Adverse Pregnancy Outcomes and Postpartum Care as a Pathway to Future Health.

Adverse pregnancy outcomes (APOs) collectively represent the leading causes of maternal and neonatal morbidity and mortality. Beyond the potentially devastating impact of APOs during pregnancy and the puerperium, women diagnosed with APOs have a 2-fold to 4-fold increased risk of future cardiovascular disease. Fortunately, APOs occur at an opportune time, in early-adulthood to mid-adulthood, when primary and secondary prevention strategies can alter the disease trajectory and improve long-term health outcomes. This chapter takes a life-course approach to (1) the epidemiology of APOs, (2) evidence-based strategies for clinicians to manage APOs, and (3) future directions for APO research and clinical practice.

Understanding Gestational Diabetes, Future Diabetes Risk, and Diabetes Prevention: A Qualitative Study of Patient, Provider, and Staff Perspectives.

Gestational diabetes mellitus (GDM) increases type 2 diabetes risk; however, postpartum diabetes screening rates are low. Using semi-structured interviews and focus groups, this study investigates the understanding of GDM and its relationship to future diabetes risk and diabetes prevention among patients with public or no insurance (n = 36), health care providers (n = 21), and clinic staff (n = 9) from Federally Qualified Health Centers. Five main themes emerged: 1) general understanding of GDM diagnosis with focus on neonatal complications; 2) variable recall of diet, exercise, and weight recommendations; 3) overwhelming medication and self-monitoring routines; 4) short-term focus of type 2 diabetes risk and screening; and 5) limited understanding of all options for diabetes prevention. The results may inform diabetes screening and prevention interventions in primary care settings.

Obesity-related multimorbidity and risk of cardiovascular disease in the middle-aged population in the United States.

To investigate the prevalence of obesity-related multimorbidity (co-occurrence of ≥2 obesity-related chronic diseases, ORCDs) and the risk of cardiovascular disease in the presence of multimorbidity in middle-aged adults in the United States. National Health and Nutrition Examination Survey data from 2007 to 2016 were used. Target ORCDs included hypertension (H), diabetes (D), coronary heart disease (C), and stroke (S). Age-standardized prevalence for obesity-related multimorbidity in its combination and permutation was calculated. Risk for cardiovascular disease (C or S) was estimated conditional on demographics, degree of obesity, and presence and duration of pre-existing ORCDs. Analyses were conducted at Washington University in 2019. The analytic sample included 14,243 individuals age 40-79 years, representing a population size of 110,003,550. Age-standardized prevalence for obesity-related multimorbidity was 12.3%. Hypertension was most commonly the first diagnosed ORCD for populations with 2-4 ORCDs, followed by diabetes for populations with 2-3 ORCDs. Compared with no pre-existing hypertension/diabetes/stroke, pre-existing hypertension in combination with diabetes/stroke significantly increased risk of coronary heart disease [H + S (multivariable-adjusted hazard ratio, aHR 27.6, 95% CI 10.9-70.2), D + H + S (aHR 20.3, 95% CI 7.9-52.2)]. Compared with no hypertension/diabetes/coronary heart disease, pre-existing hypertension in combination with diabetes/coronary heart disease significantly increased risk of stroke [C + D + H (aHR 32.6, 95% CI 12.2-87.1), C + H (aHR 25.4, 95% CI 12.1-53.6), D + H (aHR 5.3, 95% CI 2.6-10.8)]. Obesity-related multimorbidity is prevalent and highly associated with cardiovascular disease development. To reduce the detrimental health impact of multimorbidity, intervention strategies should target preventing increasing multimorbidity and detecting/managing diabetes and hypertension prior to the onset of cardiovascular disease.

Postpartum diabetes screening among low income women with gestational diabetes in Missouri 2010-2015.

BACKGROUND: Gestational diabetes increases risk for type 2 diabetes seven-fold, creating a large public health burden in a young population. In the US, there are no large registries for tracking postpartum diabetes screening among women in under-resourced communities who face challenges with access to care after pregnancy. Existing data from Medicaid claims is limited as women often lose this coverage within months of delivery. In this study, we aim to leverage data from electronic health records and administrative claims to better assess postpartum diabetes screening rates among low income women. METHODS: A retrospective population of 1078 women with gestational diabetes who delivered between 1/1/2010 and 10/8/2015 was generated by linking electronic health record data from 21 Missouri Federally Qualified Health Centers (FQHCs) with Medicaid administrative claims. Screening rates for diabetes were calculated within 12 weeks and 1 year of delivery. Initial screening after the first postpartum year was also documented. RESULTS: Median age in the final population was 28 (IQR 24-33) years with over-representation of black non-Hispanic and urban women. In the final population, 9.7% of women had a recommended diabetes screening test within 12 weeks and 18.9% were screened within 1 year of delivery. An additional 125 women received recommended screening for the first time beyond 1 year postpartum. The percentage of women who had a postpartum visit (83.9%) and any glucose testing (40.6%) in the first year far exceeded the proportion of women with recommended screening tests. CONCLUSIONS: Linking electronic health record and administrative claims data provides a more complete picture of healthcare follow-up among low income women after gestational diabetes. While screening rates are higher than reported with claims data alone, there are opportunities to improve adherence to screening guidelines in this population.

Implications of supermarket access, neighbourhood walkability and poverty rates for diabetes risk in an employee population.

OBJECTIVE: Diabetes is a growing public health problem, and the environment in which people live and work may affect diabetes risk. The goal of the present study was to examine the association between multiple aspects of environment and diabetes risk in an employee population. DESIGN: This was a retrospective cross-sectional analysis. Home environment variables were derived using employees' zip code. Descriptive statistics were run on all individual- and zip-code-level variables, stratified by diabetes risk and worksite. A multivariable logistic regression analysis was then conducted to determine the strongest associations with diabetes risk. SETTING: Data were collected from employee health fairs in a Midwestern health system, 2009-2012. SUBJECTS: The data set contains 25 227 unique individuals across four years of data. From this group, using an individual's first entry into the database, 15 522 individuals had complete data for analysis. RESULTS: The prevalence of high diabetes risk in this population was 2·3 %. There was significant variability in individual- and zip-code-level variables across worksites. From the multivariable analysis, living in a zip code with higher percentage of poverty and higher walk score was positively associated with high diabetes risk, while living in a zip code with higher supermarket density was associated with a reduction in high diabetes risk. CONCLUSIONS: Our study underscores the important relationship between poverty, home neighbourhood environment and diabetes risk, even in a relatively healthy employed population, and suggests a role for the employer in promoting health.

New Pharmacologic Agents for Diabetes Treatment.

Therapeutic options for diabetes management have expanded dramatically in the last five years. While there continues to be consensus that lifestyle modification aimed at 5-7% weight loss and metformin are the appropriate first line therapies for type 2 diabetes, there are many options for intensification of diabetes management. The American Diabetes Association (ADA) and the American Association of Clinical Endocrinologists (AACE) have released recent guidelines that prioritize use of the newer classes of medications.1,2 There are a number of considerations in selecting medications, including risk of hypoglycemia, effect on body weight, adverse event profile, renal function, and cost/insurance coverage. The objective of this article is to discuss mechanism, efficacy, and safety for each new class of medications. We conclude with a quick reference for the use of these medications in primary and specialty care, based on their various attributes and patient and provider preferences.

Outside the exam room: policies for connecting clinic to community in diabetes prevention and treatment.

The public health burden and racial/ethnic, sex, and socioeconomic disparities in obesity and in diabetes require a population-level approach that goes beyond provision of high-quality clinical care. The Robert Wood Johnson Foundation's Commission to Build a Healthier America recommended 3 strategies for improving the nation's health: 1) invest in the foundations of lifelong physical and mental well-being in our youngest children; 2) create communities that foster health-promoting behaviors; and 3) broaden health care to promote health outside the medical system. We present an overview of evidence supporting these approaches in the context of diabetes and suggest policies to increase investments in 1) adequate nutrition through breastfeeding and other supports in early childhood, 2) community and economic development that includes health-promoting features of the physical, food, and social environments, and 3) evidence-based interventions that reach beyond the clinical setting to enlist community members in diabetes prevention and management.

Enhancing workplace wellness efforts to reduce obesity: a qualitative study of low-wage workers in St Louis, Missouri, 2013-2014.

INTRODUCTION: The objective of this study was to examine workplace determinants of obesity and participation in employer-sponsored wellness programs among low-wage workers. METHODS: We conducted key informant interviews and focus groups with 2 partner organizations: a health care employer and a union representing retail workers. Interviews and focus groups discussed worksite factors that support or constrain healthy eating and physical activity and barriers that reduce participation in workplace wellness programs. Focus group discussions were transcribed and coded to identify main themes related to healthy eating, physical activity, and workplace factors that affect health. RESULTS: Although the union informants recognized the need for workplace wellness programs, very few programs were offered because informants did not know how to reach their widespread and diverse membership. Informants from the health care organization described various programs available to employees but noted several barriers to effective implementation. Workers discussed how their job characteristics contributed to their weight; irregular schedules, shift work, short breaks, physical job demands, and food options at work were among the most commonly discussed contributors to poor eating and exercise behaviors. Workers also described several general factors such as motivation, time, money, and conflicting responsibilities. CONCLUSION: The workplace offers unique opportunities for obesity interventions that go beyond traditional approaches. Our results suggest that modifying the physical and social work environment by using participatory or integrated health and safety approaches may improve eating and physical activity behaviors. However, more research is needed about the methods best suited to the needs of low-wage workers.

The Impact of Behavior Change Counseling Delivered via a Digital Health Tool Versus Routine Care Among Adolescents With Obesity: Pilot Randomized Feasibility Study.

BACKGROUND: Youth overweight and obesity is a public health crisis and increases the risk of poor cardiovascular health (CVH) and chronic disease. Health care providers play a key role in weight management, yet few tools exist to support providers in delivering tailored evidence-based behavior change interventions to patients. OBJECTIVE: The goal of this pilot randomized feasibility study was to determine the feasibility of implementing the Patient-Centered Real-Time Intervention (PREVENT) tool in clinical settings, generate implementation data to inform scale-up, and gather preliminary effectiveness data. METHODS: A pilot randomized clinical trial was conducted to examine the feasibility, implementation, and preliminary impact of PREVENT on patient knowledge, motivation, behaviors, and CVH outcomes. The study took place in a multidisciplinary obesity management clinic at a children's hospital within an academic medical center. A total of 36 patients aged 12 to 18 years were randomized to use PREVENT during their routine visit (n=18, 50%) or usual care control (n=18, 50%). PREVENT is a digital health tool designed for use by providers to engage patients in behavior change education and goal setting and provides resources to support change. Patient electronic health record and self-report behavior data were collected at baseline and 3 months after the intervention. Implementation data were collected via PREVENT, direct observation, surveys, and interviews. We conducted quantitative, qualitative, and mixed methods analyses to evaluate pretest-posttest patient changes and implementation data. RESULTS: PREVENT was feasible, acceptable, easy to understand, and helpful to patients. Although not statistically significant, only PREVENT patients increased their motivation to change their behaviors as well as their knowledge of ways to improve heart health and of resources. Compared to the control group, PREVENT patients significantly improved their overall CVH and blood pressure (P<.05). CONCLUSIONS: Digital tools can support the delivery of behavior change counseling in clinical settings to increase knowledge and motivate patients to change their behaviors. An appropriately powered trial is necessary to determine the impact of PREVENT on CVH behaviors and outcomes. TRIAL REGISTRATION: ClinicalTrials.gov NCT06121193; https://www.clinicaltrials.gov/study/NCT06121193.

Effectiveness and Safety of Different Estradiol Regimens in Transgender Females: A Randomized Controlled Trial.

Background: A goal of gender-affirming hormone therapy (GAHT) for transgender women is to use estradiol to suppress endogenous production of testosterone. However, the effects of different estradiol regimens and route of administration on testosterone suppression is unknown. This is the first open-label randomized trial comparing different GAHT regimens for optimal estradiol route and dosing. Objective: To evaluate 1 month and 6 months testosterone suppression <50 ng/dL with pulsed (once- or twice-daily sublingual 17-beta estradiol) and continuous (transdermal 17-beta estradiol) GAHT. Methods: This study was conducted at an outpatient adult transgender clinic. Thirty-nine transgender women undergoing initiation of GAHT were randomly assigned to receive either once-daily sublingual, twice-daily sublingual, or transdermal 17-beta estradiol. All participants received spironolactone as an antiandrogen. Doses were titrated at monthly intervals to achieve total testosterone suppression <50 ng/dL. Results: Transdermal 17-beta estradiol resulted in more rapid suppression of total testosterone, lower estrone levels, with no differences in estradiol levels when compared to once-daily and twice-daily sublingual estradiol. Moreover, there was no difference in the mean estradiol dose between the once-daily and twice-daily sublingual 17-beta estradiol group. Conclusion: Continuous exposure with transdermal 17-beta estradiol suppressed testosterone production more effectively and with lower overall estradiol doses relative to once or twice daily sublingual estradiol. Most transgender women achieved cisgender women testosterone levels within 2 months on 1 or 2 0.1 mg/24 hours estradiol patches. Given no difference between once- or twice-daily sublingual estradiol, pulsed 17-beta estradiol likely provides no benefit for testosterone suppression.

Food insecurity, SNAP participation and glycemic control in low-income adults with predominantly type 2 diabetes: a cross-sectional analysis using NHANES 2007-2018 data.

INTRODUCTION: Diabetes, characterized by elevated blood glucose levels, affects 13% of US adults, 95% of whom have type 2 diabetes (T2D). Social determinants of health (SDoH), such as food insecurity, are integral to glycemic control. The Supplemental Nutrition Assistance Program (SNAP) aims to reduce food insecurity, but it is not clear how this affects glycemic control in T2D. This study investigated the associations between food insecurity and other SDoH and glycemic control and the role of SNAP participation in a national socioeconomically disadvantaged sample. RESEARCH DESIGN AND METHODS: Adults with likely T2D and income <185% of the federal poverty level (FPL) were identified using cross-sectional National Health and Nutrition Examination Survey (NHANES) data (2007-2018). Multivariable logistic regression assessed the association between food insecurity, SNAP participation and glycemic control (defined by HbA1c 7.0%-8.5% depending on age and comorbidities). Covariates included demographic factors, clinical comorbidities, diabetes management strategies, and healthcare access and utilization. RESULTS: The study population included 2084 individuals (90% >40 years of age, 55% female, 18% non-Hispanic black, 25% Hispanic, 41% SNAP participants, 36% low or very low food security). Food insecurity was not associated with glycemic control in the adjusted model (adjusted OR (aOR) 1.181 (0.877-1.589)), and SNAP participation did not modify the effect of food insecurity on glycemic control. Insulin use, lack of health insurance, and Hispanic or another race and ethnicity were among the strongest associations with poor glycemic control in the adjusted model. CONCLUSIONS: For low-income individuals with T2D in the USA, health insurance may be among the most critical predictors of glycemic control. Additionally, SDoH associated with race and ethnicity plays an important role. SNAP participation may not affect glycemic control because of inadequate benefit amounts or lack of incentives for healthy purchases. These findings have implications for community engaged interventions and healthcare and food policy.

The adoption of social determinants of health documentation in clinical settings.

OBJECTIVE: To understand the frequency of social determinants of health (SDOH) diagnosis codes (Z-codes) within the electronic health record (EHR) for patients with prediabetes and diabetes and examine factors influencing the adoption of SDOH documentation in clinical care. DATA SOURCES: EHR data and qualitative interviews with health care providers and stakeholders. STUDY DESIGN: An explanatory sequential mixed methods design first examined the use of Z-codes within the EHR and qualitatively examined barriers to documenting SDOH. Data were integrated and interpreted using a joint display. This research was informed by the Framework for Dissemination and Utilization of Research for Health Care Policy and Practice. DATA COLLECTION/EXTRACTION METHODS: We queried EHR data for patients with a hemoglobin A1c > 5.7 between October 1, 2015 and September 1, 2020 (n = 118,215) to examine the use of Z-codes and demographics and outcomes for patients with and without social needs. Semi-structured interviews were conducted with 23 participants (n = 15 health care providers; n = 7 billing and compliance stakeholders). The interview questions sought to understand how factors at the innovation-, individual-, organizational-, and environmental-level influence SDOH documentation. We used thematic analysis to analyze interview data. PRINCIPAL FINDINGS: Patients with social needs were disproportionately older, female, Black, uninsured, living in low-income and high unemployment neighborhoods, and had a higher number of hospitalizations, obesity, prediabetes, and type 2 diabetes than those without a Z-code. Z-codes were not frequently used in the EHR (<1% of patients), and there was an overall lack of congruence between quantitative and qualitative results related to the prevalence of social needs. Providers faced barriers at multiple levels (e.g., individual-level: discomfort discussing social needs; organizational-level: limited time, competing priorities) for documenting SDOH and identified strategies to improve documentation. CONCLUSIONS: Providers recognized the impact of SDOH on patient health and had positive perceptions of screening for and documenting social needs. Implementation strategies are needed to improve systematic documentation.

Gestational diabetes knowledge improves with interactive online training modules: a pre-post analysis.

Background: The risk of developing type 2 diabetes mellitus (T2DM) is up to 50% among women with gestational diabetes mellitus (GDM). GDM also increases risks for pre-term birth, macrosomia, fetal hypoglycemia, and C-section delivery. Education for expectant mothers with GDM about nutrition, exercise, and the risks of developing T2DM after delivery enhances the probability of postpartum diabetes screening. However, the availability of diabetes education is limited. To bridge this gap, our team developed four training modules on GDM tailored for nurses and community health workers. This pilot study assesses changes in knowledge, self-efficacy for providing diabetes education, attitudes, and intentions to recommend diabetes prevention before and after training completion. Methods: These interactive online modules, each lasting 45-60 minutes and featuring engaging case studies and integrated knowledge assessment questions, were disseminated through various professional organizations to clinical staff providing care for women with GDM. Optional pre- and post-training surveys were conducted to gauge the effectiveness of the modules. Collected data did not follow a normal distribution pattern. We provided an overview of the baseline characteristics of the population, self-efficacy, attitudes, intentions, and GDM knowledge by calculating the median scores and interquartile ranges. We assessed the changes in scores on self-efficacy, attitudes, intentions, and GDM knowledge before and after training using non-parametric Wilcoxon matched-pair signed rank tests. Results: Eighty-two individuals completed baseline evaluation and 20 individuals accessed all modules and completed post-training assessments. Among those completing the training, improvement was noted in GDM knowledge [56.5% (16.0) v. 78.3% (22.0), p < 0.001], Self-efficacy for providing diabetes education [6.60 (2.73) v. 9.33 (0.87), p < 0.001], attitudes toward the value of tight control [4.07 (0.79) v. 4.43 (0.86), p = 0.003], and intentions to recommend diabetes prevention measures [4.81 (0.63) v. 5.00 (0.00), p = 0.009)]. Conclusions: Completion of our interactive online modules improved knowledge, intention to recommend diabetes prevention methods, self-efficacy to provide diabetes education, and attitudes toward the value of tight control among individuals caring for women with GDM. Enhanced accessibility to such curricula is crucial to improve access to diabetes education. Trial registration: This study was registered at clinicaltrials.gov, identifier: NCT04474795.

Effectiveness and Safety of Different Estradiol Regimens in Transgender Women (TREAT Study): Protocol for a Randomized Controlled Trial.

BACKGROUND: Current guidelines for gender-affirming hormone therapy (GAHT) for transgender women are mostly based on clinical experience from experts in the field and treatments used on postmenopausal women. While care is currently provided with the best available evidence, there is a critical gap in knowledge about the safest and most effective estradiol routes of administration for GAHT in transgender women; this statement is supported by the World Professional Association for Transgender Health on their Standards of Care for the Health of Transgender and Gender Diverse People, version 8. Furthermore, the reported rates of cardiometabolic adverse events in transgender women highlight the importance of investigating changes in lipoproteins, glucose, and insulin sensitivity, among other markers while receiving GAHT. OBJECTIVE: This study aims to evaluate the degree of testosterone suppression achieved at 1, 6, and 12 months in treatment-naive transgender women when randomized to GAHT with estradiol and spironolactone as antiandrogens. As a secondary aim, this study will assess the treatment effect on metabolic and coagulation factors from baseline to 6 and 12 months after initiating GAHT. METHODS: This is a prospective pilot, open-label, randomized clinical trial conducted at an adult transgender clinic in a tertiary medical center. The 3 treatment arms include once-daily sublingual 17-ß estradiol, twice-daily sublingual 17-ß estradiol, and transdermal 17-ß estradiol. All participants received spironolactone as an antiandrogen. Transgender women aged 18 to 45 years who are being evaluated for the initiation of GAHT with 17-ß estradiol and did not have a history of coagulopathy, cigarette smoking, liver disease, dyslipidemia requiring treatment, or use of gonadotropin-releasing hormone agonist were eligible to enroll. The main outcome is the total testosterone suppression at 1 and 6 months after the initiation of GAHT, and the secondary outcome is to assess treatment effect in a lipid panel; homeostatic model assessment for insulin resistance; coagulation factors II, IX, and XI; Von Willebrand factor; activated protein C resistance; protein C; and protein S at baseline, 6 months, and 12 months after therapy is initiated. RESULTS: This study was funded in March 2022, and enrollment concluded in August 2022. It was concluded in July 2023, and currently, the results are being analyzed for publication. CONCLUSIONS: The Transgender Estradiol Affirming Therapy (TREAT) study offers a rigorous and reproducible approach to answer important questions regarding GAHT in transgender women, specifically, the most effective 17-ß estradiol regimen to suppress testosterone levels to 50 ng/dL, as currently recommended. TRIAL REGISTRATION: ClinicalTrials.gov NCT05010707; https://clinicaltrials.gov/study/NCT05010707. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/53092.

Constructing an Adapted Cascade of Diabetes Care Using Inpatient Admissions Data: Cross-sectional Study.

BACKGROUND: The diabetes mellitus cascade of care has been constructed to evaluate diabetes care at a population level by determining the percentage of individuals diagnosed and linked to care as well as their reported glycemic control. OBJECTIVE: We sought to adapt the cascade of care to an inpatient-only setting using the electronic health record (EHR) data of 81,633 patients with type 2 diabetes. METHODS: In this adaptation, linkage to care was defined as prescription of diabetes medications within 3 months of discharge, and control was defined as hemoglobin A1c (HbA1c) below individual target levels, as these are the most reliably captured items in the inpatient setting. We applied the cascade model to assess differences in demographics and percent loss at each stage of the cascade; we then conducted two-sample chi-square equality of proportions tests for each demographic. Based on findings in the previous literature, we hypothesized that women, Black patients, younger patients (<45 years old), uninsured patients, and patients living in an economically deprived area called the Promise Zone would be disproportionately unlinked and uncontrolled. We also predicted that patients who received inpatient glycemic care would be more likely to reach glycemic control. RESULTS: We found that out of 81,633 patients, 28,716 (35.2%) were linked to care via medication prescription. Women and younger patients were slightly less likely to be linked to care than their male and older counterparts, while Black patients (n=19,141, 23.4% of diagnosed population vs n=6741, 23.5% of the linked population) were as proportionately part of the linked population as White patients (n=58,291, 71.4% of diagnosed population vs n=20,402, 71.0% of the linked population). Those living in underserved communities (ie, the Promise Zone) and uninsured patients were slightly overrepresented (n=6789, 8.3% of diagnosed population vs n=2773, 9.7% of the linked population) in the linked population as compared to patients living in wealthier zip codes and those who were insured. Similar patterns were observed among those more likely to reach glycemic control via HbA1c. However, conclusions are limited by the relatively large amount of missing glycemic data. CONCLUSIONS: We conclude that inpatient EHR data do not adequately capture the care cascade as defined in the outpatient setting. In particular, missing data in this setting may preclude assessment of glycemic control. Future work should integrate inpatient and outpatient data sources to complete the picture of diabetes care.

Associations among social needs, health and healthcare utilization, and desire for navigation services among US Medicaid beneficiaries with type 2 diabetes.

The purpose of this study was to better understand the number and types of social needs experienced by Medicaid beneficiaries with type 2 diabetes, and how their social needs are associated with key health indicators. Also examined were factors that influence patients' interest in navigation services for health and social needs to inform future interventions and service delivery. The study expands upon prior research, much of which has focused on only one social need (e.g., food insecurity) or one health outcome. The hypothesis was that among individuals with type 2 diabetes, those with a greater number of social needs would report more health-related problems and be more interested in receiving social needs navigation services. Participants completed a cross-sectional survey by phone (n = 95) or online (n = 14). Most (85%) reported having at least one social need (M = 2.5, SD = 2.2), most commonly not having enough money for unexpected expenses (68%) or necessities like food, shelter and clothing (31%), medical costs (24%), and utilities (23%). Results supported our comprehensive conceptual model. Having more social needs was associated with greater perceived stress, diabetes distress, problems with sleep and executive and cognitive functioning, less frequent diabetes self-care activities, more days of poor mental health and activity limitations, worse self-reported health and more hospitalisations. Number of social needs also was positively associated with interest in having a social needs navigator. Social needs were not associated with days of poor physical health, BMI, self-reported A1C or smoking status. Social needs were associated with a wide range of indicators of poor health and well-being. Participants with the greatest social need burden were most open to intervention.

The Impact of Neighborhood Deprivation on Glycemic Control for Patients with Type 2 Diabetes During Pregnancy.

Background: The impact of neighborhood level factors on glycemic control and pregnancy outcomes is understudied. The primary objective was to determine whether there is an association between glycemic control during pregnancy and level of neighborhood deprivation, defined by area deprivation index (ADI). Materials and Methods: We conducted a retrospective cohort study of women with type 2 diabetes who received care at a tertiary referral center from 2007 to 2017. Patients living in more deprived neighborhoods (ADI >85th national percentile) were compared to those living in less deprived neighborhoods (ADI ≤85th percentile). The primary outcome was change in hemoglobin A1c (HbA1c) over time. Demographic characteristics were compared between groups, and trends in mean A1c through each trimester were tested with repeated measures analysis. Results: Of 237 women meeting study criteria, 93 (39.2%) lived in less deprived (low ADI) and 144 (60.8%) lived in more deprived neighborhoods (high ADI). Women living in more deprived neighborhoods were more likely to be Black (86.8% vs. 53.8%, p < 0.01), less likely to be married (11.3% vs. 31.2%, p < 0.01), and had more severe diabetes (p = 0.05). Both groups achieved significant improvement in HbA1c across each trimester using repeated measures analysis. Those living in more deprived neighborhoods had significantly more improvement in HbA1c from their initial visit to the third trimester compared to those in less deprived neighborhoods, (p = 0.01) such that there was no longer a statistically significant disparity in HbA1c by the third trimester (6.69 ± 0.97 Less deprived vs. 6.95 ± 1.22 more deprived, p = 0.19). Conclusions: Low-income women living in more deprived neighborhoods enter pregnancy with significantly worse glycemic control than those living in less deprived neighborhoods, but the gap in glycemic control largely closes by the end of pregnancy with similar maternal and neonatal outcomes.

Barriers and facilitators to diabetes screening and prevention after a pregnancy complicated by gestational diabetes.

OBJECTIVE: Gestational diabetes mellitus (GDM) is increasing in the United States, with higher rates among minoritized racial and ethnic populations and lower income populations. GDM increases risk for type 2 diabetes (T2DM), and postpartum diabetes screening and prevention are imperative. This qualitative study examines barriers and facilitators to postpartum T2DM screening and prevention among non-privately insured individuals with a history of GDM in a state prior to Medicaid expansion. METHODS: Thirty-six non-privately insured women with a history of GDM completed semi-structured interviews. Four focus groups and seven interviews were conducted with 30 nurse practitioners, physicians, physician assistants, nurses and registered dietitians from Federally Qualified Health Centers in St. Louis, MO. Interviews and focus groups were audio-recorded and transcribed. Data were analyzed using an integrative thematic analysis informed by the socio-ecological model. RESULTS: Barriers and facilitators to T2DM screening and prevention occur across multiple environments (society, healthcare system, interpersonal, and individual). Societal barriers include insurance issues, unemployment, and lack of transportation, childcare, safe housing, and healthy food access, while facilitators include government sponsored programs and community organizations. Healthcare system barriers include care fragmentation, scheduling policies and time constraints while facilitators include care coordination, pregnancy support groups, and education materials. Interpersonal barriers include negative care experiences, cultural differences, communication challenges, competing priorities, and lack of a social support network, while facilitators include family and friend support and positive care experiences. Individual barriers include health complications and unhealthy food and exercise patterns, while facilitators include child wellbeing, empowered attitudes and healthy food and exercise patterns. CONCLUSIONS: The socioecological model highlights the societal and systemic determinants that encompass individual and interpersonal factors affecting postpartum T2DM screening and prevention. This framework can inform multi-level interventions to increase postpartum T2DM screening and prevention in this high-risk population, including policy changes to alleviate higher-level barriers.

10-year weight loss outcomes after Roux-en-Y gastric bypass and attendance at follow-up visits: a single-center study.

BACKGROUND: Long-term durability of weight loss is a prerequisite for a greater acceptance of bariatric surgery. OBJECTIVES: To examine long-term weight trajectory in patients undergoing Roux-en-Y gastric bypass (RYGB) and determine factors predicting long-term follow-up and weight outcomes. SETTING: University hospital. METHODS: A retrospective cohort of adults who underwent RYGB during 1997-2010 were identified and followed until 2017. Predictors for attendance at periodic follow-up visits, reduction in body mass index (BMI), and percent excess BMI lost were determined using multivariable logistic regression and linear mixed-effects models. The latter was used to predict long-term weight outcomes for a typical patient. RESULTS: The study included 1104 patients with a mean age of 45.5 (standard deviation [SD] 9.9) years and a preoperative BMI of 54.7 (SD 10.9) kg/m2. Follow-up data were available for 92.8% of the patients after 1 year, 50.0% after 5 years, and 35.2% after 10 years post-surgery. Black patients, compared with White patients, were less likely to attend follow-up visits. Attendance at follow-up visits at least every other year was not associated with larger weight loss, but higher preoperative BMI, being White (versus Black), and female sex were. Predicted BMI reduction for a typical patient, a 45-year-old White female with a preoperative BMI of 54.7 kg/m2 and private health insurance, undergoing laparoscopic RYGB in 2004, was 18.3 (standard error [SE] .36) kg/m2 at year 5 and 17.6 (SE .49) kg/m2 at year 10. CONCLUSION: RYGB results in clinically significant and durable weight loss. Attendance at periodic follow-up visits does not appear to be associated with long-term weight loss outcomes. Future work should focus on strategies to remove barriers to post-operative care.