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

OBJECTIVE: Prior studies have supported that waist circumference correlates better with visceral adipose tissue and is a better predictor of cardiovascular disease than are BMI and waist-to-hip ratio. In this study, we reexamine the role of waist size on the risk of hypertension and type 2 diabetes in African-origin populations from three contrasting environments. RESEARCH DESIGN AND METHODS: A cross-sectional survey was conducted of 5,042 men and women 25-74 years of age from Nigeria, Jamaica, and the U.S. The relationship between waist, blood pressure, and fasting blood glucose was assessed using multiple linear regression analyses. Logistic regression analyses using sex-specific empirical waist cut-points were used to determine the risks of hypertension and type 2 diabetes. RESULTS: Waist circumference was positively correlated with blood pressure and fasting blood glucose (P < 0.05). Increasing waist quartiles were significantly associated with higher risks of hypertension in the three populations, as estimated from age-adjusted odds ratios obtained from sex-specific logistic regression models. A highly elevated risk of type 2 diabetes-10-fold for Jamaican men and 23-fold for African-American women-was observed in the comparison of lowest to highest quartiles of waist circumference. CONCLUSIONS: Substantial reduction in hypertension and diabetes in men and women is achievable if the waist size is decreased in these populations. Intervention programs designed to reduce waist circumference through lifestyle modification, including exercise and diet, may have significant public health significance in reducing the incidence of hypertension and adult-onset diabetes in these populations.

Comments:

• Comment in: Diabetes Care 1999 May;22(5):876-7

PMID: 9802730, UI: 99017730

Diabetes Care 1998 Nov;21(11):1828-35

Differential effects of BMI on diabetes risk among black and white Americans.

Resnick HE, Valsania P, Halter JB, Lin X

Epidemiology, Demography, and Biometry Program, National Institute on Aging, Bethesda, Maryland 20892, USA. resnickh@nih.gov

OBJECTIVE: To determine whether the associations of BMI and fat distribution with diabetes risk are modified by race. RESEARCH DESIGN AND METHODS: Data from the National Health and Nutrition Examination Survey, Epidemiologic Follow-up Study (1971-1992), were used to investigate potential interactions of BMI and fat distribution with race. Incident diabetes was defined by self-report of physician-diagnosed diabetes, hospital and nursing home discharge records, and death certificates. RESULTS: Among the 1,531 black and 9,852 white subjects who were nondiabetic at baseline, 1,139 (10.0%) developed diabetes during 20 years of follow-up. Although the cumulative risk of diabetes increased with baseline BMI in all four race-sex groups, the sex-specific odds ratios (ORs) for black:white subjects decreased with increasing BMI. In particular, for BMI of 22 kg/m2, the OR of diabetes for black:white individuals was 1.87 and 1.76 (P < 0.01) for men and women, respectively; for BMI of 32 kg/m2, the OR decreased to 0.99 and 1.20 (NS) for men and women, respectively. Skinfold ratio was also associated with increased diabetes risk in all race-sex groups, but did not modify the association between race and diabetes. CONCLUSIONS: These findings suggest that the effect of BMI on diabetes risk is different for black and white Americans, with a larger risk for blacks than whites at low BMI and an equivalent risk for both groups at high BMI. A lower degree of visceral adiposity among blacks at higher BMI or a greater impact of visceral adiposity among blacks at low BMI may help explain the interaction of race and BMI on diabetes risk.

PMID: 9802729, UI: 99017729

Diabetes Care 1998 Nov;21(11):1812-8

Impaired glucose tolerance, type 2 diabetes, and carotid wall thickness: the Insulin Resistance Atherosclerosis Study.

Wagenknecht LE, D'Agostino RB Jr, Haffner SM, Savage PJ, Rewers M

Department of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, North Carolina 27157, USA. lwagenkn@rc.phs.wfubmc.edu

OBJECTIVE: To assess whether people with impaired glucose tolerance (IGT) exhibit an increased risk of atherosclerosis as measured by the thickness of the carotid artery. RESEARCH DESIGN AND METHODS: We examined the relationship between glucose tolerance status and subclinical atherosclerosis in the Insulin Resistance Atherosclerosis Study (IRAS). The IRAS is an epidemiological study of 1,625 Hispanic, African-American, and white men and women, with approximately equal numbers of subjects with normal glucose tolerance (NGT), IGT, and type 2 diabetes as assessed by an oral glucose tolerance test. Half of those with diabetes were previously unaware of their condition and were defined as having new diabetes. Persons using insulin were excluded. The intima-media thickness (IMT) of the common carotid artery (CCA) and internal carotid artery (ICA) was measured as an index of subclinical atherosclerosis using B-mode ultrasonography. RESULTS: Adjusted for demographics and smoking, CCA-IMT increased most notably at the level of established diabetes (802, 822, 831, and 896 microm for NGT, IGT, new diabetes, and established diabetes, respectively). Adjustment for coronary heart disease (CHD) risk factors, which tended to worsen across glucose tolerance category, further minimized the slightly graded relationship. The relationship with the ICA-IMT was steeper and again suggested that the increased wall thickness is associated with diabetes, not with IGT. The relationship between glucose tolerance category and IMT was similar in men and women. CONCLUSIONS: We observed considerably greater IMT among persons with established diabetes but no significant increase in persons with IGT. These data suggest that the increased risk of CHD observed in persons with diabetes may largely develop after the onset of overt diabetes.

Publication Types:

• Multicenter study

PMID: 9802726, UI: 99017726

Diabetes Care 1998 Nov;21(11):1790-6

Association of hormone replacement therapy and carotid wall thickness in women with and without diabetes.

Dubuisson JT, Wagenknecht LE, D'Agostino RB Jr, Haffner SM, Rewers M, Saad MF, Laws A, Herrington DM

Physician Assistant Program, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA.

OBJECTIVE: Atherosclerosis is the major underlying cause of death for women with type 2 diabetes. We examined the relationship between use of postmenopausal hormone replacement therapy(HRT) and subclinical atherosclerosis among women with type 2 diabetes, impaired glucose tolerance (IGT), and normal glucose tolerance. RESEARCH DESIGN AND METHODS: A cross-sectional analysis was conducted among 623 postmenopausal women in the Insulin Resistance Atherosclerosis Study (IRAS). Current users of HRT, n = 200, were compared with 104 former users and 319 never users. Intimal-medial wall thicknesses (IMTs) of the common carotid (CCA) and internal carotid (ICA) arteries were used as measures of atherosclerosis. RESULTS: Significant differences between HRT user groups were noted for certain demographic, socioeconomic, and lifestyle factors. After adjustment for these and other coronary heart disease risk factors, current users had a 69 microm thinner ICA IMT than never users (P = 0.06). Former users had a 96 pm thinner ICA IMT than never users (P = 0.03). No significant difference was observed for the CCA. Although women with type 2 diabetes had thicker carotid IMT than women without diabetes, the association between HRT use and thinner IMT was similar in both groups. The difference between current and never users was attenuated by adjustment for HDL and LDL cholesterol. Neither duration of HRT use nor HRT regimen was associated with IMT in either artery. CONCLUSIONS: This analysis suggests that current and former use of HRT is associated with reduced atherosclerosis and that women with type 2 diabetes may receive the same benefit from HRI as women without diabetes.

Publication Types:

• Multicenter study

PMID: 9802722, UI: 99017722

Am J Cardiol 1998 Oct 1;82(7):902-4

Risk factors for new coronary events in older African-American men and women.

Aronow WS, Ahn C

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

Independent risk factors for new coronary events in older African-American men were (1) age (risk ratio = 1.037), (2) cigarette smoking (risk ratio = 2.231), (3) hypertension (risk ratio = 2.531), (4) serum total cholesterol (risk ratio = 1.012), (5) serum high-density lipoprotein (HDL) cholesterol (inverse association) (risk ratio = 0.948), and (6) prior coronary artery disease (CAD) (risk ratio = 2.288). Independent risk factors for new coronary events in older African-American women were (1) cigarette smoking (risk ratio = 2.202), (2) hypertension (risk ratio = 2.344), (3) diabetes mellitus (risk ratio = 1.632), (4) serum total cholesterol (risk ratio = 1.008), (5) serum HDL cholesterol (inverse association) (risk ratio = 0.936), (6) age (risk ratio = 1.026), and (7) prior CAD (risk ratio = 2.368).

PMID: 9781976, UI: 98453237

Metabolism 1998 Oct;47(10):1174-9

Relationships between insulin resistance and lipoproteins in nondiabetic African Americans, Hispanics, and non-Hispanic whites: the Insulin Resistance Atherosclerosis Study.

Howard BV, Mayer-Davis EJ, Goff D, Zaccaro DJ, Laws A, Robbins DC, Saad MF, Selby J, Hamman RF, Krauss RM, Haffner SM

Medlantic Research Institute, Washington, DC 20010-2933, USA.

The study purpose was to explore the association between dyslipidemia and insulin resistance in three ethnic groups. The Insulin Resistance Atherosclerosis Study (IRAS) is a multicenter epidemiologic study conducted at four clinical centers in California, Texas, and Colorado. The study population for this analysis consisted of 931 non-Hispanic white, African American, and Hispanic men and women (aged 45 to 64 years) without diabetes. The IRAS clinical examinations included lipoprotein measures, a 75-g glucose tolerance test, and the frequently sampled intravenous glucose tolerance (FSIGT) test. The results show a consistent relationship between insulin-mediated glucose disposal and dyslipidemia in African American, Hispanic, and non-Hispanic white men and women. Further, LDL size was inversely associated with insulin resistance in all three ethnic groups. These findings indicate that dyslipidemia is a fundamental part of the insulin resistance syndrome in all of the ethnic groups studied.

Publication Types:

• Multicenter study

PMID: 9781617, UI: 98452877

J Perinatol 1998 Sep-Oct;18(5):372-6

Frequency, timing, and diagnoses of antenatal hospitalizations in women with high-risk pregnancies.

Brooten D, Kaye J, Poutasse SM, Nixon-Jensen A, McLean H, Brooks LM, Groden S, Polis NS, Youngblut JM

Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH 44106-4904, USA.

OBJECTIVE: To examine the frequency, time of gestation, and reasons for antenatal hospitalizations in women with medically high-risk pregnancies. STUDY DESIGN: This secondary analysis reports all antenatal hospitalizations from a clinical trial testing transitional care to women with high-risk pregnancies. Data were collected from 1992 to 1996. Pregnant women with pregestational (n = 16) or gestational diabetes (n = 21), hypertension (n = 29), and diagnosed (n = 47) or at high risk for preterm labor (n = 37) were included. Diagnoses for each hospitalization and lengths of stay were collected from chart review and validated by attending physicians. Gestation was determined via ultrasonography. The sample (N = 150) consisted of predominantly African-American women, never married, between the ages of 15 and 40 with Medicaid insurance. RESULTS: Eighty-three percent (n = 125) of the women had one or more antenatal hospitalization with a mean length of stay of 123 hours. All women with diabetes were hospitalized at least once. Women with pregestational diabetes had the greatest number of hospitalizations whereas those with gestational diabetes had the least. Major reasons for hospitalizations were preterm labor, glucose control, premature cervical dilation, and preeclampsia. CONCLUSION: Some hospitalizations could potentially be avoided or reduced through expanded patient education, improved screening, and more aggressive monitoring for early signs and symptoms of impending complications.

Publication Types:

• Clinical trial
• Randomized controlled trial

PMID: 9766414, UI: 98437804

Lancet 1998 Sep 26;352(9133):1012-5

Diabetes in older adults: comparison of 1997 American Diabetes Association classification of diabetes mellitus with 1985 WHO classification.

Wahl PW, Savage PJ, Psaty BM, Orchard TJ, Robbins JA, Tracy RP

Department of Biostatistics, School of Public Health and Community Medicine, University of Washington, Seattle, USA. pwahl@u.washington.edu

BACKGROUND: We aimed to compare the prevalence of abnormal glucose tolerance identified by the 1985 WHO and the 1997 American Diabetes Association (ADA) diagnostic categories based on information collected in the Cardiovascular Health Study, an epidemiological study of elderly people. METHODS: We measured glucose concentrations during fasting and 2 h after a 75 g oral glucose-tolerance test in participants aged 65-100 years in the Cardiovascular Health Study. From a 1989 cohort, we analysed the glucose measurements of 4515 individuals without a previous diagnosis of diabetes and of 262 additional measurements from an African-American cohort recruited in 1992-93. FINDINGS: In the 1989 cohort, the prevalence of untreated diabetes with ADA diagnostic fasting criteria was 7.7% versus a prevalence of 14.8% by the WHO criteria. In the African-American cohort, the prevalence of untreated diabetes was 2.7% with ADA criteria and 11.8% with WHO criteria. 3509 (77.7%) of the 4515 participants in the 1989 cohort had normal glucose concentrations according to ADA fasting criteria, compared with 2401 (53.2%) according to WHO criteria. In the African-American cohort, the corresponding numbers were 239 (91.2%) versus 153 (58.4%). All differences in prevalence of abnormal glucose tolerance between ADA and WHO classifications were significant (p<0.0001). INTERPRETATION: Among elderly individuals, there was a significant difference in the prevalence of diabetes identified by the WHO diagnostic criteria based on oral glucose-tolerance test and the ADA fasting criteria. Consequently, many individuals currently classified as non-diabetic according to ADA criteria would previously have had a diagnosis of diabetes according to WHO criteria. Longitudinal studies are needed to assess the value of the criteria in the identification of individuals at increased risk of diabetes-associated chronic complications.

Comments:

• Comment in: Lancet 1998 Sep 26;352(9133):1000-1
• Comment in: Lancet 1999 Jan 2;353(9146):68-9
• Comment in: Lancet 1999 Jan 2;353(9146):69-70

PMID: 9759743, UI: 98430543

Int J Epidemiol 1998 Aug;27(4):636-41

Sixteen-year coronary mortality in black and white men with diabetes screened for the Multiple Risk Factor Intervention Trial (MRFIT).

Vaccaro O, Stamler J, Neaton JD

Department of Clinical and Experimental Medicine, Federico II University, Naples, Italy.

BACKGROUND: Risk of coronary heart disease (CHD) mortality associated with diabetes is high and it is unclear to what extent the high mortality is due to modifiable risk factors. To explore this, mortality and predictors of CHD death are compared in a large cohort of black and white men with diabetes. METHODS: In all, 610 black and 3997 white men who reported taking medication for diabetes and had no history of hospitalization for heart attack were screened by 22 centres for the Multiple Risk Factor Intervention Trial (MRFIT). At screening major risk factors for CHD were determined. Participants have been followed for an average of 16 years for vital status. Cause-specific mortality and predictors of CHD are compared for blacks and whites using proportional hazards regression. RESULTS: Serum cholesterol and systolic blood pressure levels were similar in blacks and whites with diabetes, while diastolic blood pressure and percentage of smokers were higher in blacks (89 versus 86 mmHg and 47% versus 34%) and median income was lower. Coronary heart disease was the leading cause of death, accounting for 31% (68/221) and 44% (564/1293) of deaths among blacks and whites, respectively. Adjusted relative risks of CHD death and all cause mortality for blacks compared to whites were 0.71 (95% CI: 0.53-0.95) and 0.94 (95% CI: 0.75-1.11). Differences in reporting cause of death probably account for some of the black/white difference in CHD. High serum cholesterol, high blood pressure, and smoking increased risk of CHD death similarly in blacks and whites. CONCLUSIONS: Serum cholesterol, blood pressure, and smoking are major influences on CHD mortality risk in both white and black men with diabetes. High prevalence of these factors indicates substantial potential for CHD prevention in both ethnic groups.

PMID: 9758118, UI: 98429085

Nurse Pract Forum 1998 Jun;9(2):108-14

Type 2 diabetes in people of color.

Hosey G, Gordon S, Levine A

Portland Area Indian Health Service Diabetes Program, Bellingham, WA 98225, USA.

Type 2 diabetes is a major public health concern for people of color throughout the United States. The prevalence of type 2 diabetes among African-Americans, Hispanics and American Indian/Alaskan Natives is from two to six times greater than that of the US non-Hispanic white population. Rates of end-stage renal disease, amputations, and diabetic retinopathy are also significantly higher. The medical risk factors of familial history, insulin resistance, obesity, history of gestational diabetes, impaired glucose tolerance, and physical inactivity are the same for all populations. The disproportionate impact of diabetes in people of color may be because of an interaction of genetic risk factors and environmental factors. Recognizing the impact of culture in disease management and self-care practices can improve diabetes care.

Publication Types:

• Review
• Review, tutorial

PMID: 9752126, UI: 98424680

J Assoc Acad Minor Phys 1998;9(3):48-52

Prevention and control of hypertension and diabetes in an underserved population through community outreach and disease management: a plan of action.

Gerber JC, Stewart DL

Hoechst Marion Roussel Pharmaceuticals, Inc., Kansas City, Missouri, USA.

Hypertension and diabetes are overrepresented in the African-American population and can be particularly devastating in this population. These diseases share genetic predisposition, medical risk factors, and environmental influences as etiologic factors, and they may be interrelated, at least in part, by obesity and accompanying hyperinsulinemia. Noncompliance with treatment plans is a significant barrier to health improvement in both diseases, but increased attention to patient involvement in care is a potential solution to this long-standing problem. The Baltimore Alliance for the Prevention and Control of Hypertension and Diabetes was established in January 1998 to promote care to the underserved community of West Baltimore, Maryland, and to improve outcomes of hypertension and diabetes. Based at the University of Maryland School of Medicine, the Baltimore Alliance comprises a community health worker program, a church-based education and screening effort, managed care and pharmaceutical company (Hoechst Marion Roussel) partners, a health policy and services research group, and inpatient/outpatient clinical care sites in the health system. Mobilization, cultural relevance, and partnership are employed to ensure that the Alliance's goals of increased patient enrollment and retention in treatment programs will be achieved. Thereby, improved outcomes--clinical, humanistic, and economic--will result. Novel as well as classic approaches to patient education, compliance, and goal achievement are being pursued. Complete expert systems for hypertension and diabetes disease management are being created and will be implemented in the near future. Baseline practices and current outcomes are being identified to act as historical controls. The organization and administration of the Alliance will serve as a prototype that others may follow.

PMID: 9747058, UI: 98419195

Arch Intern Med 1998 Sep 14;158(16):1761-8

Time trends in the use of cholesterol-lowering agents in older adults: the Cardiovascular Health Study.

Lemaitre RN, Furberg CD, Newman AB, Hulley SB, Gordon DJ, Gottdiener JS, McDonald RH Jr, Psaty BM

Department of Medicine, University of Washington, Seattle, USA.

OBJECTIVES: To describe recent temporal patterns of cholesterol-lowering medication use and the characteristics that may have influenced the initiation of cholesterol-lowering therapy among those aged 65 years or older. SUBJECTS AND METHODS: A cohort of 5201 adults 65 years or older were examined annually between June 1989 and May 1996. We added 687 African American adults to the cohort in 1992-1993. We measured blood lipid levels at baseline and for the original cohort in the third year of follow-up. We assessed the use of cholesterol-lowering drugs at each visit. RESULTS: The prevalence of cholesterol-lowering drug use in 1989-1990 was 4.5% among the men and 5.9% among the women; these figures increased over the next 6 years to 8.1% and 10.0%, respectively, in 1995-1996. There was a 4-fold increase in the use of 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors during the 6 years of follow-up, from 1.9% of all participants in 1989-1990 to 7.5% in 1995-1996. The use of bile acid sequestrants, nicotinic acid, and probucol declined from initial levels of less than 1% each. Among the participants who were untreated in 1989-1990, but eligible for cholesterol-lowering therapy after a trial of dietary therapy according to the 1993 guidelines of the National Cholesterol Education Panel, less than 20% initiated drug therapy in the 6 years of follow-up, even among subjects with a history of coronary heart disease. Among participants untreated at baseline but eligible for either cholesterol-lowering therapy or dietary therapy, initiation of cholesterol-lowering drug therapy was directly associated with total cholesterol levels, hypertension, and a history of coronary heart disease, and was inversely related to age, high-density lipoprotein cholesterol levels, and difficulties with activities of daily living. Other characteristics that form the basis of the 1993 National Cholesterol Education Panel guidelines-diabetes, smoking, family history of premature coronary heart disease, and total number of risk factors-were not associated with the initiation of cholesterol-lowering drug therapy. CONCLUSIONS: Given the clinical trial evidence for benefit, those aged 65 to 75 years and with prior coronary heart disease appeared undertreated with cholesterol-lowering drug therapy.

PMID: 9738605, UI: 98408985

Lancet 1998 Mar 28;351(9107):934-9

Mortality differences between black and white men in the USA: contribution of income and other risk factors among men screened for the MRFIT. MRFIT Research Group. Multiple Risk Factor Intervention Trial.

Davey Smith G, Neaton JD, Wentworth D, Stamler R, Stamler J

Department of Social Medicine, University of Bristol, UK.

BACKGROUND: Studies of underlying differences in adult mortality between black and white individuals in the USA have been constrained by limitations of data or small study size. We investigated the extent to which differences in socioeconomic position between black and white men contribute to differences in all-cause and cause-specific mortality. METHODS: 361,662 men were screened for the Multiple Risk Factor Intervention Trial between 1973 and 1975, in 22 sites. Median family income of households by zipcode (postal) area of residence was available for 20,224 black and 300,685 white men as well as data on age, cigarette smoking, blood pressure, serum cholesterol, previous heart attack, and treatment for diabetes. We classified deaths during 16 years of follow-up into specific causes and compared differences in death rates between black men and white men, before and after adjustment for differences in income and other risk factors. FINDINGS: Age-adjusted relative risk of death (black vs white) was 1.47 (95% CI 1.42-1.53). Adjustment for diastolic blood pressure, serum cholesterol, cigarette smoking, medication for diabetes, and previous admission to hospital for heart attack decreased the relative risk to 1.40 (1.35-1.46). Adjustment for income but not the other risk factors decreased the risk to 1.19 (1.14-1.24) and adjustment for other risk factors did not alter this estimate. For cardiovascular death, relative risk on adjustment for income was decreased from 1.36 to 1.09; for cancer from 1.47 to 1.25; and for non-cardiovascular and non-cancer deaths from 1.71 to 1.26. For some specific causes of death, including prostate cancer, myeloma, and hypertensive heart disease, the higher death rates among black men did not seem to reflect differences in income. Rates of death for suicide and melanoma were lower among black than white men, as were those for coronary heart disease after adjustment for income. INTERPRETATION: Socioeconomic position is the major contributor to differences in death rates between black and white men. Differentials in mortality from some specific causes do not simply reflect differences in income, however, and more detailed investigations are needed of how differences are influenced by environmental exposures, lifetime socioeconomic conditions, lifestyle, racism, and other sociocultural and biological factors.

PMID: 9734939, UI: 98404008

Diabetes Care 1998 Sep;21(9):1576-7

High prevalence of albuminuria among African-Americans with short duration of diabetes.

Thaler LM, El-Kebbi IM, Ziemer DC, Gallina DL, Dunbar VG, Phillips LS

Publication Types:

• Letter

PMID: 9727919, UI: 98394902

Metabolism 1998 Aug;47(8):998-1004

Characteristics of young offspring of type 2 diabetic parents in a biracial (black-white) community-based sample: the Bogalusa Heart Study.

Srinivasan SR, Elkasabani A, Dalferes ER Jr, Bao W, Berenson GS

Tulane Center for Cardiovascular Health, Tulane University Medical Center, New Orleans, LA, USA.

The impact of race (black-white) and family history of type 2 diabetes mellitus on metabolic characteristics in early life was examined in a community-based sample from Bogalusa, LA. Study subjects included offspring of type 2 diabetics (n = 53, 47% black) and nondiabetics (n = 52, 40% black), with the mean age of each group ranging from 14.2 to 15.6 years. Offspring were given a 1-hour oral glucose tolerance test. Measures of body fatness such as body weight, body-mass index (BMI; weight/height2), and triceps and subscapular thicknesses were significantly higher only in white offspring of diabetics versus nondiabetics; measures of abdominal fat (waist circumference and waist-to-hip ratio) were significantly higher among offspring of diabetics of both races. Among the measures of glucose homeostasis, basal glucose, insulin, insulin-to-C-peptide ratio (a measure of hepatic insulin extraction), insulin resistance index (derived from basal glucose and insulin levels), and glucose response after glucose challenge were higher in the offspring of diabetics of both races. The differences in insulin-to-C-peptide ratio and glucose response remained significant after adjusting for BMI; further, these two variables were independently associated with parental diabetes in both races. Waist-to-hip ratio, glucose response, C-peptide response (a measure of insulin secretion) were lower, and basal insulin-to-C-peptide ratio and postglucose suppression of free fatty acids greater in blacks versus whites, regardless of status of parental diabetes. Black-white differences in postglucose suppression of free fatty acids disappeared after adjusting for BMI. Thus, blacks and whites with parental type 2 diabetes show multiple abnormalities in parameters governing glucose homeostasis early in life, and some of these traits differ between the races, regardless of status of parental diabetes.

PMID: 9711999, UI: 98375817

Ophthalmology 1998 Aug;105(8):1373-9

Demographic and clinical characteristics of patients with diabetes presenting to an urban public hospital ophthalmology clinic.

Baker RS, Watkins NL, Wilson MR, Bazargan M, Flowers CW Jr

Division of Ophthalmology, Charles R. Drew University of Medicine and Science, Los Angeles, California 90059, USA.

OBJECTIVE: This study aims to describe the clinical and sociodemographic characteristics of patients with diabetes who are newly presenting to an inner city public hospital eye clinic. This study also aims to determine the prevalence and severity of ocular morbidity in this population at time presentation and to assess the adequacy of the ophthalmic surveillance to which this population was exposed before presentation. DESIGN: A clinic-based, cross-sectional study. PARTICIPANTS: A total of 118 consecutive patients with diabetes participated. METHOD: During a 2-month interval, all patients with diabetes newly presenting to the Los Angeles County King-Drew Medical Center eye clinic were recruited who were at risk for diabetic eye complications according to American Diabetes Association criteria. Each patient underwent a standardized interviewer-administered questionnaire and a comprehensive ophthalmic examination. RESULTS: Of the 118 patients, 65 (55%) were Hispanic and 51 (43%) were African American. Forty-six percent had a grade school education or less, 91% were unemployed, and 64% had no health insurance. Type two diabetes was predominant (91%), including 24 (22%) of new onset. Thirty-six patients with diabetes (31%) reported duration of diabetes greater than 10 years at time of presentation. At time of presentation, 62% had clinically apparent ophthalmic disease, whereas 40% had advanced ocular disease, including 6.8% of the sample that were legally blind. Sixty-nine patients (58.5%) reported never having had a dilated fundus examination, whereas 31 (63%) of the 49 patients reporting a previous dilated examination were last examined more than 2 years before presentation. Timing of ophthalmic examination was classified as appropriate for 38 patients (32%), marginal for 20 patients (17%), and inappropriate for 60 patients (51%). CONCLUSION: In the setting of an inner city county hospital eye clinic, where the patient population is predominately minority and of low socioeconomic status, ophthalmic surveillance of high-risk patients with diabetes is inadequate and advanced disease often is present at initial presentation. Strategies must be developed to increase the routine use of eye services within this population.

PMID: 9709745, UI: 98375476

Clin Chem 1998 Aug;44(8 Pt 2):1821-5

Obesity and cardiovascular disease.

Sowers JR

Department of Internal Medicine, Wayne State University School of Medicine, Detroit, MI 48201, USA. sowers@oncgate.roc.wayne.edu

Obesity, diabetes mellitus, and hypertension are common, interrelated medical problems in Westernized, industrialized societies. These interrelated medical conditions are associated with an increased risk of cardiovascular disease and are more prevalent in several minority groups, including African-American and Hispanic populations. The associated cardiovascular risks of these problems are more thoroughly addressed in another review in this supplement. Obesity markedly enhances the development of Type 2 diabetes. Moreover, it enhances the cardiovascular risk associated with other risk factors, such as hypertension and dyslipidemia. Weight reduction in association with an aerobic exercise program improves metabolic abnormalities and reduces blood pressure in individuals with diabetes and hypertension.

Publication Types:

• Review
• Review, tutorial

PMID: 9702991, UI: 98366551

Diabetes Care 1998 Aug;21(8):1278-81

Was there an epidemic of diabetes in nonwhite adolescents in Allegheny County, Pennsylvania?

Libman IM, LaPorte RE, Becker D, Dorman JS, Drash AL, Kuller L

Diabetes Research Center, Rangos Research Center, Pittsburgh, PA 15213, USA. iml1@vms.cis.pitt.edu

OBJECTIVE: To determine the incidence of IDDM in children aged < 20 years at diagnosis in Allegheny County, Pennsylvania, for the period from 1 January 1990 to 31 December 1994 and to compare the incidence between whites and nonwhites in the same area and for the same time period. RESEARCH DESIGN AND METHODS: All new patients diagnosed between January 1990 and December 1994 who were aged < 20 years, on insulin, and residents of Allegheny County at diagnosis were identified from medical records of 23 hospitals in the Allegheny County area. To verify the completeness of the hospitals using the capture-recapture method, pediatricians and diabetologists were used as a secondary source. RESULTS: A total number of 257 patients were identified. The overall age-standardized incidence rate was 16.7/100,000. Nonwhites had a slightly higher incidence (17.6/100,000) than whites (16.5/100,000). In the 15-19 years age-group, the incidence in nonwhites (30.4/100,000) was almost three times higher than that in white (11.2/100,000) and more than two times higher than that in the previous period (from 1985 to 1989) (13.8/100,000). CONCLUSIONS: For the first time in the Allegheny County registry, and in any other registry, nonwhites showed a higher incidence of IDDM than whites. The high incidence in the 15-19 years age-group was responsible for this phenomenon. This epidemic of diabetes in adolescent nonwhites may be the result of a rising incidence of classical IDDM or another type of diabetes. Further studies using population-based registries are needed to determine whether this increase is being seen in other areas and other ethnic groups and to clarify the reasons for the increase in IDDM among blacks.

PMID: 9702433, UI: 98367810

Diabetes Care 1998 Aug;21(8):1250-7

History of gestational diabetes leads to distinct metabolic alterations in nondiabetic African-American women with a parental history of type 2 diabetes.

Osei K, Gaillard TR, Schuster DP

Department of Medicine, Ohio State University Hospitals, Columbus, USA.

OBJECTIVE: Gestational diabetes mellitus (GDM) and positive parental history of type 2 diabetes are predictors of the future development of type 2 diabetes in several populations. However, the relative importance of parental history of diabetes and/or history of GDM as risk factors for the pathogenesis of diabetes in African-Americans remains unknown. Thus, the objectives of the present study were 1) to characterize the glucose homeostatic regulations and 2) to examine the contribution of parental history of type 2 diabetes to the potential metabolic alterations found in nondiabetic African-American women with a history of GDM (HGDM). RESEARCH DESIGN AND METHODS: We evaluated beta-cell secretion, insulin sensitivity (SI), and glucose-dependent glucose disposal (SG) in 15 glucose-tolerant African-American women with a parental history of type 2 diabetes and prior GDM (HGDM) and 35 women with a parental history of type 2 diabetes but without prior GDM (NHGDM). Fifteen healthy nonobese nondiabetic subjects without a family history of diabetes served as control subjects. Body composition was determined by bioelectrical impedance analyzer, and body fat distribution pattern was determined by waist-to-hip ratio (WHR). Insulin-modified frequently sampled intravenous glucose tolerance (FSIGT) test was performed in each subject. SI and SG were determined by the minimal model method. RESULTS: The mean age, BMI, percent body fat content, and lean body mass were not different between the subgroups of relatives with and without a history of GDM, but were greater than those of the healthy control subjects. Mean fasting and postchallenge serum glucose levels were slightly but significantly greater in the HGDM versus NHGDM subjects and the healthy control subjects. However, the 2-h glucose levels were greater in the relatives with and without GDM when compared with the healthy control subjects. In contrast, mean postprandial serum insulin responses were significantly lower between t = 30 and 120 min in the HGDM versus NHGDM groups and the healthy control subjects. The mean serum insulin levels were not different in the NHGDM subjects and healthy control subjects. During the FSIGT test, acute first-phase insulin release (t = 0-5 min) was significantly lower in the HGDM versus NHGDM groups and healthy control subjects. Mean SI was significantly (P < 0.05) lower in the HGDM versus NHGDM subjects and healthy control subjects (1.87 +/- 0.47 vs. 2.87 +/- 0.35 and 3.09 +/- 0.27 x 10(-4).min-1.[microU/ml]-1, respectively). SG was significantly lower in HGDM than NHGDM subjects and healthy control subjects (2.11 +/- 0.15 vs. 3.25 +/- 0.50 and 2.77 +/- 0.22 x 10(-2).min-1, respectively). Mean glucose effectiveness at zero insulin concentrations (GEZI) was significantly lower in the HGDM subjects when compared with the NHGDM and healthy control subjects. CONCLUSIONS: The present study demonstrates that in African-American women with a parental history of type 2 diabetes and GDM, defects in early-phase beta-cell secretion, as well as a decreased SI, SG, and GEZI, persist when compared with those without GDM. We suggest that African-American women with a positive history of GDM have additional genetic defects that perhaps differ from that conferred by a parental history of diabetes alone. Alternatively, the metabolic and hormonal milieu during GDM may be associated with permanent alterations in beta-cell function, SI, and glucose effectiveness in African-American women. These defects could play a significant role in the development of GDM, and perhaps in the subsequent development of type 2 diabetes, in African-American women.

PMID: 9702429, UI: 98367806

Diabetes Care 1998 Aug;21(8):1230-5

Is the risk of diabetic retinopathy greater in non-Hispanic blacks and Mexican Americans than in non-Hispanic whites with type 2 diabetes? A U.S. population study.

Harris MI, Klein R, Cowie CC, Rowland M, Byrd-Holt DD

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

OBJECTIVE: To compare the risk for diabetic retinopathy in non-Hispanic white, non-Hispanic black, and Mexican-American adults with type 2 diabetes in the U.S. population. RESEARCH DESIGN AND METHODS: Representative population-based samples of people aged > or = 40 years in each of the three racial/ethnic groups were studied in the 1988-1994. Third National Health and Nutrition Examination Survey (NHANES III). Diagnosed diabetes was ascertained by medical history interview, and undiagnosed diabetes by measurement of fasting plasma glucose. A fundus photograph of a single eye was taken with a nonmydriatic camera, and a standardized protocol was used to grade diabetic retinopathy. Information on risk factors for retinopathy was obtained by interview and standard laboratory procedures. RESULTS: Prevalence of any lesions of diabetic retinopathy in people with diagnosed diabetes was 46% higher in non-Hispanic blacks and 84% higher in Mexican Americans, compared with non-Hispanic whites. Blacks and Mexican Americans also had higher rates of moderate and severe retinopathy and higher levels of many putative risk factors for retinopathy. Blacks had lower retinopathy prevalence among those with undiagnosed diabetes. In logistic regression, retinopathy in people with diagnosed diabetes was associated only with measures of diabetes severity (duration of diabetes, HbA1c, level, treatment with insulin and oral agents) and systolic blood pressure. After adjustment for these factors, the risk of retinopathy in Mexican Americans was twice that of non-Hispanic whites, but non-Hispanic blacks were not at higher risk for retinopathy. These risks were similar when people with undiagnosed diabetes were included in the logistic regression models. CONCLUSIONS: The prevalence and severity of diabetic retinopathy is greater in non-Hispanic blacks and Mexican Americans with type 2 diabetes in the U.S. population than in non-Hispanic whites. For blacks, this can be attributed to their higher levels of risk factors for retinopathy, but the excess risk in Mexican Americans is unexplained.

PMID: 9702425, UI: 98367802

Obes Res 1998 Jul;6(4):268-77

The body mass index-mortality relationship in white and African American women.

Stevens J, Plankey MW, Williamson DF, Thun MJ, Rust PF, Palesch Y, O'Neil PM

Department of Nutrition, School of Public Health, University of North Carolina, Chapel Hill 27599, USA.

OBJECTIVE: To examine the association of body mass index to all-cause and cardiovascular disease (CVD) mortality in white and African American women. RESEARCH METHODS AND PROCEDURES: Women who were members of the American Cancer Society Prevention Study I were examined in 1959 to 1960 and then followed 12 years for vital status. Data for this analysis were from 8,142 black and 100,000 white women. Body mass index (BMI) was calculated from reported height and weight. Associations were examined using Cox proportional hazards modeling with some analyses stratified by smoking (current or never) and educational status (less than complete high school or high school graduate). RESULTS: There was a significant interaction between ethnicity and BMI for both all-cause (p<0.05) and CVD mortality (p<0.001). BMI (as a continuous variable) was associated with all-cause mortality in white women in all four groups defined by smoking and education. In black women with less than a high school education, there were no significant associations between BMI mortality. For high school-educated black women, there was a significant association between BMI and all-cause mortality. Among never smoking women with at least a high school education, models using the lowest BMI as the reference indicated a 40% higher risk of all-cause mortality at a BMI of 35.9 in black women vs. 27.3 in white women. DISCUSSION: The impact of BMI on mortality was modified by educational level in black women; however, BMI was a less potent risk factor in black women than in white women in the same category of educational status.

PMID: 9688103, UI: 98351389

JAMA 1998 Jul 22-29;280(4):356-62

Ethnic and socioeconomic differences in cardiovascular disease risk factors: findings for women from the Third National Health and Nutrition Examination Survey, 1988-1994.

Winkleby MA, Kraemer HC, Ahn DK, Varady AN

Stanford Center for Research in Disease Prevention, Stanford University School of Medicine, Palo Alto, Calif 94304, USA. marilynvwinkleby@scrdp.stanford.edu

CONTEXT: Cardiovascular disease (CVD) risk factors are higher among ethnic minority women than among white women in the United States. However, because ethnic minority women are disproportionately poor, socioeconomic status (SES) may substantially explain these risk factor differences. OBJECTIVE: To determine whether differences in CVD risk factors by ethnicity could be attributed to differences in SES. DESIGN: Third National Health and Nutrition Examination Survey conducted between 1988 and 1994. SETTING: Eighty-nine mobile examination centers. PARTICIPANTS: A total of 1762 black, 1481 Mexican American, and 2023 white women, aged 25 to 64 years, who completed both the home questionnaire and medical examination. MAIN OUTCOME MEASURES: Ethnicity and years of education (SES) in relation to systolic blood pressure, cigarette smoking, body mass index (BMI, a measure of weight in kilograms divided by the square of height in meters), physical inactivity, non-high-density lipoprotein cholesterol (non-HDL-C [the difference between total cholesterol and HDL-C]), and non-insulin-dependent diabetes mellitus. RESULTS: As expected, most CVD risk factors were higher among ethnic minority women than among white women. After adjusting for years of education, highly significant differences in blood pressure, BMI, physical inactivity, and diabetes remained for both black and Mexican American women compared with white women (P<.001). In addition, women of lower SES from each of the 3 ethnic groups had significantly higher prevalences of smoking and physical inactivity and higher levels of BMI and non-HDL-C than women of higher SES (P<.001). CONCLUSIONS: These findings provide the greatest evidence to date of higher CVD risk factors among black and Mexican American women than among white women of comparable SES. The striking differences by both ethnicity and SES underscore the critical need to improve screening, early detection, and treatment of CVD-related conditions for black and Mexican American women, as well as for women of lower SES in all ethnic groups.

Comments:

• Comment in: JAMA 1998 Dec 16;280(23):1989-90

PMID: 9686553, UI: 98349342

J Natl Med Assoc 1998 Jul;90(7):425-32

Social support among African-American adults with diabetes, Part 2: A review.

Ford ME, Tilley BC, McDonald PE

Henry Ford Health System, Center for Medical Treatment Effectiveness Programs, Detroit, MI 48202, USA.

Diabetes mellitus affects African Americans in disproportionate numbers relative to whites. Proper management of this disease is critical because of the increased morbidity and mortality associated with poor diabetes management. The role of social support in promoting diabetes management and improved glycemic control among African Americans is a little-explored area. This review, the second in a two-part series, examines the relationship between social support and glycemic control among African-American adults with diabetes. The main findings of the study are that African Americans tend to rely more heavily than whites on their informal social networks to meet their disease management needs and that social support is significantly associated with improved diabetes management among members of this population. However, there remains a critical need to systematically include substantial numbers of African-American respondents in studies examining the relationship between social support and glycemic control. Only then can the effects of age, gender, socioeconomic status, and other variables on this relationship in African Americans become clear and interventions incorporating relevant aspects of social support be developed.

Publication Types:

• Review
• Review, tutorial

PMID: 9685778, UI: 98350395

Ethn Dis 1998;8(2):249-53

African American Study of Kidney Disease and hypertension (AASK)--clinical trial update.

Agodoa L

Division of Kidney, Urologic, and Hematologic Diseases, NIDDK, National Institutes of Health, Bethesda, Maryland, USA. agodoa@ep.niddk.nih.gov

African Americans are disproportionately afflicted with end-stage kidney failure (ESRD). Whereas they constitute approximately 12 percent of the US population, they comprise 32 percent of the prevalent ESRD population. Diabetes mellitus is the predominant cause of ESRD in the U.S. population. However, hypertension is the most frequently reported cause of ESRD in African Americans. In 1990, the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) of the National Institutes of Health launched an initiative to investigate the underlying cause, and to study mechanisms that could slow progression of hypertensive kidney disease in African Americans. An important component of this initiative is the clinical trial African American Study of Kidney Disease and Hypertension (AASK). This report provides an update on the Institute's initiative on hypertensive kidney disease in African Americans and, specifically, on the clinical trial.

PMID: 9681290, UI: 98346268

Diabetes Educ 1998 May-Jun;24(3):319-24

Diabetes knowledge and sources of information among African American and white older women.

Schoenberg NE, Amey CH, Coward RT

Department of Behavioral Sciences and Anthropology, University of Kentucky, Lexington 40536-0086, USA.

African American women have a disproportionate risk of diabetes-related morbidity and mortality. Despite this risk, evidence indicates that educational interventions are not aimed at this population. We also currently lack basic information about the source of diabetes information for African American women and how such sources might affect their knowledge of the disease. We interviewed 51 women with diabetes to address such deficits in our understanding and, conceivably, to contribute culturally sensitive recommendations to enhance glucose control. To detect ethnic variations in knowledge and information source, half of our selected sample was African American and half was white. Results indicate that African American respondents achieved lower scores on the Diabetes Knowledge Test than their white counterparts. However, few differences were noted in the source of diabetes information, with both groups receiving their information from a wide variety of sources. Implications for health providers and educators are discussed.

PMID: 9677949, UI: 98342913

Ophthalmic Epidemiol 1998 Jun;5(2):91-100

Correlates of recency of eye examination among elderly African-Americans.

Bazargan M, Baker RS, Bazargan S

Department of Family Medicine, Charles R. Drew University of Medicine & Science, Los Angeles, CA 90059, USA.

This study uses a theoretical model of health services utilization to assess the effects of predisposing, enabling, and need-for-care characteristics on recency of eye examinations among a sample of 998 elderly African-American persons. More than 64% of participants reported that they had had eye examinations within the last 12 months. Multiple logistics regression analysis explains 13.3% of the variance of eye examinations. This data indicates that recency of eye examination is related to health locus of control, private insurance, Medicare, insulin-dependent diabetes, and presence of eye disease. No significant relationship between recency of eye examination and self-rated health status, social support, vision impairment, and non-insulin-dependent diabetes were detected. The lack of association between non-insulin-dependent diabetes and the recency of eye examination suggests that the amount of preventive care in place may not be adequate. This data shows that the unique contributions of need characteristics account for a major variance of recency of eye examination. However, enabling characteristics play a significant role in sending the participants of this study to eye-specialists, even after need-for-care factors are held constant.

PMID: 9672909, UI: 98336780

West J Med 1998 Jun;168(6):504-11

Quality of diabetes care for non-English-speaking patients. A comparative study.

Tocher TM, Larson E

Community Health Center of Snohomish County, Everett, WA 98201, USA. tocher@juno.com

To determine the quality of care provided to non-English-speaking patients with non-insulin-dependent (type 2) diabetes mellitus compared with English-speaking patients, we did a retrospective cohort study of 622 patients with type 2 diabetes, of whom 93 were non-English-speaking and 529 were English-speaking. They were patients at primary and specialty care clinics at a university and a county hospital, and the study was based on clinical and administrative database records with a 12-month follow-up. Professional interpreters were provided to all non-English-speaking patients. Patients were identified using interpreter services records, which reliably included all patients who did not speak English. After adjusting for demographic differences, significantly more non-English-speaking patients received care that met the American Diabetes Association guidelines of 2 or more glycohemoglobin tests per year (odds ratio, 1.9; 95% confidence interval, 1.2-3.0) and 2 or more clinic visits per year (odds ratio, 2.6; 95% confidence interval, 1.2-5.4). More non-English-speaking patients had 1 or more dietary consultations (odds ratio, 2.8; 95% confidence interval, 1.3-6.1). No other significant differences were found in routine laboratory test use or in the number of ophthalmologic examinations. Outcome variables also did not differ, including standardized glycohemoglobin and other laboratory results, complication rates, use of health services, and total charges. At these institutions, the quality of diabetes care for non-English-speaking patients appear to be as good as, if not better than, for English-speaking patients. Physicians may be achieving these results through more frequent visits and laboratory testing.

PMID: 9655991, UI: 98320074

Diabetes Care 1998 Jul;21(7):1090-5

Diabetes in the African-American Medicare population. Morbidity, quality of care, and resource utilization.

Chin MH, Zhang JX, Merrell K

Section of General Internal Medicine, University of Chicago, Illinois 60637, USA. mchin@medicine.bsd.uchicago.edu

OBJECTIVE: To determine whether African-American Medicare recipients with diabetes are at increased risk for morbidity, poor quality of care, and high resource utilization. RESEARCH DESIGN AND METHODS: We analyzed 1,376 patients with diabetes who were > or = 65 years of age and in the 1993 Medicare Current Beneficiary Survey. Morbidity measures were the Katz Index of Activities of Daily Living, Instrumental Activities of Daily Living, overall health perception, Charlson Comorbidity Index score, and diabetic complications. Quality of care standards were glycosylated hemoglobin measurements, ophthalmological visits, lipid testing, mammography, influenza vaccination, readmission within 30 days of hospital discharge, and outpatient visits within 4 weeks of hospital discharge. We stratified Medicare reimbursement by type of service and adjusted for sex, education, and age in multivariable analyses. RESULTS: Compared with white patients, African-American patients had worse health perception and lower quality of care. They were more likely to visit the emergency department and had fewer physician visits per year. African-Americans had higher reimbursement for home health services, but total reimbursement was similar after case-mix adjustment. CONCLUSIONS: Improved access to preventive care for older African-Americans with diabetes may improve health perception and use of the emergency department. The potential effect on total reimbursement is unclear. Future policy interventions to improve quality of care among Medicare patients with diabetes should especially target African-Americans.

PMID: 9653601, UI: 98317483

Transplantation 1998 Jun 15;65(11):1510-2

Successful long-term kidney-pancreas transplants in diabetic patients with high C-peptide levels.

Sasaki TM, Gray RS, Ratner RE, Currier C, Aquino A, Barhyte DY, Light JA

Transplantation Services, Washington Hospital Center, DC 20010, USA.

BACKGROUND: Pancreas transplants are rarely done in type 2 (noninsulin dependent) diabetic patients. Most researchers believe that in type 2 diabetic patients, peripheral insulin resistance plays a central role and also is associated with relative insulin deficiency or an insulin secretory defect. This suggests that in patients receiving transplants, the new beta cells will be overstimulated, leading to beta cell "exhaustion" and graft failure. METHODS: Early in our experience, simultaneous pancreas-kidney transplant candidates were selected using only clinical criteria for type 1 diabetes, i.e., early onset of diabetes and rapid onset of insulin use. Pretransplant sera were available for C-peptide analysis in 70 of 94 of those patients. Forty-four percent (31/70) were African American (AA). RESULTS: Thirteen patients (12 AA) with a nonfasting C-peptide level >1.37 ng/ml were identified. In these patients with high C-peptide levels, pancreas and kidney survival rates were 10O%. The results did not differ statistically from the low C-peptide group (< or =1.37 ng/ ml). There were no differences between patient and pancreas-kidney survival rates when the patients were separated into AA and non-AA groups. The follow-up was 1-89 months, with a mean of 45.5 months. CONCLUSIONS: Long-term pancreas graft function is attainable and beta cell "exhaustion" does not occur in patients with high preoperative C-peptide (>1.37 ng/ ml) levels. AA and non-AA patients have equivalent long-term patient, kidney, and pancreas-kidney graft survival rates.

PMID: 9645815, UI: 98307747

J Natl Med Assoc 1998 Jun;90(6):361-5

Social support among African-American adults with diabetes. Part 1: Theoretical framework.

Ford ME, Tilley BC, McDonald PE

Henry Ford Health System, Center for Medical Treatment Effectiveness Programs, Detroit, MI 48202, USA.

Diabetes mellitus affects African Americans in disproportionate numbers relative to whites. Proper management of this disease is critical because of the increased morbidity and mortality associated with poor diabetes management. The role of social support in promoting diabetes management and improved glycemic control among African Americans is a little-explored area. This article, the first in a two-part series, provides a theoretical framework for examining the relationship between social support and glycemic control among African-American adults.

Publication Types:

• Review
• Review, tutorial

PMID: 9640907, UI: 98305089

J Foot Ankle Surg 1998 May-Jun;37(3):186-90

Cost of diabetes-related amputations in minorities.

Ashry HR, Lavery LA, Armstrong DG, Lavery DC, van Houtum WH

Department of Orthopaedics, University of Texas Health Science Center, San Antonio 78284-7776, USA.

The objective of this study was to identify the direct cost and length of hospitalization of diabetes-related lower extremity amputations among Hispanics, African Americans, non-Hispanic whites, and Asians. The authors used a database from the office of Statewide Planning and Development in California that identified all hospitalizations for lower extremity amputations in the state in 1991. Amputation level was defined by the ICD-9-CM codes 84.11-84.18. The total hospital charges for diabetes-related lower extremity amputations for the state of California in 1991 was $141 million. The mean hospital charge (HC) per patient with all ethnic groups combined was $27,930; and the mean length of stay (LOS) was 15.9 days. African Americans had significantly higher mean charges ($32,383) and longer stays (17.3 days) compared to all other ethnic groups (p < .05). Toe-level amputations had lower HC (p < .05) and LOS (p < .01) than other amputation levels for all race groups. One-quarter of the population received multiple amputations during their hospital stay. These patients incurred significantly higher hospital charges ($44,731) and stayed in the hospital longer (23.4 days) than those receiving only a single amputation. There was a considerable variation in the HC and LOS among ethnic groups by level of amputation. The direct charges reported in this study suggest considerably higher overall direct costs than have been previously reported in the medical literature. The greater burden of disease experienced by African Americans is probably related to their higher amputation cost and longer hospitalization.

PMID: 9638541, UI: 98302397

Neurology 1998 Jun;50(6):1688-93

Illicit drug-associated ischemic stroke in the Baltimore-Washington Young Stroke Study.

Sloan MA, Kittner SJ, Feeser BR, Gardner J, Epstein A, Wozniak MA, Wityk RJ, Stern BJ, Price TR, Macko RF, Johnson CJ, Earley CJ, Buchholz D

Department of Neurology, University of Maryland School of Medicine, Baltimore, USA.

BACKGROUND: Limited information exists on the frequency, trends in occurrence, risk factors, mechanisms, and outcome of ischemic stroke associated with illicit drug use among young adults in a geographically defined population. METHODS: We reviewed ischemic stroke in young adults (aged 15 to 44 years) in 46 regional hospitals for 1988 and 1991. We examined stroke mechanisms and outcome in patients with recent drug use. RESULTS: Recent illicit drug use was noted in 51/422 (12.1%) stroke patients. Patients with drug use were more likely than other stroke patients to be black (p=0.01), aged 25 to 39 years (p=0.004), and smokers (p=0.006), and were less likely to have hypertension (p=0.004) or diabetes mellitus (p=0.004). Drug use was the probable cause of stroke in 20 (4.7%) patients. Among 31 (7.3%) patients with drug use as a possible stroke mechanism, more likely diagnoses included cardioembolic stroke in 18, hematologic/collagen vascular in 6, nonatherosclerotic vasculopathy in 5, and atherosclerosis in 3. There was no difference in outcome between drug-associated and non-drug associated stroke. CONCLUSIONS: Recent illicit drug use occurs in 12.1% of young adult stroke patients. Drug-associated young adult stroke seems to relate to vascular mechanisms other than those related to hypertension or diabetes. Case-control studies are needed.

PMID: 9633712, UI: 98295469

Am J Epidemiol 1998 Jun 1;147(11):1053-61

Influence of diabetes during pregnancy on gestational age-specific newborn weight among US black and US white infants.

Kieffer EC, Alexander GR, Kogan MD, Himes JH, Herman WH, Mor JM, Hayashi R

Department of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, USA.

This study examined the impact of maternal diabetes on birth weight for gestational age patterns of all term black infants and white infants in the United States using data derived from the 1990-1991 US Live Birth File of the National Center for Health Statistics. Infants of both black mothers and white mothers exhibited the expected fetal overgrowth associated with maternal diabetes. However, the increase in birth weight was much greater in infants of black than white diabetic mothers in comparison with their nondiabetic counterparts, as measured by the discrepancy in birth weight between infants of diabetic and nondiabetic mothers at each gestational week, the incidence of large for gestational age, high birth weight, small for gestational age, and low birth weight. After adjustment for maternal hypertension, prenatal care use, and sociodemographic factors, the disparity in mean birth weight associated with diabetes was 211.67 g in black infants and 115.74 g in white infants. The adjusted odds ratios of birth weight > or = 4,000 g were 2.98 (95% confidence interval 2.89-3.12) for black infants and 1.83 (95% confidence interval 1.78-1.89) for white infants. Given the potential risks for mothers and infants consequent to maternal diabetes and fetal hyperinsulinemia, further investigation of the prevalence, characteristics, and outcomes of diabetes during pregnancy among black mothers and infants is warranted.

PMID: 9620049, UI: 98281348

Am J Cardiol 1998 May 15;81(10):1246-9

Baseline serum total cholesterol and coronary heart disease incidence in African-American women (the NHANES I epidemiologic follow-up study). National Health and Nutrition Examination Survey.

Gillum RF, Mussolino ME, Sempos CT

Centers for Disease Control and Prevention, Hyattsville, Maryland 20782, USA.

Proportional-hazards analyses for African-American women aged 25 to 74 revealed a variable association of coronary heart disease risk with baseline serum total cholesterol (after adjusting for age fifth vs first quintile: RR = 1.62, 95% confidence interval [CI] 0.89 to 2.98, p = 0.12; after adjusting for age, systolic blood pressure, body mass index, smoking, history of diabetes, low education, and low family income: RR = 1.88, 95% CI 1.02 to 3.45, p = 0.04). Perhaps due to the relatively small number of events, the association of serum total cholesterol with coronary heart disease incidence in African-American women was not consistently significant.

PMID: 9604962, UI: 98265998

Ann Intern Med 1998 May 15;128(10):817-26

The effect of antilymphocyte induction therapy on renal allograft survival. A meta-analysis of individual patient-level data. Anti-Lymphocyte Antibody Induction Therapy Study Group.

Szczech LA, Berlin JA, Feldman HI

University of Pennsylvania, Philadelphia, USA.

PURPOSE: Randomized, controlled trials have not shown that the perioperative use of antilymphocyte antibodies (induction therapy) improves survival of cadaveric kidney allografts. This study combined individual patient-level data from published trials to examine the effect of induction therapy on allograft survival. DATA SOURCES: Randomized, controlled trials identified from MEDLINE. STUDY SELECTION: Published trials that compared adult recipients of cadaveric renal allografts who did and did not receive antilymphocyte antibodies in the perioperative period were selected if individual patient-level data were available. DATA EXTRACTION AND ANALYSIS: Individual patient-level data were collected for each of 628 study patients. Multivariable Cox proportional hazards regression was used to estimate the effect of induction therapy on allograft survival. RESULTS: The adjusted rate ratio for allograft failure with induction therapy compared with conventional therapy was 0.62 (95% CI, 0.43 to 0.90) (P = 0.012) over 2 years and 0.82 (CI, 0.62 to 1.09) (P = 0.17) over 5 years. The effect of induction therapy on allograft survival diminished over time; no benefit overall was seen after 2 years after transplantation (rate ratio, 1.13 [CI, 0.72 to 1.78]) (P > 0.2). Greater HLA-DR mismatch, delayed allograft function, diabetes mellitus in the recipient, African-American ethnicity of the recipient, and presensitization (panel-reactive antibody levels > or = 20%) were significantly associated with allograft failure at 5 years. Among high-risk patients, only those who were presensitized benefited from induction therapy at 2 years (rate ratio, 0.12 [CI, 0.03 to 0.44]) (P = 0.001). Results were similar at 5 years. CONCLUSIONS: Using individual-level data, this study showed a benefit of induction therapy at 2 years, particularly among presensitized patients. Although the benefit of this therapy subsequently waned, presensitized patients continued to have benefit at 5 years.

Publication Types:

• Meta-analysis

Comments:

• Comment in: Ann Intern Med 1998 May 15;128(10):863-5

PMID: 9599193, UI: 98243006

Stroke 1998 May;29(5):908-12

Cigarette smoking as a determinant of high-grade carotid artery stenosis in Hispanic, black, and white patients with stroke or transient ischemic attack.

Mast H, Thompson JL, Lin IF, Hofmeister C, Hartmann A, Marx P, Mohr JP, Sacco RL

Stroke Unit, The Neurological Institute, Columbia-Presbyterian Medical Center, New York, NY 10032, USA. ah267@columbia.edu

BACKGROUND AND PURPOSE: We sought to investigate the association of cigarette smoking with high-grade carotid artery stenosis in Hispanic, black, and white patients with cerebral ischemia in two independent samples. METHODS: Prospectively collected data from the Northern Manhattan Stroke Study (NOMASS) (n=431) and the Berlin Cerebral Ischemia Databank (BCID) (n=483) were used separately for a cross-sectional study estimating the association between cigarette smoking and high-grade carotid stenosis (defined as a luminal narrowing of > or =60%, diagnosed by duplex and/or Doppler ultrasound). In both studies, cerebral ischemia patients with normal sonographic findings or nonstenosing plaques of their carotid arteries served as a comparison group. Multivariate logistic regression models were used for statistical tests to determine the association between smoking and the dependent variable for high-grade carotid stenosis. Age, sex, hypertension, diabetes, hypercholesterolemia, and race/ethnicity were considered potential confounders. Further analyses of the NOMASS data estimated the effect of the amount of cigarette use and the impact of race/ethnicity. RESULTS: High-grade carotid stenoses were found in 14% of the NOMASS and in 21% of the Berlin patients. In Berlin the entire sample was white, whereas in New York only 19% of the cohort were white. In both samples, smoking was independently associated with severe carotid stenosis (NOMASS: odds ratio [OR], 1.5; 95% confidence interval [CI], 1.1 to 2.0; BCID: OR, 3.9; 95% CI, 2.4 to 6.4). Patients smoking 20 pack-years or more showed a significant association (OR, 2.0; 95% CI, 1.1 to 3.9), whereas no significant effect was found for lower amounts of cigarette use. In NOMASS, white smokers displayed a significant (OR, 3.2; 95% CI, 1.1 to 8.9) association with high-grade carotid stenosis, the association for black smokers was less strong, and no association was found among Hispanics. CONCLUSIONS: Smoking is an independent determinant of severe carotid artery stenosis in patients with focal cerebral ischemia. The association differs by race/ethnicity, with the greatest effect observed among whites.

Publication Types:

• Multicenter study

PMID: 9596233, UI: 98255672

Neurology 1998 May;50(5):1238-45

Cognitive test performance among nondemented elderly African Americans and whites.

Manly JJ, Jacobs DM, Sano M, Bell K, Merchant CA, Small SA, Stern Y

Department of Neurology, the Gertrude H. Sergievsky Center, Columbia University College of Physicians and Surgeons, New York, NY 10032-3702, USA.

We examined the neuropsychological test performance of a randomly selected community sample of English-speaking non-Hispanic African American and white elders in northern Manhattan. All participants were diagnosed as nondemented by a neurologist, whose assessment was made independent of neuropsychological test scores. African American elders obtained significantly lower scores on measures of verbal and nonverbal learning and memory, abstract reasoning, language, and visuospatial skill than whites. After using a stratified random sampling technique to match groups on years of education, many of the discrepancies became nonsignificant; however, significant ethnic group differences on measures of figure memory, verbal abstraction, category fluency, and visuospatial skill remained. Discrepancies in test performance of education-matched African Americans and whites could not be accounted for by occupational attainment or history of medical conditions such as hypertension and diabetes. These findings emphasize the importance of using culturally appropriate norms when evaluating ethnically diverse elderly for dementia.

Publication Types:

• Clinical trial
• Randomized controlled trial

PMID: 9595969, UI: 98255408

J Am Med Womens Assoc 1998 Spring;53(2):96-104, 107

The prevalence of risk factors among women in the United States by race and age, 1992-1994: opportunities for primary and secondary prevention.

Hahn RA, Teutsch SM, Franks AL, Chang MH, Lloyd EE

Division of Prevention Research and Analytic Methods, Epidemiology Program Office at the Centers for Disease Control and Prevention, USA.

OBJECTIVE: To analyze the prevalence of 11 modifiable behavioral risk factors, including multiple risk factors, among white, black, Asian and Pacific Islander, American Indian, and Hispanic women in the United States. DESIGN: We used Behavioral Risk Factor Surveillance System (BRFSS) data for 1992 to 1994 to examine risk factors (smoking; obesity; diabetes; heavy alcohol consumption; sedentary lifestyle; and inadequate use of seat belts, pap smears, consumption of fruits or vegetables, mammography and colorectal screening, and immunization), among women age 18 to 49, 50 to 64, and 65 and older. We also conducted a multiple regression analysis, comparing the odds of having either 1-2 versus 0 or 3 or more versus 0 risk factors among racial/ethnic groups, controlling for education and family income, to see if racial/ethnic differences can be attributed to socioeconomic differences. RESULTS: US women engage in a variety of behaviors that place them at risk for many causes of morbidity and mortality. Risk profiles vary substantially among racial/ethnic populations: Pacific Islanders have relatively low prevalences of most major risk factors, while blacks and American Indians have relatively high prevalences of many major risk factors. Prevalence differences among racial/ethnic populations are diminished but not eliminated when socioeconomic factors are accounted for. CONCLUSIONS: Appropriately designed programs to help women reduce their behavioral risk factors are needed. Action by health care providers, communities, and policy makers can substantially improve the health of women in the United States.

PMID: 9595904, UI: 98258268

Diabetes Care 1998 May;21(5):875-7

Culturally appropriate lifestyle interventions in minority populations. More than meets the eye?

Gregg EW, Narayan KM

Publication Types:

• Comment
• Letter

Comments:

• Comment on: Diabetes Care 1997 Oct;20(10):1503-11

PMID: 9589264, UI: 98251156

Am J Clin Nutr 1998 May;67(5):821-7

Fat distribution and insulin response in prepubertal African American and white children.

Gower BA, Nagy TR, Trowbridge CA, Dezenberg C, Goran MI

Department of Nutrition Sciences, University of Alabama at Birmingham, and the UAB Obesity Research Center, 35294, USA. bgower@uab.edu

Ethnic differences in obesity-related disease prevalence may relate to differences in fat distribution or metabolism. We conducted a study in 73 African American and white children to examine the relation between fat distribution and insulin and to determine whether ethnic differences in fat distribution or in adiposity-insulin relations contribute to differences in insulin concentrations. Fasting and postchallenge insulin concentrations were determined by oral-glucose-tolerance test, total body fat by dual-energy X-ray absorptiometry, and subcutaneous abdominal (SAAT) and intraabdominal (IAAT) adipose tissue by computerized tomography. African Americans had greater fasting insulin (x +/- SD: 79 +/- 37 compared with 55 +/- 23 pmol/L, P < 0.01), incremental 30-min insulin (567 +/- 438 compared with 300 +/- 304 pmol/L, P < 0.001), and incremental area under the insulin curve (AUC; 262 +/- 209 compared with 164 +/- 156 pmol/L, P < 0.01). In multiple linear regression, fasting insulin was independently related to total fat within both ethnic groups (model R2 = 0.42 and 0.52 for African Americans and whites, respectively), incremental 30-min insulin to total fat and IAAT in whites only (model R2 = 0.71), and AUC to SAAT in African Americans only (model R2 = 0.49). Adjusting insulin indexes for adiposity did not eliminate the significant effect of ethnicity. In general, relations between adiposity and insulin were stronger in whites than in African Americans. African American children had higher insulin concentrations than white children after total body fat, IAAT, and SAAT were controlled for. However, strong relations between adiposity (total and abdominal) and insulin in both groups suggest that obesity may contribute to disease risk regardless of ethnicity.

PMID: 9583837, UI: 98243195

Clin Transplant 1998 Apr;12(2):93-8

Assessment of function and survival as measures of renal graft outcome following kidney and kidney-pancreas transplantation in type I diabetics.

Douzdjian V, Bunke CM, Baillie GM, Uber L, Rajagopalan PR

Department of Surgery, Medical University of South Carolina, Charleston, USA.

Reports on renal graft outcome after kidney-alone (KA) and simultaneous pancreas-kidney (SPK) transplants have focused on graft survival instead of function. The aim of this study is to compare renal graft outcome after KA and SPK using graft function and survival as the measures of outcome. The records of 102 transplants performed in type I diabetics from 10/90 to 9/96 were reviewed (SPK 42, KA 60). Serum creatinine (Cr) and calculated glomerular filtration rate (GFR) were used as estimates of graft function. Cr were similar in SPK and KA on day 3 (4.8 +/- 2.9 vs. 4.8 +/- 2.8 mg/dl, P = 0.9) and day 7 (2.5 +/- 1.8 vs. 3.0 +/- 2.5 mg/dl, P = 0.3). GFR was higher KA at 6 months (57 +/- 18 vs. 51 +/- 12 ml/min, P = 0.08), 1 yr (55 +/- 23 vs. 51 +/- 11 ml/min, P = 0.4) and 3 yr (60 +/- 22 vs. 42 +/- 16 ml/min, P = 0.03). Kidney graft survival was similar in KA and SPK at 1 and 5 yr (87% vs. 89% and 44% vs. 47%, P = 0.8). Immunologic failure of the renal graft occurred more frequently in SPK (58% vs. 48%, P = 0.04) whereas death with function was more common in KA (33% vs. 17%, P = 0.04). In KA, risk factors for failure of the renal graft included acute rejection (P = 0.008, relative risk or rr = 3.4) and African American recipient (P = 0.06, rr = 2.8). In SPK, risk factors included donor age > 40 yr (P = 0.05, rr = 5.3) and African American donor (P = 0.03, rr = 4.5). Logistic regression analysis revealed the following risk factors for GFR < 50 ml/min at 1 yr: acute rejection (P = 0.03, rr = 2.2) and Cr > 3 mg/dl on day 7 (P = 0.06, rr = 2.3). In conclusion, although renal graft survival was similar after KA and SPK, better graft function was observed in KA at 3 yr. Assessment of renal graft function allows us to evaluate outcome from a different perspective than graft survival, and these two measures of outcome complement each other.

PMID: 9575395, UI: 98236307

Diabetes Care 1998 Apr;21(4):555-62

Physical activity and NIDDM in African-Americans. The Pitt County Study.

James SA, Jamjoum L, Raghunathan TE, Strogatz DS, Furth ED, Khazanie PG

Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor 48109, USA. sjames@umich.edu

OBJECTIVE: Studies directly examining the association between physical activity and NIDDM in African-Americans are rare. Consequently, the strength of this association in this ethnic minority group remains unclear. The current study broadly characterizes the types of physical activity engaged in by a community sample of working-class African-Americans and then quantifies the association between physical activity and NIDDM risk in this population. RESEARCH DESIGN AND METHODS: During the 1993 reexamination of participants in the Pitt County Study in North Carolina, data on NIDDM history, current use of insulin or oral hypoglycemic drugs, and approximately 12-h overnight fasting blood glucose (FBG) were obtained from 598 women and 318 men, ages 30-55 years. The presence of NIDDM was determined by current insulin or medication use and FBG > or = 140 mg/dl. Study participants were assigned to one of four categories of physical activity: strenuous, moderate, low, or inactive. RESULTS: The weighted prevalence of NIDDM in the sample was 7.1%. After adjustment was made for age, sex, education, BMI, and waist-to-hip ratio, NIDDM risk for moderately active subjects was one-third that for the physically inactive subjects (odds ratio [OR], 0.35; 95% CI, 0.12-0.98). The ORs for low (OR, 0.51; 95% CI, 0.20-1.29) and strenuous (OR, 0.65; 95% CI, 0.26-1.63) activity also tended to be lower. A summary OR that contrasted any activity versus no activity was 0.51 (95% CI, 0.23-1.13). CONCLUSIONS: Moderate physical activity was strongly associated with reduced risk for NIDDM in this sample. While replication of these findings is needed, public health interventions designed to increase moderate (leisure-time) physical activity in black adults should be strongly encouraged.

PMID: 9571342, UI: 98232833

Diabetes Care 1998 Apr;21(4):501-5

Diabetes in urban African-Americans. VI. Utility of fasting or random glucose in identifying poor glycemic control.

el-Kebbi IM, Ziemer DC, Gallina DL, Phillips LS

Department of Medicine, Emory University School of Medicine, Atlanta, Georgia 30303, USA. ielkebb@emory.edu

OBJECTIVE: African-Americans have an increased prevalence of both diabetes and diabetes complications, creating an imperative for improved metabolic control. Because American Diabetes Association guidelines recommend that action be taken when HbA1c is > 8.0%, but access to rapid-turnaround HbA1c assays remains limited, we tested the utility of fasting and random plasma glucose cutoffs as indicators of HbA1c > 8.0%. RESEARCH DESIGN AND METHODS: Using receiver operating characteristics (ROC) analysis, we evaluated the sensitivity, specificity, and predictive value of fasting and random plasma glucose measurements in identifying an HbA1c > 8.0% (fasting n = 974, random n = 552). The population studied was predominantly African-American, middle-aged, and non-insulin-dependent. RESULTS: Fasting plasma glucose was a significant indicator of HbA1c > 8.0%, both in the whole group and in subgroups for diet, sulfonylureas, and insulin; the corresponding areas under the ROC curve were 0.87, 0.90, 0.87, and 0.84, respectively (all P < 0.0001). A fasting plasma glucose cutoff of > 9.2 mmol/l (165 mg/dl) provided a sensitivity of 80% and a specificity of 83% for the whole group and a 77% positive predictive value. Random plasma glucose was also a good indicator of HbA1c > 8.0%, both in the whole group and in subgroups for diet, sulfonylureas, and insulin; the corresponding areas under the ROC curve were 0.85, 0.91, 0.85, and 0.77, respectively (all P < 0.0001). A cutoff > 9.8 mmol/l (177 mg/dl) provided a sensitivity of 78% and a specificity of 77% for the whole group and a 78% positive predictive value. Overall, a plasma glucose > 11.1 mmol/l (200 mg/dl) identified an HbA1c > 8.0% with a predictive value of approximately 90% if done while fasting and a predictive value of approximately 80-85% if random. The utility of both fasting and random plasma glucose cutoffs was subsequently confirmed in a prospective study of another 2,309 and 1,396 patients, respectively. CONCLUSIONS: Although glucose levels cannot replace HbA1c determinations, measurement of fasting or random plasma glucose may be used during a clinic visit to identify poorly controlled type 2 patients with reasonable certainty and allow timely patient education and therapeutic intervention.

PMID: 9571331, UI: 98232822

Diabetes 1998 Apr;47(4):685-7

Structure and organization of the human uncoupling protein 2 gene and identification of a common biallelic variant in Caucasian and African-American subjects.

Argyropoulos G, Brown AM, Peterson R, Likes CE, Watson DK, Garvey WT

Department of Medicine, Medical University of South Carolina, Charleston 29425, USA.

PMID: 9568704, UI: 98227655

Arch Intern Med 1998 Apr 13;158(7):793-800

End-stage renal disease in specific ethnic and racial groups: risk factors and benefits of antihypertensive therapy.

Powers DR, Wallin JD

Section of Nephrology, Louisiana State University School of Medicine, New Orleans 70112, USA.

During the past few years, it has become apparent that there are factors that place a person at greater risk for the development and progression of renal failure. This has been documented since the early 1980s by the United States Renal Data System that has collected data confirming that end-stage renal disease occurs at a greater rate in certain subpopulations of Americans. It is evident from an examination of the data that African Americans and American Indians have an incidence of end-stage renal disease that is not proportional to their percentage of the total population. In fact, African Americans and American Indians are reported to have at least a 4-fold greater incidence of end-stage renal disease than white Americans. There have been 5 factors identified: hypertension, glucose intolerance, insulin resistance, salt sensitivity, and hyperlipidemia, which may play a greater role in these subpopulations. In addition, as with other populations, lifestyle issues may serve to alter these primary risk factors or may act as direct modulators of renal disease progression. There is also a possibility that interactions between risk factors frequently occur that may modify the development or progression of the disease. This article reviews these risk factors and emphasizes the interaction between hypertension and the other factors. In addition, the effects of antihypertensive agents on risk factors and on renal outcome are emphasized. Where possible, issues specific to African Americans and American Indians are underscored; however, one must accept that the database on these populations is only now developing. This review should help the clinician make appropriate choices when prescribing antihypertensive therapy for patients who may be at risk of developing progressive renal failure.

Publication Types:

• Review
• Review, tutorial

PMID: 9554686, UI: 98213407

J Natl Med Assoc 1998 Mar;90(3):147-56

Diabetes mellitus and its complications in an African-American community: project DIRECT.

Herman WH, Thompson TJ, Visscher W, Aubert RE, Engelgau MM, Liburd L, Watson DJ, Hartwell T

Program Development Branches, National Center for Chronic Disease Prevention and Health Promotion, Center for Disease Control and Prevention, Atlanta, Georgia, USA.

Project DIRECT (Diabetes Intervention Reaching and Educating Communities Together) is a multilevel community-based intervention project designed to address diabetes and its complications in an African-American community. This article presents results of the Project DIRECT pilot study and describes risk factors for diabetes, diabetes prevalence, complications, and care practices. During 1993, a pilot study was conducted among persons 20 to 74 years of age in Wake County, North Carolina. The study involved household interviews and examinations, and more extensive health center interviews and examinations based on the race of the head of the household, previous diagnosis of diabetes, and results of capillary glucose tests done in the household. Of the black population aged 20 to 74 years, 52 +/- 3% reported being inactive and 51 +/- 3% were overweight; the prevalence of diagnosed diabetes was 5.2 +/- 0.9%; the prevalence of undiagnosed diabetes was 5.7 +/- 2.7%; and the prevalence of impaired glucose tolerance was 11.4 +/- 7.5%. Blacks with diabetes were significantly more likely than nonblacks with diabetes to have uncontrolled hypertension and to smoke cigarettes. Blacks with diabetes were significantly less likely to report having health insurance or to have a private health-care provider. Diabetes mellitus is a major public health problem in the African-American community of Wake County. Modifiable risk factors for diabetes and undiagnosed diabetes are common. Project DIRECT is attempting to improve the health-related quality of life of this population by reducing the burden of diabetes and its complications through a multilevel, community-based intervention.

PMID: 9549978, UI: 98211148

Diabetes Care 1998 Mar;21(3):416-22

Chronic treatment of African-American type 2 diabetic patients with alpha-glucosidase inhibition.

Johnston PS, Feig PU, Coniff RF, Krol A, Kelley DE, Mooradian AD

Bayer Pharmaceuticals, West Haven, Connecticut, USA.

OBJECTIVE: To evaluate the long-term efficacy, safety, and tolerability of the alpha-glucosidase inhibitor miglitol in the treatment of African-American patients with type 2 diabetes. RESEARCH DESIGN AND METHODS: A total of 345 African-American type 2 diabetic patients (mean age 55.6 years, BMI 31.9 kg/m2, duration of diabetes 4.9 years, baseline HbA1C 8.7%) treated with either diet alone or sulfonylurea were randomized to 1 year of double-blind treatment with either placebo (n = 117) or miglitol (n = 228) at doses of 50 or 100 mg t.i.d., titrated based on tolerability. The primary efficacy criterion was change from baseline in HbA1C at the 6-month visit. Secondarily efficacy parameters included changes from baseline in plasma glucose and serum insulin (both fasting and 120 min after a standardized test meal), fasting lipids, and urinary albumin-to-creatinine ratio. Safety and tolerability evaluations were primarily based on reporting of adverse events and symptoms and on periodic laboratory analyses. RESULTS: Miglitol treatment was associated with a mean placebo-subtracted reduction in HbA1C from baseline of 1.19% at 6 months. Fasting and 120-min postprandial plasma glucose levels were reduced in parallel to HbA1C, in association with miglitol treatment. Significant reductions versus placebo in 120-min postprandial insulin levels, in LDL cholesterol, and in fasting triglycerides, were also seen in the miglitol group at individual study time points. Softer, more frequent stools and flatulence were significantly more common in the miglitol group. Urinary tract infections, hematuria, and herpes simplex infections were significantly more common in the placebo group. CONCLUSIONS: Miglitol treatment appears to be at least as efficacious in the African-American type 2 population as in the U.S. type 2 population at large, with comparable tolerability. alpha-Glucosidase treatment may be an important therapeutic option in these patients in view of their greater risk for microvascular complications and the accumulating body of evidence that better glucose control reduces the risk of these complications.

Publication Types:

• Clinical trial
• Randomized controlled trial

PMID: 9540025, UI: 98200846

Diabetes Care 1998 Feb;21(2):291-5

The association between diabetic complications and exercise capacity in NIDDM patients.

Estacio RO, Regensteiner JG, Wolfel EE, Jeffers B, Dickenson M, Schrier RW

Department of Medicine, Denver Health and University of Colorado Health Sciences Center, Colorado 80262, USA.

OBJECTIVE: Exercise capacity has been used as a noninvasive parameter for predicting cardiovascular events. It has been demonstrated previously in NIDDM patients that several risk factors (i.e., obesity, smoking, hypertension, and African-American race) are associated with an impaired exercise capacity. We studied 265 male and 154 female NIDDM patients who underwent graded exercise testing with expired gas analyses to determine the possible influences of diabetic neuropathy, nephropathy, and retinopathy on exercise capacity. RESEARCH DESIGN AND METHODS: Univariate and multiple linear regression analyses were performed to determine the relationship between diabetic neuropathy, urinary albumin excretion (UAE), and retinopathy with respect to peak oxygen consumption (VO2). Neuropathy was assessed by neurological symptom and disability scores, autonomic function testing, and quantitative sensory exams involving thermal and vibratory sensation. Three categories of UAE were used: normal albuminuria (< 20 micrograms/min), microalbuminuria (20-200 micrograms/min), and overt albuminuria (> 200 micrograms/min). Retinopathy was assessed by stereoscopic fundus photographs. Multiple linear regression analyses were then performed controlling for age, sex, length of diagnosed diabetes, duration of hypertension, race and ethnicity, GHb, BMI, and smoking to determine whether there was an independent effect of these diabetic complications on exercise capacity. RESULTS: Univariate analyses revealed that the presence of diabetic retinopathy (P = 0.03), neuropathy (P = 0.002), microalbuminuria (P = 0.04), and overt albuminuria (P = 0.06) were associated with a lower peak VO2. Multiple linear regression analyses were performed to determine independent relationships with peak VO2. The results revealed that increasing retinopathy stage (Parameter estimate [PE] = -0.59 +/- 0.3 ml.kg-1.min-1; P = 0.026) and increasing UAE stage (PE = -0.62 +/- 0.3 ml.kg-1.min-1; P = 0.04) were associated with a decrease in peak VO2. CONCLUSIONS: In the present study of NIDDM subjects, a significant independent association was demonstrated between diabetic nephropathy and retinopathy with exercise capacity. These results were obtained controlling for age, sex, length of diagnosed diabetes, hypertension, race, and BMI. Thus the findings in this large NIDDM population without a history of coronary artery disease indicate a potential pathogenic relationship between microvascular disease and exercise capacity.

Publication Types:

• Clinical trial
• Randomized controlled trial

PMID: 9539998, UI: 98200819

Hypertension 1998 Apr;31(4):906-11

Identification of human plasma kallikrein gene polymorphisms and evaluation of their role in end-stage renal disease.

Yu H, Bowden DW, Spray BJ, Rich SS, Freedman BI

Department of Biochemistry, Wake Forest University Baptist Medical Center, Winston-Salem, NC 27157-1053, USA.

Kallikreins are serine proteases that release kinins from kininogens. Kinins, via their effects on cardiovascular and renal function, may be involved in the pathogenesis of hypertension and renal failure. Two groups of kallikreins exist, glandular or tissue kallikrein and plasma kallikrein. In this study, we examined the human plasma kallikrein gene KLK3 to determine whether it contributed to end-stage renal disease (ESRD) susceptibility. We identified two novel polymorphic sequences closely linked to the KLK3 gene, designated KLK3b and KLK3c (heterozygosities: 0.64 to 0.68 and 0.48 to 0.52, respectively). We mapped the KLK3 gene and the marker KLK3c to the long arm of human chromosome 4 between F11 and D4S426 using a radiation hybrid panel. The study population consisted of 142 sibling pairs concordant for ESRD from 121 African American families. The 142 sibling pairs were stratified into 78 pairs with hypertension- and chronic glomerulonephritis-associated ESRD and 64 with non-insulin-dependent diabetes mellitus-associated ESRD. Linkage analyses, using SIBPAL of SAGE, and exclusion analysis, using MAPMAKERS/SIBS, were performed. Linkage analysis of affected sibling pairs did not reveal any evidence of linkage of KLK3 to ESRD in all 142 sib-pairs or in the two stratified subsets. Exclusion analysis indicated that the KLK3 gene could be excluded from contributing to ESRD at a relative risk of 3 when the maximum log of the odds score of -2 was used as the criterion for exclusion. However, an association analysis using the relative predispositional effect technique showed that alleles 7 and 9 of KLK3b were consistently associated with ESRD. Alleles 7 and 9 were present in 11.2% and 10.8% of the 113 unrelated ESRD probands and in 6.6% and 6.6% of the 204 race-matched control subjects without renal disease (allele P=.0041 and .0016, respectively). Alleles 7 and 9 were also present in 13% and 10.4% of the proband's first siblings (allele P=.00014 and .0087, respectively). The association of KLK3b alleles with ESRD raises the possibility that polymorphisms in KLK3 may play a role in ESRD susceptibility. The lack of linkage might reflect our relatively small family set.

PMID: 9535413, UI: 98195090

J Community Health 1998 Feb;23(1):15-27

Maximizing participation by black Americans in population-based diabetes research: the Project DIRECT pilot experience.

Burrus BB, Liburd LC, Burroughs A

Research Triangle Institute, North Carolina 27709, USA.

Diabetes and its associated complications and risk factors have a higher prevalence among blacks than whites. To reduce the burden of diabetes within the black community, research is needed to assess the behavioral, social, and environmental correlates associated with this disproportionate burden. Because of some well known instances of historical exploitation and abuse from medical and public health research conducted in black communities, this population has little enthusiasm for additional research, despite pressing health needs. This paper describes the process used to eliminate barriers and enhance trust between the target community and the researchers conducting a population survey of diabetes in Wake County, North Carolina. A community advisory board was organized to (1) review the survey instruments and methodologies, (2) identify persons from the community to serve as interviewers, and (3) promote the survey using the major local communication channels. The response rate to both the household survey and the comprehensive medical exam was 77%. Eighty-one percent of eligible black respondents completed the household exam and 80% completed the comprehensive medical exam. Advantages of building collaborative relationships between the community and research team are discussed.

PMID: 9526723, UI: 98187471

Gac Med Mex 1997 Nov-Dec;133(6):617-9

[Diabetes mellitus in Latino population of Mexican origin in Texas].

Otiniano ME

Departamento de Medicina Intema, Facultad de Medicina, Universidad de Texas, Houston 77225, USA.

PMID: 9504091, UI: 98164847

Transplantation 1998 Feb 27;65(4):515-23

Racial differences in renal transplantation after immunosuppression with tacrolimus versus cyclosporine. FK506 Kidney Transplant Study Group.

Neylan JF

Emory University, Atlanta, Georgia 30322, USA.

BACKGROUND: Results of a multicenter, randomized, clinical trial demonstrated that tacrolimus was more effective than cyclosporine in preventing acute rejection in cadaveric renal transplant patients. As African-Americans comprised approximately 25% of the study population, their outcome was analyzed relative to the experience of Caucasian patients. METHODS: Of the 205 patients randomized to tacrolimus, 56 (27.3%) were African-American and 114 (55.6%) were Caucasian. Of the 207 patients randomized to cyclosporine, 48 (23.2%) were African-American and 123 (59.4%) were Caucasian. The efficacy variables were 1-year patient survival, graft survival, and incidence of acute rejection. RESULTS: The incidence of acute rejection was significantly lower in African-American and Caucasian patients treated with tacrolimus than with cyclosporine. Additionally, no African-American patient who was treated with tacrolimus experienced moderate or severe acute rejection, as determined by blinded independent review. The incidence of nephrotoxicity, cardiovascular and gastrointestinal events, malignancies, and opportunistic infections was similar between treatments and race groups. However, there was an increased incidence of posttransplant diabetes mellitus in tacrolimus-treated patients, particularly in African-Americans, and tacrolimus was associated with significantly lower lipid levels in both Caucasians and African-Americans. African-American patients required a 37% mean higher dose of tacrolimus than Caucasian patients to achieve comparable blood concentrations. CONCLUSIONS: Tacrolimus is more effective than cyclosporine in preventing acute rejection in both African-American and Caucasian patients. However, tacrolimus was associated with an increased risk of posttransplant diabetes mellitus, particularly in African-Americans, which was reversible in some patients.

Publication Types:

• Clinical trial
• Multicenter study
• Randomized controlled trial

PMID: 9500626, UI: 98160262

Gerontologist 1998 Feb;38(1):25-36

Emergency department utilization, hospital admissions, and physician visits among elderly African American persons.

Bazargan M, Bazargan S, Baker RS

Charles Drew University of Medicine and Science, Research Centers in Minority Institutions, Los Angeles, CA 90059, USA. mobazarg.cdrewu.edu

This study uses a theoretical model of health services utilization to examine (a) emergency department utilization, (b) hospital admissions, and (c) office-based physician visits among a sample of 998 low-income elderly African American persons. Poisson Regression analysis was used to estimate the parameters specified in the Andersen behavioral model. Some of the more interesting results include the following: (a) a greater frequency of emergency room visits among respondents with a lower level of accessibility to physician services, (b) a lack of a significant relationship between some chronic illnesses such as diabetes and heart problems and the frequency of office-based physician visits, (c) a greater number of hospital admissions among insured persons, and (d) a significant impact of the health locus of control indexes on all three types of health care utilization. The results of this study challenge the assumption that hospital and emergency use are the results of nondiscretionary behavior.

PMID: 9499651, UI: 98160626

JAMA 1998 Mar 4;279(9):669-74

Intensity and amount of physical activity in relation to insulin sensitivity: the Insulin Resistance Atherosclerosis Study.

Mayer-Davis EJ, D'Agostino R Jr, Karter AJ, Haffner SM, Rewers MJ, Saad M, Bergman RN

Department of Epidemiology and Biostatistics, School of Public Health, University of South Carolina, Columbia 29208, USA. ejmayerd@sph.sc.edu

CONTEXT: Exercise training is associated with improved insulin sensitivity (SI), but the potential impact of habitual, nonvigorous activity is uncertain. OBJECTIVE: To determine whether habitual, nonvigorous physical activity, as well as vigorous and overall activity, is associated with better SI. DESIGN: A multicultural epidemiologic study. SETTING: The Insulin Resistance Atherosclerosis Study, conducted in Oakland, Calif; Los Angeles, Calif; the San Luis Valley, Colo; and San Antonio, Tex. PARTICIPANTS: A total of 1467 men and women of African American, Hispanic, and non-Hispanic white ethnicity, aged 40 to 69 years, with glucose tolerance ranging from normal to mild non-insulin-dependent diabetes mellitus. MAIN OUTCOME MEASURE: Insulin sensitivity as measured by an intravenous glucose tolerance test. RESULTS: The mean SI for individuals who participated in vigorous activity 5 or more times per week was 1.59 min(-1) x microU(-1) x mL(-1) x 10(-4) (95% confidence interval [CI], 1.39-1.79) compared with 0.90 (95% CI, 0.83-0.97) for those who rarely or never participated in vigorous activity, after adjusting for potential confounders (P<.001). When habitual physical activity (estimated energy expenditure [EEE]) was assessed by 1-year recall of activities, the correlation coefficient between SI and total EEE was 0.14 (P<.001). After adjustment for confounders, vigorous and nonvigorous levels of EEE (metabolic equivalent levels > or = 6.0 and <6.0, respectively) were each positively and independently associated with SI (P< or =.01 for each). The association was attenuated after adjustment for the potential mediators, body mass index (a measure of weight in kilograms divided by the square of the height in meters), and waist-to-hip ratio. Results were similar for subgroups of sex, ethnicity, and diabetes. CONCLUSIONS: Increased participation in nonvigorous as well as overall and vigorous physical activity was associated with significantly higher SI. These findings lend further support to current public health recommendations for increased moderate-intensity physical activity on most days.

PMID: 9496984, UI: 98156698

Clin Pediatr (Phila) 1998 Feb;37(2):143-52

Non-insulin dependent diabetes mellitus (NIDDM) in minority youth: research priorities and needs.

Rosenbloom AL, House DV, Winter WE

Department of Pediatrics, University of Florida College of Medicine, Children's Medical Services Center, Gainesville 32608, USA.

The prevalence of non-insulin dependent diabetes mellitus (NIDDM) is increasing in Native American and African-American youth, with females more frequently affected than males. This increase is related to increasing rates of obesity and to the greater demand for insulin at adolescence. This review examines the epidemiologic data about NIDDM in minority youth and addresses questions about the type of diabetes minority youth have, the relative contributions of environment and genetics to their diabetes, and whether prevention or control is possible. The heterogeneity of NIDDM in the minority youth population includes: typical NIDDM; atypical diabetes mellitus (ADM), which has been described in a substantial number of African-American youngsters; and a small proportion with a range of defects in the pathway of insulin action. Clinical and experimental evidence that insulin resistance or insulin deficiency is the primary defect in NIDDM are reviewed, as is evidence that fetal undernutrition may be a contributing factor. The numerous reports of linkages, associations, and mutations or polymorphisms in candidate genes account for a very small proportion of non-type 1 diabetes. Environmental and genetic contributors to obesity are also important. Research issues relating to the questions discussed include the need for data comparing various populations and assessing risk factors associated with the epidemic of NIDDM and obesity, costs to the health system and attendant personal and societal costs, clarification of the types of NIDDM in minority populations that will permit appropriate therapy and counseling, and extensive studies of environmental and genetic factors. Genetic studies include a genome wide search and continued analysis for candidate genes for both NIDDM and obesity. Environmental factors for study include the role of fetal and perinatal nutrition and drug exposure. Finally, collaborative multicenter studies are needed of prevention or control of obesity and NIDDM.

Publication Types:

• Review
• Review literature

PMID: 9492123, UI: 98151087

Clin Pediatr (Phila) 1998 Feb;37(2):97-102

Non-insulin dependent diabetes mellitus in African-American youths of Arkansas.

Pihoker C, Scott CR, Lensing SY, Cradock MM, Smith J

Children's Hospital and Medical Center, Seattle, Washington 98105, USA.

Non-insulin dependent diabetes mellitus (NIDDM) occurs more frequently in certain adult populations, including African-Americans. Recently an increase in the incidence of NIDDM has been observed among African-American youths in Arkansas. Clinical presentations among these youths vary from asymptomatic to severe diabetic ketoacidosis. From a chart review, data were examined to determine which physical, biochemical, and autoimmune characteristics were most helpful in appropriate classification of NIDDM vs insulin dependent diabetes mellitus (IDDM). It is apparent that several diagnostic and treatment issues need to be addressed to improve the management of African-American youths with NIDDM.

PMID: 9492117, UI: 98151081

Obstet Gynecol 1998 Mar;91(3):454-8

Correlates of postmenopausal female hormone use among black women in the United States.

Rosenberg L, Palmer JR, Rao RS, Adams-Campbell LL

Slone Epidemiology Unit, Boston University School of Medicine, Brookline, Massachusetts 02146, USA. lrosenberg@slone.bu.edu

OBJECTIVE: To assess correlates of the use of postmenopausal female hormone supplements among black women. METHODS: We assessed information obtained from 64,564 U.S. black women 21-69 years of age who enrolled in the Black Women's Health Study in 1995 by completing postal questionnaires. Included in the present analyses were 13,352 women 40-69 years of age who had ceased menstruating. Most resided in ten states, with 66% from California, New York, Illinois, Michigan, Georgia, and New Jersey; 41.0% had completed college. RESULTS: Among the 13,352 women 40 years of age or older who had ceased menstruating, 49.2% reported ever use of female hormone supplements and 33.3% were using them currently. Unopposed oral estrogens accounted for 63.4% of the medications being used currently. The use of supplements was highest in the western U.S. and lowest in the Northeast. The strongest correlate of use was menopause due to bilateral oophorectomy. Use peaked at 50-54 years of age and then declined, and also was associated positively with lower body mass index, greater years of education, participation in vigorous exercise, and past oral contraceptive use. Use was associated inversely with having a positive history of diabetes, heart attack, or breast cancer. Some of the drug use reported was at variance with suggested guidelines: unopposed estrogen was taken by some women who had a uterus, and estrogen together with a progestin was taken by some women who had had a hysterectomy. CONCLUSION: These data indicate that patterns of use of postmenopausal female hormone supplements among black women who participated in the present study are similar to those documented in white women. Women with risk factors for coronary artery disease were not more likely to use supplements than women at lower risk, a pattern that is not in accordance with suggestions that the greatest benefit of supplements may accrue to high-risk women. Because users differ from nonusers in important characteristics that may affect the incidence of coronary heart disease, breast cancer, and other illnesses, observational studies of the health effects of these medications must control carefully for correlates of use.

Comments:

• Comment in: Obstet Gynecol 1998 Jul;92(1):159-60

PMID: 9491877, UI: 98150841

Am Surg 1998 Feb;64(2):175-7

Sociology of care in patients with severe peripheral vascular disease.

Zeltsman D, Kerstein MD

Department of Surgery, Mercy Catholic Medical Center, Philadelphia, Pennsylvania, USA.

Peripheral vascular disease (PVD) remains a leading cause of limb amputation, resulting in a significant morbidity and disability. This study was undertaken to evaluate whether earlier referral of the patients with severe limb-threatening PVD to a vascular surgeon could result in a higher limb-salvage rate. Seventy-one consecutive patients, 48 men and 23 women, with mean ages of 67.1 and 70.4 years, respectively, were studied; there were 64 blacks (42 men, 22 women). Risk factors included smoking (39 men, 20 women) and diabetes mellitus (31 men, 11 women). The delay in seeking medical attention in patients with rest pain was 9 to 24 weeks (mean, 14.2), and with nonhealing ulcers the delay was 4 to 20 weeks (mean, 6.7). An additional delay of 11.7 weeks was noted if the patient was seen by a primary-care physician, and only 4 weeks if the patient was seen in the Emergency Department. Ten primary amputations were performed; 61 patients underwent limb-salvaging revascularization procedures, with a success rate of 87 per cent; 8 patients had below-the-knee amputation as a result of failed bypass. Delay in referral of patients with severe PVD can cause an increase in limb loss.

PMID: 9486893, UI: 98146314

J Pediatr 1998 Jan;132(1):90-7

Can cardiovascular risk be predicted by newborn, childhood, and adolescent body size? An examination of longitudinal data in urban African Americans.

Hulman S, Kushner H, Katz S, Falkner B

Albert Einstein Medical Center, Biomedical Computer Research Institute, Krogman Growth Center, University of Pennsylvania, Allegheny University, Philadelphia 19141-3098, USA.

OBJECTIVE: Recent retrospective studies of older adults have demonstrated a correlation between lower birth weight and hypertension and insulin resistance. We tested this finding in our sample of urban African Americans with prospective data on growth and blood pressure and also tested other variables (in addition to birth weight) for their relationship to adult cardiovascular risk. STUDY DESIGN: A prospective study of birth weight, growth, and blood pressure (Philadelphia Perinatal Collaborative Project) followed a sample of 137 African Americans, with nine examinations from birth through 28.0 +/- 2.7 years. Metabolic measurements (oral glucose tolerance testing, euglycemic hyperinsulinemic clamp, and plasma lipid concentration) were performed on the subjects as adults. Bivariate correlations among parameters were computed using the Pearson r. The chi-squared statistic was used to determine associations of outcomes with birth weight. Stepwise multiple linear regressions were computed using newborn, early childhood, adolescent, and young adult parameters to predict adult outcomes. RESULTS: Birth weight and blood pressure at age 28 years are not correlated (Pearson r = 0.06). Birth weight is also unrelated to adult obesity. However, weight at 0.3 years and after and body mass index at 7 years and after are correlated with adult weight. Furthermore, weight at age 14 years is significantly negatively correlated with measures of insulin-stimulated glucose use, indicating that obese adolescents may be at greater risk than nonobese adolescents for development of non-insulin dependent diabetes in adulthood. CONCLUSIONS: We found no relationship between birth weight and adult outcomes pertaining to cardiovascular risk in this sample of adult African Americans. However, we did find evidence that somatic growth (body weight and body mass index) is significantly related to obesity and attenuated insulin-stimulated glucose utilization in adulthood. These findings indicate that the origins of adult cardiovascular disease are related to somatic growth, but not intrauterine growth, and are evident during childhood.

PMID: 9470007, UI: 98130783

Ethn Dis 1997 Autumn;7(3):250-8

Body fat distribution and race differences in apolipoprotein A1.

Ferguson JE, Croft JB, Thompson SJ, Addy CL, Sheridan DP, Wheeler FC, Macera CA

South Carolina Department of Health and Environmental Control, Columbia, USA.

OBJECTIVE: This is the first study to assess the role of waist-to-hip ratio in explaining race differences in levels of serum apolipoprotein A1, a protective risk factor for atherosclerosis. METHODS: Linear regression analyses were used in a community-based survey of 3,043 adults (23.5% African-American) to assess associations of race, age, anthropometric measures, education, diabetes, blood pressure medication use, cigarette smoking, and leisure-time physical activity with apolipoprotein A1 levels. RESULTS: Higher apolipoprotein A1 levels were observed among African-American than among white adults (African-American men: +15.6 mg/dl than white men, African-American women: +3.1 mg/dl more than white women; p < 0.05). Waist-to-hip ratio and other variables did not account for race differences among men. African-American women had +8.6 mg/dl higher levels than white women after adjustment for differing distributions of waist-to-hip ratio, age, body mass index and education. Cigarette smoking, physical activity, and medical history accounted for no further differences among women. CONCLUSIONS: Higher levels of obesity indicators and lower educational attainment among African-American women reduced a potentially greater beneficial race difference in apolipoprotein A1. These findings also suggest that other environmental and biochemical factors may play roles in explaining the higher protective levels of apolipoprotein A1 observed among African-American children and adults.

PMID: 9467708, UI: 98128889

Mt Sinai J Med 1998 Jan;65(1):27-32

HIV-associated nephropathy.

Winston J, Klotman PE

Mount Sinai School of Medicine, New York, NY 10029, USA.

BACKGROUND: Patients with HIV-1 infection are at risk for developing renal diseases with diverse etiologies. Acute renal failure occurs in up to 20% of hospitalized patients with HIV infection, and chronic renal disease of diverse etiology has been reported. The single most common cause of chronic renal insufficiency in HIV-1+ patients is HIV-associated nephropathy (HIVAN). Typical morphologic features include enlarged kidneys, microcystic tubule dilatation, tubulointerstitial inflammation, and focal and segmental glomerulosclerosis. METHODS: The pathogenesis, epidemiology, and treatment options for HIVAN are discussed. In studying the epidemiology of the disease, we reviewed several renal disease databases, including the United States Renal Data Systems and New York State End Stage Renal Disease Network. We have previously reported our experience with HIVAN at Mount Sinai Medical Center. RESULTS: The exact cause of the renal disease remains unknown. The importance of a direct effect of HIV-1 viral protein(s) or renal HIV-1 gene expression in disease pathogenesis is supported in the murine model of HIVAN, but definitive proof of renal cell infection in humans is lacking. Further study is required to clarify this issue. We estimate that HIVAN is the fourth leading cause of end-stage renal disease (ESRD) among Blacks between the ages of 20 and 64 years, only slightly behind hypertension, diabetes, and chronic glomerulonephritis. At Mount Sinai Hospital HIVAN accounts for 20% of newly diagnosed ESRD in young black adults. It has become the third leading cause of ESRD in this group, after hypertension and diabetes. CONCLUSIONS: In seropositive patients with renal disease, renal biopsies should be performed to confirm the diagnosis and determine the true incidence. Special attention should be directed toward understanding the underlying cause(s) of HIVAN. A multicenter trial to explore the potential for antiviral therapy in this disease should be initiated.

Publication Types:

• Review
• Review, tutorial

PMID: 9458681, UI: 98120264

Diabet Med 1997 Dec;14(12):1073-7

Audit of public sector primary diabetes care in Cape Town, South Africa: high prevalence of complications, uncontrolled hyperglycaemia, and hypertension.

Levitt NS, Bradshaw D, Zwarenstein MF, Bawa AA, Maphumolo S

Department of Medicine, University of Cape Town, South Africa.

This study was undertaken to investigate the prevalence of diabetes complications and level of glycaemic and blood pressure control in Black African patients at the primary care level in the public sector Cape Town, South Africa. A stratified random sample of 300 patients attending the three largest ambulatory diabetes clinics in community health centres in Black African residential areas of Cape Town (100 patients from each) during the last 6 months of 1992 was selected. Each patient had a clinical examination, interview, and 1 year retrospective record review. Eighty-one per cent of the sampled patients were reviewed, 90% were non-insulin-dependent (NIDDM) and 10% were treated with insulin. The mean duration of diabetes was 8 (range 0-28) years. Acceptable glycaemic control was present in 49.4% (95% Confidence Intervals 45.6-53.5) of patients while 38.5% (CI 24.8-52.2) of hypertensive patients had acceptable blood pressure control. The prevalence of any grade of retinopathy was 55.4% (CI 48.90-62.9), proliferative and preproliferative retinopathy 15.6% (CI 8.5-22.8), cataracts 7.9% (CI 4.4-11.4), peripheral neuropathy 27.6% (CI 15.2-39.4), absent foot pulses 8.2% (CI 5.2-12.6), amputations 1.4% (CI 0.4-2.4), persistent proteinuria 5.3% (CI 2.5-8.1) and an elevated albumin-creatinine ratio 36.7% (CI 29.0-44.4). The complications were not documented in the clinic records of the preceding year with the exception of 1 patient with absent foot pulses and the 12 patients with proteinuria. The high prevalence of suboptimal glycaemic and blood pressure control as well as complications of diabetes, largely unrecorded in the preceding years' clinic notes, demonstrates the deficiency of and need for preventative diabetes care at the primary care level. The design, institution, and evaluation of effective intervention programmes are a priority to improve the quality of care provided and the health of diabetic patients.

PMID: 9455936, UI: 98115471

J Natl Med Assoc 1997 Nov;89(11):728-30

Published erratum appears in J Natl Med Assoc 1998 Jul;90(7):389

A retrospective analysis of the efficacy and safety of metformin in the African-American patient.

Briscoe TA, Anderson D, Usifo OS, Cooper GS

Department of Medicine, Morehouse School of Medicine, Atlanta, Georgia 30310, USA.

A retrospective analysis was conducted to determine the effects of metformin on glycosylated hemoglobin (HbA1c), body weight, and adverse events in an African-American population. Thirty-six patients who were receiving combination therapy with metformin and either a sulfonylurea or insulin were identified from a hospital pharmacy database. Nineteen patients met the criteria for efficacy analysis. The combination of metformin with either a sulfonylurea or insulin resulted in a decrease of the average HbA1c from a baseline of 10.07% to 7.92% (delta = 2.15%). The effect of combination therapy on weight was variable; however, twice as many patients lost weight compared with those who gained weight. Metformin appeared to be well-tolerated, with gastrointestinal symptoms being the most commonly reported adverse events.

PMID: 9375476, UI: 98043046

Eval Health Prof 1998 Mar;21(1):52-65

The reliability of the Diabetes Care Profile for African Americans.

Fitzgerald JT, Anderson RM, Gruppen LD, Davis WK, Aman LC, Jacober SJ, Grunberger G

University of Michigan Medical School, USA.

The Diabetes Care Profile (DCP) is an instrument used to assess social and psychological factors related to diabetes and its treatment. The reliability of the DCP was established in populations consisting primarily of Caucasians with type 2 diabetes. This study tests whether the DCP is a reliable instrument for African Americans with type 2 diabetes. Both African American (n = 511) and Caucasian (n = 235) patients with type 2 diabetes were recruited at six sites located in the metropolitan Detroit area. Scale reliability was calculated by Cronbach's coefficient alpha. The scale reliabilities ranged from .70 to .97 for African Americans. These reliabilities were similar to those of Caucasians, whose scale reliabilities ranged from .68 to .96. The Feldt test was used to determine differences between the reliabilities of the two patient populations. No significant differences were found. The DCP is a reliable survey instrument for African American and Caucasian patients with type 2 diabetes.

PMID: 10183339, UI: 98415377

Arterioscler Thromb Vasc Biol 1997 Dec;17(12):3534-41

Association of apo E polymorphism with plasma lipid levels in a multiethnic elderly population.

Pablos-Mendez A, Mayeux R, Ngai C, Shea S, Berglund L

Division of General Medicine, College of Physicians & Surgeons, Columbia University, New York, NY 10032-3702, USA.

Apolipoprotein E polymorphisms are important determinants of blood lipid levels and have been associated with longevity and atherosclerosis. However, information is limited on the effects of apo E variation on the lipids of nonwhite and elderly individuals. We tested the hypothesis that apo E polymorphisms are associated with plasma lipid levels in an elderly, multiethnic population. Cross-sectional data from 1068 noninstitutionalized individuals from northern Manhattan over the age of 64 who were not on a lipid-lowering diet or drug were analyzed. The ethnic distribution was 34% African-Americans, 47% Hispanics, and 19% non-Hispanic Caucasians. In the entire group, the most prevalent apo E allele was epsilon 3 (76%), followed by epsilon 4 (16%) and epsilon 2 (8%); epsilon 4 was more prevalent in African-Americans (21%) than in non-Hispanic Caucasians (12%) or Hispanics (14%). The apo epsilon 2 allele was the most important correlate of plasma lipids, but association varied across ethnoracial groups. After being adjusted for age, sex, obesity, diabetes mellitus, and alcohol intake, LDL cholesterol levels declined with each apo epsilon 2 allele by 8.8 mg/dL in Hispanics and by 25.6 and 18.1 mg/dL in non-Hispanic Caucasians and African-Americans, respectively (P < .001). No significant independent effect was noted for any apo E genotype on HDL cholesterol. Overall, there was a reduction in the total/HDL cholesterol ratio, per apo epsilon 2 allele, of 0.82 in non-Hispanic Caucasians and 0.43 and 0.48 in African-American and Hispanic individuals, respectively (P < .05). In a multivariate model, apo epsilon 4 did not significantly affect plasma lipid levels. Plasma triglyceride levels were inversely correlated with the number of apo epsilon 4 alleles (175, 159, and 143 mg/dL with 0, 1, and 2 alleles, respectively; P =.002), and this effect increased with age. Thus, in an elderly, multiethnic population, apolipoprotein E polymorphisms were important determinants of blood lipids, with differing effects depending on ethnicity. The presence of apo epsilon 2 was associated with lower LDL cholesterol levels and total/HDL cholesterol ratio, although apo epsilon genotype did not influence HDL cholesterol levels. Prospective studies are needed to test whether apo epsilon 2 protects against incident cardiovascular disease in the elderly.

PMID: 9437203, UI: 98099849

Muscle Nerve 1998 Jan;21(1):72-80

Risks for sensorimotor peripheral neuropathy and autonomic neuropathy in non-insulin-dependent diabetes mellitus (NIDDM).

Cohen JA, Jeffers BW, Faldut D, Marcoux M, Schrier RW

Department of Neurology, Kaiser Permanente, Denver, Colorado 80262, USA.

Identification of risk factors for development of diabetic sensorimotor peripheral neuropathy (DSPN) and diabetic autonomic neuropathy (DNA) may help to prevent or modify these complications. The ABCD Trial, a prospective study of diabetic complications, has identified risk factors of the presence and staging of peripheral neuropathy based on neurological symptom scores, neurological disability scores, autonomic function testing and quantitative sensory examination. DSPN is independently associated with diabetes duration [odds ratio (OR) = 1.5 per 10 years], body weight (OR = 1.1 per 5 kg), age (OR = 1.8 per 10 years), retinopathy (OR = 2.3), overt albuminuria (OR = 2.5), height (OR = 1.2 per 10 cm), duration of hypertension (OR = 1.1 per 10 years), insulin use (OR = 1.4), and race/ethnicity [African American vs. non-Hispanic white (OR = 0.4) and Hispanic vs. non-Hispanic white (OR = 0.8)]. DAN is independently associated with diabetes duration (OR = 1.2 per 10 years), body weight (OR = 1.1 per 5 kg), glycosylated hemoglobin (OR = 1.1 per 2.5%), overt albuminuria (OR = 1.6), and retinopathy (OR = 1.8).

Publication Types:

• Clinical trial
• Randomized controlled trial

PMID: 9427226, UI: 98087098

Womens Health 1997 Fall-Winter;3(3-4):275-300

Diabetes in African American women: the silent epidemic.

McNabb W, Quinn M, Tobian J

Chicago Diabetes Research and Training Center, University of Chicago, IL 60637, USA.

Non-insulin-dependent diabetes mellitus is a serious metabolic disorder that affects an estimated 16 million Americans. Among African American women, diabetes has reached epidemic proportions, with 1 in 4 black women 55 years and older having diabetes. It is only within the last decade that diabetes research has begun to examine racial differences in the etiology, treatment, and long-term complications of diabetes. This review bring together the research that focuses on African American women within the context of diabetes research in the general population. Particular emphasis is placed on diabetes risk factors, complications of diabetes, and pharmacologic and nonpharmacologic treatment approaches. Diabetes prevention and public health issues related to diabetes and the African American women are discussed. The literature reviewed points to the importance of screening and early detection of diabetes among high-risk African American women, as well as the need for improved quality of care and patient educational services and programs in diabetes appropriate to the needs of African American women.

Publication Types:

• Review
• Review literature

PMID: 9426497, UI: 98087903

J Diabetes Complications 1997 Sep-Oct;11(5):298-306

Incentives and barriers to retinopathy screening among African-Americans with diabetes.

Walker EA, Basch CE, Howard CJ, Zybert PA, Kromholz WN, Shamoon H

Diabetes Research and Training Center, Albert Einstein College of Medicine, Bronx, New York 10461, USA.

Diabetes-related ophthalmic complications are the leading cause of newly diagnosed blindness among adults. These eye complications are often asymptomatic in the early stages, yet the majority of diabetes patients are not screened yearly. To develop a health promotion intervention to increase the rate of screening for diabetic retinopathy by dilated fundus exam (DFE), we assessed the knowledge and health beliefs related to preventing diabetic eye complications among a sample of African-Americans with diabetes. The study design was cross-sectional, using a telephone interview to collect data. From a random sample of 104 African-Americans with diabetes, 67 (64%) were completed: 54 women; mean age of 58 years. The telephone interview schedule contained items grouped into subscales for Perceived Incentives, Perceived Barriers to getting a DFE, Causes of Eye Problems, Risk of Eye Problems, and Effective Treatments for Eye Problems. Descriptive statistics were used to analyze the quantitative data. Transcribed qualitative responses to the open-ended questions were analyzed for themes. The incentives "having eye problems" and "doctor said it was important to go" each had 91% responding it was an incentive to go for a DFE. Only about one-third agreed that any particular item was a barrier to receiving a DFE (e.g., economic factors). In the subscale for Risk of Eye Problems, "retinopathy" had the lowest level of perceived risk (30%). Only 21% of the sample reported there were effective treatments for retinopathy. Eighty-seven percent reported the faulty belief that "diabetic eye problems have symptoms." Only 36% of the sample said they had heard of retinopathy and of those, only 8% could describe it correctly. Among general response themes were: fear, spirituality (faith and hope), priorities, economic or logistical factors, and external/internal motivation. Perceived incentives for receiving a DFE were acknowledged at far greater rates than perceived barriers. Having a yearly DFE in the absence of symptoms must be emphasized in health promotion materials. There are effective, early treatments for diabetic eye problems, and this information should be used to counter the fear of a dreaded diagnosis with the hope of treatment and cure. Ways of coping with fear of having the exam should be included in health education. DFEs must become a routine yearly exam and not just a reaction to recognized problems. Health education must address the specific needs of high-risk minority populations.

PMID: 9424171, UI: 97475400

Transplant Proc 1997 Dec;29(8):3718

Hypertension does not contribute to end-stage renal disease in black recipients of kidney/pancreas transplants.

Froelich J, Posner M, Beck R, Tesi RJ

Sangstat Medical Company, Menlo Park, California 94025, USA.

PMID: 9414899, UI: 98076579

Transplant Proc 1997 Dec;29(8):3710-2

Genes within and flanking the major histocompatibility region are risk factors for diabetes, insulin resistance, hypertension, and microalbuminuria in African-American women.

Acton RT, Bell DS, Collins J, Giger JN, Go RC, Harrison R, McDonald R, Rivers C, Roseman JM, Taylor HA Jr, Vanichanan C

Department of Microbiology, University of Alabama at Birmingham 35294-4400, USA.

PMID: 9414895, UI: 98076575

J Natl Black Nurses Assoc 1997 Spring-Summer;9(1):66-75

Diabetes outcomes and practices: comparison of African Americans and Caucasians.

Bailey BJ, Lherisson-Cedeno D

Department of Nursing & Health Science, School of Science, California State University, Hayward, USA.

When compared to Caucasians, diabetes mellitus and its complications are more prevalent among African Americans. Locus of control and social support were suggested as correlates of diabetes outcomes and health care practices that might have clinical implications. A sample of 24 African Americans and 80 Caucasians with Type II diabetes completed questionnaires and gave venous blood specimens. African Americans had significantly higher glycohemoglobin values (p = .049) and BMI values (p = .048). African Americans also took fewer doses of medication (p = .046) and tested their blood glucose less frequently (p = .062). Correlation patterns for the two groups differed as well. Social support variables were more often related to health care practices and outcomes for African Americans than for Caucasians. The findings indicate that nursing interventions resulting in increased social support could be especially effective for African Americans with Type II diabetes.

PMID: 9384104, UI: 98045412

Hypertension 1997 Dec;30(6):1549-53

Improvement of insulin sensitivity by short-term exercise training in hypertensive African American women.

Brown MD, Moore GE, Korytkowski MT, McCole SD, Hagberg JM

Preventive Cardiology, Cardiology Division, University of Pittsburgh Medical Center, Penn, USA. mb@umail.umd.edu

African American women have a high prevalence of insulin resistance, non-insulin-dependent diabetes mellitus, obesity, and hypertension that may be linked to low levels of physical activity. We sought to determine whether 7 days of aerobic exercise improved glucose and insulin metabolism in 12 obese (body fat >35%), hypertensive (systolic blood pressure > or =140 and/or diastolic blood pressure > or =90 mmHg) African American women (mean age 51+/-8 years). Insulin-assisted frequently-sampled intravenous glucose tolerance tests were performed at baseline and 14 to 18 hours after the 7th exercise session. There was no significant change in maximal oxygen consumption, body composition, or body weight after the 7 days of aerobic exercise. The insulin sensitivity index increased (2.68+/-0.45 x 10[-5] to 4.23+/-0.10 x 10[-5] [min(-1)/pmol/L], P=.02). Fasting (73+/-9 to 50+/-9 pmol/L, P=.02) and glucose-stimulated (332+/-58 to 261+/-45 pmol/L, P=.05) plasma insulin levels decreased. Additional measures related to the insulin resistance syndrome also changed with the 7 days of exercise: basal plasma norepinephrine concentrations were reduced (2.46+/-0.27 to 1.81+/-0.27 nmol/L, P=.02) and sodium excretion rate increased from 100+/-13 to 137+/-7 mmol/d (P=.03); however, there was no change in potassium excretion or 24-hour ambulatory blood pressure. We conclude that a short-term aerobic exercise program improves insulin sensitivity in African American hypertensive women independent of changes in fitness levels, body composition, or body weight. The present study indicates that short-term exercise can improve insulin resistance in hypertensive, obese, sedentary African American women and confirms previous reports that a portion of the exercise-induced improvements in glucose and insulin metabolism may be the result of recent exercise.

PMID: 9403581, UI: 98065839

J Am Soc Nephrol 1997 Dec;8(12):1942-5

Family history of end-stage renal disease among incident dialysis patients.

Freedman BI, Soucie JM, McClellan WM

Department of Internal Medicine/Nephrology, Bowman Gray School of Medicine of Wake Forest University, Winston-Salem, North Carolina 27157-1053, USA.

As part of a larger study of genetic risk factors for the occurrence of renal failure, the prevalence of a family history of end-stage renal disease (ESRD) in first- and second-degree relatives of all incident dialysis patients treated in Georgia, North Carolina, and South Carolina (ESRD Network 6) in 1994 was ascertained. Family histories were obtained from 4365 dialysis patients (83% of those eligible), and 856 (20%) reported having a family history of ESRD. Among race-sex groups, 14.1% of Caucasian men, 14.6% of Caucasian women, 22.9% of African-American men, and 23.9% of African-American women reported a first- or second-degree relative with ESRD (P = 0.001). The prevalence of relatives with ESRD varied by the reported etiology: 22.2% in diabetes mellitus; 18.9% in hypertension, 22.7% in glomerulonephritis; and 13.0% of other etiologies (P = 0.001). Patient characteristics independently associated with family history of ESRD included race, younger age, higher levels of education, and etiology of ESRD. In this report, it is concluded that a large proportion of incident ESRD cases have close relatives with ESRD in whom preventive actions might be directed. Genetic analyses in multiply affected families may identify the inherited factors contributing to progressive renal failure.

PMID: 9402097, UI: 98063689

MMWR Morb Mortal Wkly Rep 1997 Oct 31;46(43):1023-7

Preventive-care knowledge and practices among persons with diabetes mellitus -- North Carolina, Behavioral Risk Factor Surveillance System, 1994-1995.

Diabetes mellitus is the leading cause of lower-extremity amputation, end-stage renal disease, and blindness among persons aged 18-65 years in the United States. Diabetes preventive care resulting in improved self-care, better glycemic control, and regular foot and eye examinations can substantially reduce the complications of diabetes. Assessment of the level of preventive care among persons with diabetes can assist in targeting public health efforts to reduce complications. To estimate the prevalence of diabetes and the levels of preventive-care knowledge and practices among persons with diabetes in North Carolina, the North Carolina Office of Epidemiology and the state Diabetes Control Program (DCP), in collaboration with CDC, analyzed data from the Behavioral Risk Factor Surveillance System (BRFSS) for 1994-1995. This report summarizes the results of that analysis, which indicate a low level of diabetes preventive-care knowledge and practices among persons with diabetes in North Carolina.

PMID: 9367137, UI: 98032959

MMWR Morb Mortal Wkly Rep 1997 Oct 31;46(43):1018-23

Diabetes-specific preventive-care practices among adults in a managed-care population -- Colorado, Behavioral Risk Factor Surveillance System, 1995.

The prevalence of diagnosed diabetes in the United States is 3%; however, diabetes accounts for approximately 15% of total U.S. health-care expenditures. Preventive-care practices (e.g., glycemic control and regular foot and ophthalmic examinations) can reduce the occurrence and progression of diabetic complications. Although managed-care organizations (MCOs) have assessed the use of such practices through chart reviews, telephone surveys of MCO patients with diabetes are a less expensive method for collecting accurate data. The ongoing, state-based Behavioral Risk Factor Surveillance System (BRFSS) telephone survey can be used to assess levels of care provided by MCOs and self-care practices among persons with diabetes in MCO populations. In 1995, a Colorado-based MCO collaborated with the Colorado Diabetes Control Program (CDCP) to use the state-based BRFSS to assess care practices among MCO enrollees. This report presents findings from the CDCP analysis of data on MCO enrollees aged > or = 30 years who had diabetes; the findings indicate that, although approximately three fourths of enrollees reported most preventive-care practices, two thirds had never heard the term hemoglobin "A-one-C," one fourth had not had their feet examined during the preceding year, and nearly one fifth did not receive an annual dilated-eye examination.

PMID: 9367136, UI: 98032958

Clin Transplant 1997 Oct;11(5 Pt 2):480-4

HLA-DQ matching in cadaveric renal transplantation.

Freedman BI, Thacker LR, Heise ER, Adams PL

Department of Medicine, Bowman Gray School of Medicine of Wake Forest University, Winston-Salem, North Carolina 27157-1053, USA.

The impact of matching for the human leukocyte antigen (HLA)-DQ phenotype in cadaveric renal transplantation is unclear. We analyzed the effect of matching serologically defined HLA-DQ phenotypes on renal allograft survival in 12,050 first cadaveric renal transplants (recipients were 63.5% white and 36.5% African-American). Recipients were entered into the South-Eastern Organ Procurement Foundation (SEOPF) database between 1 October 1987 and 6 June 1995. A series of life table analyses were done to test the equality of survival curves for HLA-DQ match, both alone and accommodating for differences in recipient race and HLA-DR match. Cox regression models were then performed to detect differences in allograft survival based upon HLA-DQ match. Initial adjustments were done by recipient race. Subsequent adjustments were done by recipient and donor race, age and sex, cold ischemia time (CIT), body mass index (BMI), cyclosporine A (CyA) use, peak panel reactive antibody (PRA) titer, year of transplant, presence of diabetes mellitus (DM), and degree of HLA-A,B and HLA-DR match as covariates. The effect of varying degrees of HLA-DQ match on graft survival were similar between the two races (p = 0.87). In all recipients, an 8.3% reduction in graft failure was observed for each increase in HLA-DQ match using the Cox regression model adjusted only for recipient race (p = 0.004). A non-significant 3.0% reduction in graft failure (p = 0.38) was observed for each level of increasing HLA-DQ match when using the Cox regression model adjusted for recipient and donor race, age and sex, CIT, BMI, CyA use, year of transplant, DM, HLA-A,B and -DR match. In this model, superior HLA-A,B match and HLA-DR match, recipient and donor age, male donor sex, shorter CIT, white race of recipient, lower peak PRA, CyA use, and absence of DM significantly improved graft survival (all < or = 0.004). We conclude that HLA-DQ matching does not significantly affect cadaveric renal allograft survival once adjusted for other known predictors of graft outcome.

PMID: 9361945, UI: 98028038

Am J Clin Nutr 1997 Nov;66(5):1224-31

Insulin sensitivity and intake of vitamins E and C in African American, Hispanic, and non-Hispanic white men and women: the Insulin Resistance and Atherosclerosis Study (IRAS).

Sanchez-Lugo L, Mayer-Davis EJ, Howard G, Selby JV, Ayad MF, Rewers M, Haffner S

Department of Public Health Sciences, Bowman Gray School of Medicine, Wake Forest University, Winston-Salem, NC, USA.

Elevated fasting insulin concentrations and insulin resistance have been associated with non-insulin-dependent diabetes mellitus (NIDDM), obesity, atherosclerosis, and hypertension. Vitamin E supplementation in persons with and without NIDDM may be related to greater insulin sensitivity (SI). The cross-sectional associations of the intake of vitamins E and C with SI and insulin concentrations were evaluated among African American, Hispanic, and non-Hispanic white men and women with a wide spectrum of glucose tolerance included in the Insulin Resistance and Atherosclerosis Study (IRAS) (n = 1151). Insulin sensitivity was measured by minimal model analysis of a 12-sample, insulin-modified, frequently sampled intravenous glucose tolerance test. Nutrient intake (including vitamin supplement use) was assessed with a food-frequency questionnaire modified to include foods consumed by the three ethnic groups. Linear-regression models were used, including rank of SI and the log of fasting insulin as the outcome variables. Pearson correlation coefficients for vitamins E and C in relation to rank SI were r = 0.07 (P = 0.01) and r = 0.07 (P = 0.02), respectively. After adjustment for total energy and BMI these associations were no longer statistically significant and did not differ between ethnic groups. Results were similar when vitamins E and C were combined in categories of low and high antioxidant intake. Models replicated with log of fasting insulin as the outcome variable also did not produce significant associations with vitamins E or C. Thus, these cross-sectional analyses do not support the hypothesis of improved SI with increased intake of vitamins E and C.

Publication Types:

• Multicenter study

PMID: 9356542, UI: 98019355

Diabetes Educ 1997 Sep-Oct;23(5):563-8

Diabetes in urban African Americans: functional health literacy of municipal hospital outpatients with diabetes.

Nurss JR, el-Kebbi IM, Gallina DL, Ziemer DC, Musey VC, Lewis S, Liao Q, Phillips LS

Center for the Study of Adult Literacy, Georgia State University, Atlanta 30303, USA. litjrn@Agsusgi2.gsu.edu

Functional health literacy was assessed in 63 patients from the diabetes outpatient clinic, 20 from the general medicine clinic, and a total of 48 from two satellite medical clinics. All patients received a demographic questionnaire, visual screening, and the Test of Functional Health Literacy in Adults, an instrument with good validity and internal consistency used to measure the ability to read and understand medical instructions. Functional health literacy was adequate in only 47% of new patients at the diabetes clinic and only 25% of established patients at all sites. There were no significant differences in functional health literacy among established patients across all sites. Overall, patients' mean functional health literacy level was inadequate to marginal. Of the patients with inadequate functional health literacy, 43% denied difficulty in reading. Patient education strategies and materials are needed to address this important barrier to healthcare delivery.

PMID: 9355373, UI: 98017007

Ann Epidemiol 1997 Oct;7(7):479-85

Do ethnic differences in dietary cation intake explain ethnic differences in hypertension prevalence? Results from a cross-sectional analysis.

Bauer UE, Mayne ST

Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, CT, USA.

PURPOSE: To better understand how the magnitude of the association between ethnicity and hypertension is affected by ethnic differences in dietary cation intake, we describe differences in dietary cation intakes and prevalence of hypertension across four ethnic groups (African-Americans, European-Americans, Mexican-Americans, and Puerto Ricans). We also assess the cross-sectional association between: (i) hypertension and self-reported dietary intakes of sodium, potassium, and calcium for each ethnic group; and (ii) ethnicity and hypertension before and after adjustment for dietary cation intakes. METHODS: Data from the Second National Health and Nutrition Examination Survey (1976-1980) and the Hispanic Health and Nutrition Examination Survey (1982-1984) were analyzed. Multiple logistic regression was used to estimate odds ratio (OR) for hypertension for each ethnic group, with adjustment for age, body mass index (BMI), and diabetes status. Comparisons were made to assess whether the magnitude for the ethnicity ORs changed when the three nutrient variables were entered into the model. RESULTS: Mexican-American and Puerto Rican men and women showed clinically and statistically significantly higher mean intakes of the three cations than did African-American men and women, who reported clinically and statistically significantly lower mean intakes of sodium, potassium, and calcium than did European-American men and women. Mean dietary intakes of potassium and calcium were higher for normotensives than for hypertensives among all ethnic groups, except African-American and Mexican-American women. In multivariate modeling, stark differences in ORs for hypertension persisted across ethnic groups despite inclusion of the nutrient variables. CONCLUSION: In this cross-sectional study, adjustment for dietary cation intakes did not alter the magnitude of the ethnic differences in prevalence of hypertension.

PMID: 9349915, UI: 98010757

Epidemiology 1997 Nov;8(6):621-8

Socioeconomic status and health in blacks and whites: the problem of residual confounding and the resiliency of race.

Kaufman JS, Cooper RS, McGee DL

Department of Preventive Medicine and Epidemiology, Loyola University Stritch School of Medicine, Maywood, IL, USA.

A large number of epidemiologic studies have focused on racial/ethnic differences, particularly between blacks and whites. Because health endpoints and racial categorizations are associated with socioeconomic status, investigators generally adjust for socioeconomic indicators. The intention is usually to control for confounding, thereby making groups comparable and excluding socioeconomic status as an alternative explanation to hypotheses of innate physiologic differences. A threat to the validity of these analyses is therefore the presence of residual confounding. We identify four potential sources of residual confounding in this analytical design: categorization of socioeconomic status variables, measurement error in socioeconomic indicators, use of aggregated socioeconomic status measures, and incommensurate socioeconomic indicators. Using simulations and examples from the literature, we demonstrate that the effect of residual confounding is to bias interpretation of data toward the conclusion of independent racial/ethnic group effects. Investigators often refer to possible "genetic" differences on the basis of models that control for socioeconomic status. We propose that such conclusions on the basis of this analytical strategy are generally unwarranted. Racial/ethnic differences in disease are a pressing public health concern, but the current approach does not often provide a basis for inference about putative biological factors in the etiology of this disparity.

Comments:

• Comment in: Epidemiology 1997 Nov;8(6):609-11

PMID: 9345660, UI: 98005544

J Clin Endocrinol Metab 1997 Oct;82(10):3395-8

Molecular scanning of beta-3-adrenergic receptor gene in total congenital lipoatrophic diabetes mellitus.

Silver K, Walston J, Plotnick L, Taylor SI, Kahn CR, Shuldiner AR

Johns Hopkins University School of Medicine, Division of Endocrinology and Metabolism, Baltimore, Maryland 21287, USA. ksilver@umppal.ab.umd.edu

Total congenital lipoatrophic diabetes is characterized by absence of subcutaneous adipose tissue, hypertriglyceridemia, and insulin resistance. We hypothesized that mutations in the beta-3-adrenergic receptor (beta 3AR) gene might result in the lipoatrophic phenotype by preventing triglyceride storage in adipocytes; thereby, resulting in secondary insulin resistance. We screened the beta 3AR gene in 7 subjects with total congenital lipoatropic diabetes. We found a heterozygous substitution of a guanine to cytosine at position -153 (G-153C) in the 5'-untranslated region of 3 African-American lipoatrophic siblings and 1 sibling without lipoatrophy but with insulin resistance. To determine whether the base change was related to the lipoatrophic phenotype, we genotyped 69 African-Americans without lipoatrophy and found the G-153C substitution in 2 control subjects (allele frequency = 0.01). No other single-stranded polymorphism variants were found in any of the 7 lipoatrophic subjects. Direct sequencing of both alleles of 1 lipoatrophic subject demonstrated a thymidine insertion at position -300 in both alleles. All lipoatrophic subjects along with 20 African-American control subjects were homozygous for the base insertion, suggesting an error in the published sequence. In conclusion, mutations in the beta 3AR gene do not appear to be involved in the development of congenital total lipoatrophy.

PMID: 9329375, UI: 97469958

J Natl Med Assoc 1997 Oct;89(10):665-71

Causes of chest pain and symptoms suggestive of acute cardiac ischemia in African-American patients presenting to the emergency department: a multicenter study.

Maynard C, Beshansky JR, Griffith JL, Selker HP

Department of Medicine, New England Medical Center, Tufts University School of Medicine, Boston, Massachusetts 02111, USA.

This study examines whether race is a significant determinant of the diagnoses of acute myocardial infarction or angina pectoris in patients with symptoms suggestive of acute cardiac ischemia. The study population was comprised of 3401 (34%) African-American and 6600 (66%) white patients who presented to emergency departments with symptoms suggestive of acute cardiac ischemia. The main outcome measure was a diagnosis of acute myocardial infarction or angina pectoris. African Americans were younger, predominantly female, and more often had hypertension, diabetes mellitus, or smoked. The diagnosis of acute myocardial infarction was confirmed in 6% of African-American and 12% of white men, and in 4% of African-American and 8% of white women. After adjusting for age, gender, medical history, signs and symptoms, and hospital, African Americans were half as likely to develop acute myocardial infarction and were 60% as likely to have acute cardiac ischemia. Despite having less acute cardiac ischemia, African Americans in this study had high risk levels for coronary artery disease.

Publication Types:

• Multicenter study

PMID: 9347680, UI: 98007272

Stroke 1997 Oct;28(10):1908-12

Familial history of stroke and stroke risk. The Family Heart Study.

Liao D, Myers R, Hunt S, Shahar E, Paton C, Burke G, Province M, Heiss G

Department of Epidemiology, School of Public Health, University of North Carolina at Chapel Hill 27514, USA. duanping_liao@unc.edu

BACKGROUND AND PURPOSE: Although familial history of stroke is generally perceived to be an important marker of stroke risk, very few epidemiological studies have been published to address this hypothesis. We sought to examine whether familial history of stroke is associated with the prevalence of stroke in the Family Heart Study, a National Heart, Lung, and Blood Institute-supported multicenter study of the familial, genetic, and nongenetic determinants of cardiovascular disease in populations. METHODS: The personal and familial histories of stroke were assessed in 3168 individuals (probands) who were at least 45 years old and 29,325 of their first-degree relatives with the use of a standardized questionnaire. RESULTS: The age-, ethnicity-, and sex-adjusted stroke prevalences were 4.8%, 4.9%, and 3.9% in probands with a positive familial, paternal, and maternal history of stroke, respectively, in comparison with 2.0% in probands without any positive familial history (P < .01). The age-, ethnicity-, and sex-adjusted odds ratios (95% confidence interval) of stroke were 2.00 (1.13, 3.54) for a positive paternal and 1.41 (0.80, 2.50) for a positive maternal history of stroke. Additional statistical adjustment for the proband's history of elevated cholesterol level, cigarette smoking status, history of coronary heart disease, hypertension, and diabetes did not alter the associations. A similar pattern was seen for African Americans and European Americans. CONCLUSIONS: The increased risk of stroke among persons with a positive familial history of stroke compared with those without a familial history of stroke is consistent with the expression of genetic susceptibility, a shared environment, or both in the etiology of stroke.

Publication Types:

• Multicenter study

PMID: 9341694, UI: 98000901

Med Care 1997 Oct;35(10):1031-43

The risk of hospitalization for congestive heart failure among older adults.

Wolinsky FD, Overhage JM, Stump TE, Lubitz RM, Smith DM

School of Public Health, Saint Louis University Health Sciences Center, MO 63108-3342, USA.

OBJECTIVES: The purpose of the study was to estimate the 8-year rate of hospitalization for congestive heart failure (CHF), to report the resources consumed, and to evaluate previously reported risk factors in a nationally representative sample of 7,286 older white and black adults. METHODS: Secondary analysis of baseline interview data was linked to Medicare hospitalization and death records for 1984 to 1991. Hospitalization for CHF was defined as having one or more episodes with an International Classification of Diseases (ninth revision, clinical modification) discharge code of 428. Combined and separate analyses of first-listed and second-through fifth-listed CHF discharge diagnoses were conducted. Multivariable proportional hazards models were used to evaluate the risks in pooled analyses of all white and black men and women and in separate stratified analyses of white men and white women. RESULTS: Over the 8-year period, 1,102 or 15.1% of the 7,286 older white and black adults were hospitalized for CHF (7.1% with first-listed and 8.1% with second- through fifth-listed diagnoses). The 1- and 5-year combined postdischarge mortality rates were 34.7% and 69.0%, respectively. In descending order, the major risk factors for being hospitalized for CHF in the combined, pooled analysis were age, being a white man, having lower body functional limitations, and having self-reported medical histories of coronary heart disease, heart attack, diabetes, and angina. The increased risk associated with age was not linear, and it diminished significantly over the course of life. Some significant differences were observed in the risk factors for hospitalization for first-listed versus second- through fifth-listed CHF and in the risk factors for white women versus white men. CONCLUSIONS: Hospitalization for CHF among older adults is a common, costly event with a poor prognosis. The differential risk for white men remains unexplained and warrants further study.

Publication Types:

• Meta-analysis

PMID: 9338529, UI: 97478234

Diabetes Care 1997 Oct;20(10):1569-75

Disparity in glycemic control and adherence between African-American and Caucasian youths with diabetes. Family and community contexts.

Auslander WF, Thompson S, Dreitzer D, White NH, Santiago JV

George Warren Brown School of Social Work, Washington University, St. Louis, MO 63130, USA.

OBJECTIVE: To describe sociodemographic, family, and community factors that contribute to the glycemic control of African-American and Caucasian youths with diabetes, we investigated two questions: 1) Is there a disparity in glycemic control between African-American and Caucasian youths with diabetes, and if so, what sociodemographic, family, and community factors explain the disparity? and 2) Is there a difference in the adherence to treatment between African-American and Caucasian youths with diabetes, and if so, what sociodemographic, family, and community factors explain the difference? RESEARCH DESIGN AND METHODS: This cross-sectional study included 146 youths with diabetes (95 Caucasians and 51 African-Americans) and their mothers. The youths were invited to participate if they had been diagnosed with diabetes at least 1 year before the study, did not have another chronic illness, and were < 18 years of age. RESULTS: The findings indicate that African-American youths with diabetes are in significantly poorer metabolic control than their Caucasian counterparts (1.5% difference in HbA1c levels). Single-parent household status and lower levels of adherence partially account for the poorer glycemic control. Examination of the adherence subscales indicates that African-Americans report significantly lower adherence to diet and glucose testing than Caucasian youths. CONCLUSIONS: This study suggests that African-American youths with diabetes may be at greater risk for poor glycemic control due to the higher prevalence of single parenting and lower levels of adherence found in this population.

PMID: 9314637, UI: 97460212

Diabetes Care 1997 Oct;20(10):1518-23

The PATHWAYS church-based weight loss program for urban African-American women at risk for diabetes.

McNabb W, Quinn M, Kerver J, Cook S, Karrison T

Chicago Diabetes Research and Training Center, University of Chicago, IL 60637, USA.

OBJECTIVE: This study was carried out to test the effectiveness of PATHWAYS, a weight loss program designed specifically for urban African-American women, when administered in urban churches by trained lay facilitators. RESEARCH DESIGN AND METHODS: Thirty-nine obese women were recruited from three urban African-American churches. After randomization and the collection of baseline data on weight and lifestyle practices, subjects in the experimental group (n = 19) were assigned to receive a 14-week weight loss program (PATHWAYS) conducted by trained lay volunteers; control group subjects (n = 20) were put on a waiting list to receive the program at the conclusion of the study period. RESULTS: Of the 39 women enrolled, 15 experimental group subjects and 18 control group subjects were available for posttreatment data collection. After completing the program, PATHWAYS participants lost an average of 10.0 lb, and the control group subjects gained an average of 1.9 lb. Posttreatment difference in weight loss between the groups was statistically significant (P < 0.0001). Waist circumference among PATHWAYS participants decreased 2.5 inches, while waist circumference among control group subjects remained relatively the same. This difference between the groups was statistically significant (P < 0.05). CONCLUSIONS: A weight loss program administered by trained lay volunteers was effective in producing significant and clinically meaningful weight loss among African-American women who often do not benefit from typical weight loss programs. Ongoing research is focusing on whether the weight loss can be maintained or enhanced through monthly reinforcement sessions.

Publication Types:

• Clinical trial
• Controlled clinical trial

PMID: 9314627, UI: 97460202

Diabetes Care 1997 Oct;20(10):1503-11

A randomized controlled trial of weight reduction and exercise for diabetes management in older African-American subjects.

Agurs-Collins TD, Kumanyika SK, Ten Have TR, Adams-Campbell LL

Division of Epidemiology and Cancer Control, Howard University Cancer Center, Washington, DC 20006, USA. tagurs-collins@fac.howard.edu

OBJECTIVE: To evaluate a weight loss and exercise program designed to improve diabetes management in older African-Americans. RESEARCH DESIGN AND METHODS: Overweight African-Americans (n = 64) ages 55-79 years with NIDDM were randomized to either an intervention (12 weekly group sessions, 1 individual session, and 6 biweekly group sessions) or usual care (1 individual session, and 6 biweekly group sessions) or usual care (1 class and 2 informational mailings). Clinical and behavioral variables were assessed at 0, 3, and 6 months of treatment. RESULTS: Significant net differences in the intervention versus usual care were observed for weight (-2.0 kg, P = 0.006), physical activity, and dietary intake of fat, saturated fat, cholesterol, and nutrition knowledge at 3 months (all P < 0.05) and for weight at 6 months (-2.4 kg; P = 0.006) and mean HbA1c values at 3 and 6 months (respectively, -1.6 and -2.4%, both P < 0.01). After the adjustment for changes in weight and activity, the intervention participants were approximately twice as likely to have a one unit decrease in HbA1c value as those in usual care. Blood pressure increase sin usual care participants resulted in net differences (intervention minus control) at 3 and 6 months of -3.3 (P = 0.09) and -4.0 (P = 0.05) mmHg diastolic, respectively, and -8.4 (P = 0.06) and -5.9 (P > 0.10) mmHg systolic, respectively. Blood lipid profiles improved more in intervention than usual care participants, but not significantly. CONCLUSIONS: The intervention program was effective in improving glycemic and blood pressure control. The decrease in HbA1c values was generally independent of the relatively modest changes in dietary intake, weight, and activity and may reflect indirect program effects on other aspects of self-care.

Publication Types:

• Clinical trial
• Randomized controlled trial

Comments:

• Comment in: Diabetes Care 1998 May;21(5):875-7

PMID: 9314625, UI: 97460200

Diabetes 1997 Oct;46(10):1652-7

Organization and partial sequence of the hepatocyte nuclear factor-4 alpha/MODY1 gene and identification of a missense mutation, R127W, in a Japanese family with MODY.

Furuta H, Iwasaki N, Oda N, Hinokio Y, Horikawa Y, Yamagata K, Yano N, Sugahiro J, Ogata M, Ohgawara H, Omori Y, Iwamoto Y, Bell GI

Department of Biochemistry and Molecular Biology, University of Chicago, IL 60637, USA.

Hepatocyte nuclear factor-4 alpha (HNF-4 alpha) is a member of the nuclear receptor superfamily, a class of ligand-activated transcription factors. A nonsense mutation in the gene encoding this transcription factor was recently found in a white family with one form of maturity-onset diabetes of the young, MODY1. Here, we report the exon-intron organization and partial sequence of the human HNF-4 alpha gene. In addition, we have screened the 12 exons, flanking introns and minimal promoter region for mutations in a group of 57 unrelated Japanese subjects with early-onset NIDDM/MODY of unknown cause. Eight nucleotide substitutions were noted, of which one resulted in the mutation of a conserved arginine residue, Arg127 (CGG)-->Trp (TGG) (designated R127W), located in the T-box, a region of the protein that may play a role in HNF-4 alpha dimerization and DNA binding. This mutation was not found in 214 unrelated nondiabetic subjects (53 Japanese, 53 Chinese, 51 white, and 57 African-American). The R127W mutation was only present in three of five diabetic members in this family, indicating that it is not the only cause of diabetes in this family. The remaining seven nucleotide substitutions were located in the proximal promoter region and introns. They are not predicted to affect the transcription of the gene or mRNA processing and represent polymorphisms and rare variants. The results suggest that mutations in the HNF-4 alpha gene may cause early-onset NIDDM/MODY in Japanese but they are less common than mutations in the HNF-1 alpha/MODY3 gene. The information on the sequence of the HNF-4 alpha gene and its promoter region will facilitate the search for mutations in other populations and studies of the role of this gene in determining normal pancreatic beta-cell function.

PMID: 9313765, UI: 97458990

Diabetes Educ 1997 Jul-Aug;23(4):419-24

Frequency and impact of SMBG on glycemic control in patients with NIDDM in an urban teaching hospital clinic.

Oki JC, Flora DL, Isley WL

Department of Medicine, University of Missouri-Kansas City, School of Medicine 64108, USA. joki@pop.umkc.edu

Few published reports have documented the value of SMBG on glycemic control in patients with non-insulin-dependent diabetes mellitus (NIDDM), and no reports have evaluated predominantly African American patients who are at high risk for NIDDM and associated complications. In this study a 13-item survey was given to 98 patients with NIDDM to assess the frequency of self-monitoring of blood glucose (SMBG) and its impact on glycemic control. Sixty-one patients performed SMBG and 37 did not. More SMBG testers were taking insulin compared with the nontesters. GHb was comparable between groups. Among the testers there was no difference in mean GHb values based on the frequency of SMBG. Most testers performed SMBG before meals (93%) and recorded their values (85%); many had difficulty obtaining a good blood sample (30%). The most common reason for not testing was cost of supplies (77%). Performance of SMBG in these NIDDM patients was not associated with better glycemic control. Cost was a prohibitive factor for the nontesters.

PMID: 9305007, UI: 97450017

Stroke 1997 Sep;28(9):1693-701

Does the association of risk factors and atherosclerosis change with age? An analysis of the combined ARIC and CHS cohorts. The Atherosclerosis Risk in Communities (ARIC) and Cardiovascular Health Study (CHS) investigators.

Howard G, Manolio TA, Burke GL, Wolfson SK, O'Leary DH

Department of Public Health Sciences, Bowman Gray School of Medicine of Wake Forest University, Winston Salem, NC 27157-1063, USA. GHOWARD@PHS.BGSM.EDU

INTRODUCTION: A decrease in the estimated relative risk of cerebrovascular and cardiovascular diseases associated with known disease risk factors has been observed among elderly cohorts, perhaps suggesting that continued risk factor management in the elderly may not be as efficacious as with younger age groups. In this paper, the differential magnitude of the association of risk factors with atherosclerosis across the age spectrum from 45 years to older than 75 years is presented. METHODS: Subclinical atherosclerosis as measured by carotid ultrasonography and risk factor prevalence were assessed using similar methods among participants aged 45 to 64 years in the Atherosclerosis Risk in Communities (ARIC) study and among participants 65 years and older in the Cardiovascular Health Study (CHS). Pooling these two cohorts provided data on the relationship of risk factors and atherosclerosis on nearly 19,000 participants over a broad age range. Regression analyses were used to assess the consistency of the magnitude of the association of risk factors with atherosclerosis across the age spectrum separately for black and white participants in cross-sectional analyses. RESULTS: As expected, each of the risk factors was globally (across all ages) associated with increased atherosclerosis. However, the magnitude of the association did not differ across the age spectrum for hypertension, low density lipoprotein cholesterol (LDL-c), fibrinogen, or body mass index (BMI). For whites, there was a significantly greater impact of smoking and HDL-C among older age strata but a smaller impact of diabetes. For black women, the impact of HDL-C decreased among the older age strata. CONCLUSIONS: These data suggest that most risk factors continue to be associated with increased atherosclerosis at older ages, possibly suggesting a continued value in investigation of strategies to reduce atherosclerosis by controlling risk factors at older ages.

PMID: 9303011, UI: 97448686

Am J Obstet Gynecol 1997 Aug;177(2):425-8

Women with sickle cell trait are at increased risk for preeclampsia.

Larrabee KD, Monga M

University of Texas Health Science Center, Houston 77030, USA.

OBJECTIVE: Our purpose was to determine the rate of preeclampsia in women who are positive for sickle cell trait. STUDY DESIGN: All African-American women were tested for sickle cell trait with the "sickledex" screen at the fist prenatal visit and prospectively enrolled in this study from March 1994 to June 1995. "Sickledex" screens were confirmed with hemoglobin electrophoresis. Demographic data were collected at the time of enrollment. Outcome data, including preeclampsia (as defined by The American College of Obstetricians and Gynecologists criteria), gestational age at delivery, birth weight, and postpartum endometritis were collected immediately post partum. Assuming a 10% rate of positive sickle cell trait, 1100 patients were required to demonstrate a doubling in the rate of preeclampsia with 80% power and p < 0.05. The Student t test, the Mann-Whitney U test, chi 2 analysis, and Fisher's exact tests were used for statistical analysis. RESULTS: Of 1584 women enrolled in the study, 162 were positive for sickle cell trait. Sickle cell trait-positive women were older than the sickle cell trait-negative women (24.4 +/- 4.6 vs 23.0 +/- 4.4 years, p < 0.001), but there was no significant difference in parity. The rate of preeclampsia was significantly increased in sickle cell-positive women (24.7% vs 10.3%, p < 0.0001). There was no significant difference in the rate of chronic hypertension, diabetes, or smoking. Parous sickle cell-positive women more frequently gave a history of preeclampsia in a previous pregnancy (21.4% vs 9.3%, p < 0.0001). There was a statistically significant decrease in gestational age at delivery and birth weight in sickle cell trait-positive women (36.7 +/- 2.7 vs 37.7 +/- 3.0 weeks, p < 0.0001; and 3082 +/- 591 vs 3369 +/- 573 gm, p < 0.0001). The rate of postpartum endometritis was significantly increased in the women positive for sickle cell trait (12.3% vs 5.1%, p < 0.001), although both groups had a similar cesarean section rate (14.8% vs 12.6%, not significant). CONCLUSION: This is the first prospective study to demonstrate that sickle cell trait-positive women are at significantly higher risk for development of perinatal complications that have traditionally been associated with sickle disease.

PMID: 9290462, UI: 97435795