Iron deficiency (ID) is the most common nutritional deficiency following metabolic and bariatric surgery. Preoperative anemia and/or low serum levels of ferritin, which are common among candidates for metabolic and bariatric surgery (MBS), are associated with increased risk of developing severe postoperative ID. This study investigates iron status among candidates for MBS and its relationship to the development of severe postoperative anemia. From an established bariatric surgery registry, surgery candidates with iron assessment as well as longitudinal anemia follow-up were identified. The relationship between ferritin levels < 30 ng/mL stratified by levels of transferrin saturation < 20% and < 15% was analyzed to identify risk factors associated with the onset of severe postoperative anemia (hemoglobin level < 8 g/dL). Four thousand seven hundred and nine patients were studied. 14.6% had ferritin concentrations < 30 ng/mL and another 20% 30-99 ng/dL coupled with transferrin saturations (TSATs) < 20% to indicate absolute ID and functional ID. The overall prevalence of ID was 35%. The overall risk of severe postoperative anemia was 10.5% at 5 years and 19.8% at 10 years. Ferritin levels of < 30 ng/mL and TSAT < 20% were each associated with greater risk of developing severe anemia (p < 0.0001). Patients with ferritins < 30 ng/mL and TSATs < 15% had the most severe ID with the greatest risk of developing earlier and more severe anemia which was confirmed after adjusted analysis (p < 0.0001). A preoperative ferritin level < 30 ng/mL with TSAT < 15% is an excellent predictor for severe postoperative anemia.

BACKGROUND:Severe obesity and its association with advanced knee osteoarthritis (OA) are established risk factors for surgical complications and associated costs of total knee arthroplasty (TKA). This clinical trial examines the functional knee outcomes of severely obese patients who have severe knee OA undergoing bariatric surgery versus immediate TKA and examines the impact of surgical weight loss on the pursuit of TKA. METHODS:The Surgical Weight-loss to improve Functional status Trajectories trial following total knee arthroplasty was a multicenter, prospective trial examining outcomes of weight loss surgery and TKA in patients who have severe obesity (body mass index ≥ 40 or greater than 35 who have comorbidities) and symptomatic Kellgren-Lawrence grades 3 or 4 radiographic knee OA. Study patients were recruited prospectively from November 2015 to October 2024 and divided into two groups: the bariatric arm (patients undergoing bariatric surgery) and the TKA arm (patients undergoing TKA). Each study arm underwent a comprehensive battery of knee functional assessments at baseline, six, 12, and 24 months, as well as reevaluations in the bariatric surgery arm to assess the need for delaying or proceeding with TKA at 12 and 24 months. There were 232 study subjects who completed surgery and knee evaluation (n = 159: immediate TKA versus n = 73: bariatric surgery). The study groups had comparable degrees of knee disability at study initiation. RESULTS:Longitudinal functional analysis demonstrated major improvement extending to two years in patient-reported outcomes and performance-based functional assessments in both study arms, with a slight superiority in the TKA arm. Total weight loss % was higher in bariatric surgery patients (28.7%, P < 0.0001). Bariatric surgery resulted in 45 and 36% delays in TKA at 12 and 24 months, respectively, due to improved knee status. CONCLUSIONS:Knee function and mobility improved significantly in both study arms, with superiority in the Knee Injury and Osteoarthritis Outcome and Western Ontario and McMaster Universities Osteoarthritis Index scores in the TKA group. Improved knee function with surgical weight loss can be associated with up to a 2-year delay in the need for TKA.

Prevalence of metabolic syndrome (MetS) defined as 3 or more cardiometabolic risk factors has grown to 43% among US adults. Lifestyle interventions produce benefits, but with limited sustainability. To determine whether a 6-month habit-based lifestyle program adds benefit to education and activity monitoring for sustained MetS remission at 24 months. The Enhancing Lifestyles in Metabolic Syndrome (ELM) study was a single-blind, individually randomized clinical trial of participants with MetS recruited from July 2019 to January 2022 at 5 locations in the US and followed up for 24 months. Eligible participants were motivated for lifestyle change and were contacted using electronic medical records and social or mass media; those who did not meet medical or logistical criteria were excluded. In all, 14 817 adults were screened during a 2.5 year period. Data were analyzed from March 2024 to May 2025. All participants received education and an activity monitor. Those in the intervention group also received 19 small group in-person meetings during 6 months, which sought to establish the following habits as part of their daily routine: vegetables at meals, brisk walks, sensory awareness, and emotion regulation. Repetition of these habits was encouraged by attention to participants’ experience of immediate benefits and peer support. The comparator group received 24 evidence-based educational mailings monthly during the 24 months. MetS remission at 24 months determined by blinded laboratory evaluation and clinical examination. Secondary outcomes were cardiometabolic and lifestyle risk factors at 6 and 24 months. The analysis included 618 participants (mean [SD] age, 55.5 [11.0] years; 468 female [74.7%] and 150 male [24.3%] individuals), of whom 306 (49.5%) were randomized to the intervention and 312 (50.5%) to the comparator. The 24-month follow-up period was completed by 517 participants (83.7%). Obesity, measured by body mass index, was present in 513 participants (83%). At 6 months, the proportion achieving MetS remission was 24.8% in intervention group and 17.9% in comparator (adjusted odds ratio, 1.64; 95% CI, 1.07-2.53; P = .03), supported by improvements in waist circumference, triglycerides, fasting glucose, body mass index, weight, hemoglobin A 1c , MetS severity, perceived stress, vegetable intake, moderate-intensity physical activity, daily steps, sensory awareness, and the habits of daily brisk walks and vegetables at meals. At 24 months, the proportion achieving sustained MetS remission was 27.8% (85 of 306 participants) in intervention group and 21.2% (66 of 312) in the comparator (adjusted odds ratio, 1.46; 95% CI, 1.01-2.14; P < .05), supported by sustained improvement in fasting glucose, vegetable intake, daily steps, sensory awareness, and the habit of daily brisk walks. This randomized clinical trial found that sustained MetS remission after treatment may be possible by promoting simple habits through a behavior-based lifestyle program focused on immediate benefits. ClinicalTrials.gov Identifier: NCT04036006

ABSTRACT Objective As patient response to obesity medication can vary, it is crucial to identify both those likely and unlikely to respond to treatment. This post hoc analysis aimed to examine predictive characteristics in patients who achieved weight—related targets with fixed‐dose, extended‐release combination of naltrexone and bupropion (NB‐ER). Methods This pooled analysis included patients from three Phase 3, placebo‐controlled COR trials (NCT00532779, NCT00567255, NCT00456521). The impact of baseline characteristics in predicting changes in weight‐related anthropometric targets at 56 weeks in those who completed treatment and were ≥ 90% adherent to NB‐ER was evaluated with univariable and multivariable analyses. Results Of the 1692 patients analyzed, similar proportions of patients receiving NB‐ER versus placebo were female and White. Among patients treated with NB‐ER with ≥ 90% adherence, 73.2% achieved ≥ 5% body weight (BW) reduction, 47.6% achieved ≥ 10% BW reduction, 27.8% achieved ≥ 15% BW reduction, 33.7% achieved target body mass index, and 23.7% achieved target waist circumference thresholds. Among the baseline characteristics assessed, female sex and White race most consistently predicted the likelihood of achieving the target outcomes. Conclusion Adherence to NB‐ER was associated with achieving anthropometric targets; however, the ability to predict a successful response in advance of NB‐ER treatment is still limited.

Altered energy metabolism is a shared driver across cardiometabolic diseases-the leading cause of death globally1. Energy metabolism varies between individuals and is partly heritable2-9. Here, to investigate the genetic basis of energy metabolism, we perform an exome-sequencing analysis of 1,032,116 people from America, Europe and Asia, and estimate associations between rare protein-coding variants and the ratio of triglyceride to high-density-lipoprotein cholesterol (TG:HDL)-an energy-state biomarker that we associate with diverse cardiometabolic risk factors and diseases. We identify 59 independent genes (P < 1.04 × 10-7) that are enriched for liver- and adipose-expressed master regulators of energy balance, storage and metabolism; 23 (39%) of these genes encode approved or clinical-stage drug targets. Ultra-rare protein-truncating variants in FNIP1 (allele frequency, 0.01%), which encodes a suppressor of energy expenditure and mitochondrial metabolism, are associated with a lower TG:HDL ratio, lower liver fat, lower glycaemia, favourable fat distribution and around 60% lower odds of cardiometabolic disease. FNIP1 knockdown in primary human hepatocytes induces lipid breakdown and lysosomal gene expression, while combined hepatic knockdown of Fnip1 with its paralogue Fnip2 or knockdown of its interactor Flcn protect against weight gain, reduce liver fat and enhance insulin sensitivity in mice fed a high-fat diet. Our study implicates the FNIP1 pathway in human energy metabolism and highlights its inhibition as a potential therapeutic strategy in cardiometabolic disease.

BACKGROUND:The fixed-dose, extended-release combination of naltrexone and bupropion (NB-ER), approved for obesity treatment, is hypothesized to affect the reward system and reduce food cravings. METHODS:A pooled, on-treatment, post hoc analysis was performed on data from 1967 patients who completed a phase 3 trial of NB-ER (NCT00532779, NCT00567255, NCT00456521, NCT00474630). Changes in weight and cravings based on Control of Eating Questionnaire (CoEQ) and Food Craving Inventory (FCI) scores, as well as mood and craving control, were examined for NB-ER vs placebo at weeks 8, 16, 28, and 56. RESULTS:Patients treated with NB-ER (n = 1206) vs placebo (n = 761) experienced greater weight reductions through 56 weeks (-9.5% ± 8.0% vs -2.7% ± 6.9%). Patients treated with NB-ER vs placebo reported larger improvements in estimated treatment differences (ETDs) for craving control (2.68 [95% CI, 0.85, 4.50]), positive mood (1.35 [95% CI, 0.47, 2.23]), and cravings for savory (-1.81 [95% CI, -3.32, -0.30]) per CoEQ scores. Per FCI scores, patients had improvements in ETDs for cravings for high fats (-0.65 [95% CI, -0.98, -0.32]) and fast-food fats (-0.18 [95% CI, -0.39, -0.03]). Change in body weight at week 56 with NB-ER vs placebo did not differ by baseline CoEQ or FCI scores. CONCLUSIONS:Patients receiving NB-ER experienced greater improvements in cravings, craving control, mood, and weight vs placebo. NB-ER also led to weight reduction in individuals with both low and high baseline cravings. NB-ER is a suitable treatment option for patients with obesity seeking improvements in body weight, mood, cravings, and craving control.

BACKGROUND:Using common clinical parameters, we aimed to noninvasively identify and predict metabolic dysfunction-associated steatohepatitis (MASH)/MASH with clinically significant fibrosis. RESEARCH DESIGN AND METHODS:Patients aged ≥18 with electronic health record (EHR) documented liver function tests and liver biopsies between 2016 and 2021 were retrospectively identified from the Geisinger Health System Research Liver Registry. MASH cases were confirmed using the nonalcoholic fatty liver disease (NAFLD) activity score. Training and validation datasets were used to create an algorithm/predictive model assessing EHR-derived predictors of MASH/MASH with clinically significant fibrosis (fibrosis stage F2-F4). Predictive accuracy was evaluated using the area under the curve. RESULTS:The analysis included 2698 patients. We created a composite likelihood score using variables significant for MASH and/or MASH with clinically significant fibrosis: liver enzymes (alanine aminotransferase [ALT], aspartate aminotransferase [AST]), prior year AST, metabolic disease, pulse (heart rate), and body mass index. The score had higher sensitivity and specificity for predicting MASH than Fibrosis-4 (FIB-4) Index, AST to platelet ratio index (APRI), and NAFLD fibrosis score (NFS); sensitivity and specificity were comparable to FIB-4 and APRI for predicting MASH with clinically significant fibrosis but superior to NFS. CONCLUSION:The composite likelihood score could potentially be a tool for early MASH screening.

Background: The association between interpersonal continuity of care (CoC) and progression from the prediabetic state to Type 2 Diabetes (T2D) remains unknown. Aim: To evaluate the association between interpersonal CoC and the progression to T2D among persons with prediabetes. Design and Setting: A retrospective cohort study using electronic health record (EHR) data from 6620 patients at Geisinger, a large rural health care system in Danville, PA. Methods: Cox regression methods were used to estimate the hazard ratio associated with progression to T2D within 3-years of being diagnosed with prediabetes. Results: One additional visit with the primary care provider most frequently seen by the patient associated with 14% decreased risk (HR = 0.86; 95% CI = 0.85, 0.87; P < .001) of transitioning to type 2 diabetes within 3 years of being diagnosed with prediabetes. Conclusions: This study demonstrates an association between increased interpersonal CoC after person is diagnosed with prediabetes and a reduced risk of progressing to T2D within 3 years.

Genome-wide association studies (GWAS) have identified numerous body mass index (BMI) loci. However, most underlying mechanisms from risk locus to BMI remain unknown. Leveraging omics data through integrative analyses could provide more comprehensive views of biological pathways on BMI. We analyzed genotype and blood gene expression data from up to 5619 samples in the Framingham Heart Study (FHS). Using 3992 single-nucleotide polymorphisms (SNPs) at 97 BMI loci and 1408 transcripts within 1 Mb, we performed separate association analyses of transcript with BMI and SNP with transcript (PBMI and PSNP, respectively) and then a correlated meta-analysis between the full summary data sets (PMETA). Transcripts were prioritized if we identified transcripts that met Bonferroni-corrected significance within each omic, showed stronger associations in the correlated meta-analysis than each omic, and had corresponding SNPs in the SNP-transcript-BMI association that were at least nominally associated with BMI in FHS data. We tested for generalization of identified association in a Hispanic ancestry sample of blood gene expression data and other samples in hypothalamus, nucleus accumbens, liver, and visceral adipose tissue (VAT) with significant threshold: PMETA < 0.05 & PMETA < PSNP & PMETA < PBMI. Among 308 significant SNP-transcript-BMI associations, we identified seven genes (NT5C2, GSTM3, SNAPC3, SPNS1, TMEM245, YPEL3, and ZNF646) in five association regions. We generalized results for SNAPC3 and YPEL3 in Hispanic ancestry sample, for YPEL3 in the nucleus accumbens, ZNF646 and GSTM3 in VAT, and NT5C2, SNAPC3, TMEM245, YPEL3, and ZNF646 in liver. The identified genes help link the genetic variation at obesity-risk loci to biological mechanisms and health outcomes, thus translating GWAS findings to function.

PURPOSE:To assess trends in continuity of care (COC) by geographic context (i.e., rural vs urban) among a cohort of persons with prediabetes prior to and after diagnosis of prediabetes. METHODS:We use cross-sectional data from Geisinger's electronic health record between 1997 and 2017. Our dependent variable is the Modified Modified Continuity Index (MMCI), a measure of dispersion among primary care providers seen. Our primary independent variable is a binary indicator variable for rurality constructed from the 2010 Census Bureau's Urban and Rural Classification. We control for age, sex, race/ethnicity, and baseline clinical characteristics. We use fractional logistic regression with bootstrapped standard errors. FINDINGS:Urban residing patients had greater odds of increased COC in the 3-year period prior to a diagnosis of prediabetes (aOR = 1.10, 95% CI = 1.03, 1.18; P = .007). However, there were no significant differences in COC among rural and urban residing patients upon diagnosis of prediabetes in unadjusted and fully adjusted regression models. Other factors significantly associated with COC across the observed time periods (pre- and post-diagnosis of prediabetes) include age, male, and hypertension in the patients' problem list at baseline. CONCLUSIONS:Among persons diagnosed with prediabetes, rurality was associated with decreased COC in the 3-year period prior to being diagnosed. However, in the 3-year period after diagnosis of prediabetes, geographic disparities in COC were not observed. Rural residing patients need enhanced continuity of primary care to potentially improve opportunistic screening for prediabetes.

OBJECTIVE:This study aimed to characterize bariatric surgery-induced changes in serum metabolites while accounting for changes in glomerular filtration rate (GFR) to understand the metabolic benefits to the kidney of bariatric surgery. METHODS:This was a prospective, single-center cohort of 27 adults with severe obesity who underwent bariatric surgery. Serum metabolomics and measured GFR (mGFR) were performed 1-3 months prior to and 6 months after surgery. In generalized estimating equation (GEE) models, we examined bariatric surgery- and mGFR-associated changes in serum metabolites. We used MetaboAnalyst to perform pathway analyses. RESULTS:Bariatric surgery was significantly associated with changes in 223 serum metabolites after adjustment. Following bariatric surgery, several pathways were downregulated (alpha-linoleic acid and linoleic acid, methionine, kynurenine, and alanine-glucose metabolism pathways; raw p < 0.05) or upregulated (phenylacetate, bile acid biosynthesis, taurine and hypo-taurine metabolism, porphyrin metabolism pathways; raw p < 0.05). Creatinine demonstrated a significant mGFR-independent decrease following surgery. The top metabolites significantly associated with mGFR included N,N,N-trimethyl-alanyl proline betaine (TMAP), followed by creatinine. CONCLUSIONS:We discovered several GFR-independent metabolomic changes after bariatric surgery which may underlie its beneficial kidney effects including decreased inflammation, oxidation, and insulin resistance. Further studies are needed to investigate the potential mechanistic role of identified metabolites to clarify mechanisms of obesity-related kidney disease.

Iron deficiency has been recognized as a potentially modifiable nutritional complication of metabolic and bariatric surgery (MBS) since prior to the turn of the century. Despite this, it remains the most common and clinically significant nutritional complication of this surgery with the potential to negate quality of life and the health benefits of surgical weight loss. This narrative review summarizes the current literature regarding iron deficiency as it relates to patients with severe obesity and those who undergo MBS. Advances in the clinical knowledge of iron homeostasis in severe obesity as a chronic disease, current diagnostic criteria for the diagnosis of iron deficiency in this patient population, the significance of preoperative iron deficiency, postoperative iron deficiency, and the status of supplementation and treatment will be reviewed with emphasis on gaps in knowledge and needed areas of further study. (Surg Obes Relat Dis 2024;20:1370-1380.) (c) 2024 American Society for Metabolic and Bariatric Surgery. Published by Elsevier Inc. All rights are reserved, including those for text and data mining, AI training, and similar technologies.

BACKGROUND AND AIMS:Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) promote weight loss by suppressing appetite, enhancing satiety, regulating glucose metabolism, and delaying gastric motility. We sought to determine whether GLP-1 RA use could affect medical procedures such as EGD. METHODS:We conducted a retrospective study of 35,183 patients who underwent EGD between 2019 and 2023, 922 of whom were using a GLP-1 RAs. Data were collected regarding demographics, diabetes status, retained gastric contents during EGD, incidence of aborted EGD, and necessity for repeat EGD. RESULTS:GLP-1 RA use was associated with a 4-fold increase in the retention of gastric contents (P < .0001), 4-fold higher rates of aborted EGD (P < .0001), and twice the likelihood of requiring repeat EGD (P = .0001), even after stratifying for the presence of diabetes. CONCLUSIONS:GLP-1 RA use can lead to delayed gastric emptying, affecting EGD adequacy regardless of the presence of diabetes, and may warrant dose adjustment to improve the safety and efficacy of these procedures.

Iron is an essential nutrient in living organisms with multiple vital functions. Iron deficiency (ID) can cause long term health consequences beyond iron deficiency anemia (IDA). The high prevalence of ID and its long-term effects in patients with obesity and after metabolic and bariatric surgery (MBS) is recognized. Nevertheless, there is limited knowledge of the optimal route or dose for treatment of patients with obesity and post-MBS, and an evidence-based universal guideline for prevention and treatment of ID in short- and long-term post-MBS (PMBS) is not yet available. ID in the general population is currently treated with oral or parenteral iron, where oral iron treatment is considered the preferred option with parenteral iron as a second-line treatment in case there is intolerance or lack of response to oral iron. In patients with obesity with chronic low-grade inflammation and PMBS patients with altered gut anatomy and function, there are also alterations in the bioavailability and higher risks of side effects of available oral irons. The conclusions of current studies exploring effective treatment of iron deficiency in this population have been inconsistent and further well-planned randomized and prospective studies are needed. This is a narrative review of the literature on the available treatment options and strategies for treatment of ID in PMBS patients to recognize the knowledge gaps and provides topics of future research.

The prevalence of obesity in the United States and across the world continues to climb, imparting increased risk of chronic disease. This impact is doubly felt in nephrology because obesity not only increases the risk of chronic kidney disease (CKD) but also exacerbates existing cardiovascular morbidity and mortality. The role of medical weight loss therapy in CKD has been debated, but increasing evidence suggests that intentional weight loss is protective against adverse kidney and cardiovascular outcomes. This may be particularly true with the advent of novel pharmacotherapies taking advantage of the incretin system, resulting in weight loss approaching that seen with surgical interventions. Moreover, these novel therapies have repeatedly demonstrated protective effects on the cardiovascular system. Here, we review the impact of obesity and weight loss on CKD, and the biological basis and clinical evidence for incretin therapy. This perspective provides recommended prescribing practices as a practical tool to engage nephrologists and patients with CKD in the treatment of obesity-related

Background:Certification of obesity medicine for physicians in the United States occurs mainly via the American Board of Obesity Medicine (ABOM). Obesity medicine is not recognized as a subspecialty by the American Board of Medical Specialties (ABMS) or the American Osteopathic Association (AOA). This review examines the value of specialization, status of current ABOM Diplomates, governing bodies involved in ABMS/AOA Board Certification, and the advantages and disadvantages of an ABMS/AOA recognized obesity medicine subspecialty. Methods:Data for this review were derived from PubMed and appliable websites. Content was driven by the expertise, insights, and perspectives of the authors. Results:The existing ABOM obesity medicine certification process has resulted in a dramatic increase in the number of Obesity Medicine Diplomates. If ABMS/AOA were to recognize obesity medicine as a subspecialty under an existing ABMS Member Board, then Obesity Medicine would achieve a status like other ABMS recognized subspecialities. However, the transition of ABOM Diplomates to ABMS recognized subspecialists may affect the kinds and the number of physicians having an acknowledged focus on obesity medicine care. Among transition issues to consider include: (1) How many ABMS Member Boards would oversee Obesity Medicine as a subspecialty and which physicians would be eligible? (2) Would current ABOM Diplomates be required to complete an Obesity Medicine Fellowship? If not, then what would be the process for a current ABOM Diplomate to transition to an ABMS-recognized Obesity Medicine subspecialist (i.e., "grandfathering criteria")? and (3) According to the ABMS, do enough Obesity Medicine Fellowship programs exist to recognize Obesity Medicine as a subspecialty? Conclusions:Decisions regarding a transition to an ABMS recognized Obesity Medicine Subspecialty versus retention of the current ABOM Diplomate Certification should consider which best facilitates medical access and care to patients with obesity, and which best helps obesity medicine clinicians be recognized for their expertise.

Context. The transition from pre-diabetes (pre-DM) to type 2 diabetes (T2D) can be prevented or delayed through lifestyle modifications. Primary care and continuity of care may help patients maintain an HbA1c within the pre-diabetic range. Objective. To determine whether continuity of care impedes progression to T2D. Study Design & Analysis. Multivariate logistic regression of a retrospective cohort of primary care patients. Setting or Dataset. Data come from the Geisinger healthcare system's EHR between 1997 and 2017. Population Studied. Primary care patients with pre-DM were included in the analysis if they had an HbA1c between 5.7-6.4%, were 18-75 years, a BMI >27kg/m2, and at least one primary care visit in the 3 years prior to diagnosis (N=5889). Data were retrospectively collected for 3 years before and 3 years after diagnosis of pre-DM. Intervention/Instrument. We measure relational primary care continuity as a count of the number of visits with the primary care provider (PCP) most frequently seen in the 3 years prior to diagnosis. Outcome Measures. Our primary outcome of interest is a binary indicator for transition from pre-DM to T2D within 3 years, controlling for the total number of primary care and specialty visits over the 6-year period, sex, race, and ethnicity. We also control for baseline characteristics including age, hypertension, hyperlipidemia, HbA1c, and BMI. Finally, we control for the patient's percent of weight lost at 1-year after baseline and a binary indicator variable for whether the patient lost ≥3% of their baseline weight and then regained ≥2% by year 3 of follow-up. Results. The median age at baseline was 55, 56% identified as female, and the majority are non-Hispanic whites. At baseline 29% and 33% of the sample had hypertension and hyperlipidemia, respectively. The median baseline HbA1c was 5.9% and the median baseline BMI was 33.89 kg/m2. Each additional visit with the primary care provider most frequently seen in the 3 years before diagnosis of pre-DM is associated with a 6% decrease in the odds of transitioning to T2D within 3 years after their pre-DM diagnosis (OR=0.95; 95% CI=0.92; 0.97, p<0.000). Finally, the total number of PCP (OR=1.03; p<0.001) and specialty visits (OR=0.99, p<0.05) over the 6-year period were significant. Conclusion. Establishing continuity of primary care prior to diagnosis of pre-DM may decrease the likelihood of transitioning to T2D.