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Summary: Cumulative cortisol burden is known to influence neuropsychiatric and metabolic disorders. To better understand the relationship between daily cortisol exposure and measures of the diurnal circadian cortisol rhythm, we examined the cross-sectional association of the cortisol awakening response (CAR) with wake-up cortisol, bedtime cortisol, diurnal slope, and total cortisol area under the curve (AUC). Up to 18 salivary cortisol samples were collected over 3 days from 935 White, Hispanic, and Black individuals (mean age 65±9.8 years) in the Multi-Ethnic Study of Atherosclerosis. Outcome measures included awakening cortisol, CAR (awakening to 30min post-awakening), early decline (30min to 2h post-awakening), late decline (2h post-awakening to bedtime), and the corresponding AUCs. Total cortisol AUC was a summary measure of cumulative cortisol exposure. Higher CAR was associated with significantly lower wake-up cortisol (β =−0.56; 95% CI: −0.59 to −0.53) and a higher early decline AUC (β =0.38; 95% CI: 0.34–0.42) but was not associated with total cortisol AUC (β =0.04; 95% CI: −0.01 to 0.09), or other diurnal cortisol curve components following multivariable adjustment. Total cortisol AUC was significantly and positively associated with wake-up cortisol (β =0.36; 95% CI: 0.32–0.40), bedtime cortisol (β =0.61; 95% CI: 0.58–0.64), and other AUC measures, following multivariable adjustment. Associations were similar by sex, race/ethnicity, and age categories. We conclude that bedtime cortisol showed the strongest correlation with total cortisol AUC, suggesting it may be a marker of daily cortisol exposure. [ABSTRACT FROM AUTHOR]

The author discusses the validity of meta-analysis in diabetes. Meta-analysis is the statistical technique for extracting and mixing data to create a summary result of the included studies. A systematic review may or may not include a meta-analysis depending on the presentation and heterogeneity of the data.

Abstract: The objective was to examine the cross-sectional association of diurnal salivary cortisol curve components and urinary catecholamines with diabetes status. Up to 18 salivary cortisol samples over 3 days and overnight urinary catecholamines were collected from 1002 participants in the Multi-Ethnic Study of Atherosclerosis. Diabetes was defined as a fasting blood glucose of at least 126 mg/dL or medication use. Cortisol curve measures included awakening cortisol, cortisol awakening response, early decline, late decline, and cortisol area under the curve (AUC). Urinary catecholamines included epinephrine, norepinephrine, and dopamine. Participants with diabetes had significantly lower cortisol awakening response (β = −0.19; 95% confidence interval [CI], −0.34 to −0.04) than those without diabetes in multivariable models. Whereas men with diabetes had a nonsignificant trend toward lower total AUC (β = −1.56; 95% CI, −3.93 to 0.80), women with diabetes had significantly higher total AUC (β = 2.62; 95% CI, 0.72 to 4.51) (P = .02 for interaction) compared with those without diabetes. Men but not women with diabetes had significantly lower urinary catecholamines compared with those without diabetes (P < .05). Diabetes is associated with neuroendocrine dysregulation, which may differ by sex. Further studies are needed to determine the role of the neuroendocrine system in the pathophysiology of diabetes. [Copyright &y& Elsevier]

Abstract: Background: Women with a history of gestational diabetes mellitus (GDM) are at high risk for type 2 diabetes mellitus (T2DM). Objective: We reviewed prospective studies of antepartum glucose tolerance test results as risk factors for development of T2DM among women with a history of GDM. Methods: We searched 4 electronic databases and hand-searched 13 journals for literature published through January 2007. The search strategy consisted of medical subject headings and text words for GDM, T2DM, and other relevant terms. Articles were excluded for the following reasons: (1) not written in English; (2) no human data; (3) no original data; (4) <90% of sample was diagnosed with GDM without a separate analysis for women with GDM; (5) case report or series; (6) diagnosis of GDM not based on 3-hour 100-g oral glucose tolerance test (OGTT) or 2-hour 75-g OGTT; (7) T2DM not evaluated as outcome; (8) no relative measure of association or incidence reported; or (9) design did not address antepartum OGTT as a predictor of T2DM. Two investigators independently reviewed citations, performed serial data abstraction on full articles, and assessed the quality of each article. Data were abstracted for study participants and characteristics, T2DM diagnosis, length of follow-up, regression model covariates, and measures of association and variability. Results: Of 11,400 unique citations, we identified 11 articles that evaluated antepartum glucose testing and risk of T2DM in women with a history of GDM. Five studies found that the fasting blood glucose (FBG) on the antepartum diagnostic OGTT was a significant predictor of T2DM (odds ratio [OR] range: 11.1–21.0; relative risk [RR] range: 1.37–1.5; relative hazard [RH] = 2.47). Risk of incident T2DM was predicted by the antepartum 2-hour OGTT plasma glucose in 3 studies (OR range: 1.02–1.03; RR = 1.3) and by the antepartum OGTT glucose AUC in 3 other studies (OR range: 3.64–15; RH = 2.13). Overall, study quality was limited by high losses to follow-up (>20% in 6 studies) and short duration. Few studies adjusted for adiposity, an established diabetes risk factor. Conclusion: FBG, OGTT 2-hour blood glucose, and OGTT glucose AUC appeared to be strong and consistent predictors of subsequent T2DM among women who met diagnostic criteria for GDM using the OGTT. [Copyright &y& Elsevier]

Many studies have investigated the role of estrogen during menopause; however, less attention has been paid to the role of androgen. Given the possible opposite effects of estrogen and androgen on cardiovascular disease risk, it is suggested that relative androgen excess may better predict the increased risk of cardiovascular disease in women over the age of 50 years than estrogen levels alone. Three phases of hormonal milieu changes are hypothesized as a better way to identify the hormone-cardiovascular disease risk association. A first phase, prepause, occurs before estrogen levels decline (approximately 2 years before menopause). A second phase, interpause, occurs from the end of prepause until approximately age 55. A third phase, postpause, occurs after interpause. The duration of the interpause phase, characterized by relative androgen excess, may be an independent risk factor of cardiovascular disease. This hypothesis could provide a basis for further clinical and epidemiologic research, and it could have important implications for establishing the initiation and duration of estrogen replacement therapy use as a means to prevent cardiovascular disease. [ABSTRACT FROM PUBLISHER]

The article discusses disparities in health services and research related to diabetes, particularly with the growing minority groups in the U.S. and the increasing popularity of personalized medicine. Topics discussed include the prevalence of various diseases among different ethnic groups in the U.S., the importance of understanding the biological factor in addressing health care disparities and the need to do more research about biomarkers for diabetes.

Purpose of Review: Among patients with type 2 diabetes (T2D), cardiovascular disease (CVD) is the leading cause of death regardless of ethnicity. However, recent studies suggest that special considerations should be taken into account when caring for African Americans with T2D, as risk factors, incidence, prevalence, and mortality differ from other populations. This review highlights literature supporting the unique characteristics of managing cardiovascular risk and mortality in African Americans (AAs) with T2D. Recent Findings: African Americans have an increased risk of developing T2D and have a higher prevalence of T2D compared with non-Hispanic whites. Certain cardiovascular risk factors, including hypertension and obesity, are particularly challenging in African Americans with T2D and influence CVD and mortality. Treatment regimens including lifestyle modification, pharmacologic interventions, and surgery to manage T2D in patients of all populations may not produce equitable outcomes in African Americans. Particularly, newer cardiovascular outcome trials for sodium-glucose co-transporter 2 (SGLT2) inhibitors and glucose-like peptide 1 receptor (GLP-1R) agonists have disparate effect estimates for major adverse cardiovascular event reduction in African Americans. Thus, research focused on cardiovascular risk reduction in African Americans is of paramount importance. Summary: In summary, there are numerous discrepancies in the outcomes of recent cardiovascular risk trials for the diagnosis, assessment and treatment of African Americans with T2D. Future investigations must lead to improved cardiovascular outcomes through evidence-based care of T2D in African Americans if we are to continue to lower the burden of CVD in the USA. [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]

A letter to the editor is presented in response to the article "A Systematic Review and Meta-Analysis of the Association Between Depression and Insulin Resistance" by C. Kan and colleagues in a 2013 issue.

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 of us are asking ourselves what we can do to effect change. How can we be impactful allies in the medical profession? How can we support and protect our Black students and foster their careers? This Viewpoint examines the importance of improving diversity and inclusion among physicians and scientists at academic institutions . [ABSTRACT FROM AUTHOR]

Recent studies demonstrated risks to patient safety associated with implementation of electronic applications for medication management in ambulatory care. This study was aimed at demonstrating similar phenomenon in a hospital setting. After introduction of computerized order set targeting hypoglycemia, the frequency of hypoglycemia significantly decreased from 1/1/07 to 12/31/08. In contrast, the frequency of hyperglycemia increased at the same time from 1/1/07 to 12/31/07. Only after subsequent introduction of a hospital-wide standardized insulin order set including hyperglycemia policies frequency of hyperglycemic episodes declined. Hypo/hyperglycemia is associated with adverse clinical outcomes in the inpatient setting. Retroactive analysis showed that if hypoglycemic and hyperglycemic policies were introduced simultaneously, unexpected increase in frequency of hyperglycemic episodes could have been avoided. These data are informative in identifying unanticipated consequences of an insulin management order sets focused entirely on hypoglycemia. A balanced approach in implementing insulin management guidelines concurrently addressing both hypoglycemia and hyperglycemia policies is warranted. [ABSTRACT FROM AUTHOR]

Introduction Considering that estradiol (E2) and n-3 polyunsaturated fatty acids (PUFAs) have roles in neurogenesis and in neurotransmission, we examined whether the association of PUFAs with incident depressive symptoms in postmenopausal women is modified by hormone therapy (HT) use or estrogen status. Methods Women (N = 1616) free of depressive symptoms at baseline (2000–2002) in the Multi-Ethnic Study of Atherosclerosis were classified by HT usage and quartiles of dietary eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA), and the sum EPA + DHA. Women with serum E2 ≤0.073 nmol/L (sample median), were classified low on E2. Poisson regression was used to model incident depressive symptoms at examination 3 (2004-05), defined by the Center for Epidemiological Studies Depression Scale ≥16 or taking an antidepressant, first as a function of HT use and n-3 PUFA quartiles, and second, as a function of low E2 status and n-3 PUFA quartiles. Results Among HT non- users, positive, graded relationships (p-trends ≤ 0.003) were found between PUFAs and incident depressive symptoms. Compared to the lowest quartile, the adjusted risk ratios (RRs) for the highest were 2.10, 2.39, and 2.04 for EPA, DHA, and EPA + DHA, respectively. For HT users, no associations were seen. When analyses were run for E2 status, the RRs over quartiles of the PUFAs were positive and graded for low E2 women, but were null for High E2 women. Conclusions Higher intakes of DHA and EPA were associated with higher risk of depressive symptoms in nonusers of HT, contrary to hypothesis. [ABSTRACT FROM AUTHOR]

Type 2 diabetes mellitus (DM) affects an estimated 25.8 million people in the United States and is the 7th leading cause of death. While effective therapy can prevent or delay the complications that are associated with diabetes, according to the Center for Disease Control, 35% of Americans with DM are undiagnosed, and another 79 million Americans have blood glucose levels that greatly increase their risk of developing DM in the next several years. One of the Healthy People 2020 goals is to reduce the disease and economic burden of DM and improve the quality of life for all persons who have, or are at risk for, DM. Achieving this goal requires a concentrated focus on improving the management of diabetes and in targeting prevention of macrovascular complications. This article reviews established and emerging therapeutic approaches for managing DM and prevention of macrovascular complications. [ABSTRACT FROM AUTHOR]

Many organizations persist in working with others that engage in known, remediable structural discrimination. We name this practice interorganizational structural discrimination (ISD) and argue it is a pivotal contributor to inequities in science and medicine. We urge organizations to leverage their relationships and demand progress from collaborators. [ABSTRACT FROM AUTHOR]

Summary 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. [ABSTRACT FROM AUTHOR]

In the aftermath of gun violence, those impacted and left to mourn are regarded as second victims. These individuals experience and are often burdened by mental and physical sequelae while attempting to cope with the trauma. The objective of this report is to highlight the support and resources of congregational and faith-based leaders available in an urban city with a high prevalence of gun violence. We describe information and insights presented during a symposium uniting medical-religious partners to discuss actions and programs to address trauma from gun violence. Faith-based persons from various Abrahamic religions, ranging from imams to reverends to hospital-based chaplains, discussed key strategies to allocate resources to second victims. These strategies included religious rituals meant to cope with trauma, memorials, and providing insight into resiliency for difficult times. Resources were identified for both within the hospital and community. Such medical-religious resources should be considered for future interventions which aim to attenuate the consequences of gun violence for second victims. [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 =2.5µm (PM2.5)] 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 (PM2.5, NO2, NOx and black carbon) at participants' homes the year prior to urine collection. Secondarily, short-term PM2.5 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 NOx concentration was associated with 6.3% higher mean EPI level [95% confidence interval (CI): 0.3%, 12.6%]. A 2-µg/m³ higher annual ambient PM2.5 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%). NO2, black carbon, and short-term PM2.5 exposures were not significantly associated with any of the catecholamines. CONCLUSIONS: We found an association between EPI and long-term concentrations of PM2.5 and NOx and an association between DA and long-term ambient PM2.5. These novel findings provide modest support for the hypothesis that air pollutant exposures are related to sympathetic nervous system activation. [ABSTRACT FROM AUTHOR]

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 30 min post-awakening), early decline (30 min to 2 h post-awakening) and late decline (2 h 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. [ABSTRACT FROM AUTHOR]

Objective We examined associations between intensive lifestyle intervention (ILS) and changes in testosterone and associations with mood among middle-aged men. Design Secondary analysis of men (n = 886) participating in the Diabetes Prevention Program which randomized glucose-intolerant, overweight men to ILS, metformin, or placebo between 1996 and 1999. Main outcome measures Changes in testosterone between baseline and 1-year follow-up asnd associations of these changes with mood measures (Beck Depression Inventory [BDI-II], Beck Anxiety Inventory [BAI]). Results Median baseline testosterone was 10.98 nmol/l and 44% (n = 385) had testosterone < 10.41 nmol/l or 300 ng/dl. Testosterone increases were greater among men randomized to ILS vs. metformin vs. placebo (1.15 nmol/l vs. −0.12 nmol/l vs. −0.27 nmol/l, p < 0.001). The association between changes in testosterone and mood differed by study arm (p < 0.001 for interaction); there were no significant associations between changes in testosterone and mood changes among men in the ILS or placebo arms. Among men in the metformin arm, increases in testosterone were significantly associated with decreases in BDI-II (improved depressive symptoms) (β-coefficient −0.2336, p = 0.0002) indicating a 0.23 decrease in BDI-II for every 1 nmol/l increase in testosterone and decreases in BAI (improved anxiety symptoms) (β-coefficient −0.2147, p = 0.0014). Similar patterns were observed for bioavailable testosterone. Conclusions Among overweight middle-aged men with glucose-intolerance, ILS increased endogenous testosterone slightly but without significant improvements in mood. Metformin did not increase testosterone, but among metformin users, testosterone increases were associated with improvements in mood. Thus, interventions that increase endogenous testosterone may not also improve mood. [ABSTRACT FROM AUTHOR]

Introduction Copeptin levels are elevated in severe medical conditions, an effect that is attributed to elevated arginine vasopressin (AVP) levels in response to physiological stress, resulting in activation of hypothalamus–pituitary–adrenal (HPA) axis. In the current study, we wanted to determine if copeptin is responsive to psychological stress, correlates with cortisol and adrenocorticotropin hormone (ACTH), and if associations differed by sex. Materials and methods In a cross-sectional study that included 100 healthy men (41%) and women (59%) (aged 18–30 years; mean 24.6 ± 3 years), who underwent the Trier Social Stress Test (TSST), we examined the association between percent change (peak-baseline/baseline) in copeptin levels and percent change in log ACTH and cortisol. Three baselines samples were drawn followed by blood sampling at 20, 35, 50, 65 and 85 min after TSST. Results There was a significant positive association between the percent change in copeptin and the percent change in log-transformed salivary cortisol (β-coefficient = 0.95; p = 0.02). The association between percent change in copeptin and log-transformed serum cortisol was not statistically significant in the overall population. There was a trend for a non-significant association between percent change in copeptin and percent change in log-transformed ACTH (β-coefficient = 1.14; p = 0.06). In males, there was a significant positive association between the percent change in copeptin levels and log-transformed salivary (β-coefficient = 1.33, p = 0.016) and serum cortisol (β-coefficient = 0.69, p = 0.01), whereas in women there was no statistically significant association. Conclusions We found a significant positive association between percent change in copeptin and percent change in salivary and serum cortisol among males only. [ABSTRACT FROM AUTHOR]

Hypercortisolism is associated with insulin resistance (IR) and diabetes mellitus (DM); however, to our knowledge prior studies have not examined the association of diurnal cortisol curve features with measures of glycemia or IR in a population-based setting. Using log-transformed salivary cortisol data on 850 ethnically diverse men and women from the Multi-Ethnic Study of Atherosclerosis, we investigated the cross-sectional association of cortisol curve features with (1) glycemia in those with and without DM and (2) IR, in non-diabetic subjects. The log-transformed salivary cortisol curve features included wake-up cortisol, cortisol awakening response (CAR), early decline slope (30 min to 2 h post-awakening), late decline slope (2 h post-awakening to bedtime), overall decline slope (0 min to bedtime, excluding 30 min cortisol), bedtime cortisol and total area under the curve (AUC). Overall, following multivariable adjustment, among those with diabetes mellitus (DM), early decline slope, overall decline slope, bedtime cortisol, and AUC were significantly and positively associated with a 5.4% (95% CI: 1.3, 9.7), 54.7% (95% CI: 12.4, 112.9), 4.0% (95% CI: 1.6,6.4), and 6.8% (95% CI: 3.3,10.4) higher HbA1c per 1 unit increase in log cortisol feature, respectively. Cortisol curve features were not associated with HbA1c among non-diabetic participants; however, wake-up cortisol and AUC were associated with a 8.2% lower (95% CI: −13.3,−2.7) and 7.9% lower (95% CI: −14.6, −0.6) log HOMA-IR, respectively. This was attenuated by adjustment for waist circumference. Among participants with DM, cortisol curve parameters suggestive of higher hypothalamic-pituitary-adrenal (HPA) axis activity and dysfunction were associated with higher HbA1c. In non-diabetic participants, greater HPA activity was paradoxically associated with lower insulin resistance. [ABSTRACT FROM AUTHOR]

Summary Objective Prior studies have shown a bidirectional association between depression and type 2 diabetes mellitus (T2DM); however, the prospective associations of anger and anxiety with T2DM have not been established. We hypothesized that trait anger and anxiety would predict incident T2DM, independently of depressive symptoms. Research design and methods In the Multi-ethnic Study of Atherosclerosis (MESA), we prospectively examined the association of trait anger and trait anxiety (assessed via the Spielberger Trait Anger and Anxiety Scales, respectively) with incident T2DM over 11.4 years in 5598 White, Black, Hispanic, and Chinese participants (53.2% women, mean age 61.6 years) at baseline without prevalent T2DM or cardiovascular disease. We used Cox proportional hazards models to calculate the hazard ratios (HR) of incident T2DM by previously defined anger category (low, moderate, high), and anxiety quartile, as there were no previously defined categories. Results High total trait anger was associated with incident T2DM (HR 1.50; 95% CI 1.08–2.07) relative to low total trait anger. The association was attenuated following adjustment for waist circumference (HR 1.32; 95% CI 0.94–1.86). Higher anger reaction was also associated with incident T2DM (HR = 1.07; 95% CI 1.03–1.11) that remained significant after adjusting for potential confounders/explanatory factors. In contrast, trait anxiety did not predict incident T2DM. Conclusions High total trait anger and anger reaction are potential modifiable risk factors for T2DM. Further research is needed to explore the mechanisms of the anger–diabetes relationship and to develop preventive interventions. [ABSTRACT FROM AUTHOR]

Aims: To explore causes of early readmission, i.e., hospital readmission within 30 days of discharge, among patients with diabetes. Methods: We performed thematic analysis of semi-structured interviews among 20 adults with diabetes hospitalized with an early readmission at an urban academic medical center. Results: Five themes emerged as contributors to readmission risk: (1) poor health literacy (lack of knowledge about diabetes and discharge instructions), (2) health system failure (of the discharge process and post- discharge support), (3) failure of expected protective factors, (e.g., following the discharge instructions, being aware of medication changes upon discharge, and having help and social support), (4) social determinants of health impeding care, and (5) loss of control over illness. A majority of patients reported needing assistance with transportation, obtaining and taking medications, and preparing food. Most patients denied an active role in exacerbating their condition prior to readmission, and many believed that being readmitted was out of their control. Conclusions: Our findings suggest several interventions that may reduce the risk of early readmission for patients with diabetes, including inpatient diabetes education, improving communication of discharge instructions, and involving patients more in medication reconciliation and post-discharge planning. [ABSTRACT FROM AUTHOR]

• Among participants with diabetes. • Annual increases in cortisol features associated with increased glucose over time. • Flattening of cortisol decline associated with increased annual % change in glucose. • This suggests a detrimental role of cortisol contributing to glycemia in diabetes. Little is known about the longitudinal association between fasting glucose (FG) and the diurnal cortisol profile among those with normal fasting glucose (NFG), impaired fasting glucose (IFG) and diabetes. To assess the temporality of the relationship between cortisol and glucose, we examined the association of: A) change (Δ) in diurnal cortisol curve features with ΔFG; B) prior annual percent change in FG with diurnal cortisol curve features; and C) baseline cortisol curve features with ΔFG over 6 years among participants with NFG, IFG and diabetes in the Multi-Ethnic Study of Atherosclerosis. The main outcome measures were: A) 6-year ΔFG (n = 512); B) diurnal cortisol curve features (wake-up cortisol levels, cortisol awakening response, total area under the curve, overall decline slope and bedtime cortisol) (n = 1275); and C) 6-year ΔFG (n = 700). After full multivariable adjustment among participants with diabetes, each annual percent change increase in wake-up cortisol, total area under the curve (AUC), and overall decline slope was associated with a significant increase in FG over 6 years in all models (all p < 0.05). A 1% prior annual increase in FG was associated with a 2.8 % lower (−2.8 %; 95 % CI: −5.3 % to −0.4 %) bedtime cortisol among participants with NFG at baseline. A 1 % flatter overall decline slope was associated with a 0.19 % increase in subsequent annual % change in FG over 6 years among participants with diabetes. Among participants with diabetes there was a positive association of change in wake-up cortisol, total AUC and overall decline slope with change in FG. Baseline overall decline slope was positively associated with change in FG among the baseline diabetes group. These results suggest a detrimental role of cortisol contributing to glycemia among individuals with diabetes. [ABSTRACT FROM AUTHOR]

"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., Competing Interests: No potential conflicts of interest relevant to this article were reported., (©2024 by the American Diabetes Association.)

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., (© The Author(s) 2023. Published by Oxford University Press on behalf of the Endocrine Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

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., (© 2022 The Author. Clinical Pharmacology & Therapeutics © 2022 American Society for Clinical Pharmacology and Therapeutics.)

The proliferation of diabetes quality measures in the US since the mid-1990s has increased the burden of measurement without commensurate improvements in the quality of care or health outcomes. Measures in use today do not represent or incentivize achievement of care goals in all domains of quality that are necessary to achieve optimal diabetes health. We recommend reimagining and improving diabetes quality measurement through the following propositions: widespread adoption of new measures and modernization of existing measures across six domains of quality; use of a subset of new and modernized metrics as top-line measures for reporting and reimbursement; and optional use of the remaining new and modernized measures for evaluative purposes at all levels of the care delivery system to identify and address gaps in care quality and outcomes. These propositions would support practices and policies at all levels of the health care system to improve the health of people with diabetes.

Context: Multiple studies suggest that adults who were normal weight at diabetes diagnosis are at higher risk for all-cause mortality than those who had overweight or obesity at diagnosis., Objective: While obesity is a known risk factor for cardiometabolic disease, differences in body fat distribution in those without obesity are understudied, especially in African Americans., Methods: In 1005 participants of the Jackson Heart Study, without cardiovascular disease at baseline, we used logistic regression to investigate the longitudinal association of body fat distribution by CT scan with metabolic syndrome (MetS) or type 2 diabetes (T2D). We used the harmonized International Diabetes Federation criteria to define MetS. We included only normal weight or overweight participants (BMI: 18.5 to < 30.0 kg/m 2 ). We created separate models for MetS and T2D adjusted for a standard set of covariates. We excluded participants with prevalent MetS or T2D, respectively in sensitivity., Results: Higher visceral fat, subcutaneous fat, BMI, and insulin resistance (HOMA-IR) were significantly associated with MetS and T2D after adjustment. Visceral fat was strongly associated with both outcomes (MetS OR = 2.07 [1.66-2.68]; T2D OR = 1.51 [1.21-1.88]), and the association for MetS persisted in the normal weight only group. Estimates were robust to sensitivity analysis and were only modestly mediated by insulin resistance. Physical activity was not associated with MetS or T2D., Conclusion: Visceral fat is strongly associated with developing MetS, even in normal weight individuals, suggesting that excess visceral fat plays a role in cardiometabolic risk beyond that of overall adiposity and obesity in African Americans., (© The Author(s) 2022. Published by Oxford University Press on behalf of the Endocrine Society.)

Competing Interests: I declare no competing interests.

Context: Diabetes is a leading metabolic disorder with a substantial cost burden, especially in inpatient settings. The complexity of inpatient glycemic management has led to the emergence of inpatient diabetes management service (IDMS), a multidisciplinary team approach to glycemic management., Objective: To review recent literature on the financial and clinical impact of IDMS in hospital settings., Methods: We searched PubMed using a combination of controlled vocabulary and keyword terms to describe the concept of IDMS and combined the search terms with a comparative effectiveness filter for costs and cost analysis developed by the National Library of Medicine., Findings: In addition to several improved clinical endpoints such as glycemic management outcomes, IDMS implementation is associated with hospital cost savings through decreased length of stay, preventing hospital readmissions, hypoglycemia reduction, and optimizing resource allocation. There are other downstream potential cost savings in long-term patient health outcomes and avoidance of litigation related to suboptimal glycemic management., Conclusion: IDMS may play an important role in helping both academic and community hospitals to improve the quality of diabetes care and reduce costs. Clinicians and policymakers can utilize existing literature to build a compelling business case for IDMS to hospital administrations and state legislatures in the era of value-based healthcare.

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 (<80 mg/dL) and HbA1c (<5.0%) from baseline and averaged across follow-up with incident CVD and mortality over 13 years. We used normal glycemic ranges (80 to <100 mg/dL and 5.0 to <5.7%) as references and analyzed glycemic levels with visit-matched covariates. We adjusted for potential confounding by age, sex, race/ethnicity, education, income, smoking status, body mass index, total cholesterol level, cholesterol medications, high-density lipoprotein cholesterol, and hypertension. Low baseline glucose and HbA1c were positively, but not significantly, associated with mortality, whereas low average fasting glucose and HbA1c were strongly and significantly associated with incident CVD [glucose OR, 2.04 (95% CI, 1.38-3.00); HbA1c OR, 2.01 (95% CI, 1.58-2.55)] and mortality [glucose OR, 1.93 (95% CI, 1.33-2.79); HbA1c OR, 2.51 (95% CI, 2.00-3.15)]. These results were not due to type 2 diabetes or medication use. Glucose variability did not explain CVD risk beyond average glucose levels. Chronic low fasting glucose and HbA1c may be better indicators of risk than a single low measurement.

Problem: The Johns Hopkins University School of Medicine Department of Medicine (DOM) sought ways of enhancing community engagement after the death of Freddie Gray and consequent unrest in Baltimore City., Approach: The DOM launched a five-part noon lecture series in May 2015-"Journeys in Medicine"-to facilitate discussion among DOM faculty, staff, trainees, and community residents regarding the city's unrest. This evolved into a department-wide civic engagement initiative in July 2016 to enhance employee and community engagement. The civic engagement committee is composed of two collaborative steering committees: Staff Engagement and Community Engagement., Outcomes: The DOM has sponsored and/or participated in programs to address major concerns raised during the Journeys in Medicine series-improving the strained relationship between police and the community, mentoring young people, involving more DOM employees in community activities, sharing research results with the community, and addressing cultural differences to enhance relationships and communication. To enhance staff engagement, a Nursing Diversity Council, complementing the Faculty Diversity Council, has been established. DOM faculty and staff have participated in and championed several disease-focused physical activity endeavors (e.g., walks) that, collectively, have raised over $40,000. Community service projects include supporting registration and screenings at a local health fair, a professional clothing drive, and DOM Days of Service., Next Steps: The Johns Hopkins University School of Medicine DOM is developing an administrator leadership program and continuing to participate in meaningful activities, leading to tangible outcomes designed to strengthen connections to the surrounding neighborhood and enhance engagement among all DOM employees.

Background: Subclinical hypercortisolism and hypothalamic-pituitary-adrenal (HPA) axis dysfunction are associated with type 2 diabetes (T2DM), cardiovascular disease, and metabolic dysfunction. Intronic methylation of FKBP5 has been implicated as a potential indicator of chronic cortisol exposure. Our overall objective in this study was to determine the association of chronic cortisol exposure, measured via percent methylation of FKBP5 at intron 2, with percent glycosylated hemoglobin (HbA1c), low-density lipoprotein cholesterol (LDL-cholesterol), waist circumference (WC), and body mass index (BMI), in a clinic-based sample of 43 individuals with T2DM., Results: Greater percent methylation of the FKBP5 intron 2 at one CpG-dinucleotide region was significantly associated with higher HbA1c ( β  = 0.535, p  = 0.003) and LDL cholesterol ( β  = 0.344, p  = 0.037) and a second CpG-dinucleotide region was significantly associated with higher BMI and WC ( β  = 0.516, p  = 0.001; β  = 0.403, p  = 0.006, respectively)., Conclusions: FKBP5 methylation may be a marker of higher metabolic risk in T2DM, possibly secondary to higher exposure to cortisol. Further work should aim to assess the longitudinal association of FKBP5 with cardiovascular disease and glycemic outcomes in T2DM as a first step in understanding potential preventive and treatment-related interventions targeting the HPA axis., Competing Interests: Patients who were willing to participate provided written informed consent. This study was approved by the Johns Hopkins University School of Medicine Institutional Review Board.The authors declare that they have no competing interests.Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Objective: The Diabetes Early Re-admission Risk Indicator (DERRI ™ ) was previously developed and internally validated as a tool to predict the risk of all-cause re-admission within 30 days of discharge (30-day re-admission) of hospitalized patients with diabetes. In this study, the predictive performance of the DERRI ™ with and without additional predictors was assessed in an external sample., Methods: We conducted a retrospective cohort study of adult patients with diabetes discharged from two academic medical centers between January 1, 2000 and December 31, 2014. We applied the previously developed DERRI ™ , which includes admission laboratory results, sociodemographics, a diagnosis of certain comorbidities, and recent discharge information, and evaluated the effect of adding metabolic indicators on predictive performance using multivariable logistic regression. Total cholesterol and hemoglobin A1c (A1c) were selected based on clinical relevance and univariate association with 30-day re-admission., Results: Among 105,974 discharges, 19,032 (18.0%) were followed by 30-day re-admission for any cause. The DERRI ™ had a C-statistic of 0.634 for 30-day re-admission. Total cholesterol was the lipid parameter most strongly associated with 30-day re-admission. The DERRI ™ predictors A1c and total cholesterol were significantly associated with 30-day re-admission; however, their addition to the DERRI ™ did not significantly change model performance (C-statistic, 0.643 [95% confidence interval, 0.638 to 0.647]; P = .92)., Conclusion: Performance of the DERRI ™ in this external cohort was modest but comparable to other re-admission prediction models. Addition of A1c and total cholesterol to the DERRI ™ did not significantly improve performance. Although the DERRI ™ may be useful to direct resources toward diabetes patients at higher risk, better prediction is needed., Abbreviations: A1c = hemoglobin A1c; CI = confidence interval; DERRI ™ = Diabetes Early Re-admission Risk Indicator; GEE = generalized estimating equation; HDL-C = high-density-lipoprotein cholesterol; ICD-9-CM = International Classification of Diseases, Ninth Revision, Clinical Modification; LDL-C = low-density-lipoprotein cholesterol.

Purpose of Review: This review focuses on evaluating and identifying gaps in the current literature regarding culturally specific dietary influences for patients with type 2 diabetes. As this topic has previously been examined in African American populations, we chose to focus on four other distinct populations (Hispanic, Middle Eastern, Western Pacific, South Asian). Given the rapid increase in global rates of type 2 diabetes and high rates of diabetes among certain ethnic groups, it is important to understand how culturally adapted strategies in diabetes management have been described in different regions and populations., Recent Findings: The specific role of nutrition in controlling diabetes is tied to cultural habits and customs. Variation in cultural practices, including diet, create unique environments in which patients with diabetes must navigate. The role of family, particularly among Hispanics, is crucial to cultural adaptations of diabetes management. Incorporating alternative medicine, namely observed in Chinese and Indian populations, also guided diabetes care strategies. Language barriers, health literacy, and acculturation were all unique factors affecting cultural approaches to diabetes management in these four populations. Understanding such cultural determinants is crucial to addressing diabetes disparities and improving outcomes.

Context: The degree to which changes in visceral adipose tissue (VAT) and subcutaneous adipose tissue (SAT) relate to corresponding changes in plasma sex steroids is not known., Objective: We examined whether changes in VAT and SAT areas assessed by computed tomography were associated with changes in sex hormones [dehydroepiandrosterone sulfate (DHEAS), testosterone, estradiol, estrone, and sex hormone binding globulin (SHBG)] among Diabetes Prevention Program participants., Design: Secondary analysis of a randomized trial., Participants: Overweight and glucose-intolerant men (n = 246) and women (n = 309)., Interventions: Intensive lifestyle change with goals of weight reduction and 150 min/wk of moderate intensity exercise or metformin administered 850 mg twice a day or placebo., Main Outcome Measures: Associations between changes in VAT, SAT, and sex hormone changes over 1 year., Results: Among men, reductions in VAT and SAT were both independently associated with significant increases in total testosterone and SHBG in fully adjusted models. Among women, reductions in VAT and SAT were both independently associated with increases in SHBG and associations with estrone differed by menopausal status. Associations were similar by race/ethnicity and by randomization arm. No significant associations were observed between change in fat depot with change in estradiol or DHEAS., Conclusions: Among overweight adults with impaired glucose intolerance, reductions in either VAT and SAT were associated with increased total testosterone in men and higher SHBG in men and women. Weight loss may affect sex hormone profiles via reductions in visceral and subcutaneous fat., (Copyright © 2017 Endocrine Society)

Purpose of Review: The goal of this review is to describe diabetes within a population health improvement framework and to review the evidence for a diabetes population health continuum of intervention approaches, including diabetes prevention and chronic and acute diabetes management, to improve clinical and economic outcomes., Recent Findings: Recent studies have shown that compared to usual care, lifestyle interventions in prediabetes lower diabetes risk at the population-level and that group-based programs have low incremental medial cost effectiveness ratio for health systems. Effective outpatient interventions that improve diabetes control and process outcomes are multi-level, targeting the patient, provider, and healthcare system simultaneously and integrate community health workers as a liaison between the patient and community-based healthcare resources. A multi-faceted approach to diabetes management is also effective in the inpatient setting. Interventions shown to promote safe and effective glycemic control and use of evidence-based glucose management practices include provider reminder and clinical decision support systems, automated computer order entry, provider education, and organizational change. Future studies should examine the cost-effectiveness of multi-faceted outpatient and inpatient diabetes management programs to determine the best financial models for incorporating them into diabetes population health strategies.

Context: Prior 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., Objective: To 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., Design: Longitudinal study., Setting: Multi-Ethnic Study of Atherosclerosis (MESA) Stress I & II Studies (2004-2006 & 2010-2012)., Participants: 1685 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 Measures: Log-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., Results: Over 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/m 2 , 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)., Conclusions: We 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., (Copyright © 2016 Elsevier Inc. All rights reserved.)