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OBJECTIVE: Suicide rates continue to rise, necessitating identification of novel risk factors to prevent suicide. Obesity and suicide mortality have been examined, but no studies have examined associations between weight change, suicide mortality, and depression among adults in the U.S. METHODS: People who died by suicide from 2000-2015 with a recorded height and weight in the first and second 6 months preceding their death (“index date”; n = 387) were extracted from a larger sample from the Mental Health Research Network; each was matched with five people in the control group by age, sex, index year, and healthcare site (n = 1,935). Data were analyzed in 2020. RESULTS: People who died by suicide were predominantly male (71%), Caucasian (69%), depressed (55%), middle aged (M = 57 years), with chronic health issues (57%), [Control: 66% Caucasian; M age = 56 years; 43% chronic health issues, 14% depressed]. T-test analyses showed BMI change within a year before the index date differed between those who died by suicide (M = −0.72±2.42 kg/m(2)) and the control group, (M = 0.06±4.99 kg/m(2)) p < 0.001, d = .17. A 1-unit decrease in BMI was associated with 9% increased risk of suicide after adjusting for demographics, mental disorders, and Charlson score (aOR = 0.91, 95% CI = 0.87-0.95, p < 0. 001). BMI change and suicide were associated for those without depression (p < 0.001). CONCLUSIONS: Weight loss in the year before suicide was associated with increased suicide mortality after accounting for physical and mental health indicators.

The authors sought to develop and validate models using electronic health records to predict suicide attempt and suicide death following an outpatient visit.Across seven health systems, 2,960,929 patients age 13 or older (mean age, 46 years; 62% female) made 10,275,853 specialty mental health visits and 9,685,206 primary care visits with mental health diagnoses between Jan. 1, 2009, and June 30, 2015. Health system records and state death certificate data identified suicide attempts (N=24,133) and suicide deaths (N=1,240) over 90 days following each visit. Potential predictors included 313 demographic and clinical characteristics extracted from records for up to 5 years before each visit: prior suicide attempts, mental health and substance use diagnoses, medical diagnoses, psychiatric medications dispensed, inpatient or emergency department care, and routinely administered depression questionnaires. Logistic regression models predicting suicide attempt and death were developed using penalized LASSO (least absolute shrinkage and selection operator) variable selection in a random sample of 65% of the visits and validated in the remaining 35%.Mental health specialty visits with risk scores in the top 5% accounted for 43% of subsequent suicide attempts and 48% of suicide deaths. Of patients scoring in the top 5%, 5.4% attempted suicide and 0.26% died by suicide within 90 days. C-statistics (equivalent to area under the curve) for prediction of suicide attempt and suicide death were 0.851 (95% CI=0.848, 0.853) and 0.861 (95% CI=0.848, 0.875), respectively. Primary care visits with scores in the top 5% accounted for 48% of subsequent suicide attempts and 43% of suicide deaths. C-statistics for prediction of suicide attempt and suicide death were 0.853 (95% CI=0.849, 0.857) and 0.833 (95% CI=0.813, 0.853), respectively.Prediction models incorporating both health record data and responses to self-report questionnaires substantially outperform existing suicide risk prediction tools.

Although mental health conditions are risk factors for suicide, limited data are available on suicide mortality associated with specific mental health conditions in the U.S. population. This study aimed to fill this gap.This study used a case-control design. Patients in the case group were those who died by suicide between 2000 and 2013 and who were patients in eight health care systems in the Mental Health Research Network (N=2,674). Each was matched with 100 general population patients from the same system (N=267,400). Diagnostic codes for five mental health conditions in the year before death were obtained from medical records: anxiety disorders, attention deficit-hyperactivity disorder (ADHD), bipolar disorder, depressive disorders, and schizophrenia spectrum disorder.Among patients in the case group, 51.3% had a recorded psychiatric diagnosis in the year before death, compared with 12.7% of control group patients. Risk of suicide mortality was highest among those with schizophrenia spectrum disorder, after adjustment for age and sociodemographic characteristics (adjusted odds ratio [AOR]=15.0) followed by bipolar disorder (AOR=13.2), depressive disorders (AOR=7.2), anxiety disorders (AOR=5.8), and ADHD (AOR=2.4). The risk of suicide death among those with a diagnosed bipolar disorder was higher in women than men.Half of those who died by suicide had at least one diagnosed mental health condition in the year before death, and most mental health conditions were associated with an increased risk of suicide. Findings suggest the importance of suicide screening and providing an approach to improve awareness of mental health conditions.

Aim The broad objective of this study was to examine multiple dimensions of depression in a large, diverse population of adults with diabetes. Specific aims were to measure the association of depression with: (1) patient characteristics; (2) outcomes; and (3) diabetes-related quality of care. Methods Cross-sectional analyses were performed using survey and chart data from the Translating Research Into Action for Diabetes (TRIAD) study, including 8790 adults with diabetes, enrolled in 10 managed care health plans in 7 states. Depression was measured using the Patient Health Questionnaire (PHQ-8). Patient characteristics, outcomes and quality of care were measured using validated survey items and chart data. Results Nearly 18% of patients had major depression, with prevalence 2–3 times higher among patients with low socioeconomic status. Pain and limited mobility were strongly associated with depression, controlling for other patient characteristics. Depression was associated with slightly worse glycemic control, but not other intermediate clinical outcomes. Depressed patients received slightly fewer recommended diabetes-related processes of care. Conclusions In a large, diverse cohort of patients with diabetes, depression was most prevalent among patients with low socioeconomic status and those with pain, and was associated with slightly worse glycemic control and quality of care.

Background: Versus whites, blacks with diabetes have poorer control of hemoglobin A1c (HbA1c), higher systolic blood pressure (SBP), and higher low-density lipoprotein (LDL) cholesterol as well as higher rates of morbidity and microvascular complications. Objective: To examine whether several mutable risk factors were more strongly associated with poor control of multiple intermediate outcomes among blacks with diabetes than among similar whites. Design: Case-control study. Subjects: A total of 764 blacks and whites with diabetes receiving care within 8 managed care health plans. Measures: Cases were patients with poor control of at least 2 of 3 intermediate outcomes (HbA1c ≥ 8.0%, SBP ≥ 140 mmHg, LDL cholesterol ≥ 130 mg/dL) and controls were patients with good control of all 3 (HbA1c

Author(s): Ettner, Susan L; Cadwell, Betsy L; Russell, Louise B; Brown, Arleen; Karter, Andrew J; Safford, Monika; Mangione, Carol; Beckles, Gloria; Herman, William H; Thompson, Theodore J; TRIAD Study Group | Abstract: BackgroundResearch on self-care for chronic disease has not examined time requirements. Translating Research into Action for Diabetes (TRIAD), a multi-site study of managed care patients with diabetes, is among the first to assess self-care time.ObjectiveTo examine associations between socioeconomic position and extra time patients spend on foot care, shopping/cooking, and exercise due to diabetes.DataEleven thousand nine hundred and twenty-seven patient surveys from 2000 to 2001.MethodsBayesian two-part models were used to estimate associations of self-reported extra time spent on self-care with race/ethnicity, education, and income, controlling for demographic and clinical characteristics.ResultsProportions of patients spending no extra time on foot care, shopping/cooking, and exercise were, respectively, 37, 52, and 31%. Extra time spent on foot care and shopping/cooking was greater among racial/ethnic minorities, less-educated and lower-income patients. For example, African-Americans were about 10 percentage points more likely to report spending extra time on foot care than whites and extra time spent was about 3 min more per day.DiscussionExtra time spent on self-care was greater for socioeconomically disadvantaged patients than for advantaged patients, perhaps because their perceived opportunity cost of time is lower or they cannot afford substitutes. Our findings suggest that poorly controlled diabetes risk factors among disadvantaged populations may not be attributable to self-care practices.

OBJECTIVE—Given limited reports on diabetes among U.S. Asian and Pacific Islander youth, we describe the clinical characteristics, incidence, and prevalence of diabetes among Asian, Pacific Islander, and mixed Asian–Pacific Islander youth. RESEARCH DESIGN AND METHODS—Data were collected from 245 Asian, Pacific Islander, and Asian–Pacific Islander participants in the SEARCH for Diabetes in Youth Study, a population-based study of diabetes in youth (aged RESULTS—Most participants with type 2 diabetes were obese (range Asian 71% to Pacific Islander 100%) with mean BMI >33 kg/m2. In those with type 1 diabetes, Pacific Islanders were more likely to be obese, with a mean BMI of 26 vs. 20 kg/m2 for Asian and Asian–Pacific Islander youth (P < 0.0001). The incidence of type 1 diabetes for youth aged 0–9 years was 6.4 per 100,000 person-years and 7.4 per 100,000 person-years for youth aged 10–19 years. The incidence of type 2 diabetes was 12.1 per 100,000 person-years for youth aged 10–19 years. CONCLUSIONS—While Asian and Asian–Pacific Islanders with type 1 and type 2 diabetes had lower mean BMIs than Pacific Islanders, all Asian, Pacific Islander, and Asian–Pacific Islanders with type 2 diabetes had mean BMIs above adult ethnicity-specific definitions of obesity. While the majority of Asian, Pacific Islander, and Asian–Pacific Islander youth had type 1 diabetes, older Asian, Pacific Islander, and Asian–Pacific Islander youth (aged 10–19 years) have an incidence of type 2 diabetes almost double that of type 1 diabetes. Public health efforts to prevent type 2 diabetes and obesity in Asian, Pacific Islander, and Asian–Pacific Islander adolescents are needed.

Although patients with diabetes may benefit from physical activity, few studies have examined sustained walking in this population.To examine the factors associated with sustained walking among managed care patients with diabetes.Longitudinal, observational cohort study with questionnaires administered 2.5 years apart.Five thousand nine hundred thirty-five patients with diabetes walking at least 20 minutes/day at baseline.The primary outcome was the likelihood of sustained walking, defined as walking at least 20 minutes/day at follow-up. We evaluated a logistic regression model that included demographic, clinical, and neighborhood variables as independent predictors of sustained walking, and expressed the results as predicted percentages.The absence of pain was linked to walking behavior, as 62% of patients with new pain, 67% with ongoing pain, and 70% without pain were still walking at follow-up (p = .03). Obese patients were less likely (65%) to sustain walking than overweight (71%) or normal weight (70%) patients (p = .03). Patientsor =65 years (63%) were less likely to sustain walking than patients between 45 and 64 (70%) oror =44 (73%) years (p = .04). Only 62% of patients with a new comorbidity sustained walking compared with 68% of those who did not (p.001). We found no association between any neighborhood variables and sustained walking in this cohort of active walkers.Pain, obesity, and new comorbidities were moderately associated with decreases in sustained walking. Whereas controlled intervention studies are needed, prevention, or treatment of these adverse conditions may help patients with diabetes sustain walking behavior.

Background: Performance of diabetes clinical care processes has improved recently, but control of hemoglobin A1c (A1c) and other vascular disease risk factors has improved more slowly. Objectives: To identify patient factors associated with control of vascular disease risk factors among diabetes patients receiving recommended care processes. Population: Managed care enrollees who participated in the TRIAD (Translating Research into Action for Diabetes) Study and received at least 5 of 7 recommended care processes during the 12 months before the second survey (2002-2003). Methods: Comparison of 1003 patients with good control of A1c (

OBJECTIVE: We sought to determine whether greater implementation of clinical care strategies in managed care is associated with attenuation of known racial/ethnic disparities in diabetes care. RESEARCH DESIGN AND METHODS: Using cross-sectional data, we examined the quality of diabetes care as measured by frequencies of process delivery as well as medication management of intermediate outcomes, for 7426 black, Latinos, Asian/Pacific Islanders, and white participants enrolled in 10 managed care plans within 63 provider groups. We stratified models by intensity of 3 clinical care strategies at the provider group level: physician reminders, physician feedback, or use of a diabetes registry. RESULTS: Exposure to clinical care strategy implementation at the provider group level varied by race and ethnicity, with

OBJECTIVE: To describe demographic and clinical characteristics associated with self-reported receipt of tests and measurements recommended by the American Diabetes Association (ADA) for children and youths with diabetes. METHODS: The study included 1514 SEARCH for Diabetes in Youth study participants who completed a survey about diabetes care received. Quality-of-care measures were based on ADA guidelines for eye examinations and glycohemoglobin (hemoglobin A1c [HbA1c]), lipid level, microalbuminuria, and blood pressure measurements, and a composite variable of these 5 indicators was created. Multivariate logistic regression models were used to assess the association of selected demographic and clinical characteristics with the reported receipt of all recommended tests and measurements according to age and diabetes type subgroups. RESULTS: Overall, 95% of the participants reported having their blood pressure checked at all or most visits, 88% had lipid levels measured, 83% had kidney function tested, 68% underwent HbA1c testing, and 66% underwent an eye examination, in accordance with ADA recommendations. Participants aged 18 years or older, particularly those with type 2 diabetes, tended to have fewer tests of all kinds performed. Age and family income emerged as important correlates of overall quality of care in multivariate models; older age and lower income were associated with not meeting guidelines. CONCLUSIONS: Although there was relatively good adherence to ADA-recommended guidelines for most indicators, efforts are needed to improve rates of HbA1c testing and eye examinations, particularly among older youths.

Liu LL, Lawrence JM, Davis C, Liese AD, Pettitt DJ, Pihoker C, Dabelea D, Hamman R, Waitzfelder B, Kahn HS. Prevalence of overweight and obesity in youth with diabetes in USA: the SEARCH for Diabetes in Youth Study. Objective: Obesity's association with type 2 diabetes (T2DM) is well established, but is less clear with type 1 diabetes (T1DM). We calculated the prevalence of overweight and obesity among diabetic youth in the USA from a six-center, population-based study of racially and ethnically diverse youth with diabetes, and we compared these rates with estimates among nondiabetic youth. Design/setting: Diabetic participants were examined in 2001−2004 for the SEARCH for Diabetes in Youth study (SEARCH) and nondiabetic participants were examined during the same years of the National Health and Nutrition Examination Survey (NHANES). Participants: 3953 diabetic youth and 7666 nondiabetic youth aged 3−19 yr. Main outcome measures: Overweight was defined as body mass index (BMI) from the 85th to

Background Our understanding of social disparities in diabetes-related health behaviors is incomplete. The purpose of this study was to determine if having less education is associated with poorer diabetes-related health behaviors. Methods This observational study was based on a cohort of 8,763 survey respondents drawn from ~180,000 patients with diabetes receiving care from 68 provider groups in ten managed care health plans across the United States. Self-reported survey data included individual educational attainment ("education") and five diabetes self-care behaviors among individuals for whom the behavior would clearly be indicated: foot exams (among those with symptoms of peripheral neuropathy or a history of foot ulcers); self-monitoring of blood glucose (SMBG; among insulin users only); smoking; exercise; and certain diabetes-related health seeking behaviors (use of diabetes health education, website, or support group in last 12 months). Predicted probabilities were modeled at each level of self-reported educational attainment using hierarchical logistic regression models with random effects for clustering within health plans. Results Patients with less education had significantly lower predicted probabilities of being a non-smoker and engaging in regular exercise and health-seeking behaviors, while SMBG and foot self-examination did not vary by education. Extensive adjustment for patient factors revealed no discernable confounding effect on the estimates or their significance, and most education-behavior relationships were similar across sex, race and other patient characteristics. The relationship between education and smoking varied significantly across age, with a strong inverse relationship in those aged 25–44, modest for those ages 45–64, but non-evident for those over 65. Intensity of disease management by the health plan and provider communication did not alter the examined education-behavior relationships. Other measures of socioeconomic position yielded similar findings. Conclusion The relationship between educational attainment and health behaviors was modest in strength for most behaviors. Over the life course, the cumulative effect of reduced practice of multiple self-care behaviors among less educated patients may play an important part in shaping the social health gradient.

Background: Although disease management programs are widely implemented, little is known about their effectiveness. Objective: To determine whether disease management by physician groups is associated with diabetes care processes, control of intermediate outcomes, or the amount of medication used when intermediate outcomes are above target levels. Design: Cross-sectional study. Setting: Patients were randomly sampled from 63 physician groups nested in 7 health plans sponsored by Translating Research into Action for Diabetes (87%) and from 4 health plans with individual physician contracts (13%). Patients: 8661 adults with diabetes who completed a survey (2000-2001) and had medical record data. Measurements: Physician group and health plan directors described their organizations' use of physician reminders, performance feedback, and structured care management on a survey; their responses were used to determine measures of intensity of disease management. The current study measured 8 processes of care, including most recent hemoglobin A1c level, systolic blood pressure, serum low-density lipoprotein cholesterol level, and several measures of medication use. Results: Increased use of any of 3 disease management strategies was significantly associated with higher adjusted rates of retinal screening, nephropathy screening, foot examinations, and measurement of hemoglobin A1c levels. Serum lipid level testing and influenza vaccine administration were associated with greater use of structured care management and performance feedback. Greater use of performance feedback correlated with an increased rate of foot examinations (difference, 5 percentage points [95% CI, 1 to 8 percentage points]), and greater use of physician reminders was associated with an increased rate of nephropathy screening (difference, 15 percentage points [CI, 6 to 23 percentage points]). No strategies were associated with intermediate outcome levels or level of medication management. Limitations: Physician groups were not randomly sampled from population-based listings, and disease management strategies were not randomly allocated across groups. Conclusions: Disease management strategies were associated with better processes of diabetes care but not with improved intermediate outcomes or level of medication management. A greater focus on direct measurement, feedback, and reporting of intermediate outcome levels or of level of medication management may enhance the effectiveness of these programs.

To examine racial/ethnic and socioeconomic variation in diabetes care in managed-care settings.We studied 7,456 adults enrolled in health plans participating in the Translating Research Into Action for Diabetes study, a six-center cohort study of diabetes in managed care. Cross-sectional analyses using hierarchical regression models assessed processes of care (HbA(1c) [A1C], lipid, and proteinuria assessment; foot and dilated eye examinations; use or advice to use aspirin; and influenza vaccination) and intermediate health outcomes (A1C, LDL, and blood pressure control).Most quality indicators and intermediate outcomes were comparable across race/ethnicity and socioeconomic position (SEP). Latinos and Asians/Pacific Islanders had similar or better processes and intermediate outcomes than whites with the exception of slightly higher A1C levels. Compared with whites, African Americans had lower rates of A1C and LDL measurement and influenza vaccination, higher rates of foot and dilated eye examinations, and the poorest blood pressure and lipid control. The main SEP difference was lower rates of dilated eye examinations among poorer and less educated individuals. In almost all instances, racial/ethnic minorities or low SEP participants with poor glycemic, blood pressure, and lipid control received similar or more appropriate intensification of therapy relative to whites or those with higher SEP.In these managed-care settings, minority race/ethnicity was not consistently associated with worse processes or outcomes, and not all differences favored whites. The only notable SEP disparity was in rates of dilated eye examinations. Social disparities in health may be reduced in managed-care settings.

To examine prevalence of tobacco use and coexistence of cardiometabolic risk factors according to smoking status in youth with diabetes mellitus.Youth aged 10 to 22 years who participated in the SEARCH for Diabetes in Youth study (n = 3466) were surveyed about their tobacco use and examined for cardiometabolic risk factors: waist circumference, systolic and diastolic blood pressure, physical activity, and lipid profile.The prevalence of tobacco use in youth aged 10 to 14 years, 15 to 19 years, and ≥20 years with type 1 diabetes mellitus was 2.7%, 17.1%, and 34.0%, respectively, and the prevalence in youth with type 2 diabetes mellitus was 5.5%, 16.4%, and 40.3%, respectively. Smoking was more likely in youth with annual family incomes$50 000, regardless of diabetes mellitus type. Cigarette smoking was associated with higher odds of high triglyceride levels and physical inactivity in youth with type 1 diabetes mellitus. Less than 50% of youth aged 10 to 14 years (52.2% of participants) reported having ever been counseled by their healthcare provider to not smoke or to stop smoking.Tobacco use is prevalent in youth with diabetes mellitus. Aggressive tobacco prevention and cessation programs should be a high priority to prevent or delay the development of cardiovascular disease.

Objective To examine the associations between demographic and diabetes management variables and the health-related quality of life (HRQOL) of youths with type 1 or type 2 diabetes mellitus (DM). Design Cross-sectional study. Settings Selected populations in Ohio, Washington, South Carolina, Colorado, Hawaii, and California; health service beneficiaries in 3 American Indian populations; and participants in the Pima Indian Study in Arizona. Participants Two thousand four hundred forty-five participants aged 8 to 22 years in the SEARCH for Diabetes in Youth Study. Main Outcome Measure Pediatric Quality of Life Inventory scores. Results Among youths with type 2 DM, HRQOL was lower compared with those with type 1. Among those with type 1 DM, worse HRQOL was associated with a primary insurance source of Medicaid or another government-funded insurance, use of insulin injections vs an insulin pump, a hemoglobin A 1c value of at least 9%, and more comorbidities and diabetes complications. There was a significant age × sex interaction, such that, in older groups, HRQOL was lower for girls but higher for boys. For youths with type 2 DM, injecting insulin at least 3 times a day compared with using an oral or no diabetes medication was associated with better HRQOL, and having 2 or more emergency department visits in the past 6 months was associated with worse HRQOL. Conclusions Youths with types 1 and 2 DM reported HRQOL differences by type of treatment and complications. The significant age × sex interaction suggests that interventions to improve HRQOL should consider gender differences in diabetes adjustment and management in different age groups.