For a list of other recent or past published articles, see Research Update, published quarterly by the Division of Research.
2008
Gunderson EP, Sternfeld B, Wellons MF, Whitmer RA, Chiang V, Quesenberry Jr CP, Lewis CE, Sidney S.
Childbearing may increase visceral adipose tissue independent of overall increase in body fat. Obesity 2008;16(5):1078–84. PubMed Funding Sources: National Heart, Lung, and Blood Institute; National Institute of Diabetes and Digestive and Kidney Diseases Career Development Award.
The authors prospectively examined changes in adiposity assessed via computed tomography and dual energy x-ray absorptiometry among 122 premenopausal women (50 black, 72 white) examined in 1995 to 1996, and again in 2000 to 2001. Among 14 women delivering one birth and 108 with no births, visceral adipose tissue increased by 40% and 14% above initial levels for 1 birth and 0 birth groups, respectively, during the five-year interval adjusted for age, race, and changes in total and subcutaneous adiposity. Pregnancy may be associated with preferential accumulation of adipose tissue in the visceral compartment for similar gains in total body fat. Further investigation is needed to confirm these findings and determine whether excess visceral fat deposition with pregnancy adversely affects metabolic risk profiles among women.
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Whitmer RA, Gustafson DR, Barrett-Connor E, Haan MN, Gunderson EP, Yaffe K.
Central obesity and increased risk of dementia more than three decades later. Neurology. 2008 Sep 30;71(14):1057-64. PubMed Funding Source: Not available.
This study evaluated the association between midlife central obesity and risk of dementia three decades later. A longitudinal analysis was conducted on 6,583 Kaiser Permanente Northern California members who had their sagittal abdominal diameter (SAD) measured in 1964 to 1973. Diagnoses of dementia were from medical records an average of 36 years later. A total of 1,049 participants (15.9%) were diagnosed with dementia. Compared with those in the lowest quintile of SAD, those in the highest had nearly a threefold increased risk of dementia. Conclusions show that central obesity in midlife increases risk of dementia independent of diabetes and cardiovascular comorbidities.
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Gunderson EP.
Breast-feeding and diabetes: long-term impact on mothers and their infants. Curr Diab Rep 2008;8(4):279-86. PubMed Funding Source: National Institute of Diabetes and Digestive and Kidney Diseases.
In the general population, breast-feeding slows infant growth up to two years of age and is associated with a 22% to 24% lower risk of becoming overweight from preschool age to adulthood. Yet, evidence is inconclusive about whether breast-feeding protects the offspring of mothers with diabetes during pregnancy against overweight and subsequent type 2 diabetes, or whether lactation protects against type 2 diabetes after delivery in women with previous gestational diabetes. Given the paucity of evidence and equivocal findings about the long-term effects of breast-feeding on future health of women with diabetes during pregnancy and their infants, further research is recommended.
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Ahmed AT, Karter AJ, Warton EM, Doan JU, Weisner CM.
The relationship between alcohol consumption and glycemic control among patients with diabetes: The Kaiser Permanente Northern California Diabetes Registry. J Gen Intern Med 2008;23(3):275-82. PubMed Funding Source: National Institute on Alcohol Abuse and Alcoholism AA015721-02.
Alcohol consumption was linearly (p<0.001) and inversely (p=0.001) associated with A1C among diabetes patients. This supports current clinical guidelines for moderate levels of alcohol consumption among diabetes patients, and suggests that physicians can advise their diabetes patients who drink moderately that continuing to do so will not adversely affect glycemic control. As glycemic control affects incidence of complications of diabetes, the lower A1C levels associated with moderate alcohol consumption may translate into lower risk for complications.
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Hedderson MM, Williams MA, Holt VL, Weiss NS, Ferrara A.
Body mass index and weight gain prior to pregnancy and risk of gestational diabetes mellitus. Am J Obstet Gynecol 2007. PubMed Funding Sources: National Institute of Diabetes and Digestive and Kidney Diseases R01 DK54834; American Diabetes Association Research Award.
The objective of this study was to evaluate obesity and rate of weight change during the five years before pregnancy and risk of gestational diabetes mellitus (GDM) in a nested case-control study. Women who gained weight at a rate of 2.3 to 10.0 kg/year had a 2.5-fold increased risk of GDM, independent of age, race-ethnicity, parity and “baseline” body mass index. These results suggest that weight gain within five years before pregnancy increases the risk of GDM.
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Karter AJ, Stevens MR, Gregg EW, Brown AF, Tseng CW, Marrero DG, Duru OK, Gary TL, Piette JD, Waitzfelder B, Herman WH, Beckles GL, Safford MM, Ettner SL.
Educational disparities in rates of smoking among diabetic adults: the Translating Research Into Action for Diabetes Study. Am J Public Health 2008;98(2):365-70. PubMed Funding Sources: Centers for Disease Control and Prevention U-48-CCU916373; National Institute of Child Human Development R01 HD046113-01.
Using survey data from this study, educational disparities in smoking rates were evaluated among 6,538 diabetic patients over age 25. There was a strong educational gradient (i.e., those with less education were more likely to smoke) among subjects aged 25 to 44, a modest gradient among those aged 45 to 64, and no gradient among those aged 65 years or older. Authors observed that 50% of poorly educated, young adults with diabetes smoke, greatly magnifying the already increased health risk associated with early-onset diabetes. This alarming smoking rate calls for targeted public health interventions for smoking prevention and cessation among young, poorly educated people with diabetes.
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Schmittdiel JA, Uratsu CS, Karter AJ, Heisler M, Subramanian U, Mangione CM, Selby JV.
Why don't diabetes patients achieve recommended risk factor targets? Poor adherence versus lack of treatment intensification. J Gen Intern Med 2008. PubMed Funding Sources: Centers for Disease Control U58/CCU923527-04-1; Office of Research in Women’s Health Building Interdisciplinary Careers in Women’s Health K12 Career Development Award K12HD052163.
Despite availability of effective hypertension, hyperlipidemia, and hyperglycemia therapies, target levels of systolic blood pressure (SBP), LDL-cholesterol (LDL-c), and hemoglobin A1c control are often not achieved. The authors examined the relative importance of patient medication nonadherence versus clinician lack of therapy intensification in explaining above target SBP, LDL-c, and A1c levels in 161,697 Kaiser Permanente Northern California diabetes patients in 2005. While both nonadherence and lack of treatment intensification occurred frequently in patients above target, lack of therapy intensification was more common across all three risk factors. Quality improvement efforts should focus on these modifiable barriers to cardiovascular disease risk factor control.
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Moffet HH, Adler N, Schillinger D, Ahmed AT, Laraia B, Selby JV, Neugebauer R, Liu JY, Parker MM, Warton M, Karter AJ.
Cohort Profile: The Diabetes Study of Northern California (DISTANCE)--objectives and design of a survey follow-up study of social health disparities in a managed care population. Int J Epidemiol. 2008 Mar 7; [Epub ahead of print] PubMed
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Ferrara A, Mangione CM, Kim C, Marrero DG, Curb D, Stevens M, Selby JV; for the Translating Research into Action for Diabetes (TRIAD) Study Group.
Sex disparities in control and treatment of modifiable cardiovascular disease risk factors among patients with diabetes: Translating Research into Action for Diabetes (TRIAD). Diabetes Care 2008 Jan;31(1):69-74. PubMed Funding Source: Centers for Disease Control and Prevention.
Cardiovascular disease (CVD) mortality has decreased in men but not in women with diabetes. The authors investigated whether gender differences in control and treatment of CVD risk factors might underlie this disparity. In a cohort of diabetes patients sampled from ten U.S. managed care health plans, results showed that women were less likely to have systolic blood pressure (SBP) and low density lipoprotein cholesterol (LDL-C) in control than men. Women were also less likely to receive appropriate management for hypercholesterolemia than men. Poorer control of SBP and LDL-C for women may contribute to the gender disparity in CVD mortality trends.
2007
Gunderson EP, Lewis CE, Tsai AL, Chiang V, Carnethon M, Quesenberry CP Jr, Sidney S.
A 20-year prospective study of childbearing and incidence of diabetes in young women, controlling for glycemia before conception: the Coronary Artery Risk Development in Young Adults (CARDIA) Study. Diabetes 2007;56(12):2990-6. PubMed Funding Sources: National Heart, Lung, and Blood Institute N01-HC-48047, N01-HC-48048, N01-HC-48049, N01-HC-48050, N01-HC-95095; National Institute of Diabetes, Digestive and Kidney Diseases Career Development Award K01 DK059944; American Diabetes Association Research Award.
This study investigated the natural course of childbearing in a biracial (black and white), population-based cohort of 2,408 women who were free of diabetes and normoglycemic at baseline in 1985 and 1986, and had measurements of fasting glycemia and/or glucose tolerance during 20 years of follow-up. Of 193 incident diabetes cases in 42,782 person-years (4.5 cases/1,000 person-years), 84 (44%) had 1+ interim births. Among nulliparas at baseline, adjusted relative hazards (95%CI) were 0.9 (0.6-1.4) for 1+ births without gestational diabetes mellitus (GDM) and 3.8 (2.2-6.6) for 1+ births with GDM versus 0 births. Childbearing did not elevate diabetes incidence among those with normal glucose tolerance during pregnancy. GDM conferred the highest risk of developing diabetes independent of family history of diabetes and preconception glycemia and obesity.
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Karter AJ, Moffet HH, Liu J, Parker MM, Ahmed AT, Go AS, Selby JV.
Glycemic response to newly initiated diabetes therapies. Am J Manag Care 2007;13(11):598-606. PubMed Funding Sources: Novartis Pharmaceuticals; National Institute of Diabetes and Digestive and Kidney Diseases R01 DK65664; National Institute of Child Health and Human Development R01 HD046113-02.
The authors studied glycemic response among 15,126 type 2 diabetic patients who initiated single new antihyperglycemic agents (metformin, sulfonylureas, thiazolidinediones, or insulin added to medical nutrition therapy or to existing diabetes therapies). No significant difference in effect between the four therapies was observed. Despite an excellent response (~1 point lower glycosylated hemoglobin [A1C]), most patients failed to achieve glycemic target (A1C<7%) because therapy intensification occurred too late in the course of deteriorating glycemic control. Findings suggest that patients and providers must commit to earlier, more aggressive therapy intensification, triggered promptly after A1C exceeds the recommended glycemic target.
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Karter AJ, Stevens MR, Brown AF, Duru OK, Gregg EW, Gary TL, Beckles GL, Tseng CW, Marrero DG, Waitzfelder B, Herman WH, Piette JD, Safford MM, Ettner SL.
Educational disparities in health behaviors among patients with diabetes: The Translating Research Into Action for Diabetes (TRIAD) Study. BMC Public Health 2007;7(1):308. PubMed Funding Sources: Centers for Disease Control and Prevention; National Institute of Diabetes and Digestive and Kidney Diseases.
The authors studied the relationship between educational attainment and health behaviors among 8,763 survey respondents from the TRIAD Study, a cohort of patients with diabetes receiving care from ten managed care health plans across the U.S. Patients with less education were more likely to smoke and less likely to engage in regular exercise and health-seeking behaviors (utilizing health education classes or Web sites). Self-monitoring of blood glucose and foot self-examination did not vary by education. Education-behavior relationships were similar across sex and race, and were not altered by the intensity of disease management by the health plan or quality of provider communication.
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Selby JV, Swain BE, Gerzoff RB, Karter AJ, Waitzfelder BE, Brown AF, Ackermann RT, Duru OK, Ferrara A, Herman W, Marrero DG, Caputo D, Narayan KM; for the TRIAD Study Group.
Understanding the gap between good processes of diabetes care and poor intermediate outcomes: Translating Research Into Action for Diabetes (TRIAD). Med Care 2007;45(12):1144-53. PubMed Funding Sources: Centers for Disease Control and Prevention; National Institute of Diabetes and Digestive and Kidney Diseases.
This study examined patient factors associated with control of cardiovascular disease risk factors among diabetes patients who appeared to be receiving good quality care using recommended process measures. Compared to patients (N=1003) with good control of hemoglobin A1c (<8%), systolic blood pressure (<140 mm Hg), and low density lipoprotein-cholesterol (<130 mg/dL), patients with poor control for at least two of these factors (n=812) were more likely to be nonwhite (especially African-American), have lower levels of education and to note lower trust in their physicians, greater worries about medical care costs, higher rates of smoking, and lower levels of physical activity. Adjustment for these psychosocial and behavioral factors did not appear to explain the observed racial and socioeconomic disparities in control.
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Kim C, McEwen LN, Kerr EA, Piette JD, Chames MC, Ferrara A, Herman WH. Preventive counseling among women with histories of gestational diabetes mellitus. Diabetes Care 2007(10);30:2489-95. PubMed ***************************
Kim C, McEwen LN, Piette JD, Goewey J, Ferrara A, Walker EA.
Risk perception for diabetes among women with histories of gestational diabetes. Diabetes Care 2007;30(9):2281-6. PubMed
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Ferrara A.
Increasing prevalence of gestational diabetes mellitus: a public health perspective. Diabetes Care 2007;30 Suppl 2:S141-6. PubMed Funding Sources: National Institute of Diabetes and Digestive and Kidney Diseases; Kaiser Permanente Research Program on Genes, Environment and Health funded by the Wayne and Gladys Valley Foundation, the Ellison Medical Foundation, and Kaiser Foundation Hospitals Health Plan.
Recent data show that gestational diabetes mellitus (GDM) prevalence has increased by about 10 to 100 percent in several race-ethnicity groups during the past 20 years. The trend toward older maternal age, the epidemic of obesity and diabetes, along with the decrease in physical activity and the adoption of modern lifestyles in developing countries may all contribute to an increase in the prevalence of GDM. Since GDM is associated with several perinatal complications, and since women with GDM and their offspring are also at increased risk of developing diabetes later, it is critical to assess trends in GDM prevalence to allocate appropriate resources to perinatal management and postpartum diabetes prevention strategies.
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Gunderson EP.
Breastfeeding after gestational diabetes pregnancy: subsequent obesity and type 2 diabetes in women and their offspring. Diabetes Care 2007;30:S161-8. PubMed Funding Sources: Career Development Award 2 K01 DK059944 from the National Institute of Diabetes and Digestive and Kidney Diseases; Research Award from the American Diabetes Association.
In the general population, breastfeeding is associated with a reduced risk of the offspring being overweight later in life by 20 to 50 percent across the age spectrum; from preschool children to adults. There is a dose-response gradient with increasing duration of breastfeeding, and lowest risk with prolonged, exclusive breastfeeding. The evidence and its biological plausibility were critically examined. Also examined was evidence that breastfeeding influences the risk of overweight and type 2 diabetes among the offspring of women with gestational diabetes, and the mother’s future risk of type 2 diabetes. Given the equivocal findings for women with gestational diabetes and their offspring, further research is recommended.
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Karter AJ, Parker MM, Moffet HH, Ahmed AT, Chan J, Spence MM, Selby JV, Ettner SL.
Effect of cost-sharing changes on self-monitoring of blood glucose. Am J Manag Care 2007;13:408-16. PubMed Funding Source: National Institute of Diabetes and Digestive and Kidney Diseases R01-DK6167.
The authors studied the impact of two changes in cost-sharing policy on self-monitoring of blood glucose test strip utilization among prevalent test strip users. Prior to the first policy change, test strip utilization was inversely related to co-payment amounts. To comply with Senate Bill 64, co-payments for health plan members were waived, but utilization did not increase above and beyond that expected by secular changes, even among the economically disadvantaged patients and those paying the most for strips prior to the policy. However, after a two-year period of receiving free strips, the introduction of a 20% co-insurance (under $10) for test strips did result in a statistically significant, albeit not clinically relevant, decrease in utilization.
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Karter AJ, Stevens MR, Gregg EW, Brown AF, Tseng CW, Marrero DG, Duru OK, Gary TL, Piette JD, Waitzfelder B, Herman WH, Beckles GL, Safford MM, Ettner SL.
Educational disparities rates of smoking among diabetic adults: The Translating Research Into Action for Diabetes Study. Am J Public Health 2008 Feb;98(2):365-70. PubMed Funding Sources: Centers for Disease Control and Prevention; National Institute of Diabetes and Digestive and Kidney Diseases U-48-CCU916373.
Educational disparities in smoking rates were evaluated among 6,538 diabetic patients over 25 years of age in managed care settings. Fifteen percent of the subjects reported current smoking; there was a strong educational gradient among the youngest subjects (ages 25 to 44), a modest gradient among those aged 45 to 64, and no gradient among those aged 65 years or older. The prevalence of smoking observed among the youngest subjects with less than a high school education subjects was 50%, greatly magnifying the already increased health risk associated with early-onset diabetes. This alarming smoking rate calls for targeted public health interventions for smoking prevention and cessation among young, poorly educated people with diabetes.
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Whitmer RA.
Type 2 diabetes and risk of cognitive impairment and dementia. Curr Neurol Neurosci Rep 2007;7:373-80. PubMed Funding Source: National Institute of Diabetes and Digestive and Kidney Diseases 066308.
Diabetes is a major public health burden. Several lines of mechanistic evidence implicate a role of insulin and glucose metabolism on risk of developing dementia, including Alzheimer's disease. Population-based studies have shown that those with type 2 diabetes mellitus have an increased risk of cognitive impairment, dementia, and neurodegeneration. There are many mechanisms through which diabetes could increase risk of dementia, including glycemia, insulin resistance, oxidative stress, advanced glycation endproducts, inflammatory cytokines, and microvascular and macrovascular disease. This paper presents a review of the evidence on diabetes and increased risk of dementia and cognitive impairment.
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Beckles GL, Williamson DF, Brown AF, Gregg EW, Karter AJ, Kim C, Dudley RA, Safford MM, Stevens MR, Thompson TJ.
Agreement between self-reports and medical records was only fair in a cross-sectional study of performance of annual eye examinations among adults with diabetes in managed care. Med Care 2007;45:876-83. PubMed
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Keating NL, Zaslavsky AM, Herrinton LJ, Selby JV, Wolf RE, Ayanian JZ.
Quality of diabetes care among cancer survivors with diabetes. Med Care 2007;45:869-75. PubMed
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Lewis JD, Capra AM, Achacoso NS, Ferrara A, Levin TR, Quesenberry CP, Habel LA. Medical therapy for diabetes is associated with increased use of lower endoscopy. Pharmacoepidemiol Drug Saf 2007. PubMed
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Whitmer RA.
The epidemiology of adiposity and dementia. Curr Alzheimer Res 2007;4:117-22. PubMed Funding Sources: National Institute of Diabetes and Digestive and Kidney Diseases DK066308; National Institute on Aging AG027504.
Adipose tissue is the largest endocrine gland in the body, yet only recently has its role in neurodegenerative disease been considered. This study shows that obesity and overweight, as measured by body mass index and skinfold thickness, in middle-age are strongly associated with an increased risk of dementia, Alzheimer disease, and vascular dementia, independent of the development of diabetes and cardiovascular-related morbidities. There is also value in assessing regional body shape distributions of adiposity, particularly the role of abdominal obesity. Mechanistic pathways, e.g., adipocyte secreted proteins and hormones, and inflammatory cytokines, could explain the association between obesity and increased risk of dementia.
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Whitmer RA, Gunderson EP, Quesenberry CP Jr, Zhou J, Yaffe K.
Body mass index in midlife and risk of Alzheimer disease and vascular dementia. Curr Alzheimer Res 2007;4:103-9. PubMed Funding Sources: National Institute of Diabetes and Digestive and Kidney Diseases DK066308; National Institute on Aging AG027504.
Prior work has suggested that obesity and overweight increase risk of dementia. It is unknown if there is a difference in the risk of developing Alzheimer disease (AD) versus vascular dementia (VaD) associated with high body weight. The goal of this study was to examine the association between midlife BMI and risk of both AD and VaD an average of 36 years later. Data results suggest that midlife BMI is strongly predictive of both AD and VaD, independent of stroke, cardiovascular and diabetes comorbidities. Future studies need to unveil the mechanisms between adiposity and excess risk of AD and VaD.
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Schmittdiel J, Vijan S, Fireman B, Lafata J, Oestreicher N, Selby JV.
Predicted quality-adjusted lifeyears as a composite measure of the clinical value of diabetes risk factor control. Medical Care 2007;45: 315-21. PubMed Funding Source: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services, IDSRN Task Order #12, Contract 290-00-0015.
This study used quality-adjusted life years (QALYs) to create a composite indicator of the clinical value of diabetes risk factor control that appropriately weighs the clinical importance of A1c, LDL-c, and blood pressure. There was significant cross-sectional variability in average case-mix adjusted QALYs (generated from patient age, gender, most recent risk factor values, and comorbidities) for diabetes patients across centers in 2003, and longitudinally between 2001 and 2003. Analyses demonstrated the greater impact of blood pressure versus LDL-c or A1c control on QALYs, and the greater value of risk factor control in those with poor versus near or in-control blood pressure. Using predicted QALYs to measure value holds promise as a sensitive composite indicator for quality measurement that can provide useful information to providers, plans, and consumers.
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McEwen LN, Kim C, Karter AJ, Haan MN, Ghosh D, Lantz PM, Mangione CM, Thompson TJ, Herman WH.
Risk factors for mortality among patients with diabetes: The Translating Research Into Action for Diabetes (TRIAD) Study.
Diabetes Care July, 2007. PubMed
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Hedderson MM, Ferrara A, Williams MA, Holt VL, Weiss NS.
Androgenicity of progestins in hormonal contraceptives and the risk of gestational diabetes mellitus. Diabetes Care 2007 PubMed Funding Sources: National Institute of Diabetes & Digestive & Kidney Diseases R01 DK 54834; American Diabetes Association Research Award.
There is some evidence that use of hormonal contraceptives (HCs), particularly the more androgenic formulations, can alter a woman’s glucose tolerance. The association between HC use, categorized by the androgenicity of the progestin component, and risk of gestational diabetes mellitus (GDM) was examined in a nested case-control study. There was a suggestion that, compared with no HC use, use of a low-androgen HC before pregnancy was associated with a slight reduction in risk of GDM (OR: 0.84, 95% CI: 0.58-1.22), whereas use of a high-androgen HC was associated with a modest increase in GDM risk (OR: 1.43, 95% CI: 0.92-2.22). The effects of HC use on GDM risk may vary by the androgenicity of the progestin component.
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Ferrara A, Weiss NS, Hedderson MM, Quesenberry CP Jr, Selby JV, Ergas IJ, Peng T, Escobar GJ, Pettitt DJ, Sacks DA.
Pregnancy plasma glucose levels exceeding the American Diabetes Association thresholds, but below the National Diabetes Data Group thresholds for gestational diabetes mellitus, are related to the risk of neonatal macrosomia, hypoglycaemia and hyperbilirubinaemia. Diabetologia 2007;50:298-306. PubMed Funding Sources: National Institute of Diabetes & Digestive & Kidney Diseases; American Diabetes Association; Kaiser Permanente Community Benefit Program.
The criteria for the diagnosis of gestational diabetes mellitus (GDM) have been in flux, the American Diabetes Association (ADA) thresholds recommended in 2000 being lower than those of the National Diabetes Data Group (NDDG) that have been in use since 1979. The authors sought to determine whether infants of women meeting only the ADA criteria are at increased risk of complications. In a cohort of 45,245 women who did not meet the NDDG criteria and were not treated for GDM, nested case–control studies were conducted of three complications that occurred in their infants: macrosomia, hypoglycaemia, and hyperbilirubinaemia. Women with GDM by ADA criteria only had an increased risk of having an infant with macrosomia (OR=3.40, 95% CI=1.55-7.43), hypoglycaemia (OR=2.61, 95% CI=0.99-6.92), or hyperbilirubinaemia (OR=2.22, 95% CI=0.98-5.04).
2006
Hedderson MM, Weiss NS, Sacks DA, Pettitt DJ, Selby JV, Quesenberry CP, Ferrara A.
Pregnancy weight gain and risk of neonatal complications: macrosomia, hypoglycemia, and hyperbilirubinemia. Obstet Gynecol 2006;108:1153-61. PubMed Funding Sources: National Institute of Diabetes and Digestive and Kidney Diseases R01 DK 54834; American Diabetes Association; Kaiser Community Benefit Program.
The authors examined whether pregnancy weight gains outside the Institute of Medicine (IOM) recommendations and rates of maternal weight gain are associated with neonatal complications. A nested case-control study was conducted with three case groups: macrosomia, neonatal hypoglycemia, and hyperbilirubinemia, and one control group. Women who gained more than recommended by the IOM were more likely than women whose weight gain was in the recommended range to have an infant with macrosomia (OR: 3.05 95% CI: 2.19, 4.26), hypoglycemia (OR: 1.38 95% CI: 1.01, 1.89), or hyperbilirubinemia (OR: 1.43 95% CI: 1.06, 1.93).
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Lo JC, Zhao X, Scuteri A, Brockwell S, Sowers MR.
The association of genetic polymorphisms in sex hormone biosynthesis and action with insulin sensitivity and diabetes mellitus in women at midlife. Am J Med 2006;119:S69-78. PubMed Funding Sources: National Institutes of Health, Department of Health and Human Services, National Institute on Aging, National Institute of Nursing Research, NIH Office of Research on Women’s Health, AG017719, NR004061, AG012505, AG012535, AG012531, AG012539, AG012546, AG012553, AG012554, AG012495.
This study investigates the association of polymorphisms in genes encoding sex hormone biosynthesis and action with insulin sensitivity and diabetes mellitus in a multiethnic cohort of midlife women enrolled in the Study of Women's Health Across the Nation (SWAN). Significant associations of polymorphisms in the genes encoding aromatase (CYP 19) and the estrogen receptors (ESR1 and ESR2) were observed with metabolic phenotype that varied by race/ethnicity. The strongest associations related 17-hydroxysteroid dehydrogenase genotype to diabetes in Caucasian women that has not been previously reported.
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Ahmed AT, Karter AJ, Liu J.
Alcohol consumption is inversely associated with adherence to diabetes self-care behaviours. Diabet Med 2006;23:795-802. PubMed Half of adults with diabetes drink alcohol. This study demonstrated that diabetes patients who drink alcohol are less likely to follow recommended diabetes self-care behaviors than those who do not drink, and the more they drink, the less likely they are to be adherent to recommended self-care behaviors. While the present study did not determine whether consuming alcohol caused the patients to be less adherent to self-care recommendations, clinicians should nevertheless routinely assess alcohol consumption among their diabetes patients, and consider alcohol consumption a marker for poorer adherence to self-care behaviors. Funding Source: Kaiser Permanente Community Benefit Program.
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Whitmer RA, Yaffe K.
Obesity and dementia: lifecourse evidence and mechanisms. Aging Health 2006:2;571-8.
Given the current epidemic of obesity and the expected age-related increase in dementia incidence, even a modest association between these two conditions has far reaching public health implications. However, due to the effects of both AD-associated weight loss and age-related changes in body composition, there are methodological challenges in assessing obesity as a risk factor for developing dementia. There is a need to take a “life course approach” and to consider the role of risk factors prior to old age. There is also value in assessing regional body shape distributions of adiposity. Several mechanistic pathways such as comorbid disease, leptin, adiponectin, and inflammatory cytokines could explain the association between obesity and increased risk of dementia.
Funding Source: National Institutes of Health AG027504.
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Karter AJ, Parker MM, Moffet HH, Spence MM, Chan J, Ettner SL, Selby JV.
Longitudinal study of new and prevalent use of self-monitoring of blood glucose. Diabetes Care 2006;29:1757-63. PubMed The authors conducted longitudinal analyses of changes in glycemic control among 16,091 patients initiating self-monitoring of blood glucose (SMBG) (new user cohort) and 15,347 ongoing users of SMBG (prevalent user cohort). Greater SMBG practice frequency among new users was associated with a graded decrease in hemoglobin A1c (A1C) (relative to nonusers) regardless of diabetes therapy (p<0.0001). Changes in SMBG frequency during a 4-year period among prevalent users were associated with an inverse, graded change in A1C only among pharmacologically treated patients (p<0.0001). These observational findings are consistent with short-term benefits of initiating SMBG practice for all patients, but continuing benefits only for pharmacologically treated patients. Funding Source: National Institutes of Health R01 DK61678-02.
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Lo JC, Feigenbaum SL, Escobar GJ, Yang J, Crites YM, Ferrara A.
Increased prevalence of gestational diabetes mellitus among women with diagnosed polycystic ovary syndrome: a population-based study. Diabetes Care 2006;29:1915-7. PubMed This is a population-based study of pregnant women without pre-existing diabetes mellitus who underwent screening for gestational diabetes. Women were characterized by evidence of current or prior diagnosis of polycystic ovary syndrome (PCOS), a common reproductive disorder associated with menstrual irregularity and androgen excess. Using electronic data sources, it was found that the prevalence of diagnosed PCOS was 1.7% among pregnant women, and women with PCOS had more than 2-fold increased odds of gestational diabetes compared to women without PCOS or symptoms suggestive of PCOS.
Funding Source: National Institutes of Health.
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Duru OK, Mangione CM, Steers MW, Herman WH, Karter AJ, Kountz D, Marrero DG, Safford MM, Waitzfelder B, Gerzoff RB, Huh S, Brown AF, and the TRIAD Study Group.
The Association between Clinical Care Strategies and the Attenuation of Racial/Ethnic Disparities in Diabetes Care. The Translating Research Into Action for Diabetes (TRIAD) Study. Medical Care. 2006;44(12):1121-1128. PubMed Paper evaluated whether clinical care strategies in managed care are associated with racial/ethnic disparities in diabetes care. Using cross-sectional data, we examined the quality of diabetes care as measured by frequencies of process delivery and the likelihood of aggressive intermediate outcome management for 7426 African Americans, Latinos, Asians/Pacific Islanders and whites enrolled in 10 managed care plans within 63 provider groups. Overall, no disparities in the receipt of processes of care were observed for Latinos or Asians/Pacific Islanders in comparison to whites. Although African American-white process of care disparities in frequencies of LDL cholesterol testing were attenuated with higher-intensity implementation of 2 clinical care strategies, the likelihood of aggressive intermediate outcome management did not consistently correlate with intensity of strategy implementation for any racial/ethnic groups. These findings therefore suggest that clinical care strategies appear unlikely to affect documented racial/ethnic disparities in intermediate outcomes for patients with diabetes in managed care.
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Johnson SL, Tierney EF, Onyemere KU, Tseng C-W, Safford MM, Karter AJ, Ferrara A, Duru OK, Brown AF, Narayan KMV, Thompson TJ, Herman WH.
Who Is Tested for Diabetic Kidney Disease and Who Initiates Treatment: Translating Research Into Action for Diabetes. Diabetes Care. 2006;29(8):1733-8. PubMed
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Kirk JK, D’Agostino Jr RB, Bell RA, Passmore LV, Bonds DE, Passmore LV, Karter AJ, Narayan KMV.
Disparities in A1C levels Between African Americans and Non-Hispanic White Adults With Diabetes: A Meta-Analysis. Diabetes Care. 2006 Sep;29(9):2130-6. PubMed
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Palmer AJ, Dinneen S, Gavin JR 3rd, Gray A, Herman WH, Karter AJ.
Cost-utility analysis in a UK setting of self-monitoring of blood glucose in patients with type 2 diabetes. Curr Med Res Opin 2006;22:861-72. PubMed
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Schulz M, Liese AD, Fang F, Gilliard TS, Karter AJ.
Is the association between dietary glycemic index and type 2 diabetes modified by waist circumference? Diabetes Care 2006;29:1102-4. PubMed
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Schillinger D, Barton LR, Karter AJ, Wang F, Adler N.
Does literacy mediate the relationship between education and health outcomes? A study of a low-income population with diabetes. Public Health Rep 2006;121:245-54. PubMed
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Rodondi N, Peng T, Karter AJ, Bauer DC, Vittinghoff E, Tang S, Pettitt D, Kerr EA, Selby JV.
Therapy modifications in response to poorly controlled hypertension, dyslipidemia, and diabetes mellitus. Ann Intern Med 2006;144:475-84. PubMed
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Karter AJ.
Role of self-monitoring of blood glucose in glycemic control. Endocr Pract 2006; 12 Suppl 1:110-7. PubMed Although self-monitoring of blood glucose (SMBG) is widely used in diabetes care, the practice is still controversial. The high cost of test strips has prompted increased attention toward the evidence basis for practice guidelines and reimbursement of SMBG. Existing guidelines lack specific information for patients and providers regarding SMBG intensity and frequency, particularly for patients not treated with insulin. Moreover, guidelines fail to distinguish SMBG initiation from ongoing use. Patients need more effective health education to integrate SMBG into their self-care. Providers need support to better utilize pat ients’ SMBG results in making appropriate therapeutic decisions.
Funding Source: National Institutes of Health R01 DK61678-02.
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Epidemiology and adverse cardiovascular risk profile of diagnosed polycystic ovary syndrome. PubMed Lo JC, Feigenbaum SL, Yang J, Pressman AR, Selby JV, Go AS. J Clin Endocrinol Metab 2006 Apr;91(4):1357-63.
Using data from Kaiser Permanente Northern California, diagnosed polycystic ovary syndrome (PCOS), a condition characterized by menstrual and reproductive abnormalities, insulin resistance and obesity, were found to be highly prevalent. Furthermore, women with PCOS were found to have increased odds of having diabetes mellitus, hypertension, and dyslipidemia, even after adjusting for body mass index and other known confounders. These data confirm that PCOS is associated with a higher frequency of cardiovascular risk factors, and emphasize the need for additional studies to investigate the association of PCOS with adverse cardiovascular outcome.
Funding Source: National Institutes of Health.
2005
Pioglitazone initiation and subsequent hospitalization for congestive heart failure. PubMed Karter AJ, Ahmed AT, Liu J, Moffet HH, Parker MM. Diabet Med 2005;22:986-93.
Recent publications and numerous commentaries have implicated a whole class of oral diabetes medications (Thiazolidinediones or TZDs) as causing an increased risk of congestive heart failure (CHF) in diabetic subjects without previous CHF. The use of TZDs has been scaled back in several European countries because of the concern of CHF risk. This study followed a cohort of 23,440 diabetic Kaiser Permanente patients without pre-existing CHF who initiated new diabetes therapies. No increase in risk of CHF hospitalization with TZD initiation was detected. The authors discuss the importance of design of observational pharmacoepidemiologic analyses, and explain why previous studies reporting a TZD-associated CHF risk were likely biased.
Funding Source: American Diabetes Association ***************************
Abdominal obesity predicts declining insulin sensitivity in non-obese normoglycaemics: the Insulin Resistance Atherosclerosis Study (IRAS). PubMed Karter AJ, D'Agostino RB Jr, Mayer-Davis EJ, Wagenknecht LE, Hanley AJ, Hamman RF, Bergman R, Saad MF, Haffner SM; for the IRAS investigators. Diabetes Obes Metab 2005;7:230-8.
The authors studied the longitudinal relationship between obesity and five year changes in insulin sensitivity in normoglycemic subjects. Higher baseline waist circumference, but not body mass index (BMI), predicted declining insulin sensitivity. Waist circumference was a strong predictor of declining insulin sensitivity among lean subjects, a modest predictor among overweight subjects, but was not predictive among obese individuals. Waist circumference should be considered, in addition to BMI, when identifying individuals at high risk of diabetes or the insulin resistance syndrome.
Funding Source: National Heart, Lung, and Blood Institute
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Achieving good glycemic control: initiation of new antihyperglycemic therapies in patients with Type 2 diabetes from the Kaiser Permanente Northern California Diabetes Registry. PubMed Karter AJ, Moffet HH, Liu J, Parker MM, Ahmed AT, Ferrara A, Selby JV. Am J Manag Care 2005;11:262-70.
The authors compared the real world effectiveness of newly initiated antihyperglycemic therapies in Type 2 diabetic patients with poor glycemic control. Therapy initiation resulted in an impressive population benefit. However, since therapy initiators typically had very poor control, the majority of new initiators still had not achieved good control (HbA1c<7%) within 12 months. Careful monitoring and prompt therapy intensification remain important.
Funding Source: Pfizer, Inc.
2004
Sex differences in quality of health care related to ischemic heart disease prevention in patients with diabetes: The Translating Research Into Action for Diabetes (TRIAD) Study, 2000-2001. PubMed Ferrara A, Williamson DF, Karter AJ, Thompson TJ, Kim C. Diabetes Care 2004;27:2974-6.
Diabetes is a greater risk factor for ischemic heart disease (IHD) in women than in men. This difference may be attributable to biological and behavioral factors, or possibly differences in the quality of health care related to IHD prevention. In a population-based cohort of patients with diabetes sampled from 10 managed care health plans and 68 provider groups in the United States, it was found that women were significantly less likely than men to use aspirin. Among patients not using aspirin, aspirin was advised significantly less often in women than in men. Use of lipid-lowering medications and lipid profile testing was significantly less frequent in women than in men.
Funding Source: Centers for Disease Control and Prevention.
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Can disease management reduce health care costs by improving quality? PubMed Fireman B, Bartlett J, Selby J. Health Affairs 2004;23:63-75.
Disease management (DM) promises to achieve cost savings by improving the quality of care for chronic diseases. During the past decade, Kaiser Permanente Northern California has implemented extensive DM programs. Examining quality indicators, utilization, and costs for 1996 to 2002 for adults with four conditions, findings showed substantial quality improvement, but not cost savings. The causal pathway—from improved care to reduced morbidity to cost savings—has not produced sufficient savings to offset the rising costs of improved care. It was concluded that the rationale for DM programs, like the rationale for any medical treatments, should rest on their effectiveness and value.
Funding Sources:The Permanente Medical Group; The Garfield Fund; The Care Management Institute.
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Gestational diabetes and nutritional recommendations. PubMed Gunderson EP. Curr Diab Rep 2004;4:377-86.
The goals of medical nutrition therapy for gestational diabetes mellitus (GDM) are to meet the maternal and fetal nutritional needs, and to achieve and maintain optimal glycemic control. Nutrition requirements during pregnancy are similar for women with and without GDM. The American Diabetes Association and American College of Obstetrics and Gynecology recommend nutrition therapy for GDM that emphasizes food choices to promote appropriate weight gain and normoglycemia without ketonuria, and moderate energy restriction for obese women. Current controversies in GDM nutrition therapy involve manipulation of dietary composition, gestational weight gain, and energy and carbohydrate restriction. Randomized controlled trials are needed to determine which dietary compositions and patterns promote normoglycemia as well as optimal maternal and infant outcomes. Until better evidence is available, nutrition therapy will remain a cornerstone of GDM management with potential benefits that cannot be fully realized in clinical practice.
Funding Source: Career Development Award from the National Institute of Diabetes and Digestive and Kidney Diseases 1 K01 DK59944-01A1.
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Tuberculosis In California Dialysis Patients PubMed Ahmed AT, Karter AJ. Int J Tuberc Lung Dis 2004;8:341-5.
This cohort study examined the incidence of tuberculosis disease (TB) among 2,806 patients who initiated dialysis between 1995 and 1999. The incidence of TB in the dialysis cohort was 134 per 100,000 person-years, compared to an incidence of 11.9/100,000 in the California population, yielding a relative risk of 11.3. Extrapulmonary disease occurred in eight of 11 patients for whom site of disease was recorded. Physicians caring for dialysis patients must remain vigilant for signs of TB in this vulnerable population.
Funding Source: None
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An Increase In The Incidence Of Gestational Diabetes Mellitus: Northern California, 1991-2000.PubMed Ferrara A, Kahn HS, Quesenberry CP, Riley C, Hedderson MM. Obstet Gynecol 2004;103: 526-33.
This paper explores whether the increases in diabetes prevalence is also occurring for GDM. Trends in the yearly cumulative incidence of GDM were examined between 1991 and 2000 in a cohort study of 267,051 pregnancies. The age- and ethnicity-adjusted yearly cumulative incidence of GDM increased steadily from 5.1% in 1991 to 7.4% in 1997 and leveled off through 2000 (6.9%). The increase in yearly cumulative incidence of GDM was independent of changes in age and ethnicity. A true increase in GDM incidence might contribute to the increases in the prevalence of diabetes and obesity.
Funding Source: Centers for Disease Control and Prevention
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Missed Appointments And Poor Glycemic Control: An Opportunity To Identify High-RiskDiabetic Patients.PubMed Karter AJ, Parker MM, Moffet HH, Ahmed AT, Ferrara A, Liu JY, Selby JV. Med Care 2004;42:110-5.
When patients miss their scheduled medical appointments, it may interfere with the continuity and effectiveness of their health care. The relationship between missed appointments and glycemic control (HbA1c) in 84,040 diabetic patients was evaluated. Twelve percent of patients missed >30% of scheduled appointments. After adjusting for demographic factors and clinical status, these patients had significantly poorer glycemic control, were less likely to practice daily self-monitoring of blood glucose, and had poorer oral medication refill adherence. Frequently missed appointments are readily ascertained in clinical settings and may have clinical utility for identifying patients who might benefit from targeted case management.
Funding Source: Kaiser Permanente Community Benefit Program
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High Rates Of Co-Occurrence Of Hypertension, Elevated Low-Density Lipoprotein Cholesterol, And Diabetes Mellitus In A Large Managed Care Population.PubMed Selby JV, Peng T, Karter AJ, Alexander M, Sidney S, Lian J, Arnold A, Pettitt D. Am J Manag Care 2004;10(2 Pt 2):163-70.
This study examined the prevalence and co-occurrence of diabetes mellitus (DM), hypertension (HT), and elevated low-density lipoprotein cholesterol (dyslipidemia, or DL) in adult members of Kaiser Permanente, Northern California. Prevalence of these three conditions were 23.8%, 17.6%, and 6.6% for HT, DL, and DM. More than 50% of persons with either HT or DL also had at least one other condition. Of all persons with DM, 74% had HT, 73% had DL, and 56% had both. Under full ascertainment, prevalence increased to 27.6%, 35.6%, and 8.7% for HT, DL, and DM, and co-occurrence increased further. Because HT, DL, and DM co-occur in most affected individuals, disease management strategies should aim to manage these conditions within the same programs.
Funding Source: Pfizer, Inc.
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Referral Management And The Care Of Patients With Diabetes: The Translating Research Into Action For Diabetes (TRIAD) Study.PubMed Kim C, Williamson DF, Herman WH, Safford MM, Selby JV, Marrero DG, Curb JD, Thompson TJ, Narayan KM, Mangione CM; TRIAD Study Group. Am J Manag Care. 2004;10 (2 Pt 2):137-43.
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Excess Gains In Weight And Waist Circumference Associated With Childbearing: The Coronary Artery Risk Development In Young Adults Study. (CARDIA)PubMed Gunderson EP, Murtaugh MA, Lewis CE, Quesenberry CP, West DS, Sidney S. Int J Obes Relat Metab Disord 2004;28:525-35.
Substantial excess weight gain is associated with both short pregnancies and a first birth in women overweight prior to initiation of childbearing. Excess weight gain was not associated with higher order births. Increases in waist girth were cumulative with both first and higher order births among overweight as well as normal weight women. Interventions to prevent obesity should be targeted at women who are overweight prior to initiation of childbearing. The impact of excess waist circumference gains associated with childbearing on women’s future health risk should be evaluated further.
Funding Sources: National Heart, Lung, and Blood Institute; National Institute of Arthritis and Musculoskeletal and Skin Diseases; Office of Research on Women’s Health, Building Interdisciplinary Research Careers in Women’s Health, and Career Development Award; National Institute of Diabetes and Digestive and Kidney Diseases.
2003 Gestational Diabetes Mellitus And Lesser Degrees Of Pregnancy Hyperglycemia: Association With Increased Risk Of Spontaneous Preterm Birth. PubMed Hedderson MM,* Ferrara A, Sacks DA. Obstet Gynecol 2003;102:850-6.
This study examined whether different degrees of maternal glucose intolerance are associated with the risk of spontaneous preterm birth. A cohort of 46,230 pregnancies screened by a 50-g, 1-hour oral glucose tolerance test (OGTT) between 24-28 weeks of gestation was identified. Glucose tolerance status was categorized as: normal screening, abnormal screening, Carpenter Coustan (plasma glucose measurements during the diagnostic OGTT met the thresholds, but were lower than the National Diabetes Data Group [NDDG] thresholds), and gestational diabetes mellitus (GDM) by the NDDG criteria. After adjusting for age, race, and perinatal complications, it was found that pregnancies with abnormal screening, Carpentar Coustan, and GDM had significantly higher risk of spontaneous preterm birth than pregnancies with normal screening. The risk of spontaneous preterm birth increased with increasing levels of pregnancy glycemia and this association was independent of perinatal complications that could have triggered iatrogenic early delivery.
Funding Sources: National Institute of Diabetes and Digestive and Kidney Diseases R01 DK54834; American Diabetes Association; Kaiser Foundation Research Institute.
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Determining the Value of Disease Management Programs. PubMed Selby JV, Scanlon D, Lafata JE, Villagra V, Beich J, Salber PR. Joint Commission Journal on Quality and Safety, September 2003, 29(9): 491-499.
A conference sponsored by the Agency for Healthcare Research and Quality (AHRQ) and held in October 2002 explored new approaches to measuring and reporting the value of Disease Management (DM) for diabetes mellitus.Quantifying the value of DM requires measuring clinical benefit and net impact on health care costs for the entire population with diabetes. If quality is measured with indicators that are clearly linked to outcomes, clinical benefit can be estimated. Natural history models combine the expected benefits of improvements in multiple indicators to yield a single, composite measure, the quality-adjusted life-year. Such metrics could fairly express, in terms of survival and complications prevention, relatively disparate DM programs’ benefits. Measuring and comparing health care costs requires data validation and appropriate case-mix adjustment. Comparing value across programs may provide more accurate assessments of performance, enhance quality improvement efforts within systems, and contribute generalizable knowledge on the utility of DM approaches.Conference attendees recommended pilot projects to further explore use of natural history models for measuring and reporting the value of DM.
Funding Source: Agency for Healthcare Research and Quality (AHRQ) 1 R13 HS12067.
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Race and ethnicity: vital constructs for diabetes research.PubMed Karter AJ. Diabetes Care 2003;26:2189-93.
Definitions of race and ethnicity are sometimes fluid, complex or ambiguous. Nonetheless, they have a long history of utility, facilitating identification of subgroups that have higher rates of disease, differing levels of risk factors, receive unequal quality of or access to care, as well as potentially providing important leads about etiology, and more recently helping us to understand the roles of genes and environment. The author discusses methodological issues including study designs for the contingencies of racial/ethnic differences, and the importance of reporting observations of ethnic differences in outcomes, exposures or processes of care.
Funding Source: None
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Out-of-pocket costs and diabetes preventive services: The Translating Research Into Action for Diabetes (TRIAD) Study. PubMed Karter AJ, Stevens MR, Herman WH, Ettner S, Marrero DG, Safford MM, Engelgau MM, Curb JD, Brown AF, The TRIAD Study Group. Diabetes Care 2003;26:2294-99.
Overview: This study investigated the effect of out-of-pocket expenditures on patients’ use of recommended diabetes preventive services. This observational study (2000-2001) was conducted among 11,922 diabetic survey respondents in 10 managed care health plans and 68 provider groups across the United States. Conditional probabilities of having a dilated eye exam, diabetes health education and, among insulin users, daily self-monitoring of blood glucose was lower for higher level of self-reported out-of-pocket expenditure. Results were similar across income levels and other patient characteristics. Benefit packages structured to derive greater fiscal contribution from the health plan membership may result in sub-optimal use of diabetes preventive services and thus may lead to poorer clinical outcomes, greater future costs, and lower health plan quality ratings.
Funding Source: Centers for Disease Control and Prevention (Division of Diabetes Translation) and the National Institute of Diabetes and Digestive and Kidney Diseases (Grant number: U-48-CCU916373).
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Use of antibiotics is not associated with decreased risk of myocardial infarction among patients with diabetes. PubMed Karter AJ, Thom DH, Liu J, Moffet HH, Ferrara A, SelbyJV. Diabetes Care 2003;26:2100-6.
Some studies have suggested the potential benefits of antibiotics among patients with CHD, but this has not been investigated for patients with diabetes. This case-control study assessed the effect of previous antibiotic exposure among diabetes patients with acute, non-fatal or fatal myocardial infarction (MI) (cases; n=1401) and among individually age- and sex-matched controls (4 controls for each case) from the KPNC Diabetes Registry. After adjusting for age, sex, race, education attainment, time since diabetes diagnosis, diabetes type and treatment, use of diet and exercise, total cholesterol, high density cholesterol, triglyceride levels, hypertension, elevated urinary albumin excretion, serum creatinine, body mass index and smoking, we found no evidence of a protective effect of any of the therapeutic classes of antibiotics during any of three time frames. Our study does not support the hypothesis that use of antibiotics has a protective effect for prevention of CHD in diabetic patients.
Funding Source: American Diabetes Association
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Current Use Of Unopposed Estrogen And Estrogen Plus Progestin And The Risk Of Acute Myocardial Infarction Amongwomen With Diabetes: The Northern California Kaiser Permanente Diabetes Registry, 1995-1998. PubMed Ferrara A, Quesenberry CP, Karter AJ, Njoroge CW, Jacobson AS, Selby JV. Circulation 2003; 107:43-8.
This study investigated the association of current hormone replacement therapy (HRT) with the 3-year risk of acute myocardial infarction (MI) among diabetic women. Among 24,420 women who did not have a recent MI, current HRT was associated with 16% lower rate of MI. Lower MI risk was observed only for women using estrogen plus progestin, and only for women using low or medium estrogen dose. Among 580 women who had a recent MI, current HRT was associated with 80% higher rate of recurrent MI; this rate was fourfold higher during the first year of HRT. Data from clinical trials in diabetic women are needed.
Funding Sources: American Heart Association; Kaiser Foundation Research Institute.
2002
Prevalence of Gestational Diabetes Mellitus Detected by the National Diabetes Data Group or the Carpenter and Coustan Plasma Glucose Thresholds PubMed Ferrara A, Hedderson MM, Quesenberry CP, Selby JV Diabetes Care 2002;25 1625-1630.
Our aim was to estimate the magnitude of change in prevalenceof GDM using the Carpenter and Coustan thresholds as comparedwith the NDDG thresholds by age and ethnicity. 26,481 women who gave birth in 1996 were screened usinga 50-g, 1-h oral glucose tolerance test, and 4,190 women underwenta diagnostic 100-g, 3-h oral glucose tolerance test after anabnormal screening. Overall, the GDM prevalence among screenedwomen was 3.2% (95% CI 3.0–3.4) by NDDG and 4.8% (95%CI 4.5–5.1) by Carpenter and Coustan criteria, and basedon either threshold, it increased with age (P < 0.001). Theage-adjusted GDM prevalence by NDDG and Carpenter and Coustancriteria, respectively, was 5.0 and 7.4% in Asians, 3.9 and5.6% in Hispanics, 3.0 and 4.0% in African-Americans, and 2.4and 3.8% in whites. Proportional increments were larger in womenaged <25 years (70%) and in whites (58%). The prevalence of GDM increased, on average,by 50% with use of the Carpenter and Coustan thresholds. Relativeincrements were greater in low-risk age and ethnic groups. Thisinformation would be useful for clinical settings in predictingcost of GDM based on demographic characteristics of the population.
Funding source: National Institute of Diabetes and Digestive and Kidney Diseases
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Ethnic disparities in diabetic complications in an insured population PubMed Karter A, Ferrara A., Liu J, Moffet H, Ackerson L, Selby J JAMA 2002; 287:2519-2527.
This study assessed ethnic disparities in the incidence of diabetic complications within Kaiser from 1995-98 among 62,432 diabetic patients: Asian (12%), Black (14%), Latino (10%) and White (64%). Patterns of ethnic differences were not consistent across complications and frequently persisted despite adjustment for a wide range of demographic, socioeconomic, behavioral and clinical factors. This study confirms previous reports of elevated incidence of end stage renal disease among ethnic minorities, despite uniform medical care coverage, while providing new evidence that rates of myocardial infarction, stroke and congestive heart failure are similar or lower relative to Whites; notably, rates of lower extremity amputation are substantially lower in Asians relative to other ethnic groups, including Whites. The persistence of ethnic disparities after adjustment suggests possible genetic etiology or the contribution of unmeasured environmental factors or a combination of these factors.
Funding sources: American Diabetes Association; Kaiser Foundation Research Institute.
2001
Hormone Replacement Therapy Is Associated With Better Glycemic Control In Women With Type 2 Diabetes: The Northern California Kaiser Permanente Diabetes Registry. PubMed Ferrara A, Karter AJ, Ackerson LM, Liu JY, Selby JV. Diabetes Care 2001;24:1144-50.
In a cohort of 15,435 women with type 2 diabetes, glycated hemoglobin (HbA1c) and HRT were assessed by reviewing records in the health plan’s computerized laboratory and pharmacy systems. Sociodemographic and clinical information were collected by a survey. Women currently using HRT had better glycemic control than women not using HRT, because their HbA1c levels were significantly lower than the HbA1c levels of women not using HRT. No differences in HbA1c levels were observed between women using unopposed estrogens and women using opposed estrogens. In a Generalized Estimating Equation model, HRT remained significantly and independently associated with lower HbA1c levels. Clinical trials will be necessary to understand whether HRT may improve glycemic control.
Funding Sources: American Heart Association Western States Affiliate; SmithKline Beecham Pharmaceuticals.
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Self-Monitoring Of Blood Glucose Levels And Glycemic Control: The Northern California Kaiser Permanente Diabetes Registry. PubMed Karter AJ, Ackerson LM, Darbinian JA, D’Agostino RB, Ferrara A, Liu J, Selby JV. Am J Med 2001;111:1-9.
Using a cohort study design, glycated hemoglobin (HbA1c) (measured in 1997) in patients adhering to or exceeding recommended self-monitoring blood glucose practice were compared with those who monitored less frequently or not at all. Models were adjusted for sociodemographics and disease severity, medication refill adherence, appointment “no show” rate, annual eye exam attendance, use of diet and exercise, smoking, and alcohol consumption. Adherent practice was associated with clinically and statistically (p<0.0001) better glycemic control (0.4 to 1.0 points lower HbA1c depending on the diabetes type and therapy). These findings support the clinical recommendations suggested by the American Diabetes Association and Kaiser Permanente Clinical Practice Guidelines.
Funding Sources: American Diabetes Association; Kaiser Foundation Research Institute.
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Developing A Prediction Rule From Automated Clinical Data Bases To Identify High Risk Patients In A Large Population With Diabetes. PubMed Selby JV, Karter AJ, Ackerson LM, Ferrara A, Liu J. Diabetes Care 2001;24:1547-55.
Using automated data from 1994-1995, markers were identified for predicting risk of vascular, infection, and metabolic complications during 1996 in patients with diabetes mellitus. A history of prior complications or of related outpatient diagnoses were the strongest predictors of each complication. Other important predictors of two or all three complications were treatment with insulin alone, serum creatinine of 1.3 mg/dl or above, and use of two or more antihypertensive medications. A simple risk score was shown to be much more efficient than simply targeting patients with elevated HbA(1c) levels for identifying high-risk patients, and could be used to improve disease management programs.
Funding Source: Pfizer Pharmaceuticals.
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