Cultural Competence in Diabetes Mellitus Care: An Urgent Need

Background:Multicultural societies exist worldwide. Two important challenges can be appreciated in this scenario. Minority populations, due to a combination of genetic and lifestyle factors, have a particularly high risk for developing type 2 diabetes mellitus (DM). In addition, the quality of health care provided to minority populations, including that for DM, has lagged behind that provided to the white population. Because multiple medical, social, and cultural factors influence the development and progression of type 2 DM, management of patients becomes even more challenging if health care providers cannot identify and address the many contributing factors.Objective:The objective of this article was to raise awareness about the most common social and cultural factors that may influence the development of type 2 DM, progression of the disease, and adherence to treatment plans in patients from culturally diverse populations.Methods:A PubMed search of English-language articles published primarily between 1996 and 2006 was conductedusing the search terms Latino, Hispanic, culture, and diabetes, and a list of social and cultural factors associated with type 2 DM was created based on relevant articles and on the author's expertise and experience in the Latino Diabetes Initiative at the Joslin Diabetes Center.Results:There is increasing evidence that social and cultural factors such as body image, educational level, fears, general family integration and support, health literary, language, myths, and nutritional preferences, among others, may affect the success of the physician patient relationship and influence patients' adherence to treatment. Specific strategies to help clinicians remember to address multiple factors in the day-to-day management of patients with type 2 DM who are from culturally diverse populations include asking questions about patients' personal goals, ascertaining what behaviors they have adopted from mainstream culture, understanding how family ties may affect DM care and prevention, and being aware of patients' educational level when implementing any educational activity.Conclusions:The standards of DM care apply to every individual with this disease and should continue to be the core of every clinicians practice. However, improving health care providers' cultural competence may help improve the quality of care provided to minority groups and may ultimately reduce health care disparities. Increased cultural competence may also improve patient-provider trust and communication, as well as help patients adhere to prevention and treatment plans.     

Efficacy and Safety of Dulaglutide in Hispanic/Latino Patients with Type 2 Diabetes in the Award Clinical Program

Objective: The aim of this post hoc analysis was to assess the efficacy and safety of once-weekly dulaglutide in Hispanic/Latino patients with type 2 diabetes (T2D) in phase 3 AWARD trials 1 to 6.Methods: Hispanic/Latino data at Week 26 were pooled across studies for each dulaglutide dose to analyze the change from baseline in glycosylated hemoglobin (HbA1c), percent to HbA1c goal, and adverse events (AEs). Change from baseline in HbA1c, change from baseline in weight and hypoglycemia were analyzed by Hispanic/Latino and non-Hispanic/Latino subgroups for each study.Results: Of the 3,136 patients randomized to dulaglutide 1.5 or 0.75 mg, 949 were reported as having Hispanic/Latino ethnicity. Baseline characteristics were similar for Hispanic/Latino and overall populations, except there were slightly more Hispanic/Latino females and weight was slightly lower for Hispanic/Latino patients. Hispanic/Latino patients receiving dulaglutide 1.5 mg had a reduction in HbA1c of 1.25% (95% confidence interval [CI]: -1.35, -1.15); dulaglutide 0.75 mg had a reduction of 1.07% (95% CI: -1.18, -0.96). Reductions in HbA1c and percent to goal HbA1c <7% and ≤6.5% were similar between Hispanic/Latino patients and the overall population. Weight change and hypoglycemia were similar between Hispanic/Latino and non-Hispanic/Latino subgroups for all studies. Treatment-emergent AEs were consistent with the overall population.Conclusion: Dulaglutide improved glycemic control with the potential for weight loss in Hispanic/Latino patients with T2D. Dulaglutide was well tolerated and had a low risk of hypoglycemia when used without insulin secretagogues or insulin. In the Hispanic/Latino population, dulaglutide efficacy and safety was consistent with that of the overall population.Abbreviations:AE = adverse eventAWARD = Assessment of Weekly AdministRation of dulaglutide in DiabetesBID = twice dailyCARMELA = The Cardiovascular Risk Factor Multiple Evaluation of Latin AmericaCI = confidence intervalGLP-1 RA = glucagon-like peptide-1 receptor agonistHbA1c = glycosylated hemoglobinT2D = type 2 diabetes     

Transcultural Diabetes Care in The United States – A Position Statement by the American Association of Clinical Endocrinologists

The American Association of Clinical Endocrinologists (AACE) has created a transculturalized diabetes chronic disease care model that is adapted for patients across a spectrum of ethnicities and cultures. AACE has conducted several transcultural activities on global issues in clinical endocrinology and completed a 3-city series of conferences in December 2017 that focused on diabetes care for ethnic minorities in the U.S. Proceedings from the “Diabetes Care Across America” series of transcultural summits are presented here. Information from community leaders, practicing health care professionals, and other stakeholders in diabetes care is analyzed according to biological and environmental factors. Four specific U.S. ethnicities are detailed: African Americans, Latino/Hispanics, Asian Americans, and Native Americans. A core set of recommendations to culturally adapt diabetes care is presented that emphasizes culturally appropriate terminology, transculturalization of white papers, culturally adapting clinic infrastructure, flexible office hours, behavioral medicine—especially motivational interviewing and building trust—culturally competent nutritional messaging and health literacy, community partnerships for care delivery, technology innovation, clinical trial recruitment and retention of ethnic minorities, and more funding for scientific studies on epigenetic mechanisms of cultural impact on disease expression. It is hoped that through education, research, and clinical practice enhancements, diabetes care can be optimized in terms of precision and clinical outcomes for the individual and U.S. population as a whole.Lay AbstractThe American Association of Clinical Endocrinologists (AACE) has created a diabetes care model for patients of different backgrounds. AACE led meetings in New York, Houston, and Miami with health care professionals and community leaders to improve diabetes care. Information from these meetings looked at biological and environmental diabetes risks. Four American patient groups were studied: African Americans, Latinos, Asian Americans, and Native Americans. Diabetes care should use culturally appropriate language and search for better ways to apply science and clinic design. Talking to patients more clearly can improve their diabetes control. There are many other needed changes in the American health care system discussed in this paper. It is hoped that through better education, research, and practice, diabetes care can be improved for the entire U.S. population. This means that important differences among patients' ethnic and cultural backgrounds are addressed.Executive Summary

• Cultural adaptation of evidence-based recommendations is a necessary component of optimal diabetes care.
• Biological factors that contribute to the pathophysiology of diabetes vary according to race and ethnicity and can be affected by social determinants that vary with culture.
• The “Transcultural Diabetes Nutrition Algorithm” was developed in 2010 to optimize diabetes nutrition care globally and represents a validated methodology where evidence-based recommendations from a source culture can be adapted and implemented in a different culture using a toolkit.
• The 2015 AACE Pan-American Workshop examined diabetes care in 9 Latin American nations and concluded that there should only be one level of diabetes care for a population and that level should be “excellent;” also, that A1C measurements should be utilized and that more educational and nutritional options are needed to optimize diabetes care.
• The “Diabetes Care Across America – A Series of Transcultural Summits” was an AACE program conducted in 2017 in New York, Houston, and Miami to examine cultural factors that influence diabetes care domestically; the findings of this program are presented here.
• The African American, Hispanic/Latino, Asian American, and Native American populations are each comprised of different ancestries, anthropometrics/body compositions and physical appearances, and cultures and degrees of acculturation, with a significant evidence base that associates specific gene variants with specific phenotypic traits affecting diabetes care.
• For each ethno-cultural population, health messaging and diabetes care will need to consider issues of potential distrust of health care professionals, history of discrimination, religious practices, food preferences, attitudes toward physical activity, and despite the full range of socio-economics, the impact of poverty on engagement, self-monitoring, adherence with lifestyle and medical recommendations, and recruitment for clinical trials.
• Diabetes care should be as precise as possible, incorporating clinical trial evidence that best reflects the ethno-cultural attributes of a specific patient, with particular emphasis on cardiovascular disease risk mitigation, technology to assess the effects of eating patterns on glycemic status, adjusting traditional eating patterns to more healthy options that are still acceptable to the patient, flexibility in lifestyle and medication recommendations that take into account cultural factors, and the utilization of community-based resources to improve implementation.
• Pragmatic first steps to prepare a diabetes practice for an ethno-culturally diverse patient population include: learning more about biological-cultural interactions; gaining experience with lifestyle and behavioral medicine, especially motivational interviewing; creating a safe and immersive clinical environment; incorporating translation services, social prescribing, wearable technologies, web-based resources, and community engagement; and establishing referral networks with clinical trialists in diabetes research to improve recruitment of different populations.

ABSTRACTAbbreviations: A1C = hemoglobin A1c; AACE = American Association of Clinical Endocrinologists; ABCD = adiposity-based chronic disease; BMI = body mass index; CPA = clinical practice algorithm; CPG = clinical practice guideline; DBCD = dysglycemia-based chronic disease; DPP = Diabetes Prevention Program; GWAS = genome-wide association study; HCP = health care professional(s); IHS = Indian Health Service; LDL = low-density lipoprotein; MetS = metabolic syndrome; T2D = type 2 diabetes mellitus; tDNA = transcultural Diabetes Nutrition Algorithm; TG = triglyceride; WC = waist circumference     

Utilization of the Behavior Change Wheel framework to develop a model to improve cardiometabolic screening for people with severe mental illness

Background

Individuals with severe mental illness (e.g., schizophrenia, bipolar disorder) die 10–25 years earlier than the general population, primarily from premature cardiovascular disease (CVD). Contributing factors are complex, but include systemic-related factors of poorly integrated primary care and mental health services. Although evidence-based models exist for integrating mental health care into primary care settings, the evidence base for integrating medical care into specialty mental health settings is limited. Such models are referred to as “reverse” integration. In this paper, we describe the application of an implementation science framework in designing a model to improve CVD outcomes for individuals with severe mental illness (SMI) who receive services in a community mental health setting.

Methods

Using principles from the theory of planned behavior, focus groups were conducted to understand stakeholder perspectives of barriers to CVD risk factor screening and treatment identify potential target behaviors. We then applied results to the overarching Behavior Change Wheel framework, a systematic and theory-driven approach that incorporates the COM-B model (capability, opportunity, motivation, and behavior), to build an intervention to improve CVD risk factor screening and treatment for people with SMI.

Results

Following a stepped approach from the Behavior Change Wheel framework, a model to deliver primary preventive care for people that use community mental health settings as their de facto health home was developed. The CRANIUM (cardiometabolic risk assessment and treatment through a novel integration model for underserved populations with mental illness) model focuses on engaging community psychiatrists to expand their scope of practice to become responsible for CVD risk, with significant clinical decision support.

Conclusion

The CRANIUM model was designed by integrating behavioral change theory and implementation theory. CRANIUM is feasible to implement, is highly acceptable to, and targets provider behavior change, and is replicable and efficient for helping to integrate primary preventive care services in community mental health settings. CRANIUM can be scaled up to increase CVD preventive care delivery and ultimately improve health outcomes among people with SMI served within a public mental health care system.

     

HIV and Latino migrant workers in the USA

Abstract

Migrant workers from Latin America are an essential source of economic development in the US agricultural industry. A majority of migrants are from Mexico and are undocumented and they represent a vulnerable and marginalized group in American society. There is a growing concern for HIV disease in the migrant community. The HIV prevalence rate among migrants is higher than the average rates in USA and in countries of Latin America. There are many behavioural, social, cultural, and health care risk factors and barriers that place migrants at increased risk for HIV infection. Many migrant workers contract HIV while working and living in the USA, which has contributed to rising HIV infection rates in Mexico. In order to prevent an increasing epidemic of HIV disease in Latino migrant workers, there is an urgent call for new and improved health care policies at the international, federal, state, and local levels.     

Role of Endocrinologists In Eliminating Health Care Disparities

ObjectiveTo review some of the persistent disparities in health and health care in the United States related to race, ethnicity, and socioeconomic status, with a focus on diabetes mellitus and obesity, and to discuss the role of endocrinologists in preventing these disparities.MethodsSome of the efforts made by the US government, such as public health strategies, to address health disparities are outlined, and statistics about diabetes and obesity are presented.ResultsThe elimination of health disparities, recognized as a national challenge for decades, is a national priority as defined in the national goals for Healthy People 2010. Health disparities refer to the differences in the quality of health and health care access and outcomes across racial, ethnic, and socioeconomic groups. Such disparities may be related to the patient (education, socioeconomic status, environment, language), the health care system (location, structural barriers, financial resources), or the provider, including a lack of diversity in the health care workforce. Endocrinologists are responsible for the care of many patients with chronic diseases, including obesity and diabetes mellitus. Both of these chronic diseases are diagnosed with increased frequency in minority populations and are preventable, difficult to manage, and associated with many complications and high health care costs.ConclusionThe role of endocrinologists is to provide equitable, affordable, accessible, high-quality, timely, cost-effective, and culturally sensitive health care. They must be involved in population health decisions and development of optimal health care policy so that endocrine disorders can ultimately be prevented. In addition, they must educate themselves, their patients, and the community regarding maintenance of healthy lifestyles to prevent complications. (Endocr Pract. 2009;15:612-623)     

Association of Plasma Parathyroid Hormone with Metabolic Syndrome and Risk for Cardiovascular Disease

ObjectiveTo review the current literature investigating the association of plasma parathyroid hormone (PTH) with the prevalence of metabolic syndrome and the risk for cardiovascular disease (CVD).MethodsWe conducted a search of PubMed and Medline database using the terms hyperparathyroidism, metabolic syndrome, hypertension, hyperlipidemia, hyper-glycemia, and CVD. We reviewed relevant studies from 2004 to 2012.ResultsThe current literature assessing the association of plasma PTH levels with metabolic syndrome and CVD is inconsistent; however, positive associations among hyperparathyroidism, metabolic syndrome, and CVD were found in a majority of the studies. The differences in the study populations may partly explain the mixed results.ConclusionIn the general population, a high serum PTH level predisposes patients to CVD mortality. Further research is needed to determine the role of PTH in the etiology of metabolic syndrome and CVD. (Endocr Pract. 2013;19:712-717)     

Effect of Gender on Awareness of Cardiovascular Risk Factors,Preventive Action Taken,and Barriers to Cardiovascular Health in a Group of Austrian Subjects

BackgroundThe incidence of cardiovascular disease (CVD) is increasing in industrialized countries. Preventive action is an important factor in minimizing CVD-associated morbidity and mortality. However, it is not known whether gender differences affect CVD or risk factor awareness influencing self-assessment of personal risk and preventive action.ObjectiveThis study was performed to assess individual CVD and risk factor awareness, preventive action taken, and barriers to cardiovascular health.MethodsThe study included 573 women and 336 men, randomly chosen to complete an anonymous questionnaire to assess individual CVD and risk factor awareness, preventive action taken, and barriers to cardiovascular health. The data were analyzed using SAS software.ResultsCardiovascular disease was identified in 75% of patients, in both sexes, as the leading cause of death; however, both groups showed significant lack of knowledge about CVD risk factors. Type 2 diabetes was identified correctly in only 27.5%. Preventive action was linked more often to family members in 66.5% of women and 62.8% of men. The primary barrier to cardiovascular health in adults was incorrect assessment of personal CVD risk. More than half of female respondents (56.4%) and male respondents (52.7%) underestimated their risk of CVD.ConclusionKnowledge about risk factors for CVD needs to be improved in members of both sexes. Because women, in particular, have difficulty in correctly assessing their personal CVD risk, future education programs are warranted to inform both women and men about CVD and its risk factors, thereby helping them to correctly assess their individual risk. However, greater effort is needed to inform men, compared with women, about the various ways in which to prevent CVD and to motivate them to take preventive action.     

Lessons from the field--health care experiences and preferences in a Latino community

As part of Midwest Bioethics Center's PATHWAYS to Improve End-of-Life Care project, we conducted an exploratory study in the Latino community of Kansas City to understand health beliefs, practices, and values, particularly as they relate to end-of-life care. We conducted ten focus groups and interviewed more than seventeen individuals who serve the Latino community in a social service, ministry, or health care capacity. We found that people were very concerned with "barriers to health care" (our term), and very willing to reveal their preferences for health care decision making and end-of-life care treatment options. We believe that bioethicists should conduct other, similar projects because they can improve our engagement with the Latino population and help Latinos find a greater voice in health care settings.     

Impact of Race/Ethnicity on the Efficacy and Safety of Commonly used Insulin Regimens: A Post HOC Analysis of Clinical Trials in Type 2 Diabetes Mellitus

ObjectiveTo explore the impact of race/ethnicity on the efficacy and safety of commonly used insulin regimens in patients with type 2 diabetes mellitus.MethodsIn this post hoc analysis, pooled data from 11 multinational clinical trials involving 1455 patients with type 2 diabetes were used to compare specific insulin treatments in Latino/Hispanic, Asian, African-descent, and Caucasian patients. Insulin treatments included once daily insulin glargine or neutral protamine Hagedorn (BASAL), insulin lispro mix 75/25 twice daily (LMBID), or insulin lispro mix 50/50 three times daily (LMTID).ResultsRace/ethnicity was associated with significant outcome differences for each of the insulin regimens. BASAL therapy was associated with greater improvement in several measures of glycemic control among Latino/Hispanic patients compared with Caucasian patients (lower end point hemoglobin A1c, greater reduction in hemoglobin A1c from baseline, and a larger proportion of patients achieving hemoglobin A1c level < 7%). In contrast, LMBID therapy was associated with higher end point hemoglobin A_1c and a smaller decrease in hemoglobin A_1c from baseline in Latino/Hispanic and Asian patients than in Caucasian patients. Furthermore, fewer Asian patients attained a hemoglobin A_1c level < 7% than did Caucasians patients. For LMTID therapy, hemoglobin A_1c outcomes were comparable across patient groups. Fasting blood glucose and glycemic excursions varied among racial/ethnic groups for the 3 insulin regimens. Weight change was comparable among racial/ethnic groups in each insulin regimen. During treatment with LMTID, Asian patients experienced higher incidence and rate of severe hypoglycemia than Caucasian patients.ConclusionsLatino/Hispanic, Asian, and African-descent patients with type 2 diabetes show different metabolic responses to insulin therapy, dependent in part on insulin type and regimen intensity. (Endocr Pract. 2010: 818-828:pp)     

Oral microbiota of children in a school-based dental clinic

ObjectivesDental caries disproportionately affects disadvantaged subjects. This study hypothesized that there were greater caries extent and higher levels of caries-associated and anaerobic subgingival bacterial species in oral samples of Hispanic and immigrant children compared with non-Hispanic and US born children.MethodsChildren from a school-based dental clinic serving a community with a large Hispanic component were examined, and the extent of caries was recorded. Microbial samples were taken from teeth and the tongues of children. Samples were analyzed using DNA probes to 18 oral bacterial species.ResultsSeventy five children were examined. Extent of caries increased with child age in immigrant, but not in US born or Hispanic children. There were no differences in the microbiota based on ethnicity or whether the child was born in US or not. There was a higher species detection frequency from teeth than tongue samples. Levels of Streptococcus mutans and other Streptococcus spp increased with caries extent. Prevotella intermedia, Tannerella forsythia and Selenomonas spp were detected at low levels in these children.ConclusionsWe conclude that, while there was a high rate of dental caries in disadvantaged school children, there were no differences in the caries-associated microbiota, including S. mutans, based on ethnicity or immigration status. Furthermore, while anaerobic subgingival, periodontal pathogens were also detected in children, there was no difference in species detection based on ethnicity or immigration status. Increased levels of streptococci, including S. mutans, however, were detected with high caries levels. This suggested that while it is beneficial to target preventive and treatment programs to disadvantaged populations, there is likely no additional benefit to focus on subgroups within a population already at high risk for dental disease.     

Disparities in Utilization and Outcomes With Continuous Subcutaneous Insulin Infusion in Young Adults With Type 1 Diabetes

ObjectiveTo evaluate which factors determine utilization patterns and outcomes of continuous subcutaneous insulin infusion (CSII) in young adults with type 1 diabetes.MethodsUtilizing the Optum deidentified electronic health record data set between 2008 to 2018 to perform a retrospective cohort study, we identified 2104 subjects with type 1 diabetes aged 18 to 30 years. We evaluated the effect of race on determining CSII utilization, HbA1c (%), and hospital admission for diabetic ketoacidosis (DKA). Crude and adjusted estimates were computed using logistic regression and linear mixed models.ResultsThere was low CSII utilization among individuals who were Black, Hispanic, male, and those with governmental insurance. These groups also demonstrated higher HbA1c levels. Subjects who were Black, Hispanic, and those with governmental insurance had higher odds of DKA. Even when commercially insured, Black and Hispanic subjects demonstrated higher HbA1c levels, and Black individuals had higher odds of DKA.ConclusionIn a large electronic health record database in the U.S., there was low CSII utilization overall, particularly in Black and Hispanic minorities, despite CSII showing superior HbA1c control without an increase in DKA events.     

The Rationale for Prandial Glycemic Control in Diabetes Mellitus

Background:Diabetes mellitus (DM) is of epidemic proportions worldwide, and its microvascular and macrovascular complications have been well described. Achieving glycemic control has been demonstrated to reduce patients' risk of developing these complications.Objective:The objective of this article was to examine how prandial hyperglycemia-especially postprandial hyperglycemia (PPHG)-affects overall glycemic control and the complications of DM and to discuss the pharmacologic agents available to reduce PPHG.Methods:Materials used for this article were identified through a MEDLINE search of the literature (1975–2006). English-language randomized, controlled, prospective, cohort, and observational studies were chosen using the search terms postprandial hyperglycemia, oxidative stress, cardiovascular disease, macrovascular disease, microvascular disease, lipidemia, and coagulation.Results:Data show that controlling prandial hyperglycemia reduces the risk of cardiovascular disease (CVD) andmicrovascular complications, lowers glycosylated hemoglobin levels, causes less oxidative stress, and leads to a more favorable coagulation and postprandial lipidemia profile. Guidelines for targeting PPHG are becoming standard, and various pharmacologic agents (eg, a-glucosidase inhibitors, amylin analogues, incretin mimetics, rapid-acting insulins and insulin analogues, meglitinide analogues) that target PPHG may also improve overall glycemic control and reduce CVD risk.Conclusions:Although the level of hyperglycemia that leads to microvascular and macrovascular complications inpatients with DM remains to be elucidated, it appears prudent to address prandial hyperglycemia, especially PPHG, rather than focus solely on fasting glucose levels. Clinicians should consider incorporating agents that lower PPHG in their treatment of patients with DM.     

Cancer screening barriers and facilitators for under and never screened populations: A mixed methods study

BackgroundCancer screening is below targets in Ontario, Canada. Our objective was to identify and quantify the barriers and facilitators for breast, cervical and colorectal cancer screening for under and never screened (UNS) residents living in Ontario between 2011 and 2013.MethodsWe used a multi-phased mixed methods study design. Results from thematic analysis of focus group discussions with health care providers and UNS community members were used to develop an on-line, province-wide, cross-sectional survey to estimate the prevalence of barriers and facilitators for the provincial population. Adjusted prevalence odds ratios and 95% confidence intervals were estimated for UNS compared to regularly screened participants using logistic regression.ResultsFour focus groups were held with health service providers and sixteen with UNS community members. Top barriers and facilitators themed around provider-patient communication, fear and embarrassment, history of physical or sexual abuse, social determinants of health (including low literacy, lack of awareness, and health insurance), symptoms appearing, and family and friends. 3075 participants completed the online survey. Compared to regularly screened participants, UNS had significantly higher odds of reporting: no regular health care provider; not feeling comfortable talking about screening; or the Doctor or Nurse Practitioner not suggesting screening. UNS also had significantly higher odds of reporting the facilitators: the test being less scary/painful or uncomfortable; friend/family insisting on getting screened; starting to have symptoms; or an easier test that could be done at home.ConclusionsInterventions addressing fear through individual, interpersonal and structural facilitators may increase cancer screening.     

Cystic Fibrosis-Related Diabetes Mellitus: Etiology,Evaluation, and Management

ObjectiveTo review the pathophysiology, diagnosis, and management of cystic fibrosis-related diabetes mellitus (CFRD).MethodsWe performed a MEDLINE search of the literature, using the search terms “cystic fibrosis-related diabetes, “CFRD,” and “cystic fibrosis and diabetes,” to identify pertinent articles available in English.ResultsIn patients with cystic fibrosis (CF), CFRD is a major cause for an accelerated decline in health. It is the result of multiple pathophysiologic mechanisms, including destruction of pancreatic islet cells, impaired hepatic response to the antigluconeogenic effects of insulin, and impaired insulin sensitivity. Nutritional management and adequate caloric intake are paramount to successful management of CF. Although insulin remains the standard of care for treating CFRD in conjunction with fasting hyperglycemia, a small but growing body of literature supports the use of oral therapies. In this article, we discuss the benefits of and possible adverse reactions to the various classes of oral and injectable agents used in the treatment of diabetes mellitus, with special attention to the population of patients with CF.ConclusionOrally administered agents can have a role in the treatment of CFRD. Further study is needed to determine the optimal combination of therapeutic modalities for CFRD. (Endocr Pract. 2008;14:1169-1179)     

Identifying Probable Diabetes Mellitus Among Hispanics/Latinos from Four U.S. Cities: Findings from the Hispanic Community Health Study/Study of Latinos

Objective: The aim of this study was to compare the ability of American Diabetes Association (ADA) diagnostic criteria to identify U.S. Hispanics/Latinos from diverse heritage groups with probable diabetes mellitus and assess cardiovascular risk factor correlates of those criteria.Methods: Cross-sectional analysis of data from 15,507 adults from 6 Hispanic/Latino heritage groups, enrolled in the Hispanic Community Health Study/Study of Latinos. The prevalence of probable diabetes mellitus was estimated using individual or combinations of ADA-defined cut points. The sensitivity and specificity of these criteria at identifying diabetes mellitus from ADA-defined prediabetes and normoglycemia were evaluated. Prevalence ratios of hypertension, abnormal lipids, and elevated urinary albumin-creatinine ratio for unrecognized diabetes mellitus—versus prediabetes and normoglycemia—were calculated.Results: Among Hispanics/Latinos (mean age, 43 years) with diabetes mellitus, 39.4% met laboratory test criteria for probable diabetes, and the prevalence varied by heritage group. Using the oral glucose tolerance test as the gold standard, the sensitivity of fasting plasma glucose (FPG) and hemoglobin A1c—alone or in combination—was low (18, 23, and 33%, respectively) at identifying probable diabetes mellitus. Individuals who met any criterion for probable diabetes mellitus had significantly higher (P<.05) prevalence of most cardiovascular risk factors than those with normoglycemia or prediabetes, and this association was not modified by Hispanic/Latino heritage group.Conclusion: FPG and hemoglobin A1c are not sensitive (but are highly specific) at detecting probable diabetes mellitus among Hispanics/Latinos, independent of heritage group. Assessing cardiovascular risk factors at diagnosis might prompt multitarget interventions and reduce health complications in this young population.Abbreviations:2hPG = 2-hour post–glucose load plasma glucoseADA = American Diabetes AssociationBMI = body mass indexCV = cardiovascularFPG = fasting plasma glucoseHbA1c = hemoglobin A1cHCHS/SOL = Hispanic Community Health Study/Study of LatinosHDL-C = high-density-lipoprotein cholesterolNGT = normal glucose toleranceNHANES = National Health and Nutrition Examination SurveyOGTT = oral glucose tolerance testTG = triglycerideUACR = urine albumin-creatinine ratio     

Structural violence and compassionate compatriots: immigrant health care in South Florida

Abstract

Based on more than twenty in-depth interviews with health care professionals in Miami-Dade County clinics and hospitals, this study explores immigrant access to health care. We focus on some of the debates that took place during the 2009–10 process of US health care reform, which uncovered a pervasive public fear that immigrants illegitimately access health care. This study found the opposite: immigrants in South Florida often avoid primary health care even when offered freely and legally. This is because of bewilderment about bureaucratic requirements, fear of deportation and bills, and cultural folkways. We present the former two barriers as forms of structural and symbolic violence. We conclude by describing South Florida's compassionate compatriots, as a means by which immigrants can be guided through the health care system.     

Diabetes,obesity, and erectile dysfunction

Background: Diabetes mellitus (DM) and obesity affect large parts of the population in the United States and around the world. These disorders are among the most common risk factors for erectile dysfunction (ED), because of their effects on the vasculature and the hormonal milieu.Objective: This article reviews the current literature on the connection between DM, obesity, and ED.Methods: Using the search terms erectile dysfunction, endothelial dysfunction, hypogonadism, diabetes, and obesity, a systematic review of the available literature in the PubMed database was conducted. Relevant English-language publications (to August 2008) were identified.Results: ED is highly prevalent in men with both DM and obesity, and may act as a harbinger for cardiovascular disease (CVD) in this high-risk population. In addition to male hypogonadism and macrovascular disease, endothelial dysfunction is central to the connection between the metabolic syndrome and ED. Conversely, improved glycemic control and weight loss have been found to improve erectile function.Conclusion: ED is very prevalent in men with DM and obesity. It is increasingly being recognized as an early clinical indicator and motivator for patients with CVD. The role of pharmacologic ED treatments in improving endothelial function is currently being investigated.     

Improving Ambulatory Diabetes Care In High-Risk Racial Minorities:Use Of Culture-Specific Education And Close Follow-Up

ObjectiveTo describe a project aimed at improving diabetes care in the ambulatory setting among 2 high-risk racial minorities (African American and Hispanic patients) by using culture-specific education provided by trained diabetes educators from the same racial groups as the targeted patients.MethodsTwo nurse educators, 1 Hispanic and 1 African American, completed a standardized chronic disease management program, as did 2 patients with diabetes from each of the aforementioned ethnic groups in preparation for training other patients. The study patients participated in group classes or one-on-one sessions to learn about appropriate management of their diabetes, related complications, and improved lifestyle habits. Close follow-up by telephone and regular appointments ensured that appropriate glucose monitoring and laboratory tests were performed. Outcome measures before and after the intervention were recorded, with final project follow-up at 24 months. A control group was identified during the same period, which received standard care (follow-up with a physician every 3 to 6 months).ResultsAn improvement in control of diabetes occurred, as determined by a significant decline in hemoglobin A1c levels in both minority study groups. Emergency department visits also decreased significantly.Lipid profiles and microalbumin showed improvement as well. More than 90% of patients kept appointments and had all laboratory studies performed.Conclusion: The project intervention had a notable effect, physically and psychologically, on the 2 ethnic sample populations studied. These results have major implications, both clinically and financially, for public health policy planning for diabetes care in minority populations. (Endocr Pract 2010;16:171-177)     

Salt Sensitivity,Insulin Resistance and Public Health in India

ObjectiveTo provide a current overview of the worldwide prevalence and pattern of cardiovascular disease and discuss the role of sodium intake and salt sensitivity, with a focus on the Asian Indian population.MethodsAn extensive search of the literature from PubMed and the Cochrane Library was undertaken. Moreover, the pathophysiologic basis of the relationship between sodium intake and insulin sensitivity in various populations was reviewed.ResultsHigh blood pressure is the most common cause of cardiovascular disease and mortality globally. Although salt sensitivity is a frequent determinant of hypertension, a strong link between salt sensitivity and cardiovascular disease associated with insulin resistance has not received adequate attention. This may be particularly relevant to the public health challenges of increasing prevalences of obesity, diabetes, and cardiometabolic syndrome in India where, according to recent estimates, approximately 60% of the world’s cases of cardiovascular disease occur and the salt consumption is among the highest in any large population.ConclusionThere is evidence for a strong link between increased salt sensitivity and insulin resistance leading to metabolic syndrome and cardiovascular disease. This relationship may be particularly relevant to the escalating epidemic of cardiovascular disease in the southern Asian Indian population. A broad-based community action to achieve at least a modest restriction of salt intake can yield important health benefits and is urgently needed. (Endocr Pract. 2010;16:940-944)