Toward prevention and control of type 2 diabetes: challenges at the U.S.-Mexico border and beyond.
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Diabetes Mellitus, Type 2↗
Biomedical subjects
Barbara A Bowman
Publications and source records attributed to Barbara A Bowman.
Primary prevention of type 2 diabetes mellitus by lifestyle intervention: implications for health policy.
More than 18 million Americans currently have diabetes mellitus. The economic and human cost of the disease is devastating. In the United States, diabetes is the most common cause of blindness among working-age adults, the most common cause of nontraumatic amputations and end-stage renal disease, and the sixth most common cause of death. For the cohort of Americans born in 2000, the estimated lifetime risk for diabetes is more than 1 in 3. In the next 50 years, the number of diagnosed cases of diabetes is predicted to increase by 165% in the United States, with the largest relative increases seen among African Americans, American Indians, Alaska Natives, Asian and Pacific Islanders, and Hispanic/Latino persons. Compelling scientific evidence indicates that lifestyle change prevents or delays the occurrence of type 2 diabetes in high-risk groups. This body of evidence from randomized, controlled trials conducted in 3 countries has definitively established that maintenance of modest weight loss through diet and physical activity reduces the incidence of type 2 diabetes in high-risk persons by about 40% to 60% over 3 to 4 years. The number of persons at high risk for type 2 diabetes is similar to the number of persons who have diabetes. This paper summarizes scientific evidence supporting lifestyle intervention to prevent type 2 diabetes and discusses major policy challenges to broad implementation of lifestyle intervention in the health system.
Behavior Therapy↗
Are persons with diabetes practicing healthier behaviors in the year 2001? Results from the Behavioral Risk Factor Surveillance System.
BACKGROUND: To examine changes in modifiable health-risk behaviors of diabetic persons in the United States. METHODS: A cross-sectional study was conducted of noninstitutionalized adults aged 18 years or older, in states that participated in the Behavioral Risk Factor Surveillance System in 1995 and 2001. Changes in self-reported health-risk behaviors among persons with diabetes are examined for those years (5,218 in 1995 and 13,733 in 2001 for the core instrument; 3,227 in 1995 and 9,304 in 2001 for the diabetes module). RESULTS: From 1995 to 2001, the percentage of persons with diabetes who were obese, had ever been told their blood pressure or blood cholesterol was high, or had their blood cholesterol checked in the past year increased significantly. Significant increases were also reported among diabetic persons who were former smokers, received an annual influenza vaccination, ever received a pneumococcal vaccination, performed daily self-monitoring of blood glucose, received annual foot examination, and received annual dilated eye exam. CONCLUSIONS: Continued emphasis needs to be placed on a multirisk factor approach to prevent, delay, and reduce the complications of diabetes.
Adult↗
Intraindividual variation in serum retinol concentrations among participants in the third National Health and Nutrition Examination Survey, 1988-1994.
BACKGROUND: The biological variability in serum retinol concentrations has never been examined in a large sample, and its effect on population distribution estimates and the clinical assessment of vitamin A status is unknown. OBJECTIVE: We evaluated the biological CV of serum retinol and examined the effect of the CV on both population distribution estimates and clinical assessments of vitamin A status by using data from the third National Health and Nutrition Examination Survey, 1988-1994. DESIGN: We described the biological CV [(SD/x) x 100] and examined associations between the CV and other factors via multivariate analysis of variance and linear regression. We used linear regression to predict the mean retinol concentration from a single concentration and established 95% CIs for each participant. We estimated the adjusted prevalence of inadequate vitamin A status (retinol < 1.05 micromol/L) on the basis of the CIs. We estimated an uncertainty range for serum retinol concentrations for which the CIs included the established cutoff. RESULTS: The mean biological CV across all strata was 6.45%. The biological CV varied significantly between racial-ethnic groups (P < 0.05). Prevalence estimates of inadequate serum retinol concentrations were reduced after adjustment for the total variation, with an adjusted overall prevalence of 0.62% compared with an unadjusted prevalence of 2.63%. CONCLUSIONS: The actual population prevalence of inadequate vitamin A status may be 75% lower than the estimates previously reported. Confirmation of vitamin A status may be needed for persons in the United States with observed serum retinol concentrations near the recognized cutoff.
Adolescent↗
Prevalence of obesity, diabetes, and obesity-related health risk factors, 2001.
CONTEXT: Obesity and diabetes are increasing in the United States. OBJECTIVE: To estimate the prevalence of obesity and diabetes among US adults in 2001. DESIGN, SETTING, AND PARTICIPANTS: Random-digit telephone survey of 195 005 adults aged 18 years or older residing in all states participating in the Behavioral Risk Factor Surveillance System in 2001. MAIN OUTCOME MEASURES: Body mass index, based on self-reported weight and height and self-reported diabetes. RESULTS: In 2001 the prevalence of obesity (BMI > or =30) was 20.9% vs 19.8% in 2000, an increase of 5.6%. The prevalence of diabetes increased to 7.9% vs 7.3% in 2000, an increase of 8.2%. The prevalence of BMI of 40 or higher in 2001 was 2.3%. Overweight and obesity were significantly associated with diabetes, high blood pressure, high cholesterol, asthma, arthritis, and poor health status. Compared with adults with normal weight, adults with a BMI of 40 or higher had an odds ratio (OR) of 7.37 (95% confidence interval [CI], 6.39-8.50) for diagnosed diabetes, 6.38 (95% CI, 5.67-7.17) for high blood pressure, 1.88 (95% CI,1.67-2.13) for high cholesterol levels, 2.72 (95% CI, 2.38-3.12) for asthma, 4.41 (95% CI, 3.91-4.97) for arthritis, and 4.19 (95% CI, 3.68-4.76) for fair or poor health. CONCLUSIONS: Increases in obesity and diabetes among US adults continue in both sexes, all ages, all races, all educational levels, and all smoking levels. Obesity is strongly associated with several major health risk factors.
Adult↗
Laboratory issues: use of nutritional biomarkers.
Biomarkers of nutritional status provide alternative measures of dietary intake. Like the error and variation associated with dietary intake measures, the magnitude and impact of both biological (preanalytical) and laboratory (analytical) variability need to be considered when one is using biomarkers. When choosing a biomarker, it is important to understand how it relates to nutritional intake and the specific time frame of exposure it reflects as well as how it is affected by sampling and laboratory procedures. Biological sources of variation that arise from genetic and disease states of an individual affect biomarkers, but they are also affected by nonbiological sources of variation arising from specimen collection and storage, seasonality, time of day, contamination, stability and laboratory quality assurance. When choosing a laboratory for biomarker assessment, researchers should try to make sure random and systematic error is minimized by inclusion of certain techniques such as blinding of laboratory staff to disease status and including external pooled standards to which laboratory staff are blinded. In addition analytic quality control should be ensured by use of internal standards or certified materials over the entire range of possible values to control method accuracy. One must consider the effect of random laboratory error on measurement precision and also understand the method's limit of detection and the laboratory cutpoints. Choosing appropriate cutpoints and reducing error is extremely important in nutritional epidemiology where weak associations are frequent. As part of this review, serum lipids are included as an example of a biomarker whereby collaborative efforts have been put forth to both understand biological sources of variation and standardize laboratory results.
Behavior↗
Translating the science of primary, secondary, and tertiary prevention to inform the public health response to diabetes.
Diabetes is emerging as a major focus of public health efforts in the United States and worldwide because the burden of the disease is increasing rapidly. The increasing prevalence of diabetes is alarming because of the broad spectrum of acute and long-term complications that typically occur in combination and lead to extensive disability and substantial mortality, while imposing substantial human and economic costs on individuals, families, communities, health care systems, and society. Diabetes management was once considered the domain of the physician-patient relationship, guided by basic science and clinical research. Research focused on the physician-patient relationship is now being complemented with risk reduction media campaigns, health services research, and community-based participatory research. This article summarizes key scientific studies of primary, secondary, and tertiary prevention that provide evidence that diabetes complications can be prevented and controlled. We also discuss how findings from large-scale randomized clinical trails support the critical need for complementary public health approaches to address and eliminate persistent health disparities, using health systems, health communications, and community intervention research and practice.
Cost of Illness↗
Community-based lifestyle interventions to prevent type 2 diabetes.
OBJECTIVE: To conduct a literature review of community-based interventions intended to prevent or delay type 2 diabetes. RESEARCH DESIGN AND METHODS: Recently published findings about the potential to prevent or delay type 2 diabetes with intensive lifestyle interventions prompted a literature search for community-based diabetes prevention interventions. The literature review design was a search of databases for publications in 1990-2001 that identified reports on community-based interventions designed to prevent or modify risk factors for type 2 diabetes. RESULTS: The search revealed 16 published interventions, 8 of which were conducted in the U.S. and involved populations disproportionately burdened by diabetes (e.g., American Indians, Native Hawaiians, Mexican Americans, and African Americans). Of the studies reporting results among youth, there were posttest improvements in intervention groups in knowledge, preventive behaviors, and self-esteem. Among studies reporting results among adults, most reported improvements in intervention groups in knowledge or adoption of regular physical activity. Several investigators offered important reflections about the process of engaging communities and sharing decision making in participatory research approaches, as well as insights about the expectations and limitations of community-based diabetes prevention research. Many of the studies reported limitations in their design, including the lack of control or comparison groups, low response rates or lack of information on nonresponders, or brief intervention periods. CONCLUSIONS: There is a critical need to conduct and publish reports on well-designed community-based diabetes prevention research and share information on the process, results, and lessons learned. Armed with recent positive findings about diabetes prevention and literature documenting community-based efforts, advocates at local, state, and national levels can collaborate to stem the rising tide of diabetes in communities.
Diabetes Mellitus, Type 2↗
Learning from listening: common concerns and perceptions about diabetes prevention among diverse American populations.
Recent research findings confirming the feasibility and effectiveness of interventions to prevent or delay the onset of type 2 diabetes are of keen interest to many stakeholders, including communities from which diabetes exacts a heavy toll. To inform communication and program planners at national and local levels, the Division of Diabetes Translation, Centers for Disease Control and Prevention, turned to people and communities affected by diabetes for their views about diabetes prevention. We review the key themes that emerged across diverse populations and some examples of subthemes relevant to particular groups. Adults at risk for type 2 diabetes and community leaders from five racial and ethnic groups participated in 27 focus groups from five geographic locations across the country. We explored participants' knowledge, attitudes, and beliefs about diabetes and factors that would enable or impede lifestyle interventions at individual and community levels. Multiple analysts categorized responses using the qualitative technique of constant comparison. Many themes, some cutting across groups and some unique to specific groups, emerged about the negative effect of modern lifestyles on the health of adults and children. But positive findings about diabetes prevention generated hope that diabetes was not inevitable. All the focus groups noted that interventions were difficult to initiate and maintain and that social support, modeling stories, and community connections were needed. Listening to community members identified common and group-specific themes. These findings can inform health promotion messages and support adaptive community interventions for diabetes prevention.
Attitude to Health↗
Differences in the relation of obesity to serum triacylglycerol and VLDL subclass concentrations between black and white children: the Bogalusa Heart Study.
BACKGROUND: Obese children and adults, particularly those with abdominal obesity, have an elevated serum triacylglycerol concentration. Furthermore, triacylglycerol concentrations are generally higher in whites than in blacks, and the relation of obesity to triacylglycerol concentrations may be stronger in whites. However, there is little information on the relation of obesity to the metabolically distinct subclasses of VLDL in children. OBJECTIVE: The objective was to examine possible differences between blacks (n = 367) and whites (n = 549) in mean concentrations of triacylglycerols, in mean concentrations of small and large VLDL, and in the relation of waist circumference to concentrations of triacylglycerol and VLDL subclasses. DESIGN: We measured VLDL subclass concentrations and assessed the relation of various obesity indexes to triacylglycerols in a cross-sectional study of 10- to 17-y-olds. RESULTS: The mean triacylglycerol concentration was 0.3 mmol/L (25 mg/dL) higher in white than in black children, primarily because of a 0.2-mmol/L (140%) difference in mean concentrations of large VLDL. In contrast, the mean concentrations of small VLDL differed by only 0.05 mmol/L (29%). In addition, the relations of waist girth to concentrations of triacylglycerol and large VLDL were 2- to 6-fold stronger among white children than among black children. Although white children had higher concentrations of large VLDL than did black children, this difference increased from 0.1 to 0.4 mmol/L across quintiles of waist circumference. Waist circumference was not significantly related to concentrations of small VLDL. CONCLUSION: These contrasting associations with obesity, which differ between white and black children, suggest that information on VLDL subclasses could provide additional information on the risk of obesity-related ischemic heart disease.
Adolescent↗
Hypovitaminosis D prevalence and determinants among African American and white women of reproductive age: third National Health and Nutrition Examination Survey, 1988-1994.
BACKGROUND: Recent reports of rickets among African American children drew attention to the vitamin D status of these infants and their mothers. African American women are at higher risk of vitamin D deficiency than are white women, but few studies have examined determinants of hypovitaminosis D in this population. OBJECTIVE: We examined the prevalence and determinants of hypovitaminosis D among African American and white women of reproductive age. DESIGN: We examined 1546 African American women and 1426 white women aged 15-49 y who were not pregnant and who participated in the third National Health and Nutrition Examination Survey (1988-1994). Hypovitaminosis D was defined as a serum 25-hydroxyvitamin D concentration < or =37.5 nmol/L. Multiple logistic regression was used to examine the independent association of dietary, demographic, and behavioral determinants of hypovitaminosis D. RESULTS: The prevalence of hypovitaminosis D was 42.4 +/- 3.1% ( +/- SE) among African Americans and 4.2 +/- 0.7% among whites. Among African Americans, hypovitaminosis D was independently associated with consumption of milk or breakfast cereal <3 times/wk, no use of vitamin D supplements, season, urban residence, low body mass index, and no use of oral contraceptives. Even among 243 African Americans who consumed the adequate intake of vitamin D from supplements (200 IU/d), 28.2 +/- 2.7% had hypovitaminosis D. CONCLUSIONS: The high prevalence of hypovitaminosis D among African American women warrants further examination of vitamin D recommendations for these women. The determinants of hypovitaminosis D among women should be considered when these women are advised on dietary intake and supplement use.
Adult↗
Angular stomatitis and riboflavin status among adolescent Bhutanese refugees living in southeastern Nepal.
BACKGROUND: Between 1990 and 1993, fear of ethnic persecution led 83,000 ethnic Nepalese to flee from Bhutan to refugee camps in Nepal, where they remained at the time of this study. Reported cases of angular stomatitis (AS), ie, thinning or fissuring at the mouth angles, increased 6-fold from December 1998 to March 1999, from 5.5 to 35.6 cases per 1000 per month. This increase came after the removal of a fortified cereal from rations. OBJECTIVES: The main objectives were to assess the prevalence of AS and of low concentrations of riboflavin, folate, vitamin B-12, and iron by using biochemical measures; to determine whether riboflavin status was associated with AS; and to assess the potential of AS as a screening measure for low riboflavin concentrations. DESIGN: In October 1999, we performed a survey among a random sample of 463 adolescent refugees in which we conducted interviews and physical examinations and obtained blood specimens for riboflavin assessment. Riboflavin status was assessed with the erythrocyte glutathione reductase (EC 1.6.4.2) activity coefficient. After we excluded those adolescents who had taken vitamins during the past month, 369 were eligible for analyses. RESULTS: AS was common (26.8%; 95% CI: 22.3, 31.3), the prevalence of low riboflavin concentrations was high (85.8%; 80.7, 90.9), and riboflavin status was associated with AS. Adolescents with AS had significantly lower riboflavin concentrations than did adolescents without AS (P = 0.02). The adjusted odds ratio for AS and low riboflavin concentrations was 5.1 (1.55, 16.5). CONCLUSION: Globally, riboflavin deficiency is rare. Its emergence in food-dependent populations can be a harbinger of other B-vitamin deficiencies.
Adolescent↗
Assessment of infant feeding: the validity of measuring milk intake.
Accurate assessment of infant feeding is needed for clinical practice and research. We identified 32 studies that evaluated the validity of direct observation, test weighing, or doubly labeled water methods. Correlations with validation standards were highest for doubly labeled water and test weighing, and lowest for observation. Cost and availability of isotope may limit the doubly labeled water method to research studies, whereas observation may be useful for clinical practice. Test weighing could be applied to either setting, but it may be practical to sample less frequently over 24 hours. Validity results and intended use of the measurement should be considered when selecting a method.
Body Weight↗
Changes in health behaviors among older Americans, 1990 to 2000.
OBJECTIVES: The authors used a large population-based survey to examine changes from 1990 to 2000 in age distribution by sex and race or ethnicity, to estimate both state-specific and national trends in the proportion of older Americans, and to examine changes in risk factors and quality-of-life indicators among those Americans. METHODS: The Behavioral Risk Factor Surveillance System (BRFSS), a cross-sectional telephone survey of adults aged > or =18 years. BRFSS data were analyzed for the District of Columbia and all states that participated from 1990 to 2000. SAS and SUDAAN were used in the analyses to account for the complex sampling design. RESULTS: The percentage of Americans aged > or =75 years increased 23.0% from 1990 to 2000, with the magnitude of the increase varying by state. In 2000, Florida had the highest percentage of persons aged > or =75 (10.27%) and Alaska the lowest (3.49%). Compared with 1990, older Americans in 2000 were more likely to be obese (16.3% vs. 13.5%) or diabetic (14.3% vs. 11.0%). Older Americans in 2000 were also more likely to exercise, consume more fruits and vegetables daily, and to have recently obtained a routine medical checkup. In addition, they were less likely to smoke tobacco or drink any alcohol. CONCLUSIONS: Increases in the population of older people will have a tremendous impact on health care in the states and will affect their future plans for serving the elderly. Although older Americans are living more healthfully than previously, there is an enormous need for targeted health promotion programs to prevent chronic diseases in this age group.
Aged↗
HFE genotype and transferrin saturation in the United States.
PURPOSE: Examine the penetrance (defined by high transferrin saturation [TS]) of C282Y and H63D in the U.S. population. METHODS: 5171 participants from the Third National Health and Nutrition Examination Survey, 1992 to 1994. RESULTS: 77.1% (95% confidence interval [CI], 2.3, 95.1) of men and 51.9% (95% CI, 0, 84.2) of women with C282Y homozygosity had high TS. The associations of H63D homozygosity with high TS were stronger in people aged 50 years or older than in younger persons. Among Mexican-Americans, simple H63D heterozygosity was associated with high TS. CONCLUSIONS: The associations between HFE genotype and high TS may vary by sex, age, and ethnic group.
Adolescent↗
Vitamin or supplement use among adults, behavioral risk factor surveillance system, 13 states, 2001.
OBJECTIVE: The authors examined vitamin/supplement (V/S) use and its relationship to sociodemographics, health behaviors, and health conditions among adults in 13 states. METHODS: This investigation used 2001 data from a cross-sectional study of non-institutionalized adults aged > or = 18 years, the Behavioral Risk Factor Surveillance System. RESULTS: Of 45,415 respondents with complete data (18,723 males and 26,692 females), 56.5% (n=5,652) reported current V/S use. After adjusting for age, sex, race/ethnicity, and education, the authors found a statistically significant association between V/S use and positive health risk behavior (adjusted odds ratio [OR]=1.46; p<0.001). Also, WS use was found to increase with age (p<0.001). No association was found between V/S use and the absence of specific chronic disease conditions (adjusted OR=0.93; p=0.052). CONCLUSIONS: People who used V/S in the states surveyed were more likely to demonstrate positive health risk behaviors than those who did not report V/S use. Thus it appears that individuals who are most likely to use V/S are least likely to need V/S. It is crucial that individuals report quantity and frequency of V/S use when providing medical or diet histories to health care providers.
Adolescent↗
The knowledge-action gap in diabetes.
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Diabetes Mellitus↗