Hypertension and diabetes in Detroit Hispanics.

The purpose of this study was to explore the prevalence of hypertension and diabetes alone and together in a sample of Hispanics. There were 111 participants with a mean age of 51 years. Twenty-six percent of the participants were hypertensive, a proportion well above the Healthy People 2010 target of 16%. The majority of hypertensive participants had isolated systolic hypertension, which is consistently associated with greater cardiovascular risk. Thirty-seven percent of the hypertensives were also diabetic. Diabetics were significantly more likely than non-diabetics to have stage 3 hypertension than either stage 1 or stage 2 (chi(2) [1] = 7.17, p <.01). It is important for nurses to screen Hispanic clients who are 18 years and older for high blood pressure. Early case finding will help nurses increase awareness and control of high blood pressure among Hispanics, which is crucial to avoid the enormous human and financial burdens of cardiovascular morbidity and mortality.     

Obesity and undiagnosed diabetes in the U.S

OBJECTIVE—To study whether obese individuals, who are at higher risk for diabetes and disparities in care than nonobese individuals, are more likely to have undiagnosed diabetes.RESEARCH DESIGN AND METHODS—We performed an analysis of 5,514 adult participants in the 1999–2004 National Health and Nutrition Examination Survey. Particpants were interviewed about sociodemographic and medical data, including whether they had been diagnosed with diabetes, and were examined for height, weight, and fasting plasma glucose level ≥126 mg/dl or by previous physician diagnosis. After categorizing participants into normal weight, overweight, and obese according to BMI, the prevalance and diagnosis of diabetes across BMI categories was compared using χ².RESULTS—Of the 9.8% (weighted sample) of participants who had diabetes, based on fasting glucose levels and self-reported diagnosis, 28.1% were undiagnosed, translating to an estimated 5.2 million people in the U.S. population. The proportion undiagnosed was not significantly different among normal-weight (22.2%), overweight (32.5%), or obese adults (27.4%). Nevertheless, obese adults comprise more than half of the undiagnosed diabetes cases (2.7 million). Relative to normal-weight adults, the adjusted odds ratio (OR) for having undiagnosed diabetes was 1.50 (0.73–3.08) in overweight and 1.37 (0.72–2.63) in obese adults.CONCLUSIONS—Despite a higher underlying risk of diabetes and widespread clinical recognition of this higher risk, obesity does not increase the likelihood that an individual''s diabetes will be diagnosed.The rise in obesity has led to a comparable rise in type 2 diabetes, a major cause of death, morbidity, and disability (1,2). National guidelines differ, however, on whether screening asymptomatic individuals is recommended (3,4). The American Diabetes Association advocates screening adults aged 45 years and older, whereas the U.S. Preventive Services Task Force found insufficient evidence to recommend mass screening (3,4). Lack of uniform screening guidelines and potential delays in diagnosing diabetes is of particular concern in obese populations, not only because of their high risk for developing diabetes but also because evidence suggests that obese individuals experience healthcare disparities that include delays in receiving preventive care (5). We examined whether BMI category affects the likelihood of having undiagnosed diabetes among U.S. adults.     

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.     

Diabetes Preventive Services and Policy Implications in the U.S.

OBJECTIVE

To investigate whether the patient or physician practice characteristics predict the use of diabetes preventive care services.

RESEARCH DESIGN AND METHODS

This was a cross-sectional study of a nationally representative sample of 27,169 adult ambulatory care visits, using the 2007 National Ambulatory Medical Care Survey data. The outcome variable is whether any preventive care services, defined as diagnostic tests (glucose, urinalysis, A1C, and blood pressure) or patient education (diet/nutrition, exercise, and stress management), were ordered/provided. Multivariate analysis was performed to identify independent predictors of diabetes preventive care services, controlling for patient and physician practice characteristics. All analyses were adjusted for the complex survey design and analytic weights.

RESULTS

Compared with people without diabetes, diabetic patients were older (63 vs. 53 years; P < 0.01) and were more likely to be nonwhite and covered by Medicare insurance. In multivariate analyses, younger patients and the availability of primary care physicians, electronic medical records, and on-site laboratory tests were associated with more effective preventive care services (P < 0.05). If physician compensation relied on productivity, preventive care services were less likely (odds ratio 0.4 [95% CI 0.27–0.82 for men and 0.26–0.81 for women]). Although the patterns of patient education and diagnostic testing were similar, the provision of patient education was less likely than that of diagnostic testing.

CONCLUSIONS

Primary care physicians and practice features seem to steer diabetes preventive services. Given the time constraints of physicians, strategies to strengthen structural capabilities of primary care practices and enhance partnerships with public health systems on diabetic patient education are recommended.Diabetes is a common chronic condition and costly disease that demands effective preventive care services (1). In 2007, an estimated 23.6 million people in the U.S. had diabetes (2). Patients with diabetes have an increased risk of morbidity and mortality from several conditions, such as cardiovascular, cerebrovascular, or kidney diseases and heart failure (3–5). Previous studies have shown that interventions or intensive management of glucose and hypertension are likely to reduce the morbidity and mortality of diabetes-related complications (6,7). In addition, economic analysis indicates that mean total costs associated with microvascular complications have almost doubled compared with those for patients without these complications (1). Thus, both intervention and economic studies suggest the critical importance of providing effective interventions and preventive care services for patients with diabetes. However, underuse of recommended preventive services is reported for people with diabetes (5). Furthermore, it is unclear whether patient or physician practice characteristics predict the use of diabetes preventive services. Given the racial/ethnic differences in mean glucose, diabetes prevalence, and diabetes-related cardiovascular disease (8,9), it is important to identify whether there are disparities in the provision of preventive care services for patients with diabetes.To our knowledge, no previous study has examined the utilization patterns of preventive care services for patients with diabetes in a national sample of adult ambulatory care visits. Therefore, the newly released data from the 2007 National Ambulatory Medical Care Survey (NAMCS) were selected to investigate the use of diabetes preventive services during routine care for preventing the long-term complications of diabetes. The objective of this analysis was to identify whether patient or physician practice characteristics predict the likelihood of diabetes preventive care services.     

Physical activity in U.S. adults with diabetes and at risk for developing diabetes, 2003

OBJECTIVE: Given the risk of obesity and diabetes in the U.S., and clear benefit of exercise in disease prevention and management, this study aimed to determine the prevalence of physical activity among adults with and at risk for diabetes. RESEARCH DESIGN AND METHODS: The Medical Expenditure Panel Survey is a nationally representative survey of the U.S. population. In the 2003 survey, 23,283 adults responded when asked about whether they were physically active (moderate or vigorous activity, > or =30 min, three times per week). Information on sociodemographic characteristics and health conditions were self-reported. Additional type 2 diabetes risk factors examined were age > or =45 years, non-Caucasian ethnicity, BMI > or =25 kg/m(2), hypertension, and cardiovascular disease. RESULTS: A total of 39% of adults with diabetes were physically active versus 58% of adults without diabetes. The proportion of active adults without diabetes declined as the number of risk factors increased until dropping to similar rates as people with diabetes. After adjustment for sociodemographic and clinical factors, the strongest correlates of being physically active were income level, limitations in physical function, depression, and severe obesity (BMI > or =40 kg/m(2)). Several traditional predictors of activity (sex, education level, and having received past advice from a health professional to exercise more) were not evident among respondents with diabetes. CONCLUSIONS: The majority of patients with diabetes or at highest risk for developing type 2 diabetes do not engage in regular physical activity, with a rate significantly below national norms. There is a great need for efforts to target interventions to increase physical activity in these individuals.     

Influence of familial risk on diabetes risk-reducing behaviors among U.S. adults without diabetes

OBJECTIVE

To test the association of family history of diabetes with the adoption of diabetes risk–reducing behaviors and whether this association is strengthened by physician advice or commonly known factors associated with diabetes risk.

RESEARCH DESIGN AND METHODS

We used cross-sectional data from the 2005–2008 National Health and Nutrition Examination Survey (NHANES) to examine the effects of family history of diabetes on the adoption of selected risk-reducing behaviors in 8,598 adults (aged ≥20 years) without diabetes. We used multiple logistic regression to model three risk reduction behaviors (controlling or losing weight, increasing physical activity, and reducing the amount of dietary fat or calories) with family history of diabetes.

RESULTS

Overall, 36.2% of U.S. adults without diabetes had a family history of diabetes. Among them, ~39.8% reported receiving advice from a physician during the past year regarding any of the three selected behaviors compared with 29.2% of participants with no family history (P < 0.01). In univariate analysis, adults with a family history of diabetes were more likely to perform these risk-reducing behaviors compared with adults without a family history. Physician advice was strongly associated with each of the behavioral changes (P < 0.01), and this did not differ by family history of diabetes.

CONCLUSIONS

Familial risk for diabetes and physician advice both independently influence the adoption of diabetes risk–reducing behaviors. However, fewer than half of participants with familial risk reported receiving physician advice for adopting these behaviors.The Centers for Disease Control and Prevention (CDC) recently reported that 25.8 million people in the U.S. (8.3% of the population) have diabetes (1). A total of 1.9 million new cases of diabetes were diagnosed in people aged ≥20 years in 2010 in the U.S., and 25.6 million (11.3%) people in this age-group have diabetes. Worldwide, it is estimated that 280 million people had diabetes in 2010—a number that is projected to increase to 430 million by 2030 (2). Studies have reported strong and consistent evidence that lifestyle factors might prevent or delay type 2 diabetes among people at high risk, including those with a family history of the disease (3,4). In 2002, the World Health Report (5) identified risk-reducing behaviors (such as controlling or losing weight, increasing physical activity, and reducing fat or calories) as important lifestyle risk factors for a number of chronic diseases, including diabetes, cardiovascular disease, and cancer.Many variables, including genetic, environmental, medical, and socioeconomic factors, influence the development of diabetes (6). The association of family history of diabetes with risk for the disease has been well documented (7). Although a 2009 National Institutes of Health State of the Science conference concluded that there was insufficient evidence to support the routine use of family history as a screening tool for risk of common complex conditions in primary care (8), an individual patient’s family history remains a critical element in risk assessment for many chronic conditions, including diabetes (9). While accurate and complete family history information needs to be collected to identify high-risk individuals, substantial barriers exist to obtaining this information in primary care practice, though clinicians are trained to do so. These barriers include lack of time to collect the information, lack of proper training to interpret the information, and lack of reimbursement (10).Evidence also supports the effectiveness of physician advice on lifestyle modifications to prevent or delay the risk of chronic diseases (11). A recent study on diabetes risk reduction behaviors found that the proportion of adults with prediabetes who reported performing risk reduction behaviors was higher among those who received physician advice compared with those who did not receive such advice (12).In light of the evidence summarized above, we used data from the 2005–2008 National Health and Nutrition Examination Survey (NHANES), a large population-based and nationally representative survey of the U.S., to test the hypotheses that a family history of diabetes is associated with greater adoption of diabetes risk–reducing behaviors and that the association is strengthened by the receipt of physician advice regarding these behaviors, in addition to other commonly known factors associated with diabetes risk.     

Hypercholesterolemia in diabetes and glucose intolerance in the U.S. population

The prevalence of hypercholesterolemia, according to the guidelines of the National Cholesterol Education Program, has been determined in a national survey of diabetes and glucose intolerance. Rates of elevated total cholesterol in people with diabetes in the United States are only slightly greater than in those without diabetes after adjusting for age and sex. Nevertheless, high or borderline high total cholesterol is common in diabetes and is present in 70% of adults with diagnosed diabetes and 77% with undiagnosed diabetes in the U.S. population. Of these individuals, 95% have evidence of coronary heart disease or two or more risk factors for heart disease and should therefore have their low-density lipoprotein (LDL) cholesterol measured. Based on our national data, LDL cholesterol levels warranting dietary treatment for hypercholesterolemia would be expected in 85% of these people. Although elevated LDL cholesterol is uncommon in people with diabetes who have total cholesterol of less than 200 mg/dl, other risk factors for coronary heart disease are very frequent (100% of men, 73% of women), and low total and LDL cholesterol may mask low high-density lipoprotein cholesterol. Therefore, investigation of blood lipid levels and coronary heart disease risk factors should be routine in all patients with diabetes, and treatment strategies should include management of lipid disorders and the multiple other risk factors for coronary heart disease that are highly prevalent in these patients.     

Presence of diabetes risk factors in a large U.S. eighth-grade cohort

OBJECTIVE: The study was conducted in 12 middle schools to determine the prevalence of diabetes, pre-diabetes, and diabetes risk factors in eighth-grade students who were predominantly minority and evaluate the feasibility of collecting physical and laboratory data in schools. RESEARCH DESIGN AND METHODS: Anthropometric measurements and fasting and 2-h post-glucose load blood draws were obtained from approximately 1,740 eighth-grade students. RESULTS: Mean recruitment rate was 50% per school, 49% had BMI > or = 85th percentile, 40.5% had fasting glucose > or = 100 mg/dl, 0.4% had fasting glucose > or = 126 mg/dl, and 2.0% had 2-h glucose > or = 140 mg/dl and 0.1% > or = 200 mg/dl. Mean fasting insulin value was 30.1 microU/ml, 36.2% had fasting insulin > or = 30 microU/ml, and 2-h mean insulin was 102.1 microU/ml. Fasting and 2-h glucose and insulin values increased across BMI percentiles, and fasting glucose was highest in Hispanic and Native American students. CONCLUSIONS: There was a high prevalence of risk factors for diabetes, including impaired fasting glucose (> or =100 mg/dl), hyperinsulinism suggestive of insulin resistance (fasting insulin > or = 30 microU/ml), and BMI > or = 85th percentile. These data suggest that middle schools are appropriate targets for population-based efforts to decrease overweight and diabetes risk.     

Prevalence of diabetes in New York City, 2002-2008: comparing foreign-born South Asians and other Asians with U.S.-born whites, blacks, and Hispanics

OBJECTIVE

To describe diabetes prevalence in New York City by race/ethnicity and nativity.

RESEARCH DESIGN AND METHODS

Data were from the New York City 2002–2008 Community Health Surveys. Respondents were categorized on the basis of self-reported race/ethnicity and birth country: foreign-born South Asian (Indian subcontinent), foreign-born other Asian, U.S.-born non-Hispanic black, U.S.-born non-Hispanic white, and U.S.-born Hispanic. Diabetes status was defined by self-reported provider diagnosis. Multivariable models examined diabetes prevalence by race/ethnicity and birth country.

RESULTS

Prevalence among foreign-born South Asians was nearly twice that of foreign-born other Asians (13.6 vs. 7.4%, P = 0.001). In multivariable analyses, normal-BMI foreign-born South Asians had nearly five times the diabetes prevalence of comparable U.S.-born non-Hispanic whites (14.1 vs. 2.9%, P < 0.001) and 2.5 times higher prevalence than foreign-born other Asians (P < 0.001).

CONCLUSIONS

Evaluating Asians as one group masks the higher diabetes burden among South Asians. Researchers and clinicians should be aware of differences in this population.More than 220 million people worldwide have diabetes, and an estimated 6 million are diagnosed annually (1,2). International studies have shown that South Asians (Indian subcontinent) appear to be at greater risk for diabetes than other ethnic groups (3). The few U.S. studies conducted report similar findings, but most were either not population-based, not current, or limited by a small sample size (4–6). Our study uniquely uses a recent population-based sample large enough to allow for subgroup prevalence estimation. Community studies, especially those in urban areas with large immigrant populations such as New York City, can provide insight into racial and ethnic disease patterns.     

Dental and other health care visits among U.S. adults with diabetes

OBJECTIVE: This study compared yearly dental visits of diabetic adults with those of nondiabetic adults. For adults with diabetes, we compared the frequency of past-year dental visits with past-year visits for diabetes care, dilated eye examinations, and foot examinations. RESEARCH DESIGN AND METHODS: We conducted a cross-sectional study using a sample of 105,718 dentate individuals aged > or =25 years, including 4,605 individuals with diabetes who participated in the 1995-1998 Behavioral Risk Factor Surveillance System in 38 states. RESULTS: Dentate adults (i.e., those with at least some natural teeth) with diabetes were less likely than those without diabetes to have seen a dentist within the preceding 12 months (65.8 vs. 73.1%, P = 0.0000). Adults with diabetes were less likely to have seen a dentist than to have seen a health care provider for diabetes care (86.3%); the percentage who saw a dentist was comparable with the percentage who had their feet examined (67.7%) or had a dilated eye examination (62.3%). The disparity in dental visits among racial or ethnic groups and among socioeconomic groups was greater than that for any other type of health care visit for subjects with diabetes. CONCLUSIONS: Promotion of oral health among diabetic patients may be necessary, particularly in Hispanic and African-American communities. Information on oral health complications should be included in clinical training programs. Oral and diabetes control programs in state health departments should collaborate to promote preventive dental services, and the oral examination should be listed as a component of continuous care in the American Diabetes Association's standards of medical care for diabetic patients.     

Clinical work with suicide loss survivors: Implications of the U.S. postvention guidelines

The loss of a loved one to suicide can present difficult challenges for suicide loss survivors (people bereaved by suicide) as well as for clinicians who would seek to help them. Building on the recommendations in the new document Responding to Grief, Trauma, and Distress after a Suicide: U.S. National Guidelines, this article provides an overview of clinical work with suicide loss survivors. It includes discussions of the common themes of suicide bereavement, the psychological tasks for integration of a suicide loss, and the options for providing grief therapy after a suicide. The article will be of value to caregivers who work with suicide loss survivors in counseling or therapeutic context.