Estimating prevalence of type 1 and type 2 diabetes in a population of African Americans with diabetes mellitus.

The pathogenesis, treatment, and outcomes of type 1 and type 2 diabetes differ. Current surveys derive population-based estimates of diabetes prevalence by type using limited clinical information and applying classification rules developed in white populations. How well these rules perform when deriving similar estimates in African American populations is unknown. For this study, data were collected on a group of African Americans with diabetes who enrolled at the Diabetes Unit of Grady Memorial Hospital in Atlanta, Georgia, from April 16, 1991, to November 1, 1996. The data were used to develop some simple classification rules for African Americans based on a classification tree and a logistic regression model. Sensitivities and specificities, in which fasting C-peptide was used as the gold standard, were determined for these rules and for two current rules developed in mostly white, non-Hispanic populations. Rules that yielded precise (minimum variance unbiased) estimates of the prevalence of type 1 diabetes were preferred. The authors found that a rule based on the logistic regression model was best for estimating type 1 prevalences ranging from 1% to 17%. They concluded that simple classification rules can be used to estimate prevalence of diabetes by type in African American populations and that the optimal rule differs somewhat from the current rules.

Diabetes in urban African Americans. III. Management of type II diabetes in a municipal hospital setting.

OBJECTIVE: Management of type II diabetes is difficult, particularly in urban populations with limited resources and access to care. To evaluate the effectiveness of structured care delivered by non-physician providers, patients were studied prospectively for 6 months in a municipal hospital diabetes clinic. DESIGN AND METHODS: The population was approximately 90% African American and had median known diabetes duration of approximately 1 year, 54% had incomes below the Federal Poverty Guideline. Primary management was provided by nurse-practitioners and dietitians, and primary outcome measures were hemoglobin A1c (HbA1c), fasting plasma glucose, and changes in body weight. RESULTS: Responses were analyzed in 325 new patients returning for visits at 2, 4, 6, and 12 months; metabolic profiles at presentation were similar to those of subjects who missed intervening visits. Lean patients largely continued on pharmacologic therapy and improved HbA1c from 9.4% to 7.4% at 2 months (P < 0.001), remained stable through 6 months, then rose to 7.9% at 1 year. Obese patients (71%) received dietary instruction. Weaning of pharmacologic therapy was attempted for the first 2 months, resulting in a decline of HbA1c from 9.6% to 8.0% (P < 0.001), with 70% treated with diet alone. In the obese, HbA1c continued to decrease through 6 months (7.7%). Thereafter, providers saw patients at their own discretion and intensified therapy as needed. Although by 1 year, HbA1c had risen to only 8.2%, some patients required reinstitution of pharmacologic therapy; 59% were on diet alone. While 52% lost 4 lb or more (mean 9.3) by 2 months, little additional weight was lost. Interestingly, glycemic control was improved both in those who lost > or = 8.5 lb in the first 2 months (HbA1c 9.6% to 8.1% at 12 months), and in those who gained weight (HbA1c 10.2% to 8.2%). In the obese patients using pharmacologic agents at presentation, 35% were able to discontinue oral agents or insulin by 1 year, with good glycemic control (HbA1c < 8%). For patients who were initially on diet alone, a fasting plasma glucose > 177 mg/dL predicted the need for pharmacologic therapy with 97% certainty. CONCLUSIONS: In urban African American patients, nonpharmacologic management of type II diabetes substantially improves metabolic control; decreases in HbA1c are comparable in those who do and do not lose weight. Therapy managed by nonphysician providers can be an effective cornerstone of diabetes care in this socioeconomically disadvantaged population.

Diabetes in urban African-Americans. II. High prevalence of microalbuminuria and nephropathy in African-Americans with diabetes.

OBJECTIVE: African-Americans with diabetes have an increased risk of endstage renal disease, but underlying mechanisms are poorly understood. We undertook this study to evaluate prevalence and risk factors for renal disease in an African-American population with diabetes. RESEARCH DESIGN AND METHODS: We measured urine albumin excretion in 578 consecutive patients presenting for the first time to the Grady Memorial Hospital Diabetes Unit in Atlanta, GA. The unit serves an urban population that is predominantly African-American; 85% of patients have non-insulin-dependent diabetes mellitus (NIDDM). Subjects provided 24-h and/or approximately 3-h urine collections for measurement of albumin and creatinine. RESULTS: Correlation of the albumin/creatinine ratio (micrograms/mg) with the 24-h albumin excretion rate was 0.89 (P < 0.001, n = 123). Although the median duration of diabetes was only 1 year, among all subjects, the estimated prevalence of microalbuminuria (30-300 mg albumin/24 h) was 25% and that of nephropathy ( > 300 mg albumin/24 h) was 11%. Among African-Americans with NIDDM (n = 466), the estimated prevalence of microalbuminuria was 24% and that of nephropathy was 12%; prevalence remained high (25 and 5%, respectively) among 219 patients with < 1 year known duration of diabetes. Metabolic control was not associated with disease. However, among all subjects with NIDDM, the odds ratio for nephropathy among subjects with disease duration > 5 years compared with those with disease duration < 1 year was 4.65 (95% confidence interval [CI] 2.24-9.79), and the odds ratio for nephropathy among subjects with hypertension compared with those without hypertension was 2.64 (CI 1.42-4.93). Odds ratios were comparable among African-Americans with NIDDM. Trends were similar but less significant for subjects with microalbuminuria. CONCLUSIONS: Albuminuria can be identified reliably and conveniently by the albumin/creatinine ratio in brief urine collections. In our patients, clinically significant albuminuria occurred in 36% of persons at first presentation. Since increased risk was associated with hypertension and control of hypertension can slow progression of renal disease, screening for albuminuria and treatment of hypertension should be aggressive in urban populations of African-Americans with diabetes.

Dyslipidemia and ischemic heart disease mortality among men and women with diabetes.

BACKGROUND: We investigated whether the greater increased risk of ischemic heart disease mortality associated with diabetes among women compared with men could be explained by their more pronounced lipoprotein abnormalities. METHODS AND RESULTS: Seventy-six men and 45 women with diabetes and 327 men and 496 women without diabetes were followed for an average of 16 years in a population-based study. Cox proportional hazards models were used to determine the relative hazard of ischemic heart disease mortality for changes in lipoprotein subfractions after adjustment for age, hypertension, obesity, smoking, exercise, alcohol consumption, and estrogen use (among women). The relative hazard of ischemic heart disease mortality among diabetic women was 1.76 (P = .10) for a 10-mg/dL decrement in high-density lipoprotein cholesterol (HDL-C) and 3.13 (P = .01) for a 1-U increment in log very-low-density lipoprotein cholesterol (VLDL-C). The risk of ischemic heart disease mortality among diabetic women relative to nondiabetic women for an HDL-C level of 50 mg/dL and a log(e) VLDL-C of 3 (about 20 mg/dL) were 4.1 and 3.4, respectively (P < .05). These lipoprotein changes were not associated with ischemic heart disease mortality among men or among nondiabetic women. CONCLUSIONS: Excess ischemic heart disease mortality among diabetic women is partially explained by deleterious levels of HDL-C and VLDL-C. HDL-C levels of < or = 50 mg/dL and VLDL-C levels of > or = 20 mg/dL appear to predict ischemic heart disease mortality among these women and may help identify women who would benefit most from intervention.

Survey of physician practice behaviors related to diabetes mellitus in the U.S. Physician adherence to consensus recommendations.

OBJECTIVE: To summarize the frequency of physician adherence to consensus recommendations for prevention of diabetic complications. RESEARCH DESIGN AND METHODS: Survey data from a nationwide stratified probability sample of primary-care physicians were analyzed. Adherence to recommendations were reported by physician specialty, age-group, and type of diabetes treated. RESULTS: Adherence was high for eye exams, blood pressure measurements, neurological and circulatory exams, and laboratory procedures using blood. Adherence was low for examination of the teeth and gums, examination of the feet, and laboratory procedures involving the collection of urine. Internists generally had the highest adherence rates and pediatricians the lowest. Reported adherence decreased with physician age. Adherence was higher for the management of individuals with IDDM than for those with NIDDM. CONCLUSIONS: Recommendations for the care of diabetic individuals need to be more widely implemented. Recommendations targeted specifically to pediatricians may be necessary.

Surveillance for diabetes mellitus--United States, 1980-1989.

PROBLEM/CONDITION: In the United States, diabetes mellitus is the most important cause of lower-extremity amputation and end-stage renal disease; the major cause of blindness among working-age adults; a major cause of disability, premature mortality, congenital malformations, perinatal mortality, and health-care costs; and an important risk factor for the development of many other acute and chronic conditions (e.g., diabetic ketoacidosis, ischemic heart disease, stroke). Surveillance data describing diabetes and its complications are critical to increasing recognition of the public health burden of diabetes, formulating health-care policy, identifying high-risk groups, developing strategies to reduce the burden of this disease, and evaluating progress in disease prevention and control. REPORTING PERIOD COVERED: In this report, data are summarized from CDC's diabetes surveillance system; trends in diabetes and its complications are evaluated by age, sex, and race for the years 1980-1989. DESCRIPTION OF SYSTEM: CDC has established an ongoing and evolving surveillance system to analyze and compile periodic, representative data on the disease burden of diabetes and its complications in the United States. Data sources currently include vital statistics, the National Health Interview Survey, the National Hospital Discharge Survey, and Medicare claims data for end-stage renal disease. RESULTS AND INTERPRETATION: In 1989, approximately 6.7 million persons in the United States reported that they had diabetes mellitus, and a similar number probably had this disabling chronic disease without being aware of it. The disease burden of diabetes and its complications is large and is likely to increase as the population grows older. Effective primary, secondary, and tertiary prevention strategies are needed, and these efforts need to be intensified among groups at highest risk, including blacks. Important gaps exist in periodic and representative data for describing the disease burden. ACTIONS TAKEN: CDC is assisting diabetes control programs in 26 states and one territory. These programs attempt to reduce the burden of diabetes by preventing blindness, lower-extremity amputations, cardiovascular disease, and adverse outcomes of pregnancy among persons with diabetes. Because of important limitations in measuring the burden of diabetes, CDC is exploring sources of surveillance data for blindness, adverse outcomes of pregnancy, and the public health burden of diabetes among minority groups.