Racial and ethnic disparities in diabetes risk after gestational diabetes mellitus

Aims/hypothesis  

To investigate racial/ethnic disparities in diabetes risk after gestational diabetes mellitus (GDM).     

The impact of restricted gestational weight gain by dietary intervention on fetal growth in women with gestational diabetes mellitus

Aims/hypothesis

We aimed to investigate the impact of maternal gestational weight gain (GWG) during dietary treatment on fetal growth in pregnancies complicated by gestational diabetes (GDM).

Methods

This was a retrospective cohort study of 382 women consecutively diagnosed with GDM before 34 weeks’ gestation with live singleton births in our centre (Center for Pregnant Women with Diabetes, Rigshospitalet, Copenhagen, Denmark) between 2011 and 2017. The women were stratified into three groups according to restricted (53%), appropriate (16%) and excessive (31%) weekly GWG during dietary treatment (using the Institute of Medicine guidelines) to estimate compliance with an energy-restricted ‘diabetes diet’ (6000 kJ/day [1434 kcal/day], with approximately 50% of energy intake coming from carbohydrates with a low glycaemic index, and a carbohydrate intake of 175 g/day). Insulin therapy was initiated if necessary, according to local clinical guidelines.

Results

Glucose tolerance, HbA_1c, weekly GWG before dietary treatment (difference between weight at GDM diagnosis and pre-pregnancy weight, divided by the number of weeks) and SD score for fetal abdominal circumference were comparable across the three groups at diagnosis of GDM at 27⁶?±?5¹ weeks (gestation time is given as weeks^days). The women were followed for 10⁰?±?5¹ weeks, during which 54% received supplementary insulin therapy and the average (mean) GWG during dietary treatment was 0 kg, 3 kg and 5 kg in the three groups, respectively. Excessive weekly GWG during dietary treatment, reflecting poor dietary adherence was associated with increasing HbA_1c (p?=?0.014) from diagnosis of GDM to late pregnancy and infants with a birthweight-SD score of 0.59?±?1.6. In contrast, restricted weekly GWG during dietary treatment, reflecting strict dietary adherence, was associated with decreasing HbA_1c (p?=?0.001) from diagnosis of GDM to late pregnancy and infants with a birthweight-SD score of 0.15?±?1.1, without increased prevalence of infants born small for gestational age. Excessive GWG during dietary treatment and late-pregnancy HbA_1c were identified as potentially modifiable clinical predictors of infant birthweight-SD score (p?=?0.02 for both variables) after correction for confounders.

Conclusions/interpretation

Restricted GWG during dietary treatment was associated with healthier fetal growth in women with GDM. GWG during dietary treatment and late-pregnancy HbA_1c were identified as potentially modifiable clinical predictors of infant birthweight-SD score.

     

Racial and ethnic disparities in influenza vaccination among elderly adults

Objectives: To examine whether access to care factors account for racial/ethnic disparities in influenza vaccination among elderly adults in the United States.
Design: Indicators of access to care (predisposing, enabling, environmental/system, and health need) derived from Andersen's behavioral model were identified in the National Health Interview Survey questionnaire. The relationship of these indicators to influenza vaccination and race/ethnicity was assessed with multiple logistic regression models.
Main Results: Significant differences in vaccination were observed between non-Hispanic (NH) whites (66%) and Hispanics (50%, P <.001) and between NH whites (66%) and NH blacks (46%, P <.001). Controlling for predisposing and enabling access to care indicators, education, marital status, regular source of care, and number of doctor visits, reduced the prevalence odds ratios (POR) comparing Hispanics to non-Hispanic whites from 1.89 to 1.27. For NH blacks, controlling for access to care indicators changed the POR only from 2.24 (95% CI, 1.9 to 2.7) to 1.93 (95% CI, 1.6 to 2.4).
Conclusions: This study confirmed the existence of sizable racial/ethnic differences in influenza vaccination among elderly adults. These disparities were only partially explained by differences in indicators of access to care, especially among non-Hispanic blacks for whom large disparities remained. Factors not available in the National Health Interview Survey, such as patient attitudes and provider performance, should be investigated as possible explanations for the racial/ethnic disparity in influenza vaccination among non-Hispanic blacks.     

The association of gestational diabetes mellitus with fetal birth weight

Aims

Gestational diabetes mellitus (GDM) and different time-point glucose levels might have different effects on fetal birth weight. The aim of this study was to further evaluate the associations of GDM and different time-point blood glucose levels with fetal birth weight in a prospective cohort study.

瘦素与妊娠糖尿病患者胰岛素抵抗及胎儿发育的相关性

目的 探讨瘦素及可溶性瘦素受体(sLR)在妊娠糖尿病发病及胎儿发育中的作用.方法 选取2014年1月至12月在厦门大学附属成功医院连续产检并分娩的673名孕妇为研究对象,跟踪随访至孕晚期.根据糖耐量试验结果,采用随机抽样法选取50例血糖控制良好的妊娠糖尿病患者纳入妊娠糖尿病组,根据一般资料进行匹配选取50名糖耐量试验结果阴性者纳入正常妊娠组.根据妊娠周数分为孕早期和孕晚期亚组,比较两组不同孕期血清及脐血瘦素、sLR、脂联素、抵抗素及生化指标水平,计算稳态模型评估-胰岛素抵抗指数(HOMA-IR),精确测量新生儿生长发育指标,使用多元Logistic回归分析孕早期胰岛素抵抗的危险因素,同时采用Spearman相关性分析血清瘦素与sLR、脂联素、抵抗素及生化指标水平的相关性.结果 与正常妊娠组相比,妊娠糖尿病组孕早期血清瘦素、甘油三酯、总胆固醇、低密度脂蛋白-胆固醇(LDL-C)、空腹胰岛素(FINS)、HOMA-IR明显升高(t=0.938～6.864,P均＜0.05),sLR、脂联素显著降低(t=9.237、2.216,P均＜0.05),抵抗素、高密度脂蛋白-胆固醇(HDL-C)、空腹血糖差异无统计学意义(P均＞0.05).与正常妊娠组相比,妊娠糖尿病组孕晚期血清瘦素、抵抗素、空腹血糖、FINS、甘油三酯、总胆固醇、LDL-C、HOMA-IR明显升高(t=0.429 ～ 13.787,P均＜0.05),sLR、脂联素显著降低(t=2.216、5.623,P均＜0.05),HDL-C差异无统计学意义(P＞0.05).与正常妊娠组相比,妊娠糖尿病组脐血瘦素、抵抗素明显升高(t=1.007、11.857,P均＜0.05),sLR、脂联素显著降低(t=0.201、4.558,P均＜0.05).多元Logistic回归分析显示,瘦素(OR =1.288,95％ CI:1.137 ～4.370)、抵抗素(OR=1.223,95％CI:1.035～ 1.570)、总胆固醇(OR=1.216,95％CI:1.026 ～1.823)、甘油三酯(OR=1.357,95％CI:1.008～ 3.572)、LDL-C (OR=1.634,95％ CI:1.251～3.764)是妊娠糖尿病组孕早期发生胰岛素抵抗的独立危险因素,sLR (OR =0.714,95％ CI:0.161～0.893)、脂联素(OR =0.352,95％CI:0.112 ～0.510)是妊娠糖尿病组孕早期发生胰岛素抵抗的保护性因素.妊娠糖尿病组孕晚期母体血瘦素含量与sLR、脂联素均呈负相关(r=-0.16、-1.13,P均=0.000),与抵抗素呈正相关(r=0.269,P=0.019).妊娠糖尿病组脐血瘦素含量与sLR、脂联素均呈负相关(r=-0.147、-1.250,P均=0.000),与抵抗素、体重、Ponderal 指数均呈正相关(r =0.410、0.673、0.301,P均＜0.05),与头围、身长无关(P均＞0.05).结论 瘦素及sLR与妊娠糖尿病患者胰岛素抵抗存在相关性,但与胎儿宫内生长和发育无关.     

Maternal serum and fetal cord blood irisin levels in gestational diabetes mellitus

Aim

To investigate the relationship between maternal and cord blood irisin in gestational diabetes mellitus (GDM).

Methods

Twenty women with GDM and 20 pregnant women with uncomplicated pregnancies were recruited for this case–control study. Maternal serum irisin and cord blood irisin levels were measured by enzyme-linked immunosorbent assay kit at the time of birth. The association of maternal serum and cord blood irisin levels with metabolic parameters was analyzed.

Results

Women with GDM had significantly lower mean serum irisin levels compared to control group (258.3 ± 127.9 vs. 393 ± 178.9 ng/ml, p < 0.05). Mean cord blood irisin levels for GDM and control groups were not significantly different (357.2 ± 248.0 vs. 333.2 ± 173.4 ng/ml, p > 0.05). No significant differences were found in terms of maternal age, gestational week at birth, BMI at birth, birth weight, neonatal height, systolic and diastolic blood pressure between the groups as well (p > 0.05). Serum irisin level was negatively correlated with BMI at birth and HOMA-IR (r = −0.401, p = 0.010; r = −0.395, p = 0.012, respectively). No correlations between irisin levels and others parameters were found in both groups.

Conclusions

Maternal serum irisin levels of patients with GDM are significantly lower compared with non-GDM controls. However, no significant difference was found between cord blood irisin levels of patients with GDM and healthy pregnant women.     

Racial and ethnic disparities in antifibrotic therapy in idiopathic pulmonary fibrosis

Background and Objective

Racial disparities have been documented in care of many respiratory diseases but little is known about the impact of race on the treatment of interstitial lung diseases. The purpose of this study was to determine how race and ethnicity influence treatment of idiopathic pulmonary fibrosis.

Methods

Adults with idiopathic pulmonary fibrosis (>18 years) were identified using TriNetX database and paired-wised comparisons were performed for antifibrotic treatment among White, Black, Hispanic and Asian patients. Mortality of treated and untreated IPF patients was compared after propensity score matching for age, sex, nicotine dependence, oxygen dependence and predicted FVC. Additional comparisons were performed in subgroups of IPF patients older than 65 years of age and with lower lung function.

Results

Of 47,184 IPF patients identified, the majority were White (35,082), followed by Hispanic (6079), Black (5245) and Asian (1221). When subgroups were submitted to matched cohort pair-wise comparisons, anti-fibrotic usage was lower among Black patients compared to White (6.2% vs. 11.4%, p-value <0.0001), Hispanic (10.8% vs. 20.2%, p-value <0.0001) and Asian patients (9.6% vs. 14.7%, p-value = 0.0006). Similar treatment differences were noted in Black individuals older than 65 years and those with lower lung function. Mortality among White patients, but not Hispanic, Black, or Asian patients, was lower in patients on antifibrotic therapy versus not on therapy.

Conclusion

This study demonstrated that Black IPF patients had lower antifibrotic use compared to White, Hispanic and Asian patients. Our findings suggest that urgent action is needed to understand the reason why racial disparities exist in the treatment of IPF.     

Racial and ethnic disparities in mobility device use in late life

OBJECTIVE: Although racial and ethnic disparities in disability are well established and technology is increasingly used to bridge gaps between functional deficits and environmental demands, little research has focused on racial and ethnic disparities in device use. This study investigated whether use of mobility devices differs by race and ethnicity and explored several reasons for this difference. METHODS: The sample included community-dwelling adults aged 65 and older from the 2002 and 2004 waves of the Health and Retirement Study. We used predisposing, need, and enabling factors to predict mobility device use alone and combined with personal care. RESULT: Blacks had the highest rates of using mobility devices, followed by Hispanics and then Whites. Need and enabling factors explained differences between Blacks and Whites in wheelchair use but not cane use or use of devices without personal care. Other predisposing factors explained most differences between Hispanics and Whites. DISCUSSION: Because minorities appear to be using mobility devices in proportion to underlying need, increasing device use by minorities may not reduce disparities in mobility disability. Efforts to address racial/ethnic disparities in mobility disability in late life, therefore, may need to focus on differences in underlying functional decline rather than the accommodation of it.     

Racial and ethnic disparities in sarcoidosis: from genetics to socioeconomics

Sarcoidosis is a multisystem granulomatous disease of unknown cause that occurs worldwide. The clinical expression of sarcoidosis varies by race. These racial differences may be the result of genetic and socioeconomic factors. Many of these genetic associations are race-specific in that they are found in either African Americans or whites but not both. Socioeconomic differences may also explain the racial disparities between African American and white patients with sarcoidosis. Finally, the phenotypic differences be-tween races may relate to an interaction between genetics and socioeconomic factors.The influences of genetics and socioeconomic status on the development and phenotypic expression of sarcoidosis will be better understood as the mechanisms of disease development are uncovered.     

Racial and ethnic disparities in access to physicians with HIV-related expertise

OBJECTIVE: Professional medical associations recommend that physicians who treat patients with human immunodeficiency virus (HIV) have a measurable form of disease-specific expertise, such as high HIV patient volume or infectious diseases certification. Although it is known that racial/ethnic minorities generally have worse access to care than do whites, previous work has not examined disparities in the use of physicians with HIV-related expertise. DESIGN, SETTING, AND PARTICIPANTS: We linked data from a prospective cohort study of 2,207 persons with HIV receiving care in the United States with a cross-sectional survey of 404 physicians caring for them. Using multivariate analysis, we estimated the association of patient race/ethnicity with the experience and training of their physicians, controlling for health status, socioeconomic status, demographic characteristics, and geographic variation in provider supply. RESULTS: Compared with white patients, African Americans were less likely to have an infectious diseases specialist as a regular source of care (odds ratio [OR], 0.60; 95% confidence interval [CI], 0.37 to 0.95). Persons of Alaskan Native, American Indian, Asian, Pacific Islander, or mixed racial background were also less likely than whites to have an infectious diseases specialist (OR, 0.44; 95% CI, 0.23 to 0.83). Conversely, Latino patients had physicians whose HIV patient volume was, on average, 24% higher than the physicians of white patients (incident rate ratio, 1.24; 95% CI, 1.03 to 1.50). CONCLUSIONS: Some groups of racial/ethnic minorities are less likely than are whites to have infectious diseases specialists as a regular source of care. The finding that the physicians of Latino patients had relatively higher HIV caseloads suggests that this particular patient subpopulation has access to HIV expertise. Further work to explain racial/ethnic differences in access to physicians will help in the design of programs and policies to eliminate them.     

The degree of fetal metformin exposure does not influence fetal outcome in gestational diabetes mellitus

The purpose of the study was to examine in vivo placental transfer of metformin, its association with neonatal outcome in metformin-treated gestational diabetes (GDM) patients, and influence of metformin exposure on maternal glycemic control and weight gain. Two hundred and seventeen GDM patients were randomized to metformin or insulin in Turku University Hospital, Finland. Metformin concentrations were determined by mass spectrometry in maternal serum at 36 gestational weeks (gw) and at birth, and in umbilical cord blood. Main outcome measures were birth weight, gw at birth, umbilical artery pH and neonatal hypoglycemia, maternal weight gain, HbA1c and fructosamine concentration. Median umbilical cord/maternal serum metformin concentration ratio was 0.73. There were no differences in birth weight measured in grams or SD units (p = 0.49), or gw at birth (p always ≥0.49) between insulin- and metformin-treated patients stratified by trough metformin concentration tertiles measured at 36 gw. Rate of neonatal hypoglycemia (p = 0.92) and umbilical artery pH value (p = 0.78) was similar in insulin- and metformin-treated patients stratified by cord metformin concentration tertiles. Maternal glycemic control was similar in metformin concentration tertiles at 36 gw. Maternal weight gain was 223 g greater per week (p = 0.038) in the lowest metformin tertile compared to other tertiles combined. Maternal and fetal exposure to metformin is similar. Maternal or fetal metformin concentrations do not predict maternal glycemic control or neonatal outcome, but low maternal exposure may lead to greater maternal weight gain.     

Racial and ethnic disparities in the treatment of dementia among Medicare beneficiaries

OBJECTIVES: Numerous studies have documented disparities in health care utilization between non-Hispanic White and minority elders. We investigated differences in anti-dementia medication use between non-Hispanic White and minority community-dwelling Medicare beneficiaries with dementia. METHODS: Using multivariate analysis with generalized estimating equations, we estimated prevalence ratios (PRs) for anti-dementia medication use by race/ethnicity for 1,120 beneficiaries with dementia from years 2001 through 2003 of the Medicare Current Beneficiary Survey. RESULTS: After adjusting for demographics, socioeconomics, health care access and utilization, comorbidities, and service year, we found that anti-dementia medication use was approximately 30% higher among non-Hispanic Whites compared to other racial/ethnic groups (PR=0.73, 95% confidence interval [CI]=0.59, 0.91). As for individual racial/ethnic groups, prevalence disparities remained significant for non-Hispanic Blacks (PR=0.75, 95% CI=0.57, 0.99) and non-Hispanic others (PR=0.50, 95% CI=0.26, 0.96) but were attenuated for Hispanics (PR=0.84, 95% CI=0.59, 1.20). DISCUSSION: Results provide evidence that racial/ethnic disparities in utilization of drugs used to treat dementia exist and are not accounted for by differences in demographic, economic, health status, or health utilization factors. Findings provide a foundation for further research that should use larger numbers of minority patients and consider dementia type and severity, access to specialty dementia care, and cultural factors.