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Low socioeconomic position (SEP) across the lifecourse is associated with Type 2 diabetes (T2DM). We examined whether these economic disparities differ by race and sex. We included 5448 African American (AA) and white participants aged ≥45 years from the national (United States) REasons for Geographic and Racial Differences in Stroke (REGARDS) cohort without T2DM at baseline (2003–07). Incident T2DM was defined by fasting glucose ≥126 mg/dL, random glucose ≥200 mg/dL, or using T2DM medications at follow-up (2013–16). Derived SEP scores in childhood (CSEP) and adulthood (ASEP) were used to calculate a cumulative (CumSEP) score. Social mobility was defined as change in SEP. We fitted race-stratified logistic regression models to estimate the association between each lifecourse SEP indicator and T2DM, adjusting for covariates; additionally, we tested SEP-sex interactions. Over a median of 9.0 (range 7–14) years of follow-up, T2DM incidence was 167.1 per 1000 persons among AA and 89.9 per 1000 persons among white participants. Low CSEP was associated with T2DM incidence among AA (OR = 1.61; 95%CI 1.05–2.46) but not white (1.06; 0.74–2.33) participants; this was attenuated after adjustment for ASEP. In contrast, low CumSEP was associated with T2DM incidence for both racial groups. T2DM risk was similar for stable low SEP and increased for downward mobility when compared with stable high SEP in both groups, whereas upward mobility increased T2DM risk among AAs only. No differences by sex were observed. Among AAs, low CSEP was not independently associated with T2DM, but CSEP may shape later-life experiences and health risks.

Background: Estimates of the burden of cardio-metabolic risk factors in Latin America and the Caribbean (LAC) rely on relative risks (RRs) from non-LAC countries. Whether these RRs apply to LAC remains unknown. Methods: We pooled LAC cohorts. We estimated RRs per unit of exposure to body mass index (BMI), systolic blood pressure (SBP), fasting plasma glucose (FPG), total cholesterol (TC) and non-HDL cholesterol on fatal (31 cohorts, n=168,287) and non-fatal (13 cohorts, n=27,554) cardiovascular diseases, adjusting for regression dilution bias. We used these RRs and national data on mean risk factor levels to estimate the number of cardiovascular deaths attributable to non-optimal levels of each risk factor. Results: Our RRs for SBP, FPG and TC were like those observed in cohorts conducted in high-income countries; however, for BMI, our RRs were consistently smaller in people below 75 years of age. Across risk factors, we observed smaller RRs among older ages. Non-optimal SBP was responsible for the largest number of attributable cardiovascular deaths ranging from 38 per 100,000 women and 54 men in Peru, to 261 (Dominica, women) and 282 (Guyana, men). For non-HDL cholesterol, the lowest attributable rate was for women in Peru (21) and men in Guatemala (25), and the largest in men (158) and women (142) from Guyana. Interpretation: RRs for BMI from studies conducted in high-income countries may overestimate disease burden metrics in LAC; conversely, RRs for SBP, FPG and TC from LAC cohorts are similar to those estimated from cohorts in high-income countries. Funding: Wellcome Trust (214185/Z/18/Z)

Objective: We examined whether life course socioeconomic position (SEP) was associated with incidence of type 2 diabetes (t2DM) among African Americans. Design: Secondary analysis of data from the Jackson Heart Study, 2000-04 to 2012, using Cox proportional hazard regression to estimate hazard ratios (HR) with 95% CI for t2DM incidence by measures of life course SEP. Participants: Sample of 4,012 nondiabetic adults aged 25-84 years at baseline. Outcome Measure: Incident t2DM identi­fied by self-report, hemoglobin A1c ≥6.5%, fasting plasma glucose ≥126 mg/dL, or use of diabetes medication. Results: During 7.9 years of follow-up, 486 participants developed t2DM (incidence rate 15.2/1000 person-years, 95% CI: 13.9-16.6). Among women, but not men, childhood SEP was inversely associated with t2DM incidence (HR=.97, 95% CI: .94-.99) but was no longer associated with adjust­ment for adult SEP or t2DM risk factors. Up­ward SEP mobility increased the hazard for t2DM incidence (adjusted HR=1.52, 95% CI: 1.05-2.21) among women only. Life course allostatic load (AL) did not explain the SEP-t2DM association in either sex. Conclusions: Childhood SEP and up­ward social mobility may influence t2DM incidence in African American women but not in men. Ethn Dis. 2019;29(1):39-46; doi:10.18865/ed.29.1.39

OBJECTIVE To assess county-level socioeconomic disparities in medical service usage for infections among Medicare beneficiaries with diabetes (MBWDs) who had fee-for-service health insurance claims during 2012. DESIGN We used Medicare claims data to calculate percentage of MBWDs with infections. SETTING Medicare beneficiaries. PARTICIPANTS We estimated the percentage of MBWDs who used medical services for each of 3 groups of infections by sex and quintiles of the prevalence of social factors in the person's county of residence: anatomic site-specific infections; pathogen-specific infections; and HHST infections (human immunodeficiency virus/acquired immunodeficiency syndrome, viral hepatitis, sexually transmitted diseases, and tuberculosis). MAIN OUTCOME MEASURES Using quintiles of county-specific socioeconomic determinants, we calculated absolute and relative disparities in each group of infections for male and female MBWDs. We also used regression-based summary measures to estimate the overall average absolute and relative disparities for each infection group. RESULTS Of the 4.5 million male MBWDs, 15.8%, 25.3%, and 2.7% had 1 or more site-specific, pathogen-specific, and HHST infections, respectively. Results were similar for females (n = 5.2 million). The percentage of MBWDs with 1 or more infections in each group increased as social disadvantage in the MBWDs' county of residence increased. Absolute and relative county-level socioeconomic disparities in receipt of medical services for 1 or more infections (site- or pathogen-specific) were 12.9 or less percentage points and 65.5% or less, respectively. For HHST infections, percentage of MBWDs having 1 or more HHST infections for persons residing in the highest quintile (Q5) was 3- to 4-fold higher (P < .001) than persons residing in the lowest quintile (Q1). CONCLUSIONS Infection burden among MBWDs is generally associated with county-level contextual socioeconomic disadvantage, and the extent of health disparities varies by infection category, socioeconomic factor, and quintiles of socioeconomic disadvantage. The findings imply ongoing need for efforts to identify effective interventions for reducing county-level social disparities in infections among patients with diabetes.

ObjectivesBy race/ethnicity and socioeconomic position (SEP), to estimate and examine changes over time in (1) mortality rate, (2) mortality disparities and (3) excess mortality risk attributed to diagnosed diabetes (DM).DesignPopulation-based cohort study using National Health Interview Survey data linked to mortality status from the National Death Index from survey year up to 31 December 2015 with 5 years person-time.ParticipantsUS adults aged ≥25 years with (31 586) and without (332 451) DM.Primary outcomeAge-adjusted all-cause mortality rate for US adults with DM in each subgroup of SEP (education attainment and income-to-poverty ratio (IPR)) and time (1997–2001, 2002–2006 and 2007–2011).ResultsAmong adults with DM, mortality rates fell from 23.5/1000 person-years (p-y) in 1997–2001 to 18.1/1000 p-y in 2007–2011 with changes of −5.2/1000 p-y for non-Hispanic whites; −5.2/1000 p-y for non-Hispanic blacks; and −5.4/1000 p-y for Hispanics. Rates significantly declined within SEP groups, measured as education attainment (high school=−4.8/1000 p-y) and IPR group (poor=−7.9/1000 p-y; middle income=−4.7/1000 p-y; and high income=−6.2/1000 p-y; but not for near poor). For adults with DM, statistically significant all-cause mortality disparity showed greater mortality rates for the lowest than the highest SEP level (education attainment and IPR) in each time period. However, patterns in mortality trends and disparity varied by race/ethnicity. The excess mortality risk attributed to DM significantly decreased from 1997–2001 to 2007–2011, within SEP levels, and among Hispanics and non-Hispanic whites; but no statistically significant changes among non-Hispanic blacks.ConclusionsThere were substantial improvements in all-cause mortality among US adults. However, we observed SEP disparities in mortality across race/ethnic groups or for adults with and without DM despite targeted efforts to improve access and quality of care among disproportionately affected populations.

The prevalence of diabetes mellitus has increased rapidly in the United States since the mid-1990s. By 2014, an estimated 29.1 million persons, or 9.3% of the total population, had received a diagnosis of diabetes (1). Recent evidence indicates that the prevalence of diagnosed diabetes among non-Hispanic black (black), Hispanic, and poorly educated adults continues to increase but has leveled off among non-Hispanic whites (whites) and persons with higher education (2). During 2004-2010, CDC reported marked racial/ethnic and socioeconomic position disparities in diabetes prevalence and increases in the magnitude of these disparities over time (3). However, the magnitude and extent of temporal change in socioeconomic position disparities in diagnosed diabetes among racial/ethnic populations are unknown. CDC used data from the National Health Interview Survey (NHIS) for the periods 1999-2002 and 2011-2014 to assess the magnitude of and change in socioeconomic position disparities in the age-standardized prevalence of diagnosed diabetes in the overall population and among blacks, whites, and Hispanics. During each period, significant socioeconomic position disparities existed in the overall population and among the assessed racial/ethnic populations. Disparities in prevalence increased with increasing socioeconomic disadvantage and widened over time among Hispanics and whites but not among blacks. The persistent widening of the socioeconomic position gap in prevalence suggests that interventions to reduce the risk for diabetes might have a different impact according to socioeconomic position.

Why was the cohort set up? Latin America and the Caribbean (LAC) are characterized by much diversity in terms of socio-economic status, ecology, environment, access to health care,1,2 as well as the frequency of risk factors for and prevalence or incidence of non-communicable diseases;3–7 importantly, these differences are observed both between and within countries in LAC.8,9 LAC countries share a large burden of non-communicable (e.g. diabetes and hypertension) and cardiovascular (e.g. ischaemic heart disease) diseases, with these conditions standing as the leading causes of morbidity, disability and mortality in most of LAC.10–12 These epidemiological estimates—e.g. morbidity—cannot inform about risk factors or risk prediction, which are relevant to identify prevention avenues. Cohort studies, on the other hand, could provide this evidence. Pooled analysis, using data from multiple cohort studies, have additional strengths such as increased statistical power and decreased statistical uncertainty.13 LAC cohort studies have been under-represented,14 or not included at all,15–17 in international efforts aimed at pooling data from multiple cohort studies. We therefore set out to pool data from LAC cohorts to address research questions that individual cohort studies would not be able to answer. Drawing from previous successful regional enterprises (e.g. Asia Pacific Cohort Studies Collaboration),18,19 we established the Cohorts Consortium of Latin America and the Caribbean (CC-LAC). The main aim of the CC-LAC is to start a collaborative cohort data pooling in LAC to examine the association between cardio-metabolic risk factors (e.g. blood pressure, glucose and lipids) and non-fatal and fatal cardiovascular outcomes (e.g. stroke or myocardial infarction). In so doing, we aim to provide regional risk estimates to inform disease burden metrics, as well as other ambitious projects including a cardiovascular risk score to strengthen cardiovascular prevention in LAC. Initial funding has been provided by a fellowship from the Wellcome Trust Centre for Global Health Research at Imperial College London (Strategic Award, Wellcome Trust–Imperial College Centre for Global Health Research, 100693/Z/12/Z). Additional funding is being provided by an International Training Fellowship from the Wellcome Trust (214185/Z/18/Z). At the time of writing, the daily operations and pooled database are hosted at Imperial College London, though a mid-term goal is to transfer this expertise and operations to LAC. The collaboration relies fundamentally on a strong regional network of health researchers and practitioners

Exposure to socioeconomic stressors during early life may influence the incidence of type 2 diabetes (T2DM). We examined data from 1,207 African American (AA) and 4,149 white REGARDS participants aged ≥45 years with no evidence of T2DM at baseline (2003-2007), who completed the Childhood and Family Life Questionnaire (2011-2013) and the 2nd in-home visit (2013-2016). Incident T2DM cases were identified by self-reported physician diagnosis plus use of hypoglycemic drugs, fasting plasma glucose ≥126 mg/dL, or random plasma glucose ≥200 mg/dL. We estimated incidence rate as cases/1000 persons. Childhood SEP (CSEP) was derived from participants’ parental/caregiver education level and material assets. Adult SEP (ASEP) was derived from participants’ own education level and annual household income at baseline. SEP scores were categorized as low/medium/high. We fit multivariable logistic regression models to estimate adjusted odds ratios (aOR) with 95% confidence intervals (95% CI) for the separate and simultaneous effects of SEP measures on T2DM incidence, stratified by race. In 9.1 years of follow-up, 572 new cases of T2DM occurred; crude incidence rate=106.8/1000 (AA=168.2/1000; white= 88.9/1000). Controlled for age, sex, and percent life lived in Stroke Belt, low CSEP was associated with incident T2DM in AAs (aOR=1.65, 95% CI 1.05-2.52) but not in whites (aOR=1.01, 95% CI 0.703-1.46). Low ASEP was associated with incident DM in both racial groups: AA aOR=2.57 (95% CI 1.42-4.64); white aOR=2.42 (95% CI 1.69-3.45). With both SEP measures in the model, CSEP was no longer significant in AA but ASEP remained significant in both racial groups. Controlling for traditional T2DM risk factors the ASEP ORs remained significant in AA and whites. Low CSEP was associated with incident T2DM among AA but not whites; however, this may reflect indirect action through low ASEP. Low ASEP was associated with T2DM in both racial groups, partly explained by traditional T2DM risk factors. Disclosure G.L.A. Beckles: None. C. Wu: None. L.A. McClure: None. A.P. Carson: Research Support; Self; Amgen Inc.. K.M. Bullard: None. G. Imperatore: None. F. Unverzagt: None. V.J. Howard: None.

Purpose Given the importance of family history in the early detection and prevention of type 2 diabetes, we quantified the public health impact of reported family health history on diagnosed diabetes (DD), undiagnosed diabetes (UD), and prediabetes (PD) in the United States. Methods We used population data from the National Health Examination and Nutrition Survey 2009 to 2014 to measure the association of reported family history of diabetes with DD, UD, and PD. Results Using polytomous logistic regression and multivariable adjustment, family history prevalence ratios were 4.27 (CI: 3.57, 5.12) for DD, 2.03 (CI: 1.56, 2.63) for UD, and 1.26 (CI: 1.09, 1.44) for PD. In the United States, we estimate that 10.1 million DD cases, 1.4 million UD cases, and 3.9 million PD cases can be attributed to having a family history of diabetes. Conclusions These findings confirm that family history of diabetes has a major public health impact on diabetes in the United States. In spite of the recent interest and focus on genomics and precision medicine, family health history continues to be an integral component of public health campaigns to identify persons at high risk for developing type 2 diabetes and early detection of diabetes to prevent or delay complications.

OBJECTIVE: To estimate the 2009 prevalence of diagnosed diabetes in Puerto Rico among adults ≥ 20 years of age in order to gain a better understanding of its geographic distribution so that policymakers can more efficiently target prevention and control programs. METHODS: A Bayesian multilevel model was fitted to the combined 2008-2010 Behavioral Risk Factor Surveillance System and 2009 United States Census data to estimate diabetes prevalence for each of the 78 municipios (counties) in Puerto Rico. RESULTS: The mean unadjusted estimate for all counties was 14.3% (range by county, 9.9%-18.0%). The average width of the confidence intervals was 6.2%. Adjusted and unadjusted estimates differed little. CONCLUSIONS: These 78 county estimates are higher on average and showed less variability (i.e., had a smaller range) than the previously published estimates of the 2008 diabetes prevalence for all United States counties (mean, 9.9%; range, 3.0%-18.2%).

Background Peripheral neuropathy is a serious complication of diabetes and several conditions that may lead to the loss of lower extremity function and even amputations. Since the introduction of statins, their use has increased markedly. Recent reports suggest a role for statins in the development of peripheral neuropathy. The aims of the present study were to assess the association between statin use and peripheral neuropathy, and to determine whether this association varied by diabetes status. Methods Data from the lower extremity examination supplement of the 1999–2004 National Health and Nutrition Examination Survey were used. Results The overall prevalence of statin use was 15% and the prevalence of peripheral neuropathy was 14.9%. The prevalence of peripheral neuropathy was significantly higher among those who used statins compared with those who did not (23.5% vs 13.5%, respectively; P

Individual-level characteristics are associated with eye care use. The influence of contextual factors on vision and eye health, as well as health behavior, is unknown.To examine the association between county-level characteristics and eye care use after accounting for individual-level characteristics using a conceptual framework.This investigation was a cross-sectional study of respondents 40 years and older participating in the Behavioral Risk Factor Surveillance System surveys between 2006 and 2010 from 22 states that used the Visual Impairment and Access to Eye Care module. Multilevel regressions were used to examine the association between county-level characteristics and eye care use after adjusting for individual-level characteristics (age, sex, race/ethnicity, educational attainment, annual household income, employment status, health care insurance coverage, eye care insurance coverage, personal established physician, poor vision or eye health, and diabetes status). Data analysis was performed from March 23, 2014, to June 7, 2016.Eye care visit and receipt of a dilated eye examination in the past year.Among 117 295 respondents who resided in 828 counties, individual-level data were obtained from the Behavioral Risk Factor Surveillance System surveys. All county-level variables were aggregated at the county level from the Behavioral Risk Factor Surveillance System surveys except for a high geographic density of eye care professionals, which was obtained from the 2010 Area Health Resource File. After controlling for individual-level characteristics, the odds of reporting an eye care visit in the past year were significantly higher among people living in counties with high percentages of black individuals (adjusted odds ratio [aOR], 1.12; 95% CI, 1.01-1.24; P = .04) or low-income households (aOR, 1.12; 95% CI, 1.00-1.25; P = .045) or with a high density of eye care professionals (aOR, 1.18; 95% CI, 1.07-1.29; P .001) than among those living in counties with the lowest tertile of each county-level characteristic. The odds of reporting receipt of a dilated eye examination in the past year were also higher among people living in counties with the highest percentages of black individuals (aOR, 1.20; 95% CI, 1.07-1.34; P = .002) or low-income households (aOR, 1.17; 95% CI, 1.04-1.32; P = .01). However, the odds of reported receipt of a dilated eye examination in the past year were lower in counties with the highest percentages of people with poor vision and eye health compared with counties with lower percentages (aOR, 0.85; 95% CI, 0.77-0.94; P = .002).Contextual factors, measured at the county level, were associated with eye care use independent of individual-level characteristics. The findings suggest that, while individual characteristics influence health care use, it is also important to address contextual factors to improve eye care use and ultimately vision health.

Background In recent decades, the United States experienced increasing prevalence and incidence of diabetes, accompanied by large disparities in county-level diabetes prevalence and incidence. However, whether these disparities are widening, narrowing, or staying the same has not been studied. We examined changes in disparity among U.S. counties in diagnosed diabetes prevalence and incidence between 2004 and 2012. Methods We used 2004 and 2012 county-level diabetes (type 1 and type 2) prevalence and incidence data, along with demographic, socio-economic, and risk factor data from various sources. To determine whether disparities widened or narrowed over the time period, we used a regression-based β-convergence approach, accounting for spatial autocorrelation. We calculated diabetes prevalence/incidence percentage point (ppt) changes between 2004 and 2012 and modeled these changes as a function of baseline diabetes prevalence/incidence in 2004. Covariates included county-level demographic and, socio-economic data, and known type 2 diabetes risk factors (obesity and leisure-time physical inactivity). Results For each county-level ppt increase in diabetes prevalence in 2004 there was an annual average increase of 0.02 ppt (p

OBJECTIVE Although several studies have examined the association between socioeconomic status (SES) and mortality in the general population, few have investigated this relationship among people with diabetes. This study sought to determine how risk of mortality associated with measures of SES among adults with diagnosed diabetes is mitigated by association with demographics, comorbidities, diabetes treatment, psychological distress, or health care access and utilization. RESEARCH DESIGN AND METHODS The study included 6,177 adults aged 25 years or older with diagnosed diabetes who participated in the National Health Interview Surveys (1997–2003) linked to mortality data (follow-up through 2006). SES was measured by education attained, financial wealth (either stocks/dividends or home ownership), and income-to-poverty ratio. RESULTS In unadjusted analysis, risk of death was significantly greater for people with lower levels of education and income-to-poverty ratio than for those at the highest levels. After adjusting for demographics, comorbidities, diabetes treatment and duration, health care access, and psychological distress variables, the association with greater risk of death remained significant only for people with the lowest level of education (relative hazard 1.52 [95% CI 1.04–2.23]). After multivariate adjustment, the risk of death was significantly greater for people without certain measures of financial wealth (e.g., stocks, home ownership) (1.56 [1.07–2.27]) than for those with them. CONCLUSIONS The findings suggest that after adjustments for demographics, health care access, and psychological distress, the level of education attained and financial wealth remain strong predictors of mortality risk among adults with diabetes.

To examine whether socioeconomic status, as measured by educational attainment and annual household income, is associated with lifetime risk for workplace eye injury in a large US population.In analyses of data from the Behavioral Risk Factor Surveillance System (2005-2007, N = 43,510), we used logistic regression analysis and propensity score matching to assess associations between socioeconomic measures and lifetime risk for workplace eye injury among those aged ≥50 years.The lifetime prevalence of self-reported workplace eye injury was significantly higher among men (13.5%) than women (2.6%) (P 0.001). After adjusting for age, race/ethnicity, eye care insurance, health status, and risk-taking behaviors, men with less than high school education (adjusted odds ratio [OR] = 2.24, 95% CI: 1.74-2.87) or high school education (adjusted OR = 1.92, 95% CI: 1.57-2.33) were more likely to report having had a lifetime workplace eye injury than those with more than a high school education. Men with an annual household income$15,000 were also more likely to report having had a lifetime workplace eye injury than those whose income was$50,000 (adjusted OR = 1.44, 95% CI: 1.07-1.95). After adjusting for other factors, no statistically significant associations between education, income, and lifetime workplace eye injury were found among women.Socioeconomic status was associated with lifetime risk for workplace eye injury among men but not women. Greater public awareness of individual and societal impacts of workplace eye injuries, especially among socioeconomically disadvantaged men, could help support efforts to develop a coordinated prevention strategy to minimize avoidable workplace eye injuries.

OBJECTIVE To assess the cardiovascular risk profile of youths across socioeconomic groups in the U.S. RESEARCH DESIGN AND METHODS Analysis of 1999–2008 National Health and Nutrition Examination Surveys (NHANES) including 16,085 nonpregnant 6- to 24-year-olds to estimate race/ethnicity-adjusted prevalence of obesity, central obesity, sedentary behaviors, tobacco exposure, elevated systolic blood pressure, glycated hemoglobin, non-HDL cholesterol (non–HDL-C), and high-sensitivity C-reactive protein according to age-group, sex, and poverty-income ratio (PIR) tertiles. RESULTS Among boys aged 6–11 years, 19.9% in the lowest PIR tertile were obese and 30.0% were centrally obese compared with 13.2 and 21.6%, respectively, in the highest-income tertile households (Pobesity < 0.05 and Pcentral obesity < 0.01). Boys aged 12–17 years in lowest-income households were more likely than their wealthiest family peers to be obese (20.6 vs. 15.6%, P < 0.05), sedentary (14.8 vs. 9.3%, P < 0.05), and exposed to tobacco (19.0 vs. 6.5%, P < 0.01). Compared with girls aged 12–17 years in highest-income households, lowest-income household girls had higher prevalence of obesity (17.9 vs. 13.1%, P < 0.05), central obesity (41.5 vs. 29.2%, P < 0.01), sedentary behaviors (20.4 vs. 9.4%, P < 0.01), and tobacco exposure (14.1 vs. 5.9%, P < 0.01). Apart from higher prevalence of elevated non–HDL-C among low-income women aged 18–24 years (23.4 vs. 15.8%, P < 0.05), no other cardiovascular disease risk factor prevalence differences were observed between lowest- and highest-income background young adults. CONCLUSIONS Independent of race/ethnicity, 6- to 17-year-olds from low-income families have higher prevalence of obesity, central obesity, sedentary behavior, and tobacco exposure. Multifaceted cardiovascular health promotion policies are needed to reduce health disparities between income groups.

OBJETIVE: To examine the relationship between access to health care and undiagnosed diabetes among the high-risk, vulnerable population in the border region between the United States of America and Mexico. METHODS: Using survey and fasting plasma glucose data from Phase I of the U.S.-Mexico Border Diabetes Prevention and Control Project (February 2001 to October 2002), this epidemiological study identified 178 adults 18-64 years old with undiagnosed diabetes, 326 with diagnosed diabetes, and 2 966 without diabetes. Access to health care among that sample (n = 3 470), was assessed by type of health insurance coverage (including "none"), number of health care visits over the past year, routine pattern of health care utilization, and country of residence. RESULTS: People with diabetes who had no insurance and no place to go for routine health care were more likely to be undiagnosed than those with insurance and a place for routine health care (odds ratio [OR] 2.6, 95% confidence interval [CI] 1.0-6.6, and OR 4.5, 95% CI 1.4-14.1, respectively). When stratified by country, the survey data showed that on the U.S. side of the border there were more people with undiagnosed diabetes if they were 1) uninsured versus the insured (28.9%, 95% CI 11.5%-46.3%, versus 9.1%, 95% CI 1.5%-16.7%, respectively) and if they 2) had made no visits or 1-3 visits to a health care facility in the past year versus had made > 4 visits (40.8%, 95% CI 19.6%-62.0%, and 23.4%, 95% CI 9.9%-36.9%, respectively, versus 2.4%, 95% CI -0.9%-5.7%) (all, P < 0.05). No similar pattern was found in Mexico. CONCLUSIONS: Limited access to health care-especially not having health insurance and/or not having a place to receive routine health services-was significantly associated with undiagnosed diabetes in the U.S.-Mexico border region.OBJETIVO: Examinar la relación entre el acceso a la atención de salud y la diabetes no diagnosticada en la población de alto riesgo y vulnerable de la zona fronteriza entre México y los Estados Unidos. MÉTODOS: Mediante el uso de los datos de la encuesta y de la glucosa plasmática en ayunas de la fase I del Proyecto de Prevención y Control de la Diabetes en la Frontera México-Estados Unidos (de febrero del 2001 a octubre del 2002), en este estudio epidemiológico se identificaron 178 adultos de 18 a 64 años con diabetes no diagnosticada, 326 con diabetes diagnosticada y 2 966 sin diabetes. Se evaluó el acceso a la atención de salud en dicha muestra (n = 3 470), mediante el tipo de cobertura del seguro de salud (incluida "ninguna"), el número de consultas de atención de salud en el último año, las características de utilización de los servicios de salud y el país de residencia. RESULTADOS: La probabilidad de no tener un diagnóstico fue mayor en las personas que padecían diabetes y que no tenían seguro ni ningún lugar al que acudir para recibir la atención de salud que en las que sí contaban con seguro y un lugar para recibir atención de salud (razón de momios [OR], 2,6, intervalo de confianza [IC] del 95% 1,0-6,6, y OR de 4,5, IC 95% 1,4-14,1, respectivamente). Al estratificar los datos por país, los datos de la encuesta mostraron que, en el lado estadounidense de la frontera, había un mayor número de personas con diabetes no diagnosticada si: 1) no tenían seguro, frente a los asegurados (28,9%, IC 95% 11,5%-46,3%, en comparación con el 9,1%, IC 95% 1,5%-16,7%, respectivamente), y si: 2) no habían tenido consultas o habían tenido de una a tres consultas en un centro de atención de salud en el último año, en comparación con > 4 consultas (40,8%, IC 95% 19,6%- 62,0%, y 23,4%, IC 95% 9,9%-36,9%, respectivamente, en comparación con el 2,4%, IC 95% -0,9%-5,7%) (todos, p < 0.05). No se observó una pauta parecida en México. CONCLUSIÓN: En la región fronteriza entre México y los Estados Unidos, el acceso limitado a la atención de salud, especialmente si no se cuenta con un seguro de salud o no se tiene un lugar al que acudir para recibir atención de salud, mostró una relación significativa con la diabetes no diagnosticada.

Diabetes is a serious public health problem in the border region between the United States of America and Mexico, reflecting and by some measures surpassing the extent of national diabetes burden of each country. The U.S.-Mexico Border Diabetes Prevention and Control Project, a two-phase prevalence study on type 2 diabetes and its risk factors, was conceived and developed by culturally diverse groups of people representing more than 100 government agencies and nongovernmental organizations; health care providers; and residents of 10 U.S. and Mexican border states, using a participatory approach, to address this disproportionate incidence of diabetes. This report describes the project's history, conceptualization, participatory approach, implementation, accomplishments, and challenges, and recommends a series of steps for carrying out other binational participatory projects based on lessons learned.La diabetes es un problema grave de salud pública en la zona fronteriza entre México y los Estados Unidos, que refleja y, en cierta medida, sobrepasa la magnitud de la carga nacional de la diabetes de cada país. El Proyecto de Prevención y Control de la Diabetes en la Frontera México-Estados Unidos, un estudio de prevalencia de dos fases sobre la diabetes tipo 2 y sus factores de riesgo, se ideó y elaboró por grupos de personas culturalmente diversos que representaban a más de 100 organismos estatales y organizaciones no gubernamentales, profesionales de salud y residentes de 10 estados de la zona fronteriza entre México y los Estados Unidos, con la aplicación de un enfoque participativo, a fin de estudiar esta desproporcionada incidencia de diabetes. En este informe se describen la historia, la conceptualización, el enfoque participativo, la ejecución, los logros y los retos del proyecto, y se recomienda una serie de pasos para la realización de otros proyectos participativos binacionales, a partir de las lecciones aprendidas.

Diabetes is a serious public health problem in the border region between the United States of America and Mexico, reflecting and by some measures surpassing the extent of national diabetes burden of each country. The U.S.-Mexico Border Diabetes Prevention and Control Project, a two-phase prevalence study on type 2 diabetes and its risk factors, was conceived and developed by culturally diverse groups of people representing more than 100 government agencies and nongovernmental organizations; health care providers; and residents of 10 U.S. and Mexican border states, using a participatory approach, to address this disproportionate incidence of diabetes. This report describes the project's history, conceptualization, participatory approach, implementation, accomplishments, and challenges, and recommends a series of steps for carrying out other binational participatory projects based on lessons learned.

OBJECTIVE Iron deficiency has been reported to elevate A1C levels apart from glycemia. We examined the influence of iron deficiency on A1C distribution among adults without diabetes. RESEARCH DESIGN AND METHODS Participants included adults without self-reported diabetes or chronic kidney disease in the National Health and Nutrition Examination Survey 1999–2006 who were aged ≥18 years of age and had complete blood counts, iron studies, and A1C levels. Iron deficiency was defined as at least two abnormalities including free erythrocyte protoporphyrin >70 μg/dl erythrocytes, transferrin saturation RESULTS Among women (n = 6,666), 13.7% had iron deficiency and 4.0% had iron deficiency anemia. Whereas 316 women with iron deficiency had A1C ≥5.5%, only 32 women with iron deficiency had A1C ≥6.5%. Among men (n = 3,869), only 13 had iron deficiency and A1C ≥5.5%, and only 1 had iron deficiency and A1C ≥6.5%. Among women, iron deficiency was associated with a greater odds of A1C ≥5.5% (odds ratio 1.39 [95% CI 1.11–1.73]) after adjustment for age, race/ethnicity, and waist circumference but not with a greater odds of A1C ≥6.5% (0.79 [0.33–1.85]). CONCLUSIONS Iron deficiency is common among women and is associated with shifts in A1C distribution from

Objective To examine diabetic retinopathy, dilated eye examination, and eye care education among African Americans before and after a community-level public health intervention. Methods We analyzed data from Project DIRECT (Diabetes Interventions Reaching and Educating Communities Together) participants with self-reported diabetes (617 in 1996-1997 and 672 in 2003-2004) in Raleigh (intervention community) and Greensboro (comparison community), North Carolina. All analyses were weighted to adjust for the complex sample design of pre and post cross-sectional surveys. Estimates were age standardized to the 2000 US Census population. We used multivariate logistic regression to calculate odds ratios and corresponding 95% confidence intervals. Results We found no significant difference in prevalence of diabetic retinopathy between the control and intervention communities ( p > .05). However, after adjusting for other confounders, receipt of eye care education (OR, 1.59; 95% CI, 1.19-2.13) was independently associated with receipt of dilated eye examination among African Americans with diabetes. Compared with individuals without diabetic retinopathy, those with diabetic retinopathy were more likely to use eye care services (OR, 1.89; 95% CI, 1.41-2.54). Conclusions Diabetic retinopathy is a considerable problem among African American communities. Community intervention efforts, such as comprehensive eye care education, that specifically target improvement in diabetic retinopathy and use of eye care services could help better serve this population.

Author(s): Ettner, Susan L; Cadwell, Betsy L; Russell, Louise B; Brown, Arleen; Karter, Andrew J; Safford, Monika; Mangione, Carol; Beckles, Gloria; Herman, William H; Thompson, Theodore J; TRIAD Study Group | Abstract: BackgroundResearch on self-care for chronic disease has not examined time requirements. Translating Research into Action for Diabetes (TRIAD), a multi-site study of managed care patients with diabetes, is among the first to assess self-care time.ObjectiveTo examine associations between socioeconomic position and extra time patients spend on foot care, shopping/cooking, and exercise due to diabetes.DataEleven thousand nine hundred and twenty-seven patient surveys from 2000 to 2001.MethodsBayesian two-part models were used to estimate associations of self-reported extra time spent on self-care with race/ethnicity, education, and income, controlling for demographic and clinical characteristics.ResultsProportions of patients spending no extra time on foot care, shopping/cooking, and exercise were, respectively, 37, 52, and 31%. Extra time spent on foot care and shopping/cooking was greater among racial/ethnic minorities, less-educated and lower-income patients. For example, African-Americans were about 10 percentage points more likely to report spending extra time on foot care than whites and extra time spent was about 3 min more per day.DiscussionExtra time spent on self-care was greater for socioeconomically disadvantaged patients than for advantaged patients, perhaps because their perceived opportunity cost of time is lower or they cannot afford substitutes. Our findings suggest that poorly controlled diabetes risk factors among disadvantaged populations may not be attributable to self-care practices.

Diabetes is a common and costly disease. In 2007, an estimated 24 million people in the United States had diabetes, with almost half of these being women. Diabetes increases the risk of morbidity and mortality from several conditions, including cardiovascular disease, several types of cancers, influenza and pneumococcal infection, and kidney, eye, and periodontal diseases. The aim of this study was to examine the quality of care that women with diabetes receive and to assess how receipt of some clinical preventive services and screening for common conditions associated with diabetes vary according to socioeconomic factors. Our findings indicate that use of diabetes-specific preventive care among women is low, with the youngest women (or =45 years) and those with low educational levels being the least likely to receive the recommended services. Women with diabetes were less likely than women without diabetes to receive a Pap smear, with the oldest women (or =65 years) being the most vulnerable. Women with diabetes who were poor and nonwhite were less likely than more affluent and white women to receive a pneumococcal vaccination. This study's findings suggest that having a chronic disease may serve as a barrier to the receipt of recommended preventive care among women. Effective interventions should be designed to meet the needs of the most vulnerable women with diabetes, in particular, those who are at the extremes of the life cycle, are poor, and have low levels of education. Programs should use a life stage approach to address the unique needs of women with diabetes.

OBJECTIVE—This study examined the association between access to health care and three classifications of diabetes status: diagnosed, undiagnosed, and no diabetes. RESEARCH DESIGN AND METHODS—Using data from the 1999–2004 National Health and Nutrition Examination Survey, we identified 110 “missed patients” (fasting plasma glucose >125 mg/dl but without diagnoses of diabetes), 704 patients with diagnosed diabetes, and 4,782 people without diabetes among adults aged 18–64 years. The population percentage undetected among adults with diabetes and the odds ratio of being undetected among adults who reported not having diabetes were compared between groups based on their access to health care. RESULTS—Among those with diabetes, the percentages having undetected diabetes were 42.2% (95% CI 36.7–47.7) among the uninsured, 25.9% (22.9–28.9) among the insured, 49.3% (43.0–55.6) for those uninsured >1 year, 38.7% (29.2–48.2) for those uninsured ≤1 year, and 24.5% (21.7–27.3) for those continuously insured over the past year. Type of insurance, number of times receiving health care in the past year, and routine patterns of health care utilization were also associated with undetected diabetes. Multivariate adjustment indicated that having undetected diabetes was associated with being uninsured (odds ratio 1.7 [95% CI 1.0–2.9]) and with being uninsured >1 year (2.6 [1.4–5.0]). CONCLUSIONS—Limited access to health care, especially being uninsured and going without insurance for a long period, was significantly associated with being a “missed patient” with diabetes. Efforts to increase detection of diabetes may need to address issues of access to care.

Population dynamics predict a drastic growth in the number of older minority women, and resultant increases in the number of fractures. Low bone mineral density (BMD) is an important risk factor for fracture. Many studies have identified the lifestyle and health related factors that correlate with BMD in Whites. Few studies have focused on non-Whites. The objective of the current analyses is to examine the lifestyle, anthropometric and health related factors that are correlated with BMD in a population based cohort of Caribbean women of West African ancestry. We enrolled 340 postmenopausal women residing on the Caribbean Island of Tobago. Participants completed a questionnaire and had anthropometric measures taken. Hip BMD was measured by DXA. We estimated volumetric BMD by calculating bone mineral apparent density (BMAD). BMD was 10% and 20% higher across all age groups in Tobagonian women compared to US non-Hispanic Black and White women, respectively. In multiple linear regression models, 35–36% of the variability in femoral neck and total hip BMD respectively was predicted. Each 16 kilogram (one standard deviation (SD)) increase in weight was associated with 7% higher BMD; and weight explained over 10% of the variability of BMD. Each eight year (1 SD) increase in age was associated with 6% lower BMD. Current use of both thiazide diuretics and oral hypoglycemic medication were associated with 4–5% higher BMD. For femoral neck BMAD, 26% of the variability was explained by a multiple linear regression model. Current statin use was associated with 5% higher BMAD and a history of breast feeding or coronary heart disease were associated with 1–1.5% of higher BMAD. In conclusion, African Caribbean women have the highest BMD on a population level reported to date for women. This may reflect low European admixture. Correlates of BMD among Caribbean women of West African ancestry were similar to those reported for U.S. Black and White women.

OBJECTIVE—Recent data suggest that residential environment may influence health behaviors and outcomes. We assessed whether perception of neighborhood problems was associated with diabetes behaviors and outcomes. RESEARCH DESIGN AND METHODS—This cross-sectional analysis included 7,830 diabetic adults enrolled in Translating Research Into Action for Diabetes, a study of diabetes care and outcomes in managed care settings. Perception of neighborhood problems was measured using a summary score of participants’ ratings of crime, trash, litter, lighting at night, and access to exercise facilities, transportation, and supermarkets. Outcomes included health behaviors and clinical outcomes. Hierarchical regression models were used to account for clustering of patients within neighborhoods and to adjust for objective neighborhood socioeconomic status (percentage living in poverty) and potential individual-level confounders (age, sex, race/ethnicity, education, income, comorbidity index, and duration of diabetes). RESULTS—After adjustment, residents of neighborhoods in the lowest tertile (most perceived problems) reported higher rates of current smoking (15 vs. 11%) than those in the highest tertile and had slightly lower participation in any weekly physical activity (95 vs. 96%). In addition, their blood pressure control was worse (25 vs. 31% CONCLUSIONS—Neighborhood problems were most strongly associated with more smoking and higher blood pressure, both of which have significant implications for cardiovascular risk. Potential mechanisms that explain these associations should be further explored in longitudinal studies.

Reduction of health disparities and advancement of health equity in the United States require high-quality data indicative of where the nation stands vis-a-vis health equity, as well as proper analytic tools to facilitate accurate interpretation of these data. This article opens with an overview of health equity and social determinants of health. It then proposes a set of recommended practices in measurement of health disparities, health inequities, and social determinants of health at the national level to support the advancement of health equity, highlighting that (1) differences in health and its determinants that are associated with social position are important to assess; (2) social and structural determinants of health should be assessed and multiple levels of measurement should be considered; (3) the rationale for methodological choices made and measures chosen should be made explicit; (4) groups to be compared should be simultaneously classified by multiple social statuses; and (5) stakeholders and their communication needs can often be considered in the selection of analytic methods. Although much is understood about the role of social determinants of health in shaping the health of populations, researchers should continue to advance understanding of the pathways through which they operate on particular health outcomes. There is still much to learn and implement about how to measure health disparities, health inequities, and social determinants of health at the national level, and the challenges of health equity persist. We anticipate that the present discussion will contribute to the laying of a foundation for standard practice in the monitoring of national progress toward achievement of health equity.

Correlates of BMD were examined in a cross-sectional analysis of men of West African ancestry. BMD, measured at the total hip and the femoral neck subregion, was associated with age, anthropometric, lifestyle, and medical factors in multiple linear regression models. These models explained 25–27% of the variability in total hip and femoral neck BMD, respectively, and 13% of the variability in estimated volumetric BMD. To examine the correlates of bone mineral density (BMD) in men of West African ancestry. Two thousand five hundred and one men aged 40 to 93 years were recruited from the Caribbean Island of Tobago. Participants completed a questionnaire and physical examination. We measured hip BMD and body composition, using DXA. Volumetric BMD was estimated as bone mineral apparent density (BMAD). BMD was 10% and 20% higher in African Caribbean males compared to U.S. non-Hispanic black and white males, respectively. In multiple linear regression models, greater lean mass, history of working on a fishing boat or on a farm, frequent walking, and self-reported diabetes were significantly associated with higher BMD. Fat mass, history of farming, and self-reported hypertension were also associated with higher BMAD. Older age, mixed African ancestry, and history of a fracture were associated with lower BMD and BMAD. Lean body mass explained 20%, 18% and 6% of the variance in BMD at the total hip, femoral neck and BMAD, respectively. African Caribbean males have the highest BMD on a population level ever reported. Lean mass was the single most important correlate. Variability in BMD/BMAD was also explained by age, mixed African ancestry, anthropometric, lifestyle, and medical factors.

Despite consensus about the importance of measuring quality of diabetes care and the widespread use of self-reports and medical records to assess quality, little is known about the degree of agreement between these data sources.To evaluate agreement between self-reported and medical record data on annual eye examinations and to identify factors associated with agreement.Data from interviews and medical records were available for 8409 adults with diabetes who participated in the baseline round of the Translating Research Into Action for Diabetes (TRIAD) Study.Agreement between self-reports and medical records was evaluated as concordance and Cohen's kappa coefficient.Self-reports indicated a higher performance of annual dilated eye examinations than did medical records (75.9% vs. 38.8%). Concordance between the data sources was 57.9%. Agreement was only fair (kappa coefficient = 0.25; 95% confidence interval, 0.23-0.26). Nearly two-thirds (64.6%) of discordance was due to lack of evidence in the medical record to support self-reported performance of the procedure. After adjustment, agreement was most strongly related to health plan (chi = 977.9, df = 9; P0.0001), and remained significantly better for 3 of the 10 health plans (P0.00001) and for persons younger than 45 years of age (P = 0.00002).The low level of agreement between self-report and medical records suggests that many providers of diabetes care do not have easily available accurate information on the eye examination status of their patients.

Objectives. We examined the role of family history of diabetes in awareness of diabetes risk factors and engaging in health behaviors. Methods. We conducted a cross-sectional analysis of 1122 African American adults without diabetes who were participants in Project DIRECT (Diabetes Interventions Reaching and Educating Communities Together). Results. After adjustment for age, gender, income, education, body mass index, and perceived health status, African Americans with a family history of diabetes were more aware than those without such a history of several diabetes risk factors: having a family member with the disease (relative risk [RR] = 1.09; 95% confidence interval [CI] = 1.03, 1.15), being overweight (RR = 1.12; 95% CI = 1.05, 1.18), not exercising (RR=1.17; 95% CI=1.07, 1.27), and consuming energy-dense foods (RR = 1.10; 95% CI = 1.00, 1.17). Also, they were more likely to consume 5 or more servings of fruits and vegetables per day (RR=1.31; 95% CI=1.02, 1.66) and to have been screened for diabetes (RR = 1.21; 95% CI = 1.12, 1.29). Conclusions. African Americans with a family history of diabetes were more aware of diabetes risk factors and more likely to engage in certain health behaviors than were African Americans without a family history of the disease. (Am J Public Health. 2007;97:907‐912. doi:10.2105/AJPH.2005.077032)

Monitoring national trends in disparities in different diseases could provide measures to evaluate the impact of intervention programs designed to reduce health disparities. In the US, most of the reports that track health disparities provided either relative or absolute disparities or both. However, these two measures of disparities are not only different in scale and magnitude but also the temporal changes in the magnitudes of these measures can occur in opposite directions. The trends for absolute disparity and relative disparity could move in opposite directions when the prevalence of disease in the two populations being compared either increase or decline simultaneously. If the absolute disparity increases but relative disparity declines for consecutive time periods, the absolute disparity increases but relative disparity declines for the combined time periods even with a larger increase in absolute disparity during the combined time periods. Based on random increases or decreases in prevalence of disease for two population groups, there is a higher chance the trends of these two measures could move in opposite directions when the prevalence of disease for the more advantaged group is very small relative to the prevalence of disease for the more disadvantaged group. When prevalence of disease increase or decrease simultaneously for two populations, the increase or decrease in absolute disparity has to be sufficiently large enough to warrant a corresponding increase or decrease in relative disparity. When absolute disparity declines but relative disparity increases, there is some progress in reducing disparities, but the reduction in absolute disparity is not large enough to also reduce relative disparity. When evaluating interventions to reduce health disparities using these two measures, it is important to consider both absolute and relative disparities and consider all the scenarios discussed in this paper to assess the progress towards reducing or eliminating health disparities.

Objectives. We examined the relationship between socioeconomic position (SEP) and sensory impairment. Methods. We used data from the 2007 to 2010 National Health Interview Surveys (n = 69 845 adults). Multivariable logistic regressions estimated odds ratios (ORs) for associations of educational attainment, occupational class, and poverty–income ratio with impaired vision or hearing. Results. Nearly 20% of respondents reported sensory impairment. Each SEP indicator was negatively associated with sensory impairment. Adjusted odds of vision impairment were significantly higher for farm workers (OR = 1.41; 95% confidence interval [CI] = 1.01, 2.02), people with some college (OR = 1.29; 95% CI = 1.16, 1.44) or less than a high school diploma (OR = 1.36; 95% CI = 1.19, 1.55), and people from poor (OR = 1.35; 95% CI = 1.20, 1.52), low-income (OR = 1.28; 95% CI = 1.14, 1.43), or middle-income (OR = 1.19; 95% CI = 1.07, 1.31) families than for the highest-SEP group. Odds of hearing impairment were significantly higher for people with some college or less education than for those with a college degree or more; for service groups, farmers, and blue-collar workers than for white-collar workers; and for people in poor families. Conclusions. More research is needed to understand the SEP–sensory impairment association.

OBJECTIVE—To examine racial/ethnic and socioeconomic variation in diabetes care in managed-care settings. RESEARCH DESIGN AND METHODS—We studied 7,456 adults enrolled in health plans participating in the Translating Research Into Action for Diabetes study, a six-center cohort study of diabetes in managed care. Cross-sectional analyses using hierarchical regression models assessed processes of care (HbA1c [A1C], lipid, and proteinuria assessment; foot and dilated eye examinations; use or advice to use aspirin; and influenza vaccination) and intermediate health outcomes (A1C, LDL, and blood pressure control). RESULTS—Most quality indicators and intermediate outcomes were comparable across race/ethnicity and socioeconomic position (SEP). Latinos and Asians/Pacific Islanders had similar or better processes and intermediate outcomes than whites with the exception of slightly higher A1C levels. Compared with whites, African Americans had lower rates of A1C and LDL measurement and influenza vaccination, higher rates of foot and dilated eye examinations, and the poorest blood pressure and lipid control. The main SEP difference was lower rates of dilated eye examinations among poorer and less educated individuals. In almost all instances, racial/ethnic minorities or low SEP participants with poor glycemic, blood pressure, and lipid control received similar or more appropriate intensification of therapy relative to whites or those with higher SEP. CONCLUSIONS—In these managed-care settings, minority race/ethnicity was not consistently associated with worse processes or outcomes, and not all differences favored whites. The only notable SEP disparity was in rates of dilated eye examinations. Social disparities in health may be reduced in managed-care settings.

Background. Diabetes-related morbidity and mortality are primarily attributable to complications such as heart disease, stroke, lower extremity amputation, kidney disease, blindness, and visual impairment, many of which potentially can be delayed or prevented. Methods. We examined the association of diabetes self-management education (DSME) with preventive health practices and behaviors among 22,682 persons with type 2 diabetes using data from the 2001 and 2002 Behavioral Risk Factor Surveillance System (BRFSS). BRFSS is an ongoing, state-based, random-digit-dialed telephone survey of noninstitutionalized adults aged z18 years. Results. Approximately 48% of all adults with type 2 diabetes had never attended a DSME course. Among both diabetic persons who used insulin and those who did not, persons who received DSME were significantly more likely than those who had not received training to be physically active, to have received an annual dilated eye exam and flu vaccine, to have received a pneumococcal vaccine, to have checked their blood sugar daily, and to have had a physician or other health professional check their feet for sores or irritations and their hemoglobin A1C level in the past year. Conclusions. These data indicate the importance of DSME in the promotion of health practices that could prevent or delay potential diabetes complications among persons with type 2 diabetes. Published by Elsevier Inc.

Although people with diabetes mellitus have a high risk of depression and depression may increase mortality among people with other conditions, the impact of depression on mortality risk among people with diabetes needs further examination. Using survival analysis, the authors analyzed longitudinal data from the NHANES I Epidemiologic Follow-up Study (1982-1992). The findings showed that the presence of severe depressive symptoms significantly elevated mortality risk among US adults with diabetes; the same pattern was not observed among people without diabetes. After results were controlled for sociodemographic, lifestyle, and health-status variables, diabetic persons with Centers for Epidemiologic Studies Depression (CES-D) Scale scores of 16 or more had 54% greater mortality than those with scores under 16 (p = 0.004). After exclusion of participants who died during the first year of follow-up, mortality remained higher among those with CES-D scores greater than or equal to 22 as compared with those with CES-D scores less than 16, but not among those with CES-D scores between 16 and 21. No significant relation between depression and mortality was found in the nondiabetic population. This analysis indicates that diabetes modifies the effect of depression on mortality. It also demonstrates the importance of observing subgroups, rather than aggregated populations, when examining the effect of depression on mortality.

The aim of the present study was to examine associations between the presence of diabetes mellitus and health-related quality of life (HRQOL) among older adults. Using data from 37,054 adults aged 50 years or older who participated in the 2001 BRFSS, we examined the independent association between diabetes and four measures of HRQOL developed by the U.S. Centers for Disease Control and Prevention. Multivariate logistic regression was used to obtain adjusted odds ratios (ORs) and 95% confidence intervals (CIs). On average, older adults with diabetes reported nearly twice as many unhealthy days (physical or mental) as those without the condition (mean: 10.1 [S.E.: 0.32] versus 5.7 [0.43]) after age adjustment. The proportion of older adults reporting 14 or more unhealthy days (physical or mental) was significantly higher among those with diabetes (n = 4032; 11%) compared to those without the condition (OR: 1.64; 95% CI: 1.20, 2.23) after multivariate adjustment. Among older diabetic adults, the adjusted relative odds of having 14 or more unhealthy days (physical or mental) was 1.71 (95% CI: 1.31, 2.22) times greater for those treated with insulin compared to those not treated with insulin. Diabetes is independently associated with lower levels of HRQOL among older adults. These results reinforce the importance of preventing diabetes and its complications through health education messages stressing a balanced diet and increased physical activity.

Diabetes is a serious chronic disease that affects women in all life stages, from adolescence to the older years. Diabetes also imposes a significant economic burden on individuals, families, and society. The National Public Health Initiative on Diabetes and Women's Health was formed to guide the nation in addressing diabetes and women's health issues. This paper documents the rationale for developing an initiative on diabetes and women's health and the processes used to implement it.

Purpose Health and administrative systems are facing spatial clustering in chronic diseases such as diabetes. This study explores how geographic distribution of diabetes in the United States is associated with socioeconomic and built environment characteristics and health-relevant policies. Methods We compiled nationally representative county-level data from multiple data sources. We standardized characteristics to a mean = 0 and a SD = 1 and modeled county-level age-adjusted diagnosed diabetes incidence in 2013 using 2-level hierarchical linear regression. Results Incidence of age-standardized diagnosed diabetes in 2013 varied across U.S. counties (n = 3109), ranging from 310 to 2190 new cases/100,000, with an average of 856.4/100,000. Socioeconomic and health-related characteristics explained ∼42% of the variation in diabetes incidence across counties. After accounting for other characteristics, counties with higher unemployment, higher poverty, and longer commutes had higher incidence rates than counties with lower levels. Counties with more exercise opportunities, access to healthy food, and primary care physicians had fewer diabetes cases. Conclusions Features of the socioeconomic and built environment were associated with diabetes incidence; identifying the salient modifiable features of counties can inform targeted policies to reduce diabetes incidence.

OBJECTIVE To determine whether competing demands for time affect diabetes self-care behaviors, processes of care, and intermediate outcomes. RESEARCH DESIGN AND METHODS We used survey and medical record data from 5,478 participants in Translating Research Into Action for Diabetes (TRIAD) and hierarchical regression models to examine the cross-sectional associations between competing demands for time and diabetes outcomes, including self-management, processes of care, and intermediate health outcomes. RESULTS Fifty-two percent of participants reported no competing demands, 7% reported caregiving responsibilities only, 36% reported employment responsibilities only, and 6% reported both caregiving and employment responsibilities. For both women and men, employment responsibilities (with or without caregiving responsibilities) were associated with lower rates of diabetes self-care behaviors, worse processes of care, and, in men, worse HbA1c. CONCLUSIONS Accommodations for competing demands for time may promote self-management and improve the processes and outcomes of care for employed adults with diabetes.

OBJECTIVE: To estimate the prevalence of physical disability associated with diabetes among U.S. adults > or =60 years of age. RESEARCH DESIGN AND METHODS: We analyzed data from a nationally representative sample of 6,588 community-dwelling men and women > or =60 years of age who participated in the Third National Health and Nutrition Examination Survey. Diabetes and comorbidities (coronary heart disease, intermittent claudication, stroke, arthritis, and visual impairment) were assessed by questionnaire. Physical disability was assessed by self-reported ability to walk one-fourth of a mile, climb 10 steps, and do housework. Walking speed, lower-extremity function, and balance were assessed using physical performance tests. RESULTS: Among subjects > or =60 years of age with diabetes, 32% of women and 15% of men reported an inability to walk one-fourth of a mile, climb stairs, or do housework compared with 14% of women and 8% of men without diabetes. Diabetes was associated with a 2- to 3-fold increased odds of not being able to do each task among both men and women and up to a 3.6-fold increased risk of not being able to do all 3 tasks. Among women, diabetes was also associated with slower walking speed, inferior lower-extremity function, decreased balance, and an increased risk of falling. Of the >5 million U.S. adults > or =60 years of age with diabetes, 1.2 million are unable to do major physical tasks. CONCLUSIONS: Diabetes is associated with a major burden of physical disability in older U.S. adults, and these disabilities are likely to substantially impair their quality of life.

Objectives: To review the magnitude, characteristics, and public health importance of type 2 diabetes in North American youth. Results: Among 15- to 19-year-old North American Indians, prevalence of type 2 diabetes per 1000 was 50.9 for Pima Indians, 4.5 for all US American Indians, and 2.3 for Canadian Cree and Ojibwav Indians in Manitoba. From 1967-1976 to 1987-1996, prevalence increased 6-fold for Pima Indian adolescents. Among African Americans and whites aged 10 to 19 years in Ohio, type 2 diabetes accounted for 33% of all cases of diabetes. Youth with type 2 diabetes were generally 10 to 19 years old, were obese and had a family history of type 2 diabetes, had acanthosis nigricans, belonged to minority popu- lations, and were more likely to be girls than boys. At follow-up, glucose control was often poor, and diabetic complications could occur early. Conclusions: Type 2 diabetes is an important problem among American Indian and First Nation youth. Other populations have not been well studied, but cases are now occurring in all population groups, especially in ethnic minorities. Type 2 diabetes among youth is an emerging public health problem, for which there is a great potential to improve primary and secondary prevention.

OBJECTIVE: To assess the prevalence and correlates of recommended preventive care among adults with diabetes in Kansas. RESEARCH DESIGN AND METHODS: A cross-sectional telephone survey was conducted among a sample of adults (> or = 18 years of age) with self-reported diabetes. Recommended preventive care was defined based on four criteria: number of health-care provider (HCP) visits per year (> or = 4 for insulin users and > or = 2 for nonusers), number of foot examinations per year (> or = 4 for insulin users and > or = 2 for nonusers), an annual dilated eye examination, and a blood pressure measurement in the past 6 months. RESULTS: The mean age of the 640 respondents was 61 years, 58% were women, and 86% were white. In the preceding year, 62% of respondents reported the appropriate number of visits to a HCP 27% the appropriate number of foot examinations, 65% an annual dilated eye examination, and 89% a blood pressure measurement in the preceding 6 months. Only 17% (95% CI 14-20) met all four criteria for recommended care. The adjusted odds of receiving recommended care were higher for males than for females (odds ratio [OR] 1.6; 95% CI 1.1-2.5), higher for people whose HCP scheduled follow-up appointments than for those who self-initiated follow-up (OR 2.7; 95% CI 1.6-4.8), and higher for former smokers than for current smokers (OR 3.1; 95% CI 1.6-6.9). CONCLUSIONS: Preventive care for people with diabetes is not being delivered in compliance with current guidelines, especially for women and current smokers. Scheduling follow-up visits for patients, targeting certain high-risk populations, and developing protocols to improve foot care may be effective in improving care.

OBJECTIVES: This study estimated the prevalence of self-rated visual impairment among US adults with diabetes and identified correlates of such impairment. METHODS: Self-reported data from the 1995 Behavioral Risk Factor Surveillance System survey of adults 18 years and older with diabetes were analyzed. Correlates of visual impairment were examined by multiple logistic regression analysis. RESULTS: The prevalence of self-rated visual impairment was 24.8% (95% confidence interval [CI] = 22.3%, 27.3%). Among insulin users, multivariable-adjusted odds ratios were 4.9 (95% CI = 2.6, 9.2) for those who had not completed high school and 1.8 (95% CI = 1.0, 2.8) for those who had completed high school compared with those with higher levels of education. Comparable estimates of odds ratios for nonusers of insulin were 2.2 (95% CI = 1.4, 3.4) and 1.3 (95% CI = 0.9, 2.0), respectively. Among nonusers, the adjusted odds for minority adults were 2.4 (95% CI = 1.0, 3.7) times the odds for non-Hispanic Whites. CONCLUSIONS: By these data, 1.6 million US adults with diabetes reported having some degree of visual impairment. Future research on the specific causes of visual impairment may help in estimating the avoidable public health burden.

OBJECTIVE—We compared inflammatory markers among women with a history of gestational diabetes mellitus (hGDM), women with diagnosed diabetes, and unaffected women in a population-based sample. RESEARCH DESIGN AND METHODS—We conducted cross-sectional analyses of 6,346 nonpregnant women in the Third National Health and Nutrition Examination Survey (1988–1994). Women were classified as having hGDM (n = 87), diagnosed diabetes (n = 244), or neither condition (n = 6,015). Inflammatory markers included ferritin, leukocyte count, and C-reactive protein levels. RESULTS—After adjustment, women with diagnosed diabetes had the most marked differences in inflammatory markers compared with unaffected women. Differences between unaffected women and women with hGDM were minimal. CONCLUSIONS—Women with diagnosed diabetes have less favorable inflammation profiles than unaffected women and greater ferritin levels than women with hGDM. After adjustment, women with hGDM who have not developed diagnosed diabetes have inflammation profiles similar to those of unaffected women.

The pathogenesis, treatment, and outcomes of type 1 and type 2 diabetes differ. Current surveys derive population-based estimates of diabetes prevalence by type using limited clinical information and applying classification rules developed in white populations. How well these rules perform when deriving similar estimates in African American populations is unknown. For this study, data were collected on a group of African Americans with diabetes who enrolled at the Diabetes Unit of Grady Memorial Hospital in Atlanta, Georgia, from April 16, 1991, to November 1, 1996. The data were used to develop some simple classification rules for African Americans based on a classification tree and a logistic regression model. Sensitivities and specificities, in which fasting C-peptide was used as the gold standard, were determined for these rules and for two current rules developed in mostly white, non-Hispanic populations. Rules that yielded precise (minimum variance unbiased) estimates of the prevalence of type 1 diabetes were preferred. The authors found that a rule based on the logistic regression model was best for estimating type 1 prevalences ranging from 1% to 17%. They concluded that simple classification rules can be used to estimate prevalence of diabetes by type in African American populations and that the optimal rule differs somewhat from the current rules.

The Population Attributable Risk (PAR) represents the proportion of the deaths (in a specified time) in the whole population that may be preventable if a cause of mortality were totally eliminated. This population-based measure was used to assess the potential impact of three public health interventions for type 2 diabetes (early detection + standard therapy; early detection + intensive therapy; and primary prevention) on the mortality risk from all causes and from cardiovascular (CVD) diseases. Potential reduction in mortality risks for several levels of compliance or implementation (25%, 50%, 75%, 100%) for each intervention were also estimated. Results suggest that among males aged 45-74 years, the interventions may have greater population-wide impact on total deaths among black males, and greater impact on the CVD deaths among white males. Overall, primary prevention (reduction in all-cause mortality 6.2-10.0%, and CVD mortality 7.9-9.0%) may offer greater marginal benefit than screening and early treatment (reduction in all-cause mortality 3.5-8.3%, and CVD mortality 2.8-8.6%). Often the question facing policy makers is not simply whether to but how much of an intervention is worth implementing? Estimated benefits for various intensities of intervention (as provided) may be useful to assess the likely marginal benefits of each intervention, and can be especially useful if combined with estimated marginal costs.

Background Sex-specific prediabetes estimates are not available for older-adult Americans. Purpose To estimate prediabetes prevalence, using nationally representative data, in civilian, non-institutionalized, older U.S. adults. Methods Data from 7,995 participants aged ≥50 years from the 1999−2010 National Health and Nutrition Examination Surveys were analyzed in 2013. Prediabetes was defined as hemoglobin A1c=5.7%−6.4% (39−47 mmol/mol [HbA1c5.7]), fasting plasma glucose of 100−125 mg/dL (impaired fasting glucose [IFG]), or both. Crude and age-adjusted prevalences for prediabetes, HbA1c5.7, and IFG by sex and three age groups were calculated, with additional adjustment for sex, age, race/ethnicity, poverty status, education, living alone, and BMI. Results From 1999 to 2005 and 2006 to 2010, prediabetes increased for adults aged 50−64 years (38.5% [95% CI=35.3, 41.8] to 45.9% [42.3, 49.5], p =0.003) and 65−74 years (41.3% [37.2, 45.5] to 47.9% [44.5, 51.3]; p =0.016), but not significantly for adults aged ≥75 years (45.1% [95% CI=41.1, 49.1] to 48.9% [95% CI=45.2, 52.6]; p >0.05). Prediabetes increased significantly for women in the two youngest age groups, and HbA1c5.7 for both sexes (except men aged ≥75 years), but IFG remained stable for both sexes. Men had higher prevalences than women for prediabetes and IFG among adults aged 50−64 years, and for IFG among adults aged ≥75 years. Across demographic subgroups, adjusted prevalence gains for both sexes were similar and most pronounced for HbA1c5.7, virtually absent for IFG, but greater for women than men for prediabetes. Conclusions Given the large, growing prediabetes prevalence and its anticipated burden, older adults, especially women, are likely intervention targets.