Hypoglycemia in Older Adults: Time Trends and Treatment Differences in Patients Aged ≥75 Years With Type 2 Diabetes

ObjectivesHypoglycemia is a potentially life-threatening drug event under antidiabetic treatment. The aim of the study was to examine time trends in severe hypoglycemia in older adults with type 2 diabetes mellitus (T2DM) and antidiabetic treatment.DesignMulticenter prospective diabetes patient follow-up registry (DPV).Setting and ParticipantsPatients aged ≥75 years with T2DM and documented treatment between 2005 and 2019.MethodsOutcomes of interest were rates of severe hypoglycemia, diabetes therapy, body mass index, HbA1c, and estimated glomerular filtration rate. Time trends of outcomes were analyzed in the whole cohort and compared between age groups (75–<80, 80–<85, ≥85 years).ResultsA total of 136,931 patients from 188 diabetes centers were included. The adjusted HbA1c decreased from 7.3% (95% confidence interval 7.3–7.4) in 2005 to 7.2% (7.2–7.2) in 2019 (P < .001), with no significant difference between age groups (P = .47). Rates of severe hypoglycemia decreased from 6.7 (6.0–7.4) to 4.1 of 100 person-years (3.7–4.5) (P < .001) in the entire population. Patients aged ≥85 years had constantly lower HbA1c levels compared with younger groups (P < .001). Although severe hypoglycemia decreased the most in the ≥85 age group (P < .001), severe hypoglycemia remained consistently higher in this group compared with the 75 to <80 years group (P < .001).Conclusions and ImplicationsDuring the analyzed time, the risk for severe hypoglycemia decreased. Although drugs with intrinsic risk for hypoglycemia were used less frequently, antidiabetic treatment in older adults should be further improved to continue reducing severe hypoglycemia in this age group, potentially accepting less strict metabolic control and age-specific target ranges.     

Do Risk Factors Explain the Increased Prevalence of Type 2 Diabetes Among California Asian Adults?

Asian subgroup-specific information on type 2 diabetes mellitus (DM) is scarce. Using the California Health Interview Survey 2007 data, we examined Chinese, Korean, Japanese, Filipinos, and Vietnamese adults (n = 3,688) and Caucasian adults (n = 33,981) for the prevalence of DM and risk factors. The age-adjusted prevalence of DM was the highest among Filipinos (8.05%) followed by Japanese (7.07%), Vietnamese (7.03%), and Koreans (6.3%). Chinese (5.93%) was the only Asian group studied whose prevalence was lower than Caucasians (5.94%). From multiple logistic regression, after adjusting for risk factors, Japanese had the highest likelihood of DM (OR = 1.75, CI = [1.12–2.73], P < 0.05), followed by Filipinos (1.66, [1.13–2.43], P < 0.01), and Koreans (1.59, [1.00–2.52], P < 0.05), relative to Caucasians. Our results suggest that even after accounting for lifestyle and other risk factor differences between Caucasians and key Asian subgroups in California, Japanese, Filipinos, and Koreans have a 1.6–1.75 greater likelihood of DM compared to Caucasians.     

The Live Well,Be Well Study: A Community-Based, Translational Lifestyle Program to Lower Diabetes Risk Factors in Ethnic Minority and Lower–Socioeconomic Status Adults

Objectives. We evaluated a community-based, translational lifestyle program to reduce diabetes risk in lower–socioeconomic status (SES) and ethnic minority adults.Methods. Through an academic–public health department partnership, community-dwelling adults at risk for diabetes were randomly assigned to individualized lifestyle counseling delivered primarily via telephone by health department counselors or a wait-list control group. Primary outcomes (6 and 12 months) were fasting glucose level, triglycerides, high- and low-density lipoprotein cholesterol, weight, waist circumference, and systolic blood pressure. Secondary outcomes included diet, physical activity, and health-related quality of life.Results. Of the 230 participants, study retention was 92%. The 6-month group differences for weight and triglycerides were significant. The intervention group lost 2 pounds more than did the control group (P = .03) and had decreased triglyceride levels (difference in change, 23 mg/dL; P = .02). At 6 months, the intervention group consumed 7.7 fewer grams per day of fat (P = .05) and more fruits and vegetables (P = .02) than did control participants.Conclusions. Despite challenges designing effective translational interventions for lower-SES and minority communities, this program modestly improved some diabetes risk factors. Thus, individualized, telephone-based models may be a promising alternative to group-based interventions.The prevalence of type 2 diabetes continues to rise at an alarming rate in the United States. Approximately 25.6 million adults (11.3% of the US population aged 20 years or older) have diabetes, and another estimated 79 million have prediabetes.1 Greater risk of diabetes is observed for ethnic minority1–5 and lower–socioeconomic status (SES) groups6 compared with White adults of similar ages.Several clinical trials have tested intensive lifestyle interventions or pharmacological agents in preventing or delaying type 2 diabetes in adults at risk.7–9 These trials showed impressive diabetes risk reductions for lifestyle interventions associated with relatively modest amounts of weight loss and exercise.7–9 Translating this knowledge into lifestyle interventions delivered in real-world settings is thus a major priority.10–12To reduce observed disparities in risk of diabetes, translational studies need to be community-based and designed for lower-SES and ethnic minority populations. Although many translational lifestyle interventions are available, most were designed for clinical settings;13–21 only a few are offered in community settings.22–26 Of community-based translations, only 3 were designed specifically for lower-SES or minority populations,23–25 and only 1 of these—Project HEED, or Help Educate to Eliminate Diabetes—was evaluated with a randomized controlled trial design.23 HEED was successful in obtaining significant group differences in weight loss at 12 months, but no other significant clinical or behavioral changes were observed.We conducted a randomized controlled trial of a low-intensity lifestyle intervention for lower-SES, ethnic minority, Spanish- and English-speaking adults. This was a collaborative project between the University of California, San Francisco, and the City of Berkeley Division of Public Health. Public health departments are a good venue for community-based translations to reduce disparities because they serve vulnerable populations most at risk for chronic disease and engage in chronic disease prevention.     

Relationship Between Food Insecurity and Functional Limitations in Older Adults from 2005–2014 NHANES

Abstract

Background: Food insecurity refers to the physical, social, and economic inability to access and secure sufficient, safe and nutritious food. Food insecurity has been found to be associated with poor health status, obesity, and chronic disease. To date, a relationship between food insecurity and functional limitations has not been described in of older adults.

Methods: We examined 9309 adults ≥60 years old from the 2005–2014 National Health and Nutrition Examination Surveys (NHANES). Food security was categorized as full, marginal, low, and very low. Functional limitations were assessed as having difficulty in physical, basic or instrumental activities of daily living.

Results: Of adults ≥60 years old (mean age: 70.5?±?0.08, 51% female), the prevalence of full, marginal, low, or very low food insecurity was 7572 (81%), 717 (7%), 667 (8%), and 353 (4%), respectively. The prevalence of any functional limitations was 5895 (66.3%). The adjusted odds (OR [95%CI]) of having any functional limitation in marginal, low, and very low food security levels compared to full food security are: 1.08 [1.02–1.13], 1.16 [1.10–1.22], 1.14 [1.07–1.21], respectively. The association between levels of food insecurity and functional limitation is modified by race/ethnicity.

Conclusions: Functional limitation is significantly associated with increasing food insecurity in older adults.     

Do Community Social Capital and Built Environment Associate With Homebound in Older Adults? The JAGES Niigata Study

BackgroundHomebound status is one of the most important risk factors associated with functional decline and long-term care in older adults. Studies show that neighborhood built environment and community social capital may be related to homebound status. This study aimed to clarify the association between homebound status for community-dwelling older adults and community environment—including social capital and neighborhood built environment—in rural and urban areas.MethodsWe surveyed people aged 65 years and older residing in three municipalities of Niigata Prefecture, Japan, who were not certified as requiring long-term care. The dependent variable was homebound status; explanatory variables were community-level social capital and neighborhood built environment. Covariates were age, sex, household, marital status, socioeconomic status, instrumental activities of daily living, the Geriatric Depression Scale-15, self-rated health, number of diseases under care, and individual social capital. The association between community social capital or neighborhood built environment and homebound status, stratified by rural/urban areas, was investigated using multilevel logistic regression analysis.ResultsAmong older adults (n = 18,099), the homebound status prevalence rate was 6.9% in rural areas and 4.2% in urban areas. The multilevel analysis showed that, in rural areas, fewer older adults were homebound in communities with higher civic participation and with suitable parks or pavements for walking and exercising. However, no significant association was found between community social capital or neighborhood built environment and homebound status for urban older adults.ConclusionCommunity social capital and neighborhood built environment were significantly associated with homebound status in older adults in rural areas.Key words: community social capital, neighborhood built environment, epidemiology, homebound, urban rural differences     

Birth Weight and Risk Factors for Cardiovascular Disease and Type 2 Diabetes in US Children and Adolescents: 10 Year Results from NHANES

Previous studies have shown that birth weight and other birth characteristics may be associated with risk for type 2 diabetes and cardiovascular disease (CVD) later in life; however, results using large US national survey data are limited. Our goal was to determine the aforementioned associations using nationally representative data. We studied children and adolescents 6–15 years using data from the National Health and Nutrition Examination Survey cycles 2001–2010. Survey and examination data included demographic and early childhood characteristics, current health status, physical activity information, anthropometric measurements, dietary data (total energy, saturated fat, sodium, and sugar intakes), biomarkers related to selected risk factors of CVD [systolic blood pressure (SBP), plasma C-reactive protein (CRP) and lipid profiles], and type 2 diabetes [fasting glucose, insulin, and homeostasis model assessment (HOMA)]. Birth weight (proxy-reported) was inversely associated with SBP among girls; SBP levels increased 1.4 mmHg for each 1,000 g decrease in birth weight (p = 0.003) after controlling for potential confounders. Birth weight was not associated with levels of CRP or lipid profiles across the three racial groups. In addition, birth weight was inversely related to levels of fasting insulin and HOMA among non-Hispanic Whites; for each 1,000 g decrease in birth weight, fasting insulin levels increased 9.1 % (p = 0.007) and HOMA scores increased 9.8 % (p = 0.007). Birth weight was inversely associated with the levels of SBP, fasting insulin, and HOMA. These results support a role for birth weight, independent of the strong effects of current body weight status, in increasing risk for CVD and type 2 diabetes.     

Twenty-Four Months’ Resistance and Endurance Training Improves Muscle Size and Physical Functions but Not Muscle Quality in Older Adults Requiring Long-Term Care

The journal of nutrition, health & aging - To assess the effects of 24 months training on muscle quality, size, strength, and gait abilities in older adults who need long-term care. Design:...     

A Profile of Black and Latino Older Adults Receiving Care in Nursing Homes: 2011–2017

ObjectiveTo identify if disparate trends in the access and use of nursing home (NH) services among Black and Latino older adults compared with White older adults persist. Access was operationalized as the NHs that served Black, Latino, and White residents. Use was operationalized as the utilization of NH services by Black, Latino, and White residents.DesignThis was an observational study analyzing facility-level data from LTCfocus for 2011 to 2017.Setting and ParticipantsAll NH residents present in US NHs participating in the Centers for Medicare and Medicaid Services program on the first Thursday in April in the years 2011 to 2017. NHs with fewer than 4500 bed-days per year are excluded in the LCTfocus dataset. Black, Latino, and White were the racial/ethnic groups of interest.MethodsWe calculated the mean percentage of each racial/ethnic group in NHs (Black, Latino, White) annually along with the number of NHs that provided care for these groups. We conducted a simple trend analysis using ordinary least squares to estimate the change in NH access and use by racial/ethnic group over time.ResultsOur NH sample ranged from 15,564 in 2011 to 14,956 in 2017. Latino residents' use of NHs increased by 20.47% and Black residents increased by 11.42%, whereas there was a 1.36% decrease in White residents’ use of NHs. In this 7-year span, there was a 4.44% and 6.41% decline in the number of NHs that serve any Black and Latino older adults, respectively, compared with a 2.26% decline in NHs that serve only White older adults (access).Conclusions and ImplicationsOur findings reveal a continued disproportionate rise in Black and Latino older adults’ use of NHs while the number of NHs that serve this population have declined. This work can inform federal and state policies to ensure access to long-term care services and supports in the community for all older adults and prevent inappropriate NH closures.     

Design of a Randomized Controlled Trial of a Web-Based Intervention to Reduce Cardiovascular Disease Risk Factors Among Remote Reservation–Dwelling American Indian Adults with Type 2 Diabetes

We describe a randomized controlled trial, the Lakota Oyate Wicozani Pi Kte (LOWPK) trial, which was designed to determine whether a Web-based diabetes and nutritional intervention can improve risk factors related to cardiovascular disease (CVD) among a group of remote reservation?Cdwelling adult American Indian men and women with type 2 diabetes who are at high risk for CVD. Enrollment on a rolling basis of 180 planned participants began during 2009; an average 18-month follow-up was completed by June 2011. The primary outcome variable is change in glycosylated hemoglobin level after an average 18-month follow-up period. Secondary outcome variables include changes in low-density lipoprotein cholesterol, systolic blood pressure, body mass index, and smoking status, as well as an evaluation of intervention cost-effectiveness. If effective, the LOWPK trial may serve as a guide for future chronic disease intervention trials in remote, technologically challenged settings.     

Evaluation of a Synchronous,Online Diabetes Nutrition Education Program for American Indians and Alaska Natives With Type 2 Diabetes: Facilitators and Participants’ Experiences

ObjectiveTo explore the overall experiences of key players involved in a culturally adapted, online, synchronous diabetes nutrition education program across 5 reservation tribal and intertribal urban Indian clinics.MethodsA multimethods design, including postclass surveys with Likert-scale and short-answer questions, was completed after each of the 5 classes. Participants (n = 54) and class facilitators/coordinators (n = 10) completed postclass surveys (n = 189 and 58, respectively). A subset of participants (n = 24) and all class facilitators/coordinators (n = 10) engaged in online focus groups after the conclusion of program implementation. Qualitative thematic methods and frequency distributions were used to analyze the data.ResultsMost participants reported that the classes were enjoyable (94%), culturally respectful (77%), and easily accessed online (68%). Qualitative themes included (1) class satisfaction, (2) class improvements, (3) preference for class facilitator, and (4) recommendations to improve recruitment and retention.Conclusions and ImplicationsThese findings will guide program modifications to provide improved diabetes nutrition education for American Indians and Alaska Natives adults with type 2 diabetes.     

Supervised Exercise in Water: Is It a Viable Alternative in Overweight/Obese People with or without Type 2 Diabetes? A Pilot Study

The study of the effects of a water-based exercise program in overweight/obese people with or without type 2 diabetes is a topic of relatively recent interest. This type of exercise presents some advantages in reducing the risk of injury or trauma, and it can be a valuable therapeutic card to play for sedentary or physically inactive patients who have chronic metabolic diseases. This work aims to make a contribution showing the effects of a water-based exercise intervention, supervised by graduates in sports sciences, in a group of overweight/obese people with or without type 2 diabetes. In total, 93 adults (age 60.59 ± 10.44 years), including 72 women (age 60.19 ± 10.97 years) and 21 men (age 61.95 ± 8.48 years), were recruited to follow a water-based exercise program (2 sessions/week, for 12 weeks) at the C.U.R.I.A.Mo. Healthy Lifestyle Institute of Perugia University. Results showed an improvement in body mass index (−0.90 ± 1.56, p = 0.001), waist circumference (−4.32 ± 6.03, p < 0.001), and systolic (−7.78 ± 13.37, p = 0.001) and diastolic (−6.30 ± 10.91, p = 0.001) blood pressure. The supervised water-based intervention was useful in managing patients with metabolic diseases who often present with other health impairments, such as musculoskeletal problems or cardiovascular or rheumatic disease that could contraindicate gym-based exercise.     

Physical Limitations Contribute to Food Insecurity and the Food Insecurity–Obesity Paradox in Older Adults at Senior Centers in Georgia

The purpose of this study was to explore the relationship of obesity and physical limitations with food insecurity among Georgians participating in the Older Americans Act (OAA) congregate meal-site program (N = 621, median age = 76 years, 83% female, 36% Black, and 64% White, convenience sample). Food insecurity was assessed using the modified 6-item US Household Food Security Survey Module; obesity was defined as Body Mass Index (BMI) or waist circumference (WC) class I or II obesity; and physical limitations (arthritis, joint pain, poor physical function, weight-related disability) were based on the Disablement Process. A series of multivariate logistic regression models found weight-related disability and obesity (WC class II) may be potential risk factors for food insecurity. Thus, obesity and weight-related disability may be risk factors to consider when assessing the risk of food insecurity and the need for food assistance in this vulnerable subgroup of older adults.     

Polychlorinated Biphenyl Exposures and Cognition in Older U.S. Adults: NHANES (1999–2002)

Background: Polychlorinated biphenyls (PCBs) are ubiquitously present in humans because of their resistance to degradation and accumulation in fatty tissues. Data on neurotoxic effects in older adults are limited.Objective: We examined the cross-sectional association between serum PCB concentrations and cognitive function in older adults from the general U.S. population.Methods: We analyzed data from 708 respondents, 60–84 years of age, participating in the National Health and Nutrition Examination Survey (1999–2002). We used the summed concentrations of 12 lipid-standardized PCB congeners as the measure of exposure and assessed cognitive function with the Digit-Symbol Coding test. We adjusted analyses for age, education, race/ethnicity, and poverty/income ratio.Results: The median concentration of lipid-standardized PCBs in serum was 271 ng/g (interquartile range, 193–399 ng/g). We found a significant interaction between dioxin-like PCB concentration and age in association with cognitive score (p = 0.04). Among older individuals (70–84 years of age), a 100-ng/g increase in serum concentrations of dioxin-like PCBs was associated with a significantly lower cognitive score (–2.7 points; 95% CI: –5.1, –0.2; p = 0.04); however, in younger individuals (60–69 years of age), there was a nonsignificant positive association (2.9 points; 95% CI: –1.8, 7.7; p = 0.32). Among the older participants, the negative association was more pronounced in women than in men.Conclusion: Our findings support the hypothesis that PCB exposure has adverse cognitive effects even at levels generally considered to pose low or no risk, perhaps affecting mainly those of advanced age.Citation: Bouchard MF, Oulhote Y, Sagiv SK, Saint-Amour D, Weuve J. 2014. Polychlorinated biphenyl exposures and cognition in older U.S. adults: NHANES (1999–2002). Environ Health Perspect 122:73–78; http://dx.doi.org/10.1289/ehp.1306532     

Incremental Costs and Cost Effectiveness of Intensive Treatment in Individuals with Type 2 Diabetes Detected by Screening in the ADDITION-UK Trial: An Update with Empirical Trial–Based Cost Data

Background

There is uncertainty about the cost effectiveness of early intensive treatment versus routine care in individuals with type 2 diabetes detected by screening.

Change in Diabetes Prevalence and Control among New York City Adults: NYC Health and Nutrition Examination Surveys 2004–2014

National examination surveys provide trend information on diabetes prevalence, diagnoses, and control. Few localities have access to such information. Using a similar design as the National Health and Nutrition Examination Survey (NHANES), two NYC Health and Nutrition Examination Surveys (NYC HANES) were conducted over a decade, recruiting adults ≥?20 years using household probability samples (n =?1808 in 2004; n =?1246 in 2013–2014) and physical exam survey methods benchmarked against NHANES. Participants had diagnosed diabetes if told by a health provider they had diabetes, and undiagnosed diabetes if they had no diagnosis but a fasting plasma glucose ≥?126 mg/dl or A1C?≥?6.5%. We found that between 2004 and 2014, total diabetes prevalence (diagnosed and undiagnosed) in NYC increased from 13.4 to 16.0% (P =?0.089). In 2013–2014, racial/ethnic disparities in diabetes burden had widened; diabetes was highest among Asians (24.6%), and prevalence was significantly lower among non-Hispanic white adults (7.7%) compared to that among other racial/ethnic groups (P <?0.001). Among adults with diabetes, the proportion of cases diagnosed increased from 68.3 to 77.3% (P =?0.234), and diagnosed cases with very poor control (A1C >?9%), decreased from 26.9 to 18.0% (P =?0.269), though both were non-significant. While local racial/ethnic disparities in diabetes prevalence persist, findings suggest modest improvements in diabetes diagnosis and management.     

State Variation in Long-Term Care Availability,Regulation, and Cost and Suicide Mortality Among Older Adults in the United States: 2010–2015

ObjectivesResidential long-term care (LTC) facilities may be key settings for the prevention of suicide among older adults; however, little is known about the relationship between statewide policies determining characteristics of LTC facilities and suicide mortality. The primary goal of this study was to evaluate the association between state policies regarding availability, regulation, and cost of LTC and suicide mortality among adults aged 55 and older in the United States over a 5-year period.DesignLongitudinal ecological study.Setting and ParticipantsLTC residents from 16 states reporting mortality data to the National Violent Death Reporting System (NVDRS) from 2010 to 2015.MethodsWe linked suicide data from the NVDRS and data sources on LTC services and regulations for 16 states. We applied a natural language-processing algorithm to identify suicide deaths related to LTC. We used fixed effect regression models to assess whether state variation in LTC characteristics is related to variation in the rate of suicide (both overall and related to LTC) among older adults.ResultsThere were 25,040 suicides among those aged 55 and older reported to the NVDRS during the study period; 382 suicides were determined to be associated with LTC in some manner. After adjusting for state-level characteristics, greater average nursing home capacity was significantly associated with increase in the cumulative incidence of suicide related to LTC (β = 0.087, SE = 0.026, P < .01), but not overall suicide incidence. Neither cost nor regulation measures were significantly associated with state-level LTC-related suicide incidence.Conclusions and ImplicationsState-level variations in LTC facility capacity are related to variation in LTC-related suicide incidence among older adults. Given the challenges of preventing suicide among older adults through facility- or individual-level interventions, policies governing the features and provision of LTC services may therefore serve as a means for public health suicide prevention.     

Energy Balance–Related Behaviors,Perinatal, Sociodemographic,and Parental Risk Factors Associated with Obesity in Italian Preschoolers

Objective: The obesity epidemic stems from the complex interplay between genetics and environmental factors. Identifying age-specific risk factors in preschoolers may allow implementing more effective intervention strategies.

The aim of the present investigation was to examine the association of overweight/obesity with several perinatal, parental, socioeconomic status (SES), and lifestyle-related risk factors in a large sample of Italian preschoolers.

Methods: One thousand eleven children (age 2.0 to 5.7 years) were included in the study. Family pediatricians measured weight and height and collected information on obesity risk factors by means of questionnaires. Perinatal risk factors were recalled from electronic medical records. Weight status was defined according to cutoffs of the International Obesity Task Force (IOTF).

Results: Seven hundred sixty-four children (75.6%) were normal weight, and 247 (24.4%) were overweight/obese. Multivariate analysis showed that skipping breakfast (odds ratio [OR] = 3.7; 95% confidence interval [CI], 1.32–10.51), daily drinking of sugar-sweetened beverages (OR = 2.0; 95% CI, 1.02–4.03), meat consumption <5 times/week (OR = 2.2; 95% CI, 1.11–4.57), and formula feeding (OR = 2.1; 95% CI, 0.8–4.5) were significantly (p < 0.05) associated with increased risk of obesity.

Conclusions: Though exclusive formula or mixed feeding represents an age-specific risk factor for overweight/obesity, lifestyle factors associated with increased risk in Italian preschoolers include habits that are common to school-age children, such as skipping breakfast and consumption of sugar-sweetened beverages. The reduced consumption of meat emerged as a risk factor for overweight/obesity, but future research is required to better understand this relationship. Our data suggest, on the whole, that prevention of such unhealthy behaviors must be pursued in preschoolers by means of age-specific interventions.