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Trials of intensive glucose control have not improved cardiovascular disease (CVD) risk in populations with type 2 diabetes; however, in the general population, reports are inconsistent about the effects of maintaining lower glucose levels. Some speculate that low glycemic values are associated with increased glycemic variability, which is in turn associated with higher CVD risk. It has also been suggested that fasting glucose and hemoglobin A1c (HbA1c) in the lower ranges have a different relationship with CVD and mortality. In 4990 participants from the Multi-Ethnic Study of Atherosclerosis, we used logistic regression to investigate associations of low fasting glucose (

Latino immigrants have lower prevalence of depression, obesity and cardiovascular disease than US-born Latinos when they are recently arrived in the US, but this health advantage erodes with increasing duration of US residence. Cumulative exposure to psychosocial stress and its physiological sequelae may mediate the relationship between nativity and duration of US residence and poor health. We used data from Latino cohort study participants ages 45-84 to examine cross-sectional (n=558) and longitudinal (n=248) associations between nativity and duration of US residence and features of the diurnal cortisol curve including: wake-up cortisol, cortisol awakening response (CAR, wake-up to 30min post-awakening), early decline (30min to 2h post-awakening) and late decline (2h post-awakening to bed time), wake-to-bed slope, and area under the curve (AUC). In cross-sectional analyses, US-born Latinos had higher wake-up cortisol than immigrants with fewer than 30 years of US residence. In the full sample, over 5 years the CAR and early decline became flatter and AUC became larger. Over 5 years, US-born Latinos had greater increases in wake-up cortisol and less pronounced flattening of the early diurnal cortisol decline than immigrants with fewer than 30 years of US residence. Immigrants with 30 or more years of US residence also had less pronounced flattening of the early decline relative to more recent immigrants, and also had a less pronounced increase in AUC. In sum, we saw limited cross-sectional evidence that US-born Latinos have more dysregulated cortisol than recently-arrived Latino immigrants, but over time US-born Latinos had slower progression of cortisol dysregulation.

ContextPrior studies have shown a cross-sectional association between body mass index (BMI) and salivary diurnal cortisol profile features (cortisol features); however, to our knowledge prior population-based studies have not examined the longitudinal association of body-mass index (BMI) with cortisol features.ObjectiveTo examine the association of (1) prior annual BMI percent change over 7years with cortisol features, (2) baseline cortisol features with subsequent change in BMI over 6years and (3) the association of change in cortisol features with change in BMI over 6years.DesignLongitudinal study.SettingMulti-Ethnic Study of Atherosclerosis (MESA) Stress I & II Studies (2004-2006 & 2010-2012).Participants1685 ethnically diverse men and women attended either MESA Stress exam (mean age 65±10years at MESA Stress I; mean age 69±9years at MESA Stress II).Outcome measuresLog-transformed cortisol features including wake-up cortisol, cortisol awakening response, early decline slope (30min to 2h post-awakening), late decline slope (2h post-awakening to bedtime), bedtime, and total area under the curve (AUC) cortisol.ResultsOver 7years, following multivariable adjustment, (1) a 1% higher prior annual BMI % increase was associated with a 2.9% (95% CI: -5.0%, -0.8%) and 3.0% (95% CI: -4.7%, -1.4%) lower current wake-up and total AUC cortisol, respectively; (2) there was no significant association between baseline cortisol features and subsequent change in BMI and (3) among participants with BMI≥30kg/m2, flattening of the late decline slope was associated with increases in BMI (every 1-unit increase late decline slope were associated with a 12.9% increase (95%CI: -1%, 26.8%) in BMI, respectively).ConclusionsWe found a significant association between prior annual BMI % change and cortisol features, but no significant association between baseline cortisol features and subsequent change in BMI. In participants with obesity increases in BMI were associated with less pronounced declined. Collectively, our results suggest that greater adiposity may lead to a blunted diurnal cortisol profile.

"Implicit bias," also called "unconscious bias," refers to associations outside of conscious awareness that adversely affect one's perception of a person or group. Awareness of implicit bias has been increasing in the realm of diabetes care. Here, the authors highlight several types of unconscious bias on the part of clinicians and patients, including biases based on race, ethnicity, and obesity. They discuss how these biases can negatively affect patient-centered clinical interactions and diabetes care delivery, and they recommend implementation of evidence-based interventions and other health system policy approaches to reduce the potential impact of such biases in health care settings. [ABSTRACT FROM AUTHOR]

OBJECTIVE: We examined longitudinal associations between emotional distress (specifically, depressive symptoms and diabetes distress) and medication adherence in Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness Study (GRADE), a large randomized controlled trial comparing four glucose-lowering medications added to metformin in adults with relatively recent-onset type 2 diabetes mellitus (T2DM). RESEARCH DESIGN AND METHODS: The Emotional Distress Substudy assessed medication adherence, depressive symptoms, and diabetes distress in 1,739 GRADE participants via self-completed questionnaires administered biannually up to 3 years. We examined baseline depressive symptoms and diabetes distress as predictors of medication adherence over 36 months. Bidirectional visit-to-visit relationships were also examined. Treatment satisfaction, beliefs about medication, diabetes care self-efficacy, and perceived control over diabetes were evaluated as mediators of longitudinal associations. RESULTS: At baseline, mean ± SD age of participants (56% of whom were White, 17% Hispanic/Latino, 18% Black, and 66% male) was 58.0 ± 10.2 years, diabetes duration 4.2 ± 2.8 years, HbA1c 7.5% ± 0.5%, and medication adherence 89.9% ± 11.1%. Higher baseline depressive symptoms and diabetes distress were independently associated with lower adherence over 36 months (P < 0.001). Higher depressive symptoms and diabetes distress at one visit predicted lower adherence at the subsequent 6-month visit (P < 0.0001) but not vice versa. Treatment assignment did not moderate relationships. Patient-reported concerns about diabetes medications mediated the largest percentage (11.9%–15.5%) of the longitudinal link between emotional distress and adherence. CONCLUSIONS: Depressive symptoms and diabetes distress both predict lower adherence to glucose-lowering medications over time among adults with T2DM. Addressing emotional distress and concerns about anticipated negative effects of taking these treatments may be important to support diabetes treatment adherence. [ABSTRACT FROM AUTHOR]

BackgroundThe cross-sectional area of total muscle mass has been reported to decrease by about 40% for those 20-60 years of age. Depressive symptoms may discourage motivation to engage in physical activity such as strength training shown to negate muscle loss. Inflammation related to depressive symptoms may also contribute to muscle atrophy. Physiological differences by sex and race/ethnicity may also modify the association between depression and muscle mass. Evidence on the relationship between depression (or depressive symptoms) and adiposity has been mounting; however, little is known about the depressive symptoms-muscle mass association. We sought to determine the association between elevated depressive symptoms (EDS) and lean muscle mass and whether this varies by sex and race/ethnicity.MethodsEvaluating 1605 adults (45-84 years of age) from the Multi-ethnic Study of Atherosclerosis Abdominal Body Composition, Inflammation and Cardiovascular Disease Study, we examined the cross-sectional association between EDS (Center for Epidemiologic Studies for Depression Scale score≥16 and/or antidepressant use) and computed tomography-measured abdominal lean muscle mass using linear regression. Muscles were evaluated as a whole and by functionality (locomotion vs. stabilization/posture). Covariates included height, body mass index, sociodemographics, comorbidities, inflammatory markers and health behaviors (pack-years of smoking, alcohol locomotion compared to men, total intentional exercise, daily caloric intake). Sex and race/ethnicity were assessed as potential modifiers. Statistical significance was at a p

Cardiovascular disease risk factor control as primary prevention in patients with type 2 diabetes mellitus has changed substantially in the past few years. The purpose of this scientific statement is to review the current literature and key clinical trials pertaining to blood pressure and blood glucose control, cholesterol management, aspirin therapy, and lifestyle modification. We present a synthesis of the recent literature, new guidelines, and clinical targets, including screening for kidney and subclinical cardiovascular disease for the contemporary management of patients with type 2 diabetes mellitus.

The Centers for Population Health and Health Disparities program promotes multilevel and multifactorial health equity research and the building of research teams that are transdisciplinary. We summarized 5 areas of scientific training for empowering the next generation of health disparities investigators with research methods and skills that are needed to solve disparities and inequalities in cancer and cardiovascular disease. These areas include social epidemiology, multilevel modeling, health care systems or health care delivery, community-based participatory research, and implementation science. We reviewed the acquisition of the skill sets described in the training components; these skill sets will position trainees to become leaders capable of effecting significant change because they provide tools that can be used to address the complexities of issues that promote health disparities.

BackgroundFew studies have investigated the relationship of anthropometric measurements with computed tomography (CT) body fat composition, and even fewer determined if these relationships differ by sex and race.MethodsCT scans from 1,851 participants in the population based Multi-Ethnic Study of Atherosclerosis were assessed for visceral and subcutaneous fat areas by semi-automated segmentation of body compartments. Regression models were used to investigate relationships for anthropometry with visceral and subcutaneous fat separately by sex and race/ethnicity.ResultsParticipants were 50% female, 41% Caucasian, 13% Asian, 21% African American, and 25% Hispanic. For visceral fat, the positive relationship with weight (p = 0.028), waist circumference (p

A major challenge in characterizing features of the daily cortisol curve is variability in features over time. Few studies have examined the stability of daily features of the cortisol curve over long periods or the predictors of long term changes. Repeated salivary cortisol measures on 580 adults from the MESA Stress study were used to examine the stability of various features of the daily cortisol curve (wakeup value, the cortisol awakening response (CAR), the early and late decline slope and the area under the curve (AUC)), over short periods (several days) and long periods (approximately 6-years) and to investigate the association of demographic factors with the changes. Intraclass correlation coefficients (ICCs) were used to estimate the short and long term stability. Piecewise linear mixed models were used to assess factors associated with changes in features over time. For most features, short term stability (ICCs: 0.17-0.74) was higher than long term stability (ICCs: 0.05-0.42), and long term stability was highest when several days were averaged for each time point. The decline over the day showed the highest long term stability: when several days for each wave were averaged the stability of the daily decline slope across 6 years was similar (or higher) than the stability across short periods. AUC had high stability over short periods (ICCs: 0.65-0.74) but much lower stability across long periods (ICC: 0.05). All features of daily cortisol curve investigated changed significantly over the approximately 6 year follow-up period. The wakeup cortisol became higher; the CAR became smaller; both the early and late decline became flatter; and the AUC became larger. Hispanics experienced significantly larger increases in the wakeup value; and African-Americans and Hispanics showed less flattening over time of the early decline slope than Non-Hispanic Whites. Our findings have implications for characterization of features in studies linking cortisol to health outcomes. The presence of variability over time suggests opportunities for future investigation of the predictors of changes over time as well as the links between these changes and health outcomes.

Our obligation to social justice In the wake of the brutal murders of Ahmaud Arbery, Sean Reed, Breonna Taylor, and George Floyd and amidst international outcries for social justice, many [...]

In the past year, the COVID-19 pandemic has inflicted untold human suffering, remade the global economy, and highlighted numerous weaknesses in political, health, and social systems. In the United States, [...]

It was early evening in the fall of 1994 as I began my long call. I met the daughter of the next patient I was admitting while she was waiting [...]

Endocrine care of pediatric and adult patients continues to be plagued by health and health care disparities that are perpetuated by the basic structures of our health systems and research modalities, as well as policies that impact access to care and social determinants of health. This scientific statement expands the Society's 2012 statement by focusing on endocrine disease disparities in the pediatric population and sexual and gender minority populations. These include pediatric and adult lesbian, gay, bisexual, transgender, queer, intersex, and asexual (LGBTQIA) persons. The writing group focused on highly prevalent conditions--growth disorders, puberty, metabolic bone disease, type 1 (T1D) and type 2 (T2D) diabetes mellitus, prediabetes, and obesity. Several important findings emerged. Compared with females and non-White children, non- Hispanic White males are more likely to come to medical attention for short stature. Racially and ethnically diverse populations and males are underrepresented in studies of pubertal development and attainment of peak bone mass, with current norms based on European populations. Like adults, racial and ethnic minority youth suffer a higher burden of disease from obesity, T1D and T2D, and have less access to diabetes treatment technologies and bariatric surgery. LGBTQIA youth and adults also face discrimination and multiple barriers to endocrine care due to pathologizing sexual orientation and gender identity, lack of culturally competent care providers, and policies. Multilevel interventions to address these disparities are required. Inclusion of racial, ethnic, and LGBTQIA populations in longitudinal life course studies is needed to assess growth, puberty, and attainment of peak bone mass. Growth and development charts may need to be adapted to non-European populations. In addition, extension of these studies will be required to understand the clinical and physiologic consequences of interventions to address abnormal development in these populations. Health policies should be recrafted to remove barriers in care for children with obesity and/or diabetes and for LGBTQIA children and adults to facilitate comprehensive access to care, therapeutics, and technological advances. Public health interventions encompassing collection of accurate demographic and social needs data, including the intersection of social determinants of health with health outcomes, and enactment of population health level interventions will be essential tools. [ABSTRACT FROM AUTHOR]

Background: Autonomic nervous system effects have been hypothesized as a mechanism of air pollutant health effects, though scant prior epidemiologic research has examined the association between air pollutants and catecholamines. Objectives: To examine the association of long-term air pollutants with three urinary catecholamines: dopamine (DA), epinephrine (EPI), and norepinephrine (NE). As a secondary aim, we also examined the association between short-term (or acute) exposure to fine particulate matter [particulate matter with aerodynamic diameter [less than or equal to] 2.5[micro]m ([PM.sub.2.5])] and those catecholamines. Methods: We used data from the Multi-Ethnic Study of Atherosclerosis (MESA) and two of its ancillary studies, the MESA Air Pollution Study and the MESA Stress Study, to provide exposure and outcome data. DA, EPI, and NE from urine samples were collected from 2004 to 2006 from 1,002 participants in the New York, New York, and Los Angeles, California, study sites. Spatiotemporal models incorporated cohort-specific monitoring and estimated annual average pollutant concentrations ([PM.sub.2.5], N[O.sub.2], N[O.sub.x] and black carbon) at participants' homes the year prior to urine collection. Secondarily, short-term [PM.sub.2.5] was evaluated (day of, day prior, and 2- to 5-d lags prior to urine collection). Several covariates were considered confounders (age, race, sex, site, socioeconomic status, cardiovascular disease risk factors, psychosocial stressors, and medication use) in linear regression models. Results: A 17 ppb higher annual N[O.sub.x] concentration was associated with 6.3% higher mean EPI level [95% confidence interval (CI): 0.3%, 12.6%]. A 2-[micro]g/[m.sup.3] higher annual ambient [PM.sub.2.5] concentration was associated with 9.1% higher mean EPI (95% CI: 3.2%, 15.3%) and 4.4% higher DA level (95% CI: 1%, 7.9%). N[O.sub.2], black carbon, and short-term [PM.sub.2.5] exposures were not significantly associated with any of the catecholamines. Conclusions: We found an association between EPI and long-term concentrations of [PM.sub.2.5] and N[O.sub.x] and an association between DA and long-term ambient [PM.sub.2.5]. These novel findings provide modest support for the hypothesis that air pollutant exposures are related to sympathetic nervous system activation., Introduction Catecholamines act as both neurotransmitters and hormones produced by the sympathetic branch of the autonomic nervous system (ANS). Among other things, catecholamines play an important role in regulating heart [...]

In order to achieve health equity, we must implement innovative health system, public health, and policy‐level interventions to address the historical root causes of structural and institutional racism embedded in our medical and social systems. A history of unconsented medical and research experimentation on vulnerable groups and residual healthcare provider biases toward minoritized patients has led to patient distrust of medical systems and poor quality of care. Historical discriminatory housing and lending policies resulted in racial residential segregation and neighborhoods with inadequate housing, healthy food access, and educational resources, resulting in present‐day social determinants of health (SDOH). To reduce these disparities and achieve health equity, four disruptive healthcare innovations are recommended: (i) infuse health equity principles into clinical workflows by implementing National Culturally and Linguistically Appropriate Services Standards; (ii) address poverty‐related SDOH; (iii) deliver care and recruit for research in nonclinical settings to reach marginalized communities; and (iv) leverage health system subject matter experts to advocate for health equity policies. During the COVID‐19 pandemic we leveraged the diversity of our workforce to deliver bilingual and culturally tailored COVID‐19 testing, education, and vaccines to the Hispanic and Black communities in nonclinical settings, the primary marginalized communities served by our health system that were also disproportionately impacted by COVID‐19 infections, hospitalizations, and deaths. Now that we understand the importance of using innovative health equity strategies to reach marginalized communities, we must continue to re‐engineer our healthcare systems to deliver care outside of our brick and mortar to overcome barriers in access to care and mistrust in the healthcare establishment stemming from past abuses and remaining experiences of bias. [ABSTRACT FROM AUTHOR]