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IMPORTANCE: Rural Black participants need effective intervention to achieve better blood pressure (BP) control. OBJECTIVE: Among Black rural adults with persistently uncontrolled hypertension attending primary care clinics, to determine whether peer coaching (PC), practice facilitation (PF), or both (PCPF) are superior to enhanced usual care (EUC) in improving BP control. DESIGN, SETTING, AND PARTICIPANTS: A cluster randomized clinical trial was conducted in 69 rural primary care practices across Alabama and North Carolina between September 23, 2016, and September 26, 2019. The participating practices were randomized to 4 groups: PC plus EUC, PF plus EUC, PCPF plus EUC, and EUC alone. The baseline EUC approach included a laptop for each participating practice with hyperlinks to participant education on hypertension, a binder of practice tips, a poster showing an algorithm for stepped care to improve BP, and 25 home BP monitors. The trial was stopped on February 28, 2021, after final data collection. The study included Black participants with persistently uncontrolled hypertension. Data were analyzed from February 28, 2021, to December 13, 2022. INTERVENTIONS: Practice facilitators helped practices implement at least 4 quality improvement projects designed to improve BP control throughout 1 year. Peer coaches delivered a structured program via telephone on hypertension self-management throughout 1 year. MAIN OUTCOMES AND MEASURES: The primary outcome was the proportion of participants in each trial group with BP values of less than 140/90 mm Hg at 6 months and 12 months. The secondary outcome was a change in the systolic BP of participants at 6 months and 12 months. RESULTS: A total of 69 practices were randomized, and 1209 participants’ data were included in the analysis. The mean (SD) age of participants was 58 (12) years, and 748 (62%) were women. In the intention-to-treat analyses, neither intervention alone nor in combination improved BP control or BP levels more than EUC (at 12 months, PF vs EUC odds ratio [OR], 0.94 [95% CI, 0.58-1.52]; PC vs EUC OR, 1.30 [95% CI, 0.83-2.04]; PCPF vs EUC OR, 1.02 [95% CI, 0.64-1.64]). In preplanned subgroup analyses, participants younger than 60 years in the PC and PCPF groups experienced a significant 5 mm Hg greater reduction in systolic BP than participants younger than 60 years in the EUC group at 12 months. Practicewide BP control estimates in PF groups suggested that BP control improved from 54% to 61%, a finding that was not observed in the trial’s participants. CONCLUSIONS AND RELEVANCE: The results of this cluster randomized clinical trial demonstrated that neither PC nor PF demonstrated a superior improvement in overall BP control compared with EUC. However, PC led to a significant reduction in systolic BP among younger adults. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02866669

Background/Objective: Because racial disparities in hypertension treatment persist, the objective of the present study was to examine patient vs. practice characteristics that influence antihypertensive selection and treatment intensity for non-Hispanic Black (hereafter “Black”) patients with uncontrolled hypertension in the rural southeastern USA. Methods: We enrolled 25 Black patients from each of 69 rural practices in Alabama and North Carolina with uncontrolled hypertension (systolic blood pressure (BP) ≥ 140 mm Hg) in a 4-arm cluster randomized trial of BP control interventions. Patients’ antihypertensive medications were abstracted from medical records and reconciled at the baseline visit. Treatment intensity was computed using the defined daily dose (DDD) method of the World Health Organization. Correlates of greater antihypertensive medication intensity were assessed by linear regression modeling, and antihypertensive medication classes were compared by baseline systolic BP (SBP) level. Results: A total of 1431 patients were enrolled and had complete baseline data. Antihypertensive treatment intensity averaged 3.7 ± 2.6 equivalent medications at usual dosages and was significantly related to higher baseline systolic BP, older age, male sex, insurance availability, higher BMI, and concurrent diabetes, but not to practice type or medication barriers in regression models. Renin-angiotensin system inhibitors were the most commonly used medications, followed by diuretics and calcium channel blockers. Conclusion/Relevance: Antihypertensive treatment intensity for Black patients in the rural southeastern USA with a history of uncontrolled hypertension averaged the equivalent of almost four medications at usual dosages and was significantly associated with baseline SBP levels and other patient characteristics, but not clinic type. Trial Registration: ClinicalTrials.gov NCT02866669.

The coronavirus disease 2019 (COVID‐19) pandemic is a rapidly changing circumstance with dramatic policy changes and universal efforts to deal with the initial crisis and minimize its consequences. To identify changes to organ donation and transplantation during this time, an anonymous web‐based survey was distributed to 19 select organ procurement organizations (OPOs) throughout the United States comparing 90‐day activity during March‐May 2020 and March‐May 2019. Seventeen OPOs responded to the survey (response rate of 89.5%). Organ authorization decreased by 11% during the current pandemic (n = 1379 vs n = 1552, P= .0001). Organ recovery for transplantation fell by 17% (P= .0001) with a further 18% decrease in the number of organs transplanted (P= .0001). Donor cause of death demonstrated a 4.5% decline in trauma but a 35% increase in substance abuse cases during the COVID‐19 period. All OPOs reported significant modifications in response to the pandemic, limiting the onsite presence of staff and transitioning to telephonic approaches for donor family correspondence. Organ donation during the current climate has seen significant changes and the long‐term implications of such shifts remain unclear. These trends during the COVID‐19 era warrant further investigation to address unmet needs, plan for a proportionate response to the virus and mitigate the collateral impact. This study describes the collateral impact of the COVID‐19 pandemic over a 90‐day period on several aspects of organ donation, including a substantial decline in transplant activity across the United States. Commentary from Bucuvalas and Lai is on page 2973.

Our aim in this study was to determine whether a cognitive-behavioural therapy plus small changes lifestyle intervention can produce comparable improvements in insulin users vs patients not using insulin with uncontrolled type 2 diabetes (T2D) and comorbid depressive or regimen-related distress (RRD) symptoms.

Background:Racial disparities in blood pressure (BP) control persist, but whether differences by race in antihypertensive medication intensification (AMI) contribute is unknown. Objective:To compare AMI by race for patients with elevated home BP readings. Methods:This prospective cohort study followed adult patients from 6 rural primary care practices who used home BP monitoring (HBPM) and recorded/reported values. For providers, AMI was encouraged when mean HBPM systolic blood pressure (SBP) values were ⩾135 mm Hg; patients received phone-based coaching on HBPM technique and sharing HBPM findings. AMI was assessed between baseline and 12 months using defined daily dose (DDD) and summed to create a total antihypertensive DDD value. Results:A total of 217 patients (mean age = 61.4 ± 10.2 years; 66% female; 57% black) provided usable HBPM data. Among 90 (41%) intensification-eligible hypertensive patients (ie, mean HBPM SBP values for 6-months ⩾135 mm Hg), mean total antihypertensive DDD was increased in 61% at 12 months. Blacks had significantly higher mean DDD at baseline and 12 months, but intensification (+0.72 vs +0.65; P= 0.83) was similar by race. However, intensification was greater in males than females (+1.1 vs +0.39; P= 0.031). Reduction in mean SBP following intensification was greater in white versus black patients (−8.2 vs −3.9 mm Hg; P= 0.14). Conclusion/Relevance:Treatment intensification in HBPM users was similar by race, differed significantly by gender, and may produce a greater response in white patients. Differential AMI in HBPM users does not appear to contribute to persistent racial disparities in BP control.

Descriptions of river network topology do not include lakes/reservoirs that are connected to rivers. We describe the properties and scaling patterns of river network topology across the contiguous United States: how lake/reservoir abundance, median lake/reservoir size, and median lake/reservoir spacing change with river size. Typically, lake/reservoir abundance decreases, median lake/reservoir size increases, but median lake/reservoir spacing is uniform across river size. There is a characteristic lake/reservoir size of 0.01–0.05 km2and a characteristic lake/reservoir spacing of 1–5 km that shifts to 27–61 km in larger rivers. Climate explains more of the variance in river network topology than both glacial history and constructed reservoirs. Our results provide conceptual models for building river network topologies to assess how lake/reservoir abundance, size, and spacing effect the transport, storage, and cycling of water, materials, and organisms across networks. Rivers and lakes/reservoirs serve different hydrologic, ecologic, and economic roles and are often studied as separate systems. Yet there are many lakes/reservoirs connected to rivers and this connectivity has profound impacts on sediment storage and transport, biogeochemical cycles, and aquatic habitat in both rivers and lakes/reservoirs. Defining the topology of river networks is critical for understanding these processes across entire networks of connected rivers and lakes/reservoirs. We defined river network topology by scaling the abundance, size, and spacing of lakes/reservoirs with river size and identified broadscale controls of network topology. Lakes/reservoirs connected to rivers decrease in abundance, increase in size, but are uniform in spacing as river size increasesRiver network topology with lakes/reservoirs can be classified into four types across the contiguous United StatesClimate is a major control of river network topology with lakes/reservoirs

BACKGROUNDThere is limited information available in North Carolina on the current burden of, and racial disparities in, diabetic retinopathy (DR), a major complication associated with diabetes mellitus (DM). This study aims to describe the overall trend of, and racial/ethnic disparities in, DR among adults with DM in North Carolina.METHODSData were from 13 waves (2000, 2002–2010, 2012, 2013, and 2015) of the Behavioral Risk Factor Surveillance System. The study sample included 16,976 adults aged ≥ 40 years with DM in North Carolina. DR was identified by self-report by the question, “Has a doctor ever told you that diabetes has affected your eyes or that you had retinopathy?” The overall prevalence of DR was assessed during the time period, and was compared between whites and blacks. All analyses were conducted using Stata 13.0.RESULTSThe prevalence of self-reported DR in North Carolina decreased from 27.2% in 2000 to 18.3% in 2015, a reduction of 33% (Trend P= .003). The age-adjusted DR prevalence in whites decreased from 21.7% to 17.6% (Trend P= .04), and in blacks from 39.4% to 20.2% (Trend P= .002). The declining rates in DR were not statistically different between whites and blacks (P= .06). Blacks were more likely to report DR (adjusted odds ratio = 1.20, 95% confidence interval, 1.03–1.40) during 2000–2015.CONCLUSIONThe prevalence of self-reported DR in adults with DM declined significantly in North Carolina in the past 15 years. While racial differences in some years appeared to be decreasing, the black-white disparity in DR prevalence during the entire period persisted. Focused efforts on reducing the gap are needed.

ABSTRACTIn patients with type 2 diabetes secondary to excess nutrients and energy balance, relative – not absolute – insulin deficiency plays a key role in disease development and progression. Although patients with type 2 diabetes who have features of insulin resistance would usually have hyperinsulinemia, insulin therapy remains recommended by guidelines particularly when patients fail to achieve glycemic goals. This approach does not prevent complications particularly macrovascular complications. This raises a controversial question regarding the benefit of using exogenous insulin for glycemic control in patients with type 2 diabetes who have features of insulin resistance. To address this concern, the authors performed a literature search looking for either randomized trials or meta-analyses directly comparing exogenous insulin to non-insulin therapy in the treatment of patients with type 2 diabetes. Our main outcomes of interest were effect on glycemic control and insulin resistance at various time points in the usual trajectory of type 2 diabetes. In trials investigating early short-term initiation of intensive insulin therapy, insulin therapy was beneficial in rapidly achieving glycemic control and reversing glucotoxicity. Following the initial 2 weeks to 3 months of adequate glycemic control in patients on intensive insulin therapy, there is little evidence that continuing insulin therapy provides greater glycemic control or improves insulin resistance beyond what can be achieved with other therapies. In conclusion, long-term insulin use appears neutral if not potentially harmful with respect to insulin resistance and cardiovascular outcomes. While this review has limitations and should be dealt cautiously, it raises questions regarding the benefit of insulin in patients with type 2 diabetes with features of insulin resistance. Further research is needed to confirm these findings.

Racial disparities related to hypertension prevalence and control persist, with Black persons continuing to have both high prevalence and suboptimal control. The Black Belt region of the US Southeast is characterized by multiple critical priority populations: rural, low-income, and minority (Black).

Background:Limited population-based evidence is available about risk factor management following stroke. We examined age, race, sex, and regional (Stroke Belt vs. other) differences in discharge antihypertensive prescribing and smoking cessation counseling after ischemic stroke using population level data from a national cohort study.Methods:Medical record data was abstracted from 1042 participants enrolled in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study who had an adjudicated ischemic stroke between 2003-2016. Participants with a history of prior stroke, in-hospital death, hospice discharge, incomplete records, and non-smokers for smoking cessation analyses were excluded resulting in 798 cases for discharge antihypertensive prescribing and 117 cases for smoking cessation counseling in the final analyses. Differences were assessed using modified Poisson regression adjusting for patient and hospital level factors.Results:Overall, 86% received discharge antihypertensives while 50% of current smokers received counseling at discharge. Participants who were older, female, had a greater number of CV risk factors, and higher BMIs were significantly more likely to receive discharge antihypertensives compared to younger participants, males, those with fewer risk factors and lower BMIs, respectively (age RR 1.05; 95% CI, 1.02-1.09; female sex RR 1.09; 95% CI, 1.03-1.16; total risk factors RR 1.07; 95% CI, 1.04-1.10; BMI RR 1.01; 95% CI, 1.00-1.01). There was an increasing trend in receipt of smoking cessation counseling over time (RR 1.12; 95% CI, 1.04-1.21).Conclusions:Discharge antihypertensive prescribing varies modestly by patient-level variables. There were no differences in smoking cessation counseling by age, sex, race, or study region. Smoking cessation counseling has improved over time, yet only half of smokers received cessation counseling.

The findings and recommendations of the North American consensus conference on training in hepatopancreaticobiliary (HPB)surgery held in October 2014 are presented. The conference was hosted by the Society for Surgical Oncology (SSO), the Americas Hepato‐Pancreatico‐Biliary Association (AHPBA), and the American Society of Transplant Surgeons (ASTS). The current state of training in HPBsurgery in North America was defined through three pathways—HPB, surgical oncology, and solid organ transplant fellowships. Consensus regarding programmatic requirements included establishment of minimum case volumes and inclusion of quality metrics. Formative assessment, using milestones as a framework and inclusive of both operative and nonoperative skills, must be present. Specific core HPBcases should be defined and used for evaluation of operative skills. The conference concluded with a focus on the optimal means to perform summative assessment to evaluate the individual fellow completing a fellowship in HPBsurgery. Presentations from the hospital perspective and the American Board of Surgery led to consensus that summative assessment was desired by the public and the hospital systems and should occur in a uniform but possibly modular manner for all HPBfellowship pathways. A task force composed of representatives of the SSO,AHPBA, and ASTSare charged with implementation of the consensus statements emanating from this consensus conference. The authors present consensus statements and plans for future tripartite training in hepatopancreaticobiliary surgery.

In most mental illnesses, onset occurs before the age of 25 and the earliest stages are critical. The youth bear a large share of the burden of disease associated with mental illnesses. Yet, Canadian youths with mental health difficulties face delayed detection; long waiting lists; inaccessible, unengaging services; abrupt transitions between services; and, especially in remoter regions, even a complete lack of services. Responding to this crisis, the Canadian Institutes of Health Research announced a 5-year grant that was awarded to ACCESS, a pan-Canadian network of youths, families, clinicians, researchers, policymakers, community organisations and Indigenous communities. Using strategies developed collaboratively by all stakeholders, ACCESS will execute a youth mental healthcare transformation via early detection, rapid access and appropriate, high-quality care. The project includes an innovative, mixed-methods service research component. Similar in many respects to other national youth mental health initiatives, ACCESS also exhibits important differences of scale, scope and approach.

The emergence of a new youth mental health paradigm has challenged how we think about the provision of mental health care for adolescents and young adults. This editorial tracks the origins of this new paradigm within the field of mental health both internationally and in Ireland.

AimsTo identify whether clinical information routinely collected and recorded on clinical files is available for the identification of metabolic syndrome and to assess the prevalence of risk factors for the syndrome in a sample of people with intellectual disabilities (ID) and mental illness treated with antipsychotic medication.MethodsA retrospective analysis was performed for 76 adults with ID and comorbid mental illness, for whom treatment with antipsychotic medication was established. Statistical analysis was performed using SPSS 16.0. The Student t-test for parametric data and ?2-test for non-parametrical data were used.ResultsFive of the six criteria for metabolic syndrome were available in all or a high proportion of the files, however no measurement for waist circumference was recorded in any of the files. Aripiprazole appears to be the least risky antipsychotic for metabolic syndrome.ConclusionIt is important to develop a systematic protocol to record diagnostic variables for metabolic syndrome in at risk populations such as those with ID and mental illness treated with regular antipsychotics.

Background:Regimen-related emotional distress in patients with type 2 diabetes mellitus (T2DM) is associated with poor glycemic control, but the mediators of this relationship are not well described. Objective:This cross-sectional study at baseline examines these relationships, including the specific role of medication adherence in rural African American women. Methods:At baseline in the EMPOWER randomized trial, the investigators collected the following data: Regimen-Related Distress (RRD; subscale of the validated Diabetes Distress Scale), diabetes medications, medication adherence using the Morisky Medication Adherence Scale, and hemoglobin A1C(A1C). Results:The study enrolled 189 rural African American women with T2DM (mean age = 53 ± 11 years, A1C = 9.1% ± 1.8%, body mass index = 37.7% ± 8.2%; 61% on insulin); 56% reported elevated RRD (mean ≥ 3.0), and this was associated with significantly lower medication adherence (4.4 vs 6.4, P< 0.001) and significantly higher A1C (9.5% vs 8.6%, P< 0.001). In multivariate modeling, both elevated RRD (exp β = 2.1; 95% CI = 1.1-4.2; P< 0.05) and lower medication adherence (exp β = 3.3; 95% CI = 1.1-9.6; P< 0.05) were independently associated with higher A1C values. In mediation analysis, medication adherence was a significant mediator of the effects of RRD on A1C. Conclusion:Among rural African American women with T2DM, elevated levels of RRD were common and were associated with higher A1C values, in part via effects on medication adherence. Complex treatment regimens accompanied by psychological distress may be associated with poorer glycemic control.

The authors report on the establishment of the nation's first Organ Procurement Organization–based organ recovery facility with a goal of increasing efficiencies, reducing costs, and reducing procurement surgeon travel.

Flood‐type disturbances affect both periphyton and macroinvertebrate communities depending on their frequency, magnitude and duration, but some impacts can be mitigated by geomorphic constraints. We studied four rivers in the Adirondack Mountains; the Indian River experienced regulated flow releases creating bank‐full floods four times/week whereas other study sites provided a continuum of control conditions for comparison. We sampled periphyton and macroinvertebrate communities in each river along with channel hydrology, hydraulics and geomorphology. Periphyton abundance varied seasonally and among rivers depending on nitrate concentrations and scour. Flow releases created a static mosaic of patches consisting of heavily scoured bed sediment in the thalweg (high shear stress areas—HSS) which had very low periphyton abundance; boulders and rocky shoals created low shear stress areas (LSS) supporting mats of filamentous algae. Macroinvertebrate densities were highest in HSS areas whereas LSS areas had lower macroinvertebrate densities that were more similar to reference rivers, although both LSS and HSS areas had the lowest species diversity and richness. Macroinvertebrate composition in HSS areas was dominated by filter‐feeders, whereas LSS areas had more gatherers and scrapers. While all rivers had high boulder densities, the Indian River could be considered geomorphically moribund—its substrate was immobile and the channel experienced no adjustments in spite of high flood frequencies. These physical characteristics help mitigate the severe hydrologic conditions that releases create because the static mosaic of low and HSS patches allow certain macroinvertebrates adapted to this level of disturbance to persist. This static mosaic is different from the shifting mosaic pattern often observed in streams following flood‐type disturbances. Geomorphically moribund rivers may lack ecological sensitivity to hydrologic disturbances, and decisions to limit flow modification (e.g. recreational flow releases, hydropower generation) should consider whether assumed ecological impacts are likely to occur given local geomorphic conditions and constraints. Copyright © 2010 John Wiley & Sons, Ltd.

OBJECTIVE To determine if the use of steatotic grafts adversely affects outcomes in liver transplantation. DESIGN A retrospective review of a prospectively maintained database. SETTING A single center. PATIENTS Four hundred ninety adults who underwent liver transplantation from January 1, 2002, to December 31, 2008, at a single center. Graft biopsies were available in 310 (63.3%) cases. Grafts were classified based on amount of macrovesicular steatosis: 5% or less (n = 222), more than 5% to less than 35% (n = 66), and 35% or more (n = 22). MAIN OUTCOME MEASURES Recipient demographics, Model for End-Stage Liver Disease (MELD) score, patient/graft survival, complications, transfusion rates, and liver function test results. RESULTS One-, 3-, and 5-year patient and graft survivals, respectively, were similar (90.38%, 84.7%, and 74.4%, respectively, P = .3; and 88.7%, 82.5%, and 73.3%, respectively, P = .15). Median follow-up was 25 months. Recipient age, sex, body mass index, laboratory MELD score, and ischemia times were similar among all groups. Packed red blood cell (3 vs 8 U, P &lt; .001), fresh frozen plasma (2 vs 4 U, P = .007), and cryoprecipitate transfusion rates were significantly increased in grafts with 35% or more steatosis. Intensive care unit (5 vs 11 days, P = .02) and hospital (11 vs 21 days, P &lt; .001) stay was also increased in those with grafts with 35% or more steatosis compared with those with 5% or less steatosis. The grafts with 35% or more steatosis had higher transaminase peaks and longer times for bilirubin to normalize (P &lt; .001). CONCLUSIONS Use of carefully selected steatotic grafts was not associated with higher rates of primary nonfunction or poorer outcomes. However, the use of steatotic grafts is associated with increased resource use in the perioperative period.Arch Surg. 2010;145(7):653-660--

Segregation at major genes controlling plant height, photoperiod response, and vernalization response in wheat (Triticum aestivumL. em. Thell.) may have pleiotropic effects on several traits. Allelic variation at these loci can be monitored using polymerase chain reaction (PCR) markers. The effect of segregation at these loci on maturity and agronomic traits was measured for sets of recombinant inbred lines (RIL) developed from five crosses between spring wheat lines adapted to Montana and the Northern Great Plains. Results from field trials grown in multiple years in Bozeman, MT, showed that variation at Rht‐B1and Rht‐D1had large effects on most agronomic traits in two populations, including grain yield, grain protein concentration, and test weight. Variation at photoperiod response loci Ppd‐B1and Ppd‐D1influenced both heading date and date of flag leaf senescence under field conditions for two of three populations in which they were segregating. The insensitive allele at Ppd‐B1was associated with higher grain yield in one population. Variation at Vrn‐B1had a significant effect on heading date in the field for both populations in which it was segregating, with spring allele lines being earlier. Our results suggest that variation at Rht loci impacting plant height had large pleiotropic effects. Variation at photoperiod and vernalization loci impacted maturity characteristics but had less consistent effects on economic characteristics such as grain yield, test weight, and grain protein concentration.

The association between neighborhood disadvantage and health is well-documented. However, whether these associations may differ across rural and urban areas is unclear. This study examines the association between a multi-item neighborhood social and economic environment (NSEE) measure and diabetes prevalence across urban and rural communities in the US.

The natural tendency of woody debris to accumulate into complex debris jams has been adapted by the restoration industry because of the morphological and ecological benefits of these structures. While much work has been done on woody debris, there is a lack of understanding of the dynamics of debris jams including the controls on their formation and the associated changes in hydraulics. Treatment of jams as static structures, whose hydraulics may be described by that of a single‐solid object, prevents optimal success of wood‐based restoration projects. This paper reviews the state of the science on the initiation and accumulation of wood forming a debris jam. This review is used to develop a conceptual model of the evolution of a single debris jam focussing on the relationship between the structure and hydraulics and the feedback that exists between them. The proposed mechanisms behind debris jam evolution are supported by a case‐study of three natural jams. Incorporation of this model into restoration and management plans will result in more successful and cost‐efficient projects. Copyright © 2008 John Wiley & Sons, Ltd.

OBJECTIVE To assess the relationship between insulin resistance and body mass index (BMI) z score associated with dietary modification that focuses on limiting sweetened beverage consumption in overweight children. DESIGN A retrospective cohort study conducted between July 1, 2004, and April 28, 2006. SETTING Community-based primary care practices treating children. PATIENTS Forty-five children (aged ≤18 years) at or above the 95th percentile of BMI for age and sex. INTERVENTION Children and parents were instructed by a dietitian regarding caloric reduction and modification of sweetened beverage intake. MAIN OUTCOME MEASURES Insulin resistance at baseline was calculated from fasting insulin and glucose levels (ie, homeostatic model assessment [HOMA]) and change in BMI z score from baseline to 12-week follow-up. RESULTS Change in BMI z score in response to a decrease in sweetened beverages correlated (Pearson product moment correlation coefficient = 0.42; P &lt; .01) with baseline insulin resistance. Those with a decrease in or an unchanged BMI z score had significantly greater insulin resistance than those whose BMI z score increased (mean [SD] HOMA, 6.2 [4.2] vs 2.6 [2.0], P &lt; .01). Linear regression confirmed that HOMA was a significant predictor of change in BMI z score when controlling for age, race, and sex. CONCLUSIONS Among overweight children in primary care practices, a significant relationship was found between insulin resistance and the change in BMI z score associated with a dietitian-mediated intervention that includes a focus on decreasing sweetened beverage consumption. Estimating insulin resistance may inform dietary recommendations for overweight children.Arch Pediatr Adolesc Med. 2008;162(8):764-768--