Diabetes - References

Kidney Int 1999 Sep 3;56(3):1136-1148

Body weight-for-height relationships predict mortality in maintenance hemodialysis patients.

Kopple JD, Zhu X, Lew NL, Lowrie EG

[Record supplied by publisher]

BACKGROUND: Protein-energy malnutrition is a strong predictor of mortality in maintenance hemodialysis (MHD) patients. This association has generally been described for serum chemistry measures of protein-energy malnutrition. We hypothesized that body weight-for-height relationships also predict survival in MHD patients. METHODS: During the last three months of 1993, data were obtained on 12,965 men and women concerning clinical characteristics (height, postdialysis weight, age, gender, race, and presence or absence of diabetes mellitus) and laboratory measurements (predialysis serum albumin, creatinine and cholesterol, and the urea reduction ratio). Patient survival during the next 12 months was evaluated retrospectively. RESULTS: In comparison to values for normal Americans determined from the National Health and Nutrition Evaluation Survey II data, weight-for-height relationships tended to be slightly lower than normal in African American men and women and Caucasian men undergoing MHD and were normal or slightly greater in the taller Caucasian women. In both men and women, the mortality rate decreased progressively as the patients' weight-for-height increased. MHD patients who weighed more than normal had the lowest mortality rates. After adjustment for clinical characteristics and laboratory measurements, the inverse relationship between mortality rates and weight-for-height percentiles was still highly significant for patients within the lower 50th percentile of body weight-for-height. Serum albumin correlated directly with weight-for-height in patients in the lower 50th percentile of weight-for-height. Serum creatinine and cholesterol correlated directly with weight-for-height in the entire population of men and women. In contrast, the urea reduction ratio was inversely correlated with weight-for-height. CONCLUSIONS: These data indicate that weight-for-height is a strong predictor of 12-month mortality in male and female MHD patients. Multivariate analyses indicate that body weight-for-height is an independent predictor of higher mortality in those patients who are in the lower 50th percentile for this measurement.

PMID: 10469384

Am J Kidney Dis 1999 Aug;34(2):254-8

Familial clustering of end-stage renal disease in blacks with HIV-associated nephropathy.

Freedman BI, Soucie JM, Stone SM, Pegram S

Internal Medicine/Infectious Diseases, Wake Forest University School of Medicine, Winston-Salem, NC, USA. bfreedma@wfubmc.edu

Human immunodeficiency virus-associated nephropathy (HIVAN) develops more often in HIV-infected blacks than whites. Blacks also show marked familial clustering of other causes of end-stage renal disease (ESRD), particularly diabetes mellitus-, hypertension-, and systemic lupus erythematosus-associated ESRD. We compared the family history of ESRD in 201 blacks with ESRD caused by HIVAN (cases) to that of 50 HIV-infected blacks without renal disease (controls) to determine whether HIV-associated ESRD shows familial aggregation. Cases were identified using the Southeastern Kidney Council/ESRD Network 6 Family History of ESRD database. Cases initiated dialysis between September 1993 and October 1998. Controls were consecutively identified, HIV-infected blacks with serum creatinine concentrations of 1.3 mg/dL or less and no proteinuria, treated in an infectious disease clinic during September 1998. Cases and controls had similar mean ages and family sizes. First- or second-degree relatives with ESRD were reported by 24.4% of the cases compared with 6% of the controls (P = 0.004). Logistic regression analysis, controlling for sex, family size, and age, showed cases were 5.4 times more likely than controls to have close relatives with ESRD (P = 0.007). The 49 HIVAN cases who reported a positive family history had a mean of 1.2 additional relatives with ESRD per case (60 total relatives with ESRD). HIVAN was not listed as the cause of ESRD in any of the 27 relatives who underwent dialysis in Network 6 facilities. We conclude that ESRD clusters in the families of nearly 25% of blacks initiating renal replacement therapy for HIVAN. This familial aggregation of ESRD appears to be independent of HIV infection. Although environmental factors cannot be excluded, it is possible an inherited susceptibility to renal failure is present in many blacks with HIV infection who subsequently develop nephropathy.

PMID: 10430971, UI: 99362889

Am J Cardiol 1999 Jul 1;84(1):31-6

Prediction of coronary heart disease mortality in blacks and whites: pooled data from two national cohorts.

Liao Y, McGee DL, Cooper RS

Department of Preventive Medicine and Epidemiology, Loyola University Stritch School of Medicine, Maywood, Illinois 60153, USA. yliao@wpo.it.luc.edu

Statistical models used to predict personal risk of death from coronary heart disease (CHD) have been based on studies among white populations. We compared the predictive functions derived from black and white men and women, using the pooled data of 2 national cohorts: the First National Health and Nutrition Examination Survey (NHANES I) Epidemiologic Follow-up Study and the Second National Health and Nutrition Examination Survey (NHANES II) Mortality Study. The participants included 6,937 white men, 940 black men, 9,202 white women, and 1,463 black women aged 30 to 74 years who were free of CHD at baseline. The 2 cohorts were followed for 20 and 15 years, respectively. There were no significant differences between blacks and whites in the magnitude of the Cox coefficients for most of the personal risk factors (i.e., age, systolic blood pressure, serum total cholesterol, smoking, and diabetes mellitus status) for men and women. The receiver operating characteristic (ROC) analyses, with all risk factors considered collectively, suggest that the models have similar ability to rank personal relative risk among blacks and whites. The areas under the ROC curve were 0.77 and 0.76 for white and black men, respectively, and 0.84 and 0.82 for white and black women, respectively. However, the equation derived from white men overestimated the 15-year cumulative CHD mortality in black men by about 60%. Thus, predictive functions derived from 1 demographic group (e.g., whites) can be applied to another subgroup (e.g., blacks) to rank personal risk. However, prediction of absolute risk is less accurate.

PMID: 10404847, UI: 99331733

Diabetes Care 1999 Jul;22(7):1105-9

Work disability and diabetes.

Mayfield JA, Deb P, Whitecotton L

Department of Family Practice, Bowen Research Center, Indiana University, Indianapolis, USA.

OBJECTIVE: To determine the rates and demographic determinants of work disability, hours worked per week, work-loss days, and wages in individuals with diabetes. RESEARCH DESIGN AND METHODS: A probit regression analysis was performed on a cross-sectional population-based survey of U.S. noninstitutionalized civilian population (National Medical Expenditures Survey--2, 1987). The sample was restricted to individuals aged > or = 25 years. A total of 1,502 individuals reported having diabetes, and 20,405 did not. Information on workforce participation and income were collected quarterly. Work disability was defined as a self-report of having been unable to work because of illness or disability for > or = 2 quarters in 1987. RESULTS: Work disability was reported by 25.6% of individuals with diabetes, compared with 7.8% of those without diabetes. Work disability rates were higher for older people, females, and African-Americans, and lower for Hispanics and for individuals with greater non-wage income. Individuals with diabetes engaged in the workforce had more work-loss days than did nondiabetic individuals, but had similar hourly wages. Predicted mean earnings were significantly lower for individuals with diabetes at all ages, resulting in $4.7 million loss in earnings in 1987 due to work disability. CONCLUSIONS: Work disability is significantly higher for individuals with diabetes than for those without diabetes at all ages, and results in a significant decrease in earnings. A disproportionate burden of work disability is borne by older individuals and women with diabetes. Better information on the determinants of work disability in individuals with diabetes is needed.

PMID: 10388975, UI: 99317206

Profiles Healthc Mark 1999 Jan-Feb;15(1):23-6

"Control your diabetes" campaign encourages a healthy lifestyle. National Diabetes Education Program.

Herreria J

PMID: 10387457, UI: 99256577

South Med J 1999 Jun;92(6):593-9

Diabetes-related lower-extremity amputations disproportionately affect Blacks and Mexican Americans.

Lavery LA, van Houtum WH, Ashry HR, Armstrong DG, Pugh JA

Department of Orthopaedics, University of Texas Health Science Center, San Antonio, USA.

BACKGROUND: We sought to identify the age-adjusted incidence of lower-extremity amputation (LEA) in Mexican Americans, blacks, and non-Hispanic whites with diabetes in south Texas. METHODS: We summarized medical records for hospitalizations for LEAs for 1993 in six metropolitan statistical areas in south Texas. RESULTS: Age-adjusted incidence per 10,000 patients with diabetes was 146.59 in blacks, 60.68 in non-Hispanic whites, and 94.08 in Mexican Americans. Of the patients, 47% of amputees had a history of amputation, and 17.7% were hospitalized more than once during 1993. Mexican Americans had more diabetes-related amputations (85.9%) than blacks (74.7%) or non-Hispanic whites (56.3%). CONCLUSIONS: This study is the first to identify the incidence of diabetes-related lower-extremity amputations in minorities using primary data. Minorities had both a higher incidence and proportion of diabetes-related, LEAs compared with non-Hispanic whites. Public health initiatives and national strategies, such as Healthy People 2000 and 2010, need to specifically focus on high-risk populations and high-risk geographic areas to decrease the frequency of amputation and reamputation.

PMID: 10372853, UI: 99300068

J Clin Endocrinol Metab 1999 Jun;84(6):2037-42

The roles of insulin sensitivity, insulin-like growth factor I (IGF-I), and IGF-binding protein-1 and -3 in the hyperandrogenism of African-American and Caribbean Hispanic girls with premature adrenarche.

Vuguin P, Linder B, Rosenfeld RG, Saenger P, DiMartino-Nardi J

Department of Pediatrics, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York 10467, USA.

Recent reports indicate that girls with premature adrenarche are at risk of developing functional ovarian hyperandrogenism and polycystic ovarian syndrome (PCOS). As insulin and insulin-like growth factors (IGFs) have been implicated in the pathogenesis of PCOS, we hypothesize that they may also have a role in the hyperandrogenism of premature adrenarche. Thirty-five prepubertal girls (23 Caribbean Hispanics and 12 Black African-Americans) underwent a 60-min ACTH and LH-releasing hormone test. Insulin sensitivity (S(I)) was assessed using the frequently sampled i.v. glucose tolerance test with tolbutamide. Fasting levels of IGF-I, IGF-binding protein-1 (IGFBP-1), IGFBP-3, sex hormone-binding globulin, and free testosterone (T) were also obtained. The mean age of the patients was 6.8 yr, and bone age was 8.0 yr. Twenty-five patients had a family history of noninsulin-dependent diabetes mellitus and 19 patients had acanthosis nigricans. The mean S(I) for the entire group was 6.78 +/- 5.21 x 10(-4) min/microU x mL (normal prepubertal S(I), 6.5 +/- 0.54 x 10(-4) min(-1) x microU(-1) x mL(-1)). However, 15 of the 35 girls had an S(I) that was more than 2 SD below the mean reported for normal prepubertal children. Of these 15 patients, 13 were obese, and 14 had acanthosis nigricans. For the entire group of girls, the mean ACTH-stimulated levels of 17-hydroxypregnenolone (17OHPreg), dehydroepiandrosterone (DHEA), androstenedione (AS), 17-hydroxyprogesterone (17OHP), and T and the ACTH-stimulated ratios of 17OHPreg/17OHP, 17OHPreg/DHEA, 17OHP/AS, and DHEA/AS did not differ from the levels reported for Tanner stage II-III pubertal girls. The girls were divided into two groups based on their S(I) (group I, S(I) >2 SD below the mean for age; group II, normal S(I)). The group I girls with a reduced S(I) had significantly higher ACTH-stimulated levels of 17OHPreg (group I, 760 +/- 87.84 ng/dL; group II, 428.9 +/- 46.28 ng/dL; P = 0.002), 17OHPreg/17OHP ratio (group I, 3.95 +/- 0.36; group II, 2.96 +/- 0.35; P = 0.05), 17OHPreg/DHEA (group I, 2.06 +/- 0.21; group II, 1.4 +/- 0.13; P = 0.01), and free T (group I, 1 +/- 0.23 ng/dL; group II, 0.49 +/- 0.19 ng/dL; P = 0.014). Levels of sex hormone-binding globulin were lower in the group I girls. Furthermore, for the entire group of girls, the S(I) correlated inversely with ACTH-stimulated levels of 17OHPreg, DHEA, and AS and the ACTH-stimulated ratio of 17OHPreg/17OHP. IGF-I correlated inversely with S(I) (r = -0.94; P < 0.001) and correlated directly with the ACTH-stimulated levels of 17OHPreg (r = 0.8; P < 0.001) and AS (r = 0.63; P < 0.05). IGF-I also correlated with the ACTH-stimulated ratios of 17OHPreg/17OHP (r = 0.61; P < 0.05), 17OHPreg/DHEA (r = 0.9; P < 0.001), 17OHP/AS (r = 0.79; P < 0.001), and DHEA/AS (r = 0.96; P < 0.001). IGFBP-1 correlated inversely with the ACTH-stimulated levels of 17OHPreg (r = -0.38; P < 0.05) and DHEA (r = -0.36; P < 0.05). To summarize, the ACTH-stimulated delta5-steroid levels were higher in prepubertal girls with premature adrenarche and reduced S(I). There was a significant inverse correlation among ACTH-stimulated hormone levels, S(I), and IGFBP-1, whereas IGF-I correlated directly with ACTH-stimulated androgens. These findings support the hypothesis that insulin and IGFs may have a role in the hyperandrogenism of premature adrenarche just as they do in PCOS. Hence, in certain girls with premature adrenarche, hyperandrogenism may be the first presentation of PCOS and/or insulin resistance.

PMID: 10372707, UI: 99299922

J Gerontol A Biol Sci Med Sci 1999 May;54(5):M230-6

Reported and measured physical functioning in older inner-city diabetic African Americans.

Miller DK, Lui LY, Perry HM 3rd, Kaiser FE, Morley JE

Division of Geriatric Medicine, St. Louis University, Geriatric Research, Education and Clinical Center, St. Louis VA Medical Center, Missouri 63104, USA. millerdk@slu.edu

BACKGROUND: The impact of diabetes on disability and physical functioning in older African Americans and potential causes of the excessive disability associated with diabetes in other studies have been inadequately investigated. METHODS: A population-based survey was performed comparing 116 self-reported diabetic inner-city African Americans aged 70 years and older to 522 nondiabetic persons from the same population. A subsample (n = 168) received a physical examination focused on body habitus, upper and lower body strength, balance, and timed physical performance tasks. Blood tests were obtained from 173 subjects. RESULTS: Diabetic individuals reported worse general health (p = .01), instrumental activities of daily living (p = .02), and modified versions of the Rosow-Breslau scale (p<.001) and the Stanford Health Assessment Questionnaire (p = .002). Diabetic persons also reported more falls (0.59 per person vs. 0.20, p = .019) and injurious falls (12% vs. 6%, p = .025). There were minimal differences in the strength, balance, and timed performance measures (analyzed separately by gender). In multivariable analyses, impairments in visual function and pain and light touch perception appeared to explain some of the association between diabetic status and poor general health, disability, and falls, with lesser contribution from the number of medical problems, number of medications, and glycemic control. CONCLUSIONS: Older inner-city diabetic blacks demonstrated worse general health, excess disability, and more falls compared to controls, although deficits in strength, balance, and timed performance could not be demonstrated. The cause of decreased functional status in diabetic elders deserves additional investigation, focusing especially on sensory function, glycemic control, and contribution from specific medical problems and medications.

PMID: 10362005, UI: 99288851

Ethn Dis 1999 Winter;9(1):22-32

Ethnic variation in the health burden of self-reported diabetes in adults aged 75 and older.

Black SA, Jakobi PL, Rush RD, DiNuzzo AR, Garcia D

Center on Aging, Department of Internal Medicine, University of Texas Medical Branch, Galveston 77555-0860, USA. sblack@utmb.edu

OBJECTIVE: The health burden of self-reported diabetes was compared across three ethnic groups of older adults. METHODS: Analysis of variance and logistic regression were used to compare ethnic differences in the rates of co-morbid chronic health conditions, complications, and disability for older diabetics vs non-diabetics, in a sample of 173 Mexican Americans, 201 African Americans, and 181 non-Hispanic whites, all aged 75 and older. RESULTS: The prevalence of self-reported diabetes was significantly higher in older Mexican Americans (17.6%) and African Americans (16.4%) than in non-Hispanic whites (8.5%). In all three ethnic groups, and after controlling for sociodemographic characteristics, diabetics were found to be generally at higher risk for chronic conditions such as heart disease, stroke, and hypertension, circulation and foot problems, obesity, and impaired vision and activities of daily living. Multivariate analyses indicated that the burden of diabetes appeared to be greatest among non-Hispanic white diabetics. We suggest that this is the result of higher diabetes-mortality rates among minority diabetics at earlier ages. CONCLUSIONS: Diabetes is known to be increasing in prevalence and incidence, particularly among the elderly, the fastest growing segment of the population. Our findings indicate that regardless of ethnicity, diabetes carries an increased burden that affects both the functioning and the quality of life of older adults.

PMID: 10355472, UI: 99281603

Ethn Dis 1999 Winter;9(1):3-9

Abnormal urinary protein excretion in African Americans with type 2 diabetes mellitus.

Konen JC, Summerson JH, Bell RA

Department of Family Medicine, Carolinas Medical Center, Charlotte, North Carolina 28232-2861, USA. jkonen@carolinas.org

The purpose of this investigation was to determine the prevalence and correlates of abnormal urinary albumin excretion and to examine the possible additive effects of cardiovascular risk factors on urinary albumin excretion in African Americans with type 2 diabetes mellitus. One hundred fifty-one African-American subjects who met WHO criteria for type 2 diabetes were included in this cross-sectional analysis. Subjects were identified through computerized medical records from a family medicine clinic and a community health center. Urinary albumin excretion ratios (UAER) were determined from overnight samples. The prevalence of abnormal urinary protein excretion was 51%. Of those with abnormal protein excretion, 36% had microalbuminuria and 15% had macroalbuminuria. Diabetes duration, waist to hip ratio, blood pressure, and total- and LDL cholesterol were significantly higher in subjects with macroalbuminuria. Regression analysis indicated that mean arterial blood pressure, diabetes duration and total cholesterol were independently associated with UAER. Mean UAER significantly increased with the addition of one or more syndrome X risk factors to pure diabetes. Our results indicate that African Americans with type 2 diabetes mellitus have a high prevalence of abnormal urinary protein excretion, which is associated with a clustering of additional cardiovascular risk factors. The fact that this increased risk was associated with hypertension indicates that screening for albuminuria in this population is essential and that a majority of African Americans with diabetes may be at risk for developing cardiovascular complications.

PMID: 10355470, UI: 99281601

J Hypertens Suppl 1999 Feb;17(1):S19-24

Difficult-to-treat hypertensive populations: focus on African-Americans and people with type 2 diabetes.

Flack JM, Hamaty M

Department of Internal Medicine, Wayne State University School of Medicine, John D. Dingell VA Medical Center, and the Detroit Medical Center, Michigan 48201, USA. jflack@oncgate.roc.wayne.edu

The awareness, treatment, and control of hypertension has risen steadily over the past three decades, until the early 1990s. However, blood pressure control to < 140/90 mmHg is attained in fewer than 25% of all hypertensive patients and fewer than 50% of drug-treated hypertensive patients, except for white women. Two special populations, African-Americans and diabetics, share several important attributes. First, they both have a high prevalence of hypertension, including stage 3 hypertension (as defined by the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of Hypertension VI: > or =180/110 mmHg), relative to other subgroups. African-Americans have an approximate 8% prevalence of stage 3 hypertension, and elevated systolic blood pressure is highly prevalent among diabetic people, particularly older African-American women. Second, both groups have high levels of blood-pressure-related target-organ damage, which contributes to their inordinately high absolute risk for cardiovascular disease complications (i.e. stroke, congestive heart failure, renal failure) at a given level of blood pressure. Moreover, the reduced natriuretic capacity common to each group contributes to the attenuated efficacy of antihypertensive drug monotherapy, particularly for drug classes other than diuretics and calcium antagonists. These two special populations are also typically salt-sensitive, an intermediate blood pressure phenotype that raises blood pressure medication requirements. This phenomenon has been associated with an attenuation in the normal nocturnal fall in blood pressure. The high absolute risk for cardiovascular disease among diabetics led to the formulation of more aggressive treatment recommendations for antihypertensive drug therapy. In diabetics, blood pressure therapy is initiated at blood pressures > or = 130/85 mmHg, and treatment goals are at least to this level, unless proteinuria is > or = 1g/day (in which case the goals are < 125/75 mmHg). The more aggressive treatment targets for diabetics will not be reached with most currently available single antihypertensive agents in many African-Americans. While at best only 50-60% of hypertensive patients can be controlled with single drug therapy, that percentage falls dramatically in persons with stage 3 hypertension and renal insufficiency, thereby necessitating the use of combination drug therapy. Treatment alone is not enough; treatment to goal blood pressure is an essential first step towards optimal target-organ protection. While circulating levels of renin are suppressed, in general, in these special populations, each group manifests an inordinate burden of blood-pressure-related target-organ damage that has been linked to excessive levels of angiotensin II or a reduced bradykinin and nitric oxide tissue effect. The renin-angiotensin-aldo-sterone-kinin system is therefore an attractive therapeutic target that might conceivably provide target-organ protection over and above that attributable solely to lowering the blood pressure.

Publication Types:

• Review
• Review, tutorial

PMID: 10340840, UI: 99270688

Diabetes Care 1999 Feb;22(2):345-54

Emerging epidemic of type 2 diabetes in youth.

Rosenbloom AL, Joe JR, Young RS, Winter WE

Children's Medical Services Center, University of Florida College of Medicine, Gainesville 32608, USA. rosenal@peds.ufl.edu

This review considers the epidemiologic evidence of an increasing incidence of type 2 diabetes in youth, the classification and diagnostic issues related to diabetes in young populations, pathophysiologic mechanisms relevant to the increasing incidence, the role of genetics and environment, and the community challenge for prevention and treatment. Type 2 diabetes in youth has been recognized to be frequent in populations of native North Americans and to comprise some 30 percent of new cases of diabetes in the 2nd decade of life, largely accounted for by minority populations and associated with obesity. Among Japanese schoolchildren, type 2 diabetes is seven times more common than type 1, and its incidence has increased more than 30-fold over the past 20 years, concomitant with changing food patterns and increasing obesity rates. The forms of diabetes seen in children and youth include typical type 1, occurring in all races; type 2, seen predominantly in minority youth; atypical diabetes, seen as an autosomal dominantly transmitted disorder in African-American populations; and maturity-onset diabetes of the young (MODY), seen rarely and only in Caucasians. Of the nonautoimmune forms of diabetes seen in youth, only type 2 diabetes is increasing in incidence. Proper classification requires consideration of onset (acute/severe versus insidious), ethnicity, family history, presence of obesity, and if necessary, studies of diabetes related autoimmunity. Insulin resistance predicts the development of diabetes in Pima Indians, in offspring of parents with type 2 diabetes, and in other high-risk populations. African-American children and youth have greater insulin responses during glucose tolerance testing and during hyperglycemic clamp study than do whites. There is also evidence of altered beta-cell function preceding the development of hyperglycemia. Of particular interest is the evidence that abnormal fetal and infantile nutrition is associated with the development of type 2 diabetes in adulthood. The thrifty phenotype hypothesis states that poor nutrition in fetal and infant life is detrimental to the development and function of the beta-cells and insulin sensitive tissues, leading to insulin resistance under the stress of obesity. The thrifty genotype hypothesis proposes that defective insulin action in utero results in decreased fetal growth as a conservation mechanism, but at the cost of obesity-induced diabetes in later childhood or adulthood. The vast majority of type 2 diabetes in adults is polygenic and associated with obesity. Monogenic forms (MODY, maternally transmitted mitochondrial mutations) are rare, but are more likely to appear in childhood. Linkage studies of the common polygenic type 2 diabetes have emphasized the heterogeneity of the disorder. The prevention and treatment of type 2 diabetes in children and youth is a daunting challenge because of the enormous behavioral influence, difficulty in reversing obesity, and typical nonadherence in this age-group. The emerging epidemic of type 2 diabetes in the pediatric population, especially among minorities whose proportion in the U.S. population is increasing, presents a serious public health problem. The full effect of this epidemic will be felt as these children become adults and develop the long-term complications of diabetes.

Publication Types:

• Review
• Review, academic

PMID: 10333956, UI: 99266498

Diabetes Care 1999 Jan;22(1):78-85

Social environment and year of birth influence type 1 diabetes risk for African-American and Latino children.

Lipton RB, Drum M, Li S, Choi H

Division of Epidemiology and Biostatistics, University of Illinois at Chicago, School of Public Health 60612, USA. rlipton@uic.edu

OBJECTIVE: Credible epidemiological data, primarily from European-origin populations, indicate that environmental factors play an important role in the incidence of type 1 diabetes. RESEARCH DESIGN AND METHODS: A population-based registry of incident cases of type 1 diabetes among African-American and Latino children in Chicago was used to explore the influence of individual and neighborhood characteristics on diabetes risk. New cases of insulin-treated diabetes in African-American and Latino Chicagoans aged 0-17 years for 1985-1990 (n = 400) were assigned to one of 77 community areas based on street address. Census tables provided denominators, median household income, percentage of adults > or = 25 years old who had completed high school and college, and a crowding variable for each community area individual-level data were birth cohort, sex, and ethnicity. Outcomes in Poisson regression were sex-, ethnic-, and birth cohort-specific incidence rates. RESULTS: Significant univariate associations between diabetes risk and ethnicity, birth cohort, crowding, and the percentage of adults in each community area who had completed high school and college were observed. African-Americans had a relative risk (RR) of 1.42 (95% CI, 1.14-1.76) compared with Latinos. Risk varied significantly by birth cohort in both ethnic groups. For every 10% increase in the proportion of adults who completed college, the RR for diabetes increased by 25% (RR, 1.25 [95% CI, 1.09-1.44]). Social class variables were significant determinants of risk for African Americans, but not for Latinos. CONCLUSIONS: The strong birth cohort and social class associations observed in this study implicate an infectious exposure linked with age.

PMID: 10333907, UI: 99266449

Diabetes Care 1999 Jan;22(1):71-7

Sex differences in African-Americans regarding sensitivity to insulin's glucoregulatory and antilipolytic actions.

Sumner AE, Kushner H, Sherif KD, Tulenko TN, Falkner B, Marsh JB

Institute for Women's Health, Allegheny University of the Health Sciences, Philadelphia, Pennsylvania, USA. annes@intra.niddk.nih.gov

OBJECTIVE: The purpose of this study was to determine if there are sex differences in African-Americans regarding the effect of obesity on sensitivity to insulin as a glucoregulatory and antilipolytic hormone. RESEARCH DESIGN AND METHODS: Data from study participants, 127 nondiabetic African-Americans (mean age 32 +/- 4 years), included anthropometric measurements, an oral glucose tolerance test (OGTT), a 2-h euglycemic-hyperinsulinemic clamp, and a fasting triglyceride level. Sensitivity to insulin as a glucoregulatory hormone was determined by M/FFM, where M is the mean glucose infusion rate during the second hour of the clamp and FFM is fat-free mass. Sensitivity to insulin's antilipolytic action was assessed during the OGTT by the percent suppression of free fatty acid (FFA) concentrations between 0 and 120 min. The higher the suppression of FFAs, the greater the sensitivity to insulin's antilipolytic action. RESULTS: The participants were classified by BMI into three groups: nonobese (31 men, 24 women), obese (17 men, 14 women), and severely obese (12 men, 29 women). The women had higher percentages of body fat (P < 0.001), and the men had greater FFM (P < 0.001). The M/FFM values for men versus women in each BMI group were nonobese, 8.8 +/- 2.8 vs. 10.8 +/- 4.4; obese, 7.2 +/- 3.4 vs. 8.5 +/- 3.4; and severely obese, 4.7 +/- 2.1 vs. 6.1 +/- 2.2. The difference between the BMI groups was significant (P < 0.001), as was the difference between men and women (P < 0.01). In addition, there was a significant sex difference in percent suppression of FFAS (P < 0.001). The men and women had similar fasting insulin and FFA concentrations; however, in the men only, the percent suppression of FFA declined with increasing obesity (nonobese, 83 +/- 15%; obese, 73 +/- 18%; and severely obese, 69 +/- 19%; P = 0.02). The women in all three BMI groups had lower FFA levels of 86-88%. CONCLUSIONS: Obese African-American men and women are resistant to insulin as a glucoregulatory hormone, but only obese men are resistant to insulin's antilipolytic action; obese African-American women are sensitive to insulin's antilipolytic action. The combined presence of sensitivity to insulin's antilipolytic action with resistance to insulin's glucoregulatory action in obese African-American women may contribute to their high prevalence of obesity and type 2 diabetes.

PMID: 10333906, UI: 99266448

Diabetes Care 1999 May;22(5):779-83

Black-white differences in risk of developing retinopathy among individuals with type 2 diabetes.

Harris EL, Sherman SH, Georgopoulos A

Kaiser Permanente Center for Health Research, Portland, Oregon, USA. harrisem@chr.mts.kpnw.org

OBJECTIVE: To assess racial differences in risk of developing retinopathy among individuals with type 2 diabetes, after taking into account differences in the distribution of risk factors for retinopathy. RESEARCH DESIGN AND METHODS: The participants were 105 individuals with type 2 diabetes, aged 40-69 years, who had no evidence of retinopathy at the time of a diabetic eye disease screening project. After an average of 4 years of follow-up, the subjects were reevaluated using nonmydriatic funds photography. RESULTS: Retinopathy occurred more often among black than white participants (50 vs. 19%). This difference could not be explained by differences in risk factors for retinopathy or potential confounders (odds ratio [95% CI] 2.96 [1.00-8.78] after adjustment for level of glycosylated hemoglobin, systolic blood pressure, type of diabetes treatment, and sex). CONCLUSIONS: These results are consistent with the concept that racial differences in risk of developing retinopathy exist among individuals with type 2 diabetes and that these differences may be caused by differential (genetic) susceptibility to the adverse effects of increased levels of blood glucose and/or blood pressure. Discovery of the etiology of this differential susceptibility would allows us to identify and target secondary prevention efforts to individuals with type 2 diabetes who are at increased risk of retinopathy.

PMID: 10332681, UI: 99265085

Diabetes Care 1999 May;22(5):736-42

Antidiabetic treatment trends in a cohort of elderly people with diabetes. The cardiovascular health study, 1989-1997.

Smith NL, Heckbert SR, Bittner VA, Savage PJ, Barzilay JI, Dobs AS, Psaty BM

Department of Medicine, University of Washington, Seattle, USA. nlsmith@u.washington.edu

OBJECTIVE: This study characterizes the pharmaceutical treatment of type 2 diabetes from 1989-1990 to 1996-1997 in an elderly cohort. RESEARCH DESIGN AND METHODS: A total of 5,888 adults aged > or = 65 years were recruited and attended a baseline clinic visit in 1989-1990 (n = 5,201, original cohort) or 1992-1993 (n = 687. African-American [new] cohort) as participants of the Cardiovascular Health Study. Fasting serum glucose (FSG) was measured at baseline. Medication use was ascertained by drug inventory at all annual clinic visits. Diabetes was defined at baseline as insulin or oral hypoglycemic agent (OHA) use or as having an FSG > or = 7.0 mmol/l (126 mg/dl), the current consensus definition of diabetes. RESULTS: A total of 387 (7%) original (FSG = 9.8 mmol/l [177 mg/dl]) and 115 (17%) new (FSG = 10.6 mmol/l [191 mg/dl]) cohort members had pharmacologically treated diabetes at baseline. Among those in the original and in the new cohorts who survived follow-up, respectively, OHA use decreased from 80 to 48% (P < 0.001) and from 67 to 50% (P < 0.003) and insulin use increased from 20 to 33% (P = 0.001) and from 33 to 37% (P = 0.603). There were 396 (8%) original (FSG = 8.8 mmol/l [159 mg/dl]) and 45 (7%) new (FSG = 10.0 mmol/l [181 mg/dl]) cohort members with diabetes untreated at baseline. Among them, respectively, OHA use reached 38 and 30% and insulin use reached 6 and 16% in 1996-1997. CONCLUSIONS: Diabetes was common in this elderly cohort, and > 80% of treated patients with diabetes at baseline were not achieving fasting glucose goals of < or = 6.7 mmol/l (120 mg/dl). Many untreated at baseline remained untreated after 7 years of follow-up.

Publication Types:

• Multicenter study

PMID: 10332674, UI: 99265078

Diabetes Care 1999 May;22(5):706-12

Correlates of physical activity in a sample of older adults with type 2 diabetes.

Hays LM, Clark DO

Indiana University Center for Aging Research, Regenstrief Institute for Health Care, Indianapolis 46202, USA. lmays@indiana.edu

OBJECTIVE: Physical activity is integral to the management of type 2 diabetes. Unfortunately, the majority of adults with type 2 diabetes do not regularly engage in physical activity. The purpose of this study was to assess physical activity behavior and its correlates (i.e., physical activity knowledge, barriers, and performance and outcome expectations) in older adults with type 2 diabetes. RESEARCH DESIGN AND METHODS: A subgroup of 260 adults with type 2 diabetes was identified from a larger stratified random sample of adults aged > or = 55 years. Participants completed an interviewer-administered survey designed from focus group findings and social learning theory. RESULTS: The majority of the respondents (54.6%) reported 0 min of weekly physical activity. This was especially true of older female respondents. Performance expectation scores were lower among respondents who were in the oldest age-group, namely, white women. Physical activity knowledge varied by age-group, and barriers to physical activity were prevalent in all groups. The following are significant correlates of reported weekly physical activity: younger age, more education, fewer motivational barriers, and greater perceived health and performance expectations. CONCLUSIONS: Given the importance of physical activity to diabetes management, the low prevalence of physical activity found in this and other studies should raise concerns among clinicians. Future research to identify predictors of physical activity is needed to guide clinicians in the promotion of physical activity.

PMID: 10332670, UI: 99265074

Diabetes Care 1999 May;22(5):700-5

Risk for metabolic control problems in minority youth with diabetes.

Delamater AM, Shaw KH, Applegate EB, Pratt IA, Eidson M, Lancelotta GX, Gonzalez-Mendoza L, Richton S

University of Miami School of Medicine, FL 33101, USA. adelamat@peds.med.miami.edu

OBJECTIVE: We examined and quantified the degree of risk for poor glycemic control and hospitalizations for diabetic ketoacidosis (DKA) among black, Hispanic, and white children and adolescents with diabetes. RESEARCH DESIGN AND METHODS: We examined ethnic differences in metabolic control among 68 black, 145 Hispanic, and 44 white children and adolescents with type 1 diabetes (mean age 12.9 [range 1-21] years), who were primarily of low socioeconomic status. Clinical and demographic data were obtained by medical chart review. Glycohemoglobins were standardized and compared across ethnic groups. Odds ratios among the ethnic groups for poor glycemic control and hospitalizations for DKA were also calculated. RESULTS: The ethnic groups were not different with respect to age, BMI, insulin dose, or hospitalizations for DKA, but black children were older at the time of diagnosis than Hispanics (P < 0.05) and were less likely to have private health insurance than white and Hispanic children (P < 0.001). Black youths had higher glycohemoglobin levels than white and Hispanic youths (P < 0.001 after controlling for age at diagnosis). Black youths were also at greatest risk for poor glycemic control (OR = 3.9, relative to whites; OR = 2.5, relative to Hispanics). CONCLUSIONS: These results underscore and quantify the increased risk for glycemic control problems of lower-income, black children with diabetes. In the absence of effective intervention, these youths are likely to be overrepresented in the health care system as a result of increased health complications related to diabetes.

PMID: 10332669, UI: 99265073

Transplant Proc 1999 May;31(3B Suppl):7S-8S

Costs savings associated with thymoglobulin for treatment of acute renal transplant rejection in patient subsets.

Schnitzler MA, Woodward RS, Lowell JA, Singer GG, Amir L, Horn HR, Kano JM, Schroeder TJ, Brennan DC

Health Administration Program, Washington University, St Louis, Missouri 63110. schnitz@wuecona.wustl.edu

Publication Types:

• Clinical trial
• Multicenter study
• Randomized controlled trial

PMID: 10330959, UI: 99261344

Arch Ophthalmol 1999 May;117(5):573-83

The Ocular Hypertension Treatment Study: design and baseline description of the participants.

Gordon MO, Kass MA

Department of Ophthalmology and Visual Sciences, Washington University, St Louis, MO 63110, USA.

BACKGROUND: The Ocular Hypertension Treatment Study (OHTS) seeks to evaluate the safety and efficacy of topical ocular hypotensive medication in preventing or delaying the onset of visual field loss and/or optic nerve damage in subjects with ocular hypertension at moderate risk for developing primary open angle glaucoma. OBJECTIVE: To describe the study protocol, the questions to be answered, and the baseline characteristics of the subjects. DESIGN: Multicenter randomized clinical trial with 2 groups: topical ocular hypotensive medication and close observation. SETTING: Subjects were enrolled and evaluated at 22 participating clinical centers. Visual fields and stereoscopic optic disc photographs were read in masked fashion. METHODS: We determined eligibility from a comprehensive eye examination, medical and ocular history, visual field testing, and stereoscopic optic disc photography. RESULTS: We describe the baseline characteristics of 1637 subjects randomized between February 28, 1994, and October 31, 1996. The mean age was 55 years; 56.9% of the subjects were women; and 25% were African American. The baseline intraocular pressure was 24.9 +/- 2.7 mm Hg (mean +/- SD). Systemic diseases and conditions reported by subjects included previous use of medication for ocular hypertension, 37%; systemic hypertension, 38%; cardiovascular disease, 6%; diabetes mellitus, 12%; and family history of glaucoma, 44%. The mean horizontal cup-disc ratio by contour estimated from stereophotography was 0.36 +/- 0.18. Qualifying Humphrey 30-2 visual fields had to be normal and reliable for entry into the study. Health-related quality of life (36-item short form health survey) scores in the OHTS sample were better than the age- and sex-matched population norms. African American subjects had larger baseline cup-disc ratios and higher reported rates of elevated blood pressure and diabetes than the rest of the subjects. CONCLUSIONS: The intraocular pressure among enrolled subjects was sufficiently high to provide an adequate test of the potential benefit of ocular hypotensive medication in preventing or delaying glaucomatous damage. The large number of African American subjects enrolled should provide a good estimate of the African American response to topical medication.

Publication Types:

• Clinical trial
• Multicenter study
• Randomized controlled trial

PMID: 10326953, UI: 99256885

Am J Cardiol 1999 May 1;83(9):1350-5

Gender differences and practice implications of risk factors for frequent hospitalization for heart failure in an urban center serving predominantly African-American patients.

Ofili EO, Mayberry R, Alema-Mensah E, Saleem S, Hamirani K, Jones C, Salih S, Lankford B, Oduwole A, Igho-Pemu P

Department of Medicine and the Medical Treatment Effectiveness Center, Morehouse School of Medicine, Atlanta, Georgia 30310, USA.

To identify the clinical correlates of recurrent heart failure hospitalization in a large urban hospital serving predominately African-American patients, and to provide further insight into modifiable risks for heart failure readmissions, a retrospective period prevalence review of the records of all adult patients admitted with a primary diagnosis of heart failure (International Classification of Diseases-9 code 428.0) between January and December 1995 was performed.The main outcome was the number of heart failure hospitalizations over 12 months. Twelve hundred patients were identified. Mean age was 64 +/- 16 years, 94% were black, 57% were women, and 40% were > or = 65 years old. Ninety-eight percent had a history of systemic hypertension and 55% had uncontrolled hypertension. Other comorbidities were left ventricular (LV) hypertrophy (64%), coronary artery disease (52%), and tobacco abuse (28%). Sixty-five percent of patients were on angiotensin-converting enzyme (ACE) inhibitors, 51% on calcium antagonists, and 8% on beta blockers. Most patients had suboptimal dosing of ACE inhibitors and there was inappropriate use of calcium antagonists in 56% of patients with moderate or severe systolic dysfunction. Diabetes mellitus and echocardiographic wall motion abnormality were independently associated with frequent admissions for women but not for men. Medication-related increase in heart failure hospitalization was seen for calcium antagonists in patients with severe LV dysfunction (odds ratio 2.24, 95% confidence intervals 1.0 to 5.03; p <0.03). Uncontrolled hypertension, underdosing of ACE inhibitors, and overuse of calcium antagonists in patients with significant LV dysfunction are potential targets for intervention.

PMID: 10235094, UI: 99249173

Pediatrics 1999 May;103(5 Pt 1):952-6

Ethnic differences in mortality from insulin-dependent diabetes mellitus among people less than 25 years of age.

Lipton R, Good G, Mikhailov T, Freels S, Donoghue E

University of Illinois at Chicago School of Public Health, Chicago, Illinois, USA.

OBJECTIVE: To determine whether the risk of death from type 1 insulin-dependent diabetes mellitus (IDDM) was similar among young non-Hispanic black, non-Hispanic white, and Hispanic patients. DESIGN: Retrospective study of death certificates for Chicago residents between 1 and 24 years of age with any mention of diabetes during 1987 through 1994. Prevalence was estimated by an ongoing incidence registry in the city, the 1990 US Census, and published studies. Autopsy reports and/or medical records were examined to determine more clearly the circumstances of death. Case-fatality rates for IDDM in non-Hispanic black, non-Hispanic white, and Hispanic patients were calculated. Deaths in those with diabetes were compared with the mortality experience of the underlying population using race-specific standardized mortality ratios. RESULTS: A total of 30 diabetes-related deaths occurred in the 8-year interval: 23 among non-Hispanic black, 5 among Hispanic, and 2 among non-Hispanic white paients. The average annual case-fatality rate for all ethnic groups combined was 247.2/10(5) (95% CI: 166. 9-353.5). Race-specific rates were 447.8/10(5) (283.9-671.7) for non-Hispanic black patients, 175.6/10(5) (56.9-409.2) for Hispanic patients, and 48.2/10(5) (5.8-174.0) for non-Hispanic white patients; there were no gender differences in risk. A total of 8 individuals died at the onset of disease (7 non-Hispanic black patients and 1 Hispanic patient). Compared with the underlying population, ethnic-specific standardized mortality ratios were elevated significantly for non-Hispanic black and Hispanic patients but not for non-Hispanic white patients. CONCLUSIONS: Short-term mortality is elevated substantially among non-Hispanic black and Hispanic youth with IDDM. The ninefold greater risk of death for non-Hispanic black compared with non-Hispanic white youth with diabetes may indicate gaps in access to comprehensive diabetes care.

PMID: 10224171, UI: 99240844

J Basic Clin Physiol Pharmacol 1998;9(2-4):407-18

Acanthosis nigricans.

Stuart CA, Driscoll MS, Lundquist KF, Gilkison CR, Shaheb S, Smith MM

Department of Medicine, University of Texas Medical Branch at Galveston, USA.

Acanthosis nigricans is a lesion affecting localized areas of the skin in persons with obesity and/or hyperinsulinemia. Roughening of the skin correlates with histological papilomatosis and the apparent darkening is due to hyperkeratosis. Biochemical mechanisms for developing this hyperplastic lesion are unclear, but likely involve local cutaneous growth factors. Cross sectional surveys of unselected populations have demonstrated that young children have low prevalences of obesity and acanthosis nigricans, but the prevalences of both increase with increasing age until plateaus are reached after the age of ten. Nearly 40% of Native American teenagers have acanthosis nigricans, whereas about 13% of African American, 6% of Hispanic, and less than 1% of white, non-Hispanic children aged 10-19 have clinically apparent acanthosis nigricans. We conclude that the presence of this skin lesion is a clinical surrogate of laboratory-documented hyperinsulinemia. Acanthosis nigricans identifies a subgroup within an ethnic group who have the highest insulin concentration, the most severe insulin resistance, and thus the highest risk for the development of type 2 diabetes.

Publication Types:

• Review
• Review, tutorial

PMID: 10212845, UI: 99229315

Kidney Int 1999 Apr;55(4):1560-7

Influence of excess weight on mortality and hospital stay in 1346 hemodialysis patients.

Fleischmann E, Teal N, Dudley J, May W, Bower JD, Salahudeen AK

Department of Medicine and Preventive Medicine, University of Mississippi Medical Center, Jackson, USA.

BACKGROUND: Body mass index (BMI) at its extremes contributes to morbidity and mortality in the general population. Its influence on morbidity and mortality in patients on hemodialysis is not clearly defined. METHODS: The BMI in 1346 patients attending limited-care hemodialysis units across the state of Mississippi was determined, and its relation to one-year mortality and hospital stay was assessed using the Cox proportional hazard model. RESULTS: Of these patients, 89% were black, and 11% were white. Thirty-eight percent of patients were overweight (BMI > 27.5), and 13% were underweight (BMI < 20). The highest (27.60 +/- 0.29, mean +/- SE) and the lowest (24.54 +/- 0.48) BMI were noted in black females and white males, respectively. BMI, race, hematocrit (Hct), and biochemical markers of better nutrition positively influenced the survival, whereas age, serum globulin, and diabetes had a negative influence. In a Cox multivariate analysis, BMI, age, diabetes, prealbumin, and creatinine, but not race, serum albumin, Hct, or serum globulin, retained significant influence on survival. Compared with the normal weight (BMI between 20 and 27.5), the one-year survival rate was significantly higher in the overweight patients and lower in the underweight patients. With a one-unit increase in BMI over 27.5, the relative risk for dying was reduced by 30% (P < 0.04), and with a one-unit decrease in BMI below 20, the relative risk was increased by 1.6-fold (P < 0.01). Furthermore, underweight patients had significantly lower levels of biochemical markers of nutrition and higher frequency and longer duration of hospital stay. CONCLUSION: Adequate dialysis with special attention to proper nutrition aimed to achieve the high end of normal BMI may help to reduce the high mortality and morbidity in hemodialysis patients.

Comments:

• Comment in: Kidney Int 1999 Apr;55(4):1580-1

PMID: 10201023, UI: 99217080

Am J Cardiol 1999 Apr 1;83(7):1144-5, A10

Risk factors for new atherothrombotic brain infarction in older African-American men and women.

Aronow WS, Ahn C, Gutstein H

Hebrew Hospital Home, Bronx, New York 10475, USA.

Independent risk factors for new atherothrombotic brain infarction (ABI) in older African-American men were hypertension (risk ratio 4.381), diabetes mellitus (risk ratio 2.872), and previous ABI (risk ratio 1.904). Independent risk factors for new coronary events in older African-American women were cigarette smoking (risk ratio 2.754), hypertension (risk ratio 5.914), diabetes mellitus (risk ratio 3.464), serum total cholesterol (risk ratio 1.008), serum high-density lipoprotein cholesterol (inverse association) (risk ratio 0.958), age (risk ratio 1.026), and previous ABI (risk ratio 2.601).

PMID: 10190539, UI: 99204814

Diabetes Care 1999 Apr;22(4):562-8

Insulin sensitivity in subjects with type 2 diabetes. Relationship to cardiovascular risk factors: the Insulin Resistance Atherosclerosis Study.

Haffner SM, D'Agostino R Jr, Mykkanen L, Tracy R, Howard B, Rewers M, Selby J, Savage PJ, Saad MF

Department of Medicine, University of Texas Health Science Center at San Antonio 78284-7873, USA.

OBJECTIVE: Among nondiabetic subjects, insulin resistance has been associated with increased cardiovascular risk factors, including dyslipidemia, hypertension, impaired fibrinolysis, and coagulation. Less is known about the relationship between insulin resistance and cardiovascular risk factors in subjects with type 2 diabetes. RESEARCH DESIGN AND METHODS: To examine this issue, we determined insulin sensitivity (SI) in 479 type 2 diabetic subjects by minimal model analyses of frequently sampled intravenous glucose tolerance tests in the Insulin Resistance Atherosclerosis Study (IRAS), a large multicenter study of insulin sensitivity and cardiovascular disease in African-Americans, Hispanics, and non-Hispanic whites. We defined insulin-sensitive subjects as having SI > or = 1.61 x 10(-4) min-1.microU-1.ml-1 (above median in nondiabetic subjects of all ethnic groups in the IRAS). Using this definition, only 37 type 2 diabetic subjects were insulin sensitive, and the remaining 442 were insulin resistant. RESULTS: After adjustment for age, sex, ethnicity, and clinic, insulin resistance was significantly correlated with total triglycerides, VLDL cholesterol, VLDL triglyceride, fibrinogen, PAI-1, and fasting glucose, and was inversely correlated with HDL cholesterol level and LDL size. Carotid intimal-medial thickness was greater in insulin-resistant than in insulin-sensitive subjects, but this difference was not statistically significant. After further adjustment for waist circumference (marker of visceral adiposity), insulin-resistant subjects continued to have higher plasminogen activator inhibitor 1 and VLDL triglyceride levels, lower HDL cholesterol levels, and smaller LDL particle size than did insulin-sensitive subjects. After further adjustment for fasting glucose levels, these results were very similar. CONCLUSIONS: We conclude that insulin-resistant type 2 diabetic subjects have more atherogenic cardiovascular risk factor profiles than insulin-sensitive type 2 diabetic subjects and that this is only partially related to increased obesity and an adverse body fat distribution.

Publication Types:

• Multicenter study

PMID: 10189532, UI: 99205530

Bull N Y Acad Med 1995 Winter;72(2):470-82

Differential mortality in New York City (1988-1992). Part One: excess mortality among non-Hispanic blacks.

Fang J, Madhavan S, Cohen H, Alderman MH

Department of Epidemiology and Social Medicine, Albert Einstein College of Medicine, Bronx, NY 10461, USA.

To determine the distribution of mortality for non-Hispanic blacks and non-Hispanic whites in New York City, death certificates issued in New York City during 1988 through 1992, and the relevant 1990 US census data for New York City, have been examined. Age-adjusted death rates for blacks and whites by gender and cause of death were computed based on the US population in 1940. Also, standard mortality ratios and excess mortality were calculated using the New York City mortality rate as reference. The results showed that New York City blacks had higher age-adjusted death rates than whites regardless of cause, including stroke, AIDS, homicide, and diabetes. The rate for New York City blacks was also higher than the US total for both genders. Using New York City mortality rates as a reference, more than 80% of excess deaths in blacks occurred before age 65. Injury/poisoning was the leading cause of excess death (20.1%) in black males, while in black females, cardiovascular disease was the largest single cause of excess deaths (24.8%). The higher death rates, especially premature death, of blacks in New York City are related to conditions such as violence, substance abuse, and AIDS, for which prevention rather than medical care is the more likely solution, as well as to cardiovascular diseases, where both prevention through behavioral change, and health and medical care, can influence outcome.

PMID: 10101383, UI: 99201599

Am J Med Sci 1999 Mar;317(3):189-92

Traditional coronary risk factors in African Americans.

Potts JL, Thomas J

Department of Medicine, Meharry Medical College, Nashville, Tennessee 37208, USA.

The importance of traditional coronary artery disease risk factors in the development of coronary heart disease is well known. African Americans have a higher prevalence of such risk factors as hypertension, diabetes mellitus, obesity, cigarette smoking, and left ventricular hypertrophy, which might account for the disproportionate rate of coronary heart disease mortality in African Americans. Compelling data from randomized lipid-lowering trials show conclusively that lowering cholesterol levels, specifically low-density lipoprotein cholesterol, lowers coronary heart disease morbidity and mortality. Recent data has also demonstrated the beneficial effects of lowering blood pressure on cardiovascular mortality. Left ventricular hypertrophy, which results from elevated blood pressure, seems to raise coronary heart disease risks independently. Diabetes mellitus, cigarette use, physical inactivity, stress, and obesity play critical roles collectively and individually in increasing coronary heart disease, morbidity, and mortality. Clustering of coronary heart disease risk factors in African Americans must be strongly considered to play a critical role in the excess mortality from coronary heart disease seen in African Americans. New innovative approaches are required if the course of coronary heart disease is to be altered.

Publication Types:

• Review
• Review, tutorial

PMID: 10100693, UI: 99198792

Am J Med Sci 1999 Mar;317(3):183-8

The role of hypertension, obesity, and diabetes in causing renal vascular disease.

Crook ED

Department of Medicine/Division of Nephrology, University of Mississippi Medical Center, Jackson 39216, USA.

The Jackson Heart Study will be an epidemiological study of African Americans in Jackson, Mississippi, to identify risk factors for development and progression of cardiovascular disease. One of the potential risk factors to be assessed in this study is renal vascular disease. Atherosclerotic renal vascular disease is a disease of the elderly, is predominantly seen in white people, and is strongly associated with diffuse atherosclerotic disease and high-grade hypertensive retinopathy. Patients with ischemic nephropathy may constitute up to 16% of new dialysis patients and die more quickly while on renal replacement therapy. Although often not present, hypertension is a commonly observed consequence (but probably not a cause) of renal vascular disease, and the control of blood pressure may not halt the progression of the disease. Approximately 20-25% of patients with moderate to severe renal artery stenosis will be diabetic. Diabetic patients fair less well with intervention and have a higher progression to end-stage renal disease or death. Obesity is not commonly seen in patients with renal vascular disease. The Jackson Heart Study may be able to assess the true incidence of atherosclerotic renal vascular disease in African Americans and its impact of cardiovascular morbidity and mortality.

Publication Types:

• Review
• Review, tutorial

PMID: 10100692, UI: 99198791

Diabetes Care 1999 Mar;22(3):426-9

Prevalence of undiagnosed diabetes and abnormalities of carbohydrate metabolism in a U.S. Army population.

Chapin BL, Medina S, Le D, Bussell N, Bussell K

Department of Internal Medicine, Texas Tech University School of Medicine at El Paso, USA. bchapin@fcgnetworks.net

OBJECTIVE: The Third National Health and Nutrition Examination Survey (NHANES III) reported that 4.3-6.3% of adult Americans have undiagnosed diabetes. 15.6% have impaired glucose tolerance, and 10.1% have impaired fasting glucose. By design, NHANES III excluded people in the U.S. military. The purpose of this study was to determine the prevalence of undiagnosed diabetes, impaired glucose tolerance, and impaired fasting glucose among U.S. Army soldiers. RESEARCH DESIGN AND METHODS: A 2-h, 75-g oral glucose tolerance test was performed on a prospective, consecutive sample of 625 asymptomatic soldiers presenting to a U.S. Army medical clinic for physical examinations. Age of subjects was 32 +/- 9 years (mean +/- SD), and 81.0% of subjects were male. BMI was 26.2 +/- 3.7 kg/m2. Race/ethnicity categories included Caucasian (54.4%), African-American (24.4%), Hispanic (17.4%), and other (3.7%). A family history of diabetes was reported by 25.4% of the subjects, and the number of exercise sessions per week was 4.0 +/- 1.5. RESULTS: The prevalence of undiagnosed diabetes was 3 of 625 (0.5%) (95% CI, 0.1-1.4): impaired glucose tolerance, 11 of 598 (1.8%) (0.9-3.3); and impaired fasting glucose 6 of 585 (1.0%) (0.4-2.2). CONCLUSIONS: In this low-diabetes risk U.S. Army population, the prevalence of undiagnosed diabetes, impaired glucose tolerance, and impaired fasting glucose were 0.5, 1.8, and 1.0%, respectively. The prevalence rates found in this study are approximately one-tenth of those found in NHANES III.

PMID: 10097923, UI: 99197996

Diabetologia 1999 Mar;42(3):380-1

Missense mutation Gly574Ser in the transcription factor HNF-1alpha is a marker of atypical diabetes mellitus in African-American children.

Boutin P, Gresh L, Cisse A, Hara M, Bell G, Babu S, Eisenbarth G, Froguel P

Publication Types:

• Letter

PMID: 10096793, UI: 99194457

Am J Public Health 1999 Mar;89(3):302-7

Prevalence and social correlates of cardiovascular disease risk factors in Harlem.

Diez-Roux AV, Northridge ME, Morabia A, Bassett MT, Shea S

Division of General Medicine, Columbia College of Physicians and Surgeons, USA. diezrou@medicine1.cpmc.columbia.edu

OBJECTIVES: This study examined the prevalence, social correlates, and clustering of cardiovascular disease risk factors in a predominantly Black, poor, urban community. METHODS: Associations of risk factor prevalences with sociodemographic variables were examined in a population-based sample of 695 men and women aged 18 to 65 years living in Central Harlem. RESULTS: One third of the men and women were hypertensive, 48% of the men and 41% of the women were smokers, 25% of the men and 49% of the women were overweight, and 23% of the men and 35% of the women reported no leisure-time physical activity over the past month. More than 80% of the men and women had at least 1 of these risk factors, and 9% of the men and 19% of the women had 3 or more risk factors. Income and education were inversely related to hypertension, smoking, and physical inactivity. Having 3 or more risk factors was associated with low income and low education (extreme odds ratio [OR] = 10.2, 95% confidence interval [CI] = 3.0, 34.5 for education; OR = 3.7, CI = 1.6, 8.9 for income) and with a history of unstable work or of homelessness. CONCLUSIONS: Disadvantaged, urban communities are at high risk for cardiovascular disease. These results highlight the importance of socioenvironmental factors in shaping cardiovascular risk.

PMID: 10076477, UI: 99175773

Arch Intern Med 1999 Mar 8;159(5):505-10

Heart failure survival among older adults in the United States: a poor prognosis for an emerging epidemic in the Medicare population.

Croft JB, Giles WH, Pollard RA, Keenan NL, Casper ML, Anda RF

Cardiovascular Health Branch, Division of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA 30341-3724, USA. jbc0@cdc.gov

OBJECTIVE: To describe the 6-year probability of survival for older adults after their first hospitalization for heart failure. SETTING: National Medicare hospital claims records for 1984 through 1986 and Medicare enrollment records from 1986 through 1992. DESIGN: We identified a national cohort of 170 239 (9% black patients) Medicare patients, 67 years or older, with no evidence of heart failure in 1984 or 1985, who were hospitalized and discharged for the first time in 1986 with a principal diagnosis of heart failure. For groups defined by race, sex, age, Medicaid eligibility, and comorbid conditions, we compared the probability of survival with Cox proportional hazards regression. RESULTS: Only 19% of black men, 16% of white men, 25% of black women, and 23% of white women survived 6 years. One third died within the first year. Men had lower median survival and 38% greater risk of mortality than did women (P<.05). White men had 10% greater risk of mortality than did black men (P<.05). Medicaid eligibility (white adults only) and diabetes were associated with increased mortality (P<.05). CONCLUSIONS: The prognosis for older adults with heart failure underscores the importance of prevention strategies and early detection and treatment modalities that can prevent, improve, or reverse myocardial dysfunction, particularly for the growing number of adults who are at increased risk for developing heart failure because of hypertension, diabetes, or myocardial infarction.

PMID: 10074960, UI: 99173255

J Health Care Poor Underserved 1998 Aug;9(3):236-47

African American women and diabetes: a sociocultural context.

Rajaram SS, Vinson V

Department of Sociology, University of Nebraska, Omaha 68182-0291, USA.

Diabetes is the fourth leading cause of death among African American women. One in four black women (23.4 percent) older than age 55 has diabetes. In evaluating the experience of black women with diabetes, an understanding of their social context is essential. Resulting from historical and sociocultural factors, black women have relatively lower income and education levels and consequently, poorer health and restricted access to quality health care. In a sense, being black, female, elderly, and chronically ill places this group in quadruple jeopardy. Tackling the problem of diabetes among African American women is a public health priority and requires a multilevel approach.

Publication Types:

• Review
• Review, tutorial

PMID: 10073206, UI: 99172861

Arch Med Res 1999 Jan-Feb;30(1):40-8

Renovasculopathies of hypertension in Hispanic residents of Dallas, Texas.

Tracy RE, Guileyardo JM

Department of Pathology, Louisana State University Medical Center, New Orleans, USA.

BACKGROUND: Mean blood pressure levels (MBP) appear to rise with age slowly in the population of Mexico City and more swiftly in the U.S. in the black and white population, judging from published survey data. Some evidence suggests that MBP rises at intermediate rates in Hispanics in the U.S. METHOD: This question is explored here in two ways, by review of published survey data and by a novel approach that uses renal tissues obtained from forensic autopsies to estimate MBP. Past studies have revealed good agreement between the two methods of estimating MBP. RESULTS: Good agreement is again observed from the results of this study. Results from both methods agree that MBP is much lower at all ages in Mexican men and women than in blacks and whites in the U.S. Both methods also agree that Hispanics in the U.S. demonstrate an intermediate rise in MBP. A speculative first look at a small sample of U.S. Hispanics suggest that MBP rates of recent immigrants tend to resemble those of Mexico, while MBP levels of migrants of long-term residence resemble the native-born U.S. populations. CONCLUSIONS: The findings underscore the need for definitive testing to confirm if Mexicans who relocate to the U.S. may acquire an acceleration of the renovasculopathies, and of the lifelong progression toward hypertension that this implies.

PMID: 10071424, UI: 99170818

J Cult Divers 1998 Fall;5(3):94-100

Differences in functional status, health status, and community-based service use between black and white diabetic elders.

Witucki JM, Wallace DC

College of Nursing, University of Tennessee, Knoxville, USA.

This study examined differences between 280 black and 269 white diabetic elders (n = 549) in functional and health status and use of community-based services. Cox's Interaction Model of Client Health Behavior provided the theoretical framework. Nonparametric analysis of variance, independent groups t-tests, and chi-square statistics were used. There were no significant differences between the groups in health status or ADL difficulty as a measure of functional status. White diabetic elders had significantly more IADL difficulty. Community-based service use was significantly lower among black diabetic elders, but both groups underutilized services. Findings have implications for health care delivery systems, health policy, case management, health outcomes evaluation, and advanced practice.

PMID: 10025302, UI: 99149441

Diabetes Educ 1998 Nov-Dec;24(6):689, 697-8, 700

The healing process: reflections on African American history and diabetes care.

Wisdom K

Publication Types:

• Editorial

PMID: 10025292, UI: 99149431

Diabetes Educ 1998 Nov-Dec;24(6):689-92

Into the heart of darkness: reflections on racism and diabetes care.

Anderson RM

I have learned that effective diabetes care must be tailored to the lived experience of patients. Developing individually tailored self-management plans requires acknowledging the importance of other people's culture, goals, resources, and values. It has involved crossing the social distance created by the roles of healthcare professional and patient, and encountering patients in their full humanity. In these encounters, I have learned about myself as well. My experience over the past 7 years has made it clear to me that I was naive to believe that I could grow up in a country permeated by racism and free myself of its taint by simply rejecting it as an ideology. I have seen how profoundly my attitudes, perceptions, and habits of thought have been shaped by my cultural experience. I have developed a better appreciation of how far I (and we) have to go in achieving an equitable society. At times the process has been difficult and painful. However, I have come to believe that providing effective diabetes care engenders personal learning in both patients and health professionals. I believe that such learning will offer significant benefits to both groups.

Publication Types:

• Editorial

PMID: 10025291, UI: 99149430

J Am Pharm Assoc (Wash) 1999 Jan-Feb;39(1):17-22

Pharmacy access to sterile syringes for injection drug users: attitudes of participants in a syringe exchange program.

Junge B, Vlahov D, Riley E, Huettner S, Brown M, Beilenson P

Department of Epidemiology, Johns Hopkins University School of Hygiene & Public Health, Baltimore, USA. bjunge@jhsph.edu

OBJECTIVE: To examine attitudes of participants of a van-based syringe exchange program (SEP) toward the hypothetical prospect of pharmacy-based syringe access. DESIGN: One-time, cross-sectional survey. SETTING: Baltimore, Maryland. PARTICIPANTS: 206 injection drug users who participate in the Baltimore SEP. INTERVENTIONS: Face-to-face interviews. MAIN OUTCOME MEASURES: Location preferred for obtaining syringes, drug and syringe use, past experience with pharmacies, and willingness to pay. RESULTS: The sample was 67% men, 95% African American, and 95% unemployed; mean age was 39.8 years. A total of 19% of respondents had bought syringes at a pharmacy during the prior six months. Some 37% reported having been turned down when asking for syringes at a pharmacy, most commonly due to lack of identification to prove diabetic status (50%). If legal restrictions were lifted, 92% of respondents would obtain syringes from pharmacies, and would be willing to pay a mean price of $0.80 (median = $1.00) per syringe. Women were more likely than men to report the intention to switch from van-based SEP to pharmacy (57% versus 38%, p = .045). CONCLUSION: If current legal restrictions were lifted, pharmacies would be a viable syringe source appealing particularly to women, suggesting gender-specific access issues that should be addressed. The per-syringe price that study participants would be willing to pay exceeds typical retail prices, suggesting that pharmacists could charge enough per syringe to recoup operational costs.

PMID: 9990182, UI: 99143993

J Vasc Surg 1999 Feb;29(2):352-9

Diabetes mellitus is the major risk factor for African Americans who undergo peripheral bypass graft operation.

Brothers TE, Robison JG, Elliott BM

Department of Surgery, Section of Vascular Surgery, Medical University of South Carolina, USA.

OBJECTIVE: African Americans, especially African American women, have a greater risk of lower extremity ischemia that necessitates an infrainguinal bypass graft operation and amputation. Because the prevalence of diabetes mellitus is proportionally greater in this ethnic/racial group, the relative contribution of diabetes was compared with other potential risk factors. METHODS: This study was designed as a retrospective case control study at the University and Veterans Hospitals. In a 5-year period, 764 consecutive patients who required infrainguinal revascularizations were compared with a statewide population that was described by the 1995 Behavior Risk Factor Surveillance System database. The main outcome measure was the requirement for infrainguinal revascularization. RESULTS: Diabetes mellitus was more common among African American women who underwent bypass graft operation (70%; odds ratio [OR], 24.9; 95% confidence interval [CI], 20.3 to 30.4) than African American men (46%; OR, 11.6; 95% CI, 8.9 to 15.2), white women (49%; OR, 15.9; 95% CI, 13.0 to 19.5), or white men (42%; OR, 14.8; 95% CI, 12.5 to 17.4). Overall, bypass graft operation was associated more strongly with diabetes mellitus for all groups (OR, 15.7; 95% CI, 13.5 to 18. 3) than with smoking (OR, 4.5; 95% CI, 3.8 to 5.2) or hypertension (OR, 4.6; 95% CI, 4.0 to 5.3). Life-table analysis revealed limb salvage to be worse at 3 years among African American patients (64% vs 75%; P <.005) despite similar primary and cumulative secondary graft patency rates. CONCLUSION: Diabetes mellitus is the dominant risk factor that contributes to the need for bypass graft operation, especially among African American women. A greater prevalence of diabetes mellitus may account for the higher incidence of tissue necrosis and the increased requirement for distal bypass grafting and may contribute to the reduction in long-term limb salvage that was observed with these women.

PMID: 9950993, UI: 99137875

Ethn Dis 1998 Autumn;8(3):319-30

Gender differences in cardiovascular risk factors in obese, nondiabetic first degree relatives of African Americans with type 2 diabetes mellitus.

Gaillard TR, Schuster DP, Osei K

Division of Endocrinology, Diabetes and Metabolism, The Ohio State University, Columbus, USA.

African-American females with type 2 diabetes mellitus are at greater risk for cardiovascular morbidity and mortality when compared to diabetic African-American males and whites. To explain the gender differences in morbidity and mortality secondary to cardiovascular diseases (CVD) associated with type 2 diabetes mellitus (DM) in middle-aged, African Americans (AA), we have postulated that increased incidence of CVD in AA females could be ascribed in part to greater clustering of pre-existing CVD risks when compared to their AA male counterparts. We have therefore investigated the metabolic and anthropometric risk factors for CVD in an AA population who are genetically at greater risk for type 2 DM. We studied 84 healthy first-degree relatives of AA patients with type 2 diabetes, 42 males and 42 females with a mean age 42.5+/-8.4 years, age range 25-65 years, matched for age and waist-to-hip circumference ratio (WHR) in order to determine the impact of body fat distribution pattern on CVD risks. A standard oral glucose tolerance test (OGTT) and an insulin-modified frequently sampled intravenous glucose tolerance (FSIGT) test were performed for each subject. In addition, lipid and lipoprotein levels, anthropometric parameters, blood pressure, sociodemographics and physical activity levels were obtained for each subject. Insulin sensitivity index (Si) and glucose-dependent glucose disposal (Sg) were determined using Bergman's Minimal Model method. Hepatic insulin extraction (HIE) was calculated as the molar ratio of basal and postprandial c-peptide and insulin concentrations. Mean age, annual income and percent participation in physical activity did not differ between genders. Despite the identical WHR, body mass index (BMI) (34.8+/-7.5 vs 30.3+/-6.7 kg/m2, P=0.005), and % body fat (43.8+/-7.3 vs 28.1+/-7.7%, P=0.001) were greater in females than males, respectively. The systolic blood pressure(SBP), but not the diastolic blood pressure (DBP), was significantly lower in our female vs male group. Mean fasting and 2-hour postprandial serum glucose and insulin levels were significantly greater in the female group. In contrast, the corresponding serum c-peptide levels were not significantly different between the groups. Thus, the basal and postprandial hepatic insulin extractions (HIE) were 30% lower in the females than in the males. The mean absolute levels of cholesterol (C), low density lipoprotein-C (LDL-C), very low-density lipoprotein-C (VLDL-C), high-density lipoprotein-C (HDL-C), and triglycerides were not significantly different between the genders. Mean Si was significantly lower in the females when compared to males (Si, 1.62+/-1.66 vs 2.45+/-1.81 x 10(-4) x min(-1) (microU/ml)(-1), P=0.03). The mean Sg was identical in both groups (2.66+/-1.99 vs 2.67+/-1.35 x 10(-2) x min(-1), P=0.97). We found no significant correlations between Si and SBP and DBP, WHR, or lipids and lipoproteins in the females. In contrast, Si correlated significantly with WHR (R=-0.346, P=0.05), HDL-C (R=0.310, P=0.05), but not with BP, LDL-C, and triglyceride levels in the males. We conclude that nondiabetic African-American females manifest several metabolic and anthropometric risk factors for cardiovascular diseases that precede the disease by decades. Therefore, obese AA females with family history of type 2 DM should be particularly targeted for diabetes and CVD risk prevention programs using effective and practical weight reduction modalities.

PMID: 9926902, UI: 99124092

Metabolism 1999 Jan;48(1):107-12

Hyperinsulinism and sex hormones in young adult African Americans.

Falkner B, Sherif K, Sumner A, Kushner H

Institute for Women's Health and the Department of Medicine, Allegheny University for the Health Sciences, Philadelphia, PA 19129, USA.

Hyperinsulinemia is a risk factor for cardiovascular disease, and is linked with non-insulin-dependent diabetes mellitus (NIDDM), hyperlipidemia, obesity, and hypertension. Sex hormones also play a role in the metabolic alterations associated with the risk for cardiovascular disease. A reduction in sex hormone-binding globulin (SHBG) may be predictive of future NIDDM particularly in women. The postmenopausal decline in estrogen is also associated with an increase in risk factor expression in women. Since African Americans experience a greater prevalence of NIDDM, obesity, and hypertension, conditions associated with hyperinsulinemia, the purpose of this study was to determine if alterations in sex hormone levels are associated with the plasma insulin concentration in young adult African Americans, and to determine if there are sex differences in the effect of insulin on lipids and sex hormones. In a sample of 221 nondiabetic African American men (n = 105) and women (n = 116) with a mean age of 31 years, we examined the relationship of the plasma insulin concentration with the body mass index (BMI), blood pressure, plasma lipids, and sex hormones, including free testosterone, estradiol, and SHBG. Plasma insulin increased with the BMI and other measures of adiposity (P<.001) in men and women. Significant correlations of insulin with plasma lipids were also present in both sexes. There was a significant inverse correlation of insulin with SHBG in both men (r = .28, P = .007) and women (r = .27, P = .02). There was a significant direct correlation of insulin with free testosterone in women (r = .032, P<.001). Stepwise multiple regression analyses with insulin as the dependent variable detected the BMI, triglyceride, and apolipoprotein A1 as significant contributors to the plasma insulin concentration in men. In women, the multiple regression model detected percent body fat, low-density lipoprotein (LDL) cholesterol, and free testosterone as significant contributors to plasma insulin. These data on young African Americans demonstrate a significant relationship between hyperinsulinemia and obesity, atherogenic lipid status, and lower SHBG. In the premenopausal women, the lower SHBG is linked with higher free testosterone, favoring a condition of relative androgen excess.

PMID: 9920153, UI: 99116881

Clin Transpl 1997;:305-14

Impact of new variables reported to the UNOS registry.

Cho YW, Terasaki PI

1. Donor age is now a predominant factor influencing graft outcome. 2. A new finding here is that recipient peripheral vascular disease, PVD is also a major factor. This factor was independent of whether the patient had diabetes or not. Presensitization, as shown by a high PRA is additive to PVD. 3. Hypertension in the donor was important only when a history of more than 10 years was noted in the older donors over age 50. 4. Angina and cardiovascular disease in the patient resulted in a slightly higher death rate, but was only of importance in patients over age 50. 5. Cadaver donor pretreatment was of importance only in donors over age 30. 6. White patients with private insurance had a slightly higher graft survival rate than those on Medicare or Medicaid. Black patients with private insurance had almost the same graft survival as White patients with private insurance. The lowest graft survival was noted for Black patients on Medicaid.

PMID: 9919414, UI: 99118058

Nurs Times 1998 Nov 11-17;94(45):54-5

Nurse-led diabetes clinics benefit black and Asian patients.

Matthias M, While A, Shah S

Streatham Hill Primary Healthcare Centre.

There is strong epidemiological data that shows that prevalence of diabetes varies with ethnic origin. This article describes the establishment of diabetic clinics within general practices in an attempt to identify and meet the needs of minority ethnic groups in relation to this condition. A future article will describe opportunistic screening of the target population.

PMID: 9919280, UI: 99117924

Geriatr Nephrol Urol 1998;8(2):77-83

A comparison of the quality of life reported by elderly whites and elderly blacks on dialysis.

Kutner NG, Devins GM

Department of Rehabilitation Medicine, Emory University School of Medicine, Atlanta, GA, USA.

OBJECTIVE: To compare indicators of quality of life reported by elderly whites and elderly blacks on chronic dialysis. DESIGN: Survey of surviving patients from a previously identified prevalent cohort. SETTING: 58 dialysis facilities located throughout the state of Georgia. SUBJECTS: 46 whites (mean age = 72) and 85 blacks (mean age = 70) on chronic dialysis > or = 3.5 years. MAIN OUTCOME MEASURES: Number of days in bed during past 3 months; number of nights hospitalized during past 6 months; score summarizing limitations in functional status; 10 dialysis symptoms/complaints; 9 indicators of subjective well-being. RESULTS: Elderly whites, more than elderly blacks, complained of nausea, fatigue, and longer time to recover following a hemodialysis treatment. Whites also were more likely than blacks to perceive kidney failure/dialysis as intrusive for their health and for their diet, to report health dissatisfaction, and to report life dissatisfaction. CONCLUSION: Although blacks were more likely than whites to have diabetes as a primary diagnosis and blacks' educational level was lower than that of whites, all the statistically significant quality of life differences identified in this elderly cohort showed better quality of life among black patients than among white patients.

PMID: 9893215, UI: 99109093

Br J Dermatol 1998 Oct;139(4):665-71

Prevalence and epidemiology of toenail onychomycosis in diabetic subjects: a multicentre survey.

Gupta AK, Konnikov N, MacDonald P, Rich P, Rodger NW, Edmonds MW, McManus R, Summerbell RC

Division of Dermatology, Department of Medicine, Sunnybrook Health Science Center and the University of Toronto, Toronto, Canada. agupta@execulink.com

The number of individuals diagnosed with diabetes mellitus is increasing. The diabetic may present with complications involving all systems of the body. While onychomycosis is often observed in diabetics, there have been no large studies on the prevalence of the condition in this patient group. We examined the prevalence of onychomycosis in diabetics attending diabetes and dermatology clinics in London, Ontario, Canada and Boston, MA, U.S.A. Diabetic subjects seen in dermatology offices were for unrelated dermatoses; those referred specifically for the management of onychomycosis were excluded from the sample. A total of 550 diabetic subjects was evaluated (283 males and 267 females), age 56.1 +/- 0.7 years (mean +/- SEM). Patients with type I diabetes constituted 34% of the sample. The racial origin was: 531 Caucasians, 17 Asians, one African-American and one American-Indian. Abnormal-appearing nails and mycological evidence of onychomycosis (mostly due to dermatophytes) were present in 253 (46%) and 144 (26%), respectively, of 550 subjects. The development of onychomycosis was significantly correlated with age (P < 0.0001) and male gender (P < 0.0001). Males were 2.99 times more likely to have onychomycosis compared with females (95% confidence interval, CI 1.94-4 61). After controlling for age and sex, the risk odds ratio for diabetic subjects to have toenail onychomycosis was 2.77 times compared with normal individuals (95% CI 2.15-3.57). After controlling for age and sex, a stepwise logistic regression demonstrated that significant predictors for onychomycosis included a family history of onychomycosis (P = 0.0001), concurrent intake of immunosuppressive therapy (P = 0.035) and peripheral vascular disease (P = 0.023). Toenail onychomycosis was present in 26% of the sample and is projected to affect approximately one-third of subjects with diabetes. Predisposing factors include increasing age, male gender, family history of onychomycosis, concurrent intake of immunosuppressive agents and peripheral vascular disease.

Publication Types:

• Multicenter study

PMID: 9892911, UI: 99111307

JAMA 1999 Jan 6;281(1):53-60

The protective effect of moderate alcohol consumption on ischemic stroke.

Sacco RL, Elkind M, Boden-Albala B, Lin IF, Kargman DE, Hauser WA, Shea S, Paik MC

Department of Neurology, Sergievsky Center, Columbia University College of Physicians and Surgeons, New York, NY, USA. rls1@columbia.edu

CONTEXT: Moderate alcohol consumption has been shown to be protective for coronary heart disease, but the relationship between moderate alcohol consumption and ischemic stroke is more controversial. OBJECTIVE: To determine the association between alcohol consumption and risk of ischemic stroke. DESIGN: Population-based case-control study conducted between July 1993 and June 1997. SETTING: Multiethnic population in northern Manhattan, New York, NY, aged 40 years or older. PATIENTS AND OTHER PARTICIPANTS: Cases (n = 677) had first ischemic stroke and were matched to community controls (n = 1139) derived through random digit dialing by age, sex, and race/ethnicity. Mean +/- SD age of cases was 70.0+/-12.7 years; 55.8% were women; 19.5% were white, 28.4% black, and 50.7% Hispanic. MAIN OUTCOME MEASURE: First ischemic stroke (fatal or nonfatal). RESULTS: Moderate alcohol consumption, up to 2 drinks per day, was significantly protective for ischemic stroke after adjustment for cardiac disease, hypertension, diabetes, current smoking, body mass index, and education (odds ratio [OR], 0.51; 95% confidence interval [CI], 0.39-0.67). This protective effect of alcohol consumption was detected in both younger and older groups, in men and women, and in whites, blacks, and Hispanics. In a quadratic model of stroke risk, increased risk of ischemic stroke was statistically significant among those consuming 7 or more drinks per day (OR, 2.96; 95% CI, 1.05-8.29). CONCLUSIONS: Moderate alcohol consumption was independently associated with a decreased risk of ischemic stroke in our elderly, multiethnic, urban subjects, while heavy alcohol consumption had deleterious effects. Our data support the National Stroke Association Stroke Prevention Guidelines regarding the beneficial effects of moderate alcohol consumption.

PMID: 9892451, UI: 99107469

Am J Epidemiol 1999 Jan 1;149(1):55-63

Estimating prevalence of type 1 and type 2 diabetes in a population of African Americans with diabetes mellitus.

Boyle JP, Engelgau MM, Thompson TJ, Goldschmid MG, Beckles GL, Timberlake DS, Herman WH, Ziemer DC, Gallina DL

Division of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA 30341-3724, USA.

The pathogenesis, treatment, and outcomes of type 1 and type 2 diabetes differ. Current surveys derive population-based estimates of diabetes prevalence by type using limited clinical information and applying classification rules developed in white populations. How well these rules perform when deriving similar estimates in African American populations is unknown. For this study, data were collected on a group of African Americans with diabetes who enrolled at the Diabetes Unit of Grady Memorial Hospital in Atlanta, Georgia, from April 16, 1991, to November 1, 1996. The data were used to develop some simple classification rules for African Americans based on a classification tree and a logistic regression model. Sensitivities and specificities, in which fasting C-peptide was used as the gold standard, were determined for these rules and for two current rules developed in mostly white, non-Hispanic populations. Rules that yielded precise (minimum variance unbiased) estimates of the prevalence of type 1 diabetes were preferred. The authors found that a rule based on the logistic regression model was best for estimating type 1 prevalences ranging from 1% to 17%. They concluded that simple classification rules can be used to estimate prevalence of diabetes by type in African American populations and that the optimal rule differs somewhat from the current rules.

PMID: 9883794, UI: 99098263

Mor Mortal Wkly Rep CDC Surveill Summ 1998 Dec 11;47(5):35-69

Cardiovascular disease risk factors and preventive practices among adults--United States, 1994: a behavioral risk factor atlas. Behavioral Risk Factor Surveillance System State Coordinators.

Hahn RA, Heath GW, Chang MH

Division of Prevention Research and Analytic Methods, Epidemiology Program Office, National Center for Chronic Disease Prevention and Health Promotion, USA.

PROBLEM/CONDITIONS: Cardiovascular disease (CVD), including coronary heart disease (CHD) and stroke, is the leading cause of death in the United States, and state rates of CVD vary by state and by region of the country. Several behavioral risk factors (i.e., overweight, physical inactivity, smoking, hypertension, and diabetes mellitus) and preventive practices (i.e., weight loss and smoking cessation) are associated with the development of CVD and also vary geographically. This summary displays and analyzes geographic variation in the prevalences of selected CVD risk factors. REPORTING PERIOD: 1994 (1992 for prevalence of hypertension). DESCRIPTION OF SYSTEM: The Behavioral Risk Factor Surveillance System (BRFSS) is a state-based random-digit-dialing telephone survey of noninstitutionalized adults aged > or =18 years; 50 states and the District of Columbia participated in BRFSS in 1994, and 48 states and the District of Columbia participated in 1992. METHODS: Several different analyses were conducted: a) analysis of state risk factor and preventive practice prevalences by sex and race (i.e., black and white); b) mapping; c) cluster analysis; d) correlations of state prevalence rates by sex and race; and e) regression of state risk factor prevalences on state CHD and stroke mortality rates. RESULTS: Mapping the prevalence of selected CVD risk factors and preventive health practices indicates substantial geographic variation for black and white men and women, as confirmed by cluster analysis. Data for blacks are limited by small sample size, especially in western states. Geographic clustering is found for physical inactivity, smoking, and risk factor combinations. Risk factor prevalences are generally lower in the West and higher in the East. White men and white women are more similar in state risk factor rates than other race-sex pairs; white women and black women ranked second in similarity. State prevalences of physical inactivity and hypertension are strongly associated with state mortality rates of CVD. INTERPRETATION: Geographic patterns of risk factor prevalence suggest the presence (or absence) of sociocultural environments that promote (or inhibit) the given risk factor or preventive behavior. Because the risk factors examined in this summary are associated with CVD, further exploration of the reasons underlying observed geographic patterns might be useful. The BRFSS will continue to provide geographic data about cardiovascular health behaviors with a possible emphasis on more data-based small- area analyses and mapping. This will permit states to more adequately monitor trends that affect the burden of CVD in their regions and the United States. Mapping also facilitates the exploration of patterns of morbidity, health-care use, and mortality, as well as the epidemiology of risk factors. Finally, by identifying those segments of the population with high levels of these risk factors and lower levels of the preventive health practices, public health personnel can better allocate resources and target intervention efforts for the prevention of CVD.

PMID: 9859955, UI: 99075298

Circulation 1998 Nov 10;98(19 Suppl):II46-9; discussion II49-50

Effect of payer status on outcomes of coronary artery bypass surgery in blacks.

Higgins RS, Paone G, Borzak S, Jacobsen G, Peterson E, Silverman NA

Division of Cardiac and Thoracic Surgery, Henry Ford Hospital, Detroit, MI 48202, USA.

BACKGROUND: Black patients with coronary artery disease have a higher mortality rate than white Americans. They also have a higher prevalence of hypertension, diabetes mellitus, and renal disease, which may have an effect on mortality rates. The deleterious effect of these comorbidities may be exacerbated by impaired access to secondary prevention strategies and longitudinal care. Therefore, the presence or absence of comprehensive care as indicated by payer status may then affect survival on surgically treated patients. In this study we examined the role of cardiovascular risk factors and insurance carrier status on early outcomes of coronary artery bypass grafting (CABG) surgery in blacks versus white Americans. METHODS AND RESULTS: From January 1990 to December 1996, 2776 patients (2003 men, 773 women; mean age 63 +/- 10 years), underwent isolated CABG in a multispecialty practice serving a major metropolitan population. There were 494 (17.8%) black patients and 2282 (82.2%) white patients. The proportion of black patients in each payer category was 17.8% commercial, 14.1% managed care, 52.9% Medicaid, and 19.5% Medicare. The effect of preoperative risk factors, including status of operation (elective, urgent, or emergent), sex, race, redo CABG, presence of renal disease, diabetes mellitus, congestive heart failure, myocardial infarction, the completeness of revascularization, age, and left ventricular ejection fraction were analyzed with the chi 2 test for categorical variables and the Student t test for age and ejection fraction. A multiple logistic regression analysis was performed to assess the effect of all variables on mortality rates simultaneously. Black patients had a higher incidence of diabetes mellitus, hypertension, and renal disease than white patients (P < 0.001). Overall, 30-day mortality rate was 2.5% (58 of 2282) in white patients versus 5.5% (25 of 494) for black patients (P < 0.003). Multivariate analysis showed that only emergency surgery status (OR 3.59, P < 0.01), redo CABG (OR 3.78, P < 0.001), hypertension (OR 2.32, P < 0.03), history of congestive heart failure (OR 2.1, P < 0.004), older age (OR 1.07, P < 0.001), and low ejection fraction (OR 0.98, P < 0.003) correlated with mortality rates. Race and payer status were not significant predictors of death. CONCLUSIONS: These data on CABG surgery in black patients suggest that early death is due to associated risk factors and not due to race or insurance payer status.

PMID: 9852879, UI: 99069981

Diabetes Care 1998 Dec;21 Suppl 3:C11-4

Diabetes in America: epidemiology and scope of the problem.

Harris MI

National Institute of Diabetes and Digestive and Kidney Diseases, NIH, Bethesda, MD 20892, USA. harrism@ep.niddk.nih.gov

Epidemiological studies performed over the past 40 years have shown that the prevalence of diagnosed diabetes has increased dramatically in the U.S. and that a substantial proportion of the population has undiagnosed diabetes, impaired fasting glucose, and impaired glucose tolerance. Diabetes is most prevalent in minority populations, such as African-Americans, Native Americans, and Mexican Americans. Increasing prevalence of diabetes has led to increases in microvascular complications such as blindness, end-stage renal disease, and lower limb amputations. Poor glycemic control contributes to the high incidence of these complications, yet community-based studies of diabetic patients show their mean fasting plasma glucose concentration is generally > 180 mg/dl compared with 100 mg/dl for nondiabetic individuals. In people with diabetes, risk factors for cardiovascular disease including elevated fasting plasma glucose, blood pressure, total cholesterol, triglycerides, and obesity partly explain the high proportion of deaths (60-70%) caused by cardiovascular disease in people with diabetes. More intensive diabetes management and improved glycemic control could minimize long-term complications of the disease and would be expected to reduce the morbidity, mortality, and costs associated with diabetes.

PMID: 9850480, UI: 99067466

Diabetes Care 1998 Dec;21 Suppl 3:C3-6

Epidemiology of type 2 diabetes: risk factors.

Haffner SM

Department of Medicine, University of Texas Health Center, San Antonio 78284-7873, USA.

A number of cross-sectional and prospective studies that compared the insulin sensitivity of various national and ethnic populations within the U.S. to the total U.S. population were analyzed to find possible risk factors for the development of type 2 diabetes. It was found that the risks for diabetes in African-Americans, Hispanics, and Native Americans are approximately 2, 2.5, and 5 times greater, respectively, than in Caucasians. Studies of the prevalence of type 2 diabetes in Mexican Americans and non-Hispanic whites in San Antonio showed that there is an inverse relationship between socioeconomic status and the prevalence of diabetes. It also appears that cultural effects lead to an increased incidence of obesity in these populations, which may lead to insulin resistance. Genetic factors may also be a contributing factor. A 5-year, prospective study of insulin resistance in Pima Indians showed a relationship between impaired glucose tolerance and subsequent development of type 2 diabetes. In a 7-year study in Mexican Americans, those subjects who had both high insulin secretion and impaired insulin sensitivity had a 14-fold increased risk of developing type 2 diabetes. Regardless of cultural and ethnic factors, the San Antonio Heart Study, which compared Mexican Americans and non-Hispanic whites, showed that in both groups, the strongest predictors of developing type 2 diabetes are elevated fasting insulin concentrations and low insulin secretion.

PMID: 9850478, UI: 99067464

Cancer Nurs 1998 Dec;21(6):421-9

A narrative analysis: a black woman's perceptions of breast cancer risks and early breast cancer detection.

Lawson EJ

Department of Sociology, University of North Texas, Denton 76203-1157, USA.

The oncology nurse's role in breast cancer management is enhanced by knowledge of the patient's perceptions of risks. This case study elucidates the process by which perceived risks of breast cancer are embedded in sequences of biographic experiences including childhood sexual abuse, childhood injuries, and an abusive marriage. The case study shows that risk perceptions and subsequent delayed breast cancer detection is related to (a) a belief that breast cancer results from "bad luck, or fate"; (b) lack of cancer-related symptoms; (c) belief that a higher power determines ill health; (d) reluctance to turn to others for help while in an abusive marriage; (e) family history of cancer invulnerability since generations of family members died of diabetes, heart disease, and pregnancy-related illnesses; and (f) fear of gynecologic exams resulting from childhood sexual abuse. Furthermore, nonapplicability of traditional breast cancer risk factors such as heredity, age older than 30 years at first full-term pregnancy, early menarche, and late menopause prohibit an accurate assessment of self-risk. This case study suggests that breast cancer risk perception often differs from that of biomedical factors, and that an understanding of risk judgments is essential for appropriate therapeutic responses.

PMID: 9849000, UI: 99065848

JAMA 1998 Nov 25;280(20):1764-8

Dose of hemodialysis and survival: differences by race and sex.

Owen WF Jr, Chertow GM, Lazarus JM, Lowrie EG

Department of Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA. wfowen@bics.bwh.harvard.edu

CONTEXT: Although blacks receive lower doses of hemodialysis than whites, their survival when receiving dialysis treatment is better than that for whites. Previous studies of the relationship between the dose of dialysis and patient survival have not controlled for differences in patient characteristics. OBJECTIVE: To examine the association of mortality with the dose of hemodialysis for clusters of patients categorized by race and sex. DESIGN: Retrospective analysis of laboratory data and mortality outcomes from 1994, using a national database of hemodialysis patients. PATIENTS: A total of 18144 black and white patients receiving hemodialysis 3 times weekly who either lived the entire year receiving hemodialysis or died. MAIN OUTCOME MEASURES: The fractional reduction of urea in a single dialysis session as the measured hemodialysis dose (urea reduction ratio [URR]) after controlling for race, sex, age, and diabetes mellitus. Mortality was determined by strata of URRs and albumin and creatinine levels. RESULTS: Across all age categories, blacks had lower URRs than whites, and men had lower URRs than women. In an age-adjusted model for evaluating interactions among URRs, race, sex, and diabetes, the association of URR with mortality risk was weak among blacks, particularly black men. After adjustment for age and diabetes, death probability curves were most steep for white women with URR values less than 60%. The death probability curves were least steep for black men. There was no meaningful difference between death probability and albumin or creatinine concentration among the race by sex clusters. CONCLUSION: Using URR, the usual measure of hemodialysis dose, the assumption that the association between dialysis dose and survival is uniform across demographic groups appears incorrect. Comparisons of the quality of dialysis patient care should not rely on URR alone to predict patient survival.

PMID: 9842952, UI: 99057086

JAMA 1998 Nov 25;280(20):1757-63

Published erratum appears in JAMA 1999 Jan 27;281(4):325

The cost-effectiveness of screening for type 2 diabetes. CDC Diabetes Cost-Effectiveness Study Group, Centers for Disease Control and Prevention.

CONTEXT: Type 2 diabetes mellitus is a common and serious disease in the United States, but one third of those affected are unaware they have it. OBJECTIVE: To estimate the cost-effectiveness of early detection and treatment of type 2 diabetes. DESIGN: A Monte Carlo computer simulation model was developed to estimate the lifetime costs and benefits of 1-time opportunistic screening (ie, performed during routine contact with the medical care system) for type 2 diabetes and to compare them with current clinical practice. Cost-effectiveness was estimated for all persons aged 25 years or older, for age-specific subgroups, and for African Americans. Data were obtained from clinical trials, epidemiologic studies, and population surveys, and a single-payer perspective was assumed. Costs and benefits are discounted at 3% and costs are expressed in 1995 US dollars. SETTING: Single-payer health care system. PARTICIPANTS: Hypothetical cohort of 10000 persons with newly diagnosed diabetes from the general US population. MAIN OUTCOME MEASURES: Cost per additional life-year gained and cost per quality-adjusted life-year (QALY) gained. RESULTS: The incremental cost of opportunistic screening among all persons aged 25 years or older is estimated at $236449 per life-year gained and $56649 per QALY gained. Screening is more cost-effective among younger people and among African Americans. The benefits of early detection and treatment accrue more from postponement of complications and the resulting improvement in quality of life than from additional life-years. CONCLUSIONS: Early diagnosis and treatment through opportunistic screening of type 2 diabetes may reduce the lifetime incidence of major microvascular complications and result in gains in both life-years and QALYs. Incremental increases in costs attributable to screening and earlier treatment are incurred but may well be in the range of acceptable cost-effectiveness for US health care systems, especially for younger adults and for some subpopulations (eg, minorities) who are at relatively high risk of developing the major complications of type 2 diabetes. Although current recommendations are that screening begin at age 45 years, these results suggest that screening is more cost-effective at younger ages. The selection of appropriate target populations for screening should consider factors in addition to the prevalence of diabetes.

PMID: 9842951, UI: 99057085

Diabetes Care 1998 Dec;21(12):2129-34

Hyperfiltration in African-American patients with type 2 diabetes. Cross-sectional and longitudinal data.

Chaiken RL, Eckert-Norton M, Bard M, Banerji MA, Palmisano J, Sachimechi I, Lebovitz HE

Division of Endocrinology and Metabolism, State University of New York-Health Science Center at Brooklyn 11203, USA.

OBJECTIVE: Hyperfiltration may play a role in the development of diabetic nephropathy. African-American patients with diabetes have more than a fourfold increase in end-stage renal disease. The purpose of this study is to evaluate the impact of hyperfiltration on renal function in African-American patients with type 2 diabetes. RESEARCH DESIGN AND METHODS: Renal function of 194 African-American patients with diagnosed type 2 diabetes from 1 month to 36 years was assessed by studies of isotopic glomerular filtration rate (GFR), serum creatinine, creatinine clearance, and 24-h urinary albumin excretion rates. Thirty-four patients with a duration of diagnosed type 2 diabetes from 1 month to 10 years were found to have hyperfiltration (GFR > or = 140 ml.min-1.1.73 m-2). Fifteen of these patients received longitudinal follow-up of renal function for as long as 15 years after the initial study. RESULTS: Hyperfiltration is present in 15 (36%) of 42 patients whose duration of diagnosed type 2 diabetes is < 1 year, and it persists for up to 10 years in 14-20% of patients with diagnosed type 2 diabetes. Patients with hyperfiltration are younger than their counterparts without hyperfiltration when matched for duration of diagnosed diabetes. When followed over time, those patients with hyperfiltration were not more likely to develop impaired renal function as measured by GFR or creatinine clearance. CONCLUSIONS: Hyperfiltration does not identify patients at risk for deterioration in renal function.

PMID: 9839105, UI: 99056484

Curr Opin Cardiol 1998 Sep;13(5):298-303

Diabetic vascular disease and hypertension.

Hamaty M, Lamberti M, Sowers JR

Division of Endocrinology, Metabolism and Hypertension, Wayne State University School of Medicine, Detroit, MI 48201, USA.

There is increasing evidence that essential hypertension is associated with a panoply of metabolic abnormalities. Included in these abnormalities are insulin resistance, dyslipidemia, enhanced coagulation, and decreased fibrinolytic activity, microalbuminuria, and platelet abnormalities and endothelial dysfunction. Visceral obesity appears to be the most common and predictive underlying factor for all of these metabolic abnormalities accompanying hypertension as well as increased cardiovascular disease (CVD) risk. As the prevalence of obesity is increasing, there is cause for concern that CVD increases will parallel this risk factor, particularly in especially high-risk populations, such as African-American women. Other important risk factors, such as increased oxidative stress, may require special therapeutic strategies, including the use of angiotensin-converting enzyme (ACE) inhibitors and angiotensin blockers as cornerstones of antihypertensive drug therapy.

Publication Types:

• Review
• Review, tutorial

PMID: 9823785, UI: 99039391

J Natl Med Assoc 1998 Oct;90(10):605-13

A project to reduce the burden of diabetes in the African-American Community: Project DIRECT.

Engelgau MM, Narayan KM, Geiss LS, Thompson TJ, Beckles GL, Lopez L, Hartwell T, Visscher W, Liburd L

Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, Georgia 30341, USA.

Project DIRECT (Diabetes Interventions Reaching and Educating Communities Together) is the first comprehensive community diabetes demonstration project in the United States in an African-American community. This article describes its intervention components and evaluation design. The development and implementation of Project DIRECT has included the community since the project's beginning. Interventions are targeted in three areas: health promotion (improving diet and physical activity levels), outreach (improving diabetes awareness, detection of undiagnosed diabetes, and ensuring that persons with diabetes who are not receiving continuing diabetes care are integrated into the health-care system), and diabetes care (improving self-care, increasing access, and improving the quality of diabetes preventive care received within the health-care system). Evaluation will be internal (conducted by Project DIRECT staff to assess process outcomes in persons directly exposed to each specific intervention) and external (review of outcomes to assess the impact of the multi-intervention program at the level of the entire community). Because diabetes exacts a disproportionate toll among African Americans, the findings from this project should aid in developing strategies to lessen the burden of this disorder, particularly among minority populations.

PMID: 9803725, UI: 99020566

Diabetes Care 1998 Nov;21(11):1836-42

Association of waist circumference with risk of hypertension and type 2 diabetes in Nigerians, Jamaicans, and African-Americans.

Okosun IS, Cooper RS, Rotimi CN, Osotimehin B, Forrester T

Department of Preventive