Abstract: OBJECTIVE: To determine the proportion of the American population who would merit metformin treatment, according to recent American Diabetes Association (ADA) consensus panel recommendations to prevent or delay the development of diabetes. RESEARCH DESIGN AND METHODS: Risk factors were evaluated in 1,581 Screening for Impaired Glucose Tolerance (SIGT), 2,014 Third National Health and Nutrition Examination Survey (NHANES III), and 1,111 National Health and Nutrition Examination Survey 2005-2006 (NHANES 2005-2006) subjects, who were non-Hispanic white and black, without known diabetes. Criteria for consideration of metformin included the presence of both impaired fasting glucose (IFG) and impaired glucose tolerance (IGT), with > or =1 additional diabetes risk factor: age <60 years, BMI > or =35 kg/m(2), family history of diabetes, elevated triglycerides, reduced HDL cholesterol, hypertension, or A1C >6.0%. RESULTS: Isolated IFG, isolated IGT, and IFG and IGT were found in 18.0, 7.2, and 8.2% of SIGT; 22.3, 6.4, and 9.4% of NHANES III; and 21.8, 5.0, and 9.0% of NHANES 2005-2006 subjects, respectively. In SIGT, NHANES III, and NHANES 2005-2006, criteria for metformin consideration were met in 99, 96, and 96% of those with IFG and IGT; 31, 29, and 28% of all those with IFG; and 53, 57, and 62% of all those with IGT (8.1, 9.1, and 8.7% of all subjects), respectively. CONCLUSIONS: More than 96% of individuals with both IFG and IGT are likely to meet ADA consensus criteria for consideration of metformin. Because >28% of all those with IFG met the criteria, providers should perform oral glucose tolerance tests to find concomitant IGT in all patients with IFG. To the extent that our findings are representative of the U.S. population, approximately 1 in 12 adults has a combination of pre-diabetes and risk factors that may justify consideration of metformin treatment for diabetes prevention.
Abstract: Health utilities are measures of health-related quality of life (HRQL) used in cost-effectiveness research. We evaluated whether changes in body weight were associated with changes in health utilities in the Diabetes Prevention Program (DPP) and whether associations differed by treatment assignment (lifestyle intervention, metformin, placebo) or baseline obesity severity. We constructed physical (PCS-36) and mental component summary (MCS-36) subscales and short-form-6D (SF-6D) health utility index for all DPP participants completing a baseline 36-item short form (SF-36) HRQL assessment (N = 3,064). We used linear regression to test associations between changes in body weight and changes in HRQL indicators, while adjusting for other demographic and behavioral variables. Overall differences in HRQL between treatment groups were highly statistically significant but clinically small after 1 year. In multivariable models, weight change was independently associated with change in SF-6D score (increase of 0.007 for every 5 kg weight loss; P < 0.001), but treatment effects independent of weight loss were not. We found no significant interaction between baseline obesity severity and changes in SF-6D with changes in body weight. However, increases in physical function (PCS-36) with weight loss were greater in persons with higher baseline obesity severity. In summary, improvements in HRQL are associated with weight loss but not with other effects of obesity treatments that are unrelated to weight loss. Although improvements in the SF-6D did not exceed commonly reported thresholds for a minimally important difference (0.04), these changes, if causal, could still have a significant impact on clinical cost-effectiveness estimates if sustained over multiple years.
Abstract: AIMS/HYPOTHESIS: Diabetes prevention and care are limited by lack of screening. We hypothesised that screening could be done with a strategy similar to that used near-universally for gestational diabetes, i.e. a 50 g oral glucose challenge test (GCT) performed at any time of day, regardless of meal status, with one 1 h sample. METHODS: At a first visit, participants had random plasma and capillary glucose measured, followed by the GCT with plasma and capillary glucose (GCTplasma and GCTcap, respectively). At a second visit, participants had HbA(1c) measured and a diagnostic 75 g OGTT. RESULTS: The 1,573 participants had mean age of 48 years, BMI 30.3 kg/m(2) and 58% were women and 58% were black. Diabetes (defined by WHO) was present in 4.6% and prediabetes (defined as impaired glucose tolerance [2 h glucose 7.8-11.1 (140-199 mg/dl) with fasting glucose <or=6.9 (125 mg/dl)] and/or impaired fasting glucose with plasma glucose 6.1-6.9 mmol/l [110-125 mg/dl]) in 18.7%. The GCTplasma provided areas under the receiver-operating-characteristic curves of 0.90, 0.82 and 0.79 for detection of diabetes, diabetes or prediabetes, and prediabetes, respectively, all of which were higher than GCTcap, random and capillary glucose, and HbA(1c) (p < 0.02 for all). The performance of GCTplasma was unaffected by time after meals or time of day, and was better in blacks than whites, but otherwise comparable in men and women, and in groups with differing prevalence of glucose intolerance. GCTplasma screening would cost approximately US$84 to identify one person with previously unrecognised diabetes or prediabetes. CONCLUSIONS/INTERPRETATION: GCT screening for prediabetes and previously unrecognised diabetes would be accurate, convenient and inexpensive. Widespread use of GCT screening could help improve disease management by permitting early initiation of therapy aimed at preventing or delaying the development of diabetes and its complications.
Abstract: BACKGROUND: Weight loss through dietary modification is key to type 2 diabetes self-management, yet few nationally representative data exist on dietary trends among people with diabetes. OBJECTIVE: To examine dietary changes, via nutrient intakes, among US adults with diabetes between 1988 and 2004. DESIGN: Nutrition data from the cross-sectional National Health and Nutrition Examination Surveys (Phase I: 1988-1990 and Phase II: 1991-1994) and 1999-2004 of adults with self-reported diabetes were examined. Twenty-four-hour dietary recall data were used to assess changes in energy; carbohydrate; protein; total, saturated, polyunsaturated, and monounsaturated fat; cholesterol; fiber; sodium; and alcohol intake. STATISTICAL ANALYSES: Consumption of total energy and specific nutrients per day were estimated by survey, controlled for age and sex, using multiple linear regression and adjusted means (with standard errors). RESULTS: Between 1988 and 2004 there was no significant change in self-reported total energy consumption among adults with self-reported diabetes (1,941 kcal/day in 1988-1990 to 2,109 kcal/day in 2003-2004, P for trend=0.22). However, there was a significant increase in the consumption of carbohydrate (209 g/day in 1988-1990 to 241 g/day in 2003-2004; P for trend=0.02). In analyses stratified by age group, changes in dietary consumption were noted among persons aged 45 to 64 years; specifically, increases in total energy (1,770 to 2,100 kcal/day, P for trend =0.01) and carbohydrate consumption (195 to 234 g/day, P for trend=0.02). CONCLUSIONS: Despite recommendations to lose weight, daily energy consumption by individuals with diabetes showed no significant change, except in individuals aged 45 to 64 years, where an increase was observed. Overall, there was an increase in carbohydrate consumption. Emphasizing the equal importance of energy reduction and changes in dietary composition for people with diabetes is important for optimal self-management.
Abstract: OBJECTIVE: To examine the association between physicians' reimbursement perceptions and outpatient test performance among patients with diabetes mellitus. STUDY DESIGN: Cross-sectional analysis. METHODS: Participants were physicians (n = 766) and their managed care patients with diabetes mellitus (n = 2758) enrolled in 6 plans in 2003. Procedures measured included electrocardiography, radiography or x-ray films, urine microalbumin levels, glycosylated hemoglobin levels, and Pap smears for women. Hierarchical logistic regression models were adjusted for health plan and physician-level clustering and for physician and patient covariates. To minimize confounding by unmeasured health plan variables, we adjusted for health plan as a fixed effect. Therefore, we estimated variation between physicians using only the variance within health plans. RESULTS: Patients of physicians who reported reimbursement for electrocardiography were more likely to undergo electrocardiography than patients of physicians who did not perceive reimbursement (unadjusted mean difference, 4.9%; 95% confidence interval, 1.1%-8.9%; and adjusted mean difference, 3.9%; 95% confidence interval, 0.2%-7.8%). For the other tests examined, no significant differences in procedure performance were found between patients of physicians who perceived reimbursement and patients of physicians who did not perceive reimbursement. CONCLUSIONS: Reimbursement perception was associated with electrocardiography but not with other commonly performed outpatient procedures. Future research should investigate how associations change with perceived amount of reimbursement and their interactions with other influences on test-ordering behavior such as perceived appropriateness.
Abstract: Objectives. We estimated the prevalence of overweight and diabetes among US immigrants by region of birth.Methods. We analyzed data on 34456 US immigrant adults from the National Health Interview Survey, pooling years 1997 to 2005. We estimated age- and gender-adjusted and multivariable adjusted overweight and diabetes prevalence by region of birth using logistic regression.Results. Both men (odds ratio [OR]=3.3; 95% confidence interval [CI]=1.9, 5.8) and women (OR=4.2; 95% CI=2.3, 7.7) from the Indian subcontinent were more likely than were European migrants to have diabetes without corresponding increased risk of being overweight. Men and women from Mexico, Central America, or the Caribbean were more likely to be overweight (men: OR=1.5; 95% CI=1.3, 1.7; women: OR=2.0; 95% CI=1.7, 2.2) and to have diabetes (men: OR=2.0; 95% CI=1.4, 2.9; women: OR=2.0; 95% CI=1.4, 2.8) than were European migrants.Conclusions. Considerable heterogeneity in both prevalence of overweight and diabetes by region of birth highlights the importance of making this distinction among US immigrants to better identify subgroups with higher risks of these conditions.
Abstract: BACKGROUND: Rapidly transitioning societies are experiencing dramatic increases in obesity and cardio-metabolic risk; however, few prospective studies from developing countries have quantified these increases or described their joint relationships. METHODS: We collected dietary, physical activity, demographic, anthropometric and cardio-metabolic risk factor data from 376 Guatemalan young adults in 1997-98 (aged 20-29 years) and in 2002-04 (aged 25-34 years). RESULTS: In total, 42 % of men and 56 % of women experienced weight gain >5 kg in 5 years. Percent body fat (%BF) and waist circumference (WC) increased by 4.2 % points and 5.5 cm among men, and 3.2 % points and 3.4 cm among women, respectively. Five-year increases in both %BF and WC were associated with lower physical activity, urban residence and shorter height among men but not among women (test for heterogeneity P < 0.05 for residence and physical activity). Changes in %BF and WC and concomitant changes in cardio-metabolic risk factors were similar for men and women. In standardised regression, change in %BF was associated with changes in TAG (beta=0.19; 95 % CI 0.08, 0.30), total:HDL cholesterol (beta=0.22; 95 % CI 0.12, 0.33) and systolic (beta=0.22; 95 % CI 0.12, 0.33) and diastolic (beta=0.18; 95 % CI 0.08, 0.28) blood pressure, but not with glucose; associations were similar for WC. CONCLUSIONS: Over 5 years this relatively young population of Guatemalan adults experienced rapid increases in multiple measures of adiposity, which were associated with adverse changes in lipid and blood pressure levels.
Abstract: OBJECTIVE: To compare diabetes prevalence among Asian Americans by World Health Organization and U.S. BMI classifications. RESEARCH DESIGN AND METHODS: Data on Asian American adults (n = 7,414) from the National Health Interview Survey for 1997-2005 were analyzed. Diabetes prevalence was estimated across weight and ethnic group strata. RESULTS: Regardless of BMI classification, Asian Indians and Filipinos had the highest prevalence of overweight (34-47 and 35-47%, respectively, compared with 20-38% in Chinese; P < 0.05). Asian Indians also had the highest ethnic-specific diabetes prevalence (ranging from 6-7% among the normal weight to 19-33% among the obese) compared with non-Hispanic whites: odds ratio (95% CI) for Asian Indians 2.0 (1.5-2.6), adjusted for age and sex, and 3.1 (2.4-4.0) with additional adjustment for BMI. CONCLUSIONS: Asian Indian ethnicity, but not other Asian ethnicities, was strongly associated with diabetes. Weight classification as a marker of diabetes risk may need to accommodate differences across Asian subgroups.
Abstract: AIMS: To examine whether A1c, blood pressure, and cholesterol values changed for U.S. adults with diagnosed diabetes between 1988-1994 and 2005-2006. We then project the impact of these changes on life expectancy and diabetes-related complications. METHODS: We estimated changes in hemoglobin A1c, blood pressure, and total cholesterol between 1988-1994 and 2005-2006 using regression analysis and data from the National Health and Nutrition Examination Survey. We projected the potential effects on life expectancy and complications using the CDC-RTI Diabetes Cost-Effectiveness Model. RESULTS: A1c fell by 0.68 percentage points (P=0.001) among U.S. adults with diagnosed diabetes. Among those with diabetes and hypertension, systolic and diastolic blood pressure fell by 5.66 and 8.15mmHg, respectively (P=0.005 and P=0.001). Among those with diabetes and high cholesterol, total cholesterol fell by 36.41mg/dL (P=0.001). These improvements were projected to increase life expectancy for persons with newly diagnosed diabetes by 1.0 year. CONCLUSIONS: Risk factor control has improved in the United States. Persons newly diagnosed with type 2 diabetes in 2005 have a better prognosis than persons diagnosed with diabetes 11 years earlier.
Abstract: Although the idea of preventing type 2 diabetes has been articulated since the discovery of insulin, only in the past decade have clinical trials demonstrated that diabetes can be prevented or delayed. These trials found lifestyle intervention reduces diabetes incidence by over 50% and is more efficacious than metformin. Evidence from prevention trials comes from persons with "pre-diabetes" in which blood glucose levels are elevated but not yet in the diabetes range. In normoglycemic persons, lifestyle or drug intervention has little impact on diabetes incidence. Prevention programs are often conducted outside the clinical sector where participants' glycemic status is usually unknown; these programs may include many normoglycemic participants, which greatly reduces cost-effectiveness. An economically sustainable system for diabetes prevention will require effective partnerships among the clinical sector, community-based lifestyle programs, and third-party payers to ensure that limited resources for diabetes prevention are focused on persons at high risk of diabetes.
Abstract: OBJECTIVES: In participatory decision-making (PDM), physicians actively engage patients in treatment and other care decisions. Patients who report that their physicians engage in PDM have better disease self-management and health outcomes. We examined whether physicians' diabetes-specific treatment PDM preferences as well as their self-reported practices are associated with the quality of diabetes care their patients receive. METHODS: 2003 cross-sectional survey and medical record review of a random sample of diabetes patients (n=4198) in 10 US health plans across the country and their physicians (n=1217). We characterized physicians' diabetes care PDM preferences and practices as 'no patient involvement,' 'physician-dominant,' 'shared,' or 'patient-dominant' and conducted multivariate analyses examining their effects on the following: (1) three diabetes care processes (annual hemoglobin A1c test; lipid test; and dilated retinal exam); (2) patients'satisfaction with physician communication; and (3) whether patients' A1c, systolic blood pressure (SBP), and low-density lipoprotein cholesterol (LDL) were in control. RESULTS: Most physicians preferred 'shared' PDM (58%) rather than 'no patient involvement' (9%), 'physician-dominant' (28%) or 'patient dominant' PDM (5%). However, most reported practicing 'physician-dominant' PDM (43%) with most of their patients, rather than 'no patient involvement' (13%), 'shared' (37%) or 'patient-dominant' PDM (7%). After adjusting for patient and physician-level characteristics and clustering by health plan, patients of physicians who preferred 'shared' PDM were more likely to receive A1c tests [90% vs. 82%, AOR: 2.05, 95% CI: 1.03-3.07] and patients of physicians who preferred 'patient-dominant' treatment decision-making were more likely to receive lipid tests [60% vs. 50%, AOR: 1.58, 95% CI: 1.04-2.39] than those of providers who preferred 'no patient involvement' in treatment decision-making. There were no differences in patients' satisfaction with their doctor's communication or control of A1c, SBP or LDL depending on their physicians' PDM preferences. Physicians' self-reported PDM practices were not associated with any of the examined aspects of diabetes care in multivariate analyses. CONCLUSIONS: Patients whose physicians prefer more patient involvement in decision-making are more likely than patients whose physicians prefer more physician-directed styles to receive some recommended risk factor screening tests, an important first step toward improved diabetes outcomes. Involving patients in treatment decision-making alone, however, appears not to be sufficient to improve biomedical outcomes.
Abstract: In the wake of dynamic economic and political transitions worldwide, the Institute of Medicine recently released its report advocating investments in global health from the United States (US). The expert panel reinforces the 'transnational and interdisciplinary' nature of global health research and practice as an endeavor 'to improve health and achieve greater equity for all people worldwide.' This report was judiciously timed given the growing recognition of global health, and is also acknowledged for incorporating themes that are particularly pertinent to the twenty-first century. New paradigms are introduced, denouncing the dichotomous distinction between rich and poor countries with the rapidly transitioning countries emerging as global powers, and affirming the need for models of respectful partnership and wider translation of science into practice. Cultivating sustainable partnerships and investing in the understanding and combat of diseases worldwide will become increasingly important for the US to maintain its global competitiveness, and may offer lessons in innovation, efficiency, and organization of institutions and human resources.
Abstract: The emergence of non-communicable diseases (NCD) in South Asia and other low- and middle-income countries presents a growing and costly public health challenge. The surreptitious and rapid escalation of these chronic conditions will soon surpass attempts to quantify and appropriately respond to these overwhelming health threats. Given the elevated risk of cardio-metabolic diseases (diabetes, cardiovascular disease, and kidney disease) and projected morbidity and mortality burdens in the Asian Indian population group, the lack of representative data to support national response strategies will likely result in crippling health and socioeconomic losses. We describe how systematic research may help to reconcile India's data deficits and may be applied towards prioritizing resource allocation and addressing shortfalls in disease prevention and control efforts. Expanding the scope of and contextualizing NCD health research in India may also have tremendous benefits for resource allocation and planning in other developing countries.
Abstract: Aim: To determine glycosylated hemoglobin (HbA1c) cut-points for glucose intolerance in Asian Indians. Methods: 2188 participants without known diabetes were randomly selected from the Chennai Urban Rural Epidemiology Study. All had fasting plasma glucose [FPG] and 2hr post glucose [2hr PG] measurements after 75g load and were classified as impaired fasting glucose [IFG] (ADA criteria: FPG >/=5.5 mmol/L and < 7 mmol/L and WHO criteria: FPG >/=6.1mmol/L and <7 mmol/L; impaired glucose tolerance [IGT]: 2hr PG >/= 7.8 mmol/L and < 11.1 mmol/L, or diabetes: FPG >/=7mmol/L and/or 2hr PG >/= 11.1 mmol/L. HbA1c was measured using the Biorad Variant machine. Based on Receiver Operating Characteristic curves, optimum sensitivity and specificity were derived for defining HbA1c cut points for diabetes, IGT and IFG. Results: Mean values of HbA1c among NGT, IGT and diabetes subjects were 5.5+/-0.4%, 5.9+/-0.6% and 8.3+/-2.0% respectively [p for trend <0.001] with considerable overlap. To identify diabetes based on 2hr PG, HbA1c cut point of 6.1% had area under the curve (AUC) of 0.941 with 88.0% sensitivity and 87.9% specificity. When diabetes was defined as FPG >/= 7.0mmol/L, the HbA1c cut point was 6.4% (AUC=0.966, sensitivity 93.3%, specificity 92.3%). For IGT, AUC = 0.708; IFG - WHO, AUC = 0.632 and IFG - ADA, AUC=0.708, the HbA1c cut point was 5.6%. Conclusion: In Asian Indians, HbA1c cut point of 6.1% and 6.4% defined diabetes by 2hr PG or FPG criteria respectively. A value of 5.6% optimally identified IGT or IFG, but was less than 70% accurate.
Abstract: Allocating scarce resources for dysglycemia intervention requires identification of persons who will benefit. Identification has two steps: screening followed by diagnosis. Lowering a screening test's cut-off score identifies more persons with dysglycemia, but causes more normoglycemic persons to receive diagnostic testing. Raising a test's cut-off score reduces needless diagnostic testing, but increases the number falsely identified as not having dysglycemia. With limited budgets for intervention, raising a screening test's cut-off score may be appropriate. With ample budgets, lowering the test's cut-off score may be appropriate. Screening tests are most efficient in populations with high prevalence of dysglycemia.
Abstract: OBJECTIVE: Hispanics have higher rates of diabetes and diabetes-related complications than do non-Hispanic whites. A meta-analysis was conducted to estimate the difference between the mean values of A1C for these two groups. RESEARCH DESIGN AND METHODS: We executed a PubMed search of articles published from 1993 through July 2007. Data sources included PubMed, Web of Science, Cumulative Index to Nursing and Allied Health, the Cochrane Library, Combined Health Information Database, and Education Resources Information Center. Data on sample size, age, sex, A1C, geographical location, and study design were extracted. Cross-sectional data and baseline data from clinical trials and cohort studies for Hispanics and non-Hispanic whites with diabetes were included. Studies were excluded if they included individuals <18 years of age or patients with pre-diabetes or gestational diabetes. RESULTS: A total of 495 studies were reviewed, of which 73 contained data on A1C for Hispanics and non-Hispanic whites, and 11 met the inclusion criteria. Meta-analysis revealed a statistically significant mean difference (P < 0.0001) of -0.46 (95% CI -0.63 to -0.33), correlating to an approximately 0.5% higher A1C for Hispanics. Grouping studies by design (cross-sectional or cohort), method of data collection for A1C (chart review or blood sampling), and care type (managed or nonmanaged) yielded similar results. CONCLUSIONS: In this meta-analysis, A1C was approximately 0.5% higher in Hispanic patients with diabetes than in non-Hispanic patients. Understanding the reasons for this disparity should be a focus for future research.
Abstract: OBJECTIVE: Limited data exist on the association between in utero exposure to maternal diabetes and obesity and type 2 diabetes in diverse youth. These associations were explored in African-American, Hispanic, and non-Hispanic white youth participating in the SEARCH Case-Control Study. RESEARCH DESIGN AND METHODS: A total of 79 youth with type 2 diabetes and 190 nondiabetic control youth aged 10-22 years attended a research visit. In utero exposures to maternal diabetes and obesity were recalled by biological mothers. RESULTS: Youth with type 2 diabetes were more likely to have been exposed to maternal diabetes or obesity in utero than were nondiabetic control youth (P < 0.0001 for each). After adjusting for offspring age, sex, and race/ethnicity, exposure to maternal diabetes (odds ratio [OR] 5.7 [95% CI 2.4-13.4]) and exposure to maternal obesity (2.8 [1.5-5.2]) were independently associated with type 2 diabetes. Adjustment for other perinatal and socioeconomic factors did not alter these associations. When offspring BMI was added, the OR for the association between in utero exposure to obesity and type 2 diabetes was attenuated toward the null (OR 1.1 [0.5-2.4]). Overall, 47.2% (95% CI 30.9-63.5) of type 2 diabetes in youth could be attributed to intrauterine exposure to maternal diabetes and obesity. CONCLUSIONS: Intrauterine exposures to maternal diabetes and obesity are strongly associated with type 2 diabetes in youth. Prevention efforts may need to target, in addition to childhood obesity, the increasing number of pregnancies complicated by obesity and diabetes.
Abstract: BACKGROUND: Although patients with diabetes may benefit from physical activity, few studies have examined sustained walking in this population. OBJECTIVE: To examine the factors associated with sustained walking among managed care patients with diabetes. DESIGN: Longitudinal, observational cohort study with questionnaires administered 2.5 years apart. PARTICIPANTS: Five thousand nine hundred thirty-five patients with diabetes walking at least 20 minutes/day at baseline. MEASUREMENTS: The primary outcome was the likelihood of sustained walking, defined as walking at least 20 minutes/day at follow-up. We evaluated a logistic regression model that included demographic, clinical, and neighborhood variables as independent predictors of sustained walking, and expressed the results as predicted percentages. RESULTS: The absence of pain was linked to walking behavior, as 62% of patients with new pain, 67% with ongoing pain, and 70% without pain were still walking at follow-up (p = .03). Obese patients were less likely (65%) to sustain walking than overweight (71%) or normal weight (70%) patients (p = .03). Patients > or =65 years (63%) were less likely to sustain walking than patients between 45 and 64 (70%) or < or =44 (73%) years (p = .04). Only 62% of patients with a new comorbidity sustained walking compared with 68% of those who did not (p < .001). We found no association between any neighborhood variables and sustained walking in this cohort of active walkers. CONCLUSIONS: Pain, obesity, and new comorbidities were moderately associated with decreases in sustained walking. Whereas controlled intervention studies are needed, prevention, or treatment of these adverse conditions may help patients with diabetes sustain walking behavior.
Abstract: BACKGROUND: With positive results from diabetes prevention studies, there is interest in convenient ways to incorporate screening for glucose intolerance into routine care and to limit the need for fasting diagnostic tests. OBJECTIVE: The aim of this study is to determine whether random plasma glucose (RPG) could be used to screen for glucose intolerance. DESIGN: This is a cross-sectional study. PARTICIPANTS: The participants of this study include a voluntary sample of 990 adults not known to have diabetes. MEASUREMENTS: RPG was measured, and each subject had a 75-g oral glucose tolerance test several weeks later. Glucose intolerance targets included diabetes, impaired glucose tolerance (IGT), and impaired fasting glucose(110) (IFG(110); fasting glucose, 110-125 mg/dl, and 2 h glucose < 140 mg/dl). Screening performance was measured by area under receiver operating characteristic curves (AROC). RESULTS: Mean age was 48 years, and body mass index (BMI) was 30.4 kg/m(2); 66% were women, and 52% were black; 5.1% had previously unrecognized diabetes, and 24.0% had any "high-risk" glucose intolerance (diabetes or IGT or IFG(110)). The AROC was 0.80 (95% CI 0.74-0.86) for RPG to identify diabetes and 0.72 (0.68-0.75) to identify any glucose intolerance, both highly significant (p < 0.001). Screening performance was generally consistent at different times of the day, regardless of meal status, and across a range of risk factors such as age, BMI, high density lipoprotein cholesterol, triglycerides, and blood pressure. CONCLUSIONS: RPG values should be considered by health care providers to be an opportunistic initial screening test and used to prompt further evaluation of patients at risk of glucose intolerance. Such "serendipitous screening" could help to identify unrecognized diabetes and prediabetes.
Abstract: OBJECTIVES: The Balanced Budget Act of 1997 authorized Medicare to expand the coverage of glucose monitors and strips to non-insulin users with diabetes and self-management training to non-hospital-based programs. We examined the impact of this expansion on self-monitoring of blood glucose among Medicare beneficiaries who were not using insulin to treat their diabetes. METHODS: With data from the 1996-2000 Behavioral Risk Factor Surveillance System and a logistic regression model using a complex survey design, we compared the probability of self-monitoring of blood glucose among Medicare beneficiaries at the frequency recommended by the American Academy of Family Physicians' clinical guidelines before and after the Medicare expansion. We also compared the change in the frequency of self-monitoring of blood glucose during these periods between Medicare beneficiaries and persons with private insurance by using a difference-in-difference model. RESULTS: Medicare expansion was positively associated with the probability of self-monitoring of blood glucose for both Medicare beneficiaries and persons with private insurance; the magnitude was between 7.1 and 16.6 percentage points. CONCLUSIONS: The Medicare expansion effectively increased the frequency of the recommended self-monitoring of blood glucose in the Medicare population.
Abstract: This paper identifies the overarching patterns of immigrant health in the US. Most studies indicate that foreign-born individuals are in better health than native-born Americans, including individuals of the same race/ethnicity. They tend to have lower mortality rates and are less likely to suffer from circulatory diseases, overweight/obesity, and some cancers. However, many foreign-born groups have higher rates of diabetes, some infections, and occupational injuries. There is heterogeneity in health among immigrants, whose health increasingly resembles that of natives with duration of US residence. Prospective studies are needed to better understand migrant health and inform interventions for migrant health maintenance.
Abstract: OBJECTIVE: Age, BMI, and race/ethnicity are used in National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) and American Diabetes Association (ADA) guidelines to prompt screening for pre-diabetes and diabetes, but cutoffs have not been evaluated rigorously. RESEARCH DESIGN AND METHODS: Random plasma glucose (RPG) was measured and 75-g oral glucose tolerance tests were performed in 1,139 individuals without known diabetes. Screening performance was assessed by logistic regression and area under the receiver operating characteristic curve (AROC). RESULTS: NIDDK/ADA indicators age >45 years and BMI >25 kg/m(2) provided significant detection of both diabetes and dysglycemia (both AROCs 0.63), but screening was better with continuous-variable models of age, BMI, and race and better still with models of age, BMI, race, sex, and family history (AROC 0.78 and 0.72). However, screening was even better with RPG alone (AROCs 0.81 and 0.72). RPG >125 mg/dl could be used to prompt further evaluation with an OGTT. CONCLUSIONS: Use of age, BMI, and race/ethnicity in guidelines for screening to detect diabetes and pre-diabetes may be less important than evaluation of RPG. RPG should be investigated further as a convenient, inexpensive screen with good predictive utility.
Abstract: Although immigrants are a rapidly growing subgroup, little is known about overweight/obesity among the foreign-born in the United States, especially regarding the effect of age at arrival. This study determined whether overweight/obesity prevalence is associated with age at arrival of immigrants to the United States. We analyzed data on 6,421 adult immigrants from the New Immigrant Survey (NIS), a study that is nationally representative of adult immigrants with newly acquired legal permanent residence (LPR). Multiple regression analyses tested the effects of duration of residence and age at arrival on overweight/obesity, defined by BMI of > or = 25 kg/m(2), and self-reported dietary change score. We found the relationship between duration of residence and overweight/obesity prevalence varied by age at arrival (P < 0.001). Immigrants < or = 20-years old at arrival who had resided in the United States > or = 15 years were 11 times (95% confidence interval: 5.33, 22.56) more likely to be overweight/obese than immigrants < 20-years old at arrival who had resided in the United States < or = 1 year. By comparison, there was no difference in overweight/obesity prevalence by duration among immigrants who arrived at >50 years of age. Higher self-reported dietary change is also associated with overweight/obesity. In conclusion, immigrants younger than 20 at arrival in the United States may be at higher risk of overweight/obesity with increasing duration of residence than those who arrive at later ages. Obesity prevention among young US immigrants should be a priority.
Abstract: In India, thirty-five million people have diabetes-a number expected to more than double by 2025, disproportionately affecting working-age people. The economic impact of this increase could be devastating to India's emerging economy. In this paper we discuss drivers of the epidemic, analyze current policies and practices in India, and conclude with recommendations, focusing on multisectoral and international collaboration. We see these recommendations as providing a blueprint for addressing diabetes in India by illuminating opportunities and barriers for policymakers and others.
Abstract: OBJECTIVES: To estimate the number of people with diabetic retinopathy (DR), vision-threatening DR (VTDR), glaucoma, and cataracts among Americans 40 years or older with diagnosed diabetes mellitus for the years 2005-2050. METHODS: Using published prevalence data of DR, VTDR, glaucoma, and cataracts and data from the National Health Interview Survey and the US Census Bureau, we projected the number of Americans with diabetes with these eye conditions. RESULTS: The number of Americans 40 years or older with DR and VTDR will triple in 2050, from 5.5 million in 2005 to 16.0 million for DR and from 1.2 million in 2005 to 3.4 million for VTDR. Increases among those 65 years or older will be more pronounced (2.5 million to 9.9 million for DR and 0.5 million to 1.9 million for VTDR). The number of cataract cases among whites and blacks 40 years or older with diabetes will likely increase 235% by 2050, and the number of glaucoma cases among Hispanics with diabetes 65 years or older will increase 12-fold. CONCLUSION: Future increases in the number of Americans with diabetes will likely lead to significant increases in the number with DR, glaucoma, and cataracts. Our projections may help policy makers anticipate future demands for health care resources and possibly guide the development of targeted interventions. CLINICAL RELEVANCE: Efforts to prevent diabetes and to optimally manage diabetes and its complications are needed.
Abstract: The emergence of type 2 diabetes in India, coinciding with the country's rapid economic development in the past several decades, is often characterized as a modern epidemic resulting directly from westernization. We draw on India's agricultural, linguistic, medical, economic, religious and gastronomic history to examine the possibility that type 2 diabetes mellitus may have existed in ancient India, having subsequently declined in the two centuries leading up to the present. The implications of such a possibility vis-a-vis the role of westernization in the global diabetes aetiology are discussed. Additionally, an argument is made for careful application of the terms 'westernization' and 'globalization' in discussions of chronic disease aetiology, where their often totalizing discourses may obscure the sociocultural particularities of manifestations of these conditions in various global arenas.
Abstract: OBJECTIVE: The albumin-to-creatinine ratio (ACR) reflects urinary albumin excretion and is increasingly being accepted as an important clinical outcome predictor. Because of the great public health need for a simple and inexpensive test to identify individuals at high risk for developing type 2 diabetes, it has been suggested that the ACR might serve this purpose. We therefore determined whether the ACR could predict incident diabetes in a well-characterized cohort of pre-diabetic Americans. RESEARCH DESIGN AND METHODS: A total of 3,188 Diabetes Prevention Program (DPP) participants with a mean BMI of 34 kg/m(2) and elevated fasting glucose, impaired glucose tolerance, and baseline urinary albumin excretion measurements were followed for incident diabetes over a mean of 3.2 years. RESULTS: Of the participants, 94% manifested ACR levels below the microalbuminuria range and 21% ultimately developed diabetes during follow-up. Quartiles of ACR (median [range] within quartiles: 1, 3.0 [0.7-3.7]; 2, 4.6 [3.7-5.5]; 3, 7.1 [5.5-9.7]; and 4, 16.5 [9.7-1,578]) were positively associated with age, markers of adiposity and insulin secretion and resistance, blood pressure, and use of antihypertensive agents with antiproteinuric effects and inversely related to male sex and serum creatinine. An elevated hazard rate for developing diabetes with doubling of ACR disappeared after adjustment for covariates. Within the DPP intervention groups (placebo, lifestyle, and metformin), we found no consistent trend in incident diabetes by quartile or decile of ACR. CONCLUSIONS: An ACR at levels below the microalbuminuria range does not independently predict incident diabetes in adults at high risk of developing type 2 diabetes.
Abstract: A paradoxical pattern has been suggested in the literature on doctors' strikes: when health workers go on strike, mortality stays level or decreases. We performed a review of the literature during the past forty years to assess this paradox. We used PubMed, EconLit and Jstor to locate all peer-reviewed English-language articles presenting data analysis on mortality associated with doctors' strikes. We identified 156 articles, seven of which met our search criteria. The articles analyzed five strikes around the world, all between 1976 and 2003. The strikes lasted between nine days and seventeen weeks. All reported that mortality either stayed the same or decreased during, and in some cases, after the strike. None found that mortality increased during the weeks of the strikes compared to other time periods. The paradoxical finding that physician strikes are associated with reduced mortality may be explained by several factors. Most importantly, elective surgeries are curtailed during strikes. Further, hospitals often re-assign scarce staff and emergency care was available during all of the strikes. Finally, none of the strikes may have lasted long enough to assess the effects of long-term reduced access to a physician. Nonetheless, the literature suggests that reductions in mortality may result from these strikes.
Abstract: In this commentary, we discuss the potential utility of low-cost screening algorithms for the prediction of risk for cardiovascular disease. Strategies such as these might enhance screening and prevention programs but require validation. Testing the usefulness of low-cost prediction models in developing regions is the next logical step in carrying this concept forward.
Abstract: AIMS: To compare the utility of metabolic syndrome (MetS) to random plasma glucose (RPG) in identifying people with diabetes or prediabetes. METHODS: RPG was measured and an OGTT was performed in 1155 adults. Test performance was measured by area under the receiver-operating-characteristic curve (AROC). RESULTS: Diabetes was found in 5.1% and prediabetes in 20.0%. AROC for MetS with fasting plasma glucose (FPG) was 0.80 to detect diabetes, and 0.76 for diabetes or prediabetes--similar to RPG alone (0.82 and 0.72). However, the AROC for MetS excluding fasting plasma glucose was lower: 0.69 for diabetes (p<0.01 vs. both RPG and MetS with FPG), and 0.69 for diabetes or prediabetes. AROCs for MetS with FPG and RPG were comparable and higher for recognizing diabetes in blacks vs. whites, and females vs. males. MetS with FPG was superior to RPG for identifying diabetes only in subjects with age <40 or BMI <25. CONCLUSIONS: MetS features can be used to identify risk of diabetes, but predictive usefulness is driven largely by FPG. Overall, to identify diabetes or prediabetes in blacks and whites with varying age and BMI, MetS is no better than RPG--a more convenient and less expensive test.
Abstract: Type 2 diabetes is a complex, multi-factorial condition, caused by environment factors and an inheritance pattern that is polygenic. Preventing diabetes is a major clinical, research and public health priority. Lifestyle intervention studies, programs that promote changes in diet, activity, and behavior, have been shown to be effective ways to prevent type 2 diabetes, perhaps even in patients with genotypes that might put them at increased risk for developing the disease. Clinicians should be helping their patients to make positive lifestyle changes, and researchers must find ways to translate lifestyle interventions into real world settings in order to stop the epidemic of diabetes.
Abstract: OBJECTIVE: To examine the association between physician-reported percent of total compensation from salary and quality of diabetes care. DESIGN: Cross-sectional analysis. PARTICIPANTS: Physicians (n = 1248) and their patients with diabetes mellitus (n = 4200) enrolled in 10 managed care plans. MEASUREMENTS: We examined the associations between physician-reported percent compensation from salary and processes of care including receipt of dilated eye exams and foot exams, advice to take aspirin, influenza immunizations, and assessments of glycemic control, proteinuria, and lipid profile, intermediate outcomes such as adequate control of hemoglobin A1c, lipid levels, and systolic blood pressure levels, and satisfaction with provider communication and perceived difficulty getting needed care. We used hierarchical logistic regression models to adjust for clustering at the health plan and physician levels, as well as for physician and patient covariates. We adjusted for plan as a fixed effect, meaning we estimated variation between physicians using the variance within a particular health plan only, to minimize confounding by other unmeasured health plan variables. RESULTS: In unadjusted analyses, patients of physicians who reported higher percent compensation from salary (>90%) were more likely to receive 5 of 7 diabetes process measures and more intensive lipid management and to have an HbA1c<8.0% than patients of physicians who reported lower percent compensation from salary (<10%). However, these associations did not persist after adjustment. CONCLUSIONS: Our findings suggest that salary, as opposed to fee-for-service compensation, is not independently associated with diabetes processes and intermediate outcomes.
Abstract: OBJECTIVE: We sought to study the occurrence of cardiometabolic risk variables, their clustering, and their association with insulin resistance among healthy adolescents in urban south India. RESEARCH DESIGN AND METHODS: School children aged 12-19 years (n = 2,640; 1,323 boys and 1,317 girls) from diverse socioeconomic backgrounds were studied. Demographic, social, and medical details were obtained; anthropometry and blood pressure were measured. Fasting plasma glucose, insulin, and lipid profiles were measured. Clusters of risk variables were identified by factor analysis. Association of insulin resistance (homeostasis model assessment) with individual risk variables and their clusters were assessed. RESULTS: One or more cardiometabolic abnormalities (i.e., low HDL cholesterol, elevated triglycerides, fasting plasma glucose, or blood pressure) was present in 67.7% of children (in 64.8% of normal weight and 85% of overweight children). Insulin resistance was associated with the above abnormalities except HDL cholesterol. It also showed significant positive association with BMI, waist circumference, body fat percentage, and total cholesterol (P < 0.0001). Factor analysis identified three distinct clusters, with minor differences in the sexes: 1) waist circumference and blood pressure; 2) dyslipidemia, waist circumference, and insulin; and 3) waist circumference, glucose, and plasma insulin, with minor differences in the sexes. Insulin was a component of the lipid and glucometabolic cluster. In girls, it was a component of all three clusters. CONCLUSIONS: Cardiometabolic abnormalities are present in nearly 68% of young, healthy, Asian-Indian adolescents and even among those with normal weight. Insulin resistance is associated with individual cardiometabolic factors, and plasma insulin showed association with clustering of some variables.
Abstract: There is increased recognition that determinants of health should be investigated in a life-course perspective. Retirement is a major transition in the life course and offers opportunities for changes in physical activity that may improve health in the aging population. The authors examined the effect of retirement on changes in physical activity in the GLOBE Study, a prospective cohort study known by the Dutch acronym for "Health and Living Conditions of the Population of Eindhoven and surroundings," 1991-2004. They followed respondents (n = 971) by postal questionnaire who were employed and aged 40-65 years in 1991 for 13 years, after which they were still employed (n = 287) or had retired (n = 684). Physical activity included 1) work-related transportation, 2) sports participation, and 3) nonsports leisure-time physical activity. Multinomial logistic regression analyses indicated that retirement was associated with a significantly higher odds for a decline in physical activity from work-related transportation (odds ratio (OR) = 3.03, 95% confidence interval (CI): 1.97, 4.65), adjusted for sex, age, marital status, chronic diseases, and education, compared with remaining employed. Retirement was not associated with an increase in sports participation (OR = 1.12, 95% CI: 0.71, 1.75) or nonsports leisure-time physical activity (OR = 0.80, 95% CI: 0.54, 1.19). In conclusion, retirement introduces a reduction in physical activity from work-related transportation that is not compensated for by an increase in sports participation or an increase in nonsports leisure-time physical activity.
Abstract: OBJECTIVE: At birth, the lifetime risk of developing diabetes is one in three, but lifetime risks across BMI categories are unknown. We estimated BMI-specific lifetime diabetes risk in the U.S. for age-, sex-, and ethnicity-specific subgroups. RESEARCH DESIGN AND METHODS: National Health Interview Survey data (n = 780,694, 1997-2004) were used to estimate age-, race-, sex-, and BMI-specific prevalence and incidence of diabetes in 2004. U.S. Census Bureau age-, race-, and sex-specific population and mortality rate estimates for 2004 were combined with two previous studies of mortality to estimate diabetes- and BMI-specific mortality rates. These estimates were used in a Markov model to project lifetime risk of diagnosed diabetes by baseline age, race, sex, and BMI. RESULTS: Lifetime diabetes risk at 18 years of age increased from 7.6 to 70.3% between underweight and very obese men and from 12.2 to 74.4% for women. The lifetime risk difference was lower at older ages. At 65 years of age, compared with normal-weight male subjects, lifetime risk differences (percent) increased from 3.7 to 23.9 percentage points between overweight and very obese men and from 8.7 to 26.7 percentage points for women. The impact of BMI on diabetes duration also decreased with age. CONCLUSIONS: Overweight and especially obesity, particularly at younger ages, substantially increases lifetime risk of diagnosed diabetes, while their impact on diabetes risk, life expectancy, and diabetes duration diminishes with age.
Abstract: OBJECTIVE: To determine the cost-effectiveness of vitamin therapy (antioxidants plus zinc) for all indicated patients diagnosed with age-related macular degeneration (AMD). DESIGN: We compared the impacts of vitamin therapy with those of no vitamin therapy using a computerized, stochastic, agent-based model. The model simulated the natural history of AMD and patterns of ophthalmic service use in the United States in a cohort from age 50 years until 100 or death. PARTICIPANTS AND/OR CONTROLS: The model created 20 million simulated individuals. These individuals each received both the intervention (vitamin therapy after diagnosis) and the control (no vitamin therapy). Expected outcomes generated when vitamins were taken after diagnosis were compared with the expected outcomes generated when they were not. METHODS: The model created individuals representative of patients in the U.S. Incidence of early AMD was based on published studies, as was vision loss and response to choroidal neovascularization therapies. Post-incident disease progression was governed by previously unpublished data drawn from the Age-Related Eye Disease Study. MAIN OUTCOME MEASURES: Extent of disease progression, years and severity of visual impairment, cost of ophthalmic care and nursing home services, and quality-adjusted life years (QALYs). Costs and benefits were considered from the health care perspective and discounted using a 3% rate. The analysis was run for 50 years starting in 2003. RESULTS: Compared with no therapy, vitamin therapy yielded a cost-effectiveness ratio of $21,387 per QALY gained and lowered the percentage of patients with AMD who ever developed visual impairment in the better-seeing eye from 7.0% to 5.6%. CONCLUSIONS: Our model demonstrates that vitamin therapy for AMD improves quality of life at a reasonable cost.
Abstract: OBJECTIVE: To review existing data to determine whether racial/ethnic disparities exist for self-monitoring of blood glucose (SMBG) among adults in the United States. STUDY DESIGN: A literature search of diabetes-related studies published from 1970 through June 2005 was conducted. Our search strategy included SMBG in minority populations with diabetes. METHODS: Studies were selected for review if they reported SMBG rates from a specific racial/ethnic minority group or if there were comparisons of SMBG rates across racial/ethnic groups. RESULTS: Twenty-two studies were reviewed that met the search criteria. Twelve studies included data from a single racial/ethnic minority group, and 10 studies included comparisons between non-Hispanic Whites and at least one racial/ethnic minority group. Data represented studies conducted in a variety of settings, such as healthcare facilities in a state or region of the United States and nationally representative surveys. Most of the data indicate that SMBG rates are generally low, regardless of the population. In comparative studies, some racial/ethnic differences overall were found in SMBG rates among all racial/ethnic minority groups when compared to non-Hispanic Whites. Across studies, patients taking insulin performed SMBG more frequently than did those not taking insulin. CONCLUSIONS: Despite widespread recommendations for self-monitoring of blood glucose, compliance is reported to be low in all groups in the United States, especially among racial/ ethnic minorities.
Abstract: OBJECTIVE: To estimate the levels of self-reported access of eye care services in the nation. METHODS: We analyzed data from the 2002 National Health Interview Survey (30 920 adults aged > or =18 years). We estimated the number of US adults at high risk for serious vision loss and assessed factors associated with the use of eye care services. RESULTS: An estimated 61 million adults in the United States were at high risk for serious vision loss (they had diabetes, had vision or eye problems, or were aged > or =65 years); 42.0% of the 78 million adults who had dilated eye examinations in the past 12 months were among this group. Among the high-risk population, the probability of having a dilated eye examination increased with age, education, and income (P<.01). The probability of receiving an examination was higher for the insured, women, persons with diabetes, and those with vision or eye problems (P<.01). Approximately 5 million high-risk adults could not afford eyeglasses when needed; being female, having low income, not having insurance, and having vision or eye problems were each associated with such inability (P<.01). CONCLUSIONS: There is substantial inequity in access to eye care in the United States. Better targeting of resources and efforts toward people at high risk may help reduce these disparities.
Abstract: BACKGROUND: The prevalence of diabetes is higher among Mexican Americans than among non-Hispanic whites. Higher serum levels of organochlorine pesticides in Mexican Americans have been reported. Few studies have explored the association between pesticide exposure and diabetes. OBJECTIVES: We set out to examine the association between self-reported diabetes and serum concentrations of organochlorine pesticides among Mexican Americans residing in the southwestern United States from 1982 to 1984. METHODS: This study was conducted among a sample of 1,303 Mexican Americans 20-74 years of age from the Hispanic Health and Nutrition Examination Survey. Serum concentrations were available for seven pesticides or pesticide metabolites at quantifiable levels in at least 1% of the study population: p,p'-DDT (dichlorodiphenyltrichloroethane), p,p'-DDE (dichlorodiphenyldichloro-ethylene), dieldrin, oxychlordane, beta-hexachlorocyclohexane, hexachlorobenzene, and trans-nonachlor. We used logistic regression to evaluate the association of self-reported diabetes with exposure to organochlorine pesticides, with and without adjustment for total serum lipids. Nonfasting serum glucose values were compared among exposure groups. RESULTS: Self-reported diabetes was significantly associated with serum levels above the detectable limit for trans-nonachlor, oxychlordane, and beta-hexachlorocyclohexane and among those with the highest level of exposure to p,p'-DDT and p,p'-DDE. On adjustment for total serum lipids, the association with p,p'-DDT remained significant. Serum glucose levels were elevated among those exposed to trans-nonachlor and beta-hexachlorocyclohexane. CONCLUSION: This study suggests that higher serum levels of certain organochlorine pesticides may be associated with increased prevalence of diabetes. Additional studies with more extensive clinical assessment are needed to confirm this association.
Abstract: BACKGROUND: Performance of diabetes clinical care processes has improved recently, but control of hemoglobin A1c (A1c) and other vascular disease risk factors has improved more slowly. OBJECTIVES: To identify patient factors associated with control of vascular disease risk factors among diabetes patients receiving recommended care processes. POPULATION: Managed care enrollees who participated in the TRIAD (Translating Research into Action for Diabetes) Study and received at least 5 of 7 recommended care processes during the 12 months before the second survey (2002-2003). METHODS: Comparison of 1003 patients with good control of A1c (<8%), systolic blood pressure (<140 mm Hg) and LDL-cholesterol (<130 mg/dL) versus 812 patients with poor control for at least 2 of these factors. RESULTS: Poorly controlled patients were younger, more frequently female, African American, with lower education and income (P < 0.001 for each). General health status was lower, body mass index higher, and insulin treatment more frequent; history of prior coronary heart disease was less frequent. They were more likely to indicate depression and hopelessness and to identify costs as a barrier to self-care; less likely to report trust in their regular physician; and more likely to smoke cigarettes and be physically inactive. Adjusting for demographic and clinical variables, concerns about costs, low trust in one's physician, current smoking, and physical inactivity remained associated with poor control. However, inclusion of these 4 variables in a single model did not diminish associations of race/ethnicity or education with control. CONCLUSIONS: Clinical, socioeconomic, psychosocial, and behavioral factors were independently associated with poor control. However, these factors did not fully explain observed racial and socioeconomic disparities in control.
Abstract: The aim of this study was to determine the anthropometric cut points for risk of cardiometabolic risk factors in an urban Asian Indian population. The Chennai Urban Rural Epidemiology Study representatively sampled 26001 individuals aged 20 years or older and detailed measures were obtained in every 10th subject: 90.4% (2350/2600). An oral glucose tolerance test was performed in all individuals except self-reported diabetic subjects. Anthropometric measurements such as body mass index (BMI) and waist circumference (WC) were obtained and serum lipid estimations were done in all subjects. Sensitivity, specificity, and distance on receiver operating characteristic curve were used to determine the optimal cut points for BMI and WC with cardiometabolic risk factors. Maximum sensitivity and specificity of BMI for all cardiometabolic risk factors such as diabetes mellitus, prediabetes, hypertension, hypertriglyceridemia, hypercholesterolemia, and low high-density lipoprotein cholesterol ranged from 22.7 to 23.2 kg/m(2) for men and 22.7 to 23.8 kg/m(2) for women, and that of WC ranged from 86 to 88.2 cm for men and 81 to 83.8 cm for women. The optimal BMI cut point for identifying any 2 cardiometabolic risk factors was 23 kg/m(2) in both sexes, whereas that of WC was 87 cm for men and 82 cm for women. The study validates the World Health Organization Asia Pacific guidelines of BMI of 23 kg/m(2) for the designation of overweight; WC of 87 cm for men and 82 cm for women appear to be appropriate cut points to identify cardiometabolic risk factors including prediabetes in urban Asian Indians.
Abstract: OBJECTIVE: Control of blood glucose levels reduces vascular complications among people with diabetes, but less than half of the adults with diabetes in the United States are achieving good glycemic control. This study examines 1999-2002 national data on the association between race/ethnicity and glycemic control among adults with previously diagnosed diabetes. DESIGN: We analyzed data from the National Health and Nutrition Examination Survey (NHANES) 1999-2002, a cross-sectional survey of a nationally representative sample of the non-institutionalized civilian US population. Participants were non-pregnant adults, 20 years or older, with a previous diagnosis of diabetes, and who had participated in both the interview and examination in NHANES 1999-2002 (N=843). Glycemic control was determined by levels of glycosylated hemoglobin (A1C). We compared glycemic control by race/ethnicity and potential confounders including measures of socioeconomic status, obesity, healthcare access and diabetes treatment. RESULTS: Overall, 44% of adults with previously diagnosed diabetes had good glycemic control (A1C levels < 7%). Mexican Americans and non-Hispanic Blacks were less likely to achieve good control (35.4% and 36.9%, respectively) compared with non-Hispanic Whites (48.6%). After multivariable adjustment for measures of socioeconomic status, obesity, healthcare access and utilization and diabetes treatment, differences in glycemic control by race/ethnicity remained. CONCLUSION: Glycemic control is low among all racial/ethnic groups, but is lower among non-Hispanic Blacks and Mexican Americans. These results provide guidance for public health workers and health professionals in targeting programs to improve glycemic control among adults with diagnosed diabetes in the United States.
Abstract: BACKGROUND: Diabetes is an independent risk factor for the development of coronary heart disease (CHD). We evaluated whether there are racial/ethnic differences in predicted probability of CHD among persons with type 2 diabetes from the 1999-2002 National Health and Nutrition Examination Survey. METHODS: Adults with type 2 diabetes without cardiovascular disease (n=585) were evaluated; the United Kingdom Prospective Diabetes Study (UKPDS) Risk Engine was used to develop estimates of CHD and Framingham Risk Score (FRS) was used to assess the 10-year CHD risk. Chi-square tests and analysis of variance were used to assess differences between racial/ethnic groups in risk factors and predicted probability for CHD. RESULTS: Risk factors for CHD differed significantly amongst the three racial/ethnic groups. Whites had lower mean A1C concentrations (7.3%+/-0.2) than blacks (8.1%+/-0.2, P<0.05) or Mexican Americans (8.1%+/-0.2, P<0.05). Systolic blood pressure was higher in blacks compared with whites (P<0.05) and in Mexican American men compared with white men (P<0.05). Total cholesterol differed insignificantly by race/ethnicity whereas high-density lipoprotein cholesterol was higher in blacks compared with whites and Mexican Americans. Blacks had the greatest 5, 10, 15, and 20-year predicted risks of CHD among men, whereas whites had the greatest predicted risks among women. When evaluated by the FRS, the 10-year predicted risk of CHD was estimated to be 22.5% by UKPDS and 17% using FRS. CONCLUSIONS: UKPDS estimates of probability of CHD were similar across race/ethnicities, indicating that the risk factors tended to balance out. Despite differences in individual risk factors, the estimated risk for CHD was similar for all persons with diabetes.
Abstract: BACKGROUND: Whether mortality rates among diabetic adults or excess mortality associated with diabetes in the United States has declined in recent decades is not known. OBJECTIVE: To examine whether all-cause and cardiovascular disease mortality rates have declined among the U.S. population with and without self-reported diabetes. DESIGN: Comparison of 3 consecutive, nationally representative cohorts. SETTING: Population-based health surveys (National Health and Nutrition Examination Surveys I, II, and III) with mortality follow-up assessment. PATIENTS: Survey participants age 35 to 74 years with and without diabetes. MEASUREMENTS: Diabetes was determined by self-report for each survey (1971-1975, 1976-1980, and 1988-1994), and mortality rates were determined through 1986, 1992, and 2000 for the 3 surveys, respectively. RESULTS: Among diabetic men, the all-cause mortality rate decreased by 18.2 annual deaths per 1000 persons (from 42.6 to 24.4 annual deaths per 1000 persons; P = 0.03) between 1971 to 1986 and 1988 to 2000, accompanying decreases in the nondiabetic population. Trends for cardiovascular disease mortality paralleled those of all-cause mortality, with 26.4 annual deaths per 1000 persons in 1971 to 1986 and 12.8 annual deaths per 1000 persons in 1988 to 2000 (P = 0.06). Among women with diabetes, however, neither all-cause nor cardiovascular disease mortality declined between 1971 to 1986 and 1988 to 2000, and the all-cause mortality rate difference between diabetic and nondiabetic women more than doubled (from a difference of 8.3 to 18.2 annual deaths per 1000 persons). The difference in all-cause mortality rates by sex among people with diabetes in 1971 to 1986 were essentially eliminated in 1988 to 2000. LIMITATIONS: Diabetes was assessed by self-report, and statistical power to examine the factors explaining mortality trends was limited. CONCLUSIONS: Progress in reducing mortality rates among persons with diabetes has been limited to men. Diabetes continues to greatly increase the risk for death, particularly among women.
Abstract: BACKGROUND: Policy makers are divided on whether to focus public health efforts to prevent type 2 diabetes on subpopulations at high risk or on the entire population. We examined the extent to which increases in the prevalence of overweight, obesity, and severe obesity have contributed to the increase in diabetes prevalence among U.S. adults between 1976-1980 and 1999-2004. METHODS: Using assembled data of 37,606 U.S. adults aged 20 to 74 years from 3 consecutive U.S. national surveys (NHANES II, III, and NHANES 1999-2004), we compared the body mass index distributions among prevalent diabetes cases over time and divided changes in prevalence of 5 diabetes-body mass index categories by changes in the diabetes prevalence observed in the total population. RESULTS: Prevalence of diabetes among adults aged 20 to 74 increased from 5.08% in 1976-1980 to 8.83% in 1999-2004. Of the 3.75 additional cases per hundred that existed in 1999-2004 as compared to 1976-1980, we estimated that -8% were among persons of normal or below normal weight (body mass index<25); 27% were among those who were overweight (body mass index 25 to 30); and 32%, 23%, and 26% among those with class I (body mass index 30 to 35), class II (body mass index 35 to 40), and class III obesity (body mass index>40), respectively. Thus, of the additional prevalent diabetes cases that existed in 1999-2004 as compared to 1976-1980, 81% were obese (i.e. body mass index>30) and 49% had class II or III obesity (body mass index>35), a group that increased in prevalence from 4% to 13% of the overall adult population. CONCLUSIONS: The increases in diabetes prevalence over recent decades have been disproportionately comprised of persons with extreme levels of obesity.
Abstract: Diabetes mellitus affects not only life expectancy but also quality of life. The Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial's health-related quality of life (HRQOL) and cost-effectiveness components will enable the assessment of the relative importance of the various outcomes from the point of view of patients, provide an understanding of the balance between the burdens and benefits of the intervention strategies, and offer valuable insights into adherence. The HRQOL measures used include the Diabetes Symptoms Distress Checklist; the 36-Item Short Form Health Survey, Version 2 (SF-36) (RAND Corporation, Santa Monica, CA); the Patient Health Questionnaire (PHQ) depression measure (Pfizer Inc, New York, NY); the World Health Organization (WHO) Diabetes Treatment Satisfaction Questionnaire (DTSQ); and the EuroQol Feeling Thermometer (EuroQol Group, Rotterdam, Netherlands). The cost-effectiveness analysis (CEA) in ACCORD will provide information about the relative economic efficiency of the different interventions being compared in the trial. Effectiveness will be measured in terms of cardiovascular event-free years gained and quality-adjusted life-years gained (using the Health Utilities Index Mark 3 [HUI-3] [Health Utilities Inc., Dundas, Ontario, Canada] to measure health-state utility). Costs will be direct medical costs assessed from the perspective of a single-payer health system collected by means of patient and clinic cost forms and hospital discharge summaries. The primary HRQOL and CEA hypotheses mirror those in the main ACCORD trial, addressing the effects of the 3 main ACCORD interventions considered separately. There are also secondary (pairwise reference case) comparisons that do not assume independence of treatment effects on HRQOL. CEA will be done on a subsample of 4,311 ACCORD participants and HRQOL on a subsample of 2,053 nested within the CEA subsample. Most assessments will occur through questionnaires at baseline and at 12, 36, and 48 months.
Abstract: The relation between height and lower extremity peripheral insensate neuropathy among persons with and without diabetes was examined by use of the 1999-2002 US National Health and Nutrition Examination Survey with 5,229 subjects aged 40 or more years. A monofilament was used to determine whether any of three areas on each foot were insensate. Peripheral insensate neuropathy was defined as the presence of one or more insensate areas. Its prevalence was nearly twice as high among persons with diabetes (21.2%) as among those without diabetes (11.5%; p < 0.001). Men (16.2%) had 1.7 times the prevalence of peripheral insensate neuropathy as did women (9.4%), but the difference was not significant after adjustment for height. Greater height was associated with increased peripheral insensate neuropathy prevalence among persons with and without diabetes (p < 0.001). This association was characterized by a sharp increase in prevalence among persons who were taller than 175.5 cm. Peripheral insensate neuropathy risk was significantly higher among those taller than 175.5 cm (adjusted odds ratio = 2.3, 95% confidence interval: 1.5, 3.5). The authors conclude that body height is an important correlate of peripheral insensate neuropathy. This association largely accounts for the difference in peripheral insensate neuropathy prevalence between men and women. Height may help health-care providers to identify persons at high risk of peripheral insensate neuropathy.
Abstract: OBJECTIVE: We examined factors associated with screening for albuminuria and initiation of ACE inhibitor or angiotensin receptor blocker (ARB) treatment in diabetic patients. RESEARCH DESIGN AND METHODS: We conducted surveys and medical record reviews for 5,378 patients participating in a study of diabetes care in managed care at baseline (2000-2001) and follow-up (2002-2003). Factors associated with testing for albuminuria were examined in cross-sectional analysis at baseline. Factors associated with initiating ACE inhibitor/ARB therapy were determined prospectively. RESULTS: At baseline, 52% of patients not receiving ACE inhibitor/ARB therapy and without known diabetic kidney disease (DKD) were screened for albuminuria. Patients > or =65 years of age, those with higher HbA(1c), those with cardiovascular disease (CVD), and those without hyperlipidemia were less likely to be screened. Of the patients with positive screening tests, 47% began ACE inhibitor/ARB therapy. Initiation of therapy was associated with positive screening test results, BMI > or =25 kg/m(2), treatment with insulin or oral antidiabetic agents, peripheral neuropathy, systolic blood pressure > or =140 mmHg, and CVD. Of the patients receiving ACE inhibitor/ARB therapy or with known DKD, 63% were tested for albuminuria. CONCLUSIONS: Screening for albuminuria was inadequate, especially in older patients or those with competing medical concerns. The value of screening could be increased if more patients with positive screening tests initiated ACE inhibitor/ARB therapy. The efficiency of screening could be improved by limiting screening to diabetic patients not receiving ACE inhibitor/ARB therapy and without known DKD.
Abstract: BACKGROUND: Progress of diabetes care is a subject of public health concern. OBJECTIVE: To assess changes in quality of diabetes care in the United States by using standardized measures. DESIGN: National population-based, serial cross-sectional surveys. SETTING: National Health and Nutrition Examination Survey (1988-1994 and 1999-2002) and the Behavioral Risk Factor Surveillance System (1995 and 2002). PARTICIPANTS: Survey participants 18 to 75 years of age who reported a diagnosis of diabetes. MEASUREMENTS: Glycemic control, blood pressure, low-density lipoprotein (LDL) cholesterol level, annual cholesterol level monitoring, and annual foot and dilated eye examination, as defined by the National Diabetes Quality Improvement Alliance measures. RESULTS: In the past decade, the proportion of persons with diabetes with poor glycemic control (hemoglobin A1c > 9%) showed a nonstatistically significant decrease of 3.9% (95% CI, -10.4% to 2.5%), while the proportion of persons with fair or good lipid control (LDL cholesterol level < 3.4 mmol/L [<130 mg/dL]) had a statistically significant increase of 21.9% (CI, 12.4% to 31.3%). Mean LDL cholesterol level decreased by 0.5 mmol/L (18.8 mg/dL). Although mean hemoglobin A1c did not change, the proportion of persons with hemoglobin A(1c) of 6% to 8% increased from 34.2% to 47.0%. The blood pressure distribution did not change. Annual lipid testing, dilated eye examination, and foot examination increased by 8.3% (CI, 4.0% to 12.7%), 4.5% (CI, 0.5% to 8.5%), and 3.8% (CI, -0.1% to 7.7%), respectively. The proportion of persons reporting annual influenza vaccination and aspirin use improved by 6.8 percentage points (CI, 2.9 percentage points to 10.7 percentage points) and 13.1 percentage points (CI, 5.4 percentage points to 20.7 percentage points), respectively. LIMITATIONS: Data are self-reported, and the surveys do not have all National Diabetes Quality Improvement Alliance indicators. CONCLUSION: Diabetes processes of care and intermediate outcomes have improved nationally in the past decade. But 2 in 5 persons with diabetes still have poor LDL cholesterol control, 1 in 3 persons still has poor blood pressure control, and 1 in 5 persons still has poor glycemic control.
Abstract: OBJECTIVE: To examine associations between physician reimbursement incentives and diabetes care processes and explore potential confounding with physician organizational model. DATA SOURCES: Primary data collected during 2000-2001 in 10 managed care plans. STUDY DESIGN: Multilevel logistic regressions were used to estimate associations between reimbursement incentives and process measures, including the receipt of dilated eye exams, foot exams, influenza immunizations, advice to take aspirin, and assessments of glycemic control, proteinuria, and lipid profile. Reimbursement measures included the proportions of compensation received from salary, capitation, fee-for-service (FFS), and performance-based payment; the performance-based payment criteria used; and interactions of these criteria with the strength of the performance-based payment incentive. DATA COLLECTION: Patient, provider group, and health plan surveys and medical record reviews were conducted for 6,194 patients with diabetes. PRINCIPAL FINDINGS: Without controlling for physician organizational model, care processes were better when physician compensation was based primarily on direct salary rather than FFS reimbursement (four of seven processes were better, with relative risks ranging from 1.13 to 1.23) or capitation (six were better, with relative risks from 1.06 to 1.36); and when quality/satisfaction scores influenced physician compensation (three were better, with relative risks from 1.17 to 1.26). However, these associations were substantially confounded by organizational model. CONCLUSIONS: Physician reimbursement strategies are associated with diabetes care processes, although their independent contributions are difficult to assess, due to high correlation with physician organizational model. Regardless of causality, a group's use of quality/satisfaction scores to determine physician compensation may indicate delivery of high-quality diabetes care.
Abstract: OBJECTIVE: To examine trends in death rates for hyperglycemic crisis (diabetic ketoacidosis or hyperglycemic hyperosmolar state) among adults with diabetes in the U.S. from 1985 to 2002. RESEARCH DESIGN AND METHODS: Deaths with hyperglycemic crisis as the underlying cause were identified from national mortality data. Death rates were calculated using estimates of adults with diabetes from the National Health Interview Survey as the denominator and age adjusted to the 2000 U.S. population. The trends from 1985 to 2002 were tested using joinpoint regression analysis. RESULTS: Deaths due to hyperglycemic crisis dropped from 2,989 in 1985 to 2,459 in 2002. During the time period, age-adjusted death rates decreased from 42.4 to 23.8 per 100,000 adults with diabetes (4.4% decrease per year, P for trend <0.01). Death rates declined in all age-groups, with the greatest decrease occurring among individuals aged > or =65 years. Age-adjusted death rates fell for all race-sex subgroups, with black men experiencing the smallest decline. About one-fifth of deaths occurred at home or on arrival at the hospital, and the death rates for hyperglycemic crisis occurring at these places declined only modestly over time (2.1% decrease per year, P for trend = 0.049). CONCLUSIONS: Overall death rates due to hyperglycemic crisis among adults with diabetes have declined in the U.S. However, scope for further improvement remains, especially to further reduce death rates among black men and to prevent deaths occurring at home.
Abstract: OBJECTIVE: Among individuals with diabetes, a comparison of HbA(1c) (A1C) levels between African Americans and non-Hispanic whites was evaluated. Data sources included PubMed, Web of Science, the Cumulative Index to Nursing and Allied Health, the Cochrane Library, the Combined Health Information Database, and the Education Resources Information Center. RESEARCH DESIGN AND METHODS: We executed a search for articles published between 1993 and 2005. Data on sample size, age, sex, A1C, geographical location, and study design were extracted. Cross-sectional data and baseline data from clinical trials and cohort studies for African Americans and non-Hispanic whites with diabetes were included. Diabetic subjects aged <18 years and those with pre-diabetes or gestational diabetes were excluded. We conducted a meta-analysis to estimate the difference in the mean values of A1C for African Americans and non-Hispanic whites. RESULTS: A total of 391 studies were reviewed, of which 78 contained A1C data. Eleven had data on A1C for African Americans and non-Hispanic whites and met selection criteria. A meta-analysis revealed the standard effect to be 0.31 (95% CI 0.39-0.25). This standard effect correlates to an A1C difference between groups of approximately 0.65%, indicating a higher A1C across studies for African Americans. Grouping studies by study type (cross-sectional or cohort), method of data collection for A1C (chart review or blood draw), and insurance status (managed care or nonmanaged care) showed similar results. CONCLUSIONS: The higher A1C observed in this meta-analysis among African Americans compared with non-Hispanic whites may contribute to disparity in diabetes morbidity and mortality in this population.
Abstract: OBJECTIVE: Simple process-of-care indicators are commonly recommended to assess and compare quality of diabetes care across health plans. We sought to determine whether variation in the number of simple diabetes processes of care across provider groups is associated with variation in other quality indicators, including cardiometabolic risk factor levels, patient satisfaction with care, or patient-rated quality of care. RESEARCH DESIGN AND METHODS: We used cross-sectional survey and chart audit data for 8,733 patients with diabetes who received care from 68 provider groups nested in 10 health plans that participated in the Translating Research Into Action for Diabetes study. Analyses using hierarchical regression models assessed associations of the mean number of seven simple process measures with each of the following: HbA(1c) (A1C), systolic blood pressure (SBP), HDL and LDL cholesterol levels, patient satisfaction with care, and patient-rated quality of care. RESULTS: After adjusting for case-mix differences across groups and plans, an average of one additional documented process of care for each patient in a group or plan was associated with significantly lower mean LDL cholesterol levels (-4.51 mg/dl [95% CI 1.46-7.58]) but not with A1C, SBP, or HDL cholesterol levels. The number of care processes documented was associated with patient satisfaction measures and self-rated quality of diabetes care. CONCLUSIONS: Variation in the number of simple process-of-care indicators across provider groups or health plans is associated with differences in patient-centered measures of quality, but assessment of the quality of cardiometabolic risk factor control will require more advanced clinical performance indicators.
Abstract: OBJECTIVE: Opportunistic screening for undiagnosed type 2 diabetes and pre-diabetes (either impaired glucose tolerance or impaired fasting glucose) is recommended by the American Diabetes Association. The aim of this study was to determine efficient cutoff points for three screening tests for detecting undiagnosed diabetes alone or both undiagnosed diabetes and pre-diabetes. RESEARCH DESIGN AND METHODS: We estimated the number of individuals with undiagnosed diabetes alone or with both undiagnosed diabetes and pre-diabetes that could be detected by using different cutoff points for each screening test as the product of the prevalence of each condition, the sensitivity of the tests at each cutoff point for identifying each condition, and the number of individuals who would be eligible for screening in the U.S. We estimated the total cost of opportunistic screening by multiplying the cost for screening one person by the number of individuals screened. RESULTS: The most efficient cutoff points for both detecting pre-diabetes and undiagnosed diabetes (100 mg/dl for the fasting plasma glucose test, 5.0% for the HbA(1c) test, and 100 mg/dl for the random capillary blood glucose test) were less than those for detecting undiagnosed diabetes alone (110 mg/dl for the fasting plasma glucose test, 5.7% for the HbA(1c) test, and 120 mg/dl for the random capillary blood glucose test). CONCLUSIONS: A lower cutoff value should be used when screening for pre-diabetes and undiagnosed diabetes together than when screening for undiagnosed diabetes alone.
Abstract: OBJECTIVE: To review existing data to determine whether ethnic disparities exist for diabetes-related preventive care among adults in the United States. STUDY DESIGN: Literature review. METHODS: We identified diabetes-related studies published between 1993 and 2003, using a reproducible search strategy. Studies were selected for review if there were ethnic comparisons or if data on a specific ethnic minority were reported. From these studies, we extracted data on commonly accepted diabetes-related preventive-care measures (testing for glycemia, eye examinations, foot examinations, lipid profile, influenza vaccination, nephropathy assessment, smoking-cessation counseling). The sources were US healthcare facilities, national survey samples, Veterans Affairs facilities, Medicare databases, and managed care data. RESULTS: Thirty-six studies met our search criteria. Data were extracted on glycemia testing (15 studies), eye examination rates (27 studies), foot examination rates (18 studies), lipid-profile assessment (15 studies), percentage of patients receiving influenza vaccinations (8 studies), nephropathy assessment (7 studies), and counseling referrals for smoking cessation (4 studies). The majority of the data indicated that the rates of diabetes monitoring are generally low regardless of the population being studied. The major ethnic differences reported were lower rates of eye examination, influenza vaccination, and lipid-profile testing among Hispanics and African Americans than among non-Hispanic whites. CONCLUSIONS: Despite the availability of evidence-based guidelines, rates of diabetes preventive care are low, particularly for some measures in ethnic minority groups. Additional data are needed to further elucidate these disparities.
Abstract: CONTEXT: Prevalence of obesity in the United States has increased dramatically in recent decades, but the magnitude of change in cardiovascular disease (CVD) risk factors among the growing proportion of overweight and obese Americans remains unknown. OBJECTIVE: To examine 40-year trends in CVD risk factors by body mass index (BMI) groups among US adults aged 20 to 74 years. DESIGN, SETTING, AND PARTICIPANTS: Analysis of 5 cross-sectional, nationally representative surveys: National Health Examination Survey (1960-1962); National Health and Nutrition Examination Survey (NHANES) I (1971-1975), II (1976-1980), and III (1988-1994); and NHANES 1999-2000. MAIN OUTCOME MEASURES: Prevalence of high cholesterol level (> or =240 mg/dL [> or =6.2 mmol/L] regardless of treatment), high blood pressure (> or =140/90 mm Hg regardless of treatment), current smoking, and total diabetes (diagnosed and undiagnosed combined) according to BMI group (lean, <25; overweight, 25-29; and obese, > or =30). RESULTS: The prevalence of all risk factors except diabetes decreased over time across all BMI groups, with the greatest reductions observed among overweight and obese groups. Compared with obese persons in 1960-1962, obese persons in 1999-2000 had a 21-percentage-point lower prevalence of high cholesterol level (39% in 1960-1962 vs 18% in 1999-2000), an 18-percentage-point lower prevalence of high blood pressure (from 42% to 24%), and a 12-percentage-point lower smoking prevalence (from 32% to 20%). Survey x BMI group interaction terms indicated that compared with the first survey, the prevalence of high cholesterol in the fifth survey had fallen more in obese and overweight persons than in lean persons (P<.05). Survey x BMI changes in blood pressure and smoking were not statistically significant. Changes in risk factors were accompanied by increases in lipid-lowering and antihypertensive medication use, particularly among obese persons. Total diabetes prevalence was stable within BMI groups over time, as nonsignificant 1- to 2-percentage-point increases occurred between 1976-1980 and 1999-2000. CONCLUSIONS: Except for diabetes, CVD risk factors have declined considerably over the past 40 years in all BMI groups. Although obese persons still have higher risk factor levels than lean persons, the levels of these risk factors are much lower than in previous decades.
Abstract: OBJECTIVE: To examine ethnic disparities in the quality of diabetes care among adults with diabetes in the US through a systematic qualitative review. DATA SOURCES: Material published in the English language was searched from 1993 through June 2003 using PubMed, Web of Science, Cumulative Index to Nursing and Allied Health, the Cochrane Library, Combined Health Information Database, and Education Resources Information Center. STUDY SELECTION AND DATA EXTRACTION: Studies of patients with diabetes in which at least 50% of study participants were ethnic minorities and studies that made ethnic group comparisons were eligible. Research on individuals having prediabetes, those <18 years of age, or women with gestational diabetes were excluded. Reviewers used a reproducible search strategy. A standardized abstraction and grading of articles for publication source and content were used. Data on glycemia, blood pressure, and low-density lipoprotein cholesterol (LDL-C) were extracted in patients with diabetes. A total of 390 studies were reviewed, with 78 meeting inclusion criteria. DATA SYNTHESIS: Ethnic minorities had poorer outcomes of care than non-Hispanic whites. These disparities were most pronounced for glycemic control and least evident for LDL-C control. Most studies showed blood pressure to be poorly controlled among ethnic minorities. CONCLUSIONS: Control of risk factors for diabetes (glycemia, blood pressure, LDL-C) is challenging and requires routine assessment. These findings indicate that additional efforts are needed to promote diabetes quality of care among minority populations.
Abstract: OBJECTIVE: PEDIATRICS (ISSN 0031 4005). Published in the public domain by the American Academy of Pediatrics. Several studies have reported increases in the occurrence of type 2 diabetes in youths. People with prediabetic states such as impaired fasting glucose (IFG) are at increased risk for developing diabetes and cardiovascular disease (CVD). The objective of this study was to examine the prevalence of IFG and its relationship with overweight and CVD risk factors in a nationally representative sample of US adolescents who were aged 12 to 19 years. METHODS: We used data from the 1999-2000 National Health and Nutrition Examination Survey (NHANES). Adolescents who had fasted for 8 hours or more were included in the study (n = 915). IFG was defined as a fasting glucose of 100 to 125 mg/dL. Participants were classified as overweight when their age- and gender-specific BMI was > or = 95th percentile and as at-risk for overweight when their BMI was > or = 85th and < 95th percentile. RESULTS: In 1999-2000, the prevalence of IFG in US adolescents was 7.0% and was higher in boys than in girls (10.0% vs 4.0%). Prevalence of IFG was higher in overweight adolescents (17.8%) but was similar in those with normal weight and those who were at risk for overweight (5.4% vs 2.8%). The prevalence of IFG was significantly different across racial/ethnic groups (13.0%, 4.2%, and 7% in Mexican Americans, non-Hispanic black individuals, and non-Hispanic white individuals, respectively). Adolescents with IFG had significantly higher mean hemoglobin A1c, fasting insulin, total and low-density lipoprotein cholesterol, triglycerides, and systolic blood pressure and lower high-density lipoprotein cholesterol than those with normal fasting glucose concentrations. CONCLUSIONS: These data, representing 27 million US adolescents, reveal a very high prevalence of IFG (1 in 10 boys and 1 in 25 girls) among adolescents; the condition affects 1 in every 6 overweight adolescents. Adolescents with IFG have features of insulin resistance and worsened CVD risk factors. Evidence for prevention is still forthcoming in this age group.
Abstract: In a series of three papers in the British Medical Journal (June 28, 2003), Wald et al. proposed that the Polypill can reduce the incidence of coronary heart disease by 88%, and stroke by 80%, if taken by all people aged > or = 55, as well as people of any age with existing cardiovascular disease or diabetes. We review the rationale and uniqueness behind this idea, identify the concerns and questions that need to be addressed, discuss whether this strategy is a threat or an opportunity for public health, and hope that this will stimulate further debate.
Abstract: OBJECTIVE: There is conflicting evidence about whether nonwhite Americans with diabetes have an increased risk of cardiovascular disease (CVD). Because geographic region is known to influence the risk of CVD in the U.S., we sought to determine the effects of race and region on cardiovascular morbidity among elderly Americans with diabetes. RESEARCH DESIGN AND METHODS: We performed a national, retrospective, cohort study using the Medicare claims of 126,153 white and 17,962 black patients with diabetes, aged > or =65 years in 1994, who were followed through 1999 for incident acute myocardial infarction, ischemic heart disease, stroke, and heart failure. The effect of race, sex, and region on the incidence of these diseases was assessed using Cox proportional hazards regression, adjusting for baseline demographics and comorbidities. RESULTS: The incidence of any CVD ranged from 23.9/100 person-years among southern black men to 29.2/100 person-years among non-southern black women. The risk of CVD was lower among southern black men (hazard ratio 0.87 [95% CI 0.82-0.92]) and women (0.95 [0.91-0.99]) than their southern white counterparts. In the three other U.S. regions combined (northeast, midwest, and west), black men had a similar risk for CVD (1.01 [0.95-1.07]), and black women had a greater risk (1.10 [1.05-1.16]) than non-southern white men and women, respectively. CONCLUSIONS: Among elderly Americans with diabetes, the incidence of CVD is unlikely to differ a great deal between whites and blacks. Residence in the South seems to confer a modest benefit for elderly black people with diabetes.
Abstract: OBJECTIVE: To examine the association between the organizational model and diabetes processes of care. RESEARCH DESIGN AND METHODS: We used data from the Translating Research into Action for Diabetes (TRIAD), a multicenter study of diabetes care in managed care, including 8354 patients with diabetes. We identified five model types: for-profit group/network, for-profit independent practice association (IPA), nonprofit group/network, nonprofit IPA, and nonprofit group/staff. Process measures included retinal, renal, foot, lipid, and HbA(1c) testing; aspirin recommendations; influenza vaccination; and a sum of these seven processes of care over 1 year. Hierarchical regression models were constructed for each process measure and accounted for clustering at the health plan and provider group levels and adjusted for participant age, sex, race, ethnicity, diabetes treatment and duration, education, income, health status, and survey language. RESULTS: Participant membership in the model types ranged from 9% in nonprofit IPA models to 38% in nonprofit group/staff models. Over 75% of participants received most of the processes of care, regardless of model type. However, among for-profit plans, group/network models provided on average more processes of care than IPA models (5.5 vs. 4.7, P < 0.0001), and group/network models generally increased the probability of receiving a process by >or=10 percentage points. Among nonprofit plans, no effect of model type was found. CONCLUSIONS: Among for-profit plans, group/network models provided better diabetes processes of care than IPA models. Although reasons are speculative, this may be due to the clinical infrastructure available in group models that is not available in IPA models.
Abstract: Facing limited resources and increases in demand from competing programs, policymakers and health care providers seek guidance from economic studies on how to use health care resources wisely. Previous economic studies mainly focused on estimating the cost of diabetes and cost-effectiveness of different interventions. These studies found that diabetes is costly and that its cost will continue to increase; thus, more resources should be devoted to research aimed at finding effective means to prevent the disease and its complications. In addition, the cost-effectiveness of interventions varies greatly in terms of quality-adjusted life-years gained; therefore, efficient uses of resources should be an important consideration when interventions are prioritized. The need for economic studies will continue to grow because of increasing demand for limited resources from the growing number of interventions available. Future studies should be of better quality and broadened in areas of research.
Abstract: BACKGROUND: No studies have compared care in the Department of Veterans Affairs (VA) with that delivered in commercial managed care organizations, nor have studies focused in depth on care comparisons for chronic, outpatient conditions. OBJECTIVE: To compare the quality of diabetes care between patients in the VA system and those enrolled in commercial managed care organizations by using equivalent sampling and measurement methods. DESIGN: Cross-sectional patient survey with retrospective review of medical records. SETTING: 5 VA medical centers and 8 commercial managed care organizations in 5 matched geographic regions. PARTICIPANTS: 8205 diabetic patients: 1285 in the VA system and 6920 in commercial managed care. MEASUREMENTS: We compared scores on identically specified quality measures for 7 diabetes care processes and 3 diabetes intermediate outcomes and on 4 dimensions of satisfaction. Scores were expressed as the percentage of patients receiving indicated care and were adjusted for patients' demographic and health characteristics. RESULTS: Patients in the VA system had better scores than patients in commercial managed care on all process measures (for example, 93% vs. 83% for annual hemoglobin A1c; P = 0.006; 91% vs. 75% for annual eye examination; P < 0.001). Blood pressure control was poor in both groups (52% to 53% of persons had blood pressure < 140/90 mm Hg), but patients in the VA system had better control of low-density lipoprotein cholesterol and hemoglobin A1c (for example, 86% vs. 72% for low-density lipoprotein cholesterol level < 3.37 mmol/L [<130 mg/dL]; P = 0.002). Satisfaction was similar in the 2 groups. LIMITATIONS: Our results may not be generalizable to all regions or health plans, and some of the differences in performance could reflect differences in documentation. CONCLUSIONS: Diabetes processes of care and 2 of 3 intermediate outcomes were better for patients in the VA system than for patients in commercial managed care. However, both VA and commercial managed care had room for improvement, especially for blood pressure control.
Abstract: OBJECTIVE: To examine the effect of referral management on diabetes care. STUDY DESIGN: Cross-sectional analysis. PATIENTS AND METHODS: Translating Research Into Action for Diabetes (TRIAD) is a multicenter study of managed care enrollees with diabetes. Prospective referral management was defined as "gatekeeping" and mandatory preauthorization from a utilization management office, and retrospective referral management as referral profiling and appropriateness reviews. Outcomes included dilated eye exam; self-reported visit to specialists; and perception of difficulty in getting referrals. Hierarchical models adjusted for clustering and patient age, gender, race, ethnicity, type and duration of diabetes treatment, education, income, health status, and comorbidity. RESULTS: Referral management was commonly used by health plans (55%) and provider groups (52%). In adjusted analyses, we found no association between any referral management strategies and any of the outcome measures. CONCLUSIONS: Referral management does not appear to have an impact on referrals or perception of referrals related to diabetes care.
Abstract: Translation research transforms currently available knowledge into useful measures for everyday clinical and public health practice. We review the progress in diabetes translation research and identify future challenges and opportunities in this field. Several promising interventions to optimize implementation of efficacious diabetes treatments are available. Many of these interventions, singly or in combination, need to be more formally tested in larger randomized or quasi-experimental practical trials using outcomes of special interest to patients (for example, patient satisfaction and quality of life) and policymakers (for example, cost and cost-effectiveness). The long-term outcomes (such as morbidity, mortality, quality of life, and costs) of strategies aimed at improving diabetes care must be assessed. Translation research also needs to incorporate ways of studying complex systems of care. The challenges and opportunities offered by translation research are tremendous.
Abstract: A diabetes epidemic emerged during the 20th century and continues unchecked into the 21st century. It has already taken an extraordinary toll on the U.S. population through its acute and chronic complications, disability, and premature death. Trend data suggest that the burden will continue to increase. Efforts to pre- vent or delay the complications of diabetes or, better yet, to prevent or delay the development of diabetes itself are urgently needed.
Abstract: Among US adults with diabetes, using data from the National Health and Nutrition Examination Survey for 1971-1974, 1976-1980, 1988-1994, and 1999-2000, the authors describe 30-year trends in total cholesterol, blood pressure, and smoking levels. Using Bayesian models, the authors calculated mean changes per year and 95% credible intervals for age-adjusted mean total cholesterol and blood pressure levels and the prevalence of high total cholesterol (> or =5.17 mmol/liter), high blood pressure (systolic blood pressure: > or =140 mmHg and/or diastolic blood pressure: > or =90 mmHg), and smoking. Between 1971-1974 and 1999-2000, mean total cholesterol declined from 5.95 mmol/liter to 5.48 mmol/liter (-0.02 (95% credible interval: -0.03, -0.01) mmol/liter per year). The proportion with high cholesterol decreased from 72% to 55%. Mean blood pressure declined from 146/86 mmHg to 134/72 mmHg (systolic blood pressure: -0.5 (95% credible interval: -1.1, 0.5) mmHg per year; diastolic blood pressure: -0.6 (95% credible interval: -1.0, -0.03) mmHg per year). The proportion with high blood pressure decreased from 64% to 37%, and smoking prevalence decreased from 32% to 17%. Although these trends are encouraging, still one of two people with diabetes has high cholesterol, one of three has high blood pressure, and one of six is a smoker.
Abstract: Because of the ongoing worldwide diabetes epidemic and new evidence that type 2 diabetes can be prevented or delayed, we are compelled to implement prevention efforts. Health policy makers need to bridge the evidence gap left by prevention trials that did not include all groups at risk for developing diabetes. Intensive interventions may be appropriate for groups with similar risk as those studied in clinical trials, while less intense efforts may be considered for those groups that have not been studied. Factors such as structure of the health care system and individual social and economic situations may influence the implementation of prevention efforts. Currently, no universally validated and well-tested method exists to identify all people at high risk for developing diabetes. However, groups that will be targeted for prevention efforts can be identified through several reasonable strategies.
Abstract: As we enter the twenty-first century, the burden of chronic diseases, such as obesity, type 2 diabetes, and CVDs, is expected to increase dramatically. These diseases are a consequence of several factors that include an aging population,changes in demographic composition, and an excess of contemporary lifestyle. The prevention and control of overweight, obesity, metabolic syndrome, and diabetes pose special challenges for clinical and public heath practice as well as for basic, clinical, and population science research.
Abstract: The purpose of this paper was to examine the relationship between fasting glucose levels and development of diabetes among residents of Penghu, Taiwan. From July 1995 to June 1996, a population-based cohort study was conducted among residents aged >or=40 years on the island of Penghu, Taiwan. Of the 1601 surveyed, 1306 (81.6%) did not have diabetes. Six hundred of these 1306 persons were re-examined 3 years later. Participants with fasting plasma glucose (FPG) concentration <110 mg/dl (<6.1 mmol/l) were classified as normoglycemic, those with a glucose concentration of 110-126 mg/dl (6.1-7.0 mmol/l) had impaired fasting glucose (IFG), and those with a fasting glucose concentration of >or=126 mg/dl (7.0 mmol/l) were considered to have diabetes. During the 3-year follow-up, 4.3% of the total population (1.4% per year, 95% CI 0.9-1.9%) developed diabetes. Of those with IFG at baseline, 9.6% (3.2% per year, 95% CI 1.8-5.0%) progressed to diabetes, but only 2.5% (0.8% per year, 95% CI 0.4-1.2%) of normoglycemic people did so. The multivariate-adjusted odds ratio of developing diabetes was 4.4 (95% CI 1.9-10.6) for persons with IFG compared with those who were normoglycemic at baseline. Other significant predictors of progression to diabetes were higher waist-hip ratio (WHR), triglyceride and apolipoprotein B (apo B) levels. In this Asian Chinese population, IFG is a strong predictor of diabetes. The high rate of conversion from IFG to diabetes, combined with the previously observed high IFG prevalence, suggests future high prevalence rates of diabetes in Taiwan.
Abstract: AIMS/HYPOTHESIS: The aim of this study was to examine the relation between serum total homocysteine concentrations and microvascular complications in Pima Indians with Type 2 diabetes. METHODS: Homocysteine concentrations were measured in frozen sera of 396 diabetic participants in a longitudinal study who were 40 years of age or older and who had attended one or more examinations between 1982 and 1985. Retinopathy was assessed by fundoscopy and nephropathy by an albumin:creatinine ratio greater than 300 mg/g. The incidence rate ratio for a 5 micro mol/l difference in homocysteine was calculated using proportional hazard regression. RESULTS: The incidence of each complication was assessed in subjects without that complication at baseline and with more than one follow-up examination: 229 for nephropathy, 212 for retinopathy and 266 for proliferative retinopathy. There were 101 incident cases of nephropathy, 113 of retinopathy and 40 of proliferative retinopathy during a mean follow-up of 8.6, 7.5 and 8.9 years, respectively. Incidence of nephropathy was associated with homocysteine concentrations: IRR=1.42 (95% CI, 1.09-1.84, p=0.01); this remained statistically significant controlled for age, sex and duration of diabetes (p=0.03), but not when controlled for baseline renal function (p=0.4). Homocysteine concentrations were not associated with the incidence of any retinopathy IRR=1.14 (95%CI 0.89-1.46, p=0.3) but were associated with the incidence of proliferative retinopathy IRR=1.62 (95% CI 1.16-2.28, p=0.005); this association remained statistically significant when controlled for baseline renal function and diabetes duration (p=0.02). CONCLUSIONS/INTERPRETATION: Increased homocysteine concentrations are associated with an increased risk for incidence of nephropathy and proliferative retinopathy; the relation with incidence of nephropathy seems to be explained by an association with baseline albuminuria status concentrations, whereas the relation with incidence of proliferative retinopathy does not.
Abstract: OBJECTIVE: To examine racial/ethnic differences in healthcare coverage, utilization, and satisfaction, among US adults with diabetes. DESIGN AND SETTING: We conducted a cross-sectional analysis among 9443 adults with diabetes who participated in the 1999 Behavioral Risk Factor Surveillance System (BRFSS), a telephone survey of the civilian non-institutionalized US population aged > or = 18 yrs. MAIN OUTCOME MEASURES: We compared healthcare coverage, utilization, and satisfaction across 4 race/ethnicity categories: non-Hispanic Whites (NHW), non-Hispanic Blacks (NHB), Hispanics (HSP), and others, and examined whether these factors were associated with self-rated health status. RESULTS: By self-report, more NHB (14.8%), HSP (20.7%), and members of other races (21.8%) were uninsured, compared to NHW (6.4%). Similarly, cost was a barrier to visiting a doctor for 23.9% of HSP, 19.5% of NHB, and 13.4% of members of other races; however, only 8.2% of non-Hispanic Whites reported cost as a barrier. More NHW (90.1%) and NHB (90.7) reported having had a check-up in the past year, compared to HSP (84.5%) or others (84.1%). All 3 variables exhibited significant differences by race or ethnicity (all P<.01). After adjustment for age, sex, income, education, and insulin use, the association with race/ethnicity persisted for health insurance coverage (P<.001), and for cost as a barrier (P<.003). Reporting cost as a barrier to visiting a doctor (P=.013), and rating one's overall health care as fair or poor (P=.001), were associated with poorer health status. CONCLUSIONS: These results suggest that ethnic minorities with diabetes report less healthcare coverage and more cost-related barriers to utilization, compared to non-Hispanic Whites. Persons with fair/poor health status were more likely to report cost barriers and poor satisfaction. Future research should focus on the reasons for such differences and on interventions to improve health care for minority populations.
Abstract: By the end of the 20th century, the worldwide diabetes pandemic had affected an estimated 151 million persons. Strategies to mitigate both the human and economic burden are urgently needed. Efficacious treatments are currently available but the quality of diabetes care being delivered is suboptimal in both developed and developing countries. Some progress to improve quality has been made thought national strategies. These efforts need two elements: "translation" research that will establish the methods needed to assure that clinical research findings are delivered effectively in every day practice settings; and development and implementation of quality improvement measures that will reliably track progress. New interventions that prevent diabetes among those at high risk also now hold much promise and need to be implemented.
Abstract: OBJECTIVE: To estimate the percent and number of overweight adults in the U.S. with prediabetes who would be potential candidates for diabetes prevention as per the American Diabetes Association Position Statement (12). RESEARCH DESIGN AND METHODS: We analyzed data from the Third National Health and Nutrition Examination Survey (NHANES III; 1988-1994) and projected our estimates to the year 2000. We defined impaired glucose tolerance (IGT; 2-h glucose 140-199 mg/dl), impaired fasting glucose (IFG; fasting glucose 110-125 mg/dl), and prediabetes (IGT or IFG) per American Diabetes Association (ADA) criteria. The ADA recently recommended that all overweight people (BMI >or=25 kg/m(2)) who are >or=45 years of age with prediabetes could be potential candidates for diabetes prevention, as could prediabetic people aged >25 years with risk factors. In NHANES III, 2-h postload glucose concentrations were done only among subjects aged 40-74 years. Because we were interested in overweight people who had both the 2-h glucose and fasting glucose tests, we limited our estimates of IGT, IFG, and prediabetes to those aged 45-74 years. RESULTS-Overall, 17.1% of overweight adults aged 45-74 years had IGT, 11.9% had IFG, 22.6% had prediabetes, and 5.6% had both IGT and IFG. Based on those data, we estimated that in the year 2000, 9.1 million overweight adults aged 45-74 had IGT, 5.8 million had IFG, 11.9 million had prediabetes, and 3.0 million had IGT and IFG. CONCLUSIONS: Almost 12 million overweight individuals aged 45-74 years in the U.S. may benefit from diabetes prevention interventions. The number will be substantially higher if estimation is extended to individuals aged >75 and 25-44 years.
Abstract: OBJECTIVE: Patient satisfaction is regarded as a component of the quality of medical care. We examined the association between quality of care and patient satisfaction. DESIGN: Cross-sectional study. SETTING: Population-based random sample in North Carolina, United States, 1997. PARTICIPANTS: 591 African-Americans aged > or = 18 years with self-reported diabetes were interviewed for providers' delivery of 10 preventive measures and patients' performance of four preventive measures for diabetes care. MAIN OUTCOME MEASURES: Satisfaction with health care providers with respect to 11 items, on a 4-point scale (excellent, good, fair, and poor). Average satisfaction scores were compared according to levels of quality of care. RESULTS: Patient satisfaction was positively associated with income, employment, diabetes education, ease of getting care during the last year, having health care coverage and having one physician for diabetes care (P < 0.05 for each). Adjusted for age, sex, education, employment, and income, 8 of 10 preventive care practices by providers during the previous year--monitoring of concentrations of glycosylated hemoglobin (HbA1c) and cholesterol; performing eye, foot, and gum examinations; and physician counseling on self-monitoring of blood glucose concentrations, exercise, and weight reduction--were associated with higher satisfaction scores (P < 0.05). Patients' performance of three of four preventive practices--taking medications for diabetes as prescribed, performing daily self-examination of the feet, and going for an eye examination with dilation of the pupils--were also associated with higher satisfaction scores (P < 0.05). CONCLUSION: Quality of diabetes care was positively associated with patient satisfaction with provider of care. Prospective studies are needed to confirm this association and its direction.
Abstract: OBJECTIVE: To examine the influence of obesity and prevention of weight gain on the incidence of type 2 diabetes. RESEARCH DESIGN AND METHODS: We examined participants in the San Antonio Heart Study, a prospective population-based study of Mexican Americans and non-Hispanic whites residing in San Antonio, Texas. BMI was stratified into four categories: normal (<25 kg/m(2)), overweight (> or =25 kg/m(2) and <30 kg/m(2)), obese (> or =30 kg/m(2) and <35 kg/m(2)), and very obese (> or =35 kg/m(2)). The number and proportion of incident cases prevented by targeting each BMI category were estimated. In addition, we calculated the decrease in risk of developing type 2 diabetes associated with weight gain prevention across both the BMI and age spectra. RESULTS: Preventing normal individuals from becoming overweight would result in the greatest reduction in incidence of type 2 diabetes. This would result in a 62 and 74% reduction in the incidence of type 2 diabetes in Mexican Americans and non-Hispanic whites, respectively. Preventing the entire population from gaining, on average, 1 BMI unit would result in a reduction in incidence of type 2 diabetes of 12.4 and 13.0% in Mexican Americans and non-Hispanic whites, respectively. CONCLUSIONS: The majority of cases of type 2 diabetes were in individuals who were overweight or mildly obese with a family history of type 2 diabetes. Public health resources should be directed toward the prevention of weight gain among normal and overweight individuals in order to prevent the maximum number of cases of type 2 diabetes.
Abstract: All four main studies of lifestyle intervention on diabetes incidence found a clear benefit for diet and exercise intervention compared with usual care. Although the study populations differed by race and ethnicity, the mean BMI, and the intensity of the lifestyle intervention provided, all investigators found substantial diabetes risk reduction with modest weight loss and increased physical activity. Results of these trials give health care providers useful and heartening information to share with patients at risk for diabetes. The challenge remains to find feasible and cost-efficient methods to identify people at risk and to deliver effective lifestyle interventions. Findings from trials of pharmacologic agents such as metformin, acarbose, and troglitazone are encouraging; however, the ADA recommends that drug therapy should not be used routinely to prevent diabetes until more information regarding the cost-effectiveness of such intervention is known [20]. Results from trials that found a lower incidence of diabetes among those randomly assigned to angiotensin-converting enzyme inhibitors, statins, or hormone therapy are intriguing but must be viewed with caution because they are based on post hoc analyses. Because it is difficult to conduct randomized controlled trials of major operative procedures such as bariatric surgery, observational studies that compare surgical interventions for weight loss with traditional weight-loss management may be the best evidence available. These studies have the potential for healthy-person bias in that people who choose bariatric surgery may have other healthy behaviors that are often difficult to measure and control for; such behaviors could account for their lower incidence of diabetes. Undeniably, the best test to diagnose those at high risk for diabetes is not yet known. New strategies that identify those with pre-diabetes and that overcome the limitations of the current tests, particularly the 2-hour post-challenge glucose test, are needed.
Abstract: Type 2 diabetes mellitus is a serious, growing, and costly public health problem. The disease is chronic and degenerative, and thus primary prevention is desirable. Observational studies have linked type 2 diabetes to specific lifestyle behaviors. Several recent major clinical trials confirm that type 2 diabetes can be delayed or prevented in people at high risk; multicomponent lifestyle modification can reduce the incidence of diabetes up to 58%. The American Diabetes Association has recently recommended that lifestyle interventions to prevent or delay diabetes be delivered to people with prediabetes. Delivery of lifestyle interventions in practice is fraught with challenges, but there are several tools and practical strategies available for the implementation of trial findings.
Abstract: BACKGROUND: Walking is associated with reduced diabetes incidence, but few studies have examined whether it reduces mortality among those who already have diabetes. OBJECTIVE: To estimate the association between walking and the risk for all-cause and cardiovascular disease (CVD) mortality among persons with diabetes. DESIGN: Prospective cohort study of a representative sample of the US population. SETTING: Interviewer-administered survey in the general community. PARTICIPANTS: We sampled 2896 adults 18 years and older with diabetes as part of the 1990 and 1991 National Health Interview Survey. MAIN OUTCOME MEASURE: All-cause and CVD mortality for 8 years. RESULTS: Compared with inactive individuals, those who walked at least 2 h/wk had a 39% lower all-cause mortality rate (hazard rate ratio [HRR], 0.61; 95% confidence interval [CI], 0.48-0.78; 2.8% vs 4.4% per year) and a 34% lower CVD mortality rate (HRR, 0.66; 95% CI, 0.45-0.96; 1.4% vs 2.1% per year). We controlled for sex, age, race, body mass index (calculated as weight in kilograms divided by the square of height in meters), smoking, and comorbid conditions. The mortality rates were lowest for persons who walked 3 to 4 h/wk (all-cause mortality HRR, 0.46; 95% CI, 0.29-0.71; CVD mortality HRR, 0.47; 95% CI, 0.24-0.91) and for those who reported that their walking involved moderate increases in heart and breathing rates (all-cause mortality HRR, 0.57; 95% CI, 0.41-0.80; CVD mortality HRR, 0.69; 95% CI, 0.43-1.09). The protective association of physical activity was observed for persons of varying sex, age, race, body mass index, diabetes duration, comorbid conditions, and physical limitations. CONCLUSIONS: Walking was associated with lower mortality across a diverse spectrum of adults with diabetes. One death per year may be preventable for every 61 people who could be persuaded to walk at least 2 h/wk.
Abstract: CONTEXT: Although diabetes mellitus is one of the most prevalent and costly chronic diseases in the United States, no estimates have been published of individuals' average lifetime risk of developing diabetes. OBJECTIVE: To estimate age-, sex-, and race/ethnicity-specific lifetime risk of diabetes in the cohort born in 2000 in the United States. DESIGN, SETTING, AND PARTICIPANTS: Data from the National Health Interview Survey (1984-2000) were used to estimate age-, sex-, and race/ethnicity-specific prevalence and incidence in 2000. US Census Bureau data and data from a previous study of diabetes as a cause of death were used to estimate age-, sex-, and race/ethnicity-specific mortality rates for diabetic and nondiabetic populations. MAIN OUTCOME MEASURES: Residual (remaining) lifetime risk of diabetes (from birth to 80 years in 1-year intervals), duration with diabetes, and life-years and quality-adjusted life-years lost from diabetes. RESULTS: The estimated lifetime risk of developing diabetes for individuals born in 2000 is 32.8% for males and 38.5% for females. Females have higher residual lifetime risks at all ages. The highest estimated lifetime risk for diabetes is among Hispanics (males, 45.4% and females, 52.5%). Individuals diagnosed as having diabetes have large reductions in life expectancy. For example, we estimate that if an individual is diagnosed at age 40 years, men will lose 11.6 life-years and 18.6 quality-adjusted life-years and women will lose 14.3 life-years and 22.0 quality-adjusted life-years. CONCLUSIONS: For individuals born in the United States in 2000, the lifetime probability of being diagnosed with diabetes mellitus is substantial. Primary prevention of diabetes and its complications are important public health priorities.
Abstract: This study develops forecasts of the number of people with diagnosed diabetes and diagnosed diabetes prevalence in the United States through the year 2050. A Markov modeling framework is used to generate forecasts by age, race and ethnicity, and sex. The model forecasts the number of individuals in each of three states (diagnosed with diabetes, not diagnosed with diabetes, and death) in each year using inputs of estimated diagnosed diabetes prevalence and incidence; the relative risk of mortality from diabetes compared with no diabetes; and U.S. Census Bureau estimates of current population, live births, net migration, and the mortality rate of the general population. The projected number of people with diagnosed diabetes rises from 12.0 million in 2000 to 39.0 million in 2050, implying an increase in diagnosed diabetes prevalence from 4.4% in 2000 to 9.7% in 2050.
Abstract: OBJECTIVE: We evaluated various strategies to identify individuals aged 45-74 years with pre-diabetes (either impaired glucose tolerance or impaired fasting glucose). RESEARCH DESIGN AND METHODS: We conducted a cost analysis to evaluate the effectiveness (proportion of cases identified), total costs, and efficiency (cost per case identified) of five detection strategies: an oral glucose tolerance test (OGTT), a fasting plasma glucose (FPG) test, an HbA(1c) test, a capillary blood glucose (CBG) test, and a risk assessment questionnaire. For the first strategy, all individuals received an OGTT. For the last four strategies, only those with a positive screening test received an OGTT. Data were from the Third U.S. National Health and Nutrition Examination Survey, 2000 census, Medicare, and published literature. One-time screening costs were estimated from both a single-payer perspective and a societal perspective. RESULTS: The proportion of pre-diabetes and undiagnosed diabetes identified ranged from 69% to 100% (12.1-17.5 million). The cost per case identified ranged from US dollars 176 to US dollars 236 from a single-payer perspective and from US dollars 247 to US dollars 332 from a societal perspective. Testing all with OGTT was the most effective strategy, but the CBG test and risk assessment questionnaire were the most efficient. If people are substantially less willing to take an OGTT than a FPG test, then the FPG testing strategy was the most effective strategy. CONCLUSIONS: There is a tradeoff between effectiveness and efficiency in choosing a strategy. The most favorable strategy depends on if the goal of the screening program is to identify more cases or to pursue the lowest cost per case. The expected percentage of the population willing to take an OGTT is also a consideration.
Abstract: BACKGROUND: Improving diabetes care in the United States is a topic of concern. OBJECTIVE: To document the quality of diabetes care during 1988-1995. DESIGN: National population-based cross-sectional surveys. SETTING: Third U.S. National Health and Nutrition Examination Survey (NHANES III) (1988-1994) and the Behavioral Risk Factors Surveillance System (BRFSS) (1995). PARTICIPANTS: Participants in NHANES III (n = 1026) or BRFSS (n = 3059) who were 18 to 75 years of age and reported a physician diagnosis of diabetes. Women with gestational diabetes were excluded. MEASUREMENTS: Glycemic control, blood pressure, low-density lipoprotein (LDL) cholesterol level, biannual cholesterol monitoring, and annual foot and dilated eye examination, as defined by the Diabetes Quality Improvement Project. RESULTS: 18.0% of participants (95% CI, 15.7% to 22.3%) had poor glycemic control (hemoglobin A(1c) level > 9.5%), and 65.7% (CI, 62.0% to 69.4%) had blood pressure less than 140/90 mm Hg. Cholesterol was monitored biannually in 85.3% (CI, 83.1% to 88.6%) of participants, but only 42.0% (CI, 34.9% to 49.1%) had LDL cholesterol levels less than 3.4 mmol/L (<130 mg/dL). During the previous year, 63.3% (CI, 59.6% to 67.0%) had a dilated eye examination and 54.8% (CI, 51.3% to 58.3%) had a foot examination. When researchers controlled for age, sex, ethnicity, education, health insurance, insulin use, and duration of diabetes, insured persons were more likely than uninsured persons to have a dilated eye examination (66.5% [CI, 62.6% to 70.4%]) vs. 43.2% [CI, 29.5% to 56.9%]) and were less likely to have a hemoglobin A(1c)level greater than or equal to 9.5%. Persons taking insulin were more likely than those who were not to have annual dilated eye examination (72.2% [CI, 66.3% to 78.1%] vs. 57.6% [CI, 53.7% to 61.5%]) and foot examination (67.3% [CI, 61.4% to 73.2%] vs. 47.1% [CI, 43.2% to 51.0%]) but were also more likely to have poor glycemic control (24.2% [CI, 18.3% to 30.1%] vs. 15.5% [CI, 11.6% to 19.4%]). CONCLUSIONS: According to U.S. data collected during 1988-1995, a gap exists between recommended diabetes care and the care patients actually receive. These data offer a benchmark for monitoring changes in diabetes care.
Abstract: OBJECTIVE: To describe the distribution of HbA(1c) levels among children and young adults in the U.S. and to evaluate the effects of age, sex, race/ethnicity, socioeconomic status, parental history of diabetes, overweight, and serum glucose on HbA(1c) levels. RESEARCH DESIGN AND METHODS: We analyzed HbA(1c) data from the Third National Health and Nutrition Examination Survey, 1988-1994, for 7,968 participants aged 5-24 years who had not been treated for diabetes. After adjusting for the complex sample design, we compared the distributions of HbA(1c) in subgroups and developed multiple linear regression models to examine factors associated with HbA(1c). RESULTS: Mean HbA(1c) level was 4.99% (SD 0.50%) and varied from 4.93% (95% CI +/-0.04) in non-Hispanic whites to 5.05% (+/-0.02) in Mexican-Americans to 5.17% (+/-0.02) in non-Hispanic blacks. There were very small differences among subgroups. Within each age- group, among men and women, among overweight and nonoverweight subjects, and at any level of education, mean HbA(1c) levels were higher in non-Hispanic blacks than in non-Hispanic whites. After adjusting for confounders, HbA(1c) levels for non-Hispanic blacks (5.15%, 95% CI +/-0.04) and Mexican-Americans (5.01%, +/-0.04) were higher than those for non-Hispanic whites (4.93%, +/-0.04). CONCLUSIONS: These data provide national reference levels for HbA(1c) distributions among Americans aged 5-24 years and show statistically significant racial/ethnic differences in HbA(1c) levels that are not completely explained by demographic and health-related variables.
Abstract: Microalbuminuria (MA) is associated with adverse health outcomes in diabetic and hypertensive adults. The prevalence and clinical significance of MA in nondiabetic populations is less clear. The purpose of this study was to generate national estimates of the prevalence of MA in the US population. Untimed urinary albumin concentrations (UACs) and creatinine concentrations were evaluated in a nationally representative sample of 22,244 participants aged 6 years and older. Persons with hematuria and menstruating or pregnant women were excluded from analysis. The percent prevalence of clinical proteinuria (UAC > or = 300 mg/L) was similar for males and females. However, the prevalence of MA (urinary albumin-creatinine ratio [ACR], 30 to 299 mg/g) was significantly lower in males (6.1%) compared with females (9.7%). MA prevalence was greater in children than young adults and increased continuously starting at 40 years of age. MA prevalence was greater in non-Hispanic blacks and Mexican Americans aged 40 to 79 years compared with similar-aged non-Hispanic whites. MA prevalence was 28.8% in persons with previously diagnosed diabetes, 16.0% in those with hypertension, and 5.1% in those without diabetes, hypertension, cardiovascular disease, or elevated serum creatinine levels. In adults aged 40+ years, after excluding persons with clinical proteinuria, albuminuria (defined as ACR > or = 30 mg/g) was independently associated with older age, non-Hispanic black and Mexican American ethnicity, diabetes, hypertension, and elevated serum creatinine concentration. MA is common, even among persons without diabetes or hypertension. Age, sex, race/ethnicity, and concomitant disease contribute to the variability of MA prevalence estimates.
Abstract: BACKGROUND: Several interventions can be applied to prevent complications of type 2 diabetes. This article examines the optimal allocation of resources across 4 interventions to treat patients newly diagnosed with type 2 diabetes. The interventions are intensive glycemic control, intensified hypertension control, cholesterol reduction, and smoking cessation. METHODS: A linear programming model was designed to select sets of interventions to maximize quality-adjusted life years (QALYs), subject to varied budget and equity constraints. RESULTS: For no additional cost, approximately 211,000 QALYs can be gained over the lifetimes of all persons newly diagnosed with diabetes by implementing interventions rather than standard care. With increased availability of funds, additional health benefits can be gained but with diminishing marginal returns. The impact of equity constraints is extensive compared to the solution with the same intervention costs and no equity constraint. Under the conditions modeled, intensified hypertension control and smoking cessation interventions were provided most often, and intensive glycemic control and cholesterol reduction interventions were provided less often. CONCLUSIONS: A resource allocation model identifies trade-offs involved when imposing budget and equity constraints on care for individuals with newly diagnosed diabetes.
Abstract: OBJECTIVE: To systematically review the effectiveness of self-management training in type 2 diabetes. RESEARCH DESIGN AND METHODS: MEDLINE, Educational Resources Information Center (ERIC), and Nursing and Allied Health databases were searched for English-language articles published between 1980 and 1999. Studies were original articles reporting the results of randomized controlled trials of the effectiveness of self-management training in people with type 2 diabetes. Relevant data on study design, population demographics, interventions, outcomes, methodological quality, and external validity were tabulated. Interventions were categorized based on educational focus (information, lifestyle behaviors, mechanical skills, and coping skills), and outcomes were classified as knowledge, attitudes, and self-care skills; lifestyle behaviors, psychological outcomes, and quality of life; glycemic control; cardiovascular disease risk factors; and economic measures and health service utilization. RESULTS: A total of 72 studies described in 84 articles were identified for this review. Positive effects of self-management training on knowledge, frequency and accuracy of self-monitoring of blood glucose, self-reported dietary habits, and glycemic control were demonstrated in studies with short follow-up (<6 months). Effects of interventions on lipids, physical activity, weight, and blood pressure were variable. With longer follow-up, interventions that used regular reinforcement throughout follow-up were sometimes effective in improving glycemic control. Educational interventions that involved patient collaboration may be more effective than didactic interventions in improving glycemic control, weight, and lipid profiles. No studies demonstrated the effectiveness of self-management training on cardiovascular disease-related events or mortality; no economic analyses included indirect costs; few studies examined health-care utilization. Performance, selection, attrition, and detection bias were common in studies reviewed, and external generalizability was often limited. CONCLUSIONS: Evidence supports the effectiveness of self-management training in type 2 diabetes, particularly in the short term. Further research is needed to assess the effectiveness of self-management interventions on sustained glycemic control, cardiovascular disease risk factors, and ultimately, microvascular and cardiovascular disease and quality of life.
Abstract: OBJECTIVE: Since 1997, the American Diabetes Association has recommended that aspirin therapy be considered for adults with diabetes who have cardiovascular disease (CVD) or CVD risk factors. We examined the prevalence of regular aspirin use among adults in the U.S. with diagnosed diabetes. RESEARCH DESIGN AND METHODS: The Third National Health and Nutrition Examination Survey (1988-1994) used a probability sample of the U.S. population and included an interview, physical examination, and laboratory studies. Among the survey participants were 1,503 adults (age > or =21 years) with self-reported diabetes. We defined regular aspirin use as reported having taken aspirin > or = 15 times in the previous month. CVD conditions were self-reported heart attack and stroke and symptoms of angina and claudication. CVD risk factors included smoking, hypertension, obesity, albuminuria, lipid abnormalities, and family history of heart attack. RESULTS: An estimated 27% of adults with diabetes had CVD, and an additional 71% had one or more CVD risk factors. Aspirin was used regularly by 37% of those with CVD and by 13% of those with risk factors only Adjusted odds of regular aspirin use were significantly greater for individuals with CVD than for those with one CVD risk factor (odds ratio [OR] = 4.3); for non-Hispanic whites than for blacks, Mexican-Americans, and others (OR = 2.5); and for individuals age 40-59 years than for those <40 years (OR = 33.3). CONCLUSIONS: Nearly every adult in the U.S. with diabetes has at least one risk factor for CVD and thus may be considered a potential candidate for aspirin therapy. During 1988-1994, only 20% (95% CI 16-23) took aspirin regularly Major efforts are needed to increase aspirin use.
Abstract: The purpose of this study was to compare the prevalence of diabetes and risk factors for the disease in three ethnic groups in Taiwan; the Hakaas, Fukienese, and aborigines. A cross-sectional study of men and women aged 50-79 years were invited to attend a standardized interview and physical examination. Diabetes mellitus was defined as a fasting plasma glucose (concentration of greater than or = 126) or a previous diagnosis of diabetes. Demographic, socioeconomic, and risk factor data were obtained. A total of 1293 persons (468 Hakaas, 440 Fukienese, and 385 aborigines) completed the examination. Hakaas had the highest age-adjusted prevalence of diabetes, 17.9% in men and 15.5% in women, followed by Fukienese, 14.5% in men and 12.8% in women. Aborigines had a prevalence of 10.0% in men and 13.3% in women. Diabetes prevalence was positively associated with family history of diabetes, obesity, hypertension, and hypertriglyceridemia. The ethnic variation in diabetes prevalence was reduced after adjustment for age, sex and significant factors. The multivariate-adjusted odds ratios (95% confidence interval) were 1.27 (0.76-2.12) for Fukienese and 1.44 (0.89-2.33) for Hakaas compared with aborigines. Diabetes mellitus is a major public health problem in Taiwan and warrants prevention efforts tailored to the country's different ethnic groups.
Abstract: OBJECTIVE: Physical activity and insulin sensitivity are related in epidemiological studies, but the consistency of this finding among populations that greatly differ in body size is uncertain. The present multiethnic epidemiological study examined whether physical activity was related to insulin concentrations in two populations at high risk for diabetes that greatly differ by location, ethnic group, and BMI. RESEARCH DESIGN AND METHODS: The study populations consisted of 2,321 nondiabetic Pima Indian men and women aged 15-59 years from Arizona and 2,716 nondiabetic men and women aged 35-54 years from Mauritius. Insulin sensitivity was estimated by mean insulin concentration (average of the fasting and postload insulin), and total (i.e., leisure and occupational) physical activity was assessed by questionnaire. RESULTS: Pima men and women who were more active had significantly (P < 0.05) lower mean insulin concentrations than those less active (BMI and age-adjusted means were 179 vs. 200 and 237 vs. 268 pmol/l). Similar findings were noted in Mauritian men and women (94 vs. 122 and 127 vs. 148 pmol/l). In both populations, activity remained significantly associated with mean insulin concentration controlled for age, BMI, waist-to-thigh or waist-to-hip ratio, and mean glucose concentrations. CONCLUSIONS: Physical activity was negatively associated with insulin concentrations both in the Pima Indians, who tend to be overweight, and in Mauritians, who are leaner. These findings suggest a beneficial role of activity on insulin sensitivity that is separate from any influence of activity on body composition.
Abstract: Fingerprint ridge counts, which remain constant from the 19th week of pregnancy, are related to fingertip growth during early gestation. Each finger corresponds neurologically to a spinal-cord segment ranging from C6 (thumb, relatively cephalad) to C8 (fifth finger, relatively caudad). The authors hypothesized that large ridge-count differences between fingertips (cephalad > caudad) might reflect fetal inhibition of caudal growth. Among 69 male Atlanta, Georgia, military recruits (1994-1997; aged 17-22 years), they tested associations of the anthropometric waist-to-thigh ratio with 20 ridge-count differences. Waist-to-thigh ratio was associated with the ridge-count difference between the right fourth and fifth fingertips only (dR45; r = 0.36, p = 0.003). The race-adjusted standardized regression coefficient was 0.22 (95% confidence interval: 0.03, 0.41). Since upper-body tissue distribution indicates disease risk, the authors then tested the association of age (an indicator of survivorship) with dR45 in a sample of 135 male patients from Bangalore, India (1989-1990; aged 38-82 years). Age was inversely associated with dR45 (r = -0.17, p = 0.04), notably among the 75 men with diabetes (r = -0.22, p = 0.06). An increased dR45 predicts an upper-body tissue distribution originating before the midpoint of pregnancy. The cause of this developmental pattern is unknown, but it may lead to reduced survivorship.
Abstract: OBJECTIVES: This study determined the prevalence of and risk factors for substance use among rural Taiwanese. METHODS: We used a survey of a representative sample of 6318 participants aged 13 to 35 years in I-Lan, Taiwan, in 1996 through 1997. RESULTS: Perceived use of illicit drugs by peers, tobacco smoking, betel quid chewing, and male gender were the strongest predictors of illicit drug use. The prevalence of illicit drug use ranged from 0.3% among those who did not use any other substance to 7.1% among those using tobacco, betel quid, and alcohol. CONCLUSIONS: Preventive measures should address substance use in general rather than aiming at single substances.
Abstract: OBJECTIVE: To evaluate the performance, in settings typical of opportunistic and community screening programs, of screening tests currently recommended by the American Diabetes Association (ADA) for detecting undiagnosed diabetes. RESEARCH DESIGN AND METHODS: Volunteers aged > or =20 years without previously diagnosed diabetes (n = 1,471) completed a brief questionnaire and underwent recording of postprandial time and measurement of capillary blood glucose (CBG) with a portable sensor. Participants subsequently underwent a 75-g oral glucose tolerance test; fasting serum glucose (FSG) and 2-h postload serum glucose (2-h SG) concentrations were measured. The screening tests we studied included the ADA risk assessment questionnaire, the recommended CBG cut point of 140 mg/dl, and an alternative CBG cut point of 120 mg/dl. Each screening test was evaluated against several diagnostic criteria for diabetes (FSG > or =126 mg/dl, 2-h SG > or =200 mg/dl, or either) and dysglycemia (FSG > or =110 mg/dl, 2-h SG > or =140 mg/dl, or either). RESULTS: Among all participants, 10.7% had undiagnosed diabetes (FSG > or =126 or 2-h SG > or =200 mg/dl), 52.1% had a positive result on the questionnaire, 9.5% had CBG > or =140 mg/dl, and 18.4% had CBG > or =120 mg/dl. The questionnaire was 72-78% sensitive and 50-51% specific for the three diabetes diagnostic criteria; CBG > or =140 mg/dl was 56-65% sensitive and 95-96% specific, and CBG > or =120 mg/dl was 75-84% sensitive and 86-90% specific. CBG > or =120 mg/dl was 44-62% sensitive and 89-90% specific for dysglycemia. CONCLUSIONS: Low specificity may limit the usefulness of the ADA questionnaire. Lowering the cut point for a casual CBG test (e.g., to 120 mg/dl) may improve sensitivity and still provide adequate specificity.
Abstract: OBJECTIVE: To project the number of people with diagnosed diabetes in the U.S. through 2050, accounting for changing demography and diabetes prevalence rates. RESEARCH DESIGN AND METHODS: We combined age-, sex-, and race-specific diagnosed diabetes prevalence rates-predicted from 1980-1998 trends in prevalence data from the National Health Interview Survey-with Bureau of Census population demographic projections. Sensitivity analyses were performed by varying both prevalence rate and population projections. RESULTS: The number of Americans with diagnosed diabetes is projected to increase 165%, from 11 million in 2000 (prevalence of 4.0%) to 29 million in 2050 (prevalence of 7.2%). The largest percent increase in diagnosed diabetes will be among those aged > or =75 years (+271% in women and +437% in men). The fastest growing ethnic group with diagnosed diabetes is expected to be black males (+363% from 2000-2050), with black females (+217%), white males (+148%), and white females (+107%) following. Of the projected 18 million increase in the number of cases of diabetes in 2050, 37% are due to changes in demographic composition, 27% are due to population growth, and 36% are due to increasing prevalence rates. CONCLUSIONS: If recent trends in diabetes prevalence rates continue linearly over the next 50 years, future changes in the size and demographic characteristics of the U.S. population will lead to dramatic increases in the number of Americans with diagnosed diabetes.
Abstract: BACKGROUND: The present analyses were conducted to examine the extent to which insulin sensitivity and insulin secretion, assessed using simple indices derived from an oral glucose tolerance test, are influenced by genetic factors, and to assess whether these genetic factors overlap with those influencing susceptibility to type 2 diabetes in Pima Indians. METHODS: Indices calculated from fasting and 2-h post-load insulin (I(0), I(120)) and glucose (G(0), G(120)) concentrations included insulin sensitivity index [ISI(0)=10(4)/(I(0).G(0))] and corrected insulin response [CIR(120)=I(120)/[G(120).(G(120)-70 mg/dl)]]. Heritability (h(2)) was determined using variance components methods in 1421 non-diabetic individuals from 446 sibships. Among 595 individuals in 186 sibships, genome-wide quantitative trait linkage analyses of ISI(0) and CIR(120) were conducted and affected-sibling analyses of diabetic siblings stratified by prediabetic measurements of ISI(0) and CIR(120) were also performed. RESULTS: Both ISI(0) (h(2)=0.37+/-0.06) and CIR(120) (h(2)=0.25+/-0.07) were moderately heritable. Modest evidence for linkage with CIR(120) (logarithm of odds (LOD)=1.6) was observed on chromosome 1q in a region previously shown to have linkage with young-onset diabetes in Pimas. When diabetic siblings were stratified by CIR(120), evidence for linkage in this region was strongest (LOD=1.5) among those with a low CIR(120). Additional regions with modest evidence for linkage with ISI(0) were observed on chromosomes 9p (LOD=2.0) and 14p (LOD=1.7). CONCLUSIONS: The present analyses suggest that insulin sensitivity and insulin secretion are influenced by genetic factors in Pima Indians. The linkage analyses suggest that the putative diabetes-susceptibility gene on chromosome 1q affects insulin secretion. Published in 2001 by John Wiley & Sons, Ltd.
Abstract: BACKGROUND: We examined levels of diabetes preventive care services and glycemic and lipid control among African Americans with diabetes in two North Carolina communities. METHODS: Cross-sectional, population-based study of 625 African-American adults with diagnosed diabetes. Participants had a household interview to determine receipt of preventive care services including glycosylated hemoglobin (HbA(1c)), blood pressure, lipid, foot, dilated eye, and dental examinations; diabetes education; and health promotion counseling. A total of 383 gave blood samples to determine HbA(1c) and lipid values. RESULTS: Annual dilated eye, foot, and lipid examinations were reported by 70% to 80% of the population, but only 46% reported HbA(1c) tests. Rates of regular physical activity (31%) and daily self-monitoring of blood glucose (40%) were low. Sixty percent of the population had an HbA(1c) level >8% and one fourth had an HbA(1c) level >10%. Half of the population had a low-density lipoprotein value >130 mg/dL. Lack of insurance was the most consistent correlate of inadequate care (odds ratio [OR]=2.3; 95% confidence interval [CI]=1.3-3.9), having HbA(1c) >9.5% (OR=2.1, 95% CI=1.1-4.2), and LDL levels >130 mg/dL (OR=2.1; 95% CI=1.0-4.5). CONCLUSIONS: Levels of diabetes preventive care services were comparable to U.S. estimates, but glycemic and lipid control and levels of self-management behaviors were poor. These findings indicate a need to understand barriers to achieving and implementing good glycemic and lipid control among African Americans with diabetes.
Abstract: OBJECTIVE: Increasing obesity within the general population has been accompanied by rising rates of diabetes. The extent to which obesity has increased among people with diabetes is unknown, as are the potential consequences for diabetes outcomes. RESEARCH DESIGN AND METHODS: Community medical records (hospital and ambulatory) of all Rochester, Minnesota, residents aged > or =30 years who first met standardized research criteria for diabetes from 1970 to 1989 (n = 1,306) were reviewed to obtain data on BMI and related characteristics as of the diabetes identification date (+/-3 months). Vital status as of 31 December 1999 and date of death for those who died were obtained from medical records, State of Minnesota death tapes, and active follow-up. RESULTS: As of the identification date, data on BMI were available for 1,290 cases. Of the 272 who first met diabetes criteria in 1970-1974, 33% were obese (BMI > or =30), including 5% who were extremely obese (BMI > or =40). These proportions increased to 49% (P < 0.001) and 9% (P = 0.012), respectively, for the 426 residents who first met diabetes criteria in 1985-1989. BMI increased significantly with increasing calendar year of diabetes identification in multivariable regression analysis. Analysis of survival revealed an increased hazard of mortality for BMI > or =41, relative to BMI of 23-25 (hazard ratio 1.60, 95% CI 1.09-2.34, P = 0.016). CONCLUSIONS: The prevalence of obesity and extreme obesity among individuals at the time they first met criteria for diabetes has increased over time. This is disturbing in light of the finding that diabetic individuals who are extremely obese are at increased risk of mortality compared with their nonobese diabetic counterparts.
Abstract: OBJECTIVES: To review the magnitude, characteristics, and public health importance of type 2 diabetes in North American youth. RESULTS: Among 15- to 19-year-old North American Indians, prevalence of type 2 diabetes per 1000 was 50.9 for Pima Indians, 4.5 for all US American Indians, and 2.3 for Canadian Cree and Ojibway Indians in Manitoba. From 1967-1976 to 1987-1996, prevalence increased 6-fold for Pima Indian adolescents. Among African Americans and whites aged 10 to 19 years in Ohio, type 2 diabetes accounted for 33% of all cases of diabetes. Youth with type 2 diabetes were generally 10 to 19 years old, were obese and had a family history of type 2 diabetes, had acanthosis nigricans, belonged to minority populations, and were more likely to be girls than boys. At follow-up, glucose control was often poor, and diabetic complications could occur early. CONCLUSIONS: Type 2 diabetes is an important problem among American Indian and First Nation youth. Other populations have not been well studied, but cases are now occurring in all population groups, especially in ethnic minorities. Type 2 diabetes among youth is an emerging public health problem, for which there is a great potential to improve primary and secondary prevention.
Abstract: The metabolic characteristics of type 2 diabetes, insulin resistance, and diminished insulin secretion are costly to measure directly. To evaluate the utility of several simple indices derived from insulin and glucose measurements, the indices were examined from 1982 to 1997 with respect to correlation with more sophisticated measures of insulin sensitivity and secretion in Pima Indians in the Gila River Indian Community of Arizona. Ability to predict the incidence of diabetes in 1,731 persons was also examined. Indices were calculated from fasting and 2-hour glucose (G0, G120) and insulin (I0, I120) concentrations obtained during an oral glucose tolerance test. Fasting serum insulin concentration and the insulin sensitivity index (10(4)/(I0 x G0)) each showed a moderate correlation with the estimate of insulin sensitivity derived from the hyperinsulinemic-euglycemic clamp (absolute value r approximately 0.60). They also strongly predicted the incidence of diabetes (incidence rate ratio comparing the most and least insulin-resistant tertile groups approximately 3.0). Corrected insulin response (I120/(G120 x (G120 - 70))) was modestly correlated with insulin secretion as measured by an intravenous glucose tolerance test (r = 0.35). Impaired insulin secretion assessed by this index predicted incidence of diabetes, particularly after control for insulin sensitivity index (incidence rate ratio = 1.6). Thus, simple indices of insulin sensitivity and secretion may be reasonable surrogates for more sophisticated measures in epidemiologic studies.
Abstract: BACKGROUND: Birth weight is positively associated with body mass index (BMI, kg/m2) in later life, but is inversely associated with cardiovascular risk. To understand this paradox, we examined the relationships between birth weight, adult BMI, and estimations of lean and fat tissue in young men. METHODS: From 192 applicants for military service (ages 17-22 y, mean BMI 23.2 kg/m2) with known birth weights we measured the circumference and anterior skinfold thickness at midthigh to estimate thigh muscle+bone area and subcutaneous fat area. Linear regression models including birth weight as the independent variable were adjusted for race and adult height. RESULTS: BMI was linearly associated with birth weight (standardized regression coefficient, [SRC]=+0.27; P=0.0004), as was the thigh muscle+bone area (SRC=+0.22; P=0.0029), but not the thigh subcutaneous fat area (SRC=+0.13; P=0.086). The BMI-birth weight association was reduced by 68% when the regression model was further adjusted for thigh muscle+bone area. Separate adjustment for thigh subcutaneous fat, however, reduced the BMI-birth weight association by only 30%. Waist circumference was also associated with birth weight (SRC=+0.24; P=0.0014), sagittal abdominal diameter was weakly associated (SRC=+0.17; P=0.028), but waist/thigh ratio and abdominal diameter index were not associated with birth weight. INTERPRETATION: The larger BMI associated with higher birth weight may reflect increments in lean tissue more than increments in fat. Birth weight's influence on lean tissue is observed in the thigh and, among fit young men, perhaps at the waist. Increased muscularity in young men may partly explain the cardiovascular benefit in middle age ascribed to higher birth weight.
Abstract: BACKGROUND: The long-term effect of type 2 diabetes on cognitive function is uncertain. OBJECTIVE: To determine whether older women with diabetes have an increased risk of cognitive impairment and cognitive decline. DESIGN: Prospective cohort study. SETTING: Four research centers in the United States (Baltimore, Md; Portland, Ore; Minneapolis, Minn; and the Monongahela Valley, Pennsylvania). PARTICIPANTS: Community-dwelling white women 65 years and older (n = 9679). MEASUREMENTS: Physician-diagnosed diabetes and other aspects of health history were assessed by interview. Three tests of cognitive function, the Digit Symbol test, the Trails B test, and a modified version of the Mini-Mental State Examination (m-MMSE), were administered at baseline and 3 to 6 years later. Change in cognitive function was defined by the change in the score for each test. Major cognitive decline was defined as the worst 10th percentile change in the score for each test. RESULTS: Women with diabetes (n = 682 [7.0%]) had lower baseline scores than those without diabetes on all 3 tests of cognitive function (Digit Symbol and Trials B tests, P<.01; m-MMSE, P = .03) and experienced an accelerated cognitive decline as measured by the Digit Symbol test (P<.01) and m-MMSE (P = .03). Diabetes was also associated with increased odds of major cognitive decline as determined by scores on the Digit Symbol (odds ratio = 1.63; 95% confidence interval, 1.20-2.23) and Trails B (odds ratio, 1.74; 95% confidence interval, 1.27-2.39) tests when controlled for age, education, depression, stroke, visual impairment, heart disease, hypertension, physical activity, estrogen use, and smoking. Women who had diabetes for more than 15 years had a 57% to 114% greater risk of major cognitive decline than women without diabetes. CONCLUSION: Diabetes is associated with lower levels of cognitive function and greater cognitive decline among older women.
Abstract: Definitive studies of the effectiveness of screening for type 2 diabetes are currently not available. RCTs would be the best means to assess effectiveness, but several barriers prevent these studies from being conducted. Prospective observational studies may characterize some of the benefits of screening by creating screened and unscreened groups for comparison. The availability of better data systems and health services research techniques will facilitate such comparisons. Unfortunately, the interpretation of the results of such studies is extremely problematic. Several screening tests have been evaluated. Risk assessment questionnaires have generally performed poorly as stand-alone tests. Screening with biochemical tests performs better. Venous and capillary glucose measurements may perform more favorably than urinary glucose or HbA(1c) measurements, and measuring postprandial glucose levels may have advantages over measuring fasting levels. However, performance of all screening tests is dependent on the cutoff point selected. Unfortunately, there are no well-defined and validated cutoff points to define positive tests. A two-stage screening test strategy may assist with a more efficient use of resources, although such approaches have not been rigorously tested. The optimal interval for screening is unknown. Even though periodic, targeted, and opportunistic screening within the existing health care system seems to offer the greatest yield and likelihood of appropriate follow-up and treatment, much of the reported experience with screening appears to be episodic poorly targeted community screening outside of the existing health care system. Statistical models have helped to answer some of the key questions concerning areas in which there is lack of empirical data. Current models need to be refined with new clinical and epidemiological information, such as the UKPDS results (200). In addition, future models need to include better information on the natural history of the preclinical phase of diabetes. Data from ongoing clinical trials of screening and treatment of impaired glucose tolerance, such as the Diabetes Prevention Program, may eventually offer more direct evidence for early detection and treatment of asymptomatic hyperglycemia (201). It will be important to use comprehensive cardiovascular disease modules that assess the conjoint influence of glucose and cardiovascular risk factor reduction, information on QOL, and refined economic evaluations using common outcome measures (cost per life-year or QALY gained) (11,178,202-204). Such studies should consider all of the costs associated with a comprehensive screening program, including, at a minimum, the direct costs of screening, diagnostic testing, and care for patients with diabetes detected through screening. Finally, combinations of screening tests and different screening intervals should be evaluated within economic studies to allow selection of the optimal approach within the financial and resource limitations of the health care system.
Abstract: An estimated 135 million people worldwide had diagnosed diabetes in 1995, and this number is expected to rise to at least 300 million by 2025. The number of people with diabetes will increase by 42% (from 51 to 72 million) in industrialized countries between 1995 and 2025 and by 170% (from 84 to 228 million) in industrializing countries. Several potentially modifiable risk factors are related to diabetes, including insulin resistance, obesity, physical inactivity and dietary factors. Diabetes may be preventable in high-risk groups, but results of ongoing clinical trials are pending. Several efficacious and economically acceptable treatment strategies are currently available (control of glycemia, blood pressure, lipids; early detection and treatment of retinopathy, nephropathy, foot-disease; use of aspirin and ACE inhibitors) to reduce the burden of diabetes complications. Diabetes is a major public health problem and is emerging as a pandemic. While prevention of diabetes may become possible in the future, there is considerable potential now to better utilize existing treatments to reduce diabetes complications. Many countries could benefit from research aimed at better understanding the reasons why existing treatments are under-used and how this can be changed.
Abstract: OBJECTIVE: To estimate the prevalence of physical disability associated with diabetes among U.S. adults > or =60 years of age. RESEARCH DESIGN AND METHODS: We analyzed data from a nationally representative sample of 6,588 community-dwelling men and women > or =60 years of age who participated in the Third National Health and Nutrition Examination Survey. Diabetes and comorbidities (coronary heart disease, intermittent claudication, stroke, arthritis, and visual impairment) were assessed by questionnaire. Physical disability was assessed by self-reported ability to walk one-fourth of a mile, climb 10 steps, and do housework. Walking speed, lower-extremity function, and balance were assessed using physical performance tests. RESULTS: Among subjects > or =60 years of age with diabetes, 32% of women and 15% of men reported an inability to walk one-fourth of a mile, climb stairs, or do housework compared with 14% of women and 8% of men without diabetes. Diabetes was associated with a 2- to 3-fold increased odds of not being able to do each task among both men and women and up to a 3.6-fold increased risk of not being able to do all 3 tasks. Among women, diabetes was also associated with slower walking speed, inferior lower-extremity function, decreased balance, and an increased risk of falling. Of the >5 million U.S. adults > or =60 years of age with diabetes, 1.2 million are unable to do major physical tasks. CONCLUSIONS: Diabetes is associated with a major burden of physical disability in older U.S. adults, and these disabilities are likely to substantially impair their quality of life.
Abstract: A cohort of 766 patients with non-insulin-dependent diabetes mellitus (NIDDM) from a general teaching hospital in Taipei, Taiwan were followed prospectively to assess survival experience and associated risk factors. Data were abstracted from the medical records and additional information was obtained from patients or their closest relatives using a structured questionnaire. Date and cause of death were determined from death certificates. Standardized mortality ratios were calculated by the direct method. Chi2-Square test and Cox's proportional hazard analysis were used to control for potential confounders. During a median follow-up of 3.5 years (range 1 month to 4.6 years), 131 deaths occurred. Of these, 29.8% were due to cardiopulmonary disease (ICD 401-429), 13.0% due to cerebrovascular disease (ICD 430-438), 13.0% due to acute diabetes metabolic complications (250.1, 250.2), and 11.4% due to nephropathy (580-589). Adjusted for age, people with NIDDM had 2.2 (95% CI 1.6-2.9) times the risk of death than members of the general population, and cause-specific standardized mortality ratios were: CPD 4.6, nephropathy 8.8, cerebrovascular disease 1.9, and neoplasm 0.7. Age, fasting plasma glucose, hypertension, and proteinuria were positively and independently associated with all-cause mortality (P < 0.05 for each). Thus, NIDDM patients have higher mortality rates than the general population in Taiwan, and age, fasting plasma glucose, hypertension, and proteinuria are associated with this excess risk. Proper application of available interventions may control these factors with a consequent reduction in mortality. Particular attention is needed to prevent deaths from the acute metabolic complications of diabetes.
Abstract: OBJECTIVE: To examine the relationships between HDL cholesterol subfractions and the incidence of type 2 diabetes and to evaluate potential sex differences in these relationships. RESEARCH DESIGN AND METHODS: Proportional hazards analyses were performed to examine the relationships between HDL subfractions and the development of type 2 diabetes in Pima Indian women and men. Results were controlled for age, BMI, systolic blood pressure, and 2-h glucose. RESULTS: Some 54 of 123 women and 25 of 50 men developed type 2 diabetes during a mean follow-up of 10 (2-19) years. For women, in separate models, high levels of total HDL, HDL2a, and HDL3 were negatively associated with incidence of type 2 diabetes; results were unchanged in models further controlled for fasting insulin level or alcohol consumption. For men, the results were inconsistent and associated with wide confidence intervals; high total HDL and HDL3 were positively associated with incidence of type 2 diabetes in models further controlled for fasting insulin level, but the risk estimates were attenuated in models further controlled for alcohol consumption. CONCLUSIONS: High levels of total HDL, HDL2a, and HDL3 were potential protective factors against type 2 diabetes in women after accounting for alcohol consumption and insulin resistance. High levels of total HDL and HDL3 were predictive of type 2 diabetes in men; the relationship in men appeared to be due to an association with alcohol consumption. The sex differences in the effects of HDL cholesterol may be related to the effects of sex hormones or lipoproteins.
Abstract: Little is known about carotenoids, a diverse group of plant compounds with antioxidant activity, and their association with diabetes, a condition characterized by oxidative stress. Data from phase I of the Third National Health and Nutrition Examination Survey (1988-1991) were used to examine concentrations of alpha-carotene, beta-carotene, cryptoxanthin, lutein/zeaxanthin, and lycopene in 40- to 74-year-old persons with a normal glucose tolerance (n = 1,010), impaired glucose tolerance (n = 277), newly diagnosed diabetes (n = 148), and previously diagnosed diabetes (n = 230) based on World Health Organization criteria. After adjustment for age, sex, race, education, serum cotinine, serum cholesterol, body mass index, physical activity, alcohol consumption, vitamin use, and carotene and energy intake, geometric means of beta-carotene were 0.363, 0.316, and 0.290 micromol/liter for persons with a normal glucose tolerance, impaired glucose tolerance, and newly diagnosed diabetes, respectively (p = 0.004 for linear trend), and geometric means for serum lycopene were 0.277, 0.259, and 0.231 micromol/liter, respectively (p = 0.044 for linear trend). All serum carotenoids were inversely related to fasting serum insulin after adjustment for confounders (p < 0.05 for each carotenoid). If confirmed, these data suggest new opportunities for research that include exploring a possible role for carotenoids in the pathogenesis of insulin resistance and diabetes.
Abstract: The purpose of this study was to estimate the prevalence of type 2 diabetes and impaired fasting glucose (IFG) in Penghu, Taiwan and compare these estimates with those of the US (NHANES III). Diabetes and IFG (American Diabetes Association criteria, 1997) were assessed among a stratified random sample of 2500 residents of Penghu Islands, Taiwan. The prevalence (age-adjusted to world adult population) of diabetes and IFG were 16.8% (95% CI 15.0-18.6) and 21.0% (95% CI 19.0-23.0), respectively, among Penghu Islanders in Taiwan. Age sex-specific diabetes prevalence ranged from 10.0% in men aged 40-49 years to 29.4% in women aged 60-69 years. Prevalence of IFG ranged from 14.7% in women aged 40-49 years to 30.7% in men aged 50-59 years. Age, body mass index (BMI), and family history of diabetes were each independently associated with both diabetes and IFG. In addition, female gender, apolipoprotein B and triglyceride concentrations were associated with diabetes, and hypertension and apolipoprotein B concentration with IFG. Among persons > or = 40 years in Penghu, Taiwan, the prevalence of diabetes is up to a third higher and the prevalence of IFG is up to three times higher than comparably aged Americans, despite their having a mean BMI 2.2-3.2 kg/m2 lower than Americans. The alarmingly high prevalence of IFG in Taiwan may indicate an emerging diabetes epidemic.
Abstract: The Population Attributable Risk (PAR) represents the proportion of the deaths (in a specified time) in the whole population that may be preventable if a cause of mortality were totally eliminated. This population-based measure was used to assess the potential impact of three public health interventions for type 2 diabetes (early detection + standard therapy; early detection + intensive therapy; and primary prevention) on the mortality risk from all causes and from cardiovascular (CVD) diseases. Potential reduction in mortality risks for several levels of compliance or implementation (25%, 50%, 75%, 100%) for each intervention were also estimated. Results suggest that among males aged 45-74 years, the interventions may have greater population-wide impact on total deaths among black males, and greater impact on the CVD deaths among white males. Overall, primary prevention (reduction in all-cause mortality 6.2-10.0%, and CVD mortality 7.9-9.0%) may offer greater marginal benefit than screening and early treatment (reduction in all-cause mortality 3.5-8.3%, and CVD mortality 2.8-8.6%). Often the question facing policy makers is not simply whether to but how much of an intervention is worth implementing? Estimated benefits for various intensities of intervention (as provided) may be useful to assess the likely marginal benefits of each intervention, and can be especially useful if combined with estimated marginal costs.
Abstract: OBJECTIVES: This study assessed the impact of diabetes on mortality associated with pneumonia and influenza among non-Hispanic Black and White US adults. METHODS: Data were derived from the National Mortality Followback Survey (1986) and the National Health Interview Survey (1987-1989). RESULTS: Regardless of race, sex, and socioeconomic status, people with diabetes who died at 25 to 64 years of age were more likely to have pneumonia and influenza recorded on the death certificate than people without diabetes who died at comparable ages (odds ratio [OR] = 4.0, 95% confidence interval [CI] = 2.3, 7.7). For those 65 years and older, the risk remained elevated among Whites with diabetes (OR = 2.2, 95% CI = 1.7, 2.7) but not among Blacks with diabetes (OR = 1.0, 95% CI = 0.6, 1.7). It was estimated that about 17,000 (10.3%) of the 167,000 deaths associated with pneumonia and influenza that occurred in 1986 were attributable to diabetes. CONCLUSIONS: The impact of diabetes on deaths associated with pneumonia and influenza is substantial. Targeted immunizations among people with diabetes may reduce unnecessary deaths associated with pneumonia and influenza.
Abstract: OBJECTIVES: Recent estimates suggest that obesity accounts for 5.7% of US total direct health care costs, but these estimates have not accounted for the increased death rate among obese people. This article examines whether the estimated direct health care costs attributable to obesity are offset by the increased mortality rate among obese individuals. METHODS: Data on death rates, relative risks of death with obesity, and health care costs at different ages were used to estimate direct health care costs of obesity from 20 to 85 years of age with and without accounting for increased death rates associated with obesity. Sensitivity analyses used different values of relative risk of death, given obesity, and allowed the relative costs due to obesity per unit of time to vary with age. RESULTS: Direct health care costs from 20 to 85 years of age were estimated to be approximately 25% lower when differential mortality was taken into account. Sensitivity analyses suggested that direct health care costs of obesity are unlikely to exceed 4.32% or to be lower than 0.89%. CONCLUSIONS: Increased mortality among obese people should be accounted for in order not to overestimate health care costs.
Abstract: OBJECTIVES: This study estimated the prevalence of self-rated visual impairment among US adults with diabetes and identified correlates of such impairment. METHODS: Self-reported data from the 1995 Behavioral Risk Factor Surveillance System survey of adults 18 years and older with diabetes were analyzed. Correlates of visual impairment were examined by multiple logistic regression analysis. RESULTS: The prevalence of self-rated visual impairment was 24.8% (95% confidence interval [CI] = 22.3%, 27.3%). Among insulin users, multivariable-adjusted odds ratios were 4.9 (95% CI = 2.6, 9.2) for those who had not completed high school and 1.8 (95% CI = 1.0, 2.8) for those who had completed high school compared with those with higher levels of education. Comparable estimates of odds ratios for nonusers of insulin were 2.2 (95% CI = 1.4, 3.4) and 1.3 (95% CI = 0.9, 2.0), respectively. Among nonusers, the adjusted odds for minority adults were 2.4 (95% CI = 1.0, 3.7) times the odds for non-Hispanic Whites. CONCLUSIONS: By these data, 1.6 million US adults with diabetes reported having some degree of visual impairment. Future research on the specific causes of visual impairment may help in estimating the avoidable public health burden.
Abstract: A pilot trial was conducted to test adherence to specific lifestyle interventions among Pima Indians of Arizona, and to compare them for changes in risk factors for diabetes mellitus. Ninety-five obese, normoglycaemic men and women, aged 25-54 years, were randomized to treatments named 'Pima Action' (Action) and 'Pima Pride' (Pride), which were tested for 12 months. Action involved structured activity and nutrition interventions, and Pride included unstructured activities emphasizing Pima history and culture. Adherence to interventions, changes in self-reported activity and diet, and changes in weight, glucose concentrations, and other risk factors were assessed regularly. Thirty-five eligible subjects who had declined randomization were also followed as an 'observational' group and 22 members of this group were examined once at a median of 25 months for changes in weight and glucose concentration. After 12 months of intervention, members of both intervention groups reported increased levels of physical activity (median: Action 7.3 h month(-1), Pride 6.3 h month(-1), p < 0.001 for each), and Pride members reported decreased starch intake (28 g, p = 0.008). Body mass index, systolic and diastolic blood pressures, weight, 2-h glucose and 2-h insulin had all increased in Action members (p < 0.003 for each), and waist circumference had decreased in Pride members (p = 0.05). Action members gained more weight than Pride members (2.5 kg vs 0.8 kg, p = 0.06), and had a greater increase in 2-h glucose than Pride members (1.33 mM vs 0.03 mM, p = 0.007). Members of the observational group gained an average of 1.9 kg year(-1) in weight and had an increase of 0.36 mM year(-1) in 2-h glucose. Sustaining adherence in behavioural interventions over a long term was challenging. Pimas may find a less direct, less structured, and more participative intervention more acceptable than a direct and highly structured approach.
Abstract: OBJECTIVE: To assess the relationship between dietary calcium and blood pressure. METHODS: Cross-sectional study of 404 adult Pima Indians of Arizona. Dietary variables were assessed by the 24-hour recall. Hypertension (HTN) was defined as systolic blood pressure (SBP) > or = mmHg or diastolic blood pressure (DBP) > or = 90 mmHg or drug treatment. RESULTS: Controlled for age and sex, dietary calcium intake was higher in subjects with HTN than in those without (p < 0.01), and higher dietary calcium was associated with a higher prevalence of HTN (odds ratio comparing highest with lowest tertile group of calcium = 2.6, 95% CI 1.4-4.8). Age-sex-adjusted men DBP in low, middle and high tertiles of calcium was 74, 76, and 79 mmHg, respectively (p < 0.001). SBP was not significantly different in the three tertiles (p = 0.07). Multiple regression analyses that controlled for age, sex, body mass index, sodium, potassium and alcohol also suggested a positive association between DBP and dietary calcium (p < 0.01), an association which was stronger at higher glucose concentrations (p < 0.01 for the calcium-glucose interaction). CONCLUSION: In Pima Indians, a population with a high incidence of diabetes, the inverse association between dietary calcium and blood pressure reported in other populations was not found.
Abstract: Project DIRECT (Diabetes Interventions Reaching and Educating Communities Together) is the first comprehensive community diabetes demonstration project in the United States in an African-American community. This article describes its intervention components and evaluation design. The development and implementation of Project DIRECT has included the community since the project's beginning. Interventions are targeted in three areas: health promotion (improving diet and physical activity levels), outreach (improving diabetes awareness, detection of undiagnosed diabetes, and ensuring that persons with diabetes who are not receiving continuing diabetes care are integrated into the health-care system), and diabetes care (improving self-care, increasing access, and improving the quality of diabetes preventive care received within the health-care system). Evaluation will be internal (conducted by Project DIRECT staff to assess process outcomes in persons directly exposed to each specific intervention) and external (review of outcomes to assess the impact of the multi-intervention program at the level of the entire community). Because diabetes exacts a disproportionate toll among African Americans, the findings from this project should aid in developing strategies to lessen the burden of this disorder, particularly among minority populations.
Abstract: OBJECTIVE: To estimate the levels of use of preventive care and to identify correlates of such care among people with diabetes in the U.S. RESEARCH DESIGN AND METHODS: A cross-sectional study was conducted using a sample of 2,118 adults, age > or =18 years, with self-reported diabetes in 22 states that participated in the 1994 Behavioral Risk Factor Surveillance System. Most subjects were age > or =45 years (83%), women (51%), and white (75%) and were diagnosed at ages > or =30 years (83%), had type 2 diabetes (89%), and were not using insulin (66%). RESULTS: Among all people with diabetes, 78% practiced self-monitoring of blood glucose, and 25% were aware of the term "glycosylated hemoglobin" or "hemoglobin A one C" (HbA1c). In the last year, 72% of the subjects visited a health care provider for diabetes care at least once, 61% had their feet inspected at least once, and 61% received a dilated eye examination. Controlled for age and sex, the odds ratios (ORs) for insulin use were for self-monitoring (OR [95% CI]; 4.0 [2.6-6.1]); having heard of HbA1c or receipt of a dilated eye examination (1.9 [1.4-2.5]); at least one visit to a provider (3.4 [1.9-7.2]); and feet inspected at least once (2.1 [1.5-2.9]). In addition, people <45 years, those who did not complete high school, and those without insurance coverage were high-risk groups for underuse of preventive care. Only 3% of insulin users and 1% of nonusers met all five of the American Diabetes Association standards in the previous year. CONCLUSIONS: Underuse of recommended preventive care practices is common among people with diabetes.
Abstract: The role of plasma lipoproteins in the development of non-insulin-dependent diabetes mellitus (NIDDM) was studied in 787 non-diabetic (2-h glucose < 11.1 mmol/l) Pima Indians (265 men and 522 women). Subjects were followed for a mean of 9.8 (range: 1.8-16.4) years, during which 261 (76 men and 185 women) developed NIDDM. In men and women, very-low-density lipoprotein (VLDL) cholesterol, VLDL triglyceride, low-density lipoprotein triglyceride and total triglyceride, controlled for age, predicted NIDDM (P < 0.01 for each). These effects diminished when controlled for age, sex, body mass index, systolic blood pressure and 2-h glucose. However, high-density lipoprotein (HDL) cholesterol, controlled for age, body mass index, systolic blood pressure and 2-h glucose, was a significant protective factor for NIDDM in women (hazard rate ratio (HRR) = 0.35, 95% CI (0.23-0.54), P < 0.001, 90th compared with 10th percentile) but not in men (HRR = 1.04, 95% CI (0.53-2.05), P = 0.915). This association remained significant in women when controlled for fasting or 2-h plasma insulin concentrations, other estimates of insulin resistance or alcohol consumption. The protective effect of HDL cholesterol was similar among women with normal (2-h glucose < 7.8 mmol/1) or impaired (7.8 mmol/l < or = 2-h glucose < 11.1 mmol/l) glucose tolerance at baseline. These results indicate that lipoprotein disorders are an early accompaniment of the abnormalities that lead to NIDDM.
Abstract: BACKGROUND: Low serum cholesterol concentrations are associated with high death rates from cancer, trauma, and infectious diseases, but the meaning of these associations remains controversial. The present report evaluates whether low cholesterol is likely to be a causal factor for mortality from all causes or from specific causes. METHODS AND RESULTS: Among 4553 Pima Indians > or =20 years old, a population with low serum cholesterol (median, 4.50 mmol/L), 1077 deaths occurred during a mean follow-up of 12.8 years. Trauma was the most common cause. The relationship between serum cholesterol measured at 2-year intervals and age- and sex-standardized mortality rates was U-shaped. Cholesterol was related positively to mortality from cardiovascular diseases and diabetes (including nephropathy) and negatively to mortality from cancer and alcohol-related diseases. The relationship was U-shaped for mortality from infectious diseases, and cholesterol was not related to mortality from trauma. Change in cholesterol from one examination to the next was positively related to mortality from diabetes. In proportional-hazards models adjusted for potential confounders, the relationship between baseline cholesterol and mortality was U-shaped for all causes and diabetes and positive for cardiovascular diseases. Other relationships were nonsignificant. Among 3358 subjects followed > or =5 years, the relationship was significant and positive only for mortality from cardiovascular diseases. CONCLUSIONS: Despite a high exposure risk for Pima Indians, if low cholesterol level is a causal factor, the relationships between low serum cholesterol and high mortality rates probably result from diseases lowering cholesterol rather than from a low cholesterol causing the diseases.
Abstract: AIMS: To quantify the increased risk of non-fatal injury when children travel unrestrained in a car, and to identify other preventable risk factors. METHODS: Case-control study of 78 children presenting to an accident and emergency (A&E) department having sustained an injury while travelling in a car, and 97 children attending an A&E outpatient clinic with conditions unrelated to road traffic accidents. RESULTS: Seat restraint was associated with a 93% lower risk of child accident injury. A driver with points on the licence was over five times more likely to have had an accident resulting in child injury than a driver without points. Child accident injury was also associated with the driver's accident history. CONCLUSIONS: These data allow the effect of achieving new target levels of seat restraint use to be estimated. Strategies aimed at reducing the risk of further accident among drivers with a history of accident may have a beneficial impact on childhood accident injuries.
Abstract: OBJECTIVE: Little is known about medial arterial calcification (MAC) other than its association with age, sex, diabetes, and diabetes complications. Familial aggregation of this disorder was studied to determine the importance of potential genetic factors and to assess whether such familial aggregation was independent of that of diabetes. RESEARCH DESIGN AND METHODS: Members of 1,256 Pima Indian nuclear families with 3,339 offspring were examined radiologically for MAC of the feet. Multiple logistic regression analyses were used to compare the presence of the disorder in a parent with the presence of MAC in an offspring and to determine whether familial aggregation of MAC was independent of parental diabetes. RESULTS: Controlled for age, sex, diabetes, serum cholesterol, and blood pressure, offspring of one parent with MAC had 3.3 (95% CI 1.5-7.6) times the odds of MAC as did offspring of parents without MAC, and offspring with both parents affected had an even higher risk (odds ratio, 8.1; 95% CI 3.4-18.8). Controlled for offspring age and sex and for parental age and diabetes, parental MAC was associated with the disorder in offspring (P < 0.001), but the effect of parental diabetes on MAC in the offspring was not significant when controlled for parental MAC (P = 0.36). Furthermore, offspring of nondiabetic parents with MAC, controlled for age, sex, diabetes, and diabetes duration, had 1.7 (95% CI 0.9-3.1) times the odds of MAC than did offspring of diabetic parents with MAC. CONCLUSIONS: Independent of parental age and diabetes and offspring age, sex, diabetes, and diabetes complications, parental MAC confers an increased risk of MAC in offspring. These findings suggest that the factors responsible for the familial clustering of MAC may be different from those for diabetes.
Abstract: OBJECTIVE: To examine the relationship of weight fluctuation to mortality rates and incidence of vascular disease. SUBJECTS: A cohort of Pima Indians, 572 of whom had non-insulin-dependent diabetes mellitus and 766 without diabetes. DESIGN: Individuals were invited biennially to research examinations. The root mean square error (RMSE) of the linear trend of weight with time for the first four examinations after age 20 years was used as an index of weight fluctuation. Subjects were followed from the fourth examination until death or until 31 December 1991. The mortality rate ratio (MRR) and its 95% confidence interval (CI) for those with a high weight fluctuation index relative to those with a lower value were determined. The median duration of follow up was 9.3 (range 0.1-22.6) years. MEASUREMENTS: All cause mortality (n = 356); incidence of diabetic retinopathy (n = 145), diabetic nephropathy (n = 132) and electrocardiographic abnormalities (n = 82). RESULTS: There was no significant relationship between weight fluctuation and mortality for diabetic subjects (MRR = 1.0, 95% CI 0.8-1.3, p = 0.91). Nondiabetic subjects with a high weight fluctuation index had a higher mortality rate than those with a lower index (MRR = 1.5, 95% CI 1.0-2.1, p = 0.03); the association was stronger among men than among women. The excess mortality in the high weight fluctuation group was not due to cardiovascular diseases, but to noncardiovascular causes and the risk for alcohol-related death was particularly increased. Weight fluctuation was not associated with the incidence of diabetic retinopathy, nephropathy or electrocardiographic abnormalities. CONCLUSIONS: A high weight fluctuation index was associated with higher mortality rates in nondiabetic, but not in diabetic, Pima Indians. The excess mortality is largely due to noncardiovascular causes of death and may reflect lifestyle factors associated with weight fluctuation, rather than its metabolic effects.
Abstract: OBJECTIVE--To determine the prevalence and predictors of smoking in urban India. DESIGN--Cross sectional. SETTING--Delhi, urban India, 1985-6. SUBJECTS--Random sample of 13,558 men and women aged 25-64 years. MAIN OUTCOME MEASURES--Smoking prevalence; subjects who were currently smoking and who had smoked > or = 100 cigarettes or beedis or chuttas in their lifetime were defined as smokers. RESULTS--45% (95% confidence interval 43.8 to 46.2) of men and 7% (6.4 to 7.6) of women were smokers. Education was the strongest predictor of smoking, and men with no education were 1.8 (1.5 to 2.0) times more likely to be smokers than those with college education, and women with no education were 3.7 (2.9 to 4.8) times more likely. Among smokers, 52.6% of men and 4.9% of women smoked only cigarettes while the others also smoked beedi or chutta. Compared with cigarette smokers, people smoking beedi or chutta were more likely to be older and married; have lower education, manual occupations, incomes, and body mass index; and not drink alcohol or take part in leisure exercise. CONCLUSION--There are two subpopulations of smokers in urban India, and the prevention strategy required for each may be different. The educated, white collar cigarette smoker in India might respond to measures that make non-smoking fashionable, while the less educated, low income people who smoke beedi or chutta may need strategies aimed at socioeconomic improvement.
Abstract: OBJECTIVE: To evaluate 2-h plasma glucose (2HPG), fasting plasma glucose (FPG), glycosylated hemoglobin (HbA1), a combination of FPG and HbA1 (FPG-HbA1), and other factors as screening tests for identifying high-risk subjects for a clinical trial of prevention of NIDDM and to identify strategies to minimize the total number of oral glucose tolerance tests (OGTTs) required to recruit eligible subjects to the trial. RESEARCH DESIGN AND METHODS: One thousand, one hundred and eight nondiabetic Pima Indians aged 25-64 years were followed for up to 5 years, and factors predicting NIDDM, defined by World Health Organization criteria (2HPG > or = 11.1 mmol/l), were assessed using Cox's proportional hazards analysis. Various threshold values of FPG, HbA1, and FPG-HbA1 were determined, which, when combined with an OGTT, identified subjects with impaired glucose tolerance (IGT) (2HPG > or = 7.8 and < 11.1 mmol/l) at a number of specified risks for developing NIDDM in 5 years. The value of each of the three tests was then assessed by calculating (for each threshold) the numbers to be screened, the numbers requiring an OGTT, and the sample size of IGT subjects needed to detect a 33% reduction in NIDDM by an experimental intervention at a power of 80%. RESULTS: During a median of 4.3 years of follow-up, 91 (8.2%) of the 1.108 nondiabetic subjects developed NIDDM. The estimated 5-year cumulative incidence rate was 13.5%. Each of the variables, 2HPG, FPG, HbA1, FPG-HbA1, BMI, IGT, and systolic (sBP), diastolic (dBP), and mean (MBP) blood pressures, predicted NIDDM (P < 0.05 for each) when controlled for age and sex. In a stepwise proportional hazards analysis model, 2HPG and FPG-HbA1 (P < 0.001 for each) were selected as the best set of predictors of NIDDM and of fasting hyperglycemia (FPG > or = 7.8 mmol/l). CONCLUSIONS: A two-step strategy, in which high-risk individuals are first identified by FPG or FPG-HbA1 and then the OGTT is used to select subjects with IGT, requires fewer OGTTs than when using 2HPG as the initial screening test without substantially increasing the numbers that would need to be screened. Such a strategy also offers the advantage of reducing the necessary sample size and is therefore an effective, efficient, and convenient method of identifying eligible subjects for a clinical trial of prevention of NIDDM.
Abstract: Impaired glucose tolerance (IGT), which is asymptomatic and requires a glucose tolerance test for detection, is a well-known risk factor for diabetes mellitus. Outside the research setting it is rarely identified in people who lack specific risk factors for diabetes except during pregnancy, at which time screening with an oral glucose challenge is a routine procedure. A 75-g oral glucose tolerance test was performed during the latter part of pregnancy or during a routine epidemiology survey in 15-39-year-old Pima Indian women with no history of abnormal glucose tolerance. Those with IGT by World Health Organization criteria were included in this study. Diabetes incidence in women was compared between those whose IGT was first detected during pregnancy and those who were not pregnant when IGT was first recognized. Seventeen of 73 pregnant women and 114 of 244 non-pregnant women developed diabetes within 10 years. When controlled for plasma glucose concentration, age, body mass index, parity and duration of follow-up, those who were not pregnant were at higher risk of developing diabetes than those who were pregnant (hazard rate ratio = 1.71, 95% confidence interval = 1.01-2.91). Previous studies had reported that women with IGT during pregnancy are at higher risk of diabetes than women with normal glucose tolerance. This study suggests that women with IGT during pregnancy are at lower risk than non-pregnant women with a similar plasma glucose concentration who, in the clinical setting, are likely to remain unrecognized.
Abstract: OBJECTIVE: To examine the relationship between locus of control (LOC) (internal and external) and physical activity in Pima Indians and to determine whether this relationship is affected by the presence of diabetes. RESEARCH DESIGN AND METHODS: A population-based sample of 580 Pima Indians was recruited from an ongoing research study. LOC was measured on a 1-40 modified Rotter scale, and past year total physical activity (leisure and work physical activity levels combined) was measured by interviewer-administered questionnaire. RESULTS: Among both men and women without diabetes, individuals with an internal LOC (score 1-16) were significantly (P < 0.01) more active than those with an external (score 17-40) LOC (70 vs. 30 median metabolic equivalent [MET] hours per week for men: 12 vs. 5 median MET hours per week for women). Controlled for age and BMI, an internal LOC was significantly associated with a higher level of physical activity among men (P = 0.04) and women (P = 0.001) without diabetes, but not among those with diabetes. CONCLUSIONS: Nondiabetic Pima Indians with an internal LOC are more physically active than those with an external LOC. Enhancing perceptions of internal control may influence physical activity and thus have implications for diabetes prevention.
Abstract: The relationships of rate of weight gain and weight fluctuation to incidence of non-insulin-dependent diabetes mellitus (NIDDM) were examined in Pima Indians. The 1,458 subjects were participants in a prospective study with examinations approximately every 2 years. Rate of weight gain was defined as the slope of the regression line of weight with time for two or more consecutive examinations > or = 2 years apart and weight fluctuation as the root-mean-square departure from this line for four examinations. Among men, incidence of NIDDM was strongly and significantly related to rate of weight gain (e.g., age-adjusted incidence = 56.7/1,000 person-years in those with weight gain > or = 3 kg/year and 16.9/1,000 person-years for those losing weight [Ptrend < 0.01]). In women, weight gain was significantly related to diabetes incidence only in those who were not initially overweight (body mass index < 27.3 kg/m2). In contrast to the relationship with weight gain, weight fluctuation was not associated with incidence of diabetes in either sex. These findings suggest that weight control in overweight individuals may be a more effective strategy for prevention of NIDDM in men than in women, whereas prevention of obesity may prevent diabetes in both sexes. Concern about a diabetogenic effect of weight fluctuation should not deter weight-control efforts.
Abstract: Obesity and family history of diabetes are both risk factors for non-insulin-dependent diabetes mellitus (NIDDM), but it has been proposed that lean individuals with NIDDM have a greater load of diabetes susceptibility genes. If this is the case, one might expect a high prevalence of NIDDM in relatives of diabetic individuals with a low body mass index (BMI). Among Pima Indians participating in an epidemiological study, prevalence of NIDDM was evaluated in relation to BMI of a diabetic parent or to the average parental BMI when both parents had diabetes in 1,535 offspring from 547 families. Prevalence of NIDDM was also evaluated in relation to BMI of a randomly selected index diabetic sibling in 1,722 siblings from 721 families. NIDDM was diagnosed by an oral glucose tolerance test. Compared with offspring of diabetic parent(s) at the 25th percentile of BMI, the odds ratio (OR) for diabetes in offspring of diabetic parents at the 75th percentile was 0.6 (95% confidence interval [CI] 0.5-0.7), adjusted for age, sex, BMI in offspring, number of diabetic parents, and age at onset of diabetes and sex of the diabetic parent(s). In the analysis according to BMI in a diabetic sibling, the corresponding OR was 0.8 (95% CI 0.6-0.9). Risk ratios were only modestly higher when the analysis was restricted to relatives of subjects whose BMI had been determined before the onset of diabetes. NIDDM in the presence of a low BMI is more strongly familial than that at a higher BMI.(ABSTRACT TRUNCATED AT 250 WORDS)
Abstract: In order to determine whether weight loss explains high mortality rates in those with a low body mass index (BMI), the relationships between BMI, rate of weight gain and mortality were examined in Pima Indians. Subjects were 814 diabetic and 1814 nondiabetic participants in a longitudinal survey who had at least two examinations after age 20. Median duration of follow-up was 8.1 (range 0.03-25.1) years. BMI showed a U-shaped relationship with mortality rates in men with the lowest rates in the 30-35 kg/m2 category; an inverse relationship was seen in women. Subjects who were losing weight had higher mortality rates than those who were gaining. However, excess mortality among the lightest subjects was present among those who were gaining weight. Among nondiabetic subjects, the mortality ratio (MR) for BMI < 25 kg/m2 compared with 30-35 kg/m2 was 1.5 [95% confidence interval (CI) 1.0-2.2] unadjusted for weight gain, while the adjusted MR was 1.3 [95% CI 0.9-1.9]. Weight loss, which may reflect underlying illness, is associated with high mortality rates in Pima Indians but does not fully account for the high mortality in the lightest individuals.
Abstract: Many risk factors for non-insulin-dependent diabetes mellitus (NIDDM), such as obesity, physical inactivity, and high-fat diet, can potentially be modified. Furthermore, some of the metabolic abnormalities, such as insulin resistance and impaired glucose tolerance, that predict diabetes can be improved by behavior modification and drug treatment. Thus, at least to some extent, NIDDM may be preventable. Several small clinical trials have addressed the hypothesis that NIDDM can be prevented by dietary modification, physical activity, or drug treatment. Some studies suggest a preventive effect, but the conclusions are limited by considerations of sample size, randomization, or intensity of the interventions. Consequently, the hypothesis that NIDDM is preventable requires further testing.
Abstract: Non-insulin-dependent diabetes mellitus (NIDDM) is a chronic disease which may take several years to develop, presumably starting in most cases with genetic susceptibility. Development of NIDDM is influenced by obesity and physical inactivity. As these risk factors can be altered by behavioral modification, and some of the physiologic abnormalities predicting diabetes, such as insulin resistance and impaired glucose tolerance, can be improved by behavioral modification and with drugs, NIDDM is potentially preventable. This potential needs to be demonstrated by randomized clinical trials.
Abstract: OBJECTIVE--To compare the one-step procedure proposed by the World Health Organization (WHO) with the two-step procedure proposed by the National Diabetes Data Group (NDDG) for the identification of abnormalities of glucose tolerance during pregnancy. RESEARCH DESIGN AND METHODS--One hundred twenty-seven non-diabetic Pima Indian women had a 75-g 2-h glucose tolerance test (WHO criteria). Those with an elevated 1-h glucose concentration (> or = 7.8 mmol/l) were referred for a 100-g 3-h glucose tolerance test (National Diabetes Data Group criteria). The effectiveness of the two test procedures was determined by comparing the frequency of macrosomia and cesarean section as outcomes of pregnancy. RESULTS--Of 42 women with 1-h plasma glucose concentrations > or = 7.8 mmol/l, 13 had no 100-g test, 27 had a normal test, and 2 had an abnormal test. Both women (100%) with abnormal two-step 100-g tests also had abnormal one-step 75-g tests, but only 2 of the 11 women (18%) with an abnormal one-step test had an abnormal two-step test. Sixteen of the 127 women delivered babies weighing > or = 4,000 g. Six of these women (38%) were correctly identified as abnormal using the one-step test and one (6%) using the two-step test. Of seven women delivering by cesarean section, four (57%) had abnormal one-step tests, but none had an abnormal two-step test. CONCLUSIONS--The one-step WHO test for glucose tolerance during pregnancy was abnormal in a greater percentage of women with adverse outcomes than the more cumbersome two-step NDDG test. The one-step test has the added advantage of being directly comparable to the standard glucose tolerance test used in nonpregnant women.
Abstract: The prevalence of measles, mumps and rubella antibodies for ages over six months was obtained using a stratified random sample of stored sera submitted in 1988 prior to the implementation of MMR vaccine. Besides reflecting the different vaccination policies for the three viruses the results showed that males display earlier sero-conversion for all three infections and a higher proportion of older males are susceptible. Two-thirds of children aged 6-15 months had antibodies to measles, the majority of which were apparently vaccine induced. However, the possibility that a few children contract natural measles before the recommended age for MMR vaccine cannot be ruled out. A system of continuous sero-surveillance to monitor the effect of MMR vaccine is suggested.
Abstract: OBJECTIVES--To develop structure, process, and outcome indicators within a quality rating index for audit of public health medicine. DESIGN--Development of an audit matrix and indicator of quality through a series of group discussions with public health physicians, from which self administered weighted questionnaires were constructed by a modified Delphi technique. SETTING--Five Scottish health boards. SUBJECTS--Public health physicians in the five health boards. MAIN MEASURES--Indicators of quality and a quality rating index for seven selected service categories for each of seven agreed roles of public health medicine: assessment of health and health care needs in information services, input into managerial decision making in health promotion, fostering multisectoral collaboration in environmental health services, health service research and evaluation for child services, lead responsibility for the development and/or running of screening services, and public health medicine training and staff development in communicable disease. RESULTS--Indicators in the form of questionnaires were developed for each topic. Three types of indicator emerged: "global," "restricted," and "specific." A quality rating index for each topic was developed on the basis of the questionnaire scores. Piloting of indicators showed that they are potentially generalisable; evaluation of the system is under way across all health boards in Scotland. CONCLUSION--Measurable indicators of quality for public health medicine can be developed.
Abstract: This paper presents some preliminary findings from one particular Cardiovascular Diseases and Alimentary Comparison (CARDIAC) Study data collection center. The population and the environment of the Western Isles, Scotland, from where the subjects were drawn, are described. The methodology was as according to the CARDIAC Study protocol. The results show that in this population there is a high mean serum total cholesterol level, a high prevalence of smokers, and a high mean body mass index. However, knowledge, attitudes, and reported behavior change regarding diet were encouraging. Much further data processing work remains to be done.
