Search

Background Chronic pain is a highly prevalent health condition among veterans. Traditional pharmacological interventions present unique challenges for chronic pain management including prescription opioid addiction and overdose. In alignment with the 2016 Comprehensive Addiction and Recovery Act and VA’s Stepped Care Model to meet veterans’ pain management needs, the Offices of Rural Health and Pain Management, Opioid Safety, and Prescription Drug Monitoring Program (PMOP) funded an enterprise-wide initiative to implement a Step 3 integrated tele-pain program: Empower Veterans Program (EVP). EVP provides veterans with chronic pain self-care skills using a whole health driven approach to pain management. Objectives The Comprehensive Addiction and Recovery Act prompted the strategic approach to offer non-pharmacological options to meet veterans’ pain management needs. EVP, a 10-week interdisciplinary group medical appointment, leverages Acceptance and Commitment Therapy, Mindful Movement, and Whole Health to provide veterans with chronic pain self-care skills. This evaluation was conducted to describe participant characteristics, graduation, and satisfaction rates; and assess pre-post patient-reported outcomes (PRO) associated with EVP participation. Methods A sample of 639 veterans enrolled in EVP between May, 2015 and December, 2017 provided data to conduct descriptive analyses to assess participant demographics, graduation, and satisfaction rates. PRO data were analyzed using a within-participants pre-post design, and linear mixed-effects models were used to examine pre-post changes in PRO. Results Of 639 participants, 444 (69.48%) graduated EVP. Participant median program satisfaction rating was 8.41 (Interquartile Range: 8.20–9.20). Results indicate pre-post EVP improvements (Bonferroni-adjusted p Discussion Data suggest that EVP has significant positive outcomes in pain, psychological, physical, HRQoL, acceptance, and mindfulness measures for veterans with chronic pain through non-pharmacological means. Future evaluations of intervention dosing effect and long-term effectiveness of the program is needed.

Exposure to maternal hyperglycemia in utero has been associated with adverse metabolic outcomes in offspring. However, few studies have investigated the relationship between maternal hyperglycemia and offspring cortisol levels. We assessed associations of gestational diabetes mellitus (GDM) with cortisol biomarkers in two longitudinal prebirth cohorts: Project Viva included 928 mother–child pairs and Gen3G included 313 mother–child pairs. In Project Viva, GDM was diagnosed in N = 48 (5.2%) women using a two-step procedure (50 g glucose challenge test, if abnormal followed by 100 g oral glucose tolerance test [OGTT]), and in N = 29 (9.3%) women participating in Gen3G using one-step 75 g OGTT. In Project Viva, we measured cord blood glucocorticoids and child hair cortisol levels during mid-childhood (mean (SD) age: 7.8 (0.8) years) and early adolescence (mean (SD) age: 13.2 (0.9) years). In Gen3G, we measured hair cortisol at 5.4 (0.3) years. We used multivariable linear regression to examine associations of GDM with offspring cortisol, adjusting for child age and sex, maternal prepregnancy body mass index, education, and socioeconomic status. We additionally adjusted for child race/ethnicity in the cord blood analyses. In both Project Viva and Gen3G, we observed null associations of GDM and maternal glucose markers in pregnancy with cortisol biomarkers in cord blood at birth (β = 16.6 nmol/L, 95% CI −60.7, 94.0 in Project Viva) and in hair samples during childhood (β = −0.56 pg/mg, 95% CI −1.16, 0.04 in Project Viva; β = 0.09 pg/mg, 95% CI −0.38, 0.57 in Gen3G). Our findings do not support the hypothesis that maternal hyperglycemia is related to hypothalamic–pituitary–adrenal axis activity.

Introduction: Previous studies have suggested an association between insulin resistance (IR) trajectories and adverse changes in cardiac structure and function in nondiabetic populations. We studied the associations between IR trajectories and incident heart failure (HF) and all-cause death in nondiabetic participants of the Atherosclerosis Risk in Communities (ARIC) study. We hypothesized that long-term moderate and high IR levels would increase the risk of incident HF and all-cause death. Methods: We included 7,835 participants (3,505 men and 4,330 women) aged 45-64 from the ARIC study without diabetes mellitus at any visit, and no history of prevalent HF, myocardial infarction, stroke, arterial or coronary surgery, or cancer at baseline. We estimated IR using Homeostatic Model Assessment-Insulin Resistance (HOMA-IR), triglyceride to high-density lipoprotein cholesterol ratio (TG/HDL-C), triglyceride glucose (TyG) index and metabolic score for IR (METS-IR). Serum insulin was not available at visits 2 and 3, so HOMA-IR was calculated for visits 1, 4, and 5. Latent class analysis identified two HOMA-IR trajectories, low-increasing and high-increasing, and three trajectories for TG/HDL-C, TyG index, and METS-IR: low-increasing, moderate-stable, and high-decreasing. We employed Cox proportional-hazards models to examine the associations of IR trajectories with incident HF and all-cause death adjusting for potential confounders. Results: Compared to participants in the low-increasing group, those in the high-increasing group of HOMA-IR were more likely to have incident HF and all-cause death (Table 1). For TG/HDL-C, TyG index and METS-IR, we found an increased risk of incident HF in the moderate-stable and high-decreasing groups relative to the low-increasing group. For all-cause death, consistent associations were found only in women (Table 1). Conclusions: Reduction of insulin resistance in nondiabetic individuals may be a suitable target for prevention strategies to reduce cardiovascular disease.

Background The COVID-19 pandemic has been a catalyst for rapid uptake of virtual care through the use of virtual health resources (VHR). In the Department of Veterans Affairs (VA) Healthcare System, virtual care has been critical to maintaining healthcare access for patients during COVID-19. In the current study we describe primary care patient aligned care team (PACT) VHR use patterns within one VA medical center (i.e., hospital facility and five community-based outpatient clinics) pre- and post-COVID-19 onset. Methods VHR provider and patient use data from 106 individual PACTs were extracted monthly between September 2019 to September 2020. Data were extracted from VHA web-based project application and tracking databases. Using longitudinal data, mixed effect models were used to compare pre- and post-COVID onset slopes. Results Findings highlight an increase in patient users of secure messaging (SM) and telehealth. The rate of utilization among these patients increased for SM but not for telehealth visits or online prescription refill (RxRefill) use. Finally, VetLink Kiosk check ins that are done at in person visits, diminished abruptly after COVID-19 onset. Conclusions These data provide a baseline of VHR use at the PACT level after the initial impact of the COVID-19 pandemic and can inform healthcare delivery changes within the VA systems over time. Moreover, this project produced a data extraction blueprint, that is the first of its kind to track VA VHR use leveraging secondary data sources.

The inflammatory potential of diet, assessed by Empirical Dietary Inflammatory Pattern (EDIP), may play a crucial role in the development of metabolic syndrome (MetS). However, limited research on this relationship is available. We hypothesized that EDIP is positively associated with MetS and its components. This longitudinal study included 1,177 participants (526 with type 1 diabetes mellitus (T1DM) and 651 without) from the Coronary Artery Calcification in Type 1 Diabetes study. Dietary assessment and anthropometric and biochemical measurements were assessed at baseline and 14-year follow-up. MetS status was defined using the Harmonization criteria. EDIP scores were computed based on a food frequency questionnaire. Generalized linear mixed models were applied and subgroup analyses were performed by diabetes status. Mean age of study participants was 38 years and 48% were male at baseline. EDIP was positively associated with MetS (β(T3 versus T1)=0.81, p

Introduction: Cardiovascular disease (CVD) is the leading cause of death in people with T1D, and women with T1D are disproportionately affected. However, few studies have examined how T1D affects vascular health in women across the lifespan. Methods: Women ages 18-79 with (N=309) and without T1D (n=351) were examined cross-sectionally for markers of CVD: pulse wave velocity (PWV) , augmentation index (AiX) , pulse height (PH) , brachial artery distensibility (BrachD) , subendocardial viability index (SVI) , and carotid intima thickness (cIMT) . Menopausal status was self-reported. Body composition was measured by Dual Xray Absorptiometry. CVD markers were examined by diabetes status and age using linear regression models adjusted for menopausal status. Results: Age did not differ in women with and without diabetes (49 ± 12 vs. 50±14 years, p=0.32) . Women with T1D had higher systolic blood pressure (SBP) , cIMT, PWV and PH, and lower BrachD and SVI than non-diabetic women (Table 1) . Changes in blood pressure, cIMT, AiX, and SVI with age differed by diabetes status, as demonstrated by a significant interaction. While SBP and Aix were increased more in women with T1D at younger ages, cIMT and SVI worsened with age to a greater extent in T1D. Conclusions: Women with T1D have worse CVD markers than women without diabetes across the lifespan, with more arterial stiffness at younger ages and more atherosclerosis and lower SVI later in life. Disclosure C.J.Chartier-logan: None. A.C.Alman: None. V.Shah: Advisory Panel; Medscape, Sanofi, Consultant; Dexcom, Inc., Research Support; Dexcom, Inc., Eli Lilly and Company, Insulet Corporation, Novo Nordisk. J.K.Snell-bergeon: Stock/Shareholder; GlaxoSmithKline plc.

To examine the associations of dietary patterns and nutrients with coronary artery calcification (CAC) and pericardial adiposity (PAT) in adults with and without type 1 diabetes. We conducted a six-year longitudinal analysis of data from Coronary Artery Calcification in Type 1 Diabetes study [n = 1255; T1D: n = 563; non-DM: n = 692] collected at baseline, year 3 and year 6. Participants completed a validated food frequency questionnaire, a physical examination, and fasting (12 h overnight fast) biochemical analyses. CAC and PAT were measured using electron beam computed tomography. Dietary patterns were identified using factor analysis. Generalized estimating equations were used to examine associations of dietary patterns and nutrients with CAC and PAT in models adjusted for traditional cardiovascular risks. The ‘starchy veggies, meats and alcohol pattern’ was associated with significantly increased risk of CAC presence in all adjusted models; an increasing trend was observed with CAC progression. Increasing intake of dietary proteins and total fats were also associated with higher risk of the presence and/or progression of CAC in adjusted models (all p

Upfront surgery is the current standard for resectable intrahepatic cholangiocarcinoma (ICC) despite high treatment failure with this approach. We sought to examine the use of neoadjuvant chemotherapy (NAC) as an alternative strategy for this population. The National Cancer Database was used to identify patients with resectable ICC undergoing curative-intent surgery (2006–2014). Utilization trends were examined and survival estimates between NAC and upfront surgery were compared; propensity score-matched models were used to examine the association of NAC with overall survival (OS) for all patients and risk-stratified cohorts. Models accounted for clustering within hospitals, and results represent findings from a complete-case analysis. Among 881 patients with ICC, 8.3% received NAC, with no changes over time (Cochran–Armitage p = 0.7). Median follow-up was 50.9 months, with no difference in unadjusted survival with NAC versus upfront surgery (median OS 51.8 vs. 35.6 months, and 5-year OS rates of 38.2% vs. 36.6%; log rank p = 0.51), and no survival benefit in the propensity score-matched analysis (hazard ratio [HR] 0.78, 95% CI 0.54–1.11; p = 0.16). However, for patients with stage II–III disease, NAC was associated with a trend towards improved survival (median OS of 47.6 months vs. 25.9 months, and 5-year OS rates of 34% vs. 25.7%; log-rank p = 0.10) and a statistically significant survival benefit in the propensity score-matched analysis. (HR 0.58, 95% CI 0.37–0.91; p = 0.02). NAC is associated with improved OS over upfront surgery in patients with resectable ICC and high-risk of treatment failure. These data support the need for prospective studies to examine NAC as an alternative strategy to improve OS in this population.

Type 1 diabetes (T1D) has been associated with increased risks of atherosclerotic cardiovascular disease, and poor glycemic control and oxidative stress play a major role in its pathology. There is a lack of data on the role of dietary antioxidant micronutrients, including vitamins and trace elements, in glycemic control in T1D. The aim of this study is to examine associations of dietary intakes of micronutrients with glycemic status. We report data from a cross-sectional analysis from the coronary artery calcification in type 1 diabetes (CACTI) study ( n = 1257 ; T1D: n = 568 ; nondiabetic controls: n = 689 ) collected between the years 2000 and 2002. Participants completed a validated food frequency questionnaire, a physical examination, and biochemical analyses. Linear regression was used to examine the associations of dietary antioxidant micronutrients with HbA1c and estimated insulin sensitivity (eIS) in models adjusted for relevant covariates and stratified by diabetes status. In adults with T1D, we observed higher dietary manganese intake associated with higher eIS in the model adjusted for age, sex, diabetes duration, and total calories. In nondiabetic controls, higher intake of manganese associated with lower HbA1c and higher eIS values that persisted in models adjusted for all relevant covariates. On the other hand, dietary copper revealed a positive association with HbA1c in models adjusted for all covariates, except BMI and plasma lipids. No associations were noted for vitamins C and E and dietary carotenoids in either group. These findings reveal dietary antioxidant micronutrients, especially trace elements such as copper and manganese deserve special attention in glycemic control in adults with T1D as well as in nondiabetic controls.This trial is register with NCT00005754.

Introduction Transforming Health and Resilience through Integration of Values-based Experiences (THRIVE) is a complimentary and integrative health program. THRIVE is delivered through shared medical appointments where participants engage in provider-led education and group discussion on wellness-related topics. THRIVE has been associated with improved patient-reported outcomes in a female veteran cohort. This quality improvement study evaluated the association between THRIVE participation and Veterans Health Administration (VHA) healthcare costs across a 1 year period. Materials and Methods A cohort study design (n = 184) used VHA administrative data to estimate the cost difference between 1 year pre- and post-THRIVE participation. The 1 year post-cost of the THRIVE cohort was then compared to the 1 year cost of a quasi-experimental waitlist control group (n = 156). Data sources included VHA administrative and electronic health records. Results Patients were roughly 51 years old, were typically White/Caucasian, and had a service priority level representing catastrophic disability. The adjusted post-THRIVE cost was $26,291 [95% confidence interval (CI): $23,014–29,015]; $1,720 higher than the previous year’s cost but was not statistically significant (P = 0.289). However, a comparison between the THRIVE cohort and a group of waitlist THRIVE patients (n = 156) the intervention group on average was $8,108 more than the waitlist group (95% CI: $3,194–14,005; P Conclusions In summary, data analysis of veterans’ annual healthcare cost trajectories were inconclusive. This preliminary study produced mixed results requiring more research with larger samples and randomized control trial methodology. Evidence of whether the THRIVE intervention can maintain cost effectiveness while maintaining its supported evidence of healthcare quality is needed.

Low back pain (LBP) disproportionately impacts US military veterans compared with nonveterans. Although the effect of psychological conditions on LBP is regularly studied, there is little published to date investigating nightmare disorder (NMD) and LBP. The purpose of this study was to (1) investigate whether an association exists between NMD and LBP and (2) estimate the effect of NMD diagnosis on time to LBP. We used a retrospective cohort design with oversampling of those with NMD from the Veterans Health Administration (n = 15 983). We used logistic regression to assess for a cross-sectional association between NMD and LBP and survival analysis to estimate the effect of NMD on time to LBP, up to 60-month follow-up, conditioning on age, sex, race, index year, Charlson Comorbidity Index, depression, anxiety, insomnia, combat exposure, and prisoner of war history to address confounding. Odds ratios (with 95% confidence intervals [CIs]) indicated a cross-sectional association of 1.35 (1.13 to 1.60) and 1.21 (1.02 to 1.42) for NMD and LBP within 6 months and 12 months pre- or post-NMD diagnosis, respectively. Hazard ratios (HRs) indicated the effect of NMD on time to LBP that was time-dependent—HR (with 95% CIs) 1.27 (1.02 to 1.59), 1.23 (1.03 to 1.48), 1.19 (1.01 to 1.40), and 1.10 (0.94 to 1.29) in the first 3, 6, 9, and 12 months post-diagnosis, respectively—approximating the null (1.00) at >12 months. The estimated effect of NMD on LBP suggests that improved screening for NMD among veterans may help clinicians and researchers predict (or intervene to reduce) risk of future back pain.

Background: People with type 1 diabetes (T1D) have a greater risk of developing cardiovascular diseases than people without diabetes. Inflammation plays a key role in atherosclerosis and diet has been known to modify inflammation. However, little is known about this association in T1D. Methods: We conducted a six-year longitudinal analysis of data from Coronary Artery Calcification in Type 1 Diabetes study [n=1255; T1D: n=563; non-DM: n=692] collected at baseline, year 3 and year 6. Participants completed a validated food frequency questionnaire, a physical examination, and fasting (12h overnight fast) biochemical analyses. Biomarkers of inflammation and atherosclerosis [C-reactive protein (CRP), fibrinogen, plasminogen activator inhibitor-1 (PAI-1), homocysteine (hcy) and adiponectin] were determined in serum samples at three time points. Dietary patterns were identified using factor analysis. Generalized estimating equations were used to examine associations of dietary patterns with inflammation in models adjusted for traditional cardiovascular risks. Results: In a multivariate model, increasing intake of carbohydrates and total fats were positively associated with CRP [β (95% CI): 0.013 (0.003, 0.023) and 0.025 (0.011, 0.039), respectively) and fibrinogen (0.007 (0.005, 0.010) and 0.010 (0.006, 0.014), respectively) when adjusted for age, sex, time, total calories, and diabetes status. Dietary fiber revealed an inverse association with CRP [-0.014 (-0.021, -0.007)], PAI-1 [-0.009 (-0.015, -0.003)], and hcy [-0.002 (-0.005, 0.000)], and a positive association with adiponectin [0.005 (0.000, 0.009)]. A dietary pattern characterized by ‘veggies, meats and alcohol’ was positively associated with adiponectin [0.022 (0.001, 0.043)]. Conclusions: Dietary carbohydrates and total fats were associated with biomarkers of inflammation and atherosclerosis, while fiber revealed protective associations in adults with and without T1D. Disclosure A. Basu: None. L. Chien: None. A. C. Alman: None. J. K. Snell-bergeon: Stock/Shareholder; Self; GlaxoSmithKline plc. Funding National Institutes of Health (R01HL61753)

OBJECTIVE Type 1 diabetes is associated with a higher risk of cardiovascular disease (CVD) in women. Although menopause increases risk of CVD, it is uncertain how menopause affects risk of CVD in women with type 1 diabetes. We examined whether risk of CVD changes differentially in women with and those without type 1 diabetes over the transition through menopause. RESEARCH DESIGN AND METHODS Premenopausal women with type 1 diabetes (n = 311) and premenopausal women without diabetes (n = 325) enrolled in the Coronary Artery Calcification in Type 1 Diabetes (CACTI) study and attended up to four study visits over 18 years. Coronary artery calcium (CAC) volume was measured from computed tomography scans obtained at each visit. Longitudinal repeated-measures modeling estimated the effect of diabetes on CAC volume over time and the effect of menopause on the diabetes-CAC relationship. RESULTS CAC volume was higher at baseline and increased more over time in women with type 1 diabetes than in women without diabetes. A significant diabetes-by-menopause interaction was found (P < 0.0001): postmenopausal women with type 1 diabetes had significantly higher CAC volumes than premenopausal women (5.14 ± 0.30 vs. 2.91 ± 0.18 mm3), while there was no difference in women without diabetes (1.78 ± 0.26 vs. 1.78 ± 0.17 mm3). This interaction remained significant after adjusting for CVD risk factors. CONCLUSIONS Type 1 diabetes was associated with higher CAC volume and accelerated progression of CAC over time. Menopause increased CAC progression more in women with diabetes than in women without diabetes independent of age and other CVD risk factors known to worsen with menopause.

Background: Diet has been associated with poor glycemic control in diabetes. Few studies have examined this association in people with type 1 diabetes (T1D), who are at a higher risk for cardiovascular disease than people without diabetes. Methods: We report data from cross-sectional and longitudinal analyses from a coronary artery calcification in type 1 diabetes (CACTI) study (n = 1257, T1D: n = 568, non-diabetic controls: n = 689) collected between the years 2000 and 2002. Participants completed a validated food frequency questionnaire, a physical examination, and biochemical analyses. Dietary patterns based on variations in food group intake were created with principal components analysis. Linear regression was used to examine the associations of dietary patterns, macronutrients, and food groups with HbA1c in a model adjusted for relevant covariates and stratified by diabetes status. Results: Three dietary patterns were identified: “fruits, veggies, meats, cereal”, “baked desserts” and “convenience foods and alcohol” patterns. At baseline, a higher intake of the “baked dessert” pattern was significantly associated with higher HbA1c in T1D at baseline as well at year 6 of the study when adjusted for age, sex, BMI, total calories, and diabetes duration. No such associations were observed in the case of non-diabetic controls. Dietary saturated fats and animal fats were also positively associated with HbA1c in adults with T1D at baseline and/or at year 6. Conclusions: The habitual intake of a dietary pattern that is characterized by an increased intake of added sugar and saturated fats, such as in baked desserts, may increase risks of poor glycemic control in T1D.

Saliva has immense potential as a diagnostic fluid for identification and monitoring of several systemic diseases. Composition of the microbiome and inflammation has been associated and reflective of oral and overall health. In addition, the relative ease of collection of saliva further strengthens large-scale diagnostic purposes. However, the future clinical utility of saliva cannot be fully determined without a detailed examination of daily fluctuations that may occur within the oral microbiome and inflammation due to circadian rhythm. In this study, we explored the association between the salivary microbiome and the concentration of IL-1β, IL-6 and IL-8 in the saliva of 12 healthy adults over a period of 24 h by studying the 16S rRNA gene followed by negative binomial mixed model regression analysis. To determine the periodicity and oscillation patterns of both the oral microbiome and inflammation (represented by the cytokine levels), two of the twelve subjects were studied for three consecutive days. Our results indicate that the Operational Taxonomic Units (OTUs) belonging to Prevotella, SR1 and Ruminococcaceae are significantly associated to IL-1β while Prevotella and Granulicatella were associated with IL-8. Our findings have also revealed a periodicity of both the oral microbiome (OTUs) and inflammation (cytokine levels) with identifiable patterns between IL-1β and Prevotella, and IL-6 with Prevotella, Neisseria and Porphyromonas. We believe that this study represents the first measure and demonstration of simultaneous periodic fluctuations of cytokine levels and specific populations of the oral microbiome.

To examine the associations of dietary patterns and nutrients with coronary artery calcification (CAC) and pericardial adiposity (PAT) in adults with and without type 1 diabetes.We conducted a six-year longitudinal analysis of data from Coronary Artery Calcification in Type 1 Diabetes study [n = 1255; T1D: n = 563; non-DM: n = 692] collected at baseline, year 3 and year 6. Participants completed a validated food frequency questionnaire, a physical examination, and fasting (12 h overnight fast) biochemical analyses. CAC and PAT were measured using electron beam computed tomography. Dietary patterns were identified using factor analysis. Generalized estimating equations were used to examine associations of dietary patterns and nutrients with CAC and PAT in models adjusted for traditional cardiovascular risks.The 'starchy veggies, meats and alcohol pattern' was associated with significantly increased risk of CAC presence in all adjusted models; an increasing trend was observed with CAC progression. Increasing intake of dietary proteins and total fats were also associated with higher risk of the presence and/or progression of CAC in adjusted models (all p 0.05). PAT was positively associated with dietary total fats, and inversely associated with dietary intakes of saturated fats, omega-3 fats and fiber in models adjusted for age, sex, total calories, time, diabetes status, systolic blood pressure, serum lipids and physical activity.Diets high in total fats and proteins, and in meats (processed and red) and alcohol may increase risks of CAC, while saturated fats, omega-3-fats and fiber may be protective against pericardial adiposity as a risk factor for coronary artery disease. ClinicalTrials.gov Identifier: NCT00005754.

Background Smokers have lower risk of obesity, which some consider a “beneficial” side effect of smoking. However, some studies suggest that smoking is simultaneously associated with higher central adiposity and, more specifically, ectopic adipose deposition. Little is known about the association of smoking with intermuscular adipose tissue (IMAT), an ectopic adipose depot associated with cardiovascular disease (CVD) risk and a key determinant of muscle quality and function. We tested the hypothesis that smokers have higher abdominal IMAT and lower lean muscle quality than never smokers. Methods and findings We measured abdominal muscle total, lean, and adipose volumes (in cubic centimeters) and attenuation (in Hounsfield units [HU]) along with subcutaneous (SAT) and visceral adipose tissue (VAT) volumes using computed tomography (CT) in 3,020 middle-aged Coronary Artery Risk Development in Young Adults (CARDIA) participants (age 42–58, 56.3% women, 52.6% white race) at the year 25 (Y25) visit. The longitudinal CARDIA study was initiated in 1985 with the recruitment of young adult participants (aged 18–30 years) equally balanced by female and male sex and black and white race at 4 field centers located in Birmingham, AL, Chicago, IL, Minneapolis, MN, and Oakland, CA. Multivariable linear models included potential confounders such as physical activity and dietary habits along with traditional CVD risk factors. Current smokers had lower BMI than never smokers. Nevertheless, in the fully adjusted multivariable model with potential confounders, including BMI and CVD risk factors, adjusted mean (95% CI) IMAT volume was 2.66 (2.55–2.76) cm3 in current smokers (n = 524), 2.36 (2.29–2.43) cm3 in former smokers (n = 944), and 2.23 (2.18–2.29) cm3 in never smokers (n = 1,552) (p = 0.007 for comparison of former versus never smoker, and p < 0.001 for comparison of current smoker versus never and former smoker). Moreover, compared to participants who never smoked throughout life (41.6 [41.3–41.9] HU), current smokers (40.4 [39.9–40.9] HU) and former smokers (40.8 [40.5–41.2] HU) had lower lean muscle attenuation suggesting lower muscle quality in the fully adjusted model (p < 0.001 for comparison of never smokers with either of the other two strata). Among participants who had ever smoked, pack-years of smoking exposure were directly associated with IMAT volume (β [95% CI]: 0.017 [0.010–0.025]) (p < 0.001). Despite having less SAT, current smokers also had higher VAT/SAT ratio than never smokers. These findings must be viewed with caution as residual confounding and/or reverse causation may contribute to these associations. Conclusions We found that, compared to those who never smoked, current and former smokers had abdominal muscle composition that was higher in adipose tissue volume, a finding consistent with higher CVD risk and age-related physical deconditioning. These findings challenge the belief that smoking-associated weight loss or maintenance confers a health benefit., James Terry and colleagues reveal the higher levels of abdominal adipose tissue in smokers compared to nonsmokers., Author summary Why was this study done? Smoking and obesity are, separately, well-known health risks for cancer and cardiovascular disease (CVD). Smokers often have lower risk of obesity measured using BMI, leading to the misconception of a “beneficial side effect” to smoking. Even with a lower BMI, smokers may have a higher risk of depositing fat (more properly called adipose tissue) in and around organs and tissues compared to those who never smoked. This type of fat carries higher risk and may interfere with organ and tissue functions. What did the researchers do and find? We used computed tomography (CT) to measure abdominal fat deposited just below the skin’s surface (subcutaneous fat), around organs including the intestines (visceral fat) and abdominal muscles (intermuscular fat), and inside the muscles (intramuscular fat) in 3,020 middle-aged participants in the Coronary Artery Risk Development in Young Adults (CARDIA) study. We found that current smokers had higher proportions of fat within their abdominal muscles and visceral fat around their internal organs compared to never smokers, whereas those who had quit smoking had intermediate levels of visceral and intramuscular fat. What do these findings mean? Despite lower BMI and subcutaneous fat, smokers appear to be at risk of accumulating organ-associated fat and intramuscular fat that have been shown to increase circulating blood fats and sugar. This may, in turn, explain some of the hidden, higher risk of CVD and disability in smokers.

Background: Among the modifiable risk factors, diet plays an important role in the risks and progression of poor glycemic control in diabetes. However, few studies have examined this association in people who have type 1 diabetes (T1D), who are at a greater risk of developing cardiovascular diseases than people without diabetes. Methods: We conducted cross-sectional and longitudinal analyses of data from CACTI study [n=1257; T1D: n=568; nondiabetic controls: n=689] collected between March 2000 and April 2002. Participants completed a validated food frequency questionnaire, a physical examination and fasting biochemical analyses (12h fast). At baseline, dietary patterns based on variations in food group intake were created with principal components analysis (PCA). Linear regression was used to examine associations of dietary patterns with HbA1c in a model adjusted for age and sex and stratified by diabetes status. Results: Three dietary patterns were identified using PCA as follows: ’fruits, veggies, meats, cereal’, ’baked desserts’ and ’convenience foods and alcohol’ patterns. At baseline, higher intake of ’baked dessert’ pattern was significantly associated with higher HbA1c in T1D (β±SE: 0.10±0.05, p=0.03), but not in nondiabetic controls (0.06±0.04, p=0.21) when adjusted for age, sex and baseline total calories, as well as diabetes duration for T1D. At year-6, baseline higher intake of ’baked dessert’ pattern tended to be associated with increasing HbA1c in T1D (β±SE: 0.11±0.06, p=0.06), but not in nondiabetic controls (0.01±0.04, p=0.68) when adjusted for the same covariates. Conclusions: Habitual intake of a dietary pattern that is characterized by an increased intake of added sugar and saturated fats, such as in baked desserts may increase risks of poor glycemic control in T1D. Disclosure A. Basu: None. A.C. Alman: None. J.K. Snell-Bergeon: Stock/Shareholder; Self; GlaxoSmithKline plc. Funding American Diabetes Association (7-13-CD-10 to J.K.S-B.)

Introduction: Adults with type 1 diabetes (T1D) have at least a two-fold risk of developing coronary artery disease (CAD) compared to adults without diabetes (Non-DM); Periodontal disease is also increased in T1D, due at least in part to hyperglycemia. There is increasing recognition that periodontal disease is linked to CAD through systemic inflammation, which may be a mechanism through which diabetes increases CAD. In this study, we examined the association between self-reported gum disease and coronary artery calcium (CAC) in the prospective Coronary Artery Calcification in Type 1 Diabetes (CACTI) cohort. Methods: There were 1416 adults (652 with T1D, 764 Non-DM, mean±SD age 37±8years, 48% men) enrolled in the CACTI cohort in 2000. The cohort completed four visits between 2000 and 2018: at baseline and after 3, 6 and 14 years of follow-up. At each visit, participants self-reported gum disease diagnosis. CAC volume was measured by computed tomography at each visit and was square root transformed for analysis. Linear mixed effects models were used to examine the association between self-reported gum disease and change in CAC volume. Results: At baseline, 12% of Non-DM and 16% of T1D participants (p=0.054) reported having gum disease. The prevalence of gum disease increased across visits to 18% in participants with T1D vs. 13% in Non-DM participants at visit 2 (p=0.01); 22% in participants with T1D at visit 3 vs. 14% in Non-DM participants (p=0.0009) and 25% in participants with T1D vs. 17% in Non-DM participants at visit 4 (p=0.023). Self-reported gum disease was associated with a significantly greater increase in CAC volume over time (Table, p Conclusion: Periodontal disease prevalence was increased in adults with T1D, and was independently associated with increase in CAC volume over 14 years of follow-up in this population.

Highlights • PANcreatic-DERived factor (PANDER) is a novel hormone regulating glucose levels. • Fasting PANDER levels were measured in T2D and non-T2D matched subjects from U.S. • Associations between PANDER and other hormones or metabolic parameters were examined. • PANDER was associated with increased HbA1c and fasting blood glucose in T2D subjects. • PANDER was not associated with adiponectin, HOMA-β and HOMA-IR., Aim PANcreatic-DERived factor (PANDER, FAM3B) is a novel hormone that regulates glucose levels via interaction with both the endocrine pancreas and liver. Prior studies examining PANDER were primarily conducted in murine models or in vitro but little is known regarding the circulating concentration of PANDER in humans, especially with regard to the association of type 2 diabetes (T2D) or overall glycemic regulation. To address this limitation, we performed a cross-sectional analysis of circulating serum PANDER concentration in association with other hormones that serve as either markers of insulin resistance (insulin and adiponectin) or to metabolic parameters of glycemic control such as fasting HbA1c and blood glucose (FBG). Methods Fasting serum was obtained from a commercial biorepository from 300 de-identified adult subjects with 150 T2D and non-T2D adult subjects collected from a population within the United States, respectively, matched on gender, age group and race/ethnicity. Concentration of PANDER, insulin and adiponectin were measured for all samples as determined by commercial ELISA. Metadata was provided for each subject including demography, anthropometry, and cigarette and alcohol use. In addition, fasting blood glucose (FBG) and HbA1c were available on T2D subjects. Results Multiple linear regression analyses were performed to examine the relationships between circulating log PANDER concentration on HbA1c, fasting glucose, log insulin, log HOMA-β and log HOMA-IR among T2D subjects and for insulin and adiponectin in non-T2D subjects. A significant linear association was identified between PANDER with fasting HbA1c (β 0.832 ± SE 0.22, p = 0.0003) and FBG (β 20.66 ± SE 7.43, p = 0.006) within T2D subjects. However, insulin, HOMA-β, HOMA-IR and adiponectin (p > 0.05) were not found to be linearly associated with PANDER concentration. Conclusion Within T2D subjects, PANDER is modestly linearly associated with increased HbA1c and FBG in a US population. In addition, highest circulating PANDER levels were measured in T2D subjects with HbA1c above 9.9. No association was identified with PANDER and insulin resistance or pancreatic β-cell function in T2D subjects.

Objective To examine the association between pericardial adipose tissue (PAT) and the ratio of PAT to subcutaneous adipose tissue (SAT) with insulin resistance in adults with and without type 1 diabetes (T1D). Methods Data for this report came from a substudy of the Coronary Artery Calcification in Type 1 Diabetes cohort (n = 83; 38 with T1D, 45 without T1D). Insulin resistance was measured by hyperinsulinemic-euglycemic clamp. Abdominal computed tomography (CT) was used to measure visceral adipose tissue (VAT) and SAT. PAT was measured from CT scans of the heart. Results PAT and the ratio of PAT to SAT was higher in males compared to females. After adjustment for demographics, diabetes, blood pressure and lipid factors, BMI, VAT, and log PAT/SAT ratio, log PAT was positively associated with the glucose infusion rate (GIR) in females only (β = 3.36 ± 1.96, P = 0.097, P for sex interaction = 0.055). Conversely, the log PAT/SAT ratio was significantly associated with decreased GIR in both males and females (β = −2.08 ± 1.03, P = 0.047, P for sex interaction = 0.768). Conclusions A significant association between the PAT/SAT ratio and insulin resistance was found, independent of BMI, VAT, and PAT. These results highlight the importance of considering fat distribution independent of volume.

OBJECTIVE To assess associations between nonalcoholic fatty liver disease (NAFLD) and measures of brain health in a population-based sample of adults. METHODS Participants from the CARDIA study (Y25 exam; age 43-55 years) with concurrent computed tomography quantification of liver fat, visceral adipose tissue (VAT), and brain magnetic resonance (MR) images were included (n = 505). NAFLD was identified after exclusion of other causes of liver fat. Total tissue volume (TTV) and gray matter cerebral blood flow (GM-CBF) were estimated using 3T brain MR images. RESULTS NAFLD prevalence was 18%. NAFLD was associated with lower TTV and GM-CBF after adjusting for intracranial volume, demographics, and health behaviors (P

BACKGROUND The Veteran Administration (VA) Office of Patient-Centered Care and Cultural Transformation is invested in improving veteran health through a whole-person approach while taking advantage of the electronic resources suite available through the VA. Currently, there is no standardized process to collect and integrate electronic patient-reported outcomes (ePROs) of complementary and integrative health (CIH) into clinical care using a web-based survey platform. This quality improvement project enrolled veterans attending CIH appointments within a VA facility and used web-based technologies to collect ePROs. OBJECTIVE This study aimed to (1) determine a practical process for collecting ePROs using patient email services and a web-based survey platform and (2) conduct analyses of survey data using repeated measures to estimate the effects of CIH on patient outcomes. METHODS In total, 100 veterans from one VA facility, comprising 11 cohorts, agreed to participate. The VA patient email services (Secure Messaging) were used to manually send links to a 16-item web-based survey stored on a secure web-based survey storage platform (Qualtrics). Each survey included questions about patient outcomes from CIH programs. Each cohort was sent survey links via Secure Messaging (SM) at 6 time points: weeks 1 through 4, week 8, and week 12. Process evaluation interviews were conducted with five primary care providers to assess barriers and facilitators to using the patient-reported outcome survey in usual care. RESULTS This quality improvement project demonstrated the usability of SM and Qualtrics for ePRO collection. However, SM for ePROs was labor intensive for providers. Descriptive statistics on health competence (2-item Perceived Health Competence Scale), physical and mental health (Patient-Reported Outcomes Measurement Information System Global-10), and stress (4-item Perceived Stress Scale) indicated that scores did not significantly change over time. Survey response rates varied (18/100, 18.0%-42/100, 42.0%) across each of the 12 weekly survey periods. In total, 74 of 100 participants provided ≥1 survey, and 90% (66/74) were female. The majority, 62% (33/53) of participants, who reported the use of any CIH modality, reported the use of two or more unique modalities. Primary care providers highlighted specific challenges with SM and offered solutions regarding staff involvement in survey implementation. CONCLUSIONS This quality improvement project informs our understanding of the processes currently available for using SM and web-based data platforms to collect ePROs. The study results indicate that although it is possible to use SM and web-based survey platforms for ePROs, automating scheduled administration will be necessary to reduce provider burden. The lack of significant change in ePROs may be due to standard measures taking a biomedical approach to wellness. Future work should focus on identifying ideal ePRO processes that would include standardized, whole-person measures of wellness.

Adipose tissue (AT) volume and quality may contribute to cardiovascular risk. AT volume and attenuation can be derived from computed tomography (CT) scans, with greater attenuation indicating poor AT quality and increased fibrosis. We examined whether AT quantity and quality were associated with coronary artery calcium (CAC) in a sample of adults without diabetes (non-DM), with type 1 diabetes (T1D), and with type 2 diabetes (T2D). 294 non-DM adults (mean age±SD 55±9 years), 226 adults with T1D (mean age±SD 52±9 years), and 52 adults with T2D (mean age±SD 53±9 years) completed CT scans for CAC measurement and abdominal CT scans at lumbar 4-5 for visceral (VAT) and subcutaneous (SAT) AT volume and attenuation measurement. Adults with T2D had significantly more VAT and SAT when adjusting for age and sex compared with T1D and non-DM adults, but after adjusting for BMI there was no difference in VAT volume by diabetes status. Adults with T2D had significantly lower SAT volume when adjusted for BMI as compared with both non-DM and T1D adults (157 cm3 vs. 177 cm3 and 183 cm3, p=0.0008). Adults with T1D had significantly higher SAT attenuation as compared with non-DM and T2D adults (p AT attenuation was significantly higher in T1D and independently associated with subclinical atherosclerosis in a sample of non-DM, T1D, and T2D adults. AT fibrosis is associated with metabolic dysfunction, decreased angiogenesis, and increased inflammation; our results suggest that despite similar AT volume, T1D adults have adverse fat quality that may indicate fibrosis. This may be a mechanism through which T1D is associated with greater levels of CAC. Disclosure A. Keshawarz: None. A.C. Alman: None. C.C. Low Wang: Advisory Panel; Spouse/Partner; Bayer Healthcare, LLC, CSL Behring, Genentech/Roche, Hema Biologics, Novo Nordisk Pharmaceuticals, Inc, Octapharma Pharmazeutika, Shire. Speaker's Bureau; Self; Medical Education Resources. S. Mitchell: None. I.E. Schauer: Other Relationship; Spouse/Partner; Kestrel Labs. J.E.B. Reusch: Board Member; Self; American Diabetes Association. Other Relationship; Self; Merck & Co., Inc. J.G. Regensteiner: None. J.K. Snell-Bergeon: None. Funding American Diabetes Association (7-13-CD-10 to J.K.S-B.)

Background: Among the modifiable risk factors, diet plays an important role in the risks and progression of atherosclerotic cardiovascular disease (ASCVD). However, few studies have examined this association in people with type 1 diabetes (T1D) who are at a greater risk of developing ASCVD than nondiabetic (non-DM) controls. Methods: We conducted cross-sectional and longitudinal analyses of data from CACTI study [n=1257; T1D: n=568; non-DM: n=689] collected between March 2000 and April 2002. Participants completed a validated food frequency questionnaire, a physical examination and fasting biochemical analyses (12h fast), and coronary artery calcification (CAC) was measured using electron beam computed tomography. At baseline, dietary patterns based on variations in food group intake were created with principal components analysis (PCA). Logistic regression was used to examine associations of dietary patterns with the CAC prevalence in a model adjusted for age and sex and stratified by diabetes status. Results: Three dietary patterns were identified using PCA as follows: ‘fruits, veggies, meats, cereal’, ‘baked desserts’ and ‘convenience foods and alcohol’ patterns. At baseline, no significant associations of dietary patterns with CAC prevalence were observed. At year-6, ‘baked dessert’ pattern was significantly associated with increased risk of CAC ( Conclusions: Habitual intake of a dietary pattern that is characterized by an increased intake of added sugar and fats, such as in baked desserts may increase risks of atherosclerosis in T1D. Thus, dietary adjustments to improve this pattern may be atheroprotective. Disclosure A. Basu: None. A.C. Alman: None. J.K. Snell-Bergeon: None. Funding American Diabetes Association (7-13-CD-10 to J.K.S-B.)

Depression is increased in people with type 1 diabetes (T1D), and may lead to poor disease self-management and suboptimal glycemic control. Depressive symptoms were assessed in adults with and without longstanding T1D (mean±SD T1D duration 38±8.6 years). A total of 414 participants with T1D (mean±SD age 51±9 years) and 488 participants without T1D (mean±SD age 55±9 years) completed the Beck Depression Inventory II (BDI-II) and the Diabetes Self-Management Questionnaire (DSMQ). BDI-II scores were significantly higher in people with T1D (mean±SD 5.4±5.6%) than in those without T1D (3.8±4.7, p13), whereas 7.1% of women and 1.7% of men without T1D reported clinically elevated symptoms of depression (p=0.004). Among participants with T1D, a higher BDI-II score was significantly correlated to HbA1c (r=0.21, p=0.0005). In age, sex, and T1D duration adjusted linear regression models, BDI-II scores >13 were associated with significantly lower total scores on the DSMQ (p Our data demonstrate elevated levels of depressive symptoms in adults with T1D, particularly men, which were associated with lower self-management behaviors. Interventions are needed to address the role of depression on glycemic control and behaviors around glucose management, diet and physical activity in adults. Disclosure C.R. Geno Rasmussen: None. K.A. Driscoll: None. R.M. Sippl: None. A.C. Alman: None. A. Keshawarz: None. J.K. Snell-Bergeon: None. Funding American Diabetes Association (7-13-CD-10 to J.K.S-B.); National Heart, Lung, and Blood Institute; JDRF International

Transforming Health and Resiliency through Integration of Values-based Experiences (THRIVE) is an evidence-based 14-week curriculum-based group medical appointment clinical program. THRIVE is based on principles of integrative medicine, positive psychology, and acceptance and commitment therapy. The goal of this paper is to review findings from a local THRIVE program implementation piloted in the Women's Health outpatient clinics on mental and physical health indicators.Pilot data were obtained for 14 THRIVE cohorts of female veterans enrolled from outpatient clinics at the James A. Haley veterans' Hospital in Tampa, FL between 2016 and 2018 (N = 201). THRIVE assessments were conducted as part of the THRIVE program, at the first visit (baseline), mid-way, and at the end of the program. Data were collected using self-administered paper-pencil method on standardized scales for physical and mental health (Patient Health Questionnaire, Generalized Anxiety Disorder Questionnaire, Acceptance and Action Questionnaire-II, Satisfaction With Life Scale, and the physical and mental function components of the Short Form Survey). Linear mixed effects models were used to examine change in physical and mental health scales over time while adjusting for age, race (white vs. other), and cohort. In addition, we examined whether the rate of change differed by age or race.Improvement was seen for most scales across the 3 assessments (p 0.05) with the exception of physical composite score of the Short Form Survey (p = 0.487). Participants reported that pain interfering with work significantly decreased from "quite a bit" at baseline to "moderately" by assessment 3 (p = 0.042). Older ages had lower baseline scores on the Patient Health Questionnaire and Acceptance and Action Questionnaire than younger ages, but younger ages had a greater rate of improvement over the intervention (p for interaction 0.016 and 0.056, respectively). Whites reported greater improvement in life satisfaction than non-whites (p for interaction 0.043). For physical composite score, whites had higher baseline score, but did not report significant improvement in physical function over the assessment period, while non-whites had lower baseline score, but did report significant improvement in physical function (p for interaction 0.059). Non-white veterans reported more pain interfering with work relative to white veterans (OR 5.9, 95% CI 1.79-19.43, p = 0.004).We found significant improvement on self-reported mental health scales as well as improvement in how much pain interferes with work in a pilot sample of women veterans over the 14-week program.

Background and aims Pericardial adipose tissue (PAT) is located on both sides of the pericardium. We tested whether PAT was associated with prevalent diabetes at the year 25 exam of the Coronary Artery Risk Development in Young Adults (CARDIA) study. Methods and results The CARDIA Year 25 exam (2010–2011) included complete data for all covariates on 3107 participants. Prevalent diabetes ( n = 436) was defined as high fasting (≥126 mg/dl) or 2-h postload glucose (≥200 mg/dl) or HbA 1c (≥6.5%) or use of diabetes medications. Volume of PAT was measured from computed tomographic scans. Logistic regression was performed to examine the relationship between quartiles of PAT and diabetes. In regression models adjusted for field center, sex, race, age, systolic blood pressure, total cholesterol, log triglycerides, and treatment with blood pressure and cholesterol lowering medication, PAT volume in the 4th quartile was significantly associated with diabetes status after adjustment for BMI (OR 2.57, 95% CI 1.66, 3.98) or visceral adipose tissue (OR 2.08, 95% CI 1.32, 3.29). PAT volume in the 2nd and 3rd quartiles was not significantly associated with diabetes status relative to the first quartile. Conclusions Metabolically active pericardial adipose tissue is associated with prevalent diabetes only at higher volumes independent of overall obesity.

Background: Intake of sufficient dietary fiber has been recommended for glucose control, and typically low fiber intake is observed in the general population. The role of fiber in glycemic control in reported literature is inconsistent and few reports are available in populations with type 1 diabetes (T1D). Methods: We conducted a cross-sectional analysis of data from the CACTI study [n=1257; T1D: n=568; nondiabetic controls: n=689] collected between March 2000 and April 2002. Participants completed a validated food frequency questionnaire, a physical examination and fasting biochemical analyses (12h fast) at screening visit. We used linear regression models to examine associations of total dietary fiber with HbA1c as a continuous variable. Models were stratified by diabetes status, and adjusted for age, sex and total calories, and diabetes duration in the T1D group. We also examined correlations of fiber with HbA1c. Results: Baseline dietary fiber intake and HbA1c in the T1D group were 16g [median (IQ): 11-22g) and 7.9±1.3% mean (SD), respectively, and in the nondiabetic controls were 15g [median (IQ): 11-21g) and 5.4±0.4%, respectively. Pearson partial correlation coefficients revealed a significant but weak inverse association of total dietary fiber with HbA1c when adjusted for age, sex, diabetes status and total calories (r= -0.07, p=0.01). In adjusted linear regression models, total dietary fiber was significantly and inversely associated with HbA1c in the T1D group [estimate (beta±SE)= -0.32±0.15, p=0.034], as well as in the nondiabetic controls [-0.10±0.04, p=0.009]. Thus, at observed levels of intake, total dietary fiber reveals a protective association against poor glycemic control in T1D adults and in nondiabetic controls. Disclosure A. Basu: None. A.C. Alman: None. J.K. Snell-Bergeon: Stock/Shareholder; Self; Abbott. Research Support; Self; Roche Diagnostics Corporation.

Type 1 diabetes (T1D) and menopause are associated with higher risk of coronary artery calcium (CAC). Accumulation of pericardial adipose tissue (PAT), a pro-inflammatory visceral fat higher in post-menopausal women and associated with increased CAC, may be a mechanism by which T1D is associated with higher CAC risk. We examined the effect of PAT on the relationship between T1D and CAC in women over time. PAT and CAC volume data were collected from CT heart scans over 4 study visits from 725 women enrolled in the Coronary Artery Calcification in Type 1 Diabetes (CACTI) study (mean baseline age ± SD, 37 ± 9 years). We used repeated measures modeling to examine changes in square root-transformed CAC volume over time by T1D, menopausal status, and quartile of PAT volume after adjusting for age, central obesity, and study visit. PAT levels did not differ by T1D status (33.5 vs. 33.7, p=0.8), but there was a significant interaction between PAT, menopause, and T1D (p=0.02) in relation to CAC volume (Figure 1). In T1D women, higher PAT was associated with higher CAC volume regardless of menopause status, but the effect was greater in post-menopausal women. There was no difference in CAC in nondiabetic (non-DM) women across PAT quartiles or by menopause status. CAC was higher in T1D than non-DM women regardless of menopause status and PAT quartile. PAT has a greater effect on CAC in women with T1D than non-DM women, despite similar PAT volumes. Disclosure A. Keshawarz: None. L. Pyle: None. A.C. Alman: None. C. Sassano: None. E. Westfeldt: None. R.M. Sippl: None. J.K. Snell-Bergeon: Stock/Shareholder; Self; Abbott. Research Support; Self; Roche Diagnostics Corporation.

Approximately 45% of first of myocardial infarctions (MI) are silent. People with diabetes are more likely to have MIs than those without diabetes. Little is known, however, about silent MIs (SMIs) among those with prediabetes. The prognosis of SMIs is similar to clinical MIs making timely detection imperative. We aimed to assess the association between prediabetes and incident SMI in four long duration cohort studies. We pooled data from the following studies: Cardiovascular Health, Atherosclerotic Risk in Communities, Health Aging and Body Composition, and Multi-Ethnic Study of Atherosclerosis (n=30,898). Population characteristics were: mean age 61.3 years, 45% male, 66.4% white, 40.0% had hypertension and 35.3% had hyperlipidemia. Diabetes status was based on fasting glucose (100-125mg/dL=prediabetes and >=126mg/dL=diabetes). Participants were also defined as having diabetes if they were taking medications for diabetes or reported a previous diagnosis. At baseline, 36% did not have diabetes, 50% had prediabetes and 14% had diabetes. Among participants with prediabetes, 3% experienced SMI over a mean follow-up of 9.6 years compared with 2% among those without diabetes. In Cox Proportional Hazards Models, we found an increased risk of incident SMI among those with prediabetes compared to those without diabetes (Hazard Ratio=1.25; 95% CI: 1.04-1.5, p=0.02), adjusting for age, sex, race, smoking status, hypertension, and high cholesterol. Significant baseline predictors of SMI in addition to having prediabetes included being male, older age, current smoking, and hypertension. People with prediabetes, comprising 50% of these cohort study populations, may be at increased risk for SMI, and could benefit from increased focus on prevention and treatment of cardiovascular risk factors. Disclosure J.C. Zgibor: None. M. Malmi: None. W. Wang: None. K.E. Kip: None. D.D. Schocken: None. A.C. Alman: None. R.B. Stacey: None.

People with type 1 diabetes mellitus manifest a greater burden of both periodontal disease and coronary artery disease (CAD); however, little is known about their interrelation. Coronary artery calcium (CAC) measures subclinical atherosclerosis and predicts major adverse coronary events. The relation between periodontal disease and CAC progression in individuals with type 1 diabetes has not been previously described. We determined the prevalence and progression of CAC in relation to self-reported periodontal disease. Multivariate logistic and tobit regression models were used to examine the relation between periodontal disease duration and CAC progression and whether this relation differs by diabetes status after controlling for age, gender, total and high-density lipoprotein cholesterol, hypertension, smoking, body mass index (BMI), duration of diabetes, and baseline CAC. A total of 473 patients with type 1 diabetes and 548 without diabetes were followed for a mean of 6.1 years. At baseline, the prevalence and duration of periodontal disease did not differ between subjects with and without diabetes (14.5% vs 13.4%, p = 0.60; 6 vs 9 years, p = 0.18). Duration of periodontal disease was not significantly associated with baseline CAC prevalence. In patients with type 1 diabetes, periodontal disease duration was significantly related to CAC progression (p = 0.004) but not in subjects without diabetes (p = 0.63). In conclusion, this study suggests that periodontal disease is an independent predictor of long-term progression of CAC in patients with type 1 diabetes.

Objective In their Strategic Impact Goal Statement, the American Heart Association focused on primordial prevention of cardiovascular risk factors by defining metrics for ideal cardiovascular health (ICH). The prevalence of ICH among youth with type 1 diabetes is unknown. Youth with type 1 diabetes face an increased risk of cardiovascular disease (CVD) as they age. The purpose of this report was to examine the prevalence of ICH in a population of youth with type 1 diabetes and to examine the association of ICH with measures of cardiovascular structure and function. Research design and methods This report is based on SEARCH CVD an ancillary study to the SEARCH for Diabetes in Youth. A total of 190 adolescents with type 1 diabetes had complete data on all of the ICH metrics at baseline and had measures of arterial stiffness [pulse wave velocity (PWV), brachial distensibility (BrachD), and augmentation index (AIx)] and carotid intima-media thickness completed at a follow-up visit [on average 5 yr after baseline (interquartile range 4–5)]. Results No subjects met the ICH criteria for all 7 metrics. Meeting an increasing number of ICH metrics was significantly associated with lower arterial stiffness [lower PWV of the trunk (β = −0.02 ±0.01; p = 0.004) and AIx (β = −2.2 ±0.66; p = 0.001), and increased BrachD (β = 0.14 ±0.07; p = 0.04)]. Conclusions Increasing number of ICH metrics was significantly associated with decreased arterial stiffness, but prevalence of ICH in this population was low. Youth with type 1 diabetes could benefit from improvements in their cardiovascular health.

OBJECTIVE In 2010, the American Heart Association defined seven metrics (smoking, BMI, physical activity, diet, total cholesterol, blood pressure, and fasting plasma glucose) for ideal cardiovascular health (ICH). Subsequent studies have shown that the prevalence of achieving these metrics is very low in the general population. Adults with type 1 diabetes are at increased risk of cardiovascular disease (CVD), but no studies to date have been published on the prevalence of ICH in this population. RESEARCH DESIGN AND METHODS Data for this analysis were collected as part of the prospective Coronary Artery Calcification in Type 1 Diabetes study. This analysis involved 546 subjects with type 1 diabetes and 631 subjects without diabetes who had complete information for calculating the ICH metrics. RESULTS Overall, the prevalence of ICH was low in this population, with none meeting the ideal criteria for all seven metrics. The prevalence of ideal physical activity (10.0%) and diet (1.1%) were particularly low. ICH was significantly associated with both decreased prevalence (odds ratio [OR] 0.70; 95% CI 0.62–0.80) and progression (OR 0.77; 95% CI 0.66–0.90) of coronary artery calcification (CAC). CONCLUSIONS ICH is significantly associated with decreased prevalence and progression of CAC; however, prevalence of ICH metrics was low in adults both with and without type 1 diabetes. Efforts to increase the prevalence of ICH could have a significant impact on reducing the burden of CVD.

Density of adipose tissue can be measured by CT attenuation in Hounsfield Units (HU). Increased visceral fat density has been associated with coronary artery calcification (CAC). However, the relationship between pericardial fat density and CAC is unknown. We examined the association of pericardial fat density (PAT HU) with the presence (CAC > 0) and progression of CAC in the Coronary Artery Calcification in Type 1 Diabetes study (CACTI). CACTI is a prospective cohort study of adults with and without type 1 diabetes (T1D) with a mean age of 38 years (±9) at baseline. Participants were free of CVD at the time of enrollment in the study. PAT volume was measured from baseline EBCT scans within a range of HU from -190 to -30. CAC was measured at baseline and at the follow-up exam with a mean follow-up of 6 years (±0.5). Logistic regression was used to examine the association between PAT HU and CAC. Prevalence of CAC was defined as any CAC (>0) at baseline. Progression of CAC was defined as a change in volume of ≥2.5 square-root transformed units between the baseline and followup exams. PAT volume and triglycerides were log transformed. Interaction terms for diabetes and PAT HU were tested in the models. PAT data were available on 1319 subjects for the prevalence model, and 952 for the progression model. PAT HU was significantly higher (less-negative) in those with T1D compared to those without (-75.7 ±3.7 vs -77.8 ±4.2; p

A number of epidemiologic studies were published that looked at the association between coronary heart disease (CHD) and periodontal disease. However, debate exists about whether this association is a true relationship or simply an example of an uncontrolled confounder. This retrospective cohort study examines the relationship between periodontal disease and CHD.Digital panoramic radiographs were used to assess alveolar bone loss (ABL) using a Schei ruler. Participants consisted of Veterans Administration (VA) patients who were eligible for dental benefits and had a digital panoramic radiograph taken at the VA Medical Center, Denver, Colorado. Information on CHD and other important clinical variables were obtained from electronic medical records.The examination of the relationship between ABL and CHD revealed a significant non-linear relationship with a threshold at ≈ 20% bone loss with a doubling of the probability ratios of CHD compared to those at 7.5% bone loss.To our knowledge, this is the first study to demonstrate a non-linear relationship between ABL and CHD. A significant positive association between ABL and CHD was found at even low levels of bone loss between 10% and 20%.

Pericardial adipose tissue (PAT) is ectopic fat deep (epicardial adipose tissue) and superficial (paracardial adipose tissue) to the pericardium of the heart. PAT has been cross-sectionally associated with diabetes, but the association with development of diabetes is unclear. Using data from the Multi-Ethnic Study of Atherosclerosis (MESA), we tested whether PAT at baseline was associated with incident diabetes over nearly 10 years of follow-up. The baseline visit (visit 1) was conducted between 2000-2002. Four follow-up visits were conducted at 2 year intervals with visit 5 between 2010 and 2012. Diabetes was defined as a fasting glucose ≥126 mg/dl or the use of antidiabetic medication. Diabetes-free participants at baseline were followed for incident diabetes at any subsequent visit (visits 2-5). Volume of PAT was measured from computed tomographic (CT) scans taken at visits 1 - 4. CT scans were completed on all participants at baseline. Repeat scans were performed on random halves at visits 2 and 3, and a subset at visit 4. Multivariable Cox proportional hazards models were used to assess the association between PAT and incident diabetes. The figure presents the mean PAT by visit and the mean PAT at baseline among those without diabetes at any time during the study period and those that develop diabetes over the 10 years of follow-up. In Cox regression models adjusted for age, race, and sex, each SD increment of baseline PAT (42.0 mL) was associated with a hazard ratio (HR) for incident diabetes of 1.6 (95% CI 1.5-1.7, p We found that PAT was highly stable over time, accumulating very slowly. Its baseline value strongly predicts incident diabetes independent of overall body mass and central fatness.