Peer Reviewed: Factors Predicting Glycemic Control in Middle-Aged and Older Adults With Type 2 Diabetes

Introduction

Few studies have prospectively assessed the explanatory effects of demographics, clinical conditions, treatment modality, and general lifestyle behaviors on glycemic control in large heterogeneous samples of middle-aged and older adults with type 2 diabetes. We hierarchically examined these factors, focused especially on the effects of modifiable factors (ie, general lifestyle behaviors), and compared predictive patterns between middle-aged and older adults.

Methods

We used nationally representative data from the 1998 and 2000 Health and Retirement Study (HRS) and the HRS 2003 Diabetes Study. We analyzed data from 379 middle-aged adults (aged 51-64 y) and 430 older adults (aged ≥65 y) who self-reported having type 2 diabetes at baseline.

Results

Among middle-aged adults, demographic factors and clinical conditions were the strongest predictors of hemoglobin A1c (HbA1c) levels. However, among older adults, treatment modality (diet only, oral medication, or insulin only or in combination with other regimens) significantly affected HbA1c levels. Lifestyle (physical activity, smoking, drinking, and body weight control), independent of the effects of demographics, clinical conditions, and treatment modality, significantly affected HbA1c levels. An increase of 1 healthy behavior was associated with a decrease in HbA1c levels of more than 1 percentage point.

Conclusion

Our findings provide support for current diabetes guidelines that recommend a lifestyle regimen across the entire span of diabetes care and highlight the need to help both sociodemographically and clinically disadvantaged middle-aged adults with type 2 diabetes as well as older adults who exhibit poor adherence to medication recommendations to achieve better glycemic control.     

Peer Reviewed: Assessing Colorectal Cancer Screening Knowledge at Tribal Fairs

Introduction

Increasing public awareness and knowledge about the need for colorectal cancer (CRC) screening among American Indians is key to reducing health disparities. The objective of this study was to assess Navajo adults'' knowledge of CRC risk factors and prevention, CRC screening, and self-reported experience with CRC screening.

Methods

We collected data generated by a self-administered survey given to Navajo adults, most of whom lived on the reservation. Data were collected at 2 annual tribal fairs in 2006. Fair attendees who visited an exhibit booth completed a CRC knowledge survey. The study design was nonrandomized.

Results

Of the 285 Navajo adults who participated, most were bilingual (74%) and female (80%). Of the respondents aged 50 years or older, 77% had heard of CRC screening and 28% reported being screened for colon or colorectal cancer. Knowledge was high (mean, 5.78 [standard deviation (SD), 1.28]) (8.0 was the highest possible knowledge score). Respondents with little or no formal schooling had lower scores (mean, 5.4), indicating less knowledge of CRC and associated screening tests than did those with more education (mean, 6.0).

Conclusion

Among a sample of Navajo adults aged 50 years or older, participants with more education were more likely to be knowledgeable about CRC and to have received screening. This survey, led by a Navajo investigator with Navajo surveyors, revealed a high awareness of CRC and screening, but overall CRC screening was low. CRC education for Navajo adults who have little or no formal schooling should be improved.     

Peer Reviewed: Playground Renovations and Quality at Public Parks in Boston, Massachusetts, 1996-2007

Introduction

Recreational and transportation infrastructure can promote physical activity among children and adolescents. The Play Across Boston community-based research project sought to estimate and compare playground renovation rates across Boston areas before and after a playground quality assessment, to describe changes in playground quality among a subset of parks, and to document features of local transportation infrastructure around parks.

Methods

We used an observational pretest-posttest design to estimate playground renovation rates among 103 city-operated parks. Renovation rates were calculated on the basis of annual city Parks Department capital budgets from fiscal years 1996 through 2007. We used the same design to describe changes between a 2000 to 2001 baseline assessment of playground quality and a 2007 follow-up measured via observation of a subsample of 18 low-scoring parks in disadvantaged areas. We used χ ² analysis to compare percentages of playgrounds renovated across city areas before and after baseline assessment, logistic regression analysis to calculate odds ratios comparing renovation rates after baseline by city area, and paired t tests to compare playground quality at baseline and follow-up.

Results

Overall playground renovation rates before (29%) and after (34%) baseline assessment were similar. Parks scoring low on playground quality at baseline were renovated after baseline at a higher rate than high-scoring playgrounds. After accounting for baseline playground quality, parks in disadvantaged areas were renovated at a rate similar to those in other areas. Playground quality scores improved between baseline (mean, 38.3; 95% confidence interval, 35.3-41.3) and 2007 in a subsample of previously low-scoring parks in disadvantaged areas.

Conclusion

The findings of the 2007 follow-up assessment indicate an equitable rate of playground renovation across city areas according to need.     

Peer Reviewed: Evidence-Based Interventions and Screening Recommendations for Colorectal Cancer in Comprehensive Cancer Control Plans: A Content Analysis

Introduction

Colorectal cancer is the third most commonly diagnosed cancer and third leading cause of cancer death in the United States. The extent to which Comprehensive Cancer Control (CCC) programs in states, tribal governments and organizations, territories, and Pacific Island jurisdictions address evidence-based recommendations and interventions for colorectal cancer in their CCC plans is largely unknown.

Methods

We downloaded CCC plans posted on the Cancer Control PLANET Web site for review. We searched the plans for key terms, identifying potential evidence-based content surrounding colorectal cancer prevention and early detection. Content was abstracted for further review and classification.

Results

Of 55 plans reviewed, 54 (98%) referred to evidence-based recommendations or interventions for colorectal cancer or indicated they intended to refer to the evidence base when developing programs. More than 57% (n = 31) of programs referred to the American Cancer Society guidelines, 41% (n = 22) referred to the United States Preventive Services Task Force, and 11% (n = 6) referred to the Guide to Community Preventive Services. Few programs mentioned Research Tested Intervention Programs (n = 1), National Cancer Institute''s Physician Data Query (n = 4), Cochrane Reviews (n = 2), or Put Prevention Into Practice (n = 2) in reference to evidence-based interventions for colorectal cancer prevention.

Conclusion

Most CCC programs discussed either evidence-based screening guidelines or interventions in their cancer plans, although many mentioned this information exclusively as background information. We recommend that program planners be trained to locate evidence-based interventions and use consistent common language to describe them in their plans. CCC program planners should be encouraged to conduct and publish intervention studies.     

Peer Reviewed: Control of Risk Factors Among People With Diagnosed Diabetes,by Lower Extremity Disease Status

Introduction

We examined the control of modifiable risk factors among a national sample of diabetic people with and without lower extremity disease (LED).

Methods

The sample from the 1999-2004 National Health and Nutrition Examination Survey consisted of 948 adults aged 40 years or older with diagnosed diabetes and who had been assessed for LED. LED was defined as peripheral arterial disease (ankle-brachial index <0.9), peripheral neuropathy (≥1 insensate area), or presence of foot ulcer. Good control of modifiable risk factors, based on American Diabetes Association recommendations, included being a nonsmoker and having the following measurements: HbA1c less than 7%, systolic blood pressure less than or equal to 130 mm Hg, diastolic blood pressure less than or equal to 80 mm Hg, high density lipoprotein (HDL) cholesterol greater than 50 mg/dL, and body mass index (BMI) between 18.5 kg/m² and 24.9 kg/m².

Results

Diabetic people with LED were less likely than were people without LED to have recommended levels of HbA1c (39.3% vs 53.5%) and HDL cholesterol (29.7% vs 41.1%), but there were no differences in systolic or diastolic blood pressure, BMI classification, or smoking status between people with and without LED. Control of some risk factors differed among population subgroups. Notably, among diabetic people with LED, non-Hispanic blacks were more likely to have improper control of HbA1c (adjusted odds ratio [AOR] = 2.0; 95% confidence interval [CI], 1.1-3.9), systolic blood pressure (AOR = 1.9; 95% CI, 1.1-3.2), and diastolic blood pressure (AOR = 2.6; 95% CI, 1.1-5.8), compared with non-Hispanic whites.

Conclusion

Control of 2 of 6 modifiable risk factors was worse in diabetic adults with LED compared with diabetic adults without LED. Among diabetic people with LED, non-Hispanic blacks had worse control of 3 of 6 risk factors compared with non-Hispanic whites.     

Peer Reviewed: Factors Associated With Cervical Cancer Screening in Puerto Rico

Introduction

Racial/ethnic disparities in cervical cancer screening exist in the United States; rates are lowest among women who live in Puerto Rico. We identified factors associated with cervical cancer screening among women aged 18 years or older living in Puerto Rico.

Methods

We included women who participated in the Puerto Rico Behavioral Risk Factor Surveillance System in 2006 who had not had a hysterectomy (n = 2,206). We calculated the weighted population prevalence estimates of Papanicolaou (Pap) test screening in the past 3 years and used logistic regression models to assess factors associated with screening.

Results

Most participants (71.9% [95% confidence interval (CI)Most participants (71.9% [95% confidence interval (CI) = 69.4%-74.4%]) reported having had a Pap test in the preceding 3 years. Factors associated with screening in multivariate analysis included routine checkup in the past year and leisure-time physical activity. Compared with women with a household income less than $15,000, those with higher incomes were more likely to have had a Pap test. Similarly, divorced or separated women were more likely to have been screened (odds ratio [OR] = 1.13; 95% CI = 1.12-1.15) than those who were married/living together. We did not find associations between screening behavior and education, health care coverage, body mass index, or smoking status.

Conclusion

The prevalence of cervical cancer screening in Puerto Rico is below the 90% recommendation established by Healthy People 2010. Our findings regarding factors associated with Pap screening behavior identified population subgroups who are underscreened and who may benefit from targeted interventions and screening programs.     

Peer Reviewed: Collaboration to Increase Colorectal Cancer Screening Among Low-Income Uninsured Patients

Background

Colorectal cancer (CRC) is the second leading cause of cancer-related deaths in the United States. CRC screening allows for prevention through the removal of precancerous lesions and early detection of cancer.

Community Context

Ride for Life Alaska (RFL), a nonprofit organization that raises funds to fight cancer, and the Anchorage Neighborhood Health Center (ANHC), which is Alaska''s largest community health center, joined efforts to provide CRC screening and outreach to an ethnically diverse group of low-income underinsured or uninsured patients residing in and around Anchorage, Alaska.

Methods

RFL and ANHC worked with gastroenterologists, medical practices, and pathology services to contribute pro bono and reduced-fee services for CRC screening. Information to patients was distributed through signs in the clinic, flyers, and the ANHC website.

Outcomes

CRC screening was increased in this population. During 2007-2009, there were 2,561 immunochemical fecal occult blood tests given to patients, and 1,558 were completed (61%); 24% were positive. Sixteen gastroenterologists, 4 medical practices, and 2 laboratories provided 111 follow-up colonoscopies and pathology services to patients identified through the CRC screening program who did not have other funding resources available for follow-up care.

Interpretation

This program provides a model for leveraging scarce screening resources by drawing on multiple partners to increase CRC screening. Recommendations for those seeking to initiate similar programs are to have memoranda of agreement in place and a clear scope of work for all participating people and organizations to avoid delays in program implementation; hire a screening care coordinator to manage patient care and collaborate with medical practices; and identify program champions who have the energy and persistence to craft such partnerships.     

Peer Reviewed: Hospice Use Among Cancer Decedents in Alabama, 2002-2005

Introduction

Most studies that describe hospice use among cancer patients use the Surveillance, Epidemiology, and End Results (SEER)-Medicare database, which has known limitations. We used vital records data to describe patterns of hospice use among cancer decedents in Alabama.

Methods

To ascertain hospice use, we linked death certificates from 2002 through 2005 for people who died from cancer to listings of deaths reported by hospices. To evaluate accessibility of care, we calculated straight-line distances between decedent residence at death and the hospice providing care. We used these distances to estimate the reach of each hospice and identify the number of hospice nonusers residing in these areas.

Results

During the study period, 52.0% of cancer decedents in Alabama received hospice care from 165 hospices. Nearly two-thirds of Alabama counties contain at least 1 hospice. Whites (53.6%) used hospice at a significantly higher rate than blacks (47.0%), but the rate of use was similar for women (53.2%) and men (51.0%). For people who were eligible for Medicare, 53.0% received hospice care. The median distance between decedent’s residence and the hospice providing care was 9.8 miles. This distance was slightly shorter for blacks than whites and roughly equal by sex.

Conclusion

Alabamians use hospice at lower rates than observed elsewhere. Barriers to hospice care in Alabama must be identified and addressed.     

Peer Reviewed: Postpartum Screening for Diabetes Among Women With a History of Gestational Diabetes Mellitus

Introduction

To make recommendations for future clinical, public health, and research practices for women with abnormal glucose tolerance during pregnancy, we reviewed the latest evidence regarding rates of postpartum diabetes screening and types of screening tests.

Methods

We searched PubMed for journal articles published from January 2008 through December 2010 that reported on postpartum screening and studies designed to prevent progression to type 2 diabetes among women with gestational diabetes mellitus (GDM). Two authors independently reviewed titles and abstracts from 265 articles.

Results

From 34% to 73% of women with GDM completed postpartum glucose screening. Predictors of higher screening rates included older age, nulliparity, and higher income or education. Screening rates varied by race/ethnicity; Asian women were more likely to be screened than were other racial/ethnic minorities. Women who received prenatal care, who were treated with insulin during pregnancy, or who completed a 6-week postpartum visit were also more likely to receive screening. A moderate proportion of women screened had type 2 diabetes (1.2%-4.5%) or prediabetes (12.2%-36.0%).

Conclusion

Rates of postpartum screening among women with a history of GDM are low; only half of women in most populations are screened. Our findings can inform future screening initiatives designed to overcome barriers to screening for both providers and patients. Well-designed lifestyle interventions specific to women with a history of abnormal glucose tolerance during pregnancy and also studies to determine the efficacy and safety of pharmacological interventions will be important to help prevent progression to diabetes among these high-risk women.     

Peer Reviewed: Barriers to Colorectal Cancer Screening: Physician and General Population Perspectives,New Mexico, 2006

Introduction

Colorectal cancer (CRC) screening rates are low in New Mexico. We used statewide surveys of primary care physicians and the general population to characterize CRC screening practices and compare perceptions about screening barriers.

Methods

In 2006, we surveyed 714 primary care physicians in New Mexico about their CRC screening practices, beliefs, and perceptions of patient, provider, and system barriers. A 2004 state-specific CRC screening module for the Behavioral Risk Factor Surveillance System (BRFSS) survey asked 3,355 participants aged 50 years or older why they had not ever or had not recently completed a fecal occult blood test (FOBT) or lower endoscopy.

Results

The 216 physicians (30% response rate) reported offering screening to a median 80% of their average-risk patients in the past year and estimated that a median 50% were current with screening. They attributed low screening proportions mainly to patient factors (embarrassment, fear of pain, lack of insurance). However, just 51% of physician respondents used health maintenance flow sheets, and only 13% used electronic medical records to identify patients due for CRC screening. The BRFSS respondents most often reported that lack of physician discussion was responsible for not being current with screening (45% FOBT, 34% endoscopy); being asymptomatic was also often cited as an explanation for lack of screening (22% FOBT, 36% endoscopy).

Conclusion

Physicians and adults in the general population had markedly different perspectives on barriers to CRC screening. Increasing screening may require system supports to help physicians readily identify patients due for CRC testing and interventions to educate patients about the rationale for screening.     

Peer Reviewed: Development of a Community-Based Participatory Colorectal Cancer Screening Intervention to Address Disparities,Arkansas, 2008-2009

Background

The death rate from colorectal cancer is high and affects poor and medically underserved populations disproportionately. In the United States, health disparities are particularly acute in the Lower Mississippi River Delta region. Because many in the region have limited access to basic health care resources, they are not screened for cancer, even though screening is one of the most effective strategies to prevent colorectal cancer. Community-based participatory research is a promising approach to prevent colorectal cancer in this population.

Community Context

The Empowering Communities for Life program was implemented in 2 underserved counties in the Arkansas Lower Mississippi River Delta. The program arose from a 9-year partnership between the University of Arkansas for Medical Sciences and 9 cancer councils across Arkansas.

Methods

Empowering Communities for Life is a community-based participatory intervention designed to increase colorectal cancer screening in rural, underserved communities through fecal occult blood testing. Community and academic partners collaborated to develop research infrastructure, intervention materials and methods, and the assessment instrument.

Outcome

Project outcomes were strengthened community-academic partnerships, certification of community partners in conducting human subjects research, development of a randomized controlled design to test the intervention''s efficacy, an interactive PowerPoint presentation, an informational pamphlet, the certification of 6 lay health advisors and 22 role models to provide the intervention, and an assessment tool using an audience response system.

Interpretation

Lessons learned in working collaboratively with diverse groups include the importance of meeting face to face and listening.     

Peer Reviewed: Chronic Disease and Its Risk Factors Among Refugees and Asylees in Massachusetts, 2001-2005

Introduction

Better understanding of the health problems of refugees and people who are granted political asylum (asylees) in the United States may facilitate successful resettlement. We examined the prevalence of risk factors for and diagnoses of chronic disease among these groups in Massachusetts.

Methods

We retrospectively analyzed health screening data from 4,239 adult refugees and asylees who arrived in Massachusetts from January 1, 2001, through December 31, 2005. We determined prevalence of obesity/overweight, hypertension, coronary artery disease (CAD), diabetes, and anemia. Analyses included multivariate logistic regression to determine associations between CAD and diabetes with region of origin.

Results

Almost half of our sample (46.8%) was obese/overweight, and 22.6% had hypertension. CAD, diabetes, and anemia were documented in 3.7%, 3.1%, and 12.8%, respectively. People from the Europe and Central Asia region were more likely than those from other regions to have CAD (odds ratio, 5.55; 95% confidence interval, 2.95-10.47).

Conclusions

The prevalence of obesity/overweight and hypertension was high among refugees and asylees, but the prevalence of documented CAD and diabetes was low. We noted significant regional variations in prevalence of risk factors and chronic diseases. Future populations resettling in the United States should be linked to more resources to address their long-term health care needs and to receive culturally appropriate counseling on risk reduction.     

Peer Reviewed: Associations Between Severe Obesity and Depression: Results From the National Health and Nutrition Examination Survey, 2005-2006

Introduction

My objectives were to investigate the association between obesity and depression in a representative sample of American adults, investigate sex and severity of obesity as modifiers of the association between depression and body mass index, determine whether large waist circumference is associated with depression, and explore whether specific health behaviors and poor physical health are possible mediators of the association between obesity and depression, if found.

Methods

The sample consisted of 3,599 nonpregnant adults aged 20 years or older from the National Health and Nutrition Examination Survey, 2005-2006. I operationalized obesity as body mass index (BMI) and waist circumference from the anthropometric measurements of participants and current depression from Patient Health Questionnaire (PHQ-9) scores. I ran logistic regression models with depression as the dependent variable.

Results

In unadjusted analyses, large waist circumference (≥88 cm for women and ≥102 cm for men) and class III obesity (BMI ≥40 kg/m²) were associated with higher prevalence of depression in women only. All of these associations dramatically weakened after adjusting for demographic factors, self-rated health status, and number of chronic conditions.

Conclusion

These findings support an association between depression and obesity in women who are severely obese. Future studies should investigate poor physical health as a possible mediator of the association between obesity and depression in this population of women.     

Peer Reviewed: Lay Representations of Cancer Prevention and Early Detection: Associations With Prevention Behaviors

Introduction

The Common Sense Model of illness representations posits that how people think about an illness affects how they try to prevent the illness. The purpose of this study was to determine whether prevention representations vary by cancer type (colon, lung, and skin cancer) and whether representations are associated with relevant behaviors.

Methods

We analyzed data from the Health Information National Trends Survey (HINTS 2005), a nationally representative survey of American adults (N = 5,586) conducted by telephone interview.

Results

Respondents reported that all 3 types of cancer can be prevented through healthy behaviors; however, fewer did so for colon cancer. More respondents reported screening as a prevention strategy for colon cancer than did so for lung or skin cancer. Representations were associated with colon cancer screening, smoking status, and sunscreen use.

Conclusion

Representations of cancer were associated with relevant health behaviors, providing a target for health messages and interventions.     

Peer Reviewed: Physician Visits and Colorectal Cancer Testing Among Medicare Enrollees in North Carolina and South Carolina, 2005

Introduction

Many Medicare enrollees do not receive colorectal cancer tests at recommended intervals despite having Medicare screening coverage. Little is known about the physician visits of Medicare enrollees who are untested. Our study objective was to evaluate physician visits of enrollees who lack appropriate testing to identify opportunities to increase colorectal cancer testing.

Methods

We used North Carolina and South Carolina Medicare data to compare type and frequency of physician visits for Medicare enrollees with and without a colorectal cancer test in 2005. Type of physician visit was defined by the physician specialty as primary care, mixed specialty (more than 1 specialty, 1 of which was primary care), and nonprimary care. We used multivariate modeling to assess the influence of type and frequency of physician visits on colorectal cancer testing.

Results

Approximately half (46.5%) of enrollees lacked appropriate colorectal cancer testing. Among the untested group, 19.8% had no physician visits in 2005. Enrollees with primary care visits were more likely to be tested than those without a primary care visit. Many enrollees who had primary care visits remained untested. Enrollees with visits to all physician types had a greater likelihood of having colorectal cancer testing.

Conclusions

We identified 3 categories of Medicare enrollees without appropriate colorectal cancer testing: those with no visits, those who see primary care physicians only, and those with multiple visits to physicians with primary and nonprimary care specialties. Different strategies are needed for each category to increase colorectal cancer testing in the Medicare population.     

Peer Reviewed: Health Behaviors and Quality of Life of Cancer Survivors in Massachusetts, 2006: Data Use for Comprehensive Cancer Control

Introduction

Nearly 12 million cancer survivors are living in the United States. Few state-based studies have examined the health status and health-related quality of life (HRQOL) of this growing population. The objective of this study was to use Massachusetts Behavioral Risk Factor Surveillance System (BRFSS) data to describe cancer survivors'' demographics, health behaviors, quality of life, use of preventive care services, and influenza vaccination rates.

Methods

The demographic characteristics of cancer survivors and respondents without cancer were estimated on the basis of responses to questions in the 2006 Massachusetts BRFSS. We used multivariate logistic regression to compare health behaviors, comorbidities, quality of life, and cancer screening and influenza vaccination rates for cancer survivors compared with respondents who did not have cancer.

Results

Cancer survivors and respondents who did not have cancer had similar rates of health behavioral risk factors including smoking, obesity, and physical activity. Rates of chronic disease (eg, heart disease, asthma) and disability were higher among cancer survivors. Cancer survivors reported higher rates of influenza vaccination and breast, colorectal, and cervical cancer screening than did respondents who did not have cancer. Survivors'' self-reported health status and HRQOL (physical and mental health) improved as length of survivorship increased.

Conclusion

This state-based survey allowed Massachusetts to assess health-related issues for resident cancer survivors. These findings will help state-based public health planners develop interventions to address the long-term physical and psychosocial consequences of cancer diagnosis and treatment.