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Hanna M, Wabnitz A, Grewal P. Sex and stroke risk factors: A review of differences and impact. J Stroke Cerebrovasc Dis 2024; 33:107624. [PMID: 38316283 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 12/24/2023] [Accepted: 02/02/2024] [Indexed: 02/07/2024] Open
Abstract
OBJECTIVES There is an increase in stroke incidence risk over the lifetime of women, given their longer life expectancy. However, an alarming trend for sex disparities, particularly in certain stroke risk factors, shows a concerning need for focus on sex differences in stroke prevention and treatment for women. In this article, we are addressing sex differences in both traditional and sex-specific stroke risk factors. METHODS We searched PubMed from inception to December 2022 for articles related to sex differences and risk factors for stroke. We reviewed full-text articles for relevance and ultimately included 152 articles for this focused review. RESULTS Women are at increased risk for stroke from both traditional and non-traditional stroke risk factors. As women age, they have a higher disease burden of atrial fibrillation, increased risk of stroke related to diabetes, worsening lipid profiles, and higher prevalence of hypertension and obesity compared to men. Further, women carry sex hormone-specific risk factors for stroke, including the age of menarche, menopause, pregnancy, and its complications, as well as hormonal therapy. Men have a higher prevalence of tobacco use and atrial fibrillation, as well as an increased risk for stroke related to hyperlipidemia. Additionally, men have sex-specific risks related to low testosterone levels. CONCLUSIONS By identifying biological sex-specific risk factors for stroke, developing robust collaborations, researching, and applying the knowledge for risk reduction strategies, we can begin to tailor prevention and reduce the global burden of stroke morbidity and mortality.
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Affiliation(s)
- Mckay Hanna
- Department of Neurology, Medical University of South Carolina, Charleston, SC 29425, United States
| | - Ashley Wabnitz
- Department of Neurology, Medical University of South Carolina, Charleston, SC 29425, United States
| | - Parneet Grewal
- Department of Neurology, Medical University of South Carolina, Charleston, SC 29425, United States.
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Verghese D, Muller L, Velamakanni S. Addressing Cardiovascular Risk Across the Arc of a Woman's Life: Sex-Specific Prevention and Treatment. Curr Cardiol Rep 2023; 25:1053-1064. [PMID: 37498450 DOI: 10.1007/s11886-023-01923-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/07/2023] [Indexed: 07/28/2023]
Abstract
PURPOSE OF REVIEW Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in women in the United States of America. Despite this, women are underdiagnosed, less often receive preventive care, and are undertreated for CVD compared to men. There has been an increase in sex-specific risk factors and treatments over the past decade; however, sex-specific recommendations have not been included in the guidelines. We aim to highlight recent evidence behind the differential effect of traditional risk factors and underscore sex-specific risk factors with an intention to promote awareness, improve risk stratification, and early implementation of appropriate preventive therapies in women. RECENT FINDINGS Women are prescribed fewer antihypertensives and lipid-lowering agents and receive less cardiovascular care as compared to men. Additionally, pregnancy complications have been associated with increased cardiovascular mortality later in life. Findings from the ARIC study suggest that there is a perception of lower risk of cardiovascular disease in women. The SWEDEHEART study which investigated sex differences in treatment, noted a lower prescription of guideline-directed therapy in women. Women are less likely to be prescribed statin medications by their providers in both primary and secondary prevention as they are considered lower risk than men, while also being more likely to decline and discontinue treatment. A woman's abnormal response to pregnancy may serve as her first physiological stress test which can have implications on her future cardiovascular health. This was supported by the CHAMPs study noting a higher premature cardiovascular risk after maternal complications. Adverse pregnancy outcomes have been associated with a 1.5-4.0 fold increase in future cardiovascular events in multiple studies. In this review, we highlight the differences in traditional risk factors and their impact on women. Furthermore, we address the sex-specific risk factors and pregnancy-associated complications that increase the risk of CVD in women. Adherence to GDMT may have implications on overall mortality in women. An effort to improve early recognition of CVD risk with implementation of aggressive risk factor control and lifestyle modification should be emphasized. Future studies should specifically report on differences in outcomes between males and females. Increased awareness and knowledge on sex-specific risks and prevention are likely to lower the prevalence and improve outcomes of CVD in women.
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Affiliation(s)
- Dhiran Verghese
- Section of Non-Invasive Cardiology, Division of Cardiovascular Medicine, Department of Medicine, NCH Rooney Heart Institute, 34102, Naples, FL, USA
| | - Laura Muller
- Section of Non-Invasive Cardiology, Division of Cardiovascular Medicine, Department of Medicine, NCH Rooney Heart Institute, 34102, Naples, FL, USA
| | - Shona Velamakanni
- Section of Non-Invasive Cardiology, Division of Cardiovascular Medicine, Department of Medicine, NCH Rooney Heart Institute, 34102, Naples, FL, USA.
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Ohkuma T, Iwase M, Fujii H, Kitazono T. Sex differences in cardiovascular risk, lifestyle, and psychological factors in patients with type 2 diabetes: the Fukuoka Diabetes Registry. Biol Sex Differ 2023; 14:32. [PMID: 37211595 PMCID: PMC10201708 DOI: 10.1186/s13293-023-00517-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 05/08/2023] [Indexed: 05/23/2023] Open
Abstract
BACKGROUND The excess risk of cardiovascular diseases associated with diabetes is greater in women than in men. The present study aimed to examine sex differences in the control of cardiovascular risk factors, as well as lifestyle and psychological factors, in patients with type 2 diabetes. METHODS A total of 4923 Japanese patients with type 2 diabetes were included in this cross-sectional study. Female/male differences in cardiovascular risk factor levels, and corresponding odds ratios for achieving recommended ranges for preventing cardiovascular diseases and having unhealthy lifestyle and psychological factors were computed by linear and logistic regression models. RESULTS Women were less likely than men to achieve recommended ranges for glycated hemoglobin, low-density lipoprotein cholesterol, non-high-density lipoprotein cholesterol, and obesity-related anthropometric indices such as body mass index and waist circumference, but were more likely than men to be on target for high-density lipoprotein cholesterol and triglycerides. Women were also more likely than men to have an unhealthy lifestyle and psychological factors, including less dietary fiber intake, less leisure-time physical activity, shorter sleep duration, more constipation, and more depressive symptoms. Similar findings were observed when the participants were subgrouped by age (< 65 and ≥ 65 years) and past history of cardiovascular disease. CONCLUSIONS We observed significant sex differences for a range of cardiovascular risk factors, as well as lifestyle and psychological factors, suggesting the importance of adopting a sex-specific approach for the daily clinical management of diabetes.
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Affiliation(s)
- Toshiaki Ohkuma
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Maidashi 3-1-1, Higashi-Ku, Fukuoka, 812-8582, Japan.
| | - Masanori Iwase
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Maidashi 3-1-1, Higashi-Ku, Fukuoka, 812-8582, Japan
- Diabetes Center, Hakujyuji Hospital, Fukuoka, Japan
| | - Hiroki Fujii
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Maidashi 3-1-1, Higashi-Ku, Fukuoka, 812-8582, Japan
- Division of Internal Medicine, Fukuoka Dental College, Fukuoka, Japan
| | - Takanari Kitazono
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Maidashi 3-1-1, Higashi-Ku, Fukuoka, 812-8582, Japan
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Akushevich I, Kravchenko J, Yashkin A, Doraiswamy PM, Hill CV. Expanding the scope of health disparities research in Alzheimer's disease and related dementias: Recommendations from the "Leveraging Existing Data and Analytic Methods for Health Disparities Research Related to Aging and Alzheimer's Disease and Related Dementias" Workshop Series. ALZHEIMER'S & DEMENTIA (AMSTERDAM, NETHERLANDS) 2023; 15:e12415. [PMID: 36935764 PMCID: PMC10020680 DOI: 10.1002/dad2.12415] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 02/06/2023] [Accepted: 02/15/2023] [Indexed: 03/18/2023]
Abstract
Topics discussed at the "Leveraging Existing Data and Analytic Methods for Health Disparities Research Related to Aging and Alzheimer's Disease and Related Dementias" workshop, held by Duke University and the Alzheimer's Association with support from the National Institute on Aging, are summarized. Ways in which existing data resources paired with innovative applications of both novel and well-known methodologies can be used to identify the effects of multi-level societal, community, and individual determinants of race/ethnicity, sex, and geography-related health disparities in Alzheimer's disease and related dementia are proposed. Current literature on the population analyses of these health disparities is summarized with a focus on identifying existing gaps in knowledge, and ways to mitigate these gaps using data/method combinations are discussed at the workshop. Substantive and methodological directions of future research capable of advancing health disparities research related to aging are formulated.
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Affiliation(s)
- Igor Akushevich
- Social Science Research InstituteBiodemography of Aging Research UnitDuke UniversityDurhamNorth CarolinaUSA
| | - Julia Kravchenko
- Duke University School of MedicineDepartment of SurgeryDurhamNorth CarolinaUSA
| | - Arseniy Yashkin
- Social Science Research InstituteBiodemography of Aging Research UnitDuke UniversityDurhamNorth CarolinaUSA
| | - P. Murali Doraiswamy
- Departments of Psychiatry and MedicineDuke University School of MedicineDurhamNorth CarolinaUSA
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Ramezankhani A, Parizadeh D, Azizi F, Hadaegh F. Sex differences in the association between diabetes and hypertension and the risk of stroke: cohort of the Tehran Lipid and Glucose Study. Biol Sex Differ 2022; 13:10. [PMID: 35292081 PMCID: PMC8922930 DOI: 10.1186/s13293-022-00421-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Accepted: 03/06/2022] [Indexed: 12/11/2022] Open
Abstract
Background We assessed the sex differences in the association between blood pressure categories and glucose intolerance status with overall and ischemic stroke among Iranian adults. Methods This prospective study was conducted on 5349 individuals (2446 men) aged ≥ 40 years. Cox models were used to estimate adjusted hazard ratios (HRs) and men-to-women ratios of HRs (RHRs) of overall and ischemic stroke for systolic (SBP) and diastolic (DBP) blood pressure, pre-hypertension, hypertension, fasting plasma glucose (FPG), pre-diabetes and type 2 diabetes (T2D). Results Each 0.55 mmol/L increase in FPG was associated with a higher HR of overall stroke in men than women [RHRs 1.05 (1.01–1.09)]. The associations between each 10 mmHg increase in DBP and stroke events were stronger in men than women, with RHRs of 1.20 (1.00–1.45) and 1.29 (1.04–1.60) for overall and ischemic stroke, respectively. Hypertension was associated with a higher HR of overall [RHRs: 2.41 (1.21–4.8)] and ischemic stroke [2.37 (1.12–5.01)] in men than women. We also found that T2D was associated with higher risks of overall and ischemic stroke in men than women: the RHRs were 2.16 (1.24–3.75) and 1.93 (1.05–3.55) for overall and ischemic stroke, respectively. Conclusion Hypertension and T2D induced higher risk of overall and ischemic stroke in men than women among Iranian population. Supplementary Information The online version contains supplementary material available at 10.1186/s13293-022-00421-7. The associations between diastolic blood pressure and stroke events were stronger in men than women. The fasting blood plasma level was associated with higher risk of stroke events in men than women. Hypertension and diabetes were associated with higher risk of stroke events in men than women. The association between systolic blood pressure with ischemic stroke was higher in men than women.
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Affiliation(s)
- Azra Ramezankhani
- Prevention of Metabolic Disorders Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Donna Parizadeh
- Prevention of Metabolic Disorders Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Fereidoun Azizi
- Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Farzad Hadaegh
- Prevention of Metabolic Disorders Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran. .,Prevention of Metabolic Disorders Research Center, Research Institute for Endocrine Sciences (RIES), Shahid Beheshti University of Medical Science, Number 24, Yemen Street, Shahid Chamran Highway, P.O. Box: 19395-4763, Tehran, Iran.
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Shi Q, Lin Y, Fonseca VA, Shi L. Optimizing treatment goals for long-term health outcomes among patients with type 2 diabetes mellitus. BMJ Open Diabetes Res Care 2021; 9:9/1/e002396. [PMID: 34675042 PMCID: PMC8532550 DOI: 10.1136/bmjdrc-2021-002396] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 10/03/2021] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Considerable confusions on treatment target have resulted from recent changes in guidelines. Evidence in medical guidelines came from clinical trials with highly selected patients, whereas treatment goals may differ in some subgroups. This study aimed to assess optimal treatment goals (A1C, blood pressure, low-density lipoprotein cholesterol (LDL-C)) for patients with type 2 diabetes mellitus (T2DM), which lead to optimal health outcomes by different treatment strategies. RESEARCH DESIGN AND METHODS A retrospective longitudinal study was conducted for veterans with T2DM by using US Veterans Affairs Administrative Database (2005-2015). Medical records were prepared for repeated evaluation performed at 6-month intervals and multivariate longitudinal regression was used to estimate the risk of microvascular and macrovascular complication events. Second-degree polynomial and splines were applied to identify the optimal goals in their associations with lowest risk of clinical outcomes, controlling for demographic characteristics, medical history, and medications. RESULTS A total of 124 651 patients with T2DM were selected, with mean of 6.72 follow-up years. In the general population, to achieve the lowest risk of microvascular and macrovascular complication, the optimal goals were A1C=6.81%, LDL-C=109.10 mg/dL; and A1C=6.76%, LDL-C=111.65 mg/dL, systolic blood pressure (SBP)=130.60 mmHg, respectively. The optimal goals differed between age and racial subgroups. Lower SBP for younger patients and lower LDL-C for black patients were associated with better health outcomes. CONCLUSIONS Optimal treatment goals were identified and multi-faceted treatment strategies targeting hyperglycemia and hyperlipidemia and hypertension may improve health outcome in veterans with T2DM. In addition to guidelines' recommended goals, health systems may examine their own large diverse patients with T2DM for better quality of care.
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Affiliation(s)
- Qian Shi
- Department of Health Policy and Management, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana, USA
| | - Yilu Lin
- Department of Health Policy and Management, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana, USA
| | - Vivian A Fonseca
- Department of Medicine and Pharmacology, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Lizheng Shi
- Department of Health Policy and Management, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana, USA
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Alzubaidi H, Hasan S, Saidawi W, Mc Namara K, Chandir S, Krass I. Outcomes of a novel pharmacy screening intervention to address the burden of type 2 diabetes and cardiovascular disease in an Arabic-speaking country. Diabet Med 2021; 38:e14598. [PMID: 33969536 DOI: 10.1111/dme.14598] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 05/05/2021] [Indexed: 12/28/2022]
Abstract
AIMS Aim of this study is to evaluate the capacity of a pharmacist-delivered screening model for type 2 diabetes and cardiovascular disease (CVD) in identifying and referring individuals at risk. METHOD A screening programme was implemented in 12 community pharmacies in three cities in the United Arab Emirates. Trained pharmacists screened adults (≥40 years) without a previous diagnosis of diabetes or CVD. Most participants were recruited during their visits to the pharmacies; pharmacy-based advertising and social media were also used. The screening included medical history, anthropometric measurements, point-of-care glycated haemoglobin (HbA1c ) levels, and a lipid panel. High-risk individuals (HbA1c ≥ 5.7% [39 mmol/mol], a high diabetes risk score, or a 10-year CVD risk ≥7.5%) were given a referral letter and advised to visit their physician. Risk factors for elevated HbA1c were identified by logistic regression. RESULTS Of the 568 screened participants, 332/568 (58%) were identified to be at risk: HbA1c levels were consistent with diabetes 67/560 (12%) or prediabetes 148/560 (26%), high diabetes risk score 243/566 (43%), CVD risk score > 7.5% 79/541 (15%). Obese people were more likely to have prediabetes or diabetes OR (95% CI): 3.2 (1.3, 7.5), as were those who spent more than 11 h/day sitting: 5.7 (1.8, 17.6). Of the 332 at-risk participants, 206 (62%) responded to a telephone follow-up at six weeks; one-third had discussed screening results with their physician. CONCLUSIONS Community pharmacists detected and referred individuals at risk for diabetes or CVD, although participant follow-up with their physician could be improved. Pharmacy screening is feasible and will potentially improve outcomes.
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Affiliation(s)
- Hamzah Alzubaidi
- College of Pharmacy, University of Sharjah, Sharjah, United Arab Emirates
- Sharjah Institute for Medical Research, University of Sharjah, Sharjah, United Arab Emirates
| | - Sanah Hasan
- Department of Clinical Sciences, College of Pharmacy and Health Sciences, Ajman University, Ajman, United Arab Emirates
| | - Ward Saidawi
- Sharjah Institute for Medical Research, University of Sharjah, Sharjah, United Arab Emirates
| | - Kevin Mc Namara
- School of Medicine, Deakin University, Geelong, Vic., Australia
- Centre for Population Health Research, Deakin University, Burwood, Vic., Australia
| | - Subhash Chandir
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
- IRD Global, Singapore, Singapore
| | - Ines Krass
- School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Camperdown, NSW, Australia
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Madsen TE, Long DL, Carson AP, Howard G, Kleindorfer DO, Furie KL, Manson JE, Liu S, Howard VJ. Sex and Race Differences in the Risk of Ischemic Stroke Associated With Fasting Blood Glucose in REGARDS. Neurology 2021; 97:e684-e694. [PMID: 34045272 DOI: 10.1212/wnl.0000000000012296] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 05/07/2021] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVE To investigate sex and race differences in the association between fasting blood glucose (FBG) and risk of ischemic stroke (IS). METHODS This prospective longitudinal cohort study included adults age ≥45 years at baseline in the Reasons for Geographic And Racial Differences in Stroke Study, followed for a median of 11.4 years. The exposure was baseline FBG (mg/dL); suspected IS events were ascertained by phone every 6 months and were physician-adjudicated. Cox proportional hazards were used to assess the adjusted sex/race-specific associations between FBG (by category and as a restricted cubic spline) and incident IS. RESULTS Of 20,338 participants, mean age was 64.5 (SD 9.3) years, 38.7% were Black, 55.4% were women, 16.2% were using diabetes medications, and 954 IS events occurred. Compared to FBG <100, FBG ≥150 was associated with 59% higher hazards of IS (95% confidence interval [CI] 1.21-2.08) and 61% higher hazards of IS among those on diabetes medications (95% CI 1.12-2.31). The association between FBG and IS varied by race/sex (hazard ratio, FBG ≥150 vs FBG <100: White women 2.05 [95% CI 1.23-3.42], Black women 1.71 [95% CI 1.10-2.66], Black men 1.24 [95% CI 0.75-2.06], White men 1.46 [95% CI 0.93-2.28], p FBG×race/sex = 0.004). Analyses using FBG splines suggest that sex was the major contributor to differences by race/sex subgroups. CONCLUSIONS Sex differences in the strength and shape of the association between FBG and IS are likely driving the significant differences in the association between FBG and IS across race/sex subgroups. These findings should be explored further and may inform tailored stroke prevention guidelines.
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Affiliation(s)
- Tracy E Madsen
- From the Departments of Emergency Medicine (T.E.M.), Neurology (K.L.F.), Epidemiology (S.L.), Medicine (S.L.), and Surgery (S.L.), and Center for Global Cardiometabolic Health, Brown University School of Public Health (S.L.), Alpert Medical School of Brown University, Providence, RI; Departments of Biostatistics (D.L.L., G.H.) and Epidemiology (A.P.C., V.J.H.), School of Public Health, University of Alabama at Birmingham; Department of Neurology (D.O.K.), University of Michigan Medical School, Ann Arbor; and Department of Medicine, Division of Preventive Medicine (J.E.M.), Brigham and Women's Hospital/Harvard Medical School, Boston, MA.
| | - D Leann Long
- From the Departments of Emergency Medicine (T.E.M.), Neurology (K.L.F.), Epidemiology (S.L.), Medicine (S.L.), and Surgery (S.L.), and Center for Global Cardiometabolic Health, Brown University School of Public Health (S.L.), Alpert Medical School of Brown University, Providence, RI; Departments of Biostatistics (D.L.L., G.H.) and Epidemiology (A.P.C., V.J.H.), School of Public Health, University of Alabama at Birmingham; Department of Neurology (D.O.K.), University of Michigan Medical School, Ann Arbor; and Department of Medicine, Division of Preventive Medicine (J.E.M.), Brigham and Women's Hospital/Harvard Medical School, Boston, MA
| | - April P Carson
- From the Departments of Emergency Medicine (T.E.M.), Neurology (K.L.F.), Epidemiology (S.L.), Medicine (S.L.), and Surgery (S.L.), and Center for Global Cardiometabolic Health, Brown University School of Public Health (S.L.), Alpert Medical School of Brown University, Providence, RI; Departments of Biostatistics (D.L.L., G.H.) and Epidemiology (A.P.C., V.J.H.), School of Public Health, University of Alabama at Birmingham; Department of Neurology (D.O.K.), University of Michigan Medical School, Ann Arbor; and Department of Medicine, Division of Preventive Medicine (J.E.M.), Brigham and Women's Hospital/Harvard Medical School, Boston, MA
| | - George Howard
- From the Departments of Emergency Medicine (T.E.M.), Neurology (K.L.F.), Epidemiology (S.L.), Medicine (S.L.), and Surgery (S.L.), and Center for Global Cardiometabolic Health, Brown University School of Public Health (S.L.), Alpert Medical School of Brown University, Providence, RI; Departments of Biostatistics (D.L.L., G.H.) and Epidemiology (A.P.C., V.J.H.), School of Public Health, University of Alabama at Birmingham; Department of Neurology (D.O.K.), University of Michigan Medical School, Ann Arbor; and Department of Medicine, Division of Preventive Medicine (J.E.M.), Brigham and Women's Hospital/Harvard Medical School, Boston, MA
| | - Dawn O Kleindorfer
- From the Departments of Emergency Medicine (T.E.M.), Neurology (K.L.F.), Epidemiology (S.L.), Medicine (S.L.), and Surgery (S.L.), and Center for Global Cardiometabolic Health, Brown University School of Public Health (S.L.), Alpert Medical School of Brown University, Providence, RI; Departments of Biostatistics (D.L.L., G.H.) and Epidemiology (A.P.C., V.J.H.), School of Public Health, University of Alabama at Birmingham; Department of Neurology (D.O.K.), University of Michigan Medical School, Ann Arbor; and Department of Medicine, Division of Preventive Medicine (J.E.M.), Brigham and Women's Hospital/Harvard Medical School, Boston, MA
| | - Karen L Furie
- From the Departments of Emergency Medicine (T.E.M.), Neurology (K.L.F.), Epidemiology (S.L.), Medicine (S.L.), and Surgery (S.L.), and Center for Global Cardiometabolic Health, Brown University School of Public Health (S.L.), Alpert Medical School of Brown University, Providence, RI; Departments of Biostatistics (D.L.L., G.H.) and Epidemiology (A.P.C., V.J.H.), School of Public Health, University of Alabama at Birmingham; Department of Neurology (D.O.K.), University of Michigan Medical School, Ann Arbor; and Department of Medicine, Division of Preventive Medicine (J.E.M.), Brigham and Women's Hospital/Harvard Medical School, Boston, MA
| | - JoAnn E Manson
- From the Departments of Emergency Medicine (T.E.M.), Neurology (K.L.F.), Epidemiology (S.L.), Medicine (S.L.), and Surgery (S.L.), and Center for Global Cardiometabolic Health, Brown University School of Public Health (S.L.), Alpert Medical School of Brown University, Providence, RI; Departments of Biostatistics (D.L.L., G.H.) and Epidemiology (A.P.C., V.J.H.), School of Public Health, University of Alabama at Birmingham; Department of Neurology (D.O.K.), University of Michigan Medical School, Ann Arbor; and Department of Medicine, Division of Preventive Medicine (J.E.M.), Brigham and Women's Hospital/Harvard Medical School, Boston, MA
| | - Simin Liu
- From the Departments of Emergency Medicine (T.E.M.), Neurology (K.L.F.), Epidemiology (S.L.), Medicine (S.L.), and Surgery (S.L.), and Center for Global Cardiometabolic Health, Brown University School of Public Health (S.L.), Alpert Medical School of Brown University, Providence, RI; Departments of Biostatistics (D.L.L., G.H.) and Epidemiology (A.P.C., V.J.H.), School of Public Health, University of Alabama at Birmingham; Department of Neurology (D.O.K.), University of Michigan Medical School, Ann Arbor; and Department of Medicine, Division of Preventive Medicine (J.E.M.), Brigham and Women's Hospital/Harvard Medical School, Boston, MA
| | - Virginia J Howard
- From the Departments of Emergency Medicine (T.E.M.), Neurology (K.L.F.), Epidemiology (S.L.), Medicine (S.L.), and Surgery (S.L.), and Center for Global Cardiometabolic Health, Brown University School of Public Health (S.L.), Alpert Medical School of Brown University, Providence, RI; Departments of Biostatistics (D.L.L., G.H.) and Epidemiology (A.P.C., V.J.H.), School of Public Health, University of Alabama at Birmingham; Department of Neurology (D.O.K.), University of Michigan Medical School, Ann Arbor; and Department of Medicine, Division of Preventive Medicine (J.E.M.), Brigham and Women's Hospital/Harvard Medical School, Boston, MA
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Ahmed S, Spence JD. Sex differences in the intestinal microbiome: interactions with risk factors for atherosclerosis and cardiovascular disease. Biol Sex Differ 2021; 12:35. [PMID: 34001264 PMCID: PMC8130173 DOI: 10.1186/s13293-021-00378-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 04/29/2021] [Indexed: 02/06/2023] Open
Abstract
Background There are clearly sex differences in cardiovascular disease. On average, women experience cardiovascular events at an older age, and at any age, women, on average, have less atherosclerotic plaque than men. The role of the human intestinal microbiome in health and disease has garnered significant interest in recent years, and there have been indications of sex differences in the intestinal microbiome. The purpose of this narrative review was to evaluate evidence of sex differences in the interaction between the intestinal microbiome and risk factors for cardiovascular disease. Several studies have demonstrated changes in microbiota composition and metabolic profile as a function of diet, sex hormones, and host metabolism, among other factors. This dysbiosis has consequently been associated with several disease states, including atherosclerosis and cardiovascular disease. In this respect, there is a growing appreciation for the microbiota and its secreted metabolites, including trimethylamine N-oxide (TMAO), derived from intestinal bacterial metabolic pathways involving dietary choline and l-carnitine, as novel risk factors for atherosclerosis and cardiovascular outcomes. Although traditional risk factors for vascular disease have been studied broadly over the years, there exists little research to evaluate interactions of cardiovascular risk factors with a potentially sexually dimorphic intestinal microbiome. This review evaluates the role of sex differences in the composition of the intestinal microbiome, including effects of sex hormones on the microbiome, and the effects of these sex differences on cardiovascular risk factors. Diabetes and obesity exhibit sexual dimorphism, while the data concerning hypertension and dyslipidemia remain inconclusive based on the available literature. In addition, an increased proportion of gram-negative species capable of driving metabolic endotoxemia and a low-grade inflammatory response, as well as decreased numbers of butyrate-producing species, have been observed in relation to traditional vascular risk factors. In this context, circulating SCFAs and TMAO are recognized as key metabolites of the intestinal microbiome that can be readily measured in the blood for the evaluation of metabolic profile. Conclusion Novel strategies focused on resolving intestinal dysbiosis as a means to slow progression of atherosclerosis and reduce the risk of cardiovascular disease should be evaluated through a lens of sex differences.
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Affiliation(s)
- Shamon Ahmed
- University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - J David Spence
- Stroke Prevention and Atherosclerosis Research Centre, Robarts Research Institute, Western University, 1400 Western Road, London, Ontario, N6G 2V4, Canada.
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Pujante Alarcón P, Menéndez Torre EL, Morales Sánchez P, Rodríguez Escobedo R, Conde Barreiro S, Rojo Martínez G, Delgado Alvarez E. Cardiovascular diseases in people with diabetes mellitus in Spain according to the Primary Care Clinical Database (BDCAP) in 2017. Med Clin (Barc) 2021; 158:153-158. [PMID: 33810870 DOI: 10.1016/j.medcli.2020.12.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 12/26/2020] [Accepted: 12/29/2020] [Indexed: 11/16/2022]
Abstract
INTRODUCTION AND OBJECTIVES Atherosclerotic cardiovascular disease and heart failure are the leading cause of morbidity and mortality in patients with diabetes. The objective of this work is to know the prevalence of atherosclerotic cardiovascular diseases and heart failure in people diagnosed with diabetes in Spain during 2017 and compare them with those not diagnosed with diabetes according to age and sex. METHODS Data for diagnoses of diabetes mellitus (DM), acute myocardial infarction (AMI), stroke, peripheral artery disease (PAD) or heart failure (HF) for 2017 were obtained from the National Health System's Primary Care Clinical Database (BDCAP). RESULTS Comparing people with diabetes and people without diabetes over 35 years of age, the Odds Ratio (OR) for being diagnosed with acute myocardial infarction, stroke, peripheral artery disease or heart failure is about 2 in those over 64 years of age and more than 4 in patients under that age. This OR is superior in females versus males for all diagnoses apart from peripheral artery disease. CONCLUSIONS This study shows the high cardiovascular comorbidity of patients with diabetes in Spain, with a greater excess of risk in patients under 65 years of age, more pronounced in women. We should offer more intensive treatment for DM2 in women.
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Affiliation(s)
- Pedro Pujante Alarcón
- Servicio de Endocrinología y Nutrición, Hospital Universitario Central de Asturias, Oviedo, Asturias, España; Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Asturias, España.
| | - Edelmiro Luis Menéndez Torre
- Servicio de Endocrinología y Nutrición, Hospital Universitario Central de Asturias, Oviedo, Asturias, España; Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Asturias, España
| | - Paula Morales Sánchez
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Asturias, España
| | - Raúl Rodríguez Escobedo
- Servicio de Endocrinología y Nutrición, Hospital Universitario Central de Asturias, Oviedo, Asturias, España
| | | | - Gemma Rojo Martínez
- Servicio de Endocrinología y Nutrición, Hospital Regional de Málaga, IBIMA, Málaga, España
| | - Elías Delgado Alvarez
- Servicio de Endocrinología y Nutrición, Hospital Universitario Central de Asturias, Oviedo, Asturias, España; Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Asturias, España
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11
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Huebschmann AG, Huxley RR, Kohrt WM, Zeitler P, Regensteiner JG, Reusch JEB. Sex differences in the burden of type 2 diabetes and cardiovascular risk across the life course. Diabetologia 2019; 62:1761-1772. [PMID: 31451872 PMCID: PMC7008947 DOI: 10.1007/s00125-019-4939-5] [Citation(s) in RCA: 186] [Impact Index Per Article: 37.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Accepted: 05/29/2019] [Indexed: 12/11/2022]
Abstract
By 2017 estimates, diabetes mellitus affects 425 million people globally; approximately 90-95% of these have type 2 diabetes. This narrative review highlights two domains of sex differences related to the burden of type 2 diabetes across the life span: sex differences in the prevalence and incidence of type 2 diabetes, and sex differences in the cardiovascular burden conferred by type 2 diabetes. In the presence of type 2 diabetes, the difference in the absolute rates of cardiovascular disease (CVD) between men and women lessens, albeit remaining higher in men. Large-scale observational studies suggest that type 2 diabetes confers 25-50% greater excess risk of incident CVD in women compared with men. Physiological and behavioural mechanisms that may underpin both the observed sex differences in the prevalence of type 2 diabetes and the associated cardiovascular burden are discussed in this review. Gender differences in social behavioural norms and disparities in provider-level treatment patterns are also highlighted, but not described in detail. We conclude by discussing research gaps in this area that are worthy of further investigation.
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Affiliation(s)
- Amy G Huebschmann
- Center for Women's Health Research, University of Colorado School of Medicine, MS C263, 12348 E. Montview Boulevard, Aurora, CO, 80045, USA
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Rachel R Huxley
- College of Science, Health and Engineering, La Trobe University, Melbourne, VIC, Australia
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Wendy M Kohrt
- Center for Women's Health Research, University of Colorado School of Medicine, MS C263, 12348 E. Montview Boulevard, Aurora, CO, 80045, USA
- Division of Geriatric Medicine, University of Colorado School of Medicine, Aurora, CO, USA
- Department of Medicine, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, CO, USA
| | - Philip Zeitler
- Division of Pediatric Endocrinology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Judith G Regensteiner
- Center for Women's Health Research, University of Colorado School of Medicine, MS C263, 12348 E. Montview Boulevard, Aurora, CO, 80045, USA
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO, USA
- Division of Cardiology, University of Colorado School of Medicine (CU-SOM), Aurora, CO, USA
| | - Jane E B Reusch
- Center for Women's Health Research, University of Colorado School of Medicine, MS C263, 12348 E. Montview Boulevard, Aurora, CO, 80045, USA.
- Department of Medicine, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, CO, USA.
- Division of Endocrinology, Metabolism and Diabetes, University of Colorado School of Medicine, Aurora, CO, USA.
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12
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Malla G, Long DL, Judd SE, Irvin MR, Kissela BM, Lackland DT, Safford MM, Levine DA, Howard VJ, Howard G, Rhodes JD, Voeks JH, Kleindorfer DO, Anderson A, Meschia JF, Carson AP. Does the Association of Diabetes With Stroke Risk Differ by Age, Race, and Sex? Results From the REasons for Geographic and Racial Differences in Stroke (REGARDS) Study. Diabetes Care 2019; 42:1966-1972. [PMID: 31391199 PMCID: PMC7011202 DOI: 10.2337/dc19-0442] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 07/15/2019] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Given temporal changes in diabetes prevalence and stroke incidence, this study investigated age, race, and sex differences in the diabetes-stroke association in a contemporary prospective cohort, the REasons for Geographic and Racial Differences in Stroke (REGARDS) Study. RESEARCH DESIGN AND METHODS We included 23,002 non-Hispanic black and white U.S. adults aged ≥45 years without prevalent stroke at baseline (2003-2007). Diabetes was defined as fasting glucose ≥126 mg/dL, random glucose ≥200 mg/dL, or use of glucose-lowering medication. Incident stroke events were expert adjudicated and available through September 2017. RESULTS The prevalence of diabetes was 19.1% at baseline. During follow-up, 1,018 stroke events occurred. Among adults aged <65 years, comparing those with diabetes to those without diabetes, the risk of stroke was increased for white women (hazard ratio [HR] 3.72 [95% CI 2.10-6.57]), black women (HR 1.88 [95% CI 1.22-2.90]), and white men (HR 2.01 [95% CI 1.27-3.27]) but not black men (HR 1.27 [95% CI 0.77-2.10]) after multivariable adjustment. Among those aged ≥65 years, diabetes increased the risk of stroke for white women and black men, but not black women (HR 1.05 [95% CI 0.74-1.48]) or white men (HR 0.86 [95% CI 0.62-1.21]). CONCLUSIONS In this contemporary cohort, the diabetes-stroke association varied by age, race, and sex together, with a more pronounced effect observed among adults aged <65 years. With the recent increase in the burden of diabetes complications at younger ages in the U.S., additional efforts are needed earlier in life for stroke prevention among adults with diabetes.
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Affiliation(s)
- Gargya Malla
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL
| | - D Leann Long
- Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, AL
| | - Suzanne E Judd
- Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, AL
| | - Marguerite R Irvin
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL
| | - Brett M Kissela
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati Gardner Neuroscience Institute, Cincinnati, OH
| | - Daniel T Lackland
- Department of Neurology, Medical University of South Carolina, Charleston, SC
| | - Monika M Safford
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Deborah A Levine
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Virginia J Howard
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL
| | - George Howard
- Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, AL
| | - J David Rhodes
- Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, AL
| | - Jenifer H Voeks
- Department of Neurology, Medical University of South Carolina, Charleston, SC
| | - Dawn O Kleindorfer
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati Gardner Neuroscience Institute, Cincinnati, OH
| | - Aaron Anderson
- Department of Neurology, Emory University School of Medicine, Atlanta, GA
| | | | - April P Carson
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL
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Wang Y, O'Neil A, Jiao Y, Wang L, Huang J, Lan Y, Zhu Y, Yu C. Sex differences in the association between diabetes and risk of cardiovascular disease, cancer, and all-cause and cause-specific mortality: a systematic review and meta-analysis of 5,162,654 participants. BMC Med 2019; 17:136. [PMID: 31296205 PMCID: PMC6625042 DOI: 10.1186/s12916-019-1355-0] [Citation(s) in RCA: 94] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Accepted: 05/29/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Studies have suggested sex differences in the mortality rate associated with diabetes. We conducted a meta-analysis to estimate the relative effect of diabetes on the risk of all-cause, cancer, cardiovascular disease (CVD), infectious disease, and respiratory disease mortality in women compared with men. METHODS Studies published from their inception to April 1, 2018, identified through a systematic search of PubMed and EMBASE and review of references. We used the sex-specific RRs to derive the women-to-men ratio of RRs (RRR) and 95% CIs from each study. Subsequently, the RRR for each outcome was pooled with random-effects meta-analysis weighted by the inverse of the variances of the log RRRs. RESULTS Forty-nine studies with 86 prospective cohorts met the inclusion criteria and were eligible for analysis. The pooled women-to-men RRR showed a 13% greater risk of all-cause mortality associated with diabetes in women than in men (RRR 1.13, 95% CI 1.07 to 1.19; P < 0.001). The pooled multiple-adjusted RRR indicated a 30% significantly greater excess risk of CVD mortality in women with diabetes compared with men (RRR 1.30, 95% CI 1.13 to 1.49; P < 0.001). Compared with men with diabetes, women with diabetes had a 58% greater risk of coronary heart disease (CHD) mortality, but only an 8% greater risk of stroke mortality (RRRCHD 1.58, 95% CI 1.32 to 1.90; P < 0.001; RRRstroke 1.08, 95% CI 1.01 to 1.15; P < 0.001). However, no sex differences were observed in pooled results of populations with or without diabetes for all-cancer (RRR 1.02, 95% CI 0.98 to 1.06; P = 0.21), infectious (RRR 1.13, 95% CI 0.90 to 1.38; P = 0.33), and respiratory mortality (RRR 1.08, 95% CI 0.95 to 1.23; P = 0.26). CONCLUSIONS Compared with men with the same condition, women with diabetes have a 58% and 13% greater risk of CHD and all-cause mortality, respectively, although there was a significant heterogeneity between studies. This points to an urgent need to develop sex- and gender-specific risk assessment strategies and therapeutic interventions that target diabetes management in the context of CHD prevention.
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Affiliation(s)
- Yafeng Wang
- Department of Epidemiology and Biostatistics, School of Health Sciences, Wuhan University, 185 Donghu Road, Wuchang District, Wuhan, 430071, China
| | - Adrienne O'Neil
- Melbourne School of Population and Global Health, University of Melbourne, Carlton, Australia
| | - Yurui Jiao
- Department of Endocrinology, Second Clinical Medical College, Shanxi Medical University, 382 Wuyi Road, Taiyuan, 030001, China
| | - Lijun Wang
- Department of Neurology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Jingxin Huang
- School of Nursing, Guangdong Pharmaceutical University, 283 Jianghai Avenue, Haizhu District, Guangzhou, China
| | - Yutao Lan
- School of Nursing, Guangdong Pharmaceutical University, 283 Jianghai Avenue, Haizhu District, Guangzhou, China
| | - Yikun Zhu
- Department of Endocrinology, Second Clinical Medical College, Shanxi Medical University, 382 Wuyi Road, Taiyuan, 030001, China.
| | - Chuanhua Yu
- Department of Epidemiology and Biostatistics, School of Health Sciences, Wuhan University, 185 Donghu Road, Wuchang District, Wuhan, 430071, China. .,Global Health Institute, Wuhan University, Wuhan, China.
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14
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Xu G, You D, Wong L, Duan D, Kong F, Zhang X, Zhao J, Xing W, Li L, Han L. Risk of all-cause and CHD mortality in women versus men with type 2 diabetes: a systematic review and meta-analysis. Eur J Endocrinol 2019; 180:243-255. [PMID: 30668524 PMCID: PMC6391911 DOI: 10.1530/eje-18-0792] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 01/21/2019] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Previous studies have shown sex-specific differences in all-cause and CHD mortality in type 2 diabetes. We performed a systematic review and meta-analysis to provide a global picture of the estimated influence of type 2 diabetes on the risk of all-cause and CHD mortality in women vs men. METHODS We systematically searched PubMed, EMBASE and Web of Science for studies published from their starting dates to Aug 7, 2018. The sex-specific hazard ratios (HRs) and their pooled ratio (women vs men) of all-cause and CHD mortality associated with type 2 diabetes were obtained through an inverse variance-weighted random-effects meta-analysis. Subgroup analyses were used to explore the potential sources of heterogeneity. RESULTS The 35 analyzed prospective cohort studies included 2 314 292 individuals, among whom 254 038 all-cause deaths occurred. The pooled women vs men ratio of the HRs for all-cause and CHD mortality were 1.17 (95% CI: 1.12-1.23, I2 = 81.6%) and 1.97 (95% CI: 1.49-2.61, I2 = 86.4%), respectively. The pooled estimate of the HR for all-cause mortality was approximately 1.30 in articles in which the duration of follow-up was longer than 10 years and 1.10 in articles in which the duration of follow-up was less than 10 years. The pooled HRs for all-cause mortality in patients with type 2 diabetes was 2.33 (95% CI: 2.02-2.69) in women and 1.91 (95% CI: 1.72-2.12) in men, compared with their healthy counterparts. CONCLUSIONS The effect of diabetes on all-cause and CHD mortality is approximately 17 and 97% greater, respectively, for women than for men.
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Affiliation(s)
- Guodong Xu
- Department of Epidemiology, Zhejiang Provincial Key Laboratory of Pathophysiology, School of Medicine, Ningbo University, Ningbo
| | - Dingyun You
- Department of Science and Technology, Kunming Medical University, Kunming, China
| | - Liping Wong
- Department of Social and Preventive Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Donghui Duan
- Department of Epidemiology, Zhejiang Provincial Key Laboratory of Pathophysiology, School of Medicine, Ningbo University, Ningbo
| | - Fanqian Kong
- Department of Epidemiology, Zhejiang Provincial Key Laboratory of Pathophysiology, School of Medicine, Ningbo University, Ningbo
| | - Xiaohong Zhang
- Department of Epidemiology, Zhejiang Provincial Key Laboratory of Pathophysiology, School of Medicine, Ningbo University, Ningbo
| | - Jinshun Zhao
- Department of Epidemiology, Zhejiang Provincial Key Laboratory of Pathophysiology, School of Medicine, Ningbo University, Ningbo
| | - Wenhua Xing
- Department of Epidemiology, Zhejiang Provincial Key Laboratory of Pathophysiology, School of Medicine, Ningbo University, Ningbo
- Correspondence should be addressed to L Han or L Li or W Xing; or or
| | - Li Li
- Department of Endocrinology and Metabolism, Ningbo First Hospital, Ningbo, Zhejiang, China
- Correspondence should be addressed to L Han or L Li or W Xing; or or
| | - Liyuan Han
- Department of Epidemiology, Zhejiang Provincial Key Laboratory of Pathophysiology, School of Medicine, Ningbo University, Ningbo
- Correspondence should be addressed to L Han or L Li or W Xing; or or
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15
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Al-Salameh A, Chanson P, Bucher S, Ringa V, Becquemont L. Cardiovascular Disease in Type 2 Diabetes: A Review of Sex-Related Differences in Predisposition and Prevention. Mayo Clin Proc 2019; 94:287-308. [PMID: 30711127 DOI: 10.1016/j.mayocp.2018.08.007] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Revised: 07/24/2018] [Accepted: 08/06/2018] [Indexed: 12/31/2022]
Abstract
Type 2 diabetes mellitus is a major risk factor for cardiovascular disease. However, compiled data suggest that type 2 diabetes affects the risk of cardiovascular disease differentially according to sex. In recent years, large meta-analyses have confirmed that women with type 2 diabetes have a higher relative risk of incident coronary heart disease, fatal coronary heart disease, and stroke compared with their male counterparts. The reasons for these disparities are not completely elucidated. A greater burden of cardiometabolic risk in women was proposed as a partial explanation. Indeed, several studies suggest that women experience a larger deterioration in major cardiovascular risk factors and put on more weight than do men during their transition from normoglycemia to overt type 2 diabetes. This excess weight is associated with higher levels of biomarkers of endothelial dysfunction, inflammation, and procoagulant state. Moreover, sex differences in the prescription and use of some cardiovascular drugs may compound an "existing" disparity. We searched PubMed for articles published in English and French, by using the following terms: ("cardiovascular diseases") AND ("diabetes mellitus") AND ("sex disparity" OR "sex differences" OR "sex related differences" OR "sex-related differences" OR "sex disparities"). In this article, we review the available literature on the sex aspects of primary and secondary prevention of cardiovascular disease in people with type 2 diabetes, in the predisposition to cardiovascular disease in those people, and in the control of diabetes and associated cardiovascular risk factors.
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Affiliation(s)
- Abdallah Al-Salameh
- Centre de recherche en Epidémiologie et Santé des Populations (CESP), Université Paris-Sud, Université Paris-Saclay, INSERM, Villejuif, France; Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Le Kremlin-Bicêtre, France; Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Centre de Recherche Clinique Paris-Sud, Le Kremlin-Bicêtre, France.
| | - Philippe Chanson
- Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Le Kremlin-Bicêtre, France; Faculté de Médecine, Université Paris-Sud, Université Paris-Saclay, Le Kremlin-Bicêtre, France; INSERM U1185, Faculté de Médecine, Université Paris-Sud, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Sophie Bucher
- Centre de recherche en Epidémiologie et Santé des Populations (CESP), Université Paris-Sud, Université Paris-Saclay, INSERM, Villejuif, France; General Practice Department, Paris-Sud Faculty of Medicine, Paris-Sud University, Le Kremlin-Bicêtre, France
| | - Virginie Ringa
- Centre de recherche en Epidémiologie et Santé des Populations (CESP), Université Paris-Sud, Université Paris-Saclay, INSERM, Villejuif, France
| | - Laurent Becquemont
- Centre de recherche en Epidémiologie et Santé des Populations (CESP), Université Paris-Sud, Université Paris-Saclay, INSERM, Villejuif, France; Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Centre de Recherche Clinique Paris-Sud, Le Kremlin-Bicêtre, France; Pharmacology Department, Paris-Sud Faculty of Medicine, Paris-Sud University, Le Kremlin-Bicêtre, France
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16
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Millett ERC, Peters SAE, Woodward M. Sex differences in risk factors for myocardial infarction: cohort study of UK Biobank participants. BMJ 2018; 363:k4247. [PMID: 30404896 PMCID: PMC6364292 DOI: 10.1136/bmj.k4247] [Citation(s) in RCA: 175] [Impact Index Per Article: 29.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVES To investigate sex differences in risk factors for incident myocardial infarction (MI) and whether they vary with age. DESIGN Prospective population based study. SETTING UK Biobank. PARTICIPANTS 471 998 participants (56% women; mean age 56.2) with no history of cardiovascular disease. MAIN OUTCOME MEASURE Incident (fatal and non-fatal) MI. RESULTS 5081 participants (1463 (28.8%) of whom were women) had MI over seven years' mean follow-up, resulting in an incidence per 10 000 person years of 7.76 (95% confidence interval 7.37 to 8.16) for women and 24.35 (23.57 to 25.16) for men. Higher blood pressure indices, smoking intensity, body mass index, and the presence of diabetes were associated with an increased risk of MI in men and women, but associations were attenuated with age. In women, systolic blood pressure and hypertension, smoking status and intensity, and diabetes were associated with higher hazard ratios for MI compared with men: ratio of hazard ratios 1.09 (95% confidence interval 1.02 to 1.16) for systolic blood pressure, 1.55 (1.32 to 1.83) for current smoking, 2.91 (1.56 to 5.45) for type 1 diabetes, and 1.47 (1.16 to 1.87) for type 2 diabetes. There was no evidence that any of these ratios of hazard ratios decreased with age (P>0.2). With the exception of type 1 diabetes, the incidence of MI was higher in men than in women for all risk factors. CONCLUSIONS Although the incidence of MI was higher in men than in women, several risk factors were more strongly associated with MI in women compared with men. Sex specific associations between risk factors and MI declined with age, but, where it occurred, the higher relative risk in women remained. As the population ages and the prevalence of lifestyle associated risk factors increase, the incidence of MI in women will likely become more similar to that in men.
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Affiliation(s)
| | - Sanne A E Peters
- The George Institute for Global Health, University of Oxford, Oxford OX1 2BQ, UK
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
| | - Mark Woodward
- The George Institute for Global Health, University of Oxford, Oxford OX1 2BQ, UK
- The George Institute for Global Health, University of New South Wales, Newtown, NSW, Australia
- Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA
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17
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Moise N, Bertoni AG. Invited Commentary: Sex and Race Differences in Diabetes and Cardiovascular Disease-Achieving the Promise of Sex and Race Subgroup Analyses in Epidemiologic Research. Am J Epidemiol 2018; 187:411-414. [PMID: 29036280 DOI: 10.1093/aje/kwx327] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 07/27/2017] [Indexed: 12/14/2022] Open
Abstract
Diabetes confers a higher risk of cardiovascular disease on women than on men. The reasons for these sex differences, such as poorer cardiovascular risk factor profiles, have received considerable attention. However, a recent report on sex × diabetes interactions on cardiovascular disease identified that few if any prior studies have confirmed these sex differences in black individuals, despite known diabetes-related disparities. In this issue of the Journal, George et al. (Am J Epidemiol. 2018;187(3):403-410.) found marginally significant multiplicative sex × diabetes interactions in black but not white study participants after adjustments for traditional and behavioral risk factors, competing risk, and change in diabetes status over time. This study is notable for its attempt to fill an important literature gap, and it elegantly addressed multiple statistical considerations in assessing sex × diabetes interactions according to race strata. The findings also highlighted several important considerations for conducting race and sex subgroup analyses.
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Affiliation(s)
- Nathalie Moise
- Center for Behavioral Cardiovascular Health, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Alain G Bertoni
- Maya Angelou Center for Health Equity and Department of Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem, North Carolina
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18
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Read SH, McAllister DA, Colhoun HM, Farran B, Fischbacher C, Kerssens JJ, Leese GP, Lindsay RS, McCrimmon RJ, McGurnaghan S, Philip S, Sattar N, Wild SH. Incident ischaemic stroke and Type 2 diabetes: trends in incidence and case fatality in Scotland 2004-2013. Diabet Med 2018; 35:99-106. [PMID: 29044687 DOI: 10.1111/dme.13528] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/12/2017] [Indexed: 11/27/2022]
Abstract
AIM To describe trends in first ischaemic stroke incidence and case fatality in adults with and without a diagnosis of Type 2 diabetes prior to their ischaemic stroke event in Scotland between 2004 and 2013. METHODS Using population-wide hospital admission, death and diabetes datasets, we conducted a retrospective cohort study. Negative binomial and logistic regression models were used to calculate year-specific incidence and case-fatality rates for people with Type 2 diabetes and for people without diabetes. RESULTS During 41.0 million person-years of follow-up there were 69 757 ischaemic stroke events. Type 2 diabetes prevalence among patients who experienced ischaemic stroke increased from 13.5% to 20.3% between 2004 and 2013. Stroke incidence rates declined by 2.7% (95% CI 2.4, 3.0) annually for people with and without diabetes [diabetes/year interaction: rate ratio 0.99 (95% CI 0.98, 1.01)]. Type 2 diabetes was associated with an increased risk of ischaemic stroke in men [rate ratio 1.23 (95% CI 1.17, 1.30)] and women [rate ratio 1.41 (95% CI 1.35, 1.48)]. Case-fatality rates were 14.2% and 12.7% in people with Type 2 diabetes and without diabetes, respectively. Case fatality declined by 3.5% (95% CI 2.7, 4.5) annually [diabetes/year interaction: odds ratio 1.01 (95% CI 0.98, 1.02)]. CONCLUSIONS Ischaemic stroke incidence declined no faster in people with a diagnosis of Type 2 diabetes than in people without diabetes. Increasing prevalence of Type 2 diabetes among stroke patients may mean that declines in case fatality over time will be less marked in the future.
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Affiliation(s)
- S H Read
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - D A McAllister
- Institutes of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - H M Colhoun
- Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, UK
| | - B Farran
- Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, UK
| | - C Fischbacher
- Information Services Division, NHS National Services, Edinburgh, UK
| | - J J Kerssens
- Information Services Division, NHS National Services, Edinburgh, UK
| | - G P Leese
- Department of Diabetes and Endocrinology, University of Dundee, Dundee, UK
| | - R S Lindsay
- Institutes of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - R J McCrimmon
- Division of Molecular and Clinical Medicine, University of Dundee, Dundee, UK
| | - S McGurnaghan
- Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, UK
| | - S Philip
- Department of Diabetes and Endocrinology, NHS Grampian, Aberdeen, UK
| | - N Sattar
- BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - S H Wild
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
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Dupre ME, Nelson A, Lynch SM, Granger BB, Xu H, Churchill E, Willis JM, Curtis LH, Peterson ED. Socioeconomic, Psychosocial and Behavioral Characteristics of Patients Hospitalized With Cardiovascular Disease. Am J Med Sci 2017; 354:565-572. [PMID: 29208253 DOI: 10.1016/j.amjms.2017.07.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Revised: 06/13/2017] [Accepted: 07/24/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND Recent studies have drawn attention to nonclinical factors to better understand disparities in the development, treatment and prognosis of patients with cardiovascular disease. However, there has been limited research describing the nonclinical characteristics of patients hospitalized for cardiovascular care. METHODS Data for this study come from 520 patients admitted to the Duke Heart Center from January 1, 2015 through January 10, 2017. Electronic medical records and a standardized survey administered before discharge were used to ascertain detailed information on patients' demographic (age, sex, race, marital status and living arrangement), socioeconomic (education, employment and health insurance), psychosocial (health literacy, health self-efficacy, social support, stress and depressive symptoms) and behavioral (smoking, drinking and medication adherence) attributes. RESULTS Study participants were of a median age of 65 years, predominantly male (61.4%), non-Hispanic white (67.1%), hospitalized for 5.11 days and comparable to all patients admitted during this period. Results from the survey showed significant heterogeneity among patients in their demographic, socioeconomic and behavioral characteristics. We also found that the patients' levels of psychosocial risks and resources were significantly associated with many of these nonclinical characteristics. Patients who were older, women, nonwhite and unmarried had generally lower levels of health literacy, self-efficacy and social support, and higher levels of stress and depressive symptoms than their counterparts. CONCLUSIONS Patients hospitalized with cardiovascular disease have diverse nonclinical profiles that have important implications for targeting interventions. A better understanding of these characteristics will enhance the personalized delivery of care and improve outcomes in vulnerable patient groups.
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Affiliation(s)
- Matthew E Dupre
- Duke Clinical Research Institute, Duke University, Durham, North Carolina; Department of Population Health Sciences, Duke University, Durham, North Carolina; Department of Sociology, Duke University, Durham, North Carolina.
| | - Alicia Nelson
- Department of Community and Family Medicine, Duke University, Durham, North Carolina
| | - Scott M Lynch
- Department of Sociology, Duke University, Durham, North Carolina
| | - Bradi B Granger
- Duke School of Nursing, Duke University Medical Center, Durham, North Carolina
| | - Hanzhang Xu
- Duke School of Nursing, Duke University Medical Center, Durham, North Carolina
| | - Erik Churchill
- Duke Office of Clinical Research, Duke University Medical Center, Durham, North Carolina
| | - Janese M Willis
- Department of Community and Family Medicine, Duke University, Durham, North Carolina
| | - Lesley H Curtis
- Duke Clinical Research Institute, Duke University, Durham, North Carolina; Department of Population Health Sciences, Duke University, Durham, North Carolina
| | - Eric D Peterson
- Duke Clinical Research Institute, Duke University, Durham, North Carolina; Department of Medicine, Duke University, Durham, North Carolina
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20
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Dong X, Cai R, Sun J, Huang R, Wang P, Sun H, Tian S, Wang S. Diabetes as a risk factor for acute coronary syndrome in women compared with men: a meta-analysis, including 10 856 279 individuals and 106 703 acute coronary syndrome events. Diabetes Metab Res Rev 2017; 33. [PMID: 28103417 DOI: 10.1002/dmrr.2887] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Revised: 09/17/2016] [Accepted: 01/16/2017] [Indexed: 11/11/2022]
Abstract
BACKGROUND Diabetes mellitus is a significant cause of death and disability worldwide and is a strong risk factor for acute coronary syndrome (ACS). Whether diabetes confers the same excess risk of ACS in both sexes is unknown. Therefore, we undertook a meta-analysis to estimate the relative risk (RR) for ACS associated with diabetes in men and women. METHODS We systematically searched PubMed, Embase, and Cochrane Library databases for both case-control and cohort studies published between January 1, 1966, and January 1, 2015. Studies were included if they reported sex-specific estimates of the RR, hazard ratio, or odds ratio for the association between diabetes and ACS. We pooled the sex-specific RR and the ratio between women and men using a random-effect model with inverse-variance weighting. RESULTS We included 9 case-control and 10 cohort studies with data for 10 856 279 individuals and at least 106 703 fatal and nonfatal ACS events. The pooled maximum-adjusted RR of ACS associated with diabetes was 2.46 (95% CI, 1.92-3.17) in women and 1.68 (95% CI, 1.39-2.04) in men. In patients with diabetes compared with those without diabetes, women had a significantly greater risk of ACS-the pooled women-to-men RR and the ratio of relative risks was 1.38 (95% CI, 1.25-1.52; P < .001), with no evidence of publication bias. CONCLUSIONS The excess risk of ACS associated with diabetes is significantly higher in women than in men. This finding may be explained by more adverse cardiovascular risk profiles and suggests that further work is needed to clarify the relevant biological, behavioural, and social mechanisms.
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Affiliation(s)
- Xue Dong
- Department of Endocrinology, Affiliated ZhongDa Hospital of Southeast University, Medical School of Southeast University, Nanjing, China
| | - Rongrong Cai
- Medical School of Southeast University, Nanjing, China
| | - Jie Sun
- Medical School of Southeast University, Nanjing, China
| | - Rong Huang
- Medical School of Southeast University, Nanjing, China
| | - Pin Wang
- Medical School of Southeast University, Nanjing, China
| | - Haixia Sun
- Medical School of Southeast University, Nanjing, China
| | - Sai Tian
- Medical School of Southeast University, Nanjing, China
| | - Shaohua Wang
- Department of Endocrinology, Affiliated ZhongDa Hospital of Southeast University, Medical School of Southeast University, Nanjing, China
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21
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Maciejewski ML, Hammill BG, Bayliss EA, Ding L, Voils CI, Curtis LH, Wang V. Prescriber Continuity and Disease Control of Older Adults. Med Care 2017; 55:405-410. [PMID: 27755393 PMCID: PMC5352484 DOI: 10.1097/mlr.0000000000000658] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Medicare beneficiaries with multiple chronic conditions are typically seen by multiple providers, particularly specialists. Clinically appropriate referrals to multiple specialists may compromise the continuity of care for multiple chronic condition beneficiaries and create care plans that patients may find challenging to reconcile, which may impact patient outcomes. OBJECTIVE The objective was to examine whether glycemic control or lipid control was associated with the number of prescribers of cardiometabolic medications. RESEARCH DESIGN, SUBJECTS, AND MEASURES A retrospective cross-sectional cohort analysis of 51,879 elderly Medicare fee-for-service beneficiaries with diabetes and 129,762 beneficiaries with dyslipidemia living in 10 east coast states. Glycemic control was defined as having an HbA1c<7.5. Lipid control was defined as an low-density lipoprotein<100 for beneficiaries with heart disease or diabetes or an low-density lipoprotein<130 for all other beneficiaries. We examined the association between the number of prescribers of cardiometabolic medications and disease or lipid control in 2011 through logistic regression, controlling for age, sex, race, Medicaid enrollment, 17 chronic conditions and state-fixed effects. RESULTS Among beneficiaries with diabetes, 76% with one prescriber had well-controlled diabetes in 2011, which decreased to 65% for beneficiaries with 5+ prescribers. In adjusted analyses, Medicare beneficiaries with 3 or more prescribers were less likely to have glycemic control than beneficiaries with a single prescriber. Among those with dyslipidemia, nearly all (91%-92%) beneficiaries had lipid control. After adjustment for demographics and comorbidity burden, beneficiaries with 3 prescribers were less likely to have lipid control than beneficiaries with a single prescriber. CONCLUSIONS Multiple prescribers were associated with worse disease control, possibly because patients with more severe diabetes or dyslipidemia have multiple prescribers or because care fragmentation is associated with worse disease control.
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Affiliation(s)
- Matthew L. Maciejewski
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center
- Division of General Internal Medicine, Department of Medicine, Duke University Medical Center
| | | | - Elizabeth A. Bayliss
- Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado Department of Family Medicine, University of Colorado Denver, Aurora, Colorado
| | - Laura Ding
- Department of Biostatistics and Bioinformatics, Duke University
| | - Corrine I. Voils
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center
- Division of General Internal Medicine, Department of Medicine, Duke University Medical Center
| | - Lesley H. Curtis
- Duke Clinical Research Institute, Duke University Medical Center
| | - Virginia Wang
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center
- Division of General Internal Medicine, Department of Medicine, Duke University Medical Center
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Liu F, Yang X, Li J, Cao J, Chen J, Li Y, Liu X, Zhao L, Shen C, Yu L, Huang J, Gu D. Association of fasting glucose levels with incident atherosclerotic cardiovascular disease: An 8-year follow-up study in a Chinese population. J Diabetes 2017; 9:14-23. [PMID: 26840038 DOI: 10.1111/1753-0407.12380] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Revised: 12/28/2015] [Accepted: 01/20/2016] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Identification of the population at high risk of developing atherosclerotic cardiovascular disease (ASCVD) is critical for its prevention. The aim of the present study was to evaluate the use of fasting blood glucose (FBG) to predict ASCVD. METHODS In all, 18 610 participants, aged 35-74 years at enrollment, were included in this prospective study. Baseline information was collected using a standardized questionnaire, physical examinations, and laboratory tests. During follow-up, disease status and vital information were updated. Cox proportional hazards regression analysis was used to estimate associations, with normal FBG (70-99 mg/dL) as the reference group. Anthropometric measurements, socioeconomic status, and conventional cardiovascular risk factors were included in the multivariate-adjusted model. RESULTS After 7.8 years follow-up (145 223 person-years), there were 519 cases of ASCVD. The multivariate-adjusted hazard ratios (HR), with 95% confidence intervals (CI), for ASCVD in patients with low FBG (<70 mg/dL), impaired fasting glucose (IFG; 100-125 mg/dL), and diabetes (≥126 mg/dL, use of antidiabetic medication and/or self-report) were 1.35 (0.84, 2.15), 1.02 (0.81, 1.27), and 1.68 (1.26, 2.23), respectively. Although IFG was associated with the development of diabetes (multivariate-adjusted HR 3.67; 95% CI 3.20, 4.21), it was only associated with incident ASCVD in the univariate model (HR 1.52; 95% CI 1.23, 1.88). The association of diabetes with coronary heart disease was more pronounced than that with stroke. Gender and residential differences were also identified. CONCLUSIONS In the present study, IFG was associated with the development of diabetes but not incident ASCVD. Prevention strategies to reduce the development of diabetes in people with IFG are critical to improve cardiovascular health.
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Affiliation(s)
- Fangchao Liu
- Department of Epidemiology, Fuwai Hospital, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xueli Yang
- Department of Epidemiology, Fuwai Hospital, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jianxin Li
- Department of Epidemiology, Fuwai Hospital, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jie Cao
- Department of Epidemiology, Fuwai Hospital, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jichun Chen
- Department of Epidemiology, Fuwai Hospital, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ying Li
- Department of Epidemiology, Fuwai Hospital, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaoqing Liu
- Division of Epidemiology, Guangdong Provincial People's Hospital and Cardiovascular Institute, Guangzhou, China
| | - Liancheng Zhao
- Department of Epidemiology, Fuwai Hospital, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Chong Shen
- Department of Epidemiology and Biostatistics, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Ling Yu
- Department of Cardiology, Fujian Provincial People's Hospital, Fuzhou, China
| | - Jianfeng Huang
- Department of Epidemiology, Fuwai Hospital, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Dongfeng Gu
- Department of Epidemiology, Fuwai Hospital, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Liu Z, Zhou Z, Huang G, Xiao Y, Li Z, Liu C, Na R. Long-term effects intensive medical therapy on the development and progression of subclinical atherosclerosis and the metabolic syndrome in Chinese patients with type 2 diabetes mellitus. Medicine (Baltimore) 2016; 95:e5201. [PMID: 27861342 PMCID: PMC5120899 DOI: 10.1097/md.0000000000005201] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Few studies have investigated the progression of subclinical atherosclerosis and metabolic syndrome (MetS) in Chinese patients with type 2 diabetes mellitus (T2DM). This study was to compare the long-term effects of intensive medical therapy on the development and progression of subclinical atherosclerosis and MetS in Chinese T2DM patients with that of a conventional treatment regimen. METHODS A total of 316 T2DM patients were randomized to receive conventional pharmacological treatment or intensive medical therapy, consisting of diet and exercise counseling, from 2002 to 2014 at our hospital in Changsha, China. Clinical indicators of subclinical atherosclerosis and MetS were evaluated over the 12-year follow-up period. A χ analysis or t tests was used to compare the data between the 2 groups. Risk factors for subclinical atherosclerosis were identified using Cox proportional hazard models. RESULTS The incidence of subclinical atherosclerosis increased in both groups over time, and did not differ significantly between the 2 groups at the end of the study. However, after 6 years of treatment, the risk of subclinical atherosclerosis was significantly lower in the intensive medical therapy group, based on intima-media thickness (IMT) measurements, compared with that in the conventional treatment (44.2% vs. 69.7%; P < 0.01). Age, creatinine, and IMT of the common iliac artery were significantly associated with subclinical atherosclerosis. Although the indicators of MetS did not differ significantly at the end of study, the success rate for the management of MetS in the intensive medical therapy group was significantly higher than that in the conventional treatment group in 2006, 2008, 2010, and 2012. CONCLUSIONS The incidence of atherosclerosis in the intensive medical therapy group was significantly lower than that in the conventional treatment group from 2006 to 2010 (P < 0.05), and the incidence of MetS in the intensive medical therapy group was significantly higher than that in the conventional treatment group from 2006 to 2012. Kaplan-Meier estimations showed that the risk of subclinical atherosclerosis in the intensive medical therapy group was significantly lower than that in the conventional treatment group (P < 0.001), whereas the risk of MetS was not significantly different between the treatment groups (P > 0.05).
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Affiliation(s)
- Zhiwen Liu
- Department of Endocrinology, Xuhui District Central Hospital, Shanghai
| | | | | | | | - Zhen Li
- B-Ultrasound Room, Second Xiangya Hospital of Central South University, Changsha, China
| | - Cong Liu
- Department of Endocrinology, Xuhui District Central Hospital, Shanghai
| | - Risu Na
- Department of Endocrinology, Xuhui District Central Hospital, Shanghai
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24
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Carter AN, Ralston PA, Young-Clark I, Ilich JZ. Diabetic indicators are the strongest predictors for cardiovascular disease risk in African American adults. AMERICAN JOURNAL OF CARDIOVASCULAR DISEASE 2016; 6:129-137. [PMID: 27679747 PMCID: PMC5030392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Accepted: 08/21/2016] [Indexed: 06/06/2023]
Abstract
African Americans have higher risk of developing type 2 diabetes and cardiovascular disease (CVD) compared to other racial groups. Modifiable and non-modifiable factors play a role in the development of both diseases. This study assessed diabetes indicators in relation to other CVD risk factors taking into account confounders, among African American adults. This was a cross-sectional study in mid-life and older African Americans (≥45 years) who were recruited from the local churches. Fasting blood was collected and serum analyzed for diabetes indicators, apolipoproteins, adipokines, and lipid profile. CVD risk scores were determined using the American Heart Association and Framingham Risk Score assessments. Homeostasis Model Assessments (HOMAs) were calculated using glucose and insulin concentrations. Confounding variables were assessed by questionnaires. Data were analyzed using SPSS software, version 21, and p<0.05 was deemed significant. Descriptive statistics was used to analyze continuous variables. Frequencies and percentages were used to examine categorical variables. T-tests compared different groups while Pearson correlations provided preliminary relationships and determined variables for multiple regression analyses. A total of n=79 participants were evaluated (69% women), 59.3±9.2 years, BMI=34.7±8.3 (mean ± SD). As expected, AA men had higher fasting blood glucose than women (123.6±54.9 mg/dL versus 99.0±21.8 mg/dL), and AA women had higher insulin (11.8±13.1 mg/dL versus 7.6±6.0 mg/dL). Our study confirmed that it is likely for AA men to have significantly lower adiponectin concentrations in comparison to AA women. Based on the CVD risk assessments, men had a significantly higher risk of developing CVD than women, which has been shown previously. Apolipoproteins, adipokines, and lipid profile also negatively influenced the cardiovascular health outcomes in men. Dietary intake, probably by influencing participants' weight/adiposity, contributed to the differences in cardiovascular outcomes between men and women. In conclusion, the findings of this study revealed that diabetes and serum glucose appeared to be the leading factors for high CVD risk, on the contrary to some other indicators reported in some studies, e.g. hypertension or dyslipidemia.
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Affiliation(s)
- Ashley N Carter
- Department of Nutrition, Food and Exercise Sciences, Florida State UniversityTallahassee, Florida, USA
| | - Penny A Ralston
- Center on Better Health and Life for Underserved Populations, Florida State UniversityTallahassee, Florida, USA
| | - Iris Young-Clark
- Center on Better Health and Life for Underserved Populations, Florida State UniversityTallahassee, Florida, USA
| | - Jasminka Z Ilich
- Department of Nutrition, Food and Exercise Sciences, Florida State UniversityTallahassee, Florida, USA
- Institute for Successful Longevity Affiliate, Florida State UniversityTallahassee, Florida, USA
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25
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Gore MO, McGuire DK, Lingvay I, Rosenstock J. Predicting cardiovascular risk in type 2 diabetes: the heterogeneity challenges. Curr Cardiol Rep 2016; 17:607. [PMID: 26031671 DOI: 10.1007/s11886-015-0607-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Type 2 diabetes mellitus has reached epidemic proportions around the world, and the increase in cardiovascular risk attributable to diabetes estimated to range from 2- to 4-fold poses grave public health concern. Though in some contexts type 2 diabetes has been equated with coronary heart disease equivalent risk, there is considerable evidence that incremental cardiovascular risk does not uniformly affect all people with type 2 diabetes. This heterogeneity in cardiovascular risk is multifactorial and only partially understood but is a key consideration for our understanding of the nexus of diabetes and cardiovascular disease and for the development of optimal and individualized cardiovascular risk reduction strategies. This review provides a brief synopsis of the concept of cardiovascular risk heterogeneity in diabetes, including epidemiologic evidence, discussion of established and potential determinants of heterogeneity, and clinical, research, and regulatory implications.
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Affiliation(s)
- M Odette Gore
- Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX, USA,
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26
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Jones SA, Moore LV, Moore K, Zagorski M, Brines SJ, Diez Roux AV, Evenson KR. Disparities in physical activity resource availability in six US regions. Prev Med 2015; 78:17-22. [PMID: 26067479 PMCID: PMC4547867 DOI: 10.1016/j.ypmed.2015.05.028] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2015] [Revised: 05/13/2015] [Accepted: 05/16/2015] [Indexed: 11/16/2022]
Abstract
OBJECTIVE We conducted an ecological study to determine physical activity resource availability overall and by sociodemographic groups in parts of six states (CA, IL, MD, MN, NC, NY). METHODS Data on parks and recreational facilities were collected from 3 sources in 2009-2012. Three measures characterized park and recreational facility availability at the census tract level: presence of ≥1 resource, number of resources, and resource kernel density. Associations between resource availability and census tract characteristics (predominant racial/ethnic group, median income, and proportion of children and older adults) were estimated using linear, binomial, and zero-inflated negative binomial regression in 2014. Pooled and stratified analyses were conducted. RESULTS The study included 7139 census tracts, comprising 9.5% of the 2010 US population. Overall the availability of parks and recreational facilities was lower in predominantly minority relative to non-Hispanic white census tracts. Low-income census tracts and those with a higher proportion of children had an equal or greater availability of park resources but fewer recreational facilities. Stratification revealed substantial variation in resource availability by site. CONCLUSION The availability of physical activity resources varied by sociodemographic characteristics and across regions. Improved knowledge of resource distribution can inform strategies to provide equitable access to parks and recreational facilities.
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Affiliation(s)
- Sydney A Jones
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Latetia V Moore
- Division of Nutrition, Physical Activity, and Obesity, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Kari Moore
- Department of Epidemiology and Biostatistics, Drexel University, School of Public Health, Philadelphia, PA, USA
| | - Melissa Zagorski
- Epidemiology Department, University of Michigan, Ann Arbor, MI, USA
| | - Shannon J Brines
- School of Natural Resources and Environment, University of Michigan, Ann Arbor, MI, USA
| | - Ana V Diez Roux
- Department of Epidemiology and Biostatistics, Drexel University, School of Public Health, Philadelphia, PA, USA
| | - Kelly R Evenson
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Reinier K, Nichols GA, Huertas-Vazquez A, Uy-Evanado A, Teodorescu C, Stecker EC, Gunson K, Jui J, Chugh SS. Distinctive Clinical Profile of Blacks Versus Whites Presenting With Sudden Cardiac Arrest. Circulation 2015; 132:380-7. [PMID: 26240262 PMCID: PMC4526124 DOI: 10.1161/circulationaha.115.015673] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Accepted: 05/28/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND Sudden cardiac arrest (SCA) is a major contributor to mortality, but data are limited among nonwhites. Identification of differences in clinical profile based on race may provide opportunities for improved SCA prevention. METHODS AND RESULTS In the ongoing Oregon Sudden Unexpected Death Study (SUDS), individuals experiencing SCA in the Portland, OR, metropolitan area were identified prospectively. Patient demographics, arrest circumstances, and pre-SCA clinical profile were compared by race among cases from 2002 to 2012 (for clinical history, n=126 blacks, n=1262 whites). Incidence rates were calculated for cases from the burden assessment phase (2002-2005; n=1077). Age-adjusted rates were 2-fold higher among black men and women (175 and 90 per 100 000, respectively) compared with white men and women (84 and 40 per 100 000, respectively). Compared with whites, blacks were >6 years younger at the time of SCA and had a higher prearrest prevalence of diabetes mellitus (52% versus 33%; P<0.0001), hypertension (77% versus 65%; P=0.006), and chronic renal insufficiency (34% versus 19%; P<0.0001). There were no racial differences in previously documented coronary artery disease or left ventricular dysfunction, but blacks had more prevalent congestive heart failure (43% versus 34%; P=0.04) and left ventricular hypertrophy (77% versus 58%; P=0.02) and a longer QTc interval (466±36 versus 453±41 milliseconds; P=0.03). CONCLUSIONS In this US community, the burden of SCA was significantly higher in blacks compared with whites. Blacks with SCA had a higher prearrest prevalence of risk factors beyond established coronary artery disease, providing potential targets for race-specific prevention.
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MESH Headings
- Aged
- Aged, 80 and over
- Black People/ethnology
- Black People/statistics & numerical data
- Death, Sudden, Cardiac/epidemiology
- Death, Sudden, Cardiac/ethnology
- Death, Sudden, Cardiac/etiology
- Diabetes Complications/complications
- Diabetes Complications/epidemiology
- Diabetes Complications/ethnology
- Female
- Humans
- Hypertension/complications
- Hypertension/epidemiology
- Hypertension/ethnology
- Incidence
- Male
- Middle Aged
- Oregon
- Prevalence
- Prospective Studies
- Renal Insufficiency, Chronic/complications
- Renal Insufficiency, Chronic/epidemiology
- Renal Insufficiency, Chronic/ethnology
- Retrospective Studies
- Risk Factors
- White People/ethnology
- White People/statistics & numerical data
- Black or African American
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Affiliation(s)
- Kyndaron Reinier
- From The Heart Institute, Cedars-Sinai Medical Center, Los Angeles CA (K.R., A.H.-V., A.U.-E., C.T., S.S.C.); Kaiser Permanente Center for Health Research, Portland, OR (G.A.N.); and Knight Cardiovascular Institute (E.C.S.), Department of Pathology (K.G.), and Department of Emergency Medicine (J.J.), Oregon Health and Science University, Portland
| | - Gregory A Nichols
- From The Heart Institute, Cedars-Sinai Medical Center, Los Angeles CA (K.R., A.H.-V., A.U.-E., C.T., S.S.C.); Kaiser Permanente Center for Health Research, Portland, OR (G.A.N.); and Knight Cardiovascular Institute (E.C.S.), Department of Pathology (K.G.), and Department of Emergency Medicine (J.J.), Oregon Health and Science University, Portland
| | - Adriana Huertas-Vazquez
- From The Heart Institute, Cedars-Sinai Medical Center, Los Angeles CA (K.R., A.H.-V., A.U.-E., C.T., S.S.C.); Kaiser Permanente Center for Health Research, Portland, OR (G.A.N.); and Knight Cardiovascular Institute (E.C.S.), Department of Pathology (K.G.), and Department of Emergency Medicine (J.J.), Oregon Health and Science University, Portland
| | - Audrey Uy-Evanado
- From The Heart Institute, Cedars-Sinai Medical Center, Los Angeles CA (K.R., A.H.-V., A.U.-E., C.T., S.S.C.); Kaiser Permanente Center for Health Research, Portland, OR (G.A.N.); and Knight Cardiovascular Institute (E.C.S.), Department of Pathology (K.G.), and Department of Emergency Medicine (J.J.), Oregon Health and Science University, Portland
| | - Carmen Teodorescu
- From The Heart Institute, Cedars-Sinai Medical Center, Los Angeles CA (K.R., A.H.-V., A.U.-E., C.T., S.S.C.); Kaiser Permanente Center for Health Research, Portland, OR (G.A.N.); and Knight Cardiovascular Institute (E.C.S.), Department of Pathology (K.G.), and Department of Emergency Medicine (J.J.), Oregon Health and Science University, Portland
| | - Eric C Stecker
- From The Heart Institute, Cedars-Sinai Medical Center, Los Angeles CA (K.R., A.H.-V., A.U.-E., C.T., S.S.C.); Kaiser Permanente Center for Health Research, Portland, OR (G.A.N.); and Knight Cardiovascular Institute (E.C.S.), Department of Pathology (K.G.), and Department of Emergency Medicine (J.J.), Oregon Health and Science University, Portland
| | - Karen Gunson
- From The Heart Institute, Cedars-Sinai Medical Center, Los Angeles CA (K.R., A.H.-V., A.U.-E., C.T., S.S.C.); Kaiser Permanente Center for Health Research, Portland, OR (G.A.N.); and Knight Cardiovascular Institute (E.C.S.), Department of Pathology (K.G.), and Department of Emergency Medicine (J.J.), Oregon Health and Science University, Portland
| | - Jonathan Jui
- From The Heart Institute, Cedars-Sinai Medical Center, Los Angeles CA (K.R., A.H.-V., A.U.-E., C.T., S.S.C.); Kaiser Permanente Center for Health Research, Portland, OR (G.A.N.); and Knight Cardiovascular Institute (E.C.S.), Department of Pathology (K.G.), and Department of Emergency Medicine (J.J.), Oregon Health and Science University, Portland
| | - Sumeet S Chugh
- From The Heart Institute, Cedars-Sinai Medical Center, Los Angeles CA (K.R., A.H.-V., A.U.-E., C.T., S.S.C.); Kaiser Permanente Center for Health Research, Portland, OR (G.A.N.); and Knight Cardiovascular Institute (E.C.S.), Department of Pathology (K.G.), and Department of Emergency Medicine (J.J.), Oregon Health and Science University, Portland.
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Tian X, Xiong H, Wu D, Zhang R, Lu M, Zhang YT. Age and sex-specific relationships between blood pressure variability and carotid intima-media thickness. AUSTRALASIAN PHYSICAL & ENGINEERING SCIENCES IN MEDICINE 2015. [DOI: 10.1007/s13246-015-0361-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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Sex Differences in the Excess Risk of Cardiovascular Diseases Associated with Type 2 Diabetes: Potential Explanations and Clinical Implications. CURRENT CARDIOVASCULAR RISK REPORTS 2015; 9:36. [PMID: 26029318 PMCID: PMC4442131 DOI: 10.1007/s12170-015-0462-5] [Citation(s) in RCA: 111] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Strong evidence suggests that type 2 diabetes confers a stronger excess risk of cardiovascular diseases in women than in men; with women having a 27 % higher relative risk of stroke and a 44 % higher relative risk of coronary heart disease compared with men. The mechanisms that underpin these sex differences in the associations between diabetes and cardiovascular disease risk are not fully understood. Some of the excess risk may be the result of a sex disparity in the management and treatment of diabetes, to the detriment of women. However, accruing evidence suggests that real biological differences between men and women underpin the excess risk of diabetes-related cardiovascular risk in women such that there is a greater decline in risk factor status in women than in men in the transition from normoglycemia to overt diabetes. This greater risk factor decline appears to be associated with women having to put on more weight than men, and thus attain a higher body mass index, to develop diabetes. Further studies addressing the mechanisms responsible for sex differences in the excess risk of cardiovascular diseases associated with diabetes are needed to improve the prevention and management of diabetes in clinical practise.
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Appelman Y, van Rijn BB, Ten Haaf ME, Boersma E, Peters SAE. Sex differences in cardiovascular risk factors and disease prevention. Atherosclerosis 2015; 241:211-8. [PMID: 25670232 DOI: 10.1016/j.atherosclerosis.2015.01.027] [Citation(s) in RCA: 351] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Revised: 01/22/2015] [Accepted: 01/22/2015] [Indexed: 11/25/2022]
Abstract
Cardiovascular disease (CVD) has been seen as a men's disease for decades, however it is more common in women than in men. It is generally assumed in medicine that the effects of the major risk factors (RF) on CVD outcomes are the same in women as in men. Recent evidence has emerged that recognizes new, potentially independent, CVD RF exclusive to women. In particular, common disorders of pregnancy, such as gestational hypertension and diabetes, as well as frequently occurring endocrine disorders in women of reproductive age (e.g. polycystic ovary syndrome (PCOS) and early menopause) are associated with accelerated development of CVD and impaired CVD-free survival. With the recent availability of prospective studies comprising men and women, the equivalency of major RF prevalence and effects on CVD between men and women can be examined. Furthermore, female-specific RFs might be identified enabling early detection of apparently healthy women with a high lifetime risk of CVD. Therefore, we examined the available literature regarding the prevalence and effects of the traditional major RFs for CVD in men and women. This included large prospective cohort studies, cross-sectional studies and registries, as randomised trials are lacking. Furthermore, a literature search was performed to examine the impact of female-specific RFs on the traditional RFs and the occurrence of CVD. We found that the effects of elevated blood pressure, overweight and obesity, and elevated cholesterol on CVD outcomes are largely similar between women and men, however prolonged smoking is significantly more hazardous for women than for men. With respect to female-specific RF only associations (and no absolute risk data) could be found between preeclampsia, gestational diabetes and menopause onset with the occurrence of CVD. This review shows that CVD is the main cause of death in men and women, however the prevalence is higher in women. Determination of the CV risk profile should take into account that there are differences in impact of major CV RF leading to a worse outcome in women. Lifestyle interventions and awareness in women needs more consideration. Furthermore, there is accumulating evidence that female-specific RF are of influence on the impact of major RF and on the onset of CVD. Attention for female specific RF may enable early detection and intervention in apparently healthy women. Studies are needed on how to implement the added RF's in current risk assessment and management strategies to maximize benefit and cost-effectiveness specific in women.
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Affiliation(s)
- Yolande Appelman
- Department of Cardiology, VU University Medical Center, Boelelaan 1117, 1081 HV Amsterdam, The Netherlands.
| | - Bas B van Rijn
- Department of Obstetrics, Division Woman and Baby, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands; Academic Unit of Human Development and Health, Princess Anne Hospital, University of Southampton, Coxford Rd, Southampton, Hampshire SO16 5YA, United Kingdom.
| | - Monique E Ten Haaf
- Department of Cardiology, VU University Medical Center, Boelelaan 1117, 1081 HV Amsterdam, The Netherlands.
| | - Eric Boersma
- Thoraxcenter Cardiology, Erasmus MC, 's-Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands.
| | - Sanne A E Peters
- The George Institute for Global Health, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Roosevelt Drive, Oxford, OX3 7LF, United Kingdom; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Universiteitsweg 100, 3584 CG Utrecht, The Netherlands.
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Johnson D, Sacrinty M, Mehta H, Douglas C, Paladenech C, Robinson K. Cardiac rehabilitation in African Americans: evidence for poorer outcomes compared with whites, especially in women and diabetic participants. Am Heart J 2015; 169:102-7. [PMID: 25497254 DOI: 10.1016/j.ahj.2014.09.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Accepted: 09/12/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND Cardiac rehabilitation (CR) improves coronary artery disease risk factors and mortality. Outcomes after CR in African Americans (AAs) compared with whites have not been studied extensively. METHODS A total of 1,096 patients (169 AAs, 927 whites) were enrolled in a 36-session CR program for ischemic heart disease or postcardiac surgery. The program consisted of exercise, lifestyle modification, and pharmacotherapy. RESULTS After CR, quality of life, blood pressure, and low-density lipoprotein cholesterol improved significantly in both AAs and whites, although to a lesser degree in AAs. Whites also had significant improvements in weight and triglyceride concentrations. Overall, mean peak exercise capacity, measured in metabolic equivalents (METs), improved by only 1.6 (95% CI 1.3-1.8) in AAs compared with 2.4 (2.3-2.6) in CCs (P< .001 for AAs vs CCs). African American women had the least improvement in METs, but changes were still significant (1.1 [CI 0.9-1.4]). The subgroup with the least improvement in METs was AA diabetic patients (1.4 (CI 1.1-1.7]). CONCLUSION African Americans derive a significant benefit from CR, but not to the same degree as whites, based on changes in risk factors and in exercise capacity. Within both ethnic groups, both women and diabetic patients appeared to have markedly less improvement.
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Affiliation(s)
- Dominic Johnson
- Department of Internal Medicine/Cardiology, Wake Forest School of Medicine, Winston-Salem, NC
| | - Matthew Sacrinty
- Department of Internal Medicine/Cardiology, Wake Forest School of Medicine, Winston-Salem, NC
| | - Hardik Mehta
- Department of Internal Medicine/Cardiology, Wake Forest School of Medicine, Winston-Salem, NC
| | - Christopher Douglas
- Department of Internal Medicine/Cardiology, Wake Forest School of Medicine, Winston-Salem, NC
| | - Connie Paladenech
- Department of Internal Medicine/Cardiology, Wake Forest School of Medicine, Winston-Salem, NC
| | - Killian Robinson
- Department of Internal Medicine/Cardiology, Wake Forest School of Medicine, Winston-Salem, NC.
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Anagnostis P, Majeed A, Johnston DG, Godsland IF. Cardiovascular risk in women with type 2 diabetes mellitus and prediabetes: is it indeed higher than men? Eur J Endocrinol 2014; 171:R245-55. [PMID: 25117464 DOI: 10.1530/eje-14-0401] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
The relative risk for cardiovascular disease (CVD) events and mortality in diabetic women (in comparison with non-diabetic women) is believed to be greater than that in diabetic men. However, the absolute risk for CVD mortality and morbidity does not appear to be higher in women. In general, there is heterogeneity between studies, and whether there is any definite difference in the CVD risk between sexes at any level of glycaemia is not known. The same arguments also apply when comparing the CVD risk factors, such as lipid profiles and systemic inflammation indices, which seem to be worse in women than in men with diabetes mellitus (DM). The same questions emerge at any given glycaemic state: are women at worse risk and do they have a worse risk factor profile than men? These issues have yet to be resolved. Similar, though less extensive, data have been reported for prediabetes. Furthermore, women with DM are suboptimally treated compared with men regarding lipid and blood pressure targets. Large prospective studies representative of the general population are therefore needed to define the differences between sexes regarding CVD events and mortality at a given glucose level and after adjusting for any other confounders.
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Affiliation(s)
- Panagiotis Anagnostis
- Division of DiabetesEndocrinology and Metabolism, Department of Medicine, Diabetes Endocrinology and Metabolic Medicine, Faculty of Medicine, Imperial College London, Room G1, Norfolk Place, St Mary's Campus, London W2 1NH, UKDepartment of Primary Care and Public HealthFaculty of Medicine, Imperial College London, London, UK
| | - Azeem Majeed
- Division of DiabetesEndocrinology and Metabolism, Department of Medicine, Diabetes Endocrinology and Metabolic Medicine, Faculty of Medicine, Imperial College London, Room G1, Norfolk Place, St Mary's Campus, London W2 1NH, UKDepartment of Primary Care and Public HealthFaculty of Medicine, Imperial College London, London, UK
| | - Desmond G Johnston
- Division of DiabetesEndocrinology and Metabolism, Department of Medicine, Diabetes Endocrinology and Metabolic Medicine, Faculty of Medicine, Imperial College London, Room G1, Norfolk Place, St Mary's Campus, London W2 1NH, UKDepartment of Primary Care and Public HealthFaculty of Medicine, Imperial College London, London, UK
| | - Ian F Godsland
- Division of DiabetesEndocrinology and Metabolism, Department of Medicine, Diabetes Endocrinology and Metabolic Medicine, Faculty of Medicine, Imperial College London, Room G1, Norfolk Place, St Mary's Campus, London W2 1NH, UKDepartment of Primary Care and Public HealthFaculty of Medicine, Imperial College London, London, UK
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Peters SAE, Huxley RR, Woodward M. Diabetes as risk factor for incident coronary heart disease in women compared with men: a systematic review and meta-analysis of 64 cohorts including 858,507 individuals and 28,203 coronary events. Diabetologia 2014; 57:1542-51. [PMID: 24859435 DOI: 10.1007/s00125-014-3260-6] [Citation(s) in RCA: 424] [Impact Index Per Article: 42.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Accepted: 04/17/2014] [Indexed: 01/07/2023]
Abstract
AIMS/HYPOTHESIS A previous pooled analysis suggested that women with diabetes are at substantially increased risk of fatal CHD compared with affected men. Additional findings from several larger and more contemporary studies have since been published on the sex-specific associations between diabetes and incident CHD. We performed an updated systematic review with meta-analysis to provide the most reliable evidence of any sex difference in the effect of diabetes on subsequent risk of CHD. METHODS PubMed MEDLINE was systematically searched for prospective population-based cohort studies published between 1 January 1966 and 13 February 2013. Eligible studies had to have reported sex-specific RR estimates for incident CHD associated with diabetes and its associated variability that had been adjusted at least for age. Random-effects meta-analyses with inverse variance weighting were used to obtain sex-specific RRs and the RR ratio (RRR) (women:men) for incident CHD associated with diabetes. RESULTS Data from 64 cohorts, including 858,507 individuals and 28,203 incident CHD events, were included. The RR for incident CHD associated with diabetes compared with no diabetes was 2.82 (95% CI 2.35, 3.38) in women and 2.16 (95% CI 1.82, 2.56) in men. The multiple-adjusted RRR for incident CHD was 44% greater in women with diabetes than in men with diabetes (RRR 1.44 [95% CI 1.27, 1.63]) with no significant heterogeneity between studies (I (2) = 20%). CONCLUSIONS/INTERPRETATION Women with diabetes have more than a 40% greater risk of incident CHD compared with men with diabetes. Sex disparities in pharmacotherapy are unlikely to explain much of the excess risk in women, but future studies are warranted to more clearly elucidate the mechanisms responsible for the substantial sex difference in diabetes-related risk of CHD.
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Affiliation(s)
- Sanne A E Peters
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
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Peters SAE, Huxley RR, Woodward M. Diabetes as a risk factor for stroke in women compared with men: a systematic review and meta-analysis of 64 cohorts, including 775,385 individuals and 12,539 strokes. Lancet 2014; 383:1973-80. [PMID: 24613026 DOI: 10.1016/s0140-6736(14)60040-4] [Citation(s) in RCA: 518] [Impact Index Per Article: 51.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Diabetes mellitus is a major cause of death and disability worldwide and is a strong risk factor for stroke. Whether and to what extent the excess risk of stroke conferred by diabetes differs between the sexes is unknown. We did a systematic review and meta-analysis to estimate the relative effect of diabetes on stroke risk in women compared with men. METHODS We systematically searched PubMed for reports of prospective, population-based cohort studies published between Jan 1, 1966, and Dec 16, 2013. Studies were selected if they reported sex-specific estimates of the relative risk (RR) for stroke associated with diabetes, and its associated variability. We pooled the sex-specific RRs and their ratio comparing women with men using random-effects meta-analysis with inverse-variance weighting. FINDINGS Data from 64 cohort studies, representing 775,385 individuals and 12,539 fatal and non-fatal strokes, were included in the analysis. The pooled maximum-adjusted RR of stroke associated with diabetes was 2·28 (95% CI 1·93-2·69) in women and 1·83 (1·60-2·08) in men. Compared with men with diabetes, women with diabetes therefore had a greater risk of stroke--the pooled ratio of RRs was 1·27 (1·10-1·46; I(2)=0%), with no evidence of publication bias. This sex differential was seen consistently across major predefined stroke, participant, and study subtypes. INTERPRETATION The excess risk of stroke associated with diabetes is significantly higher in women than men, independent of sex differences in other major cardiovascular risk factors. These data add to the existing evidence that men and women experience diabetes-related diseases differently and suggest the need for further work to clarify the biological, behavioural, or social mechanisms involved. FUNDING None.
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Affiliation(s)
- Sanne A E Peters
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands; Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Rachel R Huxley
- School of Population Health, University of Queensland, Brisbane, QLD, Australia.
| | - Mark Woodward
- The George Institute for Global Health, University of Sydney, Sydney, Australia; Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA; The George Institute for Global Health, Nuffield Department of Population Health, University of Oxford, Oxford, UK
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Vimalananda VG, Biggs ML, Rosenzweig JL, Carnethon MR, Meigs JB, Thacker EL, Siscovick DS, Mukamal KJ. The influence of sex on cardiovascular outcomes associated with diabetes among older black and white adults. J Diabetes Complications 2014; 28:316-22. [PMID: 24461547 PMCID: PMC4004690 DOI: 10.1016/j.jdiacomp.2013.12.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Revised: 12/17/2013] [Accepted: 12/18/2013] [Indexed: 01/05/2023]
Abstract
AIMS It is unknown whether sex differences in the association of diabetes with cardiovascular outcomes vary by race. We examined sex differences in the associations of diabetes with incident congestive heart failure (CHF) and coronary heart disease (CHD) between older black and white adults. METHODS We analyzed data from the Cardiovascular Health Study (CHS), a prospective cohort study of community-dwelling individuals aged ≥65 from four US counties. We included 4817 participants (476 black women, 279 black men, 2447 white women and 1625 white men). We estimated event rates and multivariate-adjusted hazard ratios for incident CHF, CHD, and all-cause mortality by Cox regression and competing risk analyses. RESULTS Over a median follow-up of 12.5years, diabetes was more strongly associated with CHF among black women (HR, 2.42 [95% CI, 1.70-3.40]) than black men (1.39 [0.83-2.34]); this finding did not reach statistical significance (P for interaction=0.08). Female sex conferred a higher risk for a composite outcome of CHF and CHD among black participants (2.44 [1.82-3.26]) vs. (1.44 [0.97-2.12]), P for interaction=0.03). There were no significant sex differences in the HRs associated with diabetes for CHF among whites, or for CHD or all-cause mortality among blacks or whites. The three-way interaction between sex, race, and diabetes on risk of cardiovascular outcomes was not significant (P=0.07). CONCLUSIONS Overall, sex did not modify the cardiovascular risk associated with diabetes among older black or white adults. However, our results suggest that a possible sex interaction among older blacks merits further study.
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Affiliation(s)
- Varsha G Vimalananda
- Section of Endocrinology, Diabetes and Nutrition, Department of Medicine, Boston University School of Medicine, Boston, MA, USA.
| | - Mary L Biggs
- Department of Biostatistics, School of Public Health, University of Washington, Seattle, WA, USA
| | - James L Rosenzweig
- Section of Endocrinology, Diabetes and Nutrition, Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Mercedes R Carnethon
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - James B Meigs
- General Medicine Division, Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Evan L Thacker
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
| | - David S Siscovick
- Cardiovascular Health Research Unit, Departments of Medicine and Epidemiology, University of Washington, Seattle, WA, USA
| | - Kenneth J Mukamal
- General Medicine Division, Department of Medicine, Harvard Medical School, Boston, MA, USA
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Palmas W, Findley SE, Mejia M, Batista M, Teresi J, Kong J, Silver S, Fleck EM, Luchsinger JA, Carrasquillo O. 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. Diabetes Care 2014; 37:963-9. [PMID: 24496805 PMCID: PMC3964489 DOI: 10.2337/dc13-2142] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
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.
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Schroeder EB, Bayliss EA, Daugherty SL, Steiner JF. Gender differences in cardiovascular risk factors in incident diabetes. Womens Health Issues 2014; 24:e61-8. [PMID: 24439948 PMCID: PMC3932744 DOI: 10.1016/j.whi.2013.09.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2013] [Revised: 09/24/2013] [Accepted: 09/26/2013] [Indexed: 11/18/2022]
Abstract
BACKGROUND Cardiovascular disease is a major cause of morbidity and mortality for women and men with diabetes. Previous cross-sectional studies of prevalent diabetes have found that women are less likely to meet American Diabetes Association (ADA) and American Heart Association guidelines for control of cardiovascular risk factors (hemoglobin A1c, low-density lipoprotein [LDL] cholesterol, and blood pressure), but have not studied the critical period immediately after diagnosis. METHODS To assess gender differences in cardiovascular risk factors at the time of diabetes diagnosis (baseline) and 1 year later (follow-up), we conducted a retrospective cohort study of 6,547 individuals with incident diabetes in an integrated care delivery system. We assessed mean cardiovascular risk factor values by gender and adjusted odds ratios of attaining ADA goals. FINDINGS Compared with men, at baseline women had lower hemoglobin A1c (7.9% vs. 8.2%; p < .001), higher LDL cholesterol (118.9 vs. 111.5 mg/dL; p < .001), higher systolic blood pressure (131.9 vs. 130.5 mmHg; p < .001), and lower diastolic blood pressure (79.1 vs. 79.7 mmHg; p = .006). At follow-up, the hemoglobin A1c gender gap had closed (6.9% vs. 6.9%; p = .39), and the gender gaps had decreased for blood pressure (129.8/77.0 vs. 128.9/77.6; p = .009) and LDL cholesterol (104.0 vs. 98.2 mg/dL; p < .001). These associations varied by age. Adjusted odds ratios showed similar relationships. CONCLUSIONS In this cohort of individuals with incident diabetes, men and women had important differences in risk factor control at the time of diabetes diagnosis. These differences varied by age and decreased over time.
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Affiliation(s)
- Emily B Schroeder
- Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado; Department of Medicine, University of Colorado Denver, Aurora, Colorado.
| | - Elizabeth A Bayliss
- Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado; Department of Family Medicine, University of Colorado Aurora, Denver, Colorado
| | - Stacie L Daugherty
- Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado; Department of Medicine, University of Colorado Denver, Aurora, Colorado
| | - John F Steiner
- Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado; Department of Medicine, University of Colorado Denver, Aurora, Colorado
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Franch-Nadal J, Mata-Cases M, Vinagre I, Patitucci F, Hermosilla E, Casellas A, Bolivar B, Mauricio D. Differences in the Cardiometabolic Control in Type 2 Diabetes according to Gender and the Presence of Cardiovascular Disease: Results from the eControl Study. Int J Endocrinol 2014; 2014:131709. [PMID: 25328520 PMCID: PMC4189942 DOI: 10.1155/2014/131709] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Accepted: 09/07/2014] [Indexed: 11/17/2022] Open
Abstract
The objective of this cross-sectional study was to assess differences in the control and treatment of modifiable cardiovascular risk factors (CVRF: HbA1c, blood pressure [BP], LDL-cholesterol, body mass index, and smoking habit) according to gender and the presence of cardiovascular disease (CVD) in patients with type 2 diabetes mellitus (T2DM) in Catalonia, Spain. The study included available data from electronic medical records for a total of 286,791 patients. After controlling for sex, age, diabetes duration, and treatment received, both men and women with prior CVD had worse cardiometabolic control than patients without previous CVD; women with prior CVD had worse overall control of CVRFs than men except for smoking; and women without prior CVD were only better than men at controlling smoking and BP, with no significant differences in glycemic control. Finally, although the proportion of women treated with lipid-lowering medications was similar to (with prior CVD) or even higher (without CVD) than men, LDL-cholesterol levels were remarkably uncontrolled in both women with and women without CVD. The results stress the need to implement measures to better prevent and treat CVRF in the subgroup of diabetic women, specifically with more intensive statin treatment in those with CVD.
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Affiliation(s)
- Josep Franch-Nadal
- Primary Health Care Center Raval, Gerència d'Àmbit d'Atenció Primària Barcelona Ciutat, Institut Catala de la Salut, Avenida Drassanes 17-21, 08001 Barcelona, Spain
- Unitat de Suport a la Recerca Barcelona Ciutat, Institut Universitari de Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Avenida Gran Via de les Corts Catalanes, 587 Àtic, 08007 Barcelona, Spain
- *Josep Franch-Nadal: and
| | - Manel Mata-Cases
- Unitat de Suport a la Recerca Barcelona Ciutat, Institut Universitari de Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Avenida Gran Via de les Corts Catalanes, 587 Àtic, 08007 Barcelona, Spain
- Primary Health Care Center La Mina, Gerència d'Àmbit d'Atenció Primària Barcelona Ciutat, Institut Catala de la Salut, C/Mar s/n, Sant Adrià de Besòs, 08930 Barcelona, Spain
| | - Irene Vinagre
- Department of Endocrinology and Nutrition, Diabetes Unit, Hospital Clinic, University of Barcelona, C/Villarroel 170, 08036 Barcelona, Spain
| | - Flor Patitucci
- Primary Health Care Center Raval, Gerència d'Àmbit d'Atenció Primària Barcelona Ciutat, Institut Catala de la Salut, Avenida Drassanes 17-21, 08001 Barcelona, Spain
| | - Eduard Hermosilla
- Unitat de Suport a la Recerca Barcelona Ciutat, Institut Universitari de Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Avenida Gran Via de les Corts Catalanes, 587 Àtic, 08007 Barcelona, Spain
| | - Aina Casellas
- Unitat de Suport a la Recerca Barcelona Ciutat, Institut Universitari de Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Avenida Gran Via de les Corts Catalanes, 587 Àtic, 08007 Barcelona, Spain
| | - Bonaventura Bolivar
- Unitat de Suport a la Recerca Barcelona Ciutat, Institut Universitari de Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Avenida Gran Via de les Corts Catalanes, 587 Àtic, 08007 Barcelona, Spain
| | - Dídac Mauricio
- Unitat de Suport a la Recerca Barcelona Ciutat, Institut Universitari de Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Avenida Gran Via de les Corts Catalanes, 587 Àtic, 08007 Barcelona, Spain
- Department of Endocrinology & Nutrition, Health Sciences Research Institute and Hospital Universitari Germans Trias i Pujol, Carretera Canyet s/n, 08916 Badalona, Spain
- *Dídac Mauricio:
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Thanh Le P, Huisingh CE, Huisingh A. Glycemic Control and Diabetic Dyslipidemia in Adolescents with Type 2 Diabetes. Endocr Pract 2013; 19:972-979. [DOI: 10.4158/ep13016.or] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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Cardio-Metabolic Risk Factors Control in Newly Diagnosed Type 2 Diabetic Subjects. ROMANIAN JOURNAL OF DIABETES NUTRITION AND METABOLIC DISEASES 2013. [DOI: 10.2478/rjdnmd-2013-0026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract Background and Aims. The aim of this study was to assess the control of the cardiometabolic risk factors in subjects with newly diagnosed type 2 diabetes (T2DM) one year after initiating the clinical management. Material and Methods. We conducted a prospective observational study including 673 persons with newly diagnosed T2DM, registered at the Clinical Center of Diabetes Cluj-Napoca, between 2006-2008. Results: Of the total T2DM subjects who were followed-up until the end of the first year after diagnosis, the proportion of those reaching the optimal goals for major risk factors was 72.1% for HbA1c, 58.6% for blood pressure (BP) and 40.3% for LDL cholesterol. All three goals were met by only 6.9%. Achieving glycemic targets is associated with a lower HbA1c value at diagnosis (OR:0.66, 95%IC: 0.54-0.81). The parameters which were initially identified as associated with achieving the objectives of the clinical management were represented by age, male gender, clinical parameters (HbA1c, body mass index, BP), hypertension, pharmacotherapy. Conclusions: Implementing clinical management in newly diagnosed T2DM subjects resulted in improved glycemic control and cardiovascular risk factors one year after diagnosis. The management of newly diagnosed people with T2DM focused specifically on achieving the glycemic target
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Accounting for clinical action reduces estimates of gender disparities in lipid management for diabetic veterans. J Gen Intern Med 2013; 28 Suppl 2:S529-35. [PMID: 23807061 PMCID: PMC3695267 DOI: 10.1007/s11606-013-2340-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Women with diabetes have higher low-density lipoprotein (LDL) levels than men, resulting in apparent disparities between genders on quality indicators tied to LDL thresholds. OBJECTIVE To investigate whether gender disparities persist when accounting for clinical action with statins or cardiovascular risk. DESIGN Retrospective cohort study. PARTICIPANTS Veterans Health Administration patients (21,780 women and 646,429 men) aged 50-75 with diabetes. MAIN MEASURES Threshold measure: LDL < 100 mg/dL; clinical action measure: LDL < 100 mg/dL; or LDL ≥ 100 mg/dL and the patient was prescribed a moderate or high-dose statin at the time of the test; or LDL ≥ 100 mg/dL and the patient received other appropriate clinical action within 90 days; adherence: continuous multiple interval measure of gaps in dispensed medication (CMG). KEY RESULTS Women were much less likely to have LDL < 100 mg/dL than were men (55 % vs. 68 %). This disparity narrowed from 13 % to 6 % for passing the clinical action measure (79 % vs. 85 %). These gender differences persisted among those with ischemic heart disease (IHD). Women had a lower odds of passing the clinical action measure (odds ratio 0.68, 95 % confidence interval 0.66-0.71). Among those with IHD, the gender gap increased with age. Differences in pass rates were explained by women's higher LDL levels, but not by their slightly worse adherence (3 % higher CMG). CONCLUSIONS Women and men veterans receive more similar quality of care for lipids in diabetes than previously indicated. Less reassuringly, the remaining gender differences appear to be as common in women at high cardiovascular risk as in those at low risk. Rather than focus on simply improving LDL levels in all women with diabetes, future efforts should ensure that patients with high cardiovascular risk are appropriately treated with statins when clinically indicated, feasible, and concordant with patient preferences.
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Winston GJ, Palmas W, Lima J, Polak JF, Bertoni AG, Burke G, Eng J, Gottesman R, Shea S. Pulse pressure and subclinical cardiovascular disease in the multi-ethnic study of atherosclerosis. Am J Hypertens 2013; 26:636-42. [PMID: 23388832 DOI: 10.1093/ajh/hps092] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Brachial pulse pressure (PP) has been found to be associated with markers of subclinical cardiovascular disease, including carotid intima-media thickness and left-ventricular mass index (LVMI), but it is unclear whether these associations are independent of traditional cardiovascular risk factors and of the steady, nonpulsatile component of blood pressure (BP). Moreover, it is unknown whether these associations are modified by gender, age, or race/ethnicity. METHODS We used multivariate linear regression models to assess the relationship between brachial PP and three markers of subclinical cardiovascular disease (CVD) (common carotid intima-media thickness (CC-IMT), internal carotid intima-media thickness (IC-IMT), and LVMI) in four race/ethnic groups in the Multi-Ethnic Study of Atherosclerosis. The models were adjusted for traditional Framingham risk factors (age, low-density lipoprotein-cholesterol, high-density lipoprotein-cholesterol, diabetes, smoking status), use of lipid-lowering medication, use of antihypertensive medication, study site, and mean arterial pressure (MAP). RESULTS The assessment was done on 6,776 participants (2,612 non-Hispanic white, 1,870 African-American, 1,494 Hispanic, and 800 Chinese persons). The associations between brachial PP and CC-IMT, IC-IMT, and LVMI were significant in fully adjusted models. The three subclinical markers also showed significant interactions with gender (P < 0.0001), with stronger interactions in men. There was an interaction with age for LVMI (P = 0.004) and IC-IMT (P = 0.008). Race/ethnicity modified the association of PP with CC-IMT. CONCLUSIONS Brachial PP was independently associated with subclinical CVD after adjustment for cardiovascular risk factors and mean arterial pressure (MAP). The strength of the association differed significantly for strata of gender, age, and race/ethnicity.
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Affiliation(s)
- Ginger J Winston
- Division of Clinical Epidemiology and Evaluative Sciences Research, Department of Medicine, Weill Cornell Medical College, New York, NY, USA
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Mwendwa DT, Ali MK, Sims RC, Cole AP, Lipscomb MW, Levy SA, Callender CO, Campbell AL. Dispositional depression and hostility are associated with inflammatory markers of cardiovascular disease in African Americans. Brain Behav Immun 2013; 28:72-82. [PMID: 23123367 DOI: 10.1016/j.bbi.2012.10.019] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2012] [Revised: 10/09/2012] [Accepted: 10/22/2012] [Indexed: 11/29/2022] Open
Abstract
Prior research has demonstrated that state depressive symptoms and hostility can modulate inflammatory immune responses and directly contribute to cardiovascular disease (CVD) onset and development. Previous studies have not considered the contribution of dispositional depressive symptoms to the inflammatory process. They have also largely excluded African Americans, despite their disproportionate risk for CVD. The first aim of the study was to examine the impact of state and dispositional depression and hostility on CVD-associated inflammatory biomarkers interleukin-6 (IL-6) and C-reactive protein (CRP) in an African American sample. The second aim was to examine synergistic influences of hostility and state and dispositional depression on IL-6 and CRP. The final aim was to examine whether the relations between state and dispositional depression, hostility, IL-6, and CRP varied as a function of gender and education. Anthropometric measures, blood serum samples, and psychosocial data were collected from 198 African Americans from the Washington, DC metropolitan area. Hierarchical and stepwise regression analyses indicated that (1) increased levels of hostility were associated with increased levels of CRP; (2) hostility and IL-6 were more strongly associated among participants with lower educational attainment; and (3) dispositional depression and CRP were more strongly associated among participants with greater hostility and lower educational attainment. Findings suggest that enduring personality dispositions, such as dispositional depression and hostility, are critical to a thorough assessment of cardiovascular profiles in African Americans. Future studies should investigate causal pathways that link depressive and hostile personality styles to inflammatory activity for African American men and women.
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Affiliation(s)
- Denee T Mwendwa
- Department of Psychology, Howard University, 525 Bryant Street, NW, Room N-179, CB Powell Building, Washington, DC 20059, USA.
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Holland AT, Zhao B, Wong EC, Choi SE, Wong ND, Palaniappan LP. Racial/ethnic differences in control of cardiovascular risk factors among type 2 diabetes patients in an insured, ambulatory care population. J Diabetes Complications 2013; 27:34-40. [PMID: 23062328 PMCID: PMC3587775 DOI: 10.1016/j.jdiacomp.2012.08.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2012] [Revised: 07/20/2012] [Accepted: 08/17/2012] [Indexed: 01/15/2023]
Abstract
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.
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Affiliation(s)
- Ariel T. Holland
- Palo Alto Medical Foundation Research Institute, Palo Alto, CA, USA
| | - Beinan Zhao
- Palo Alto Medical Foundation Research Institute, Palo Alto, CA, USA
| | - Eric C. Wong
- Palo Alto Medical Foundation Research Institute, Palo Alto, CA, USA
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Rückert IM, Maier W, Mielck A, Schipf S, Völzke H, Kluttig A, Greiser KH, Berger K, Müller G, Ellert U, Neuhauser H, Rathmann W, Tamayo T, Moebus S, Andrich S, Meisinger C. Personal attributes that influence the adequate management of hypertension and dyslipidemia in patients with type 2 diabetes. Results from the DIAB-CORE Cooperation. Cardiovasc Diabetol 2012; 11:120. [PMID: 23035799 PMCID: PMC3503646 DOI: 10.1186/1475-2840-11-120] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2012] [Accepted: 10/01/2012] [Indexed: 01/13/2023] Open
Abstract
Background Hypertension and dyslipidemia are often insufficiently controlled in persons with type 2 diabetes (T2D) in Germany. In the current study we evaluated individual characteristics that are assumed to influence the adequate treatment and control of hypertension and dyslipidemia and aimed to identify the patient group with the most urgent need for improved health care. Methods The analysis was based on the DIAB-CORE project in which cross-sectional data from five regional population-based studies and one nationwide German study, conducted between 1997 and 2006, were pooled. We compared the frequencies of socio-economic and lifestyle factors along with comorbidities in hypertensive participants with or without the blood pressure target of < 140/90 mmHg. Similar studies were also performed in participants with dyslipidemia with and without the target of total cholesterol/HDL cholesterol ratio < 5. Furthermore, we compared participants who received antihypertensive/lipid lowering treatment with those who were untreated. Univariable and multivariable logistic regression models were used to assess the odds of potentially influential factors. Results We included 1287 participants with T2D of whom n = 1048 had hypertension and n = 636 had dyslipidemia. Uncontrolled blood pressure was associated with male sex, low body mass index (BMI), no history of myocardial infarction (MI) and study site. Uncontrolled blood lipid levels were associated with male sex, no history of MI and study site. The odds of receiving no pharmacotherapy for hypertension were significantly greater in men, younger participants, those with BMI < 30 kg/m2 and those without previous MI or stroke. Participants with dyslipidemia received lipid lowering medication less frequently if they were male and had not previously had an MI. The more recent studies HNR and CARLA had the greatest numbers of well controlled and treated participants. Conclusion In the DIAB-CORE study, the patient group with the greatest odds of uncontrolled co-morbidities and no pharmacotherapy was more likely comprised of younger men with low BMI and no history of cardiovascular disease.
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Affiliation(s)
- Ina-Maria Rückert
- Institute of Epidemiology II, Helmholtz Zentrum München, German Research Center for Environmental Health (GmbH) and German Center for Diabetes Research (DZD e,V,), Ingolstädter Landstrasse 1, D-85764, München/Neuherberg, Germany.
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Palmas W, Teresi JA, Findley S, Mejia M, Batista M, Kong J, Silver S, Luchsinger JA, Carrasquillo O. Protocol for the Northern Manhattan Diabetes Community Outreach Project. A randomised trial of a community health worker intervention to improve diabetes care in Hispanic adults. BMJ Open 2012; 2:e001051. [PMID: 22454189 PMCID: PMC3330252 DOI: 10.1136/bmjopen-2012-001051] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVE Hispanics in the USA are affected by the diabetes epidemic disproportionately, and they consistently have lower access to care, poorer control of the disease and higher risk of complications. This study evaluates whether a community health worker (CHW) intervention may improve clinically relevant markers of diabetes care in adult underserved Hispanics. METHODS AND ANALYSIS The Northern Manhattan Diabetes Community Outreach Project (NOCHOP) is a two-armed randomised controlled trial to be performed as a community-based participatory research study performed in a Primary Care Setting in Northern Manhattan (New York City). 360 Hispanic adults with poorly controlled type 2 diabetes mellitus (haemoglobin A1c >8%), aged 35-70 years, will be randomised at a 1:1 ratio, within Primary Care Provider clusters. The two study arms are (1) a 12-month CHW intervention and (2) enhanced usual care (educational materials mailed at 4-month intervals, preceded by phone calls). The end points, assessed after 12 months, are primary = haemoglobin A1c and secondary = blood pressure and low-density lipoprotein-cholesterol levels. In addition, the study will describe the CHW intervention in terms of components and intensity and will assess its effects on (1) medication adherence, (2) medication intensification, (3) diet and (4) physical activity. ETHICS AND DISSEMINATION All participants will provide informed consent; the study protocol has been approved by the Institutional Review Board of Columbia University Medical Center. CHW interventions hold great promise in improving the well-being of minority populations who suffer from diabetes mellitus. The NOCHOP study will provide valuable information about the efficacy of those interventions vis-à-vis clinically relevant end points and will inform policy makers through a detailed characterisation of the programme and its effects. CLINICAL TRIAL REGISTRATION NUMBER NCT00787475 at clinicaltrials.gov.
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Affiliation(s)
- Walter Palmas
- Department of Medicine, Columbia University, New York, New York, USA
| | | | - Sally Findley
- Joseph Mailman School of Public Health, Columbia University, New York, New York, USA
| | | | | | - Jian Kong
- Hebrew Home for the Aged, Riverdale, New York, USA
| | | | - Jose A Luchsinger
- Department of Medicine, Columbia University, New York, New York, USA
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Ford ES. Trends in the control of risk factors for cardiovascular disease among adults with diagnosed diabetes: findings from the National Health and Nutrition Examination Survey 1999-2008*. J Diabetes 2011; 3:337-47. [PMID: 21767347 DOI: 10.1111/j.1753-0407.2011.00148.x] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The aim of the present study was to examine trends in the control of key risk factors for cardiovascular disease among adults with diagnosed diabetes in the US from 1999 to 2008. METHODS Data for up to 2623 adults aged ≥20 years with diagnosed diabetes who participated in 2-year cycles of the National Health and Nutrition Examination Surveys from 1999 to 2008 were examined. RESULTS Significant improvements were seen in the control of HbA1c (37.0%-55.2%), blood pressure (35.2%-51.0%), and low-density lipoprotein-cholesterol (LDL-C; 32.5%-52.9%). Both men and women experienced significant improvement in HbA1c and LDL-C. Whites showed significant improvement in glycemic control, LDL-C control, and the control of all three risk factors. African Americans showed significant improvement in glycemic control and blood pressure control, and Mexican Americans showed significant improvement in glycemic control and the control of all three risk factors. Compared with Whites, African Americans (prevalence ratio [PR] = 0.84; 95% confidence interval [CI] 0.74-0.96) and Mexican Americans (PR = 0.82; 95% CI 0.72-0.92) had worse glycemic control, and Mexican Americans had worse control of LDL-C (PR = 0.70; 95% CI 0.57-0.87) and of all three risk factors (PR = 0.46; 95% CI 0.23-0.90). There was little change in the prevalence of not currently smoking, having C-reactive protein <3 g/L, and having a urinary albumin:creatinine ratio <30 mg/g. The prevalence of body mass index <30 kg/m(2) decreased from 45.4% to 37.6% (P(linear trend) = 0.045). CONCLUSIONS Significant improvements in recommended levels of HbA1c, blood pressure, and LDL-C occurred in diabetic adults in the US between 1999 and 2008.
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Affiliation(s)
- Earl S Ford
- Division of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.
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Cultural Considerations: Pharmacological and Nonpharmacological Means for Improving Blood Pressure Control among Hispanic Patients. Int J Hypertens 2011; 2012:831016. [PMID: 22028956 PMCID: PMC3199045 DOI: 10.1155/2012/831016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2011] [Accepted: 08/19/2011] [Indexed: 01/13/2023] Open
Abstract
Cardiovascular disease is a leading cause of morbidity and mortality in the United States, and its prevention and treatment remain a priority for the medical community. Ethnic variations account for some differences in the prevalence of hypertension and blood pressure (BP) control rates among Hispanics, indicating the need for culturally appropriate management models. Aggressive treatment strategies are key to achieving optimal BP control in high-risk Hispanic patients. Hypertension in this ethnic group continues to be a major health concern. Of note, when provided access to comprehensive care, Hispanics demonstrate similar response rates to treatment as the majority of non-Hispanic whites. This highlights the importance of effective, culturally responsive hypertension management among high-risk Hispanic patients for achieving observable, positive health outcomes.
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Hayashi T, Kawashima S, Nomura H, Itoh H, Watanabe H, Ohrui T, Yokote K, Sone H, Hattori Y, Yoshizumi M, Ina K, Kubota K. Age, gender, insulin and blood glucose control status alter the risk of ischemic heart disease and stroke among elderly diabetic patients. Cardiovasc Diabetol 2011; 10:86. [PMID: 21978180 PMCID: PMC3200162 DOI: 10.1186/1475-2840-10-86] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2011] [Accepted: 10/06/2011] [Indexed: 11/30/2022] Open
Abstract
Background We analyzed the effects of insulin therapy, age and gender on the risk of ischemic heart disease (IHD) and cerebrovascular accident (CVA) according to glycemic control. Methods and Results We performed a prospective cohort study (Japan Cholesterol and Diabetes Mellitus Study) of type 2 diabetes patients (n = 4014) for 2 years. The primary endpoint was the onset of fatal/non-fatal IHD and/or CVA, which occurred at rates of 7.9 and 7.2 per 1000 person-years, respectively. We divided diabetic patients into four groups based on age (≤ 70 and > 70) and hemoglobin A1C levels (≤ 7.0 and > 7.0%). Multiple regression analysis revealed that IHD was associated with high systolic blood pressure and low HDL-C in patients under 70 years of age with fair glycemic control and was associated with low diastolic blood pressure in the older/fair group. Interestingly, insulin use was associated with IHD in the older/poor group (OR = 2.27, 95% CI = 1.11-5.89; p = 0.026) and was associated with CVA in the older/fair group (OR = 2.09, 95% CI = 1.06-4.25; p = 0.028). CVA was associated with lower HDL-C and longer duration of diabetes in younger/poor glycemic control group. Results by stepwise analysis were similar. Next, patients were divided into four groups based on gender and diabetic control(hemoglobinA1C < or > 7.0%). Multiple regression analysis revealed that IHD was associated with high systolic blood pressure in male/fair glycemic control group, age in male/poor control group, and short duration of diabetic history in females in both glycemic control groups. Interestingly, insulin use was associated with IHD in the male/poor group(OR = 4.11, 95% CI = 1.22-8.12; p = 0.018) and with CVA in the female/poor group(OR = 3.26, 95% CI = 1.12-6.24; p = 0.02). CVA was associated with short duration of diabetes in both female groups. Conclusions IHD and CVA risks are affected by specific factors in diabetics, such as treatment, gender and age. Specifically, insulin use has a potential role in preventing IHD but may also be a risk factor for CVA among the diabetic elderly, thus revealing a need to develop improved treatment strategies for diabetes in elderly patients. The Japan Cholesterol and Diabetes Mellitus Study was formulated to evaluate them(Umin Clinical Trials Registry, clinical trial reg. no. UMIN00000516; http://www.umin.ac.jp/ctr/index.htm).
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Affiliation(s)
- Toshio Hayashi
- Department of Geriatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan.
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