BACKGROUND: Health disparities exist across socioeconomic status levels, yet empirical evidence between financial well-being (FWB) and health are limited. METHODS: This cross-sectional study combined data from 25 370 adults aged ≥18 years in the 2019 National Health Interview Survey with estimated household FWB scores from the Consumer Financial Protection Bureau's 2016 National Financial Well-being Survey. FWB associations with health service visits, biometric screenings, smoking status, body mass index and physical and mental conditions were tested using age-adjusted, sex-adjusted and health insurance coverage-adjusted linear regression analysis. RESULTS: In 2019, the mean FWB for US adults was 56.1 (range 14 (worse) to 95 (best)). With increasing time since the last health service visit or screening, FWB was increasingly lower compared with adults with visits or screenings <1 year (≥10 years or 'never', FWB ranged from -1 (blood sugar check) to -6.5 (dental examination/cleaning) points). FWB was lower with declining general health status (excellent (reference), very good (-0.5 points), good (-3.4 points) and fair/poor (-6.6 points)). Adults with physical health conditions had FWB lower than adults without (range -0.4 (high cholesterol) to -4.6 (disability) points). FWB were lower in adults who have ever been diagnosed with anxiety disorder (-1.8 points) or depression (-2 points). Adults managing their anxiety or depression (no/minimal symptoms currently) had greater FWB (anxiety: 3 points and depression: 4.1 points) than those with symptoms. CONCLUSION: Given the observed associations between FWB and health-related measures, it is crucial to consider FWB in primary and secondary health prevention efforts, recognising the relationship between economics, health and wellness.

National prevalence of diabetes distress is unknown among US adults. This cross-sectional study examined the prevalence among US adults with diabetes using 2021 National Health Interview Survey data. Multivariable multinomial logistic regressions were used to estimate adjusted prevalence and prevalence ratios for diabetes distress. Adjusted prevalence of moderate and severe diabetes distress was 24.3% (95% CI, 22.5%-26.1%) and 6.6% (95% CI, 5.6%-7.8%), respectively. Prevalence was higher among people aged 18 to 64 years, women, and those with lower incomes. Findings highlight the importance of examining economic and social factors and integrating diabetes distress screening into diabetes management and services.

INTRODUCTION: Metabolic and bariatric surgery (MBS) is an effective intervention to manage diabetes and obesity. The population-based incidence of MBS is unknown. OBJECTIVE: To estimate the incidence of MBS among US adults with obesity by diabetes status and selected sociodemographic characteristics. RESEARCH DESIGN AND METHODS: This cross-sectional study used data from the 2016-2020 Nationwide Inpatient Sample and Nationwide Ambulatory Surgery Sample to capture MBS procedures. The National Health Interview Survey was used to establish the denominator for incidence calculations. Participants included US non-pregnant adults aged ≥18 years with obesity. The main outcome was incident MBS without previous MBS, defined by International Classification of Diseases, Tenth Revision Procedure Codes, Diagnosis Related Group system codes, and Current Procedural Terminology codes. Adjusted incidence and annual percentage change (2016-2019) were estimated using logistic regression. RESULTS: Among US adults with obesity, over 900 000 MBS procedures were performed in inpatient and hospital-owned ambulatory surgical centers in the USA during 2016-2020. The age- and sex-adjusted incidence of MBS per 1000 adults was 5.9 (95% CI 5.4 to 6.4) for adults with diabetes and 2.0 (95% CI 1.9 to 2.1) for adults without diabetes. MBS incidence was significantly higher for women and adults with class III obesity regardless of diabetes status. The highest incidence of MBS occurred in the Northeast region. Sleeve gastrectomy was the most common MBS surgical approach. CONCLUSIONS: Incident MBS procedures were nearly threefold higher among adults with obesity and diabetes than those with obesity but without diabetes. Continued monitoring of the trends of MBS and other treatment modalities can inform our understanding of treatment accessibility to guide prevention efforts aimed at reducing obesity and diabetes.

We analyzed 2021 and 2022 National Health Interview Survey data to describe the prevalence of past 12-month telemedicine use among US adults with no prediabetes or diabetes diagnosis, diagnosed prediabetes, and diagnosed diabetes. In 2021 and 2022, telemedicine use prevalence was 34.1% and 28.2% among adults without diagnosed diabetes or prediabetes, 47.6% and 37.6% among adults with prediabetes, and 52.8% and 39.4% among adults with diabetes, respectively. Differences in telemedicine use were identified by region, urbanicity, insurance status, and education among adults with prediabetes or diabetes. Findings suggest that telemedicine use can be improved among select populations with prediabetes or diabetes.

INTRODUCTION: Previous research suggests that rural-urban disparities in diabetes mortality, hospitalization, and incidence rates may manifest differently across US regions. However, no studies have examined disparities in diabetes prevalence by metropolitan residence and region. METHODS: We used data from the 2019-2022 National Health Interview Survey to compare diabetes status, socioeconomic characteristics, and weight status among adults in each census region (Northeast, Midwest, South, West) according to county metropolitan status of residence (large central metro, large fringe metro, small/medium metro, and nonmetro). We used χ(2) tests and logistic regression models to assess the association of metropolitan residence with diabetes prevalence in each region. RESULTS: Diabetes prevalence ranged from 7.0% in large fringe metro counties in the Northeast to 14.8% in nonmetro counties in the South. Compared with adults from large central metro counties, those from small/medium metro counties had significantly higher odds of diabetes in the Midwest (age-, sex-, and race and ethnicity-adjusted odds ratio [OR] = 1.24; 95% CI, 1.06-1.45) and South (OR = 1.15; 95% CI, 1.02-1.30). Nonmetro residence was also associated with diabetes in the South (OR = 1.62 vs large central metro; 95% CI, 1.43-1.84). After further adjustment for socioeconomic and body weight status, small/medium metro associations with diabetes became nonsignificant, but nonmetro residence in the South remained significantly associated with diabetes (OR = 1.22; 95% CI, 1.07-1.39). CONCLUSION: The association of metropolitan residence with diabetes prevalence differs across US regions. These findings can help to guide efforts in areas where diabetes prevention and care resources may be better directed.

Social determinants of health (SDOH) are the conditions in which people are born, grow, live, work, and age that influence health outcomes, and structural and systemic drivers of health (SSD) are the social, cultural, political, and economic contexts that create and shape SDOH. With the integration of constructs from previous examples, we propose an SSD model that broadens the contextual effect of these driving forces or factors rooted in the Centers for Disease Control and Prevention's SDOH framework. Our SSD model (1) presents systems and structures as multidimensional, (2) considers 10 dimensions as discrete and intersectional, and (3) acknowledges health-related effects over time at different life stages and across generations. We also present an application of this SSD model to the housing domain and describe how SSD affect SDOH through multiple mechanisms that may lead to unequal resources, opportunities, and consequences contributing to a disproportionate burden of disease, illness, and death in the US population. Our enhanced SDOH framework offers an innovative and promising model for multidimensional, collaborative public health approaches toward achieving health equity and eliminating health disparities.

The objective of this study was to examine the state-level association between household energy insecurity and diabetes prevalence in 2020. We obtained 1) state-level data on household energy characteristics from the 2020 Residential Energy Consumption Survey and 2) diagnosed diabetes prevalence from the US Diabetes Surveillance System. We found states with a higher percentage of household energy insecurity had greater diabetes prevalence compared with states with lower percentages of energy insecurity. Interventions related to energy assistance may help reduce household energy insecurity, mitigate the risk of diabetes-related complications, and alleviate some of the burden of diabetes management during extreme temperatures.

BACKGROUND: The purpose of this study was to examine the association between racial and economic segregation and diabetes mortality among US counties from 2016 to 2020. METHODS: We conducted a cross-sectional ecological study that combined county-level diabetes mortality data from the National Vital Statistics System and sociodemographic information drawn from the 2016-2020 American Community Survey (n=2380 counties in the USA). Racialized economic segregation was measured using the Index Concentration at the Extremes (ICE) for income (ICE(income)), race (ICE(race)) and combined income and race (ICE(combined)). ICE measures were categorised into quintiles, Q1 representing the highest concentration and Q5 the lowest concentration of low-income, non-Hispanic (NH) black and low-income NH black households, respectively. Diabetes was ascertained as the underlying cause of death. County-level covariates included the percentage of people aged ≥65 years, metropolitan designation and population size. Multilevel Poisson regression was used to estimate the adjusted mean mortality rate and adjusted risk ratios (aRR) comparing Q1 and Q5. RESULTS: Adjusted mean diabetes mortality rate was consistently greater in counties with higher concentrations of low-income (ICE(income)) and low-income NH black households (ICE(combined)). Compared with counties with the lowest concentration (Q1), counties with the highest concentration (Q5) of low-income (aRR 1.93; 95% CI 1.79 to 2.09 for ICE(income)), NH black (aRR 1.93; 95% CI 1.79 to 2.09 for ICE(race)) and low-income NH black households (aRR 1.32; 95% CI 1.18 to 1.47 for ICE(combined)) had greater diabetes mortality. CONCLUSION: Racial and economic segregation is associated with diabetes mortality across US counties.

OBJECTIVE: We examined national trends in diabetes-related complications (heart failure [HF], myocardial infarction [MI], stroke, end-stage renal disease [ESRD], nontraumatic lower-extremity amputation [NLEA], and hyperglycemic crisis) among U.S. adults with diagnosed diabetes during 2000-2020 by age-group, race and ethnicity, and sex. We also assessed trends in inequalities among those subgroups. RESEARCH DESIGN AND METHODS: Hospitalization rates for diabetes-related complications among adults (≥18 years) were estimated using the 2000-2020 National (Nationwide) Inpatient Sample. The incidence of diabetes-related ESRD was estimated using the United States Renal Data System. The number of U.S. adults with diagnosed diabetes was estimated from the National Health Interview Survey. Annual percent change (APC) was estimated for assessment of trends. RESULTS: After declines in the early 2000s, hospitalization rates increased for HF (2012-2020 APC 3.9%, P < 0.001), stroke (2009-2020 APC 2.8%, P < 0.001), and NLEA (2009-2020 APC 5.9%, P < 0.001), while ESRD incidence increased (2010-2020 APC 1.0%, P = 0.044). Hyperglycemic crisis increased from 2000 to 2020 (APC 2.2%, P < 0.001). MI hospitalizations declined during 2000-2008 (APC -6.0%, P < 0.001) and were flat thereafter. On average, age inequalities declined for hospitalizations for HF, MI, stroke, and ESRD incidence but increased for hyperglycemic crisis. Sex inequalities increased on average for hospitalizations for stroke and NLEA and for ESRD incidence. Racial and ethnic inequalities declined during 2012-2020 for ESRD incidence but increased for HF, stroke, and hyperglycemic crisis. CONCLUSIONS: There was a continued increase of several complications in the past decade. Age, sex, and racial and ethnic inequalities have worsened for some complications.

INTRODUCTION: We investigated 2018 gestational diabetes mellitus (GDM) prevalence estimates in three surveillance systems (National Vital Statistics System, State Inpatient Database, and Pregnancy Risk Assessment Monitoring Survey). METHODS: We calculated GDM prevalence for jurisdictions represented in each system; a subset of data was analyzed for people 18-39 years old in 22 jurisdictions present in all three systems to observe dataset-specific demographics and GDM prevalence using comparable categories. RESULTS: GDM prevalence estimates varied widely by data system and within the data subset despite comparable demographics. DISCUSSION: Understanding the differences between GDM surveillance data systems can help researchers better identify people and places at higher risk of GDM.

BACKGROUND: Household food insecurity has been linked to adverse health outcomes, but pathways driving these associations are not well understood. The stress experienced by those in food insecure households and having to prioritize between food and other essential needs could lead to physiological dysregulations (i.e., allostatic load [AL]) and, as a result, adversely impact their health. OBJECTIVE: To assess the association between household food security status and AL and differences by gender, race and ethnicity, and Supplemental Nutrition Assistance Program (SNAP) participation. METHODS: We used data from 7640 US adults in the 2015-2016 and 2017-March 2020 National Health and Nutrition Examination Survey to estimate means and prevalence ratios (PR) for AL scores (based on cardiovascular, metabolic, and immune biomarkers) associated with self-reported household food security status from multivariable linear and logistic regression models. RESULTS: Adults in marginally food secure (mean = 3.09, SE = 0.10) and food insecure households (mean = 3.05, SE = 0.08) had higher mean AL than those in food secure households (mean = 2.70, SE = 0.05). Compared to adults in food secure households in the same category, those more likely to have an elevated AL included: SNAP participants (PR = 1.12; 95% confidence interval, CI = 1.03, 1.22) and Hispanic women (PR = 1.20; 95% CI = 1.05, 1.37) in marginally food secure households; and non-Hispanic Black women (PR = 1.14; 95% CI = 1.03, 1.26), men (PR = 1.13; 95% CI = 1.02, 1.26), and non-SNAP non-Hispanic White adults (PR = 1.22; 95% CI = 1.08, 1.39) in food insecure households. CONCLUSIONS: AL may be one pathway by which household food insecurity affects health and may vary by gender, race and ethnicity, and SNAP participation.

INTRODUCTION: Racial and ethnic minority groups and individuals with limited educational attainment experience a disproportionate burden of diabetes. Prediabetes represents a high-risk state for developing type 2 diabetes, but most adults with prediabetes are unaware of having the condition. Uncovering whether racial, ethnic, or educational disparities also occur in the prediabetes stage could help inform strategies to support health equity in preventing type 2 diabetes and its complications. We examined the prevalence of prediabetes and prediabetes awareness, with corresponding prevalence ratios according to race, ethnicity, and educational attainment. METHODS: This study was a pooled cross-sectional analysis of the National Health and Nutrition Examination Survey data from 2011 to March 2020. The final sample comprised 10,262 U.S. adults who self-reported being Asian, Black, Hispanic, or White. Prediabetes was defined using hemoglobin A1c and fasting plasma glucose values. Those with prediabetes were classified as "aware" or "unaware" based on survey responses. We calculated prevalence ratios (PR) to assess the relationship between race, ethnicity, and educational attainment with prediabetes and prediabetes awareness, controlling for sociodemographic, health and healthcare-related, and clinical characteristics. RESULTS: In fully adjusted logistic regression models, Asian, Black, and Hispanic adults had a statistically significant higher risk of prediabetes than White adults (PR:1.26 [1.18,1.35], PR:1.17 [1.08,1.25], and PR:1.10 [1.02,1.19], respectively). Adults completing less than high school and high school had a significantly higher risk of prediabetes compared to those with a college degree (PR:1.14 [1.02,1.26] and PR:1.12 [1.01,1.23], respectively). We also found that Black and Hispanic adults had higher rates of prediabetes awareness in the fully adjusted model than White adults (PR:1.27 [1.07,1.50] and PR:1.33 [1.02,1.72], respectively). The rates of prediabetes awareness were consistently lower among those with less than a high school education relative to individuals who completed college (fully-adjusted model PR:0.66 [0.47,0.92]). DISCUSSION: Disparities in prediabetes among racial and ethnic minority groups and adults with low educational attainment suggest challenges and opportunities for promoting health equity in high-risk groups and expanding awareness of prediabetes in the United States.

The epidemic of diabetes continues to exert great burden and cost on affected people, their families, and society. Current estimates of the burden of prediabetes and diabetes in youth and adults for the U.S. are made available through the Centers for Disease Control and Prevention (CDC) (https://www.cdc.gov/diabetes/data/statistics-report/index.html and https://gis.cdc.gov/grasp/diabetes/DiabetesAtlas.html) and for regions of the world by the International Diabetes Federation (https://diabetesatlas.org/2022-reports/). These data are typically updated every year or two. | | CDC’s estimates for the prevalence of both diagnosed and undiagnosed diabetes, prevalence of prediabetes among adults, incidence of newly diagnosed diabetes, risk factors for diabetes-related complications, and burden of coexisting conditions and complications provide valuable information, but many questions are not addressed in these national data. Therefore, commencing with this month’s issue, Diabetes Care and CDC begin a partnership to enhance knowledge among the journal’s readership by highlighting important aspects of the national burden of diabetes that expand upon the data and information provided on the CDC’s website. Through this collaboration, we will at least twice a year publish in Diabetes Care in-depth explorations of timely and clinically significant topics authored by members of CDC. As with all original manuscripts submitted to Diabetes Care, they will undergo peer review to ensure they are scientifically rigorous and informative.

OBJECTIVE: Race and ethnicity data disaggregated into detailed subgroups may reveal pronounced heterogeneity in diabetes risk factors. We therefore used disaggregated data to examine the prevalence of type 2 diabetes risk factors related to lifestyle behaviors and barriers to preventive care among adults in the U.S. RESEARCH DESIGN AND METHODS: We conducted a pooled cross-sectional study of 3,437,640 adults aged ≥18 years in the U.S. without diagnosed diabetes from the Behavioral Risk Factor Surveillance System (2013-2021). For self-reported race and ethnicity, the following categories were included: Hispanic (Cuban, Mexican, Puerto Rican, Other Hispanic), non-Hispanic (NH) American Indian/Alaska Native, NH Asian (Chinese, Filipino, Indian, Japanese, Korean, Vietnamese, Other Asian), NH Black, NH Pacific Islander (Guamanian/Chamorro, Native Hawaiian, Samoan, Other Pacific Islander), NH White, NH Multiracial, NH Other. Risk factors included current smoking, hypertension, overweight or obesity, physical inactivity, being uninsured, not having a primary care doctor, health care cost concerns, and no physical exam in the past 12 months. RESULTS: Prevalence of hypertension, lifestyle factors, and barriers to preventive care showed substantial heterogeneity among both aggregated, self-identified racial and ethnic groups and disaggregated subgroups. For example, the prevalence of overweight or obesity ranged from 50.8% (95% CI 49.1-52.5) among Chinese adults to 79.8% (73.5-84.9) among Samoan adults. Prevalence of being uninsured among Hispanic subgroups ranged from 11.4% (10.9-11.9) among Puerto Rican adults to 33.0% (32.5-33.5) among Mexican adults. CONCLUSIONS: These findings underscore the importance of using disaggregated race and ethnicity data to accurately characterize disparities in type 2 diabetes risk factors and access to care.

OBJECTIVE: Preventive care services are important to prevent or delay complications associated with diabetes. We report trends in receipt of six American Diabetes Association-recommended preventive care services during 2008-2020. RESEARCH DESIGN AND METHODS: We used 2008-2020 data from the cross-sectional Medical Expenditures Panel Survey to calculate the proportion of U.S. adults ≥18 years of age with diagnosed diabetes who reported receiving preventive care services, overall and by subpopulation (n = 25,616). We used joinpoint regression to identify trends during 2008-2019. The six services completed in the past year included at least one dental examination, dilated-eye examination, foot examination, and cholesterol test; at least two A1C tests, and an influenza vaccine. RESULTS: From 2008 to 2020, proportions of U.S. adults with diabetes receiving any individual preventive care service ranged from 32.6% to 89.9%. From 2008 to 2019, overall trends in preventive services among these adults were flat except for an increase in influenza vaccination (average annual percent change: 2.6% [95% CI 1.1%, 4.2%]). Trend analysis of subgroups was heterogeneous: influenza vaccination and A1C testing showed improvements among several subgroups, whereas cholesterol testing (patients aged 45-64 years; less than a high school education; Medicaid insurance) and dental visits (uninsured) declined. In 2020, 8.2% (95% CI 4.5%, 11.9%) of those with diabetes received none of the recommended preventive care services. CONCLUSIONS: Other than influenza vaccination, we observed no improvement in preventive care service use among U.S. adults with diabetes. These data highlight services and specific subgroups that could be targeted to improve preventive care among adults with diabetes.

We examined the prevalence of diagnosed depression, anxiety, and ADHD among youth by diabetes type, insurance type, and race/ethnicity. These mental disorders were more prevalent among youth with diabetes, particularly those with type 2 diabetes, with non-Hispanic White youth with Medicaid and diabetes having a higher prevalence than other races/ethnicities.

INTRODUCTION: In 2019 among US adults, 1 in 9 had diagnosed diabetes and 1 in 5 had diagnosed depression. Since these conditions frequently coexist, compounding their health and economic burden, we examined state-specific trends in depression prevalence among US adults with and without diagnosed diabetes. METHODS: We used data from the 2011 through 2019 Behavioral Risk Factor Surveillance System to evaluate self-reported diabetes and depression prevalence. Joinpoint regression estimated state-level trends in depression prevalence by diabetes status. RESULTS: In 2019, the overall prevalence of depression in US adults with and without diabetes was 29.2% (95% CI, 27.8%-30.6%) and 17.9% (95% CI, 17.6%-18.1%), respectively. From 2011 to 2019, the depression prevalence was relatively stable for adults with diabetes (28.6% versus 29.2%) but increased for those without diabetes from 15.5% to 17.9% (average annual percent change [APC] over the 9-year period = 1.6%, P = .015). The prevalence of depression was consistently more than 10 percentage points higher among adults with diabetes than those without diabetes. The APC showed a significant increase in some states (Illinois: 5.9%, Kansas: 3.5%) and a significant decrease in others (Arizona: -5.1%, Florida: -4.0%, Colorado: -3.4%, Washington: -0.9%). In 2019, although it varied by state, the depression prevalence among adults with diabetes was highest in states with a higher diabetes burden such as Kentucky (47.9%), West Virginia (47.0%), and Maine (41.5%). CONCLUSION: US adults with diabetes are more likely to report prevalent depression compared with adults without diabetes. These findings highlight the importance of screening and monitoring for depression as a potential complication among adults with diabetes.

INTRODUCTION: This study examined national trends in age, sex, racial and ethnic, and socioeconomic inequalities for diagnosed diabetes prevalence and incidence among US adults from 2008-2021. METHODS: Adults (≥18 years) were from the National Health Interview Survey (2008-2021). The annual between-group variance (BGV) for sex, race, and ethnicity, and the slope index of inequality (SII) for age, education, and poverty-to-income ratio (PIR) along with the average annual percent change (AAPC) were estimated in 2023 to assess trends in inequalities over time in diabetes prevalence and incidence. For BGV and SII, a value of 0 represents no inequality while a value further from 0 represents greater inequality. RESULTS: On average over time, PIR inequalities in diabetes prevalence worsened (SII: -8.24 in 2008 and -9.80 in 2021; AAPC for SII: -1.90%, p=0.003) while inequalities in incidence for age (SII: 17.60 in 2008 and 8.85 in 2021; AAPC for SII: -6.47%, p<0.001), sex (BGV: 0.09 in 2008, 2.05 in 2009, 1.24 in 2010, and 0.27 in 2021; AAPC for BGV: -12.34%, p=0.002), racial and ethnic (BGV: 4.80 in 2008 and 2.17 in 2021; AAPC for BGV: -10.59%, p=0.010), and education (SII: -9.89 in 2008 and -2.20 in 2021; AAPC for SII: 8.27%, p=0.001) groups improved. CONCLUSIONS: From 2008-2021, age, sex, racial and ethnic, and education inequalities in the incidence of diagnosed diabetes improved but persisted. Income-related diabetes prevalence inequalities worsened over time. To close these gaps, future research could focus on identifying factors driving these trends including the contribution of morbidity and mortality.

INTRODUCTION: In 2021, the U.S. Preventive Services Task Force (USPSTF) recommended prediabetes and diabetes screening for asymptomatic adults aged 35-70 years with overweight/obesity, lowering the age from 40 years in its 2015 recommendation. The USPSTF suggested considering earlier screening in racial and ethnic groups with high diabetes risk at younger ages or lower BMI. This study examined the clinical performance of these USPSTF screening recommendations as well as alternative age and BMI cutoffs in the U.S. adult population overall, and separately by race and ethnicity. METHODS: Nationally representative data were collected from 3,243 nonpregnant adults without diagnosed diabetes in January 2017-March 2020 and analyzed from 2021 to 2022. Screening eligibility was based on age and measured BMI. Collectively, prediabetes and undiagnosed diabetes were defined by fasting plasma glucose ≥100 mg/dL or hemoglobin A(1c) ≥5.7%. The sensitivity, specificity, and predictive values of alternate screening criteria were examined overall, and by race and ethnicity. RESULTS: The 2021 criteria exhibited marginally higher sensitivity (58.6%, 95% CI=55.5, 61.6 vs 52.9%, 95% CI=49.7, 56.0) and lower specificity (69.3%, 95% CI=65.7, 72.2 vs 76.4%, 95% CI=73.3, 79.2) than the 2015 criteria overall, and within each racial and ethnic group. Screening at lower age and BMI thresholds resulted in even greater sensitivity and lower specificity, especially among Hispanic, non-Hispanic Black, and Asian adults. Screening all adults aged 35-70 years regardless of BMI yielded the most equitable performance across all racial and ethnic groups. CONCLUSIONS: The 2021 USPSTF screening criteria will identify more adults with prediabetes and diabetes in all racial and ethnic groups than the 2015 criteria. Screening all adults aged 35-70 years exhibited even higher sensitivity and performed most similarly by race and ethnicity, which may further improve early detection of prediabetes and diabetes in diverse populations.

AIMS: The overall prevalence of diabetes has increased over the past two decades in the United States, disproportionately affecting low-income populations. We aimed to examine the trends in income-related inequalities in diabetes prevalence and to identify the contributions of determining factors. METHODS: We estimated income-related inequalities in diagnosed diabetes during 2001-2018 among US adults aged 18 years or older using data from the National Health Interview Survey (NHIS). The concentration index was used to measure income-related inequalities in diabetes and was decomposed into contributing factors. We then examined temporal changes in diabetes inequality and contributors to those changes over time. RESULTS: Results showed that income-related inequalities in diabetes, unfavorable to low-income groups, persisted throughout the study period. The income-related inequalities in diabetes decreased during 2001-2011 and then increased during 2011-2018. Decomposition analysis revealed that income, obesity, physical activity levels, and race/ethnicity were important contributors to inequalities in diabetes at almost all time points. Moreover, changes regarding age and income were identified as the main factors explaining changes in diabetes inequalities over time. CONCLUSIONS: Diabetes was more prevalent in low-income populations. Our study contributes to understanding income-related diabetes inequalities and could help facilitate program development to prevent type 2 diabetes and address modifiable factors to reduce diabetes inequalities.

INTRODUCTION: A healthy diet is recommended to support diabetes management, including HbA1c, blood pressure, and cholesterol (ABC) control, but food insecurity is a barrier to consuming a healthy diet. We determined the prevalence of food insecurity and diet quality among US adults with diabetes and the associations with ABC management. RESEARCH DESIGN AND METHODS: Cross-sectional analyses were conducted among 2075 adults ≥20 years with diagnosed diabetes who participated in the 2013-2018 National Health and Nutrition Examination Surveys. Food insecurity was assessed using a standard questionnaire and diet quality was assessed using quartiles of the 2015 Healthy Eating Index. Adjusted ORs (aOR, 95% CI) were calculated from logistic regression models to determine the association between household food insecurity/diet quality and the ABCs while controlling for sociodemographic characteristics, healthcare utilization, smoking, medication for diabetes, blood pressure, or cholesterol, and body mass index. RESULTS: Overall, 17.6% of adults had food insecurity/low diet quality; 14.2% had food insecurity/high diet quality; 33.1% had food security/low diet quality; and 35.2% had food security/high diet quality. Compared with adults with food security/high diet quality, those with food insecurity/low diet quality were significantly more likely to have HbA1c ≥7.0% (aOR=1.85, 95% CI 1.23 to 2.80) and HbA1c ≥8.0% (aOR=1.79, 95% CI 1.04 to 3.08); food insecurity/high diet quality was significantly associated with elevated HbA1c; and food security/low diet quality with elevated A1c. CONCLUSIONS: Food insecurity, regardless of diet quality, was significantly associated with elevated A1c. For people with food insecurity, providing resources to reduce food insecurity could strengthen the overall approach to optimal diabetes management.

AIM: To examine changes in racial and ethnic disparities in glucose-lowering drugs (GLD) use and glycated haemoglobin A1c in US adults with diabetes from 2005 to 2018. METHODS: We conducted pooled cross-sectional analysis using data from the 2005-2018 Medical Expenditure Panel Surveys, and the 2005-2018 National Health and Nutrition Examination Survey. Individuals ≥18 years with diabetes were included. Racial and ethnic disparities were measured in (a) newer non-insulin GLD use; (b) insulin analogue use; (c) non-insulin GLDs adherence; (d) insulin adherence; and (e) glucose management, along with (f) the proportion of the disparities explained by potential contributing factors. RESULTS: From 2005 to 2018, racial and ethnic disparities persisted in newer GLD use, non-insulin GLDs adherence, insulin analogue use and glucose management. In 2018, compared with non-Hispanic white adults, non-Hispanic black, Hispanic and other race/ethnicity groups had lower rates of using newer GLDs (adjusted risk ratio: 0.44, 0.52, 0.64, respectively; p < .05 for all) and insulin analogues (adjusted risk ratio: 0.93, 0.89, 0.95, respectively; p < .05 for all except other groups), lower non-insulin GLD adherence (proportion of days covered: -4.5%, -5.6%, -4.3%, respectively; p < .05 for all), higher glycated haemoglobin A1c (0.29%, 0.32%, 0.02%, respectively; p < .05 for all except other group), and similar insulin adherences. Socioeconomic and health status were the main contributors to these disparities. CONCLUSIONS: Our findings provide evidence of racial and ethnic disparities in newer GLD use and quality of care in glucose management. Our study results can inform decision-makers of the status of racial and ethnic disparities and identify ways to reduce these disparities.

IMPORTANCE: Improvements in control of factors associated with diabetes risk in the US have stalled and remain suboptimal. The benefit of continually improving goal achievement has not been evaluated to date. OBJECTIVE: To quantify potential gains in life expectancy (LE) among people with type 2 diabetes (T2D) associated with lowering glycated hemoglobin (HbA1c), systolic blood pressure (SBP), low-density lipoprotein cholesterol (LDL-C), and body mass index (BMI) toward optimal levels. DESIGN, SETTING, AND PARTICIPANTS: In this decision analytical model, the Building, Relating, Assessing, and Validating Outcomes (BRAVO) diabetes microsimulation model was calibrated to a nationally representative sample of adults with T2D from the National Health and Nutrition Examination Survey (2015-2016) using their linked short-term mortality data from the National Death Index. The model was then used to conduct the simulation experiment on the study population over a lifetime. Data were analyzed from January to October 2021. EXPOSURE: The study population was grouped into quartiles on the basis of levels of HbA1c, SBP, LDL-C, and BMI. LE gains associated with achieving better control were estimated by moving people with T2D from the current quartile of each biomarker to the lower quartiles. MAIN OUTCOMES AND MEASURES: Life expectancy. RESULTS: Among 421 individuals, 194 (46%) were women, and the mean (SD) age was 65.6 (8.9) years. Compared with a BMI of 41.4 (mean of the fourth quartile), lower BMIs of 24.3 (first), 28.6 (second), and 33.0 (third) were associated with 3.9, 2.9, and 2.0 additional life-years, respectively, in people with T2D. Compared with an SBP of 160.4 mm Hg (fourth), lower SBP levels of 114.1 mm Hg (first), 128.2 mm Hg (second), and 139.1 mm Hg (third) were associated with 1.9, 1.5, and 1.1 years gained in LE in people with T2D, respectively. A lower LDL-C level of 59 mg/dL (first), 84.0 mg/dL (second), and 107.0 mg/dL (third) were associated with 0.9, 0.7, and 0.5 years gain in LE, compared with LDL-C of 146.2 mg/dL (fourth). Reducing HbA1c from 9.9% (fourth) to 7.7% (third) was associated with 3.4 years gain in LE. However, a further reduction to 6.8% (second) was associated with only a mean of 0.5 years gain in LE, and from 6.8% to 5.9% (first) was not associated with LE benefit. Overall, reducing HbA1c from the fourth quartile to the first is associated with an LE gain of 3.8 years. CONCLUSIONS AND RELEVANCE: These findings can be used by clinicians to motivate patients in achieving the recommended treatment goals and to help prioritize interventions and programs to improve diabetes care in the US.

This cohort study estimates the progression to diabetes among older adults with hemoglobin A(1c)-defined prediabetes in clinical settings in the US.

AIMS: We examined changes in the prevalence of elevated depressive symptoms among US adults with diabetes, prediabetes, and normal glycemic status during 2005-2016. METHODS: We analyzed data from 32,676 adults in the 2005-2016 National Health and Nutrition Examination Surveys. We defined diabetes as self-reporting a physician diagnosis of diabetes or A1C ≥ 6.5% [48 mmol/mol], and prediabetes as A1C 5.7-6.4% [39-46 mmol/mol]. We used the 9-item Patient Health Questionnaire (PHQ-9) score ≥ 10 or antidepressant use to define 'clinically significant depressive symptoms' (CSDS) and PHQ-9 score ≥ 12 as 'Major Depressive Disorder' (MDD). We calculated prevalence age-standardized to the 2000 US census and used logistic-regression to compute adjusted odds of CSDS and MDD for 2005-2008, 2009-2012, and 2015-2016. We analyzed the prevalence of A1C ≥ 9.0% [75 mmol/mol], systolic blood pressure ≥ 140 mmHg and/or diastolic blood pressure ≥ 90 mmHg, non-HDL cholesterol ≥ 130 mg/dL, and current smoking among adults with diagnosed diabetes by depressive status. RESULTS: The prevalence of CSDS increased among individuals with normal glycemic status from 15.0% (13.5-16.2) to 17.3% (16.0-18.7) (p = 0.03) over 2005-2016. The prevalence of CSDS and MDD remained stable among adults with prediabetes (~ 16% and 1%, respectively) and diabetes (~ 26% and ~3%). After controlling for glycemic, sociodemographic, economic, and self-rated health variables, we found 2-fold greater odds of CSDS among unemployed individuals and 3-fold greater odds among those with fair/poor self-rated health across all survey periods. Cardiometabolic care targets for adults with diagnosed diabetes were stable from 2005 to 2016 and similar across depressive status. CONCLUSIONS: One-fourth of adults with diabetes have comorbid CSDS; this prevalence remained stable over 2005-2016 with no change in diabetes care. At the population level, depression does not appear to impact diabetes care, but further research could explore subgroups that may be more vulnerable and could benefit from integrated care that addresses both conditions.

Diabetes affects approximately one in 10 persons in the United States(†) and is a risk factor for severe COVID-19 (1), especially when a patient's diabetes is not well managed (2). The extent to which the COVID-19 pandemic has affected diabetes care and management, and whether this varies across age groups, is currently unknown. To evaluate access to and use of health care, as well as experiences, attitudes, and behaviors about COVID-19 prevention and vaccination, a nonprobability, Internet-based survey was administered to 5,261 U.S. adults aged ≥18 years during February-March 2021. Among respondents, 760 (14%) adults who reported having diabetes currently managed with medication were included in the analysis. Younger adults (aged 18-29 years) with diabetes were more likely to report having missed medical care during the past 3 months (87%; 79) than were those aged 30-59 years (63%; 372) or ≥60 years (26%; 309) (p<0.001). Overall, 44% of younger adults reported difficulty accessing diabetes medications. Younger adults with diabetes also reported lower intention to receive COVID-19 vaccination (66%) compared with adults aged ≥60 years(§) (85%; p = 0.001). During the COVID-19 pandemic, efforts to enhance access to diabetes care for adults with diabetes and deliver public health messages emphasizing the importance of diabetes management and COVID-19 prevention, including vaccination, are warranted, especially in younger adults.

Low socioeconomic position (SEP) across the lifecourse is associated with Type 2 diabetes (T2DM). We examined whether these economic disparities differ by race and sex. We included 5448 African American (AA) and white participants aged ≥45 years from the national (United States) REasons for Geographic and Racial Differences in Stroke (REGARDS) cohort without T2DM at baseline (2003-07). Incident T2DM was defined by fasting glucose ≥126 mg/dL, random glucose ≥200 mg/dL, or using T2DM medications at follow-up (2013-16). Derived SEP scores in childhood (CSEP) and adulthood (ASEP) were used to calculate a cumulative (CumSEP) score. Social mobility was defined as change in SEP. We fitted race-stratified logistic regression models to estimate the association between each lifecourse SEP indicator and T2DM, adjusting for covariates; additionally, we tested SEP-sex interactions. Over a median of 9.0 (range 7-14) years of follow-up, T2DM incidence was 167.1 per 1000 persons among AA and 89.9 per 1000 persons among white participants. Low CSEP was associated with T2DM incidence among AA (OR = 1.61; 95%CI 1.05-2.46) but not white (1.06; 0.74-2.33) participants; this was attenuated after adjustment for ASEP. In contrast, low CumSEP was associated with T2DM incidence for both racial groups. T2DM risk was similar for stable low SEP and increased for downward mobility when compared with stable high SEP in both groups, whereas upward mobility increased T2DM risk among AAs only. No differences by sex were observed. Among AAs, low CSEP was not independently associated with T2DM, but CSEP may shape later-life experiences and health risks.

IMPORTANCE: Gestational diabetes is associated with adverse maternal and offspring outcomes. OBJECTIVE: To determine whether rates of gestational diabetes among individuals at first live birth changed from 2011 to 2019 and how these rates differ by race and ethnicity in the US. DESIGN, SETTING, AND PARTICIPANTS: Serial cross-sectional analysis using National Center for Health Statistics data for 12 610 235 individuals aged 15 to 44 years with singleton first live births from 2011 to 2019 in the US. EXPOSURES: Gestational diabetes data stratified by the following race and ethnicity groups: Hispanic/Latina (including Central and South American, Cuban, Mexican, and Puerto Rican); non-Hispanic Asian/Pacific Islander (including Asian Indian, Chinese, Filipina, Japanese, Korean, and Vietnamese); non-Hispanic Black; and non-Hispanic White. MAIN OUTCOMES AND MEASURES: The primary outcomes were age-standardized rates of gestational diabetes (per 1000 live births) and respective mean annual percent change and rate ratios (RRs) of gestational diabetes in non-Hispanic Asian/Pacific Islander (overall and in subgroups), non-Hispanic Black, and Hispanic/Latina (overall and in subgroups) individuals relative to non-Hispanic White individuals (referent group). RESULTS: Among the 12 610 235 included individuals (mean [SD] age, 26.3 [5.8] years), the overall age-standardized gestational diabetes rate significantly increased from 47.6 (95% CI, 47.1-48.0) to 63.5 (95% CI, 63.1-64.0) per 1000 live births from 2011 to 2019, a mean annual percent change of 3.7% (95% CI, 2.8%-4.6%) per year. Of the 12 610 235 participants, 21% were Hispanic/Latina (2019 gestational diabetes rate, 66.6 [95% CI, 65.6-67.7]; RR, 1.15 [95% CI, 1.13-1.18]), 8% were non-Hispanic Asian/Pacific Islander (2019 gestational diabetes rate, 102.7 [95% CI, 100.7-104.7]; RR, 1.78 [95% CI, 1.74-1.82]), 14% were non-Hispanic Black (2019 gestational diabetes rate, 55.7 [95% CI, 54.5-57.0]; RR, 0.97 [95% CI, 0.94-0.99]), and 56% were non-Hispanic White (2019 gestational diabetes rate, 57.7 [95% CI, 57.2-58.3]; referent group). Gestational diabetes rates were highest in Asian Indian participants (2019 gestational diabetes rate, 129.1 [95% CI, 100.7-104.7]; RR, 2.24 [95% CI, 2.15-2.33]). Among Hispanic/Latina participants, gestational diabetes rates were highest among Puerto Rican individuals (2019 gestational diabetes rate, 75.8 [95% CI, 71.8-79.9]; RR, 1.31 [95% CI, 1.24-1.39]). Gestational diabetes rates increased among all race and ethnicity subgroups and across all age groups. CONCLUSIONS AND RELEVANCE: Among individuals with a singleton first live birth in the US from 2011 to 2019, rates of gestational diabetes increased across all racial and ethnic subgroups. Differences in absolute gestational diabetes rates were observed across race and ethnicity subgroups.

OBJECTIVES: By race/ethnicity and socioeconomic position (SEP), to estimate and examine changes over time in (1) mortality rate, (2) mortality disparities and (3) excess mortality risk attributed to diagnosed diabetes (DM). DESIGN: Population-based cohort study using National Health Interview Survey data linked to mortality status from the National Death Index from survey year up to 31 December 2015 with 5 years person-time. PARTICIPANTS: US adults aged ≥25 years with (31 586) and without (332 451) DM. PRIMARY OUTCOME: Age-adjusted all-cause mortality rate for US adults with DM in each subgroup of SEP (education attainment and income-to-poverty ratio (IPR)) and time (1997-2001, 2002-2006 and 2007-2011). RESULTS: Among adults with DM, mortality rates fell from 23.5/1000 person-years (p-y) in 1997-2001 to 18.1/1000 p-y in 2007-2011 with changes of -5.2/1000 p-y for non-Hispanic whites; -5.2/1000 p-y for non-Hispanic blacks; and -5.4/1000 p-y for Hispanics. Rates significantly declined within SEP groups, measured as education attainment (<high school=-5.7/1000 p-y; high school graduate=-4.2/1000 p-y; and >high school=-4.8/1000 p-y) and IPR group (poor=-7.9/1000 p-y; middle income=-4.7/1000 p-y; and high income=-6.2/1000 p-y; but not for near poor). For adults with DM, statistically significant all-cause mortality disparity showed greater mortality rates for the lowest than the highest SEP level (education attainment and IPR) in each time period. However, patterns in mortality trends and disparity varied by race/ethnicity. The excess mortality risk attributed to DM significantly decreased from 1997-2001 to 2007-2011, within SEP levels, and among Hispanics and non-Hispanic whites; but no statistically significant changes among non-Hispanic blacks. CONCLUSIONS: There were substantial improvements in all-cause mortality among US adults. However, we observed SEP disparities in mortality across race/ethnic groups or for adults with and without DM despite targeted efforts to improve access and quality of care among disproportionately affected populations.