Type 2 diabetes in the Hispanic or Latino population: challenges and opportunities

"Once I take that one bite": the consideration of harm reduction as a strategy to support dietary change for patients with diabetes

BACKGROUND

Despite well-established guidelines to treat diabetes, many people with diabetes struggle to manage their disease. For many, this struggle is related to challenges achieving nutrition-related lifestyle changes. We examined how people with diabetes describe barriers to maintaining a healthy diet and considered the benefits of using a harm reduction approach to assist patients to achieve nutrition-related goals.

METHODS

This is a secondary analysis of 89 interviews conducted with adults who had type 1 or type 2 diabetes. Interviews were analyzed using a content analysis approach. Themes regarding food or diet were initially captured in a "food" node. Data in the food node were then sub-coded for this analysis, again using a content analysis approach.

RESULTS

Participants frequently used addiction language to talk about their relationship with food, at times referring to themselves as "an addict" and describing food as "their drug." Participants perceived their unhealthy food choices either as a sign of weakness or as "cheating." They also identified food's ability to comfort them and an unwillingness to change as particular challenges to sustaining a healthier diet.

CONCLUSION

Participants often described their relationship with food through an addiction lens. A harm reduction approach has been associated with positive outcomes among those with substance abuse disorder. Patient-centered communication incorporating the harm reduction model may improve the patient-clinician relationship and thus improve patient outcomes and quality-of-life while reducing health-related stigma in diabetes care. Future work should explore the effectiveness of this approach in patients with diabetes.

TRIAL REGISTRATION

Registered on ClinicalTrials.gov, NCT02792777. Registration information submitted 02/06/2016, with the registration first posted on the ClinicalTrials.gov website 08/06/2016. Data collection began on 29/04/2016.

Alzheimer's disease and Alzheimer's disease-related dementias in Hispanics: Identifying influential factors and supporting caregivers

Alzheimer's disease (AD) and Alzheimer's disease-related dementias (ADRD) are the primary public health concerns in the United States and around the globe. AD/ADRD are irreversible mental illnesses that primarily impair memory and thought processes and may lead to cognitive decline among older individuals. The prevalence of AD/ADRD is higher in Native Americans, followed by African Americans and Hispanics. Increasing evidence suggests that Hispanics are the fastest-growing ethnic population in the USA and worldwide. Hispanics develop clinical symptoms of AD/ADRD and other comorbidities nearly seven years earlier than non-Hispanic whites. The consequences of AD/ADRD can be challenging for patients, their families, and caregivers. There is a significant increase in the burden of illness, primarily affecting Hispanic/Latino families. This is partly due to their strong sense of duty towards family, and it is exacerbated by the inadequacy of healthcare and community services that are culturally and linguistically suitable and responsive to their needs. With an increasing age population, low socioeconomic status, low education, high genetic predisposition to age-related conditions, unique cultural habits, and social behaviors, Hispanic Americans face a higher risk of AD/ADRD than other racial/ethnic groups. Our article highlights the status of Hispanic older adults with AD/ADRD. We also discussed the intervention to improve the quality of life in Hispanic caregivers.

Racial Disparities in Cardiovascular Risk and Cardiovascular Care in Women

PURPOSE OF REVIEW

Research on sex and gender aspects cardiovascular disease has contributed to a reduction in cardiovascular mortality in women. However, cardiovascular disease remains the leading cause of death of women in the United States. Disparities in cardiovascular risk and outcomes among women overall persist and are amplified for women of certain ethnic and racial subgroups. We review the evidence of racial and ethnic differences in cardiovascular risk and care among women and describe a path forward to achieve equitable cardiovascular care for women of racial and ethnic minority groups.

RECENT FINDINGS

There is a disproportionate effect on cardiovascular outcomes in women and certain racial and ethnic groups in part due to disparities in triage, diagnosis, treatment, which lead to amplification of inequalities in women of minority racial and ethnic background. Data suggest gender and racial bias, underappreciation of nontraditional risk factors, underrepresentation of women in clinical trials and undertreatment of disease contributes to persistent differences in cardiovascular disease outcomes in women of color. Understanding the myriad of factors that contribute to increased cardiovascular risk, and disparities in treatment and outcomes among women from racial/ethnic minority backgrounds is imperative to improving cardiovascular care for this patient population.

Cardiovascular Disease Mortality Among Hispanic Versus Non-Hispanic White Adults in the United States, 1999 to 2018

Background

Life expectancy has been higher for Hispanic versus non‐Hispanic White (NHW) individuals; however, data are limited on cardiovascular disease (CVD) mortality.

Method and Results

Using the Centers for Disease Control and Prevention’s Wide‐Ranging Online Data for Epidemiologic Research death certificate database (1999–2018), we compared age‐adjusted mortality rates for total CVD and its subtypes (ischemic heart disease, stroke, heart failure, hypertensive heart disease, other CVD), and average annual percentage changes among Hispanic and NHW adults. The age‐adjusted mortality rate per 100 000 was lower for Hispanic than NHW adults for total CVD (186.4 versus 254.6; P<0.001) and its subtypes. Between 1999 and 2018, mortality decline was higher in Hispanic than NHW adults for total CVD (average annual percentage change [AAPC], −2.90 versus −2.41) and ischemic heart disease (AAPC: −4.44 versus −3.82) (P<0.001). In contrast, stroke mortality decline was slower in Hispanic versus NHW adults (AAPC: −2.05 versus −2.60; P<0.05). Stroke mortality increased in Hispanic but stalled in NHW adults since 2011 (AAPC: 0.79 versus −0.09). For ischemic heart disease (AAPC: −0.80 versus −1.85) and stroke (AAPC: −1.32 versus −1.43) mortality decline decelerated more for Hispanic than NHW adults aged <45 years (P<0.05). For heart failure, Hispanic adults aged <45 (3.55 versus 2.16) and 45 to 64 (1.88 versus 1.54) showed greater rise in age‐adjusted mortality rate than NHW individuals (P<0.05). Age‐adjusted heart failure mortality rate also accelerated in Hispanic versus NHW men (1.00 versus 0.67; P<0.001).

Conclusions

Disaggregating data by CVD subtype and demographics unmasked heterogeneities in CVD mortality between Hispanic and NHW adults. NHW adults had greater CVD mortality rates and slower decline than Hispanic adults, whereas marked demographic differences in mortality signaled concerning trends among the Hispanic versus NHW population.

Comprehensive evaluation of disparities in cardiometabolic and reproductive risk between Hispanic and White women with polycystic ovary syndrome in the United States: a systematic review and meta-analysis

OBJECTIVE

We conducted a systematic review and meta-analysis to comprehensively compare cardiometabolic and reproductive health risk between Hispanic and White women with polycystic ovary syndrome in the United States in response to the call by the international guideline for polycystic ovary syndrome to delineate health disparities.

DATA SOURCES

Databases of MEDLINE, Web of Science, and Scopus were initially searched through October 25, 2020, and confirmed on February 1, 2021.

STUDY ELIGIBILITY CRITERIA

Observational studies comparing glucoregulatory, lipid profile, anthropometric, blood pressure, androgen, ovarian morphology, oligoanovulation, and infertility status between Hispanic and White women with polycystic ovary syndrome were included. The primary outcome was metabolic syndrome risk. Furthermore, major cardiovascular events (stroke, coronary heart disease, and heart failure) and mortality rate (cardiovascular death and total mortality) data were evaluated. Studies on adolescents (<2 years after menarche), pregnant, or menopausal-aged women (>50 years) were excluded.

METHODS

Data were pooled by random-effects models and expressed as mean differences and 95% confidence intervals. Risk of bias was assessed by the Newcastle-Ottawa Scale.

RESULTS

A total of 11 studies (n=2267; 589 Hispanic and 1678 White women) were eligible. All studies, including both White and Hispanic women, had high-quality assessment (Newcastle-Ottawa Scale score of ≥8). Hispanic women exhibited comparable metabolic syndrome prevalence (7% [95% confidence interval, -1 to 14]; P=.06; I2=0%); however, Hispanic women exhibited higher modified Ferriman-Gallwey score (0.60 [95% confidence interval, -0.01 to 1.21]; P=.05; I2=0%), fasting insulin (5.48 μIU/mL [95% confidence interval, 3.11-7.85]; P≤.01; I2=40.0%), and homeostatic model assessment of insulin resistance (1.20 [95% confidence interval, 0.50-1.89]; P≤.01; I2=43.0%) than White women. The 2 groups had comparable glucose, lipid profile, waist circumference, blood pressure, and androgen status (all P≥.08). Findings about group differences in certain reproductive outcomes (ie, ovarian dysmorphology and infertility) were contradictory and described only narratively as inclusion in the meta-analyses was not possible. No study reported on cardiovascular events or mortality.

CONCLUSION

Hispanic women with polycystic ovary syndrome exhibited greater impairments in glucoregulatory status than White women. Disparities in reproductive risks could not be concluded. The degree to which glucoregulatory aberrations translate into patient-pressing diseases (diabetes mellitus and infertility) remains a major roadblock given the paucity of available evidence. Our observations have supported the consideration of these disparities in the diagnostic, monitoring, and management practices for polycystic ovary syndrome and reinforced the need to elucidate mechanisms that account for the observed disparities to foster equity in polycystic ovary syndrome care.

A Systematic Review Exploring Acculturation and Type 2 Diabetes in Spanish-Speaking Populations

BACKGROUND

Acculturation to the United States has been previously studied in Spanish-speaking populations, but little is known about the potential relationship between acculturation and type 2 diabetes mellitus (T2DM).

OBJECTIVE

The purpose of this systematic review was to explore the relationship between acculturation and T2DM in Spanish-speaking populations in the United States.

METHODS

Selected studies collected from a review of literature were analyzed by population, ethnicity, acculturation scale, and significance.

RESULTS

Thirty-two eligible articles showed conflicting data between the effects of acculturation on T2DM.

CONCLUSION

Overall, studies yielded inconclusive results on the significance of the relationship between acculturation and diabetes in Spanish-speaking populations, which merit further investigation.

Colorectal Cancer Risk Factors and Screening Among the Uninsured of Tampa Bay: A Free Clinic Study

Introduction

Uninsured patients with low socioeconomic status are at high risk for developing colorectal cancer (CRC), and data on risk factors and prevalence of CRC in this population are limited. The purpose of this study was to assess the risk factors for CRC in uninsured patients from free clinics in the Tampa Bay area of Florida.

Methods

We conducted a retrospective cohort study among patients 50 years or older who were provided service at 9 free clinics in the Tampa Bay area between 2016 and 2018. Demographics, chronic disease characteristics, and screening data were collected via a query of paper and electronic medical records.

Results

Of the 13,982 patients seen, 5,139 (36.8%) were aged 50 years or older. Most were female (56.8%), non-Hispanic White (41.1%), and unemployed (54.9%). Patients with CRC screening were more likely to be employed compared with patients without CRC screening (54.4% vs 44.4%, P = .01). Within the cohort, 725 (22.7%) patients were active smokers, 771 (29.2%) patients currently consumed alcohol, and 23 patients (0.4%) had a history of inflammatory bowel disease. Patients had a median body mass index of 29.4 (interquartile range, 25.4–34.2) kg/m², and 1,455 (28.3%) had diabetes. Documented CRC screening was found among 341 (6.6%) patients.

Conclusion

Uninsured patients had a high prevalence of CRC risk factors but a low reported screening rate for CRC. Free clinics are uniquely positioned to provide patients at high risk for CRC with strategies to decrease their risk and to be screened for CRC.

Quality of life of Latin-American individuals with type 2 diabetes mellitus: A systematic review

OBJECTIVE

Diabetes mellitus is a serious public health problem that causes a decrease in the patients' quality of life. The present study was aimed to analyze the quality of life of patients with diabetes mellitus in Latin-American population through a systematic review, using the two instruments of greater validity and reliability at international level, SF-36 and WHOQOL.

METHODS

We performed extensive searches in Redalyc, SciELO, PubMed, Scopus and Web of Science databases. To delimit our search, we only included countries that are members of the Latin American Association of Diabetes. We identified 2168 articles, where 35 were considered relevant for this systematic review.

RESULTS

Our results showed that patients that regularly receive guidance and treatment to control the diabetes, showed better quality of life; in contrast, patients with foot ulcers or comorbidities showed the worse quality of life.

CONCLUSION

The current literature analysis suggests that this disease greatly influences in the quality of life of the patients.

Understanding the growing epidemic of type 2 diabetes in the Hispanic population living in the United States

The prevalence and incidence of type 2 diabetes (T2D) among the Hispanic population in the United States are higher than the national average. This is partly due to sociocultural factors, such as lower income and decreased access to education and health care, as well as a genetic susceptibility to obesity and higher insulin resistance. This review focuses on understanding the Hispanic population living in the United States from a multidisciplinary approach and underlines the importance of cultural, social, and biological factors in determining the increased risk of T2D in this population. An overview of the acute and chronic complications of T2D upon this population is included, which is of paramount importance to understand the toll that diabetes has upon this population, the health system, and society as a whole. Specific interventions directed to the Hispanic populations are needed to prevent and alleviate some of the burdens of T2D. Different prevention strategies based on medications, lifestyle modifications, and educational programmes are discussed herein. Diabetes self-management education (DSME) is a critical element of care of all people with diabetes and is considered necessary to improve patient outcomes. To be more effective, programmes should take into consideration cultural factors that influence the development and progression of diabetes. These interventions aim to enhance long-term effects by reducing the incidence, morbidity, and mortality of T2D in the Hispanic population of the United States.

Studying the Gut Microbiome of Latin America and Hispanic/Latino Populations. Insight into Obesity and Diabetes: Systematic Review

BACKGROUND

People from Latin America (LA) and the Hispanic/Latino community living in the United States (LUS) exhibit a high prevalence of diabetes (DM) and obesity (OB). The Gut Microbiome (GM) is capable of altering energy regulation and glucose metabolism, but for the expression of these diseases a combination of multiple factors such as ethnicity, genetic and nutritional factors are required. A systematic research was conducted to understand if the prevalence of OB and/or DM has an interaction with the GM in LA and LUS.

METHODS

Research was conducted in PubMed, Web of Science, Scielo, Embase and Google Scholar for articles between 1990 and 2017. It was restricted to human studies published in English, Spanish, or Portuguese that applied genetic techniques to study the GM in LA or LUS and discussed the association with OB and/or DM.

RESULTS

Different gut Firmicutes/Bacteroidetes relationships in several populations from LA influenced by geography, diet and lifestyles interacted with OB. Healthy people from the Mexico and US border had the same imbalance between Firmicutes and Bacteroidetes found in OB or Type 2 DM. High levels of Bacteroides and a reduced proportion of Prevotella, Megamonas, and Acidaminococcus were found in newly diagnosed type 1 DM. Once the patient was treated with insulin, an increase of Prevotella levels was seen. Inverse Firmicutes/Bacteroidetes relationship was reported before the development of Type 1 DM.

CONCLUSION

An important relation between GM and OB and/or DM exists in LA and LUS. Further elucidation of pathophysiologic mechanisms is required.

The "A to Z" of Managing Type 2 Diabetes in Culturally Diverse Populations

Type 2 diabetes affects racial/ethnic minorities at an alarming rate in the US and in many countries around the world. The quality of health care provided to these groups is often suboptimal, resulting in worse patient-related outcomes when compared to those in mainstream populations. Understanding the complex biological elements that influence the development and course of the disease in high-risk populations is extremely important but often insufficient to implement effective prevention and treatment plans. Multiple factors must be addressed in routine diabetes clinical care. This paper discusses various key factors, organized in alphabetical order. These are acculturation, biology, clinician's cultural awareness, depression and diabetes-specific emotional distress, educational level, fears, group integration, health literacy, intimacy and sexual dysfunction, judging, knowledge of the disease, language, medication adherence, nutritional preferences, other forms of medicine (alternative), perception of body image, quality of life, religion and faith, socio-economic status, technology, unconscious bias, vulnerable groups, asking why?, exercise, "you are in charge" and zip it! Considering these factors in the development of type 2 diabetes prevention and treatment programs will help improve diabetes-related outcomes in culturally diverse populations and reduce health care disparities.

Diabetes management in a foreign land: A case study on Chinese Australians

The aim of this study was to understand the experience of Chinese migrants living with type 2 diabetes in Australia and explore their culturally specific diabetes management needs, habits and expectations in the Australian context to help shape an Australian Chinese diabetes service. A case study approach was employed across two Australian cities (Melbourne and Sydney), using participant-observations and qualitative interviews. Purposive sampling was used to find diabetes education sessions for observation and facilitators for interviews before snowball technique was used to identify relevant clinicians. Thematic analysis with pattern matching was used for data analysis. A total of 18 participant-observations and 12 interviews were conducted. Chinese migrants appeared to experience multiple barriers in accessing the Australian diabetes care service further complicated by the mismatch between the expectations of Chinese patients and the services available. Chinese patients were observed to be collectivistic-orientated relying on friends for diabetes management. While health professionals appeared to be perceived as a source of reputable health information, they often did not provide ongoing support. When professional support was limited, Chinese patients adopted alternative strategies to address their diabetes, which often involved seeking help and information from peers. Some of this information was non-reputable, potentially resulting in detrimental health outcomes. In conclusion, redesigning diabetes care services in line with the principles of collectivism may more appropriately match the Chinese migrants' expectations and needs, and better support them in their diabetes journey.

Body dissatisfaction predicts poor behavioral weight loss treatment adherence in overweight Mexican American women

Poor adherence poses a major barrier to the success of behavioral weight loss (BWL) programs, particularly for overweight Mexican American women. Given the high prevalence and costs of overweight/obesity, factors that contribute to attendance and adherence problems should be identified, especially in ethnic minority populations. The current study examined the role of pre-treatment body dissatisfaction and depression in predicting attendance and adherence in a BWL intervention. Ninety-nine overweight/obese Mexican American women enrolled in the intervention and completed baseline measures. Eighty-one of the women attended at least one treatment session and provided measures of dietary and physical activity adherence. Simultaneous linear regression analyses suggested that although higher levels of body dissatisfaction and depression each played unique roles in predicting poorer attendance, only body dissatisfaction predicted adherence. Specifically, higher body dissatisfaction predicted poorer treatment adherence. Findings highlight the importance of addressing body dissatisfaction early in BWL treatment to increase attendance and adherence.

A systematic review of interventions for Hispanic women with or at risk of Gestational diabetes mellitus (GDM)

BACKGROUND AND OBJECTIVE

Gestational Diabetes Mellitus (GDM) is a serious health concern for pregnant women, with Hispanic women at particular risk for developing the condition. The aim of this review was to critically examine GDM intervention programs for Hispanic women, in the United States of America (US).

METHODS

English and Spanish electronic databases were searched for relevant studies published between 1995 and 2015. Eligible study designs included randomized controlled trial, pre/post-test and quasi experimental methods.

RESULTS

Findings indicated that there was a dearth of literature reporting on GDM interventions for Hispanic women and just seven papers met inclusion criteria. These seven studies were included in the review and they reported on interventions for: (1) pregnant women at high risk of developing GDM; (2) pregnant women with GDM. Results suggest that a combination of intensive counselling over a prolonged period of time, together with a low calorie, possibly low glycemic index diet, produces best results.

CONCLUSION

The review found that intensive nutritional counselling approaches which promote low calorie/low GI diets appear to be most effective in BGL management in this population. Interventions that are delivered in Spanish and culturally tailored may be more acceptable to participants. More research is needed to develop suitable interventions to improve GDM management among Hispanic women.

Making It All Work: Qualitative Descriptions of Hispanic Adults Managing Type 2 Diabetes With Limited Resources

The greater prevalence of type 2 diabetes is a critical issue among the U.S. Hispanic population. This study examined the struggles of Hispanic adults managing type 2 diabetes with limited resources. Ten Hispanic adults (enrolled in a larger study to determine the effects of diabetes self-management intervention), 25 to 80 years of age and living in a rural West Texas county in the United States, were selected. Three categories of challenges emerged: (a) diabetes self-care behaviors and challenges, (b) challenges with limited resources, and (c) challenges with support mechanisms. "Making it all work" was the overarching theme that tied all the categories together. This study offers lessons for health care providers and policymakers on how to maximize the availability of resources for Hispanic individuals with type 2 diabetes living within the constraints of limited resources.

Behavioral Medicine Review: Strategic Management of Diabetes Risk

There is widespread public health concern about the upsurge in diabetes and its cardiometabolic comorbidities. Unfortunately, too many patients still do not receive best practices care. This review discusses some key contributing dynamics as well as considerations for progress toward the more comprehensive, strategic management of diabetes and its associated risks.

Efficacy and Safety of Canagliflozin in Type 2 Diabetes Patients of Different Ethnicity

OBJECTIVE

To assess the efficacy and safety of the sodium glucose co-transporter 2 (SGLT2) inhibitor canagliflozin in patients of different ethnicities.

DESIGN SETTING AND PATIENTS

Post hoc analysis of data pooled from four randomized, placebo-controlled, phase 3 studies of adults with inadequately controlled type 2 diabetes mellitus (T2DM).

INTERVENTIONS

Once daily oral canagliflozin 100 mg or 300 mg, or placebo.

MAIN OUTCOME MEASURES

Efficacy endpoints included change from baseline in HbA1c, body weight (BW), systolic blood pressure (SBP), and lipids at week 26; safety and tolerability were assessed by adverse event reports.

RESULTS

Of the 2,313 patients included in this pooled analysis, 609 self-identified as Hispanic/Latino. Hispanic/Latino patients had a mean age of 54 years, mean duration of T2DM of 7 years, mean HbA1c of 8.1%, mean body mass index of 31.2 kg/m(2), and mean SBP of 126.1 mm Hg. There were more women in the non-Hispanic/Latino cohort (63%) compared with the Hispanic/Latino cohort. Placebo-subtracted changes in HbA1c were -.82% with canagliflozin 100 mg and -.94% with canagliflozin 300 mg in the Hispanic/Latino cohort, which were similar to reductions observed in the non-Hispanic/Latino cohort. Significantly greater dose-related reductions in HbA1c, BW, and SBP were observed with both canagliflozin doses compared with placebo. Canagliflozin was generally well-tolerated. Genital mycotic infections were less frequent in Hispanic/Latino women than in non-Hispanic/Latino women.

CONCLUSIONS

The SGLT2 inhibitor canagliflozin was generally well-tolerated and was associated with clinically meaningful reductions in HbA1c, BW, and SBP in both Hispanic/Latino and non-Hispanic/Latino patients with T2DM.

Efficacy and safety of canagliflozin in patients with type 2 diabetes mellitus from Latin America

OBJECTIVE

This post hoc analysis evaluated the efficacy and safety of canagliflozin, a sodium glucose co-transporter 2 inhibitor, in patients with type 2 diabetes mellitus (T2DM) from Latin America.

RESEARCH DESIGN AND METHODS

Analyses were performed in subgroups of patients from Latin America based on data from three individual, 26-week, placebo-controlled studies of canagliflozin (monotherapy [n = 116/584], add-on to metformin [n = 199/918], and add-on to metformin plus sulfonylurea [n = 76/469]) and three individual, 52-week, active-controlled studies of canagliflozin (add-on to metformin versus sitagliptin [n = 240/1101], add-on to metformin versus glimepiride [n = 155/1450], and add-on to metformin plus sulfonylurea versus sitagliptin [n = 156/755]).

MAIN OUTCOME MEASURES

Changes from baseline in HbA1c, body weight, and systolic blood pressure (BP) with canagliflozin 100 and 300 mg versus placebo or active comparator (i.e., sitagliptin or glimepiride) were evaluated in the overall study populations and Latin American subgroups. Safety was assessed based on adverse event (AE) reports.

RESULTS

Canagliflozin 100 and 300 mg provided reductions in HbA1c, body weight, and systolic BP across studies in patients from Latin America that were generally similar to those seen in the overall populations of patients with T2DM. The AE profile in patients from Latin America was equivalent to that in the overall populations; higher rates of genital mycotic infections and osmotic diuresis-related AEs were seen with canagliflozin versus comparators. Limitations of this study include the post hoc analysis of data and the small sample size of patients from Latin America.

CONCLUSION

Canagliflozin improved glycemic control, reduced body weight and systolic BP, and was generally well tolerated in patients with T2DM from Latin America.

CLINICAL TRIAL REGISTRATION

NCT01081834; NCT01106677; NCT01106625; NCT00968812; NCT01137812.

Evaluating Por Nuestra Salud: A Feasibility Study

AIMS

This feasibility study evaluated the impact of a culturally consistent diabetes educational program, led by a Latino pastor, on Latino community diabetes knowledge levels.

METHOD

Latino adults were recruited from two churches serving Latino populations, one identified as intervention, the other as nonintervention. Both churches received the American Diabetes Association's booklets on diabetes education, "Four Steps to Control Your Diabetes for Life." The intervention group also received weekly reviews of the booklet's information from the church pastor, who was educated about diabetes by a Latino family nurse practitioner. Pre- and postintervention levels of diabetes knowledge were measured using the Diabetes Knowledge Questionnaire.

RESULTS

Mean changes in the Diabetes Knowledge Questionnaire (DKQ-24) survey from pretest to posttest indicated a significant increase in knowledge in both groups. Only the grades for the participants from the pastor-led group, however, moved from failure in knowledge to high levels of passing. One hundred percent of intervention group participants reported having read the literature.

CONCLUSIONS

This pilot study supports the feasibility of a local Latino pastor, as a culturally consistent diabetes educator, to increase Latino parishioner's knowledge of diabetes.

Using interactive Internet technology to promote physical activity in Latinas: Rationale, design, and baseline findings of Pasos Hacia La Salud

Internet-based interventions show promise as an effective channel for promoting physical activity. However, a paucity of research has been conducted among underserved groups despite recent increases in Internet access and physical activity-related health disparities in these communities. Thus, the current randomized controlled trial will test the efficacy of an individually tailored, Internet-based physical activity intervention for Latinas. This program was culturally and linguistically adapted for the target population through extensive formative research. Two hundred eighteen sedentary Latinas were randomly assigned to the Tailored Physical Activity Internet Intervention or the Wellness Contact Control Internet Group. The Physical Activity Internet Intervention, based on Social Cognitive Theory and the Transtheoretical Model, utilizes a website with features including self-monitoring, goal setting, discussion forum, links to online resources, individually tailored and motivation-matched physical activity feedback reports, and exercise tip sheets. Participants receive regular emails over the first 6months with a tapered dose during the second 6months (maintenance phase) to alert them to new content on the website. The main outcome is differences in minutes/week of moderate to vigorous physical activity at six months as measured by the 7-Day Physical Activity Recall and accelerometer data. High reach, low cost, culturally relevant Internet-based interventions that encourage physical activity among Latinas could help reduce health disparities and thus have a substantial positive impact on public health.

Sedentary behavior and prevalent diabetes in Non-Latino Whites, Non-Latino Blacks and Latinos: findings from the National Health Interview Survey

BACKGROUND

Sedentary behavior is associated with type II diabetes, though little is known about prevalence of this behavior across racial/ethnic groups or how it may contribute to disparities in diabetes prevalence. In this study, we examined the association between sedentary behavior and diabetes in a diverse data set, and explored whether differences in sedentary behavior across racial/ethnic groups could contribute to disparities in diabetes.

METHODS

Participants were 27 141 adults from the 2010 US National Health Interview Survey. Logistic regression was used to assess associations between self-reported, non-occupational sitting time, race/ethnicity and physician diagnosis of type II diabetes.

RESULTS

In fully adjusted models, each hour of daily sitting was associated with 4% increased odds of diabetes (P < 0.01). Odds of diabetes were nearly double in Latinos (odds ratio [OR] = 1.83, confidence interval [CI] = 1.59-2.13) and Blacks (OR = 1.83, CI = 1.59-2.11) after adjusting for demographics and lifestyle factors. However, Blacks reported only slightly more sitting than Whites, and Latinos reported significantly less. Further adjustment for sitting hours in multivariate models did not attenuate disparities and slightly increased odds for Latinos (OR = 2.03, CI = 1.74-2.36).

CONCLUSIONS

Sitting appears to be an independent risk factor for diabetes across racial/ethnic groups, though it does not appear to account for disparities in diabetes.

Considering the Impact of Acculturation on Lifestyle Interventions for Latinos

Individuals of Latino descent are one of the fastest growing groups in the United States. They also experience multiple health disparities. To effectively treat individuals from these cultures, several issues should be considered. Assessing the degree of an individual’s acculturation and tailoring interventions to be more compatible with a patient’s cultural values are important steps to be taken.

Community engagement approach: developing a culturally appropriate intervention for Hispanic mother-child dyads

Childhood obesity affects approximately 20% of U.S. preschool children. Early prevention is needed to reduce young children's risks for obesity, especially among Hispanic preschool children who have one of the highest rates of obesity. Vida Saludable was an early childhood obesity intervention designed to be culturally appropriate for low-income Hispanic mothers with preschool children to improve maternal physical activity and reduce children's sugar-sweetened beverage consumption. It was conducted at a large southwestern United States urban health center. Presented here are the methods and rationale employed to develop and culturally adapt Vida Saludable, followed by scoring and ranking of the intervention's cultural adaptations. An empowered community helped design the customized, culturally relevant program via a collaborative partnership between two academic research institutions, a community health center, and stakeholders. Improved health behaviors in the participants may be attributed in part to this community-engagement approach. The intervention's cultural adaptations were scored and received a high comprehensive rank. Postprogram evaluation of the intervention indicated participant satisfaction. The information presented provides investigators with guidelines, a template, and a scoring tool for developing, implementing, and evaluating culturally adapted interventions for ethnically diverse populations.

Status of cardiovascular disease and stroke in Hispanics/Latinos in the United States: a science advisory from the American Heart Association

BACKGROUND AND PURPOSE

This American Heart Association (AHA) scientific statement provides a comprehensive overview of current evidence on the burden cardiovascular disease (CVD) among Hispanics in the United States. Hispanics are the largest minority ethnic group in the United States, and their health is vital to the public health of the nation and to achieving the AHA's 2020 goals. This statement describes the CVD epidemiology and related personal beliefs and the social and health issues of US Hispanics, and it identifies potential prevention and treatment opportunities. The intended audience for this statement includes healthcare professionals, researchers, and policy makers.

METHODS

Writing group members were nominated by the AHA's Manuscript Oversight Committee and represent a broad range of expertise in relation to Hispanic individuals and CVD. The writers used a general framework outlined by the committee chair to produce a comprehensive literature review that summarizes existing evidence, indicate gaps in current knowledge, and formulate recommendations. Only English-language studies were reviewed, with PubMed/MEDLINE as our primary resource, as well as the Cochrane Library Reviews, Centers for Disease Control and Prevention, and the US Census data as secondary resources. Inductive methods and descriptive studies that focused on CVD outcomes incidence, prevalence, treatment response, and risks were included. Because of the wide scope of these topics, members of the writing committee were responsible for drafting individual sections selected by the chair of the writing committee, and the group chair assembled the complete statement. The conclusions of this statement are the views of the authors and do not necessarily represent the official view of the AHA. All members of the writing group had the opportunity to comment on the initial drafts and approved the final version of this document. The manuscript underwent extensive AHA internal peer review before consideration and approval by the AHA Science Advisory and Coordinating Committee.

RESULTS

This statement documents the status of knowledge regarding CVD among Hispanics and the sociocultural issues that impact all subgroups of Hispanics with regard to cardiovascular health. In this review, whenever possible, we identify the specific Hispanic subgroups examined to avoid generalizations. We identify specific areas for which current evidence was less robust, as well as inconsistencies and evidence gaps that inform the need for further rigorous and interdisciplinary approaches to increase our understanding of the US Hispanic population and its potential impact on the public health and cardiovascular health of the total US population. We provide recommendations specific to the 9 domains outlined by the chair to support the development of these culturally tailored and targeted approaches.

CONCLUSIONS

Healthcare professionals and researchers need to consider the impact of culture and ethnicity on health behavior and ultimately health outcomes. There is a need to tailor and develop culturally relevant strategies to engage Hispanics in cardiovascular health promotion and cultivate a larger workforce of healthcare providers, researchers, and allies with the focused goal of improving cardiovascular health and reducing CVD among the US Hispanic population.

Results of the northern Manhattan diabetes community outreach project: a randomized trial studying a community health worker intervention to improve diabetes care in Hispanic adults

OBJECTIVE The Northern Manhattan Diabetes Community Outreach Project evaluated whether a community health worker (CHW) intervention improved clinically relevant markers of diabetes care in adult Hispanics. RESEARCH DESIGN AND METHODS Participants were adult Hispanics, ages 35-70 years, with recent hemoglobin A1c (A1C) ≥8% (≥64 mmol/mol), from a university-affiliated network of primary care practices in northern Manhattan (New York City, NY). They were randomized to a 12-month CHW intervention (n = 181), or enhanced usual care (educational materials mailed at 4-month intervals, preceded by phone calls, n = 179). The primary outcome was A1C at 12 months; the secondary outcomes were systolic blood pressure (SBP), diastolic blood pressure, and LDL-cholesterol levels. RESULTS There was a nonsignificant trend toward improvement in A1C levels in the intervention group (from unadjusted mean A1C of 8.77 to 8.40%), as compared with usual care (from 8.58 to 8.53%) (P = 0.131). There was also a nonsignificant trend toward an increase in SBP and LDL cholesterol in the intervention arm. Intervention fidelity, measured as the number of contacts in the intervention arm (visits, phone contacts, group support, and nutritional education), showed a borderline association with greater A1C reduction (P = 0.054). When assessed separately, phone contacts were associated with greater A1C reduction (P = 0.04). CONCLUSIONS The trend toward A1C reduction with the CHW intervention failed to achieve statistical significance. Greater intervention fidelity may achieve better glycemic control, and more accessible treatment models, such as phone-based interventions, may be more efficacious in socioeconomically disadvantaged populations.

Epicardial fat thickness correlates with carotid intima-media thickness, arterial stiffness, and cardiac geometry in children and adolescents

To determine the association between epicardial fat thickness and carotid arterial stiffness, carotid intima-media thickness (CMIT), left atrial (LA) volume, and left-ventricular (LV) geometry parameters in obese children and adolescents compared with controls. A case-control study was performed in 96 children and adolescents (obese n = 66, controls n = 30) age 9-16 years old (38 female and 58 male, mean age 11.7 ± 2.8 years) undergoing transthoracic echocardiography and carotid artery ultrasound. Clinical, anthropometric, and biochemical determinations were also recorded. Epicardial fat thickness (2.76 ± 1.2 vs. 1.36 ± 0.7 mm, p < 0.001), LA volume (35.7 ± 13.2 vs. 28.9 ± 9.8 mL, p = 0.008), LV mass (118.3 ± 38.6 vs. 96.4 ± 35.4 mL, p = 0.008), CIMT (0.48 ± 0.07 vs. 0.44 ± 0.05 mm, p = 0.019), and local pulse wave velocity (LPWV; 3.7 ± 0.5 vs. 3.2 ± 0.4 m/seg, p = 0.007) were significantly increased in obese children and adolescents compared with controls. Epicardial fat showed a significant and positive correlation with LA volume, LV mass, and LPWV as well as a significant and independent association with increased CIMT (odds ratio (OR) = 3.19 [1.88-7.99], p = 0.005) in the study population. Epicardial fat thickness is linked to obesity, carotid subclinical atherosclerosis, and cardiac geometry parameters and might be a useful tool for the cardiovascular risk stratification in children and adolescents.

The Seamos Saludables study: A randomized controlled physical activity trial of Latinas

BACKGROUND

Latinas in the U.S. are less physically active than non-Latino white women and also report higher levels of diabetes, obesity, and other conditions related to inactivity. Interventions are needed to address disparities in this high-risk group.

PURPOSE

To evaluate the efficacy of a culturally adapted, Spanish-language, individually tailored, computer expert system-driven physical activity print-based intervention for adult Latinas.

DESIGN

RCT.

SETTING/PARTICIPANTS

Participants were 266 inactive adult Latinas who participated between 2009 and 2012.

INTERVENTION

Participants were randomized to one of two treatment arms: a 6-month tailored physical activity intervention condition or wellness contact control. For both conditions, print materials were delivered by mail.

MAIN OUTCOME MEASURES

The main outcome measure was change in weekly moderate-to-vigorous physical activity (MVPA) measured by the 7-Day Physical Activity Recall interview, which was administered at baseline and post-intervention (6 months). Participants also wore accelerometers for a week at baseline and follow-up. Analyses were conducted in 2013.

RESULTS

Increases in minutes/week of MVPA measured by the 7-Day PAR were significantly greater in the intervention group compared to the control group (mean difference=41.36, SE=7.93, p<0.01). This difference was corroborated by accelerometer readings (rho=0.44, p<0.01). Further, results indicate that intervention participants had greater increases in self-efficacy, cognitive processes, and behavioral processes at 3 months compared to control paricipants (p's<0.05).

CONCLUSIONS

The tailored Spanish-language intervention was effective in increasing MVPA among predominantly low-income, less-acculturated Latinas. Such print-based interventions are poised for widespread dissemination, and thus may help address health disparities.

Bodily Aesthetic Ideals Among Latinas With Type 2 Diabetes

Purpose

The purpose of this study was to examine how attitudes and practices related to bodily aesthetic ideals and self-care might inform the engagement of Latinas with type 2 diabetes (T2DM).

Methods

Focus groups were used to collect qualitative data concerning bodily aesthetic ideals and diabetes management, including help-seeking experiences, from Latina women with T2DM (n = 29) receiving care through Latino Diabetes Initiative at the Joslin Diabetes Center. Focus groups were conducted in Spanish, audiotaped, transcribed, and content analyzed.

Results

Four main themes emerged: (1) a preference among participants for a larger than average body size, although perceptions of attractiveness were more closely linked to grooming than body size; bodily dissatisfaction centered on diabetes-induced skin changes, virilization, and fatigue rather than weight; (2) diabetic complications, especially foot pain, as a major obstacle to exercise; (3) fatalistic attitudes regarding the inevitability of diabetes and reversal of its complications; and (4) social burdens, isolation, and financial stressors as contributing to disease exacerbation.

Conclusions

Interventions that emphasize reduced body size may be less effective with Latinas who have T2DM than those that emphasize the benefits of exercise and weight loss for skin health, energy levels, and reduced virilization.

Perceptions and management of psychosocial factors affecting type 2 diabetes mellitus in Chinese Americans

Diabetes has become a global pandemic and Chinese Americans are at least 60% more likely to develop type 2 diabetes than White Americans, despite having lower body weight, due to a combination of genetic and environmental factors. Because of the increased risk, it is vitally important to address the issues of treatment adherence and diabetes self-management in the Chinese American population. Many factors affect an individual's ability to manage diabetes, including cultural beliefs, immigration experience, language abilities/health literacy, educational background, employment, and accessibility of healthcare services. In treating Chinese American patients, these factors must be considered to determine appropriate treatment. Eastern cultural and individual beliefs differ greatly from Western beliefs and, therefore, may affect the presentation of the patients. If left unacknowledged, these differences might be misinterpreted by healthcare providers as merely treatment non-adherence or unwillingness to change. Suggestions for providing culturally competent healthcare are discussed.

Food purchasing selection among low-income, Spanish-speaking Latinos

BACKGROUND

In the U.S., poverty has been linked to both obesity and disease burden. Latinos in the U.S. are disproportionately affected by poverty, and over the past 10 years, the percentage of overweight U.S. Latino youth has approximately doubled. Buying low-cost food that is calorie-dense and filling has been linked to obesity. Low-income individuals tend to favor energy-dense foods because of their low cost, and economic decisions made during food purchasing have physiologic repercussions. Diets based on energy-dense foods tend to be high in processed staples, such as refined grains, added sugars, and added fats. These diets have been linked to a higher risk of obesity, type 2 diabetes, and cardiovascular disease.

PURPOSE

This pilot study conducted ethnographic qualitative analyses combined with quantitative analyses to understand grocery shopping practices among 20 Spanish-speaking, low-income Latino families. The purpose was to analyze food selection practices in order to determine the effect of nutrition education on changes in shopping practices to later develop educational tools to promote selection of healthier food options.

METHODS

Participants received tailored, interactive, nutrition education during three to five home visits and a supermarket tour. Grocery store receipts for grocery purchases collected at baseline and at the end of the project were analyzed for each family to extract nutritional content of purchased foods. Nutritional content was measured with these factors in mind: quantity, calories, fats, carbohydrates, fiber, protein, and percentage of sugary beverages and processed food. Data were collected in 2010-2011 and analyzed in 2011-2012.

RESULTS

After receiving between three and five home-based nutrition education sessions and a supermarket tour over a 6-month period, many families adopted instructions on buying budget-friendly, healthier alternative foods. Findings indicate that participating families decreased the total number of calories and calories per dollar purchased from baseline to post-education (median total calories: baseline, 20,191; post-education, 15,991, p=0.008); median calories per dollar: baseline, 404; post-education, 320, p=0.008). The median grams of carbohydrates per dollar (baseline, 66, post-education, 45) and median calories from processed food (baseline, 11,000, post-education, 7845) were not reduced (p=0.06).

CONCLUSIONS

This pilot study demonstrated that grocery shopping practices are an important factor to address in nutrition education among Spanish-speaking, low-income individuals, and that there may be ways to encourage low-income, Latino families to purchase healthier foods. Findings challenged arguments suggesting that such an approach is not possible because of the high cost of healthier foods.

Racial/ethnic differences in control of cardiovascular risk factors among type 2 diabetes patients in an insured, ambulatory care population

AIMS

This paper examines differences in cardiovascular disease risk factor control among racial/ethnic minorities (Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, Hispanic/Latino, Black/African Americans) with type 2 diabetes compared to Non-Hispanic Whites with type 2 diabetes in an insured, outpatient setting.

METHODS

A three-year, cross-sectional sample of 15,826 patients with type 2 diabetes was studied between 2008 and 2010. Goal attainment rates for three cardiovascular disease risk factors (HbA1c, BP, LDL) were estimated. Logistic regression was used to determine the association between patient characteristics and control of risk factors.

RESULTS

Only one fifth (21.1%) of patients achieved simultaneous goal attainment (HbA1c, BP, LDL). After adjustment for patient characteristics and treatment, Black/African American women and men, and Filipino and Hispanic/Latino men were significantly less likely to simultaneously achieve all three goals, compared to Non-Hispanic Whites. Of the three goals, patients were more likely to achieve HbA1c goals (68.7%) than BP (45.7%) or LDL (58.5%) goals. Racial/ethnic differences were more apparent in risk factors that were under better control (i.e. HbA1c).

CONCLUSIONS

Cardiovascular risk factor control in type 2 diabetes is suboptimal, even in an insured population. Special attention may be required for specific racial/ethnic/gender groups.

ADRB2 G-G haplotype associated with breast cancer risk among Hispanic and non-Hispanic white women: interaction with type 2 diabetes and obesity

INTRODUCTION

Polymorphisms in the beta-2-adrenergic receptor (ADRB2) gene have been studied in relation to risk of type 2 diabetes and obesity, risk factors that have received increased attention in relation to breast cancer. We evaluated the hypothesis that ADRB2 variants (rs1042713, rs1042714) are associated with breast cancer risk in non-Hispanic white (NHW) and Hispanic (H) women using data from a population-based case-control study conducted in the southwestern United States.

METHODS

Data on lifestyle and medical history, and blood samples, were collected during in-person interviews for incident primary breast cancer cases (1,244 NHW, 606 H) and controls (1,330 NHW, 728 H). ADRB2 genotypes for rs1042713(G/A) and rs1042714(G/C) were determined using TaqMan assays. The associations of each variant and corresponding haplotypes with breast cancer were estimated using multivariable logistic regression.

RESULTS

Two copies compared to one or zero copies of the ADRB2 G-G haplotype were associated with increased breast cancer risk for NHW women [odds ratio (OR), 1.95; 95 % confidence interval (95 % CI), 1.26-3.01], but with reduced risk for H women [OR, 0.74; 95 % CI, 0.50-1.09]. Effect estimates were strengthened for women with a body mass index (BMI) ≥25 kg/m(2) [H: OR, 0.50; 95 % CI, 0.31-0.82; NHW: OR, 3.85; 95 % CI, 1.88-7.88] and for H women with a history of diabetes [H: OR, 0.32; 95 % CI, 0.12-0.89].

CONCLUSIONS

These data suggest that ethnicity modifies the association between the ADRB2 G-G haplotype and breast cancer risk, and being overweight or obese enhances the divergence of risk between H and NHW women.

The Mexican-American Trial of Community Health workers (MATCH): design and baseline characteristics of a randomized controlled trial testing a culturally tailored community diabetes self-management intervention

OBJECTIVES

Community Health Workers (CHWs) have been recommended to reduce diabetes disparities, but few robust trials of this approach have been conducted. Limitations of prior studies include: unspecified a priori outcomes; lack of blinded outcome assessments; high participant attrition rates; and lack of attention to intervention fidelity. These limitations reflect challenges in balancing methodologic rigor with the needs of vulnerable populations. The Mexican-American Trial of Community Health workers (MATCH) was a blinded randomized controlled trial testing CHW efficacy in improving physiologic outcomes and self-management behaviors among Mexican-Americans with type 2 diabetes. This paper describes methods used to overcome limitations of prior studies.

RESEARCH DESIGN AND METHODS

The primary aim was to determine if a CHW intervention would result in significant reductions in Hemoglobin A1c and rates of uncontrolled blood pressure. 144 Mexican-Americans with diabetes were randomized. The intervention consisted of self-management training delivered by CHWs over a 24-month period; the comparison population received identical information via bilingual newsletter. Blinded research assistants completed assessments at baseline, 12 months, and 24 months post-randomization.

RESULTS

The MATCH cohort was characterized by low acculturation and socioeconomic status. Study participants had low rates of medication adherence and glucose monitoring. 70% had poor glycemic control with A1c levels over 7.0, and 57.3% had blood pressures worse than ADA target levels (<130/80).

CONCLUSIONS

MATCH preserved community sensitivity and methodologic rigor. The study's attention to intervention fidelity, behavioral attention control, blinded outcomes assessment, and strategies to enhance participant retention can be replicated by researchers testing culturally-tailored CHW interventions.

Improving treatment in Hispanic/Latino patients

The prevalence of type 2 diabetes mellitus is higher in Hispanic/Latino individuals living in the United States compared with their non-Hispanic white counterparts. Many factors contribute to the increased prevalence of type 2 diabetes, including biological characteristics, socioeconomic conditions, and cultural aspects. The contribution of genetics to the risk of type 2 diabetes in Hispanic/Latino patients is becoming increasingly clear, but this inherent risk factor cannot be modified. However, certain socioeconomic and cultural factors, such as reduced access to healthcare, language barriers, cultural beliefs, and lack of cultural competence by the healthcare provider, are modifiable and should be overcome in order to improve the management of type 2 diabetes in Hispanic/Latino patients. At the healthcare system level, policies should be put into place to reduce disparities between Hispanics/Latinos and non-Hispanic whites regarding health insurance coverage and access to healthcare. At the healthcare provider and patient level, cultural beliefs should be taken into consideration when selecting adequate treatment. Overall, type 2 diabetes management should be individualized by identifying the preferred language and level of acculturation for each patient. These considerations are necessary to further improve communication through culturally appropriate educational materials and programs. These strategies may help to overcome the barriers in the treatment of type 2 diabetes in Hispanic/Latino patients.

Understanding the Hispanic/Latino patient

The Hispanic/Latino population is the largest minority group in the United States, representing approximately 16% of the population in 2010. The US Census Bureau defines Hispanic/Latino origin as ethnicity, which tends to be associated with culture and is distinct from race. Based on the US Census Bureau classifications, Hispanics/Latinos have at least 3 main racial backgrounds (white, black, and Native Indian), with the combination and proportion differing among Hispanic/Latino subgroups. The reflection of these racial differences in genetic ancestry partly explains why biological characteristics differ among Hispanic/Latino subgroups. Partly as a result of variations in biological characteristics, the risk of type 2 diabetes mellitus varies among Hispanic/Latino subgroups. According to data from the 1982 to 1984 Hispanic Health and Nutrition Examination Survey (HHANES), the prevalence of diagnosed and undiagnosed type 2 diabetes among adults aged 45 to 74 years was higher in Mexican Americans (23.9%) and Puerto Ricans (26.1%) compared with Cubans (15.8%). In addition to genetics, there are multiple social and cultural factors that affect the prevalence and course of type 2 diabetes in Hispanic/Latino individuals. Although certain aspects of Hispanic/Latino culture may become barriers in the management of type 2 diabetes in this population, these cultural characteristics may also represent an opportunity for prevention and/or improvement of care. It is important for healthcare providers to have an understanding and appreciation of Hispanic/Latino culture in order to provide their Hispanic/Latino patients with healthcare that is culturally and socially appropriate. Only by considering genetic, social, and cultural factors can type 2 diabetes be successfully prevented, treated, and managed in Hispanic/Latino patients.

Collaborative planning approach to inform the implementation of a healthcare manager intervention for Hispanics with serious mental illness: a study protocol

BACKGROUND

This study describes a collaborative planning approach that blends principles of community-based participatory research (CBPR) and intervention mapping to modify a healthcare manager intervention to a new patient population and provider group and to assess the feasibility and acceptability of this modified intervention to improve the physical health of Hispanics with serious mental illness (SMI) and at risk for cardiovascular disease (CVD).

METHODS

The proposed study uses a multiphase approach that applies CBPR principles and intervention-mapping steps--an intervention-planning approach--to move from intervention planning to pilot testing. In phase I, a community advisory board composed of researchers and stakeholders will be assembled to learn and review the intervention and make initial modifications. Phase II uses a combination of qualitative methods--patient focus groups and stakeholder interviews--to ensure that the modifications are acceptable to all stakeholders. Phase III uses results from phase II to further modify the intervention, develop an implementation plan, and train two care managers on the modified intervention. Phase IV consists of a 12-month open pilot study (N = 30) to assess the feasibility and acceptability of the modified intervention and explore its initial effects. Lastly, phase V consists of analysis of pilot study data and preparation for future funding to develop a more rigorous evaluation of the modified intervention.

DISCUSSION

The proposed study is one of the few projects to date to focus on improving the physical health of Hispanics with SMI and at risk for CVD by using a collaborative planning approach to enhance the transportability and use of a promising healthcare manager intervention. This study illustrates how blending health-disparities research and implementation science can help reduce the disproportionate burden of medical illness in a vulnerable population.

Perceived and actual diabetes risk in the Chinese and Hispanic/Latino communities in Portland, OR, USA

AIMS

The burden of diabetes is considerable for racial and ethnic minority populations in many places in the USA and worldwide, often disproportionately affecting immigrant communities. This paper reports findings from a community-based participatory research study that described diabetes risk and awareness, assessed the association between perceived and actual risk (high, two or more diabetes risk factors; low, fewer than two risk factors) and identified factors associated with disease risk among Chinese and Hispanic/Latino immigrant populations in Portland, OR, USA.

METHODS

Cross-sectional, self-reported data were collected from a purposive sample of 324 Chinese (n=159) and Hispanic/Latino (n=165) adults, aged 18-86 years [mean (SD) age, 45.2(17.9) years; 50.7% women). Analyses described differences in variable distributions. Logistic regression estimated odds ratios and 95% confidence intervals in pooled and ethnic group-specific samples.

RESULTS

  Approximately 43% of participants were at high risk for diabetes, regardless of ethnicity or age. Of those unaware of their risk, or who perceived themselves not to be at risk, 25-53% had two or more risk factors (high risk); these patterns varied by ethnicity. The proportion of participants who reported two or more risk factors and were unaware of their risk status (31.8% Hispanic/Latino; 17% Chinese) or self-identified as not at risk (12.5% Hispanic/Latino; 13.0% Chinese) was substantial. Factors associated with diabetes risk also varied by ethnicity.

CONCLUSIONS

This study assessed the degree and determinants of diabetes risk and awareness among local Hispanic/Latino and Chinese communities and identified significant variation between groups. The results are important because they highlight substantial diabetes risk among persons who misestimate or are unaware of their risk status, regardless of ethnicity, and, in the USA, the Chinese immigrant population commonly is not considered a high-risk group for Type 2 diabetes.

Metabolic syndrome and mild to moderate chronic kidney disease among minorities

The incidence and prevalence of metabolic syndrome and chronic kidney disease (CKD) are increasing in the US population as a whole, but much more rapidly among ethnic minorities. Recent studies have shown that metabolic syndrome is an independent risk factor for the development of incident CKD in African Americans and American Indians distinct from its impact on cardiovascular and all-cause mortality. The pathogenesis of metabolic syndrome in ethnic minorities often is multifactorial. We review the myriad facets of the impact of the metabolic syndrome on the pathophysiology of CKD in minorities. In addition to classic biochemical and physiologic factors, increasing attention is being drawn to the major role of novel factors such as adiponectin and socioeconomic and cultural factors in the development of obesity and insulin resistance; an understudied area that may modulate clinically relevant consequences of biochemical and pathophysiologic aberrations. We present an integrated pathophysiologic viewpoint that incorporates insights from basic science, socioeconomic inquiry, and clinical studies into a framework for clinical practice and investigation.

Effect of recreational physical activity on insulin levels in Mexican/Hispanic children

The effect of increased recreational physical activity in children on insulin levels has not yet been studied. We carried out a randomized controlled trial in 76 children 6-9 years old, 32 of them increased their physical activity and 30 maintained the same level. In the intervention group, after a week of baseline, recreational activity three times/week was programmed for 12 weeks. We compared insulin, homeostatic model assessment (HOMA) index, glucose, HDL-C, LDL-C, triglycerides, and body mass index in both groups. Thereafter, we compared groups of normal weight, overweight, and with obesity in the experimental group. The group of recreational activity increased their median daily steps (15,329 to 19,910) and decreased insulin (p < 0.001) and HOMA index (4.36 vs. 2.39, p < 0.001). The diminution of insulin levels was more significant in the overweight group (p < 0.007). In conclusion, in our group, children who increased physical activity during 12 weeks decrease insulin levels and insulin resistance without change in other metabolic and anthropometric variables.

Hypoalphalipoproteinemia in populations of Native American ancestry: an opportunity to assess the interaction of genes and the environment

PURPOSE OF THIS REVIEW

Our aim is to review the environmental and genetic factors associated with hypoalphalipoproteinemia in populations of Native American ancestry. We examine the strength of the association and outline the population-specific genetic factors that lead to a higher susceptibilty for this condition.

RECENT FINDINGS

Low HDL is the most common lipid abnormality in populations of Native American ancestry. Population-based surveys carried out in Latin America and in Mexican Americans shows that 40-60% of adults have hypoalphalipoproteinemia. The contribution of this trait to the metabolic syndrome is greater in individuals with Native American ancestry than in other ethnic groups. Several environmental factors have contributed to this phenomenon (i.e. high dietary content of carbohydrates and fat due to cultural factors and a growing incidence of obesity). In addition, results from recent genetic studies show that certain hypoalphalipoproteinemia susceptibility alleles are ethnic specific for Native Americans. The variant R230C of the ATP-binding cassette transporter subfamily A member 1 gene (ABC-A1) is common among mestizos (10.9% in Mexican mestizos) and its presence has a significant negative effect on HDL cholesterol levels (-4.2%). An additional noteworthy finding is that the R230C variant appears to be specific for the Amerindian populations. Its allele frequency is 0.28 in Mayans, 0.214 in Purepechas, 0.203 in Yaquis and 0.179 among Teenek. In contrast, the C230 allele has not been found in African, European, Chinese or South Asian populations.

SUMMARY

The assessment of the genetic and environmental determinants of hypoalphalipoproteinemia in populations of Native American origin provides an opportunity to assess the population-specific interactions between genes and the environment

Overweight Latino children and adolescents have marked endothelial dysfunction and subclinical vascular inflammation in association with excess body fat and insulin resistance

OBJECTIVE

We measured plasma markers of endothelial dysfunction, vascular inflammation, and pro-coagulation in obese Hispanic/Latino children and adolescents with normal glucose tolerance and determined their relationship to body composition and indexes of glucose and lipid metabolism.

RESEARCH DESIGN AND METHODS

A total of 38 lean or obese Hispanic children and adolescents (10-18 years of age) were selected. The overweight group (n = 21) had a BMI >85th percentile for their age and sex, and the lean group (n = 17) had a BMI between the 25th and 50th percentiles. Studies included an oral glucose tolerance test, measurements of plasma glucose and lipids, several markers of endothelial function and inflammation, and determination of body composition by dual X-ray absorptiometry.

RESULTS

The obese group had higher systolic blood pressure and plasma triglycerides and was more insulin resistant than the lean group. The obese group also had higher plasma soluble intercellular adhesion molecule (259.5 +/- 60.0 vs. 223.2 +/- 47.5 ng/ml, P = 0.047), tumor necrosis factor-alpha (2.57 +/- 1.1 vs. 1.74 +/- 0.6 pg/ml, P = 0.008), high-sensitivity C-reactive protein (2.0 vs. 0.13 mg/l, P < 0.0001), plasminogen-activated inhibitor-1 (47.0 +/- 35.7 vs. 12.0 +/- 5.2 ng/ml, P < 0.0001), tissue plasminogen activator (6.1 +/- 1.9 vs. 4.1 +/- 0.8 ng/ml, P = 0.001), and white blood cell count (6.9 vs. 5.3 x 10(3), P = 0.031) and lower levels of adiponectin (8.7 +/- 3.3 vs. 12.6 +/- 5.2 microg/ml, P = 0.022). No significant differences were observed for soluble vascular cell adhesion molecule or interleukin-6.

CONCLUSIONS

Overweight Hispanic children and adolescents with normal glucose tolerance exhibit increased plasma markers of endothelial dysfunction and subclinical inflammation in association with obesity and insulin resistance. These abnormalities may predispose them to the development of type 2 diabetes and cardiovascular disease.

Cultural approaches to diabetes self-management programs for the Latino community

The issue of diabetes within the Latino population of the United States is of such magnitude that reviewing previously published studies on culturally oriented diabetes self-management interventions is imperative to further understanding and progress on this matter. The purpose of this revision is to illustrate what has been accomplished to date, analyze the lessons learned, and restate the importance of developing culturally relevant interventions for vulnerable populations.

Behavioral Medicine Review: Strategic Management of Diabetes Risk

There is widespread public health concern about the upsurge in diabetes and its cardiometabolic comorbidities. Unfortunately, too many patients still do not receive best practices care. This review discusses some key contributing dynamics as well as considerations for progress toward the more comprehensive, strategic management of diabetes and its associated risks.