Florence J. Dallo

Education and Diabetes in a Racially and Ethnically Diverse Population

OBJECTIVES We used data from the National Health Interview Survey (1997-2002) to examine the association between education and the prevalence of diabetes in US adults and whether this relation differs by race/ethnicity. METHODS The analyses were limited to non-Hispanic Blacks, non-Hispanic Whites, and Hispanics. SUDAAN was used to account for the complex sampling design. RESULTS Educational attainment was inversely associated with the prevalence of diabetes. Individuals with less than a high-school diploma were 1.6 (95% confidence interval [CI]=1.4, 1.8) times more likely to have diabetes than those with at least a bachelors degree. Whites and Hispanics exhibited a significant relation between diabetes and having less than a high-school education (odds ratio [OR]=1.7; 95% CI=1.5, 2.0; and OR=1.6; 95% CI=1.1, 2.3, respectively). In addition, the odds of having diabetes was stronger for women (OR=1.9; 95% CI=1.6, 2.4) than for men (OR=1.4; 95% CI=1.1, 1.6) CONCLUSIONS Educational attainment was inversely associated with diabetes prevalence among Whites, Hispanics, and women but not among Blacks. Education may have a different effect on diabetes health among different racial/ethnic groups.

Effectiveness of diabetes mellitus screening recommendations

Screening guidelines proposed by the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus have been endorsed by several medical societies. However, one-third of cases are undiagnosed, and complications at the time of diagnosis indicate that disease may have been present for several years before diagnosis. This study evaluates the effectiveness of the guidelines for detecting new cases of diabetes mellitus. By using a cross-sectional, representative sample of the United States (National Health and Nutritional Examination Survey, NHANES III), the guidelines are tested on adults, 20 years and older without a prior diagnosis of diabetes. Individuals are classified as nondiabetics (n = 6,241) or as having undiagnosed diabetes (n = 274) based on their blood glucose. Screening when one risk factor is present, as stated in the guidelines, has a true-positive rate of 100% and would require that 83% of the population be tested. Screening when two risk factors are present is more efficient, with a comparable true-positive rate (98%), but requires that only 59% of the population be tested. A notable finding is the earlier age of onset among minorities, which may be associated with other health disparities. Because diabetes occurs at younger ages in minorities, screening whites who are ≥40 and minorities ≥30 years of age has a high true-positive rate (95%) and also reduces testing (60%). The screening guidelines would be effective, if followed, and would essentially eliminate undiagnosed cases of diabetes.

Racial/Ethnic Disparities in All-Cause Mortality in U.S. Adults: The Effect of Allostatic Load

Objective. We investigated the association between a cumulative biological risk or allostatic score and all-cause mortality risk. We used 13,715 records of participants aged 25 years and older from the Third National Health and Nutrition Examination Survey (NHANES III) linked to the National Death Index. Methods. We specified all-cause mortality using the underlying cause of death in the death certificate. We calculated time to death from interview date through December 31, 2000, as person-years of follow-up using the NHANES III interview month and year. We used Cox proportional hazards regression to estimate hazard ratios (HRs) relating all-cause mortality risk for those with an allostatic score of 2 and ≥3 relative to those with an allostatic score of ≤1. Results. After controlling for age, gender, race/ethnicity, education, and income, mortality rates were 40% (HR=51.40, 95% confidence interval [CI] 1.11, 1.76) and 88% (HR=51.88, 95% CI 1.56, 2.26) higher for participants with an allostatic score of 2 and ≥3, respectively, compared with those with a score of ≤1. The death rate associated with allostatic score for each racial/ethnic group differed with age. Conclusions. The allostatic score increased the risk of all-cause mortality. Moreover, this increased risk was observed for adults younger than 65 years of age regardless of their race/ethnicity Thus, allostatic score may be a contributor to premature death in the U.S.

Self-reported diabetes in Hispanic subgroup, non-Hispanic black, and non-Hispanic white populations: National Health Interview Survey, 1997-2005.

Objectives. We estimated the prevalence of self-reported diabetes in Hispanic subgroup (Puerto Rican, Mexican, Mexican American, Cuban, Dominican, Central and South American, and other Hispanic), non-Hispanic black, and non-Hispanic white populations aged 20 years and older. Methods. Using the National Health Interview Survey 1997–2005, we limited these analyses to 272,041 records of adults aged 20 years and older, including 46,749 records for Hispanic respondents. We used logistic regression to assess the strength of the association between race/ethnicity and self-reported diabetes before and after adjusting for selected characteristics. Results. Compared with non-Hispanic white respondents, Mexican American (odds ratio [OR] = 2.02; 95% confidence interval [CI] 1.75, 2.34), Mexican (OR=1.52; 95% CI 1.31, 1.91), Puerto Rican (OR=1.53; 95% CI 1.23, 1.91), other Hispanic (OR=2.08; 95% CI 1.68, 2.58), and non-Hispanic black (OR=1.47; 95% CI 1.35, 1.61) respondents had greater odds of reporting diabetes. When compared with non-Hispanic white respondents, Mexican American respondents with less than a high school diploma had the lowest odds of reporting diabetes, while those with at least a college degree had greater odds of reporting diabetes. However, Puerto Rican respondents with less than a high school education, Mexican respondents with at least some college education, and other Hispanic respondents with at least a high school diploma/general equivalency diploma had greater odds of reporting diabetes. Conclusions. Although Hispanic respondents bear a greater burden of diabetes than non-Hispanic white respondents, this burden is unevenly distributed across subgroups. These findings call attention to data disaggregation whenever possible for U.S. racial/ethnic populations classified under categories considered homogeneous.

Acculturation and Blood Pressure in a Community-Based Sample of Chaldean-American Women

With the steady increase of non-European, non-English speaking immigrants to the United States, the relationship between acculturation and risk for cardiovascular disease (CVD) is an issue of growing importance to researchers interested in the health of new immigrant populations. The influence of acculturation processes on adverse changes in blood pressure (BP), a major risk factor for CVD, has been examined in Hispanic-Americans and Asian-Americans. Published studies on this relationship in Arab-Americans are lacking, however, despite their growing numbers. With a specific focus on Chaldean-Americans, a major subgroup of the large Arab-American population located in metropolitan Detroit, Michigan, the current study investigates the influence of level of acculturation on BP in a community probability sample of 130 Chaldean-American women. Study participants were interviewed in their homes (92% response rate). Physical measurements included BP, body mass index (BMI), and waist–hip ratio. Demographic and acculturation data were obtained through a standardized questionnaire. The crude hypertension prevalence in the sample was 16%. Three dimensions of acculturation were identified through content and factor analysis: English language preference, parental school involvement, and ethnic identity. In unadjusted analyses, both English language preference and Chaldean-American ethnic identity were associated (p < 0.01) with lower mean BP, but these differences became nonsignificant when age, BMI, and waist–hip ratio were statistically controlled. Parental school involvement was not associated with BP in any analyses. In this study, the strongest predictors of BP were BMI and waist–hip ratio, both of which were inversely correlated with age, education, English language preference, employment outside the home, and parental school involvement. Future studies of acculturation and BP in Chaldean-Americans (and other Arab-American populations) should use improved measures of acculturation, broader assessments of behavioral and socioeconomic status, and larger samples that includes both genders.

Mortality Rates Among Arab Americans in Michigan

The objectives of this study were to: (1) calculate age-specific and age-adjusted cause-specific mortality rates for Arab Americans; and (2) compare these rates with those for blacks and whites. Mortality rates were estimated using Michigan death certificate data, an Arab surname and first name list, and 2000 U.S. Census data. Age-specific rates, age-adjusted all-cause and cause-specific rates were calculated. Arab Americans (75+) had higher mortality rates than whites and blacks. Among men, all-cause and cause-specific mortality rates for Arab Americans were in the range of whites and blacks. However, Arab American men had lower mortality rates from cancer and chronic lower respiratory disease compared to both whites and blacks. Among women, Arab Americans had lower mortality rates from heart disease, cancer, stroke, and diabetes than whites and blacks. Arab Americans are growing in number. Future study should focus on designing rigorous separate analyses for this population.

Quality of diabetes care for immigrants in the U.S.

OBJECTIVE To compare achievement of the American Diabetes Association diabetes care recommendations for U.S.- and foreign-born individuals with diabetes. RESEARCH DESIGN AND METHODS Using the 2001–2006 Medical Expenditure Panel Surveys, we report estimates for receipt of a cholesterol test, routine checkup, influenza vaccination, eye examination, dental checkup, foot examination, and two or more A1C tests in 1 year for foreign- (n = 1,272) and U.S.-born (n = 5,811) individuals aged ≥18 years. We define a dichotomous variable representing full compliance with the above examinations. We provide descriptive characteristics of the sample and use multivariable analysis for each procedure with random effects logit regression. RESULTS Compared with U.S.-born individuals with diabetes, foreign-born individuals are younger, have lower education levels and income, are more likely to have public or no insurance, and are less likely to have a usual source of care. With adjustment for all potential confounders, foreign-born individuals are less likely to report having had an influenza vaccination (odds ratio 0.51 [95% CI 0.31–0.71]) or to be compliant with any one of the seven recommendations (0.64 [0.34–0.95]). CONCLUSIONS These findings demonstrate that immigrants are less likely than U.S.-born individuals with diabetes to adhere to any one of seven diabetes care recommendations in general and, specifically, are less likely to report having received an influenza vaccination. Because immigrants are less likely to use health care, clinicians should take advantage of the office visit to effectively communicate to the patient the importance of receiving an influenza vaccination.

Nativity Status and Patient Perceptions of the Patient-Physician Encounter : Results From the Commonwealth Fund 2001 Survey on Disparities in Quality of Health Care

Background:Although racial and ethnic differences in healthcare have been extensively documented in the United States, little attention has been paid to the quality of health care for the foreign-born population in the United States. Objectives:This study examines the association between patient perceptions of the patient-physician interaction and nativity status. Research Design:Cross-sectional telephone survey. Subjects:A total of 6674 individuals (US-born = 5156; foreign-born = 1518) 18 years of age and older. Measures:Seven questions measuring the quality of patient-physician interactions. Results:Of the 7 outcome variables examined in the unadjusted logistic regression model, only 2 remained statistically significant in the fully adjusted model. For both the total sample and for Asians only, compared with US-born, foreign-born individuals were at greater odds [total sample, odds ratio (OR) = 1.43; 95% confidence interval (CI) = 1.01–2.04; Asians, OR = 3.25; 95% CI = 1.18–8.95] of reporting that their physician did not involve them in their care as much as they would have liked. Compared with US-born Asians, foreign-born Asians were at greater odds of reporting that their physician did not spend as much time with them as they would have liked (OR = 4.19; 95% CI = 1.68–10.46). Discussion:Findings from our study suggest that we should not only track disparities by race and ethnicity but also by nativity status.

Prevalence of Disability among US- and Foreign-Born Arab Americans: Results from the 2000 US Census

Background:Although the prevalence of disability for various racial and ethnic groups has been documented, little attention has been paid to Arab Americans in the United States. Objectives: We estimated the age- and sex-adjusted prevalence of disability among older Arab Americans and examined the association between nativity status and self-reported physical and self-care disability before and after controlling for covariates. Methods: We used data from the 5% Public Use Microdata Samples of the 2000 US Census. Our sample included 4,225 individuals 65 years of age and older who identified with an Arab ancestry. Of these, 2,280 were foreign-born and 1,945 were US-born. Results: The age- and sex-adjusted prevalence of having a physical disability was 31.2% for foreign- and 23.4% for US-born older Arab Americans, and the age- and sex- adjusted prevalence of having a self-care disability was 13.5% for foreign- and 6.8% for US-born Arab Americans. Iraqis reported the highest estimates for both disabilities (physical, 36.2%; self-care, 19.8%) compared to other Arab ethnic groups. In the crude model, foreign-born Arab Americans were more likely (OR = 1.32; 95% CI = 1.28, 1.36) to report a physical disability compared to US-born Arab Americans. When adjusting for English language ability in the final model, the odds of having a physical disability for foreign-born Arab Americans was protective compared to US-born Arab Americans (OR = 0.92; 95% CI = 0.88, 0.96). In the crude model, foreign-born Arab Americans were 1.82 times (95% CI = 1.74, 1.90) more likely to report a self-care disability compared to US-born Arab Americans. In the fully adjusted model, this association was slightly attenuated (OR = 1.32; 95% CI = 1.24, 1.41). Conclusions: These findings indicate English language ability is associated with variations in reporting a physical disability. Future studies should include better measures of acculturation. Arab Americans are heterogeneous and should be disaggregated both by subgroups and from the white category in order to reveal a more accurate health and disease status profile for these groups. These efforts will assist in tailoring more effective interventions in reducing or preventing disability among Arab Americans 65 years of age and older.

The Ancestry Question and Ethnic Heterogeneity : The Case of Arab Americans

This article uses US Census data to investigate change over time in Arab American profiles. In 2000, a higher proportion of children (0 to 13 years of age), women, and those who lived in the Northeast identified with an Arab/non-Arab ancestry compared to an Arab-only ancestry. In 1980 and 2000, a higher proportion (~90%) of those who identified with an Arab/non-Arab ancestry was US born compared to only one-half of those who identified with an Arab-only ancestry. Those who identified with an Arab-only ancestry were more likely to not be US citizens than those who identified with an Arab/non-Arab ancestry. These findings suggest Arab Americans are a heterogeneous group.