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Casagrande S.S.,Social and Scientific Systems Inc. | Fradkin J.E.,U.S. National Institute of Diabetes and Digestive and Kidney Diseases | Saydah S.H.,Centers for Disease Control and Prevention | Rust K.F.,Westat | Cowie C.C.,U.S. National Institute of Diabetes and Digestive and Kidney Diseases
Diabetes Care | Year: 2013

OBJECTIVE-To determine the prevalence of people with diabetes who meet hemoglobin A1c (A1C), blood pressure (BP), and LDL cholesterol (ABC) recommendations and their current statin use, factors associated with goal achievement, and changes in the proportion achieving goals between 1988 and 2010. RESEARCH DESIGN AND METHODS-Data were cross-sectional from the National Health and Nutrition Examination Surveys (NHANES) from 1988-1994, 1999-2002, 2003-2006, and 2007-2010. Participants were 4,926 adults aged ≥20 years who self-reported a previous diagnosis of diabetes and completed the household interview and physical examination (n = 1,558 for valid LDL levels). Main outcome measures were A1C, BP, and LDL cholesterol, in accordance with the American Diabetes Association recommendations, and current use of statins. RESULTS-In 2007-2010, 52.5% of people with diabetes achieved A1C <7.0% (,53 mmol/mol), 51.1% achieved BP <130/80 mmHg, 56.2% achieved LDL<100 mg/dL, and 18.8% achieved all three ABCs. These levels of control were significant improvements from 1988 to 1994 (all P < 0.05). Statin use significantly increased between 1988-1994 (4.2%) and 2007-2010 (51.4%, P < 0.01). Compared with non-Hispanic whites, Mexican Americans were less likely to meet A1C and LDL goals (P < 0.03), and non-Hispanic blacks were less likely to meet BP and LDL goals (P < 0.02). Compared with non-Hispanic blacks, Mexican Americans were less likely to meet A1C goals (P < 0.01). Younger individuals were less likely to meet A1C and LDL goals. CONCLUSIONS-Despite significant improvement during the past decade, achieving the ABC goals remains suboptimal among adults with diabetes, particularly in some minority groups. Substantial opportunity exists to further improve diabetes control and, thus, to reduce diabetes-related morbidity and mortality. © 2013 by the American Diabetes Association.

Menke A.,Social and Scientific Systems Inc | Casagrande S.,Social and Scientific Systems Inc | Geiss L.,Centers for Disease Control and Prevention | Cowie C.C.,U.S. National Institute of Diabetes and Digestive and Kidney Diseases
JAMA - Journal of the American Medical Association | Year: 2015

IMPORTANCE Previous studies have shown increasing prevalence of diabetes in the United States. New US data are available to estimate prevalence of and trends in diabetes. OBJECTIVE To estimate the recent prevalence and update US trends in total diabetes, diagnosed diabetes, and undiagnosed diabetes using National Health and Nutrition Examination Survey (NHANES) data. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional surveys conducted between 1988-1994 and 1999-2012 of nationally representative samples of the civilian, noninstitutionalized US population; 2781 adults from 2011-2012 were used to estimate recent prevalence and an additional 23 634 adults from 1988-2010 were used to estimate trends. MAIN OUTCOMES AND MEASURES The prevalence of diabeteswas defined using a previous diagnosis of diabetes or, if diabetes was not previously diagnosed, by (1) a hemoglobin A1c level of 6.5%or greater or a fasting plasma glucose (FPG) level of 126mg/dL or greater (hemoglobin A1c or FPG definition) or (2) additionally including 2-hour plasma glucose (2-hour PG) level of 200mg/dL or greater (hemoglobin A1c, FPG, or 2-hour PG definition). Prediabetes was defined as a hemoglobin A1c level of 5.7%to 6.4%, an FPG level of 100 mg/dL to 125mg/dL, or a 2-hour PG level of 140mg/dL to 199mg/dL. RESULTS In the overall 2011-2012 population, the unadjusted prevalence (using the hemoglobin A1c, FPG, or 2-hour PG definitions for diabetes and prediabetes) was 14.3%(95% CI, 12.2%-16.8%) for total diabetes, 9.1% (95%CI, 7.8%-10.6%) for diagnosed diabetes, 5.2% (95%CI, 4.0%-6.9%) for undiagnosed diabetes, and 38.0%(95%CI, 34.7%-41.3%) for prediabetes; among those with diabetes, 36.4%(95%CI, 30.5%-42.7%) were undiagnosed. The unadjusted prevalence of total diabetes (using the hemoglobin A1c or FPG definition) was 12.3%(95%CI, 10.8%-14.1%); among those with diabetes, 25.2%(95%CI, 21.1%-29.8%) were undiagnosed. Compared with non-Hispanic white participants (11.3%[95%CI, 9.0%-14.1%]), the age-standardized prevalence of total diabetes (using the hemoglobin A1c, FPG, or 2-hour PG definition) was higher among non-Hispanic black participants (21.8%[95% CI, 17.7%-26.7%]; P <.001), non-Hispanic Asian participants (20.6%[95%CI, 15.0%-27.6%]; P =.007), and Hispanic participants (22.6%[95%CI, 18.4%-27.5%]; P <.001). The age-standardized percentage of cases that were undiagnosed was higher among non-Hispanic Asian participants (50.9%[95%CI, 38.3%-63.4%]; P =.004) and Hispanic participants (49.0% [95%CI, 40.8%-57.2%]; P =.02) than all other racial/ethnic groups. The age-standardized prevalence of total diabetes (using the hemoglobin A1c or FPG definition) increased from 9.8%(95%CI, 8.9%-10.6%) in 1988-1994 to 10.8%(95%CI, 9.5%-12.0%) in 2001-2002 to 12.4%(95%CI, 10.8%-14.2%) in 2011-2012 (P <.001 for trend) and increased significantly in every age group, in both sexes, in every racial/ethnic group, by all education levels, and in all poverty income ratio tertiles. CONCLUSIONS AND RELEVANCE In 2011-2012, the estimated prevalence of diabetes was 12% to 14%among US adults, depending on the criteria used, with a higher prevalence among participants who were non-Hispanic black, non-Hispanic Asian, and Hispanic. Between 1988-1994 and 2011-2012, the prevalence of diabetes increased in the overall population and in all subgroups evaluated. © 2015 American Medical Association. All rights reserved.

Kimmel P.L.,Urologic | Fwu C.-W.,George Washington University | Eggers P.W.,Social and Scientific Systems Inc.
Journal of the American Society of Nephrology | Year: 2013

Social and ecologic factors, such as residential segregation, are determinants of health in the general population, but how these factors associate with outcomes among patients with ESRD is not well understood. Here, we examined associations of income inequality and residence, as social determinants of health, with survival among black and white patients with ESRD.We merged U.S. Renal Data System data from 589,036 patients who started hemodialysis from 2000 through 2008 with race-specific median household income data from the Census Bureau. We used Gini Index coefficients to assess income distributional inequality and the Dissimilarity Index to determine residential segregation. Black patients lived in areas of lower median household income compared with white patients ($26,742 versus $41,922; P<0.001). Residence in areas with higher median household income was associated with improved survival. Among whites, income inequality was associated with mortality. Among blacks exclusively, residence in highly segregated areas was associated with increased mortality. In conclusion, black hemodialysis patients in the United States are particularly susceptible to gradients in income and residential segregation. Interventions directed at highly segregated black neighborhoods might favorably affect hemodialysis patient outcomes. Copyright © 2013 by the American Society of Nephrology.

Ruhl C.E.,Social and Scientifi C Systems Inc. | Everhart J.E.,U.S. National Institute of Diabetes and Digestive and Kidney Diseases
American Journal of Gastroenterology | Year: 2013

OBJECTIVES:Other than weight-related conditions, risk factors for non-alcoholic fatty liver disease (NAFLD) are not well defined. We investigated the association of gallstones and cholecystectomy with NAFLD in a large, national, population-based study.METHODS:Among adult participants in the third US National Health and Nutrition Examination Survey, 1988-1994, ultrasonography for gallstone disease was performed, and videotapes were subsequently evaluated for NAFLD. Odds ratios (ORs) for the association of gallstone disease with NAFLD were calculated using logistic regression analysis to adjust for common associated factors.RESULTS:Among 12,232 participants without viral hepatitis or significant alcohol intake, the prevalence of gallstones was 7.4%, cholecystectomy 5.6%, and NAFLD 20.0%. Participants with cholecystectomy had higher age-sex-adjusted prevalence of NAFLD (48.4%) than those with gallstones (34.4%) or without gallstone disease (17.9%) (P<0.01 for all comparisons). Controlling for numerous factors associated with both NAFLD and gallstone disease, multivariate-adjusted analysis confirmed the association of NAFLD with cholecystectomy (OR=2.4; 95% confidence interval (CI): 1.8-3.3), but not with gallstones (OR=1.1; 95% CI: 0.84-1.4).CONCLUSIONS:The association of NAFLD with cholecystectomy, but not with gallstones, indicates that cholecystectomy may itself be a risk factor for NAFLD. ©2013 by the American College of Gastroenterology.

Ruhl C.E.,Social and Scientific Systems Inc. | Everhart J.E.,U.S. National Institute of Diabetes and Digestive and Kidney Diseases
Gastroenterology | Year: 2010

Background & Aims: Liver injury is associated with obesity and related measures, such as body mass index (BMI) and waist circumference. The relationship between liver injury and body composition has not been evaluated in a population-based study. Methods: Using data from a US population-based survey, we examined the contributions of body composition, measured by dual-energy x-ray absorptiometry (DXA), to increased serum alanine aminotransferase (ALT) activity among 11,821 adults without viral hepatitis. Trunk fat, extremity fat, trunk lean, and extremity lean mass were divided by height squared and used to categorize subjects into quintiles; logistic regression odds ratios (OR) were calculated for increased ALT. Results: Increased ALT was associated with higher measures of fat and lean mass (P < .001) after adjustment for alcohol consumption and other liver injury risk factors in separate models for each DXA measure. Trunk fat was associated with increased ALT (P ≤ .001) in models also including any 1 of the other 3 measures. Extremity fat was independently inversely associated among women (P < .001). Trunk and extremity lean mass were not independently related to increased ALT. In models that contained all 4 DXA measures, the OR (95% confidence interval [CI]) for increased ALT for the highest, relative to lowest, quintile of trunk fat/height squared was 13.8 (95% CI: 5.4-35.3) for men and 7.8 (95% CI: 3.9-15.8) for women. When BMI, waist circumference, and trunk fat were considered together, only trunk fat remained independently associated with increased ALT. Conclusions: Trunk fat is a major body composition determinant of increased ALT, supporting the hypothesis that liver injury can be induced by metabolically active intraabdominal fat. © 2010 AGA Institute.

Merrell K.,Social and Scientific Systems Inc. | Berenson R.A.,Urban Institute Health Policy Center
Health Affairs | Year: 2010

Despite widespread interest in the medical home model, there has been a lack of careful assessment of alternative methods to pay practices that serve as medical homes. This paper examines four specific payment approaches: enhanced fee-for-service payments for evaluation and management; additional codes for medical home activities within fee-for-service payments; per patient per month medical home payments to augment fee-for-service visit payments; and risk-adjusted, comprehensive per patient per month payments. Payment policies selected will affect both the adoption of the model and its longer-term evaluation. Evaluations of ongoing demonstrations should focus on payment design as well as on care - and cost. ©2010 Project HOPE - The People-to-People Health Foundation, Inc.

Ruhl C.E.,Social and Scientific Systems Inc. | Everhart J.E.,U.S. National Institute of Diabetes and Digestive and Kidney Diseases
Alimentary Pharmacology and Therapeutics | Year: 2015

Background: Validated non-invasive measures of fatty liver are needed that can be applied across populations and over time. A fatty liver index (FLI) including body mass index, waist circumference, triglycerides and gamma glutamyltransferase (GGT) activity was developed in an Italian municipality, but has not been validated widely or examined in a multiethnic population. Aims: We evaluated this FLI in the multiethnic U.S. National Health and Nutrition Examination Survey (NHANES) and also to explore whether an improved index for the U.S. population (US FLI) could be derived. The US FLI would then used to examine U.S. time trends in fatty liver prevalence. Methods: We studied 5869 fasted, viral hepatitis negative adult participants with abdominal ultrasound data on fatty liver in the 1988-1994 NHANES. Time trend analyses included 21 712 NHANES 1988-1994 and 1999-2012 participants. Results: The prevalence of fatty liver was 20%. For the FLI, the area under the receiver operating characteristic curve [AUC; 95% confidence interval (CI)] was 0.78 (0.74-0.81). The US FLI included age, race-ethnicity, waist circumference, GGT activity, fasting insulin and fasting glucose and had an AUC (95% CI) of 0.80 (0.77-0.83). Defining fatty liver as a US FLI ≥ 30, the prevalence increased from 18% in 1988-1991 to 29% in 1999-2000 to 31% in 2011-2012. Conclusions: For predicting fatty liver, the US FLI was a modest improvement over the FLI in the multiethnic U.S. population. Using this measure, the fatty liver prevalence in the U.S. population increased substantially over two decades. © 2014 John Wiley & Sons Ltd.

Ruhl C.E.,Social and Scientific Systems Inc. | Everhart J.E.,U.S. National Institute of Diabetes and Digestive and Kidney Diseases
American Journal of Epidemiology | Year: 2013

Elevated alanine aminotransferase (ALT) activity, an important marker of liver injury, has been associated inconsistently with higher mortality. We evaluated whether persons with nonelevated ALT levels are the most appropriate comparison group by examining the relationships of low ALT with mortality and body composition in the US National Health and Nutrition Examination Survey (NHANES). In NHANES 1988-1994, the mortality risk of persons in ALT deciles 1, 2, 3, and 10 was compared with that of persons in deciles 4-9 (mortality was relatively flat across these deciles) over an 18-year period (through 2006) among 14,950 viral-hepatitis-negative adults. In NHANES 1999-2006, low ALT was evaluated in association with dual-energy x-ray absorptiometry body composition measures among 15,028 adults. Multivariate-adjusted mortality was higher for decile 1 (hazard ratio (HR) = 1.42, 95% confidence interval (CI): 1.24, 1.63), decile 2 (HR = 1.27, 95% CI: 1.06, 1.53), and decile 3 (HR = 1.25, 95% CI: 1.04, 1.50) and nonsignificantly higher for decile 10 (HR = 1.21, 95% CI: 0.91, 1.61) than for deciles 4-9. Adjusted appendicular lean mass was decreased among the lowest ALT deciles. In the US population, low ALT was associated with higher mortality risk, possibly attributable to decreased appendicular lean mass. For mortality studies of elevated ALT levels, the most appropriate comparison group is persons in the middle range of ALT rather than all persons with nonelevated ALT. © 2013 The Author.

Ruhl C.E.,Social and Scientific Systems Inc. | Everhart J.E.,U.S. National Institute of Diabetes and Digestive and Kidney Diseases
Hepatology | Year: 2012

Alanine aminotransferase (ALT) is an important test for liver disease, yet there is no generally accepted upper limit of normal (ULN) in the United States. Furthermore, the ability of ALT to differentiate persons with and without liver disease is uncertain. We examined cut-offs for ALT for their ability to discriminate between persons with positive hepatitis C virus (HCV) RNA and those at low risk for liver injury in the U.S. population. Among adult participants in the 1999-2008 U.S. National Health and Nutrition Examination Survey, 259 were positive for serum HCV RNA and 3,747 were at low risk for liver injury (i.e., negative HCV RNA and hepatitis B surface antigen, low alcohol consumption, no evidence of diabetes, and normal body mass index and waist circumference). Serum ALT activity was measured centrally. Maximum correct classification was achieved at ALT = 29 IU/L for men (88% sensitivity, 83% specificity) and 22 IU/L (89% sensitivity, 82% specificity) for women. The cut-off for 95% sensitivity was an ALT = 24 IU/L (70% specificity) for men and 18 IU/L (63% specificity) for women. The cut-off for 95% specificity was ALT = 44 IU/L (64% sensitivity) for men and 32 IU/L (59% sensitivity) for women. The area under the curve was 0.929 for men and 0.915 for women. If the cut-offs with the best correct classification were applied to the entire population, 36.4% of men and 28.3% of women would have had abnormal ALT. Conclusion: ALT discriminates persons infected with HCV from those at low risk of liver disease, but would be considered elevated in a large proportion of the U.S. population. © 2011 American Association for the Study of Liver Diseases.

Ruhl C.E.,Social and Scientific Systems Inc | Everhart J.E.,U.S. National Institute of Diabetes and Digestive and Kidney Diseases
Gastroenterology | Year: 2011

Background & Aims Gallstones are common and contribute to morbidity and health care costs, but their effects on mortality are unclear. We examined whether gallstone disease was associated with overall and cause-specific mortalities in a prospective national population-based sample. Methods We analyzed data from 14,228 participants in the third US National Health and Nutrition Examination Survey (2074 years old) who underwent gallbladder ultrasonography from 1988 to 1994. Gallstone disease was defined as ultrasound-documented gallstones or evidence of cholecystectomy. The underlying cause of death was identified from death certificates collected through 2006 (mean follow-up, 14.3 years). Mortality hazard ratios (HR) were calculated using Cox proportional hazards regression analysis to adjust for multiple demographic and cardiovascular disease risk factors. Results The prevalence of gallstones was 7.1% and of cholecystectomy was 5.3%. During a follow-up period of 18 years or more, the cumulative mortality was 16.5% from all causes (2389 deaths), 6.7% from cardiovascular disease (886 deaths), and 4.9% from cancer (651 deaths). Participants with gallstone disease had higher all-cause mortality in age-adjusted (HR = 1.3; 95% confidence interval [CI]: 1.21.5) and multivariate-adjusted analysis (HR = 1.3; 95% CI: 1.11.5). A similar increase was observed for cardiovascular disease mortality (multivariate-adjusted HR = 1.4; 95% CI: 1.21.7), and cancer mortality (multivariate-adjusted HR = 1.3; 95% CI: 0.981.8). Individuals with gallstones had a similar increase in risk of death as those with cholecystectomy (multivariate-adjusted HR = 1.1; 95% CI: 0.921.4). Conclusions In the US population, persons with gallstone disease have increased mortality overall and mortalities from cardiovascular disease and cancer. This relationship was found for both ultrasound-diagnosed gallstones and cholecystectomy. © 2011 AGA Institute.

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