Limited English Proficiency Is a Barrier to Receipt of Advice about Physical Activity and Diet among Hispanics with Chronic Diseases in the United States

Pharmacist-Managed Diabetic Retinopathy in Hispanic/LatinX Population

There are three major microvascular complications of diabetes, retinopathy, nephropathy, and neuropathy, among which diabetic retinopathy (DR) is the most common. Several studies suggest that the Hispanic/LatinX population exhibit the highest cases of both diabetes and DR. Strategies aimed at reducing risk factors that could minimize the likelihood of DR development or progression could be beneficial. This retrospective study assessed DR in the Hispanic/LatinX population in pharmacist-managed cardiovascular risk reduction services. A chart review was conducted for 60 individuals who visited clinics led by both a pharmacist and a primary care physician (intervention group) and 178 individuals who saw physicians only (control group). Demographics, metabolic parameters, DR severity, and pharmacist appointment data were collected. The highest benefit of pharmacist intervention was observed in terms of a greater but insignificant decrease in HbA1c; however, there was no benefit of pharmacist's intervention on DR in general, likely due to the longer duration of diabetes and higher HbA1c at the beginning of the study. When the DR progression was examined based on the frequency of pharmacy visits, individuals who met a pharmacist more than two times per year showed more stable and lesser worsening of DR. Overall, our studies suggest that pharmacist intervention could benefit retinopathy outcome; however, well-known determinants of DR such as good glycemic control and duration of diabetes still play a critical role, in addition to challenges in receiving healthcare by the Hispanic/LatinX population. Future strategies in a prospective manner could help retinopathy outcomes in these at-risk patient populations.

Perceived Facilitators and Barriers to Implementing Culturally Inclusive Diets into Hospitals and Long-Term Care Facilities

OBJECTIVES

To identify perceived facilitators and barriers to implementing culturally inclusive foods into hospitals and long-term care (LTC) from the perspectives of registered dietitians and food service directors.

DESIGN

Cross-sectional survey.

SETTING AND PARTICIPANTS

Online nationwide survey of registered dietitians and food service directors working in hospitals or LTC.

METHODS

We analyzed and compared participants' perceived barriers to implementing culturally inclusive foods in hospitals and LTC, assessed through a question in which we provided respondents with 13 different barriers and asked them to report the top 3. Then, we conducted a qualitative analysis of perceived facilitators, which respondents described in open-ended comments.

RESULTS

The most common perceived barriers to implementing culturally inclusive foods were cost of ingredients (44%) and staff cultural knowledge and competence (44%). LTC respondents perceived barriers including (1) willingness of staff to adopt new practices, (2) time, (3) staff burnout, and (4) local/facility-level regulatory barriers more frequently than hospital respondents. Administrative buy-in, staff diversity, and patient considerations (eg, feedback and demand) were perceived facilitators to implementing culturally inclusive foods.

CONCLUSIONS AND IMPLICATIONS

Implementing culturally inclusive foods into hospitals and LTC requires administrative buy-in, willingness to change, and resources including staff diversity and cultural knowledge and awareness. Incorporating patient feedback and preferences into decisions related to dietary offerings could further motivate menu modifications. Further examination of organizational and state policies regulating diet, particularly in LTC settings, is necessary to understand both how to implement culturally inclusive foods and further, to inform investigation of health outcomes (physical and mental) associated with increasing culturally inclusive food offerings in these facilities.

Limited English Proficiency and Screening for Cervical, Breast, and Colorectal Cancers among Asian American Adults

BACKGROUND

Literature shows that limited English proficiency (LEP) influences individual healthcare-seeking behaviors. The Asian population is the fastest-growing racial/ethnic group in the US, and approximately 50% of foreign-born Asians are estimated to live with LEP.

OBJECTIVE

To examine associations of LEP and patient-provider language concordance (PPLC) with evidence-based cancer screening utilization for cervical, breast, and colorectal cancers among Asian American adults.

METHODS

We obtained LEP, PPLC, and up-to-date status on the three types of cancer screening from a nationally representative sample of Asian Americans aged ≥ 18 years in the 2010-2016 and 2018 Medical Expenditure Panel Surveys. We used multivariable logistic regression models with recommended survey weighting to examine associations of LEP and PPLC with the cancer screening uptake based on USPSTF guidelines.

RESULTS

The study population comprised 8953 respondents, representing 8.17 million Asian American adults. Overall, 11.9% of respondents experienced LEP; of those with LEP, 20% were with PPLC. In multivariable models, compared to respondents without LEP, respondents with LEP and without PPLC were significantly less likely to report up-to-date status on breast (OR = 0.44; 95% CI: 0.26-0.76), cervical (OR = 0.44; 95% CI: 0.26-0.75), or colorectal cancer screening (OR = 0.46; 95% CI: 0.26-0.80). However, these differences were not detected in respondents with LEP and with PPLC.

CONCLUSION

LEP is associated with lower up-to-date status on cancer screening among Asian Americans, while PPLC seems to moderate this association. These findings suggest the enhancement for language-appropriate and culturally competent healthcare for Asian Americans with LEP, which helps accommodate their communication needs and promotes cancer screening.

Factors associated with physical activity promotion efforts in individuals with chronic diseases: A systematic review from the perspective of patients

OBJECTIVES

To determine factors associated with healthcare provider physical activity (PA) promotion in individuals with chronic diseases from the perspective of patients.

METHODS

A systematic review of literature was conducted between March and April 2022 by searching five databases. Studies were included if they used survey data, published in English or Chinese, and investigated factors influencing healthcare provider PA promotion in chronic diseases from the perspective of adult patients. Retrieved factors were extracted and mapped to Anderson's Behavioral Model of Health Services Use. Quality of each study was assessed using the NIH Quality Assessment Tool.

RESULTS

Thirteen articles were included for final analysis. The quality of the included studies ranged from fair to good. A series of factors were positively related to healthcare provider PA promotion (e.g., having emotional support or public programs for PA). Conflicting results were found for other factors (e.g., age and gender).

CONCLUSIONS

A series of factors may impact the incorporation of PA promotion into clinical care. More studies with well-designed surveys using primary data collection are suggested to confirm these findings.

PRACTICE IMPLICATIONS

Factors identified from this review provide insights for developing of strategies related to healthcare provider PA promotion for individuals with chronic diseases.

Obesity among Latinx people in the United States: A review

Obesity is a serious, chronic disease that is associated with a range of adiposity-based comorbidities, including cardiovascular disease, type 2 diabetes, and nonalcoholic fatty liver disease. In the United States, obesity is a public health crisis, affecting more than 40% of the population. Obesity disproportionately affects Latinx people, who have a higher prevalence of obesity and related comorbidities (such as cardiovascular disease, type 2 diabetes, and nonalcoholic fatty liver disease) compared with the general population. Many factors, including genetic predisposition, environmental factors, traditional calorie-dense Latinx diets, family dynamics, and differences in socioeconomic status, contribute to the increased prevalence and complexity of treating obesity in the Latinx population. Additionally, significant heterogeneity within the Latinx population and disparities in health care access and utilization between Latinx people and the general population add to the challenge of obesity management. Culturally tailored interventions have been successful for managing obesity and related comorbidities in Latinx people. Antiobesity medications and bariatric surgery are also important options for obesity treatment in Latinx people. As highlighted in this review, when managing obesity in the Latinx population, it is critical to consider the impact of genetic, dietary, cultural, and socioeconomic factors, in order to implement an individualized treatment strategy.

Physical activity as a correlate of symptoms, quality of life, comorbidity, and disability status in Hispanics with multiple sclerosis

BACKGROUND

Hispanics with multiple sclerosis (MS) experience disproportionate rates of mobility disability compared to non-Hispanic Whites with MS. Physical activity (PA) is highlighted as a potential adjuvant therapy for improving MS symptoms and disease progression, however less than 30% of Hispanics with MS report sufficient levels of PA.

OBJECTIVES

The current study aimed to examine the correlates of PA behavior among Hispanics with MS in the North American Research Committee on Multiple Sclerosis Registry (NARCOMS).

METHODS

In Spring 2015, 136 NARCOMS participants identified as Hispanic and completed the International Physical Activity Questionnaire (IPAQ). IPAQ scores were converted to Health Contribution Scores (HCS) for estimating PA. The association between the HCS scores and MS symptoms (i.e., mobility, cognition, fatigue, spasticity, hand function, bowel/bladder, sensory, tremors, depression, and pain), quality of life (QOL), comorbid conditions, and disability status were evaluated using Pearson or Spearman correlation coefficients with follow-up multivariable regression analyses.

RESULTS

The mean age among participants was 58 years and 79% identified as female. The mean MS disease duration was 20 years and 68% reported relapsing disease course. The mean HCS score among participants was 15.6 ± 20.9. HCS was moderately associated with disability status (r_s = -0.39), mobility (r_s = -0.37), bowel/bladder function (r_s = -0.33), and physical health related QOL (r = 0.32). There were small associations between HCS and hand function (r_s = -0.29), fatigue (r_s = -0.20), and tremor (r_s = -0.25). Multivariable regression analyses indicated that disability status, mobility, bowel/bladder function, and physical health related QOL were all associated with HCS but did not independently contribute to the models when controlling for age, sex, and employment.

CONCLUSIONS

This study highlights correlates of PA behavior among Hispanics with MS. Researchers and clinicians may consider disability status, mobility, and physical health related QOL in future studies examining PA among Hispanics with MS.

A Community Health Worker-Led mHealth-Enabled Diabetes Self-Management Education and Support Intervention in Rural Latino Adults: Single-Arm Feasibility Trial (Preprint)

Background

Latinos living in rural South Texas have a higher prevalence of diabetes, but their access to diabetes self-management education and support (DSMES) is limited.

Objective

We aimed to test the feasibility of a community health worker-led, mobile health (mHealth)-based DSMES intervention to reduce disparities in accessing DSMES in underserved rural Latino residents in South Texas.

Methods

This 12-week, single-arm, pre-post trial was delivered by trained community health workers to 15 adults with type 2 diabetes. The intervention consisted of digital diabetes education, self-monitoring, a cloud-based connected platform, and community health worker support. Feasibility was evaluated as retention, actual intervention use, program satisfaction, and barriers to implementation. We also explored the intervention’s effect on weight loss and hemoglobin A_1c (HbA_1c).

Results

All 15 participants were Latino (mean age 61.87 years, SD 10.67; 9/15 female, 60%). The retention rate at posttest was 14 of 15 (93%). On average, the participants completed 37 of 42 (88%) digital diabetes education lessons with 8 participants completing all lessons. Participants spent 81/91 days (89%) step tracking, 71/91 days (78%) food logging, 43/91 days (47%) blood glucose self-monitoring, and 74/91 days (81%) weight self-monitoring. The level of program satisfaction was high. On average, participants lost 3.5 (SD 3.2) kg of body weight (P=.001), while HbA_1c level remained unchanged from baseline (6.91%, SD 1.28%) to posttest (7.04%, SD 1.66%; P=.668).

Conclusions

A community health worker-led mHealth-based intervention was feasible and acceptable to improve access to DSMES services for Latino adults living in rural communities. Future randomized controlled trials are needed to test intervention efficacy on weight loss and glycemic control.

Disparities in self-management outcomes by limited English proficiency among adults with heart disease

There are significant disparities in cardiovascular health outcomes by limited English proficiency (LEP). Self-management plans (SMPs) are associated with better patient outcomes, however little is known about the association of LEP with having an SMP among adults with heart disease. This study examined this association using 2013–2016 California Health Interview Survey data. Among adults that received an SMP, we also examined whether they had a hard copy SMP (print or electronic vs. none), and whether they reported confidence in their ability to manage their heart disease. Our sample included a total of 9102 adults, including 1232 LEP and 7870 English proficient (EP) adults. LEP was associated with significantly lower odds of SMP receipt (Adjusted Odds Ratio [AOR] 0.46, 95% Confidence Interval [CI] 0.31 to 0.68). LEP and EP adults who received an SMP were similarly likely to have a hard copy SMP and report confidence in heart disease management. The finding that LEP adults were less likely than EP adults to receive an SMP may represent a missed opportunity to improve heart health outcomes for this group.

Sociodemographic correlates of physical activity and sport among adults in Germany: 1997–2018

Introduction

Promoting physical activity (PA) is a key strategy to prevent noncommunicable diseases worldwide. In order to monitor physical activity levels in Germany, several large-scale studies have reported on prevalence rates and correlates. However, a comprehensive analysis of correlates of PA over time is currently lacking for Germany.

Methods

For the analysis, 13 national cross-sectional data sets were utilized. Data analysis was restricted to respondents aged 18 and older. In a first step, data sets were kept separate in order to explore social gradients of PA and sport. In the second step, data sets were pooled, demographic factors harmonized and binary logistic regressions were conducted.

Results

Regarding sports participation, different data sets indicate comparable social gradients. People with a higher age, lower income, lower levels of education, or a migrant background consistently have a higher risk of not engaging in sports. Compared to sports participation, social gradients are less pronounced for engaging in vigorous PA. Higher age, lower education, and lower income are also markers for an increased risk of not engaging in vigorous PA.

Discussion

The study confirms that factors of age, income, education and migrant background continue to contribute to differentials in sport and vigorous PA participation in Germany. For policy-making, this implies that PA promotion should focus on systems-based actions that might reduce population-wide inequalities. Future research might focus on pooling single studies with smaller samples in order to investigate PA and sports participation in specific disadvantaged target groups.

Relationship between county-level crime and diabetes: Mediating effect of physical inactivity

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High crime rates are associated with increased rates of type 2 diabetes.

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Area physical inactivity is an important mediator in this process.

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Over 60% of the relation between crime and diabetes was mediated by physical inactivity.

This paper assessed the extent to which physical inactivity accounts for the relationship between the crime rate and prevalence of type 2 diabetes in the United States. Using 2018 US county-level data, we compared unadjusted and adjusted prevalence of type 2 diabetes between high and low crime counties for 2,966 US counties. Average causal mediating effects of residents’ reported physical inactivity were estimated for each comparison. Counties with a higher crime rate were more likely to have higher percentages of people with type 2 diabetes than counties with a lower crime rate, even after adjusting for potential confounding factors such as racial distribution, income level, food insecurity, and neighborhood walkability (adjusted coefficient for top 40% vs. bottom 40% of crime rate distribution = 0.36; p < 0.001). Over 60% of the adjusted relationship between county-level rate of crime and type 2 diabetes was found to be mediated by physical inactivity. This study reinforces potentially overlooked public health benefits of effective anti-crime measures via improved physical activity.

Innovative Diabetes Interventions in the U.S. Hispanic Population

IN BRIEF In the United States, Hispanics have a 66% greater risk of developing type 2 diabetes and, once diagnosed, exhibit worse outcomes than non-Hispanic whites. It is therefore imperative to ensure that interventions meet the specific needs of this at-risk group. This article provides a selective review of the evidence on innovative, real-world approaches (both live and technology-based) to improving behavioral, psychosocial, and clinical outcomes in underserved Hispanics with type 2 diabetes. Key aspects of successful live interventions have included multimodal delivery, greater dosage/attendance, and at least some in-person delivery; effective technology-based approaches involved frequent but intermittent communication, bi-directional messaging, tailored feedback, multimodal delivery, and some human interaction. Across modalities, cultural tailoring also improved outcomes. Additional research is needed to address methodological limitations of studies to date and pinpoint the most efficacious components and optimal duration of interventions. Future efforts should also attend to variability within the U.S. Hispanic population to ensure acceptability and sustainability of interventions in this diverse group.

Patient-Provider Language Concordance and Health Outcomes: A Systematic Review, Evidence Map, and Research Agenda

Although patient-provider language concordance has the potential to reduce health disparities for people with limited English proficiency, no previous work has synthesized this literature. Our systematic review sought to describe the characteristics of studies examining relationships between language concordance and health outcomes, summarize the nature of observed associations, and propose an evidence map and research agenda. A comprehensive search of published articles identified 38 quantitative studies for inclusion. Most studies were cross-sectional, conducted in primary care, concentrated in Western states, and focused on Spanish speakers and physician providers. Results were split between supporting a positive association versus no association of language concordance with patient behaviors, provider behaviors, interpersonal processes of care, and clinical outcomes. Several methodological limitations were identified. Based on these results, we developed an evidence map, identified knowledge gaps, and proposed a research agenda. There is a particular need for quasi-experimental longitudinal studies with well-characterized samples.

A Systematic Review of Barriers to Access-to-Care in Hispanics With Type 2 Diabetes

INTRODUCTION

A systematic review was conducted to highlight current barriers to access-to-care for Hispanics with type 2 diabetes (T2D).

METHOD

PubMed and CINAHL databases (2010-2015) using PRISMA guidelines. 84 studies were identified, 12 quantitative studies were selected for review remained based on inclusion/exclusion criteria. There were five research questions: (1) What samples/settings were included? (2) What theories guided each study? (3) What were the study aims and (4) designs? (5) What barriers of access-to-care were identified? Barriers were placed into three categories set a priori.

RESULTS

The word "barrier" was in one study aim. Barriers of self (92%), provider (50%), and environment (25%) were identified. Self-care behaviors (diet and exercise), individual resources (cost factors), lack of providers specializing in T2D, and environmental factors affect Hispanics with T2D access-to-care.

DISCUSSION

These barriers to access underscore current importance to Hispanics with T2D. A follow-up review should be conducted as new barriers are expected to emerge.

Diabetes affects everything: Type 2 diabetes self-management among Spanish-speaking hispanic immigrants

This article is a report of qualitative findings of a mixed-methods study of the relationships among knowledge, self-efficacy, health promoting behaviors, and type 2 diabetes mellitus (T2DM) self-management among limited-english-proficient recent Hispanic immigrants, a population with increased incidence of T2DM and barriers to successful T2DM management. Semi-structured interviews were conducted with 30 participants, and physiological and demographic data also were collected. The participants generally attributed developing the disease to strong emotions and viewed T2DM as a serious disease. Although a majority understood the importance of exercise and diet in T2DM self-management, other aspects such as medication adherence were not well-understood. Obstacles to effective T2DM self-management were negative interactions and communications with health care providers and other personnel, cultural stigma related to the disease, financial constraints, immigration status, and the complexity of the disease. Suggested interventions to improve the care and self-management of this at-risk population are discussed.

Using Internet to recruit immigrants with language and culture barriers for tobacco and alcohol use screening: a study among Brazilians

Limited English proficient (LEP) individuals face disparities in accessing substance abuse treatment, but little is known on how to reach this population. This study aimed to test online recruitment methods for tobacco and alcohol screening among LEP Portuguese speakers. The study was advertised in Portuguese using Facebook, Google, online newsletters and E-mail. Participants clicked ads to consent and access a screening for tobacco and alcohol dependence. Ads yielded 690 screening responses in 90 days. Respondents had a mean age of 42.7 (SD 12), with a higher proportion of women than men, 95% born in Brazil with high levels of LEP and low levels of acculturation. Facebook ads yielded 41.4% of responses, and were the lowest cost recruitment channel ($8.9, $31.10 and $20.40 per respondent, hazardous drinker and smoker, respectively). Online recruitment of LEP populations is feasible. Future studies should test similar strategies in other LEP groups.

Position of the Academy of Nutrition and Dietetics: the role of nutrition in health promotion and chronic disease prevention

It is the position of the Academy of Nutrition and Dietetics that primary prevention is the most effective and affordable method to prevent chronic disease, and that dietary intervention positively impacts health outcomes across the life span. Registered dietitians and dietetic technicians, registered are critical members of health care teams and are essential to delivering nutrition-focused preventive services in clinical and community settings, advocating for policy and programmatic initiatives, and leading research in disease prevention and health promotion. Health-promotion and disease-prevention strategies are effective at reducing morbidity and mortality and improving quality of life, and have a significant impact on the leading causes of disease. By applying these principles within a social ecological theoretical framework, positive influence can be applied across the spectrum of engagement: at intrapersonal, interpersonal, institutional, community, and public policy levels. Through the application of efficacious and cost-effective interventions, registered dietitians and dietetic technicians, registered, can positively impact public health as well as health outcomes for the individuals that they counsel. This position paper supports the "Practice Paper of the Academy of Nutrition and Dietetics: The Role of Nutrition in Health Promotion and Chronic Disease Prevention" published on the Academy's website at: www.eatright.org/positions.

Perceptions of barriers in managing diabetes: perspectives of Hispanic immigrant patients and family members

PURPOSE

Hispanics show poorer self-management of type 2 diabetes than non-Hispanic whites. Although previous studies have reported socioeconomic and cultural barriers to diabetes self-management by Hispanics, little is known about perceived barriers to diabetes self-management from the perspectives of both Hispanics and their family members. The purpose of the study was to explore perceived barriers among Hispanic immigrants with diabetes and their family members.

METHODS

A qualitative study using 5 focus groups was conducted. A total of 73 Hispanic immigrants with type 2 diabetes (n = 36) and family members (n = 37) were recruited in the southeastern United States for a family-based intervention study of diabetes-self management. Participants were asked to describe their perceptions of barriers to self-management. The 5 sessions were audiotaped and transcribed, translated from Spanish into English, and analyzed using standard content analysis. Demographics, hemoglobin A1C levels, blood pressure, and body mass index (BMI) were obtained both for participants with diabetes and for their family members.

RESULTS

Barriers to diabetes self-management identified by participants with diabetes were in 3 major themes categorized as: suffering from diabetes, difficulties in managing the disease, and lack of resources/support. Two key themes emerged pertaining to family members: we can provide support and we lack knowledge.

CONCLUSIONS

Perceived barriers to diabetes self-management described by Hispanic immigrants with diabetes and family members indicate a lack of intervention strategies to meet their needs. Interventions should include culturally relevant resources, family support, and diabetes self-management skills education.

Exploring the impact of language services on utilization and clinical outcomes for diabetics

Background

Significant health disparities exist between limited English proficient and English-proficient patients. Little is known about the impact of language services on chronic disease outcomes such as for diabetes.

Methods/Principal Findings

To determine whether the amount and type of language services received during primary care visits had an impact on diabetes-related outcomes (hospitalization, emergency room utilization, glycemic control) in limited English proficient patients, a retrospective cohort design was utilized. Hospital and medical record data was examined for 1425 limited English proficient patients in the Cambridge Health Alliance diabetes registry. We categorized patients receiving usual care into 7 groups based on the amount and combination of language services (language concordant providers, formal interpretation and nothing) received at primary care visits during a 9 month period. Bivariate analyses and multiple logistic regression were used to determine relationships between language service categories and outcomes in the subsequent 6 months. Thirty-one percent of patients (445) had no documentation of interpreter use or seeing a language concordant provider in any visits. Patients who received 100% of their primary care visits with language concordant providers were least likely to have diabetes-related emergency department visits compared to other groups (p<0001) in the following 6 months. Patients with higher numbers of co-morbidities were more likely to receive formal interpretation.

Conclusions/Significance

Language concordant providers may help reduce health care utilization for limited English proficient patients with diabetes. However, given the lack of such providers in sufficient numbers to meet patients' communication needs, strategies are needed to both increase their numbers and ensure that the highest risk patients receive the most appropriate language services. In addition, systems serving diverse populations must clarify why some limited English proficient patients do not receive language services at some or all of their visits and whether this has an impact on quality of care.

Disparities in counseling for lifestyle modification among obese adults: insights from the Dallas Heart Study

Clinician counseling is a catalyst for lifestyle modification in obesity. Unfortunately, clinicians do not appropriately counsel all obese patients about lifestyle modification. The extent of disparities in clinician counseling is not well understood. Obese participants (BMI ≥30 kg/m(2), N = 2097) in the Dallas Heart Study (DHS), a probability-based sample of Dallas County residents ages 18-65, were surveyed regarding health-care utilization and lifestyle counseling over the year prior to DHS enrollment. Health-care utilization and counseling were compared between obese participants across three categories based on the presence of 0, 1, or 2+ of the following cardiovascular (CV) risk factors: hypertension, hypercholesterolemia, or diabetes. Logistic regression modeling was used to determine likelihood of counseling in those with 0 vs. 1+ CV risk factors, stratified by race, adjusting for age, sex, insurance status, and education. Among obese subjects who sought medical care, those with 0 CV risk factors, compared to those with 1 or 2+ CV risk factors, were less likely to report counseling about losing weight (41% vs. 67% vs. 87%, P trend <0.001), dietary changes (44% vs. 71% vs. 85%, P trend <0.001), and physical activity (46% vs. 71% vs. 86%, P trend <0.001). Blacks and Hispanics without CV risk factors had a lower odds of receiving counseling than whites without risk factors on weight loss (adjusted odds ratio (OR), 95% confidence interval (CI) for nonwhites 0.19, [0.13-0.28], whites 0.48, [0.26-0.87]); dietary changes (nonwhites 0.19, [0.13-0.27], whites 0.37, [0.21-0.64]); and physical activity (nonwhites 0.22, [0.16-0.32], whites 0.32, [0.18-0.57]). Lifestyle counseling rates by clinicians are suboptimal among obese patients without CV risk factors, especially blacks and Hispanics. Systematic education about and application of lifestyle interventions could capitalize on opportunities for primary CV risk prevention.

Lifestyle counseling in routine care and long-term glucose, blood pressure, and cholesterol control in patients with diabetes

OBJECTIVE

In clinical trials, diet, exercise, and weight counseling led to short-term improvements in blood glucose, blood pressure, and cholesterol levels in patients with diabetes. However, little is known about the long-term effects of lifestyle counseling on patients with diabetes in routine clinical settings.

RESEARCH DESIGN AND METHODS

This retrospective cohort study of 30,897 patients with diabetes aimed to determine whether lifestyle counseling is associated with time to A1C, blood pressure, and LDL cholesterol control in patients with diabetes. Patients were included if they had at least 2 years of follow-up with primary care practices affiliated with two teaching hospitals in eastern Massachusetts between 1 January 2000 and 1 January 2010.

RESULTS

Comparing patients with face-to-face counseling rates of once or more per month versus less than once per 6 months, median time to A1C <7.0% was 3.5 versus 22.7 months, time to blood pressure <130/85 mmHg was 3.7 weeks versus 5.6 months, and time to LDL cholesterol <100 mg/dL was 3.5 versus 24.7 months, respectively (P < 0.0001 for all). In multivariable analysis, one additional monthly face-to-face lifestyle counseling episode was associated with hazard ratios of 1.7 for A1C control (P < 0.0001), 1.3 for blood pressure control (P < 0.0001), and 1.4 for LDL cholesterol control (P = 0.0013).

CONCLUSIONS

Lifestyle counseling in the primary care setting is strongly associated with faster achievement of A1C, blood pressure, and LDL cholesterol control. These results confirm that the findings of controlled clinical trials are applicable to the routine care setting and provide evidence to support current treatment guidelines.

Social adaptability index predicts overall mortality in patients with diabetes

BACKGROUND

A quantifiable assessment of socioeconomic status and its bearing on clinical outcome in patients with diabetes is lacking. The social adaptability index (SAI) has previously been validated in the general population and in patients with chronic kidney disease, including those on dialysis and with kidney transplant. We hypothesize that SAI could be used in diabetes practice to identify a disadvantaged population at risk for inferior outcomes.

METHODS

The NHANES-3 database of patients who have diabetes was analyzed. The association of the SAI (calculated as the linear combination of indicators of education status, employment, income, marital status, and substance abuse) with patient survival was evaluated using Cox model.

RESULTS

The study population consisted of 1634 subjects with diabetes mellitus with mean age of 61.9±15.3 years; 40.9% males; 38.5% white, 27.7% African American, and 31.3% Mexican American. The highest SAI was in whites (6.9±2.5), followed by Mexican Americans (6.5±2.3), and then African Americans (6.1±2.6) (ANOVA, P<.001). SAI was higher in subjects living in metropolitan areas (6.8±2.6) compared to the rural population (6.3±2.4) (T test, P<.001). Also, SAI was greater in males (7.1±2.4) than in females (6.1±2.4) (T test, P<.001). SAI had significant association with survival (hazard ratio 0.9, P<.001) in the entire study population and in most of the subgroups (divided by race, sex, and urban/rural location). Furthermore, SAI divided into tertiles (≤5, 6 to 8, >8) demonstrated a significant and "dose-dependent" association with survival.

CONCLUSION

Social adaptability index is associated with mortality in the diabetic population and is useful in identifying individuals who are at risk for inferior outcomes.

Special considerations on the management of Latino patients with type 2 diabetes mellitus

BACKGROUND

Latinos are the largest minority population in the United States, and are characterized by higher rates of obesity and diabetes compared to Whites. The prevalence of diagnosed diabetes in Latinos is two-fold higher than in Caucasians, and Latinos suffer from higher rates of diabetic complications and mortality. As the diabetes epidemic continues to expand and exert greater socioeconomic strain on national healthcare systems, the success of global and national healthcare initiatives for diabetes prevention and improvement of care will depend upon strategies targeted specifically toward this population. Essential to such strategies is an understanding of success factors unique to the Latino population for diabetes prevention and achievement of optimal treatment outcomes.

METHODS

A PubMed search was conducted for literature describing type 2 diabetes and its complications in Latinos. Specifically, we sought data describing epidemiology, disparities, management considerations, and success factors in this population.

RESULTS

The title search yielded more than 2000 articles, 80 of which were deemed directly relevant to this review. The inherent limitations of this subjective selection process are acknowledged.

CONCLUSIONS

A number of studies have highlighted various ethnic disparities in Latinos with diabetes including higher HbA1c levels, greater rates of obesity and metabolic syndrome, and a larger proportion of individuals with inadequate access to care. While relatively fewer studies describe success factors for redressing cultural disparities in diabetes, the current body of literature supports primary care strategies aimed at effective provider-patient relationships and culturally tailored education and lifestyle modification regimens. Further research demonstrating effective, culturally tailored practices that are suitable to the primary care setting would be of value to providers treating Latinos with diabetes.