Katie Robinson

Medicaid expansion under the Patient Protection and Affordable Care Act (ACA) was associated with reduced uninsured rates in the diabetes belt compared with non-belt counties, say researchers writing in 

The diabetes belt, a region across 15 southern and eastern states in which residents have high rates of diabetes, is an important region for public health interventions to reduce health disparities. This area is populated by more non-Hispanic African Americans than the rest of the country, and its population has a higher prevalence of obesity and sedentary lifestyle. Access to care and lack of health insurance coverage have been identified as the main reasons for health disparities in the region. While data has shown that insurance coverage increased  with the Medicaid expansion, under the ACA, in people aged 65 years or younger with diabetes, there are still no data on how the expansion has affected insurance coverage for low income adults in the same age group who live in the diabetes belt.

In this study, researchers examined trends in uninsured rates between 2012 and 2016 among low-income adults aged 65 years or younger to determine whether the ACA’s expansion of Medicaid impacted insurance coverage in the diabetes belt. Data for 3,129 counties were used to analyze trends in uninsured rates among populations with a household income at least 138 percent below the federal poverty level.

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In 2012, 39 percent of the population in the diabetes belt and 34 percent in non-Belt counties were uninsured (P < 0.001). In 2016 in states where Medicaid was expanded, uninsured rates fell to 13 percent and 15 percent, respectively. Adjusting for county demographic and economic factors, Medicaid expansion helped reduce uninsured rates by 12.3 percent in diabetes belt counties and by 4.9 percent in non-belt counties. Meanwhile, in 2016, uninsured rates were 15 percent higher for both diabetes belt and non-belt counties in the non-expansion states than in the expansion states.

“Initial disparities in uninsured rates between diabetes belt and non-belt counties have not existed since 2014 among expansion states,” wrote the authors, led by Min-Woong Sohn, Ph.D., of the University of Virginia in Charlottesville.

“Previous studies have shown that increased access to healthcare is generally associated with improved diagnosis and treatment of diabetes, greater adherence to medication regimens, fewer emergency room visits, and more outpatient visits,” the authors wrote. “Greater access to care also seems to improve medication use for diabetes, hypertension, and hyperlipidemia and leads to improved laboratory test results and blood pressure readings.”


	However, the authors recommended that further research is needed to examine whether and how Medicaid expansion may have contributed to an increase in the use of health services in order to prevent and treat diabetes in the diabetes belt.

Jennifer M. Lobo, Soyoun Kim, Hyojung Kang, et al.

 “Trends in Uninsured Rates Before and After Medicaid Expansion in Counties Within and Outside of the Diabetes Belt.”

. January 27, 2020. DOI https://doi.org/10.2337/dc19-0874 

Articles

Medicaid expansion under the Patient Protection and Affordable Care Act (ACA) was associated with reduced uninsured rates in the diabetes belt compared with non-belt counties, say researchers writing in Diabetes Care.

Uninsured Rates Dip in the Diabetes Belt Where Medicaid Expanded

In post-myocardial infarction patients, chronically impaired renal failure and diabetes are both associated with an increased mortality risk, say researchers recently writing in 

Diabetes is associated with both an increased risk of all-cause death, mainly driven by cardiovascular mortality, and poorer outcomes after acute myocardial infarction (AMI). While impaired glomerular filtration rate (GFR) is also associated with an increased risk of cardiovascular mortality, whether diabetes still confers a higher mortality risk in patients with impaired GFR remains unknown.

“The aim of this study was to assess the long-term prognostic significance of both diabetes and renal impairment in two prospective nationwide cohorts of AMI patients: FAST-MI 2005 and FAST-MI 2010,” wrote the authors, led by Louis Potier, M.D., of UniversitÃ© de Paris in France.

Both registries consecutively included AMI patients admitted to cardiac intensive care units within 48 hours of symptom onset during a specified one-month period. The analysis included 7,839 participants (mean age 66 years, 29 percent female, 27 percent with diabetes), of which 7,656 patients had creatinine values assessed before percutaneous coronary intervention. Researchers assessed all-cause mortality at five years according to estimated GFR (eGFR) and diabetes status at inclusion.

Five-year mortality was 38 percent in patients with diabetes versus 19 percent in patients without diabetes (adjusted hazard ratio [HR] 1.47, 95% CI 1.33–1.62, P < 0.001). According to eGFR, among all participants, five-year mortality rates were 8.1 percent for eGFR >90 mL/min, 17.7 percent for 60– 90 mL/min, 36.4 percent for 45–60 mL/ min, 57.6 percent for 30–45 mL/min, and 70.6 percent for <30 mL/min.

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Further analysis suggested a gradual increase in mortality with decreasing renal function: adjusted HR versus eGFR >90 mL/min as reference 0.91 (95% CI 0.75– 1.11, P = 0.36) for eGFR 60–90 mL/min; 1.19 (0.96–1.46, P = 0.11) for 45–60 mL/ min; 1.48 (1.19–1.85, P = 0.001) for 30– 45mL/min, and 1.86 (1.48–2.35, P < 0.001) for <30 mL/min.

Moreover, increasing renal impairment was associated with an increased risk of death for participants with diabetes under a threshold of 60 mL/min but only below a threshold of 45 mL/min for participants without diabetes.

Compared with no diabetes, diabetes was associated with an increased risk of five-year death throughout eGFR categories, except for eGFR <30 mL/min: HR 1.45 (95% CI 1.01–2.09) for eGFR >90 mL/min, HR 1.54 (1.28–1.84, P < 0.001) for eGFR 60–90 mL/min, HR 1.64 (1.33–2.02, P < 0.001) for eGFR 45–60 mL/min, HR 1.28 (1.04–1.59, P = 0.02) for eGFR 30–45 mL/min.

“These results suggest that in post-myocardial infarction patients, 1) chronically impaired renal failure and diabetes are both associated with an increased risk of mortality, 2) renal function requires specific attention in patients with diabetes as soon as it is mildly impaired (45–60 mL/min), and 3) tight glycemic control, which is controversial in post-myocardial infarction patients (4), may not be essential in patients with diabetes with eGFR <30 mL/min,” the authors wrote.

The authors noted that the study was observational, with some missing data such as proteinuria in all patients and HbA1c in some patients, and that since 2010 newer glucose-lowering medications have documented an impact on cardiovascular and renal outcomes.

Louis Potier, Ronan Roussel, Marianne Zeller, et al.

 “Chronic Kidney Disease, Diabetes, and Risk of Mortality After Acute Myocardial Infarction: Insight From the FAST-MI Program.”

. January 23, 2020. doi: 10.2337/dc19-2209

In post-myocardial infarction patients, chronically impaired renal failure and diabetes are both associated with an increased mortality risk, say researchers recently writing in Diabetes Care.

Renal Failure, Diabetes Linked to Increased Mortality in Post-Myocardial Infarction

Neither intermittent nor daily dosing of vitamin D alone was associated with reduced risk of fracture, but daily supplementation with both vitamin D and calcium showed promise in a study recently published in

Approximately one in two women and one in five men aged 50 years or older will experience an osteoporotic fracture in their remaining lifetime. The incidence of hip fracture, which has an approximate 30 percent risk of death the following year, increases exponentially with age, particularly among women 60 years or older and men 70 years or older. Meanwhile, low vitamin D status causes secondary hyperparathyroidism, bone loss, and muscle weakness, and lower blood concentrations of 25-hydroxyvitamin D have been shown to be associated with higher risks of falls and fractures.

Combined daily supplementation with 800 IU of vitamin D and 1200 mg of calcium has been recommended for the prevention of fractures in older adults living in institutions and in those with low vitamin D status. However, previous studies have reported conflicting results, with uncertainty about optimal doses and regimens for supplementation and their effectiveness.

In this systematic review and meta-analysis, we “assessed  the risks of fracture associated with differences in concentrations of 25-hydroxyvitamin D in observational studies and the risks of fracture associated with supplementation with vitamin D alone or in combination with calcium in randomized controlled trials,” wrote the authors, led by Robert Clarke, M.D., of the University of Oxford in the U.K.

In a meta-analysis of 11 observational studies (39,141 participants, 6,278 fractures, 2,367 hip fractures), each increase of 10.0 ng/mL in 25-hydroxyvitamin D concentration was associated with an adjusted rate ratio (RR) for any fracture of 0.93 (95% CI, 0.89-0.96) and an adjusted RR for hip fracture of 0.80 (95% CI, 0.75-0.86).

“An increase of 10.0 ng/mL in 25-hydroxyvitamin D concentration was associated with a 7 percent lower risk of any fracture and a 20 percent lower risk of hip fracture,” the authors wrote.

In contrast, a meta-analysis of 11 randomized controlled trials (34,243 participants, 2,843 fractures, 740 hip fractures) of vitamin D supplementation alone (daily or intermittent dose of 400-30,000 IU, yielding a median difference in 25-hydroxyvitamin D concentration of 8.4 ng/mL) did not find a reduced risk of any fracture (RR, 1.06; 95% CI, 0.98-1.14) or hip fracture (RR, 1.14; 95% CI, 0.98-1.32).

“But these trials were constrained by infrequent intermittent dosing, low daily doses of vitamin D, or an inadequate number of participants,” the authors wrote.

Meanwhile, a meta-analysis of six randomized controlled trials (49,282 participants, 5,449 fractures, 730 hip fractures) of combined supplementation with vitamin D (daily doses of 400-800 IU, yielding a median difference in 25-hydroxyvitamin D concentration of 9.2 ng/mL) and calcium (daily doses of 1000-1200 mg) found a 6 percent reduced risk of any fracture (RR, 0.94; 95% CI, 0.89-0.99) and a 16 percent reduced risk of hip fracture (RR, 0.84; 95% CI, 0.72-0.97).

“Daily supplementation with both vitamin D and calcium was associated with a 16 percent reduced risk of hip fracture,” the authors wrote, but highlighted that “these randomized controlled trials had a high risk of bias.”

“Further large randomized controlled trials of combined treatment with vitamin D and calcium are needed before advocating vitamin D and calcium supplements or fortified foods with vitamin D and calcium for prevention of hip fracture,” the authors wrote.

Pang Yao, Derrick Bennett, Marion Mafham, et al.

 “Vitamin D and Calcium for the Prevention of Fracture: A Systematic Review and Meta-analysis.”

. December 20, 2019. doi:10.1001/jamanetworkopen.2019.17789

Neither intermittent nor daily dosing of vitamin D alone was associated with reduced risk of fracture, but daily supplementation with both vitamin D and calcium showed promise in a study recently published in JAMA Network Open.

Vitamin D-Calcium Combo Daily May Prevent Factures

Postmenopausal women who participate in vigorous physical activity have a lower risk of total and hip fractures, but higher knee fracture risk, say researchers recently writing in

Approximately 1.5 million fractures occur annually in women who live in the U.S., with around 14 percent of fractures occurring in the hip, an injury that has a mortality as high as 20 percent. Physical activity is inversely associated with hip fracture risk in older women, but the association of physical activity with fracture at other sites remains unclear. Meanwhile, sedentary behavior is becoming an established modifiable risk factor for major forms of morbidity and mortality, independent of physical activity habits, but its contribution to fracture has not been systematically evaluated.

“The Women’s Health Initiative is a prospective cohort study among postmenopausal women with ongoing assessment of fractures. We examined recreational physical activity, household activities, walking, and sedentary behavior in association with incident fracture and the extent to which age, race/ethnicity, or fall frequency modified this association in older, community-dwelling, ambulatory women,” wrote the authors of the study, led by Jean Wactawski-Wende, Ph.D., of The State University of New York in Buffalo.

Between October 1993 and December 1998, the study enrolled 77,206 postmenopausal women (mean age, 63.4 years; 85.6 percent white) at 40 U.S. clinical centers. Participants were observed for total and site-specific fracture incidence through September 2015.

During a mean follow-up period of 14 years, 33.1 percent of the women reported a first incident fracture. Total physical activity was inversely associated with the adjusted risk of hip fracture (>17.7 metabolic equivalent [MET] hours/week vs none: HR, 0.82; 95% CI, 0.72-0.95). Lower hip fracture rates were also observed for walking (HR, 0.88; 95% CI, 0.78-0.98), mild activity (HR, 0.82; 95% CI, 0.73-0.93), moderate to vigorous activity (HR, 0.88; 95% CI, 0.81-0.96), and yard work (HR, 0.90; 95% CI, 0.82-0.99).

Increased fracture risk was evident between knee fracture and total physical activity (>17.7 MET hours/week vs none: HR, 1.26; 95% CI, 1.05-1.50) and moderate to vigorous activity was positively associated with wrist or forearm fracture (HR, 1.09; 95% CI, 1.03-1.15). Mild activity was associated with lower risks of clinical vertebral fracture (HR, 0.87; 95% CI, 0.78-0.96) and total fractures (HR, 0.91; 95% CI, 0.87-0.94).

“Mild activity and walking were associated with lower hip fracture risk, a finding with important public health implications because these activities are common in older adults.” the authors wrote.

After controlling for total physical activity, sedentary time was positively associated with total fracture risk (>9.5 hours/d=day vs <6.5 hours/day: HR, 1.04; 95% CI, 1.01-1.07). When analyzed jointly, higher total activity reduced some of the total fracture risk associated with sedentary behavior.

activity, especially in those who are frail and unable to safely engage in more intense activities,” the authors wrote.

Sedentary behavior as an independent factor predisposing postmenopausal women to fracture requires further investigation.

Michael J. LaMonte, Jean Wactawski-Wende, Joseph C. Larson, et al.

 “Association of Physical Activity and Fracture Risk Among Postmenopausal Women.”

. October 25, 2019. doi:10.1001/jamanetworkopen.2019.14084

Postmenopausal women who participate in vigorous physical activity have a lower risk of total and hip fractures, but higher knee fracture risk, say researchers recently writing in JAMA Network Open.

Light Exercise Lowers Fracture Risk Post Menopause

Men with diabetes may have a higher risk of experiencing chronic lower back pain, say researchers writing in 

People with diabetes are often affected by lower back pain, but whether diabetes represents a risk factor for back pain has not been studied in detail. Previous studies have suggested a relationship between increased blood glucose levels and lower back pain, and that lumbar spinal stenosis may be associated with diabetes. While the two conditions have important risk factors in common, including being overweight and obesity, physical inactivity and smoking, few epidemiological studies have looked at relations between diabetes and back pain.

The aim of this prospective study with an 11-yesr follow-up period was to explore relationships between diabetes and risk of chronic lower back pain, defined as lasting more than three months, in a Norwegian population, adjusting for body mass index, physical activity and smoking. The participants, were aged 30–69 years.

In 6,802 participants without lower back pain at baseline, an increased risk of chronic lower back pain was found in men with diabetes, (relative risk (RR) 1.43, 95% CI 1.04 to 1.96, p=0.043) but no association between the two conditions was found in women (RR 1.01, 95% CI 0.69 to 1.48, p=0.98). Among 18,972 participants with chronic lower back pain at baseline, no association between diabetes and recurrence or persistence of chronic lower back pain after 11 years could be established in either sex.

“Diabetes is known to be associated with a number of complications and a higher risk of other diseases as polyneuropathy, kidney and cardiovascular diseases. The results of this study indicate that chronic lower back pain might be considered another candidate for this list of associated disorders in men,” wrote the authors, led by Ingrid Heuch, M.D., Ph.D., Oslo University Hospital in Norway.

“Our results only apply to the age interval of 30–69 years at baseline, and no statements can be made in connection with diabetes diagnosed from the age of 70 years,” the authors wrote.

While the researchers adjusted for body mass index, physical activity and smoking, they noted, “The possibility that other kinds of comorbidity may affect the association between diabetes and lower back pain cannot be excluded.”


	Ingrid Heuch, Ivar Heuch, Knut Hagen, et al.

 ”Does diabetes influence the probability of experiencing chronic low back pain? A population-based cohort study: the Nord-TrÃ¸ndelag Health Study.”

 Sept 12, 2019. doi: 10.1136/bmjopen-2019-031692

Men with diabetes may have a higher risk of experiencing chronic lower back pain, say researchers writing in BMJ Open this month. 

Men, Not Women with Diabetes May Have Higher Chronic Lower Back Pain Risk

this month find no clinically meaningful difference in all-cause mortality and other long-term negative health outcomes for hypothyroid patients who achieve normal range levels of the thyroid stimulating hormone. However, adverse health outcomes may occur when concentrations fall outside of the normal range.

Thyroid stimulating hormone levels outside of the norm can be associated with long term adverse health outcomes, particularly cardiovascular diseases, mortality and fractures. In this retrospective study, researchers investigated whether maintaining thyroid stimulating hormones at different concentrations in hypothyroid patients was associated with long term adverse outcomes.

Of 162,369 patients, researchers found no clinically meaningful difference in the pattern of long term health outcomes, including all cause mortality, heart failure, ischemic heart disease, stroke/transient ischemic attack, atrial fibrillation, all fractures, and fragility fractures, when thyroid stimulating hormone concentrations were within normal limits of between 0.4-4 mIU/L. But mortality rates rose among patients who were below <0.1 mIU/L, but also for concentrations above 4 mIU/L. Meanwhile, risk of ischemic heart disease, heart failure, and fragility fractures was increased at high thyroid stimulating hormone concentrations (greater than 10 mIU/L), and mortality was increased in both the lowest and highest thyroid stimulating hormone categories (less than 0.1 and greater than 4 mIU/L).

While current treatment guidelines in the U.S. and Europe recommend that replacement therapy should be aimed at resolving symptoms and achieving normalization of thyroid stimulating hormone, no specific optimal target for thyroid stimulating hormone exists in the context of thyroid hormone replacement.

“This study provides strong support for the current recommendations on the clinical management of hypothyroid patients and validates with hard evidence the latest American Thyroid Association and British Thyroid Association guidelines,” wrote the authors, led by Krishnarajah Nirantharakumar, M.D., of the University of Birmingham in the U.K.

Thayakaran Rasiah, Adderley Nicola J, Sainsbury, et al.

 “Thyroid replacement therapy, thyroid stimulating hormone concentrations, and long term health outcomes in patients with hypothyroidism: longitudinal study.” 

. September 3, 2019. doi: https://doi.org/10.1136/bmj.l4892

Normal thyroid stimulating hormone levels don't necessarily stave off all-cause mortality for hypothyroid patients, but adverse outcomes may intensify if levels fall below or above the norm.