OBJECTIVE: To compare the prevalence of diagnosed diabetes among U.S. adults with and without disabilities, overall and by subgroups. RESEARCH DESIGN AND METHODS: We used data on adults aged ≥18 years from the cross-sectional 2021-2022 National Health Interview Survey to report the prevalence of diagnosed diabetes by functional disability status and for each disability type (hearing, seeing, mobility, cognition, self-care, and communication) separately. With use of the Washington Group Short Set on Functioning indicator, disability was defined according to the categories of milder (reporting some difficulty), moderate (reporting a lot of difficulty), and severe (cannot do at all) by disability type. Crude prevalence and age-standardized prevalence of diabetes were also calculated for adults with any difficulty with any disability by age, sex, race/ethnicity, education, insurance, and poverty-to-income ratio. RESULTS: Diabetes prevalence increased with number of disability types, was lower among adults with no disability (5.8%) than among those with milder (9.5%) or moderate to more severe (18.3%) disability, and was 4.0-10.3 percentage points higher among those with moderate to more severe disability than among those with milder disability for vision, hearing, mobility, and cognitive disabilities. Diabetes prevalence was similar for adults with milder and moderate to more severe self-care and communication disabilities. CONCLUSIONS: Prevalence of diabetes was higher among adults with any functional disability than without and increased with increasing number of disability types. Adults with multiple disability types, or those who have difficulty with self-care or communication or other moderate to more severe disabilities, may benefit from diabetes prevention programs.

IMPORTANCE: During the 2023-2024 respiratory syncytial virus (RSV) season in the United States, 2 new RSV prevention products were recommended to protect infants in their first RSV season: nirsevimab and Pfizer's maternal RSV vaccine. Postlicensure studies are needed to assess prevention product impact and effectiveness. OBJECTIVE: To compare the epidemiology and disease burden of medically attended RSV-associated acute respiratory illness (ARI) among children younger than 5 years during the 2023-2024 RSV season with 3 prepandemic RSV seasons (2017-2020), estimate nirsevimab effectiveness against medically attended RSV-associated ARI, and compare nirsevimab binding site mutations among circulating RSV in infants with and without nirsevimab receipt. DESIGN, SETTING, AND PARTICIPANTS: This study included a prospective population-based surveillance for medically attended ARI with systematic molecular testing for RSV and whole-genome sequencing of RSV positive samples, as well as a test-negative case-control design to estimate nirsevimab effectiveness. The study was conducted in 7 academic pediatric medical centers in the United States with data from RSV seasons (September 1 through April 30) in 2017 through 2024. Participants were children younger than 5 years with medically attended ARI. EXPOSURE: For the nirsevimab effectiveness analyses, nirsevimab receipt among infants younger than 8 months as of or born after October 1, 2023. MAIN OUTCOME AND MEASURE: Medically attended RSV-associated ARI. RESULTS: Overall, 28 689 children younger than 5 years with medically attended ARI were enrolled, including 9536 during September 1, 2023, through April 30, 2024, and 19 153 during the same calendar period of 2017-2020. Of these children, 16 196 (57%) were male, and 12 444 (43.4) were female; the median (IQR) age was 15 (6-29) months. During 2023-2024, the proportion of children with RSV was 23% (2199/9490) among all medically attended episodes, similar to 2017-2020. RSV-associated hospitalization rates in 2023-2024 were similar to average 2017-2020 seasonal rates with 5.0 (95% CI, 4.6-5.3) per 1000 among children younger than 5 years; the highest rates were among children aged 0 to 2 months (26.6; 95% CI, 23.0-30.2). Low maternal RSV vaccine uptake precluded assessment of effectiveness. Overall, 10 of 765 case patients (1%) who were RSV positive and 126 of 851 control patients (15%) who were RSV negative received nirsevimab. Nirsevimab effectiveness was 89% (95% CI, 79%-94%) against medically attended RSV-associated ARI and 93% (95% CI, 82%-97%) against RSV-associated hospitalization. Among 229 sequenced specimens, there were no differences in nirsevimab binding site mutations by infant nirsevimab receipt status. CONCLUSIONS AND RELEVANCE: This analysis documented the continued high burden of medically attended RSV-associated ARI among young children in the US. There is a potential for substantial public health impact with increased and equitable prevention product coverage in future seasons.

Respiratory syncytial virus (RSV) is the leading cause of hospitalization among infants in the United States. In August 2023, CDC's Advisory Committee on Immunization Practices recommended nirsevimab, a long-acting monoclonal antibody, for infants aged <8 months to protect against RSV-associated lower respiratory tract infection during their first RSV season and for children aged 8-19 months at increased risk for severe RSV disease. In phase 3 clinical trials, nirsevimab efficacy against RSV-associated lower respiratory tract infection with hospitalization was 81% (95% CI = 62%-90%) through 150 days after receipt; post-introduction effectiveness has not been assessed in the United States. In this analysis, the New Vaccine Surveillance Network evaluated nirsevimab effectiveness against RSV-associated hospitalization among infants in their first RSV season during October 1, 2023-February 29, 2024. Among 699 infants hospitalized with acute respiratory illness, 59 (8%) received nirsevimab ≥7 days before symptom onset. Nirsevimab effectiveness was 90% (95% CI = 75%-96%) against RSV-associated hospitalization with a median time from receipt to symptom onset of 45 days (IQR = 19-76 days). The number of infants who received nirsevimab was too low to stratify by duration from receipt; however, nirsevimab effectiveness is expected to decrease with increasing time after receipt because of antibody decay. Although nirsevimab uptake and the interval from receipt of nirsevimab were limited in this analysis, this early estimate supports the current nirsevimab recommendation for the prevention of severe RSV disease in infants. Infants should be protected by maternal RSV vaccination or infant receipt of nirsevimab.

Although diabetes and cardiovascular disease account for substantial disease prevalence among adults in the United States, their prevalence among racial and ethnic subgroups is inadequately characterized. To fill this gap, CDC described the prevalence of diagnosed cardiometabolic diseases among U.S. adults, by disaggregated racial and ethnic subgroups, among 3,970,904 respondents to the Behavioral Risk Factor Surveillance System during 2013-2021. Prevalence of each disease (diabetes, myocardial infarction, angina or coronary heart disease, and stroke), stratified by race and ethnicity, was based on self-reported diagnosis by a health care professional, adjusting for age, sex, and survey year. Overall, mean respondent age was 47.5 years, and 51.4% of respondents were women. Prevalence of cardiometabolic diseases among disaggregated race and ethnicity subgroups varied considerably. For example, diabetes prevalence within the aggregated non-Hispanic Asian category (11.5%) ranged from 6.3% in the Vietnamese subgroup to 15.2% in the Filipino subgroup. Prevalence of angina or coronary heart disease for the aggregated Hispanic or Latino category (3.8%) ranged from 3.1% in the Cuban subgroup to 6.3% in the Puerto Rican subgroup. Disaggregation of cardiometabolic disease prevalence data by race and ethnicity identified health disparities among subgroups that can be used to better help guide prevention programs and develop culturally relevant interventions.

AIMS: Understanding health behaviors of people with diabetes can inform strategies to reduce diabetes-related burdens. METHODS: We used serial cross-sectional National Health and Nutrition Examination Surveys over 2007-2018 to characterize self-reported health behaviors among non-pregnant adults, with and without self-reported diabetes. We estimated weighted proportions meeting recommended health behaviors overall and by sociodemographic and glycemic levels. RESULTS: During 2007-2010, proportions of adults with diabetes meeting recommendations were: 61.9% for added sugar consumption (<10% of total calories), 17.2% for physical activity, 68.2% for weight management, 14.4% avoided alcohol, 57.5% avoided tobacco, 34.1% got adequate sleep, and 97.5% saw a healthcare provider (compared with 19.2%, 33.6%, 68.8%, 8.5%, 44.2%, 33.0% , and 82.6% respectively, among those without diabetes). During 2015-2018, adjusted analyses showed more adults with diabetes met sleep (+16.7 percentage-points[pp]; 95% CI: 10.6,22.8) and physical activity goals (+8.3pp; 95% CI: 3.8,12.8), and fewer met added sugar recommendations (-8.8pp; 95% CI -14.7, -2.9). Meeting added sugar, physical activity, and weight management varied by age, education, and glycemic level, but not race and ethnicity. CONCLUSIONS: During 2007-2018, there was some improvement in health behaviors. Improving self-management may require targeted interventions for different segments, like age groups or glycemic levels, among those with diabetes.

INTRODUCTION: The American Diabetes Association (ADA) recommends screening for prediabetes and diabetes (dysglycemia) starting at age 35, or younger than 35 years among adults with overweight or obesity and other risk factors. Diabetes risk differs by sex, race, and ethnicity, but performance of the recommendation in these sociodemographic subgroups is unknown. METHODS: Nationally representative data from the National Health and Nutrition Examination Surveys (2015-March 2020) were analyzed from 5,287 nonpregnant US adults without diagnosed diabetes. Screening eligibility was based on age, measured body mass index, and the presence of diabetes risk factors. Dysglycemia was defined by fasting plasma glucose ≥100mg/dL (≥5.6 mmol/L) or haemoglobin A1c ≥5.7% (≥39mmol/mol). The sensitivity, specificity, and predictive values of the ADA screening criteria were examined by sex, race, and ethnicity. RESULTS: An estimated 83.1% (95% CI=81.2-84.7) of US adults were eligible for screening according to the 2023 ADA recommendation. Overall, ADA's screening criteria exhibited high sensitivity [95.0% (95% CI=92.7-96.6)] and low specificity [27.1% (95% CI=24.5-29.9)], which did not differ by race or ethnicity. Sensitivity was higher among women [97.8% (95% CI=96.6-98.6)] than men [92.4% (95% CI=88.3-95.1)]. Racial and ethnic differences in sensitivity and specificity among men were statistically significant (P=0.04 and P=0.02, respectively). Among women, guideline performance did not differ by race and ethnicity. DISCUSSION: The ADA screening criteria exhibited high sensitivity for all groups and was marginally higher in women than men. Racial and ethnic differences in guideline performance among men were small and unlikely to have a significant impact on health equity. Future research could examine adoption of this recommendation in practice and examine its effects on treatment and clinical outcomes by sex, race, and ethnicity.

BACKGROUND: Adenovirus is a known cause of hepatitis in immunocompromised children, but not in immunocompetent children. In April, 2022, following multiple reports of hepatitis of unknown aetiology and adenovirus viraemia in immunocompetent children in the USA and UK, the US Centers for Disease Control and Prevention (CDC) and jurisdictional health departments initiated national surveillance of paediatric acute hepatitis of unknown aetiology. We aimed to describe the clinical and epidemiological characteristics of children identified with hepatitis of unknown aetiology between Oct 1, 2021, and Sept 30, 2022, in the USA and to compare characteristics of those who tested positive for adenovirus with those who tested negative. METHODS: In this national surveillance investigation in the USA, children were identified for investigation if they were younger than 10 years with elevated liver transaminases (>500 U/L) who had an unknown cause for their hepatitis and onset on or after Oct 1, 2021. We reviewed medical chart abstractions, which included data on demographics, underlying health conditions, signs and symptoms of illness, laboratory results, vaccination history, radiological and liver pathology findings, diagnoses and treatment received, and outcomes. Caregiver interviews were done to obtain information on symptoms and health-care utilisation for the hepatitis illness, medical history, illness in close contacts or at school or daycare, diet, travel, and other potential exposures. Blood, stool, respiratory, and tissue specimens were evaluated according to clinician discretion and available specimens were submitted to CDC for additional laboratory testing or pathology evaluation. FINDINGS: Surveillance identified 377 patients from 45 US jurisdictions with hepatitis of unknown aetiology with onset from Oct 1, 2021, to Sept 30, 2022. The median age of patients was 2·8 years (IQR 1·2-5·0) and 192 (51%) were male, 184 (49%) were female, and one patient had sex unknown. Only 22 (6%) patients had a notable predisposing underlying condition. 347 patients (92%) were admitted to hospital, 21 (6%) subsequently received a liver transplant, and nine (2%) died. Among the 318 patients without notable underlying conditions, 275 were tested for adenovirus. Of these 116 (42%) had at least one positive specimen, and species F type 41 was the most frequent type identified (19 [73%] of 26 typed specimens were HAdV-41). Proportions of patients who had acute liver failure, received a liver transplant, and died were similar between those who tested positive for adenovirus compared with those who tested negative. Adenovirus species F was detected by polymerase chain reaction in nine pathology liver evaluations, but not by immunohistochemistry in seven of the nine with adequate liver tissue available. Interviews with caregivers yielded no common exposures. INTERPRETATION: Adenovirus, alone or in combination with other factors, might play a potential role in acute hepatitis among immunocompetent children identified in this investigation, but the pathophysiologic mechanism of liver injury is unclear. To inform both prevention and intervention measures, more research is warranted to determine if and how adenovirus might contribute to hepatitis risk and the potential roles of other pathogens and host factors. FUNDING: None.

Aims We aimed to determine the association between prediabetes and diabetes with latent TB using National Health and Nutrition Examination Survey data.Methods We performed a cross-sectional analysis of 2011-2012 National Health and Nutrition Examination Survey data. Participants ≥20 years were eligible. Diabetes was defined by glycated hemoglobin (HbA1c) as no diabetes (≤5.6% [38 mmol/mol]), prediabetes (5.7-6.4% [3946mmol/mol]), and diabetes (≥6.5% [48 mmol/mol]) combined with self-reported diabetes. Latent TB infection was defined by the QuantiFERON®-TB Gold In Tube (QFT-GIT) test. Adjusted odds ratios (aOR) of latent TB infection by diabetes status were calculated using logistic regression and accounted for the stratified probability sample.Results Diabetes and QFT-GIT measurements were available for 4,958 (89.2%) included participants. Prevalence of diabetes was 11.4% (95%CI 9.8-13.0%) and 22.1% (95%CI 20.523.8%) had prediabetes. Prevalence of latent TB infection was 5.9% (95%CI 4.9-7.0%). After adjusting for age, sex, smoking status, history of active TB, and foreign born status, the odds of latent TB infection were greater among adults with diabetes (aOR 1.90, 95%CI 1.15-3.14) compared to those without diabetes. The odds of latent TB in adults with prediabetes (aOR 1.15, 95%CI 0.90-1.47) was similar to those without diabetes.Conclusions Diabetes is associated with latent TB infection among adults in the United States, even after adjusting for confounding factors. Given diabetes increases the risk of active TB, patients with co-prevalent diabetes and latent TB may be targeted for latent TB treatment.

AIMS: Among adults with diabetes in the United States, we evaluated anemia prevalence by CKD status as well as the role of CKD and anemia, as potential risk factors for all-cause mortality. METHODS: In a retrospective cohort study, we included 6,718 adult participants with prevalent diabetes from the 2003-March 2020 National Health and Nutrition Examination Survey (NHANES), a nationally representative sample of the non-institutionalized civilian population in the United States. Cox regression models evaluated the role of anemia and CKD, alone or combined, as predictors of all-cause mortality. RESULTS: Anemia prevalence among adults with diabetes and CKD was 20%. Having anemia or CKD alone, compared with having neither condition, was significantly associated with all-cause mortality (anemia: HR=2.10 [1.49-2.96], CKD: HR=2.24 [1.90-2.64]). Having both conditions conferred a greater potential risk (HR=3.41 [2.75-4.23]). CONCLUSIONS: Approximately one-quarter of the adult US population with diabetes and CKD also has anemia. The presence of anemia, with or without CKD, is associated with a two- to threefold increased risk of death by compared with adults who have neither condition, suggesting that anemia may be a strong predictor of death among adults with diabetes.

AIMS: Recent USPSTF and ADA guidelines expanded criteria of whom to test to identify prediabetes and diabetes. We described which Americans are eligible and report receiving glucose testing by USPSTF 2015 and 2021 as well as ADA 2003 and 2022 recommendations, and performance of each guideline. METHODS: We analyzed cross-sectional data from 6,007 non-pregnant U.S. adults without diagnosed diabetes in the 2013-2018 National Health and Nutrition Examination Surveys. We reported proportions of adults who met each guideline's criteria for glucose testing and reported receiving glucose testing in the past three years, overall and by key population subgroups,. Defining prediabetes (FPG 100-125mg/dL and/or HbA1c 5.7-6.4%) or previously undiagnosed diabetes (FPG≥126mg/dL and/or HbA1c≥6.5%), we assessed sensitivity and specificity. RESULTS: During 2013-2018, 76.7 million, 90.4 million, 157.7 million, and 169.5 million US adults met eligibility for glucose testing by USPSTF 2015, 2021, and ADA 2003 and 2022 guidelines, respectively. On average, 52% of adults reported receiving glucose testing within the past 3 years. Likelihood of receiving glucose testing was lower among younger adults, men, Hispanic adults, those with less than high school completion, those living in poverty, and those without health insurance or a usual place of care than their respective counterparts. ADA recommendations were most sensitive (range: 91.0% to 100.0%) and least specific (range: 18.3% to 35.3%); USPSTF recommendations exhibited lower sensitivity (51.9% to 66.6%), but higher specificity (56.6% to 74.5%). CONCLUSIONS: An additional 12-14 million US adults are eligible for diabetes screening. USPSTF 2021 criteria provide balanced sensitivity and specificity while ADA 2022 criteria maximize sensitivity. Glucose testing does not align with guidelines and disparities remain.

HIV prevalence among the general population in South Sudan, the world's newest country, is estimated at 2.9% and in Nimule, a town at the border with Uganda, it is estimated at 7.5%. However, there is limited data describing the HIV epidemic among female sex workers and sexually exploited adolescents (FSW/SEA) in the country. This study was conducted using a respondent-driven sampling (RDS) among FSW/SEA aged ≥15 years in January-February 2017 who sold or exchanged sex in the last six months in Nimule. Consenting participants were administered a questionnaire and tested for HIV according to the national algorithm. Syphilis testing was conducted using SD BIOLINE Syphilis 3.0 and Rapid Plasma Reagin for confirmation. Data were analyzed in SAS and RDS-Analyst and weighted results are presented. The 409 FSW/SEA participants with a median age of 28 years (IQR 23-35) and a median age of 23 years (IQR 18-28) when they entered the world of sex work, were enrolled in the Eagle survey. Nearly all (99.2%) FSW/SEA lacked comprehensive knowledge of HIV though almost half (48.5%) talked to a peer educator or outreach worker about HIV in the last 30 days. More than half (55.3%) were previously tested for HIV. Only 46.4% used a condom during their last vaginal or anal sexual act with a client. One in five (19.8%) FSW/SEA experienced a condom breaking during vaginal or anal sex in the last six months HIV prevalence was 24.0% (95% CI: 19.4-28.5) and 9.2% (95% CI: 6.5-11.9) had active syphilis. The multivariable analysis revealed the association between HIV and active syphilis (aOR: 6.99, 95% CI: 2.23-21.89). HIV and syphilis prevalence were higher among FSW/SEA in Nimule than the general population in the country and Nimule. Specifically, the HIV prevalence was eight times higher than the general population. Our findings underscore the importance of providing HIV and syphilis testing for FSW/SEA in conjunction with comprehensive combination prevention, including comprehensive HIV information, promotion of condom use, and availing treatment services for both HIV and syphilis.

OBJECTIVE: To assess the association of diabetes and mental, behavioral, and developmental disorders in youth, we examined the magnitude of overlap between these disorders in children and adolescents. STUDY DESIGN: In this cross-sectional study, we calculated prevalence estimates using the 2016-2019 National Survey of Children's Health. Parents reported whether their child was currently diagnosed with diabetes or with any of the following mental, behavioral, or developmental disorders: attention-deficit/hyperactivity disorder, autism spectrum disorder, learning disability, intellectual disability, developmental delay, anxiety, depression, behavioral problems, Tourette syndrome, or speech/language disorder. We present crude prevalence estimates weighted to be representative of the U.S. child population and prevalence ratios (aPR) adjusted for age, sex, and race/ethnicity. RESULTS: Among children and adolescents (aged 2-17 years; N=121,312), prevalence of mental, behavioral, and developmental disorders varied by diabetes status (diabetes: 39.9% [30.2-50.4]; no diabetes: 20.3% [19.8-20.8]). Compared with children and adolescents without diabetes, those with diabetes had a nearly two-fold higher prevalence of mental, behavioral, and developmental disorders (aPR: 1.72 [1.31-2.27]); mental, emotional, and behavioral disorders (aPR: 1.90 [1.38-2.61]); and developmental, learning, and language disorders (aPR: 1.89 [1.35-2.66]). CONCLUSIONS: These results suggest that approximately 2 in 5 children and adolescents with diabetes have a mental, behavioral, or developmental disorder. Understanding potential causal pathways may ultimately lead to future preventative strategies for mental, behavioral, and developmental disorders and diabetes in children and adolescents.

INTRODUCTION: RCTs have found that type 2 diabetes can be prevented among high-risk individuals by metformin medication and evidence-based lifestyle change programs. The purpose of this study is to estimate the use of interventions to prevent type 2 diabetes in real-world clinical practice settings and determine the impact on diabetes-related clinical outcomes. METHODS: The analysis performed in 2020 used 2010‒2018 electronic health record data from 69,434 patients aged ≥18 years at high risk for type 2 diabetes in 2 health systems. The use and impact of prescribed metformin, lifestyle change program, bariatric surgery, and combinations of the 3 were examined. A subanalysis was performed to examine uptake and retention among patients referred to the National Diabetes Prevention Program. RESULTS: Mean HbA1c values declined from before to after intervention for patients who were prescribed metformin (-0.067%; p<0.001) or had bariatric surgery (-0.318%; p<0.001). Among patients referred to the National Diabetes Prevention Program lifestyle change program, the type 2 diabetes postintervention incidence proportion was 14.0% for nonattendees, 12.8% for some attendance, and 7.5% for those who attended ≥4 sessions (p<0.001). Among referred patients to the National Diabetes Prevention Program lifestyle change program, uptake was low (13% for 1‒3 sessions, 15% for ≥4 sessions), especially among males and Hispanic patients. CONCLUSIONS: Findings suggest that metformin and bariatric surgery may improve HbA1c levels and that participation in the National Diabetes Prevention Program may reduce type 2 diabetes incidence. Efforts to increase the use of these interventions may have positive impacts on diabetes-related health outcomes.

AIMS: To report the national proportions and trends of adult hospitalizations with diabetes in the United States during 2000-2018. METHODS: We used the 2000-2018 National Inpatient Sample to identify hospital discharges with any listed and primary diagnoses for diabetes, based on International Classification of Diseases, 9th revision, Clinical Modification (ICD-9-CM) and ICD-10-CM codes. We calculated proportions and trends of adult hospitalizations with diabetes, overall and by subpopulations. We used the Nationwide Readmissions Database to assess calendar-year and 30-day readmission rates. RESULTS: From 2000 to 2018, the proportion of hospitalizations among adults ≥18 years increased from 17.1% to 27.3% (average annual percentage change [AAPC] 2.5%; P < 0.001) for any listed diabetes codes and from 1.5% to 2.1% (AAPC 2.2%; P < 0.001) for primary diagnosis of diabetes. Men, non-Hispanic Black patients, and those from poorer zip codes had higher proportions of hospitalizations with diabetes codes. CONCLUSION: In recent years, approximately one-quarter of adult hospitalizations in the United States had a listed diabetes code, increasing about 2.5% per year from 2000 to 2018. These data are important for benchmarking purposes, especially due to disruptions in health care utilization from the COVID-19 pandemic.

OBJECTIVE: To examine changes in and the relationships between diabetes management and rural and urban residence. RESEARCH DESIGN AND METHODS: Using National Health and Nutrition Examination Survey (1999-2018) data from 6,372 adults aged ≥18 years with self-reported diagnosed diabetes, we examined poor ABCS: A1C >9% (>75 mmol/mol), Blood pressure (BP) ≥140/90 mmHg, Cholesterol (non-HDL) ≥160 mg/dL (≥4.1 mmol/L), and current Smoking. We compared odds of urban versus rural residents (census tract population size ≥2,500 considered urban, otherwise rural) having poor ABCS across time (1999-2006, 2007-2012, and 2013-2018), overall and by sociodemographic and clinical characteristics. RESULTS: During 1999-2018, the proportion of U.S. adults with diabetes residing in rural areas ranged between 15% and 19.5%. In 1999-2006, there were no statistically significant rural-urban differences in poor ABCS. However, from 1999-2006 to 2013-2018, there were greater improvements for urban adults with diabetes than for rural for BP ≥140/90 mmHg (relative odds ratio [OR] 0.8, 95% CI 0.6-0.9) and non-HDL ≥160 mg/dL (≥4.1 mmol/L) (relative OR 0.45, 0.4-0.5). These differences remained statistically significant after adjustment for race/ethnicity, education, poverty levels, and clinical characteristics. Yet, over the 1999-2018 time period, minority race/ethnicity, lower education attainment, poverty, and lack of health insurance coverage were factors associated with poorer A, B, C, or S in urban adults compared with their rural counterparts. CONCLUSIONS: Over two decades, rural U.S. adults with diabetes have had less improvement in BP and cholesterol control. In addition, rural-urban differences exist across sociodemographic groups, suggesting that efforts to narrow this divide may need to address both socioeconomic and clinical aspects of care.

BACKGROUND: The Longitudinal Epidemiologic Assessment of Diabetes Risk (LEADR) study uses a novel Electronic Health Record (EHR) data approach as a tool to assess the epidemiology of known and new risk factors for type 2 diabetes mellitus (T2DM) and study how prevention interventions affect progression to and onset of T2DM. We created an electronic cohort of 1.4 million patients having had at least 4 encounters with a healthcare organization for at least 24-months; were aged ≥18 years in 2010; and had no diabetes (i.e., T1DM or T2DM) at cohort entry or in the 12 months following entry. EHR data came from patients at nine healthcare organizations across the U.S. between January 1, 2010-December 31, 2016. RESULTS: Approximately 5.9% of the LEADR cohort (82,922 patients) developed T2DM, providing opportunities to explore longitudinal clinical care, medication use, risk factor trajectories, and diagnoses for these patients, compared with patients similarly matched prior to disease onset. CONCLUSIONS: LEADR represents one of the largest EHR databases to have repurposed EHR data to examine patients' T2DM risk. This paper is first in a series demonstrating this novel approach to studying T2DM. IMPLICATIONS: Chronic conditions that often take years to develop can be studied efficiently using EHR data in a retrospective design. LEVEL OF EVIDENCE: While much is already known about T2DM risk, this EHR's cohort's 160 M data points for 1.4 M people over six years, provides opportunities to investigate new unique risk factors and evaluate research hypotheses where results could modify public health practice for preventing T2DM.

An ever-changing landscape for environmental health (EH) requires in-depth assessment and analysis of the current challenges and emerging issues faced by EH professionals. The Understanding the Needs, Challenges, Opportunities, Vision, and Emerging Roles in Environmental Health initiative addressed this need.After receiving responses from more than 1700 practitioners, during an in-person workshop, focus groups identified and described priority problems and supplied context on addressing the significant challenges facing EH professionals with state health agencies and local health departments. The focus groups developed specific problem statements detailing the EH profession and workforce's prevailing challenges and needs according to 6 themes, including effective leadership, workforce development, equipment and technology, information systems and data, garnering support, and partnerships and collaboration.We describe the identified priority problems and needs and provide recommendations for ensuring a strong and robust EH profession and workforce ready to address tomorrow's challenges. (Am J Public Health. Published online ahead of print January 16, 2020: e1-e7. doi:10.2105/AJPH.2019.305441).

Importance: Coordinated efforts by national organizations in the United States to implement evidence-based lifestyle modification programs are under way to reduce type 2 diabetes (hereinafter referred to as diabetes) and cardiovascular risks. Objective: To provide a status report on the reach and use of diabetes prevention services nationally. Design, Setting, and Participants: This nationally representative, population-based cross-sectional analysis of 2016 and 2017 National Health Interview Survey data was conducted from August 3, 2017, through November 15, 2018. Nonpregnant, noninstitutionalized, civilian respondents 18 years or older at high risk for diabetes, defined as those with no self-reported diabetes diagnosis but with diagnosed prediabetes or an elevated American Diabetes Association (ADA) risk score (>5), were included in the analysis. Analyses were conducted for adults with (and in sensitivity analyses, for those without) elevated body mass index. Main Outcomes and Measures: Absolute numbers and proportions of adults at high risk with elevated body mass index receiving advice about diet, physical activity guidance, referral to weight loss programs, referral to diabetes prevention programs, or any of these, and those affirming engagement in each (or any) activity in the past year were estimated. To identify where gaps exist, a prevention continuum diagram plotted existing vs desired goal achievement. Variation in risk-reducing activities by age, sex, race/ethnicity, educational attainment, insurance status, history of gestational diabetes mellitus, hypertension, or body mass index was also examined. Results: This analysis included 50912 respondents (representing 223.0 million adults nationally) 18 years or older (mean [SE] age, 46.1 [0.2] years; 48.1% [0.3%] male) with complete data and no self-reported diabetes diagnosis by their health care professional. Of the represented population, 36.0% (80.0 million) had either a physician diagnosis of prediabetes (17.9 million), an elevated ADA risk score (73.3 million), or both (11.3 million). Among those with diagnosed prediabetes, 73.5% (95% CI, 71.6%-75.3%) reported receiving advice and/or referrals for diabetes risk reduction from their health care professional, and, of those, 35.0% (95% CI, 30.5%-39.8%) to 75.8% (95% CI, 73.2%-78.3%) reported engaging in the respective activity or program in the past year. Half of adults with elevated ADA risk scores but no diagnosed prediabetes (50.6%; 95% CI, 49.5%-51.8%) reported receiving risk-reduction advice and/or referral, of whom 33.5% (95% CI, 30.1%-37.0%) to 75.2% (95% CI, 73.4%-76.9%) reported engaging in activities and/or programs. Participation in diabetes prevention programs was exceedingly low. Advice from a health care professional, age range from 45 to 64 years, higher educational attainment, health insurance status, gestational diabetes mellitus, hypertension, and obesity were associated with higher engagement in risk-reducing activities and/or programs. Conclusions and Relevance: Among adults at high risk for diabetes, major gaps in receiving advice and/or referrals and engaging in diabetes risk-reduction activities and/or programs were noted. These results suggest that risk perception, health care professional referral and communication, and insurance coverage may be key levers to increase risk-reducing behaviors in US adults. These findings provide a benchmark from which to monitor future program availability and coverage, identification of prediabetes, and referral to and retention in programs.

Objective: We examined whether life course socioeconomic position (SEP) was associated with incidence of type 2 diabetes (t2DM) among African Americans. Design: Secondary analysis of data from the Jackson Heart Study, 2000-04 to 2012, using Cox proportional hazard regression to estimate hazard ratios (HR) with 95% CI for t2DM incidence by measures of life course SEP. Participants: Sample of 4,012 nondiabetic adults aged 25-84 years at baseline. Outcome Measure: Incident t2DM identified by self-report, hemoglobin A1c >/=6.5%, fasting plasma glucose >/=126 mg/dL, or use of diabetes medication. Results: During 7.9 years of follow-up, 486 participants developed t2DM (incidence rate 15.2/1000 person-years, 95% CI: 13.9-16.6). Among women, but not men, childhood SEP was inversely associated with t2DM incidence (HR=.97, 95% CI: .94-.99) but was no longer associated with adjustment for adult SEP or t2DM risk factors. Upward SEP mobility increased the hazard for t2DM incidence (adjusted HR=1.52, 95% CI: 1.05-2.21) among women only. Life course allostatic load (AL) did not explain the SEP-t2DM association in either sex. Conclusions: Childhood SEP and upward social mobility may influence t2DM incidence in African American women but not in men.

AIMS: We aim to determine the association between prediabetes and diabetes with latent TB using National Health and Nutrition Examination Survey data. METHODS: We performed a cross-sectional analysis of 2011-2012 National Health and Nutrition Examination Survey data. Participants >/=20 years were eligible. Diabetes was defined by glycated hemoglobin (HbA1c) as no diabetes (</=5.6% [38 mmol/mol]), prediabetes (5.7-6.4% [39-46mmol/mol]), and diabetes (>/=6.5% [48 mmol/mol]) combined with self-reported diabetes. Latent TB infection was defined by the QuantiFERON(R)-TB Gold In Tube (QFT-GIT) test. Adjusted odds ratios (aOR) of latent TB infection by diabetes status were calculated using logistic regression and accounted for the stratified probability sample. RESULTS: Diabetes and QFT-GIT measurements were available for 4,958 (89.2%) included participants. Prevalence of diabetes was 11.4% (95%CI 9.8-13.0%) and 22.1% (95%CI 20.5-23.8%) had prediabetes. Prevalence of latent TB infection was 5.9% (95%CI 4.9-7.0%). After adjusting for age, sex, smoking status, history of active TB, and foreign born status, the odds of latent TB infection were greater among adults with diabetes (aOR 1.90, 95%CI 1.15-3.14) compared to those without diabetes. The odds of latent TB in adults with prediabetes (aOR 1.15, 95%CI 0.90-1.47) was similar to those without diabetes. CONCLUSIONS: Diabetes is associated with latent TB infection among adults in the United States, even after adjusting for confounding factors. Given diabetes increases the risk of active TB, patients with co-prevalent diabetes and latent TB may be targeted for latent TB treatment.

CONTEXT: Assessing training needs of the public health workforce is crucial for creating professional development opportunities to improve knowledge, competence, and effectiveness of this workforce. DISSEMINATION: Regional Public Health Training Centers (RPHTCs) assess workforce training needs and deliver training based on identified needs. To determine training priorities, several needs assessment surveys have been administered by RPHTCs and national public health member organizations. EVALUATION: This study identified the types of training questions being asked to public health practitioners in the various assessment surveys implemented by RPHTCs and national membership organizations. Although the surveys measured similar overarching constructs, multiple approaches with limited consistency were used to measure training needs. DISCUSSION: Although successful in responding to the needs of their targeted constituents, the limited consistency among survey types makes generalization of findings difficult. Disseminating common metrics and aggregate survey findings would increase efficiency in determining workforce training needs and developing targeted training.

OBJECTIVES: During 2010-2014, the Centers for Disease Control and Prevention implemented the National Public Health Improvement Initiative (NPHII) to assist 73 public health agencies in conducting activities to increase accreditation readiness, improve efficiency and effectiveness through quality improvement, and increase performance management capacity. A summative evaluation of NPHII was conducted to examine whether awardees met the initiative's objectives, including increasing readiness for accreditation. DESIGN: A nonexperimental, utilization-focused evaluation with a multistrand, sequential mixed-methods approach was conducted to monitor awardee accomplishments and activities. Data analysis included descriptive statistics, as well as subanalyses of data by awardee characteristics. Thematic analysis using deductive a priori codes was used for qualitative analysis. RESULTS: Ninety percent of awardees reported completing at least 1 accreditation prerequisite during NPHII, and more than half reported completing all 3 prerequisites by the end of the program. Three-fourths of awardees that completed a self-assessment reported closing gaps for at least 1 Public Health Accreditation Board (PHAB) standard. Within 3 years of the launch of PHAB accreditation, 7 NPHII awardees were accredited; another 38 had formally applied for accreditation. CONCLUSIONS: Through NPHII, awardees increased collaborative efforts around accreditation readiness, accelerated timelines for preparing for accreditation, and prioritized the completion of required accreditation activities.

PURPOSE: Assess relationships between having a medical home and health care-seeking behavior attitudes among parents of low-income children with non-urgent encounters in acute settings (emergency, urgent care centers). METHODS: We analyzed data from 1,743 publicly insured children within non-urgent encounters. Parents completed surveys assessing medical home access and attitudes regarding health care-seeking behavior. Multivariate logistic regression analyses were conducted to investigate relationships between medical home access and attitudes. RESULTS: Forty percent of children with non-urgent acute care encounters had medical homes. Having a medical home was positively associated with always calling the doctor before going to acute care settings and preference to take a child to their doctor if the doctor's office was open evenings and weekends. CONCLUSIONS: Although having a medical home is associated with positive attitudes regarding health care-seeking behavior, it may not suffice to overcome other barriers that precipitate non-urgentencounters.

Importance: Food subsidies are designed to enhance food availability, but whether they promote cardiometabolic health is unclear. Objective: To investigate whether higher consumption of foods derived from subsidized food commodities is associated with adverse cardiometabolic risk among US adults. Design, Setting, and Participants: Cross-sectional analysis of the National Health and Nutrition Examination Survey data from 2001 to 2006. Our final analysis was performed in January 2016. Participants were 10308 nonpregnant adults 18 to 64 years old in the general community. Exposure: From a single day of 24-hour dietary recall in the National Health and Nutrition Examination Survey, we calculated an individual-level subsidy score that estimated an individual's consumption of subsidized food commodities as a percentage of total caloric intake. Main Outcomes and Measures: The main outcomes were body mass index (calculated as weight in kilograms divided by height in meters squared), abdominal adiposity, C-reactive protein level, blood pressure, non-high-density lipoprotein cholesterol level, and glycemia. Results: Among 10308 participants, the mean (SD) age was 40.2 (0.3) years, and a mean (SD) of 50.5% (0.5%) were male. Overall, 56.2% of calories consumed were from the major subsidized food commodities. United States adults in the highest quartile of the subsidy score (compared with the lowest) had increased probabilities of having a body mass index of at least 30 (prevalence ratio, 1.37; 95% CI, 1.23-1.52), a ratio of waist circumference to height of at least 0.60 (prevalence ratio, 1.41; 95% CI, 1.25-1.59), a C-reactive protein level of at least 0.32 mg/dL (prevalence ratio, 1.34; 95% CI, 1.19-1.51), an elevated non-high-density lipoprotein cholesterol level (prevalence ratio, 1.14; 95% CI, 1.05-1.25), and dysglycemia (prevalence ratio, 1.21; 95% CI, 1.04-1.40). There was no statistically significant association between the subsidy score and blood pressure. Conclusions and Relevance: Among US adults, higher consumption of calories from subsidized food commodities was associated with a greater probability of some cardiometabolic risks. Better alignment of agricultural and nutritional policies may potentially improve population health.

OBJECTIVE: The contribution of subsidized food commodities to total food consumption is unknown. We estimated the proportion of individual energy intake from food commodities receiving the largest subsidies from 1995 to 2010 (corn, soyabeans, wheat, rice, sorghum, dairy and livestock). DESIGN: Integrating information from three federal databases (MyPyramid Equivalents, Food Intakes Converted to Retail Commodities, and What We Eat in America) with data from the 20012006 National Health and Nutrition Examination Surveys, we computed a Subsidy Score representing the percentage of total energy intake from subsidized commodities. We examined the scores distribution and the probability of having a high (70th percentile) v. low (30th percentile) score, across the population and subgroups, using multivariate logistic regression. SETTING: Community-dwelling adults in the USA. SUBJECTS: Participants (n 11 811) aged 1864 years. RESULTS: Median Subsidy Score was 567% (interquartile range 472654%). Younger, less educated, poorer, and Mexican Americans had higher scores. After controlling for covariates, age, education and income remained independently associated with the score: compared with individuals aged 5564 years, individuals aged 1824 years had a 50% higher probability of having a high score (P<00001). Individuals reporting less than high-school education had 21% higher probability of having a high score than individuals reporting college completion or higher (P=0003); individuals in the lowest tertile of income had an 11% higher probability of having a high score compared with individuals in the highest tertile (P=002). CONCLUSIONS: Over 50% of energy in US diets is derived from federally subsidized commodities.

OBJECTIVES: We assessed survival in American Indians and Alaska Natives (AI/ANs) with end-stage renal disease attributed to diabetes who initiated hemodialysis between 1995 and 2009. METHODS: Follow-up extended from the first date of dialysis in the United States Renal Data System until December 31, 2010, kidney transplantation, or death. We used the Kaplan-Meier method to compute survival on dialysis by age and race/ethnicity and Cox regression analysis to compute adjusted hazard ratios (HRs). RESULTS: Our study included 510 666 persons-48% Whites, 2% AI/AN persons, and 50% others. Median follow-up was 2.2 years (interquartile range = 1.1-4.1 years). At any age, AI/AN persons survived longer on hemodialysis than Whites; this finding persisted after adjusting for baseline differences. Among AI/AN individuals, those with full Indian blood ancestry had the lowest adjusted risk of death compared with Whites (HR = 0.58; 95% confidence interval = 0.55, 0.61). The risk increased with declining proportion of AI/AN ancestry. CONCLUSIONS: Survival on dialysis was better among AI/AN than White persons with diabetes. Among AI/AN persons, the inverse relationship between risk of death and level of AI/AN ancestry suggested that cultural or hereditary factors played a role in survival.

Nationally representative estimates indicate that 18.8 million adults in the United States have received a diagnosis with diabetes mellitus. When glycemic control is not optimized, diabetes imposes additional burdensome care requirements, health-care costs, and high risk of disabling complications, and this has been especially evident in socioeconomically disadvantaged and minority populations. For example, higher levels of glycated hemoglobin (A1c) have been associated with increased risk of diabetic retinopathy, increased risk of chronic kidney disease, and increased risk of cardiovascular disease. Reducing A1c levels through combined clinical and effective self-management has demonstrated reduced risk for microvascular complications. Although the most appropriate target A1c levels to achieve optimal health impact might vary among persons, the majority of adults with diabetes will benefit from reduction of A1c levels to ≤7%; targets for patients with a history of severe hypoglycemia, or with limited life expectancy, or with advanced complications, or with certain comorbid conditions might be higher. Nevertheless, an A1c level of 9% constitutes a clearly modifiable, high level of risk that few, if any, persons with diabetes should be exposed to. Accordingly, the Healthy People 2020 objectives include a 10% reduction in the proportion of the diabetes population that has poor glycemic control (A1c >9%) as a target.