Epidemiological correlates of NIDDM in Hispanics, whites, and blacks in the U.S. population

Characteristics, prevalence, and risk factors for non-insulin-dependent diabetes mellitus (NIDDM) among Hispanics, blacks, and whites aged 20-74 yr in the United States population were investigated with two national surveys that used a household interview to ascertain diagnosed diabetes and a 75-g 2-h oral glucose tolerance test to measure undiagnosed diabetes. The Hispanic Health and Nutrition Examination Survey of 1982-1984 studied Mexican Americans in the southwest U.S., Cuban Americans in the Miami, Florida, area, and Puerto Ricans in the New York City area. The National Health and Nutrition Examination Survey of 1976-1980 examined a national sample of U.S. residents, of whom data on blacks and whites were analyzed. People with diagnosed diabetes in the five populations were similar with respect to mean age (53-57 yr), age at diagnosis (45-48 yr), duration of diabetes (6.9-8.7 yr), and diabetes therapies (58-67% using pharmacological treatment). Mean age of people with undiagnosed diabetes (51-59 yr) was comparable to that of diagnosed cases, and mean fasting (7.1-7.8 mM) and 2-h postchallenge plasma glucose (14.1-15.5 mM) values for people with undiagnosed diabetes were similar among the five populations. However, obesity levels varied by race, sex, and whether diabetes was diagnosed or undiagnosed. Age-standardized prevalence of diabetes (sum of diagnosed and undiagnosed cases) was 6.2% in whites, 9.3% in Cubans, 10.2% in blacks, 13% in Mexican Americans, and 13.4% in Puerto Ricans. Thus, compared to whites, diabetes rates were 50-60% higher among Cubans and blacks and 110-120% higher among Mexican Americans and Puerto Ricans. Age-standardized rates of impaired glucose tolerance were similar among the five populations (10.3-13.8%). Increasing age, obesity, and family history of diabetes were associated with higher rates of diabetes but sex, physical activity, education, income, and acculturation were not risk factors or were only weakly associated with diabetes prevalence.     

Obesity in Hispanic Americans

The prevalence of obesity among Hispanic American populations is generally greater than among white populations in the United States. Among Mexican Americans, the prevalence of obesity was higher than among either Cuban Americans or Puerto Ricans. It is well known that the prevalence of diabetes increases with increasing levels of obesity or body mass index. However, it does not appear that the high prevalence of obesity in Mexican Americans completely accounts for the higher prevalence of diabetes seen in this ethnic group. Among Mexican Americans, the association of selected cardiovascular disease risk factors, high-density lipoprotein cholesterol subfractions and systolic blood pressure, was similar to that seen among other U.S. populations. Individuals with diabetes had higher values than seen among those without diabetes. In a comparison of nutrient intake in two Mexican-American populations, one rural and one urban, there were no major differences other than higher calorie intakes in the rural population compared with the urban population. In addition, the diet in the rural population, based on higher levels of the Keys score, was more atherogenic than that of the urban population.     

Measuring health beliefs in Spanish-speaking Mexican Americans with type 2 diabetes: adapting an existing instrument

Mexican Americans bear a disproportionate burden of type 2 diabetes, and although clinicians and researchers are beginning to develop culturally competent interventions, few instruments are available for measuring variables relevant to health outcomes. The purpose of this study was to determine the psychometric properties of a diabetes-related health belief instrument translated for use with Spanish-speaking Mexican Americans. Three hundred and twenty-six Spanish-speaking Mexican Americans from Starr County, a Texas-Mexico border community, diagnosed with type 2 diabetes participated in the study. Factor analysis was used to examine the factor structure of the instrument, and reliability testing was conducted to determine the internal consistency of the resulting factors. The final instrument had 25 items with four subscales-Barriers, Social Support for Diet, Impact of Job on Therapy, and Benefits of Therapy-and one item to measure, Control. Internal consistency coefficients for these subscales were .56, .62, .86, and .90, respectively. The translated instrument needs to be tested over time with other Hispanic populations.     

Physician utilization by Hispanic elderly persons: national perspective

BACKGROUND: The number of elderly Hispanic Americans is projected to more than double by 2010 and account for 16% of all elders by 2050. The complex health needs and diversity of that growing population poses challenges for planning and delivery of health services. OBJECTIVES: The behavioral model of health services utilization was used to examine predisposing, enabling, and need factors associated with physician use by Hispanic elders and to assess whether Mexican American, Cuban American, and Puerto Rican elders differ in their likelihood of use. RESEARCH DESIGN: Data are from the 1988 National Survey of Hispanic Elderly People, which is a nationally representative sample of Hispanic elders living within telephone exchanges with at least 30% concentration of Hispanics. SUBJECTS: There were 2,299 completed interviews. Analyses are based on a subsample of 773 Mexican Americans, 714 Cuban Americans, and 368 Puerto Ricans. MEASURES: The dependent variable, physician utilization, was self-reported number of visits in the previous year. It was dichotomized because of skewness. Independent variables include predisposing, enabling, and need factors. RESULTS: Using hierarchical logistic regression, all three sets of factors contributed to the likelihood of a visit. Enabling factors, especially insurance coverage and adult children, had the greatest impact. Cuban Americans and Puerto Ricans were 2.3 and 2.6 times more likely, respectively, to have seen a physician than were Mexican Americans. CONCLUSIONS: In seeking to improve access and use of physician services, health care providers and policy makers should consider the role of social and economic factors and national origin group.     

Home remedies for type 2 diabetes used by Mexican Americans in El Paso, Texas

The purpose of this article is to examine the use of herbal remedies to treat Type 2 diabetes among Mexican Americans in El Paso County, Texas, on the U.S.-Mexico border. Interviews were conducted in Spanish with 22 Mexican American adults diagnosed with Type 2 diabetes mellitus. Open-ended questions were used to elicit theparticipants' beliefs about the appropriate treatment of Type 2 diabetes, including both Western biomedical and herbal therapy. Kleinman's explanatory model of illness served as the framework, and the grounded theory method was used for data analysis. A majority of participants were taking prescribed Western medications in conjunction with traditional Mexican folk remedies. Participants relied on the advice of family, friends, and neighbors to provide them with guidance, and some herbs used by participants were not indicated for the treatment of diabetes. Health care providers should be aware that Mexican American clients may make choices about herbal remedies without expert guidance and advice.     

Validation of the Australian/English version of the Diabetes Management Self-Efficacy Scale

Australians' use of the English language is influenced by a British educational curriculum, exposure to international television programmes and cultural backgrounds. Hence, adapting research instruments for use with Australian populations can be challenging. This study adapted the United Kingdom's version of the 20-item Diabetes Management Self-Efficacy Scale and tested it psychometrically with Australians. Face validity of the adapted instrument was established through consultation with diabetes educators and people with type 2 diabetes. Data from a convenience sample of 88 people with type 2 diabetes were analysed to determine the psychometric properties of the adapted instrument. The results indicate that the Australian/English version of the instrument is internally consistent, stable over time and it measures self-efficacy. However, there was evidence to show that there might be some redundant items in the scale. Further psychometric testing is warranted with a larger sample to determine whether the scale requires refinement.     

Diabetes as a predictor of change in functional status among older Mexican Americans: a population-based cohort study

OBJECTIVE: Epidemiological studies have demonstrated that older Mexican Americans are at high risk for type 2 diabetes and its complications. Type 2 diabetes leads to a more rapid decline in functional status among older Mexican Americans with diabetes. This study was designed to examine the impact of diabetes on change in self-reported functional status over a 2-year period among older Mexican Americans with diabetes. RESEARCH DESIGN AND METHODS: We performed a longitudinal analysis with repeated measurements of functional limitations in a cohort of Mexican Americans aged > or =60 years in the Sacramento Area Latino Study on Aging (SALSA). Diabetes was diagnosed on the basis of self-report of physician diagnosis, medication use, and fasting plasma glucose. Functional status was measured by assessment of activities of daily living (ADL) and instrumental activities of daily living (IADL) at baseline and 1 and 2 years. RESULTS: Of 1,789 SALSA participants, 585 (33%) had diabetes at baseline. Diabetic subjects reported 74% more limitations than nondiabetic subjects in ADL (summary score for number of limitations, 0.99 vs. 0.57; P = 0.002) and 50% more limitations in IADL (summary score for number of limitations, 7.83 vs. 5.25; P < 0.0001). The annual rate of increase in limitations of ADL and IADL was 0.046 and 0.033 (log scale) on each scale among diabetic subjects compared with 0.013 and 0.003 (log scale) among nondiabetic subjects (P < 0.0005). Complications of diabetes were found to increase ADL and IADL limitations among diabetic subjects. Longer duration of diabetes was also associated with an increase in ADL and IADL limitations. CONCLUSIONS: There was lower baseline functional status and a more rapid decline in functional status among older Mexican Americans with diabetes versus those without diabetes.     

Health in patients with Type 2 diabetes: an interview study based on the Welfare Theory of Health

BACKGROUND: In his Welfare Theory of Health Nordenfelt describes health as a person's ability to fulfil vital goals in different life areas. In order to use the theory in nursing, a semi-structured interview guide was constructed including questions about which vital goals Type 2 diabetic patients have and believe are important for their own welfare in different life areas. AIM: The aim of the study was to carry out preliminary validation of the interview guide. Two hypotheses were formulated: (i) Dissatisfied or unhealthy diabetic persons score lower on health-related quality of life (HRQL) than do those classified as healthy; (ii) A person with diabetes who uses avoidance as his/her main coping strategy restructures his/her vital goals in order to avoid failure and thereby dissatisfaction increases. METHODS: Interviews with 155 randomly selected Type 2 diabetic patients were conducted using the interview guide. HRQL and coping were also measured. The interview data were analysed using content analysis. RESULTS: The results were in accordance with the health theory, i.e. a person with Type 2 diabetes may be unhealthy, but still satisfied with life as a whole. Our two hypotheses were confirmed: Dissatisfied or unhealthy subjects with Type 2 diabetes had HRQL scores in all domains but physical functioning and bodily pain that were lower than scores of those who were satisfied or healthy, and a person with Type 2 diabetes who uses avoidance as his/her main coping strategy does seem to restructure his/her vital goals to avoid failure. CONCLUSION: The theory-based interview guide tested in this study seemed to reflect the notion that health includes fulfilment of vital goals.     

Origins of U.S. Hispanics. Implications for diabetes

The purpose of this article was to characterize the origins of the United States Hispanic population and discuss the implications of these origins in the context of diabetes risk. Particular attention was focused on the genetic origins of the three major U.S. Hispanic groups, i.e., Mexican Americans, Puerto Ricans, and Cubans. The U.S. Census figures provided basic demographic information. Genetic marker data for ancestral populations were taken from a review of the literature and compendia. Genetic marker data for the Puerto Rican and Cuban populations were extracted from the literature. Genetic markers determined on approximately 1000 randomly selected Mexican Americans from Starr County, Texas, were taken as representative of the Mexican-American population. The Hispanic population is the second largest and fastest growing minority in the U.S. Estimates of the Hispanic population in 1988 indicated some 19.4 million residents, of whom 62% were classified as Mexican, 13% as Puerto Rican, and the remaining 25% as Cubans and others. Various lines of evidence can be used to characterize the Hispanic population and its origins. These include ethnohistory, self-assessment of ancestry, surname distributions, speech and cultural characteristics, quantitative traits, and genetic structure. Genetic data were used to estimate the contribution of putative ancestral populations to the contemporary gene pool. For Mexican Americans, 31% of the contemporary gene pool is estimated to be Native American derived, whereas 61 and 8% are Spanish and African derived, respectively. In Puerto Rico, the percentage of contributions of Spanish, Native American, and African admixture to the population are 45, 18, and 37%, respectively. For Cuba, the parallel estimates are 62, 18, and 20%. The high frequency of Native American-derived genes in the contemporary Hispanic population predict a higher frequency of non-insulin-dependent diabetes mellitus (NIDDM) under the assumption that genes are important in NIDDM etiology. Our results are consistent with the finding of the significant role of genes in determining risk.     

Chronic abdominal pain and depression. Epidemiologic findings in the United States. Hispanic Health and Nutrition Examination Survey.

We report data on abdominal pain and depression from a survey of Hispanic Americans by the United States National Center for Health Statistics. The point prevalence rates of chronic abdominal pain were 4.6% in Mexican Americans and 5.8% in Cuban Americans in a total of 4175 subjects. The rate was 8.3% among 1323 Puerto Ricans. In 53% the abdominal pain came in waves. Using the Depression scale of the Center for Epidemiologic Studies (CES-D), 18.7% of Mexican and Cuban Americans with pain were found to be depressed to an extent likely to require intervention, and 40.8% of Puerto Ricans were so affected. The Diagnostic Interview Schedule (DIS) gave more conservative figures for major depression in terms of DSM-III, viz., 6.8% for Mexican and Cuban Americans with chronic pain, and 12.6% for Puerto Ricans with chronic pain. Logistic regression analyses demonstrated links between depression and female sex, the single state, low education and income, and chronic abdominal pain. The most consistent relationships for depression were with chronic pain, female sex and the single state. The results confirm the strong relationships between chronic pain, mood and female gender, and other socio-demographic variables.     

An innovative approach to diabetes education for a Hispanic population utilizing community health workers

Type 2 diabetes disproportionately affects the Hispanic population. New approaches are needed to provide effective education to this population. This evidence-based project utilized community health workers (CHWs) to deliver a culturally relevant diabetes education program to a Hispanic population at a migrant clinic. The program emphasized culturally relevant interventions to improve self-efficacy. Formative evaluation was used to develop and improve the program. Participants showed improvement in diabetes knowledge and diabetes related self-efficacy scores. Outcomes also included improvement in CHWs' diabetes knowledge and development of an educational program that could be utilized in other settings serving Hispanic populations with type 2 diabetes.     

Resourcefulness and health practices of diabetic women

More than one fourth of the millions of Americans with Type 2 diabetes experience depression, of which two thirds are women. Unless the individual is resourceful, coexisting diabetes and depression adversely affect one' health practices. The effects of diabetic and depressive symptoms on health practices and the mediating and moderating role of learned resourcefulness in this relationship were examined in 90 women with Type 2 diabetes. Regression analyses showed direct negative effects of diabetic and depressive symptoms on health practices. The effects of depressive, but not diabetic, symptoms were partially mediated by resourcefulness; no moderating effects were found. The results suggest the need to test interventions to minimize symptoms associated with diabetes, particularly depression. Teaching resourcefulness to Type 2 diabetic women may promote their positive health practices by minimizing their depression.     

Effects of traditional and western environments on prevalence of type 2 diabetes in Pima Indians in Mexico and the U.S

OBJECTIVE: Type 2 diabetes and obesity have genetic and environmental determinants. We studied the effects of different environments on these diseases in Pima Indians in Mexico and the U.S. RESEARCH DESIGN AND METHODS: Adult Pima-Indian and non-Pima populations in the Sierra Madre mountains of Mexico were examined using oral glucose tolerance tests and assessments for obesity, physical activity, and other risk factors. Results were compared with those from Pima Indians in Arizona. Both Pima populations were typed for DNA polymorphisms to establish their genetic similarity. RESULTS: The age- and sex-adjusted prevalence of type 2 diabetes in the Mexican Pima Indians (6.9%) was less than one-fifth that in the U.S. Pima Indians (38%) and similar to that of non-Pima Mexicans (2.6%). The prevalence of obesity was similar in the Mexican Pima Indians (7% in men and 20% in women) and non-Pima Mexicans (9% in men and 27% in women) but was much lower than in the U.S. Pima Indians. Levels of physical activity were much higher in both Mexican groups than in the U.S. Pima Indians. The two Pima groups share considerable genetic similarity relative to other Native Americans. CONCLUSIONS: The much lower prevalence of type 2 diabetes and obesity in the Pima Indians in Mexico than in the U.S. indicates that even in populations genetically prone to these conditions, their development is determined mostly by environmental circumstances, thereby suggesting that type 2 diabetes is largely preventable. This study provides compelling evidence that changes in lifestyle associated with Westernization play a major role in the global epidemic of type 2 diabetes.     

Prevalence of diabetes in Mexican Americans, Cubans, and Puerto Ricans from the Hispanic Health and Nutrition Examination Survey, 1982-1984

The purpose of this study was to estimate the prevalence of diagnosed and undiagnosed diabetes among Mexican Americans, Cubans, and Puerto Ricans in the United States and compare these estimates to data from prior surveys for U.S. non-Hispanic whites and blacks. Data for this study are from the Hispanic Health and Nutrition Examination Survey, a multipurpose cross-sectional survey of three U.S. Hispanic populations conducted in 1982-1984. The interviewed sample of people aged 20-74 yr included 3935 Mexican Americans in the southwest, 1134 Cubans in Florida, and 1519 Puerto Ricans in the New York City area. The diabetes component consisted of interview questions on diabetes diagnosis and treatment and an oral glucose tolerance test administered to a subsample. The prevalence of diabetes was two to three times greater for Mexican Americans and Puerto Ricans than for non-Hispanic whites surveyed in 1976-1980. In Cubans, the prevalence was similar to that for non-Hispanic whites. In men and women 45-74 yr of age, the prevalence of diabetes was extremely high for both Mexican Americans (23.9%) and Puerto Ricans (26.1%) compared with Cubans (15.8%) or non-Hispanic whites (12%). The total prevalence of diabetes was not significantly different for Mexican Americans and Puerto Ricans but was significantly lower for Cubans. The relatively lower prevalence of diabetes among Cubans and the high prevalence in both Mexican Americans and Puerto Ricans may be related to socioeconomic, genetic, behavioral, or environmental factors.     

Type 2 Diabetes Self‐Management Social Support Intervention at the U.S.‐Mexico Border

ABSTRACT Objectives: To pilot test the efficacy of a culturally tailored diabetes self‐management social support intervention for Mexican American adults with Type 2 diabetes (T2DM) living in the U.S.‐Mexico border region and to test the feasibility of recruiting and training promotoras to participate in intervention delivery. Design and Sample: This study used a single‐group pretest and posttest design. The convenience sample consisted of 21 Mexican American adults with T2DM. The setting for the study was a community in the Arizona‐Sonora, Mexico border region. Interventions: A bilingual, bicultural certified diabetes educator (CDE) and a nurse researcher developed the intervention to improve T2DM self‐management activities for Mexican Americans. Data were collected using self‐report questionnaires, glycosolated hemoglobin (HbA_1c), and anthropometric measures. Results: Intervention efficacy was demonstrated by an increase in participants' diabetes self‐management activities and diabetes knowledge and a decrease in diabetes‐related distress and sedentary behaviors. There were no significant changes in physiologic outcomes. Feasibility of recruitment and training of 2 promotoras who participated in intervention delivery was established. Conclusions: Promotoras, in collaboration with a CDE, successfully delivered a culturally tailored diabetes self‐management social support intervention for Mexican American adults with T2DM. This intervention positively affected diabetes self‐management behaviors.     

Are the 2005 Dietary Guidelines for Americans Associated With Reduced Risk of Type 2 Diabetes and Cardiometabolic Risk Factors?: Twenty-year findings from the CARDIA study

OBJECTIVE

To examine the prospective association between accordance with the 2005 Dietary Guidelines for Americans (DGA) and subsequent diabetes incidence and changes in cardiometabolic risk factors.

RESEARCH DESIGN AND METHODS

The sample consisted of 4,381 black and white young adults examined repeatedly from 1985 to 2005. We used the 2005 Diet Quality Index (DQI) to rate participants’ diets based on meeting key dietary recommendations conveyed by the 2005 DGA.

RESULTS

Overall, we found no association between DQI score and diabetes risk using Cox models adjusted for potential confounders. Higher DQI scores were associated with favorable changes in HDL cholesterol and blood pressure overall (P for trend <0.05), but with increased insulin resistance among blacks (P for trend <0.01).

CONCLUSIONS

Our findings highlight the need for evaluation of the DGA’s effectiveness, particularly among ethnic minority populations. Clinicians should be aware that following the DGA might not lower diabetes risk.The Dietary Guidelines for Americans (DGA) are the basis for federal nutrition programs (1), yet there is little evidence that diets congruent with the guidelines are effective in preventing chronic disease and thus are relevant to clinical care. We examined the prospective association between a diet consistent with the key dietary recommendations of the 2005 DGA and 1) 20-year incidence of type 2 diabetes; and 2) 13-year changes in HDL cholesterol, insulin resistance, blood pressure, and triglycerides in a cohort of black and white Americans.     

Lessons learned in instrument pilot testing with Mexican American caregivers of elders

Given the fast-growing Mexican American (MA) population, it is common for investigators to be pressured into using Spanish translated instruments developed for English-speaking populations. However, these translated instruments may have limited relevance for data collection without adequate assessment and vetting. The purpose of this paper is to present lessons learned from the pilot testing of instruments designed for use with Mexican Americans. Pilot testing of two instruments was conducted with 22 Mexican American family caregivers of older adults. Issues that emerged were classified into three categories-instrumentation, methodology, and demographic data. Within the area of instrumentation, six issues were identified-level of abstraction, concreteness, pronoun use, clarity, exclusiveness, and response format. Methodological concerns were focused on test-retest administration and inclusion criteria. Issues within the demographic data were concerned with marital status, country of birth, household size and income, and validity of self-rated scales. By addressing those concerns, investigators may be more likely to have culturally sensitive measures and greater generalization to relevant MA populations.     

Factors related to activity limitations in a group of Cuban Americans before and after hip fracture

BACKGROUND AND PURPOSE: Cuban Americans over the age of 50 years, like people from a number of other cultures, have been exposed to distinctive social and psychological aspects of their culture that may affect their recovery from a major health event. The purpose of this study was to determine factors related to activity limitations in a group of Cuban Americans recovering from hip fractures. SUBJECTS: The subjects were 28 adults of Cuban-American origin with an average age of 79 years (SD=9, range=57-96) who were recovering from hip fracture. Subjects were followed for 2 months after discharge from a hospital-based inpatient rehabilitation facility. METHODS: Subjects were interviewed at the time of discharge from the rehabilitation facility and 2 months after discharge, and they completed the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) and a social support interview. Functional Independence Measure scores and information regarding rehabilitative care were obtained from the rehabilitation facility. Multilinear regression analysis was used to determine the factors related to activity limitations before and after hip fracture. RESULTS: More premorbid activity limitations were related to poorer mental health status, older age, and male sex. More activity limitations at the time of discharge from the rehabilitation hospital were related to poorer mental health status prior to admission and partial or non-weight-bearing status after hip fracture. Older age and male sex were premorbid factors that appeared to relate to function after discharge. More activity limitations during the 2 months after discharge were related to the subjects reporting more social support in the form of physical assistance, less social support in the form of emotional assistance, less negative social support in the form of demand and criticism, status for weight bearing as tolerated at the time of discharge from the rehabilitation hospital, and older age. DISCUSSION AND CONCLUSION: In this group of Cuban Americans, mental health status was related to more activity limitations prior to admission to the rehabilitation facility and early in the recovery process, but not later in the recovery process. Conversely, social support was related to activity limitations later in the recovery process, but not prior to admission or early in the recovery process. Physical therapists should be aware of the psychosocial determinants of activity limitations during the process of recovery from disease or trauma.