Differences between Adiposity Indicators for Predicting All-Cause Mortality in a Representative Sample of United States Non-Elderly Adults

<div><h3>Background</h3><p>Adiposity predicts health outcomes, but this relationship could depend on population characteristics and adiposity indicator employed. In a representative sample of 11,437 US adults (National Health and Nutrition Examination Survey, 1988–1994, ages 18–64) we estimated associations with all-cause mortality for body mass index (BMI) and four abdominal adiposity indicators (waist circumference [WC], waist-to-height ratio [WHtR], waist-to-hip ratio [WHR], and waist-to-thigh ratio [WTR]). In a fasting subsample we considered the lipid accumulation product (LAP; [WC enlargement*triglycerides]).</p> <h3>Methods and Findings</h3><p>For each adiposity indicator we estimated linear and categorical mortality risks using sex-specific, proportional-hazards models adjusted for age, black ancestry, tobacco exposure, and socioeconomic position. There were 1,081 deaths through 2006. Using linear models we found little difference among indicators (adjusted hazard ratios [aHRs] per SD increase 1.2–1.4 for men, 1.3–1.5 for women). Using categorical models, men in adiposity midrange (quartiles 2+3; compared to quartile 1) were not at significantly increased risk (aHRs<1.1) unless assessed by WTR (aHR 1.4 [95%CI 1.0–1.9]). Women in adiposity midrange, however, tended toward elevated risk (aHRs 1.2–1.5), except for black women assessed by BMI, WC or WHtR (aHRs 0.7–0.8). Men or women in adiposity quartile 4 (compared to midrange) were generally at risk (aHRs>1.1), especially black men assessed by WTR (aHR 1.9 [1.4–2.6]) and black women by LAP (aHR 2.2 [1.4–3.5]). Quartile 4 of WC or WHtR carried no significant risk for diabetic persons (aHRs 0.7–1.1), but elevated risks for those without diabetes (aHRs>1.5). For both sexes, quartile 4 of LAP carried increased risks for tobacco-exposed persons (aHRs>1.6) but not for non-exposed (aHRs<1.0).</p> <h3>Conclusions</h3><p>Predictions of mortality risk associated with top-quartile adiposity vary with the indicator used, sex, ancestry, and other characteristics. Interpretations of adiposity should consider how variation in the physiology and expandability of regional adipose-tissue depots impacts health.</p> </div

Interactions with socioeconomic position (poverty-income ratio or high-school completion) for mortality risk at p75, by 6 adiposity indicators. (aHR = multiply adjusted hazard ratio).

<p>Interactions with socioeconomic position (poverty-income ratio or high-school completion) for mortality risk at p75, by 6 adiposity indicators. (aHR = multiply adjusted hazard ratio).</p

Median (<i>p50</i>) and interquartile boundary values (p25, p75) for baseline adiposity indicators by age group and sex among U.S. adults, 1988–1994.

a<p>LAP = lipid accumulation product (estimates derived from fasting participants; n = 6,890)</p

Medical Costs Associated with Diabetes Complications in Medicare Beneficiaries Aged 65 Years or Older with Type 2 Diabetes

   Objective: To estimate medical costs associated with 17 major diabetes-related complications and treatment procedures among Medicare beneficiaries aged ≥65 years with type 2 diabetes. Methods: Data were from the 2006–2017 100% Medicare claims database among beneficiaries enrolled in fee-for-service plans. Records with type 2 diabetes and complications were identified using International Classification of Diseases codes, Ninth Revision and Tenth Revision, and diagnosis-related group codes. The index year was the year when a person was first identified with diabetes with an inpatient claim, or an outpatient claim plus another inpatient/outpatient claim in the 2 years following the first claim in Medicare. Included individuals were followed from index years until death, discontinuation of plan coverage, or December 31, 2017. Fixed-effect regression was used to estimate the cost in years when the complication event occurred and in subsequent years. The total cost for each complication was calculated for 2017 by multiplying the complication prevalence by the cost estimate. All costs were standardized to 2017 U.S. dollars. Results: Our study included 10,982,900 persons with type 2 diabetes. Follow-up ranged from 3 to 10 years. The three costliest complications were kidney failure treated by transplantation (occurring year $79,045; subsequent years$17,303), kidney failure treated by dialysis ($54,394;$38,670), and lower-extremity amputation ($38,982;$8,084). Congestive heart failure accounted for the largest share (18%) of total complication cost.  Conclusions: Costs associated with diabetes complications were substantial. Our cost estimates provide essential information needed for conducting economic evaluation of treatment/programs to prevent/delay diabetes complications in Medicare beneficiaries.  </p

Interactions with baseline diabetes for mortality risk at p75, by 6 adiposity indicators. (aHR = multiply adjusted hazard ratio).

<p>Interactions with baseline diabetes for mortality risk at p75, by 6 adiposity indicators. (aHR = multiply adjusted hazard ratio).</p

Interactions with ancestral group for mortality risk at p25, by 6 adiposity indicators. (aHR = multiply adjusted hazard ratio).

<p>Interactions with ancestral group for mortality risk at p25, by 6 adiposity indicators. (aHR = multiply adjusted hazard ratio).</p

Hazard ratios (95% CI) for all-cause mortality associated with 6 adiposity indicators presented as linear continuous models and categorical models at boundaries p25 or p75 for US nonelderly men.

<p>HR = hazard ratio, aHR = multiply adjusted hazard ratio.</p>a<p>Models for <b>men</b> were adjusted for age, age², black ancestry, tobacco exposure, and income <200% of poverty threshold.</p>b<p>Risk comparing midrange <i>vs</i> quartile 1,</p>c<p>Risk comparing quartile 4 <i>vs</i> midrange.</p>d<p>P-values determined from chi-squared test evaluating 6 adiposity indicators (5 degrees of freedom).</p

Medical Costs Associated with Diabetes Complications in Medicare Beneficiaries Aged 65 Years or Older with Type 1 Diabetes

   Aims: To estimate medical costs associated with 17 diabetes complications and treatment procedures among Medicare beneficiaries ≥65 years old with type 1 diabetes. Methods: Using the 2006–2017 100% Medicare claims database for beneficiaries enrolled in fee-for-service plans and Part D, we estimated the annual cost of 17 diabetes complications and treatment procedures. Type 1 diabetes and its complications and procedures were identified using ICD 9/10 codes, procedure codes, and diagnosis-related group codes. Individuals with type 1 diabetes were followed from the year when their diabetes was initially identified in Medicare (2006–2015) until death, discontinuing plan coverage, or December 31, 2017. Fixed-effect regression was used to estimate costs in the complication occurrence years and subsequent years. The cost-proportion of a complication was equal to the total cost of the complication, calculated by multiplying prevalence by the per person cost, divided by the total cost for all complications. All costs were standardized to 2017 US dollars. Results: Our study included 114,879 persons with type 1 diabetes with lengths of follow-up from 3 to 10 years. The costliest complications per person were kidney failure treated by transplantation (occurrence year $77,809; subsequent years$13,556), kidney failure treated by dialysis ($56,469;$41,429), and neuropathy treated by lower-extremity amputation ($40,698;$7,380). Sixteen percent of the total medical cost for diabetes complications was for treating congestive heart failure.  Conclusions: Costs of diabetes complications were large and varied by complications. Our results can assist in cost-effectiveness analysis of treatments and interventions for preventing or delaying diabetes complications in Medicare beneficiaries aged 65 years or older with type 1 diabetes.</p

Hazard ratios (95% CI) for all-cause mortality associated with 6 adiposity indicators presented as linear continuous models and categorical models at boundaries p25 or p75 for US nonelderly women.

<p>HR = hazard ratio, aHR = multiply adjusted hazard ratio.</p>a<p>Models for <b>women</b> were adjusted for age, black ancestry, tobacco exposure, and educationb</p><p>Risk comparing midrange <i>vs</i> quartile 1,</p>c<p>Risk comparing quartile 4 <i>vs</i> midrange.</p>d<p>P-values determined from chi-squared test evaluating 6 adiposity indicators (5 degrees of freedom).</p

Interactions with ancestral group for mortality risk at p75, by 6 adiposity indicators. (aHR = multiply adjusted hazard ratio).

<p>Interactions with ancestral group for mortality risk at p75, by 6 adiposity indicators. (aHR = multiply adjusted hazard ratio).</p