The Hispanic paradox in the prevalence of obesity at the county-level.

OBJECTIVE: The percentage of Hispanics in a county has a negative association with prevalence of obesity. Because Hispanic individuals are unevenly distributed in the United States, this study examined whether this protective association persists when stratifying counties into quartiles based on the size of the Hispanic population and after adjusting for county-level demographic, socioeconomic, healthcare, and environmental factors. METHODS: Data were extracted from the 2018 Robert Wood Johnson Foundation County Health Rankings. Counties were categorized into quartiles based on their percentage of Hispanics, 0%-5% (n = 1794), 5%-20% (n = 962), 20%-50% (n = 283), and >50% (n = 99). For each quartile, univariate and multivariate regression models were used to evaluate the association between prevalence of obesity and demographic, socioeconomic, healthcare, and environmental factors. RESULTS: Counties with the top quartile of Hispanic individuals had the lowest prevalence of obesity compared to counties at the bottom quartile (28.4 ± 3.6% vs. 32.7 ± 4.0%). There was a negative association between county-level percentage of Hispanics and prevalence of obesity in unadjusted analyses that persisted after adjusting for all county-level factors. CONCLUSIONS: Counties with a higher percentage of Hispanics have lower levels of obesity, even after controlling for demographic, socioeconomic, healthcare, and environmental factors. More research is needed to elucidate why having more Hispanics in a county may be protective against county-level obesity.

County-Level Factors Associated With Cardiovascular Mortality by Race/Ethnicity.

Background Persistent racial/ethnic disparities in cardiovascular disease (CVD) mortality are partially explained by healthcare access and socioeconomic, demographic, and behavioral factors. Little is known about the association between race/ethnicity-specific CVD mortality and county-level factors. Methods and Results Using 2017 county-level data, we studied the association between race/ethnicity-specific CVD age-adjusted mortality rate (AAMR) and county-level factors (demographics, census region, socioeconomics, CVD risk factors, and healthcare access). Univariate and multivariable linear regressions were used to estimate the association between these factors; R2 values were used to assess the factors that accounted for the greatest variation in CVD AAMR by race/ethnicity (non-Hispanic White, non-Hispanic Black, and Hispanic/Latinx individuals). There were 659 740 CVD deaths among non-Hispanic White individuals in 2698 counties; 100 475 deaths among non-Hispanic Black individuals in 717 counties; and 49 493 deaths among Hispanic/Latinx individuals across 267 counties. Non-Hispanic Black individuals had the highest mean CVD AAMR (320.04 deaths per 100 000 individuals), whereas Hispanic/Latinx individuals had the lowest (168.42 deaths per 100 000 individuals). The highest CVD AAMRs across all racial/ethnic groups were observed in the South. In unadjusted analyses, the greatest variation (R2) in CVD AAMR was explained by physical inactivity for non-Hispanic White individuals (32.3%), median household income for non-Hispanic Black individuals (24.7%), and population size for Hispanic/Latinx individuals (28.4%). In multivariable regressions using county-level factor categories, the greatest variation in CVD AAMR was explained by CVD risk factors for non-Hispanic White individuals (35.3%), socioeconomic factors for non-Hispanic Black (25.8%), and demographic factors for Hispanic/Latinx individuals (34.9%). Conclusions The associations between race/ethnicity-specific age-adjusted CVD mortality and county-level factors differ significantly. Interventions to reduce disparities may benefit from being designed accordingly.

Racial and Ethnic Disparities in Transthyretin Cardiac Amyloidosis.

Purpose of Review: Transthyretin amyloid cardiomyopathy (ATTR-CM) is a life-threatening disease that disproportionately affects older adults and people of African descent. This review discusses current knowledge regarding racial and ethnic disparities in the diagnosis and management of ATTR-CM. Recent Findings: Historically, ATTR-CM was thought to be a rare cause of heart failure. Recent evidence has shown that ATTR-CM is more common among older adults, men, and people of African descent. In addition, significant geographic variation exists in the identification of amyloid cardiomyopathy. Despite the high burden of ATTR-CM among Black individuals, most clinical data for ATTR-CM are from North America and Europe. Moreover, only a minority of clinical trial participants thus far have been Black patients. In addition to racial differences, socioeconomic disparities may be further compounded by the potentially prohibitive cost and limited accessibility of disease-modifying ATTR therapies. Summary: ATTR-CM is an important cause of heart failure that disproportionately affects people of African descent. Efforts to promote earlier identification of ATTR-CM in general practice will likely improve clinical outcomes for all groups. Future trials should strive to enroll a higher proportion of Black patients. Furthermore, enhanced efforts are warranted to improve treatment accessibility among racial and ethnic minority groups that may be more likely to be affected by ATTR-CM.

Documentation of hypoglycemia assessment among adults with diabetes during clinical encounters in primary care and endocrinology practices.

PURPOSE: To examine the proportion of diabetes-focused clinical encounters in primary care and endocrinology practices where the evaluation for hypoglycemia is documented; and when it is, identify clinicians' stated actions in response to patient-reported events. METHODS: A total of 470 diabetes-focused encounters among 283 patients nonpregnant adults (≥18 years) with type 1 or type 2 diabetes mellitus in this retrospective cohort study. Participants were randomly identified in blocks of treatment strategy and care location (95 and 52 primary care encounters among hypoglycemia-prone medications (i.e. insulin, sulfonylurea) and others patients, respectively; 94 and 42 endocrinology encounters among hypo-treated and others, respectively). Documentation of hypoglycemia and subsequent management plan in the electronic health record were evaluated. RESULTS: Overall, 132 (46.6%) patients had documentation of hypoglycemia assessment, significantly more prevalent among hypo-treated patients seen in endocrinology than in primary care (72.3% vs. 47.4%; P = 0.001). Hypoglycemia was identified by patient in 38.2% of encounters. Odds of hypoglycemia assessment documentation was highest among the hypo-treated (OR 13.6; 95% CI 5.5-33.74, vs. others) and patients seen in endocrine clinic (OR 4.48; 95% CI 2.3-8.6, vs. primary care). After documentation of hypoglycemia, treatment was modified in 30% primary care and 46% endocrine clinic encounters; P = 0.31. Few patients were referred to diabetes self-management education and support (DSMES). CONCLUSIONS: Continued efforts to improve hypoglycemia evaluation, documentation, and management are needed, particularly in primary care. This includes not only screening at-risk patients for hypoglycemia, but also modifying their treatment regimens and/or leveraging DSMES.

Minimally Disruptive Medicine for Patients with Diabetes.

PURPOSE OF REVIEW: Patients with diabetes must deal with the burden of symptoms and complications (burden of illness). Simultaneously, diabetes care demands practical and emotional work from patients and their families, work to access and use healthcare and to enact self-care (burden of treatment). Patient work must compete with the demands of family, job, and community life. Overwhelmed patients may not have the capacity to access care or enact self-care and will thus experience suboptimal diabetes outcomes. RECENT FINDINGS: Minimally disruptive medicine (MDM) is a patient-centered approach to healthcare that prioritizes patients' goals for life and health while minimizing the healthcare disruption on patients' lives. In patients with diabetes, particularly in those with complex lives and multimorbidity, MDM coordinates healthcare and community responses to improve outcomes, reduce treatment burden, and enable patients to pursue their life's hopes and dreams.

Assessing the Burden of Treatment.

Current healthcare systems and guidelines are not designed to adapt to care for the large and growing number of patients with complex care needs and those with multimorbidity. Minimally disruptive medicine (MDM) is an approach to providing care for complex patients that advances patients' goals in health and life while minimizing the burden of treatment. Measures of treatment burden assess the impact of healthcare workload on patient function and well-being. At least two of these measures are now available for use with patients living with chronic conditions. Here, we describe these measures and how they can be useful for clinicians, researchers, managers, and policymakers. Their work to improve the care of high-cost, high-use, complex patients using innovative patient-centered models such as MDM should be supported by periodic large-scale assessments of treatment burden.