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Objective: Depression affects up to 20-25% of adults with type 2 diabetes and may increase all-cause mortality, but few well-designed studies have examined the effects of depression on the full range of cardiovascular disease outcomes in type 2 diabetes.Research Design and Methods: A total of 2,053 participants in the ACCORD (Action to Control Cardiovascular Risk in Diabetes) Health-Related Quality of Life substudy completed the Patient Health Questionnaire (PHQ)-9 measure of depression symptoms at baseline and 12, 36, and 48 months. Cox proportional hazards regression models were used to estimate hazard ratios (HRs) (95% CI) for the time-varying impact of depression on protocol-defined clinical outcomes with and without adjustment for demographic, trial-related, clinical, and behavioral variables.Results: In fully adjusted models, depression was not significantly related to the ACCORD primary composite outcome (cardiovascular death, nonfatal heart attack, or stroke) (HR 1.53 [95% CI 0.85-2.73]) or to the ACCORD microvascular composite outcome (0.93 [0.53-1.62]), but all-cause mortality was significantly increased both in those with PHQ-assessed probable major depression (2.24 [1.24-4.06]) and PHQ score of ≥ 10 (1.84 [1.17-2.89]). The effect of depression on all-cause mortality was not related to previous cardiovascular events or to assignment to intensive or standard glycemia control. Probable major depression (by PHQ-9) had a borderline impact on the ACCORD macrovascular end point (1.42 [0.99-2.04]).Conclusions: Depression increases the risk of all-cause mortality and may increase the risk of macrovascular events among adults with type 2 diabetes at high risk for cardiovascular events. [ABSTRACT FROM AUTHOR]

Objective: To assess the cardiovascular risk profile of youths across socioeconomic groups in the U.S.Research Design and Methods: Analysis of 1999-2008 National Health and Nutrition Examination Surveys (NHANES) including 16,085 nonpregnant 6- to 24-year-olds to estimate race/ethnicity-adjusted prevalence of obesity, central obesity, sedentary behaviors, tobacco exposure, elevated systolic blood pressure, glycated hemoglobin, non-HDL cholesterol (non-HDL-C), and high-sensitivity C-reactive protein according to age-group, sex, and poverty-income ratio (PIR) tertiles.Results: Among boys aged 6-11 years, 19.9% in the lowest PIR tertile were obese and 30.0% were centrally obese compared with 13.2 and 21.6%, respectively, in the highest-income tertile households (P(obesity) < 0.05 and P(central obesity) < 0.01). Boys aged 12-17 years in lowest-income households were more likely than their wealthiest family peers to be obese (20.6 vs. 15.6%, P < 0.05), sedentary (14.8 vs. 9.3%, P < 0.05), and exposed to tobacco (19.0 vs. 6.5%, P < 0.01). Compared with girls aged 12-17 years in highest-income households, lowest-income household girls had higher prevalence of obesity (17.9 vs. 13.1%, P < 0.05), central obesity (41.5 vs. 29.2%, P < 0.01), sedentary behaviors (20.4 vs. 9.4%, P < 0.01), and tobacco exposure (14.1 vs. 5.9%, P < 0.01). Apart from higher prevalence of elevated non-HDL-C among low-income women aged 18-24 years (23.4 vs. 15.8%, P < 0.05), no other cardiovascular disease risk factor prevalence differences were observed between lowest- and highest-income background young adults.Conclusions: Independent of race/ethnicity, 6- to 17-year-olds from low-income families have higher prevalence of obesity, central obesity, sedentary behavior, and tobacco exposure. Multifaceted cardiovascular health promotion policies are needed to reduce health disparities between income groups. [ABSTRACT FROM AUTHOR]

Objective: To compare the effect of intensive versus standard glycemic control strategies on health-related quality of life (HRQL) in a substudy of the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial.Research Design and Methods: A randomly selected subsample of 2,053 ACCORD participants enrolled in the HRQL substudy was assessed at baseline and 12-, 36-, and 48-month visits. HRQL assessment included general health status (the 36-Item Short Form Health Survey [SF-36]), diabetes symptoms (the Diabetes Symptom Distress Checklist), depression (Patient Health Questionnaire [PHQ]-9), and treatment satisfaction (Diabetes Treatment Satisfaction Questionnaire [DTSQ]). Repeated-measures ANOVA models were used to estimate change in HRQL outcomes by treatment group over 48 months adjusting for model covariates. The effects of early discontinuation of the ACCORD intensive glycemic control arm on study results were explored.Results: A total of 1,956 (95%) completed the self-report HRQL instrument(s) at baseline. The intensive arm had a larger decrease in SF-36 physical health component score than the standard arm (-1.6 vs. -1.1, P = 0.0345). Treatment satisfaction (DTSQ) showed larger improvement with intensive than standard (P = 0.0004). There were no differences in mean scores of the Diabetes Symptom Checklist and PHQ-9. Effects of participant transition following discontinuation of the intensive arm on HRQL were not significant.Conclusions: The ACCORD trial strategy of intensive glycemic control did not lead to benefits in HRQL and was associated with modest improvement in diabetes treatment satisfaction. Thus patient acceptability was apparently not compromised with intensive and complex interventions such as those used in ACCORD. [ABSTRACT FROM AUTHOR]

Objective: We tested the hypothesis that intensive (systolic blood pressure [SBP] <120 mmHg) rather than standard (SBP 130-139 mmHg) blood pressure (BP) control improves health-related quality of life (HRQL) in those with type 2 diabetes.Research Design and Methods: Subjects were 1,028 ACCORD (Action to Control Cardiovascular Risk in Diabetes) BP trial HRQL substudy participants who completed baseline and one or more 12-, 36-, or 48-month HRQL evaluations. Multivariable linear regression assessed impact of BP treatment assignment on change in HRQL.Results: Over 4.0 years of follow-up, no significant differences occurred in five of six HRQL measures. Those assigned to intensive (vs. standard) BP control had statistically significant worsening of the Medical Outcomes Study 36-item short-form health survey (SF36) physical component scores (-0.8 vs. -0.2; P = 0.02), but magnitude of change was not clinically significant. Findings persisted across all prespecified subgroups.Conclusions: Intensive BP control in the ACCORD trial did not have a clinically significant impact, either positive or negative, on depression or patient-reported HRQL. [ABSTRACT FROM AUTHOR]

Background: Depressive symptoms frequently co-occur with diabetes and, when unaddressed, can function to worsen diabetes control and increase the risk of diabetes-related morbidity. Integrated care (IC) approaches aim to improve outcomes among people with diabetes and depression, but there are no current meta-analyses examining their effects., Purpose: In our study we summarize the effects of IC approaches to address depression and diabetes and examine moderating effects of IC approaches (e.g., behavioral intervention used; type of IC approach)., Data Sources: A systematic search was conducted of PubMed, PsycInfo, CINAHL, and ProQuest., Study Selection: Two reviewers triaged abstracts and full-text articles to identify relevant articles. Randomized controlled trials with enrollment of participants with diabetes and depressive symptoms and with provision of sufficient data on depression scores and hemoglobin A1c were included., Data Extraction: Two reviewers extracted demographic information, depression scores, diabetes outcomes, intervention details, and the risk of bias for each study., Data Synthesis: From 517 abstracts, 75 full-text reports were reviewed and 31 studies with 8,843 participants were analyzed. Among 26 studies with reporting of HbA1c, IC approaches were associated with a significant between-group difference regarding the percent decrease of HbA1c (d = -0.36, 95% CI -0.52 to -0.21). Studies that included a combination of behavioral interventions (behavioral activation with cognitive behavioral therapy) showed greater reductions in HbA1c. Among 23 studies with reporting of depressive symptoms, the pooled effect of IC approaches lowered depressive scores by 0.72 points (95% CI -1.15 to -0.28)., Limitations: The inclusion of a wide range of IC approaches increased study heterogeneity. A random effects model and sensitivity analyses mitigated this limitation., Conclusions: IC approaches are associated with improved glycemia and depressive symptoms in comparison with treatment as usual., (© 2024 by the American Diabetes Association.)

Objective: To describe the natural history of diabetes in Indians., Research Design and Methods: Data are from participants older than 20 years in the Centre for Cardiometabolic Risk Reduction in South Asia longitudinal study. Glycemic states were defined per American Diabetes Association criteria. Markov models were used to estimate annual transition probabilities and sojourn time through states., Results: Among 2,714 diabetes-free participants, 641 had isolated impaired fasting glucose (iIFG), and 341 had impaired glucose tolerance (IGT). The annual transition to diabetes for those with IGT was 13.9% (95% CI 12.0, 15.9) versus 8.6% (7.3, 9.8) for iIFG. In the normoglycemia ↔ iIFG → diabetes model, mean sojourn time in normoglycemia was 40.3 (34.6, 48.2) years, and sojourn time in iIFG was 9.7 (8.4, 11.4) years. For the normoglycemia ↔ IGT → diabetes model, mean sojourn time in normoglycemia was 34.5 (29.5, 40.8) years, and sojourn time in IGT was 6.1 (5.3, 7.1) years., Conclusions: Individuals reside in normoglycemia for 35-40 years; however, progression from prediabetes to diabetes is rapid., (© 2024 by the American Diabetes Association.)

Objective: To examine whether the effect of conventional lifestyle interventions on type 2 diabetes incidence differs by glucose-defined prediabetes phenotype., Research Design and Methods: We searched multiple databases until 1 April 2023 for randomized controlled trials that recruited people with isolated impaired fasting glucose (i-IFG), isolated impaired glucose tolerance (i-IGT), and impaired fasting glucose plus impaired glucose tolerance (IFG+IGT). Individual participant data were pooled from relevant trials and analyzed through random-effects models with use of the within-trial interactions approach., Results: Four trials with 2,794 participants (mean age 53.0 years, 60.7% men) were included: 1,240 (44.4%), 796 (28.5%), and 758 (27.1%) had i-IFG, i-IGT, and IFG+IGT, respectively. After a median of 2.5 years, the pooled hazard ratio for diabetes incidence in i-IFG was 0.97 (95% CI 0.66, 1.44), i-IGT 0.65 (0.44, 0.96), and IFG+IGT 0.51 (0.38, 0.68; Pinteraction = 0.01)., Conclusions: Conventional lifestyle interventions reduced diabetes incidence in people with IGT (with or without IFG) but not in those with i-IFG., (© 2023 by the American Diabetes Association.)

Objective: To assess the cost-effectiveness of collaborative versus usual care in adults with poorly controlled type 2 diabetes and depression in India., Research Design and Methods: We performed a within-trial cost-effectiveness analysis of a 24-month parallel, open-label, pragmatic randomized clinical trial at four urban clinics in India from multipayer and societal perspectives. The trial randomly assigned 404 patients with poorly controlled type 2 diabetes (HbA1c ≥8.0%, systolic blood pressure ≥140 mmHg, or LDL cholesterol ≥130 mg/dL) and depressive symptoms (9-item Patient Health Questionnaire score ≥10) to collaborative care (support from nonphysician care coordinators, electronic registers, and specialist-supported case review) for 12 months, followed by 12 months of usual care or 24 months of usual care. We calculated incremental cost-effectiveness ratios (ICERs) in Indian rupees (INR) and international dollars (Int'l-$) and the probability of cost-effectiveness using quality-adjusted life-years (QALYs) and depression-free days (DFDs)., Results: From a multipayer perspective, collaborative care costed an additional INR309,558 (Int'l-$15,344) per QALY and an additional INR290.2 (Int'l-$14.4) per DFD gained compared with usual care. The probability of cost-effectiveness was 56.4% using a willingness to pay of INR336,000 (Int'l-$16,654) per QALY (approximately three times per-capita gross domestic product). The willingness to pay per DFD to achieve a probability of cost-effectiveness >95% was INR401.6 (Int'l-$19.9). From a societal perspective, cost-effectiveness was marginally lower. In sensitivity analyses, integrating collaborative care in clinical workflows reduced incremental costs by ∼47% (ICER 162,689 per QALY, cost-effectiveness probability 89.4%), but cost-effectiveness decreased when adjusting for baseline values., Conclusions: Collaborative care for patients with type 2 diabetes and depression in urban India can be cost-effective, especially when integrated in clinical workflows. Long-term cost-effectiveness might be more favorable. Scalability across lower- and middle-income country settings depends on heterogeneous contextual factors., (© 2022 by the American Diabetes Association.)

Objective: Diabetes prevalence is increasing rapidly in rural areas of low- and middle-income countries (LMICs), but there are limited data on the performance of health systems in delivering equitable and effective care to rural populations. We therefore assessed rural-urban differences in diabetes care and control in LMICs., Research Design and Methods: We pooled individual-level data from nationally representative health surveys in 42 countries. We used Poisson regression models to estimate age-adjusted differences in the proportion of individuals with diabetes in rural versus urban areas achieving performance measures for the diagnosis, treatment, and control of diabetes and associated cardiovascular risk factors. We examined differences across the pooled sample, by sex, and by country., Results: The pooled sample from 42 countries included 840,110 individuals (35,404 with diabetes). Compared with urban populations with diabetes, rural populations had ∼15-30% lower relative risk of achieving performance measures for diabetes diagnosis and treatment. Rural populations with diagnosed diabetes had a 14% (95% CI 5-22%) lower relative risk of glycemic control, 6% (95% CI -5 to 16%) lower relative risk of blood pressure control, and 23% (95% CI 2-39%) lower relative risk of cholesterol control. Rural women with diabetes had lower achievement of performance measures relating to control than urban women, whereas among men, differences were small., Conclusions: Rural populations with diabetes experience substantial inequities in the achievement of diabetes performance measures in LMICs. Programs and policies aiming to strengthen global diabetes care must consider the unique challenges experienced by rural populations., (© 2022 by the American Diabetes Association.)

Objective: To analyze national and state-specific trends in diabetes-related hospital admissions and determine whether disparities in rates of admission exist between demographic groups and geographically dispersed states., Research Design and Methods: We conducted serial cross-sectional analyses of the National Inpatient Sample (2008, 2011, 2014, and 2016) and State Inpatient Databases for Arizona, Florida, Kentucky, Iowa, Maryland, Nebraska, New Jersey, New York, North Carolina, Utah, and Vermont for 2008, 2011, 2014, and 2016/2017 among adult patients with type 1 and type 2 diabetes-related ICD codes (ICD-9 [250.XX] or ICD-10 [E10.XXX, E11.XXX, and E13.XXX]. We measured hospitalization rates for people with diabetes (all-cause hospitalizations) and for admissions with a primary diagnosis of diabetes or diabetes-related complications (diabetes-specific hospitalizations) per 10,000 people per year., Results: Nationally, all-cause and diabetes-specific hospitalizations declined by 3.1% (95% CI -5.5, -0.7) and 19.1% (95% CI -21.6, -16.6), respectively, over 2008 to 2016. The analysis of individual states showed that diabetes-specific admissions in individuals ≥65 years old declined during this time (16.3-48.8% decrease) but increased among patients 18-29 years old (10.5-81.5% increase) and that rural diabetes-specific admissions decreased in just over half of the included states (15.2-69.2% decrease). There were no differences in changes in admission rates among different racial/ethnic groups., Conclusions: Overall, rates of diabetes-related hospitalizations decreased over 2008 to 2016/2017, but there were large state-level differences across subgroups of patients. The rise in diabetes hospitalizations among young adults is a cause for concern. These state- and subpopulation-level differences highlight the need for state-level policies and interventions to address disparities in diabetes health care use., (© 2022 by the American Diabetes Association.)

Objective: We characterized annual trends of severe hypoglycemic and hyperglycemic crises (diabetic ketoacidosis/hyperglycemic hyperosmolar state) in patients with diabetes and end-stage kidney disease (ESKD)., Research Design and Methods: This was a nationwide, retrospective study of adults (≥18 years old) with diabetes/ESKD, from the United States Renal Data System registry, between 2013 and 2017. Primary outcome was annual rates of emergency department visits or hospitalizations for hypoglycemic and hyperglycemic crises, reported as number of events/1,000 person-years. Event rates and risk factors were adjusted for patient age, sex, race/ethnicity, dialysis modality, comorbidities, treatment regimen, and U.S. region., Results: Among 521,789 adults with diabetes/ESKD (median age 65 years [interquartile range 57-73], 56.1% male, and 46% White), overall adjusted rates of hypoglycemic and hyperglycemic crises were 53.64 and 18.24 per 1,000 person-years, respectively. For both hypoglycemia and hyperglycemia crises, respectively, the risks decreased with age and were lowest in older patients (≥75 vs. 18-44 years old: incidence rate ratio 0.35, 95% CI 0.33-0.37, and 0.03, 0.02-0.03), women (1.09, 1.06-1.12, and 1.44, 1.35-1.54), and those with smoking (1.36, 1.28-1.43, and 1.71, 1.53-1.91), substance abuse (1.27, 1.15-1.42, and 1.53, 1.23-1.9), retinopathy (1.10, 1.06-1.15, and 1.36, 1.26-1.47), and insulin therapy (vs. no therapy; 0.60, 0.59-0.63, and 0.44, 0.39-0.48). For hypoglycemia, specifically, additional risk was conferred by Black race (1.11, 1.08-1.15) and amputation history (1.20, 1.13-1.27)., Conclusions: In this nationwide study of patients with diabetes/ESKD, hypoglycemic crises were threefold more common than hyperglycemic crises, greatly exceeding national reports in nondialysis patients with chronic kidney disease. Young, Black, and female patients were disproportionately affected., (© 2021 by the American Diabetes Association.)

Objective: To examine changes in and the relationships between diabetes management and rural and urban residence., Research Design and Methods: Using National Health and Nutrition Examination Survey (1999-2018) data from 6,372 adults aged ≥18 years with self-reported diagnosed diabetes, we examined poor ABCS: A 1C >9% (>75 mmol/mol), B lood pressure (BP) ≥140/90 mmHg, C holesterol (non-HDL) ≥160 mg/dL (≥4.1 mmol/L), and current S moking. We compared odds of urban versus rural residents (census tract population size ≥2,500 considered urban, otherwise rural) having poor ABCS across time (1999-2006, 2007-2012, and 2013-2018), overall and by sociodemographic and clinical characteristics., Results: During 1999-2018, the proportion of U.S. adults with diabetes residing in rural areas ranged between 15% and 19.5%. In 1999-2006, there were no statistically significant rural-urban differences in poor ABCS. However, from 1999-2006 to 2013-2018, there were greater improvements for urban adults with diabetes than for rural for BP ≥140/90 mmHg (relative odds ratio [OR] 0.8, 95% CI 0.6-0.9) and non-HDL ≥160 mg/dL (≥4.1 mmol/L) (relative OR 0.45, 0.4-0.5). These differences remained statistically significant after adjustment for race/ethnicity, education, poverty levels, and clinical characteristics. Yet, over the 1999-2018 time period, minority race/ethnicity, lower education attainment, poverty, and lack of health insurance coverage were factors associated with poorer A, B, C, or S in urban adults compared with their rural counterparts., Conclusions: Over two decades, rural U.S. adults with diabetes have had less improvement in BP and cholesterol control. In addition, rural-urban differences exist across sociodemographic groups, suggesting that efforts to narrow this divide may need to address both socioeconomic and clinical aspects of care., (© 2021 by the American Diabetes Association.)

Objective: We investigated the risk of depression and anxiety in people whose spouse did or did not have diabetes. We also examined associations between depression and anxiety and severity of spouse's diabetes., Research Design and Methods: We analyzed prospective self-reported data about diagnosed depression/anxiety and diabetes in cohabiting couples in the national Panel Study of Income Dynamics (PSID) during 1999-2017 ( n = 13,500, 128,833 person-years of follow-up, median follow-up 8.1 years). We used Poisson models to estimate incidence and incidence rate ratios (IRRs) of depression/anxiety, according to spouse's diabetes status overall and by severity of diabetes., Results: Age-, sex-, and race-adjusted incidence of depression/anxiety was 8.0/1,000 person-years (95% CI 6.5, 9.6) among those whose spouse had diabetes and 6.5/1,000 person-years (95% CI 6.0, 6.9) among those whose spouse did not have diabetes. Those whose spouse had diabetes had higher risk of depression/anxiety (IRR 1.24 [95% CI 1.01, 1.53]). Those whose spouse had diabetes-related limitations in daily activities (IRR 1.89 [95% CI 1.35, 2.67]) and diabetes combined with other chronic conditions (IRR 2.34 [95% CI 1.78, 3.09]) were more likely to develop depression/anxiety, while those whose spouse had diabetes with no limitations or additional chronic conditions had incidence of depression/anxiety similar to that of subjects whose spouses did not have diabetes., Conclusions: People living with a spouse with diabetes are at higher risk of developing depression/anxiety than people whose spouse does not have diabetes; this risk is driven by the severity of the spouse's diabetes. Strategies to address the impacts of diabetes on families need to be devised and tested., (© 2021 by the American Diabetes Association.)

Objective: To synthesize updated evidence on the cost-effectiveness (CE) of interventions to manage diabetes, its complications, and comorbidities., Research Design and Methods: We conducted a systematic literature review of studies from high-income countries evaluating the CE of diabetes management interventions recommended by the American Diabetes Association (ADA) and published in English between June 2008 and July 2017. We also incorporated studies from a previous CE review from the period 1985-2008. We classified the interventions based on their strength of evidence (strong, supportive, or uncertain) and levels of CE: cost-saving (more health benefit at a lower cost), very cost-effective (≤$25,000 per life year gained [LYG] or quality-adjusted life year [QALY]), cost-effective ($25,001-$50,000 per LYG or QALY), marginally cost-effective ($50,001-$100,000 per LYG or QALY), or not cost-effective (>$100,000 per LYG or QALY). Costs were measured in 2017 U.S. dollars., Results: Seventy-three new studies met our inclusion criteria. These were combined with 49 studies from the previous review to yield 122 studies over the period 1985-2017. A large majority of the ADA-recommended interventions remain cost-effective. Specifically, we found strong evidence that the following ADA-recommended interventions are cost-saving or very cost-effective: In the cost-saving category are 1 ) ACE inhibitor (ACEI)/angiotensin receptor blocker (ARB) therapy for intensive hypertension management compared with standard hypertension management, 2 ) ACEI/ARB therapy to prevent chronic kidney disease and/or end-stage renal disease in people with albuminuria compared with no ACEI/ARB therapy, 3 ) comprehensive foot care and patient education to prevent and treat foot ulcers among those at moderate/high risk of developing foot ulcers, 4 ) telemedicine for diabetic retinopathy screening compared with office screening, and 5 ) bariatric surgery compared with no surgery for individuals with type 2 diabetes (T2D) and obesity (BMI ≥30 kg/m 2 ). In the very cost-effective category are 1 ) intensive glycemic management (targeting A1C <7%) compared with conventional glycemic management (targeting an A1C level of 8-10%) for individuals with newly diagnosed T2D, 2 ) multicomponent interventions (involving behavior change/education and pharmacological therapy targeting hyperglycemia, hypertension, dyslipidemia, microalbuminuria, nephropathy/retinopathy, secondary prevention of cardiovascular disease with aspirin) compared with usual care, 3 ) statin therapy compared with no statin therapy for individuals with T2D and history of cardiovascular disease, 4 ) diabetes self-management education and support compared with usual care, 5 ) T2D screening every 3 years starting at age 45 years compared with no screening, 6 ) integrated, patient-centered care compared with usual care, 7 ) smoking cessation compared with no smoking cessation, 8 ) daily aspirin use as primary prevention for cardiovascular complications compared with usual care, 9 ) self-monitoring of blood glucose three times per day compared with once per day among those using insulin, 10 ) intensive glycemic management compared with conventional insulin therapy for T2D among adults aged ≥50 years, and 11 ) collaborative care for depression compared with usual care., Conclusions: Complementing professional treatment recommendations, our systematic review provides an updated understanding of the potential value of interventions to manage diabetes and its complications and can assist clinicians and payers in prioritizing interventions and health care resources., (© 2020 by the American Diabetes Association.)

Objective: Cardiovascular disease (CVD) mortality has declined substantially in the U.S. The aims of this study were to examine trends and demographic disparities in mortality due to CVD and CVD subtypes among adults with and without self-reported diabetes., Research Design and Methods: We used the National Health Interview Survey (NHIS) (1985-2014) with mortality follow-up data through the end of 2015 to estimate nationally representative trends and disparities in major CVD, ischemic heart disease (IHD), stroke, heart failure, and arrhythmia mortality among adults ≥20 years of age by diabetes status., Results: Over a mean follow-up period of 11.8 years from 1988 to 2015 of 677,051 adults, there were significant decreases in major CVD death (all P values <0.05) in adults with and without diabetes except adults 20-54 years of age. Among adults with diabetes, 10-year relative changes in mortality were significant for major CVD (-32.7% [95% CI -37.2, -27.9]), IHD (-40.3% [-44.7, -35.6]), and stroke (-29.2% [-40.0, -16.5]), but not heart failure (-0.5% [-20.7, 24.7]), and arrhythmia (-12.0% [-29.4, 77.5]); the absolute decrease of major CVD among adults with diabetes was higher than among adults without diabetes ( P < 0.001). Men with diabetes had larger decreases in CVD death than women with diabetes ( P < 0.001)., Conclusions: Major CVD mortality in adults with diabetes has declined, especially in men. Large reductions were observed for IHD and stroke mortality, although heart failure and arrhythmia deaths did not change. All race and education groups benefitted to a similar degree, but significant gaps remained across groups., (© 2018 by the American Diabetes Association.)

Objective: Understanding the real-world impacts of lifestyle modification (LSM) for diabetes prevention is imperative to inform resource allocation. The purpose of this study was to synthetize global evidence on the impact of LSM strategies on diabetes incidence and risk factors in one parsimonious model., Research Design and Methods: PubMed, Embase, Cochrane Library, and ClinicalTrials.gov were searched for studies published between January 1990 and April 2015. Effectiveness/translation studies of any design testing LSM strategies, targeting high-risk populations (with prediabetes or diabetes risk factors), and reporting diabetes incidence, weight, or glucose outcomes were included. We extracted number of diabetes cases/incidence rates and mean changes in weight (kg), fasting blood glucose (FBG, mmol/L), 2-h postload glucose (mmol/L), and hemoglobin A 1c (%). Pairwise random-effects and frequentist random-effects network meta-analyses were used to obtain pooled effects., Results: Sixty-three studies were pooled in the meta-analysis ( n = 17,272, mean age 49.7 years, 28.8% male, 60.8% white/European). In analyses restricted to controlled studies ( n = 7), diabetes cumulative incidence was 9% among intervention participants and 12% among control participants (absolute risk reduction 3%; relative risk 0.71 [95% CI 0.58, 0.88]). In analyses combining controlled and uncontrolled studies ( n = 14), participants receiving group education by health care professionals had 33% lower diabetes odds than control participants (odds ratio 0.67 [0.49, 0.92]). Intervention participants lost 1.5 kg more weight [-2.2, -0.8] and achieved a 0.09 mmol/L greater FBG decrease [-0.15, -0.03] than control participants. Every additional kilogram lost by participants was associated with 43% lower diabetes odds (β = 0.57 [0.41, 0.78])., Conclusions: Real-world LSM strategies can reduce diabetes risk, even with small weight reductions., (© 2018 by the American Diabetes Association.)

Objective: We examined the proportion of American adults without type 2 diabetes that engages in lifestyle behaviors known to reduce type 2 diabetes risk., Research Design and Methods: We conducted a cross-sectional analysis of 3,679 nonpregnant, nonlactating individuals aged ≥20 years without diabetes (self-reported diagnosis or glycated hemoglobin ≥6.5% [8 mmol/mol] or fasting plasma glucose ≥126 mg/dL) and who provided 2 days of reliable dietary data in the 2007-2012 National Health and Nutrition Examination Surveys (NHANES). We used the average of 2 days of dietary recall and self-reported leisure-time physical activity to assess whether participants met type 2 diabetes risk reduction goals (meeting four or more MyPlate recommendations [adequate consumption of fruits, vegetables, dairy, grains, meat, beans, and eggs]; not exceeding three maximum allowances for alcoholic beverages, added sugars, fat, and cholesterol; and meeting physical activity recommendations [≥150 min/week])., Results: Approximately 21%, 29%, and 13% of individuals met fruit, vegetable, and dairy goals, respectively. Half (51.6%) met the goal for total grains, compared with 18% for whole grains, and 54.2% met the meat/beans goal and 40.6% met the oils goal. About one-third (37.8%) met the physical activity goal, and 58.6% met the weight loss/maintenance goal. Overall, 3.1% (95% CI 2.4-4.0) of individuals met the majority of type 2 diabetes risk reduction goals. Younger age and lower educational attainment were associated with lower probability of meeting goals., Conclusions: A small proportion of U.S. adults engages in risk reduction behaviors. Research and interventions targeted at young and less-educated segments of the population may help close gaps in risk reduction behaviors., (© 2018 by the American Diabetes Association.)

Objective: To assess participant-level results from the first 4 years of implementation of the National Diabetes Prevention Program (National DPP), a national effort to prevent type 2 diabetes in those at risk through structured lifestyle change programs., Research Design and Methods: Descriptive analysis was performed on data from 14,747 adults enrolled in year-long type 2 diabetes prevention programs during the period February 2012 through January 2016. Data on attendance, weight, and physical activity minutes were summarized and predictors of weight loss were examined using a mixed linear model. All analyses were performed using SAS 9.3., Results: Participants attended a median of 14 sessions over an average of 172 days in the program (median 134 days). Overall, 35.5% achieved the 5% weight loss goal (average weight loss 4.2%, median 3.1%). Participants reported a weekly average of 152 min of physical activity (median 128 min), with 41.8% meeting the physical activity goal of 150 min per week. For every additional session attended and every 30 min of activity reported, participants lost 0.3% of body weight ( P < 0.0001)., Conclusions: During the first 4 years, the National DPP has achieved widespread implementation of the lifestyle change program to prevent type 2 diabetes, with promising early results. Greater duration and intensity of session attendance resulted in a higher percent of body weight loss overall and for subgroups. Focusing on retention may reduce disparities and improve overall program results. Further program expansion and investigation is needed to continue lowering the burden of type 2 diabetes nationally., (© 2017 by the American Diabetes Association.)

National surveillance data show a sustained decline in the incidence rate of diagnosed diabetes, which has been heralded as a success in the battle against diabetes in the U.S. In this Perspective, we take a closer look at these data and provide additional insights to help interpret these trends. We examine multiple sources of data on the prevalence and incidence of diabetes in the U.S. as well as data on trends in diabetes risk factors to provide context for these national surveillance findings. Although some of the incidence decline may represent real progress against diabetes, it is likely that there are also nonbiological factors at play, especially changes in diagnostic criteria for diabetes. We present and discuss data that suggest improved detection and changes in screening and diagnostic practices may have resulted in the depletion of the "susceptible population." Providing this context for the recent declines in new diabetes diagnoses observed in national data is critical to help avoid misinterpretation. We argue that it is premature to declare victory against the epidemic of diabetes in the U.S. and discuss how we might better focus current public health efforts, including a specific emphasis to address prediabetes., (© 2017 by the American Diabetes Association.)

Objective: This study tests the effectiveness of expert guidelines for diabetes prevention: lifestyle intervention with addition of metformin, when required, among people with prediabetes., Research Design and Methods: The Diabetes Community Lifestyle Improvement Program (D-CLIP) is a randomized, controlled, translation trial of 578 overweight/obese Asian Indian adults with isolated impaired glucose tolerance (iIGT), isolated impaired fasting glucose (iIFG), or IFG+IGT in Chennai, India. Eligible individuals were identified through community-based recruitment and randomized to standard lifestyle advice (control) or a 6-month, culturally tailored, U.S. Diabetes Prevention Program-based lifestyle curriculum plus stepwise addition of metformin (500 mg, twice daily) for participants at highest risk of conversion to diabetes at ≥4 months of follow-up. The primary outcome, diabetes incidence, was assessed biannually and compared across study arms using an intention-to-treat analysis., Results: During 3 years of follow-up, 34.9% of control and 25.7% of intervention participants developed diabetes (P = 0.014); the relative risk reduction (RRR) was 32% (95% CI 7-50), and the number needed to treat to prevent one case of diabetes was 9.8. The RRR varied by prediabetes type (IFG+IGT, 36%; iIGT, 31%; iIFG, 12%; P = 0.77) and was stronger in participants 50 years or older, male, or obese. Most participants (72.0%) required metformin in addition to lifestyle, although there was variability by prediabetes type (iIFG, 76.5%; IFG+IGT, 83.0%; iIGT, 51.3%)., Conclusions: Stepwise diabetes prevention in people with prediabetes can effectively reduce diabetes incidence by a third in community settings; however, people with iIFG may require different interventions., (© 2016 by the American Diabetes Association.)

Objective: To quantify the impact of diabetes status on healthy and disabled years of life for older adults in the U.S. and provide a baseline from which to evaluate ongoing national public health efforts to prevent and control diabetes and disability., Research Design and Methods: Adults (n = 20,008) aged 50 years and older were followed from 1998 to 2012 in the Health and Retirement Study, a prospective biannual survey of a nationally representative sample of adults. Diabetes and disability status (defined by mobility loss, difficulty with instrumental activities of daily living [IADL], and/or difficulty with activities of daily living [ADL]) were self-reported. We estimated incidence of disability, remission to nondisability, and mortality. We developed a discrete-time Markov simulation model with a 1-year transition cycle to predict and compare lifetime disability-related outcomes between people with and without diabetes. Data represent the U.S. population in 1998., Results: From age 50 years, adults with diabetes died 4.6 years earlier, developed disability 6-7 years earlier, and spent about 1-2 more years in a disabled state than adults without diabetes. With increasing baseline age, diabetes was associated with significant (P < 0.05) reductions in the number of total and disability-free life-years, but the absolute difference in years between those with and without diabetes was less than at younger baseline age. Men with diabetes spent about twice as many of their remaining years disabled (20-24% of remaining life across the three disability definitions) as men without diabetes (12-16% of remaining life across the three disability definitions). Similar associations between diabetes status and disability-free and disabled years were observed among women., Conclusions: Diabetes is associated with a substantial reduction in nondisabled years, to a greater extent than the reduction of longevity., (© 2016 by the American Diabetes Association. Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered.)

Objective: To assess the prevalence of diabetes and prediabetes and the associated risk factors in two Asian Indian populations living in different environments., Research Design and Methods: We performed cross-sectional analyses, using representative samples of 2,305 Asian Indians aged 40-84 years living in Chennai, India, from the Centre for cArdiometabolic Risk Reduction in South-Asia study (CARRS) (2010-2011), and 757 Asian Indians aged 40-84 years living in the greater San Francisco and Chicago areas from the U.S. Mediators of Atherosclerosis in South Asians Living in America (MASALA) study (2010-2013). Diabetes was defined as self-reported use of glucose-lowering medication, fasting glucose ≥126 mg/dL, or 2-h glucose ≥200 mg/dL. Prediabetes was defined as fasting glucose 100-125 mg/dL and/or 2-h glucose 140-199 mg/dL., Results: Age-adjusted diabetes prevalence was higher in India (38% [95% CI 36-40]) than in the U.S. (24% [95% CI 21-27]). Age-adjusted prediabetes prevalence was lower in India (24% [95% CI 22-26]) than in the U.S. (33% [95% CI 30-36]). After adjustment for age, sex, waist circumference, and systolic blood pressure, living in the U.S. was associated with an increased odds for prediabetes (odds ratio 1.2 [95% CI 0.9-1.5]) and a decreased odds for diabetes (odds ratio 0.5 [95% CI 0.4-0.6])., Conclusions: These findings indicate possible changes in the relationship between migration and diabetes risk and highlight the growing burden of disease in urban India. Additionally, these results call for longitudinal studies to better identify the gene-environment-lifestyle exposures that underlie the elevated risk for type 2 diabetes development in Asian Indians., (© 2015 by the American Diabetes Association. Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered.)

Objective: To examine β-cell function across a spectrum of glycemia among Asian Indians, a population experiencing type 2 diabetes development at young ages despite low BMI., Research Design and Methods: One-thousand two-hundred sixty-four individuals without known diabetes in the Diabetes Community Lifestyle Improvement Program in Chennai, India, had a 75-g oral glucose tolerance test, with glucose and insulin measured at 0, 30, and 120 min. Type 2 diabetes, isolated impaired fasting glucose (iIFG), isolated impaired glucose tolerance (iIGT), combined impaired fasting glucose and impaired glucose tolerance, and normal glucose tolerance (NGT) were defined by American Diabetes Association guidelines. Measures included insulin resistance and sensitivity (homeostasis model assessment of insulin resistance [HOMA-IR], modified Matsuda Index, 1/fasting insulin) and β-cell function (oral disposition index = [Δ insulin0-30/Δ glucose 0-30] × [1/fasting insulin])., Results: Mean age was 44.2 years (SD, 9.3) and BMI 27.4 kg/m(2) (SD, 3.8); 341 individuals had NGT, 672 had iIFG, IGT, or IFG plus IGT, and 251 had diabetes. Patterns of insulin resistance or sensitivity were similar across glycemic categories. With mild dysglycemia, the absolute differences in age- and sex-adjusted oral disposition index (NGT vs. iIFG, 38%; NGT vs. iIGT, 32%) were greater than the differences in HOMA-IR (NGT vs. iIFG, 25%; NGT vs. iIGT, 23%; each P < 0.0001). Compared with NGT and adjusted for age, sex, BMI, waist circumference, and family history, the odds of mild dysglycemia were more significant per SD of oral disposition index (iIFG: odds ratio [OR], 0.36; 95% CI, 0.23-0.55; iIGT: OR, 0.37; 95% CI, 0.24-0.56) than per SD of HOMA-IR (iIFG: OR, 1.69; 95% CI, 1.23-2.33; iIGT: OR, 1.53; 95% CI, 1.11-2.11)., Conclusions: Asian Indians with mild dysglycemia have reduced β-cell function, regardless of age, adiposity, insulin sensitivity, or family history. Strategies in diabetes prevention should minimize loss of β-cell function.

Objective: To compare diabetes prevalence among Asian Americans by World Health Organization and U.S. BMI classifications., Research Design and Methods: Data on Asian American adults (n = 7,414) from the National Health Interview Survey for 1997-2005 were analyzed. Diabetes prevalence was estimated across weight and ethnic group strata., Results: Regardless of BMI classification, Asian Indians and Filipinos had the highest prevalence of overweight (34-47 and 35-47%, respectively, compared with 20-38% in Chinese; P < 0.05). Asian Indians also had the highest ethnic-specific diabetes prevalence (ranging from 6-7% among the normal weight to 19-33% among the obese) compared with non-Hispanic whites: odds ratio (95% CI) for Asian Indians 2.0 (1.5-2.6), adjusted for age and sex, and 3.1 (2.4-4.0) with additional adjustment for BMI., Conclusions: Asian Indian ethnicity, but not other Asian ethnicities, was strongly associated with diabetes. Weight classification as a marker of diabetes risk may need to accommodate differences across Asian subgroups.