Ultra-processed food consumption and risk of diabetes: results from a population-based prospective cohort.

AIMS/HYPOTHESIS: Understanding the impact of the overall construct of ultra-processed foods on diabetes risk can inform dietary approaches to diabetes prevention. In this study, we aimed to evaluate the association between ultra-processed food consumption and risk of diabetes in a community-based cohort of middle-aged adults in the USA. We hypothesised that a higher intake of ultra-processed foods is associated with a higher risk of incident diabetes. METHODS: The study included 13,172 participants without diabetes at baseline (1987-1989) in the Atherosclerosis Risk in Communities (ARIC) study. Dietary intake was assessed with a 66-item semiquantitative food frequency questionnaire, and foods were categorised by processing level using the Nova classification system. Ultra-processed food was analysed categorically (quartiles of energy-adjusted intake) and continuously (per one additional serving/day). We used Cox regression to evaluate the association of ultra-processed food intake with risk of diabetes with adjustment for sociodemographic characteristics, total energy intake, health behaviours and clinical factors. RESULTS: Over a median follow-up of 21 years, there were 4539 cases of incident diabetes. Participants in the highest quartile of ultra-processed food intake (8.4 servings/day on average) had a significantly higher risk of diabetes (HR 1.13; 95% CI 1.03, 1.23) compared with participants in the lowest quartile of intake after adjustment for sociodemographic, lifestyle and clinical factors. Each additional serving of ultra-processed food consumed daily was associated with a 2% higher risk of diabetes (HR 1.02; 95% CI 1.00, 1.04). Highest quartile consumption of certain ultra-processed food groups, including sugar- and artificially sweetened beverages, ultra-processed meats and sugary snacks, was associated with a 29%, 21% and 16% higher risk of diabetes, respectively, compared with the lowest quartile. CONCLUSIONS/INTERPRETATION: We found that a higher intake of ultra-processed food was associated with higher risk of incident diabetes, particularly sugar- and artificially sweetened beverages, ultra-processed meats and sugary snacks. Our findings suggest interventions reducing ultra-processed food consumption and specific food groups may be an effective strategy for diabetes prevention.

Age of Diabetes Diagnosis and Lifetime Risk of Dementia: The Atherosclerosis Risk in Communities (ARIC) Study.

OBJECTIVE: The impact of age of diabetes diagnosis on dementia risk across the life course is poorly characterized. We estimated the lifetime risk of dementia by age of diabetes diagnosis. RESEARCH DESIGN AND METHODS: We included 13,087 participants from the Atherosclerosis Risk in Communities Study who were free from dementia at age 60 years. We categorized participants as having middle age-onset diabetes (diagnosis <60 years), older-onset diabetes (diagnosis 60-69 years), or no diabetes. Incident dementia was ascertained via adjudication and active surveillance. We used the cumulative incidence function estimator to characterize the lifetime risk of dementia by age of diabetes diagnosis while accounting for the competing risk of mortality. We used restricted mean survival time to calculate years lived without and with dementia. RESULTS: Among 13,087 participants, there were 2,982 individuals with dementia and 4,662 deaths without dementia during a median follow-up of 24.1 (percentile 25-percentile 75, 17.4-28.3) years. Individuals with middle age-onset diabetes had a significantly higher lifetime risk of dementia than those with older-onset diabetes (36.0% vs. 31.0%). Compared with those with no diabetes, participants with middle age-onset diabetes also had a higher cumulative incidence of dementia by age 80 years (16.1% vs. 9.4%), but a lower lifetime risk (36.0% vs. 45.6%) due to shorter survival. Individuals with middle age-onset diabetes developed dementia 4 and 1 years earlier than those without diabetes and those with older-onset diabetes, respectively. CONCLUSIONS: Preventing or delaying diabetes may be an important approach for reducing dementia risk throughout the life course.

Prevalence and Disparities in Telehealth Use Among US Adults Following the COVID-19 Pandemic: National Cross-Sectional Survey.

BACKGROUND: Telemedicine expanded during the COVID-19 pandemic, though use differed by age, sex, race or ethnicity, educational attainment, income, and location. It is unclear if high telehealth use or inequities persisted late into the pandemic. OBJECTIVE: This study aims to evaluate the prevalence of, inequities in, and primary reasons for telehealth visits a year after telemedicine expansion. METHODS: We used cross-sectional data from the 2022 Health Information National Trends Survey (HINTS 6), the first cycle with data on telemedicine. In total, 4830 English- and Spanish-speaking US adults (aged ≥18 years) were included in this study. The primary outcomes were telehealth visit attendance in the 12 months before March 7, 2022, to November 8, 2022, and the primary reason for the most recent telehealth visit. We evaluated sociodemographic and clinical predictors of telehealth visit attendance and the primary reason for the most recent telehealth visit through Poisson regression. Analyses were weighted according to HINTS 6 standards. RESULTS: We included 4830 participants (mean age 48.3, SD 17.5 years; 50.28% women; 65.21% White). Among US adults, 38.78% reported having a telehealth visit in the previous year. Telehealth visit attendance rates were similar across age, race or ethnicity, income, and urban versus rural location. However, individuals with a telehealth visit were less likely to live in the Midwest (adjusted prevalence ratio [aPR] 0.65, 95% CI 0.54-0.77), and more likely to be women (aPR 1.21, 95% CI 1.06-1.38), college graduates or postgraduates (aPR 1.24, 95% CI 1.05-1.46), covered by health insurance (aPR 1.56, 95% CI 1.08-2.26), and married or cohabitating (aPR 1.17, 95% CI 1.03-1.32), adjusting for sociodemographic characteristics, frequency of health care visits, and comorbidities. Among participants with a telehealth visit in the past year, the primary reasons for their most recent visit were minor or acute illness (32.15%), chronic disease management (21%), mental health or substance abuse (16.94%), and an annual exam (16.22%). Older adults were more likely to report that the primary reason for their most recent telehealth visit was for chronic disease management (aPR 2.08, 95% CI 1.33-3.23), but less likely to report that it was for a mental health or substance abuse issue (aPR 0.19, 95% CI 0.10-0.35), adjusting for sociodemographic characteristics and frequency of health care visits. CONCLUSIONS: Among US adults, telehealth visit attendance was high more than a year after telemedicine expansion and did not differ by age, race or ethnicity, income, or urban versus rural location. Telehealth could continue to be leveraged following COVID-19 to improve access to care and health equity.

Glucose Color Index: Development and Validation of a Novel Measure of the Shape of Glycemic Variability.

BACKGROUND: Standard continuous glucose monitoring (CGM) metrics: mean glucose, standard deviation, coefficient of variation, and time in range, fail to capture the shape of variability in the CGM time series. This information could facilitate improved diabetes management. METHODS: We analyzed CGM data from 141 adults with type 2 diabetes in the Hyperglycemic Profiles in Obstructive Sleep Apnea (HYPNOS) trial. Participants in HYPNOS wore CGM sensors for up to two weeks at two time points, three months apart. We calculated the log-periodogram for each time period, summarizing using disjoint linear models. These summaries were combined into a single value, termed the Glucose Color Index (GCI), using canonical correlation analysis. We compared the between-wear correlation of GCI with those of standard CGM metrics and assessed associations between GCI and diabetes comorbidities in 398 older adults with type 2 diabetes from the Atherosclerosis Risk in Communities (ARIC) study. RESULTS: The GCI achieved a test-retest correlation of R = .75. Adjusting for standard CGM metrics, the GCI test-retest correlation was R = .55. Glucose Color Index was significantly associated (p < .05) with impaired physical functioning, frailty/pre-frailty, cardiovascular disease, chronic kidney disease, and dementia/mild cognitive impairment after adjustment for confounders. CONCLUSION: We developed and validated the GCI, a novel CGM metric that captures the shape of glucose variability using the periodogram signal decomposition. Glucose Color Index was reliable within participants over a three-month period and associated with diabetes comorbidities. The GCI suggests a promising avenue toward the development of CGM metrics which more fully incorporate time series information.

Prevalence of Type 1 Diabetes Among US Children and Adults by Age, Sex, Race, and Ethnicity.

This study uses data from the 2019 to 2022 cycles of the National Health Interview Survey to estimate the prevalence of type 1 diabetes among US youths and adults.

Satisfaction with Telehealth Care in the United States: Cross-Sectional Survey.

Background: Telehealth use remains high following the COVID-19 pandemic, but patient satisfaction with telehealth care is unclear. Methods: We used cross-sectional data from the Health Information National Trends Survey (HINTS 6). 2,058 English and Spanish-speaking U.S. adults (≥18 years) with a telehealth visit in the 12 months before March-November 2022 were included in this study. The primary outcomes were telehealth visit modality and satisfaction in the 12 months before HINTS 6. We evaluated sociodemographic predictors of telehealth visit modality and satisfaction via Poisson regression. Analyses were weighted according to HINTS standards. Results: We included 2,058 participants (48.4 ± 16.8 years; 57% women; 66% White), of which 70% had an audio-video and 30% an audio-only telehealth visit. Adults with an audio-video visit were more likely to have health insurance (adjusted prevalence ratio [aPR]: 1.55, 95% confidence interval [CI]: 1.18-2.04) and have an annual household income of ≥$75,000 (aPR: 1.18, 95% CI: 1.00-1.39) and less likely to be ≥65 years (aPR: 0.79, 95% CI: 0.70-0.89), adjusting for sociodemographic characteristics. No further inequities were noted by telehealth modality. Seventy-five percent of participants felt that their telehealth visits were as good as in-person care. No significant differences in telehealth satisfaction were observed across sociodemographic characteristics, telehealth modality, or the participants' primary reason for their most recent telehealth visit in adjusted analysis. Conclusions: Among U.S. adults with a telehealth visit, the majority had an audio-video visit and were satisfied with their care. Telehealth should continue, being offered following COVID-19, as it is uniformly valued by patients.

Four high sensitivity troponin assays and mortality in US adults with cardiovascular disease: The national health and nutrition examination survey, 1999-2004.

Objective: High sensitivity cardiac troponin (hs-cTn) may be useful to monitor residual risk in secondary prevention. Our objective was to study the correlations and comparative associations with mortality of four hs-cTn assays in US adults with known cardiovascular disease (CVD). Methods: We studied 1,211 adults with a history of CVD who participated in the National Health and Nutrition Examination Survey (NHANES) 1999-2004. Using stored samples, we measured hs-cTnT (Roche) and three hs-cTnI assays (Abbott, Siemens, and Ortho). Outcomes were all-cause and CVD mortality, with follow-up through December 31, 2019. Results: Mean age was 64 years, 48 % were female, and 80 % identified as non-Hispanic White. Pearson's correlation coefficients between hs-cTn assays ranged from 0.67 to 0.85. There were 848 deaths (365 from CVD). Among adults with a history of prior non-fatal CVD, each hs-cTn assay (log-transformed, per 1-SD) was independently associated with CVD death (HRs ranging from 1.55 to 2.16 per 1-SD, all p-values <0.05) and with all-cause death (HRs ranging from 1.31 to 1.62 per 1-SD, all p-values <0.05). Associations of hs-cTnT and all-cause and CVD death remained significant after adjusting for hs-cTnI (and vice versa). Associations between hs-cTnI and CVD death remained significant after mutually adjusting for other individual hs-cTnI assays: e.g., HR 2.21 (95 % CI 1.60, 3.05) for Ortho (hs-cTnI) after adjustment for Siemens (hs-cTnI) and HR 1.81 (95 % CI 1.35, 2.43) for Ortho (hs-cTnI) after adjustment for Abbott (hs-cTnI). Conclusion: In US adults with a history of CVD, we found modest correlations between 4 hs-cTn assays. All assays were associated with all-cause and CVD mortality. The hs-cTnT assay was associated with mortality independent of the hs-cTnI assays. Hs-cTnI assays also appeared to be independent of each other. Thus, hs-cTn assays may provide distinct information for residual risk in secondary prevention adults.

Insulin Resistance and N-Terminal Pro-B-Type Natriuretic Peptide Among Healthy Adults.

Importance: It is unclear to what extent insulin resistance is associated with N-terminal pro-B-type natriuretic peptide (NT-proBNP) in the general population after accounting for body composition. Objective: To characterize the association of insulin resistance with NT-proBNP independently of measures of body composition in US adults. Design, Setting, and Participants: In a cross-sectional design, data on participants aged 20 years or older were obtained from the 1999-2004 National Health and Nutrition Examination Survey with measures of NT-pro-BNP, body mass index (BMI), and dual energy x-ray absorptiometry (DEXA)-derived measures of body composition (fat and lean masses). Linear and logistic regression was used to characterize the associations of measures of body mass and composition (BMI, waist circumference, fat mass, and lean mass) with NT-proBNP, adjusting for cardiovascular risk factors. Linear regression was used to characterize the associations of homeostasis model assessment of insulin resistance [HOMA-IR] and NT-proBNP after adjusting for cardiovascular risk factors and body composition measures. The quantitative insulin sensitivity check index [QUICKI], triglyceride-glucose index [TyG index], insulin to glucose ratio [IGR], fasting insulin, and homeostasis model assessment of ß-cell function (HOMA-ß) were also examined. Data for this study were analyzed from August 10, 2022, to June 30, 2023. Main Outcomes and Measures: Adjusted changes in NT-proBNP by insulin resistance levels. Results: A total of 4038 adults without diabetes or cardiovascular disease were included (mean [SD] age, 44 years; 51.2% female; and 74.3% White). In sex-specific analyses, insulin resistance measures were inversely associated with NT-pro-BNP. After adjustment including cardiovascular risk factors, BMI, waist circumference, and DEXA-derived fat mass and lean mass, the percent change in NT-proBNP associated with an SD increase in HOMA-IR was -16.84% (95% CI, -21.23% to -12.21%) in women and -19.04% (95% CI, -24.14 to -13.59) in men. Similar associations were observed for other indices of insulin resistance, including QUICKI (women: 17.27; 95% CI, 10.92-23.99 vs men: 22.17; 95% CI, 15.27 to 29.48), TyG index women: -11.47; 95% CI, -16.12 to -6.57 vs men: -15.81; 95% CI, -20.40 to -10.95), IGR women: -15.15; 95% CI, -19.35 to -10.74 vs men: -16.61; 95% CI, -21.63 to -11.26), and fasting insulin (women: -16.32; 95% CI, -20.63 to -11.78 vs men: -18.22; 95% CI, -23.30 to -12.79), as well as HOMA-ß (women: -10.71; 95% CI, -14.71 to -6.52 vs men: -11.72; 95% CI, -16.35 to -6.85). Conclusions and Relevance: In a national sample of US adults, insulin resistance was inversely associated with NT-proBNP, even after rigorously accounting for multiple measures of fat mass and lean mass. These results suggest that the mechanisms linking NT-proBNP to insulin resistance are partially independent of excess adiposity and may be associated with hyperinsulinemia.

Lonely but not alone: Examining correlates of loneliness among Canadian post-secondary students.

Objective: Loneliness is increasingly acknowledged as a public health concern due to its association with morbidity and mortality. The prevalence of loneliness is highest in the post-secondary population. Understanding the correlates of loneliness may assist in developing policy and program interventions. Participants and Methods: Post-secondary students (n = 28,975) from the Winter 2022 Canadian Campus Wellbeing Survey (CCWS) cycle. A multi-level logistic regression controlling for the institution was built to determine how demographic, health behaviors, mental health and institutional level factors are associated with loneliness. Results: The prevalence of loneliness was 31% in our sample. Demographic (e.g., gender, sexual orientation, social economic status), health behaviors (e.g., physical activity and substance use), mental health (e.g., mental distress and social support) and institutional factors (e.g., college or university institution) impacted the odds of reporting loneliness (p < 0.05). Conclusion: Our findings suggest loneliness might require greater attention by institutional staff and administrators.

Elevated Cardiac Biomarkers, Erectile Dysfunction, and Mortality in U.S. Men: NHANES 2001 to 2004.

BACKGROUND: The prevalence of elevated cardiac biomarkers and their link to mortality in men with erectile dysfunction in the U.S. population are unknown. OBJECTIVES: The purpose of this study was to evaluate the prevalence of elevations in N-terminal prohormone B-type natriuretic peptide, high sensitivity troponin (hs-troponin) T, and 3 hs-troponin I assays and their associations with mortality in U.S. men with and without erectile dysfunction. METHODS: We conducted cross-sectional analyses using logistic regression to examine associations of elevated cardiac biomarkers (>90th percentile) with erectile dysfunction in 2,971 male participants aged 20 years or older in the National Health and Nutrition Examination Survey (NHANES) from 2001 to 2004. We conducted prospective analyses using Cox regression to examine the mortality implications of elevations in cardiac biomarkers in the setting of erectile dysfunction. RESULTS: Elevations in hs-troponin T and the 3 hs-troponin I assays were associated with erectile dysfunction, with the strongest association for hs-troponin T (adjusted OR: 2.01; 95% CI: 1.22-3.30). Elevated N-terminal prohormone B-type natriuretic peptide was not significantly associated with erectile dysfunction (OR: 1.22; 95% CI: 0.74-2.03). There were 673 deaths during a median of 16 years of follow-up. Men with erectile dysfunction were at an elevated risk of death (adjusted HR: 1.23; 95% CI: 1.04-1.46). Those men with elevated cardiac biomarkers in the setting of erectile dysfunction were at highest risk of all-cause and cardiovascular mortality (adjusted HRs ranging from ~1.5 to 2.4). CONCLUSIONS: In this national study, the association of erectile dysfunction with elevated hs-troponin and excess mortality risk suggests that men with erectile dysfunction should be evaluated and targeted for intensive cardiovascular risk management.

Diabetic foot disease and the risk of major clinical outcomes.

AIMS: Data on the long-term consequences of diabetic foot disease (DFD) are scarce. We examined the association between DFD and major clinical outcomes in patients with diabetes in the general population. METHODS: We conducted a prospective cohort analysis of 1,428 participants with diabetes in the Atherosclerosis Risk in Communities Study. DFD and four clinical outcomes (nontraumatic lower-extremity amputation, cardiovascular disease, major fall, and death) were captured through 2018 using administrative data. We used Cox regression models to evaluate the association between incident DFD (modeled as a time-varying exposure) and the subsequent risk of clinical outcomes. RESULTS: During over two decades of follow-up (1996-1998 to 2018), the cumulative incidence of DFD was 33.3%. Risk factors for DFD included older age, poor glycemic control, long diabetes duration, and prevalent vascular disease (chronic kidney disease, retinopathy, cardiovascular disease). Following incident DFD, the five-year cumulative incidence of major clinical outcomes was 38.9% for mortality, 25.2% for cardiovascular disease, 14.5% for nontraumatic lower-extremity amputation, and 13.2% for major fall. DFD remained associated with all four clinical outcomes after multivariable adjustment, with hazard ratios ranging from 1.5 (cardiovascular disease) to 34.7 (lower-extremity amputation). CONCLUSIONS: DFD is common and confers substantial risk for major morbidity and mortality.

High-sensitivity troponins and mortality in the general population.

AIMS: Cardiac troponin T and I can be measured using a number of high-sensitivity (hs) assays. This study aimed to characterize correlations between four such assays and test their comparative associations with mortality. METHODS AND RESULTS: Among adults without cardiovascular disease in the 1999-2004 National Health and Nutrition Examination Survey, hs-troponin T was measured using one assay (Roche) and hs-troponin I using three assays (Abbott, Siemens, and Ortho). Cox regression was used to estimate associations with all-cause and cardiovascular mortality. Pearson's correlation coefficients comparing concentrations from each assay ranged from 0.53 to 0.77. There were 2188 deaths (488 cardiovascular) among 9810 participants. Each hs-troponin assay [log-transformed, per 1 standard deviation (SD)] was independently associated with all-cause mortality: hazard ratio (HR) 1.20 [95% confidence interval (CI) 1.13-1.28] for Abbott hs-troponin I; HR 1.10 (95% CI 1.02-1.18) for Siemens hs-troponin I; HR 1.23 (95% CI 1.14-1.33) for Ortho hs-troponin I; and HR 1.31 (95% CI 1.21-1.42) for Roche hs-troponin T. Each hs-troponin assay was also independently associated with cardiovascular mortality (HR 1.44 to 1.65 per 1 SD). Associations of hs-troponin T and all-cause and cardiovascular mortality remained significant after adjusting for hs-troponin I. Furthermore, associations of hs-troponin I remained significant after mutually adjusting for hs-troponin I from the other individual assays: e.g. cardiovascular mortality HR 1.46 (95% CI 1.19-1.79) for Abbott after adjustment for the Siemens assay and HR 1.29 (95% CI 1.09-1.53) for Abbott after adjustment for the Ortho assay. CONCLUSION: This study demonstrates only modest correlations between hs-troponin T and three hs-troponin I assays and that hs-troponin I assays can provide distinct risk information for mortality in the general population.

Prediabetes, intervening diabetes and subsequent risk of dementia: the Atherosclerosis Risk in Communities (ARIC) study.

AIMS/HYPOTHESIS: The aim of this work was to evaluate whether the association of prediabetes with dementia is explained by the intervening onset of diabetes. METHODS: Among participants of the Atherosclerosis Risk in Communities (ARIC) study we defined baseline prediabetes as HbA1c 39-46 mmol/mol (5.7-6.4%) and subsequent incident diabetes as a self-reported physician diagnosis or use of diabetes medication. Incident dementia was ascertained via active surveillance and adjudicated. We quantified the association of prediabetes with dementia risk before and after accounting for the subsequent development of diabetes among ARIC participants without diabetes at baseline (1990-1992; participants aged 46-70 years). We also evaluated whether age at diabetes diagnosis modified the risk of dementia. RESULTS: Among 11,656 participants without diabetes at baseline, 2330 (20.0%) had prediabetes. Before accounting for incident diabetes, prediabetes was significantly associated with the risk of dementia (HR 1.12 [95% CI 1.01, 1.24]). After accounting for incident diabetes, the association was attenuated and non-significant (HR 1.05 [95% CI 0.94, 1.16]). Earlier age of onset of diabetes had the strongest association with dementia: HR 2.92 (95% CI 2.06, 4.14) for onset before 60 years; HR 1.73 (95% CI 1.47, 2.04) for onset at 60-69 years; and HR 1.23 (95% CI 1.08, 1.40) for onset at 70-79 years. CONCLUSIONS/INTERPRETATION: Prediabetes is associated with dementia risk but this risk is explained by the subsequent development of diabetes. Earlier age of onset of diabetes substantially increases dementia risk. Preventing or delaying progression of prediabetes to diabetes will reduce dementia burden.