Jacqueline A. Pugh

Non-insulin-dependent diabetes mellitus in minorities in the United States.

For some time, diabetes specialists have recognized that noninsulin-dependent diabetes mellitus is more prevalent in minority populations [1-12]. Recent information also shows increased complications and mortality from diabetes. We review the available literature on prevalence, incidence, complications, mortality, and interventions in black persons, Hispanic persons, Native Americans, and Asians and Pacific Islanders in the United States. Methods In June 1994, we searched the MEDLINE data-base through the PlusNet search system from 1976 to the date of the search. Using the key words noninsulin-dependent diabetes, African Americans, blacks, Hispanic, Mexican Americans, Native Americans, Asians, Pacific Islanders, minorities, socioeconomic status, acculturation, genetics, diet, complications, mortality, treatment, and intervention (lifestyle or medication), we found 268 unduplicated articles. In February 1996, we repeated the search and added the key words Asian and Pacific Islander; 22 more articles were identified. Ethnic-specific data were also included from Diabetes in America [13]. Several searches were done using noninsulin-dependent diabetes mellitus, a key word for one of the minority groups, and one each of the other key wordsfor example, noninsulin-dependent diabetes mellitus and African Americans and socioeconomic status. Articles cited in the original articles or encountered during the writing of this manuscript were also included. Only articles that discussed incidence, prevalence, complications, mortality, risk factors, or interventions were included. Papers on the basic physiology of obesity or diabetes or articles that did not include minority-specific data were not included. Data on diabetes-related complications and mortality, lifestyles, socioeconomic status, acculturation, and access to health care are scarce for some minority groupsparticularly Asians and Pacific Islanders, Arab-Americans, and other ethnic subgroups (such as Puerto Ricans, Cubans, and specific Native American tribes). Further, few prospective studies have assessed the incidence of noninsulin-dependent diabetes mellitus and associated risk factors. Finally, few studies have provided data on white persons for comparison. Prevalence and Incidence of Diabetes Most minority groups in the United States have higher rates of noninsulin-dependent diabetes mellitus than do white persons [2-47] (Table 1). The 1976-1980 National Health and Nutrition Examination Survey (NHANES II) [12] found the total prevalence of diabetes in black persons (diagnosed and undiagnosed) to be 1.5 times greater than that of white persons. Other estimated prevalences for black persons range from 1.4 to 2.2 times greater than the prevalences for white persons [13, 14]. The 1976 National Health Interview Survey [15] and a recent study of U.S. Army veterans [16] confirm this increased risk for black persons even after controlling for an increased prevalence of obesity. Table 1. Prevalence of Diabetes in the United States All Hispanic groups studied to date have a greater prevalence of diabetes than do white persons [17-23]. Data from the 1982-1984 Hispanic Health and Nutrition Examination Survey (HHANES) [17] show that, among Hispanic persons living in the United States, the prevalence of noninsulin-dependent diabetes mellitus is greatest for Puerto Ricans and Hispanic persons living in the southwest and is lowest for Cubans (Table 1). Epidemiologic studies in Texas (Laredo [18], Starr County [19], and San Antonio [20]) and in Colorado [21] and New Mexico [22], show a prevalence of diabetes in Hispanic persons that is two to five times higher than that in non-Hispanic persons (Table 1). The excess of diabetes in the Mexican-American population persists even when the greater overall and centralized obesity rates of the Mexican-American population when compared with those of white persons are considered [23]. Native Americans comprise more than 500 tribal organizations; in the 1990 census, about 1.9 million persons identified themselves as an American Indian or Alaska native [24]. High prevalences of diabetes among most Native American tribes have been reported [25-37]. The Pima tribe in Arizona has one of the highest rates in the world [25]. Variation of rates among tribes may be due to ascertainment methods (many rates are derived from clinical settings) or to true variation caused by genetic differences [8, 24-37]. Indian Health Service data indicate that the overall prevalence is 2.8 times the overall U.S. rate [8]. Only Alaska natives (Eskimo and Indian) have been shown to have prevalences less than or slightly greater than the overall rates of diabetes in the United States, but evidence suggests that the prevalence may be increasing in these groups [35, 37]. Asian Americans and Pacific Islander Americans are a diverse group with more than 20 population groups [38]. The Seattle Japanese-American Community Diabetes Study [9, 10] found the prevalence of diabetes to be higher than that reported for the U.S. white population [12]. Filipinos had the highest prevalence of diabetes among the four largest ethnic Asian groups in Hawaii (Chinese, Filipino, Japanese, and Korean); all groups had higher prevalences than those of white persons [11]. In one pilot study of Arab Americans [39], the rates were also high. Although the prevalence of noninsulin-dependent diabetes mellitus is consistently higher in minorities, it is possible that prolonged durationand not an increased incidenceof noninsulin-dependent diabetes mellitus could be the explanation. Few incidence studies have been done, but thus far, incidence rates in the United States have been found to be higher in black persons [40], Mexican Americans [41, 42], the Pima tribe [43, 44] and Japanese Americans [45] than in white persons. Impaired glucose tolerance and gestational diabetes are recognized risk categories for progression to diabetes. Black persons, Hispanic persons, Native Americans, and Asian Americans have been shown to have higher rates of impaired glucose tolerance than white persons [2, 5-610, 46, 48]. Black persons, Hispanic persons, and Native Americans also have higher rates of gestational diabetes [49-53]. However, rates of gestational diabetes in Asians are similar to those of white persons in the United States [54]. Prevalence and Incidence of Complications and Mortality Table 2 lists the rates of complications between the primary minority subgroups and white persons. Table 2. Diabetes Complication Rates in Minorities and White Persons* Nephropathy Diabetic end-stage renal disease rates have been shown to be higher in all U.S. minority groups than in white persons [55-63]. The rate in black persons is 3.2 to 6.6 times higher than that in white persons; this value is reduced to 2.6 after adjustment for the underlying increased prevalence of diabetes [55]. After adjustment for systolic blood pressure, income, age, and other potential risk factors, black persons still had a 63% higher risk for developing end-stage renal disease [59]. Mexican Americans had a rate ratio for end-stage renal disease of 2.9 to 7 compared with white persons [60]. However, after adjustment for prevalence of diabetes, Mexican Americans no longer had an excess risk [64]. According to Medicare and United States Renal Data System data [61, 62], the age-adjusted incidence of diabetic end-stage renal disease is 6.3 times higher for Native Americans than for white persons in the United States; data from specific Native American tribes confirm this finding [65-69]. End-stage renal disease is the leading cause of death among diabetic Pima Indians, with incidence rates similar to those reported among persons with insulin-dependent diabetes mellitus [70]. Asians and Pacific Islanders had the lowest incidence of end-stage renal disease among minority groups, but this rate were still higher than those of white persons [62]. The mixture of insulin-dependent diabetes mellitus and noninsulin-dependent diabetes mellitus end-stage renal disease substantially differs between minorities and white persons. In a cohort study of diabetic end-stage renal disease in Texas [64], 93% of Mexican Americans with diabetic end-stage renal disease had noninsulin-dependent diabetes mellitus compared with 84% of black persons and 60% of white persons. Similarly, Cowie and colleagues [55] reported that 73% of cases of diabetic end-stage renal disease among black persons and 42% of cases among white persons were secondary to noninsulin-dependent diabetes mellitus. Survival among minority persons with diabetic end-stage renal disease who are treated with hemodialysis is better than for white persons [62, 71-73]. The reason of this survival advantage is unclear. Minorities receive transplants less often, leaving minority patients who are eligible for transplantation on dialysis [62, 74]. In addition, black persons have lower rates of voluntary withdrawal from dialysis than white persons [75]. It is not known whether this phenomenon occurs in other minorities. With regard to incipient nephropathy, Hispanic persons, black persons, and Native Americans have been found to have higher rates of proteinuria than do white persons [76-82]. Although fewer data are available for microalbuminuria, the available data also generally show higher rates for Pima Indians, Hispanic persons, and black persons [76-7880, 83-85]. Retinopathy Although minorities tend to have higher reported rates of retinopathy, this finding is not as consistent as that for end-stage renal disease. Age-standardized rates of blindness secondary to diabetes for nonwhite persons is double that for white persons [86]. Black adults with diagnosed diabetes have a higher prevalence of retinopathy [87, 88]. Two studies of retinopathy in Hispanic persons have conflicting results: One shows higher rates, and the other shows lower rates [77, 89]. Pima Indians and Native Americans in Oklahoma have also been s

Do Upper-Body and Centralized Adiposity Measure Different Aspects of Regional Body-Fat Distribution? Relationship to Non-Insulin-Dependent Diabetes Mellitus, Lipids, and Lipoproteins

Both central and upper-body adiposity are associated with high rates of type II non-insulin-dependent diabetes mellitus (NIDDM), high triglyceride levels, and low high-density lipoprotein (HDL) cholesterol levels. Previous data have also suggested that central and upperbody adiposity are relatively uncorrelated and hence may measure different aspects of regional body fat distribution. We assessed body mass index (BMI), the ratio of subscapular-to-triceps skinfold (STR), the ratio of waist-to-hip circumference (WHR), lipids, lipoproteins, and glucose tolerance in 738 Mexican Americans (ages 25-64 yr), who participated in the San Antonio Heart Study, a population-based study of diabetes and cardiovascular risk factors. NIDDM was diagnosed according to National Diabetes Data Group criteria. In general, STR and WHR were associated with high NIDDM rates, low HDL cholesterol levels, and high triglyceride levels, although WHR was somewhat more predictive of these than STR. In females, BMI, WHR, and STR all made independent contributions to prediction of NIDDM and HDL cholesterol; in males, WHR and STR both made independent contributions to prediction of triglyceride levels. This suggests that both indices may measure different aspects of body-fat distribution. Investigators should consider measuring both of these indicators of body-fat distribution in studies of diabetes and other cardiovascular risk factors, although if only a single measure is feasible, WHR appears to be preferable.

Hyperinsulinemia, upper body adiposity, and cardiovascular risk factors in non-diabetics

Previous studies have suggested that hyperinsulinemia and upper body adiposity are each separately associated with elevated BP and triglyceride (TG) levels, and with lower high density lipoprotein (HDL) cholesterol levels. The joint effect of hyperinsulinemia and upper body adiposity on lipids, lipoproteins, and BP, however, has not been previously studied. We hypothesized that the effect of body fat distribution on cardiovascular risk factors might be mediated through hyperinsulinemia. We measured BP, lipids and lipoproteins, HDL subfractions, and insulin and glucose concentrations as part of the San Antonio Heart Study, a population-based study of diabetes and cardiovascular risk factors. Insulinemia and glycemia were assessed as the sum of the fasting, half-hour, one-hour, and two-hour insulin and glucose levels, respectively, measured during a standardized oral glucose tolerance test. Individuals who had diabetes according to National Diabetes Data Group criteria were excluded from the analyses. In univariate analyses, both hyperinsulinemia and waist-to-hip ratio (WHR), a measure of upper body adiposity, were positively associated with TG and negatively associated with total HDL and HDL2 cholesterol levels. However, when the effects of glycemia and insulinemia were controlled for by analysis of variance, WHR was no longer significantly related to TG levels. By contrast, WHR continued to be inversely related to total HDL and HDL2 cholesterol even after adjustment for glycemia and insulinemia. Hyperinsulinemia was only weakly related to HDL cholesterol. These results suggest that insulinemia and glycemia might mediate the effects of upper body adiposity on TG, although not on HDL and HDL2 cholesterol. Hyperinsulinemia was also positively associated with diastolic and systolic BP in men.

Attitudes of Primary Care Providers Toward Diabetes: Barriers to guideline implementation

OBJECTIVE Primary care providers have been slow to adopt standards of care for diabetes, and continuing medical education (CME) programs have been minimally effective in changing provider behavior. The objective of this study was to explore the previously reported finding that attitudes, rather than knowledge, may impede primary care provider adherence to standards of care. RESEARCH DESIGN AND METHODS Study participants included 31 primary care providers attending an eight-session CME program on diabetes. Providers rated on a 10-point scale how the treatment of diabetes compared with that of five other chronic conditions (hypertension, hyperlipidemia, angina, arthritis, and heart failure; 1 = easier to 10 = harder; midpoint 5.5). In a subsequent open-ended qualitative interview, providers explained their scale ratings. RESULTS Diabetes was rated as significantly harder to treat than hypertension (24 of 30 >5.5; P < 0.001) and angina (20 of 30 >5.5; P = 0.03). A majority also rated hyperlipidemia (18 of 30) and arthritis (18 of 30) as easier to treat than diabetes. Explanatory themes underlying provider frustrations with diabetes include characteristics of the disease itself and the complexity of its management, and a perceived lack of support from society and the health care system for their efforts to control diabetes. CONCLUSIONS CME that addresses provider attitudes toward diabetes in addition to updating knowledge may be more effective than traditional CME in promoting adherence to standards of care. Additional changes are needed in our health care system to shift from an acute to a chronic disease model to effectively support diabetes care efforts.

Audit and feedback and clinical practice guideline adherence: making feedback actionable.

BackgroundAs a strategy for improving clinical practice guideline (CPG) adherence, audit and feedback (A&F) has been found to be variably effective, yet A&F research has not investigated the impact of feedback characteristics on its effectiveness. This paper explores how high performing facilities (HPF) and low performing facilities (LPF) differ in the way they use clinical audit data for feedback purposes.MethodDescriptive, qualitative, cross-sectional study of a purposeful sample of six Veterans Affairs Medical Centers (VAMCs) with high and low adherence to six CPGs, as measured by external chart review audits.One-hundred and two employees involved with outpatient CPG implementation across the six facilities participated in one-hour semi-structured interviews where they discussed strategies, facilitators and barriers to implementing CPGs. Interviews were analyzed using techniques from the grounded theory method.ResultsHigh performers provided timely, individualized, non-punitive feedback to providers, whereas low performers were more variable in their timeliness and non-punitiveness and relied on more standardized, facility-level reports. The concept of actionable feedback emerged as the core category from the data, around which timeliness, individualization, non-punitiveness, and customizability can be hierarchically ordered.ConclusionFacilities with a successful record of guideline adherence tend to deliver more timely, individualized and non-punitive feedback to providers about their adherence than facilities with a poor record of guideline adherence. Consistent with findings from organizational research, feedback intervention characteristics may influence the feedbacks effectiveness at changing desired behaviors.

Diabetic Retinopathy in Mexican Americans and Non-Hispanic Whites

Mexican Americans (MAs) have a threefold greater prevalence of non-insulin-dependent diabetes mellitus (NIDDM) than non-Hispanic Whites (NHWs). Because MA diabetic subjects have greater hyperglycemia and an earlier age of onset than NHW diabetic subjects, we postulated that diabetic MAs might also have more severe diabetic retinopathy. Stereoscopic retinal photographs of the seven standard fields of each eye were taken in 257 MAs and 56 NHWs with NIDDM. The photographs were read by the University of Wisconsin Fundus Photographic Reading Center and graded with standardized criteria. The MAs had a nonsignificantly increased risk of retinopathy relative to the NHWs [odds ratio (OR) = 1.71; 95% confidence interval (CI) = (0.93, 3.17)]. The risk of severe retinopathy (proliferative or preproliferative) relative to background or no retinopathy was significantly greater in MAs than in NHWs [OR = 2.37; 95% CI = (1.04, 5.39)]. After control by logistic regression for duration of disease, severity of hyperglycemia, age, and systolic blood pressure, MAs still had an increased risk of severe retinopathy relative to NHWs [OR = 3.18; 95% CI = (1.32, 7.66)]. Severe retinopathy was related to duration of disease, hyperglycemia, and insulin therapy in both ethnic groups. Previously diagnosed MA diabetic subjects also had an increased prevalence of any retinopathy [OR = 2.39; 95% CI = (1.63, 3.50)] and severe retinopathy [OR = 3.21 ; 95% CI = (2.24, 4.59)] relative to previously diagnosed White diabetic subjects (n = 896) from Wisconsin. The combination of an increased prevalence of NIDDM in MAs plus an increased severity of retinopathy in those MAs who have diabetes suggests that a major public health effort should be made to screen this ethnic group for retinopathy.

Competing Demands or Clinical Inertia: The Case of Elevated Glycosylated Hemoglobin

PURPOSE This study aimed to examine the contribution of competing demands to changes in hypoglycemic medications and to return appointment intervals for patients with type 2 diabetes and an elevated glycosylated hemoglobin (A1c) level. METHODS We observed 211 primary care encounters by adult patients with type 2 diabetes in 20 primary care clinics and documented changes in hypoglycemic medications. Competing demands were assessed from length of encounter, number of concerns patients raised, and number of topics brought up by the clinician. Days to the next scheduled appointment were obtained at patient checkout. Recent A1c values and dates were determined from the chart. RESULTS Among patients with an A1c level greater than 7%, each additional patient concern was associated with a 49% (95% confidence interval, 35%–60%) reduction in the likelihood of a change in medication, independent of length of the encounter and most recent level of A1c. Among patients with an A1c level greater than 7% and no change in medication, for every additional minute of encounter length, the time to the next scheduled appointment decreased by 2.8 days (P = .001). Similarly, for each additional 1% increase in A1c level, the time to the next scheduled appointment decreased by 8.6 days (P=.001). CONCLUSIONS The concept of clinical inertia is limited and does not fully characterize the complexity of primary care encounters. Competing demands is a principle for constructing models of primary care encounters that are more congruent with reality and should be considered in the design of interventions to improve chronic disease outcomes in primary care settings.

COPD is associated with increased mortality in patients with community-acquired pneumonia

Patients with chronic obstructive pulmonary disease (COPD) who develop community-acquired pneumonia (CAP) may experience worse clinical outcomes. However, COPD is not included as a distinct diagnosis in validated instruments that predict mortality in patients with CAP. The aim of the present study was to evaluate the impact of COPD as a comorbid condition on 30- and 90-day mortality in CAP patients. A retrospective observational study was conducted at two hospitals. Eligible patients had a discharge diagnosis and radiological confirmation of CAP. Among 744 patients with CAP, 215 had a comorbid diagnosis of COPD and 529 did not have COPD. The COPD group had a higher mean pneumonia severity index score (105±32 versus 87±34) and were admitted to the intensive care unit more frequently (25 versus 18%). After adjusting for severity of disease and processes of care, CAP patients with COPD showed significantly higher 30- and 90-day mortality than non-COPD patients. Chronic obstructive pulmonary disease patients hospitalised with community-acquired pneumonia exhibited higher 30- and 90-day mortality than patients without chronic obstructive pulmonary disease. Chronic obstructive pulmonary disease should be evaluated for inclusion in community-acquired pneumonia prediction instruments.

Continuity of care, self-management behaviors, and glucose control in patients with type 2 diabetes

Background. The influence of continuity of care on outcomes of care for patients with type 2 diabetes is poorly understood. Objective. To examine the relationships between continuity, glucose control, and advancement through stages of change for selfmanagement behaviors. Design. Prospective cohort study. Setting. Five community health centers on the Texas‐Mexico border. Subjects. A random sample of 256 adults, 18 years of age and older with an established diagnosis of type 2 diabetes. Measures. Stage of change for diet and exercise were assessed during two patient interviews, averaging 18.9 months apart. Phlebotomy was performed at each interview to measure glycosolated hemoglobin (HbA1C). Medical records were abstracted for ambulatory care utilization. A continuity score was calculated based on the number of visits and number of providers seen. Results. Patients who advanced one or more stages of change for diet had higher levels of continuity. As continuity improved, the change in HbA1C was smaller. (r = –0.25; P <0.001) This relationship remained significant after controlling for number of visits, months since diagnosis, number of days in the study, duration of diabetes, and advancement in stage of change for diet. Advancement through stage of change for diet explained a significant amount of the variance in the relationship between continuity and HbA1C (t test = –11.33; P <0.01). Conclusions. Continuity of care with a primary care provider is associated with better glucose control among patients with type 2 diabetes. This relationship appears to be mediated by changes in patient behavior regarding diet.

Screening for Diabetic Retinopathy: The wide-angle retinal camera

OBJECTIVE— To define the test characteristics of four methods of screening for diabetic retinopathy. RESEARCH DESIGN AND METHODS— Four screening methods (an exam by an ophthalmologist through dilated pupils using direct and indirect ophthalmoscopy, an exam by a physicians assistant through dilated pupils using direct ophthalmoscopy, a single 45° retinal photograph without pharmacological dilation, and a set of three dilated 45° retinal photographs) were compared with a reference standard of stereoscopic 30° retinal photographs of seven standard fields read by a central reading center. Sensitivity, specificity, and positive and negative likelihood ratios were calculated after dichotomizing the retinopathy levels into none and mild nonproliferative versus moderate to severe nonproliferative and proliferative. Two sites were used. All patients with diabetes in a VA hospital outpatient clinic between June 1988 and May 1989 were asked to participate. Patients with diabetes identified from a laboratory list of elevated serum glucose values were recruited from a DOD medical center. RESULTS— The subjects (352) had complete exams excluding the exam by the physicians assistant that was added later. The sensitivities, specificities, and positive and negative likelihood ratios are as follows: ophthalmologist 0.33, 0.99, 72, 0.67; photographs without pharmacological dilation 0.61, 0.85, 4.1, 0.46; dilated photographs 0.81, 0.97, 24, 0.19; and physicians assistant 0.14, 0.99, 12, 0.87. CONCLUSIONS— Fundus photographs taken by the 45° camera through pharmacologically dilated pupils and read by trained readers perform as well as ophthalmologists for detecting diabetic retinopathy. Physician extenders can effectively perform the photography with minimal training but would require more training to perform adequate eye exams. In this older population, many patients did not obtain adequate nonpharmacological dilation for use of the 45° camera.