The CKD Stress Scale: Development and identification of patients at risk.

AIMS: Develop a novel chronic kidney disease (CKD)-specific stress scale and examine associations with patient characteristics. MATERIALS AND METHODS: Adults with CKD stages 1 - 5 enrolled in a cross-sectional survey. Eight questions assessed patients' thoughts and feelings of stress related to CKD (CKD Stress Scale). Patients also reported their knowledge of CKD, barriers to CKD health, and demographics. The scale was evaluated using exploratory factor analysis and Cronbach's alpha. Associations were examined via linear regression. RESULTS: 245 participant enrolled with a mean age of 60 years and a mean estimated glomerular filtration rate (eGFR) of 34 mL/min/1.73m2; 49% were women (match percentage in Table 1), 74% White, 14% African American. A one-factor model of CKD Stress exhibited high internal consistency (α = 0.89). In bivariate analyses, higher CKD Stress was associated with lower eGFR, younger age, African American race (compared to White), and having a high school education or some college (compared to college degree or higher). Adjusting for these characteristics, as well as income and knowledge about CKD, only lower eGFR (b = -0.01; 95% CI [-0.01, -0.001]), younger age (b = -0.01; 95% CI [-0.01, -0.003]), African American race (b = 0.35, 95% CI [0.10, 0.60]), and receiving a high school education or some college (b = 0.20, 95% CI [0.01, 0.39]) were independently associated with more CKD-specific stress. Concurrent validity was supported by associations between stress and perceived barriers to care. CONCLUSION: Our CKD Stress Scale exhibits excellent internal reliability and identified where future educational interventions may benefit from tailoring for at-risk patients.

Obstetric Deliveries in US Women With ESKD: 2002-2015.

RATIONALE & OBJECTIVE: Women with end-stage kidney disease (ESKD) have decreased fertility and are at increased risk for pregnancy complications. This study examined secular trends and outcomes of obstetric deliveries in a US cohort of women with ESKD. STUDY DESIGN: Retrospective cohort study. SETTING & PARTICIPANTS: Women aged 18 to 44 years with ESKD and registered in the US Renal Data System from 2002 to 2015. EXPOSURE: ESKD modality (hemodialysis [HD], peritoneal dialysis, transplantation). OUTCOMES: Infant delivery, preterm delivery, cesarean delivery. ANALYTICAL APPROACH: Unadjusted delivery rates were expressed as number of delivering women per 1,000 patient-years among women aged 18 to 44 years within each year during the study period, stratified by ESKD modality. Logistic regression models were used to evaluate associations of delivery, preterm delivery, and cesarean delivery with patient characteristics. RESULTS: The delivery rate in women undergoing HD and women with a kidney transplant increased from 2.1 to 3.6 and 3.1 to 4.6 per 1,000 patient-years, respectively (P<0.001 for each). The delivery rate in patients undergoing peritoneal dialysis was lower and did not increase significantly (P=0.9). Women with a transplant were less likely to deliver preterm compared with women undergoing HD (OR, 0.92; 95% CI, 0.84-1.00), though more likely have a cesarean delivery (OR, 1.18; 95% CI, 1.06-1.31). For deliveries occurring in the 2012 to 2015 period, 75% of women treated with HD were prescribed 4 or fewer outpatient HD treatments per week and 25% were prescribed 5-plus treatments per week in the 30 days before delivery. LIMITATIONS: Ascertainment of outcomes and comorbid conditions using administrative claims data. CONCLUSIONS: The delivery rate in women of reproductive age with ESKD increased from 2002 to 2015 among those treated with transplantation or HD. Women with a functioning transplant were less likely to deliver preterm, but more likely to have a cesarean delivery. Prescriptions for outpatient intensified HD for pregnant women with ESKD were infrequent in 2012 to 2015.

Patient-selected media and knowledge of risk to kidneys of nonsteroidal anti-inflammatory drugs.

OBJECTIVES: Nonsteroidal anti-inflammatory drugs (NSAIDs) can cause community-acquired acute kidney injury, especially in high-risk populations. Both the U.S. Food and Drug Administration (FDA) medication guide and over-the-counter labeling vaguely describe kidney risks of NSAIDs and do not provide information for patients to evaluate their risk for kidney problems. The purpose of this study was to use a mobile application to evaluate the impact of patient choice of media delivering NSAID avoidance education on patient knowledge about kidney risks associated with NSAIDs. DESIGN: Prospective cohort study. The mobile application was used to deliver either a redesigned FDA medication guide or a video focused on NSAID risks (selected by the patient), followed by patient knowledge questions (PKQs) and a kidney risk assessment. SETTING AND PARTICIPANTS: One hundred fifty adult primary care patients in southeast Michigan. MAIN OUTCOME MEASURES: The primary outcome was the score on 5 NSAID PKQs between the media selected. Secondary outcomes included characterization of media choice among different demographic and NSAID kidney risk groups. The relationship between kidney risk assessment and self-reported NSAID avoidance behavior also was evaluated. RESULTS: The majority of participants (72.7%) chose to review print material. Those that chose print had significantly higher PKQ scores (5 total points) compared with participants who selected the video: mean scores 4.2 ± 0.9 with print and 3.8 ± 1.0 with video (P = 0.034). Older patients (>65 years) had significantly lower PKQ scores compared with other age groups. Forty-four percent of individuals (n = 66) reported current NSAID use, and 65% stated that they would avoid NSAIDs after the selected education material. CONCLUSION: Scores for questions related to NSAID kidney risk knowledge were higher among participants who chose print compared with video education material. Education regarding NSAID kidney risks encouraged patients to limit their use. Targeted education may be beneficial in high-risk (e.g., older) patients and should be further studied.

The Perceived Medical Condition Self-Management Scale can be applied to patients with chronic kidney disease.

Chronic Kidney Disease (CKD) is a major burden on patients and the health care system. Treatment of CKD requires dedicated involvement from both caretakers and patients. Self-efficacy, also known as perceived competence, contributes to successful maintenance of patient's CKD self-management behaviors such as medication adherence and dietary regulations. Despite a clear association between self-efficacy and improved CKD outcomes, there remains a lack of validated self-report measures of CKD self-efficacy. To address this gap, the Perceived Kidney/Dialysis Self-Management Scale (PKDSMS) was adapted from the previously validated Perceived Medical Condition Self-Management Scale. We then sought to validate this using data from two separate cohorts: a cross-sectional investigation of 146 patients with end-stage renal disease receiving maintenance hemodialysis and a longitudinal study of 237 patients with CKD not receiving dialysis. The PKDSMS was found to be positively and significantly correlated with self-management behaviors and medication adherence in both patient cohorts. The PKDSMS had acceptable reliability, was internally consistent, and exhibited predictive validity between baseline PKDSMS scores and self-management behaviors across multiple time points. Thus, the PKDSMS is a valid and reliable measure of CKD patient self-efficacy and supports the development of interventions enhancing perceived competence to improve CKD self-management.

A diagnosis of chronic kidney disease: despite fears patients want to know early.

AIMS: We elicited input from patients on their experience getting a chronic kidney disease (CKD) diagnosis to use for optimizing current CKD education interventions. METHODS: We performed structured oneon-one patient interviews. Interviews were recorded, transcribed, and coded using modified grounded theory. Participants had CKD, were not on dialysis, and were recruited from general nephrology practices. RESULTS: 49 patients enrolled from January to October 2014. Interviews revealed four major themes: 1. Reaction to diagnosis - patients described emotional reactions and subsequent behavior changes (152 statements); 2. Timing of diagnosis - patients described how they were told about their diagnosis and expectations of when a person should be told (149 statements); 3. Mediators in diagnosis delivery - patients discussed things that helped or hindered understanding and acceptance of their diagnosis (64 statements), and 4. Perceptions of diagnosis terminology - patients discussed perceptions about diagnostic terms (e.g., "chronic kidney disease") (91 statements). Cross-sectional study design and setting limit interpretation of causality and generalizability. CONCLUSIONS: Patients experience fear but prefer early diagnosis communication. More work is needed to define evidence-based guidelines for diagnosis messaging across the spectrum of care.

Healthy lifestyle and risk of kidney disease progression, atherosclerotic events, and death in CKD: findings from the Chronic Renal Insufficiency Cohort (CRIC) Study.

BACKGROUND: In general populations, healthy lifestyle is associated with fewer adverse outcomes. We estimated the degree to which adherence to a healthy lifestyle decreases the risk of renal and cardiovascular events among adults with chronic kidney disease (CKD). STUDY DESIGN: Prospective cohort. SETTING & PARTICIPANTS: 3,006 adults enrolled in the Chronic Renal Insufficiency Cohort (CRIC) Study. PREDICTORS: 4 lifestyle factors (regular physical activity, body mass index [BMI] of 20-<25kg/m(2), nonsmoking, and "healthy diet"), individually and in combination. OUTCOMES: CKD progression (50% decrease in estimated glomerular filtration rate or end-stage renal disease), atherosclerotic events (myocardial infarction, stroke, or peripheral arterial disease), and all-cause mortality. MEASUREMENTS: Multivariable-adjusted Cox proportional hazards. RESULTS: During a median follow-up of 4 years, we observed 726 CKD progression events, 355 atherosclerotic events, and 437 deaths. BMI≥25kg/m(2) and nonsmoking were associated with reduced risk of CKD progression (HRs of 0.75 [95% CI, 0.58-0.97] and 0.61 [95% CI, 0.45-0.82] for BMIs of 25 to <30 and ≥30kg/m(2), respectively, versus 20 to <25kg/m(2); HR for nonsmoking of 0.68 [95% CI, 0.55-0.84] compared to the current smoker reference group) and reduced risk of atherosclerotic events (HRs of 0.67 [95% CI, 0.46-0.96] for BMI of 25-<30 vs 20-<25kg/m(2) and 0.55 [95% CI, 0.40-0.75] vs current smoker). Factors associated with reduced all-cause mortality were regular physical activity (HR, 0.64 [95% CI, 0.52-0.79] vs inactive), BMI≥30kg/m(2) (HR, 0.64 [95% CI, 0.43-0.96] vs 20-<25kg/m(2)), and nonsmoking (HR, 0.45 [95% CI, 0.34-0.60] vs current smoker). BMI<20kg/m(2) was associated with increased all-cause mortality risk (HR, 2.11 [95% CI, 1.13-3.93] vs 20-<25kg/m(2)). Adherence to all 4 lifestyle factors was associated with a 68% lower risk of all-cause mortality compared to adherence to no lifestyle factors (HR, 0.32; 95% CI, 0.11-0.89). LIMITATIONS: Lifestyle factors were measured only once. CONCLUSIONS: Regular physical activity, nonsmoking, and BMI≥25kg/m(2) were associated with lower risk of adverse outcomes in this cohort of individuals with CKD.

Results of a novel screening tool measuring dietary sodium knowledge in patients with chronic kidney disease.

BACKGROUND: Reducing dietary sodium has potential to benefit patients with chronic kidney disease (CKD). Little research is available defining dietary sodium knowledge gaps in patients with pre-dialysis CKD. We designed a brief screening tool to rapidly identify patient knowledge gaps related to dietary sodium for patients with CKD not yet on dialysis. METHODS: A Short Sodium Knowledge Survey (SSKS) was developed and administered to patients with pre-dialysis CKD. We also asked patients if they received counseling on dietary sodium reduction and about recommended intake limits. We performed logistic regression to examine the association between sodium knowledge and patient characteristics. Characteristics of patients who answered all SSKS questions correctly were compared to those who did not. RESULTS: One-hundred fifty-five patients were surveyed. The mean (SD) age was 56.6 (15.1) years, 84 (54%) were men, and 119 (77%) were white. Sixty-seven patients (43.2%) correctly identified their daily intake sodium limit. Fifty-eight (37.4%) were unable to answer all survey questions correctly. In analysis adjusted for age, sex, race, education, health literacy, CKD stage, self-reported hypertension and attendance in a kidney education class, women and patients of non-white race had lower odds of correctly answering survey questions (0.36 [0.16,0.81]; p = 0.01 women versus men and 0.33 [0.14,0.76]; p = 0.01 non-white versus white, respectively). CONCLUSIONS: Our survey provides a mechanism to quickly identify dietary sodium knowledge gaps in patients with CKD. Women and patients of non-white race may have knowledge barriers impeding adherence to sodium reduction advice.

Pilot study of a physician-delivered education tool to increase patient knowledge about CKD.

BACKGROUND: Limited research exists on physician-delivered education interventions. We examined the feasibility and impact of an educational tool on facilitating physician-patient kidney disease communication. STUDY DESIGN: Pilot feasibility clinical trial with a historical control to examine effect size on patient knowledge and structured questions to elicit physician and patient feedback. SETTING & PARTICIPANTS: Adults with chronic kidney disease (CKD) stages 1-5, seen in nephrology clinic. INTERVENTION: 1-page educational worksheet, reviewed by physicians with patients. OUTCOMES: Kidney knowledge between patient groups and provider/patient feedback. MEASUREMENTS: Patient kidney knowledge was measured using a previously validated questionnaire compared between patients receiving the intervention (April to October 2010) and a historical cohort (April to October 2009). Provider input was obtained using structured interviews. Patient input was obtained through survey questions. Patient characteristics were abstracted from the medical record. RESULTS: 556 patients were included, with 401 patients in the historical cohort and 155 receiving the intervention. Mean age was 57 ± 16 (SD) years, with 53% men, 81% whites, and 78% with CKD stages 3-5. Compared with the historical cohort, patients receiving the intervention had higher adjusted odds of knowing they had CKD (adjusted OR, 2.20; 95% CI, 1.16-4.17; P = 0.02), knowing their kidney function (adjusted OR, 2.25; 95% CI, 1.27-3.97; P = 0.005), and knowing their stage of CKD (adjusted OR, 3.22; 95% CI, 1.49-6.92; P = 0.003). Physicians found the intervention tool easy and feasible to integrate into practice and 98% of patients who received the intervention recommended it for future use. LIMITATIONS: Study design did not randomly assign patients for comparison and enrollment was performed in clinics at one center. CONCLUSIONS: In this pilot study, a physician-delivered education intervention was feasible to use in practice and was associated with higher patient kidney disease knowledge. Further examination of physician-delivered education interventions for increasing patient disease understanding should be tested through randomized trials.

Patient-Centered Outcomes With a Multidisciplinary CKD Care Team Approach: An Observational Study.

Rationale & Objective: Multidisciplinary chronic kidney disease (CKD) care has been associated with improved clinical outcomes in comparison to general nephrology care. However, there is little research examining the impact of multidisciplinary care on patient-centered outcomes. We examined if a multidisciplinary approach to CKD care was associated with 4 patient-centered outcomes. Study Design: Cross-sectional study design using previously established surveys to assess patient-centered outcomes in participants with nondialysis CKD. Setting & Participants: Adults with CKD stages 1-5 who had not undergone transplant or were not on dialysis. Exposures: General nephrology care or multidisciplinary care. Patients receiving multidisciplinary care were seen by a pharmacist, social worker, dietitian, and nephrologist, whereas patients receiving general nephrology care only saw a nephrologist. Outcomes: Four patient-centered outcomes: CKD-specific knowledge, disease-related stress, perception of overall health, and perception of health status compared to 1 year ago. Analytical Approach: Differences were examined using a Welch 2-sample t test and linear regression model. Results: Mean age of participants was 60 years with standard deviation of 17 years. 182 (77%) patients were White, and 230 (96%) had formal education greater than or equal to high school. 121 (49%) were women, and 215 (88%) had CKD stage 3-5. 77 (31%) received multidisciplinary care. We did not identify any significant differences in patient knowledge, stress, or perception of health between multidisciplinary and general nephrology care. However, notably, patients in multidisciplinary care were older and had more advanced CKD than those in general nephrology care. Limitations: Cross-sectional study designs only identify associations. Study was conducted at clinics located within 30 miles of each other, limiting generalizability. Conclusions: Our results suggest that a team-based approach to care can better support sicker, more vulnerable patients so that they can achieve similar patient-centered outcomes compared to patients who are younger and with less advanced CKD.

Controlling Hypertension through Education and Coaching in Kidney Disease (CHECK-D): protocol of a cluster randomised controlled trial.

INTRODUCTION: Chronic kidney disease (CKD) affects 30 million Americans. Early management focused on blood pressure (BP) control decreases cardiovascular morbidity and mortality. Less than 40% of patients with CKD achieve recommended BP targets due to many barriers. These barriers include a lack of understanding of the implications of their diagnosis and how to optimise their health.This cluster randomised control trial hypothesises that the combination of early primary care CKD education, and motivational interviewing (MI)-based health coach support, will improve patient behaviours aligned with BP control by increasing patient knowledge, self-efficacy and motivation. The results will aid in sustainable interventions for future patient-centric education and coaching support to improve quality and outcomes in patients with CKD stages 3-5. Outcomes in patients with CKD stages 3-5 receiving the intervention will be compared with similar patients within a control group. Continuous quality improvement (CQI) and systems methodologies will be used to optimise resource neutrality and leverage existing technology to support implementation and future dissemination. The innovative approach of this research focuses on the importance of a multidisciplinary team, including off-site patient coaching, that can intervene early in the CKD care continuum by supporting patients with education and coaching. METHODS AND ANALYSIS: We will test impact of BP control when clinician-delivered education is followed by 12 months of MI-based health coaching. We will compare outcomes in 350 patients with CKD stages 3-5 between intervention and control groups in primary care. CQI and systems methodologies will optimise education and coaching for future implementation and dissemination. ETHICS AND DISSEMINATION: This study was approved by the University of Michigan Institutional Review Boards (IRBMED) HUM00136011, HUM00150672 and SITE00000092 and the results of the study will be published on ClinicalTrials.gov, in peer-reviewed journals, as well as conference abstracts, posters and presentations. TRIAL REGISTRATION NUMBER: NCT04087798.

Associations of Anxiety during the COVID-19 Pandemic with Patient Characteristics and Behaviors in CKD Patients: Findings from the Chronic Renal Insufficiency Cohort (CRIC) Study.

Background: Chronic kidney disease (CKD) is associated with anxiety and depression. Although the coronavirus disease 2019 (COVID-19) pandemic has increased stressors on patients with CKD, assessments of anxiety and its predictors and consequences on behaviors, specifically virus mitigation behaviors, are lacking. Methods: From June to October 2020, we administered a survey to 1873 patients in the Chronic Renal Insufficiency Cohort (CRIC) Study, asking participants about anxiety related to the COVID-19 pandemic. We examined associations between anxiety and participant demographics, clinical indexes, and health literacy and whether anxiety was associated with health-related behaviors and COVID-19 mitigation behaviors. Results: The mean age of the study population was 70 years (SD=9.6 years), 47% were women, 39% were Black non-Hispanic, 14% were Hispanic, and 38% had a history of cardiovascular disease. In adjusted analyses, younger age, being a woman, Hispanic ethnicity, cardiovascular disease, household income <$20,000, and marginal or inadequate health literacy predicted higher anxiety. Higher global COVID-19-related anxiety scores were associated with higher odds of reporting always wearing a mask in public (OR=1.3 [95% CI, 1.14 to 1.48], P<0.001) and of eating less healthy foods (OR=1.29 [95% CI, 1.13 to 1.46], P<0.001), reduced physical activity (OR=1.32 [95% CI, 1.2 to 1.45], P<0.001), and weight gain (OR=1.23 [95% CI, 1.11 to 1.38], P=0.001). Conclusions: Higher anxiety levels related to the COVID-19 pandemic were associated not only with higher self-reported adherence to mask wearing but also with higher weight gain and less adherence to healthy lifestyle behaviors. Interventions are needed to support continuation of healthy lifestyle behaviors in patients with CKD experiencing increased anxiety related to the pandemic.

Associations among perceived and objective disease knowledge and satisfaction with physician communication in patients with chronic kidney disease.

It is likely that patients with chronic kidney disease (CKD) have a limited understanding of their illness. Here we studied the relationships between objective and perceived knowledge in CKD using the Kidney Disease Knowledge Survey and the Perceived Kidney Disease Knowledge Survey. We quantified perceived and objective knowledge in 399 patients at all stages of non-dialysis-dependent CKD. Demographically, the patient median age was 58 years, 47% were women, 77% had stages 3-5 CKD, and 83% were Caucasians. The overall median score of the perceived knowledge survey was 2.56 (range: 1-4), and this new measure exhibited excellent reliability and construct validity. In unadjusted analysis, perceived knowledge was associated with patient characteristics defined a priori, including objective knowledge and patient satisfaction with physician communication. In adjusted analysis, older age, male gender, and limited health literacy were associated with lower perceived knowledge. Additional analysis revealed that perceived knowledge was associated with significantly higher odds (2.13), and objective knowledge with lower odds (0.91), of patient satisfaction with physician communication. Thus, our results present a mechanism to evaluate distinct forms of patient kidney knowledge and identify specific opportunities for education tailored to patients with CKD.

Novel educational and goal-setting tool to improve knowledge of chronic kidney disease among liver transplant recipients: A pilot study.

INTRODUCTION: Liver transplant (LT) recipients have limited understanding of post-transplant chronic kidney disease (CKD) despite an excellent pre-existing framework of transplant care. This pilot study examined the efficacy and feasibility of a tailored educational and goal-setting tool in improving CKD knowledge among LT recipients with early-stage CKD. METHODS: In this prospective cohort study, we administered the CKD educational and goal-setting tool to 81 LT recipients between 7/1/2016 and 12/31/2017. We excluded patients with simultaneous liver-kidney transplantation, eGFR<30 ml/min, non-English speaking, on hemodialysis or listed for kidney transplantation. The pre- and post-education knowledge scores were compared using a paired t-test. Linear regression was used to assess the independent predictors of change in knowledge score. RESULTS: Mean age was 56.3 years, 69.1% were males, 85.2% were Caucasians and mean eGFR was 61.2 ± 20.0 ml/min. The CKD educational and goal-setting tool improved the CKD knowledge scores among LT recipients (pre: 71.8 ± 16.6%, post: 83.3 ± 10.4%; p<0.001). In an adjusted model (r2 = 0.75), those with lower pre-education knowledge scores had the most improvement in their post-education knowledge scores (ß = -83.2; p<0.001). Two-thirds stated their most important self-management goal and reported motivation to follow this goal. Time spent for the CKD education was approximately 15 minutes. CONCLUSIONS: A simple LT-specific patient educational and goal-setting tool effectively improved CKD knowledge. Implementation of this tailored intervention will improve CKD awareness and may promote goal-setting in the target population.

Patients' and Nephrologists' Evaluation of Patient-Facing Smartphone Apps for CKD.

BACKGROUND AND OBJECTIVES: Many aspects of CKD management rely heavily on patient self-care, including medication and dietary adherence, self-monitoring of BP, and daily physical activity. Growing evidence suggests that incorporating smartphone-based applications can support self-care in CKD and chronic disease more generally. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We identified applications targeting patients with CKD by conducting a search of the US Apple App Store (iOS) and Google Play Store (Android) using the following four phrases: "kidney disease," "renal," "dialysis," and "kidney transplant." We considered the first 50 applications for each search term on each application store. We adapted a previously described framework for assessment of mobile health applications to account for kidney disease-specific content areas and evaluated applications on their types of patient engagement, quality, usability, and safety. Engagement and quality were assessed by both a patient and a nephrologist, usability was assessed by a patient, and safety was assessed by a nephrologist. Overall, two patients with CKD and three nephrologists performed the evaluations. We examined pairwise correlations between patient, nephrologist, and consumer ratings of application quality. RESULTS: Our search strategy identified 174 unique applications on Android and 165 unique applications on iOS. After excluding applications that were not related to kidney disease, were not patient facing, or were last updated before 2014, 12 Android-only applications, 11 iOS-only applications, and five dual-platform applications remained. Patient and nephrologist application quality ratings, assessed by the net promoter score, were not correlated (r=0.36; P=0.06). Consumer ratings on the application stores did not correlate with patient ratings of application quality (r=0.34; P=0.18). CONCLUSIONS: Only a small subset of CKD applications was highly rated by both patients and nephrologists. Patients' impressions of application quality are not directly linked to consumer application ratings or nephrologist impressions.

Health Behaviors in Younger and Older Adults With CKD: Results From the CRIC Study.

INTRODUCTION: A cornerstone of kidney disease management is participation in guideline-recommended health behaviors. However, the relationship of these health behaviors with outcomes, and the identification of barriers to health behavior engagement, have not been described among younger and older adults with chronic kidney disease. METHODS: Data from a cohort study of 5499 individuals with chronic kidney disease was used to identify health behavior patterns with latent class analysis stratified by age <65 and ≥65 years. Cox models, stratified by diabetes, assessed the association of health behavior patterns with chronic kidney disease (CKD) progression, atherosclerotic events, and death. Logistic regression was used to assess for barriers to health behavior engagement. RESULTS: Three health behavior patterns were identified: 1 "healthy" pattern, and 2 "less healthy" patterns comprising 1 pattern with more obesity and sedentary activity and 1 with more smoking and less obesity. Less healthy patterns were associated with an increased hazard of poor outcomes. Among participants <65 years of age, the less healthy patterns (vs. healthy pattern) was associated with an increased hazard of death in diabetic individuals (hazard ratio [HR] = 2.17, 95% confidence interval [CI] = 1.09-4.29; and HR = 2.50, 95% CI = 1.39-4.50) and cardiovascular events among nondiabetic individuals (HR = 1.49, 95% CI = 1.04-2.43; and HR = 2.97, 95% CI = 1.49-5.90). Individuals with the more obese/sedentary pattern had an increased risk of CKD progression in those who were diabetic (HR = 1.34, 95% CI = 1.13-1.59). Among older adults, the less healthy patterns were associated with increased risk of death (HR = 2.97, 95% CI = 1.43-6.19; and HR = 3.47, 95% CI = 1.48-8.11) in those who were nondiabetic. Potential barriers to recommended health behaviors include lower health literacy and self-efficacy. CONCLUSION: Identifying health behavior patterns and barriers may help target high-risk groups for strategies to increase participation in health behaviors.