Commentary: Reconsidering the Role of Context in Diabetes Prevention

Integrative approaches to methods training for early-career scientists: Rationale and process evaluation of the first cohort of the Michigan Integrative Well-Being and Inequality Training Program

Background

The Michigan Integrative Well-Being and Inequality (MIWI) Training Program aims to provide state-of-the-art, interdisciplinary training to enhance the methodological skills of early-career scientists interested in integrative approaches to understanding health disparities. The goals of this paper are to describe the scientific rationale and core design elements of MIWI, and to conduct a process evaluation of the first cohort of trainees (called "scholars") to complete this program.

Methods

Mixed methods process evaluation of program components and assessment of trainee skills and network development of the first cohort (n = 15 scholars).

Results

The program drew 57 applicants from a wide range of disciplines. Of the 15 scholars in the first cohort, 53% (n = 8) identified as an underrepresented minority, 60% (n = 9) were within 2 years of completing their terminal degree, and most (n = 11, 73%) were from a social/behavioral science discipline (e.g., social work, public health). In the post-program evaluation, scholars rated their improvement in a variety of skills on a one (not at all) to five (greatly improved) scale. Areas of greatest growth included being an interdisciplinary researcher (mean = 4.47), developing new research collaborations (mean = 4.53), and designing a research study related to integrative health (mean = 4.27). The qualitative process evaluation indicated that scholars reported a strong sense of community and that the program broadened their research networks.

Conclusions

These findings have implications for National Institutes of Health (NIH) efforts to train early-career scientists, particularly from underrepresented groups, working at the intersection of multiple disciplines and efforts to support the formation of research networks.

Measurement of Perceived Risk of Developing Diabetes Mellitus: A Systematic Literature Review

BACKGROUND

This systematic review describes approaches to measuring perceived risk of developing type 2 diabetes among individuals without diagnoses and describes the use of theories, models, and frameworks in studies assessing perceived risk. While a systematic review has synthesized perceived risk of complications among individuals with diabetes, no reviews have systematically assessed how perceived risk is measured among those without a diagnosis.

METHODS

Medline, PubMed, PsycINFO, and CINAHAL databases were searched for studies conducted through October 2022 with measures of perceived risk among adults ≥ 18 years without a diabetes diagnosis. Extracted data included study characteristics, measures, and health behavior theories, models, or frameworks used.

RESULTS

Eighty-six studies met inclusion criteria. Six examined perceived risk scales' psychometric properties. Eighty measured perceived risk using (1) a single item; (2) a composite score from multiple items or subconstructs; and (3) multiple subconstructs but no composite score. Studies used items measuring "comparative risk," "absolute or lifetime risk," and "perceived risk" without defining how each differed. Sixty-four studies used cross-sectional designs. Twenty-eight studies mentioned use of health behavior theories in study design or selection of measures.

DISCUSSION

There was heterogeneity in how studies operationalized perceived risk; only one third of studies referenced a theory, model, or framework as guiding design or scale and item selection. Use of perceived lifetime risk, absolute risk, or comparative risk limits comparisons across studies. Consideration of context, target population, and how data are utilized is important when selecting measures; we present a series of questions to ask when selecting measures for use in research and clinical settings. This review is the first to categorize how perceived risk is measured in the diabetes prevention domain; most literature focuses on perceived risk among those with diabetes diagnoses. Limitations include exclusion of non-English and gray literature and single reviewer screening and data extraction.

Theory and empiricism: A comment on "Interrogating the environmental affordances model" by Pamplin and colleagues

We strongly support efforts to generate, rigorously test, and falsify hypotheses derived from the Environmental Affordances (EA) Model of Health Disparities, as originated by the late Dr. James S. Jackson (1940-2020). Such efforts are critical to establishing robust, theoretically grounded scientific frameworks that explain the fundamental causes of racial disparities in health and wellbeing. Pamplin et al. (2021) fundamentally misrepresents the EA Model as a framework that (falsely) reifies the role of race as a determinant of health behaviors and health outcomes. Further, both their study design and analytic approach are inappropriate for testing predictions of this framework. We address these issues with the goal of recentering the scholarly conversation about how stress contributes to health, and disparities in health, over the life course.

Stress Reactivity as a Contributor to Racial and Socioeconomic Disparities: Rationale and Baseline Results From the Richmond Stress and Sugar Study

OBJECTIVE

There are pronounced racial and socioeconomic disparities in type 2 diabetes. Although "stress" as a general phenomenon is hypothesized to contribute to these disparities, few studies have objective measures of stress reactivity in diverse samples to test hypotheses about purported mechanisms. This study describes the rationale and baseline characteristics of a cohort designed to address the question: how does stress contribute to disparities in diabetes risk?

METHODS

The Richmond Stress and Sugar Study recruited 125 adults at elevated risk of type 2 diabetes using a two-by-two sampling frame wherein non-Hispanic whites and African Americans (AAs) were each recruited from neighborhoods of higher and lower socioeconomic status (SES). Stress reactivity was assessed using the Trier Social Stress Test (TSST) and salivary cortisol. Analyses of variance and multilevel modeling were used to examine how stress reactivity varied both within and across race and neighborhood SES.

RESULTS

The mean (SD) age was 57.4 (7.3) years, 49% were female, 54% were AA or another racial/ethnic minority, and mean hemoglobin A1c level was in the prediabetes range (5.8%; range, 5.50%-5.93%). Living in a lower-SES neighborhood was associated with 16% (95% confidence interval [CI] = -0.04 to 34) higher pre-TSST cortisol, 8.4% (95% CI = -14 to -3) shallower increase in response to the TSST, and 1% (95% CI = 0.3 to 1.7) steeper decline post-TSST than living in the higher neighborhood SES. Post-TSST cortisol decline was 3% greater among AA compared with non-Hispanic whites. Race-by-SES interaction terms were generally small and nonsignificant.

CONCLUSIONS

SES is associated with stress reactivity among adults at high risk of diabetes.

How patient and community involvement in diabetes research influences health outcomes: A realist review

Background

Patient and public involvement in diabetes research is an international requirement, but little is known about the relationship between the process of involvement and health outcomes.

Objective

This realist review identifies who benefits from different types of involvement across different contexts and circumstances. Search strategies Medline, CINAHL and EMBASE were searched to identify interventions using targeted, embedded or collaborative involvement to reduce risk and promote self‐management of diabetes. People at risk/with diabetes, providers and community organizations with an interest in addressing diabetes were included. There were no limitations on date, language or study type.

Data extraction and synthesis

Data were extracted from 29 projects using elements from involvement frameworks. A conceptual analysis of involvement types was used to complete the synthesis.

Main results

Projects used targeted (4), embedded (8) and collaborative (17) involvement. Productive interaction facilitated over a sufficient period of time enabled people to set priorities for research. Partnerships that committed to collaboration increased awareness of diabetes risk and mobilized people to co‐design and co‐deliver diabetes interventions. Cultural adaptation increased relevance and acceptance of the intervention because they trusted local delivery approaches. Local implementation produced high levels of recruitment and retention, which project teams associated with achieving diabetes health outcomes.

Discussion and Conclusions

Achieving understanding of community context, developing trusting relationships across sectors and developing productive partnerships were prerequisites for designing research that was feasible and locally relevant. The proportion of diabetes studies incorporating these elements is surprisingly low. Barriers to resourcing partnerships need to be systematically addressed.

Impact of maternal income on the risk of gestational diabetes mellitus in primiparous women

AIMS

Findings concerning the impact of socio-economic status on the risk of gestational diabetes mellitus (GDM) are inconclusive and little is known about the simultaneous impact of income and educational attainment on the risk of GDM. This study aims to assess the impact of maternal prepregnancy income in combination with traditional GDM risk factors on the incidence of GDM in primiparous women.

METHODS

This is an observational cohort study including 5962 Finnish women aged ≥ 20 years from the city of Vantaa, Finland, who delivered for the first time between 2009 and 2015, excluding women with pre-existing diabetes mellitus. The Finnish Medical Birth Register, Finnish Tax Administration, Statistics Finland, Social Insurance Institution of Finland and patient healthcare records provided data for the study. We divided the study population according to five maternal income levels and four educational attainment levels.

RESULTS

Incidence of GDM decreased with increasing income level in primiparous women (P < 0.001 for linearity, adjusted for smoking, age, BMI and cohabiting status). In an adjusted two-way model, the relationship was significant for both income (P = 0.007) and education (P = 0.039), but there was no interaction between income and education (P = 0.52).

CONCLUSIONS

There was an inverse relationship between both maternal prepregnancy taxable income and educational attainment, and the risk of GDM in primiparous Finnish women.

Income Disparities in the Prevalence, Severity, and Costs of Co-occurring Chronic and Behavioral Health Conditions

BACKGROUND

Behavioral health problems usually co-occur along with physical health problems, resulting in higher health care costs. These co-occurring conditions are likely to be more prevalent and serious among low income patients, affecting both the quality and costs of care.

OBJECTIVE

To examine the prevalence, severity, and health care costs of co-occurring chronic and behavioral health conditions among low income people compared with higher income people.

METHODS

Analysis of the 2011-2014 Medical Expenditure Panel Survey. Sample includes 146,000 persons aged 18-64 years. Regression analysis was used to examine how the combination of behavioral health conditions and chronic health conditions is associated with health care expenditures, and how this association differs by family income.

RESULTS

(1) Comorbid behavioral health problems are more prevalent and serious among low income people with chronic conditions compared with higher income people; (2) among patients with co-occurring chronic and behavioral problems, average annual spending is greater among the low income patients ($9472) compared with high income patients ($7457); (3) higher costs among low income patients with co-occurring conditions reflects their poorer mental and physical health, relative to higher income patients.

CONCLUSIONS

For many low income people, comorbid behavioral problems need to be understood in the social context in which they live. Simply screening low income people for behavioral health problems may not be sufficient unless there is greater understanding of the mechanisms that both cause and exacerbate chronic and behavioral health problems in the low income population.