Influenza, Tdap, and COVID-19 Vaccination Coverage and Hesitancy Among Pregnant Women - United States, April 2023.

Influenza, tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap), and COVID-19 vaccines can reduce the risk for influenza, pertussis, and COVID-19 among pregnant women and their infants. To assess influenza, Tdap, and COVID-19 vaccination coverage among women pregnant during the 2022-23 influenza season, CDC analyzed data from an Internet panel survey conducted during March 28-April 16, 2023. Among 1,814 survey respondents who were pregnant at any time during October 2022-January 2023, 47.2% reported receiving influenza vaccine before or during their pregnancy. Among 776 respondents with a live birth by their survey date, 55.4% reported receiving Tdap vaccine during pregnancy. Among 1,252 women pregnant at the time of the survey, 27.3% reported receipt of a COVID-19 bivalent booster dose before or during the current pregnancy. Data from the same questions included in surveys conducted during influenza seasons 2019-20 through 2022-23 show that the proportion of pregnant women who reported being very hesitant about influenza and Tdap vaccinations during pregnancy increased from 2019-20 to 2022-23. Pregnant women who received a provider recommendation for vaccination were less hesitant about influenza and Tdap vaccines. Promotion of efforts to improve vaccination coverage among pregnant women, such as provider recommendation for vaccination and informative conversations with patients to address vaccine hesitancy, might reduce vaccine hesitancy and increase coverage with these important vaccines to protect mothers and their infants against severe respiratory diseases.

Cardiovascular risk-enhancing factors and coronary artery calcium in South Asian American adults: The MASALA study.

Objectives: The 2018 and 2019 U.S. guidelines for the management of cholesterol and primary prevention of atherosclerotic cardiovascular disease (ASCVD) recommend consideration of cardiovascular risk-enhancing factors (REFs), including South Asian ancestry, to refine ASCVD risk estimation. However, the associations of REFs with atherosclerosis are unclear in South Asian American adults, who have a disproportionately elevated premature coronary heart disease risk. In the Mediators of Atherosclerosis in South Asians Living in America (MASALA) cohort, we investigated associations of individual REFs, or the number of REFs, with coronary artery calcium (CAC). Methods: Using baseline and follow-up data from MASALA, we evaluated the association of REFs (family history of ASCVD, low-density lipoprotein cholesterol ≥160 mg/dL, triglycerides ≥175 mg/dL, lipoprotein(a) >50 mg/dL, high-sensitivity C-reactive protein [hsCRP] ≥2.0 mg/dL, ankle-brachial index <0.9, chronic kidney disease, metabolic syndrome), individually and combined, with baseline prevalent CAC, any CAC progression (including incident CAC and CAC progression), and annual CAC progression rates using multivariable logistic regression and generalized linear models. Results: Among 866 adults, mean age was 55 [SD 9] years and 47% were female. There were no significant associations of REFs with baseline prevalent CAC or any CAC progression (incident CAC and CAC progression at Exam 2) after adjustment. Among the 56% of participants who had any CAC progression, having 3+ REFs was associated with a significantly higher annual CAC progression rate (adjusted rate ratio [aRR] 1.94, 95% CI 1.39-2.72) vs. having 0 REFs. The annual CAC progression rate was 20% higher per additional REF (aRR 1.20, 95% CI 1.09-1.32). Findings were similar after excluding statin users, and among those with low 10-year ASCVD risk (<5%). Conclusions: Among South Asian American adults, we found no association of REFs with prevalent CAC at baseline or having any CAC progression. Among those with any CAC progression, a higher number of REFs was associated with higher annual CAC progression rates.

Relationship between mental health diagnoses and COVID-19 test positivity, hospitalization, and mortality in Southeast Wisconsin.

BACKGROUND: There is a paucity of literature on the relationship between pre-existing mental health conditions and coronavirus disease-2019 (COVID-19) outcomes. The aim was to examine the association between pre-existing mental health diagnosis and COVID-19 outcomes (positive screen, hospitalization, mortality). METHODS: Electronic medical record data for 30 976 adults tested for COVID-19 between March 2020 and 10th July 2020 was analyzed. COVID-19 outcomes included positive screen, hospitalization among screened positive, and mortality among screened positive and hospitalized. Primary independent variable, mental health disorders, was based on ICD-10 codes categorized as bipolar, internalizing, externalizing, and psychoses. Descriptive statistics were calculated, unadjusted and adjusted logistic regression and Cox proportional hazard models were used to investigate the relationship between each mental health disorder and COVID-19 outcomes. RESULTS: Adults with externalizing (odds ratio (OR) 0.67, 95%CI 0.57-0.79) and internalizing disorders (OR 0.78, 95% CI 0.70-0.88) had lower odds of having a positive COVID-19 test in fully adjusted models. Adults with bipolar disorder had significantly higher odds of hospitalization in fully adjusted models (OR 4.27, 95% CI 2.06-8.86), and odds of hospitalization were significantly higher among those with externalizing disorders after adjusting for demographics (OR 1.71, 95% CI 1.23-2.38). Mortality was significantly higher in the fully adjusted model for patients with bipolar disorder (hazard ratio 2.67, 95% CI 1.07-6.67). CONCLUSIONS: Adults with mental health disorders, while less likely to test positive for COVID-19, were more likely to be hospitalized and to die in the hospital. Study results suggest the importance of developing interventions that incorporate elements designed to address smoking cessation, nutrition and physical activity counseling and other needs specific to this population to improve COVID-19 outcomes.

Association of Social Risk Domains With Poor Cardiovascular Risk Factor Control in US Adults With Diabetes, From 2006 to 2016.

Importance: Few studies have examined the association between social risk factors and poor control of cardiovascular disease (CVD) risk factors. Objective: To examine the sequential association between social risk domains and CVD risk control over time in older adults with diabetes. Design, Setting, and Participants: This cohort study analyzed core interviews from 4877 US adults with diabetes who were participating in the Health and Retirement Study, a national longitudinal survey of US adults. Participants were older than 50 years, completed the social risk domain questions, and had data on CVD risk factor measures from January 2006 to December 2016. Data were analyzed from June to July 2022. Exposures: Five social risk domains were created: (1) economic stability, (2) neighborhood or built environment, (3) education access, (4) health care access, and (5) social or community context. Main Outcomes and Measures: The 4 primary outcomes were (1) poor glycemic control (hemoglobin A1c [HbA1c] level ≥8.0%), (2) poor blood pressure (BP) control (systolic BP≥140 mm Hg and diastolic BP ≥90 mm Hg), (3) poor cholesterol control (total cholesterol/high-density lipoprotein ratio ≥5), and (4) a composite of poor CVD risk control (≥2 poorly controlled glucose level, BP, or cholesterol level). Results: Among this cohort of 4877 older adults with diabetes (mean [SD] age, 68.6 [9.8] years; 2715 women [55.7%]), 890 participants (18.3%) had an HbA1c level of 8% or higher, 774 (15.9%) had systolic BP of 140 mm Hg or higher and diastolic BP of 90 mm Hg or higher, 962 (19.7%) had total cholesterol/high-density lipoprotein ratio of 5 or higher, and 437 (9.0%) had at least 2 poorly controlled CVD risk factors. Neighborhood or built environment (ie, adverse social support) was independently associated with poor glycemic control (odds ratio [OR], 1.31; 95% CI, 1.06-1.63), whereas economic stability (ie, medication cost-related nonadherence) (OR, 1.40; 95% CI, 1.04-1.87) and health care access (ie, lack of health insurance) (OR, 1.58; 95% CI, 1.20-2.09) were independently associated with poor BP control after full adjustment. Education access (ie, lack of education) (OR, 1.24; 95% CI, 1.01-1.52) and health care access (ie, lack of health insurance) (OR, 1.31; 95% CI, 1.02-1.68) were independently associated with poor cholesterol control. Health care access (ie, lack of health insurance) was the only social risk domain that was independently associated with having at least 2 poorly controlled CVD risk factors (OR, 1.72; 95% CI, 1.26-2.37). Conclusions and Relevance: Results of this study suggest that certain social risk domains are associated with control of CVD risk factors over time. Interventions targeting domains, such as neighborhood or built environment, economic stability, and education access, may be beneficial to controlling CVD risk factors in older adults with diabetes.

Gender Differences in the Relationship Between Food Insecurity and Body Mass Index Among Adults in the USA.

BACKGROUND: In the USA, nearly 40% of adults ≥ 20 years have a body mass index (BMI) ≥ 30, and 11% of households are reported as food insecure. In adults, evidence shows women are more likely than men to be food insecure. Among adults with food insecurity, differences in BMI exist between men and women with women reporting higher BMI. Factors associated with this difference in BMI between genders are less understood. OBJECTIVE: The aim of this study was to assess gender differences in the relationship between food insecurity and BMI. DESIGN: Hierarchical models were analyzed using a general linear model by entering covariates sequentially in blocks (demographics, lifestyle behaviors, comorbidities, and dietary variables) and stratified by gender. PARTICIPANTS: The sample included 25,567 adults in the USA from the National Health and Nutrition Examination Survey (NHANES), 2005-2014. MAIN MEASURES: The dependent variable was BMI, and food insecurity was the primary predictor. KEY RESULTS: Approximately 51% of the sample was women. Food insecure women were significantly more likely to have higher BMI compared to food secure women in the fully adjusted model after controlling for demographics (ß = 1.79; 95% CI 1.17, 2.41); demographic and lifestyle factors (ß = 1.79; 95% CI 1.19, 2.38); demographic, lifestyle, and comorbidities (ß = 1.21; 95% CI 0.65, 1.77); and demographic, lifestyle, comorbidities, and dietary variables (ß = 1.23; 95% CI 0.67, 1.79). There were no significant associations between food insecure and food secure men in the fully adjusted model variables (ß = 0.36; 95% CI - 0.26, 0.98). CONCLUSION: In this sample of adults, food insecurity was significantly associated with higher BMI among women after adjusting for demographics, lifestyle factors, comorbidities, and dietary variables. This difference was not observed among men. More research is necessary to understand this relationship among women.

Association Between Cardiovascular Disease Risk Factors and Mortality in Adults With Diabetes: A Stratified Analysis by Sex, Race, and Ethnicity.

Objectives: To assess sex and racial/ethnic differences in the relationship between multiple cardiovascular disease (CVD) risk factors and mortality among a nationally representative sample of adults with diabetes. Methods: Data were analyzed from 3,503 adults with diabetes from the National Health and Nutrition Examination Survey 2001-2010 and its linked mortality data through 31 December 2011. The outcome was mortality; the independent variables were sex and race/ethnicity. Covariates included demographics, comorbidity, and lifestyle variables. Cox proportional hazards regression was used to test associations between mortality and CVD risk factors. Results: In adjusted analyses, the association between diastolic blood pressure and mortality was significantly different by sex and race/ethnicity (unadjusted p = 0.009; adjusted p = 0.042). Kaplan-Meier survival curves showed Hispanic women had the highest survival compared to Hispanic men and Non-Hispanic Black (NHB) and Non-Hispanic White (NHW) men and women; NHW men had the lowest survival probability. Conclusion: In this nationally representative sample, stratified analyses showed women had higher survival rates compared to men within each race/ethnicity group, and Hispanic women had the highest survival compared to all other groups.

Racial and ethnic differences in the relationship between infant loss after prior live birth and hypertensive disorders in pregnancy.

BACKGROUND: Race and ethnicity influence the distribution and severity of hypertensive disorders of pregnancy (HDP) in the U.S. population, although the impact of prior infant loss on this relationship requires further investigation. OBJECTIVES: The aim of this study was to assess the relationship between history of infant loss and the risk of HDP by maternal race and ethnicity. METHODS: For this large cross-sectional study, data were analyzed from the National Center for Health Statistics Vital Statistics Natality Birth Data, 2014-2017. The primary outcome was HDP, and the primary predictor was infant loss after prior live birth. Maternal race/ethnicity was the secondary predictor categorized as Non-Hispanic White (NHW), Non-Hispanic Black (NHB), Hispanic, Asian, or Other. Multiple logistic regression was used to assess the association between history of infant loss and HDP by race and ethnicity. RESULTS: The 9,439,520 women included in this sample were 51% NHW, 15% NHB, 25% Hispanic, 6% Asian, and 3% Other with a mean age of 29.8 ± 5.3 years. In adjusted analyses, infant loss after prior live birth was significantly associated with an 11% odds of HDP (OR 1.11, 95% CI 1.08, 1.13). Stratified by race, NHB (OR 1.28; 95% CI 1.21, 1.36) women had significantly higher odds of HDP, and Hispanic (OR 0.84, 95% CI 0.79, 0.90) and Asian (OR 0.85, 95% CI 0.75, 0.97) women had significantly lower odds compared to NHW women. Within races, all women with infant loss after prior live birth had significantly higher odds of HDP (p < .001), except Other women (p = .632). CONCLUSIONS: Infant loss after prior live birth was significantly associated with higher odds of HDP among NHB women after adjusting for covariates. Further research is warranted to assess underlying mechanisms associated with higher odds of HDP in NHB women.

Explanatory role of sociodemographic, clinical, behavioral, and social factors on cognitive decline in older adults with diabetes.

BACKGROUND: The aim of the study was to examine the explanatory role of sociodemographic, clinical, behavioral, and social factors on racial/ethnic differences in cognitive decline among adults with diabetes. METHODS: Adults aged 50+ years with diabetes from the Health and Retirement Survey were assessed for cognitive function (normal, mild cognitive impairment [MCI], and dementia). Generalized estimating equation (GEE) logistic regression models were used to account for repeating measures over time. Models were adjusted for sociodemographic (gender, age, education, household income and assets), behavioral (smoking), clinical (ie. comorbidities, body mass index), and social (social support, loneliness, social participation, perceived constraints and perceived mastery on personal control) factors. RESULTS: Unadjusted models showed non-Hispanic Blacks (NHB) and Hispanics were significantly more likely to progress from normal cognition to dementia (NHB OR: 2.99, 95%CI 2.35-3.81; Hispanic OR: 3.55, 95%CI 2.77-4.56), and normal cognition to MCI (NHB OR = 2.45, 95%CI 2.14-2.82; Hispanic OR = 2.49, 95%CI 2.13-2.90) compared to non-Hispanic Whites (NHW). Unadjusted models for the transition from mild cognitive decline to dementia showed Hispanics were more likely than NHW to progress (OR = 1.43, 95%CI 1.11-1.84). After adjusting for sociodemographic, clinical/behavioral, and social measures, NHB were 3.75 times more likely (95%CI 2.52-5.56) than NHW to reach dementia from normal cognition. NHB were 2.87 times more likely (95%CI 2.37-3.48) than NHW to reach MCI from normal. Hispanics were 1.72 times more likely (95%CI 1.17-2.52) than NHW to reach dementia from MCI. CONCLUSION: Clinical/behavioral and social factors did not explain racial/ethnic disparities. Racial/ethnic disparities are less evident from MCI to dementia, emphasizing preventative measures/interventions before cognitive impairment onset are important.

Association between pregestational diabetes and mortality among appropriate-for-gestational age birthweight infants.

BACKGROUND/OBJECTIVE: Existing studies have shown that pregestational diabetes is a significant risk factor for adverse birth outcomes. However, it is unclear, whether pregestational diabetes and neonatal birthweight that is appropriate for the gestational age (AGA), a proxy for overall adequate glycemic control, is associated with higher infant mortality. To address this controversy, this study investigated the relationship between pregestational diabetes and infant mortality in appropriate-for-gestational age infants in the United States. METHODS: Data from the National Vital Statistics System-Linked Birth-Infant Death dataset, including 6,962,028 live births between 2011 and 2013 were analyzed. The study was conducted in the US and data were analyzed in Milwaukee, Wisconsin. The outcome was mortality among AGA newborns, defined as annual deaths per 1000 live births with birthweights between the 10th and 90th percentiles for gestational age delivering at ≥37 weeks. The exposure was pregestational diabetes. Covariates were maternal demographics, behavioral/clinical, and infant factors. Logistic regression was used with p values <.05 considered statistically significant. RESULTS: A total of 6,962,028 live births met inclusion criteria. Of these, a total of 11,711 (1.0%) term AGA birthweight infants died before their first birthday. About 35,689 (0.5%) mothers were diagnosed with pregestational diabetes prior to pregnancy with 0.3% of infants whose mothers had diabetes dying in their first year of life. In the unadjusted model, pregestational diabetes had a significant association with increased odds of mortality in term AGA infants (OR: 1.9, 95% CI: 1.6 - 2.3). AGA mortality remained significantly higher for women with pregestational diabetes compared to controls, after adjusting for maternal demographics (OR: 1.9, 95% CI: 1.6-2.3), behavioral/clinical characteristics (OR: 1.6, 95% CI: 1.3-2.0), and infant factors (OR: 1.3, 95% CI: 1.1-1.6). CONCLUSIONS: In term pregnancies, pregestational diabetes was significantly associated with 30% higher mortality among AGA birthweight infants. Our study is innovative in its focus on AGA infants that overall is associated with good maternal glycemic control during pregnancy and in theory should confer a risk for infant mortality that is similar to pregnancies not complicated by pregestational diabetes. Despite this, we still found that even term AGA infants have higher risk of mortality in the setting of maternal pregestational diabetes. Implications of our findings underscore the importance of close antepartum surveillance and optimization of glycemic control preconception, identification of treatment targets, and health policies to reduce infant mortality. The results from this study may assist other researchers and clinicians understand how best to target future interventions to reduce term infant mortality and the burden of pregestational diabetes in the United States.

The relationship between C-Reactive protein and mortality in adults with diabetes: Influences of demographic characteristics, lifestyle behaviors, and medications.

BACKGROUND AND AIMS: This study assesses the influence of demographic, lifestyle, and medication in the association between CRP and mortality in a national sample of adults with diabetes. METHODS AND RESULTS: Cross-sectional study of data from 1999 to 2010 National Health and Nutrition Examination Survey (unweighted n = 3952; Weighted n = 19,064,710). Individuals were categorized as having diabetes if told by a provider they had diabetes, were taking insulin or other diabetes medications, or had a glycosylated hemoglobin A1c (HbA1c) ≥ 6.5%. CRP was classified into four categories: normal (≤0.1 mg/dL); moderate risk (0.11-0.3 mg/dL); high-risk (0.31-1.0 mg/dL); very high-risk (>1.0 mg/dL). Higher risk for mortality was associated with a very high-risk of CRP (HR = 1.88 (95% CI: 1.27-2.78), being a current (HR = 1.49 (95% CI: 1.10-2.01) or former (HR = 1.34 (95% CI: 1.03-1.73) smoker, and taking insulin (HR = 1.60 (95% CI: 1.25-2.05), taking anti-hypertensives (HR = 1.50 (95% CI: 1.22-1.85), and having co-morbidities such as cancer (HR = 1.32 (95% CI: 1.05-1.66) and hepatitis infection (HR = 1.76 (95% CI: 1.07-2.91), while taking Metformin (HR = 0.62 (95% CI: 0.50-0.76) had a lower risk of mortality. CONCLUSION: In this sample of adults with diabetes, demographic, lifestyle, and medication factors influenced the association between CRP and mortality. Interventions should focus on these factors to reduce mortality in adults with diabetes.

Retrospective review of patients treated for cyclic vomiting syndrome with topiramate.

BACKGROUND: Practice guidelines recommend topiramate as second-line treatment for the prevention of moderate-severe cyclic vomiting syndrome (CVS) in adults. However, data are limited to small studies in children. AIM: To characterise the response to topiramate as prophylactic therapy in adults with CVS. METHODS: We conducted a retrospective review of patients with CVS. Clinical characteristics, number of CVS episodes, emergency department (ED) visits, and hospitalisations the year before and after initiating topiramate were recorded. Response was defined as a global improvement in symptoms or >50% reduction in the number of CVS episodes, ED visits or hospitalisations. RESULTS: Sixty-five percent (88/136) of patients responded to topiramate in an intent-to-treat analysis. There was a significant decrease in the annual number of CVS episodes (18.1 vs 6.2, P < 0.0001), CVS-related ED visits (4.3 vs 1.6, P = 0.0029), and CVS-related hospitalisations (2.0 vs 1.0, P = 0.035). Logistic regression revealed that higher doses of topiramate, longer use of topiramate (≥12 months) and topiramate as monotherapy were associated with a response to treatment. Anxiety was associated with non-response to topiramate. Fifty-five percent of patients experienced side effects, and 32% discontinued the medication as a result. The most common side effects were cognitive impairment (13%), fatigue (11%) and paresthesia (10%). This represented a refractory group with topiramate being initiated in patients (92%) who had failed treatment with tricyclic antidepressants (TCAs). CONCLUSIONS: Topiramate may be an effective second-line prophylaxis for patients with moderate-severe CVS, but its use is limited by side effects. Efforts to develop better-tolerated therapies for CVS are warranted.

Food insecurity and glycemic control in individuals with diagnosed and undiagnosed diabetes in the United States.

AIMS: Investigate the relationship between food insecurity and glycemic control in adults with diagnosed and undiagnosed diabetes. METHODS: Using National Health and Nutrition Examination Survey (NHANES) between 2003-2016, food insecurity was measured using the household food insecurity scale. Glycemic control was measured using glycated hemoglobin (HbA1c) collected during the NHANES examination. Individuals were categorized into undiagnosed diabetes or diagnosed diabetes based on their measured HbA1c and response to whether they were told by a doctor or other health professional they have diabetes or were taking medications for diabetes. Sampling weights and survey procedures were used when conducting univariate and multivariable models using SAS version 9.4. RESULTS: Approximately 13.7% of the population sample (35,216 adults representing 207,271,917 US adults) reported food insecurity. Reporting food insecurity was associated with 0.37 higher HbA1c for diagnosed (95% CI 0.15-0.60) and 0.45 higher HbA1c for undiagnosed diabetes (95% CI 0.05-0.85). In the undiagnosed diabetes population, those reporting food insecurity had 80% higher likelihood of HbA1c above 7% (OR = 1.80, 95% CI 1.06-3.06). CONCLUSIONS: Food insecurity had a stronger relationship with HbA1c for those with undiagnosed diabetes. Results suggest the importance of screening for individuals with food insecurity that may be at high risk for having undiagnosed diabetes.

The relationship between financial hardship and incident diabetic kidney disease in older US adults - a longitudinal study.

BACKGROUND: Financial hardship is associated with poor health, however the association of financial hardship and incident diabetic kidney disease (DKD) is unknown. This study aimed to examine the longitudinal relationship between financial hardship and incident DKD among older adults with diabetes. METHODS: Analyses were conducted in 2735 adults age 50 or older with diabetes and no DKD using four waves of data (2006-2012) from the Health and Retirement Study, a national longitudinal cohort. The primary outcome was incident DKD. Financial hardship was based on three measures: 1) difficulty paying bills; 2) food insecurity; and 3) cost-related medication non-adherence using validated surveys. A dichotomous financial hardship variable (0 vs 1 or more) was constructed based on all three measures. Cox regression models were used to estimate the association between financial hardship, change in financial hardship experience and incident DKD adjusting for demographics, socioeconomic status, and comorbidities. RESULTS: During the median follow-up period of 4.1 years, incident DKD rate was higher in individuals with versus without financial hardship (41.2 versus 27/1000 person years). After adjustment, individuals with financial hardship (HR 1.32, 95% CI 1.04-1.68) had significantly increased likelihood of developing DKD compared to individuals without financial hardship. Persistent financial hardship (adjusted HR 1.52 95% CI 1.06-2.18) and negative financial hardship (adjusted HR 1.54 95% CI 1.02-2.33) were associated with incident DKD compared with no financial hardship experience. However, positive financial hardship was not statistically significant in unadjusted and adjusted (adjusted HR 0.89 95% CI 0.55-1.46) models. Cost-related medication non-adherence (adjusted HR 1.43 95% CI 1.07-1.93) was associated with incident DKD independent of other financial hardship measures. CONCLUSIONS: Financial hardship experience is associated with a higher likelihood of incident DKD in older adults with diabetes. Future studies investigating factors that explain the relationship between financial hardship and incident DKD are needed.

Gender differences in the relationship between social support and strain and mortality among a national sample of adults.

We assessed gender differences in the relationship between mortality and social support, strain, and affectual solidarity received from family, friends and spouses. Data of 6259 adults from the Midlife Development in the United States (MIDUS) survey were analyzed. Cox proportional hazards were used to assess relationships between mortality and support, strain, and affectual solidarity and whether the associations varied by gender. Support from family, friends, and spouses/partners and friend affectual solidarity were associated with lower mortality in the total sample. Friend strain was associated with higher mortality in the total sample. Family support and family, friend, and spouse affectual solidarity were associated with lower mortality in women. Friend and spouse strain were associated with a higher mortality for women. Support from friends, family and spouse are beneficial for reducing mortality in men and women. Friend and spouse strain are targets for minimizing mortality risk in women.

Relationship between physical and mental health comorbidities and COVID-19 positivity, hospitalization, and mortality.

BACKGROUND: Understanding the association between separate and combined mental and physical health diagnoses and COVID-19 outcomes is greatly needed to address the severity of illness. METHODS: Data on 24,034 patients screened for COVID-19 as of July 2020 were extracted from the Froedtert/Medical College of Wisconsin Epic medical record. COVID-19 outcomes were defined as positive screens, proportion hospitalized among positive screens, and proportion that died among positive and hospitalized population. The primary independent variable was a 3-category variable: physical health diagnosis alone, mental health diagnosis alone, and combined mental and physical health diagnoses. Logistic regression and Cox proportional hazard models were used to examine the independent relationship between separate and combined diagnoses and COVID-19 outcomes. RESULTS: Compared to physical health diagnosis alone, mental health diagnosis alone had lower odds of screening positive (OR=0.68, CI=0.51;0.92) and was not associated with hospitalization or mortality among positive screens. Combined had lower odds of screening positive (OR=0.78, CI=0.69;0.88) and higher odds of hospitalization among positive screens after adjusting for demographics (OR=1.58, CI=1.20;2.08) but lost significance in the fully adjusted model. No category of diagnoses was associated with mortality. LIMITATIONS: Analysis is cross-sectional and cannot speak to any causal relationships. CONCLUSIONS: Overall, compared to physical health diagnosis alone, mental health diagnosis and combined had lower odds of positive screens. However, individuals with combined were more likely to be hospitalized, after adjusting for demographics only. These findings add new evidence for risk of COVID-19 and related hospitalization in individuals who have a physical and mental health diagnosis.

The cumulative impact of social determinants of health factors on mortality in adults with diabetes and chronic kidney disease.

BACKGROUND: A growing body of evidence supports the potential role of social determinants of health on health outcomes. However, few studies have examined the cumulative effect of social determinants of health on health outcomes in adults with chronic kidney disease (CKD) with or without diabetes. This study examined the cumulative impact of social determinants of health on mortality in U.S. adults with CKD and diabetes. METHODS: We analyzed data from National Health and Nutrition Examination Surveys (2005-2014) for 1376 adults age 20 and older (representing 7,579,967 U.S. adults) with CKD and diabetes. The primary outcome was all-cause mortality. CKD was based on estimated glomerular filtration rate and albuminuria. Diabetes was based on self-report or Hemoglobin A1c of ≥6.5%. Social determinants of health measures included family income to poverty ratio level, depression based on PHQ-9 score and food insecurity based on Food Security Survey Module. A dichotomous social determinant measure (absence vs presence of ≥1 adverse social determinants) and a cumulative social determinant score ranging from 0 to 3 was constructed based on all three measures. Cox proportional models were used to estimate the association between social determinants of health factors and mortality while controlling for covariates. RESULTS: Cumulative and dichotomous social determinants of health score were significantly associated with mortality after adjusting for demographics, lifestyle variables, glycemic control and comorbidities (HR = 1.41, 95%CI 1.18-1.68 and HR = 1.41, 95%CI 1.08-1.84, respectively). When investigating social determinants of health variables separately, after adjusting for covariates, depression (HR = 1.52, 95%CI 1.10-1.83) was significantly and independently associated with mortality, however, poverty and food insecurity were not statistically significant. CONCLUSIONS: Specific social determinants of health factors such as depression increase mortality in adults with chronic kidney disease and diabetes. Our findings suggest that interventions are needed to address adverse determinants of health in this population.

Stress that Endures: Influence of Adverse Childhood Experiences on Daily Life Stress and Physical Health in Adulthood.

BACKGROUND: Understanding the influence of ACEs on reported daily stress is needed to further address the role of ACEs on adult health and well-being. METHODS: Data from 3,235 adults in the Midlife in the US (MIDUS) (Wave 1 (1995-1996) and Wave II (2004-2006)) were used. ACEs included emotional and physical abuse, household dysfunction, and financial strain. Daily stress was assessed using the National Study of Daily Experiences survey. Generalized Estimating Equations were used to examine the relationship between ACEs and Daily Stress. RESULTS: ACE exposure was associated with higher number of reported stressors per day (p<.05), stressor severity (p<.05), number of physical symptoms reported (p<.05), and negative affect (p<.05). ACE count was significantly associated with multiple stressor types (OR=1.73, 95% 1.05-2.82) and number of days reported with stressor (RR=1.14, 95% 1.00-1.30). Abuse specifically was associated with a higher number of days reported with a stressor (RR=1.23, 95% CI 1.16 - 1.30). LIMITATIONS: Assessment of ACEs is retrospective and self-reported. Secondly, this data is limited by ACE category. Specifically, sexual abuse and other forms of family dysfunction were not included in this dataset. CONCLUSIONS: ACEs are associated with increased report of daily stress as an adult, reported physical symptoms as a result of stress, and reports of poor negative affect in adulthood. These findings highlight the role that ACEs play in the occurrence of reported daily stress during adulthood. Further investigation is needed to establish treatment and interventions for individuals who have experienced ACEs to avoid worsening health conditions and promote positive coping skills.

The Association of Paternal Race and Ethnicity with Adverse Pregnancy Outcomes in a Contemporary U.S. Cohort.

OBJECTIVE: Maternal racial and ethnic disparities exist in obstetric outcomes. The contribution of paternal race and ethnicity toward obstetric outcomes has been less well documented. The objective of this study was to investigate the association between paternal race and ethnicity and several adverse pregnancy outcomes. STUDY DESIGN: This was a retrospective cohort of birth data from the CDC National Vital Statistics, years 2013-2017. All singleton live births were included in the analysis. Records with missing paternal race and ethnicity were excluded. The primary dependent variables were the following adverse maternal and perinatal outcomes: gestational diabetes, hypertensive disorder of pregnancy, preterm birth <37 weeks, cesarean delivery, low birth weight <2,500 g, 5-minute Apgar's score <7, admission to neonatal intensive care unit (NICU), and assisted ventilation at > 6 hours of life. The main exposure was paternal race and ethnicity, which was grouped into non-Hispanic white, non-Hispanic black, Hispanic, and other. Other race and ethnicity category included: American Indian, Alaskan Native, Asian, Native Hawaiian, or other Pacific Islander. Univariable and multivariable analyses were done to determine whether paternal race and ethnicity was independently associated with adverse pregnancy outcomes. RESULTS: A total of 16,482,745 births were included. In univariable analysis, all adverse obstetric outcomes were significantly associated with paternal race and ethnicity. In multivariable analysis, controlling for maternal and paternal demographic characteristics and maternal clinical factors, paternal race and ethnicity remained significantly associated with the majority of the adverse pregnancy outcomes. The strongest association was seen with: (1) paternal non-Hispanic black race and ethnicity, and higher rates of LBW and preterm birth (Odds ratio [OR] = 1.25, 95% CI: 1.24-1.27 and OR = 1.14, 95% CI: 1.13-1.15, respectively); (2) paternal Hispanic race and ethnicity and lower rates of 5-minute Apgar's score <7, and assisted ventilation at >6 hours of life (OR = 0.78, 95% CI: 0.77-0.79, and OR = 0.77, 95% CI: 0.75-0.78, respectively); and (3) other paternal race and ethnicity and higher rates of gestational diabetes, but lower rates of hypertensive disorder of pregnancy and assisted ventilation >6 hours of life (OR = 1.26, 95% CI: 1.25-1.27; OR = 0.79, 95% CI: 0.78-0.80; and OR = 0.80, 95% CI: 0.78-0.82, respectively). All associations were in comparison to paternal non-Hispanic white race and ethnicity. CONCLUSION: Paternal race and ethnicity has an independent association with adverse obstetric outcomes. The pathway and the extent of the paternal racial influence are not fully understood and deserve additional research.

Trends in Food Insecurity in the United States from 2011-2017: Disparities by Age, Sex, Race/Ethnicity, and Income.

The number of individuals in the United States who report food insecurity doubled between 2005 and 2012, with little research investigating possible disparities across time in food-insecure populations. The aim of this study was to investigate trends in food insecurity between 2001-2017 by sex, race/ethnicity, income, and age. Adults participating in the National Health Interview Survey (NHIS) between 2011-2017 were included in the study. Food insecurity was dichotomized based on affirmative responses to the Food Security Survey Module. Statistical analysis included logistic regression to investigate trends in food insecurity over time by each demographic variable (age, sex, race/ethnicity, income) adjusted by survey year and demographic variables. After adjustment, those ages ≥65 years were 39% less likely (OR = 0.61, 95% CI [0.57,0.65]) to report food insecurity compared to those ages 18-34; females were 23% more likely to be food insecure than males (OR = 1.23, 95% CI [1.19,1.27]); non-Hispanic blacks were 1.7 times more likely (OR = 1.69, 95% CI [1.62,1.76]) to be food insecure than non-Hispanic whites; and a clear gradient existed by income, with lower incomes more likely to be food insecure. Disparities in food insecurity exist across age, race/ethnicity, sex, and income and were consistent over time. These results suggest that targeted programs may be necessary to decrease food insecurity in particularly vulnerable subpopulations, and barriers to access and use of existing programs need to be investigated.

Relationship Between Multiple Measures of Financial Hardship and Glycemic Control in Older Adults With Diabetes.

Aim: To examine the relationship between multiple measures of financial hardship and glycemic control in older adults with diabetes. Methods: Using data from Health and Retirement Study (HRS), we investigated four measures of financial hardship: difficulty paying bills, ongoing financial strain, decreasing food intake due to money, and taking less medication due to cost. Using linear regression models, we investigated the relationship between each measure, and a cumulative score of hardships per person, on glycemic control (HbA1c). Results: After adjustment, a significant relationship existed with each increasing number of hardships associated with increasing HbA1c (0.09, [95%CI 0.04, 0.14]). Difficulty paying bills (0.25, [95%CI 0.14, 0.35]) and decreased medication usage due to cost (0.17, [95%CI 0.03, 0.31]) remained significantly associated with HbA1c. Conclusion: In older adults, difficulty paying bills and cost-related medication nonadherence is associated with glycemic control, and every additional financial hardship was associated with an increased HbA1c by nearly 0.1%.