Irene G. M. van Valkengoed

Prevalence of diabetes mellitus and the performance of a risk score among Hindustani Surinamese, African Surinamese and ethnic Dutch: a cross-sectional population-based study

BackgroundWhile the prevalence of type 2 diabetes mellitus (DM) is high, tailored risk scores for screening among South Asian and African origin populations are lacking. The aim of this study was, first, to compare the prevalence of (known and newly detected) DM among Hindustani Surinamese, African Surinamese and ethnic Dutch (Dutch). Second, to develop a new risk score for DM. Third, to evaluate the performance of the risk score and to compare it to criteria derived from current guidelines.MethodsWe conducted a cross-sectional population based study among 336 Hindustani Surinamese, 593 African Surinamese and 486 Dutch, aged 35–60 years, in Amsterdam. Logistic regressing analyses were used to derive a risk score based on non-invasively determined characteristics. The diagnostic accuracy was assessed by the area under the Receiver-Operator Characteristic curve (AUC).ResultsHindustani Surinamese had the highest prevalence of DM, followed by African Surinamese and Dutch: 16.7, 8.1, 4.2% (age 35–44) and 35.0, 19.0, 8.2% (age 45–60), respectively. The risk score included ethnicity, body mass index, waist circumference, resting heart rate, first-degree relative with DM, hypertension and history of cardiovascular disease. Selection based on age alone showed the lowest AUC: between 0.57–0.62. The AUC of our score (0.74–0.80) was higher than that of criteria from guidelines based solely on age and BMI and as high as criteria that required invasive specimen collection.ConclusionIn Hindustani Surinamese and African Surinamese populations, screening for DM should not be limited to those over 45 years, as is advocated in several guidelines. If selective screening is indicated, our ethnicity based risk score performs well as a screening test for DM among these groups, particularly compared to the criteria based on age and/or body mass index derived from current guidelines.

Effectiveness of Cultural Adaptations of Interventions Aimed at Smoking Cessation, Diet, and/or Physical Activity in Ethnic Minorities. A Systematic Review

Background The importance of cultural adaptations in behavioral interventions targeting ethnic minorities in high-income societies is widely recognized. Little is known, however, about the effectiveness of specific cultural adaptations in such interventions. Aim To systematically review the effectiveness of specific cultural adaptations in interventions that target smoking cessation, diet, and/or physical activity and to explore features of such adaptations that may account for their effectiveness. Methods Systematic review using MEDLINE, PsycINFO, Embase, and the Cochrane Central Register of Controlled Trials registers (1997–2009). Inclusion criteria: a) effectiveness study of a lifestyle intervention targeted to ethnic minority populations living in a high income society; b) interventions included cultural adaptations and a control group that was exposed to the intervention without the cultural adaptation under study; c) primary outcome measures included smoking cessation, diet, or physical activity. Results Out of 44904 hits, we identified 17 studies, all conducted in the United States. In five studies, specific cultural adaptations had a statistically significant effect on primary outcomes. The remaining studies showed no significant effects on primary outcomes, but some presented trends favorable for cultural adaptations. We observed that interventions incorporating a package of cultural adaptations, cultural adaptations that implied higher intensity and those incorporating family values were more likely to report statistically significant effects. Adaptations in smoking cessation interventions seem to be more effective than adaptations in interventions aimed at diet and physical activity. Conclusion This review indicates that culturally targeted behavioral interventions may be more effective if cultural adaptations are implemented as a package of adaptations, the adaptation includes family level, and where the adaptation results in a higher intensity of the intervention. More systematic experiments are needed in which the aim is to gain insight in the best mix of cultural adaptations among diverse populations in various settings, particularly outside the US.

Risk for breast cancer among women with endometriosis

Although several risk factors are common to endometriosis and breast cancer, the results of observational studies of an association have so far been inconsistent. We evaluated the relationship between endometriosis and breast cancer on the basis of data on selected cancers and medical histories from the Danish nationwide cancer and hospital registries used in a large case–cohort study. A total of 114,327 women were included in the study of whom 1,978 women had received a diagnosis of endometriosis and 16,983 had had a diagnosis of breast cancer between 1978 and 1998. Of the women with endometriosis, 236 subsequently received a diagnosis of breast cancer. The crude overall rate ratio for breast cancer after endometriosis was 1.00 and after adjustment for reproductive factors, calendar‐period, bilateral oophorectomy and benign breast disease, the rate ratio was 0.97 (95% confidence interval, 0.85–1.11). The risk for breast cancer increased with age at diagnosis of endometriosis, so that women in whom endometriosis was diagnosed at a young age (approximately <40 years) had a reduced risk for breast cancer and women in whom endometriosis was diagnosed at older ages (approximately ≥40 years) tended to have an increased risk for breast cancer. The reduced risks observed among young women may reflect their exposure to drugs with antiestrogenic effects. The increased risk associated with endometriosis among postmenopausal women may be due to common risk factors between postmenopausal endometriosis and breast cancer or an altered endogenous estrogen.

Educational inequalities in metabolic syndrome vary by ethnic group: evidence from the SUNSET study.

BACKGROUND Compared with Whites, many ethnic minority groups have higher prevalence of metabolic syndrome. The reasons for these ethnic inequalities in health are incompletely understood. The main objective was to examine whether socio-economic position (SEP) as measured by education was related to the prevalence of metabolic syndrome in different ethnic groups in Amsterdam, The Netherlands. METHODS A random sample of healthy adults aged 35-60 years. SEP was measured by educational level (secondary school and below (low), and vocational school and above (high)). Metabolic syndrome was measured according to the International Diabetic Federation guidelines. RESULTS Low education was negatively related to metabolic syndrome but only in White-Dutch people. Among White-Dutch men, the age adjusted prevalence ratio (95% confidence intervals) for low education was 1.46 (95% CI: 1.01-2.10) versus high education. Among White-Dutch women, the adjusted odds ratios for low education was 2.26 (95% CI: 1.39-3.68) versus high education. In both White-Dutch men and women, low education was related to several components of metabolic syndrome. Among African-Surinamese and Hindustani-Surinamese, no significant associations were found between low education and metabolic syndrome and its components. CONCLUSION Low education is associated with increased risk of metabolic syndrome among White-Dutch people but not among other ethnic groups. Community-based strategies to improve metabolic profiles may have to be ethnically devised. Among White-Dutch, targeting people with lower SEP may have an impact. However, among ethnic minority groups, both low and high socio-economic groups may have to be equally targeted to have an impact in reducing ethnic inequalities in health.

Association between CNDP1 genotype and diabetic nephropathy is sex-specific

OBJECTIVE The 5-5 homozygous CNDP1 (carnosinase) genotype is associated with a reduced risk of diabetic nephropathy. We investigated whether this association is sex specific and independent of susceptibility for type 2 diabetes. RESEARCH DESIGN AND METHODS Three separate groups of 114, 90, and 66 patients with type 2 diabetes and diabetic nephropathy were included in this study and compared with 93 patients with type 2 diabetes for >15 years without diabetic nephropathy and 472 population control subjects. The diabetes control group was used to determine an association in the three patient groups separately, and the population control group was used to estimate the genotype risk [odds ratio (CI)] for the population in a pooled analysis. The population control subjects were also compared with 562 patients with type 2 diabetes without diabetic nephropathy to determine whether the association was independent of type 2 diabetes. The CNDP1 genotype was determined by fragment analysis after PCR amplification. RESULTS The frequency of the 5-5 homozygous genotype was 28, 36, and 41% in the three diabetic nephropathy patient groups and 43 and 42% in the diabetic and population control subjects, respectively. The 5-5 homozygous genotype occurred significantly less frequently in women in all three patient groups compared with diabetic control subjects. The genotype risk for the population was estimated to be 0.5 (0.30–0.68) in women and 1.2 (0.77–1.69) in men. The 562 patients with type 2 diabetes without diabetic nephropathy did not differ from the general population (P = 0.23). CONCLUSIONS This study suggests that the association between the CNDP1 gene and diabetic nephropathy is sex specific and independent of susceptibility for type 2 diabetes.

Newly Proposed Body Adiposity Index (BAI) by Bergman et al. Is Not Strongly Related to Cardiovascular Health Risk

circumference/(height1.5–18)) and to assess its association with CV risk factors and cytokines. The CoLaus Study is a cross-sectional study aimed at assessing the prevalence of CV risk factors as the molecular determinants of CV disease in the white population of Lausanne, Switzerland, a town of 117,161 inhabitants, of which 79,420 are of Swiss nationality. The sampling procedure and methodology have been previously described (3). We collected data on adiposity markers (BMI, waist circumference, and body fat as assessed by tetrapolar bioimpedance), CV risk factors (systolic and diastolic blood pressure, total low-density lipoprotein and high-density lipoprotein-cholesterol, triglycerides and glucose), insulin (which enabled the assessment of homeostatic model assessment) and different cytokines (leptin, adiponectin, C-reactive protein, and tumor necrosis factor-α). Levels of these cytokines were measured using a multiplexed particle-based flow cytometric cytokine assay (4). We used Spearman nonparametric correlations to assess the relationship between the BAI and all health variables of interest, stratified by gender (Table 1). A stepwise linear regression was run to assess which adiposity markers (BAI, BMI, waist circumference, and body fat) were most associated to CV risk factors (triglycerides were log-transformed) and log-transformed cytokines, again stratifying by gender and controlling for age. The BAI correlated significantly (P < 0.05) and positively with age, other adiposity markers, most CV risk factors, and cytokines, while negative correlations were found for high-density lipoprotein cholesterol and adiponectin. The correlations between BAI and health variables were similar to those between BMI and the health variables (Table 1). Stepwise multivariate linear regression analysis showed that the BAI significantly (P < 0.05) predicted diastolic blood pressure, fasting glucose levels, high-density lipoprotein cholesterol, leptin, and adiponectin in women independently of the other adiposity markers, while no association was found for all other variables. In men, the adiposity index independently and significantly (P < 0.05) predicted adiponectin, high-density lipoproteincholesterol and C-reactive protein only. The analysis also showed that, for each gender, the other adiposity markers were associated with more CV and cytokine variables than the new BAI. We conclude that while the new BAI is significantly related to bioelectrical impedance measured body fat, it appears to be of lesser interest than other more established adiposity markers regarding the association with CV risk factors or inflammatory markers. Further studies are welcomed to further assess the clinical utility of the BAI and its relationship to CV risk factors and other health parameters, particularly in diverse populations.

Intensive lifestyle intervention in general practice to prevent type 2 diabetes among 18 to 60-year-old South Asians: 1-year effects on the weight status and metabolic profile of participants in a randomized controlled trial.

Aim To study 1-year effectiveness of an intensive, culturally targeted lifestyle intervention in general practice for weight status and metabolic profile of South-Asians at risk of type 2 diabetes. Methods 536 South-Asians at risk of type 2 diabetes were randomized to an intervention (n = 283) or control (n = 253) group. The intervention, which was targeted culturally to the South-Asian population, consisted of individual lifestyle counselling, a family session, cooking classes, and supervised physical activity programme. All components of the intervention were carried out by professionals as part of their daily clinical practice. The control group received generic lifestyle advice. Change in weight status and metabolic profile were assessed after 1 year. Results After 1 year, 201 participants were lost to follow-up. Remaining participants in intervention (n = 177) and control (n = 158) group had similar baseline characteristics. Weight loss in the intervention group was 0.2±3.3 kg, weight gain in the control group was 0.4±3.1 kg (p = 0.08). Changes in other weight-related measurements did not differ significantly between groups. Furthermore, there were no differences between groups in changes of metabolic profile. All results remained similar after repeating analyses in a multiple imputed dataset. Discussion An intensive, culturally targeted, lifestyle intervention of 1 year did not improve weight status and metabolic profile of South-Asians at risk of type 2 diabetes. The laborious recruitment, high drop-out, and lack of effectiveness emphasise the difficulty of realising health benefits in practice and suggest that this strategy might not be the optimal approach for this population. Trial Registration Nederlands Trial Register NTR1499

Transient Lowering of the Viral Set Point After Temporary Antiretroviral Therapy of Primary HIV Type 1 Infection

Whether temporary antiretroviral treatment during primary HIV infection (PHI) lowers the viral set point or affects the subsequent CD4 count decline remains unclear. The objectives of this study were to analyze the clinical, viral, and immunological effects of temporary early HAART during PHI. This is a cohort study of patients with laboratory evidence of PHI. Independent predictors of early HAART and the viral set point were analyzed using multiple regression analysis. Plasma HIV-1 RNA (pVL) and CD4 trajectories were analyzed using linear mixed models. A total of 332 patients were included in the analysis. Sixty-four patients started HAART within 180 days of seroconversion. A higher baseline pVL was independently predictive of the start of early HAART (OR: 2.69/log10pVL, p = 0.001). Thirty-two patients who interrupted early HAART were compared with 250 patients who remained untreated for more than 180 days after seroconversion. Temporary early HAART was not significantly associated with a longer AIDS-free survival but did result in an initial, but transient lowering of the viral set point. The viral set point was initially 0.6 log copies/ml lower after interruption of early HAART (p < 0.001) and remained lower during 83 weeks of follow-up. No significant difference in the slopes of CD4 decline was detected between the groups. Temporary HAART in PHI is started more frequently in patients with a higher pVL and can transiently lower the viral set point compared to never treated patients.

Prevalence and determinants of prehypertension among African Surinamese, Hindustani Surinamese, and White Dutch in Amsterdam, the Netherlands: the SUNSET study.

Background Evidence suggests that prehypertension is associated with increased risk of cardiovascular mortality. Little is known about ethnic differences in prehypertension in Europe. We aimed to assess these ethnic differences and to determine the factors associated with prehypertension in Amsterdam, the Netherlands. Design Cross-sectional study. Methods Prehypertension was defined as having a blood pressure 120-139/80-89 mmHg. Results The overall prevalence of prehypertension was 32.8% (men 37.9% and women 29.9%). The prevalence of prehypertension did not differ between the ethnic groups in men. African Surinamese and Hindustani Surinamese women, however, had a higher prevalence of prehypertension than White Dutch women. In multivariate logistic regression analysis, the odds ratios [95% confidence interval] for being prehypertensive were 2.25 (1.38-3.67; P < 0.001) for African Surinamese and 2.06 (1.18-3.60; P < 0.01) for Hindustani Surinamese women, compared with White Dutch women. BMI was strongly associated with prehypertension in both men and women. Total cholesterol was positively associated with prehypertension in women, whereas increased physical activity was negatively associated. The independent factors associated with prehypertension vary by ethnic group. In men, BMI was associated with prehypertension in the White Dutch, total cholesterol and low education in the African Surinamese, and fasting glucose in the Hindustani Surinamese. In women, total cholesterol was associated with prehypertension in the African Surinamese; the corresponding factor was the BMI in the Hindustani Surinamese. Conclusion Prehypertension is common in minority women. As a large proportion of people with prehypertension progress to clinical hypertension, targeting these people early with lifestyle-modification interventions aimed at weight loss, increased physical activity, and healthy dietary habits can provide important long-term benefits. The results indicate that the primary foci of such lifestyle interventions should vary between ethnic groups. Eur J Cardiovasc Prev Rehabil 14: 775-781

Feasibility and effectiveness of a targeted diabetes prevention program for 18 to 60-year-old South Asian migrants: design and methods of the DH!AAN study

BackgroundSouth Asian migrants are at particularly high risk of type 2 diabetes. Previous studies have shown that intensive lifestyle interventions may prevent the onset of diabetes. Such interventions have not been culturally adapted and evaluated among South Asians in industrialized countries. Therefore, we have set up a randomized controlled trial to study the effectiveness of a targeted lifestyle intervention for the risk of type 2 diabetes and cardiovascular risk factors among 18 to 60-year-old Hindustani Surinamese (South Asians) in The Hague, the Netherlands. Here we present the study design and describe the characteristics of those recruited.MethodsBetween May 18, 2009 and October 11, 2010, we screened 2307 Hindustani Surinamese (18–60 years old) living in The Hague. We sent invitations to participate to those who had an impaired fasting glucose of 5.6-6.9 mmol/l, an impaired glucose tolerance of 7.8-11.0 mmol/L, a glycated hemoglobin level of 6.0% or more and/or a value of 2.39 or more for the homeostasis model assessment of estimated insulin resistance. In total, 536 people (56.1% of those eligible) participated. People with a higher level of education and a family history of type 2 diabetes were more likely to participate. The control and intervention groups were similar with regard to important background characteristics. The intervention group will receive a culturally targeted intervention consisting of dietary counseling using motivational interviewing and a supervised physical activity program. The control group will receive generic lifestyle advice. To determine the effectiveness, a physical examination (anthropometrics, cardiorespiratory test, lipid profile, and measures of oral glucose tolerance, glycated hemoglobin, and insulin) and interview (physical activity, diet, quality of life, and intermediate outcomes) were carried out at baseline and will be repeated at 1 year and 2 years. The process and the costs will be evaluated.DiscussionThis trial will provide insight into the feasibility and effectiveness of a targeted, intensive, lifestyle intervention for the risk of type 2 diabetes and cardiovascular risk factors among 18 to 60-year-old South Asians.Trial registrationDutch Trial Register: NTR1499