Lower Independent Self-Care Readiness Persists over Time in Teens with Type 1 Diabetes and Executive Function Challenges.

PURPOSE: Management of type 1 diabetes is complex and benefits from adequate executive function (EF) (planning, organization, problem-solving). Teens with diabetes and executive dysfunction may have challenges with acquisition of self-care skills. METHODS: Over 18 months, parents of teens with type 1 diabetes aged 13-17 completed the Diabetes Family Responsibility Questionnaire (DFRQ) and Readiness for Independent Self-Care Questionnaire (RISQ) every 6 months. Parents assessed teen EF, completing the Behavior Rating Inventory of Executive Function (BRIEF). T-score ≥60 defined EF challenges. EF, demographic, and diabetes treatment variables predicted RISQ score over time using longitudinal mixed modeling with false discovery rate adjustment. RESULTS: There were 169 teen participants (54% male) aged 15.9±1.3 years, diabetes duration 8.4±3.7 years, and A1c 8.6±1.2%. About a third (31.4%) of teens had parent-reported BRIEF Global Executive Composite (GEC) scores ≥60. After adjusting for age, gender, and DFRQ, those with GEC <60 had RISQ score 4.1 points higher than those with GEC ≥60, p=0.016. Behavioral regulation index (BRI; adjusted for age, CGM use, DFRQ, and A1c) did not predict RISQ while metacognition index (MI; adjusted for age, gender, and DFRQ) did; those with MI <60 had RISQ score 5.3 points higher than those with MI ≥60, p<0.001. In all models, older teen age (p<0.05) and less parental involvement (p<0.001) predicted higher RISQ score. CONCLUSIONS: EF skills, especially metacognition, appear important for acquisition of self-care behaviors in teens with type 1 diabetes. Evaluating EF during adolescence may identify teens needing extra support during the transition process.

Transition to self-management among emerging adults with type 1 diabetes: a mixed methods study.

Introduction: Emerging adulthood is challenging for young people with type 1 diabetes (T1D). This study evaluated transition to diabetes self-management and perceptions of care transfer using mixed methods. Methods: An online survey queried demographics, management characteristics, diabetes knowledge, self-care readiness, adherence, and diabetes distress. T-tests compared survey scores between those with self-reported target A1c <7.0% versus ≥7.0%. Pearson correlations assessed associations between A1c and diabetes distress, stratified by A1c <7.0% versus ≥7.0%. Qualitative semi-structured interviews elicited perceptions of young adults; transcripts were analyzed using directed qualitative content analysis. Results: Of 141 participants (30% male, 84% non-Hispanic white) completing the survey, 41% self-reported target A1c <7.0%. Diabetes knowledge and self-care readiness scores did not differ between those with A1c <7.0% versus ≥7.0%, while diabetes distress was lower (45 ± 20 vs 52 ± 20, p=0.01) and adherence higher (77 ± 12 vs 71 ± 14, p=0.02) in those with A1c <7.0% versus ≥7.0%. Diabetes distress was significantly associated with glycemic outcomes in those reporting A1c ≥7.0% (R=0.36, p<0.01). Qualitative analysis (24 participants) revealed five themes and two sub-themes, notable for need for more mental health support, support from others with T1D, benefits of technology for care autonomy, and challenges of obtaining diabetes supplies. Discussion: Emerging adults with self-reported target A1c endorsed lower diabetes distress and higher adherence than those with elevated A1c. Mental health access, support from others with T1D, technology use, and guidance for supply acquisition may improve transition to self-management and care transfer for emerging adults with T1D.

Observed Characteristics Associated with Diabetes Device Use Among Teens with Type 1 Diabetes.

BACKGROUND: Despite advancements in diabetes technologies, disparities remain with respect to diabetes device use in youth with type 1 diabetes (T1D). We compared sociodemographic, diabetes, and psychosocial characteristics associated with device (pump and continuous glucose monitor [CGM]) use in 13- to 17-year-old teens with T1D. MATERIALS/METHODS: Data were derived from a multicenter clinical trial to optimize self-care and glycemic control in teens with T1D. We categorized teens as pump users versus non-users and CGM users versus non-users based on their diabetes device usage. Chi-square and t-tests compared characteristics according to device use. RESULTS: The sample comprised 301 teens (50% female) with baseline mean ± SD age 15.0 ± 1.3 years, T1D duration 6.5 ± 3.7 years, and HbA1c 8.5 ± 1.1% (69 ± 12 mmol/mol). Two-thirds (65%) were pump users, and 27% were CGM users. Pump users and CGM users (vs. non-users) were more likely to have a family annual household income ≥$150,000, private health insurance, and a parent with a college education (all P < .001). Pump users and CGM users (vs. non-users) also performed more frequent daily blood glucose (BG) checks (both P < .001) and reported more diabetes self-care behaviors (both P < .05). Pump users were less likely to have baseline HbA1c ≥9% (75 mmol/mol) (P = .005) and to report fewer depressive symptoms (P = .02) than pump non-users. Parents of both CGM and pump users reported a higher quality of life in their youth (P < .05). CONCLUSION: There were many sociodemographic, diabetes-specific, and psychosocial factors associated with device use. Modifiable factors can serve as the target for clinical interventions; youth with non-modifiable factors can receive extra support to overcome potential barriers to device use.

Improved CGM Glucometrics and More Visits for Pediatric Type 1 Diabetes Using Telemedicine During 1 Year of COVID-19.

PURPOSE: The COVID-19 pandemic led to rapid adoption of telemedicine for the care of youth with type 1 diabetes (T1D). We assessed the utility of a primarily virtual care model by comparing glucometrics from a pediatric sample with T1D using continuous glucose monitoring (CGM) both before and during the pandemic. METHODS: Pediatric patients aged 1 to 17 years with T1D duration ≥ 1 year if ≥ 6 years old or ≥ 6 months if < 6 years old, with ≥ 1 visit with recorded CGM data both prepandemic (April 1, 2019-March 15, 2020) and during the pandemic (April 1, 2020-March 15, 2021) were included. Data were extracted from the electronic health record. RESULTS: Our sample comprised 555 young people (46% male, 87% White, 79% pump-treated), mean age 12.3 ±â€…3.4 years, T1D duration 5.9 ±â€…3.5 years, baseline glycated hemoglobin A1c 8.0 ±â€…1.0% (64 ±â€…10.9 mmol/mol). Diabetes visit frequency increased from 3.8 ±â€…1.7 visits/prepandemic period to 4.3 ±â€…2.2 visits/pandemic period (P < 0.001); during pandemic period, 92% of visits were virtual. Glucose management indicator (GMI) improved slightly from 7.9% (63 mmol/mol) prepandemic to 7.8% (62 mmol/mol) during the pandemic (P < 0.001). Those with equal or greater visit frequency (n = 437 [79% of sample]) had significant improvement in GMI (8.0% to 7.8% [64 to 62 mmol/mol], P < 0.001), whereas those with lower visit frequency did not (7.8 [62 mmol/mol], P = 0.86). CONCLUSIONS: Children and adolescents with T1D using CGM before and during the pandemic showed an overall increase in visit frequency using primarily telemedicine-based care and improved CGM glucometrics. Further research is needed to understand factors associated with successful use of telemedicine for pediatric T1D.

Improved Glycemic Control Following Transition to Tubeless Insulin Pump Therapy in Adults With Type 1 Diabetes.

Continuous subcutaneous insulin infusion (CSII) treatment may improve long-term glycemic outcomes and enhance quality of life compared with a multiple daily injection (MDI) insulin regimen for people with type 1 diabetes. As the number of people treated with CSII via a tubeless insulin pump is increasing, there is growing interest in the long-term glycemic outcomes of this treatment option across diverse populations. This multicenter, retrospective study evaluated glycemic control in 156 adults with type 1 diabetes initiating tubeless insulin pump therapy following transition from either MDI or CSII with a tubed insulin pump. In this study, use of the tubeless insulin pump over 12 months was associated with significant improvement in A1C in adults with type 1 diabetes, most notably in those with an A1C ≥9.0% and those previously treated with MDI.

Regional differences in the management of cardiovascular risk factors among adults with diabetes: An evaluation of the Diabetes Collaborative Registry.

AIMS: To compare cardiovascular risk factor control in adults with diabetes participating in a national diabetes registry to those in the general population and to ascertain regional differences in diabetes care. METHODS: Adults with diagnosed diabetes in the Diabetes Collaborative Registry (DCR) were compared with those in the National Health and Nutrition Examination Survey (NHANES) from 2015 to 2016; standardized mean difference (SMD) > 0.2 defined significance. Regional differences were assessed in the DCR cohort; p < .05 defined significance. RESULTS: The DCR cohort was older (61 vs. 57 years, SMD = 0.38), more insured (99.7% vs. 91.0%, SMD = 0.42), and less ethnically diverse (83% non-Hispanic white vs. 76%, SMD = 0.30) compared with NHANES. The proportion of overweight/obesity, A1c < 7% (<53 mmol/mol), and BP < 140/90 were similar, but DCR participants had higher proportion with LDL < 2.59 mmol/L (61% vs. 41%, SMD = 0.39) and fewer tobacco users (17% vs. 32%, SMD = 0.35). Regionally, obesity, lack of glycaemic control, and tobacco use were highest in the Midwest, BP control was the lowest in the South, and LDL control was lowest in the Northeast. CONCLUSIONS: Significant regional differences in diabetes care delivery and outcomes were identified using a national diabetes registry. Serial analyses of the DCR may supplement national evaluations to deepen our understanding of diabetes care in the US.

Residual ß cell function and monogenic variants in long-duration type 1 diabetes patients.

BACKGROUNDIn the Joslin Medalist Study (Medalists), we determined whether significant associations exist between ß cell function and pathology and clinical characteristics.METHODSIndividuals with type 1 diabetes (T1D) for 50 or more years underwent evaluation including HLA analysis, basal and longitudinal autoantibody (AAb) status, and ß cell function by a mixed-meal tolerance test (MMTT) and a hyperglycemia/arginine clamp procedure. Postmortem analysis of pancreases from 68 Medalists was performed. Monogenic diabetes genes were screened for the entire cohort.RESULTSOf the 1019 Medalists, 32.4% retained detectable C-peptide levels (>0.05 ng/mL, median: 0.21 ng/mL). In those who underwent a MMTT (n = 516), 5.8% responded with a doubling of baseline C-peptide levels. Longitudinally (n = 181, median: 4 years), C-peptide levels increased in 12.2% (n = 22) and decreased in 37% (n = 67) of the Medalists. Among those with repeated MMTTs, 5.4% (3 of 56) and 16.1% (9 of 56) had waxing and waning responses, respectively. Thirty Medalists with baseline C-peptide levels of 0.1 ng/mL or higher underwent the clamp procedure, with HLA-/AAb- and HLA+/AAb- Medalists being most responsive. Postmortem examination of pancreases from 68 Medalists showed that all had scattered insulin-positive cells; 59 additionally had few insulin-positive cells within a few islets; and 14 additionally had lobes with multiple islets with numerous insulin-positive cells. Genetic analysis revealed that 280 Medalists (27.5%) had monogenic diabetes variants; in 80 (7.9%) of these Medalists, the variants were classified as "likely pathogenic" (rare exome variant ensemble learner [REVEL] >0.75).CONCLUSIONAll Medalists retained insulin-positive ß cells, with many responding to metabolic stimuli even after 50 years of T1D. The Medalists were heterogeneous with respect to ß cell function, and many with HLA+ diabetes risk alleles also had monogenic diabetes variants, indicating the importance of genetic testing for clinically diagnosed T1D.FUNDINGFunding for this work was provided by the Dianne Nunnally Hoppes Fund; the Beatson Pledge Fund; the NIH, National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK); and the American Diabetes Association (ADA).

Retinol binding protein 3 is increased in the retina of patients with diabetes resistant to diabetic retinopathy.

The Joslin Medalist Study characterized people affected with type 1 diabetes for 50 years or longer. More than 35% of these individuals exhibit no to mild diabetic retinopathy (DR), independent of glycemic control, suggesting the presence of endogenous protective factors against DR in a subpopulation of patients. Proteomic analysis of retina and vitreous identified retinol binding protein 3 (RBP3), a retinol transport protein secreted mainly by the photoreceptors, as elevated in Medalist patients protected from advanced DR. Mass spectrometry and protein expression analysis identified an inverse association between vitreous RBP3 concentration and DR severity. Intravitreal injection and photoreceptor-specific overexpression of RBP3 in rodents inhibited the detrimental effects of vascular endothelial growth factor (VEGF). Mechanistically, our results showed that recombinant RBP3 exerted the therapeutic effects by binding and inhibiting VEGF receptor tyrosine phosphorylation. In addition, by binding to glucose transporter 1 (GLUT1) and decreasing glucose uptake, RBP3 blocked the detrimental effects of hyperglycemia in inducing inflammatory cytokines in retinal endothelial and Müller cells. Elevated expression of photoreceptor-secreted RBP3 may have a role in protection against the progression of DR due to hyperglycemia by inhibiting glucose uptake via GLUT1 and decreasing the expression of inflammatory cytokines and VEGF.

Characterization of Glycolytic Enzymes and Pyruvate Kinase M2 in Type 1 and 2 Diabetic Nephropathy.

OBJECTIVE: Elevated glycolytic enzymes in renal glomeruli correlated with preservation of renal function in the Medalist Study, individuals with ≥50 years of type 1 diabetes. Specifically, pyruvate kinase M2 (PKM2) activation protected insulin-deficient diabetic mice from hyperglycemia-induced glomerular pathology. This study aims to extend these findings in a separate cohort of individuals with type 1 and type 2 diabetes and discover new circulatory biomarkers for renal protection through proteomics and metabolomics of Medalists' plasma. We hypothesize that increased glycolytic flux and improved mitochondrial biogenesis will halt the progression of diabetic nephropathy. RESEARCH DESIGN AND METHODS: Immunoblots analyzed selected glycolytic and mitochondrial enzymes in postmortem glomeruli of non-Medalists with type 1 diabetes (n = 15), type 2 diabetes (n = 19), and no diabetes (n = 5). Plasma proteomic (SOMAscan) (n = 180) and metabolomic screens (n = 214) of Medalists with and without stage 3b chronic kidney disease (CKD) were conducted and significant markers validated by ELISA. RESULTS: Glycolytic (PKM1, PKM2, and ENO1) and mitochondrial (MTCO2) enzymes were significantly elevated in glomeruli of CKD- versus CKD+ individuals with type 2 diabetes. Medalists' plasma PKM2 correlated with estimated glomerular filtration rate (r 2 = 0.077; P = 0.0002). Several glucose and mitochondrial enzymes in circulation were upregulated with corresponding downregulation of toxic metabolites in CKD-protected Medalists. Amyloid precursor protein was also significantly upregulated, tumor necrosis factor receptors downregulated, and both confirmed by ELISA. CONCLUSIONS: Elevation of enzymes involved in the metabolism of intracellular free glucose and its metabolites in renal glomeruli is connected to preserving kidney function in both type 1 and type 2 diabetes. The renal profile of elevated glycolytic enzymes and reduced toxic glucose metabolites is reflected in the circulation, supporting their use as biomarkers for endogenous renal protective factors in people with diabetes.

Characterization of periodontitis in people with type 1 diabetes of 50 years or longer duration.

BACKGROUND: Periodontitis is more common and severe in people with diabetes than the general population. We have reported in the Joslin Medalist Study that people with type 1 diabetes of ≥50 years (Medalists) may have endogenous protective factors against diabetic nephropathy and retinopathy. METHODS: In this cross-sectional study, the prevalence of periodontitis according to the Centers for Disease Control/American Academy of Periodontology classification in a subset (n = 170, mean age = 64.6 ± 6.9 years) of the Medalist cohort, and its associations to various criteria of periodontitis and diabetic complications were assessed. RESULTS: The prevalence of severe periodontitis in Medalists was only 13.5% which was lower than reported levels in diabetic patients of similar ages. Periodontal parameters, including bleeding on probing, plaque index, gingival index, and demographic traits, including male sex, chronological age, and age at diagnosis were significantly associated with severity of periodontitis, which did not associate with diabetes duration, hemoglobin A1c (HbA1c), body mass index, and lipid profiles. Random serum C-peptide levels inversely associated with severity of periodontitis (P = 0.03), lower probing depth (P = 0.0002), and clinical attachment loss (P = 0.03). Prevalence of cardiovascular diseases (CVD) and systemic inflammatory markers, plasma interleukin-6 (IL-6), and serum immunoglobulin G titer against Porphyromonas gingivalis positively associated with severity of periodontitis (P = 0.002 and 0.02, respectively). Antibody titer to P. gingivalis correlated positively and significantly with CVD, serum IL-6, and high-sensitivity C-reactive protein. CONCLUSIONS: Some Medalists could be protected from severe periodontitis even with hyperglycemia. Endogenous protective factors for periodontitis could possibly be related to residual insulin production and lower levels of chronic inflammation.

Cognitive Function Deficits Associated With Long-Duration Type 1 Diabetes and Vascular Complications.

OBJECTIVE: Patients with type 1 diabetes now live long enough to experience cognitive decline. During middle age, they show mild cognitive deficits, but it is unknown whether severity increases with aging or whether cognitive profiles are similar to those of age-matched peers with and without diabetes. RESEARCH DESIGN AND METHODS: We tested and compared cognition in 82 individuals with 50 or more years of type 1 diabetes (Medalists), 31 age-matched individuals with type 2 diabetes, and 30 age-matched control subjects without diabetes. Medical histories and biospecimens were collected. We also evaluated the association of complications with cognition in Medalists only. RESULTS: Compared with control subjects, both individuals with type 1 diabetes and individuals with type 2 diabetes performed worse on immediate and delayed recall (P ≤ 0.002) and psychomotor speed in both hands (P ≤ 0.01) and showed a trend toward worse executive function (P = 0.05). In Medalists, cardiovascular disease was associated with decreased executive function and proliferative diabetic retinopathy with slower psychomotor speed. CONCLUSIONS: Both patients with type 1 and patients with type 2 diabetes showed overall worse cognition than control subjects. Further, in Medalists, a relationship between complications and cognition was seen. Although both groups with diabetes showed similar deficit patterns, the underlying mechanisms may be different. Now that patients with type 1 diabetes are living longer, efforts should be made to evaluate cognition and to identify modifying behaviors to slow decline.

Diabetes Care Disparities in Long-standing Type 1 Diabetes in Canada and the U.S.: A Cross-sectional Comparison.

OBJECTIVE: To assess national differences in diabetes care and quality of life (QOL) between individuals with long-standing type 1 diabetes (≥50 years) in Canada and the U.S. RESEARCH DESIGN AND METHODS: Cross-sectional data from identical surveys administered in the Canadian Study of Longevity in Diabetes and the Joslin Medalist Study, collected in 2013-2016 and 2005-2011, respectively, were compared. Laboratory values and ophthalmic examination were completed by clinical care physicians for Canadians and the Joslin Clinic for Americans. Univariate comparisons and multivariable regression for HbA1c, QOL, insulin pump use, and coronary artery disease (CAD) were performed. Nephropathy, CAD, and peripheral arterial disease (PAD) were self-reported; neuropathy was defined by a Michigan Neuropathy Screening Instrument (Questionnaire component) score ≥3, and proliferative retinopathy was documented from ophthalmic examination. QOL was self-reported on an ordinal scale. RESULTS: Three hundred sixty-one Canadians and 668 Americans had similar ages (mean 65.78 years [SD 8.67] vs. 66.38 years [7.66], P = 0.27) and durations of diabetes (median 53.00 years [interquartile range 51.00, 58.00] vs. 53.00 years [51.00, 57.00], P = 0.51). Canadians had higher HbA1c (mean 7.53% [SD 1.03] [59 mmol/mol] vs. 7.22% [0.98] [55 mmol/mol], P < 0.0001), lower QOL (36.9% vs. 48.7% with "excellent" QOL, P = 0.0002), and less CAD (29.7% vs. 41.2%, P = 0.0003) and insulin pump use (43.3% vs. 55.6%, P = 0.0002). Other complication rates were similar. Residual differences for Canadians compared with Americans remained after adjustment for age, sex, CAD, PAD, education, and relevant a priori selected variables: 0.28% higher HbA1c (P = 0.0004); and odds ratios of 0.68 (95% CI 0.51, 0.90), 0.46 (0.31, 0.68), and 0.71 (0.52, 0.96) for higher QOL, CAD, and insulin pump use, respectively. CONCLUSIONS: Although Canadians and Americans have similar rates of complications other than CAD, further research is required to understand why Canadians have higher HbA1c levels, lower QOL, and less insulin pump use.

Association of Glycemic Control With Reduced Risk for Large-Vessel Disease After More Than 50 Years of Type 1 Diabetes.

Context: Previously we demonstrated, in individuals who have had type 1 diabetes (T1D) for 50 or more years (Medalists), that glycemic control was unrelated to diabetic complications, with the exception of cardiovascular disease (CVD), contrary to what has been documented in registry-based studies. Objective: The purpose of this study is to validate these initial findings and identify contributors to mortality on an individual basis in a large cohort. Design: Cross-sectional and longitudinal study. Setting: Joslin Diabetes Center (JDC), Boston, Massachusetts. Patients: 50-year Medalists presenting to JDC for study participation. Interventions: None. Main Outcomes Measures: Microvascular and macrovascular complications of diabetes and mortality. Results: Glycemic control was not significantly associated with small-vessel complications in Medalists but was associated with CVD in the overall cohort, yet with varying effect by tertile of cohort duration. CVD was the largest contributor to mortality, whereas hemoglobin A1c was not an independent predictor of mortality either overall or substantially by diagnosis interval. Additionally, exercise mitigated mortality risk imparted by CVD. Conclusions: Few large populations with long duration of (T1D) have been available to examine the effects of long-term exposure to hyperglycemia. These data indicate that an association of glycemic control, complications, and mortality may change in an older population with T1D. These results suggest that careful control is still warranted in older populations with T1D.

High density lipoprotein modulates osteocalcin expression in circulating monocytes: a potential protective mechanism for cardiovascular disease in type 1 diabetes.

BACKGROUND: Cardiovascular disease (CVD) is a major cause of mortality in type 1 diabetes (T1D). A pro-calcific drift of circulating monocytes has been linked to vascular calcification and is marked by the surface expression of osteocalcin (OCN). We studied OCN+ monocytes in a unique population with ≥50 years of T1D, the 50-Year Joslin Medalists (J50M). METHODS: CD45 bright/CD14+/OCN+ cells in the circulating mononuclear blood cell fraction were quantified by flow cytometry and reported as percentage of CD45 bright cells. Mechanisms were studied by inducing OCN expression in human monocytes in vitro. RESULTS: Subjects without history of CVD (n = 16) showed lower levels of OCN+ monocytes than subjects with CVD (n = 14) (13.1 ± 8.4% vs 19.9 ± 6.4%, p = 0.02). OCN+ monocytes level was inversely related to total high density lipoprotein (HDL) cholesterol levels (r = -0.424, p = 0.02), large (r = -0.413, p = 0.02) and intermediate (r = -0.445, p = 0.01) HDL sub-fractions, but not to small HDL. In vitro, incubation with OxLDL significantly increased the number of OCN+ monocytes (p < 0.01). This action of OxLDL was significantly reduced by the addition of HDL in a concentration dependent manner (p < 0.001). Inhibition of the scavenger receptor B1 reduced the effects of both OxLDL and HDL (p < 0.05). CONCLUSIONS: Low OCN+ monocytes levels are associated with lack of CVD in people with long duration T1D. A possible mechanism for the increased OCN+ monocytes could be the elevated levels of oxidized lipids due to diabetes which may be inhibited by HDL. These findings suggest that circulating OCN+ monocytes could be a marker for vascular disease in diabetic patients and possibly modified by HDL elevation.

Bone health in subjects with type 1 diabetes for more than 50 years.

AIMS: Few data regarding prevalence of and risk factors for poor bone health in aging individuals with long-standing T1D are available. In this study, we aim to describe the prevalence of bone fragility and to identify factors associated with low bone density in individuals with long-term T1D. METHODS: We examined the prevalence of non-vertebral fractures in 985 subjects enrolled in the Joslin 50-Year Medalist Study and measured bone mineral density (BMD) by dual-energy X-ray absorptiometry at the femoral neck, lumbar spine and radius in a subset (65 subjects, mean age 62.6 years, duration 52.5 years, HbA1c 7.1%) with no significant clinical or demographic differences from the rest of the cohort. RESULTS: Medalists have low prevalence of fractures (0.20% hip and 0.91% wrist) and normal Z-score values (spine +1.15, total hip +0.23, femoral neck -0.01, radius +0.26; p > 0.05 for differences vs. 0 at all sites). A significant relationship was found between lower BMD and higher total cholesterol, triglycerides and LDL levels, but not HbA1c. Low BMD at the femoral neck was associated with cardiovascular disease after adjustment for confounding factors: prevalence risk ratio of CVD [95% CI] 4.6 [1.2-18.1], p = 0.03. No other diabetic vascular complication was found to be associated with low BMD. CONCLUSIONS: These are the first data regarding bone health in aging individuals who have had diabetes for 50 or more years. The low rates of non-vertebral fractures and the normal Z-score suggest the long T1D diabetes duration did not increase the risk of bone fractures in Medalists compared to non-diabetic peers. Additionally, the association with cardiovascular disease demonstrates the BMD differences in groups are likely not due to glycemic control alone.

Has Massachusetts health care reform worked for the working poor? Results from an analysis of opportunity.

PURPOSE: Health care reform was introduced in Massachusetts (MA) in 2006 and serves as a model for what was subsequently introduced nationally as the Patient Protection and Affordable Care Act. The Boston Area Community Health survey collected data before (2002-2005) and after (2006-2010) introduction of the MA health insurance mandate, providing a unique opportunity to assess its effects in a large, epidemiologic cohort. METHODS: We report on the apparent effects of the mandate on the same participants over time, focusing specifically on the vulnerable working poor (WP). We evaluated differences in subpopulations of interest at pre- and post-reform periods to explore whether MA health care reform resulted in an overall gain in insurance coverage. RESULTS: MA health care reform was associated with net gains in health insurance coverage overall and among the subgroups studied. Our findings suggest that despite being targeted by health care reform legislation, the WP in MA continue to report lower rates of insurance coverage compared with both the nonworking poor and the not poor. CONCLUSIONS: MA health care reform legislation, including the expansion of Medicaid, resulted in substantial overall gains in coverage. Disparities in insurance coverage persist among some subgroups following health care reform implementation in MA. These results have important implications for health services researchers and policy makers, particularly in light of the ongoing implementation of the Patient Protection and Affordable Care Act.

Population-based patterns of prescription androgen use, 1976-2008.

PURPOSE: Prescription testosterone (T) has limited approved medical indications and is a controlled substance in Canada. Utilization studies in other Westernized countries have revealed sharp increases in T use in recent years. We examined medical use of androgens, including T, over a ≥30-year period among adult (18+) men in a population-based study set in a Canadian juridisdiction of universal health care. METHODS: Analyses were based on data from electronic records of dispensed prescriptions during 1976-2008 in Saskatchewan, Canada. All formulations of androgens listed in the provincial formulary (oral and injectable) were included. We examined demographics of users, androgen types used, switching patterns, and trends in the annual rate of use over time. RESULTS: There were 11 521 androgen users who were followed for an average of 11.8 years. Overall, 11 types of androgens were used, and there were 86 812 dispensing events. The mean age at first use was 56.4 years (median: 58). Men had 7.5 prescription dispensing events on average (median: 2). The most commonly used formulations were methyl-T (36.2% of users) followed by T-enanthate (32.5%), T-cypionate (22.3%), and T-undecanoate (20.0%). Most users (82%) did not switch among androgen types. The annual rate of use varied substantially over time, with a marked increase observed from 1994 to 1999 and a decrease from 2000 to 2008. CONCLUSIONS: Androgen users were largely middle aged and had relatively few dispensings. We hypothesize that observed secular trends in androgen use may align with drug treatment pattern changes for erectile dysfunction, including the advent of phosphodiesterase type 5 inhibitors.

Perceived reactions to race and health status in the Massachusetts Behavioral Risk Factor Surveillance System Survey.

OBJECTIVES: Evaluate the relationship between race, perceptions of personally mediated racism and health outcomes in the Massachusetts Behavioral Risk Factor Surveillance System (BRFSS). METHODS: Regression analysis of 8,266 respondents to the Reactions to Race module in 2006 and 2008. Questions assessing personally mediated racism were combined to measure perceptions of reactions to race. OUTCOME MEASURES: Adjusted odds ratios and 95% CI of perceived personally mediated racism, self-reported overall health, life satisfaction, health risks (smoking status, obesity, binge and heavy drinking), and preventive services (colonoscopy, flu vaccine). RESULTS: Black non-Hispanic respondents are 10.4 times (95% CI: 6.3-17.3; P<.001) and Hispanics 5.8 times (95% CI: 3.6-9.4; P<.001) more likely to report being treated worse than other races compared to White non-Hispanic respondents. Respondents of all races reporting being treated worse than other races are 3.2 times (95% CI: 1.9-5.4; P<.001) more likely to have fair/poor health and 4.1 times (95% CI: 2.1-7.9; P<.001) more likely to report life dissatisfaction than those treated the same or better than other races. There is no statistically significant association between perceived personally mediated racism and health risks or preventive services tested. CONCLUSIONS: Perceptions of personally mediated racism are significantly associated with fair/poor overall health and life dissatisfaction, but none of the health risks or preventive services tested.