Racial-ethnic disparities in the association between risk factors and diabetes: The Northern Manhattan Study

Development and acceptability of a culturally competent skills and knowledge assessment tool for patients with diabetes mellitus

Background

Patients newly diagnosed with type 2 diabetes mellitus (DM) and newly prescribed insulin need to learn essential self-care and management skills quickly. To optimize teaching, clinicians need to assess a patient's basic understanding of DM and their skills. While DM patient assessments exist, this study reports the development of an assessment of patient DM management skills and knowledge, using feedback from DM clinicians, patients, and caregivers.

Research Design and Methods

A systematic search of Pubmed/Medline and Scopus (1980-2017) of DM knowledge assessments was performed. Twenty-four studies were identified. Content from the existing assessments was adapted to create a 12 item DM-Skills Knowledge Assessment (SKA) to assess a patient's DM management skills and knowledge. To assess cultural humility, modified cognitive interviews were conducted in individual user sessions and semi-structured focus groups. Audio-transcripts of the interviews/focus groups were independently coded, and codes were grouped into key themes. Participant demographic characteristics were assessed.

Results

Five focus groups and eleven key informant interviews were conducted, including 10 DM clinicians, 12 patients/caregivers, and 15 laypersons. All 10 clinicians reported that the DM-SKA addresses the key domains of DM education deemed to be of highest importance during the transition from hospital to home and that their patients would be willing to complete the assessment. More than half of the patient/caregiver/layperson participants self-reported race/ethnicity other than non-Hispanic white and performed similarly to non-Hispanic white participants in understanding each item, willingness to complete the DM-SKA, and perception that family or community members would be willing to complete the DM-SKA. The DM-SKA has a baseline Flesch reading score of 81.3, indicating low complexity language.

Conclusion

DM clinicians agreed that the DM-SKA assesses all essential DM management skills. For patients/caregivers, it has acceptable literacy, cognitive validity, and culturally acceptable for racial/ethnic minority populations in the study, including elderly persons.

Prediabetes awareness is not associated with lower consumption of self-reported added sugar in U.S. adults

AIMS

Adults aware of having prediabetes report engaging in dietary risk-reduction behavior changes. However, no studies have assessed if prediabetes awareness influences self-reported consumption of added sugar.

METHODS

Cross-sectional data from 3314 adults, 20 years and older, with prediabetes were analyzed from 2013-2018 National Health and Nutrition Examination Survey data. Survey-weighted ordinary least squares regression was used to test whether prediabetes awareness was associated with usual intake of added sugar (g/day) using the National Cancer Institute Method by age, sex, and race/Hispanic origin after controlling for sociodemographic covariates.

RESULTS

Among 3314 adults with prediabetes, 528 reported being aware and 2786 reported being unaware of their condition. Prediabetes awareness was not significantly associated with added sugar consumption (estimated difference 1.7 g; 95% CI: - .80, 4.20; P = .18). There were no significant differences in added sugar consumption among those aware of their condition for age, sex, or race/Hispanic origin (Type 3 test for age: P = .15, male: P = .86, race, and Hispanic origin: P = .89).

CONCLUSION

Adults with prediabetes, aware of their condition, do not consume significantly lower quantities of added sugar compared to unaware adults, including no differences observed by age, sex, and race/Hispanic origin.

Safe Sleep Behaviors and Factors Associated With Infant Second Sleep Practices

OBJECTIVES

To examine the prevalence and safety of infant second-sleep practices.

METHODS

A cross-sectional online survey of parents with infants ≤12 months assessed parent-reported sleep practices: position, use of a separate sleep surface, and sleep location at 2 time points (sleep onset and after nighttime waking). A composite score examined if all 3 safe sleep practices were used at each time point. Safe sleep was defined as: supine position, sleeping in a separate space, and in a crib, bassinet, cradle, or playard. Wilcoxon sign rank test was used to examine changes between the time points. Poisson regression models compared parents who reported a second-sleep location with those who did not.

RESULTS

Of participants (n = 1500), 74% were female, 65% were White, 12% were Black, and 17% were of Hispanic ethnicity. Thirty-nine percent (n = 581) reported a second-sleep practice. Of parents who reported a second-sleep practice, 28% (n = 137) met all 3 safe sleep criteria at sleep onset; 9% (n = 42) met all 3 safe sleep criteria at both time points. A higher proportion of changes in sleep practices were to less-safe practices (P <.001). Factors associated with a second-sleep practice were parental age <25 years, parental race and ethnicity, first-time parents, homes with smoke exposure, and infants born at <37 weeks.

CONCLUSIONS

Less than 10% of infants met all 3 safe sleep criteria at sleep onset and after nighttime waking. Interventions focused on safe sleep should highlight the importance of safe sleep practices after nighttime waking.

C-reactive Protein and Racial Differences in Type 2 Diabetes Incidence: The REGARDS Study

CONTEXT

Black adults experience more type 2 diabetes mellitus and higher inflammatory markers, including C-reactive protein (CRP), than White adults. Inflammatory markers are associated with risk of incident diabetes but the impact of inflammation on racial differences in incident diabetes is unknown.

OBJECTIVE

We assessed whether CRP mediated the Black-White incident diabetes disparity.

METHODS

The REasons for Geographic And Racial Differences in Stroke (REGARDS) study enrolled 30 239 US Black and White adults aged ≥45 years in 2003-2007 with a second visit approximately 10 years later. Among participants without baseline diabetes, adjusted sex- and race-stratified risk ratios for incident diabetes at the second visit by CRP level were calculated using modified Poisson regression. Inverse odds weighting estimated the percent mediation of the racial disparity by CRP.

RESULTS

Of 11 073 participants without baseline diabetes (33% Black, 67% White), 1389 (12.5%) developed diabetes. Black participants had higher CRP at baseline and greater incident diabetes than White participants. Relative to CRP < 3 mg/L, CRP ≥ 3 mg/L was associated with greater risk of diabetes in all race-sex strata. Black participants had higher risk of diabetes at CRP < 3 mg/L, but not at CRP ≥ 3 mg/L. In women, CRP mediated 10.0% of the racial difference in incident diabetes. This mediation was not seen in men.

CONCLUSION

Higher CRP is a risk factor for incident diabetes, but the excess burden of diabetes in Black adults was only seen in those with lower CRP, suggesting that inflammation is unlikely to be the main driver of this racial disparity.

Higher fasting triglyceride predicts higher risks of diabetes mortality in US adults

BACKGROUND

It is unknown whether higher triglyceride results in higher mortality from diabetes, i.e., diabetes mortality. This study aimed to investigate the association of fasting triglyceride with diabetes mortality.

METHODS

This study included 26,582 US adults from the National Health and Nutrition Examination Surveys from 1988 to 2014. Diabetes mortality outcomes were ascertained by linkage to the National Death Index records. Cox proportional hazards models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) of triglyceride for diabetes mortality.

RESULTS

Higher levels of fasting triglyceride were associated with higher levels of glucose, glycated hemoglobin, insulin, and homeostatic model assessment for insulin resistance at baseline. A 1-natural-log-unit increase in triglyceride (e.g., from 70 to 190 mg/dL) was associated with a 115% higher multivariate-adjusted risk of diabetes diagnosis (odds ratio, 2.15; 95% CI, 2.00-2.33). During 319,758 person-years of follow-up with a mean follow-up of 12.0 years, 582 diabetes deaths were documented. Compared with people with triglyceride in the lowest quintile, people with triglyceride in the highest quintile had an 85% higher risk of diabetes mortality (HR, 1.85; 95% CI, 1.25-2.73). A 1-natural-log-unit increase in triglyceride was associated with a 40% higher multivariate-adjusted risk of diabetes mortality. The positive association between triglyceride and diabetes mortality was also presented in sub-cohorts of participants with or without diabetes.

CONCLUSIONS

This study demonstrated that higher fasting triglyceride was associated with a higher diabetes mortality risk.

Differences in Body Composition Convey a Similar Risk of Type 2 Diabetes Among Different Ethnic Groups With Disparate Cardiometabolic Risk-The HELIUS Study

OBJECTIVE

Studies have shown a disparate association between body composition and the risk of type 2 diabetes. We assessed whether associations between differences in body composition and type 2 diabetes vary among ethnic groups with disparate cardiometabolic risk.

RESEARCH DESIGN AND METHODS

We used data from the Healthy Life in an Urban Setting (HELIUS) study, including individuals aged 18-70 years of African Surinamese (n = 3,997), South Asian Surinamese (n = 2,956), Turkish (n = 3,546), Moroccan (n = 3,850), Ghanaian (n = 2,271), and Dutch (n = 4,452) origin living in Amsterdam. Type 2 diabetes was defined using the World Health Organization criteria. Logistic regression was used to assess the relation between body composition and type 2 diabetes. Waist-to-hip ratio (WHR), waist circumference, BMI, and body fat percentage by bioelectrical impedance were used to estimate body composition.

RESULTS

Per unit change in BMI, only Ghanaian (odds ratio [OR] 0.94 [95% CI 0.89-0.99]) and Moroccan (0.94 [0.89-0.99]) women had a smaller increase in type 2 diabetes compared with the Dutch population, whereas the ORs for body fat percentage were 0.94 (0.89-1.00) for Ghanaian, 0.93 (0.88-0.99) for Moroccan, and 0.95 (0.90-1.00) for South Asian Surinamese women. There was no interaction between WHR and ethnicity on the risk of type 2 diabetes, and there were no differences in men. WHR had the highest precision in predicting type 2 diabetes in both men (C statistic = 0.78) and women (C statistic = 0.81).

CONCLUSIONS

The association between differences in body composition and type 2 diabetes is roughly the same in all ethnic groups. WHR seems the most reliable and consistent predictor of type 2 diabetes regardless of ethnic background.

Association between somatostatin analogues and diabetes mellitus in gastroenteropancreatic neuroendocrine tumor patients: A Surveillance, Epidemiology, and End Results-Medicare analysis of 5235 patients

BACKGROUND

Gastroenteropancreatic neuroendocrine tumors (GEP-NETs) are increasingly common malignancies and tend to have favorable long-term prognoses. Somatostatin analogues (SSA) are a first-line treatment for many NETs. Short-term experiments suggest an association between SSAs and hyperglycemia. However, it is unknown whether there is a relationship between SSAs and clinically significant hyperglycemia causing development of diabetes mellitus (DM), a chronic condition with significant morbidity and mortality.

AIM

In this study, we aimed to compare risk of developing DM in patients treated with SSA vs no SSA treatment.

METHODS AND RESULTS

Using the Surveillance, Epidemiology, and End Results (SEER) database and linked Medicare claims (1991-2016), we identified patients age 65+ with no prior DM diagnosis and a GEP-NET in the stomach, small intestine, appendix, colon, rectum, or pancreas. We used χ² tests to compare SSA-treated and SSA-untreated patients and multivariable Cox regression to assess risk factors for developing DM. Among 8464 GEP-NET patients, 5235 patients had no prior DM and were included for analysis. Of these, 784 (15%) patients received SSAs. In multivariable analysis, the hazard ratio of developing DM with SSA treatment was 1.19, which was not statistically significant (95% CI 0.95-1.49). Significant risk factors for DM included black race, Hispanic ethnicity, prior pancreatic surgery, prior chemotherapy, tumor size >2 cm, pancreas tumors, and higher Charlson scores.

CONCLUSION

DM was very common in GEP-NET patients, affecting 53% of our cohort. Despite prior studies suggesting an association between SSAs and hyperglycemia, our analysis found similar risk of DM in SSA-treated and SSA-untreated GEP-NET patients. Further studies are needed to better understand this relationship. As NET patients have increasingly prolonged survival, it is crucial to identify chronic conditions such as DM that these patients may be at elevated risk for.

Sex Differences in Factors Contributing to the Racial Disparity in Diabetes Risk

INTRODUCTION

Diabetes incidence differs by race in the U.S., with a persistent reported Black-White disparity. However, the factors that contribute to this excess risk in middle-aged and older adults are unclear.

METHODS

This prospective cohort study included 7,171 Black and White adults aged ≥45 years without diabetes at baseline (2003‒2007) who completed a follow-up examination (2013‒2016). Modified Poisson regression was used to obtain sex-stratified RRs for diabetes. Mediation analyses using a change in β coefficient assessed individual and neighborhood factors that contribute to the racial disparity in diabetes incidence. Statistical analyses were conducted in 2018-2019.

RESULTS

The cumulative incidence of diabetes was higher for Black men (16.2%) and women (17.7%) than for White men (11.0%) and women (8.1%). Adjusting for age and prediabetes, diabetes risk was higher for Black women than for White women (RR=1.75, 95% CI=1.47, 2.07) and for Black men than for White men (RR=1.33, 95% CI=1.09, 1.64). The individual factors that attenuated the racial disparity the most were Southern dietary pattern (change in β=42.8%) and neighborhood socioeconomic environment (change in β=26.3%) among men and BMI (change in β=34.4%) and waist circumference (change in β=32.4%) among women. When including all factors collectively, the racial disparity in diabetes incidence was similar for men (RR=1.38, 95% CI=1.04, 1.83) and was attenuated for women (RR=1.41, 95% CI=1.11, 1.81).

CONCLUSIONS

The racial disparity in diabetes incidence remained after accounting for individual and neighborhood factors. Further investigation of additional factors underlying this racial disparity is needed to inform multilevel strategies for diabetes prevention.

Risk Factors and Wellness Measures Associated with Prediabetes and Newly Diagnosed Type 2 Diabetes Mellitus in Hispanic Adults

Background: To characterize the associations of clinical risk factors, lifestyle factors, and wellness measures with prediabetes and new type 2 diabetes mellitus (T2DM) diagnosis in Hispanic adults and guide primary prevention. Methods: Sangre Por Salud Biobank enrolled 3733 Hispanic adults from Phoenix, AZ, United States, from 2013 to 2018. This analysis included participants with euglycemia, prediabetes, or new T2DM diagnosis (i.e., no prior T2DM diagnosis) at enrollment. Participants completed a baseline questionnaire on cardiometabolic risk factors and wellness measures and provided biometric measurements. The associations of factors and measures with odds (95% confidence interval) of prediabetes and new T2DM diagnosis were analyzed in logistic regression models. Results: Among 3299 participants with euglycemia (n = 1301), prediabetes (n = 1718), and new T2DM diagnosis (n = 280) at enrollment, 72% were women (n = 2376/3299). In adjusted models, most cardiometabolic risk factors were positively associated with prediabetes and new T2DM diagnosis, with stronger associations for new T2DM diagnosis. Obesity (body mass index ≥30 kg/m² vs. lower) was associated with higher odds of new T2DM diagnosis (3.14 [2.30-4.28]; P < 0.01) than prediabetes versus euglycemia (1.96 [1.66-2.32]; P < 0.01) and Interaction (P = 0.01). Similarly, waist circumference, family history of diabetes, and average systolic and diastolic blood pressure were associated with higher odds of new T2DM diagnosis versus euglycemia than prediabetes versus euglycemia. Using stepwise logistic regression modeling, a parsimonious model of age, family history of diabetes, waist circumference, diastolic blood pressure, passive tobacco exposure, and self-rated general health were associated with new T2DM diagnosis versus euglycemia. Conclusions: In Hispanic adults, modifiable cardiometabolic and lifestyle factors were associated with prediabetes and new T2DM diagnosis. Personalized interventions targeting these factors and measures could guide T2DM primary prevention efforts among Hispanic adults.

30-minute postload plasma glucose levels during an oral glucose tolerance test predict the risk of future type 2 diabetes: the Hisayama Study

INTRODUCTION

To investigate the associations of 30 min postload plasma glucose (30 mPG) levels during an oral glucose tolerance test (OGTT) with the risk of future diabetes in a general Japanese population.

RESEARCH DESIGN AND METHODS

A total of 2957 Japanese community-dwelling residents without diabetes, aged 40-79 years, participated in the examinations in 2007 and 2008 (participation rate, 77.1%). Among them, 2162 subjects who received 75 g OGTT in a fasting state with measurements of plasma glucose level at 0, 30, and 120 min were followed up for 7 years (2007-2014). Cox's proportional hazards model was used to estimate HRs and their 95% CIs of each index for the development of type 2 diabetes using continuous variables and quartiles with adjustment for traditional risk factors. The influence of 30 mPG on the predictive ability was estimated with Harrell's C-statistics, integrated discrimination improvement (IDI), and the continuous net reclassification index (cNRI).

RESULTS

During follow-up, 275 subjects experienced type 2 diabetes. Elevated 30 mPG levels were significantly associated with increased risk of developing diabetes (p<0.01 for trend): the multivariable-adjusted HR was 8.41 (95% CI 4.97 to 14.24) for the highest versus the lowest quartile, and 2.26 (2.04 to 2.52) per 1 SD increase. This association was attenuated but remained significant after further adjustment for fasting and 2-hour postload plasma glucose levels. Incorporation of 30 mPG into the model including traditional risk factors with fasting and 2-hour postload plasma glucose levels for diabetes improved the predictive ability of type 2 diabetes (improvement in Harrell's C-statistics values: from 0.828 to 0.839, p<0.01; IDI: 0.016, p<0.01; cNRI: 0.103, p=0.37).

CONCLUSIONS

Elevated 30 mPG levels were associated with increased risk of diabetes, and inclusion of 30 mPG levels significantly improved the predictive ability for future diabetes, suggesting that 30 mPG may be useful for identifying high-risk populations for type 2 diabetes.

Systematic review with meta-analysis of the epidemiological evidence relating smoking to type 2 diabetes

BACKGROUND

Evidence relating tobacco smoking to type 2 diabetes has accumulated rapidly in the last few years, rendering earlier reviews considerably incomplete.

AIM

To review and meta-analyse evidence from prospective studies of the relationship between smoking and the onset of type 2 diabetes.

METHODS

Prospective studies were selected if the population was free of type 2 diabetes at baseline and evidence was available relating smoking to onset of the disease. Papers were identified from previous reviews, searches on Medline and Embase and reference lists. Data were extracted on a range of study characteristics and relative risks (RRs) were extracted comparing current, ever or former smokers with never smokers, and current smokers with non-current smokers, as well as by amount currently smoked and duration of quitting. Fixed- and random-effects estimates summarized RRs for each index of smoking overall and by various subdivisions of the data: Sex; continent; publication year; method of diagnosis; nature of the baseline population (inclusion/exclusion of pre-diabetes); number of adjustment factors; cohort size; number of type 2 diabetes cases; age; length of follow-up; definition of smoking; and whether or not various factors were adjusted for. Tests of heterogeneity and publication bias were also conducted.

RESULTS

The literature searches identified 157 relevant publications providing results from 145 studies. Fifty-three studies were conducted in Asia and 53 in Europe, with 32 in North America, and seven elsewhere. Twenty-four were in males, 10 in females and the rest in both sexes. Fifteen diagnosed type 2 diabetes from self-report by the individuals, 79 on medical records, and 51 on both. Studies varied widely in size of the cohort, number of cases, length of follow-up, and age. Overall, random-effects estimates of the RR were 1.33 [95% confidence interval (CI): 1.28-1.38] for current vs never smoking, 1.28 (95%CI: 1.24-1.32) for current vs non-smoking, 1.13 (95%CI: 1.11-1.16) for former vs never smoking, and 1.25 (95%CI: 1.21-1.28) for ever vs never smoking based on, respectively, 99, 156, 100 and 100 individual risk estimates. Risk estimates were generally elevated in each subdivision of the data by the various factors considered (exceptions being where numbers of estimates in the subsets were very low), though there was significant (P < 0.05) evidence of variation by level for some factors. Dose-response analysis showed a clear trend of increasing risk with increasing amount smoked by current smokers and of decreasing risk with increasing time quit. There was limited evidence of publication bias.

CONCLUSION

The analyses confirmed earlier reports of a modest dose-related association of current smoking and a weaker dose-related association of former smoking with type 2 diabetes risk.

BRInging the Diabetes prevention program to GEriatric populations (BRIDGE): a feasibility study

Background

The purpose of this 6-week intervention was to test the feasibility and acceptability of implementing a telehealth-adapted Diabetes Prevention Program (DPP) at a senior center.

Methods

Older adults (n = 16) attended weekly interactive webinars. At each measurement time point, participants completed questionnaires covering lifestyle, physical activity, quality of life, and food records and wore physical activity trackers. Qualitative data were gathered from 2 focus groups inviting all 16 participants with 13 and 10 participants attending, respectively.

Results

Over 2000 senior center members were contacted, approximately 2% (n = 39) responded to the recruitment email, and 16 were recruited into the study. Retention was 75%, and attendance rates averaged 80% across the six intervention sessions. The focus group participants provided positive opinions for most program components, especially the webinar group interaction and using physical activity trackers. Suggestions for improvement included a greater focus on specific needs of older adults (i.e., adapting activities) and placing a greater emphasis on dietary strategies to prevent diabetes. Mean weight loss was 2.9% (2.7 kg [95% CI 1.6, 3.7]; p value = 0.001).

Conclusion

The feasibility of providing DPP via webinar appears to be high based on the retention and attendance rates. Similar to other behavioral interventions engaging older adults, recruitment rates were low. Acceptability was evidenced by high attendance at the intervention sessions and feedback from participants during focus group sessions. The intervention efficacy should be evaluated based on CDC criteria for program recognition in a larger scale randomized trial.

Trial registration

NCT03524404. Registered 14 May 2018—retrospectively registered. Trial protocol will be provided by the corresponding author upon request.

Hispanic Secondary Stroke Prevention Initiative Design: Study Protocol and Rationale for a Randomized Controlled Trial

Background

Hispanic-Latino populations face a disproportionate stroke burden and are less likely to have sufficient control over stroke risk factors in comparison with other ethnic populations. A promising approach to improving chronic health outcomes has been the use of community health workers (CHWs).

Objective

The objective of this randomized controlled trial is to evaluate the effectiveness of a CHW intervention among Latino patients at risk of recurrent stroke.

Methods

The Hispanic Secondary Stroke Prevention Initiative (HiSSPI) is a randomized clinical trial of 300 Latino participants from South Florida who have experienced a stroke within the last 5 years. Participants randomized into the CHW intervention arm receive health education and assistance with health care navigation and social services through home visits and phone calls. The intervention also includes a mHealth component in which participants also receive daily text messages (short message service). The primary outcome is change in systolic blood pressure at 12 months. Other secondary outcomes include changes in low-density lipoprotein, glycated hemoglobin, and medication adherence.

Results

Study enrollment began in 2015 and will be completed by the end of 2018. The first results are expected to be submitted for publication in 2020.

Conclusions

HiSSPI is one of the first randomized controlled trials to examine CHW-facilitated stroke prevention and will provide rigorous evidence on the impact of CHWs on secondary stroke risk factors among Latino individuals who have had a stroke.

Trial Registration

ClinicalTrials.gov NCT02251834; https://clinicaltrials.gov/ct2/show/NCT02251834 (Archived by WebCite at http://www.webcitation.org/72DgMqftq)

International Registered Report Identifier (IRRID)

RR1-10.2196/11083

Regional Subclinical Cerebrovascular Disease Is Associated with Balance in an Elderly Multi-Ethnic Population

INTRODUCTION

White matter hyperintensity volume (WMHV) and subclinical brain infarcts (SBI) are associated with impaired mobility, but less is known about the association of WMHV in specific brain regions. We hypothesized that anterior WMHV would be associated with lower scores on the Short Physical Performance Battery (SPPB), a well-validated mobility scale.

METHODS

The SPPB was measured a median of 5 years after enrollment into the Northern Manhattan MRI sub study. Volumetric distributions for WMHV in 14 brain regions as a proportion of total cranial volume were determined. Multi-variable linear regression was performed to examine the association of SBI and regional log-WMHV with the SPPB score.

RESULTS

Among 668 participants with SPPB measurements (mean 74 ± 9 years, 37% male and 70% Hispanic), the mean SPPB score was 8.2 ± 2.9. Total (beta = -0.3 per SD, p = 0.001), anterior periventricular (beta = -0.4 per SD, p = 0.001), parietal (beta = -0.2 per SD, p = 0.02) and frontal (beta = -0.3 per SD, p = 0.002) WMHVs were associated with SPPB; other WMHV and SBI were not associated with the SPPB.

CONCLUSIONS

WMHV, especially in the anterior -cerebral regions, is associated with a lower SPPB. Prevention of subclinical cerebrovascular disease is a potential target to prevent physical decline in the elderly.

Diet Soda and Sugar-Sweetened Soda Consumption in Relation to Incident Diabetes in the Northern Manhattan Study

BACKGROUND

Artificially (diet) and sugar-sweetened (regular) soda consumption have been associated with an increased risk of diabetes, but the literature on diet soda is inconsistent and the mechanisms unclear.

OBJECTIVE

We examined the relation between diet soda and regular soda consumption with the risk of incident diabetes in a longitudinal multiethnic population-based cohort.

METHODS

The study population included 2019 participants (mean ± SD age:  69 ± 10 y; 64% women; 23% white, 22% black, 53% Hispanic) in the Northern Manhattan Study who were free of diabetes and stroke at baseline. Soda consumption was assessed by a food-frequency questionnaire at baseline and examined continuously and categorically (<1/mo: sugar-sweetened = 908, diet = 1615; 1/mo-6/wk: sugar-sweetened = 830, diet = 298; daily: sugar-sweetened = 281, diet = 106). Weibull regression models were used to estimate the associations between soda consumption and incident diabetes, adjusting for demographics and vascular risk factors including body mass index (BMI) and calorie consumption.

RESULTS

During a mean ± SD follow-up of 11 ± 5 y, 368 participants developed diabetes. Sugar-sweetened soda was positively associated with incident diabetes (per soda per day HR = 1.15, 95% CI:  1.02, 1.31). The observed association between diet soda and elevated risk of diabetes was largely explained by BMI at the time of diet assessment, though the association remained strong and independent of BMI among those who were overweight or obese (daily compared to <1/mo: HR = 1.63, 95% CI:  1.04, 2.55).

CONCLUSIONS

This study supports the importance of sugar-sweetened beverage consumption in the diabetes epidemic. However, the results support previous studies suggesting that switching to artificially sweetened diet beverages may not lower the risk of diabetes, as diet soda consumption cannot be ruled out as an independent diabetes risk factor.

Residential Proximity to Major Roadways and Risk of Incident Ischemic Stroke in NOMAS (The Northern Manhattan Study)

BACKGROUND AND PURPOSE

The evidence supporting the deleterious cardiovascular health effects of living near a major roadway is growing, although this association is not universal. In primary analyses, we hypothesized that residential proximity to a major roadway would be associated with incident ischemic stroke and that cardiovascular risk factors would modify that association.

METHODS

NOMAS (The Northern Manhattan Study) is an ongoing, population-based cohort study designed to measure cardiovascular risk factors, stroke incidence, and other outcomes in a multiethnic urban population. Recruitment occurred from 1993 to 2001 and participants are followed-up annually by telephone. Residential addresses at baseline were geocoded and Euclidean distance to nearest major roadway was estimated and categorized as in prior studies. We used Cox proportional hazard models to calculate hazard ratios and 95% confidence intervals for the association of this distance to incidence of stroke and other outcomes, adjusting for sociodemographic and cardiovascular risk factors, year at baseline, and neighborhood socioeconomic status. We assessed whether these associations varied by age, sex, smoking status, diabetes mellitus, and hypertension.

RESULTS

During a median follow-up period of 15 years (n=3287), 11% of participants were diagnosed with ischemic stroke. Participants living <100 m from a roadway had a 42% (95% confidence interval, 1.01-2.02) higher rate of ischemic stroke versus those living >400 m away. This association was more pronounced among noncurrent smokers (hazard ratio, 1.54; 95% confidence interval, 1.05-2.26) and not evident among smokers (hazard ratio, 0.69; 95% confidence interval, 0.23-2.06). There was no clear pattern of association between proximity to major roadways and other cardiovascular events including myocardial infarction, all-cause death, or vascular death.

CONCLUSIONS

In this urban multiethnic cohort, we found evidence supporting that within-city variation in residential proximity to major roadway is associated with higher risk of ischemic stroke. An individual's smoking history modified this association, with the association remaining only among participants not currently smokers.

Association of Modifiable Risk Factors in Young Adulthood With Racial Disparity in Incident Type 2 Diabetes During Middle Adulthood

Importance

In the United States, black individuals are twice as likely to develop type 2 diabetes compared with white individuals, and these disparities are particularly pronounced in young and middle age. Prior studies have identified differences in traditional risk factors that may be associated with racial disparities in diabetes incidence but have not simultaneously adjusted for risk factors measured across multiple domains (eg, the individual and the environment) and updated over time.

Objective

To determine the relative associations of modifiable biological, neighborhood, psychosocial, socioeconomic, and behavioral factors in young adulthood with the observed racial disparity in diabetes incidence between middle-aged black and white individuals.

Design, Setting, and Participants

Black and white men and women from the observational Coronary Artery Risk Development in Young Adults study, aged 18 to 30 years, without diabetes at baseline (1985-1986; N = 4251) were observed through 2015-2016. Sex-stratified multivariable-adjusted Cox proportional hazards modeling, with adjustment for time-updated covariates, was used to estimate risk for incident diabetes. Percent reduction in the β coefficient (the logarithm used to calculate the hazard ratio [HR]) was calculated to compare black to white participants.

Exposures

Self-identified race and factors including biological (eg, fasting glucose, body mass index), neighborhood (racial segregation and tract-level poverty), psychosocial (depressive symptoms), socioeconomic (eg, personal and parental educational attainment, current employment), and behavioral (eg, regular alcohol consumption, smoking) domains.

Main Outcomes and Measures

Incident type 2 diabetes mellitus.

Results

The mean (SD) age at baseline was 25 (3.6) years, 49% (n = 2066) of the sample was black, and 54% (n = 2304) were women. Over a mean follow-up of 24.5 years, 504 cases of incident diabetes were identified. Using sex-stratified multivariable-adjusted Cox proportional hazards models, black women and men were more likely to develop diabetes than white men and women (black women: HR, 2.86 [95% CI, 2.19-3.72] and risk difference [RD], 89 cases/1000 people [95% CI, 61-117]; black men: HR, 1.67 [95% CI, 1.28-2.17] and RD, 47 cases/1000 people [95% CI, 15-78]) after adjustment for age and center. Biological factors were most strongly associated with the disparity in diabetes risk between black and white individuals for women (percent reduction in β, 112%) and men (percent reduction in β, 86%). There was no longer disparity in diabetes risk between black and white middle-aged adults after adjustment for biological, neighborhood, psychosocial, socioeconomic, and behavioral factors measured over time (HR for women, 0.79 [95% CI, 0.55-1.14]; HR for men, 0.92 [95% CI, 0.62-1.38]).

Conclusions and Relevance

In this cohort study comparing black and white participants, there was a statistically significant increased risk of incident type 2 diabetes among black women and men. However, after adjustment for modifiable risk factors during young adulthood, the disparity was no longer statistically significant.

From Sea to Shining Sea and the Great Plains to Patagonia: A Review on Current Knowledge of Diabetes Mellitus in Hispanics/Latinos in the US and Latin America

The past two decades have witnessed many advances in the prevention, treatment, and control of diabetes mellitus (DM) and its complications. Increased screening has led to a greater recognition of type 2 diabetes mellitus (type 2 DM) and prediabetes; however, Hispanics/Latinos, the largest minority group in the US, have not fully benefited from these advances. The Hispanic/Latino population is highly diverse in ancestries, birth places, cultures, languages, and socioeconomic backgrounds, and it populates most of the Western Hemisphere. In the US, the prevalence of DM varies among Hispanic/Latino heritage groups, being higher among Mexicans, Puerto Ricans, and Dominicans, and lower among South Americans. The risk and prevalence of diabetes among Hispanics/Latinos are significantly higher than in non-Hispanic Whites, and nearly 40% of Hispanics/Latinos with diabetes have not been formally diagnosed. Despite these striking facts, the representation of Hispanics/Latinos in pharmacological and non-pharmacological clinical trials has been suboptimal, while the prevalence of diabetes in these populations continues to rise. This review will focus on the epidemiology, etiology and prevention of type 2 DM in populations of Latin American origin. We will set the stage by defining the terms Hispanic, Latino, and Latin American, explaining the challenges identifying Hispanics/Latinos in the scientific literature and databases, describing the epidemiology of diabetes-including type 2 DM and gestational diabetes mellitus (GDM)-and cardiovascular risk factors in Hispanics/Latinos in the US and Latin America, and discussing trends, and commonalities and differences across studies and populations, including methodology to ascertain diabetes. We will discuss studies on mechanisms of disease, and research on prevention of type 2 DM in Hispanics/Latinos, including women with GDM, youth and adults; and finalize with a discussion on lessons learned and opportunities to enhance research, and, consequently, clinical care oriented toward preventing type 2 DM in Hispanics/Latinos in the US and Latin America.

Racial Differences in Heart Age and Impact on Mortality

BACKGROUND

Heart age is an estimate of the age of a person's cardiovascular system given their cardiovascular disease (CVD) risk factors. The difference between a person's chronological age and heart age (excess heart age) represents their added CVD risk.

OBJECTIVE

To examine racial differences in excess heart age and whether race impacts the association between excess heart age and CVD mortality.

METHODS

This analysis included 5110 participants (2449 non-Hispanic white, 1287 non-Hispanic black, and 1374 Mexican-American) from the NHANES III who were free of CVD. Heart age was calculated using the sex-specific non-laboratory-based Framingham risk prediction functions. Multivariable Cox proportional-hazards regression models were used to evaluate the relationship (overall and by race) between excess heart age and CVD mortality.

RESULTS

Mean excess heart age was greatest in non-Hispanic blacks (13.0 years), followed by Mexican-Americans (10.5 years), and non-Hispanic whites (8.5 years); p < 0.001 for pairwise differences. Over a mean follow-up of 13.0 years, 394 CVD deaths occurred. Each 10 years of excess heart age was associated with 65% increased risk of CVD mortality (HR, 95% CI: 1.65, 1.53-1.78). This association was stronger in non-Hispanic whites (1.83, 1.63-2.02) compared to non-Hispanic blacks (1.50, 1.29-1.72) and Mexican American (1.60, 1.33-1.87), interaction p = 0.065.

CONCLUSIONS

Compared to non-Hispanic whites, non-Hispanic blacks and Mexican Americans have more excess heart age, but the risk of CVD death for the same level of excess heart age appears more pronounced in non-Hispanic whites. Further investigation is needed to show the usefulness of these findings in directing future efforts and resource allocation for reduction of health disparities between ethnic groups.

A 60-Week Prospective RCT of a Self-Management Intervention for Individuals With Serious Mental Illness and Diabetes Mellitus

OBJECTIVES

A 60-week randomized controlled trial assessed the effects of targeted training in illness management (TTIM) versus treatment as usual among 200 individuals with serious mental illness and diabetes mellitus.

METHODS

The study used the Clinical Global Impression (CGI), the Montgomery-Asberg Depression Rating Scale (MADRS), and the Brief Psychiatric Rating Scale (BPRS) to assess psychiatric symptoms; the Global Assessment of Functioning (GAF) and the Sheehan Disability Scale (SDS) to assess functioning; the 36-Item Short-Form Health Survey (SF-36) to assess general health, and serum glycosylated hemoglobin (HbA1c) to assess diabetes control.

RESULTS

Participants' mean±SD age was 52.7±9.5 years, and 54% were African American. They were diagnosed as having depression (48%), schizophrenia (25%), and bipolar disorder (28%). At baseline, depression severity was substantial but psychosis severity was modest. At 60 weeks, there was greater improvement among TTIM participants versus treatment-as-usual recipients on the CGI (p<.001), the MADRS (p=.016), and the GAF (p=.003). Diabetes knowledge was significantly improved among TTIM participants but not in the treatment-as-usual group. In post hoc analyses among participants whose HbA1c levels at baseline met recommendations set by the American Diabetes Association for persons with high comorbidity (53%), TTIM participants had minimal change in HbA1c over the 60-week follow-up, whereas HbA1c levels worsened in the treatment-as-usual group.

CONCLUSIONS

TTIM was associated with improved psychiatric symptoms, functioning, and diabetes knowledge compared with treatment as usual. Among participants with better diabetes control at baseline, TTIM participants had better diabetes control at 60 weeks compared with recipients of treatment as usual.