Staff resilience and innovation essential to New York City diabetes prevention programs going virtual during COVID-19 pandemic lockdowns

BACKGROUND

COVID-19 lockdowns in March 2020 forced National Diabetes Prevention Programs (DPPs) to pause, cancel or reformulate. This qualitative study sought to (a) document if/how New York City(NYC) DPPs adapted and served participants during lockdowns, and (b) identify successes and challenges to operating programs during the lockdowns and restrictions on social gathering.

METHODS

Researchers contacted 47 CDC-registered DPPs in NYC. Eleven DPP directors, lifestyle coaches, and coordinators involved in program implementation completed 1-hour semi-structured virtual interviews and received a $50 gift card. Interviews were recorded, transcribed, and analyzed using Grounded Theory (Dedoose, Version 9).

RESULTS

Interviewees represented 7 organization types: public hospitals, weight loss programs, healthcare centers, community-based organizations, health insurance companies, faith-based DPPs, and federally qualified health centers. DPPs served participants in 4 of 5 NYC boroughs. Six organizations provided DPP services during lockdowns by going virtual. Successes and challenges related to staffing, resource allocation, virtual data tracking, and participant engagement. Most programs were successful due to resilient, dedicated, and extraordinarily innovative staff.

CONCLUSION

The pandemic highlighted opportunities for successful virtual DPPs in urban settings, and the need for more robust funding, staff support, and technical assistance for sustainability and scalability of the DPP.

Abstract P562: Body Size Dissatisfaction is High in African Immigrants With Obesity: Insight From the Africans in America Cohort

Background: In African populations, attitudes towards both optimal body size and healthful weights are evolving. Due to the adverse effect of obesity on health, larger body sizes are beginning to be seen as less ideal. Our goal was to determine body size satisfaction in African immigrants who were obese.

Methods: The participants were 326 African-born Blacks enrolled in the Africans in America cohort and living in metropolitan Washington DC (female: 39%, age 40±11y (mean±SD). The African region of origin of the participants were: West: 49% (161/326), Central 12% (39/326) and East: 39% (126/326). Twenty-seven percent (89/326) of the countries of origin were francophone. Enrollees were asked to rank their current body size and ideal body size according to the Stunkard Figure Rating Scale. Body size satisfaction was determined by the difference between perceived and wish body size.

Results: BMI was higher in women than men (29.1±4.9 vs. 27.0±3.9 kg/m 2 , P<0.001). The overall prevalence of obesity was 27% (88/326) and higher in women than men (38% vs 20%, P=0.001). Among participants with obesity, there was no difference by sex in degree of dissatisfaction due to high body size (OR 2.14, 95% CI: 0.48, 9.58, P=0.32). Attitudes towards body size in participants with obesity were: 1% (1/88) considered themselves too small, 8% (7/88) just right and 91% (80/88) too large (Figure). These results did not vary by African region of origin or francophone status.

Conclusions: The majority of African immigrants with obesity were dissatisfied with their high BMI. To optimize health, risk factors associated with weight gain and body size dissatisfaction should be addressed.

A Scoping Review of Trials Designed to Achieve Remission of Type 2 Diabetes with Lifestyle Intervention Alone: Implications for Sub-Saharan Africa

According to the International Diabetes Federation, sub-Saharan Africa is experiencing the highest anticipate increase in the prevalence of type 2 diabetes (T2D) in the world and has the highest percent of people living with T2D who are undiagnosed. Therefore, diagnosis and treatment need prioritization. However, pharmacological hypoglycemics are often unavailable and bariatric surgery is not an option. Therefore, the ability to induce T2D remission through lifestyle intervention alone (LSI-alone) needs assessment. This scoping review evaluated trials designed to induce T2D remission by LSI-alone. PubMed, Embase, Cochrane, and CINAHL databases were searched for trials designed to induce T2D remission through LSI-alone. Of the 928 identified, 63 duplicates were removed. With abstract review, 727 irrelevant articles were excluded. After full-text review, 112 inappropriate articles were removed. The remaining 26 articles described 16 trials. These trials were published between 1984 and 2021 and were conducted in 10 countries, none of which were in Africa. Remission rates varied across trials. Predictors of remission were 10% weight loss and higher BMI, lower A1C and shorter T2D duration at enrollment. However, LSI-alone regimens for newly diagnosed and established T2D were very different. In newly diagnosed T2D, LSI-alone were relatively low-cost and focused on exercise and dietary counseling with or without calorie restriction (~1500 kcal/d). Presumably due to differences in cost, LSI-alone trials in newly diagnosed T2D had higher enrollments and longer duration. For established T2D trials, the focus was on arduous phased dietary interventions; phase 1: low-calorie meal replacement (<1000 kcal/day); phase 2: food re-introduction; phase 3: weight maintenance. In short, LSI-alone can induce remission in both newly diagnosed and established T2D. To demonstrate efficacy in Africa, initial trials could focus on newly diagnosed T2D. Insight gained could provide proof of concept and a foundation in Africa on which successful studies of LSI-alone in established T2D could be built.

The Africans in America study demonstrates that subclinical cardiovascular risk differs by etiology of abnormal glucose tolerance

Abnormal-glucose tolerance (Abnl-GT) is due to an imbalance between β-cell function and insulin resistance (IR) and is a major risk factor in cardiovascular disease (CVD). In sub-Saharan Africa, β-cell failure is emerging as an important cause of Abnl-GT (Abnl-GT-β-cell-failure). Visceral adipose tissue (VAT) volume and hyperlipidemia are major contributors to CVD risk when Abnl-GT is due to IR (Abnl-GT-IR). Yet, the CVD profile associated with Abnl-GT-β-cell failure is unknown. Therefore, our goals in 450 African-born Blacks (Male: 65%; Age: 39 ± 10 years; BMI 28 ± 5 kg/m²), living in America were to: (1) determine Abnl-GT prevalence and etiology; (2) assess by Abnl-GT etiology, associations between four understudied subclinical CVD risk factors in Africans: (a) subclinical myocardial damage (high-sensitivity troponin T (hs-cTnT)); (b) neurohormonal regulation (N-terminal pro-Brain-natriuretic peptide (NT-proBNP)); (c) coagulability (fibrinogen); (d) inflammation (high-sensitivity C-reactive protein (hsCRP)), as well as HbA_1c, Cholesterol/HDL ratio and VAT. Glucose tolerance status was determined by the OGTT. IR was defined by the threshold at the lowest quartile for the Matsuda Index (≤ 2.97). Abnl-GT-IR required both Abnl-GT and IR. Abnl-GT-β-cell-failure was defined as Abnl-GT without IR. VAT was assessed by CT-scan. For both the Abnl-GT-β-cell-failure and Abnl-GT-IR groups, four multiple regression models were performed for hs-cTnT; NT-proBNP; fibrinogen and hsCRP, as dependent variables, with the remaining three biomarkers and HbA_1c, Cholesterol/HDL and VAT as independent variables. Abnl-GT occurred in 38% (170/450). In the Abnl-GT group, β-cell failure occurred in 58% (98/170) and IR in 42% (72/170). VAT and Cholesterol/HDL were significantly lower in Abnl-GT-β-cell-failure group vs the Abnl-GT-IR group (both P < 0.001). In the Abnl-GT-β-cell-failure group: significant associations existed between hscTnT, fibrinogen, hs-CRP, and HbA_1c (all P < 0.05), and none with Cholesterol/HDL or VAT. In Abnl-GT-IR: hs-cTnT, fibrinogen and hsCRP significantly associated with Cholesterol/HDL (all P < 0.05) and NT-proBNP inversely related to fibrinogen, hsCRP, HbA_1c, Cholesterol/HDL, and VAT (all P < 0.05). The subclinical CVD risk profile differed between Abnl-GT-β-cell failure and Abnl-GT-IR. In Abnl-GT-β-cell failure subclinical CVD risk involved subclinical-myocardial damage, hypercoagulability and increased inflammation, but not hyperlipidemia or visceral adiposity. For Abnl-GT-IR, subclinical CVD risk related to subclinical myocardial damage, neurohormonal dysregulation, inflammation associated with hyperlipidemia and visceral adiposity. ClinicalTrials.gov Identifier: NCT00001853.

Non-invasive type 2 diabetes risk scores do not identify diabetes when the cause is β-cell failure: The Africans in America study

Background

Emerging data suggests that in sub-Saharan Africa β-cell-failure in the absence of obesity is a frequent cause of type 2 diabetes (diabetes). Traditional diabetes risk scores assume that obesity-linked insulin resistance is the primary cause of diabetes. Hence, it is unknown whether diabetes risk scores detect undiagnosed diabetes when the cause is β-cell-failure.

Aims

In 528 African-born Blacks living in the United States [age 38 ± 10 (Mean ± SE); 64% male; BMI 28 ± 5 kg/m²] we determined the: (1) prevalence of previously undiagnosed diabetes, (2) prevalence of diabetes due to β-cell-failure vs. insulin resistance; and (3) the ability of six diabetes risk scores [Cambridge, Finnish Diabetes Risk Score (FINDRISC), Kuwaiti, Omani, Rotterdam, and SUNSET] to detect previously undiagnosed diabetes due to either β-cell-failure or insulin resistance.

Methods

Diabetes was diagnosed by glucose criteria of the OGTT and/or HbA1c ≥ 6.5%. Insulin resistance was defined by the lowest quartile of the Matsuda index (≤ 2.04). Diabetes due to β-cell-failure required diagnosis of diabetes in the absence of insulin resistance. Demographics, body mass index (BMI), waist circumference, visceral adipose tissue (VAT), family medical history, smoking status, blood pressure, antihypertensive medication, and blood lipid profiles were obtained. Area under the Receiver Operator Characteristics Curve (AROC) estimated sensitivity and specificity of each continuous score. AROC criteria were: Outstanding: >0.90; Excellent: 0.80-0.89; Acceptable: 0.70-0.79; Poor: 0.50-0.69; and No Discrimination: 0.50.

Results

Prevalence of diabetes was 9% (46/528). Of the diabetes cases, β-cell-failure occurred in 43% (20/46) and insulin resistance in 57% (26/46). The β-cell-failure group had lower BMI (27 ± 4 vs. 31 ± 5 kg/m² P < 0.001), lower waist circumference (91 ± 10 vs. 101 ± 10cm P < 0.001) and lower VAT (119 ± 65 vs. 183 ± 63 cm³, P < 0.001). Scores had indiscriminate or poor detection of diabetes due to β-cell-failure (FINDRISC AROC = 0.49 to Cambridge AROC = 0.62). Scores showed poor to excellent detection of diabetes due to insulin resistance, (Cambridge AROC = 0.69, to Kuwaiti AROC = 0.81).

Conclusions

At a prevalence of 43%, β-cell-failure accounted for nearly half of the cases of diabetes. All six diabetes risk scores failed to detect previously undiagnosed diabetes due to β-cell-failure while effectively identifying diabetes when the etiology was insulin resistance. Diabetes risk scores which correctly classify diabetes due to β-cell-failure are urgently needed.

Black New Yorkers with Type 2 Diabetes: Afro-Caribbean Immigrants Have Lower BMI and Lower Waist Circumference than African Americans

OBJECTIVE

Using the 2013/2014 New York City (NYC) Health and Nutrition Examination Survey (NYCHANES) data, this exploratory study examined whether (a) type 2 diabetes (diabetes) prevalence differed between NYC Afro-Caribbeans and African Americans; (b) anthropometric, biochemical, and sociodemographic diabetes profiles differed between and within groups; and (c) diabetes odds differed between and within groups.

METHODS

Diabetes was defined as prior diagnosis, HbA1c ≥ 6.5% (7.8 mmol/L), or fasting glucose ≥ 126 mg/dL. Weighted logistic regression estimated diabetes odds by nativity and either waist circumference (WC) (cm) or BMI (kg/m²). All regression models controlled for age, hypertension, gender, education, income, marital status, physical activity, and smoking.

RESULTS

Among Afro-Caribbeans (n = 81, 65% female, age (mean ± SE) 49 ± 2 years, BMI 29.2 ± 0.7 kg/m²) and African Americans (n = 118, 50% female, age 47 ± 2 years, BMI 30.3 ± 0.9 kg/m²), Afro-Caribbeans with diabetes had lower BMI (29.9 ± 0.8 kg/m² vs. 34.6 ± 1.7 kg/m², P = 0.01) and lower WC (102 ± 2 cm vs. 114 ± 3 cm, P = 0.002) than African Americans with diabetes. Afro-Caribbeans with diabetes had lower prevalence of obesity (33.2% vs. 74.7%) and higher prevalence of overweight (57.2% vs. 13.5%) (P = 0.02) than African Americans with diabetes. Odds of diabetes did not differ between Afro-Caribbeans and African Americans. In models predicting the effect of WC, diabetes odds increased with WC (OR = 1.07 (95% CI 1.02, 1.11), P = 0.003) and age (OR = 1.09 (95% CI 1.03-1.15), P = 0.003) for African Americans only. In models predicting the effect of BMI, diabetes odds increased for Afro-Caribbeans with age (OR = 1.06 (1.01, 1.11)*, P = 0.04) and hypertension (OR = 5.62 (95% CI 1.04, 30.42), P = 0.045), whereas for African Americans, only age predicted higher diabetes odds (OR = 1.08 (95% CI 1.03, 1.14), P = 0.003).

CONCLUSIONS

In NYC, Afro-Caribbeans with diabetes have lower BMI and lower WC than African Americans with diabetes, but odds of diabetes do not differ. Combining African-descent populations into one group obscures clinical differences and generalizes diabetes risk.

Sleep and Economic Status Are Linked to Daily Life Stress in African-Born Blacks Living in America

To identify determinants of daily life stress in Africans in America, 156 African-born Blacks (Age: 40 ± 10 years (mean ± SD), range 22–65 years) who came to the United States as adults (age ≥ 18 years) were asked about stress, sleep, behavior and socioeconomic status. Daily life stress and sleep quality were assessed with the Perceived Stress Scale (PSS) and Pittsburgh Sleep Quality Index (PSQI), respectively. High-stress was defined by the threshold of the upper quartile of population distribution of PSS (≥16) and low-stress as PSS < 16. Poor sleep quality required PSQI > 5. Low income was defined as <40 k yearly. In the high and low-stress groups, PSS were: 21 ± 4 versus 9 ± 4, p < 0.001 and PSQI were: 6 ± 3 versus 4 ± 3, p < 0.001, respectively. PSS and PSQI were correlated (r = 0.38, p < 0.001). The odds of high-stress were higher among those with poor sleep quality (OR 5.11, 95% CI: 2.07, 12.62), low income (OR 5.03, 95% CI: 1.75, 14.47), and no health insurance (OR 3.01, 95% CI: 1.19, 8.56). Overall, in African-born Blacks living in America, daily life stress appears to be linked to poor quality sleep and exacerbated by low income and lack of health insurance.

Intergenerational differences in dietary acculturation among Ghanaian immigrants living in New York City: a qualitative study

Dietary acculturation may explain the increasing risk of diet-related diseases among African immigrants in the United States (US). We interviewed twenty-five Ghanaian immigrants (Youth n 13, Age (Mean ± sd) 20 y ± 5⋅4, Parents (n 6) and Grandparents (n 6) age 58⋅7 ± 9⋅7) living in New York City (NYC) to (a) understand how cultural practices and the acculturation experience influence dietary patterns of Ghanaian immigrants and (b) identify intergenerational differences in dietary acculturation among Ghanaian youth, parents and grandparents. Dietary acculturation began in Ghana, continued in NYC and was perceived as a positive process. At the interpersonal level, parents encouraged youth to embrace school lunch and foods outside the home. In contrast, parents preferred home-cooked Ghanaian meals, yet busy schedules limited time for cooking and shared meals. At the community level, greater purchasing power in NYC led to increased calories, and youth welcomed individual choice as schools and fast food exposed them to new foods. Global forces facilitated nutrition transition in Ghana as fast and packaged foods became omnipresent in urban settings. Adults sought to maintain cultural foodways while facilitating dietary acculturation for youth. Both traditional and global diets evolved as youth and adults adopted new food and healthy social norms in the US.

Increasing obesity odds among foreign-born New Yorkers are not explained by eating out, age at arrival, or duration of residence: results from NYC HANES 2004 and 2013/2014

BACKGROUND

Among the foreign-born in the United States (US) dietary acculturation and eating out may increase obesity risk. Using the 2004 (N = 1952) and 2013/14 (N = 1481) New York City (NYC) Health and Nutrition Examination Surveys, we compared for the foreign-born and US-born by survey year: 1) odds of obesity; 2) association between eating out and obesity and 3) effect of age at arrival and duration of residence among the foreign-born. Weighted logistic regression estimated odds of obesity.

RESULTS

Compared to the US-born, the foreign-born had lower odds of obesity in 2004, (aOR = 0.51 (95%CI 0.37-0.70), P = <.0001). Odds were no different in 2013/14. In 2013/14 the foreign-born who ate out had lower obesity odds (aOR = 0.49 (95%CI 0.31-0.77), P = 0.0022). The foreign-born living in the US≥10 years had greater odds of obesity in 2004 (aOR = 1.73 (95%CI 1.08-2.79), P = 0.0233) but not in 2013/14.

CONCLUSIONS

Eating out does not explain increasing obesity odds among the foreign-born.

HbA1c Performance in African Descent Populations in the United States With Normal Glucose Tolerance, Prediabetes, or Diabetes: A Scoping Review

Introduction

African descent populations in the United States have high rates of type 2 diabetes and are incorrectly represented as a single group. Current glycated hemoglobin A_1c (HbA_1c) cutoffs (5.7% to <6.5% for prediabetes; ≥6.5% for type 2 diabetes) may perform suboptimally in evaluating glycemic status among African descent groups. We conducted a scoping review of US-based evidence documenting HbA_1c performance to assess glycemic status among African American, Afro-Caribbean, and African people.

Methods

A PubMed, Scopus, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) search (January 2020) yielded 3,238 articles published from January 2000 through January 2020. After review of titles, abstracts, and full texts, 12 met our criteria. HbA_1c results were compared with other ethnic groups or validated against the oral glucose tolerance test (OGTT), fasting plasma glucose (FPG), or previous diagnosis. We classified study results by the risk of false positives and risk of false negatives in assessing glycemic status.

Results

In 5 studies of African American people, the HbA_1c test increased risk of false positives compared with White populations, regardless of glycemic status. Three studies of African Americans found that HbA_1c of 5.7% to less than 6.5% or HbA_1c of 6.5% or higher generally increased risk of overdiagnosis compared with OGTT or previous diagnosis. In one study of Afro-Caribbean people, HbA_1c of 6.5% or higher detected fewer type 2 diabetes cases because of a greater risk of false negatives. Compared with OGTT, HbA_1c tests in 4 studies of Africans found that HbA_1c of 5.7% to less than 6.5% or HbA_1c of 6.5% or higher leads to underdiagnosis.

Conclusion

HbA_1c criteria inadequately characterizes glycemic status among heterogeneous African descent populations. Research is needed to determine optimal HbA_1c cutoffs or other test strategies that account for risk profiles unique to African American, Afro-Caribbean, and African people living in the United States.

Africans Who Arrive in the United States before 20 Years of Age Maintain Both Cardiometabolic Health and Cultural Identity: Insight from the Africans in America Study

The overall consensus is that foreign-born adults who come to America age < 20 y achieve economic success but develop adverse behaviors (smoking and drinking) that lead to worse cardiometabolic health than immigrants who arrive age ≥ 20 y. Whether age of immigration affects the health of African-born Blacks living in America is unknown. Our goals were to examine cultural identity, behavior, and socioeconomic factors and determine if differences exist in the cardiometabolic health of Africans who immigrated to America before and after age 20 y. Of the 482 enrollees (age: 38 ± 1 (mean ± SE), range: 20–65 y) in the Africans in America cohort, 23% (111/482) arrived age < 20 y, and 77% (371/482) arrived age ≥ 20 y. Independent of francophone status or African region of origin, Africans who immigrated age < 20 y had similar or better cardiometabolic health than Africans who immigrated age ≥ 20 y. The majority of Africans who immigrated age < 20 y identified as African, had African-born spouses, exercised, did not adopt adverse health behaviors, and actualized early life migration advantages, such as an American university education. Due to maintenance of cultural identity and actualization of opportunities in America, cardiometabolic health may be protected in Africans who immigrate before age 20. In short, immigrant health research must be cognizant of the diversity within the foreign-born community and age of immigration.

Identifying Africans with undiagnosed diabetes: Fasting plasma glucose is similar to the hemoglobin A1C updated Atherosclerosis Risk in Communities diabetes prediction equation

AIMS

Seventy percent of Africans living with diabetes are undiagnosed. Identifying who should be referred for testing is critical. Therefore we evaluated the ability of the Atherosclerosis Risk in Communities (ARIC) diabetes prediction equation with A1C added (ARIC + A1C) to identify diabetes in 451 African-born blacks living in America (66% male; age 38 ± 10y (mean ± SD); BMI 27.5 ± 4.4 kg/m²).

METHODS

All participants denied a history of diabetes. OGTTs were performed. Diabetes diagnosis required 2-h glucose ≥200 mg/dL. The five non-invasive (Age, parent history of diabetes, waist circumference, height, systolic blood pressure) and four invasive variables (Fasting glucose (FPG), A1C, triglycerides (TG), HDL) were obtained. Four models were tested: Model-1: Full ARIC + A1C equation; Model-2: All five non-invasive variables with one invasive variable excluded at a time; Model-3: All five non-invasive variables with one invasive variable included at a time; Model-4: Each invasive variable singly. Area under the receiver operator characteristic curve (AROC) predicted diabetes. Youden Index identified optimal cut-points.

RESULTS

Diabetes occurred in 7% (30/451). Model-1, the full ARIC + A1C equation, AROC = 0.83. Model-2: With FPG excluded, AROC = 0.77 (P = 0.038), but when A1C, HDL or TG were excluded AROC remained unchanged. Model-3 with all non-invasive variables and FPG alone, AROC=0.87; but with A1C, TG or HDL included AROC declined to ≤0.76. Model-4: FPG as a single predictor, AROC = 0.87. A1C, TG, or HDL as single predictors all had AROC ≤ 0.74. Optimal cut-point for FPG was 100 mg/dL.

CONCLUSIONS

To detect diabetes, FPG performed as well as the nine-variable updated ARIC + A1C equation.

Foreign-Born Blacks Experience Lower Odds of Obesity but Higher Odds of Diabetes than US-Born Blacks in New York City

Research is limited on the health of foreign-born Blacks (FBBs), who are often grouped with African Americans. This study compared obesity and diabetes odds in FBBs and US-born Blacks (USBBs) in NYC. Analyzing the 2009-2013 NYC Community Health Survey (3701 FBBs and 6297 USBBs), weighted multivariate logistic regression examined odds of obesity and diabetes, adjusting for age, gender, education, income, marital status, children < 18, BMI (for diabetes only) and duration of residence. FBBs had lower odds of obesity [OR  0.62 (95% CI 0.54, 0.72)] and greater odds of diabetes [OR 1.24 (95% CI 1.01, 1.52)] compared to USBBs. FBBs had 1.4 times the odds of diabetes at overweight status, compared to USBBs [OR  1.40 (95% CI 1.01, 1.95)]. Living in the US ≥ 10 years was not associated with odds of obesity and diabetes. Future research should seek to uncover unique risk profiles of sub-ethnic groups in the African diaspora.

Black Immigrants from Africa and the Caribbean Have Similar Rates of Diabetes but Africans Are Less Obese: the New York City Community Health Survey 2009-2013

OBJECTIVE

This study was designed to determine (a) whether the prevalence and odds of either obesity or diabetes differed in foreign-born black Africans and Caribbeans living in New York City (NYC) and (b) whether time in the United States (US) affected odds of either outcome.

METHODS

Data were obtained from NYC Community Health Survey 2009-13 for 380 African-born blacks and 2689 Caribbean-born blacks. Weighted logistic regression estimated odds of obesity and diabetes, adjusting for age, sex, education, income, marital status, children < 18, BMI (diabetes models only), and time in the US.

RESULTS

Obesity prevalence in Africans (60.2%, male; age, 46.0 ± 13.5 years, (mean ± SD); BMI, 27.3 ± 5.6 kg/m²) was 16.7 and 30.2% in Caribbeans (39.3%, male; age, 49.7 ± 14.7 years; BMI, 28.0 ± 5.8 kg/m²). Prevalence of diabetes was 10.5% in Africans and 14.7% in Caribbeans. Africans had lower adjusted odds of obesity (aOR = 0.60 (95% CI, 0.40-0.90); P = 0.015), but there was no difference in diabetes odds between groups. Obesity odds were higher in African (aOR = 2.35 (95% CI, 1.16-4.78); P = 0.018) and Caribbean women (aOR = 2.20 (95% CI, 1.63-2.98); P < 0.001) than their male counterparts. Odds of diabetes did not differ between sexes in either group. Time in the US did not affect odds of either obesity or diabetes.

CONCLUSIONS

Africans living in NYC are less obese than Caribbeans, but odds of diabetes do not differ. Time in the US does not affect odds of either obesity or diabetes. Hence, BMI and diabetes risk profiles in blacks differ by region of origin and combining foreign-born blacks into one group masks important differences.

A Review of Diabetes Prediction Equations in African Descent Populations

Background: Predicting undiagnosed diabetes is a critical step toward addressing the diabetes epidemic in populations of African descent worldwide. Objective: To review characteristics of equations developed, tested, or modified to predict diabetes in African descent populations. Methods: Using PubMed, Scopus, and Embase databases, a scoping review yielded 585 research articles. After removal of duplicates (n = 205), 380 articles were reviewed. After title and abstract review 328 articles did not meet inclusion criteria and were excluded. Fifty-two articles were retained. However, full text review revealed that 44 of the 52 articles did not report findings by AROC or C-statistic in African descent populations. Therefore, eight articles remained. Results: The 8 articles reported on a total of 15 prediction equation studies. The prediction equations were of two types. Prevalence prediction equations (n = 9) detected undiagnosed diabetes and were based on non-invasive variables only. Non-invasive variables included demographics, blood pressure and measures of body size. Incidence prediction equations (n = 6) predicted risk of developing diabetes and used either non-invasive variables or both non-invasive and invasive. Invasive variables required blood tests and included fasting glucose, high density lipoprotein-cholesterol (HDL), triglycerides (TG), and A1C. Prevalence prediction studies were conducted in the United States, Africa and Europe. Incidence prediction studies were conducted only in the United States. In all these studies, the performance of diabetes prediction equations was assessed by area under the receiver operator characteristics curve (AROC) or the C-statistic. Therefore, we evaluated the efficacy of these equations based on standard criteria, specifically discrimination by either AROC or C-statistic were defined as: Poor (0.50 - 0.69); Acceptable (0.70 - 0.79); Excellent (0.80 - 0.89); or Outstanding (0.90 - 1.00). Prediction equations based only on non-invasive variables reported to have poor to acceptable detection of diabetes with AROC or C-statistic 0.64 - 0.79. In contrast, prediction equations which were based on both non-invasive and invasive variables had excellent diabetes detection with AROC or C-statistic 0.80 - 0.82. Conclusion: Equations which use a combination of non-invasive and invasive variables appear to be superior in the prediction of diabetes in African descent populations than equations that rely on non-invasive variables alone.

A1C Underperforms as a Diagnostic Test in Africans Even in the Absence of Nutritional Deficiencies, Anemia and Hemoglobinopathies: Insight From the Africans in America Study

Introduction: To improve detection of undiagnosed diabetes in Africa, there is movement to replace the OGTT with A1C. The performance of A1C in the absence of hemoglobin-related micronutrient deficiencies, anemia and heterozygous hemoglobinopathies is unknown. Therefore, we determined in 441 African-born blacks living in America [male: 65% (281/441), age: 38 ± 10 y (mean ± SD), BMI: 27.5 ± 4.4 kg/m²] (1) nutritional and hematologic profiles and (2) glucose tolerance categorization by OGTT and A1C. Methods: Hematologic and nutritional status were assessed. Hemoglobin <11 g/dL occurred in 3% (11/441) of patients and led to exclusion. A1C and OGTT were performed in the remaining 430 participants. ADA thresholds for A1C and OGTT were used. Diagnosis by A1C required meeting either A1C-alone or A1C&OGTT criteria. Diagnosis by OGTT-alone required detection by OGTT and not A1C. Results: Hemoglobin, mean corpuscular volume and red blood cell distribution width were 14.0 ± 1.3 g/dL, 85.5 ± 5.3 fL, and 13.2 ± 1.2% respectively. B12, folate, and iron deficiency occurred in 1% (5/430), 0% (0/430), and 4% (12/310), respectively. Heterozygous hemoglobinopathy prevalence was 18% (78/430). Overall, diabetes prevalence was 7% (32/430). A1C detected diabetes in 32% (10/32) but OGTT-alone detected 68% (22/32). Overall prediabetes prevalence was 41% (178/430). A1C detected 57% (102/178) but OGTT-alone identified 43% (76/178). After excluding individuals with heterozygous hemoglobinopathies, the rate of missed diagnosis by A1C of abnormal glucose tolerance did not change (OR: 0.99, 95% CI: 0.61, 1.62). Conclusions: In nutritionally replete Africans without anemia or heterozygous hemoglobinopathy, if only A1C is used, ~60% with diabetes and ~40% with prediabetes would be undiagnosed. Clinical Trial Registration:: www.ClinicalTrials.gov, Identifier: NCT00001853.