Steven D. Helgerson

Do Persons With Diabetes Know Their (AIC) Number

PURPOSE The objective of this study was to compare self-reported knowledge about Al C testing with information from the medical record. METHODS A telephone survey was conducted among patients with diabetes in a rural fee-for-service practice and a community health center. Self-reported information regarding Al C testing, the last Al C value, and perceived blood glucose control was compared with the most current Al C value documented in the medical record. RESULTS Seventy five percent of survey respondents reported having 1 or more Al C tests in the past year, which generally agreed with information from their medical records. However, only 24% of those who reported having a test remembered the actual value, and the self-reported values correlated weakly with the last Al C on the medical record. Among those with a documented Al C value, half described their blood glucose as very well controlled. The last Al C value, however, was <7.0% in only half of those respondents. CONCLUSIONS Persons with diabetes were aware of their previous Al C testing but did not interpret the values accurately in relation to their own glycemic control. If clinicians expect patient knowledge and understanding of glycemic control measures to improve outcomes of care, patient education will need to emphasize the meaning of these values.

Cardiovascular disease and risk factors in Montana American Indians and non-Indians

BACKGROUND Cardiovascular disease (CVD) is the leading cause of death for both American Indian and non-Indian adults. Few published studies have compared the prevalence of CVD and related risk factors in Indians to that in non-Indians in the same geographic area. OBJECTIVE To compare CVD and risk factors in American Indian and non-Indian populations in Montana. METHODS Adult American Indians (n=1000) living on or near Montanas seven reservations and non-Indian (n=905) Montanans statewide were interviewed through the 1999 Behavioral Risk Factor Surveillance Survey (BRFSS). RESULTS Indians aged > or =45 years reported a significantly higher prevalence of CVD compared to non-Indians (18% vs 10%). In persons aged 18-44 years, Indians were more likely to report hypertension (15% vs 10%), obesity (29% vs 12%), and smoking (42% vs 24%) compared to non-Indians. For persons aged > or =45 years, Indians reported higher rates of diabetes (24% vs 9%), obesity (38% vs 16%), and smoking (32% vs 13%) compared to non-Indians. Non-Indians aged > or =45 years reported having been diagnosed with high cholesterol more frequently than did Indians (32% vs 24%). CONCLUSIONS Both Indians and non-Indians in Montana reported a substantial burden of CVD. The CVD risk patterns differ in the two populations. Prevention programs should be tailored to the risk burdens in these communities with particular emphasis on smoking cessation and the prevention of obesity.

Three-year prevalence and incidence of diabetes among American Indian youth in Montana and Wyoming, 1999 to 2001.

OBJECTIVES To estimate the prevalence and incidence of type 2 diabetes among American Indian youth. STUDY DESIGN Medical records were reviewed annually for all patients with diabetes who were <20 years of age at 6 Indian Health Service facilities in Montana and Wyoming. All cases < or =5 years of age or weight per age < or =10th percentile at diagnosis or with islet cell antibodies were considered as probable type 1. Among the remaining cases, probable type 2 diabetes was defined when a child had one or more of the following characteristics: weight per age > or =95th percentile or acanthosis nigricans at diagnosis, elevated C-peptide or insulin, family history of type 2 diabetes; treatment with oral agents with or without insulin or no hypoglycemic therapy after 1 year of follow-up. RESULTS From 1999 to 2001, 53% of prevalent cases and 70% of incident cases were categorized as probable type 2 diabetes. The average annual prevalence of probable type 1 and type 2 diabetes was 0.7 and 1.3 per 1000. The average annual incidence rates for probable type 1, and type 2 diabetes were 5.8, 23.3 per 100,000. CONCLUSIONS The incidence of probable type 2 diabetes was approximately 4 times higher than type 1 diabetes among American Indian youth in Montana and Wyoming

Smoking cessation and prevention: An urgent public health priority for American Indians in the Northern Plains

Objective. The purpose of this study was to compare the prevalence of cigarette smoking and smoking cessation among American Indians living on or near Montanas seven reservations to those of non-Indians living in the same geographic region. Methods. Data for Montana Behavioral Risk Factor Surveillance System (BRFSS) respondents (n = 1,722) were compared to data from a BRFSS survey of American Indians living on or near Montanas seven reservations in 1999 (n = 1,000). Respondents were asked about smoking and smoking cessation as well as cardiovascular disease (CVD) and selected risk factors. Quit ratios were calculated for both groups. Results. American Indians were more likely to report current smoking (38%) than non-Indians (19%; p<0.001). Thirty-seven percent of Indian respondents with CVD risk factors reported current smoking, compared with 17% of non-Indians with CVD risk factors. However, there was no significant difference in reported smoking rates between Indians (21%) and non-Indians (27%) with a history of CVD. Indian smokers were more likely to report quitting for one or more days in the past year (67%), compared with non-Indians (43%). Quit ratios were significantly lower among Indians (43%) than among non-Indians (65%). Conclusions. High smoking rates in Indians, particularly among those with other CVD risk factors, demonstrate an urgent need for culturally sensitive smoking cessation interventions among Northern Plains Indians and highlight the need for the Surgeon Generals focus on smoking in minority populations.

Cardiovascular Risk Factors in Montana American Indians With and Without Diabetes

BACKGROUND Cardiovascular disease (CVD) and diabetes are prevalent and of major concern for American-Indian communities in the United States. Health professional counseling is effective in increasing patient awareness and inducing lifestyle modification. The objective of this study was to compare the prevalence of CVD, modifiable risk factors and counseling for smoking cessation, physical activity, and a healthy diet in adult American Indians with and without diabetes. METHODS A random sample of adult American Indians living on or near the seven Montana reservations was interviewed through an adapted Behavioral Risk Factor Surveillance System telephone survey in 1999 (N=1000) and 2001 (N=1006). RESULTS Respondents with diabetes, compared to those without, had a significantly higher prevalence of CVD (27% vs 8%); overweight (89% vs 71%); high blood pressure (57% vs 24%); and high cholesterol (44% vs 22%). There were no differences for insufficient physical activity (60% vs 51%) or smoking (34% vs 41%) after adjustment for age, gender, and survey year. Respondents with diabetes, compared to respondents without diabetes, were significantly more likely to report health professional counseling for smoking cessation (83% vs 58%); physical activity (73% vs 37%); and reduced fat consumption (57% vs 24%). CONCLUSIONS The prevalence of modifiable CVD risk factors was alarmingly high among adult American Indians with and without diabetes. Strategies to increase health professional counseling for healthy diet and smoking cessation are needed.

Prevalence of Diagnosed Diabetes Among American Indians and Alaska Natives, 1987: Estimates from a national outpatient data base

Objective— To estimate the prevalence of diagnosed diabetes among American Indians and Alaska Natives served by the IHS. Research Design and Methods— This was a cross-sectional study of the 1987 IHS national outpatient data base. Results— Prevalence rates of diagnosed diabetes determined from the IHS outpatient data base were consistent with recent studies of diabetes in different IHS areas. IHS-wide, age-adjusted prevalence was 69/100,000, or 2.8 times the U.S. rate. There was considerable variation in prevalence rates of diabetes throughout the country, with rates ranging from 15.3/100,000 in Alaska to 119.2/100,000 in southern Arizona. Conclusions— This study documented the high prevalence of diabetes among American Indians and Alaska Natives and the wide variation in rates between different tribal groups. This study also demonstrated the feasibility of using an outpatient data base to estimate rates of disease that have uniform methods of diagnosis and result in frequent clinic visits.

Comparing self-reported measures of diabetes care with similar measures from a chart audit in a well-defined population.

The objective of this study was to compare self-reported measures of diabetes care with measures derived from medical records in a well-defined population. Diabetes measures were collected through a 1997 Behavioral Risk Factor Surveillance System telephone survey of American Indians living on or near 7 Montana reservations (N = 398) and were compared with data collected from charts of a systematic sample of American Indians with diabetes seen in 1997 at Indian Health Service (IHS) facilities. Survey respondents were more likely to report a duration of diabetes >10 years (44 vs 31%), annual dilated retinal exam (75 vs 59o), and an influenza immunization in the past year (73 vs 57%) compared with estimates from the chart audit. Estimates of pneumococcal immunization (88 vs 42%), annual cholesterol screening (86 vs 69o), and overweight, based on body mass index (67 vs 50%), were significantly higher from the chart audit. No significant differences were found between the survey respondents and the chart audit data for annual foot exams (65 vs 61%), annual blood pressure checks (98 vs 93%), high cholesterol (35 vs 41%), and high blood pressure (54 vs 64%). These findings suggest that self-reported data may over and underestimate specific measures of diabetes care.

Defining Disparities in Cardiovascular Disease for American Indians Trends in Heart Disease and Stroke Mortality Among American Indians and Whites in Montana, 1991 to 2000

Background— Disparities in stroke and heart disease have been well defined in many populations in the United States. Relatively few studies, however, have assessed current disparities in cardiovascular disease in American Indian populations and compared trends with other regions of the United States. Methods and Results— Using mortality data, age-adjusted all-cause, heart disease, and stroke mortality rates (per 100 000) were calculated for American Indians and whites from 1991 to 1995 and 1996 to 2000. The all-cause mortality rate was strikingly higher for American Indians than for whites. For example, during 1996 to 2000, the all-cause mortality rate for American Indians (1317, ±61) was more than half again greater than that for whites (831, ±8). Heart disease mortality declined significantly in whites (237 to 216 per 100 000) in Montana over the past decade and declined, although not significantly, in American Indians (326 to 283 per 100 000). Stroke mortality also declined significantly in whites (64 to 60 per 100 000) but not in American Indians (80 to 81 per 100 000) during this time period. The proportion of deaths before age 65 years for heart disease and stroke was considerably higher in Indian men (45% and 36%) and Indian women (29% and 28%) compared with white men (21% and 11%) and white women (8% and 7%). Conclusions— The disparity in heart disease and stroke mortality exists between American Indians and whites in Montana. Regional or state-level surveillance data will be needed to describe the changing patterns of heart disease and stroke mortality and cardiovascular risk factors in many native communities in the United States and Canada.

Testing for microalbuminuria in 2002: barriers to implementing current guidelines

BACKGROUND Testing for microalbuminuria is recommended to detect early kidney damage in patients with diabetes or other diseases. However, few studies have examined laboratory practices for microalbuminuria testing in the general community. METHODS In 2002, all laboratories in Montana and reference laboratories used by Montana laboratories for microalbuminuria measurement were surveyed by mail to ascertain if they provided testing for microalbuminuria, specific tests performed, and units and cutoff values used to report microalbuminuria results. RESULTS One hundred three of 126 laboratories (82%) responded to the survey. Overall, 79% of laboratories offered quantitative testing for microalbuminuria, either on site or through a reference laboratory. Twenty-five laboratories (24%) surveyed provided quantitative testing for microalbuminuria on site. Only 14 of 23 laboratories offering albumin-creatinine ratios on site reported results in units and cutoff values consistent with current recommendations. Fewer laboratories provided 24-hour (6 of 17 laboratories) or other timed (2 of 7 laboratories) testing, and many of these laboratories did not report results using recommended units and cutoff values. Overall, only 11 of 25 laboratories (44%) with on-site testing reported microalbuminuria values from 1 or more types of specimens exclusively using recommended units and cutoff values. CONCLUSION Quantitative testing for microalbuminuria is not offered universally, and results often are reported in units and cutoff values that differ from current clinical recommendations.

Foot care practices, services and perceptions of risk among medicare beneficiaries with diabetes at high and low risk for future foot complications.

A cohort of Medicare beneficiaries with diabetes was identified from inpatient and outpatient claims data and their risk for foot complications was estimated based on claims reflecting services for recent foot problems. A telephone survey of a random sample from this cohort was conducted to assess their foot care practices, barriers, and perceptions of risk. Eight percent of respondents reported a history of foot ulcers and 7% a history of lower extremity amputation. Based on claims data, 30% of respondents were at high risk for future foot complications. Compared to those at low risk, those at high risk were more likely to report having an annual foot exam, using protective footwear, and perceiving themselves to be high risk for future foot complications. However, 50% of those with claims indicating a high risk perceived themselves to be at low risk for future foot complications. Overall, 20% of respondents seldom checked their feet daily for sores or irritations. Among this group, 60% felt that it was unimportant and 9% reported they were limited by poor vision or physical problems. Our findings suggest that strategies are needed to improve the delivery of preventive foot care services to older persons with diabetes. Additionally, emphasis is needed to help individuals understand their risk and seek and perform appropriate preventive foot care.