Background

To evaluate the U.K. Prospective Diabetes Study (UKPDS) and Framingham risk equations for predicting short-term risk of coronary heart disease (CHD) events among adults with long-standing type 2 diabetes, including those with and without preexisting CHD.

Methods

Prospective cohort of U.S. managed care enrollees aged ≥ 18 years and mean diabetes duration of more than 10 years, participating in the Translating Research into Action for Diabetes (TRIAD) study, was followed for the first occurrence of CHD events from 2000 to 2003. The UKPDS and Framingham risk equations were evaluated for discriminating power and calibration.

Results

A total of 8303 TRIAD participants, were identified to evaluate the UKPDS (n = 5914, 120 events), Framingham-initial (n = 5914, 218 events) and Framingham-secondary (n = 2389, 374 events) risk equations, according to their prior CHD history. All of these equations exhibited low discriminating power with Harrell’s c-index <0.65. All except the Framingham-initial equation for women and the Framingham-secondary equation for men had low levels of calibration. After adjsusting for the average values of predictors and event rates in the TRIAD population, the calibration of these equations greatly improved.

Conclusions

The UKPDS and Framingham risk equations may be inappropriate for predicting the short-term risk of CHD events in patients with long-standing type 2 diabetes, partly due to changes in medications used by patients with diabetes and other improvements in clinical care since the Frmaingham and UKPDS studies were conducted. Refinement of these equations to reflect contemporary CHD profiles, diagnostics and therapies are needed to provide reliable risk estimates to inform effective treatment.

Introduction

We compared the risk of diabetes for residents of Appalachian counties to that of residents of non-Appalachian counties after controlling for selected risk factors in states containing at least 1 Appalachian county.

Methods

We combined Behavioral Risk Factor Surveillance System data from 2006 and 2007 and conducted a logistic regression analysis, with self-reported diabetes as the dependent variable. We considered county of residence (5 classifications for Appalachian counties, based on economic development, and 1 for non-Appalachian counties), age, sex, race/ethnicity, education, household income, smoking status, physical activity level, and obesity to be independent variables. The classification "distressed" refers to counties in the worst 10%, compared with the nation as a whole, in terms of 3-year unemployment rate, per capita income, and poverty.

Results

Controlling for covariates, residents in distressed Appalachian counties had 33% higher odds (95% confidence interval, 1.10-1.60) of reporting diabetes than residents of non-Appalachian counties. We found no significant differences between other classifications of Appalachian counties and non-Appalachian counties.

Conclusions

Residents of distressed Appalachian counties are at higher risk of diabetes than are residents of other counties. States with distressed Appalachian counties should implement culturally sensitive programs to prevent diabetes.

Background

Versus whites, blacks with diabetes have poorer control of hemoglobin A1c (HbA1c), higher systolic blood pressure (SBP), and higher low-density lipoprotein (LDL) cholesterol as well as higher rates of morbidity and microvascular complications.

Objective

To examine whether several mutable risk factors were more strongly associated with poor control of multiple intermediate outcomes among blacks with diabetes than among similar whites.

Design

Case-control study.

Subjects

A total of 764 blacks and whites with diabetes receiving care within 8 managed care health plans.

Measures

Cases were patients with poor control of at least two of three intermediate outcomes (HbA1c≥8.0%, SBP≥140 mmHg, LDL cholesterol≥130 mg/dl) and controls were patients with good control of all three (HbA1c<8.0%, SBP<140 mmHg, LDL cholesterol<130 mg/dl). In multivariate analyses, we determined whether each of five potentially mutable risk factors, including depression, low health literacy, poor adherence to medication, low self-efficacy for reducing cardiovascular risk, and poor patient-provider communication, predicted case or control status.

Results

Among blacks but not whites, in multivariate analyses depression (odds ratio [OR] 2.28, 95% confidence interval [CI] 1.09-4.75) and having missed medication doses (OR 1.96, 95% CI 1.01-3.81) were associated with greater odds of being a case rather than a control. None of the other risk factors were associated for either blacks or whites.

Conclusions

Depression and missing medication doses are more strongly associated with poor diabetes control among blacks than in whites. These two risk factors may represent important targets for patient-level interventions to address racial disparities in diabetes outcomes.

BACKGROUND

Although patients with diabetes may benefit from physical activity, few studies have examined sustained walking in this population.

OBJECTIVE

To examine the factors associated with sustained walking among managed care patients with diabetes.

DESIGN

Longitudinal, observational cohort study with questionnaires administered 2.5 years apart.

PARTICIPANTS

Five thousand nine hundred thirty-five patients with diabetes walking at least 20 minutes/day at baseline.

MEASUREMENTS

The primary outcome was the likelihood of sustained walking, defined as walking at least 20 minutes/day at follow-up. We evaluated a logistic regression model that included demographic, clinical, and neighborhood variables as independent predictors of sustained walking, and expressed the results as predicted percentages.

RESULTS

The absence of pain was linked to walking behavior, as 62% of patients with new pain, 67% with ongoing pain, and 70% without pain were still walking at follow-up (p = .03). Obese patients were less likely (65%) to sustain walking than overweight (71%) or normal weight (70%) patients (p = .03). Patients ≥65 years (63%) were less likely to sustain walking than patients between 45 and 64 (70%) or ≤44 (73%) years (p = .04). Only 62% of patients with a new comorbidity sustained walking compared with 68% of those who did not (p < .001). We found no association between any neighborhood variables and sustained walking in this cohort of active walkers.

CONCLUSIONS

Pain, obesity, and new comorbidities were moderately associated with decreases in sustained walking. Whereas controlled intervention studies are needed, prevention, or treatment of these adverse conditions may help patients with diabetes sustain walking behavior.