Lucy M. Candib

Obesity and Diabetes in Vulnerable Populations: Reflection on Proximal and Distal Causes

Around the world obesity and diabetes are climbing to epidemic proportion, even in countries previously characterized by scarcity. Likewise, people from low-income and minority communities, as well as immigrants from the developing world, increasingly visit physicians in North America with obesity, metabolic syndrome, or diabetes. Explanations limited to lifestyle factors such as diet and exercise are inadequate to explain the universality of what can be called a syndemic, a complex and widespread phenomenon in population health produced by multiple reinforcing conditions. Underlying the problem are complex factors—genetic, physiological, psychological, familial, social, economic, and political—coalescing to overdetermine these conditions. These interacting factors include events occurring during fetal life, maternal physiology and life context, the thrifty genotype, the nutritional transition, health impact of urbanization and immigration, social attributions and cultural perceptions of increased weight, and changes in food costs and availability resulting from globalization. Better appreciation of the complexity of causation underlying the worldwide epidemic of obesity and diabetes can refocus the work of clinicians and researchers to work at multiple levels to address prevention and treatment for these conditions among vulnerable populations.

Randomized Trial of a Literacy-Sensitive, Culturally Tailored Diabetes Self-Management Intervention for Low-Income Latinos: Latinos en Control

OBJECTIVE To test whether a theory-based, literacy, and culturally tailored self-management intervention, Latinos en Control, improves glycemic control among low-income Latinos with type 2 diabetes. RESEARCH DESIGN AND METHODS A total of 252 patients recruited from community health centers were randomized to the Latinos en Control intervention or to usual care. The primarily group-based intervention consisted of 12 weekly and 8 monthly sessions and targeted knowledge, attitudes, and self-management behaviors. The primary outcome was HbA1c. Secondary outcomes included diet, physical activity, blood glucose self-monitoring, diabetes knowledge and self-efficacy, and other physiological factors (e.g., lipids, blood pressure, and weight). Measures were collected at baseline and at 4- and 12-month follow-up. Change in outcomes over time between the groups and the association between HbA1c and possible mediators were estimated using mixed-effects models and an intention-to-treat approach. RESULTS A significant difference in HbA1c change between the groups was observed at 4 months (intervention −0.88 [−1.15 to −0.60] versus control −0.35 [−0.62 to 0.07], P < 0.01), although this difference decreased and lost statistical significance at 12 months (intervention −0.46 [−0.77 to −0.13] versus control −0.20 [−0.53 to 0.13], P = 0.293). The intervention resulted in significant change differences in diabetes knowledge at 12 months (P = 0.001), self-efficacy (P = 0.001), blood glucose self-monitoring (P = 0.02), and diet, including dietary quality (P = 0.01), kilocalories consumed (P < 0.001), percentage of fat (P = 0.003), and percentage of saturated fat (P = 0.04). These changes were in turn significantly associated with HbA1c change at 12 months. CONCLUSIONS Literacy-sensitive, culturally tailored interventions can improve diabetes control among low-income Latinos; however, strategies to sustain improvements are needed.

A randomized clinical trial of a care recommendation letter intervention for somatization in primary care

PURPOSE This paper describes the impact of a care recommendation (CR) letter intervention on patients with multisomatoform disorder (MSD) and analysis of patient factors that affect the response to the intervention. METHODS One hundred eighty-eight patients from 3 family practices, identified through screening of 2,902 consecutive patients, were classified using somatization diagnoses based on the number of unexplained physical symptoms from a standardized mental health interview. In a controlled, single-crossover trial, patients were randomized to have their primary care physician receive the CR letter either immediately following enrollment or 12 months after enrollment. The CR letter notified the physician of the patient’s somatization status and provided recommendations for the patient’s care. Patients were followed for 24 months with assessments of functional status at baseline, 12, and 24 months. RESULTS Longitudinal analysis revealed a 12-month intervention effect for patients with multisomatoform disorder (MSD) of 5.5 points (P < .001) on the physical functioning (PCS) scale of the SF-36. Analysis of scores on the MCS scale of the SF-36 found no significant effect on mental functioning. The intervention was more effective for patients with 1 or more comorbid chronic physical diseases (P = .01). CONCLUSIONS The CR letter has a favorable impact on physical impairment of primary care patients with MSD, especially for patients with comorbid chronic physical disease. Multisomatoform disorder appears to be a useful diagnostic classification for managing and studying somatization in primary care patients.

The somatization in primary care study: a tale of three diagnoses

Somatization is a common phenomenon that has been defined in many ways. The two most widely used diagnoses, Somatization Disorder (SD) and Abridged Somatization Disorder (ASD), are based on lifetime unexplained symptoms. However, reports indicate instability in lifetime symptom recall among somatizing patients. Multisomatoform disorder (MSD) is a new diagnosis based on current unexplained symptoms. To understand how knowledge about SD and ASD translates to MSD, we examined the diagnostic concordance, impairment and health care utilization of these groups in a sample from the Somatization in Primary Care Study. The diagnostic concordance was high between MSD and SD, but lower between MSD and ASD. All three groups reported considerable physical impairment (measured using the PCS subscale of the SF-36). The mental health (MCS) scores for the three groups were only slightly lower than those of the general population. Over the course of one year, physical functioning fell significantly for all three groups. Mental functioning did not change significantly for any of the three groups over this period. Utilization patterns were very similar for the three groups. The high prevalence, serious impairment, and worsening physical functioning over the course of one year suggest the importance of developing interventions in primary care to alleviate the impaired physical functioning and reduce utilization in somatizing patients. MSD should be a useful diagnosis for targeting these interventions because it identifies a sizable cohort of somatizing patients reporting impairment of comparable severity to full SD, using a more efficient diagnostic algorithm based on current symptoms.

The Neighborhood Health Center — Reform Ideas of Yesterday and Today

Abstract The early health centers of the 1900s were meant to solve special out-of-hospital health problems of the poor, chiefly infectious disease and infant malnutrition. Preventive measures cons...

Translational research at community health centers: challenges and successes in recruiting and retaining low-income Latino patients with type 2 diabetes into a randomized clinical trial.

Purpose To describe methods used to recruit and retain low-income Latinos in a randomized clinical trial (RCT) of a diabetes self-management intervention at 5 community health centers (CHCs) in Massachusetts. Methods Consent from primary care providers (PCPs) was obtained to screen their patients. Trained site research coordinators (SRCs) screened, recruited, and enrolled participants following a multistep process (medical record reviews, PCP approval, a patient eligibility interview) and provided support for retention efforts. Assessment staff were trained in motivational strategies to facilitate retention and received ongoing support from a retention coordinator. Electronic tracking systems facilitated recruitment and retention activities. Results Of an initial pool of 1176 patients, 1034 were active at the time of screening, 592 (57%) were eligible by medical record review, and 487 received PCP approval (92% of reviewed patients). Of these, 293 patients completed the patient screening interview (60% of patients with PCP approval, and 76% of those reached), and 276 were eligible. Sixteen percent of all active patients refused participation, and 8% of contacted patients were unreachable. Two hundred fifty-two patients were randomized after completion of baseline assessments. Clinical, behavioral, and psychosocial assessment completion rates were 92%, 77%, and 86% at 12-month follow-up, respectively, and 93% of patients completed at least one study assessment at 12 months. Conclusions CHCs are a prime setting for translation research aimed to eliminate diabetes health disparities. Successful recruitment and retention efforts must address institutional/organizational, research team, and patient-related challenges. References 1. US Department of Health and Human Services, Centers for Disease Control and Prevention. 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Participation in research studies: factors associated with failing to meet minority recruitment goals. Ann Epidemiol. 2007;17:634-642. 24. Centers for Disease Control and Prevention, Department of Health and Human Services. Diabetes data and trends. Available at: http:www.cdc.gov/diabetes/statistics/prev/national/. Accessed March 31, 2010. 25. Surani S, Aguillar R, Komari V, Surani A, Subramanian S. Influence of Hispanic ethnicity in prevalence of diabetes mellitus in sleep apnea and relationship to sleep phase. Postgrad Med. 2009;121:108-112. 26. Link CL, McKinlay JB. Disparities in the prevalence of diabetes: is it race/ethnicity or socioeconomic status? Results from the Boston Area Community Health (BACH) survey. Ethn Dis. 2009;19:288-292. 27. Bryson CL, Ross HJ, Boyko EJ, Young BA. Racial and ethnic variations in albuminuria in the US Third National Health and Nutrition Examination Survey (NHANES III) population: associations with diabetes and level of CKD. Am J Kidney Dis. 2006; 48:720-726. 28. Gross R, Olfson M, Gameroff MJ. Depression and glycemic control in Hispanic primary care patients with diabetes. J Gen Intern Med. 2005;20:460-466. 29. Trief PM, Morin PC, Izquierdo R. Depression and glycemic control in elderly ethnically diverse patients with diabetes: the IDEATel project. Diabetes Care. 2006; 29:830-835. 30. McCarthy CR. Historical background of clinical trials involving women and minorities. Acad Med . 1994;69:695-698. 31. Rosal MC, Benjamin EM, Pekow PS, Lemon SC, von Goeler D. Opportunities and challenges for diabetes prevention at two community health centers. Diabetes Care. 2008; 31:247-254. 32. Blumenthal DS, Sung J, Coates R, Williams J, Liff J. Recruitment and retention of subjects for a longitudinal cancer prevention study in an inner-city black community. Health Serv Res. 1995;30(1 Pt 2):197-205. 33. UyBico SJ, Pavel S, Gross CP. Recruiting vulnerable populations into research: a systematic review of recruitment interventions. J Gen Intern Med. 2007;22:852-863. 34. Corbie-Smith GM. Minority recruitment and participation in health research. N C Med J. 2004; 65:385-387. 35. Bruner DW, Jones M, Buchanan D, Russo J. Reducing cancer disparities for minorities: a multidisciplinary research agenda to improve patient access to health systems, clinical trials, and effective cancer therapy. J Clin Oncol. 2006;24:2209-2215. 36. Blumenthal DS, Lukomnik JE, Hawkins DR, Jr. A proposal to provide care to the uninsured through a network of community health centers. J Health Care Poor Underserved. 1993;4:272-279. 37. Davis SK, Collins KS, Hall A. Community health centers in a changing U.S. health care system. Policy Brief Commonw Fund . 1999;(300):1-13. 38. US Department of Health and Human Services, Health Resources and Services Administration. Bureau of Primary Health Care. 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Design and methods for a randomized clinical trial of a diabetes self-management intervention for low-Income Latinos: Latinos en Control

BackgroundUS Latinos have greater prevalence of type 2 diabetes (diabetes), uncontrolled diabetes and diabetes co-morbidities compared to non-Latino Whites. They also have lower literacy levels and are more likely to live in poverty. Interventions are needed to improve diabetes control among low-income Latinos.Methods and designThis randomized clinical trial tested the efficacy of a culturally- and literacy-tailored diabetes self-management intervention (Latinos en Control) on glycemic control among low-income Latinos with diabetes, compared to usual care (control). Participants were recruited from five community health centers (CHCs) in Massachusetts. The theory-based intervention included an intensive phase of 12 weekly sessions and a follow-up maintenance phase of 8 monthly sessions. Assessments occurred at baseline, and at 4 and 12 months. The primary outcome was glycosylated hemoglobin (HbA1c). Secondary outcomes were self-management behaviors, weight, lipids and blood pressure. Additional outcomes included diabetes knowledge, self-efficacy, depression and quality of life. The study was designed for recruitment of 250 participants (estimated 20% dropout rate) to provide 90% power for detecting a 7% or greater change in HbA1c between the intervention and control groups. This is a difference in change of HbA1c of 0.5 to 0.6%.DiscussionLow-income Latinos bear a great burden of uncontrolled diabetes and are an understudied population. Theory-based interventions that are tailored to the needs of this high-risk population have potential for improving diabetes self-management and reduce health disparities. This article describes the design and methods of a theory driven intervention aimed at addressing this need.Trial registrationhttp://www.clinicaltrials.gov # NCT00848315

Complex posttraumatic stress disorder: evidence from the primary care setting

Sexual abuse is a common problem among female primary care medical patients. There is a wide spectrum of long-term sequelae, ranging from mild to the complex symptom profiles consistent with the theories of a posttraumatic sense of identity. Generally, the latter occurs in the context of severe, chronic abuse, beginning in childhood and often compounded by the presence of violence, criminal behavior, and substance abuse in the family of origin. In this study we search for empirical evidence for the existence of a complex posttraumatic stress syndrome in 99 women patients at 3 family practice outpatient clinics who report a history of sexual abuse. A structured interview was administered by trained female interviewers to gather data on family history and psychiatric symptoms and diagnoses. Empirical evidence from cluster analysis of the data supports the theory of a complex posttraumatic syndrome. The severity gradient based on symptoms roughly parallels the severity gradient based on childhood abuse and sociopathic behavior and violence in the family of origin, with the most severely abused subjects characterized by symptom patterns that fit the description of a complex posttraumatic stress syndrome.

Screening for Childhood Trauma in Adult Primary Care Patients: A Cross-Sectional Survey

OBJECTIVE Compared to screening for partner violence, screening for childhood physical and sexual abuse among adult patients has received little attention, despite associated adverse health consequences. The objective of this exploratory study was to describe the practices, skills, attitudes, and perceived barriers of a large sample of family physicians in screening adult patients for childhood sexual or physical abuse. METHOD Surveys were mailed to the 833 members of the Massachusetts Academy of Family Physicians in 2007 eliciting information about screening practices. Factors associated with routine or targeted screening among adult primary care patients were evaluated. RESULTS Less than one-third of providers reported usually or always screening for childhood trauma and correctly estimated childhood abuse prevalence rates; 25% of providers reported that they rarely or never screen patients. Confidence in screening, perceived role, and knowledge of trauma prevalence were associated with routine and targeted screening. Women and physicians reporting fewer barriers were more likely to routinely screen adult patients. CONCLUSIONS Despite the 20%-50% prevalence of child abuse exposure among adult primary care patients, screening for childhood abuse is not routine practice for most physicians surveyed; a large subgroup of physicians never screen patients. Study findings draw attention to a largely unexplored experience associated with considerable health care costs and morbidity. Results highlight the need to develop training programs about when to suspect trauma histories and how to approach adult patients.

Incest and other harms to daughters across cultures: Maternal complicity and patriarchal power

Abstract This article addresses the problematic position of mothers who know that their daughters are being sexually abused. Departing from the medical and psychiatric approaches that focus on the mother’s individual psychology or on the family system in incest, this article ranges across history and culture to examine the structural context of other instances where mothers participate in or have participated in harm to their daughters: footbinding, female genital mutilation, female infanticide, and the abortion of female fetuses. Though conducted in private, each of these practices is maintained by certain kinds of public knowledge and acceptance. All of these practices are closely connected with women’s survival in families within the intergenerational context of male domination. This exploration suggests that mothers’ participation in harm to their daughters needs to be considered within the broader context of power in their families and in the culture at large.