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Background: Clinical trials for weight loss in cancer survivors have been shown to be safe and effective. Pragmatic approaches are needed to facilitate broader adoption. The ASPIRE study evaluates real-world, lifestyle weight loss programs in Maryland on reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) outcomes. Here we report 6-month data on weight change. Methods: Participants were adults with overweight or obesity, who had a history of solid malignant tumors and completed curative intent treatment. The exclusion criteria were minimized to increase generalizability. Participants self-selected 1 of 3 programs: the Self-Directed (SD) Program provided evidence-based, written materials; the App-Directed (AD) Program additionally provided a commercially available, free smartphone app and weekly diet and exercise tips; and the Coach-Directed (CD) Program additionally included 1-on-1 telephonic coaching. SD and AD had versions with and without weight tracking; CD required weight tracking. Weights were transmitted to the study team using cellular technology with the scales provided and collected at baseline, 3, 6, and 12 months. Results: 5,644 cancer survivors were invited, mostly via electronic health records; 9% expressed interest. Of these, 67% enrolled (total n=340; n=240 in weight tracking programs; 54% black, 74% women.) Participants in CD were younger, more likely to be women, less likely to have bachelor’s degree, and weighed more than those in SD. At 6m, weights were obtained from 97.5% of participants. Within-program weight reduction was most significant in CD. In the adjusted mixed-effects models, compared with SD participants, CD participants achieved significant weight reduction (see Table) Conclusion: Remotely delivered weight loss programs are desirable and can be broad- reach. Intervention with remote coaching was effective. While selected by many participants, app-directed program with weight tracking but without coaching led to small weight reduction.

Long-term sequelae of severe acute respiratory coronavirus-2 (SARS-CoV-2) infection may include an increased incidence of diabetes. Our objective was to describe the temporal relationship between new diagnoses of diabetes mellitus and SARS-CoV-2 infection in a nationally representative database. There appears to be a sharp increase in diabetes diagnoses in the 30 days surrounding SARS-CoV-2 infection, followed by a decrease in new diagnoses in the post-acute period, up to 360 days after infection. These results underscore the need for further investigation, as understanding the timing of new diabetes onset after COVID-19 has implications regarding potential etiology and screening and treatment strategies.

BACKGROUND: Depressive symptoms and burnout are common among medical students. However, few studies have investigated their trajectory over the course of medical school. OBJECTIVE: Evaluate year-by-year changes in depressive and burnout symptoms over the course of medical school training. DESIGN: Prospective study. PARTICIPANTS: Medical students who matriculated at a private medical school in Maryland from 2010 to 2016 (n=758). MAIN MEASURES: Clinically significant depressive symptoms were defined as a score of ≥10 on the 9-item Patient Health Questionnaire (PHQ-9), and burnout was measured using the Maslach Burnout Inventory (MBI). High emotional exhaustion, high depersonalization, and low personal accomplishment were defined as scores of ≥ 27, ≥10, and ≤33 on the respective MBI subscales. KEY RESULTS: At matriculation, the prevalences of significant depressive symptoms, high emotional exhaustion, high depersonalization, and low personal accomplishment were 4.3%, 9.4%, 8.6%, and 37.7%, respectively. After adjustment for age, sex, race/ethnicity, marital status, and cohort, compared with year 1, the odds of significant depressive symptoms was significantly higher at the beginning of the 2nd, 3rd, and 4th years of study (ORs=2.63, 2.85, and 3.77, respectively; all ps

BACKGROUND: There is a lack of research regarding whether prolonged use of cocaine would lead to increase of coronary plaque burden. OBJECTIVES: To study the effects of cocaine use on the coronary artery plaque volume. We hypothesize the longer the cocaine use, the greater the plaque burden. METHODS: We used coronary computed tomography angiography to evaluate plaque volumes. The study included chronic (N = 33 with 27 HIV+) and non-cocaine users (N = 15 with 12 HIV+). Chronic cocaine use was defined as use by any route for at least 6 months, administered at least 4 times/month. The Student’s t-test was used to compare the plaque volumes between chronic and non-cocaine users. Multivariable regression analysis adjusted for age, sex, body mass index, HIV status, cigarette smoking, diabetes, and total cholesterol was performed to determine the relationship between years of cocaine use and plaque volumes. RESULTS: The total plaque volumes between groups showed no difference (p = 0.065). However, the total left anterior descending artery (LAD) plaque volume in the chronic cocaine group was significantly higher than that in the non-cocaine group (p = 0.047). For each year increase in cocaine use, total plaque volume and total LAD plaque volume increased by 7.23 mm(3) (p = 0.013) and 4.56 mm(3) (p = 0.001), respectively. In the multivariable analyses, both total plaque volume and total LAD plaque volume were significantly associated with years of cocaine use (p = 0.039 and 0.013, respectively). CONCLUSION: Prolonged cocaine use accelerates the development of sub-clinical atherosclerosis.

Objective This study was designed to determine whether intensive lifestyle intervention (ILI) aimed at weight loss lowers cancer incidence and mortality. Methods Data from the Look AHEAD trial were examined to investigate whether participants randomized to ILI designed for weight loss would have reduced overall cancer incidence, obesity-related cancer incidence, and cancer mortality, as compared with the diabetes support and education (DSE) comparison group. This analysis included 4,859 participants without a cancer diagnosis at baseline except for nonmelanoma skin cancer. Results After a median follow-up of 11 years, 684 participants (332 in ILI and 352 in DSE) were diagnosed with cancer. The incidence rates of obesity-related cancers were 6.1 and 7.3 per 1,000 person-years in ILI and DSE, respectively, with a hazard ratio (HR) of 0.84 (95% CI: 0.68-1.04). There was no significant difference between the two groups in total cancer incidence (HR, 0.93; 95% CI: 0.80-1.08), incidence of nonobesity-related cancers (HR, 1.02; 95% CI: 0.83-1.27), or total cancer mortality (HR, 0.92; 95% CI: 0.68-1.25). Conclusions An ILI aimed at weight loss lowered incidence of obesity-related cancers by 16% in adults with overweight or obesity and type 2 diabetes. The study sample size likely lacked power to determine effect sizes of this magnitude and smaller.

Introduction: A lack of effective interventions remains a major clinical gap in cardiovascular disease (CVD) prevention for individuals with type 2 diabetes (T2D) and high glycated hemoglobin (HbA1c). Our objective was to determine whether the effect of an intensive lifestyle intervention (ILI) on CVD prevention differed by baseline HbA1c among Action for Health in Diabetes (Look AHEAD) trial participants. Hypothesis: ILI will be associated with differential risk for CVD by HbA1c. Methods: Look AHEAD randomized 5145 adults, aged 45-76 years, with T2D and overweight/obesity, to ILI or a control of diabetes support and education (DSE) for a median of 9.6 years. ILI focused on weight loss through decreased caloric intake and increased physical activity. We assessed the parent trial’s pre-specified primary CVD outcome. We assessed for additive (Poisson regression) and multiplicative (Cox proportional hazards) heterogeneity of intervention effects on CVD risk by HbA1c adjusting for stratified randomization and using intention to treat analysis. Results: Baseline HbA1c ranged from 4.4% to 14.5% (mean 7.3, SD 1.2). We observed additive and multiplicative heterogeneity of effects (all p Conclusion: Among adults with T2D and overweight/obesity, the effect of a lifestyle intervention on CVD risk differed by HbA1c. There is a critical need to identify effective CVD prevention strategies for individuals with T2D and high HbA1c.

Background: Short chain fatty acids (SCFAs) are the microbially-derived end products of dietary fiber fermentation. The SCFA butyrate is a signaling molecule shown to influence blood pressure (BP) in mouse models. The association of butyrate and other SCFAs on BP in humans is unclear, due in part to predominantly cross-sectional analyses and to differences in which biospecimens (blood vs. fecal) SCFAs were measured. Longitudinal studies including both circulating and fecal SCFAs are lacking. Objective: Investigate the cross-sectional and longitudinal associations of fecal and serum SCFAs with hypertension and changes in BP. Methods: We leveraged existing data from the SPIRIT trial, which randomized 121 adult cancer survivors with overweight/obesity to a behavioral weight loss intervention, metformin, or self-directed weight loss. Of participants with serum and fecal SCFAs measured at baseline (N=111), a subset also had serum (N=93) and fecal (N=89) SCFA measurements 12 months later. We used Poisson regression with robust error variance to estimate associations of serum or fecal SCFAs with hypertension at baseline (adjusting for age, sex, BMI, and fiber intake). In longitudinal analyses, we assessed the percent change in serum or fecal SCFAs from baseline with corresponding 12-month changes in BP (covariates listed in Table ). Results: Participants were aged 60.2±8.9 years, 78.4% female, and 46.9% identified as White. Higher baseline fecal butyrate was inversely associated with prevalent hypertension (standardized PR [95%CI]: 0.71 [0.54, 0.92]). In longitudinal analyses ( Table ), a 10% increase in fecal butyrate from baseline levels was significantly and inversely associated with systolic BP, and a 10% increase in serum butyrate was significantly and inversely associated with systolic and diastolic BPs. Associations of butyrate with BP were not modified by sex or race. Conclusion: Increased serum or fecal butyrate is associated with lowered BP. Butyrate may be a target for SCFA-centered BP-lowering interventions.

IntroductionHypoglycemia is the most common serious adverse effect of diabetes treatment and a major cause of medication-related hospitalization. This study aimed to identify trends and predictors of hospital utilization for hypoglycemia among patients with type 2 diabetes using electronic health record data pooled from six academic health systems.Research design and methodsThis retrospective open cohort study included 549 041 adults with type 2 diabetes receiving regular care from the included health systems between 2009 and 2019. The primary outcome was the yearly event rate for hypoglycemia hospital utilization: emergency department visits, observation visits, or inpatient admissions for hypoglycemia identified using a validated International Classification of Diseases Ninth Revision (ICD-9) algorithm from 2009 to 2014. After the transition to ICD-10 in 2015, we used two ICD-10 code sets (limited and expanded) for hypoglycemia hospital utilization from prior studies. We identified independent predictors of hypoglycemia hospital utilization using multivariable logistic regression analysis with data from 2014.ResultsYearly rates of hypoglycemia hospital utilization decreased from 2.7 to 1.6 events per 1000 patients from 2009 to 2014 (p-trend=0.023). From 2016 to 2019, yearly event rates were stable ranging from 5.6 to 6.6, or 6.3 to 7.3, using the limited and expanded ICD-10 code sets, respectively. In 2014, the strongest independent risk factors for hypoglycemia hospital utilization were chronic kidney disease (OR 2.86, 95% CI 2.33 to 3.57), ages 18–39 years (OR 2.43 vs age 40–64 years, 95% CI 1.78 to 3.31), and insulin use (OR 2.13 vs no diabetes medications, 95% CI 1.67 to 2.73).ConclusionsRates of hypoglycemia hospital utilization decreased from 2009 to 2014 and varied considerably by clinical risk factors such that younger adults, insulin users, and those with chronic kidney disease were at especially high risk. There is a need to validate hypoglycemia ascertainment using ICD-10 codes, which detect a substantially higher number of events compared with ICD-9.

We examined the association of civil unrest with potentially stress-related outcomes among two low-income, African American communities in Baltimore following the death of Freddie Gray in police custody and whether neighborhood proximity to unrest moderated these associations. We leveraged data from a cross-sectional survey of randomly selected households in two public housing communities (n=342) collected before, during, and after the civil unrest (August 2014 to August 2015). We used multivariate regression to explore the association of unrest with depressive symptoms and elevated blood pressure adjusting for potential confounders and community attributes. After the 2015 civil unrest event in Baltimore, those living in a low-income community near the epicenter demonstrated higher rates of depressive symptoms, but not elevated blood pressure, compared with those living in a comparable neighborhood three miles away. Low-income communities in Baltimore could benefit from mental health services after periods of civil unrest.

Background: Lower body mass index (BMI) has been associated with lower serum urate (SU), but only in observational studies. We sought to determine the effects of behavioral weight loss and metformin treatment on SU in a randomized trial. Methods and Findings: The Survivorship Promotion In Reducing IGF-1 Trial (SPIRIT) was a parallel three-arm randomized controlled trial of overweight/obese adult cancer survivors without gout at a single center in Maryland, United States. Participants were randomized to: (1) coach-directed weight loss (behavioral telephonic coaching), (2) metformin (up to 2000 mg daily), or (3) self-directed weight loss (informational brochures, reference group). SU and BMI were assessed at baseline and at 3, 6, and 12 months post-randomization. The 121 participants had a mean ± standard deviation (SD) age of 60 ± 9 years, 79% were female, and 45% were Black. At baseline, BMI was 35 ± 5 kg/m2, and SU was 5.6 ± 1.3 mg/dL. Compared to the self-directed group, at 12 months, the coach-directed group reduced BMI by 0.9 kg/m2 (95% confidence interval (CI): −1.5, −0.4) and metformin reduced BMI by 0.6 kg/m2 (95% CI: −1.1, −0.1). However, compared to the self-directed group, the coach-directed group unexpectedly increased SU by 0.3 mg/dL (95% CI: 0.05, 0.6), and metformin non-significantly increased SU by 0.2 mg/dL (95% CI: −0.04, 0.5), these effects were attenuated when analyses included change in estimated glomerular filtration rate (eGFR). Conclusions: In this randomized trial of cancer survivors without gout, reductions in BMI either increased or did not change SU, potentially due to effects on eGFR. These results do not support a focus on BMI reduction for SU reduction, however, long-term studies are needed. ClinicalTrials.gov Registration: NCT02431676.

Importance The net benefit of aspirin for prevention of cardiovascular disease (CVD), particularly primary prevention, remains debated in people with and without diabetes. Recent studies suggest that the benefits of preventive aspirin may be outweighed by the potential for harm in older adults; therefore, it is important to monitor current aspirin use in order to minimize risk for future harm in the oldest segment of the population. Objective To determine the prevalence of preventive aspirin use in older US adults with and without diabetes for both primary and secondary prevention by age, sex, and CVD risk category. Design, setting, and participants This cross-sectional analysis used nationally representative data from the National Health and Nutrition Examination Survey from 2011 to 2018. A total of 7103 individuals 60 years or older with and without diabetes completed a questionnaire on preventive aspirin use. Statistical analyses were performed from July 1, 2019, to April 1, 2021. Main outcomes and measures Preventive aspirin use was defined as participants' self-reported use of low-dose aspirin therapy based on their physician's advice or their own decision. Results A total of 7103 individuals (mean [SD] age, 69.6 [0.1] years; 45.2% men; 75.8% White participants) were evaluated. Overall, 61.7% of older US adults with diabetes vs 42.2% without diabetes used aspirin. Among people with diabetes, in multivariable logistic models adjusting for race, sex, education, CVD risk category, and body mass index, the likelihood of aspirin use in older vs younger age categories (reference: 60-69 years) did not differ. Among people without diabetes, aspirin use was significantly greater in older age categories vs the reference (model 3, 70-79 years, odds ratio [OR], 1.50; 95% CI, 1.23-1.83; model 3, ≥80 years, OR, 1.59; 95% CI, 1.24-2.04). An estimated 9.9 million US adults 70 years or older with or without diabetes reported taking aspirin for primary prevention. The likelihood of aspirin use for primary prevention in those at high vs low risk for CVD did not differ among older adults with diabetes (model 3, OR, 1.69; 95% CI, 0.65-4.39) but was significantly higher in those without diabetes (model 3, OR, 2.46; 95% CI, 1.63-3.71). Women vs men with diabetes were less likely to be using aspirin for primary prevention (model 3, OR, 0.63; 95% CI, 0.48-0.83). Conclusions and relevance This cross-sectional study found that preventive aspirin use was higher among older adults with diabetes than in those without diabetes. Results suggest that 9.9 million older US adults who previously took aspirin for primary prevention would not be recommended for its continued use, particularly among those with diabetes.

Hypoglycemia is the most common serious adverse effect of diabetes treatment and a major cause of medication-related hospitalization. This study aimed to identify trends and predictors of hospital utilization for hypoglycemia among adults with type 2 diabetes. Using electronic health record data from six academic health systems, we performed a retrospective open cohort study including 532,323 patients aged ≥18 years with type 2 diabetes receiving regular care between 2009 and 2019. The primary outcome was the yearly event rate for hypoglycemia hospital utilization: emergency department visits, observation visits, or inpatient admissions for hypoglycemia identified using a validated ICD-9 algorithm. After the transition to ICD-10 in 2015, we used two ICD-10 code sets for hypoglycemia (limited and expanded) that were used in prior studies. We identified independent predictors of hypoglycemia hospital utilization using multivariable logistic regression analysis with data from 2014. We found that yearly rates of hypoglycemia hospital utilization decreased non-significantly from 3.4 to 2.6 events per 1,000 patients from 2009 to 2014. From 2016 to 2019, yearly event rates ranged from 15.5 to 16.5, or 21.1 to 21.8, using the limited and expanded ICD-10 code sets, respectively. The strongest independent risk factors for hypoglycemia hospital utilization were chronic kidney disease (OR 3.13, 95% CI 2.63-3.70), age 18-39 years (OR 3.00 vs. age 40-64 years, 95% CI 2.42-3.73), and insulin use (OR 2.61 vs. no diabetes medications, 95% CI 2.16-3.15). In this multicenter open cohort study, we found that rates of hypoglycemia hospital utilization were stable from 2009 to 2014 and varied considerably by clinical risk factors such that younger adults, insulin users, and those with chronic kidney disease were at especially high risk. There is a need to validate hypoglycemia ascertainment using ICD-10 codes, which detect a substantially higher number of events compared to ICD-9. Disclosure S. J. Pilla: None. J. L. Kraschnewski: None. E. Lehman: None. L. Kong: None. E. Francis: None. J. M. Poger: None. C. L. Bryce: None. N. M. Maruthur: Other Relationship; Self; Johns Hopkins HealthCare Solutions. H. Yeh: None. Funding National Institutes of Health (KL2TR003099); Patient-Centered Outcomes Research Institute (1306-04912)

Lipopolysaccharide-binding protein (LBP), a biomarker of gut barrier permeability to lipopolysaccharides, is higher in adults with obesity and type 2 diabetes. Behavioral weight loss and metformin have distinct effects on the gut microbiome, but their impact on gut permeability to lipopolysaccharides is unknown. This study's objective was to determine the effects of a behavioral weight-loss intervention or metformin treatment on plasma LBP.SPIRIT was a randomized trial of adults with overweight or obesity. Participants were randomized to one of three arms: metformin treatment, coach-directed behavioral weight loss on a DASH diet, or self-directed care (control). Of 121 participants, a random subset (n = 88) was selected to have LBP measured at baseline, 6 months, and 12 months post intervention. Intervention effects on LBP over time were assessed using generalized estimating equations (GEE). We also examined whether the intervention effects were modified by change in diet and weight.Arms were balanced by sex (83% female), race (51% white), and age (mean 60 years), with no differences in baseline LBP (median 4.23 μg/mL). At 1 year, mean weight change was -3.00% in the metformin arm, -3.02% in the coach-directed behavioral weight-loss arm, and +0.33% in the self-directed (control) arm. The corresponding change in LBP was +1.03, -0.98, +1.03 μg/mL. The behavioral weight-loss intervention reduced LBP compared to self-directed care (β = -0.17, 95% CI: -0.33 to -0.01); no other between-arm comparisons were significant. Behavioral weight-loss participants who reduced dietary fat showed the greatest reductions in 6-month LBP (β = -2.84, 95% CI: -5.17 to -0.50).Despite similar weight loss in the behavioral weight loss arm and the metformin arm, only the behavioral weight-loss intervention reduced LBP compared to control. Lifestyle weight-loss interventions that promote a DASH diet may be effective at reducing gut barrier permeability to lipopolysaccharides.NCT02431676, https://clinicaltrials.gov.

Background: Serum lipopolysaccharide-binding protein (LBP), a surrogate biomarker for gut barrier permeability, is higher in adults with obesity and type 2 diabetes and may trigger inflammation. It is unknown whether a behavioral weight loss intervention or metformin — current first-line treatments for obesity or diabetes — can reduce gut permeability. Objective: To determine the effects of behavioral weight loss intervention or metformin, compared to self-directed weight loss, on serum LBP. Methods: SPIRIT was a parallel-arm, randomized trial of adult cancer survivors with overweight or obesity. Participants were randomized to a self-directed weight loss (control), metformin, or coach-directed (healthy diet/physical activity) weight loss arm. Of 121 randomized participants, a random subset (n=88) had LBP measured at baseline, 6-months, and 12-months post intervention. The effects of interventions on LBP over time were assessed using generalized estimating equations (GEE). Models were further adjusted for absolute change in fiber intake to investigate potential mediation. Results: Arms were balanced by sex (83% female), race (48% black), and age (mean 60 years). There were no between-group differences in LBP at baseline (median 42.3 μg/dL). Over the 12-month period, only the coach-directed and metformin arms showed weight loss (both mean -3% from baseline). Similar increases in LBP were seen in the self-directed and metformin arms, while a decrease in LBP was seen in the coach-directed arm ( figure ). In GEE models, the difference in slopes between the coach vs. self-directed arms was statistically significant (β=-1.67, p=0.037), but not between the metformin and self-directed arms (β=0.003, p=0.997). The effect of coach-directed weight loss on LBP was similar by sex and race and was not mediated by changes in fiber intake. Conclusion: The manner of weight loss can differentially impact gut permeability and thus subsequent exposure to proinflammatory microbial products.

OBJECTIVE To determine the longer-term effects of metformin treatment and behavioral weight loss on gut microbiota and short-chain fatty acids (SCFAs). RESEARCH DESIGN AND METHODS We conducted a 3-parallel-arm, randomized trial. We enrolled overweight/obese adults who had been treated for solid tumors but had no ongoing cancer treatment and randomized them (n = 121) to either 1) metformin (up to 2,000 mg), 2) coach-directed behavioral weight loss, or 3) self-directed care (control) for 12 months. We collected stool and serum at baseline (n = 114), 6 months (n = 109), and 12 months (n = 105). From stool, we extracted microbial DNA and conducted amplicon and metagenomic sequencing. We measured SCFAs and other biochemical parameters from fasting serum. RESULTS Of the 121 participants, 79% were female and 46% were Black, and the mean age was 60 years. Only metformin treatment significantly altered microbiota composition. Compared with control, metformin treatment increased amplicon sequence variants for Escherichia (confirmed as Escherichia coli by metagenomic sequencing) and Ruminococcus torques and decreased Intestinibacter bartlettii at both 6 and 12 months and decreased the genus Roseburia, including R. faecis and R. intestinalis, at 12 months. Effects were similar in comparison of the metformin group with the behavioral weight loss group. Metformin versus control also increased butyrate, acetate, and valerate at 6 months (but not at 12 months). Behavioral weight loss versus control did not significantly alter microbiota composition but did increase acetate at 6 months (but not at 12 months). Increases in acetate were associated with decreases in fasting insulin. Additional whole-genome metagenomic sequencing of a subset of the metformin group showed that metformin altered 62 metagenomic functional pathways, including an acetate-producing pathway and three pathways in glucose metabolism. CONCLUSIONS Metformin, but not behavioral weight loss, impacted gut microbiota composition at 6 months and 12 months. Both metformin and behavioral weight loss altered circulating SCFAs at 6 months, including increasing acetate, which correlated with lower fasting insulin. Future research is needed to elucidate whether the gut microboime mediates or modifies metformin’s health effects.

Context Higher levels of insulin-like growth factor-1 (IGF-1) are associated with increased risk of cancers and higher mortality. Therapies that reduce IGF-1 have considerable appeal as means to prevent recurrence. Design Randomized, 3-parallel-arm controlled clinical trial. Interventions and Outcomes Cancer survivors with overweight or obesity were randomized to (1) self-directed weight loss (comparison), (2) coach-directed weight loss, or (3) metformin treatment. Main outcomes were changes in IGF-1 and IGF-1:IGFBP3 molar ratio at 6 months. The trial duration was 12 months. Results Of the 121 randomized participants, 79% were women, 46% were African Americans, and the mean age was 60 years. At baseline, the average body mass index was 35 kg/m2; mean IGF-1 was 72.9 (SD, 21.7) ng/mL; and mean IGF1:IGFBP3 molar ratio was 0.17 (SD, 0.05). At 6 months, weight changes were -1.0% (P = 0.07), -4.2% (P Conclusions In cancer survivors with obesity, metformin may have a short-term effect on IGF-1 reduction that wanes over time.

BACKGROUND The use of health information technology (HIT) has been proposed to improve disease management in patients with type 2 diabetes mellitus. OBJECTIVE This study aims to report the prevalence of HIT use in adults with diabetes in the United States and examine the factors associated with HIT use. METHODS We analyzed data from 7999 adults who self-reported a diabetes diagnosis as collected by the National Health Interview Survey (2016-2018). All analyses were weighted to account for the complex survey design. RESULTS Overall, 41.2% of adults with diabetes reported looking up health information on the web, and 22.8% used eHealth services (defined as filled a prescription on the web, scheduled an appointment with a health care provider on the web, or communicated with a health care provider via email). In multivariable models, patients who were female (vs male: prevalence ratio [PR] 1.16, 95% CI 1.10-1.24), had higher education (above college vs less than high school: PR 3.61, 95% CI 3.01-4.33), had higher income (high income vs poor: PR 1.40, 95% CI 1.23-1.59), or had obesity (vs normal weight: PR 1.11, 95% CI 1.01-1.22) were more likely to search for health information on the web. Similar associations were observed among age, race and ethnicity, education, income, and the use of eHealth services. Patients on insulin were more likely to use eHealth services (on insulin vs no medication: PR 1.21, 95% CI 1.04-1.41). CONCLUSIONS Among adults with diabetes, HIT use was lower in those who were older, were members of racial minority groups, had less formal education, or had lower household income. Health education interventions promoted through HIT should account for sociodemographic factors.

Obesity is a leading public health concern. The Centers for Medicare and Medicaid Services implemented a healthcare procedure code for intensive behavioural therapy (IBT) in 2012 to facilitate payment for addressing obesity in primary care settings, followed by universal coverage by insurers for all adults. Our objective was to understand utilization of IBT from 2009 to 2017 in patients with a diabetes diagnosis. Leveraging electronic health record data from the PaTH Clinical Data Research Network (CDRN), a partnership of six health systems, utilization of IBT was summarized at a yearly basis. The trend of IBT prevalence was examined for patients with diabetes by gender, race, age (>=65 vs

Aims Acculturation has been shown to be an important factor for immigrants' health in the United States. We investigate whether nativity is associated with a greater risk for cardiometabolic diseases among Asian Americans (Asians) vs. non-Hispanic whites (whites). Methods Based on data from the U.S. National Health Interview Survey in 2006–2015, 146,862 Asians and whites aged ≥30 years were evaluated. Nativity as a proxy for acculturation was defined using a combination of birthplace and the duration of U.S. residency. Cardiometabolic diseases were defined based on self-reported diagnoses of diabetes, prediabetes, or cardiovascular diseases (CVD). Using 10-year pooled data accounting for complex sampling designs and weights, multiple logistic regression models were used to assess associations. Four Asian subgroups, including Chinese, Filipinos, Asian Indians and other Asians, were evaluated in subgroup analyses. Results Compared to U.S.-born whites, prevalent type 2 diabetes and prediabetes were higher among Asians depending on nativity. However, the prevalence of CVD was lower among Asians than among whites regardless of nativity (OR≥15 years = 0.5 [95% CI:0.5–0.6], ORU.S-born = 0.7 [95% CI:0.6–0.8]). In addition, compared to U.S.-born whites, prevalent type 2 diabetes and prediabetes increased with an increasing length of U.S. residency for foreign-born Asians among Asians overall (≥15 years: ORdiabetes = 1.5 [95% CI:1.3–1.7]; ORprediabetes = 1.3 [95% CI:1.2–1.6]) and Asian Indians and Filipinos. Furthermore, a significant graded association between prediabetes and length of U.S. residency was found among foreign-born Asians. Conclusions The prevalence of diabetes and prediabetes is higher among Asian immigrants who have spent more years in the U.S., than those in U.S.-born whites. Monitoring and prevention efforts for diabetes should target this group.

Disparities in the control of hypertension and other cardiovascular disease risk factors are well-documented in the United States, even among patients seen regularly in the healthcare system. Few existing approaches explicitly address disparities in hypertension care and control. This paper describes the RICH LIFE Project (Reducing Inequities in Care of Hypertension: Lifestyle Improvement for Everyone) design.RICH LIFE is a two-arm, cluster-randomized trial, comparing the effectiveness of enhanced standard of care, "Standard of Care Plus" (SCP), to a multi-level intervention, "Collaborative Care/Stepped Care" (CC/SC), for improving blood pressure (BP) control and patient activation and reducing disparities in BP control among 1890 adults with uncontrolled hypertension and at least one other cardiovascular disease risk factor treated at 30 primary care practices in Maryland and Pennsylvania. Fifteen practices randomized to the SCP arm receive standardized BP measurement training; race/ethnicity-specific audit and feedback of BP control rates; and quarterly webinars in management practices, quality improvement and disparities reduction. Fifteen practices in the CC/SC arm receive the SCP interventions plus implementation of the collaborative care model with stepped-care components (community health worker referrals and virtual specialist-panel consults). The primary clinical outcome is BP control (140/90 mm Hg) at 12 months. The primary patient-reported outcome is change from baseline in self-reported patient activation at 12 months.This study will provide knowledge about the feasibility of leveraging existing resources in routine primary care and potential benefits of adding supportive community-facing roles to improve hypertension care and reduce disparities.Clinicaltrials.govNCT02674464.