Food Insecurity, Dietary Quality, and Health Care Utilization in Lower-Income Adults: A Cross-Sectional Study.

BACKGROUND: Food insecurity and poor nutrition are prevalent in the United States and associated with chronic diseases. Understanding relationships among food insecurity, diet, and health care utilization can inform strategies to reduce health disparities. OBJECTIVE: Our aim was to determine associations between food security status and inpatient and outpatient health care utilization and whether they differed by dietary quality in lower-income adults. DESIGN: This was a cross-sectional study of data from the 2009-2016 National Health and Nutrition Examination Survey. PARTICIPANTS/SETTING: Participants were 13,956 lower-income (<300% federal poverty level) adults 18 years and older in the United States. MAIN OUTCOME MEASURES: Self-reported health care utilization in the past 12 months included no usual source of care, any outpatient visit, any mental health service use, and any hospitalization. STATISTICAL ANALYSES: Multiple logistic regression was used to study the association between food insecurity and health care utilization. Analyses were stratified by diet-related comorbidities to account for potential confounding and mediation of health care utilization, and by dietary quality. RESULTS: In a sample of lower-income adults <300% federal poverty level, 4,319 participants (27.4%) were food insecure, 2,208 (15.0%) were marginally food secure, and 7,429 (57.6%) were food secure. Food insecurity was associated with having no usual source of care (adjusted odds ratio [aOR] 1.30; 95% CI 1.11 to 1.52), any mental health service use (aOR 2.02; 95% CI 1.61 to 2.52), and any hospitalization (aOR 1.19; 95% CI 1.01 to 1.41). Food-insecure adults were more likely to report no outpatient visits if they had diet-related comorbidities (aOR 1.45; 95% CI 1.10 to 1.92) or the lowest dietary quality (aOR 1.53; 95% CI 1.06 to 2.23). Marginal food security was associated with having no usual source of care (aOR 1.22; 95% CI 1.04 to 1.44). CONCLUSIONS: Adults with food insecurity were more likely to be hospitalized, use mental health services, and have no usual source of care. Food-insecure participants with diet-related comorbidities or poor diet were less likely to have outpatient visits. Hospitalizations and mental health visits represent underused opportunities to identify and address food insecurity and dietary intake in lower-income patients.

Incremental Risk of Developing Severe COVID-19 Among Mexican Patients With Diabetes Attributed to Social and Health Care Access Disadvantages.

OBJECTIVE: Diabetes is an important risk factor for severe coronavirus disease 2019 (COVID-19), but little is known about the marginal effect of additional risk factors for severe COVID-19 among individuals with diabetes. We tested the hypothesis that sociodemographic, access to health care, and presentation to care characteristics among individuals with diabetes in Mexico confer an additional risk of hospitalization with COVID-19. RESEARCH DESIGN AND METHODS: We conducted a cross-sectional study using public data from the General Directorate of Epidemiology of the Mexican Ministry of Health. We included individuals with laboratory-confirmed severe acute respiratory syndrome coronavirus 2 between 1 March and 31 July 2020. The primary outcome was the predicted probability of hospitalization, inclusive of 8.5% of patients who required intensive care unit admission. RESULTS: Among 373,963 adults with COVID-19, 16.1% (95% CI 16.0-16.3) self-reported diabetes. The predicted probability of hospitalization was 38.4% (37.6-39.2) for patients with diabetes only and 42.9% (42.2-43.7) for patients with diabetes and one or more comorbidities (obesity, hypertension, cardiovascular disease, and chronic kidney disease). High municipality-level of social deprivation and low state-level health care resources were associated with a 9.5% (6.3-12.7) and 17.5% (14.5-20.4) increased probability of hospitalization among patients with diabetes, respectively. In age-, sex-, and comorbidity-adjusted models, living in a context of high social vulnerability and low health care resources was associated with the highest predicted probability of hospitalization. CONCLUSIONS: Social vulnerability contributes considerably to the probability of hospitalization among individuals with COVID-19 and diabetes with associated comorbidities. These findings can inform mitigation strategies for populations at the highest risk of severe COVID-19.

Diabetes Prevalence and Its Relationship With Education, Wealth, and BMI in 29 Low- and Middle-Income Countries.

OBJECTIVE: Diabetes is a rapidly growing health problem in low- and middle-income countries (LMICs), but empirical data on its prevalence and relationship to socioeconomic status are scarce. We estimated diabetes prevalence and the subset with undiagnosed diabetes in 29 LMICs and evaluated the relationship of education, household wealth, and BMI with diabetes risk. RESEARCH DESIGN AND METHODS: We pooled individual-level data from 29 nationally representative surveys conducted between 2008 and 2016, totaling 588,574 participants aged ≥25 years. Diabetes prevalence and the subset with undiagnosed diabetes was calculated overall and by country, World Bank income group (WBIG), and geographic region. Multivariable Poisson regression models were used to estimate relative risk (RR). RESULTS: Overall, prevalence of diabetes in 29 LMICs was 7.5% (95% CI 7.1-8.0) and of undiagnosed diabetes 4.9% (4.6-5.3). Diabetes prevalence increased with increasing WBIG: countries with low-income economies (LICs) 6.7% (5.5-8.1), lower-middle-income economies (LMIs) 7.1% (6.6-7.6), and upper-middle-income economies (UMIs) 8.2% (7.5-9.0). Compared with no formal education, greater educational attainment was associated with an increased risk of diabetes across WBIGs, after adjusting for BMI (LICs RR 1.47 [95% CI 1.22-1.78], LMIs 1.14 [1.06-1.23], and UMIs 1.28 [1.02-1.61]). CONCLUSIONS: Among 29 LMICs, diabetes prevalence was substantial and increased with increasing WBIG. In contrast to the association seen in high-income countries, diabetes risk was highest among those with greater educational attainment, independent of BMI. LMICs included in this analysis may be at an advanced stage in the nutrition transition but with no reversal in the socioeconomic gradient of diabetes risk.

Food insecurity, healthcare utilization, and high cost: a longitudinal cohort study.

OBJECTIVES: Reducing utilization of high-cost healthcare services is a common population health goal. Food insecurity-limited access to nutritious food owing to cost-is associated with chronic disease, but its relationship with healthcare utilization is understudied. We tested whether food insecurity is associated with increased emergency department (ED) visits, hospitalizations, and related costs. STUDY DESIGN: Retrospective analysis of a nationally representative cohort. METHODS: Adults (≥18 years) completed a food insecurity assessment (using 10 items derived from the US Department of Agriculture Household Food Security Module) in the 2011 National Health Interview Survey and were followed in the 2012-2013 Medical Expenditures Panel Survey. Outcome measures were ED visits, hospitalizations, days hospitalized, and whether participants were in the top 10%, 5%, or 2% of total healthcare expenditures. RESULTS: Of 11,781 participants, 2056 (weighted percentage, 13.2%) were in food-insecure households. Food insecurity was associated with significantly more ED visits (incidence rate ratio [IRR], 1.47; 95% CI, 1.12-1.93), hospitalizations (IRR, 1.47; 95% CI, 1.14-1.88), and days hospitalized (IRR, 1.54; 95% CI, 1.06-2.24) after adjustment for demographics, education, income, health insurance, region, and rural residence. Food insecurity was also associated with increased odds of being in the top 10% (odds ratio [OR], 1.73; 95% CI, 1.31-2.27), 5% (OR, 2.53; 95% CI, 1.51-3.37), or 2% (OR, 1.95; 95% CI, 1.09-3.49) of healthcare expenditures. CONCLUSIONS: Food insecurity is associated with higher healthcare use and costs, even accounting for other socioeconomic factors. Whether food insecurity interventions improve healthcare utilization and cost should be tested.

Association of Methylation Signals With Incident Coronary Heart Disease in an Epigenome-Wide Assessment of Circulating Tumor Necrosis Factor α.

Importance: Tumor necrosis factor α (TNF-α) is a proinflammatory cytokine with manifold consequences for mammalian pathophysiology, including cardiovascular disease. A deeper understanding of TNF-α biology may enhance treatment precision. Objective: To conduct an epigenome-wide analysis of blood-derived DNA methylation and TNF-α levels and to assess the clinical relevance of findings. Design, Setting, and Participants: This meta-analysis assessed epigenome-wide associations in circulating TNF-α concentrations from 5 cohort studies and 1 interventional trial, with replication in 3 additional cohort studies. Follow-up analyses investigated associations of identified methylation loci with gene expression and incident coronary heart disease; this meta-analysis included 11 461 participants who experienced 1895 coronary events. Exposures: Circulating TNF-α concentration. Main Outcomes and Measures: DNA methylation at approximately 450 000 loci, neighboring DNA sequence variation, gene expression, and incident coronary heart disease. Results: The discovery cohort included 4794 participants, and the replication study included 816 participants (overall mean [SD] age, 60.7 [8.5] years). In the discovery stage, circulating TNF-α levels were associated with methylation of 7 cytosine-phosphate-guanine (CpG) sites, 3 of which were located in or near DTX3L-PARP9 at cg00959259 (ß [SE] = -0.01 [0.003]; P = 7.36 × 10-8), cg08122652 (ß [SE] = -0.008 [0.002]; P = 2.24 × 10-7), and cg22930808(ß [SE] = -0.01 [0.002]; P = 6.92 × 10-8); NLRC5 at cg16411857 (ß [SE] = -0.01 [0.002]; P = 2.14 × 10-13) and cg07839457 (ß [SE] = -0.02 [0.003]; P = 6.31 × 10-10); or ABO, at cg13683939 (ß [SE] = 0.04 [0.008]; P = 1.42 × 10-7) and cg24267699 (ß [SE] = -0.009 [0.002]; P = 1.67 × 10-7), after accounting for multiple testing. Of these, negative associations between TNF-α concentration and methylation of 2 loci in NLRC5 and 1 in DTX3L-14 PARP9 were replicated. Replicated TNF-α-linked CpG sites were associated with 9% to 19% decreased risk of incident coronary heart disease per 10% higher methylation per CpG site (cg16411857: hazard ratio [HR], 0.86; 95% CI, 0.78-1.95; P = .003; cg07839457: HR, 0.89; 95% CI, 0.80-0.94; P = 3.1 × 10-5; cg00959259: HR, 0.91; 95% CI, 0.84-0.97; P = .002; cg08122652: HR, 0.81; 95% CI, 0.74-0.89; P = 2.0 × 10-5). Conclusions and Relevance: We identified and replicated novel epigenetic correlates of circulating TNF-α concentration in blood samples and linked these loci to coronary heart disease risk, opening opportunities for validation and therapeutic applications.

Food Insecurity and Health Care Expenditures in the United States, 2011-2013.

OBJECTIVE: To determine whether food insecurity, limited or uncertain food access owing to cost, is associated with greater health care expenditures. DATA SOURCE/STUDY SETTING: Nationally representative sample of the civilian noninstitutionalized population of the United States (2011 National Health Interview Survey [NHIS] linked to 2012-2013 Medication Expenditure Panel Survey [MEPS]). STUDY DESIGN: Longitudinal retrospective cohort. DATA COLLECTION/EXTRACTION METHODS: A total of 16,663 individuals underwent assessment of food insecurity, using the 10-item adult 30-day food security module, in the 2011 NHIS. Their total health care expenditures in 2012 and 2013 were recorded in MEPS. Expenditure data were analyzed using zero-inflated negative binomial regression and adjusted for age, gender, race/ethnicity, education, income, insurance, and residence area. PRINCIPAL FINDINGS: Fourteen percent of individuals reported food insecurity, representing 41,616,255 Americans. Mean annualized total expenditures were $4,113 (standard error $115); 9.2 percent of all individuals had no health care expenditures. In multivariable analyses, those with food insecurity had significantly greater estimated mean annualized health care expenditures ($6,072 vs. $4,208, p < .0001), an extra $1,863 in health care expenditure per year, or $77.5 billion in additional health care expenditure annually. CONCLUSIONS: Food insecurity was associated with greater subsequent health care expenditures. Future studies should determine whether food insecurity interventions can improve health and reduce health care costs.

Supplemental Nutrition Assistance Program (SNAP) Participation and Health Care Expenditures Among Low-Income Adults.

Importance: Food insecurity is associated with high health care expenditures, but the effectiveness of food insecurity interventions on health care costs is unknown. Objective: To determine whether the Supplemental Nutrition Assistance Program (SNAP), which addresses food insecurity, can reduce health care expenditures. Design, Setting, and Participants: This is a retrospective cohort study of 4447 noninstitutionalized adults with income below 200% of the federal poverty threshold who participated in the 2011 National Health Interview Survey (NHIS) and the 2012-2013 Medical Expenditure Panel Survey (MEPS). Exposures: Self-reported SNAP participation in 2011. Main Outcomes and Measures: Total health care expenditures (all paid claims and out-of-pocket costs) in the 2012-2013 period. To test whether SNAP participation was associated with lower subsequent health care expenditures, we used generalized linear modeling (gamma distribution, log link, with survey design information), adjusting for demographics (age, gender, race/ethnicity), socioeconomic factors (income, education, Social Security Disability Insurance disability, urban/rural), census region, health insurance, and self-reported medical conditions. We also conducted sensitivity analyses as a robustness check for these modeling assumptions. Results: A total of 4447 participants (2567 women and 1880 men) were enrolled in the study, mean (SE) age, 42.7 (0.5) years; 1889 were SNAP participants, and 2558 were not. Compared with other low-income adults, SNAP participants were younger (mean [SE] age, 40.3 [0.6] vs 44.1 [0.7] years), more likely to have public insurance or be uninsured (84.9% vs 67.7%), and more likely to be disabled (24.2% vs 10.6%) (P < .001 for all). In age- and gender-adjusted models, health care expenditures between those who did and did not participate in SNAP were similar (difference, $34; 95% CI, -$1097 to $1165). In fully adjusted models, SNAP was associated with lower estimated annual health care expenditures (-$1409; 95% CI, -$2694 to -$125). Sensitivity analyses were consistent with these results, also indicating that SNAP participation was associated with significantly lower estimated expenditures. Conclusions and Relevance: SNAP enrollment is associated with reduced health care spending among low-income American adults, a finding consistent across several analytic approaches. Encouraging SNAP enrollment among eligible adults may help reduce health care costs in the United States.

Association of Acculturation and Health Literacy with Prevalent Dysglycemia and Diabetes Control Among Latinos in the Boston Area Community Health (BACH) Survey.

This study assessed the effect of acculturation on type 2 diabetes and whether health literacy may mediate this association. The Boston Area Community Health cohort is a multi-stage stratified random sample of adults from Boston including 744 Latinos. We defined dysglycemia as a HbA1c ≥5.7 %. Multivariable analyses examined the associations between acculturation and health literacy adjusting for demographic and clinical variables. Similar analyses were performed among participants with HbA1c ≥7.0 % to assess the association between acculturation and diabetes control. Among an insured primarily foreign born Spanish speaking Latino population, with a long residence period in the US and good healthcare utilization, higher levels of acculturation were not associated with dysglycemia. Lower levels of acculturation were associated with worse diabetes control. Health literacy level did not modify these associations. Elucidating the components of heterogeneity among Latinos will be essential for understanding the influence of acculturation on diabetes.

Hypoglycemia in Diabetes Mellitus as a Coronary Artery Disease Risk Factor in Patients at Elevated Vascular Risk.

CONTEXT: Although clinical trials have shown that hypoglycemia is associated with coronary artery disease (CAD), little is known whether hypoglycemia is a CAD risk factor in primary care. OBJECTIVE: We sought to determine whether previous hypoglycemia was associated with incident CAD, and whether this association differed in patients of different underlying vascular risk. DESIGN, SETTING AND PARTICIPANTS: This is a longitudinal cohort study of diabetes patients without CAD before January 1, 2006 (n = 9173) followed at an academic network of 13 primary care practices from January 1, 2006 to June 30, 2012. Hypoglycemic events before January 1, 2006 were identified via International Classification of Diseases Ninth Revision codes from emergency department, inpatient and outpatient visits. MAIN OUTCOME MEASURE: Patients were followed until incident CAD or June 30, 2012. Cox regression with time interaction was used to determine the association between hypoglycemia and CAD (significance set at P ≤ .05). We then tested the association among high vascular risk patients (age ≥ 55 y, hemoglobin A1c ≥ 7.5%, ≥2 risk factors [dyslipidemia, hypertension or obesity]), a subset of high vascular risk patients aged 65 years or older, and the remaining patients with lower vascular risk. RESULTS: Three percent of patients (n = 285) had previous hypoglycemia. Hypoglycemia was associated with a 2-fold CAD risk (hazard ratio [HR] 2.15; 95% confidence interval [95%CI] 1.24-3.74), adjusting for time interaction and vascular risk factors. Among high vascular risk patients, the risk was 3-fold (HR 3.01 [95%CI 1.15-7.91], n = 1823 [20% of cohort]), and over 4-fold (HR 4.62 [95%CI 1.65-12.9], n = 996) in the subset aged more than or equal to 65 years. No association was found in the remaining 80% of the cohort with lower vascular risk. CONCLUSIONS: Previous hypoglycemia was associated with CAD among high vascular risk patients. Hypoglycemia may not be a CAD risk factor for the majority of primary care patients with lower underlying vascular risk.

Material need insecurities, control of diabetes mellitus, and use of health care resources: results of the Measuring Economic Insecurity in Diabetes study.

IMPORTANCE: Increasing access to care may be insufficient to improve the health of patients with diabetes mellitus and unmet basic needs (hereinafter referred to as material need insecurities). How specific material need insecurities relate to clinical outcomes and the use of health care resources in a setting of near-universal access to health care is unclear. OBJECTIVE: To determine the association of food insecurity, cost-related medication underuse, housing instability, and energy insecurity with control of diabetes mellitus and the use of health care resources. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional data were collected from June 1, 2012, through October 31, 2013, at 1 academic primary care clinic, 2 community health centers, and 1 specialty center for the treatment of diabetes mellitus in Massachusetts. A random sample of 411 patients, stratified by clinic, consisted of adults (aged ≥21 years) with diabetes mellitus (response rate, 62.3%). MAIN OUTCOMES AND MEASURES: The prespecified primary outcome was a composite indicator of poor diabetes control (hemoglobin A1c level, >9.0%; low-density lipoprotein cholesterol level, >100 mg/dL; or blood pressure, >140/90 mm Hg). Prespecified secondary outcomes included outpatient visits and a composite of emergency department (ED) visits and acute care hospitalizations (ED/inpatient visits). RESULTS: Overall, 19.1% of respondents reported food insecurity; 27.6%, cost-related medication underuse; 10.7%, housing instability; 14.1%, energy insecurity; and 39.1%, at least 1 material need insecurity. Poor diabetes control was observed in 46.0% of respondents. In multivariable models, food insecurity was associated with a greater odds of poor diabetes control (adjusted odds ratio [OR], 1.97 [95% CI, 1.58-2.47]) and increased outpatient visits (adjusted incident rate ratio [IRR], 1.19 [95% CI, 1.05-1.36]) but not increased ED/inpatient visits (IRR, 1.00 [95% CI, 0.51-1.97]). Cost-related medication underuse was associated with poor diabetes control (OR, 1.91 [95% CI, 1.35-2.70]) and increased ED/inpatient visits (IRR, 1.68 [95% CI, 1.21-2.34]) but not outpatient visits (IRR, 1.07 [95% CI, 0.95-1.21]). Housing instability (IRR, 1.31 [95% CI, 1.14-1.51]) and energy insecurity (IRR, 1.12 [95% CI, 1.00-1.25]) were associated with increased outpatient visits but not with diabetes control (OR, 1.10 [95% CI, 0.60-2.02] and OR, 1.27 [95% CI, 0.96-1.69], respectively) or with ED/inpatient visits (IRR, 1.49 [95% CI, 0.81-2.73] and IRR, 1.31 [95% CI, 0.80-2.13], respectively). An increasing number of insecurities was associated with poor diabetes control (OR for each additional need, 1.39 [95% CI, 1.18-1.63]) and increased use of health care resources (IRR for outpatient visits, 1.09 [95% CI, 1.03-1.15]; IRR for ED/inpatient visits, 1.22 [95% CI, 0.99-1.51]). CONCLUSIONS AND RELEVANCE: Material need insecurities were common among patients with diabetes mellitus and had varying but generally adverse associations with diabetes control and the use of health care resources. Material need insecurities may be important targets for improving care of diabetes mellitus.

Improving diabetes care among patients overdue for recommended testing: a randomized controlled trial of automated telephone outreach.

OBJECTIVE: The study's objective was to assess the effects of automated telephone outreach with speech recognition (ATO-SR) on diabetes-related testing. RESEARCH DESIGN AND METHODS: We identified 1,200 health plan members who were overdue for diabetes-related testing and randomly allocated 600 to ATO-SR and 600 to usual care (no intervention). The intervention included three interactive calls encouraging recommended testing. The primary outcome was retinopathy testing, since this was the health plan's principal goal. Tests for glycemia, hyperlipidemia, and nephropathy were secondary outcomes. RESULTS: In total, 232 participants (39%) verbally responded to the calls. There was no difference between the intervention and the usual care groups in the primary outcome (adjusted hazard ratio 0.93 [95% CI 0.71-1.22]) and no effect of the intervention on any of the secondary outcomes. CONCLUSIONS: Fewer than 40% of the patients randomized to ATO-SR interacted verbally with the system. The intervention had no effect on the study's outcomes.

Racial differences in long-term adherence to oral antidiabetic drug therapy: a longitudinal cohort study.

BACKGROUND: Adherence to oral antidiabetic medications is often suboptimal. Adherence differences may contribute to health disparities for black diabetes patients, including higher microvascular event rates, greater complication-related disability, and earlier mortality. METHODS: In this longitudinal retrospective cohort study, we used 10 years of patient-level claims and electronic medical record data (1/1/1992-12/31/2001) to assess differences in short- and long-term adherence to oral antidiabetic medication among 1906 newly diagnosed adults with diabetes (26% black, 74% white) in a managed care setting in which all members have prescription drug coverage. Four main outcome measures included: (1) time from diabetes diagnosis until first prescription of oral antidiabetic medication; (2) primary adherence (time from first prescription to prescription fill); (3) time until discontinuation of oral antidiabetic medication from first prescription; and (4) long-term adherence (amount dispensed versus amount prescribed) over a 24-month follow-up from first oral antidiabetic medication prescription. RESULTS: Black patients were as likely as whites to initiate oral therapy and fill their first prescription, but experienced higher rates of medication discontinuation (HR: 1.8, 95% CI: 1.2, 2.7) and were less adherent over time. These black-white differences increased over the first six months of therapy but stabilized thereafter for patients who initiated on sulfonylureas. Significant black-white differences in adherence levels were constant throughout follow-up for patients initiated on metformin therapy. CONCLUSION: Racial differences in adherence to oral antidiabetic drug therapy persist even with equal access to medication. Early and continued emphasis on adherence from initiation of therapy may reduce persistent racial differences in medication use and clinical outcomes.

Burden and rates of treatment and control of cardiovascular disease risk factors in obesity: the Framingham Heart Study.

OBJECTIVE: Obesity is associated with an increased risk for cardiovascular disease (CVD). We sought to determine rates of treatment and control of CVD risk factors among normal weight, overweight, and obese individuals in a community-based cohort. RESEARCH DESIGN AND METHODS: Participants free of CVD (n = 6,801; mean age 49 years; 54% women) from the Framingham Offspring and Third Generation cohorts who attended the seventh Offspring examination (1998-2001) or first Third Generation (2002-2005) examination were studied. RESULTS: Obese participants with hypertension were more likely to receive antihypertensive treatment (62.3%) than normal weight (58.7%) or overweight (59.0%) individuals (P = 0.002), but no differences in hypertension control across BMI subgroups among participants with hypertension were observed (36.7% [normal weight], 37.3% [overweight], and 39.4% [obese]; P = 0.48). Rates of lipid-lowering treatment were higher among obese participants with elevated LDL cholesterol (39.5%) compared with normal weight (34.2%) or overweight (36.4%) participants (P = 0.02), but control rates among those with elevated LDL cholesterol did not differ across BMI categories (26.7% [normal weight], 26.0% [overweight], and 29.2% [obese]; P = 0.11). There were no differences in diabetes treatment among participants with diabetes across BMI groups (69.2% [normal weight], 50.0% [overweight], 55.0% [obese]; P = 0.54), but obese participants with diabetes were less likely to have fasting blood glucose <126 mg/dl (15.7%) compared with normal weight (30.4%) or overweight (20.7%) participants (P = 0.02). CONCLUSIONS: These findings emphasize the suboptimal rates of treatment and control of CVD risk factors among overweight and obese individuals.

Mortality after periprosthetic fracture of the femur.

BACKGROUND: Management of periprosthetic femoral fractures is often complex, and few studies have documented its associated mortality. METHODS: We retrospectively identified from our trauma and surgical registries 106 patients who underwent surgery for a periprosthetic femoral fracture. We then identified a contemporaneous age and sex-matched control cohort of 309 patients who had a hip fracture (femoral neck or intertrochanteric) and 311 patients who underwent primary hip or knee replacement. Mortality at one year was identified with use of the Social Security database. RESULTS: Twelve (11%) of 106 patients died within one year following surgical treatment of a periprosthetic fracture. During the same follow-up period, fifty-one (16.5%) of 309 patients died following surgery for a hip fracture and nine (2.9%) of 311 patients died following primary joint replacement. The mortality rate after a periprosthetic femoral fracture was significantly higher (p < 0.0001) compared with that for matched patients who had undergone primary joint replacement, and it was similar to the mortality rate after a hip fracture. For periprosthetic fractures, a delay of greater than two days from admission to the time of surgery was associated with an increased mortality rate at one year (p < 0.0007). Forty-nine patients underwent revision arthroplasty for the treatment of a Vancouver type-B periprosthetic fracture, and six (12%) died. In contrast, twenty-four patients with a Vancouver type-B periprosthetic fracture were treated with open reduction and internal fixation and eight (33%) died. The difference was significant (p < 0.03). CONCLUSIONS: The mortality rate within one year following surgical treatment of periprosthetic femoral fractures is high and is similar to that after treatment for hip fractures. Because revision arthroplasty for the treatment of type-B periprosthetic fractures was associated with a one-year mortality rate that was significantly less than that after surgical treatment with open reduction and internal fixation, in instances when either treatment option is feasible, revision arthroplasty may be the preferred option.

Racial differences in long-term self-monitoring practice among newly drug-treated diabetes patients in an HMO.

BACKGROUND: One approach to improving outcomes for minority diabetics may be through better self-care. However, minority patients may encounter barriers to better self-care even within settings where variations in quality of care and insurance are minimized. OBJECTIVE: The objective of the study was to evaluate racial differences in long-term glucose self-monitoring and adherence rates in an HMO using evidence-based guidelines for self-monitoring. DESIGN: Retrospective cohort study using 10 years (1/1/1993-12/31/2002) of electronic medical record data was used. PATIENTS: Patients were 1,732 insured adult diabetics of black or white race newly initiated on hypoglycemic therapy in a large multi-specialty care group practice. MEASUREMENTS: Outcomes include incidence and prevalence of glucose self-monitoring, intensity of use, and rate of adherence to national recommended standards. RESULTS: We found no evidence of racial differences in adjusted initiation rates of glucose self-monitoring among insulin-treated patients, but found lower rates of initiation among black patients living in low-income areas. Intensity of glucose self-monitoring remained lower among blacks than whites throughout follow-up [IRR for insulin = 0.41 (0.27-0.62); IRR for oral hypoglycemic = 0.75 (0.63, 0.90)], with both groups monitoring well below recommended standards. Among insulin-treated patients, <1% of blacks and <10% of whites were self-monitoring 3 times per day; 36% of whites and 10% of blacks were self-monitoring at least once per day. CONCLUSIONS: Adherence to glucose self-monitoring standards was low, particularly among blacks, and racial differences in self-monitoring persisted within a health system providing equal access to services for diabetes patients. Early and continued emphasis on adherence among black diabetics may be necessary to reduce racial differences in long-term glucose self-monitoring.

Burden and prognostic importance of subclinical cardiovascular disease in overweight and obese individuals.

BACKGROUND: The burden and prognostic importance of subclinical cardiovascular disease (CVD) in obesity has not been investigated systematically. METHODS AND RESULTS: We examined prevalence of subclinical disease in 1938 Framingham Study participants (mean age, 57 years; 59% women) by use of 5 tests (electrocardiography, echocardiography, carotid ultrasound, ankle-brachial pressure, and urinary albumin excretion) and stratified by body mass index (BMI) (normal, < 25; overweight, 25 to < 30.0; obese, > or = 30 kg/m2) and waist circumference (WC) (increased, > or = 88 cm for women or > or = 102 cm for men). We investigated risk of overt CVD associated with adiposity according to presence versus absence of subclinical disease on any of the 5 tests. Prevalence of subclinical disease was higher in overweight (40.0%; adjusted odds ratio, 1.68) and obese individuals (49.7%; odds ratio, 2.82) compared with individuals with normal BMI (29.3%) and in individuals with increased WC (44.9%; odds ratio, 1.67) compared with normal WC (31.9%). On follow-up (mean 7.2 years), 139 participants had developed overt CVD. Presence of subclinical disease was associated with > 2-fold risk of overt CVD in all BMI and WC strata, with no evidence of an interaction between BMI and subclinical disease. CVD risk was attenuated in participants with obesity or increased WC but without subclinical disease (adjusted hazard ratio for obesity, 1.57; 95% confidence interval, 0.74 to 3.33; adjusted hazard ratio for increased WC, 1.22; 95% confidence interval, 0.69 to 2.15), compared with individuals with normal BMI or WC and no subclinical disease, respectively. CONCLUSIONS: In our community-based sample, overweight and obesity were associated with high prevalence of subclinical disease, which partly contributed to the increased risk of overt CVD in these strata.

Soft drink consumption and risk of developing cardiometabolic risk factors and the metabolic syndrome in middle-aged adults in the community.

BACKGROUND: Consumption of soft drinks has been linked to obesity in children and adolescents, but it is unclear whether it increases metabolic risk in middle-aged individuals. METHODS AND RESULTS: We related the incidence of metabolic syndrome and its components to soft drink consumption in participants in the Framingham Heart Study (6039 person-observations, 3470 in women; mean age 52.9 years) who were free of baseline metabolic syndrome. Metabolic syndrome was defined as the presence of > or = 3 of the following: waist circumference > or = 35 inches (women) or > or = 40 inches (men); fasting blood glucose > or = 100 mg/dL; serum triglycerides > or = 150 mg/dL; blood pressure > or = 135/85 mm Hg; and high-density lipoprotein cholesterol < 40 mg/dL (men) or < 50 mg/dL (women). Multivariable models included adjustments for age, sex, physical activity, smoking, dietary intake of saturated fat, trans fat, fiber, magnesium, total calories, and glycemic index. Cross-sectionally, individuals consuming > or = 1 soft drink per day had a higher prevalence of metabolic syndrome (odds ratio [OR], 1.48; 95% CI, 1.30 to 1.69) than those consuming < 1 drink per day. On follow-up (mean of 4 years), new-onset metabolic syndrome developed in 717 of 4033 participants (17.8%) consuming < 1 drink/day and in 433 of 2006 persons (21.6%) [corrected] consuming > or = 1 soft drink/day [corrected] Consumption of > or = 1 soft drink per day was associated with increased odds of developing metabolic syndrome (OR, 1.44; 95% CI, 1.20 to 1.74), obesity (OR, 1.31; 95% CI, 1.02 to 1.68), increased waist circumference (OR, 1.30; 95% CI, 1.09 to 1.56), impaired fasting glucose (OR, 1.25; 95% CI, 1.05 to 1.48), higher blood pressure (OR, 1.18; 95% CI, 0.96 to 1.44), hypertriglyceridemia (OR, 1.25; 95% CI, 1.04 to 1.51), and low high-density lipoprotein cholesterol (OR, 1.32; 95% CI 1.06 to 1.64). CONCLUSIONS: In middle-aged adults, soft drink consumption is associated with a higher prevalence and incidence of multiple metabolic risk factors.