Vanessa A. Diaz

Changes in Age at Diagnosis of Type 2 Diabetes Mellitus in the United States, 1988 to 2000

PURPOSE The prevalence of diabetes in the United States is increasing. There is also concern that diabetes may be occurring at a greater frequency in youth and in young adults. We describe US population trends in self-reported age at diagnosis of type 2 diabetes mellitus. METHODS We undertook a secondary analysis of data from the National Health and Nutrition Examination Survey (NHANES) 1999–2000 and NHANES III (1988–1994). Both surveys are stratified, multistage probability samples targeting the civilian, noninstitutionalized US population, which allow calculation of population estimates. We included adults aged 20 years and older. We compared self-reported age at diagnosis of type 2 diabetes between the 2 survey periods. RESULTS The mean age at diagnosis decreased from 52.0 to 46.0 years (P <.05). Racial and ethnic differences in age at diagnosis found in 1988 to 1994 are no longer found in 1999 to 2000. CONCLUSIONS The age at diagnosis of type 2 diabetes mellitus has decreased with time. This finding likely represents a combination of changing diagnostic criteria, improved physician recognition of diabetes, and increased public awareness. Younger age at diagnosis may also reflect a true population trend of earlier onset of type 2 diabetes.

Nasal Carriage of Staphylococcus aureus and Methicillin-Resistant S aureus in the United States, 2001–2002

PURPOSE Staphylococcus aureus is a common cause of invasive infections, yet most assessments of prevalence are based on health care–based samples. We computed population-based estimates of nasal carriage of S aureus and risk factors for carriage, as well as population-based estimates of nasal carriage of methicillin-resistant S aureus (MRSA). METHODS We used the National Health and Nutrition Examination Survey (NHANES) 2001–2002 to estimate carriage of S aureus and MRSA for the non-institutionalized US population including children and adults. RESULTS An estimated 86.9 million persons (32.40% of the population) were colonized with S aureus. The prevalence of MRSA among S aureus isolates was 2.58%, for an estimated population carriage of MRSA of 0.84% or 2.2 million persons. Among individuals with S aureus isolates, individuals aged 65 years or older had the highest MRSA prevalence (8.28%). Among all the racial/ethnic groups studied, Hispanics had the highest prevalence of colonization with S aureus but, when colonized, were less likely to have MRSA. CONCLUSIONS This first nationally representative assessment of carriage of S aureus indicates that nearly one third of the population is currently colonized by this organism. Although the prevalence of MRSA remains low, more than 2.2 million people carry this resistant organism; thus, vigilance in promoting appropriate microbial transmission protocols should remain a priority.

The association between weight fluctuation and mortality: results from a population-based cohort study.

Previous studies evaluating the association between weight fluctuation and mortality are limited and have conflicting results. This study will further evaluate the association between weight fluctuation and mortality in a nationally representative cohort by performing survival analysis of NHANES I and NHANES I Epidemiologic Follow-up Study (n=8479; weighted sample=68,200,905). This cohort was followed from 1971 to 1992 and categorized using weight change over five time points into stable non-obese, stable obese, weight gain, weight loss and weight fluctuation groups. All-cause mortality (ACM) and cardiovascular mortality (CM) were evaluated. Respondents with weight fluctuation had higher ACM (HR: 1.83, 95% CI: 1.25–2.69) and CM hazards ratios (HR: 1.86, 95% CI: 1.10–3.15) than the stable non-obese group, even after controlling for pre-existing disease, initial BMI and excluding those in poor health or incapacitated. Increased mortality was also seen in the weight loss group (ACM HR: 3.36, 95% CI: 2.47–4.55), (CM HR 4.22, 95% CI: 2.60–6.84). The stable obese group did not have increased ACM, but did have increased CM prior to the exclusion of those in poor health or incapacitated. (HR: 2.17, 95% CI: 1.10–4.28). Weight fluctuation is associated with a higher risk of all-cause and cardiovascular disease mortality in the US population, even after adjustment for pre-existing disease, initial BMI and the exclusion of those in poor health or incapacitated. Thus, health care providers should promote a commitment to maintaining weight loss to avoid weight fluctuation and consider patients’ weight histories when assessing their risk status.

Acculturation and Healthy Lifestyle Among Latinos With Diabetes

PURPOSE Latinos have a high prevalence of diabetes and disproportionately experience diabetic complications. We sought to examine the association of acculturation on healthy lifestyle habits among the Latino population in the United States with diabetes. METHODS We studied Latino adults (aged ≥20 years) with previously diagnosed diabetes in the 1999–2004 National Health and Nutrition Examination Survey (unweighted N = 467; weighted N = 1,957,778). Healthy lifestyle habits were those consistent with recommendations of the American Diabetes Association (ADA) regarding exercise, smoking, obesity, and diet. Acculturation was measured with the Short Acculturation Scale, a validated 5-item scale assessing use of the Spanish language. Logistic regression analyses of acculturation and healthy behaviors were computed controlling for access to care, demographics, and disease characteristics. RESULTS In bivariate analyses, compared with their less-acculturated counterparts, individuals who were more-acculturated to any extent were less likely to have a higher fiber intake (9.4% vs 35.4%, P = .001) and lower saturated fat intake (17.2% vs 46.5%, P = .03). More-acculturated individuals were more likely to report leisure time exercise (59.2% vs 19.3%, P <.001), whereas the proportion of individuals who smoked did not differ. In logistic regression analyses using the 1994 ADA dietary guidelines, more-acculturated individuals were less likely than their less-acculturated counterparts to meet dietary criteria for saturated fat consumption (odds ratio, 0.13; 95% confidence interval [CI], 0.04–0.41). When using the stricter 2006 ADA dietary guidelines, more-acculturated individuals were less likely to have recommended consumption of both saturated fat (odds ratio, 0.06; 95% CI, 0.02–0.20) and fiber (odds ratio, 0.19; 95% CI, 0.08–0.48). Acculturation did not significantly influence exercise and smoking status in logistic regression analyses. CONCLUSIONS These results suggest that acculturation among diabetic Latinos to the general US culture is associated with adoption of some less desirable dietary habits.

Association between vitamin D and diabetic neuropathy in a nationally representative sample: results from 2001–2004 NHANES

Diabet. Med. 29, 50–55 (2012)

Use of the Nutrition Facts Label in Chronic Disease Management: Results from the National Health and Nutrition Examination Survey

Dietary modifications are common treatment strategies for patients with various chronic diseases, but it is unclear how often these individuals read food labels. The objective of this study was to determine whether patients with chronic disease who are advised to change their eating habits read nutrition labels more than patients who have not been so advised, and whether that impacts their energy and nutrient intake. Analysis of the 2005-2006 National Health and Nutrition Examination Survey, a nationally representative, cross-sectional survey of the United States population, was performed. Adults (20 years of age or older) who participated in the 2005-2006 National Health and Nutrition Examination Survey and who had type 2 diabetes, hypertension, and/or hyperlipidemia were included for analysis. There were 3,748 unweighted participants, which represents 170,958,166 in the US population. Proportions of patients with chronic disease who read nutrition labels were compared by chi(2) analysis, mean values of various components of their diet were compared by the two-sample independent t test, and odds ratios and 95% confidence intervals were determined by logistic regression. Among patients with chronic disease, the odds of reading food labels when told by their doctor or another health professional to reduce calories or weight was 50% higher than in those without physician intervention (odds ratio=1.50, 95% confidence interval: 1.12 to 2.00). Those who read food labels consumed less energy, saturated fat, carbohydrates, and sugar, and more fiber than those who did not. These findings point to the value of dietary counseling in chronic disease management.

Leukocyte telomere length and coronary artery calcification.

OBJECTIVE Leukocyte telomere length is representative of biological aging and is associated with clinical coronary artery disease but its association with coronary atherosclerosis is unclear. The objective of this study was to examine the association of telomere length with coronary artery calcification in middle aged adults. METHODS Leukocyte telomere length was measured with a quantitative PCR-based technique and coronary artery calcification (CAC) scoring was performed on a dual-source CT scanner in a sample of 325 adults aged 40-64 years old free of previously diagnosed diabetes, CHD, stroke and cancer. We used logistic regression to determine the association of presence of CAC (Agatston score >0 versus 0) with telomere length adjusted for age, gender, race and metabolic syndrome. Finally, we examined the relation of telomere length to extensiveness of CAC. RESULTS The unadjusted odds ratio of having CAC for the shortest tertile of telomere length versus the longest was 3.39 (95% CI 1.85-6.20). After adjustment for age, race, gender and metabolic syndrome the odds decreased but remained significant (OR 2.36; 95% CI 1.23-4.52). Mean telomere length was significantly shorter with more extensive coronary calcification. The correlation between telomere length and chronological age was r=-0.19 (p<.001) while the correlation between telomere length and arterial age was r=-0.22 (p<.001). CONCLUSIONS In conclusion, telomere length is negatively associated with the presence of coronary atherosclerosis in a low risk cohort free of previously diagnosed CVD.

The Association of Vitamin D Deficiency and Insufficiency with Diabetic Nephropathy: Implications for Health Disparities

Objective: To evaluate the association between vitamin D deficiency and insufficiency with diabetic nephropathy across racial/ethnic groups. Methods: Cross-sectional analysis of the 2001 to 2006 National Health and Nutrition Examination Survey. A nationally representative sample of 1216 adults (≥20 years old) with diagnosed diabetes provides population estimates for >12.6 million individuals. Nephropathy was defined as urinary albumin-to-creatinine ratio ≥30 mg/g in a random spot urine sample. Serum 25-hydroxycalciferol vitamin D levels were characterized as <20 ng/mL vitamin D deficiency, 20 to 29 ng/mL vitamin D insufficiency, and ≥30 ng/mL normal vitamin D. Results: Overall, 30.7% of adults with diabetes have nephropathy, 48.9% have vitamin D deficiency and 36.6% have vitamin D insufficiency. Minorities are more likely to have nephropathy (non-Hispanic whites, 27.8%; non-Hispanic blacks, 36.2%; Hispanics 38.5%; P = .02) and vitamin D deficiency (non-Hispanic whites, 39.5%; non-Hispanic blacks, 80.4%; Hispanic, 59.0%; P < .01). Higher proportions of individuals with nephropathy have vitamin D deficiency than individuals without nephropathy (53.2% vs 47.0%; P = .03). Logistic regressions demonstrate vitamin D deficiency and insufficiency are associated with the presence of nephropathy after adjustment for race/ethnicity, age, sex, hypertension, high cholesterol, smoking status, and use of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (odds ratio, 1.85; 95% CI, 1.06–3.23 for vitamin D deficiency; and odds ratio, 1.79; 95% CI, 1.12–2.85 for vitamin D insufficiency). Conclusions: There is a high prevalence of vitamin D deficiency and insufficiency in individuals with diabetes; minorities have the highest prevalences. Thus, evaluating vitamin D levels in people with diabetes may be warranted. There is an independent association between vitamin D deficiency and vitamin D insufficiency with the presence of nephropathy, even after adjustment for race/ethnicity and other variables. Further studies of this relationship may lead to new interventions that decrease health disparities in the progression of diabetic nephropathy.

Factors affecting Latino adults' use of antibiotics for self-medication.

Background: Recent data has suggested the use of antibiotics acquired without a prescription by Latinos in the United States. We explored Latino adults’ experience in treating common infections particularly in regards to self-medication with antibiotics. Methods: We conducted 3 focus groups (n = 28) in Charleston, South Carolina, with Latino adults (≥18 years of age) recruited throughout the community: 12 women and 16 men, ranging in age from 18 to 52 years. All of the participants were immigrants, 89% noted Mexico as their country of origin. Focus groups were conducted in Spanish and audiotaped. Transcripts were translated into English and then translated back to Spanish to assure consistency of the language. Themes were identified using an editing style. Results: Participants’ previous experiences in countries with limited restrictions on antibiotics influenced acquisition of antibiotics without a prescription in the United States. Participants believed that physician visits for a diagnosis and prescription were unnecessary when the patient was familiar with the symptom and it had previously responded to antibiotic treatment. Access to care was not reported to be a significant barrier to a physician visit when individuals felt they were “sick” or children were the patients. Participants reported using local tiendas (small stores in Latino neighborhoods that sell ethnically consistent and imported products) and importation of medication to meet their need for self-medication with antibiotics. The role of self-medication in the development of antibiotic resistance was essentially unknown among the participants. Conclusions: Successful interventions to improve use of antibiotics need to be culturally sensitive to specific attitudes and behaviors found in the Latino population.

Availability of Antibiotics for Purchase Without a Prescription on the Internet

PURPOSE Reducing inappropriate use of antibiotics is key to many antibiotic resistance initiatives. Most initiatives, however, focus almost exclusively on controlling prescribing by health care clinicians and do not focus on patient self-medication. The purpose of this study was to examine antibiotics available to patients without a prescription, a phenomenon on the Internet. METHODS We conducted an Internet search using 2 major search engines (Google and Yahoo) with the key words “purchase antibiotics without a prescription” and “online (English only).” Vendors were compared according to the classes of antibiotics available, quantity, shipping locations, and shipping time. RESULTS We found 138 unique vendors selling antibiotics without a prescription. Of those vendors, 36.2% sold antibiotics without a prescription, and 63.8% provided an online prescription. Penicillins were available on 94.2% of the sites, macrolides on 96.4%, fluoroquinolones on 61.6%, and cephalosporins on 56.5%. Nearly all, 98.6%, ship to the United States. The mean delivery time was 8 days, with 46.1% expecting delivery in more than 7 days. Among those selling macrolides (n = 133), 93.3% would sell azithromycin in quantities consistent with more than a single course of medication. Compared with vendors that require a medical interview, vendors who sell antibiotics without a prescription were more likely to sell quantities in excess of a single course, and the antibiotics were more likely to take more than 7 days to reach the customer. CONCLUSIONS Antibiotics are freely available for purchase on the Internet without a prescription, a phenomenon that encourages self-medication and low quality of care.