Relative Contributions of Socioeconomic, Local Environmental, Psychosocial, Lifestyle/Behavioral, Biophysiological, and Ancestral Factors to Racial/Ethnic Disparities in Type 2 Diabetes

Partnering for Better Health: Using Continuous Glucose Monitoring and Clinical Pharmacist Collaboration to Improve Glycemic Control in Underserved Patients With Type 2 Diabetes

PURPOSE

The purpose of this study was to examine the effect of initiating use of a continuous glucose monitor (CGM) in patients being treated for type 2 diabetes mellitus, specifically those who face barriers to obtaining this device because of its cost.

METHODS

This retrospective medical record review compared diabetes control of patients before and after use of a CGM device within a single primary care office. Patient medical records were reviewed 18 months after initial CGM was provided, and only those who received a CGM directly from the clinic were included in the review. Statistical analysis comparing the difference in mean baseline glycosylated hemoglobin (HbA1c) level with the first HbA1c level after CGM placement was completed using the paired t test for the primary outcome.

FINDINGS

A total of 41 patients who obtained at least 1 CGM reader and a minimum of a 30-day supply of sensors from the clinic were included in the review. The primary outcome resulted in a significant reduction in the mean (SD) first HbA1c level after CGM placements of -1.9% (2.5%) (P < .001) with a total of 10 and 22 patients with an HbA1c level <7% and 8%, respectively. This mean (SD) reduction in HbA1c level was also seen in both insulin-treated patients (-1.8% [2.8%], n = 30) and non-insulin-treated patients (-2% [2.8%], n=11). The largest reduction in the first HbA1c level after CGM placement was seen in those patients provided a CGM along with collaborative care with a clinical pharmacist. These patients saw a mean (SD) decrease of -2.5% [2.7%] (n = 26) in their HbA1c level with a mean (SD) decrease of -0.8% (1.6%) (n = 15) for those not comanaged by the clinical pharmacist.

IMPLICATIONS

The results of this study suggest that the use of CGM in the underserved population can lead to a significant improvement in glycemic control in patients with diabetes, regardless of treatment therapies used. Involving a multidisciplinary team in diabetes management, including clinical pharmacists, may further improve outcomes. Access to these devices in the underserved population may be crucial in reducing the risk of developing complications related to uncontrolled diabetes.

Patient-level factors associated with hemoglobin A1C testing in Alabama Medicaid beneficiaries with diabetes

AIM

We evaluated patient-level factors associated with receipt of hemoglobin A1c (HbA1c) testing among Alabama Medicaid beneficiaries with type 2 diabetes.

METHODS

We conducted a retrospective analysis of person-year observations from Medicaid claims data from 2011 to 2020. Adults aged 19-64 years with type 2 diabetes and continuous enrollment in Medicaid for study year and year prior were included. Primary outcomes were ≥ 1 and ≥ 2 HbA1c test(s) per year. We conducted multivariable Poisson regression stratified by Medicaid eligibility reason (disability, poverty) examining the association of study year, demographics, clinical factors, and healthcare utilization with HbA1c testing.

RESULTS

We analyzed 288,379 observations, 51% with disability-based, 49% poverty-based eligibility. Overall, 57% observations had ≥ 1 HbA1c, 35% had ≥ 2 HbA1c tests. More observations with disability-based than poverty-based eligibility had ≥ 1 (76% vs. 38%) and ≥ 2 HbA1c tests (49% vs. 20%). Patient-level factors were associated with a higher likelihood of having ≥ 1 HbA1c: Black race and older age (disability-based eligibility); year after 2011, female sex, and younger age (poverty-based eligibility); and rurality, insulin use, endocrinology care, diabetes complications, and ambulatory care visits (both groups).

CONCLUSIONS

Just over one-third of adult Alabama Medicaid beneficiaries with diabetes had ≥ 2 HbA1c tests per year; testing frequency differed by Medicaid eligibility.

Impact of Podiatric Surgery Consultation for Foot and Ankle Wounds on Patient Outcomes in a Community Hospital

Previous studies have demonstrated that timely podiatric surgery consultation results in positive patient outcomes. However, there are limited studies focused on readmission rates in teaching community hospitals. The primary aim of this study is to determine if consulting podiatric services was associated with lower 30-day readmission rates and impact on length of stay in patients with lower extremity wounds. The secondary aim was to investigate medical and socio-economic factors associated with better outcomes. This study was a cross-sectional descriptive study. A retrospective chart review utilizing the hospital's electronic medical record system identified patients with lower extremity wounds (based on ICD-10 codes) admitted between July 2018 and December 2020. The results showed a 3-fold decrease in 30-day readmission rates in patients with podiatric surgery consultation compared to patients without consultation with lower extremity wounds (4.2% vs 11.3%, p = .03). Multivariate regression models showed patients with gangrene (AOR = 7.61; p = .04) or osteomyelitis (AOR = 9.07; p = .013) had a higher likelihood of readmission than patients with venous ulcer (reference category) after controlling for podiatric consultation. Among the group of patients with podiatric consultation, earlier podiatric consultations resulted in decreased length of stay. This study identifies prior amputation history and lack of podiatric consultation increased 30-day readmission rates.

Social and Medical Determinants of Diabetes: A Time-Constrained Multiple Mediator Analysis

Background A number of studies have shown an association between social determinants of health and the emergence of obesity and diabetes, but whether the relationship is causal is not clear. Objective To test whether social, environmental, and medical determinants directly or indirectly affect population-level diabetes prevalence after controlling for mediator-mediator interactions. Methods Data were obtained from the CDC and supplemented with nine other data sources for 3,109 US counties. The dependent variable was the prevalence of diabetes in 2017. Independent variables were a given county's 30 social, environmental, and medical characteristics in 2015 and 2016. A network multiple mediation analysis was conducted. First, we used Least Absolute Shrinkage and Selection Operator (LASSO) regression to relate the 2017 diabetes rate in each county to 30 predictors measured in 2016, identifying statistically significant and robust predictors as the mediators within the network model and as direct determinants of 2017 diabetes. Second, each of the direct causes of diabetes was taken as a new response variable and LASSO-regressed on the same 30 independent variables measured in 2015, identifying the indirect (mediated) causes of diabetes. Subsequently, these direct and indirect predictors were used to construct a network model. The completed network was then employed to estimate the direct and mediated impact of variables on diabetes. Results For 2017 diabetes rates, 63% of the variation was explained by five variables measured in 2016: the percentage of residents who were (1) obese, (2) African American, (3) physically inactive, (4) in poor health condition, and (5) had a history of diabetes. These five direct predictors, measured in 2016, mediated the effect of indirect variables measured in 2015, including the percentage of residents who were (1) Hispanic, (2) physically distressed, (3) smokers, (4) living with children in poverty, (5) experiencing limited access to healthy foods, and (6) had low income. Conclusion All of the direct predictors of diabetes prevalence, except the percentage of residents who were African American, were medical conditions potentially influenced by lifestyles. Counties characterized by higher levels of obesity, inactivity, and poor health conditions exhibited increased diabetes rates in the following year. The impact of social determinants of illness, such as low income, children in poverty, and limited access to healthy foods, had an indirect effect on the health of residents and, consequently, increased the prevalence of diabetes.

Medication use and contextual factors associated with meeting guideline-based glycemic levels in diabetes among a nationally representative sample

Introduction

Based on the long-lasting diabetes management challenges in the United States, the objective was to examine glycemic levels among a nationally representative sample of people with diabetes stratified by prescribed antihyperglycemic treatment regimens and contextual factors.

Methods

This serial cross-sectional study used United States population-based data from the 2015 to March 2020 National Health and Nutrition Examination Surveys (NHANES). The study included non-pregnant adults (≥20 years old) with non-missing A1C and self-reported diabetes diagnosis from NHANES. Using A1C lab values, we dichotomized the outcome of glycemic levels into <7% versus ≥7% (meeting vs. not meeting guideline-based glycemic levels, respectively). We stratified the outcome by antihyperglycemic medication use and contextual factors (e.g., race/ethnicity, gender, chronic conditions, diet, healthcare utilization, insurance, etc.) and performed multivariable logistic regression analyses.

Results

The 2042 adults with diabetes had a mean age of 60.63 (SE = 0.50), 55.26% (95% CI = 51.39-59.09) were male, and 51.82% (95% CI = 47.11-56.51) met guideline-based glycemic levels. Contextual factors associated with meeting guideline-based glycemic levels included reporting an "excellent" versus "poor" diet (aOR = 4.21, 95% CI = 1.92-9.25) and having no family history of diabetes (aOR = 1.43, 95% CI = 1.03-1.98). Contextual factors associated with lower odds of meeting guideline-based glycemic levels included taking insulin (aOR = 0.16, 95% CI = 0.10-0.26), taking metformin (aOR = 0.66, 95% CI = 0.46-0.96), less frequent healthcare utilization [e.g., none vs. ≥4 times/year (aOR = 0.51, 95% CI = 0.27-0.96)], being uninsured (aOR = 0.51, 95% CI = 0.33-0.79), etc.

Discussion

Meeting guideline-based glycemic levels was associated with medication use (taking vs. not taking respective antihyperglycemic medication classes) and contextual factors. The timely, population-based estimates can inform national efforts to optimize diabetes management.

Pharmacological Treatment of Type-2-Diabetes and Cardiovascular Comorbidities: Differences between Undocumented Migrants and Natives in Italy

Diabetes prevalence is growing worldwide, especially in some populations. Though migrations seem to contribute to the presence in host countries of a significant number of patients with diabetes and its comorbidities, very little is known about the health conditions of undocumented migrants. We retrospectively studied 838 patients with type 2 diabetes mellitus (T2DM), 425 Italians followed by the diabetes clinic of a university hospital, and 413 undocumented migrants receiving assistance from a non-governmental organization. We analyzed their demographic and clinical data together with the medications they were on. The prevalence of the use of specific classes of drugs was compared between undocumented migrants and Italians by fitting a Poisson regression model, and the results were reported as prevalence rate ratios (PRRs) with a 95% confidence interval. Undocumented migrants with T2DM received fewer medications for cardiovascular (CV) conditions (PRR: 0.68, 0.60 to 0.76) than Italians, after correcting for confounding factors. Only sulfonylureas were more frequently used in undocumented migrants. The causes of these differences are not completely clear, but social, cultural, and economic factors can have an important role. More efforts are needed to provide appropriate treatment of diabetes and its CV comorbidities to undocumented migrants.

A randomized controlled trial to test the efficacy of a diabetes behavioral intervention to prevent memory decline in older blacks/African Americans with diabetes and mild cognitive impairment

BACKGROUND

The prevalence of dementia in Blacks/African Americans (AAs) is almost twice that of Whites. Inequities in access to health care, socioeconomic conditions, and diabetes contribute to this disparity. Poorly controlled diabetes, which is more prevalent in Blacks/AAs, causes microvascular disease and neurodegeneration and increases dementia risk. Improving glycemic control, therefore, may prevent cognitive decline. To address this issue, we developed Diabetes Regulation for Eyesight and Memory (DREAM), a community health worker (CHW)-led behavioral intervention to improve diabetes self-management and thereby prevent cognitive decline. DREAM consists of home-based diabetes education, goal setting, and telehealth visits with a diabetes nurse educator. Exploratory aims will investigate whether APOE genotype moderates and retinal biomarkers mediate treatment effects. This report describes the trial's rationale, methodology, and study procedures. (clinicaltrials.gov identifier NCT04259047).

METHODS

This randomized controlled trial will test the efficacy of DREAM to prevent decline in memory (primary outcome) in Blacks/AAs aged 65+ with poorly controlled diabetes and Mild Cognitive Impairment (MCI). Two hundred participants will be randomized to DREAM or an attention control condition, and will receive 11 in-home treatment sessions over two years. Outcome data are collected at 6, 12, 18, and 24 months. The primary outcome is verbal learning as measured by Hopkins Verbal Learning Test (HVLT) Total Recall scores. Participants will have retinal imaging at baseline, 12, and 24 months.

CONCLUSIONS

This research aims to prevent cognitive decline in older Blacks/AAs with diabetes and MCI. If successful, this research will preserve health in an underserved population and reduce racial health disparities.

Comparative Safety and Effectiveness of Roux-en-Y Gastric Bypass and Sleeve Gastrectomy for Weight Loss and Type 2 Diabetes Across Race and Ethnicity in the PCORnet Bariatric Study Cohort

Importance

Bariatric surgery is the most effective treatment for severe obesity; yet it is unclear whether the long-term safety and comparative effectiveness of these operations differ across racial and ethnic groups.

Objective

To compare outcomes of Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) across racial and ethnic groups in the National Patient-Centered Clinical Research Network (PCORnet) Bariatric Study.

Design, Setting, and Participants

This was a retrospective, observational, comparative effectiveness cohort study that comprised 25 health care systems in the PCORnet Bariatric Study. Patients were adults and adolescents aged 12 to 79 years who underwent a primary (first nonrevisional) RYGB or SG operation between January 1, 2005, and September 30, 2015, at participating health systems. Patient race and ethnicity included Black, Hispanic, White, other, and unrecorded. Data were analyzed from July 1, 2021, to January 17, 2022.

Exposure

RYGB or SG.

Outcomes

Percentage total weight loss (%TWL); type 2 diabetes remission, relapse, and change in hemoglobin A1c (HbA1c) level; and postsurgical safety and utilization outcomes (operations, interventions, revisions/conversions, endoscopy, hospitalizations, mortality, 30-day major adverse events) at 1, 3, and 5 years after surgery.

Results

A total of 36 871 patients (mean [SE] age, 45.0 [11.7] years; 29 746 female patients [81%]) were included in the weight analysis. Patients identified with the following race and ethnic categories: 6891 Black (19%), 8756 Hispanic (24%), 19 645 White (53%), 826 other (2%), and 783 unrecorded (2%). Weight loss and mean reductions in HbA1c level were larger for RYGB than SG in all years for Black, Hispanic, and White patients (difference in 5-year weight loss: Black, -7.6%; 95% CI, -8.0 to -7.1; P < .001; Hispanic, -6.2%; 95% CI, -6.6 to -5.9; P < .001; White, -5.9%; 95% CI, -6.3 to -5.7; P < .001; difference in change in year 5 HbA1c level: Black, -0.29; 95% CI, -0.51 to -0.08; P = .009; Hispanic, -0.45; 95% CI, -0.61 to -0.29; P < .001; and White, -0.25; 95% CI, -0.40 to -0.11; P = .001.) The magnitude of these differences was small among racial and ethnic groups (1%-3% of %TWL). Black and Hispanic patients had higher risk of hospitalization when they had RYGB compared with SG (hazard ratio [HR], 1.45; 95% CI, 1.17-1.79; P = .001 and 1.48; 95% CI, 1.22-1.79; P < .001, respectively). Hispanic patients had greater risk of all-cause mortality (HR, 2.41; 95% CI, 1.24-4.70; P = .01) and higher odds of a 30-day major adverse event (odds ratio, 1.92; 95% CI, 1.38-2.68; P < .001) for RYGB compared with SG. There was no interaction between race and ethnicity and operation type for diabetes remission and relapse.

Conclusions and Relevance

Variability of the comparative effectiveness of operations for %TWL and HbA1c level across race and ethnicity was clinically small; however, differences in safety and utilization outcomes were clinically and statistically significant for Black and Hispanic patients who had RYGB compared with SG. These findings can inform shared decision-making regarding bariatric operation choice for different racial and ethnic groups of patients.

Incidence of long-term diabetes complications and mortality in youth-onset type 2 diabetes: A systematic review

AIMS

This systematic review aims to assess the incidence of chronic kidney disease (CKD), cardiovascular disease (CVD) and mortality in people with type 2 diabetes diagnosed <20 years.

METHODS

We searched MEDLINE, Embase and Cochrane Library for longitudinal studies published between 1 January 2000 and 31 November 2021.

RESULTS

Seventeen studies (15 reporting CKD, 3 reporting CVD, 5 reporting mortality) from seven countries of sample size ranging between 96 and 4,141 were eligible. Most studies were conducted in North America and Europe (n = 14). Diabetes duration at enrolment varied from 0 to 8.3 years and follow-up duration from 1 to 12.6 years. The incidence rates (per 1,000 person-year) of albuminuria ranged between 12.4 and 114.8, macroalbuminuria or proteinuria between 10 and 35.0, end-stage kidney disease (ESKD) between 0.4 and 25.0, CVD between 3.7 and 19.5, and mortality between 1.0 and 18.6. The highest incidence rates of albuminuria, ESKD and mortality were recorded in Australian Aboriginal and Pima Indian populations. Youth-onset type 2 diabetes was associated with greater risk of developing CKD compared with type 1 diabetes in most studies.

CONCLUSION

Studies reporting CVD in youth-onset type 2 diabetes are scarce. Estimated incidence rates of CKD and mortality in youth-onset type 2 diabetes varied across different study populations, potentially higher in indigenous people. Youth with type 2 diabetes are at higher risk of adverse kidney outcomes than their type 1 counterparts. More studies are needed in regions outside of North America and Europe.

Differences in the prevalence of intermediate hyperglycaemia and the associated incidence of type 2 diabetes mellitus by ethnicity: The HELIUS study

AIMS

We aimed to describe differences in the prevalence of intermediate hyperglycaemia (IH) between six ethnic groups. Moreover, to investigate differences in the association of the classifications of IH with the incidence of T2DM between ethnic groups.

METHODS

We included 3759 Dutch, 2826 African Surinamese, 1646 Ghanaian, 2571 Turkish, 2691 Moroccan and 1970 South Asian Surinamese origin participants of the HELIUS study. IH was measured by fasting plasma glucose (FPG) and HbA1c. We calculated age-, BMI and physical-activity-adjusted prevalence of IH by sex, and calculated age and sex-adjusted hazard ratios (HR)for the association between IH and T2DM in each ethnic group.

RESULTS

The prevalence of IH was higher among ethnic minority groups (68.6-41.7%) than the Dutch majority (34.9%). The prevalence of IH categories varied across subgroups. Combined increased FPG and HbA1c was most prevalent in South-Asian Surinamese men (27.6%, 95 %CI: 24.5-30.9%), and in Dutch women (4.2%, 95 %CI: 3.4-5.1%). The HRs for T2DM for each IH-classification did not differ significantly between ethnic groups. HRs were highest for the combined classification, e.g., HR = 8.1, 95 %CI: 2.5-26.6 in the Dutch.

CONCLUSION

We found a higher prevalence of IH in ethnic minority versus majority groups, but did not find evidence for a differential association of IH with incident T2DM.

Neighborhood Socioeconomic Environment and Risk of Type 2 Diabetes: Associations and Mediation Through Food Environment Pathways in Three Independent Study Samples

OBJECTIVE

We examined whether relative availability of fast-food restaurants and supermarkets mediates the association between worse neighborhood socioeconomic conditions and risk of developing type 2 diabetes (T2D).

RESEARCH DESIGN AND METHODS

As part of the Diabetes Location, Environmental Attributes, and Disparities Network, three academic institutions used harmonized environmental data sources and analytic methods in three distinct study samples: 1) the Veterans Administration Diabetes Risk (VADR) cohort, a national administrative cohort of 4.1 million diabetes-free veterans developed using electronic health records (EHRs); 2) Reasons for Geographic and Racial Differences in Stroke (REGARDS), a longitudinal, epidemiologic cohort with Stroke Belt region oversampling (N = 11,208); and 3) Geisinger/Johns Hopkins University (G/JHU), an EHR-based, nested case-control study of 15,888 patients with new-onset T2D and of matched control participants in Pennsylvania. A census tract-level measure of neighborhood socioeconomic environment (NSEE) was developed as a community type-specific z-score sum. Baseline food-environment mediators included percentages of 1) fast-food restaurants and 2) food retail establishments that are supermarkets. Natural direct and indirect mediating effects were modeled; results were stratified across four community types: higher-density urban, lower-density urban, suburban/small town, and rural.

RESULTS

Across studies, worse NSEE was associated with higher T2D risk. In VADR, relative availability of fast-food restaurants and supermarkets was positively and negatively associated with T2D, respectively, whereas associations in REGARDS and G/JHU geographies were mixed. Mediation results suggested that little to none of the NSEE-diabetes associations were mediated through food-environment pathways.

CONCLUSIONS

Worse neighborhood socioeconomic conditions were associated with higher T2D risk, yet associations are likely not mediated through food-environment pathways.

Disparities in HbA1c testing between aging US Latino and non-Latino white primary care patients

US Latinos disproportionately face diabetes-related disparities compared to non-Latino Whites. A number of barriers, including linguistic and cultural discordance, have been consistently linked to these disparities. Glycated hemoglobin (HbA1c) testing is used to assess glycemic control among individuals living with diabetes. This study aimed to compare HbA1c levels and corresponding testing rates among non-Latino Whites and Latinos with both English and Spanish preference from a national cohort of primary care patients within community health centers. We analyzed electronic health records from patients who turned 50 years of age (n = 66,921) and were diagnosed with diabetes during or prior to the study period. They also must have been under observation for at least one year from January 1, 2013 to December 31, 2017. We calculated the rates of HbA1c tests each person received over the number of years observed and used covariate-adjusted negative binomial regression to estimate incidence rate ratios for Spanish preferring Latinos and English preferring Latinos compared to non-Latino Whites. Spanish preferring Latinos (rate ratio = 1.23, 95% CI = 1.16-1.30), regardless of HbA1c level, had higher testing rates than non-Latino Whites and English preferring Latinos. English preferring Latinos with controlled HbA1c levels had higher rates of HbA1c testing compared to non-Latino whites. Overall, the Latinos with Spanish preference maintained higher HbA1c testing rates and had disproportionately higher rates of uncontrolled HbA1c levels compared to non-Latino whites. Future efforts should focus on understanding effective approaches to increasing engagement among Spanish preferring Latinos and addressing organizational-level barriers, given HbA1c disparities.

Prevalence and trends of type 2 diabetes mellitus and prediabetes among community-dwelling heart failure patients in the United States

AIMS

This study estimated national prevalence and trends of diagnosed and undiagnosed type 2 diabetes mellitus (T2DM) and prediabetes among heart failure (HF) patients in the U.S.

METHODS

This cross-sectional study included 527 participants aged 20+ years with a diagnosis of HF, using data from the National Health and Nutrition Examination Survey 2005-2016. We assessed prevalence estimates of diagnosed and undiagnosed T2DM and prediabetes stratified by age-standardized sociodemographic and health characteristics. Trends of T2DM and prediabetes prevalence were examined using logistic regressions.

RESULTS

Prevalence rates of diagnosed and undiagnosed T2DM among HF patients were 34.7% (95% confidence interval (CI), 29.2-40.3%) and 12.8% (95% CI, 9.2-16.9%), respectively. Prediabetes affected 39.1% (95% CI, 33.6-44.9%) of HF patients. Prevalence estimates of diagnosed T2DM were significantly different between non-Hispanic White (20.1% [95% CI, 13.5-27.6%]) and Hispanic participants (52.1% [95% CI, 35.9-68.0%]) (P < 0.001). The prevalence of T2DM and prediabetes did not significantly change between 2005 and 2016.

CONCLUSIONS

Prevalence rates of T2DM and prediabetes among community-dwelling HF patients in the U.S. remained high between 2005 and 2016. Prevention of and targeted intervention for T2DM among at-risk HF patients is needed, particularly among those of Hispanic origin.

The Importance of Biobehavioral Research to Examine the Physiological Effects of Racial and Ethnic Discrimination in the Latinx Population

A growing body of research is documenting how racial and ethnic populations embody social inequalities throughout the life course. Some scholars recommend the integration of biospecimens representing the hypothalamic-pituitary-adrenal axis, neurological and endocrinological processes, and inflammation to capture the embodiment of inequality. However, in comparison to other racial and ethnic groups, there has been little research examining how Hispanic/Latinx persons embody racial and ethnic discrimination, much less resulting from institutional and structural racism. We provide a rationale for expanding biobehavioral research examining the physiological consequences of racism among Latinx persons. We identify gaps and make recommendations for a future research agenda in which biobehavioral research can expand knowledge about chronic disease inequities among Latinx populations and inform behavioral and institutional interventions. We end by cautioning readers to approach the recommendations in this article as a call to expand the embodiment of racism research to include the diverse Latinx population as the United States addresses racial inequity.

Type 2 diabetes risks and determinants in second-generation migrants and mixed ethnicity people of South Asian and African Caribbean descent in the UK

AIMS/HYPOTHESIS

Excess risks of type 2 diabetes in UK South Asians (SA) and African Caribbeans (AC) compared with Europeans remain unexplained. We studied risks and determinants of type 2 diabetes in first- and second-generation (born in the UK) migrants, and in those of mixed ethnicity.

METHODS

Data from the UK Biobank, a population-based cohort of ~500,000 participants aged 40-69 at recruitment, were used. Type 2 diabetes was assigned using self-report and HbA1c. Ethnicity was both self-reported and genetically assigned using admixture level scores. European, mixed European/South Asian (MixESA), mixed European/African Caribbean (MixEAC), SA and AC groups were analysed, matched for age and sex to enable comparison. In the frames of this cross-sectional study, we compared type 2 diabetes in second- vs first-generation migrants, and mixed ethnicity vs non-mixed groups. Risks and explanations were analysed using logistic regression and mediation analysis, respectively.

RESULTS

Type 2 diabetes prevalence was markedly elevated in SA (599/3317 = 18%) and AC (534/4180 = 13%) compared with Europeans (140/3324 = 4%). Prevalence was lower in second- vs first-generation SA (124/1115 = 11% vs 155/1115 = 14%) and AC (163/2200 = 7% vs 227/2200 = 10%). Favourable adiposity (i.e. lower waist/hip ratio or BMI) contributed to lower risk in second-generation migrants. Type 2 diabetes in mixed populations (MixESA: 52/831 = 6%, MixEAC: 70/1045 = 7%) was lower than in comparator ethnic groups (SA: 18%, AC: 13%) and higher than in Europeans (4%). Greater socioeconomic deprivation accounted for 17% and 42% of the excess type 2 diabetes risk in MixESA and MixEAC compared with Europeans, respectively. Replacing self-reported with genetically assigned ethnicity corroborated the mixed ethnicity analysis.

CONCLUSIONS/INTERPRETATION

Type 2 diabetes risks in second-generation SA and AC migrants are a fifth lower than in first-generation migrants. Mixed ethnicity risks were markedly lower than SA and AC groups, though remaining higher than in Europeans. Distribution of environmental risk factors, largely obesity and socioeconomic status, appears to play a key role in accounting for ethnic differences in type 2 diabetes risk.

Ethnicity and Self-reported Depression Among Hispanic Immigrants in the U.S

Viewed to be healthier than ethnic Hispanics born in the United States, Hispanic immigrants represent numerous subgroups with clearly heterogeneous geographic, cultural, structural, and social origins. This study asked how the factors length of U.S. residency, social status, lifestyle, and health care might explain self-reported depression within 5 large, discrete subgroups comprising immigrants from, in turn, Mexico, Puerto Rico, Cuba, the Dominican Republic, and other nations in Central and South America. The study also examined ethnicity's potential role moderating self-reported depression's associations. With pooled data from National Health Interview Surveys 1999-2015, it evaluated each ethnic group separately. Self-reported depression was associated generally with lengthening residence in the U.S., with being female, with poverty, with unemployment, with lack of education, and with lifestyle and health-care factors. These associations were not uniform across ethnic groups, however. Where self-reported depression is concerned, descriptive results suggest the proverbial health advantage may largely accrue specifically to Hispanic immigrants of Cuban and of Central/South American origin.

Socioeconomic deprivation and genetic ancestry interact to modify type 2 diabetes ethnic disparities in the United Kingdom

BACKGROUND

Type 2 diabetes (T2D) is a complex common disease that disproportionately impacts minority ethnic groups in the United Kingdom (UK). Socioeconomic deprivation (SED) is widely considered as a potential explanation for T2D ethnic disparities in the UK, whereas the effect of genetic ancestry (GA) on such disparities has yet to be studied.

METHODS

We leveraged data from the UK Biobank prospective cohort study, with participants enrolled between 2006 and 2010, to model the relationship between SED (Townsend index), GA (clustering principal components of whole genome genotype data), and T2D status (ICD-10 codes) across the three largest ethnic groups in the UK - Asian, Black, and White - using multivariable logistic regression.

FINDINGS

The Asian group shows the highest T2D prevalence (17·9%), followed by the Black (11·7%) and White (5·5%) ethnic groups. We find that both SED (OR: 1·11, 95% CI: 1·10-1·11) and non-European GA (OR South Asian versus European: 4·37, 95% CI: 4·10-4·66; OR African versus European: 2·52, 95% CI: 2·23-2·85) are significantly associated with the observed T2D disparities. GA and SED show significant interaction effects on T2D, with SED being a relatively greater risk factor for T2D for individuals with South Asian and African ancestry, compared to those with European ancestry.

INTERPRETATION

The significant interactions between SED and GA underscore how the effects of environmental risk factors can differ among ancestry groups, suggesting the need for group-specific interventions.

FUNDING

This work was supported by the National Institutes of Health (NIH) Distinguished Scholars Program (DSP) to LMR and the Division of Intramural Research (DIR) of the National Institute on Minority Health and Health Disparities (NIMHD) at NIH.

Genetic ancestry differences in pediatric asthma readmission are mediated by socioenvironmental factors

BACKGROUND

Social and financial hardships, combined with disease managment and environmental factors explain approximately 80% of the observed disparity in asthma-related readmissions between Black and White children.

OBJECTIVE

We sought to determine whether asthma-related readmissions differed by degree of African ancestry and the extent to which such an association would also be explained by socioenvironmental risk factors.

METHODS

This study used data from a prospective cohort study of 695 Black and White children aged 1 to 16 years with an asthma-related admission. The primary outcome was a similar readmission within 12 months. Each subject's African ancestry was determined by single nucleotide polymorphisms on a continuous scale ranging from 0 to 1 (0 = no African ancestry; 1 = 100% African ancestry). We also assessed 37 social, environmental, and clinical variables that we clustered into 6 domains (for example, hardship, disease management). Survival and mediation analyses were conducted.

RESULTS

A total of 134 children (19.3%) were readmitted within 12 months. Higher African ancestry was associated with asthma readmission (odds ratio 1.11, 95% confidence interval 1.05-1.18 for every 10% increase in African ancestry) with adjustment for age and gender. The association between African ancestry and readmission was mediated by hardship (sβ = 3.42, P < .001) and disease management (sβ = 0.046, P = .001), accounting for >50% of African ancestry's effect on readmission. African ancestry was no longer significantly associated with readmission (sβ = 0.035, P = .388) after accounting for these mediators.

CONCLUSIONS

African ancestry was strongly associated with readmission, and the association was mediated by family hardship and disease management. These results are consistent with the notion that asthma-related racial disparities are driven by factors like structural racism and social adversity.

The Contribution of Material, Behavioral, Psychological, and Social-Relational Factors to Income-Related Disparities in Cardiovascular Risk Among Older Adults

Supplemental digital content is available in the text.

Understanding the factors underlying health disparities is vital to developing strategies to improve health equity in old age. Such efforts should be encouraged in Korea.

Gender Differences and Their Influences on T2DM Self-Management Among Spanish-Speaking Latinx Immigrants

INTRODUCTION

Evidence suggests that gender may influence many aspects of type 2 diabetes (T2DM) self-management (SM) and we posit that limited English language-proficient Latinx immigrants face additional challenges.

METHODS

Instruments and semi-structured interviews were used to examine gender differences on health literacy, diabetes knowledge, health-promoting behaviors, diabetes, eating and exercise self-efficacy (SE), and T2DM SM practices among a cohort of limited English language-proficient Latinx immigrants. Statistical and qualitative analysis procedures were performed comparing males and females.

RESULTS

Thirty persons participated. Males tended to be older, have higher educational achievement, and more financial security than females. Physiologic measures tended worse among female participants. Health literacy and exercise SE scores were similar, but females scored lower on Eating and Diabetes SE. Forty-seven percent (n= 9) of the women reported a history of gestational diabetes mellitus and a majority of men (n = 7) cited difficulty with excessive alcohol.

CONSUMPTION

Males appeared to receive more SM support compared to females. Females more frequently noted how family obligations and a lack of support impeded their SM. Work environments negatively influenced SM practices.

CONCLUSION

Men and women have unique SM challenges and as such require individualized strategies and support to improve T2DM management.

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

BACKGROUND

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

AIM

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

METHODS AND RESULTS

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

CONCLUSION

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

The Need for Ethnoracial Equity in Artificial Intelligence for Diabetes Management: Review and Recommendations

There is clear evidence to suggest that diabetes does not affect all populations equally. Among adults living with diabetes, those from ethnoracial minority communities—foreign-born, immigrant, refugee, and culturally marginalized—are at increased risk of poor health outcomes. Artificial intelligence (AI) is actively being researched as a means of improving diabetes management and care; however, several factors may predispose AI to ethnoracial bias. To better understand whether diabetes AI interventions are being designed in an ethnoracially equitable manner, we conducted a secondary analysis of 141 articles included in a 2018 review by Contreras and Vehi entitled “Artificial Intelligence for Diabetes Management and Decision Support: Literature Review.” Two members of our research team independently reviewed each article and selected those reporting ethnoracial data for further analysis. Only 10 articles (7.1%) were ultimately selected for secondary analysis in our case study. Of the 131 excluded articles, 118 (90.1%) failed to mention participants’ ethnic or racial backgrounds. The included articles reported ethnoracial data under various categories, including race (n=6), ethnicity (n=2), race/ethnicity (n=3), and percentage of Caucasian participants (n=1). Among articles specifically reporting race, the average distribution was 69.5% White, 17.1% Black, and 3.7% Asian. Only 2 articles reported inclusion of Native American participants. Given the clear ethnic and racial differences in diabetes biomarkers, prevalence, and outcomes, the inclusion of ethnoracial training data is likely to improve the accuracy of predictive models. Such considerations are imperative in AI-based tools, which are predisposed to negative biases due to their black-box nature and proneness to distributional shift. Based on our findings, we propose a short questionnaire to assess ethnoracial equity in research describing AI-based diabetes interventions. At this unprecedented time in history, AI can either mitigate or exacerbate disparities in health care. Future accounts of the infancy of diabetes AI must reflect our early and decisive action to confront ethnoracial inequities before they are coded into our systems and perpetuate the very biases we aim to eliminate. If we take deliberate and meaningful steps now toward training our algorithms to be ethnoracially inclusive, we can architect innovations in diabetes care that are bound by the diverse fabric of our society.

Continuous Glucose Monitoring for Underserved and Minority Patients with Type 2 Diabetes in an Interprofessional Internal Medicine Clinic

Objective

Evaluate the impact of interprofessional continuous glucose monitoring (CGM) on glycemic control in underserved and minority patients with type 2 diabetes mellitus (T2DM).

Methods

The IRB-approved, retrospective quasi-experimental study was conducted between August 2018 and August 2019 at an internal medicine residency clinic. Adult patients with diagnosed T2DM, an indication for CGM (hyperglycemia, hypoglycemia, and/or glycemic variability), and at least 10 consecutive days of CGM data were included. Patients who were pregnant and/or missed one or more clinic appointments were excluded. Patients were followed weekly over a 14-day period during which data from the CGM sensor were downloaded and interpreted by the interprofessional team. Interventions with shared decision-making were made at each visit.

Results

Fifty-five patients were included, with a mean age of 61+11.2 years, 86% were of non-white race, and 56% were female. Average blood glucose levels decreased from 208.39 mg/dL at week 1 to 190.74 mg/dL at week 2, a 17.65 mg/dLreduction (p = 0.0281). Time within target range (70-180 mg/dL) increased by 6.16% (p = 0.0038), while time above range (>180 mg/dL) decreased by 5.5% (p = 0.0168). Average number of hypoglycemic events (readings <70 mg/dL) did not change significantly from week 1 to week 2 (2.94 vs. 3.64, p > 0.05). Of the 66 interventions made after week 1, 33% were made by the pharmacy team, 56% were made by the attending or resident physicians, and 11% were made by the dietician. Of 59 interventions made after week 2, 32% were made by the pharmacy team, 49% were made by the attending or resident physicians, and 19% were made by the dietician.

Conclusions

The interprofessional collaborative CGM service was associated with improvements in glucose control based on increased time within target range and reduced hyperglycemia, without increasing the risk of hypoglycemia or medication burden.

Tirzepatide: a glucose-dependent insulinotropic polypeptide (GIP) and glucagon-like peptide-1 (GLP-1) dual agonist in development for the treatment of type 2 diabetes

INTRODUCTION

The glucagon-like peptide-1 (GLP-1) receptor agonists (RA) have increasingly gained prominence in the treatment of type 2 diabetes (T2D) based on their glycemic benefits and favorable body weight and cardiorenal effects. Despite this, continued development of therapeutics with superior efficacy is important to help address persistent challenges in the attainment of metabolic goals in many patients with T2D.

AREAS COVERED

Tirzepatide is an unimolecular dual glucose-dependent insulinotropic polypeptide (GIP)/GLP-1 RA in development for the treatment of T2D. This review summarizes key characteristics of tirzepatide and Phase 1 and Phase 2 clinical trial efficacy and safety results. Additionally, it provides an overview of the ongoing Phase 3 clinical trial program in T2D and briefly summarizes recently initiated studies in patients with obesity and nonalcoholic steatohepatitis. Information in this review comes primarily from published clinical trials, manufacturer's websites, and ClinicalTrials.gov.

EXPERT OPINION

Based on data from Phase 2 trials, tirzepatide has the potential to be the most efficacious therapy in T2D with respect to both glucose and body weight control. Data from the ongoing Phase 3 clinical trial program should start to become available in late 2020 and will determine the future course of this promising therapeutic agent.

Nicotine-mediated upregulation of microRNA-141 expression determines adipokine-intervened insulin resistance

MicroRNAs (miRNAs) are non-coding RNAs that are associated with adipokine homeostasis and insulin resistance. Whereas, smoking can disturb metabolic homeostasis. Present study was aimed to investigate the level of miRNA-141 in experimental animal model that were exposed with graded doses of nicotine. We further aimed to investigate the possible interplay of miRNA-141 expression change with adipokine homeostasis and occurrence of insulin resistance in nicotine-exposed experimental animals. Nicotine (0.5, 1.0, 3.0 and 6.0 mg/Kg) was administered to early adolescent; postnatal days ranging from 25 to 30 Wistar rats for one month. Serum was analyzed for leptin, adipokines, IL-6, MDA, HbA1c, insulin, G6PDH, hexokinase, and lipid profile. While miRNA-141 expression level was determined in plasma. Higher doses of nicotine were associated with higher glucose, HbA1c, leptin, IL-6, MDA and lipids levels, while, insulin, adiponectin, G6PDH, hexokinase and HDL levels were lower. Higher doses of nicotine also impaired glucose tolerance and exhibited significant increase in miR-141 expression signifying that nicotine exposure may influence adipokines regulation altering glycemic profile. This is accompanied with aggravated inflammatory responses where genetic expression of miRNA-141 can be an accessible biomarker for metabolic disturbances with insulin resistance and glucose intolerance.

Mobile-Enhanced Peer Support for African Americans with Type 2 Diabetes: a Randomized Controlled Trial

BACKGROUND

Peer support has been shown to improve diabetes self-management and control, but no standard exists to link peer support interventions to clinical care.

OBJECTIVE

To compare a community-based diabetes self-management education (DSME) plus mobile health (mHealth)-enhanced peer support intervention to community-based diabetes self-management education (DSME) alone for African American adults with poorly controlled type 2 diabetes.

DESIGN

A randomized controlled trial.

PARTICIPANTS

African American adults, age > 19 years, receiving care within a safety-net healthcare system in Jefferson County, Alabama, with a diagnosis of type 2 diabetes and a hemoglobin A1c (A1C) ≥ 7.5%.

INTERVENTIONS

Participants in the intervention group received community-based diabetes self-management education (DSME) plus 6 months of mHealth-enhanced peer support, including 12 weekly phone calls, then 3 monthly calls from community health workers, who used a novel web application to communicate with participants' healthcare teams. In the control group, participants received community-based DSME alone.

MAIN MEASURES

The primary outcome was A1C; secondary outcomes included diabetes distress, depressive symptoms, self-efficacy or confidence in their ability to manage diabetes, and social support. We used mixed models repeated measures analyses to assess for between-arm differences and baseline to follow-up changes.

KEY RESULTS

Of 120 participants randomized, 97 completed the study. Participants in intervention and control groups experienced clinically meaningful reduction in A1C, 10.1 (SD 1.7) to 9.6 (SD 1.9) and 9.8 (SD 1.7) to 9.1 (SD 1.9) respectively, p = 0.004. Participants in the intervention group experienced a significantly larger reduction in diabetes distress compared to the control, 2.7 (SD 1.2) to 2.1 (1.0) versus 2.6 (SD 1.1) to 2.3 (SD 1.0) p = 0.041.

CONCLUSIONS

Community-based DSME with and without peer support led to improved glycemic control. Peer support linked to clinical care led to a larger reduction in diabetes distress, which has important implications for the overall wellbeing of adults with type 2 diabetes.

Increased β-Cell Responsivity Independent of Insulin Sensitivity in Healthy African American Adults

BACKGROUND

Primary insulin hypersecretion predicts type 2 diabetes (T2DM) independent of insulin resistance. Enhanced β-cell glucose responsivity contributes to insulin hypersecretion. African Americans (AAs) are at a higher risk for T2DM than non-Hispanic Whites (NHWs). Whether AAs manifest primary insulin hypersecretion is an important topic that has not been examined systematically.

OBJECTIVE

To examine if nondiabetic AA adults have a higher β-cell glucose responsivity compared with NHWs.

METHODS

Healthy nondiabetic AA (n = 18) and NHW (n=18) subjects were prospectively recruited. Indices of β-cell function, acute C-peptide secretion (X0); basal (Φ B), first-phase (Φ 1), second-phase (Φ 2), and total β-cell responsivity to glucose (Φ TOT), were derived from modeling of insulin, C-peptide, and glucose concentrations during an intravenous glucose tolerance test. Insulin sensitivity was assessed by the hyperinsulinemic-euglycemic glucose clamp technique.

RESULTS

Glucose disposal rate (GDR) during clamp was similar in AAs and NHWs (GDR: [AA] 12.6 ± 3.2 vs [NHW] 12.6 ± 4.2 mg/kg fat free mass +17.7/min, P = .49). Basal insulin secretion rates were similar between the groups. AA had significantly higher X0 (4423 ± 593 vs 1807 ± 176 pmol/L, P = .007), Φ 1 [377.5 ± 59.0 vs 194.5 ± 26.6 (109) P = 0.03], and Φ TOT [76.7 ± 18.3 vs 29.6 ± 4.7 (109/min), P = 0.03], with no significant ethnic differences in Φ B and Φ 2.

CONCLUSIONS

Independent of insulin sensitivity, AAs showed significantly higher first-phase and total β-cell responsivity than NHWs. We propose that this difference reflects increased β-cell responsivity specifically to first-phase readily releasable insulin secretion. Future studies are warranted to identify mechanisms leading to primary β-cell hypersensitivity in AAs.

A Framework for Addressing Diabetes-Related Disparities in US Latino Populations

Despite national efforts to redress racial/ethnic disparities, Latino Americans continue to share a disproportionate burden of diabetes-related morbidity and mortality. A better understanding of underlying causes and influencing factors is needed to guide future efforts to eliminate racial/ethnic disparities in diabetes control. The objectives of this review are: (1) to summarize our understanding of determinants and modifiable predictors of glycemic control; (2) to provide an overview of existing strategies to reduce diabetes-related disparities; and (3) to identify gaps in the literature regarding whether these interventions effectively address disparities in US Latino populations. Key findings include evidence that diabetes care services can be designed to accommodate heterogeneity within the Latino American community by addressing key modifiable predictors of poor glycemic control, including insurance status, diabetes care utilization, patient self-management, language access, culturally appropriate care, and social support services. Future research efforts should evaluate the effect of structurally tailored interventions that address these key modifiable predictors by targeting patients, providers, and health care delivery systems.

Racial Disparities in Diabetes Management Outcomes: Evidence from a Remote Patient Monitoring Program for Type 2 Diabetic Patients

Introduction: Despite growing documentation of the efficacy of telemedicine in diabetes management, racial disparities in telemedicine-facilitated diabetes management remain underexplored. This study examined disparities in diabetes management outcomes between black and white patients with type 2 diabetes (T2D) in a remote monitoring program. Methods: The analysis sample included 914 white T2D patients and 365 black T2D patients in Nebraska who completed a 3-month remote patient monitoring and coaching after hospital discharge from 2014 to 2017. Ordinary least squares regression was estimated to examine racial differences in hemoglobin A1c (HbA1c), and logistic regression was used to determine the odds of HbA1c > 9% at the end of the program, controlling for demographics, baseline health conditions, and patient activation and engagement with the program. Results: The proportion of white patients with HbA1c > 9% was reduced from 16% at the baseline to 7% at program completion, and the corresponding reduction among black patients was from 30% to 18%. After adjusting for the effects of baseline HbA1c and other covariates, the average HbA1c among black patients at the end of the program was 0.23 points higher than that among white patients (p < 0.01), and the adjusted odds of black patients having HbA1c > 9% was 1.68 times that of white patients (95% confidence interval [1.07-2.63]). Discussion: The remote patient monitoring and coaching program reduced the absolute gap between black and white T2D patients. However, substantial racial disparities in HbA1c still remained at the end of the program and warranted further research.

Reduced Insulin Clearance and Insulin-Degrading Enzyme Activity Contribute to Hyperinsulinemia in African Americans

BACKGROUND

African Americans (AAs) are at a higher risk for developing type 2 diabetes compared with non-Hispanic whites (NHWs). The causal role of β-cell glucose sensitivity (β-GS) and insulin clearance in hyperinsulinemia in AA adults is unclear.

OBJECTIVE

Using a cross-sectional study design, we compared β-cell function and insulin clearance in nondiabetic AAs (n = 36) and NHWs (n = 47) after a mixed meal test (MMT).

METHODS

Insulin secretion rate, glucose sensitivity, rate sensitivity, and insulin sensitivity during MMT were derived from a mathematical model. Levels of insulin-degrading enzyme (IDE) and carcinoembryonic antigen-related cell adhesion molecule-1 (CEACAM1), key players in insulin clearance, were measured (by enzyme-linked immunosorbent assay) in hepatic cytosolic fractions from age-, sex-, and body mass index-matched AA and NHW cadaveric donors (n = 10).

RESULTS

Fasting and mean postprandial plasma glucose levels were similar in both ethnic groups. AAs had significantly higher fasting and mean postprandial plasma insulin levels. However, fasting ISR, total insulin output, and insulin sensitivity during MMT were not different between the groups. β-GS and rate sensitivity were higher in AAs. Fasting and meal plasma insulin clearance were lower in AAs. Hepatic levels of IDE and CEACAM-1 were similar in AAs and NHWs. Hepatic IDE activity was significantly lower in AAs.

CONCLUSIONS

In this study, lower insulin clearance contributes to higher plasma insulin levels in AAs. Reduced insulin clearance may be explained by lower IDE activity levels in AAs. Further confirmatory studies are needed to investigate diminished insulin clearance in AAs as a result of lower IDE activity levels.

Improving Glycemic Control in African Americans With Diabetes and Mild Cognitive Impairment

BACKGROUND/OBJECTIVES

Improving glycemic control in older African Americans with diabetes and mild cognitive impairment (MCI) is important as the population ages and becomes more racially diverse.

DESIGN

Randomized controlled trial.

SETTING

Recruitment from primary care practices of an urban academic medical center. Community-based treatment delivery.

PARTICIPANTS

Older African Americans with MCI, low medication adherence, and poor glycemic control (N = 101).

INTERVENTIONS

Occupational therapy (OT) behavioral intervention and diabetes self-management education.

MEASUREMENTS

The primary outcome was a reduction in hemoglobin A1c level of at least 0.5% at 6 months, with maintenance effects assessed at 12 months.

RESULTS

At 6 months, 25 of 41 (61.0%) OT participants and 22 of 46 (48.2%) diabetes self-management education participants had a reduction in hemoglobin A1c level of at least 0.5%. The model-estimated rates were 58% (95% confidence interval [CI] = 45%-75%) and 48% (95% CI = 36%-64%), respectively (relative risk [RR] = 1.21; 95% CI = 0.84-1.75; P = .31). At 12 months, the respective rates were 21 of 39 (53.8%) OT participants and 24 of 49 (49.0%) diabetes self-management education participants. The model-estimated rates were 50% (95% CI = 37%-68%) and 48% (95% CI = 36%-64%), respectively (RR = 1.05; 95% CI = 0.70-1.57; P = .81).

CONCLUSION

Both interventions improved glycemic control in older African Americans with MCI and poor glycemic control. This result reinforces the American Diabetes Association's recommendation to assess cognition in older persons with diabetes and demonstrates the potential to improve glycemic control in this high-risk population. J Am Geriatr Soc 68:1015-1022, 2020.

Protocol for a randomised controlled trial of a co-produced, complex, health promotion intervention for women with prior gestational diabetes and their families: the Face-it study

Background

Gestational diabetes mellitus (GDM) is associated with an increased risk of future diabetes in both mother, father and offspring. More knowledge is needed about how to effectively reduce the risk of diabetes through sustained behavioural interventions in these families. The Face-it intervention is a complex health promotion intervention embedded in multi-level supportive environments. The aim of the intervention is to reduce type 2 diabetes risk and increase quality of life among families in the first year following a GDM-affected pregnancy by promoting physical activity, healthy dietary behaviours and breastfeeding through a focus on social support, motivation, self-efficacy, risk perception and health literacy.

Methods

This national multicentre study is a two-arm randomised controlled trial including 460 women with GDM in a ratio of 2 (intervention):1 (usual care). The Face-it intervention consists of three main components: 1) additional visits from municipal health visitors, 2) digital health coaching tailored to family needs and 3) a structured cross-sectoral communication system in the health care system. The intervention runs from 3 to 12 months after delivery. The primary outcome is maternal body mass index at 12 months after delivery as a proxy for diabetes risk.

The women will be examined at baseline and at follow-up, and this examination will include blood tests, oral glucose tolerance test (OGTT), anthropometrics, blood pressure, self-reported diet and physical activity, breastfeeding, quality of life, health literacy, physical and mental health status, risk perception and social support. Aside from those data collected for OGTT and breastfeeding and offspring parameters, the same data will be collected for partners. Data on offspring anthropometry will also be collected. Information on pregnancy- and birth-related outcomes will be derived from the medical records of the woman and child.

Discussion

This randomised controlled trial seeks to demonstrate whether the Face-it intervention, addressing the individual, family and health care system levels, is superior to usual care in reducing diabetes risk for mothers and their families. Coupled with a process evaluation and an economic analysis, the study will provide evidence for policymakers and health services about health promotion among families affected by GDM and the potential for reducing risk of type 2 diabetes and associated conditions.

Trial registration

ClinicalTrials.gov NCT03997773. Registered June 25, 2019 – Retrospectively registered.

Will undocumented migrants contribute to change epidemiology, presentation and pharmacologic treatment of diabetes in Western countries?

AIMS

Migrants from countries in which health and social conditions are unsatisfactory, and their offspring, are becoming a growing component of the western population. Available health data show that their morbidity is at least comparable to that of the host country population, with a significant contribution of chronic diseases as diabetes. The possibility that diabetes shows different features in undocumented migrants is the hypothesis that we tried to investigate in this study.

METHODS

We retrospectively analysed the data of 413 patients with type 2 diabetes mellitus (T2DM): 222 patients followed in a diabetes clinic at a University Hospital and 191 undocumented migrants cared for by a Charity in Milan, Italy.

RESULTS

We found that the onset of the disease was earlier in migrants; they showed a significant lower body mass index (BMI) and had lower socioeconomic conditions. They had a worse glycaemic control. The pattern of complications was also different between the two groups, with cardiovascular complications more frequent in Italians. Finally, also pharmacologic treatment differed significantly.

CONCLUSIONS

Age of onset, clinical manifestations and complications of T2DM in undocumented migrants and natives may show significant differences. This is important for both epidemiological and clinical reasons. If these preliminary observations are confirmed by larger studies, we can conclude that undocumented migrants should be screened for T2DM earlier than natives, and that therapies should be tailored to the specific features of their disease.

Elucidating the Multidimensionality of Socioeconomic Status in Relation to Metabolic Syndrome in the Hispanic Community Health Study/Study of Latinos (HCHS/SOL)

BACKGROUND

Socioeconomic (SES) factors underlying disparities in the prevalence of metabolic syndrome (MetSyn) and consequently, type 2 diabetes among Hispanics/Latino populations are of considerable clinical and public health interest. However, incomplete and/or imprecise measurement of the multidimensional SES construct has impeded a full understanding of how SES contributes to disparities in metabolic disease. Consequently, a latent-variable model of the SES-MetSyn association was investigated and compared with the more typical proxy-variable model.

METHODS

A community-based cross-sectional probability sample (2008-2011) of 14,029 Hispanic/Latino individuals of Puerto Rican, Cuban, Dominican, Central American, South American, and Mexican ancestry living in the USA was used. SES proxy's education, income, and employment were examined as effect indicators of a latent variable, and as individual predictors. MetSyn was defined using 2009 harmonized guidelines, and MetSyn components were also examined individually.

RESULTS

In multivariate regression analyses, the SES latent variable was associated with 9% decreased odds of MetSyn (95% confidence interval: 0.85, 0.96, P < .001) and was associated with all MetSyn components, except diastolic blood pressure. Additionally, greater income, education, and employment status were associated with 4%, 3%, and 24% decreased odds of having MetSyn, respectively (Ps < .001). The income-MetSyn association was only significant for women and those with current health insurance.

CONCLUSIONS

Hispanic/Latinos exhibit an inverse association between SES and MetSyn of varying magnitudes across SES variables. Public health research is needed to further probe these relationships, particularly among Hispanic/Latina women, to ultimately improve healthcare access to prevent diabetes in this underserved population.

Diabetic Neuropathy among Type 2 Diabetes Mellitus Patients at Amplas Primary Health Care in Medan City

BACKGROUND:

Diabetic neuropathy is one of the most complicated complications of diabetes patients with Type 2 diabetes.

AIM:

The purpose of this study was to determine the diagnosis of diabetic neuropathy based on Clinical Neurological Examination (CNE) and the factors that influence the occurrence of diabetic neuropathy in Type 2 DM patients at Amplas Primary Health Care (PHC) in Medan City.

METHODS:

The research design was descriptive-analytic with the cross-sectional approach. The study population was all Type 2 DM patients who came to Amplas PHC with a total sample of 53 people using the consecutive sampling. The research data source is primary data, namely the assessment of diabetic neuropathy using the Clinical Neurological Examination (CNE) criteria. Data were processed using SPSS and analysis using the chi-square test.

RESULTS:

The results showed the majority of Type 2 DM patients had mild neuropathy as many as 24 people (45.3%). The Chi-square test results showed there was a relationship between age and duration of diabetes with the incidence of diabetic neuropathy in Type 2 DM patients at Amplas Primary Health Care.

CONCLUSION:

Education and early detection with proper management can prevent more severe complications so that the quality of life of patients can be maintained better.

Mediating factors explaining the associations between polycyclic aromatic hydrocarbons exposure, low socioeconomic status and diabetes: A structural equation modeling approach

Exposure to polycyclic aromatic hydrocarbons (PAHs) is linked with increased risk of diabetes, whereas socioeconomic status (SES) may contribute to the development of diabetes. However, the mechanisms underlying the relationships between them are unclear. We used structural equation modeling (SEM) to identify mediating factors in the associations of PAHs exposure, low SES with diabetes risk. Data were collected from 2751 Wuhan participants at baseline from the Wuhan-Zhuhai Cohort Study (n = 3053). They answered the questionnaires regarding socio-demographic, participated physical examinations and provided urine samples for measurements of urinary monohydroxy-polycyclic aromatic hydrocarbons (OH-PAHs) levels. SEM was used to identify the mediating factors (such as hypertension, body mass index (BMI), triglycerides (TG) and total cholesterol (TCHO)) in the associations of low SES or PAHs exposure with diabetes risk. We observed that partial effect of PAHs exposure (β = 0.281, p = 0.034), BMI (β = 0.182, p = 0.000), TG (β = 0.358, p = 0.000), TCHO (β = 0.203, p = 0.009) or hypertension (β = 0.385, p = 0.000) on diabetes was directive. Moreover, low SES also exhibited a directive effect on PAHs exposure (β = -0.084, p = 0.000), BMI (β = 0.301, p = 0.000), hypertension (β = 0.134, p = 0.003) and TG (β = 0.087, p = 0.001). PAHs exposure directly affected TCHO levels (β = 0.080, p = 0.002) and TG (β = 0.076, p = 0.017). The proportion of the effect of PAHs exposure on diabetes mediated by TG and TCHO was 15.6%. The proportion of the effect of low SES on diabetes mediated by BMI, hypertension and TG was 89.1%. The results suggested that low SES increased diabetes risk, which may be partially explained by BMI, hypertension and triglycerides, and exposure to high levels of PAHs may have indirect contribution to increased risk for diabetes with dyslipidemia.

Understanding the complexity of socioeconomic disparities in type 2 diabetes risk: a study of 4.3 million people in Sweden

OBJECTIVE

Investigating demographic and socioeconomic factors as intersecting rather than as separate dimensions may improve our understanding of the heterogeneous distribution of type 2 diabetes in the population. However, this complexity has scarcely been investigated and we still do not know the accuracy of these factors for predicting type 2 diabetes. Improved understanding of the demographic and socioeconomic disparities predicting type 2 diabetes risk in the population would contribute to more precise and effective public health interventions.

RESEARCH DESIGN AND METHODS

We analyzed the risk of type 2 diabetes among 4 334 030 individuals aged 40-84 years who by 2010 had resided in Sweden for at least 5 years. We stratified the study population into 120 strata defined by categories of age, gender, income, education, and immigration status. We calculated measures of absolute risk (prevalence) and relative risk (prevalence ratio), and quantified the discriminatory accuracy of the information for predicting type 2 diabetes in the population.

RESULTS

The distribution of type 2 diabetes risk in the population was highly heterogeneous. For instance, immigrated men aged 70-79 years with low educational achievement and low income had a risk around 32 times higher than native women aged 40-49 years with high income and high educational achievement (ie, 17.6% vs 0.5%). The discriminatory accuracy of the information was acceptable.

CONCLUSION

A more detailed, intersectional mapping of socioeconomic and demographic distribution of type 2 diabetes can assist in public health management aiming to reduce the prevalence of the disease.

Perceptions of Family Among Low-Income Patients With Diabetes in a Text-Based Mobile Health Intervention

BACKGROUND

Diabetes disproportionately affects the US Latino population, due to socioeconomic pressures, genetics, reduced access to care and cultural practices. While efforts to improve self-care through interventions incorporating family are highly rated by Latinos, family can be both supportive and obstructive. To develop effective interventions, this role needs clarification.

METHODS

We conducted group interviews in Spanish and English with 24 participants with diabetes from a mobile health diabetes self-care intervention. We imported transcripts into Dedoose, a qualitative computer analysis program and analyzed them with a modified grounded theory technique. Utilizing an iterative process, we reexamined transcripts with new codes derived in each round of analysis until saturation was reached. We employed techniques to improve trustworthiness (co-coding, member checking). Broad categorical themes arose from the initial codes and were developed into a conceptual model of barriers to and strategies for diabetes management.

RESULTS

Family and family responsibilities emerged as both a supportive and obstructive force for diabetes self-care. While the desire to care for family motivated patients, food at family gatherings and pressure from managing multiple family responsibilities contributed to poor diet choices. Yet, some patients believed their diabetes caused their immediate family to make healthier choices.

CONCLUSIONS

Among these predominantly Latino patients, family and family responsibilities were key motivators as well as obstacles to self-care, particularly regarding nutrition. Finding the ideal design for social support mHealth-based interventions will require careful study and creation of culturally based programs to match the needs of specific populations, and may require educating family members to provide effective social support.

Health-Related Beliefs, Practices, and Experiences of Migrant Dominicans in the Northeastern United States

Introduction: The purpose of this study was to describe cultural health beliefs, practices, and experiences with professional health care in the United States by migrants from the Dominican Republic because their practices are largely unknown to professional providers. Method: A qualitative descriptive design was used, guided by Leininger’s culture care theory and four-phase analysis method with a convenience sample of 15 self-identified migrant Dominican adults in three interpreter-assisted focus groups, in a familiar apartment. Results: The following four themes emerged: Stress affects health and well-being, family support and faith in God are essential, use of folk care and professional care to treat illness and maintain health, and access to care, cost, communication and expressions of caring practices affect perceptions about the quality of professional care. Discussion: Results informed development of specific strategies to provide culturally responsive care and risk-reduction interventions that promote health and improve quality of care in the Dominican community.

Gender and age related differences in the use of medicines for chronic diseases among undocumented migrants

Purpose

The purpose of this paper is to evaluate gender-related differences in the use of drugs for chronic diseases in undocumented migrants.

Design/methodology/approach

The authors analyzed the databases of two charitable organizations providing medical help and medicines to undocumented migrants. Data were available for 9,822 patients in the period 2014–2016. The authors grouped medicines according to the Anatomical Therapeutic Chemical (ATC) classification. We considered the ATC group as an indicator of a group of diseases.

Findings

Both males and females needed medicines for chronic diseases in a comparable manner. When we analyzed the age distribution, The authors noticed that males showed a tendency to begin to be affected at an earlier age; however, this cumulative difference was not statistically significant. But when we looked at six groups of drugs separately (cardiovascular, respiratory, anti-thrombotic, neurologic, psychiatric, anti-diabetic), the authors found that females always needed drugs for chronic diseases at a later age, always with a significant difference (p<0.0001 for cardiovascular, antithrombotic, antidiabetic and psychoactive drugs; p<0.002 for neurologic products; p<0.04 for drugs used in chronic respiratory conditions).

Research limitations/implications

This is a retrospective study based on the analysis of existing databases, but the peculiar features of this population (undocumented migrants) do not allow at the moment controlled studies.

Practical implications

Our observations could be important when planning public health strategies, especially in the field of prevention.

Originality/value

This is the first report of gender differences in the use of medicines for chronic diseases within a large sample of undocumented migrants.

Racial Disparities in Cardiovascular Health Behaviors: The Coronary Artery Risk Development in Young Adults Study

INTRODUCTION

There are known racial differences in cardiovascular health behaviors, including smoking, physical activity, and diet quality. A better understanding of these differences may help identify intervention targets for reducing cardiovascular disease disparities. This study examined whether socioeconomic, psychosocial, and neighborhood environmental factors, in isolation or together, mediate racial differences in health behaviors.

METHODS

Participants were 3,081 men and women from the Coronary Artery Risk Development in Young Adults study who were enrolled in 1985-1986 (Year 0) and completed a follow-up examination in 2015-2016 (Year 30). A health behavior score was created at Years 0, 7, 20, and 30 using smoking, physical activity, and diet assessed that year. The race difference in health behavior score was estimated using linear regression in serial cross-sectional analyses. Mediation analyses computed the proportion of the race and health behavior score association attributable to socioeconomic, psychosocial, and neighborhood factors.

RESULTS

Data analysis conducted in 2016-2017 found that blacks had significantly lower health behavior scores than whites across 30 years of follow-up. Individual socioeconomic factors mediated 48.9%-70.1% of the association between race and health behavior score, psychosocial factors 20.3%-30.0%, and neighborhood factors 22.1%-41.4% (p<0.01 for all).

CONCLUSIONS

Racial differences in health behavior scores appear to be mediated predominately by correspondingly large differences in socioeconomic factors. This study highlights the profound impact of socioeconomic factors, which are mostly not under an individual's control, on health behaviors. Policy action targeting socioeconomic factors may help reduce disparities in health behaviors.

Waist circumference is an effect modifier of the association between bone mineral density and glucose metabolism

OBJECTIVE

The role of bone markers on insulin resistance (IR) remains controversial. The objective of this study is to evaluate the association between bone mineral density (BMD) and glucose metabolism and investigate if visceral hyperadiposity, evaluated by waist circumference (WC), is an effect modifier of this association.

SUBJECTS AND METHODS

Cross-sectional analysis with 468 young adults from the fourth follow-up of the 1978/79 Ribeirão Preto prospective birth cohort, Brazil. BMD, total osteocalcin (OC), fasting plasma glucose and insulin concentrations were assessed. IR, sensitivity (S) and secretion (β) were estimated by homeostasis model assessment (HOMA) indexes. Multiple linear regression models were constructed to estimate the association between BMD and glucose metabolism. Beta coefficient, R2 and p-values were provided. WC was tested as an effect modifier and OC as a confounder. The covariates were selected based on Direct Acyclic Graph.

RESULTS

Significant interaction between BMD (femoral neck and proximal femur areas) and WC on glucose metabolism was observed in the adjusted models. Subjects with increased WC presented a positive association between BMD and log HOMA1-IR while an inverse association was found in those with normal WC (femoral neck R2 = 0.17, p = 0.036; proximal femur R2 = 0.16, p = 0.086). BMD was negatively associated with log HOMA2-S in individuals with increased WC and positively in those with normal WC (femoral neck R2 = 0.16, p = 0.042; proximal femur R2 = 0.15, p = 0.097). No significant associations between BMD, log HOMA2-β and OC and glucose metabolism markers were observed.

CONCLUSIONS

BMD was associated with glucose metabolism, independently of OC, and WC modifies this association.

Changes of glucose levels precede dementia in African-Americans with diabetes but not in Caucasians

INTRODUCTION

Changes in glucose levels may represent a powerful metabolic indicator of dementia in African-Americans with diabetes. It is unclear whether these changes also occur in Caucasians.

METHODS

A secondary data analysis using electronic medical records from 5228 African-Americans and Caucasians aged ≥65 years was carried out. Mixed effects models with repeated serum glucose measurements were used to compare changes in glucose levels between African-Americans and Caucasian patients with and without incident dementia.

RESULTS

African-Americans and Caucasians with diabetes had significantly different changes in glucose levels by dementia status (P < .0001). African-Americans experienced a significant decline in glucose levels before the dementia diagnosis (estimated glucose decline 1.3421 mg/dL per year, P < .0001) than those who did not develop dementia. Caucasians with and without dementia showed stable glucose levels over time (P = .3071).

DISCUSSION

Significant changes in glucose levels precede dementia in African-American patients with diabetes but not in Caucasians.

Using Mobile Health to Improve Social Support for Low-Income Latino Patients with Diabetes: A Mixed-Methods Analysis of the Feasibility Trial of TExT-MED + FANS

BACKGROUND

Social support interventions can improve diabetes self-care, particularly for Latinos, but are time and resource intensive. Mobile health may overcome these barriers by engaging and training supporters remotely.

METHODS

We conducted a randomized controlled feasibility trial of emergency department patients with diabetes to determine the feasibility of enrolling patients and supporters, acceptability of the intervention, and preliminary efficacy results to power a larger trial. All patients received an existing mHealth curriculum (TExT-MED). After identifying a supporter, patients were randomized to intervention: supporters receiving FANS (family and friends network support), a text message support curriculum synchronized to patient messages, or control: supporters receiving a mailed pamphlet of the same information. Participants followed up at 3 months. FANS intervention participants came to postintervention interviews as part of a qualitative analysis.

RESULTS

We enrolled 44 patients (22 per arm) and followed up 36 at 3 months. Participants were positive about the program. FANS intervention improved HbA1c (intervention mean decreased from 10.4% to 9.0% vs. from 10.1% to 9.5%, delta -0.8%, confidence interval [CI] -0.4 to 2, P = 0.30), self-monitoring of glucose (intervention increased 1.6 days/week vs. control decreased 2 days/week, delta 2.3 days/week, CI 4-0.6, P = 0.02), and physical activity (mean Godin leisure time activity score improved 16.1 vs. decreased 9.6 for control, delta 25.7, CI 49.2-2.3, P = 0.10). In qualitative analysis, patients reported improved motivation, behaviors, and relationships. Supporters reported making healthier decisions for themselves.

CONCLUSIONS

mHealth is a feasible, acceptable, and promising avenue to improve social support and diabetes outcomes.

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

Importance

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

Objective

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

Design, Setting, and Participants

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

Exposures

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

Main Outcomes and Measures

Incident type 2 diabetes mellitus.

Results

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

Conclusions and Relevance

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

Predicting type 2 diabetes using genetic and environmental risk factors in a multi-ethnic Malaysian cohort

OBJECTIVE

Malaysia has a high and rising prevalence of type 2 diabetes (T2D). While environmental (non-genetic) risk factors for the disease are well established, the role of genetic variations and gene-environment interactions remain understudied in this population. This study aimed to estimate the relative contributions of environmental and genetic risk factors to T2D in Malaysia and also to assess evidence for gene-environment interactions that may explain additional risk variation.

STUDY DESIGN

This was a case-control study including 1604 Malays, 1654 Chinese and 1728 Indians from the Malaysian Cohort Project.

METHODS

The proportion of T2D risk variance explained by known genetic and environmental factors was assessed by fitting multivariable logistic regression models and evaluating McFadden's pseudo R² and the area under the receiver-operating characteristic curve (AUC). Models with and without the genetic risk score (GRS) were compared using the log likelihood ratio Chi-squared test and AUCs. Multiplicative interaction between genetic and environmental risk factors was assessed via logistic regression within and across ancestral groups. Interactions were assessed for the GRS and its 62 constituent variants.

RESULTS

The models including environmental risk factors only had pseudo R² values of 16.5-28.3% and AUC of 0.75-0.83. Incorporating a genetic score aggregating 62 T2D-associated risk variants significantly increased the model fit (likelihood ratio P-value of 2.50 × 10^-4-4.83 × 10^-12) and increased the pseudo R² by about 1-2% and AUC by 1-3%. None of the gene-environment interactions reached significance after multiple testing adjustment, either for the GRS or individual variants. For individual variants, 33 out of 310 tested associations showed nominal statistical significance with 0.001 < P < 0.05.

CONCLUSION

This study suggests that known genetic risk variants contribute a significant but small amount to overall T2D risk variation in Malaysian population groups. If gene-environment interactions involving common genetic variants exist, they are likely of small effect, requiring substantially larger samples for detection.

Racial/Ethnic Residential Segregation, Obesity, and Diabetes Mellitus

Persistent racial/ethnic disparities in obesity and type 2 diabetes mellitus seen in the US are likely due to a combination of social, biological, and environmental factors. A growing number of studies have examined the role of racial/ethnic residential segregation with respect to these outcomes because this macro-level process is believed to be a fundamental cause of many of the factors that contribute to these disparities. This review provides an overview of findings from studies of racial/ethnic residential segregation with obesity and diabetes published between 2013 and 2015. Findings for obesity varied by geographic scale of the segregation measure, gender, ethnicity, and racial identity (among Hispanics/Latinos). Recent studies found no association between racial/ethnic residential segregation and diabetes prevalence, but higher segregation of Blacks was related to higher diabetes mortality. Implications of these recent studies are discussed as well as promising areas of future research.

The Association between Educational Level and Cardiovascular and Cerebrovascular Diseases within the EPICOR Study: New Evidence for an Old Inequality Problem

BACKGROUND

A consistent association has been reported between low socioeconomic status (SES) and cardiovascular events (CE), whereas the association between SES and cerebrovascular events (CBVD) is less clear. The aim of this study was to investigate the association between SES (measured using education) and CE/CBVD in a cohort study, as well as to investigate lifestyle and clinical risk factors, to help to clarify the mechanisms by which SES influences CE/CBVD.

MATERIAL AND METHODS

We searched for diagnoses of CE and CBVD in the clinical records of 47,749 members of the EPICOR cohort (average follow-up time: 11 years). SES was determined by the relative index of inequality (RII).

RESULTS

A total of 1,156 CE and 468 CBVD were found in the clinical records. An increased risk of CE was observed in the crude Cox model for the third tertile of RII compared to the first tertile (hazard ratio [HR] = 1.39; 95% confidence interval [CI] 1.21-1.61). The increased risk persisted after adjustment for lifestyle risk factors (HR = 1.19; 95%CI 1.02-1.38), clinical risk factors (HR = 1.35; 95%CI 1.17-1.56), and after full adjustment (HR = 1.17; 95%CI 1.01-1.37). Structural equation model showed that lifestyle rather than clinical risk factors are involved in the mechanisms by which education influences CE. No significant association was found between education and CBVD. A strong relationship was observed between education and diabetes at baseline.

CONCLUSION

The most important burden of inequality in CE incidence in Italy is due to lifestyle risk factors.

ETHNIC AND RACIAL DISPARITIES IN THE BEHAVIORAL, PHARMACOLOGIC, AND SURGICAL TREATMENT OF OBESITY

Abbreviation: GLP-1 = glucagon-like peptide-1.