Household Food Insecurity, Stress, and Anxiety among Youth and Young Adults with Diabetes

Although household food insecurity (HFI) has been associated with depressive symptoms in youth and young adults (YYA) with youth-onset diabetes, little is known about the association of HFI with other mental health comorbidities. We examined the association of HFI with stress and anxiety symptoms among YYA with diabetes using cross-sectional data from the SEARCH Food Security Cohort study (assessments conducted 2018-2020;n = 1030, age =23.8± 0.3, female =58.8%, type 1 diabetes (T1D) = 881, type 2 diabetes (T2D) =149) . HFI was defined as 3+ affirmations on the USDA Household Food Security Survey Module. The Generalized Anxiety Disorder (GAD-7) and Cohen's Perceived Stress Scale (PSS-14) were used to assess outcomes of anxiety (score range 0-21) and stress (score range 0-56) , higher scores indicating greater anxiety or stress. Linear regression models were adjusted for age, sex, race/ethnicity, site, diabetes duration, parental education, income, and whether assessment was completed pre/post the coronavirus pandemic. Analyses were stratified by diabetes type. HFI was present in 17.3% of T1D and 35.6 % of T2D. Moderate/severe anxiety symptom scores (range 10-21) were found in 27.5 % (mean=6.9, s.d. =5.5) of T1D and 40.9% (mean=8.4, s.d. =6.5) of T2D. Mean stress scores were 26.7 (s.d.=6.3) for T1D and 27.9 (s.d.=6.3) for T2D. In T1D, HFI was associated with higher anxiety (β=4.8, p=<0.0001) and stress (β=4.9, p=<0.0001) symptom scores compared to those with food security adjusted for covariates. Among T2D, HFI was associated with greater anxiety symptoms (β=2.8, p=0.0247) but no association was observed with stress. These findings suggest that assessing and alleviating HFI may help improve stress and anxiety among YYA with diabetes, and further study is warranted to determine associations over time.

Evaluating sources of bias in observational studies of angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker use during COVID-19: beyond confounding.

Concerns over ACE inhibitor or ARB use to treat hypertension during COVID-19 remain unresolved. Although studies using more robust methodologies provided some clarity, sources of bias persist and it remains critical to quickly address this question. In this review, we discuss pernicious sources of bias using a causal model framework, including time-varying confounder, collider, information, and time-dependent bias, in the context of recently published studies. We discuss causal inference methodologies that can address these issues, including causal diagrams, time-to-event analyses, sensitivity analyses, and marginal structural modeling. We discuss effect modification and we propose a role for causal mediation analysis to estimate indirect effects via mediating factors, especially components of the renin--angiotensin system. Thorough knowledge of these sources of bias and the appropriate methodologies to address them is crucial when evaluating observational studies to inform patient management decisions regarding whether ACE inhibitors or ARBs are associated with greater risk from COVID-19.

Gastrointestinal and hepatic manifestations of COVID-19: A systematic review and meta-analysis.

Background and Aim: This review investigates the role of gastrointestinal and hepatic manifestations in COVID-19, particularly with regard to the prevalence of isolated gastrointestinal (GI) symptoms. Methods: We searched PubMed, Embase, and Cochrane library for COVID-19 publications from 1 December 2019 to 18 May 2020. We included any study that reported the presence of GI symptoms in a sample of >5 COVID-19 patients. Data collection and risk of bias assessment were performed independently by two reviewers. Where ≥3 studies reported data sufficiently similar to allow calculation of a pooled prevalence, we performed random effects meta-analysis. Results: This review included 17 776 COVID-19 patients from 108 studies. Isolated GI symptoms only occurred in 1% (95% confidence interval [CI] 0-6%) of patients. GI symptoms were reported in 20% (95% CI 15-24%) of patients. The most common were anorexia (21%, 95% CI 15-27%), diarrhea (13%, 95% CI 11-16%), nausea or vomiting (8%, 95% CI 6-11%), and abdominal pain (4%, 95% CI 2-6%). Transaminase elevations were present in 24% (95% CI 17-31%) of patients. Higher prevalence of GI symptoms were reported in studies published after 1st April, with prevalence of diarrhea 16% (95% CI 13-20), nausea or vomiting 12% (95% CI 8-16%), and any GI symptoms 24% (95% CI 18-34%). GI symptoms were associated with severe COVID-19 disease (odds ratio [OR] 2.1, 95% CI 1.3-3.2), but not mortality (OR 0.90, 95% CI 0.52-1.54). Conclusions: Patients with isolated GI symptoms may represent a small but significant portion of COVID-19 cases. When testing resources are abundant, clinicians should still consider testing patients with isolated GI symptoms or unexplained transaminase elevations for COVID-19. More recent studies estimate higher overall GI involvement in COVID-19 than was previously recognized.