Seth A. Berkowitz

Food Insecurity and Metabolic Control Among U.S. Adults With Diabetes

OBJECTIVE We sought to determine whether food insecurity is associated with worse glycemic, cholesterol, and blood pressure control in adults with diabetes. RESEARCH DESIGN AND METHODS We conducted a cross-sectional analysis of data from participants of the 1999–2008 National Health and Nutrition Examination Survey. All adults with diabetes (type 1 or type 2) by self-report or diabetes medication use were included. Food insecurity was measured by the Adult Food Security Survey Module. The outcomes of interest were proportion of patients with HbA1c >9.0% (75 mmol/mol), LDL cholesterol >100 mg/dL, and systolic blood pressure >140 mmHg or diastolic blood pressure >90 mmHg. We used multivariable logistic regression for analysis. RESULTS Among the 2,557 adults with diabetes in our sample, a higher proportion of those with food insecurity (27.0 vs. 13.3%, P < 0.001) had an HbA1c >9.0% (75 mmol/mol). After adjustment for age, sex, educational attainment, household income, insurance status and type, smoking status, BMI, duration of diabetes, diabetes medication use and type, and presence of a usual source of care, food insecurity remained significantly associated with poor glycemic control (odds ratio [OR] 1.53 [95% CI 1.07–2.19]). Food insecurity was also associated with poor LDL control before (68.8 vs. 49.8, P = 0.002) and after (1.86 [1.01–3.44]) adjustment. Food insecurity was not associated with blood pressure control. CONCLUSIONS Food insecurity is significantly associated with poor metabolic control in adults with diabetes. Interventions that address food security as well as clinical factors may be needed to successfully manage chronic disease in vulnerable adults.

Material Need Insecurities, Control of Diabetes Mellitus, and Use of Health Care Resources Results of the Measuring Economic Insecurity in Diabetes Study

IMPORTANCE Increasing access to care may be insufficient to improve the health of patients with diabetes mellitus and unmet basic needs (hereinafter referred to as material need insecurities). How specific material need insecurities relate to clinical outcomes and the use of health care resources in a setting of near-universal access to health care is unclear. OBJECTIVE To determine the association of food insecurity, cost-related medication underuse, housing instability, and energy insecurity with control of diabetes mellitus and the use of health care resources. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional data were collected from June 1, 2012, through October 31, 2013, at 1 academic primary care clinic, 2 community health centers, and 1 specialty center for the treatment of diabetes mellitus in Massachusetts. A random sample of 411 patients, stratified by clinic, consisted of adults (aged ≥21 years) with diabetes mellitus (response rate, 62.3%). MAIN OUTCOMES AND MEASURES The prespecified primary outcome was a composite indicator of poor diabetes control (hemoglobin A1c level, >9.0%; low-density lipoprotein cholesterol level, >100 mg/dL; or blood pressure, >140/90 mm Hg). Prespecified secondary outcomes included outpatient visits and a composite of emergency department (ED) visits and acute care hospitalizations (ED/inpatient visits). RESULTS Overall, 19.1% of respondents reported food insecurity; 27.6%, cost-related medication underuse; 10.7%, housing instability; 14.1%, energy insecurity; and 39.1%, at least 1 material need insecurity. Poor diabetes control was observed in 46.0% of respondents. In multivariable models, food insecurity was associated with a greater odds of poor diabetes control (adjusted odds ratio [OR], 1.97 [95% CI, 1.58-2.47]) and increased outpatient visits (adjusted incident rate ratio [IRR], 1.19 [95% CI, 1.05-1.36]) but not increased ED/inpatient visits (IRR, 1.00 [95% CI, 0.51-1.97]). Cost-related medication underuse was associated with poor diabetes control (OR, 1.91 [95% CI, 1.35-2.70]) and increased ED/inpatient visits (IRR, 1.68 [95% CI, 1.21-2.34]) but not outpatient visits (IRR, 1.07 [95% CI, 0.95-1.21]). Housing instability (IRR, 1.31 [95% CI, 1.14-1.51]) and energy insecurity (IRR, 1.12 [95% CI, 1.00-1.25]) were associated with increased outpatient visits but not with diabetes control (OR, 1.10 [95% CI, 0.60-2.02] and OR, 1.27 [95% CI, 0.96-1.69], respectively) or with ED/inpatient visits (IRR, 1.49 [95% CI, 0.81-2.73] and IRR, 1.31 [95% CI, 0.80-2.13], respectively). An increasing number of insecurities was associated with poor diabetes control (OR for each additional need, 1.39 [95% CI, 1.18-1.63]) and increased use of health care resources (IRR for outpatient visits, 1.09 [95% CI, 1.03-1.15]; IRR for ED/inpatient visits, 1.22 [95% CI, 0.99-1.51]). CONCLUSIONS AND RELEVANCE Material need insecurities were common among patients with diabetes mellitus and had varying but generally adverse associations with diabetes control and the use of health care resources. Material need insecurities may be important targets for improving care of diabetes mellitus.

Initial Choice of Oral Glucose-Lowering Medication for Diabetes Mellitus: A Patient-Centered Comparative Effectiveness Study

IMPORTANCE Although many classes of oral glucose-lowering medications have been approved for use, little comparative effectiveness evidence exists to guide initial selection of therapy for diabetes mellitus. OBJECTIVE To determine the effect of initial oral glucose-lowering agent class on subsequent need for treatment intensification and 4 short-term adverse clinical events. DESIGN, SETTING, AND PARTICIPANTS This study was a retrospective cohort study of patients who were fully insured members of Aetna (a large national health insurer) who had been prescribed an oral glucose-lowering medication from July 1, 2009, through June 30, 2013. Individuals newly prescribed an oral glucose-lowering agent who filled a second prescription for a medication in the same class and with a dosage at or above the World Health Organizations defined daily dose within 90 days of the end-of-days supply of the first prescription were studied. Individuals with interim prescriptions for other oral glucose-lowering medications were excluded. EXPOSURES Initiation of treatment with metformin, a sulfonylurea, a thiazolidinedione, or a dipeptidyl peptidase 4 inhibitor. MAIN OUTCOMES AND MEASURES Time to addition of a second oral agent or insulin, each component separately, hypoglycemia, other diabetes-related emergency department visits, and cardiovascular events. RESULTS A total of 15 516 patients met the inclusion criteria, of whom 8964 (57.8%) started therapy with metformin. In unadjusted analyses, use of medications other than metformin was significantly associated with an increased risk of adding a second oral agent only, insulin only, and a second agent or insulin (P < .001 for all). In propensity score and multivariable-adjusted Cox proportional hazards models, initiation of therapy with sulfonylureas (hazard ratio [HR], 1.68; 95% CI, 1.57-1.79), thiazolidinediones (HR, 1.61; 95% CI, 1.43-1.80), and dipeptidyl peptidase 4 inhibitors (HR, 1.62; 95% CI, 1.47-1.79) was associated with an increased hazard of intensification. Alternatives to metformin were not associated with a reduced risk of hypoglycemia, emergency department visits, or cardiovascular events. CONCLUSIONS AND RELEVANCE Despite guidelines, only 57.8% of individuals began diabetes treatment with metformin. Beginning treatment with metformin was associated with reduced subsequent treatment intensification, without differences in rates of hypoglycemia or other adverse clinical events. These findings have significant implications for quality of life and medication costs.

Opioids for Chronic Pain

A S PRACTICING PHYSICIANS, WE HAVE OBserved that the problems associated with opioid medications for the treatment of chronic pain are growing rapidly. In primary and specialty care, chronic nonmalignant pain is common, with 20% to 40% of adults reporting chronic pain. Opioids are the most common means of treatment for chronic pain; 15% to 20% of office visits in the United States now include the prescription of an opioid, and 4 million Americans per year are prescribed a long-acting opioid. Opioids have become the most commonly prescribed drug category in the United States, and the increasing prevalence of their prescription closely parallels the increasing emphasis, which began in the mid-1990s, on treatment of chronic pain. A partial explanation of why we got to this point is that the lessons learned from the undertreatment of pain in patients with cancer were generalized to patients with chronic pain and no clear end point of cure or death. The practice of using opioids for chronic pain treatment also has been reinforced by continuing medical education classes and state regulations encouraging physicians to adequately treat pain.

Food-Insecure Dietary Patterns Are Associated With Poor Longitudinal Glycemic Control in Diabetes: Results From the Boston Puerto Rican Health Study

OBJECTIVE To determine whether dietary patterns associated with food insecurity are associated with poor longitudinal glycemic control. RESEARCH DESIGN AND METHODS In a prospective, population-based, longitudinal cohort study, we ascertained food security (Food Security Survey Module), dietary pattern (Healthy Eating Index–2005 [HEI 2005]), and hemoglobin A1c (HbA1c) in Puerto Rican adults aged 45–75 years with diabetes at baseline (2004–2009) and HbA1c at ∼2 years follow-up (2006–2012). We determined associations between food insecurity and dietary pattern and assessed whether those dietary patterns were associated with poorer HbA1c concentration over time, using multivariable-adjusted repeated subjects mixed-effects models. RESULTS There were 584 participants with diabetes at baseline and 516 at follow-up. Food-insecure participants reported lower overall dietary quality and lower intake of fruit and vegetables. A food insecurity*HEI 2005 interaction (P < 0.001) suggested that better diet quality was more strongly associated with lower HbA1c in food-insecure than food-secure participants. In adjusted models, lower follow-up HbA1c was associated with greater HEI 2005 score (β = −0.01 HbA1c % per HEI 2005 point, per year, P = 0.003) and with subscores of total vegetables (β = −0.09, P = 0.04) and dark green and orange vegetables and legumes (β = −0.06, P = 0.048). Compared with the minimum total vegetable score, a participant with the maximum score showed relative improvements of HbA1c of 0.5% per year. CONCLUSIONS Food insecurity was associated with lower overall dietary quality and lower consumption of plant-based foods, which was associated with poor longitudinal glycemic control.

Addressing Unmet Basic Resource Needs as Part of Chronic Cardiometabolic Disease Management

Importance It is unclear if helping patients meet resource needs, such as difficulty affording food, housing, or medications, improves clinical outcomes. Objective To determine the effectiveness of the Health Leads program on improvement in systolic and diastolic blood pressure (SBP and DBP, respectively), low-density lipoprotein cholesterol (LDL-C) level, and hemoglobin A1c (HbA1c) level. Design, Setting, and Participants A difference-in-difference evaluation of the Health Leads program was conducted from October 1, 2012, through September 30, 2015, at 3 academic primary care practices. Health Leads consists of screening for unmet needs at clinic visits, and offering those who screen positive to meet with an advocate to help obtain resources, or receive brief information provision. Main Outcomes and Measures Changes in SBP, DBP, LDL-C level, and HbA1c level. We compared those who screened positive for unmet basic needs (Health Leads group) with those who screened negative, using intention-to-treat, and, secondarily, between those who did and did not enroll in Health Leads, using linear mixed modeling, examining the period before and after screening. Results A total of 5125 people were screened, using a standardized form, for unmet basic resource needs; 3351 screened negative and 1774 screened positive. For those who screened positive, the mean age was 57.6 years and 1811 (56%) were women. For those who screened negative, the mean age was 56.7 years and 909 (57%) were women. Of 5125 people screened, 1774 (35%) reported at least 1 unmet need, and 1021 (58%) of those enrolled in Health Leads. Median follow-up for those who screened positive and negative was 34 and 32 months, respectively. In unadjusted intention-to-treat analyses of 1998 participants with hypertension, the Health Leads group experienced greater reduction in SBP (differential change, −1.2; 95% CI, −2.1 to −0.4) and DBP (differential change, −1.0; 95% CI, −1.5 to −0.5). For 2281 individuals with an indication for LDL-C level lowering, results also favored the Health Leads group (differential change, −3.7; 95% CI −6.7 to −0.6). For 774 individuals with diabetes, the Health Leads group did not show HbA1c level improvement (differential change, −0.04%; 95% CI, −0.17% to 0.10%). Results adjusted for baseline demographic and clinical differences were not qualitatively different. Among those who enrolled in Health Leads program, there were greater BP and LDL-C level improvements than for those who declined (SBP differential change −2.6; 95% CI,−3.5 to −1.7; SBP differential change, −1.4; 95% CI, −1.9 to −0.9; LDL-C level differential change, −6.3; 95% CI, −9.7 to −2.8). Conclusions and Relevance Screening for and attempting to address unmet basic resource needs in primary care was associated with modest improvements in blood pressure and lipid, but not blood glucose, levels.

Evaluating Area‐Based Socioeconomic Status Indicators for Monitoring Disparities within Health Care Systems: Results from a Primary Care Network

OBJECTIVE To determine which area-based socioeconomic status (SES) indicator is best suited to monitor health care disparities from a delivery system perspective. DATA SOURCES/STUDY SETTING 142,659 adults seen in a primary care network from January 1, 2009 to December 31, 2011. STUDY DESIGN Cross-sectional, comparing associations between area-based SES indicators and patient outcomes. DATA COLLECTION Address data were geocoded to construct area-based SES indicators at block group (BG), census tract (CT), and ZIP code (ZIP) levels. Data on health outcomes were abstracted from electronic records. Relative indices of inequality (RIIs) were calculated to quantify disparities detected by area-based SES indicators and compared to RIIs from self-reported educational attainment. PRINCIPAL FINDINGS ZIP indicators had less missing data than BG or CT indicators (p < .0001). Area-based SES indicators were strongly associated with self-report educational attainment (p < .0001). ZIP, BG, and CT indicators all detected expected SES gradients in health outcomes similarly. Single-item, cut point defined indicators performed as well as multidimensional indices and quantile indicators. CONCLUSIONS Area-based SES indicators detected health outcome differences well and may be useful for monitoring disparities within health care systems. Our preferred indicator was ZIP-level median household income or percent poverty, using cut points.

Low Socioeconomic Status is Associated with Increased Risk for Hypoglycemia in Diabetes Patients: the Diabetes Study of Northern California (DISTANCE)

Background. Social risk factors for hypoglycemia are not well understood. Methods. Cross-sectional analysis from the DISTANCE study, a multi-language, ethnically-stratified random sample of adults in the Kaiser Permanente Northern California diabetes registry, conducted in 2005–2006 (response rate 62%). Exposures were income and educational attainment; outcome was patient report of severe hypoglycemia. To test the association, we used multivariable logistic regression to adjust for demographic and clinical factors. Results. 14,357 patients were included. Reports of severe hypoglycemia were common (11%), and higher in low-income vs. high-income (16% vs. 8.8) and low-education vs. high-education (11.9% vs. 8.9%) groups. In multivariable analysis, incomes of less than

Addressing basic resource needs to improve primary care quality: a community collaboration programme

15,000 (OR 1.51 95%CI 1.19–1.91),

Material Need Support Interventions for Diabetes Prevention and Control: a Systematic Review

15,000–