Publications

BACKGROUND

Atherosclerotic changes associated with dyslipidemia and increased cardiovascular disease risk are believed to begin in childhood. While previous studies have linked added sugars consumption to low high-density lipoprotein (HDL), little is known about the long-term impact of this consumption. This study aims to assess the association between added sugars intake and HDL cholesterol levels during adolescence, and whether this association is modified by obesity.

METHODS AND RESULTS

We used data from the National Heart Lung and Blood Institute's Growth and Health Study, a 10-year cohort study of non-Hispanic Caucasian and African-American girls (N=2379) aged 9 and 10 years at baseline recruited from 3 sites in 1987-1988 with biennial plasma lipid measurement and annual assessment of diet using a 3-day food record. Added sugars consumption was dichotomized into low (0% to <10% of total energy) and high (≥10% of total energy). In a mixed model controlling for obesity, race, physical activity, smoking, maturation stage, age, and nutritional factors, low compared with high added sugar consumption was associated with a 0.26 mg/dL greater annual increase in HDL levels (95% CI 0.48 to 0.04; P=0.02). Over the 10-year study period, the model predicted a mean increase of 2.2 mg/dL (95% CI 0.09 to 4.32; P=0.04) among low consumers, and a 0.4 mg/dL decrease (95% CI -1.32 to 0.52; P=0.4) among high consumers. Weight category did not modify this association (P=0.45).

CONCLUSION

Low added sugars consumption is associated with increasing HDL cholesterol levels throughout adolescence.

Excess sodium intake correlates positively with high blood pressure. Blood pressure varies by region, but whether sodium content of foods sold varies across regions is unknown. We combined nutrition and sales data from 2009 to assess the regional variation of sodium in packaged food products sold in 3 of the 9 US census divisions. Although sodium density and concentration differed little by region, fewer than half of selected food products met Food and Drug Administration sodium-per-serving conditions for labeling as "healthy." Regional differences in hypertension were not reflected in differences in the sodium content of packaged foods from grocery stores.

The objective was to determine whether automated telephone self-management support (ATSM) for low-income, linguistically diverse health plan members with diabetes affects health care utilization or cost. A government-sponsored managed care plan for low-income patients implemented a demonstration project between 2009 and 2011 that involved a 6-month ATSM intervention for 362 English-, Spanish-, or Cantonese-speaking members with diabetes from 4 publicly funded clinics. Participants were randomized to immediate intervention or a wait-list. Medical and pharmacy claims used in this analysis were obtained from the managed care plan. Medical claims included hospitalizations, ambulance use, emergency department visits, and outpatient visits. In the 6-month period following enrollment, intervention participants generated half as many emergency department visits and hospitalizations (rate ratio 0.52, 95% CI 0.26, 1.04) compared to wait-listed participants, but these differences did not reach statistical significance (P=0.06). With adjustment for prior year cost, intervention participants also had a nonsignificant reduction of $26.78 in total health care costs compared to wait-listed individuals (P=0.93). The observed trends suggest that ATSM could yield potential health service benefits for health plans that provide coverage for chronic disease patients in safety net settings. ATSM should be further scaled up to determine whether it is associated with a greater reduction in health care utilization and costs.

OBJECTIVE

The aim of this study was to determine if the association with adiposity varies by the type (added vs. naturally occurring) and form (liquid vs. solid) of dietary sugars consumed.

METHODS

Data from the 10-year National Heart, Lung, and Blood Institute (NHLBI) Growth and Health Study ( = 2,021 girls aged 9-10 years at baseline;  = 5,156 paired observations) were used. Using mixed linear models, 1-year changes in sugar intake, body mass index -score (BMI) and waist circumference (WC) were assessed.

RESULTS

The results showed mean daily added sugar (AS) intake: 10.3 tsp (41 g) liquid; 11.6 tsp (46 g) solid and naturally occurring sugar intake: 2.6 tsp (10 g) liquid; 2.2 tsp (9 g) solid. Before total energy adjustment, each additional teaspoon of liquid AS was associated with a 0.222-mm increase in WC ( = 0.0003) and a 0.002 increase in BMI ( = 0.003). Each teaspoon of solid AS was associated with a 0.126-mm increase in WC ( = 0.03) and a 0.001 increase in BMI ( = 0.03). Adjusting for total energy, this association was maintained only between liquid AS and WC among all and between solid AS and WC among those overweight/obese only. There was no significant association with naturally occurring sugar.

CONCLUSIONS

These findings demonstrate to suggest a positive association between AS intake (liquid and solid) and BMI that is mediated by total energy intake and an association with WC that is independent of it.

OBJECTIVE

Severe hypoglycemia is a rare but important complication of type 2 diabetes. Few studies have examined the epidemiology of hypoglycemia in a community-based population.

RESEARCH DESIGN AND METHODS

We included 1,206 Atherosclerosis Risk in Communities (ARIC) Study participants with diagnosed diabetes (baseline: 1996-1998). Severe hypoglycemic events were identified through 2013 by ICD-9 codes from claims for hospitalizations, emergency department visits, and ambulance use. We used Cox regression to evaluate risk factors for severe hypoglycemia.

RESULTS

The mean age of participants was 64 years, 32% were black, and 54% were female. During a median follow-up period of 15.2 years, there were 185 severe hypoglycemic events. Important risk factors after multivariable adjustment were as follows: age (per 5 years: hazard ratio [HR] 1.24; 95% CI 1.07-1.43), black race (HR 1.39; 95% CI 1.02-1.88), diabetes medications (any insulin use vs. no medications: HR 3.00; 95% CI 1.71-5.28; oral medications only vs. no medications: HR 2.20; 95% CI 1.28-3.76), glycemic control (moderate vs. good: HR 1.78; 95% CI 1.11-2.83; poor vs. good: HR 2.62; 95% CI 1.67-4.10), macroalbuminuria (HR 1.95; 95% CI 1.23-3.07), and poor cognitive function (Digit Symbol Substitution Test score: HR 1.57; 95% CI 1.33-1.84). In an analysis of nontraditional risk factors, low 1,5-anhydroglucitol, difficulty with activities of daily living, Medicaid insurance, and antidepressant use were positively associated with severe hypoglycemia after multivariate adjustment.

CONCLUSIONS

Poor glycemic control, glycemic variability as captured by 1,5-anhydroglucitol, kidney damage, and measures of cognitive and functional impairments were strongly associated with increased risk of severe hypoglycemia. These factors should be considered in hypoglycemia risk assessments when individualizing diabetes care for older adults.

Background

A common belief is that one quarter to one third of all diabetes cases remain undiagnosed. However, such prevalence estimates may be overstated by epidemiologic studies that do not use confirmatory testing, as recommended by clinical diagnostic criteria.

Objective

To provide national estimates of undiagnosed diabetes by using a confirmatory testing strategy, in line with clinical practice guidelines.

Design

Cross-sectional study.

Setting

National Health and Nutrition Examination Survey results from 1988 to 1994 and 1999 to 2014.

Participants

U.S. adults aged 20 years and older.

Measurements

Confirmed undiagnosed diabetes was defined as elevated levels of fasting glucose (≥7.0 mmol/L [≥126 mg/dL]) and hemoglobin A1c (≥6.5%) in persons without diagnosed diabetes.

Results

The prevalence of total (diagnosed plus confirmed undiagnosed) diabetes increased from 5.5% (9.7 million adults) in 1988 to 1994 to 10.8% (25.5 million adults) in 2011 to 2014. Confirmed undiagnosed diabetes increased during the past 2 decades (from 0.89% in 1988 to 1994 to 1.2% in 2011 to 2014) but has decreased over time as a proportion of total diabetes cases. In 1988 to 1994, the percentage of total diabetes cases that were undiagnosed was 16.3%; by 2011 to 2014, this estimate had decreased to 10.9%. Undiagnosed diabetes was more common in overweight or obese adults, older adults, racial/ethnic minorities (including Asian Americans), and persons lacking health insurance or access to health care.

Limitation

Cross-sectional design.

Conclusion

Establishing the burden of undiagnosed diabetes is critical to monitoring public health efforts related to screening and diagnosis. When a confirmatory definition is used, undiagnosed diabetes is a relatively small fraction of the total diabetes population; most U.S. adults with diabetes (about 90%) have received a diagnosis of the condition.

Primary Funding Source

National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases and National Heart, Lung, and Blood Institute.