Joseph C. Konen

Quality of diabetes care among low-income patients in North Carolina

BACKGROUND Diabetes is a leading cause of death and disability, disproportionately affecting most ethnic minority groups, people of low socioeconomic status, the elderly, and people in rural areas. Despite the availability of evidence-based clinical recommendations, barriers exist in the delivery of appropriate diabetes care. The purpose of this study is to examine the level of diabetes care among low-income populations in North Carolina. METHODS Baseline medical record abstractions were performed (N=429) on diabetic patients at 11 agencies serving low-income populations (community health centers, free clinics, primary care clinics, and public health clinics) across the state participating in a quality-of-diabetes-care initiative. Data were collected for four process (measurement of glycosylated hemoglobin and lipids, dilated eye examination, nephropathy assessment) and two outcome (glycemic and lipid control) measures based on the Diabetes Quality Improvement Project (DQIP) and the Health Plan Employer Data and Information Set (HEDIS), and three additional indicators (blood pressure measurement and control, and lower limb assessment). Compliance rates to individual measures were calculated overall and by demographic and health characteristics. RESULTS Diabetes care compliance rates ranged from 77.9% for blood pressure testing to 3.3% for complete foot examinations. Differences in care were observed by age, insulin use, and prevalent disease. CONCLUSIONS This study indicates low compliance with diabetes care guidelines in underserved North Carolinians, and inconsistency of care according to some demographic and health characteristics. These results stress the need for quality improvement initiatives that enhance the level of care received by patients with diabetes, particularly those most vulnerable to diabetes and its complications.

Racial Differences in Psychosocial Variables among Adults with Non–Insulin-Dependent Diabetes Mellitus

To determine whether racial differences exist in psychosocial variables among patients with non-insulin-dependent diabetes mellitus (NIDDM), the authors administered a series of questionnaires to 211 Black and White patients of the Wake Forest Family Medicine ambulatory care unit and the Reynolds Health Center, a community health center. In general, Blacks in the study population had higher levels of external locus of control, higher levels of stress, and lower levels of family functioning compared with Whites. These differences may account partially for the disparity of diabetes control and the consequences of diabetes among Blacks. Health professionals may benefit from understanding and addressing these psychosocial variables and may be more successful in implementing intervention programs in this population by tailoring programs to the psychosocial orientation of their population.

Smoking status and psychosocial variables in type 1 diabetes mellitus

While depression, anxiety, and negative affect are associated with smoking and smoking cessation outcomes in healthy individuals, these associations have not been established in smokers with chronic diseases such as diabetes mellitus, a condition which greatly increases cardiovascular disease risk. Other psychosocial variables such as stress and locus of control may also be associated with smoking but are seldom reported. We examined stress, affect, and locus of control by smoking status in patients with type 1 diabetes mellitus. Results indicated that current smokers reported significantly higher levels of perceived stress, a more negative affect, and higher powerful others locus of control compared with nonsmokers. These findings indicate that those patients who have diabetes and who smoke are at greater risk for depressive symptoms. This knowledge may aid clinicians in their attempts to help these patients quit smoking.

Racial differences in symptoms and complications in adults with type 2 diabetes mellitus.

OBJECTIVE To compare the frequency of common symptoms and complications between African- and white American adults with type 2 diabetes mellitus in a primary care setting, and to examine associations of these conditions with glycemic control. DESIGN Three hundred and four adults with type 2 diabetes participated in this cross-sectional analysis; 142 of whom were African-Americans. Patients were recruited from a family practice ambulatory care unit and a community health center. RESULTS Both male and female African-Americans had higher mean diastolic blood pressure and poorer metabolic control than their white counterparts. After adjustment for diabetes duration, glycosylated hemoglobin and diastolic blood pressure, African-American females were significantly more likely to experience constipation and hypertension but less likely to experience chest pain, claudication, peripheral neuropathy or have peripheral vascular disease. Among male subjects, African-Americans were significantly more likely to experience blurred vision and hypertension but less likely to have peripheral atherosclerotic disease. Poor glycemic control was more strongly associated with the occurrence of common diabetic symptoms in African-American subjects. CONCLUSIONS Both African- and white Americans with type 2 diabetes are likely to experience a wide variety of symptoms and vascular complications. African-American subjects appear more likely than whites to experience symptoms related to glycemic control but less likely to have, or experience symptoms and complications of, cardiovascular disease. That nearly half of these subjects seen in a primary care setting had microalbuminuria suggests that vascular complications are likely to be present in the majority of adults with type 2 diabetes, even in these currently asymptomatic. These findings may have implications for screening and preventive strategies for the treatment of this disease.

Hypertension, hyperlipidemia, and abdominal obesity and the development of microalbuminuria in patients with non-insulin-dependent diabetes mellitus.

Background: The hyperlipidemia syndrome (also called syndrome X or the deadly quartet) is a recognized constellation known to increase cardiovascular mortality, but its effect on renal decline is not well-described. This study examined the differential effects of hypertension, hyperlipidemia, and abdominal obesity on overnight urinary albumin excretion ratios (UAERs) among patients with non-insulin-dependent diabetes mellitus (NIDDM), who by definition possess the remaining component of the syndrome, insulin resistance. Methods: We conducted a survey of 317 primary care NIDDM patients measuring waist-to-hip ratios, fasting lipid levels and glycemic values, and overnight UAERs. The study was carried out between January 1989 and June 1991. Results: Using logistic regression controlling for age, race, sex, duration of NIDDM, and smoking status, elevated glycosylated hemoglobin (odds ratio [OR]=1.95, 95 percent confidence interval [CI]=1.16–3.27) or the addition of one component of the deadly quartet to pure diabetes doubled or tripled the odds of an elevated UAER (NIDDM plus obesity OR=2.00, 95 percent CI=1.02–3.93; NIDDM plus hypertension OR=3.45, 95 percent CI=1.38–8.63; NIDDM plus hyperlipidemia OR=1.60, 95 percent CI=0.53–4.81). In a dose-response manner, two additional factors exerted additive effects; all three additional factors combined with pure NIDDM multiplied the effect, with an odds ratio of 9.34 (95 percent CI=2.24–38.9). Conclusions: These data quantify the incremental effects of abdominal obesity, hypertension, and hyperlipidemia on abnormal UAERs among NIDDM patients and strongly suggest the need for aggressive and simultaneous correction of multiple risk factors to prevent end organ damage in this population.

The association of non-insulin-dependent diabetes mellitus and hypertension with urinary excretion of albumin and transferrin.

Abnormal urinary excretion of albumin is a nonspecific sign of nephropathy, commonly occurring in persons with hypertension as well as diabetes. Transferrin, rather than albumin, is more readily excreted by the kidney in those with diabetes compared with those with hypertension alone. One hundred eighty non-insulin-dependent diabetic mellitus patients were age, race, and sex matched to 90 nondiabetic control subjects who had mild to moderate hypertension. Overnight urine collections were analyzed by immunoturbidity for albumin and transferrin. The average duration of hypertension was 11 years among controls. Mean blood pressures were 134/79 mm Hg for diabetic subjects and 145/87 mm Hg for controls (P < 0.001). Diabetic patients had higher mean excretion rates of albumin (128 micrograms/min v 49 micrograms/min; P = 0.04) and transferrin (7.3 micrograms/min v 0.9 microgram/min; P = 0.0001) and higher excretion ratios of albumin (0.179 g/g creatinine v 0.069 g/g creatinine; P = 0.02) and transferrin (0.0065 g/g creatinine v 0.0013 g/g creatinine; P < 0.001) than hypertensive controls. Ratios of transferrin to albumin excretion for those with diabetes and hypertension greatly exceeded expected ratios for those with hypertension or diabetes alone if the effects of these disorders were additive. While diabetic patients were twice as likely as controls to have abnormal albumin excretion ratios (P = 0.01), they were three times as likely to have elevated transferrin excretion ratios (P = 0.0001), even though the diabetic group was half as likely as the controls to have systolic blood pressure > or = 160 mm Hg.(ABSTRACT TRUNCATED AT 250 WORDS)

Body Fat, Fat Distribution, and Psychosocial Factors Among Patients With Type 2 Diabetes Mellitus

Diabetes, a risk factor for cardiovascular disease, requires lifestyle modifications (diet, exercise, weight loss). The relations between body mass index, waist-hip ratio (WHR), and psychosocial indicators, such as affect and stress, among 302 diabetic patients from a clinic and a neighborhood health center were analyzed. Data included stress and mood scale responses, body size (height, weight, and WHR) and potential confounders (physical activity, energy intake, and diabetes duration). In univariate analyses, body mass index was positively associated with stress and inversely associated with positive affect only in women. Multiple regression analyses indicated that stress was associated with body mass index and negative mood was associated with the WHR. The findings suggested that stress and affect may be important correlates of body fat among women with Type 2 diabetes, leading to more complications. Healthcare providers can help women with Type 2 diabetes lose weight and lower the risk of cardiovascular disease by recognizing and helping them deal with these psychosocial issues.

Association of gender with symptoms and complications in type II diabetes mellitus

Females with Type II diabetes appear more likely than males to experience symptoms and vascular complications related to their disease.

Correlates of Abnormal Urinary Albumin Excretion Rates Among Primary Care Patients With Essential Hypertension

Background: The excretion of small amounts of urinary protein, known as microalbuminuria, among patients with essential hypertension is associated with increased mortality from cardiovascular disease and, possibly, future renal decline. Correlates of microalbuminuria among primary care patients with essential hypertension, however, have not been well described. Methods: One hundred forty patients enrolled in a large family practice ambulatory care center who had essential hypertension but not diabetes participated in a screening project to document cardiovascular and renal diseases in this population. Patients underwent a brief physical examination and submitted blood and urine samples for analysis. Results: Twenty-five percent of patients had elevated urinary albumin excretion (UAE) rates, defined as greater than 30 μg/min. Patients with elevated UAE rates did not differ from patients without elevated UAE rates by age, race, sex, duration of hypertension, or type of antihypertensive medication used (if any). Although no patients had abnormally elevated g1ycosylated hemoglobin, after controlling for age and duration of hypertension, elevated UAE rates were significantly related to higher mean g1ycosylated hemoglobin levels (odds ratio [OR] = 3.06,95 percent confidence interval [CI] = 1.11 to 8.41) and to current smoking (OR = 3.14,95 percent CI = 1.09 to 9.04). Conclusions: These data are the first in a primary care population to show a threefold increase in risk for elevated UAE rates among patients with essential hypertension who currently smoke or who have above-average g1ycosylated hemoglobin levels. Although cross-sectional in nature, these data can also point toward subgroups of hypertensive patients who have a worse cardiovascular prognosis.

Coronary heart disease risk factors in black and white patients with non-insulin-dependent diabetes mellitus.

OBJECTIVE To determine possible racial differences in risk factors for coronary heart disease (CHD) in black and white patients with noninsulin-dependent diabetes mellitus (NIDDM). METHODS Study of risk factors for coronary heart disease among 308 subjects who met the WHO criteria for NIDDM. RESULTS Both black and white patients were found to have a high prevalence of hypertension, obesity, low high density lipoprotein (HDL) cholesterol, low leisure-time physical activity levels, and an atherogenic dietary profile. Black males were more likely to have hypertension, reported a greater intake of dietary cholesterol, and had lower triglycerides, higher HDL cholesterol levels, a lower CHOL/HDL ratio, and a lower waist to hip ratio (WHR) than white males. Black females had higher mean arterial and diastolic blood pressures, had lower triglycerides, higher HDL cholesterol, a lower CHOL/HDL ratio, a higher subscapular/triceps ratio and lower reported leisure-time energy expenditure compared to white females. There were no racial differences found for obesity level. CONCLUSION Our results indicate that racial differences in CHD risk factors exist among black and white patients with NIDDM. The complex genetic, sociocultural and environmental interactions involving CHD risk factors that contribute to the development of CHD may eventually provide clues to the etiology of the disease.