Food Insecurity and Adequacy of Dietary Intake in Youth and Young Adults With Youth-Onset Type 1 and Type 2 Diabetes.

BACKGROUND: Household food insecurity is associated with poor dietary intake in the general population, but little is known about this association in persons with diabetes. OBJECTIVE: We examined the degree of adherence to the dietary reference intakes and 2020-2025 Dietary Guidelines for Americans overall and according to food security status and diabetes type among youth and young adults (YYA) with youth-onset diabetes. DESIGN, PARTICIPANTS, AND SETTING: The SEARCH for Diabetes in Youth study includes 1,197 YYA with type 1 diabetes (mean age = 21 ± 5 years) and 319 YYA with type 2 diabetes (25 ± 4 years). Participants (or parents if younger than age 18 years) completed the US Department of Agriculture Household Food Security Survey Module, wherein ≥3 affirmations indicate food insecurity. MAIN OUTCOME MEASURES: Diet was assessed via food frequency questionnaire and compared with age- and sex-specific dietary reference intakes for 10 nutrients and dietary components (calcium; fiber; magnesium; potassium; sodium; vitamins C, D, and E; added sugar; and saturated fat). STATISTICAL ANALYSES PERFORMED: Median regression models controlled for sex- and type-specific means for age, diabetes duration, and daily energy intake. RESULTS: Prevalence of guideline adherence was overarchingly poor, with <40% of participants meeting recommendations for eight of 10 nutrients and dietary components; however, higher adherence (>47%) was observed for vitamin C and added sugars. YYA with type 1 diabetes who were food insecure were more likely to meet recommendations for calcium, magnesium, and vitamin E (P < 0.05), and less likely for sodium (P < 0.05) than those with food security. In adjusted models, YYA with type 1 diabetes who were food secure had closer median adherence to sodium (P = 0.002) and fiber (P = 0.042) guidelines than those food insecure. No associations were observed in YYA with type 2 diabetes. CONCLUSIONS: Food insecurity is associated with lesser adherence to fiber and sodium guidelines in YYA with type 1 diabetes, which may lead to diabetes complications and other chronic diseases.

Associations of four indexes of social determinants of health and two community typologies with new onset type 2 diabetes across a diverse geography in Pennsylvania.

Evaluation of geographic disparities in type 2 diabetes (T2D) onset requires multidimensional approaches at a relevant spatial scale to characterize community types and features that could influence this health outcome. Using Geisinger electronic health records (2008-2016), we conducted a nested case-control study of new onset T2D in a 37-county area of Pennsylvania. The study included 15,888 incident T2D cases and 79,435 controls without diabetes, frequency-matched 1:5 on age, sex, and year of diagnosis or encounter. We characterized patients' residential census tracts by four dimensions of social determinants of health (SDOH) and into a 7-category SDOH census tract typology previously generated for the entire United States by dimension reduction techniques. Finally, because the SDOH census tract typology classified 83% of the study region's census tracts into two heterogeneous categories, termed rural affordable-like and suburban affluent-like, to further delineate geographies relevant to T2D, we subdivided these two typology categories by administrative community types (U.S. Census Bureau minor civil divisions of township, borough, city). We used generalized estimating equations to examine associations of 1) four SDOH indexes, 2) SDOH census tract typology, and 3) modified typology, with odds of new onset T2D, controlling for individual-level confounding variables. Two SDOH dimensions, higher socioeconomic advantage and higher mobility (tracts with fewer seniors and disabled adults) were independently associated with lower odds of T2D. Compared to rural affordable-like as the reference group, residence in tracts categorized as extreme poverty (odds ratio [95% confidence interval] = 1.11 [1.02, 1.21]) or multilingual working (1.07 [1.03, 1.23]) were associated with higher odds of new onset T2D. Suburban affluent-like was associated with lower odds of T2D (0.92 [0.87, 0.97]). With the modified typology, the strongest association (1.37 [1.15, 1.63]) was observed in cities in the suburban affluent-like category (vs. rural affordable-like-township), followed by cities in the rural affordable-like category (1.20 [1.05, 1.36]). We conclude that in evaluating geographic disparities in T2D onset, it is beneficial to conduct simultaneous evaluation of SDOH in multiple dimensions. Associations with the modified typology showed the importance of incorporating governmentally, behaviorally, and experientially relevant community definitions when evaluating geographic health disparities.

Proximity to freshwater blue space and type 2 diabetes onset: the importance of historical and economic context.

Salutogenic effects of living near aquatic areas (blue space) remain underexplored, particularly in non-coastal and non-urban areas. We evaluated associations of residential proximity to inland freshwater blue space with new onset type 2 diabetes (T2D) in central and northeast Pennsylvania, USA, using medical records to conduct a nested case-control study. T2D cases (n=15,888) were identified from diabetes diagnoses, medication orders, and laboratory test results and frequency-matched on age, sex, and encounter year to diabetes-free controls (n=79,435). We calculated distance from individual residences to the nearest lake, river, tributary, or large stream, and residence within the 100-year floodplain. Logistic regression models adjusted for community socioeconomic deprivation and other confounding variables and stratified by community type (townships [rural/suburban], boroughs [small towns], city census tracts). Compared to individuals living ≥1.25 miles from blue space, those within 0.25 miles had 8% and 17% higher odds of T2D onset in townships and boroughs, respectively. Among city residents, T2D odds were 38-39% higher for those living 0.25 to <0.75 miles from blue space. Residing within the floodplain was associated with 16% and 14% higher T2D odds in townships and boroughs. A post-hoc analysis demonstrated patterns of lower residential property values with nearer distance to the region's predominant waterbody, suggesting unmeasured confounding by socioeconomic disadvantage. This may explain our unexpected findings of higher T2D odds with closer proximity to blue space. Our findings highlight the importance of historic and economic context and interrelated factors such as flood risk and lack of waterfront development in blue space research.

Differences in U.S. Rural-Urban Trends in Diabetes ABCS, 1999-2018.

OBJECTIVE: To examine changes in and the relationships between diabetes management and rural and urban residence. RESEARCH DESIGN AND METHODS: Using National Health and Nutrition Examination Survey (1999-2018) data from 6,372 adults aged ≥18 years with self-reported diagnosed diabetes, we examined poor ABCS: A1C >9% (>75 mmol/mol), Blood pressure (BP) ≥140/90 mmHg, Cholesterol (non-HDL) ≥160 mg/dL (≥4.1 mmol/L), and current Smoking. We compared odds of urban versus rural residents (census tract population size ≥2,500 considered urban, otherwise rural) having poor ABCS across time (1999-2006, 2007-2012, and 2013-2018), overall and by sociodemographic and clinical characteristics. RESULTS: During 1999-2018, the proportion of U.S. adults with diabetes residing in rural areas ranged between 15% and 19.5%. In 1999-2006, there were no statistically significant rural-urban differences in poor ABCS. However, from 1999-2006 to 2013-2018, there were greater improvements for urban adults with diabetes than for rural for BP ≥140/90 mmHg (relative odds ratio [OR] 0.8, 95% CI 0.6-0.9) and non-HDL ≥160 mg/dL (≥4.1 mmol/L) (relative OR 0.45, 0.4-0.5). These differences remained statistically significant after adjustment for race/ethnicity, education, poverty levels, and clinical characteristics. Yet, over the 1999-2018 time period, minority race/ethnicity, lower education attainment, poverty, and lack of health insurance coverage were factors associated with poorer A, B, C, or S in urban adults compared with their rural counterparts. CONCLUSIONS: Over two decades, rural U.S. adults with diabetes have had less improvement in BP and cholesterol control. In addition, rural-urban differences exist across sociodemographic groups, suggesting that efforts to narrow this divide may need to address both socioeconomic and clinical aspects of care.

Trends and socioeconomic disparities in all-cause mortality among adults with diagnosed diabetes by race/ethnicity: a population-based cohort study - USA, 1997-2015.

OBJECTIVES: By race/ethnicity and socioeconomic position (SEP), to estimate and examine changes over time in (1) mortality rate, (2) mortality disparities and (3) excess mortality risk attributed to diagnosed diabetes (DM). DESIGN: Population-based cohort study using National Health Interview Survey data linked to mortality status from the National Death Index from survey year up to 31 December 2015 with 5 years person-time. PARTICIPANTS: US adults aged ≥25 years with (31 586) and without (332 451) DM. PRIMARY OUTCOME: Age-adjusted all-cause mortality rate for US adults with DM in each subgroup of SEP (education attainment and income-to-poverty ratio (IPR)) and time (1997-2001, 2002-2006 and 2007-2011). RESULTS: Among adults with DM, mortality rates fell from 23.5/1000 person-years (p-y) in 1997-2001 to 18.1/1000 p-y in 2007-2011 with changes of -5.2/1000 p-y for non-Hispanic whites; -5.2/1000 p-y for non-Hispanic blacks; and -5.4/1000 p-y for Hispanics. Rates significantly declined within SEP groups, measured as education attainment (high school=-4.8/1000 p-y) and IPR group (poor=-7.9/1000 p-y; middle income=-4.7/1000 p-y; and high income=-6.2/1000 p-y; but not for near poor). For adults with DM, statistically significant all-cause mortality disparity showed greater mortality rates for the lowest than the highest SEP level (education attainment and IPR) in each time period. However, patterns in mortality trends and disparity varied by race/ethnicity. The excess mortality risk attributed to DM significantly decreased from 1997-2001 to 2007-2011, within SEP levels, and among Hispanics and non-Hispanic whites; but no statistically significant changes among non-Hispanic blacks. CONCLUSIONS: There were substantial improvements in all-cause mortality among US adults. However, we observed SEP disparities in mortality across race/ethnic groups or for adults with and without DM despite targeted efforts to improve access and quality of care among disproportionately affected populations.

Association of community types and features in a case-control analysis of new onset type 2 diabetes across a diverse geography in Pennsylvania.

OBJECTIVES: To evaluate associations of community types and features with new onset type 2 diabetes in diverse communities. Understanding the location and scale of geographic disparities can lead to community-level interventions. DESIGN: Nested case-control study within the open dynamic cohort of health system patients. SETTING: Large, integrated health system in 37 counties in central and northeastern Pennsylvania, USA. PARTICIPANTS AND ANALYSIS: We used electronic health records to identify persons with new-onset type 2 diabetes from 2008 to 2016 (n=15 888). Persons with diabetes were age, sex and year matched (1:5) to persons without diabetes (n=79 435). We used generalised estimating equations to control for individual-level confounding variables, accounting for clustering of persons within communities. Communities were defined as (1) townships, boroughs and city census tracts; (2) urbanised area (large metro), urban cluster (small cities and towns) and rural; (3) combination of the first two; and (4) county. Community socioeconomic deprivation and greenness were evaluated alone and in models stratified by community types. RESULTS: Borough and city census tract residence (vs townships) were associated (OR (95% CI)) with higher odds of type 2 diabetes (1.10 (1.04 to 1.16) and 1.34 (1.25 to 1.44), respectively). Urbanised areas (vs rural) also had increased odds of type 2 diabetes (1.14 (1.08 to 1.21)). In the combined definition, the strongest associations (vs townships in rural areas) were city census tracts in urban clusters (1.41 (1.22 to 1.62)) and city census tracts in urbanised areas (1.33 (1.22 to 1.45)). Higher community socioeconomic deprivation and lower greenness were each associated with increased odds. CONCLUSIONS: Urban residence was associated with higher odds of type 2 diabetes than for other areas. Higher community socioeconomic deprivation in city census tracts and lower greenness in all community types were also associated with type 2 diabetes.

Association of Greenness with Blood Pressure among Individuals with Type 2 Diabetes across Rural to Urban Community Types in Pennsylvania, USA.

Greenness may impact blood pressure (BP), though evidence is limited among individuals with type 2 diabetes (T2D), for whom BP management is critical. We evaluated associations of residential greenness with BP among individuals with T2D in geographically diverse communities in Pennsylvania. To address variation in greenness type, we evaluated modification of associations by percent forest. We obtained systolic (SBP) and diastolic (DBP) BP measurements from medical records of 9593 individuals following diabetes diagnosis. Proximate greenness was estimated within 1250-m buffers surrounding individuals' residences using the normalized difference vegetation index (NDVI) prior to blood pressure measurement. Percent forest was calculated using the U.S. National Land Cover Database. Linear mixed models with robust standard errors accounted for spatial clustering; models were stratified by community type (townships/boroughs/cities). In townships, the greenest communities, an interquartile range increase in NDVI was associated with reductions in SBP of 0.87 mmHg (95% CI: -1.43, -0.30) and in DBP of 0.41 mmHg (95% CI: -0.78, -0.05). No significant associations were observed in boroughs or cities. Evidence for modification by percent forest was weak. Findings suggest a threshold effect whereby high greenness may be necessary to influence BP in this population and support a slight beneficial impact of greenness on cardiovascular disease risk.

The Diabetes Location, Environmental Attributes, and Disparities Network: Protocol for Nested Case Control and Cohort Studies, Rationale, and Baseline Characteristics.

BACKGROUND: Diabetes prevalence and incidence vary by neighborhood socioeconomic environment (NSEE) and geographic region in the United States. Identifying modifiable community factors driving type 2 diabetes disparities is essential to inform policy interventions that reduce the risk of type 2 diabetes. OBJECTIVE: This paper aims to describe the Diabetes Location, Environmental Attributes, and Disparities (LEAD) Network, a group funded by the Centers for Disease Control and Prevention to apply harmonized epidemiologic approaches across unique and geographically expansive data to identify community factors that contribute to type 2 diabetes risk. METHODS: The Diabetes LEAD Network is a collaboration of 3 study sites and a data coordinating center (Drexel University). The Geisinger and Johns Hopkins University study population includes 578,485 individuals receiving primary care at Geisinger, a health system serving a population representative of 37 counties in Pennsylvania. The New York University School of Medicine study population is a baseline cohort of 6,082,146 veterans who do not have diabetes and are receiving primary care through Veterans Affairs from every US county. The University of Alabama at Birmingham study population includes 11,199 participants who did not have diabetes at baseline from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study, a cohort study with oversampling of participants from the Stroke Belt region. RESULTS: The Network has established a shared set of aims: evaluate mediation of the association of the NSEE with type 2 diabetes onset, evaluate effect modification of the association of NSEE with type 2 diabetes onset, assess the differential item functioning of community measures by geographic region and community type, and evaluate the impact of the spatial scale used to measure community factors. The Network has developed standardized approaches for measurement. CONCLUSIONS: The Network will provide insight into the community factors driving geographical disparities in type 2 diabetes risk and disseminate findings to stakeholders, providing guidance on policies to ameliorate geographic disparities in type 2 diabetes in the United States. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/21377.

The Cardiometabolic Risk Profile of Young Adults With Diabetes in the U.S.

OBJECTIVE: We examined young adults with and young adults without diabetes by using demographic data and cardiometabolic risk profiles and compared the risk profiles of younger versus older (aged ≥45 years) adults with diabetes. RESEARCH DESIGN AND METHODS: Data were obtained from the National Health and Nutrition Examination Survey (NHANES) 2007-2016. Diabetes was defined by self-report of health care provider diagnosis or by A1C levels of 6.5% or higher among those without a self-reported diagnosis. The cardiometabolic risk profile included adiposity, blood pressure, serum lipids, healthy eating, physical activity (PA), and exposure to tobacco smoke. Adjusted difference in difference was calculated as the difference among younger adults with and younger adults without diabetes minus the difference among older adults with and older adults without diabetes. RESULTS: Adults with diabetes in both age-groups had higher levels of adiposity, hypertension, and cholesterol and lower levels of healthy eating and leisure-time PA. However, the differences in high cholesterol and adiposity by diabetes status were greater among young adults compared with older adults after adjustment for demographics and health insurance status. Elevated lipids were 9.6 percentage points higher (95% CI 4.6, 14.5) and obesity was 37.3 percentage points higher (95% CI 31.8, 42.7) among young adults with diabetes compared with those without diabetes than among older adults with diabetes compared with those without diabetes. CONCLUSIONS: Young adults with diabetes have high rates of cardiometabolic risk factors, which can lead to an increased disease prevalence and mortality rate among these individuals as they age.

Evaluation of measurement error in 24-hour dietary recall for assessing sodium and potassium intake among US adults - National Health and Nutrition Examination Survey (NHANES), 2014.

BACKGROUND: Understanding measurement error in sodium and potassium intake is essential for assessing population intake and studying associations with health outcomes. OBJECTIVE: The aim of this study was to compare sodium and potassium intake derived from 24-h dietary recall (24HDR) with intake derived from 24-h urinary excretion (24HUE). DESIGN: Data were analyzed from 776 nonpregnant, noninstitutionalized US adults aged 20-69 y who completed 1-to-2 24HUE and 24HDR measures in the 2014 NHANES. A total of 1190 urine specimens and 1414 dietary recalls were analyzed. Mean bias was estimated as mean of the differences between individual mean 24HDR and 24HUE measurements. Correlations and attenuation factors were estimated using the Kipnis joint-mixed effects model accounting for within-person day-to-day variability in sodium excretion. The attenuation factor reflects the degree to which true associations between long-term intake (estimated using 24HUEs) and a hypothetical health outcome would be approximated using a single 24HDR: values near 1 indicate close approximation and near 0 indicate bias toward null. Estimates are reported for sodium, potassium, and the sodium: potassium (Na/K) ratio. Model parameters can be used to estimate correlations/attenuation factors when multiple 24HDRs are available. RESULTS: Overall, mean bias for sodium was -452 mg (95% CI: -646, -259), for potassium -315 mg (CI: -450, -179), and for the Na/K ratio -0.04 (CI: -0.15, 0.07, NS). Using 1 24HDR, the attenuation factor for sodium was 0.16 (CI: 0.09, 0.21), for potassium 0.25 (CI:0.16, 0.36), and for the Na/K ratio 0.20 (CI: 0.10, 0.25). The correlation for sodium was 0.27 (CI: 0.16, 0.37), for potassium 0.35 (CI: 0.26, 0.55), and for the Na/K ratio 0.27 (CI: 0.13, 0.32). CONCLUSIONS: Compared with 24HUE, using 24HDR underestimates mean sodium and potassium intake but is unbiased for the Na/K ratio. Additionally, using 24HDR as a measure of exposure in observational studies attenuates the true associations of sodium and potassium intake with health outcomes.

Validity of predictive equations for 24-h urinary potassium excretion based on timing of spot urine collection among adults: the MESA and CARDIA Urinary Sodium Study and NHANES Urinary Sodium Calibration Study.

Background: 24-h urine collections are the suggested method to measure daily urinary potassium excretion (uK) but are costly and burdensome to implement. Objective: This study tested how well existing equations with the use of spot urine samples can estimate 24-h uK and if accuracy varies by timing of spot urine collection, age, race, or sex. Design: This cross-sectional study used data from 407 participants aged 18-39 y from the Washington, DC area in 2011 and 554 participants aged 45-79 y from Chicago in 2013. Spot urine samples were collected in individual containers for 24 h, and 1 for each timed period (morning, afternoon, evening, and overnight) was selected. For each selected timed spot urine, 24-h uK was predicted through the use of published equations. Difference (bias) between predicted and measured 24-h uK was calculated for each timed period and within age, race, and sex subgroups. Individual-level differences were assessed through the use of Bland-Altman plots and correlation tests. Results: For all equations, regardless of the timing of spot urine, mean bias was usually significantly different than 0. No one prediction equation was unbiased across all sex, race, and age subgroups. With the use of the Kawasaki and Tanaka equations, 24-h uK was overestimated at low levels and underestimated at high levels, whereas observed differential bias with the Mage equation was in the opposite direction. Depending on prediction equation and timing of urine sample, 61-75% of individual 24-h uKs were misclassified among 500-mg incremental categories from <1500 to ≥3000 mg. Correlations between predicted and measured 24-h uK were poor to moderate (0.19-0.71). Conclusion: Because predicted 24-h uK accuracy varies by timing of spot urine collection, published prediction equations, and within age-race-sex subgroups, study results making use of predicted 24-h uK in association with health outcomes should be interpreted with caution. It is possible that a more accurate prediction equation can be developed leading to different results.

Prevalence of Major Behavioral Risk Factors for Type 2 Diabetes.

OBJECTIVE: We examined the proportion of American adults without type 2 diabetes that engages in lifestyle behaviors known to reduce type 2 diabetes risk. RESEARCH DESIGN AND METHODS: We conducted a cross-sectional analysis of 3,679 nonpregnant, nonlactating individuals aged ≥20 years without diabetes (self-reported diagnosis or glycated hemoglobin ≥6.5% [8 mmol/mol] or fasting plasma glucose ≥126 mg/dL) and who provided 2 days of reliable dietary data in the 2007-2012 National Health and Nutrition Examination Surveys (NHANES). We used the average of 2 days of dietary recall and self-reported leisure-time physical activity to assess whether participants met type 2 diabetes risk reduction goals (meeting four or more MyPlate recommendations [adequate consumption of fruits, vegetables, dairy, grains, meat, beans, and eggs]; not exceeding three maximum allowances for alcoholic beverages, added sugars, fat, and cholesterol; and meeting physical activity recommendations [≥150 min/week]). RESULTS: Approximately 21%, 29%, and 13% of individuals met fruit, vegetable, and dairy goals, respectively. Half (51.6%) met the goal for total grains, compared with 18% for whole grains, and 54.2% met the meat/beans goal and 40.6% met the oils goal. About one-third (37.8%) met the physical activity goal, and 58.6% met the weight loss/maintenance goal. Overall, 3.1% (95% CI 2.4-4.0) of individuals met the majority of type 2 diabetes risk reduction goals. Younger age and lower educational attainment were associated with lower probability of meeting goals. CONCLUSIONS: A small proportion of U.S. adults engages in risk reduction behaviors. Research and interventions targeted at young and less-educated segments of the population may help close gaps in risk reduction behaviors.

Trends in lipid profiles and descriptive characteristics of U.S. adults with and without diabetes and cholesterol-lowering medication use-National Health and Nutrition Examination Survey, 2003-2012, United States.

BACKGROUND: With a cholesterol-lowering focus for diabetic adults and in the age of polypharmacy, it is important to understand how lipid profile levels differ among those with and without diabetes. OBJECTIVE: Investigate the means, differences, and trends in lipid profile measures [TC, total cholesterol; LDL-c, low-density lipoprotein; HDL-c, high-density lipoprotein; and TG, triglycerides] among US adults by diabetes status and cholesterol-lowering medication. METHODS: Population number and proportion of adults aged ≥21 years with diabetes and taking cholesterol-lowering medication were estimated using data on 10,384 participants from NHANES 2003-2012. Age-standardized means, trends, and differences in lipid profile measures were estimated by diabetes status and cholesterol medication use. For trends and differences, linear regression analysis were used adjusted for age, gender, and race/ethnicity. RESULTS: Among diabetic adults, 52% were taking cholesterol-lowering medication compared to the 14% taking cholesterol-lowering medication without diabetes. Although diabetic adults had significantly lower TC and LDL-c levels than non-diabetic adults [% difference (95% confidence interval): TC = -5.2% (-6.8 --3.5), LDL-c = -8.0% (-10.4 --5.5)], the percent difference was greater among adults taking cholesterol medication [TC = -8.0% (-10.3 --5.7); LDL-c = -13.7% (-17.1 --10.2)] than adults not taking cholesterol medication [TC = -3.5% (-5.2 --1.6); LDL-c = -4.3% (-7.1 --1.5)] (interaction p-value: TC = <0.001; LDL-c = <0.001). From 2003-2012, mean TC and HDL-c significantly decreased among diabetic adults taking cholesterol medication [% difference per survey cycle (p-value for linear trend): TC = -2.3% (0.003) and HDL-c = -2.3% (0.033)]. Mean TC, HDL-c, and LDL-c levels did not significantly change from 2003 to 2012 in non-diabetic adults taking cholesterol medication or for adults not taking cholesterol medications. CONCLUSIONS: Diabetic adults were more likely to have lower lipid levels, except for triglyceride levels, than non-diabetic adults with profound differences when considering cholesterol medication use, possibly due to the positive effects from clinical diabetes management.

Diet Quality Associated with Total Sodium Intake among US Adults Aged ≥18 Years-National Health and Nutrition Examination Survey, 2009-2012.

Diet quality or macronutrient composition of total daily sodium intake (dNa) <2300 mg/day in the United States (US) is unknown. Using data from 2011-2014 NHANES (National Health and Nutrition Examination Survey), we examined 24-h dietary recalls (n = 10,142) from adults aged ≥18 years and investigated how diet composition and quality are associated with dNa. Diet quality was assessed using components of macronutrients and Healthy Eating Index 2010 (HEI-2010). Associations were tested using linear regression analysis adjusted for total energy (kcal), age, gender, and race/ethnicity. One-day dNa in the lower quartiles were more likely reported among women, older adults (≥65 years old), and lower quartiles of total energy (kcal) (p-values ≤ 0.001). With increasing dNa, there was an increase in the mean protein, fiber, and total fat densities, while total carbohydrates densities decreased. As dNa increased, meat protein, refined grains, dairy, and total vegetables, greens and beans densities increased; while total fruit and whole fruit densities decreased. Modified HEI-2010 total score (total score without sodium component) increased as dNa increased (adjusted coefficient: 0.11, 95% confidence interval = 0.07, 0.15). Although diet quality, based on modified HEI-2010 total score, increased on days with greater dNa, there is much room for improvement with mean diet quality of about half of the optimal level.

Hyperlipidemia and Medical Expenditures by Cardiovascular Disease Status in US Adults.

BACKGROUND: Hyperlipidemia is a major risk factor for cardiovascular disease (CVD), affecting 73.5 million American adults. Information about health care expenditures associated with hyperlipidemia by CVD status is needed to evaluate the economic benefit of primary and secondary prevention programs for CVD. METHODS: The study sample includes 48,050 men and nonpregnant women ≥18 from 2010 to 2012 Medical Expenditure Panel Survey. A 2-part econometric model was used to estimate annual hyperlipidemia-associated medical expenditures by CVD status. The estimation results from the 2-part model were used to calculate per-capita and national medical expenditures associated with hyperlipidemia. We adjusted the medical expenditures into 2012 dollars. RESULTS: Among those with CVD, per person hyperlipidemia-associated expenditures were $1105 [95% confidence interval (CI), $877-$1661] per year, leading to an annual national expenditure of $15.47 billion (95% CI, $5.23-$27.75 billion). Among people without CVD, per person hyperlipidemia-associated expenditures were $856 (95% CI, $596-$1211) per year, resulting in an annual national expenditure of $23.11 billion (95% CI, $16.09-$32.71 billion). Hyperlipidemia-associated expenditures were attributable mostly to the costs of prescription medication (59%-90%). Among people without CVD, medication expenditures associated with hyperlipidemia were $13.72 billion (95% CI, $10.55-$15.74 billion), higher in men than in women. CONCLUSIONS: Hyperlipidemia significantly increased medical expenditures and the increase was higher in people with CVD than without. The information on estimated expenditures could be used to evaluate and develop effective programs for CVD prevention.

Prevalence of Cholesterol Treatment Eligibility and Medication Use Among Adults--United States, 2005-2012.

A high blood level of low-density lipoprotein cholesterol (LDL-C) remains a major risk factor for atherosclerotic cardiovascular disease (ASCVD), although data from 2005 through 2012 has shown a decline in high cholesterol (total and LDL cholesterol) along with an increase in the use of cholesterol-lowering medications. The most recent national guidelines (published in 2013) from the American College of Cardiology and the American Heart Association (ACC/AHA) expand previous recommendations for reducing cholesterol to include lifestyle modifications and medication use as part of complete cholesterol management and to lower risk for ASCVD. Because changes in cholesterol treatment guidelines might magnify existing disparities in care and medication use, it is important to describe persons currently eligible for treatment and medication use, particularly as more providers implement the 2013 ACC/AHA guidelines. To understand baseline estimates of U.S. adults on or eligible for cholesterol treatment, as well as to identify sex and racial/ethnic disparities, CDC analyzed data from the 2005-2012 National Health and Nutrition Examination Surveys (NHANES). Because the 2013 ACC/AHA guidelines focus on initiation or continuation of cholesterol treatment, adults meeting the guidelines' eligibility criteria as well as adults who were currently taking cholesterol-lowering medication were assessed as a group. Overall, 36.7% of U.S. adults or 78.1 million persons aged ≥21 years were on or eligible for cholesterol treatment. Within this group, 55.5% were currently taking cholesterol-lowering medication, and 46.6% reported making lifestyle modifications, such as exercising, dietary changes, or controlling their weight, to lower cholesterol; 37.1% reported making lifestyle modifications and taking medication, and 35.5% reported doing neither. Among adults on or eligible for cholesterol-lowering medication, the proportion taking cholesterol-lowering medication was higher for women than men and for non-Hispanic whites (whites) than Mexican-Americans and non-Hispanic blacks (blacks). Further efforts by clinicians and public health practitioners are needed to implement complementary and targeted patient education and disease management programs to reduce sex and racial/ethnic disparities among adults eligible for treatment of cholesterol.

Gender- and race-specific metabolic score and cardiovascular disease mortality in adults: A structural equation modeling approach--United States, 1988-2006.

OBJECTIVE: Consider all metabolic syndrome (MetS) components [systolic (SBP) and diastolic (DBP) blood pressures, waist circumference, HDL cholesterol, triglycerides (TG), and fasting glucose] and gender/race differential risk when assessing cardiovascular disease (CVD) risk. METHODS: We estimated a gender- and race-specific continuous MetS score using structural equation modeling and tested its association with CVD mortality using data from National Health and Nutrition Examination Survey III linked with the National Death Index. Cox proportional hazard regression tested the association adjusted for sociodemographic and behavior characteristics. RESULTS: For men, continuous MetS components associated with CVD mortality were SBP (hazard ratio = 1.50, 95% confidence interval = 1.14-1.96), DBP (1.48, 1.16-1.90), and TG (1.15, 1.12-1.16). In women, SBP (1.44, 1.27-1.63) and DBP (1.24, 1.02-1.51) were associated with CVD mortality. MetS score was not significantly associated with CVD mortality in men; but significant associations were found for all women (1.34, 1.06-1.68), non-Hispanic white women (1.29, 1.01-1.64), non-Hispanic black women (2.03, 1.12-3.69), and Mexican-American women (3.57, 2.21-5.76). Goodness-of-fit and concordance were overall better for models with the MetS score than MetS (yes/no). CONCLUSIONS: When assessing CVD mortality risk, MetS score provided additional information than MetS (yes/no).

Difference between 24-h diet recall and urine excretion for assessing population sodium and potassium intake in adults aged 18-39 y.

BACKGROUND: Limited data are available on the accuracy of 24-h dietary recalls used to monitor US sodium and potassium intakes. OBJECTIVE: We examined the difference in usual sodium and potassium intakes estimated from 24-h dietary recalls and urine collections. DESIGN: We used data from a cross-sectional study in 402 participants aged 18-39 y (∼50% African American) in the Washington, DC, metropolitan area in 2011. We estimated means and percentiles of usual intakes of daily dietary sodium (dNa) and potassium (dK) and 24-h urine excretion of sodium (uNa) and potassium (uK). We examined Spearman's correlations and differences between estimates from dietary and urine measures. Multiple linear regressions were used to evaluate the factors associated with the difference between dietary and urine measures. RESULTS: Mean differences between diet and urine estimates were higher in men [dNa - uNa (95% CI) = 936.8 (787.1, 1086.5) mg/d and dK - uK = 571.3 (448.3, 694.3) mg/d] than in women [dNa - uNa (95% CI) = 108.3 (11.1, 205.4) mg/d and dK - uK = 163.4 (85.3, 241.5 mg/d)]. Percentile distributions of diet and urine estimates for sodium and potassium differed for men. Spearman's correlations between measures were 0.16 for men and 0.25 for women for sodium and 0.39 for men and 0.29 for women for potassium. Urinary creatinine, total caloric intake, and percentages of nutrient intake from mixed dishes were independently and consistently associated with the differences between diet and urine estimates of sodium and potassium intake. For men, body mass index was also associated. Race was associated with differences in estimates of potassium intake. CONCLUSIONS: Low correlations and differences between dietary and urinary sodium or potassium may be due to measurement error in one or both estimates. Future analyses using these methods to assess sodium and potassium intake in relation to health outcomes may consider stratifying by factors associated with the differences in estimates from these methods. This trial was registered at clinicaltrials.gov as NCT01631240.

Lung function and metabolic syndrome: Findings of National Health and Nutrition Examination Survey 2007­2010.

BACKGROUND: Considerable uncertainty remains about obstructive lung function( OLF) in adults with metabolic syndrome (MetS). The aim of the present study was to examine pulmonary function status in adults with and without MetS. METHODS: We used data from 3109 participants aged ≥20 years of the National Health and Nutrition Examination Survey 2007-2010. Subjects'MetS status was established on the basis of the 2009 harmonizing definition. Participants received spirometry. RESULTS: After age adjustment, 79.3% (SE 1.1) of participants with MetS had normal lung function, 8.7% (0.9) had restrictive lung function (RLF), 7.1% (0.8) had mild OLF, and 4.8% (0.6) had moderate OLF or worse. Among participants without MetS, these estimates were 78.7% (1.2), 3.9% (0.6), 10.9%(1.1), and 6.4% (0.8), respectively. After multiple adjustment, participants with MetS were more likely to have RLF (adjusted prevalence ratio [aPR] 2.20; 95% confidence interval [CI] 1.67, 2.90) and less likely to have any OLF (aPR 0.73; 95% CI 0.62, 0.86) than those without MetS. Furthermore, participants with MetS had lower mean levels of forced expiratory volume in one second (FEV1), FEV1 % predicted, forced vital capacity (FVC), and FVC % predicted, but a higher FEV1/FVC ratio than participants without MetS. Mean levels of FEV1, FEV1 % predicted, FVC, and FVC % predicted declined significantly, but not the FEV1/FVC ratio, as the number of components increased. CONCLUSIONS: Compared with adults without MetS, spirometry is more likely to show a restrictive pattern and less likely to show an obstructive pattern among adults with MetS.