Person:

Wexler, Deborah

OBJECTIVE We sought to determine whether food insecurity is associated with worse glycemic, cholesterol, and blood pressure control in adults with diabetes. RESEARCH DESIGN AND METHODS We conducted a cross-sectional analysis of data from participants of the 1999–2008 National Health and Nutrition Examination Survey. All adults with diabetes (type 1 or type 2) by self-report or diabetes medication use were included. Food insecurity was measured by the Adult Food Security Survey Module. The outcomes of interest were proportion of patients with HbA1c >9.0% (75 mmol/mol), LDL cholesterol >100 mg/dL, and systolic blood pressure >140 mmHg or diastolic blood pressure >90 mmHg. We used multivariable logistic regression for analysis. RESULTS Among the 2,557 adults with diabetes in our sample, a higher proportion of those with food insecurity (27.0 vs. 13.3%, P < 0.001) had an HbA1c >9.0% (75 mmol/mol). After adjustment for age, sex, educational attainment, household income, insurance status and type, smoking status, BMI, duration of diabetes, diabetes medication use and type, and presence of a usual source of care, food insecurity remained significantly associated with poor glycemic control (odds ratio [OR] 1.53 [95% CI 1.07–2.19]). Food insecurity was also associated with poor LDL control before (68.8 vs. 49.8, P = 0.002) and after (1.86 [1.01–3.44]) adjustment. Food insecurity was not associated with blood pressure control. CONCLUSIONS Food insecurity is significantly associated with poor metabolic control in adults with diabetes. Interventions that address food security as well as clinical factors may be needed to successfully manage chronic disease in vulnerable adults.

Background: Obesity precedes the development of type 2 diabetes (T2D). However, the relationship between the magnitude and rate of weight gain to T2D development and complications, especially in non-White populations, has received less attention. Methods and Findings: We determined the association of rate and magnitude of weight gain to age at T2D diagnosis (AgeT2D), HbA1c at T2D diagnosis (HbA1cT2D), microalbuminuria, and diabetic retinopathy after adjusting for sex, BMI at age 20 years, lifestyles, family history of T2D and/or blood pressure and lipids in 2164 Korean subjects aged ≥30 years and newly diagnosed with diabetes. Body weight at age 20 years (Wt20y) was obtained by recall or from participants’ medical, school, or military records. Participants recalled their maximum weight (Wtmax) prior to T2D diagnosis and age at maximum weight (Agemax_wt). The rate of weight gain (Ratemax_wt) was calculated from magnitude of weight gain (ΔWt = Wtmax–Wt20y) divided by ΔTime (Agemax_wt –20 years). The mean Agemax_wt and AgeT2D were 41.5±10.9 years and 50.1±10.5 years, respectively. The Wt20y and Wtmax were 59.9±10.5 kg and 72.9±11.4 kg, respectively. The Ratemax_wt was 0.56±0.50 kg/year. After adjusting for risk factors, greater ΔWt and higher Ratemax_wt were significantly associated with earlier AgeT2D, higher HbA1cT2D after additional adjusting for AgeT2D, and microalbuminuria after further adjusting for HbA1cT2D and lipid profiles. Greater ΔWt and higher Ratemax_wt were also significantly associated with diabetic retinopathy. Conclusions: This finding supports public health recommendations to reduce the risk of T2D and its complications by preventing weight gain from early adulthood.

OBJECTIVE To assess the validity of self-report measures of diabetes medication adherence and evaluate the effect of depression on the validity of these reports. RESEARCH DESIGN AND METHODS Adults with type 2 diabetes, treated with oral medications, completed a set of medication adherence self-reports that varied response scales and time frames, were administered structured clinical interviews for depression, and provided blood samples for HbA1c as part of a screening for an intervention study. A subsample of participants with HbA1c ≥7.0% and clinically significant depression received Medication Event Monitoring System (MEMS) bottle caps to record adherence. Analyses examined relationships between adherence measures and HbA1c and, in the subsample, MEMS. Moderated linear regression evaluated whether depression severity modified relationships with HbA1c. RESULTS Participant (n = 170, 57% men, 81% white, mean HbA1c 8.3% [SD, 1.7]) adherence self-reports were significantly (r = −0.18 to −0.28; P < 0.03) associated with lower HbA1c. In the subsample (n = 88), all self-reports were significantly (r = 0.35 to 0.55; P ≤ 0.001) associated with MEMS-measured adherence. Depression significantly moderated the relationship between three of six self-reports and HbA1c; at high levels of depression, associations with HbA1c became nonsignificant. CONCLUSIONS Results support the validity of easily administered self-reports for diabetes medication adherence. One-month, percentage-based ratings of adherence had the strongest associations with MEMS and HbA1c; those requiring the report of missed doses had weaker associations. One-week self-ratings and measures that require respondents to record the number of missed doses appear to be vulnerable to bias from depression severity.

Objective: Genome-wide association studies have uncovered a large number of genetic variants associated with type 2 diabetes or related phenotypes. In many cases the causal gene or polymorphism has not been identified, and its impact on response to anti-hyperglycemic medications is unknown. The Study to Understand the Genetics of the Acute Response to Metformin and Glipizide in Humans (SUGAR-MGH, NCT01762046) is a novel resource of genetic and biochemical data following glipizide and metformin administration. We describe recruitment, enrollment, and phenotyping procedures and preliminary results for the first 668 of our planned 1,000 participants enriched for individuals at risk of requiring anti-diabetic therapy in the future. Methods: All individuals are challenged with 5 mg glipizide × 1; twice daily 500 mg metformin × 2 days; and 75-g oral glucose tolerance test following metformin. Genetic variants associated with glycemic traits and blood glucose, insulin, and other hormones at baseline and following each intervention are measured. Results: Approximately 50% of the cohort is female and 30% belong to an ethnic minority group. Following glipizide administration, peak insulin occurred at 60 minutes and trough glucose at 120 minutes. Thirty percent of participants experienced non-severe symptomatic hypoglycemia and required rescue with oral glucose. Following metformin administration, fasting glucose and insulin were reduced. Common genetic variants were associated with fasting glucose levels. Conclusions: SUGAR-MGH represents a viable pharmacogenetic resource which, when completed, will serve to characterize genetic influences on pharmacological perturbations, and help establish the functional relevance of newly discovered genetic loci to therapy of type 2 diabetes. Trial Registration ClinicalTrials.gov NCT01762046

Background: Food insecurity, the uncertain ability to access adequate food, can limit adherence to dietary measures needed to prevent and manage cardiometabolic conditions. However, little is known about temporal trends in food insecurity among those with diet-sensitive cardiometabolic conditions. Methods: We used data from the Continuous National Health and Nutrition Examination Survey (NHANES) 2005–2012, analyzed in 2015–2016, to calculate trends in age-standardized rates of food insecurity for those with and without the following diet-sensitive cardiometabolic conditions: diabetes mellitus, hypertension, coronary heart disease, congestive heart failure, and obesity. Results: 21,196 NHANES participants were included from 4 waves (4,408 in 2005–2006, 5,607 in 2007–2008, 5,934 in 2009–2010, and 5,247 in 2011–2012). 56.2% had at least one cardiometabolic condition, 24.4% had 2 or more, and 8.5% had 3 or more. The overall age-standardized rate of food insecurity doubled during the study period, from 9.06% in 2005–2006 to 10.82% in 2007–2008 to 15.22% in 2009–2010 to 18.33% in 2011–2012 (p for trend < .001). The average annual percentage change in food insecurity for those with a cardiometabolic condition during the study period was 13.0% (95% CI 7.5% to 18.6%), compared with 5.8% (95% CI 1.8% to 10.0%) for those without a cardiometabolic condition, (parallelism test p = .13). Comparing those with and without the condition, age-standardized rates of food insecurity were greater in participants with diabetes (19.5% vs. 11.5%, p < .0001), hypertension (14.1% vs. 11.1%, p = .0003), coronary heart disease (20.5% vs. 11.9%, p < .001), congestive heart failure (18.4% vs. 12.1%, p = .004), and obesity (14.3% vs. 11.1%, p < .001). Conclusions: Food insecurity doubled to historic highs from 2005–2012, particularly affecting those with diet-sensitive cardiometabolic conditions. Since adherence to specific dietary recommendations is a foundation of the prevention and treatment of cardiometabolic disease, these results have important implications for clinical management and public health.

OBJECTIVE To test cognitive behavioral therapy for adherence and depression (CBT-AD) in type 2 diabetes. We hypothesized that CBT-AD would improve adherence; depression; and, secondarily, hemoglobin A1c (A1C). RESEARCH DESIGN AND METHODS Eighty-seven adults with unipolar depression and uncontrolled type 2 diabetes received enhanced treatment as usual (ETAU), including medication adherence, self-monitoring of blood glucose (SMBG), and lifestyle counseling; a provider letter documented psychiatric diagnoses. Those randomized to the intervention arm also received 9–11 sessions of CBT-AD. RESULTS Immediately after acute treatment (4 months), adjusting for baseline, CBT-AD had 20.7 percentage points greater oral medication adherence on electronic pill cap (95% CI −31.14 to −10.22, P = 0.000); 30.2 percentage points greater SMBG adherence through glucometer downloads (95% CI −42.95 to −17.37, P = 0.000); 6.44 points lower depression scores on the Montgomery-Asberg Depression Rating Scale (95% CI 2.33–10.56, P = 0.002); 0.74 points lower on the Clinical Global Impression (95% CI 0.16–1.32, P = 0.01); and 0.72 units lower A1C (95% CI 0.29–1.15, P = 0.001) relative to ETAU. Analyses of 4-, 8-, and 12-month follow-up time points indicated that CBT-AD maintained 24.3 percentage points higher medication adherence (95% CI −38.2 to −10.3, P = 0.001); 16.9 percentage points greater SMBG adherence (95% CI −33.3 to −0.5, P = 0.043); and 0.63 units lower A1C (95% CI 0.06–1.2, P = 0.03) after acute treatment ended. For depression, there was some evidence of continued improvement posttreatment, but no between-group differences. CONCLUSIONS CBT-AD is an effective intervention for adherence, depression, and glycemic control, with enduring and clinically meaningful benefits for diabetes self-management and glycemic control in adults with type 2 diabetes and depression.

Most patients with type 2 diabetes (T2D) have suboptimal adherence to recommended diet, physical activity, and/or medication. Current approaches to improve health behaviors in T2D have been variably effective, and successful interventions are often complex and intensive. It is therefore vital to develop interventions that are simple, well-accepted, and applicable to a wide range of patients who suffer from T2D. One approach may be to boost positive psychological states, such as positive affect or optimism, as these constructs have been prospectively and independently linked to improvements in health behaviors. Positive psychology (PP) interventions, which utilize systematic exercises to increase optimism, well-being, and positive affect, consistently increase positive states and are easily delivered to patients with chronic illnesses. However, to our knowledge, PP interventions have not been formally tested in T2D. In this paper, we review a theoretical model for the use of PP interventions to target health behaviors in T2D, describe the structure and content of a PP intervention for T2D patients, and describe baseline data from a single-arm proof-of-concept (N = 15) intervention study in T2D patients with or without depression. We also discuss how PP interventions could be combined with motivational interviewing (MI) interventions to provide a blended psychological-behavioral approach.