,874 pairs of 6-month PDC and HbA1c levels were formed between 2002 and 2008. The average HbA1c levels were 7.4% for African-Americans and 6.5% for Whites. The average 6-month PDCs were 40% for African-Americans and 50% for Whites. In mixed effect generalized linear regression analyses, OHA adherence was inversely correlated with HbA1c level for both African-Americans (-0.80, p<0.0001) and Whites (-0.53, p<0.0001). The coefficient was -0.26 (p<0.0001) for the interaction of 6-month PDC and African-Americans. Significant risk factors for OHA non-adherence were race, young age, non-commercial insurance, newly-treated status, and polypharmacy.

The prevention of type 2 diabetes: an overview.

Type 2 diabetes mellitus is one of the major public health threats in the United States today, reaching epidemic rates. Epidemiological evidence suggests a strong link between obesity and the risk of developing diabetes. Increasing evidence demonstrates that lifestyle interventions can significantly delay or possibly prevent the onset of type 2 diabetes in persons with increased risk. Despite these findings, there remain important barriers to the translation of this research to the public health. These include identifying persons with an increased risk for developing the disease and the lack of easily accessible, cost-effective intervention programs. At least one study, however, has effectively implemented an evidenced-based intervention in community settings, suggesting that it may be possible to develop a model for the national scalability of primary prevention in the United States.

Educational disparities in rates of smoking among diabetic adults: the translating research into action for diabetes study.

OBJECTIVES: We assessed educational disparities in smoking rates among adults with diabetes in managed care settings. METHODS: We used a cross-sectional, survey-based (2002-2003) observational study among 6538 diabetic patients older than 25 years across multiple managed care health plans and states. For smoking at each level of self-reported educational attainment, predicted probabilities were estimated by means of hierarchical logistic regression models with random intercepts for health plan, adjusted for potential confounders. RESULTS: Overall, 15% the participants reported current smoking. An educational gradient in smoking was observed that varied significantly (P<.003) across age groups, with the educational gradient being strong in those aged 25 to 44 years, modest in those aged 45 to 64 years, and nonexistent in those aged 65 years or older. Of particular note, the prevalence of smoking observed in adults aged 25-44 years with less than a high school education was 50% (95% confidence interval: 36% to 63%). CONCLUSIONS: Approximately half of poorly educated young adults with diabetes smoke, magnifying the health risk associated with early-onset diabetes. Targeted public health interventions for smoking prevention and cessation among young, poorly educated people with diabetes are needed.

Understanding the gap between good processes of diabetes care and poor intermediate outcomes: Translating Research into Action for Diabetes (TRIAD).

BACKGROUND: Performance of diabetes clinical care processes has improved recently, but control of hemoglobin A1c (A1c) and other vascular disease risk factors has improved more slowly. OBJECTIVES: To identify patient factors associated with control of vascular disease risk factors among diabetes patients receiving recommended care processes. POPULATION: Managed care enrollees who participated in the TRIAD (Translating Research into Action for Diabetes) Study and received at least 5 of 7 recommended care processes during the 12 months before the second survey (2002-2003). METHODS: Comparison of 1003 patients with good control of A1c (<8%), systolic blood pressure (<140 mm Hg) and LDL-cholesterol (<130 mg/dL) versus 812 patients with poor control for at least 2 of these factors. RESULTS: Poorly controlled patients were younger, more frequently female, African American, with lower education and income (P < 0.001 for each). General health status was lower, body mass index higher, and insulin treatment more frequent; history of prior coronary heart disease was less frequent. They were more likely to indicate depression and hopelessness and to identify costs as a barrier to self-care; less likely to report trust in their regular physician; and more likely to smoke cigarettes and be physically inactive. Adjusting for demographic and clinical variables, concerns about costs, low trust in one's physician, current smoking, and physical inactivity remained associated with poor control. However, inclusion of these 4 variables in a single model did not diminish associations of race/ethnicity or education with control. CONCLUSIONS: Clinical, socioeconomic, psychosocial, and behavioral factors were independently associated with poor control. However, these factors did not fully explain observed racial and socioeconomic disparities in control.

Educational disparities in health behaviors among patients with diabetes: the Translating Research Into Action for Diabetes (TRIAD) Study.

BACKGROUND: Our understanding of social disparities in diabetes-related health behaviors is incomplete. The purpose of this study was to determine if having less education is associated with poorer diabetes-related health behaviors. METHODS: This observational study was based on a cohort of 8,763 survey respondents drawn from ~180,000 patients with diabetes receiving care from 68 provider groups in ten managed care health plans across the United States. Self-reported survey data included individual educational attainment ("education") and five diabetes self-care behaviors among individuals for whom the behavior would clearly be indicated: foot exams (among those with symptoms of peripheral neuropathy or a history of foot ulcers); self-monitoring of blood glucose (SMBG; among insulin users only); smoking; exercise; and certain diabetes-related health seeking behaviors (use of diabetes health education, website, or support group in last 12 months). Predicted probabilities were modeled at each level of self-reported educational attainment using hierarchical logistic regression models with random effects for clustering within health plans. RESULTS: Patients with less education had significantly lower predicted probabilities of being a non-smoker and engaging in regular exercise and health-seeking behaviors, while SMBG and foot self-examination did not vary by education. Extensive adjustment for patient factors revealed no discernable confounding effect on the estimates or their significance, and most education-behavior relationships were similar across sex, race and other patient characteristics. The relationship between education and smoking varied significantly across age, with a strong inverse relationship in those aged 25-44, modest for those ages 45-64, but non-evident for those over 65. Intensity of disease management by the health plan and provider communication did not alter the examined education-behavior relationships. Other measures of socioeconomic position yielded similar findings. CONCLUSION: The relationship between educational attainment and health behaviors was modest in strength for most behaviors. Over the life course, the cumulative effect of reduced practice of multiple self-care behaviors among less educated patients may play an important part in shaping the social health gradient.

Effect of adjunctive pramlintide treatment on treatment satisfaction in patients with type 1 diabetes.

OBJECTIVE: To assess the effect of adjunctive pramlintide treatment on treatment satisfaction in patients with type 1 diabetes treated with intensive insulin regimens. RESEARCH DESIGN AND METHODS: Intensively treated (multiple daily injection [MDI] or continuous subcutaneous insulin infusion [CSII] pump therapy) patients with type 1 diabetes completed a study-specific treatment satisfaction questionnaire following 29 weeks of either placebo (n = 136) or pramlintide (n = 130) treatment in a double-blind, noninferiority pramlintide dose titration trial. End points included patient reported outcomes, their relationship to insulin treatment regimen, A1C, weight, and insulin use. RESULTS: Pramlintide-treated patients reported greater treatment satisfaction in most questionnaire responses. Treatment satisfaction was similar for pramlintide-treated patients regardless of intensive insulin regimens (MDI versus CSII). Mean A1C was reduced to a similar degree in both pramlintide- (-0.39 +/- 0.07%) and placebo-treated (-0.45 +/- 0.07%) patients. However, pramlintide treatment was associated with reductions in mean body weight (-1.50 +/- 0.33 kg; P < 0.0001) and mealtime insulin use (-19.05 +/- 5.17%; P < 0.005) over 29 weeks, while placebo treatment resulted in weight gain (1.28 +/- 0.25 kg) and a smaller reduction in mealtime insulin use (-2.20 +/- 3.33%). CONCLUSIONS: Despite similar reductions in A1C, pramlintide treatment resulted in greater treatment satisfaction compared with placebo treatment. This was independent of insulin delivery method.

What adolescents with type I diabetes and their parents want from testing technology: a qualitative study.

The presence of diabetes in an adolescent can significantly affect his/her normal development. Mobile technology may offer the ability to lessen this negative impact. We wished to learn from adolescents with diabetes and their parents how monitoring systems that incorporated mobile communication technology could potentially help to reduce hassles associated with testing, improve compliance, and ease adolescent-parent conflict about testing behavior. We recruited adolescents between the ages of 13 and 18 years, living with type 1 diabetes mellitus and their parents for focus groups. Qualitative analysis of the focus group data followed a set procedure. From the discussions, the following themes were identified: issues with blood glucose monitoring and desired technology. Elements of desired technology included hardware requirements, software requirements, communication, and miscellaneous requirements. The reported needs of this end-user group can help others to leverage maximally the capabilities of new and existing technology to care for children managing chronic disease.

Primary care physician treatment of low HDL: Rational approach or Pandora's Box?

BACKGROUND: Guidelines for treating high low-density lipoproteins are clear, whereas guidelines for treating low high-density lipoproteins (HDL) are less so. Physicians approach to treating low HDL cholesterol is not known. OBJECTIVE: To determine primary care physicians approach to managing low HDL. METHODS: Three-thousand, nine-hundred and nineteen surveys were mailed to all primary care physicians in the State of Indiana, asking questions regarding demographics, case studies to assess the provider's approach to managing low HDL, and direct questions regarding management of HDL levels and general lipid knowledge questions. RESULTS: Seven-hundred and eighty-one surveys were returned, for a response rate of 19.9%. Fifty-eight percent of participants would initiate HDL-raising therapy after achieving the appropriate low-density lipoprotein cholesterol goal. The approaches used to raise HDL included lifestyle changes (diet, exercise, smoking cessation) (85%), niacin (83%), fibric acid derivative (61%), and alcohol (31%). Reasons inhibiting initiating therapy for raising HDL included concern over side effects (56%), perceived lack of effectiveness of currently available drugs (24%), lack of clear guidelines (22%), and lack of evidenced-based trials demonstrating benefit of raising HDL (14%). For men, 40% of physicians use 40 mg/dL as a cutoff for initiating HDL-raising therapy, while 25% using a cutoff of 35 mg/dL. For women, 24% use a cutoff of 50 mg/dL for initiating HDL-raising therapy, while 12% use 45 mg/dL as a cutoff. CONCLUSIONS: The majority of primary care physicians in the State of Indiana treated low HDL with appropriate approaches, although use of alcohol to raise HDL raises concerns.

An evaluation of cost sharing to finance a diet and physical activity intervention to prevent diabetes.

OBJECTIVE: The Diabetes Prevention Program (DPP) lifestyle intervention is a cost-effective strategy to prevent type 2 diabetes, but it is unclear how this intervention could be financed. We explored whether this intervention could be offered in a way that allows return on investment for private health insurers while remaining attractive for consumers, employers, and Medicare. RESEARCH DESIGN AND METHODS: We used the DPP and other published reports to build a Markov simulation model to estimate the lifetime progression of disease, costs, and quality of life for adults with impaired glucose tolerance. The model assumed a health-payer perspective and compared DPP lifestyle and placebo interventions. Primary outcomes included cumulative incidence of diabetes, direct medical costs, quality-adjusted life-years (QALYs), and cost per QALY gained. RESULTS: Compared with placebo, providing the lifestyle intervention at age 50 years could prevent 37% of new cases of diabetes before age 65, at a cost of $1,288 per QALY gained. A private payer could reimburse $655 (24%) of the $2,715 in total discounted intervention costs during the first 3 intervention years and still recover all of these costs in the form of medical costs avoided. If Medicare paid up to $2,136 in intervention costs over the 15-year period before participants reached age 65, it could recover those costs in the form of future medical costs avoided beginning at age 65. CONCLUSIONS: Cost-sharing strategies to offer the DPP lifestyle intervention for eligible people between ages 50 and 64 could provide financial return on investment for private payers and long-term benefits for Medicare.