Transition between paediatric and adult diabetes healthcare services: An online global survey of healthcare professionals' experiences and perceptions.

INTRODUCTION: Youth with diabetes should transition from paediatric to adult diabetes services in a deliberate, organized and cooperative way. We sought to identify healthcare professionals' (HCPs) experiences and perceptions around transition readiness planning, policies and procedures, and the actual transfer to adult services. METHODS: Data were collected via an online global survey (seven language options), broadly advertised by the International Society for Pediatric and Adolescent Diabetes (ISPAD), European Association for the Study of Diabetes (EASD), team members and partners, via newsletters, websites, e-mails and social media. RESULTS: Respondents (n = 372) were mainly physicians (74.5 %), practicing in government funded (59.4 %), paediatric (54.0 %), metropolitan settings (85.8 %) in Europe (44.9 %); 37.1 % in low and middle-income countries (LMICs). Few centers used a transition readiness checklist (32.8 %), provided written transition information (29.6 %), or had a dedicated staff member (23.7 %). Similarly, few involved a psychologist (25.8 %), had combined (35.2 %) or transition/young person-only clinics (34.9 %), or a structured transition education program (22.6 %); 49.8 % advised youth to use technology to assist the transfer. Most (91.9 %) respondents reported barriers in offering a good transition experience. Proportionally, more respondents from LMICs prioritised more funding (p = 0.01), a structured protocol (p < 0.001) and education (p < 0.001). CONCLUSION: HCPs' experiences and perceptions related to transition vary widely. There is a pressing need for an international consensus transition guideline.

START Diabetes Prevention: A Multi-Level Strategy for Primary Care Clinics.

Background: Prediabetes, a high-risk state for developing diabetes, affects more than 1 in 3 adults nationally. However, <5% of people with prediabetes are receiving any treatment for prediabetes. Prior intervention studies for increasing prediabetes treatment uptake have largely focused on individual barriers with few multi-level interventions that address clinician- and system-level barriers. Objective: To measure the effectiveness of a multi-level intervention on uptake of prediabetes treatment in a primary care clinic. Design: Pragmatic study of the START (Screen, Test, Act, Refer and Treat) Diabetes Prevention intervention. Participants: The START Diabetes Prevention intervention was implemented in a suburban primary care clinic outside of Baltimore compared to a control clinic in the same area over a 12-month period. Intervention: START Diabetes Prevention intervention included a structured workflow, shared decision-making resources and electronic health record clinical decision support tools. Main Measures: Uptake of prediabetes treatment, defined as Diabetes Prevention Program referral, metformin prescription and/or medical nutrition referral within 30 days of any PCC visit. Key Results: We demonstrated greater uptake of preventive treatment among patients with prediabetes in the intervention clinic vs. control clinic receiving usual care (11.6% vs. 6.7%, p<0.001). More patients in the intervention vs. control clinic reported their PCC discussed prediabetes with them (60% vs. 48%, p=0.002) and more felt overall that they understood what their doctor was telling them about prediabetes and that their opinion was valued. The START Diabetes Prevention Strategy had greater acceptability and usefulness to PCCs at the study end compared to baseline. Conclusions: A low-touch multi-level intervention is effective in increasing prediabetes treatment uptake. The intervention was also acceptable and feasible for clinicians, and enhanced patient understanding and discussions of prediabetes with their clinicians.

The Final Frontier in Diabetes Care: Implementing Research in Real-World Practice.

Despite extensive evidence related to the prevention and management of type 2 diabetes (T2D) and its complications, most people at risk for and people who have diabetes do not receive recommended guideline-based care. Clinical implementation of proven care strategies is of the utmost importance because without this, even the most impressive research findings will remain of purely academic interest. In this review, we discuss the promise and challenges of implementing effective approaches to diabetes prevention and care in the real-world setting. We describe successful implementation projects in three critical areas of diabetes care-diabetes prevention, glycemic control, and prevention of diabetes-related complications-which provide a basis for further clinical translation and an impetus to improve the prevention and control of T2D in the community. Advancing the clinical translation of evidence-based care must include recognition of and assessment of existing gaps in care, identification of barriers to the delivery of optimal care, and a locally appropriate plan to address and overcome these barriers. Care models that promote team-based approaches, rather than reliance on patient-provider interactions, will enhance the delivery of contemporary comprehensive diabetes care.

Using the Translating Research into Practice framework to develop a diabetes prevention intervention in primary care: a mixed-methods study.

BACKGROUND: Pre-diabetes affects one-third of US adults and increases the risk of type 2 diabetes. Effective evidence-based interventions, such as the Diabetes Prevention Program, are available, but a gap remains in effectively translating and increasing uptake of these interventions into routine care. METHODS: We applied the Translating Research into Practice (TRiP) framework to guide three phases of intervention design and development for diabetes prevention: (1) summarise the evidence, (2) identify local barriers to implementation and (3) measure performance. In phase 1, we conducted a retrospective cohort analysis of linked electronic health record claims data to evaluate current practices in the management of pre-diabetes. In phase 2, we conducted in-depth interviews of 16 primary care physicians, 7 payor leaders and 31 patients to elicit common barriers and facilitators for diabetes prevention. In phase 3, using findings from phases 1 and 2, we developed the core elements of the intervention and performance measures to evaluate intervention uptake. RESULTS: In phase 1 (retrospective cohort analysis), we found few patients with pre-diabetes received diabetes prevention interventions. In phase 2 (stakeholder engagement), we identified common barriers to include a lack of knowledge about pre-diabetes among patients and about the Diabetes Prevention Program among clinicians. In phase 3 (intervention development), we developed the START Diabetes Prevention Clinical Pathway as a systematic change package to address barriers and facilitators identified in phases 1 and 2, performance measures and a toolkit of resources to support the intervention components. CONCLUSIONS: The TRiP framework supported the identification of evidence-based care practices for pre-diabetes and the development of a well-fitted, actionable intervention and implementation plan designed to increase treatment uptake for pre-diabetes in primary care settings. Our change package can be adapted and used by other health systems or clinics to target prevention of diabetes or other related chronic conditions.

Effectiveness of artificial intelligence vs. human coaching in diabetes prevention: a study protocol for a randomized controlled trial.

BACKGROUND: Prediabetes is a highly prevalent condition that heralds an increased risk of progression to type 2 diabetes, along with associated microvascular and macrovascular complications. The Diabetes Prevention Program (DPP) is an established effective intervention for diabetes prevention. However, participation in this 12-month lifestyle change program has historically been low. Digital DPPs have emerged as a scalable alternative, accessible asynchronously and recognized by the Centers for Disease Control and Prevention (CDC). Yet, most digital programs still incorporate human coaching, potentially limiting scalability. Furthermore, existing effectiveness results of digital DPPs are primarily derived from per protocol, longitudinal non-randomized studies, or comparisons to control groups that do not represent the standard of care DPP. The potential of an AI-powered DPP as an alternative to the DPP is yet to be investigated. We propose a randomized controlled trial (RCT) to directly compare these two approaches. METHODS: This open-label, multicenter, non-inferiority RCT will compare the effectiveness of a fully automated AI-powered digital DPP (ai-DPP) with a standard of care human coach-based DPP (h-DPP). A total of 368 participants with elevated body mass index (BMI) and prediabetes will be randomized equally to the ai-DPP (smartphone app and Bluetooth-enabled body weight scale) or h-DPP (referral to a CDC recognized DPP). The primary endpoint, assessed at 12 months, is the achievement of the CDC's benchmark for type 2 diabetes risk reduction, defined as any of the following: at least 5% weight loss, at least 4% weight loss and at least 150 min per week on average of physical activity, or at least a 0.2-point reduction in hemoglobin A1C. Physical activity will be objectively measured using serial actigraphy at baseline and at 1-month intervals throughout the trial. Secondary endpoints, evaluated at 6 and 12 months, will include changes in A1C, weight, physical activity measures, program engagement, and cost-effectiveness. Participants include adults aged 18-75 years with laboratory confirmed prediabetes, a BMI of ≥ 25 kg/m2 (≥ 23 kg/m2 for Asians), English proficiency, and smartphone users. This U.S. study is conducted at Johns Hopkins Medicine in Baltimore, MD, and Reading Hospital (Tower Health) in Reading, PA. DISCUSSION: Prediabetes is a significant public health issue, necessitating scalable interventions for the millions affected. Our pragmatic clinical trial is unique in directly comparing a fully automated AI-powered approach without direct human coach interaction. If proven effective, it could be a scalable, cost-effective strategy. This trial will offer vital insights into both AI and human coach-based behavioral change strategies in real-world clinical settings. TRIAL REGISTRATION: ClinicalTrials.gov NCT05056376. Registered on September 24, 2021, https://clinicaltrials.gov/study/NCT05056376.

Effect of Isocaloric, Time-Restricted Eating on Body Weight in Adults With Obesity : A Randomized Controlled Trial.

BACKGROUND: Time-restricted eating (TRE) lowers body weight in many studies. Whether TRE induces weight loss independent of reductions in calorie intake, as seen in rodent studies, is unknown. OBJECTIVE: To determine the effect of TRE versus a usual eating pattern (UEP) on body weight in the setting of stable caloric intake. DESIGN: Randomized, isocaloric feeding study. (ClinicalTrials.gov: NCT03527368). SETTING: Clinical research unit. PARTICIPANTS: Adults with obesity and prediabetes or diet-controlled diabetes. INTERVENTION: Participants were randomly assigned 1:1 to TRE (10-hour eating window, 80% of calories before 1 p.m.) or UEP (≤16-hour window, ≥50% of calories after 5 p.m.) for 12 weeks. Both groups had the same nutrient content and were isocaloric with total calories determined at baseline. MEASUREMENTS: Primary outcome was change in body weight at 12 weeks. Secondary outcomes were fasting glucose, homeostatic model assessment for insulin resistance (HOMA-IR), glucose area under the curve by oral glucose tolerance test, and glycated albumin. We used linear mixed models to evaluate the effect of interventions on outcomes. RESULTS: All 41 randomly assigned participants (mean age, 59 years; 93% women; 93% Black race; mean BMI, 36 kg/m2) completed the intervention. Baseline weight was 95.6 kg (95% CI, 89.6 to 101.6 kg) in the TRE group and 103.7 kg (CI, 95.3 to 112.0 kg) in the UEP group. At 12 weeks, weight decreased by 2.3 kg (CI, 1.0 to 3.5 kg) in the TRE group and by 2.6 kg (CI, 1.5 to 3.7 kg) in the UEP group (average difference TRE vs. UEP, 0.3 kg [CI, -1.2 to 1.9 kg]). Change in glycemic measures did not differ between groups. LIMITATION: Small, single-site study; baseline differences in weight by group. CONCLUSION: In the setting of isocaloric eating, TRE did not decrease weight or improve glucose homeostasis relative to a UEP, suggesting that any effects of TRE on weight in prior studies may be due to reductions in caloric intake. PRIMARY FUNDING SOURCE: American Heart Association.

Impact of remission from type 2 diabetes on long-term health outcomes: findings from the Look AHEAD study.

AIMS/HYPOTHESIS: We examined the association of attainment of diabetes remission in the context of a 12 year intensive lifestyle intervention with subsequent incidence of chronic kidney disease (CKD) and CVD. METHODS: The Look AHEAD study was a multi-centre RCT comparing the effect of a 12 year intensive lifestyle intervention with that of diabetes support and education on CVD and other long-term health conditions. We compared the incidence of CVD and CKD among 4402 and 4132 participants, respectively, based on achievement and duration of diabetes remission. Participants were 58% female, and had a mean age of 59 years, a duration of diabetes of 6 year and BMI of 35.8 kg/m2. We applied an epidemiological definition of remission: taking no diabetes medications and having HbA1c <48 mmol/mol (6.5%) at a single point in time. We defined high-risk or very high-risk CKD based on the Kidney Disease Improving Global Outcomes (KDIGO) criteria, and CVD incidence as any occurrence of non-fatal acute myocardial infarction, stroke, admission for angina or CVD death. RESULTS: Participants with evidence of any remission during follow-up had a 33% lower rate of CKD (HR 0.67; 95% CI 0.52, 0.87) and a 40% lower rate of the composite CVD measure (HR 0.60; 95% CI 0.47, 0.79) in multivariate analyses adjusting for HbA1c, BP, lipid levels, CVD history, diabetes duration and intervention arm, compared with participants without remission. The magnitude of risk reduction was greatest for participants with evidence of longer-term remission. CONCLUSIONS/INTERPRETATION: Participants with type 2 diabetes with evidence of remission had a substantially lower incidence of CKD and CVD, respectively, compared with participants who did not achieve remission. This association may be affected by post-baseline improvements in weight, fitness, HbA1c and LDL-cholesterol. TRIAL REGISTRATION: ClinicalTrials.gov NCT00017953 DATA AVAILABILITY: https://repository.niddk.nih.gov/studies/look-ahead/.

Assessment and prevention of hypoglycaemia in primary care among U.S. Veterans: a mixed methods study.

Background: Hypoglycaemia from diabetes treatment causes morbidity and lower quality of life, and prevention should be routinely addressed in clinical visits. Methods: This mixed methods study evaluated how primary care providers (PCPs) assess for and prevent hypoglycaemia by analyzing audio-recorded visits from five Veterans Affairs medical centres in the US. Two investigators independently coded visit dialogue to classify discussions of hypoglycaemia history, anticipatory guidance, and adjustments to hypoglycaemia-causing medications according to diabetes guidelines. Findings: There were 242 patients (one PCP visit per patient) and 49 PCPs. Two thirds of patients were treated with insulin and 40% with sulfonylureas. Hypoglycaemia history was discussed in 78/242 visits (32%). PCPs provided hypoglycaemia anticipatory guidance in 50 visits (21%) that focused on holding diabetes medications while fasting and carrying glucose tabs; avoiding driving and glucagon were not discussed. Hypoglycaemia-causing medications were de-intensified or adjusted more often (p < 0.001) when the patient reported a history of hypoglycaemia (15/51 visits, 29%) than when the patient reported no hypoglycaemia or it was not discussed (6/191 visits, 3%). Haemoglobin A1c (HbA1c) was not associated with diabetes medication adjustment, and only 5/12 patients (42%) who reported hypoglycaemia with HbA1c <7.0% had medications de-intensified or adjusted. Interpretation: PCPs discussed hypoglycaemia in one-third of visits for at-risk patients and provided limited hypoglycaemia anticipatory guidance. De-intensifying or adjusting hypoglycaemia-causing medications did not occur routinely after reported hypoglycaemia with HbA1c <7.0%. Routine hypoglycaemia assessment and provision of diabetes self-management education are needed to achieve guideline-concordant hypoglycaemia prevention. Funding: U.S. Department of Veterans Affairs and National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK).

A National Survey of Physicians' Views on the Importance and Implementation of Deintensifying Diabetes Medications.

BACKGROUND: Guidelines recommend deintensifying hypoglycemia-causing medications for older adults with diabetes whose hemoglobin A1c is below their individualized target, but this rarely occurs in practice. OBJECTIVE: To understand physicians' decision-making around deintensifying diabetes treatment. DESIGN: National physician survey. PARTICIPANTS: US physicians in general medicine, geriatrics, or endocrinology providing outpatient diabetes care. MAIN MEASURES: Physicians rated the importance of deintensifying diabetes medications for older adults with type 2 diabetes, and of switching medication classes, on 5-point Likert scales. They reported the frequency of these actions for their patients, and listed important barriers and facilitators. We evaluated the independent association between physicians' professional and practice characteristics and the importance of deintensifying and switching diabetes medications using multivariable ordered logistic regression models. KEY RESULTS: There were 445 eligible respondents (response rate 37.5%). The majority of physicians viewed deintensifying (80%) and switching (92%) diabetes medications as important or very important to the care of older adults. Despite this, one-third of physicians reported deintensifying diabetes medications rarely or never. While most physicians recognized multiple reasons to deintensify, two-thirds of physicians reported barriers of short-term hyperglycemia and patient reluctance to change medications or allow higher glucose levels. In multivariable models, geriatricians rated deintensification as more important compared to other specialties (p=0.027), and endocrinologists rated switching as more important compared to other specialties (p<0.006). Physicians with fewer years in practice rated higher importance of deintensification (p<0.001) and switching (p=0.003). CONCLUSIONS: While most US physicians viewed deintensifying and switching diabetes medications as important for the care of older adults, they deintensified infrequently. Physicians had ambivalence about the relative benefits and harms of deintensification and viewed it as a potential source of conflict with their patients. These factors likely contribute to clinical inertia, and studies focused on improving shared decision-making around deintensifying diabetes medications are needed.

Improving Diabetes Screening in the Primary Care Clinic.

BACKGROUND: In our suburban primary care clinic, the average rate of screening for diabetes among eligible patients was only 51%, similar to national screening data. We conducted a quality improvement project to increase this rate. METHODS: During the 6-month preintervention phase, we collected baseline data on the percentage of eligible patients screened per week (percentage of patients with hemoglobin A1c checked in the prior 3 years out of patients eligible for screening who completed a visit during the week). We then implemented a two-phase intervention. In phase 1 (approximately 8 months), we generated an electronic health record (EHR) report to identify eligible patients and pended laboratory orders for physicians to sign. In phase 2 (approximately 3 months), we replaced the phase 1 intervention with an EHR clinical decision support tool that automatically identifies eligible patients. We compared screening rates in the preintervention vs. intervention period. For phase 1, we also assessed laboratory completion rates and the laboratory results. We surveyed physicians regarding intervention acceptability and satisfaction at 3, 6, 9, and 12 months during the intervention period. RESULTS: The weekly percentage of patients screened increased from an average of 51% in the preintervention phase to 65% in the intervention phase (p < 0.001). During phase 1, most patients underwent laboratory blood testing as recommended (83% within 3 months), and results were consistent with prediabetes in 23% and with diabetes in 4%. Overall, most physicians believed that the intervention appropriately identified patients due for screening and was helpful (100% of respondents agreed at 9 months vs. 71% at 3 months). CONCLUSION: We successfully implemented a systematic screening intervention involving a manual workflow and EHR tool and improved diabetes screening rates in our clinic.

Experiences and Perceptions of Telehealth Visits in Diabetes Care During and After the COVID-19 Pandemic Among Adults With Type 2 Diabetes and Their Providers: Qualitative Study.

BACKGROUND: Since the COVID-19 pandemic, telehealth has been widely adopted in outpatient settings in the United States. Although telehealth visits are publicly accepted in different settings, little is known about the situation after the wide adoption of telehealth from the perspectives of adults with type 2 diabetes mellitus (T2D) and their providers. OBJECTIVE: This study aims to identify barriers and facilitators of maintaining continuity of care using telehealth for patients with T2D in a diabetes specialty clinic. METHODS: As the second phase of a multimethod study to understand missed appointments among adults with T2D, we conducted semistructured, individual, in-depth phone or Zoom interviews with 23 adults with T2D (14/23, 61% women; mean age 55.1, SD 14.4, range 35-77 years) and 10 providers from diabetes clinics in a tertiary academic medical center in Maryland. Interviews were audio-recorded, transcribed, and analyzed using thematic content analysis by the research team. RESULTS: Adults with T2D and their providers generally reported positive experiences with telehealth visits for diabetes care with some technical challenges resulting in the need for in-person visits. We identified the following 3 themes: (1) "perceived benefits of telehealth visits," such as convenience, time and financial efficiencies, and independence from caregivers, benefits shared by both patients and providers; (2) "perceived technological challenges of telehealth visits," such as disparities in digital health literacy, frustration caused by unstable internet connection, and difficulty sharing glucose data, challenges shared by both patients and providers; and (3) "impact of telehealth visits on the quality of diabetes care," including lack of diabetes quality measures and needs and preferences for in-person visits, shared mainly from providers' perspectives with some patient input. CONCLUSIONS: Telehealth is generally received positively in diabetes care with some persistent challenges that might compromise the quality of diabetes care. Telehealth technology and glucose data platforms must incorporate user experience and user-centered design to optimize telehealth use in diabetes care. Clinical practices need to consider new workflows for telehealth visits to facilitate easier follow-up scheduling and lab completion. Future research to investigate the ideal balance between in-person and telehealth visits in diabetes care is warranted to enhance the quality of diabetes care and to optimize diabetes outcomes. Policy flexibilities should also be considered to broaden access to diabetes care for all patients with T2D.

Cooking behaviours after Diabetes Prevention Program (DPP) participation among DPP participants in Baltimore, MD.

OBJECTIVE: The Diabetes Prevention Program (DPP) is a widely implemented 12-month behavioural weight loss programme for individuals with prediabetes. The DPP covers nutrition but does not explicitly incorporate cooking skills education. The objective of the current study is to describe food and cooking skills (FACS) and strategies of recent DPP participants. DESIGN: Photo-elicitation in-depth interviews were conducted from June to August, 2021. SETTING: Baltimore, MD, USA. PARTICIPANTS: Thirteen Black women who participated in DPP. RESULTS: The DPP curriculum influenced participants' healthy cooking practices. Many participants reported shifting from frying foods to air-frying and baking foods to promote healthier cooking and more efficient meal preparation. Participants also reported that their participation in DPP made them more mindful of consuming fruits and vegetables and avoiding foods high in carbohydrates, fats, sugars and Na. With respect to food skills, participants reported that they were more attentive to reading labels and packaging on foods and assessing the quality of ingredients when grocery shopping. CONCLUSIONS: Overall, participants reported changing their food preferences, shopping practices and cooking strategies to promote healthier eating after completing the DPP. Incorporating hands-on cooking skills and practices into the DPP curriculum may support sustained behaviour change to manage prediabetes and prevent development of type 2 diabetes among participants.

Lower-Intensity Interventions for Prediabetes: A Systematic Review.

INTRODUCTION: Systematic reviews of interventions for diabetes prevention have focused on lifestyle interventions, including the Diabetes Prevention Program (DPP) and translations of the DPP. However, nationally, few people with prediabetes have joined or completed a DPP, with one cited barrier being committing to a yearlong program. This study was a systematic review to evaluate the effectiveness of lower-intensity lifestyle interventions for prediabetes on weight change, glycemia, and health behaviors. METHODS: English-language studies from PubMed, Embase, PsycINFO, and CINAHL from 2000 to February 23, 2022 were searched for RCTs of nonpregnant adults with prediabetes and elevated BMI and lower-intensity interventions (defined as ≤12 months and <14 sessions over 6 months). Two reviewers independently identified 11 trials, assessed study quality (using Cochrane risk-of-bias tool), and extracted data serially. A qualitative synthesis was conducted by outcome. RESULTS: Only 1 of 11 trials of lower-intensity interventions was of high quality (>80% follow-up rate and low risk of bias). This 6-month study compared an app with standardized dietary advice, showing a 3-kg greater body weight reduction and 0.2% greater reduction of HbA1c. DISCUSSION: The evidence on lower-intensity lifestyle interventions for diabetes prevention is limited by the small number and methodologic weaknesses of previous trials, and future research is needed in this area. Given the low uptake of and retention in evidence-based high-intensity programs, future work is needed to investigate the effectiveness of novel lower-intensity interventions offered with established DPP content of varying duration and intensity.

Design and Implementation of a Time-Restricted Eating Intervention in a Randomized, Controlled Eating Study.

The efficacy of time-restricted eating for weight loss has not been established, as prior studies were limited by a lack of controlled isocaloric designs. This study describes the design and implementation of interventions in a controlled eating study evaluating time-restricted eating. We designed a randomized, controlled, parallel-arm eating study comparing time-restricted eating (TRE) to a usual eating pattern (UEP) for the primary outcome of weight change. Participants were aged 21-69 years with prediabetes and obesity. TRE consumed 80% of calories by 1300 h (military time), and UEP consumed ≥ 50% of calories after 1700 h (military time). Both arms consumed identical macro- and micro-nutrients based on a healthy, palatable diet. We calculated individual calorie requirements, which were maintained throughout the intervention. The desired distribution of calories across eating windows in both arms was achieved, as were the weekly averages for macronutrients and micronutrients. We actively monitored participants and adapted diets to facilitate adherence. We provide the first report, to our knowledge, on the design and implementation of eating study interventions that isolated the effect of meal timing on weight while maintaining constant caloric intake and identical diets during the study period.

Complex, Varied and Evolving Manifestations of Food Agency in Daily Life Among Diabetes Prevention Program Participants in Baltimore, Maryland.

OBJECTIVE: To characterize food agency (one's capacity to procure and prepare food in particular contexts) among Diabetes Prevention Program (DPP) participants and gather perspectives about experiences with DPP. DESIGN: Photograph-elicitation in-depth interviews and survey measures. SETTING: Baltimore, Maryland (June-August 2021). PARTICIPANTS: Black women (n = 13) who participated in DPP. PHENOMENON OF INTEREST: Food agency and strategies used to procure and prepare food and the influence of DPP on daily food behaviors. Surveys measured food agency using the Cooking and Food Provisioning Action Scale and cooking behaviors. ANALYSIS: Thematic analysis of qualitative in-depth interviews and descriptive statistics for quantitative measures. RESULTS: As quantitative and qualitative data revealed, participants were frequent and confident cooks with high food agency. Participants viewed cooking as a key strategy for healthy eating and desired more hands-on cooking instruction within DPP to develop new healthy cooking skills. The primary barriers identified were related to lack of time or energy. Food procurement and preparation practices shifted over time, and DPP was a key influence on current behaviors. CONCLUSIONS AND IMPLICATIONS: Food agency is complex and manifests heterogeneously in daily life. A life course, contextual, and food agency-based approach could be considered for future diabetes prevention interventions.

A National Physician Survey of Deintensifying Diabetes Medications for Older Adults With Type 2 Diabetes.

OBJECTIVE: To determine physicians' approach to deintensifying (reducing/stopping) or switching hypoglycemia-causing medications for older adults with type 2 diabetes. RESEARCH DESIGN AND METHODS: In this national survey, U.S. physicians in general medicine, geriatrics, or endocrinology reported changes they would make to hypoglycemia-causing medications for older adults in three scenarios: good health, HbA1c of 6.3%; complex health, HbA1c of 7.3%; and poor health, HbA1c of 7.7%. RESULTS: There were 445 eligible respondents (response rate 37.5%). In patient scenarios, 48%, 4%, and 20% of physicians deintensified hypoglycemia-causing medications for patients with good, complex, and poor health, respectively. Overall, 17% of physicians switched medications without significant differences by patient health. One-half of physicians selected HbA1c targets below guideline recommendations for older adults with complex or poor health. CONCLUSIONS: Most U.S. physicians would not deintensify or switch hypoglycemia-causing medications within guideline-recommended HbA1c targets. Physician preference for lower HbA1c targets than guidelines needs to be addressed to optimize deintensification decisions.

Obesity and Overweight: Probing Causes, Consequences, and Novel Therapeutic Approaches Through the American Heart Association's Strategically Focused Research Network.

As the worldwide prevalence of overweight and obesity continues to rise, so too does the urgency to fully understand mediating mechanisms, to discover new targets for safe and effective therapeutic intervention, and to identify biomarkers to track obesity and the success of weight loss interventions. In 2016, the American Heart Association sought applications for a Strategically Focused Research Network (SFRN) on Obesity. In 2017, 4 centers were named, including Johns Hopkins University School of Medicine, New York University Grossman School of Medicine, University of Alabama at Birmingham, and Vanderbilt University Medical Center. These 4 centers were convened to study mechanisms and therapeutic targets in obesity, to train a talented cadre of American Heart Association SFRN-designated fellows, and to initiate and sustain effective and enduring collaborations within the individual centers and throughout the SFRN networks. This review summarizes the central themes, major findings, successful training of highly motivated and productive fellows, and the innovative collaborations and studies forged through this SFRN on Obesity. Leveraging expertise in in vitro and cellular model assays, animal models, and humans, the work of these 4 centers has made a significant impact in the field of obesity, opening doors to important discoveries, and the identification of a future generation of obesity-focused investigators and next-step clinical trials. The creation of the SFRN on Obesity for these 4 centers is but the beginning of innovative science and, importantly, the birth of new collaborations and research partnerships to propel the field forward.

Predictors of Follow-Up Appointment No-Shows Before and During COVID Among Adults with Type 2 Diabetes.

Background: The coronavirus disease 2019 (COVID-19) pandemic has rapidly transformed health care delivery into telehealth visits. Attending regular medical appointments are critical to prevent or delay diabetes-related complications. Although telehealth visits have addressed some barriers to in-person visits, appointment no-shows are still noted in the telehealth setting. It is not completely clear how the predictors of appointment no-shows differ between in-person and telehealth visits in diabetes care. Objective: This retrospective study examined if predictors of appointment no-shows differ (1) between pre-COVID (January 1, 2019-March 22, 2020) and COVID (March 23, 2020-December 31, 2020) periods and (2) by health care delivery modes (in-person or telehealth visits) during COVID among adults with type 2 diabetes mellitus (T2DM). Methods: We used electronic health records between January 1, 2019 and December 31, 2020 across four diabetes clinics in a tertiary academic hospital in Baltimore, Maryland. Appointments marked as completed or no-show by established adults with T2DM were included in the analyses. Results: Among 7,276 appointments made by 2,235 patients, overall appointment no-show was 14.99%. Being older and White were protective against appointment no-shows in both unadjusted and adjusted models during both time periods. The interaction terms of COVID periods (i.e., pre-COVID vs. COVID) were significant for when glycated hemoglobin drawn before this visit and for missing body mass index. Telehealth visits during COVID decreased more half of the odds of appointment no-shows. Conclusions: In the context of diabetes care, the implementation of telehealth reduced appointment no-shows. Future studies are needed to address social determinants of health, including access to internet access, to further reduce health disparities among adults with T2DM.