Abstract P558: Association of Reproductive Characteristics With Cardiometabolic Risk Factors in Women in India an Analysis of Nationally Representative Data

Introduction: In addition to established risk factors for cardiovascular disease, women have unique biological characteristics related to reproduction that may further contribute to their CV risk. Among South Asian Indians, this aspect has been understudied. This study addresses this gap by evaluating the relationship between reproductive characteristics and cardiometabolic risk factors (CMRF) among women in India.

Methods: We analyzed data from a community-based nationally representative sample of women aged 15-49 in the National Family Health Survey-5 (N= 724,115). Primary exposures (self-reported) included age at union and first delivery, use of contraception and history of pregnancy loss. Study outcomes (self-reported, objectively measured) were prevalent hypertension (HTN), diabetes mellitus (DM) and obesity. We estimated the association between each exposure and outcome using survey-weighted multivariable Poisson regression models adjusted for age, religion, caste, location, education and employment.

Results: Prevalence (95% CI) of HTN (measured blood pressure of >=140/90 mm Hg), DM (self-reported or on medications to lower blood glucose levels) and obesity (body mass index > 25kg/m 2 ) was 25.8 (25.5, 26.2)%, 1.9 (1.8, 1.9)% and 24 (23.8, 24.2)%, respectively. Younger age at union and first delivery and, use of contraception [PR (95% CI): 1.13 (1.11, 1.16)] were associated with higher obesity. Pregnancy loss (due to miscarriage or abortion) was associated with higher prevalent DM [PR (95% CI): 1.21 (1.03, 1.41)] and obesity [PR (95% CI): 1.26 (1.22, 1.31)] ( Table ).

Conclusion: Reproductive characteristics (age at union and first delivery, and pregnancy loss) are linked to higher prevalence of CMRF. These results provide impetus for screening for reproductive history and its inclusion in risk prediction algorithms for cardiovascular risk among Indian women.

Table: Cross-sectional associations between reproductive characteristics with cardiometabolic risk factors, in the NFHS-5 (N= 724,115)

Healthcare utilisation and expenditure patterns for cardio-metabolic diseases in South Asian cities: the CARRS Study

OBJECTIVE

To estimate average annual expenditures per person, total economic burden and distress health financing associated with the treatment of five cardio-metabolic diseases (CMDs-hypertension, diabetes, heart disease (angina, myocardial infarction and heart failure), stroke and chronic kidney disease) in three metropolitan cities in South Asia.

DESIGN

Cross-sectional surveys.

SETTING

We analysed community-based baseline data from the Centre for cArdio-metabolic Risk Reduction in South Asia (CARRS) Study collected in 2010-2011 representing Chennai and New Delhi (India), and Karachi (Pakistan).

PARTICIPANTS

We used data from non-pregnant adults (≥20 years) from the aforementioned cities that responded to a cost-of-illness questionnaire. We estimated health utilisation and expenditures among those reporting taking treatment(s) for the aforementioned CMDs in the last 1 year. We converted all costs to International Dollars (Int$ 2011) and inflated to 2018 values. The annual costs per person were stratified by city, sociodemographic characteristics, contributor of costs and financing methods. The total economic burden of CMDs for each city was projected using age-standardised prevalence and per-person costs of diseases reported in CARRS, applying these to population data from the most recent census. We also calculated distress financing (DF) as having to borrow or sell assets to pay for CMD treatment and identified sociodemographic groups at most risk of DF using multiple regression.

RESULTS

Of 16 287 CARRS participants, 2883 (17.7%) reported receiving treatment for CMDs. The total annual expenditures reported per patient for CMDs ranged from Int$358 to Int$2425. Medications constituted 46% of total direct expenditures and out-of-pocket (OOP) expenditures accounted for nearly 80% of financing these health expenditures. Total economic burdens of CMDs were Int$0.42 billion, Int$3.4 billion and Int$1.4 billion in Chennai, New Delhi and Karachi, respectively. Overall, 36.1% experienced DF, and women (OR=4.4), unemployed (OR=10.7) and uninsured (OR=8.1) adults experienced higher odds of DF.

CONCLUSION

CMDs are associated with large economic burdens in South Asia. Due to most payments coming from OOP expenditures and limited insurance, the odds of DF are high.

Ethnic differences in the prevalence of diabetes in underweight and normal weight individuals: The CARRS and NHANES studies

AIMS

Type 2 diabetes in lean individuals has recently come to attention. We assessed type 2 diabetes prevalence and the associated risk factors in underweight and normal weight individuals in two ethnic populations.

METHODS

We conducted cross-sectional analyses, using representative samples of 4930 Asian Indians from the CARRS-Chennai Study and 2868 Whites from the NHANES Survey. Diabetes was defined as use of glucose lowering medication, fasting glucose ≥126 mg/dl, or 2 h glucose ≥200 mg/dl. Body mass index (BMI) was classified using WHO standard criteria.

RESULTS

Prevalence of type 2 diabetes by BMI varied by ethnicity and sex. In men, type 2 diabetes prevalence was 5.4% and 23.5% in underweight and normal weight Asian Indians and 0.0% and 6.1% in underweight and normal weight Whites. In women, the prevalence was 5.6% and 13.6% in underweight and normal weight Asian Indians and 2.3% and 2.8% in underweight and normal weight Whites. Adjustment for waist circumference, insulin resistance, and insulin secretion did not explain the increased prevalence in Asian Indians.

CONCLUSIONS

These findings suggest significant ethnic differences in type 2 diabetes prevalence without overweight or obesity. Future studies should examine the pathophysiology of type 2 diabetes development in lean individuals.

Effect of lifestyle improvement program on the biomarkers of adiposity, inflammation and gut hormones in overweight/obese Asian Indians with prediabetes

AIMS

While lifestyle modification is known to offer several metabolic benefits, there is paucity of comprehensive data on changes in biomarkers of adiposity, inflammation as well as gut hormones. We investigated these biomarkers in overweight/obese individuals with prediabetes randomized to either 4 months of a lifestyle improvement program or standard care and followed them up for a year.

METHODS

Participants [standard care and intervention arm (n = 75 each)] were randomly selected from the Diabetes Community Lifestyle Improvement Program trial. Glycemic and lipid control and anthropometric measurements were assessed by standard protocols. Adipokines, inflammatory markers and gut hormones were measured using multiplex and standard ELISA kits.

RESULTS

Along with modest benefits in primary outcomes (glycemic and lipid control and weight reduction), participants in the intervention group showed significant reductions (p < 0.001) in plasma levels of leptin (17.6%), TNF-α (35%), IL-6 (33.3%), MCP-1 (22.3%) and PYY (28.3%) and increased levels of adiponectin (33.1%) and ghrelin (23.6%) at the end of 4 months of lifestyle intervention. The changes were independent of weight and persisted even at 1 year of follow-up. In contrast, participants from the standard care arm did not show any statistically significant improvements on the above parameters.

CONCLUSIONS

Participants who underwent an intensive lifestyle improvement program showed metabolic benefits as well as favorable beneficial changes in systemic levels of adipokines, cytokines and gut hormones, not only during the intervention period, but also during 12-month follow-up period.

Association between prediabetes and risk of chronic kidney disease: a systematic review and meta-analysis

AIMS

To assess the effect of prediabetes (impaired fasting glucose and/or impaired glucose tolerance) on the incidence of chronic kidney disease.

METHODS

PubMed and EMBASE were searched (for studies published up to March 2015). Effects estimated from cohort studies reporting the relationship of prediabetes to incident chronic kidney disease [kidney damage (microalbuminuria, albuminuria or proteinuria) and/or decreased glomerular filtration rate] were pooled using a random-effects model meta-analysis.

RESULTS

Nine cohort studies with a total of 185 452, mainly Asian and white, participants were followed for a total of 835 146 person-years. In eight cohort studies defining impaired fasting glucose as fasting glucose 6.1-6.9 mmol/l, the summary relative risk of chronic kidney disease after adjustment for established risk factors was 1.11 (95% CI 1.02-1.21). When a study defining impaired fasting glucose as fasting glucose 5.6-6.9 mmol/dl was added, the overall relative risk of chronic kidney disease was 1.12 (95% CI 1.02-1.21). Exclusion of the only study with information on impaired glucose tolerance did not change the relative risk (1.12; 95% CI 1.02-1.21). There was no evidence of publication bias (P value for Egger test = 0.12).

CONCLUSION

Prediabetes is modestly associated with an increase in chronic kidney disease risk, but this remains to be robustly confirmed. Chronic kidney disease screening among people with prediabetes, and aggressive management of prediabetes in those with chronic kidney disease may be warranted.

Association of Higher Consumption of Foods Derived From Subsidized Commodities With Adverse Cardiometabolic Risk Among US Adults

IMPORTANCE

Food subsidies are designed to enhance food availability, but whether they promote cardiometabolic health is unclear.

OBJECTIVE

To investigate whether higher consumption of foods derived from subsidized food commodities is associated with adverse cardiometabolic risk among US adults.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional analysis of the National Health and Nutrition Examination Survey data from 2001 to 2006. Our final analysis was performed in January 2016. Participants were 10 308 nonpregnant adults 18 to 64 years old in the general community.

EXPOSURE

From a single day of 24-hour dietary recall in the National Health and Nutrition Examination Survey, we calculated an individual-level subsidy score that estimated an individual's consumption of subsidized food commodities as a percentage of total caloric intake.

MAIN OUTCOMES AND MEASURES

The main outcomes were body mass index (calculated as weight in kilograms divided by height in meters squared), abdominal adiposity, C-reactive protein level, blood pressure, non-high-density lipoprotein cholesterol level, and glycemia.

RESULTS

Among 10 308 participants, the mean (SD) age was 40.2 (0.3) years, and a mean (SD) of 50.5% (0.5%) were male. Overall, 56.2% of calories consumed were from the major subsidized food commodities. United States adults in the highest quartile of the subsidy score (compared with the lowest) had increased probabilities of having a body mass index of at least 30 (prevalence ratio, 1.37; 95% CI, 1.23-1.52), a ratio of waist circumference to height of at least 0.60 (prevalence ratio, 1.41; 95% CI, 1.25-1.59), a C-reactive protein level of at least 0.32 mg/dL (prevalence ratio, 1.34; 95% CI, 1.19-1.51), an elevated non-high-density lipoprotein cholesterol level (prevalence ratio, 1.14; 95% CI, 1.05-1.25), and dysglycemia (prevalence ratio, 1.21; 95% CI, 1.04-1.40). There was no statistically significant association between the subsidy score and blood pressure.

CONCLUSIONS AND RELEVANCE

Among US adults, higher consumption of calories from subsidized food commodities was associated with a greater probability of some cardiometabolic risks. Better alignment of agricultural and nutritional policies may potentially improve population health.

Screening intervals for diabetic retinopathy and incidence of visual loss: a systematic review

Screening for diabetic retinopathy can help to prevent this complication, but evidence regarding frequency of screening is uncertain. This paper systematically reviews the published literature on the relationship between screening intervals for diabetic retinopathy and the incidence of visual loss. The PubMed and EMBASE databases were searched until December 2012. Twenty five studies fulfilled the inclusion criteria, as these assessed the incidence/prevalence of sight-threatening diabetic retinopathy in relation to screening frequency. The included studies comprised 15 evaluations of real-world screening programmes, three studies modelling the natural history of diabetic retinopathy and seven cost-effectiveness studies. In evaluations of diabetic retinopathy screening programmes, the appropriate screening interval ranged from one to four years, in people with no retinopathy at baseline. Despite study heterogeneity, the overall tendency observed in these programmes was that 2-year screening intervals among people with no diabetic retinopathy at diagnosis were not associated with high incidence of sight-threatening diabetic retinopathy. The modelling studies (non-economic and economic) assessed a range of screening intervals (1-5 years). The aggregated evidence from both the natural history and cost-effectiveness models favors a screening interval >1 year, but ≤2 years. Such an interval would be appropriate, safe and cost-effective for people with no diabetic retinopathy at diagnosis, while screening intervals ≤1 year would be preferable for people with pre-existing diabetic retinopathy. A 2-year screening interval for people with no sight threatening diabetic retinopathy at diagnosis may be safely adopted. For patients with pre-existing diabetic retinopathy, a shorter interval ≤1 year is warranted.

Societal correlates of diabetes prevalence: An analysis across 94 countries

AIMS

To quantify relationships between societal-level factors and diabetes prevalence and identify potential policy responses.

METHODS

Using data from International Diabetes Federation, World Health Organization, World Bank, and Food and Agricultural Organization, we extracted recent estimates for country-level variables: total caloric availability; sugar, animal fat, fruit and vegetable availability; physical inactivity markers (vehicles per capita and value-added from service sector); gross domestic product per capita (GDP); imports; and age-adjusted mortality rate. We used generalized linear models to investigate relationships between these factors and diabetes prevalence.

RESULTS

Median global diabetes prevalence was 6.4% in 2010. Every additional percentage point of calories from sugar/sweeteners and from animal fats were associated with 5% (OR: 1.05, 95% CI 1.02-1.07) and 3% (OR: 1.03, 95% CI 0.99-1.06) higher diabetes prevalence, respectively, while each additional unit in fruit and vegetable availability was associated with 3% lower diabetes prevalence (OR: 0.97, 95% CI 0.93-0.99). One percent higher GDP from the service industry was associated with a 1% higher diabetes prevalence (OR: 1.01, 95% CI 0.99-1.02).

CONCLUSION

Macro-level societal factors are associated with diabetes prevalence. Investigating how these factors affect individual-level diabetes risk may offer further insight into policy-level interventions.

Age at arrival and risk of obesity among US immigrants

Although immigrants are a rapidly growing subgroup, little is known about overweight/obesity among the foreign-born in the United States, especially regarding the effect of age at arrival. This study determined whether overweight/obesity prevalence is associated with age at arrival of immigrants to the United States. We analyzed data on 6,421 adult immigrants from the New Immigrant Survey (NIS), a study that is nationally representative of adult immigrants with newly acquired legal permanent residence (LPR). Multiple regression analyses tested the effects of duration of residence and age at arrival on overweight/obesity, defined by BMI of > or = 25 kg/m(2), and self-reported dietary change score. We found the relationship between duration of residence and overweight/obesity prevalence varied by age at arrival (P < 0.001). Immigrants < or = 20-years old at arrival who had resided in the United States > or = 15 years were 11 times (95% confidence interval: 5.33, 22.56) more likely to be overweight/obese than immigrants < 20-years old at arrival who had resided in the United States < or = 1 year. By comparison, there was no difference in overweight/obesity prevalence by duration among immigrants who arrived at >50 years of age. Higher self-reported dietary change is also associated with overweight/obesity. In conclusion, immigrants younger than 20 at arrival in the United States may be at higher risk of overweight/obesity with increasing duration of residence than those who arrive at later ages. Obesity prevention among young US immigrants should be a priority.

Doctors' strikes and mortality: a review

A paradoxical pattern has been suggested in the literature on doctors' strikes: when health workers go on strike, mortality stays level or decreases. We performed a review of the literature during the past forty years to assess this paradox. We used PubMed, EconLit and Jstor to locate all peer-reviewed English-language articles presenting data analysis on mortality associated with doctors' strikes. We identified 156 articles, seven of which met our search criteria. The articles analyzed five strikes around the world, all between 1976 and 2003. The strikes lasted between nine days and seventeen weeks. All reported that mortality either stayed the same or decreased during, and in some cases, after the strike. None found that mortality increased during the weeks of the strikes compared to other time periods. The paradoxical finding that physician strikes are associated with reduced mortality may be explained by several factors. Most importantly, elective surgeries are curtailed during strikes. Further, hospitals often re-assign scarce staff and emergency care was available during all of the strikes. Finally, none of the strikes may have lasted long enough to assess the effects of long-term reduced access to a physician. Nonetheless, the literature suggests that reductions in mortality may result from these strikes.

Health-related quality of life and cost-effectiveness components of the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial: rationale and design

Diabetes mellitus affects not only life expectancy but also quality of life. The Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial's health-related quality of life (HRQOL) and cost-effectiveness components will enable the assessment of the relative importance of the various outcomes from the point of view of patients, provide an understanding of the balance between the burdens and benefits of the intervention strategies, and offer valuable insights into adherence. The HRQOL measures used include the Diabetes Symptoms Distress Checklist; the 36-Item Short Form Health Survey, Version 2 (SF-36) (RAND Corporation, Santa Monica, CA); the Patient Health Questionnaire (PHQ) depression measure (Pfizer Inc, New York, NY); the World Health Organization (WHO) Diabetes Treatment Satisfaction Questionnaire (DTSQ); and the EuroQol Feeling Thermometer (EuroQol Group, Rotterdam, Netherlands). The cost-effectiveness analysis (CEA) in ACCORD will provide information about the relative economic efficiency of the different interventions being compared in the trial. Effectiveness will be measured in terms of cardiovascular event-free years gained and quality-adjusted life-years gained (using the Health Utilities Index Mark 3 [HUI-3] [Health Utilities Inc., Dundas, Ontario, Canada] to measure health-state utility). Costs will be direct medical costs assessed from the perspective of a single-payer health system collected by means of patient and clinic cost forms and hospital discharge summaries. The primary HRQOL and CEA hypotheses mirror those in the main ACCORD trial, addressing the effects of the 3 main ACCORD interventions considered separately. There are also secondary (pairwise reference case) comparisons that do not assume independence of treatment effects on HRQOL. CEA will be done on a subsample of 4,311 ACCORD participants and HRQOL on a subsample of 2,053 nested within the CEA subsample. Most assessments will occur through questionnaires at baseline and at 12, 36, and 48 months.

Prevention of type 2 diabetes: data from recent trials

All four main studies of lifestyle intervention on diabetes incidence found a clear benefit for diet and exercise intervention compared with usual care. Although the study populations differed by race and ethnicity, the mean BMI, and the intensity of the lifestyle intervention provided, all investigators found substantial diabetes risk reduction with modest weight loss and increased physical activity. Results of these trials give health care providers useful and heartening information to share with patients at risk for diabetes. The challenge remains to find feasible and cost-efficient methods to identify people at risk and to deliver effective lifestyle interventions. Findings from trials of pharmacologic agents such as metformin, acarbose, and troglitazone are encouraging; however, the ADA recommends that drug therapy should not be used routinely to prevent diabetes until more information regarding the cost-effectiveness of such intervention is known [20]. Results from trials that found a lower incidence of diabetes among those randomly assigned to angiotensin-converting enzyme inhibitors, statins, or hormone therapy are intriguing but must be viewed with caution because they are based on post hoc analyses. Because it is difficult to conduct randomized controlled trials of major operative procedures such as bariatric surgery, observational studies that compare surgical interventions for weight loss with traditional weight-loss management may be the best evidence available. These studies have the potential for healthy-person bias in that people who choose bariatric surgery may have other healthy behaviors that are often difficult to measure and control for; such behaviors could account for their lower incidence of diabetes. Undeniably, the best test to diagnose those at high risk for diabetes is not yet known. New strategies that identify those with pre-diabetes and that overcome the limitations of the current tests, particularly the 2-hour post-challenge glucose test, are needed.

Performance of recommended screening tests for undiagnosed diabetes and dysglycemia

OBJECTIVE

To evaluate the performance, in settings typical of opportunistic and community screening programs, of screening tests currently recommended by the American Diabetes Association (ADA) for detecting undiagnosed diabetes.

RESEARCH DESIGN AND METHODS

Volunteers aged > or =20 years without previously diagnosed diabetes (n = 1,471) completed a brief questionnaire and underwent recording of postprandial time and measurement of capillary blood glucose (CBG) with a portable sensor. Participants subsequently underwent a 75-g oral glucose tolerance test; fasting serum glucose (FSG) and 2-h postload serum glucose (2-h SG) concentrations were measured. The screening tests we studied included the ADA risk assessment questionnaire, the recommended CBG cut point of 140 mg/dl, and an alternative CBG cut point of 120 mg/dl. Each screening test was evaluated against several diagnostic criteria for diabetes (FSG > or =126 mg/dl, 2-h SG > or =200 mg/dl, or either) and dysglycemia (FSG > or =110 mg/dl, 2-h SG > or =140 mg/dl, or either).

RESULTS

Among all participants, 10.7% had undiagnosed diabetes (FSG > or =126 or 2-h SG > or =200 mg/dl), 52.1% had a positive result on the questionnaire, 9.5% had CBG > or =140 mg/dl, and 18.4% had CBG > or =120 mg/dl. The questionnaire was 72-78% sensitive and 50-51% specific for the three diabetes diagnostic criteria; CBG > or =140 mg/dl was 56-65% sensitive and 95-96% specific, and CBG > or =120 mg/dl was 75-84% sensitive and 86-90% specific. CBG > or =120 mg/dl was 44-62% sensitive and 89-90% specific for dysglycemia.

CONCLUSIONS

Low specificity may limit the usefulness of the ADA questionnaire. Lowering the cut point for a casual CBG test (e.g., to 120 mg/dl) may improve sensitivity and still provide adequate specificity.

Projection of diabetes burden through 2050: impact of changing demography and disease prevalence in the U.S

OBJECTIVE

To project the number of people with diagnosed diabetes in the U.S. through 2050, accounting for changing demography and diabetes prevalence rates.

RESEARCH DESIGN AND METHODS

We combined age-, sex-, and race-specific diagnosed diabetes prevalence rates-predicted from 1980-1998 trends in prevalence data from the National Health Interview Survey-with Bureau of Census population demographic projections. Sensitivity analyses were performed by varying both prevalence rate and population projections.

RESULTS

The number of Americans with diagnosed diabetes is projected to increase 165%, from 11 million in 2000 (prevalence of 4.0%) to 29 million in 2050 (prevalence of 7.2%). The largest percent increase in diagnosed diabetes will be among those aged > or =75 years (+271% in women and +437% in men). The fastest growing ethnic group with diagnosed diabetes is expected to be black males (+363% from 2000-2050), with black females (+217%), white males (+148%), and white females (+107%) following. Of the projected 18 million increase in the number of cases of diabetes in 2050, 37% are due to changes in demographic composition, 27% are due to population growth, and 36% are due to increasing prevalence rates.

CONCLUSIONS

If recent trends in diabetes prevalence rates continue linearly over the next 50 years, future changes in the size and demographic characteristics of the U.S. population will lead to dramatic increases in the number of Americans with diagnosed diabetes.

Use of diabetes preventive care and complications risk in two African-American communities

BACKGROUND

We examined levels of diabetes preventive care services and glycemic and lipid control among African Americans with diabetes in two North Carolina communities.

METHODS

Cross-sectional, population-based study of 625 African-American adults with diagnosed diabetes. Participants had a household interview to determine receipt of preventive care services including glycosylated hemoglobin (HbA(1c)), blood pressure, lipid, foot, dilated eye, and dental examinations; diabetes education; and health promotion counseling. A total of 383 gave blood samples to determine HbA(1c) and lipid values.

RESULTS

Annual dilated eye, foot, and lipid examinations were reported by 70% to 80% of the population, but only 46% reported HbA(1c) tests. Rates of regular physical activity (31%) and daily self-monitoring of blood glucose (40%) were low. Sixty percent of the population had an HbA(1c) level >8% and one fourth had an HbA(1c) level >10%. Half of the population had a low-density lipoprotein value >130 mg/dL. Lack of insurance was the most consistent correlate of inadequate care (odds ratio [OR]=2.3; 95% confidence interval [CI]=1.3-3.9), having HbA(1c) >9.5% (OR=2.1, 95% CI=1.1-4.2), and LDL levels >130 mg/dL (OR=2.1; 95% CI=1.0-4.5).

CONCLUSIONS

Levels of diabetes preventive care services were comparable to U.S. estimates, but glycemic and lipid control and levels of self-management behaviors were poor. These findings indicate a need to understand barriers to achieving and implementing good glycemic and lipid control among African Americans with diabetes.

Temporal trends in BMI among adults with diabetes

OBJECTIVE

Increasing obesity within the general population has been accompanied by rising rates of diabetes. The extent to which obesity has increased among people with diabetes is unknown, as are the potential consequences for diabetes outcomes.

RESEARCH DESIGN AND METHODS

Community medical records (hospital and ambulatory) of all Rochester, Minnesota, residents aged > or =30 years who first met standardized research criteria for diabetes from 1970 to 1989 (n = 1,306) were reviewed to obtain data on BMI and related characteristics as of the diabetes identification date (+/-3 months). Vital status as of 31 December 1999 and date of death for those who died were obtained from medical records, State of Minnesota death tapes, and active follow-up.

RESULTS

As of the identification date, data on BMI were available for 1,290 cases. Of the 272 who first met diabetes criteria in 1970-1974, 33% were obese (BMI > or =30), including 5% who were extremely obese (BMI > or =40). These proportions increased to 49% (P < 0.001) and 9% (P = 0.012), respectively, for the 426 residents who first met diabetes criteria in 1985-1989. BMI increased significantly with increasing calendar year of diabetes identification in multivariable regression analysis. Analysis of survival revealed an increased hazard of mortality for BMI > or =41, relative to BMI of 23-25 (hazard ratio 1.60, 95% CI 1.09-2.34, P = 0.016).

CONCLUSIONS

The prevalence of obesity and extreme obesity among individuals at the time they first met criteria for diabetes has increased over time. This is disturbing in light of the finding that diabetic individuals who are extremely obese are at increased risk of mortality compared with their nonobese diabetic counterparts.

Tobacco, betel quid, alcohol, and illicit drug use among 13- to 35-year-olds in I-Lan, rural Taiwan: prevalence and risk factors

OBJECTIVES

This study determined the prevalence of and risk factors for substance use among rural Taiwanese.

METHODS

We used a survey of a representative sample of 6318 participants aged 13 to 35 years in I-Lan, Taiwan, in 1996 through 1997.

RESULTS

Perceived use of illicit drugs by peers, tobacco smoking, betel quid chewing, and male gender were the strongest predictors of illicit drug use. The prevalence of illicit drug use ranged from 0.3% among those who did not use any other substance to 7.1% among those using tobacco, betel quid, and alcohol.

CONCLUSIONS

Preventive measures should address substance use in general rather than aiming at single substances.

Association of physical activity and serum insulin concentrations in two populations at high risk for type 2 diabetes but differing by BMI

OBJECTIVE

Physical activity and insulin sensitivity are related in epidemiological studies, but the consistency of this finding among populations that greatly differ in body size is uncertain. The present multiethnic epidemiological study examined whether physical activity was related to insulin concentrations in two populations at high risk for diabetes that greatly differ by location, ethnic group, and BMI.

RESEARCH DESIGN AND METHODS

The study populations consisted of 2,321 nondiabetic Pima Indian men and women aged 15-59 years from Arizona and 2,716 nondiabetic men and women aged 35-54 years from Mauritius. Insulin sensitivity was estimated by mean insulin concentration (average of the fasting and postload insulin), and total (i.e., leisure and occupational) physical activity was assessed by questionnaire.

RESULTS

Pima men and women who were more active had significantly (P < 0.05) lower mean insulin concentrations than those less active (BMI and age-adjusted means were 179 vs. 200 and 237 vs. 268 pmol/l). Similar findings were noted in Mauritian men and women (94 vs. 122 and 127 vs. 148 pmol/l). In both populations, activity remained significantly associated with mean insulin concentration controlled for age, BMI, waist-to-thigh or waist-to-hip ratio, and mean glucose concentrations.

CONCLUSIONS

Physical activity was negatively associated with insulin concentrations both in the Pima Indians, who tend to be overweight, and in Mauritians, who are leaner. These findings suggest a beneficial role of activity on insulin sensitivity that is separate from any influence of activity on body composition.

Family and genetic studies of indices of insulin sensitivity and insulin secretion in Pima Indians

BACKGROUND

The present analyses were conducted to examine the extent to which insulin sensitivity and insulin secretion, assessed using simple indices derived from an oral glucose tolerance test, are influenced by genetic factors, and to assess whether these genetic factors overlap with those influencing susceptibility to type 2 diabetes in Pima Indians.

METHODS

Indices calculated from fasting and 2-h post-load insulin (I(0), I(120)) and glucose (G(0), G(120)) concentrations included insulin sensitivity index [ISI(0)=10(4)/(I(0).G(0))] and corrected insulin response [CIR(120)=I(120)/[G(120).(G(120)-70 mg/dl)]]. Heritability (h(2)) was determined using variance components methods in 1421 non-diabetic individuals from 446 sibships. Among 595 individuals in 186 sibships, genome-wide quantitative trait linkage analyses of ISI(0) and CIR(120) were conducted and affected-sibling analyses of diabetic siblings stratified by prediabetic measurements of ISI(0) and CIR(120) were also performed.

RESULTS

Both ISI(0) (h(2)=0.37+/-0.06) and CIR(120) (h(2)=0.25+/-0.07) were moderately heritable. Modest evidence for linkage with CIR(120) (logarithm of odds (LOD)=1.6) was observed on chromosome 1q in a region previously shown to have linkage with young-onset diabetes in Pimas. When diabetic siblings were stratified by CIR(120), evidence for linkage in this region was strongest (LOD=1.5) among those with a low CIR(120). Additional regions with modest evidence for linkage with ISI(0) were observed on chromosomes 9p (LOD=2.0) and 14p (LOD=1.7).

CONCLUSIONS

The present analyses suggest that insulin sensitivity and insulin secretion are influenced by genetic factors in Pima Indians. The linkage analyses suggest that the putative diabetes-susceptibility gene on chromosome 1q affects insulin secretion. Published in 2001 by John Wiley & Sons, Ltd.

Effectiveness of self-management training in type 2 diabetes: a systematic review of randomized controlled trials

OBJECTIVE

To systematically review the effectiveness of self-management training in type 2 diabetes.

RESEARCH DESIGN AND METHODS

MEDLINE, Educational Resources Information Center (ERIC), and Nursing and Allied Health databases were searched for English-language articles published between 1980 and 1999. Studies were original articles reporting the results of randomized controlled trials of the effectiveness of self-management training in people with type 2 diabetes. Relevant data on study design, population demographics, interventions, outcomes, methodological quality, and external validity were tabulated. Interventions were categorized based on educational focus (information, lifestyle behaviors, mechanical skills, and coping skills), and outcomes were classified as knowledge, attitudes, and self-care skills; lifestyle behaviors, psychological outcomes, and quality of life; glycemic control; cardiovascular disease risk factors; and economic measures and health service utilization.

RESULTS

A total of 72 studies described in 84 articles were identified for this review. Positive effects of self-management training on knowledge, frequency and accuracy of self-monitoring of blood glucose, self-reported dietary habits, and glycemic control were demonstrated in studies with short follow-up (<6 months). Effects of interventions on lipids, physical activity, weight, and blood pressure were variable. With longer follow-up, interventions that used regular reinforcement throughout follow-up were sometimes effective in improving glycemic control. Educational interventions that involved patient collaboration may be more effective than didactic interventions in improving glycemic control, weight, and lipid profiles. No studies demonstrated the effectiveness of self-management training on cardiovascular disease-related events or mortality; no economic analyses included indirect costs; few studies examined health-care utilization. Performance, selection, attrition, and detection bias were common in studies reviewed, and external generalizability was often limited.

CONCLUSIONS

Evidence supports the effectiveness of self-management training in type 2 diabetes, particularly in the short term. Further research is needed to assess the effectiveness of self-management interventions on sustained glycemic control, cardiovascular disease risk factors, and ultimately, microvascular and cardiovascular disease and quality of life.

Fingerprint ridge-count difference between adjacent fingertips (dR45) predicts upper-body tissue distribution: evidence for early gestational programming

Fingerprint ridge counts, which remain constant from the 19th week of pregnancy, are related to fingertip growth during early gestation. Each finger corresponds neurologically to a spinal-cord segment ranging from C6 (thumb, relatively cephalad) to C8 (fifth finger, relatively caudad). The authors hypothesized that large ridge-count differences between fingertips (cephalad > caudad) might reflect fetal inhibition of caudal growth. Among 69 male Atlanta, Georgia, military recruits (1994-1997; aged 17-22 years), they tested associations of the anthropometric waist-to-thigh ratio with 20 ridge-count differences. Waist-to-thigh ratio was associated with the ridge-count difference between the right fourth and fifth fingertips only (dR45; r = 0.36, p = 0.003). The race-adjusted standardized regression coefficient was 0.22 (95% confidence interval: 0.03, 0.41). Since upper-body tissue distribution indicates disease risk, the authors then tested the association of age (an indicator of survivorship) with dR45 in a sample of 135 male patients from Bangalore, India (1989-1990; aged 38-82 years). Age was inversely associated with dR45 (r = -0.17, p = 0.04), notably among the 75 men with diabetes (r = -0.22, p = 0.06). An increased dR45 predicts an upper-body tissue distribution originating before the midpoint of pregnancy. The cause of this developmental pattern is unknown, but it may lead to reduced survivorship.

Aspirin use among adults with diabetes: estimates from the Third National Health and Nutrition Examination Survey

OBJECTIVE

Since 1997, the American Diabetes Association has recommended that aspirin therapy be considered for adults with diabetes who have cardiovascular disease (CVD) or CVD risk factors. We examined the prevalence of regular aspirin use among adults in the U.S. with diagnosed diabetes.

RESEARCH DESIGN AND METHODS

The Third National Health and Nutrition Examination Survey (1988-1994) used a probability sample of the U.S. population and included an interview, physical examination, and laboratory studies. Among the survey participants were 1,503 adults (age > or =21 years) with self-reported diabetes. We defined regular aspirin use as reported having taken aspirin > or = 15 times in the previous month. CVD conditions were self-reported heart attack and stroke and symptoms of angina and claudication. CVD risk factors included smoking, hypertension, obesity, albuminuria, lipid abnormalities, and family history of heart attack.

RESULTS

An estimated 27% of adults with diabetes had CVD, and an additional 71% had one or more CVD risk factors. Aspirin was used regularly by 37% of those with CVD and by 13% of those with risk factors only Adjusted odds of regular aspirin use were significantly greater for individuals with CVD than for those with one CVD risk factor (odds ratio [OR] = 4.3); for non-Hispanic whites than for blacks, Mexican-Americans, and others (OR = 2.5); and for individuals age 40-59 years than for those <40 years (OR = 33.3).

CONCLUSIONS

Nearly every adult in the U.S. with diabetes has at least one risk factor for CVD and thus may be considered a potential candidate for aspirin therapy. During 1988-1994, only 20% (95% CI 16-23) took aspirin regularly Major efforts are needed to increase aspirin use.

Prevalence of type 2 diabetes mellitus in Taiwan: ethnic variation and risk factors

The purpose of this study was to compare the prevalence of diabetes and risk factors for the disease in three ethnic groups in Taiwan; the Hakaas, Fukienese, and aborigines. A cross-sectional study of men and women aged 50-79 years were invited to attend a standardized interview and physical examination. Diabetes mellitus was defined as a fasting plasma glucose (concentration of greater than or = 126) or a previous diagnosis of diabetes. Demographic, socioeconomic, and risk factor data were obtained. A total of 1293 persons (468 Hakaas, 440 Fukienese, and 385 aborigines) completed the examination. Hakaas had the highest age-adjusted prevalence of diabetes, 17.9% in men and 15.5% in women, followed by Fukienese, 14.5% in men and 12.8% in women. Aborigines had a prevalence of 10.0% in men and 13.3% in women. Diabetes prevalence was positively associated with family history of diabetes, obesity, hypertension, and hypertriglyceridemia. The ethnic variation in diabetes prevalence was reduced after adjustment for age, sex and significant factors. The multivariate-adjusted odds ratios (95% confidence interval) were 1.27 (0.76-2.12) for Fukienese and 1.44 (0.89-2.33) for Hakaas compared with aborigines. Diabetes mellitus is a major public health problem in Taiwan and warrants prevention efforts tailored to the country's different ethnic groups.

Diabetes--a common, growing, serious, costly, and potentially preventable public health problem

An estimated 135 million people worldwide had diagnosed diabetes in 1995, and this number is expected to rise to at least 300 million by 2025. The number of people with diabetes will increase by 42% (from 51 to 72 million) in industrialized countries between 1995 and 2025 and by 170% (from 84 to 228 million) in industrializing countries. Several potentially modifiable risk factors are related to diabetes, including insulin resistance, obesity, physical inactivity and dietary factors. Diabetes may be preventable in high-risk groups, but results of ongoing clinical trials are pending. Several efficacious and economically acceptable treatment strategies are currently available (control of glycemia, blood pressure, lipids; early detection and treatment of retinopathy, nephropathy, foot-disease; use of aspirin and ACE inhibitors) to reduce the burden of diabetes complications. Diabetes is a major public health problem and is emerging as a pandemic. While prevention of diabetes may become possible in the future, there is considerable potential now to better utilize existing treatments to reduce diabetes complications. Many countries could benefit from research aimed at better understanding the reasons why existing treatments are under-used and how this can be changed.

Screening for type 2 diabetes

Definitive studies of the effectiveness of screening for type 2 diabetes are currently not available. RCTs would be the best means to assess effectiveness, but several barriers prevent these studies from being conducted. Prospective observational studies may characterize some of the benefits of screening by creating screened and unscreened groups for comparison. The availability of better data systems and health services research techniques will facilitate such comparisons. Unfortunately, the interpretation of the results of such studies is extremely problematic. Several screening tests have been evaluated. Risk assessment questionnaires have generally performed poorly as stand-alone tests. Screening with biochemical tests performs better. Venous and capillary glucose measurements may perform more favorably than urinary glucose or HbA(1c) measurements, and measuring postprandial glucose levels may have advantages over measuring fasting levels. However, performance of all screening tests is dependent on the cutoff point selected. Unfortunately, there are no well-defined and validated cutoff points to define positive tests. A two-stage screening test strategy may assist with a more efficient use of resources, although such approaches have not been rigorously tested. The optimal interval for screening is unknown. Even though periodic, targeted, and opportunistic screening within the existing health care system seems to offer the greatest yield and likelihood of appropriate follow-up and treatment, much of the reported experience with screening appears to be episodic poorly targeted community screening outside of the existing health care system. Statistical models have helped to answer some of the key questions concerning areas in which there is lack of empirical data. Current models need to be refined with new clinical and epidemiological information, such as the UKPDS results (200). In addition, future models need to include better information on the natural history of the preclinical phase of diabetes. Data from ongoing clinical trials of screening and treatment of impaired glucose tolerance, such as the Diabetes Prevention Program, may eventually offer more direct evidence for early detection and treatment of asymptomatic hyperglycemia (201). It will be important to use comprehensive cardiovascular disease modules that assess the conjoint influence of glucose and cardiovascular risk factor reduction, information on QOL, and refined economic evaluations using common outcome measures (cost per life-year or QALY gained) (11,178,202-204). Such studies should consider all of the costs associated with a comprehensive screening program, including, at a minimum, the direct costs of screening, diagnostic testing, and care for patients with diabetes detected through screening. Finally, combinations of screening tests and different screening intervals should be evaluated within economic studies to allow selection of the optimal approach within the financial and resource limitations of the health care system.

Diabetes and physical disability among older U.S. adults

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.

Relation of birth weight to lean and fat thigh tissue in young men

BACKGROUND

Birth weight is positively associated with body mass index (BMI, kg/m2) in later life, but is inversely associated with cardiovascular risk. To understand this paradox, we examined the relationships between birth weight, adult BMI, and estimations of lean and fat tissue in young men.

METHODS

From 192 applicants for military service (ages 17-22 y, mean BMI 23.2 kg/m2) with known birth weights we measured the circumference and anterior skinfold thickness at midthigh to estimate thigh muscle+bone area and subcutaneous fat area. Linear regression models including birth weight as the independent variable were adjusted for race and adult height.

RESULTS

BMI was linearly associated with birth weight (standardized regression coefficient, [SRC]=+0.27; P=0.0004), as was the thigh muscle+bone area (SRC=+0.22; P=0.0029), but not the thigh subcutaneous fat area (SRC=+0.13; P=0.086). The BMI-birth weight association was reduced by 68% when the regression model was further adjusted for thigh muscle+bone area. Separate adjustment for thigh subcutaneous fat, however, reduced the BMI-birth weight association by only 30%. Waist circumference was also associated with birth weight (SRC=+0.24; P=0.0014), sagittal abdominal diameter was weakly associated (SRC=+0.17; P=0.028), but waist/thigh ratio and abdominal diameter index were not associated with birth weight.

INTERPRETATION

The larger BMI associated with higher birth weight may reflect increments in lean tissue more than increments in fat. Birth weight's influence on lean tissue is observed in the thigh and, among fit young men, perhaps at the waist. Increased muscularity in young men may partly explain the cardiovascular benefit in middle age ascribed to higher birth weight.

Type 2 diabetes among North American children and adolescents: an epidemiologic review and a public health perspective

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 Ojibway 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 populations, 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.

Is diabetes associated with cognitive impairment and cognitive decline among older women? Study of Osteoporotic Fractures Research Group

BACKGROUND

The long-term effect of type 2 diabetes on cognitive function is uncertain.

OBJECTIVE

To determine whether older women with diabetes have an increased risk of cognitive impairment and cognitive decline.

DESIGN

Prospective cohort study.

SETTING

Four research centers in the United States (Baltimore, Md; Portland, Ore; Minneapolis, Minn; and the Monongahela Valley, Pennsylvania).

PARTICIPANTS

Community-dwelling white women 65 years and older (n = 9679).

MEASUREMENTS

Physician-diagnosed diabetes and other aspects of health history were assessed by interview. Three tests of cognitive function, the Digit Symbol test, the Trails B test, and a modified version of the Mini-Mental State Examination (m-MMSE), were administered at baseline and 3 to 6 years later. Change in cognitive function was defined by the change in the score for each test. Major cognitive decline was defined as the worst 10th percentile change in the score for each test.

RESULTS

Women with diabetes (n = 682 [7.0%]) had lower baseline scores than those without diabetes on all 3 tests of cognitive function (Digit Symbol and Trials B tests, P<.01; m-MMSE, P = .03) and experienced an accelerated cognitive decline as measured by the Digit Symbol test (P<.01) and m-MMSE (P = .03). Diabetes was also associated with increased odds of major cognitive decline as determined by scores on the Digit Symbol (odds ratio = 1.63; 95% confidence interval, 1.20-2.23) and Trails B (odds ratio, 1.74; 95% confidence interval, 1.27-2.39) tests when controlled for age, education, depression, stroke, visual impairment, heart disease, hypertension, physical activity, estrogen use, and smoking. Women who had diabetes for more than 15 years had a 57% to 114% greater risk of major cognitive decline than women without diabetes.

CONCLUSION

Diabetes is associated with lower levels of cognitive function and greater cognitive decline among older women.

Evaluation of simple indices of insulin sensitivity and insulin secretion for use in epidemiologic studies

The metabolic characteristics of type 2 diabetes, insulin resistance, and diminished insulin secretion are costly to measure directly. To evaluate the utility of several simple indices derived from insulin and glucose measurements, the indices were examined from 1982 to 1997 with respect to correlation with more sophisticated measures of insulin sensitivity and secretion in Pima Indians in the Gila River Indian Community of Arizona. Ability to predict the incidence of diabetes in 1,731 persons was also examined. Indices were calculated from fasting and 2-hour glucose (G0, G120) and insulin (I0, I120) concentrations obtained during an oral glucose tolerance test. Fasting serum insulin concentration and the insulin sensitivity index (10(4)/(I0 x G0)) each showed a moderate correlation with the estimate of insulin sensitivity derived from the hyperinsulinemic-euglycemic clamp (absolute value r approximately 0.60). They also strongly predicted the incidence of diabetes (incidence rate ratio comparing the most and least insulin-resistant tertile groups approximately 3.0). Corrected insulin response (I120/(G120 x (G120 - 70))) was modestly correlated with insulin secretion as measured by an intravenous glucose tolerance test (r = 0.35). Impaired insulin secretion assessed by this index predicted incidence of diabetes, particularly after control for insulin sensitivity index (incidence rate ratio = 1.6). Thus, simple indices of insulin sensitivity and secretion may be reasonable surrogates for more sophisticated measures in epidemiologic studies.

The use of population attributable risk to estimate the impact of prevention and early detection of type 2 diabetes on population-wide mortality risk in US males

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.

Impact of diabetes mellitus on mortality associated with pneumonia and influenza among non-Hispanic black and white US adults

OBJECTIVES

This study assessed the impact of diabetes on mortality associated with pneumonia and influenza among non-Hispanic Black and White US adults.

METHODS

Data were derived from the National Mortality Followback Survey (1986) and the National Health Interview Survey (1987-1989).

RESULTS

Regardless of race, sex, and socioeconomic status, people with diabetes who died at 25 to 64 years of age were more likely to have pneumonia and influenza recorded on the death certificate than people without diabetes who died at comparable ages (odds ratio [OR] = 4.0, 95% confidence interval [CI] = 2.3, 7.7). For those 65 years and older, the risk remained elevated among Whites with diabetes (OR = 2.2, 95% CI = 1.7, 2.7) but not among Blacks with diabetes (OR = 1.0, 95% CI = 0.6, 1.7). It was estimated that about 17,000 (10.3%) of the 167,000 deaths associated with pneumonia and influenza that occurred in 1986 were attributable to diabetes.

CONCLUSIONS

The impact of diabetes on deaths associated with pneumonia and influenza is substantial. Targeted immunizations among people with diabetes may reduce unnecessary deaths associated with pneumonia and influenza.

Prevalence of self-rated visual impairment among adults with diabetes

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.

The direct health care costs of obesity in the United States

OBJECTIVES

Recent estimates suggest that obesity accounts for 5.7% of US total direct health care costs, but these estimates have not accounted for the increased death rate among obese people. This article examines whether the estimated direct health care costs attributable to obesity are offset by the increased mortality rate among obese individuals.

METHODS

Data on death rates, relative risks of death with obesity, and health care costs at different ages were used to estimate direct health care costs of obesity from 20 to 85 years of age with and without accounting for increased death rates associated with obesity. Sensitivity analyses used different values of relative risk of death, given obesity, and allowed the relative costs due to obesity per unit of time to vary with age.

RESULTS

Direct health care costs from 20 to 85 years of age were estimated to be approximately 25% lower when differential mortality was taken into account. Sensitivity analyses suggested that direct health care costs of obesity are unlikely to exceed 4.32% or to be lower than 0.89%.

CONCLUSIONS

Increased mortality among obese people should be accounted for in order not to overestimate health care costs.

High prevalence of impaired fasting glucose and type 2 diabetes mellitus in Penghu Islets, Taiwan: evidence of a rapidly emerging epidemic?

The purpose of this study was to estimate the prevalence of type 2 diabetes and impaired fasting glucose (IFG) in Penghu, Taiwan and compare these estimates with those of the US (NHANES III). Diabetes and IFG (American Diabetes Association criteria, 1997) were assessed among a stratified random sample of 2500 residents of Penghu Islands, Taiwan. The prevalence (age-adjusted to world adult population) of diabetes and IFG were 16.8% (95% CI 15.0-18.6) and 21.0% (95% CI 19.0-23.0), respectively, among Penghu Islanders in Taiwan. Age sex-specific diabetes prevalence ranged from 10.0% in men aged 40-49 years to 29.4% in women aged 60-69 years. Prevalence of IFG ranged from 14.7% in women aged 40-49 years to 30.7% in men aged 50-59 years. Age, body mass index (BMI), and family history of diabetes were each independently associated with both diabetes and IFG. In addition, female gender, apolipoprotein B and triglyceride concentrations were associated with diabetes, and hypertension and apolipoprotein B concentration with IFG. Among persons > or = 40 years in Penghu, Taiwan, the prevalence of diabetes is up to a third higher and the prevalence of IFG is up to three times higher than comparably aged Americans, despite their having a mean BMI 2.2-3.2 kg/m2 lower than Americans. The alarmingly high prevalence of IFG in Taiwan may indicate an emerging diabetes epidemic.

HDL cholesterol subfractions and risk of developing type 2 diabetes among Pima Indians

OBJECTIVE

To examine the relationships between HDL cholesterol subfractions and the incidence of type 2 diabetes and to evaluate potential sex differences in these relationships.

RESEARCH DESIGN AND METHODS

Proportional hazards analyses were performed to examine the relationships between HDL subfractions and the development of type 2 diabetes in Pima Indian women and men. Results were controlled for age, BMI, systolic blood pressure, and 2-h glucose.

RESULTS

Some 54 of 123 women and 25 of 50 men developed type 2 diabetes during a mean follow-up of 10 (2-19) years. For women, in separate models, high levels of total HDL, HDL2a, and HDL3 were negatively associated with incidence of type 2 diabetes; results were unchanged in models further controlled for fasting insulin level or alcohol consumption. For men, the results were inconsistent and associated with wide confidence intervals; high total HDL and HDL3 were positively associated with incidence of type 2 diabetes in models further controlled for fasting insulin level, but the risk estimates were attenuated in models further controlled for alcohol consumption.

CONCLUSIONS

High levels of total HDL, HDL2a, and HDL3 were potential protective factors against type 2 diabetes in women after accounting for alcohol consumption and insulin resistance. High levels of total HDL and HDL3 were predictive of type 2 diabetes in men; the relationship in men appeared to be due to an association with alcohol consumption. The sex differences in the effects of HDL cholesterol may be related to the effects of sex hormones or lipoproteins.

Causes of death and associated factors among patients with non-insulin-dependent diabetes mellitus in Taipei, Taiwan

A cohort of 766 patients with non-insulin-dependent diabetes mellitus (NIDDM) from a general teaching hospital in Taipei, Taiwan were followed prospectively to assess survival experience and associated risk factors. Data were abstracted from the medical records and additional information was obtained from patients or their closest relatives using a structured questionnaire. Date and cause of death were determined from death certificates. Standardized mortality ratios were calculated by the direct method. Chi2-Square test and Cox's proportional hazard analysis were used to control for potential confounders. During a median follow-up of 3.5 years (range 1 month to 4.6 years), 131 deaths occurred. Of these, 29.8% were due to cardiopulmonary disease (ICD 401-429), 13.0% due to cerebrovascular disease (ICD 430-438), 13.0% due to acute diabetes metabolic complications (250.1, 250.2), and 11.4% due to nephropathy (580-589). Adjusted for age, people with NIDDM had 2.2 (95% CI 1.6-2.9) times the risk of death than members of the general population, and cause-specific standardized mortality ratios were: CPD 4.6, nephropathy 8.8, cerebrovascular disease 1.9, and neoplasm 0.7. Age, fasting plasma glucose, hypertension, and proteinuria were positively and independently associated with all-cause mortality (P < 0.05 for each). Thus, NIDDM patients have higher mortality rates than the general population in Taiwan, and age, fasting plasma glucose, hypertension, and proteinuria are associated with this excess risk. Proper application of available interventions may control these factors with a consequent reduction in mortality. Particular attention is needed to prevent deaths from the acute metabolic complications of diabetes.