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1.  Trends in the Prevalence of Type 2 Diabetes in Asians Versus Whites 
Diabetes Care  2011;34(2):353-357.
To examine trends in the prevalence of type 2 diabetes and related conditions in Asian Americans compared with non-Hispanic whites.
We analyzed data from the National Health Interview Survey (NHIS) from 1997 to 2008 to construct a nationally representative sample of 230,503 U.S. adults aged ≥18 years. Of these adults, 11,056 identified themselves as Asian Americans and 219,447 as non-Hispanic whites.
The age- and sex-adjusted prevalence of type 2 diabetes was higher in Asian Americans than in whites throughout the study period (4.3–8.2% vs. 3.8–6.0%), and there was a significant upward trend in both ethnic groups (P < 0.01). BMI also was increased in both groups, but age- and sex-adjusted BMI was consistently lower in Asian Americans. In fully adjusted logistic regression models, Asian Americans remained 30–50% more likely to have diabetes than their white counterparts. In addition, Asian Indians had the highest odds of prevalent type 2 diabetes, followed by Filipinos, other Asians, and Chinese.
Compared with their white counterparts, Asian Americans have a significantly higher risk for type 2 diabetes, despite having substantially lower BMI. Additional investigation of this disparity is warranted, with the aim of tailoring optimal diabetes prevention strategies to Asian Americans.
PMCID: PMC3024348  PMID: 21216863
2.  Patient Safety Perceptions of Primary Care Providers after Implementation of an Electronic Medical Record System 
Increasing the use of electronic medical records (EMR) has been suggested as an important strategy for improving healthcare safety.
To sequentially measure, evaluate, and respond to safety culture and practice safety concerns following EMR implementation.
Safety culture was assessed using a validated tool (Safety Attitudes Questionnaire; SAQ), immediately following EMR implementation (T1) and at 1.5 (T2) and 2.5 (T3) years post-implementation. The SAQ was supplemented with a practice-specific assessment tool to identify safety needs and barriers.
A large medical group practice with a primary care core of 17–18 practices, staffed by clinicians in family medicine, pediatrics, internal medicine.
Survey results were used to define and respond to areas of need between assessments with system changes and educational programs.
Change in safety culture over time; perceived impact of EMR on practice.
Responses were received from 103 of 123 primary care providers in T1 (83.7 % response rate), 122 of 143 in T2 (85.3 %) and 142 of 181 in T3 (78.5 %). Safety culture improved over this period, with statistically significant improvement in all domains except for stress recognition. Time constraints, communications and patient adherence were perceived to be the most important safety issues. The majority of respondents in both T2 (77.9 %) and T3 (85.4 %) surveys agreed that the EMR improved their ability to provide care more safely.
Implementation of an EMR in a large primary care practice required redesign of many organizational processes, and was associated with improvements in safety culture. Most primary care providers agreed that the EMR allowed them to provide care more safely.
PMCID: PMC3614133  PMID: 22887020
electronic medical records; EMR; safety culture; primary care; safety attitudes questionnaire
3.  Black-White Disparities in Overweight and Obesity Trends by Educational Attainment in the United States, 1997–2008 
Journal of Obesity  2013;2013:140743.
Background. Few studies have examined racial and educational disparities in recent population-based trends. Methods. We analyzed data of a nationally representative sample of 174,228 US-born adults in the National Health Interview Survey from 1997 to 2008. We determined mean BMI trends by educational attainment and race and black-white prevalence ratios (PRs) for overweight/obesity (BMI > 25 kg/m2) using adjusted Poisson regression with robust variance. Results. From 1997 to 2008, BMI increased by ≥1 kg/m2 in all race-sex groups, and appeared to increase faster among whites. Blacks with greater than a high school education (GHSE) had a consistently higher BMI over time than whites in both women (28.3 ± 0.14 to 29.7 ± 0.18 kg/m2 versus 25.8 ± 0.58 to 26.5 ± 0.08 kg/m2) and men (28.1 ± 0.17 kg/m2 to 29.0 ± 0.20 versus 27.1 ± 0.04 kg/m2 to 28.1 ± 0.06 kg/m2). For participants of all educational attainment levels, age-adjusted overweight/obesity was greater by 44% (95% CI: 1.42–1.46) in black versus white women and 2% (1.01–1.04) in men. Among those with GHSE, overweight/obesity prevalence was greater (PR: 1.52; 1.49–1.55) in black versus white women, but greater (1.07; 1.05–1.09) in men. Conclusions. BMI increased steadily in all race-sex and education groups from 1997 to 2008, and blacks (particularly women) had a consistently higher BMI than their white counterparts. Overweight/obesity trends and racial disparities were more prominent among individuals with higher education levels, compared to their counterparts with lower education levels.
PMCID: PMC3649192  PMID: 23691282
4.  A Prospective Study of the Associations Between Treated Diabetes and Cancer Outcomes 
Diabetes Care  2011;35(1):113-118.
To quantify the association of treated diabetes with cancer incidence and cancer mortality as well as cancer case fatality and all-cause mortality in adults who subsequently develop cancer and to calculate attributable fractions due to diabetes on various cancer outcomes.
Prospective data on 599 diabetic and 17,681 nondiabetic adults from the CLUE II (Give Us a Clue to Cancer and Heart Disease) cohort in Washington County, Maryland, were analyzed. Diabetes was defined by self-reported use of diabetes medications at baseline. Cancer incidence was ascertained using county and state cancer registries. Mortality data were obtained from death certificates.
From 1989 to 2006, 116 diabetic and 2,365 nondiabetic adults developed cancer, corresponding to age-adjusted incidence of 13.25 and 10.58 per 1,000 person-years, respectively. Adjusting for age, sex, education, BMI, smoking, hypertension treatment, and high cholesterol treatment using Cox proportional hazards regression, diabetes was associated with a higher risk of incident cancer (hazard ratio 1.22 [95% CI 0.98–1.53]) and cancer mortality (1.36 [1.02–1.81]). In individuals who developed cancer, adults with diabetes had a higher risk of cancer case fatality (1.34 [1.002–1.79]) and all-cause mortality (1.61 [1.29–2.01]). For colorectal, breast, and prostate cancers, the attributable fractions resulting from diabetes were larger for cancer fatality and mortality than cancer incidence.
In this prospective cohort, diabetes appears to exert a greater influence downstream on the risk of mortality in people with cancer than on upstream risk of incident cancer.
PMCID: PMC3241297  PMID: 22100961
6.  Serum and Dietary Potassium and Risk of Incident Type 2 Diabetes: The Atherosclerosis Risk in Communities (ARIC) Study 
Archives of internal medicine  2010;170(19):1745-1751.
Serum potassium levels affect insulin secretion by pancreatic beta-cells, and hypokalemia associated with diuretic use has been associated with dysglycemia. We hypothesized that adults with lower serum potassium levels and lower dietary potassium intake are at higher risk for incident diabetes, independent of diuretic use.
We analyzed data from 12,209 participants from the Atherosclerosis Risk in Communities (ARIC) Study, an on-going prospective cohort study beginning in 1986, with 9 years of in-person follow-up and 17 years of telephone follow-up. Using multivariate Cox proportional hazard models, we estimated the relative hazard (RH) of incident diabetes associated with baseline serum potassium levels.
During 9 years of in-person follow-up, 1475 participants developed incident diabetes. In multivariate analyses, we found an inverse association between serum potassium and risk of incident diabetes. Compared to those with a high-normal serum potassium (5.0-5.5 mEq/l), adults with serum potassium levels of < 4.0, 4.0-<4.5, and 4.5-<5.0, (mEq/L) had adjusted relative hazards (RH) (95% CI) of incident diabetes of 1.64 (1.29-2.08), 1.64 (1.34-2.01), and 1.39 (1.14-1.71) respectively. An increased risk persisted during an additional 8 years of telephone follow-up based on self-report with RHs of 1.2-1.3 for those with a serum potassium less than 5.0 mEq/L. Dietary potassium intake was significantly associated with risk of incident diabetes in unadjusted models but not in multivariate models.
Serum potassium is an independent predictor of incident diabetes in this cohort. Further study is needed to determine if modification of serum potassium could reduce the subsequent risk of diabetes.
PMCID: PMC3469719  PMID: 20975023
7.  Learner feedback and educational outcomes with an internet-based ambulatory curriculum: a qualitative and quantitative analysis 
BMC Medical Education  2012;12:55.
Online medical education curricula offer new tools to teach and evaluate learners. The effect on educational outcomes of using learner feedback to guide curricular revision for online learning is unknown.
In this study, qualitative analysis of learner feedback gathered from an online curriculum was used to identify themes of learner feedback, and changes to the online curriculum in response to this feedback were tracked. Learner satisfaction and knowledge gains were then compared from before and after implementation of learner feedback.
37,755 learners from 122 internal medicine residency training programs were studied, including 9437 postgraduate year (PGY)1 residents (24.4 % of learners), 9864 PGY2 residents (25.5 %), 9653 PGY3 residents (25.0 %), and 6605 attending physicians (17.0 %). Qualitative analysis of learner feedback on how to improve the curriculum showed that learners commented most on the overall quality of the educational content, followed by specific comments on the content. When learner feedback was incorporated into curricular revision, learner satisfaction with the instructive value of the curriculum (1 = not instructive; 5 = highly instructive) increased from 3.8 to 4.1 (p < 0.001), and knowledge gains (i.e., post test scores minus pretest scores) increased from 17.0 % to 20.2 % (p < 0.001).
Learners give more feedback on the factual content of a curriculum than on other areas such as interactivity or website design. Incorporating learner feedback into curricular revision was associated with improved educational outcomes. Online curricula should be designed to include a mechanism for learner feedback and that feedback should be used for future curricular revision.
PMCID: PMC3418189  PMID: 22788677
Online education; Curriculum development; Feedback; Learner satisfaction
8.  Potassium and risk of Type 2 diabetes 
The rising incidence and prevalence of Type 2 diabetes worldwide requires us to try to identify the determinants of this epidemic and to identify improved measures to prevent and treat this condition. While obesity is a major risk factor for diabetes, there are other risk factors that could potentially be corrected more easily. Potassium, both serum levels and to a lesser extent dietary intake levels, has been associated with incident diabetes. Lower levels of potassium have been found to be associated with a higher risk of diabetes in some studies. This article will review the literature available describing these associations and will help to identify where further research is needed.
PMCID: PMC3197792  PMID: 22025927
antihypertensives affecting potassium; diabetes risk; dietary potassium; serum potassium
9.  Independent but Coordinated Trials: Insights from the Practice Based Opportunities for Weight Reduction (POWER) Trials Collaborative Research Group 
The National Heart, Lung, and Blood Institute (NHLBI) funded three institutions to conduct effectiveness trials of weight loss interventions in primary care settings. Unlike traditional multi-center clinical trials, each study was established as an independent trial with a distinct protocol. Still, efforts were made to coordinate and standardize several aspects of the trials. The three trials formed a collaborative group, the “Practice Based Opportunities for Weight Reduction (POWER) Trials Collaborative Research Group.”
We describe the common and distinct features of the three trials, the key characteristics of the collaborative group, and the lessons learned from this novel organizational approach.
The Collaborative Research Group consists of three individual studies: “Be Fit, Be Well“(Washington University in St. Louis/Harvard University), “POWER Hopkins” (Johns Hopkins), and “POWER-UP” (University of Pennsylvania). There are a total of 15 participating clinics with ~1,100 participants. The common primary outcome is change in weight at 24 months of follow-up, but each protocol has trial-specific elements including different interventions and different secondary outcomes. A Resource Coordinating Unit at Johns Hopkins provides administrative support.
The Collaborative Research Group established common components to facilitate potential cross-site comparisons. The main advantage of this approach is to develop and evaluate several interventions, when there is insufficient evidence to test one or two approaches, as would be done in a traditional multi-center trial.
The challenges of the organizational design include the complex decision making process, the extent of potential data pooling, time intensive efforts to standardize reports, and the additional responsibilities of the DSMB to monitor three distinct protocols.
The POWER Trials Collaborative Research Group is a case study of an alternative organizational model to conduct independent, yet coordinated trials. Such a model is increasingly being used in NHLBI supported trials , especially given the interest in comparative effectiveness research. Nevertheless, the ultimate utility of this model will not be fully understood until the trials are completed.
PMCID: PMC3266125  PMID: 20573639
POWER; clinical trial; weight loss; effectiveness; primary care; obesity
10.  Diabetes Mellitus and Breast Cancer Outcomes: A Systematic Review and Meta-Analysis 
Journal of Clinical Oncology  2010;29(1):40-46.
The goal of this study was to perform a systematic review and meta-analysis to examine the effect of pre-existing diabetes on breast cancer–related outcomes.
We searched EMBASE and MEDLINE databases from inception through July 1, 2009, using search terms related to diabetes mellitus, cancer, and prognostic outcome. Studies were included if they reported a prognostic outcome by diabetes status, evaluated a cancer population, and contained original data published in the English language. We performed a meta-analysis of pre-existing diabetes and its effect on all-cause mortality in patients with breast cancer and qualitatively summarized other prognostic outcomes.
Of 8,828 titles identified, eight articles met inclusion/exclusion criteria and described outcomes in patients with breast cancer and diabetes. Pre-existing diabetes was significantly associated with all-cause mortality in six of seven studies. In a meta-analysis, patients with breast cancer and diabetes had a significantly higher all-cause mortality risk (pooled hazard ratio [HR], 1.49; 95% CI, 1.35 to 1.65) compared with their nondiabetic counterparts. Three of four studies found pre-existing diabetes to be associated with more advanced stage at presentation. Diabetes was also associated with altered regimens for breast cancer treatment and increased toxicity from chemotherapy.
Compared with their nondiabetic counterparts, patients with breast cancer and pre-existing diabetes have a greater risk of death and tend to present at later stages and receive altered treatment regimens. Studies are needed to investigate pathophysiologic interactions between diabetes and breast cancer and determine whether improvements in diabetes care can reduce mortality in patients with breast cancer.
PMCID: PMC3055858  PMID: 21115865
11.  Associations between quality indicators of internal medicine residency training programs 
BMC Medical Education  2011;11:30.
Several residency program characteristics have been suggested as measures of program quality, but associations between these measures are unknown. We set out to determine associations between these potential measures of program quality.
Survey of internal medicine residency programs that shared an online ambulatory curriculum on hospital type, faculty size, number of trainees, proportion of international medical graduate (IMG) trainees, Internal Medicine In-Training Examination (IM-ITE) scores, three-year American Board of Internal Medicine Certifying Examination (ABIM-CE) first-try pass rates, Residency Review Committee-Internal Medicine (RRC-IM) certification length, program director clinical duties, and use of pharmaceutical funding to support education. Associations assessed using Chi-square, Spearman rank correlation, univariate and multivariable linear regression.
Fifty one of 67 programs responded (response rate 76.1%), including 29 (56.9%) community teaching and 17 (33.3%) university hospitals, with a mean of 68 trainees and 101 faculty. Forty four percent of trainees were IMGs. The average post-graduate year (PGY)-2 IM-ITE raw score was 63.1, which was 66.8 for PGY3s. Average 3-year ABIM-CE pass rate was 95.8%; average RRC-IM certification was 4.3 years. ABIM-CE results, IM-ITE results, and length of RRC-IM certification were strongly associated with each other (p < 0.05). PGY3 IM-ITE scores were higher in programs with more IMGs and in programs that accepted pharmaceutical support (p < 0.05). RRC-IM certification was shorter in programs with higher numbers of IMGs. In multivariable analysis, a higher proportion of IMGs was associated with 1.17 years shorter RRC accreditation.
Associations between quality indicators are complex, but suggest that the presence of IMGs is associated with better performance on standardized tests but decreased duration of RRC-IM certification.
PMCID: PMC3126786  PMID: 21651768
program quality; Residency Review Committee; American Board of Internal Medicine Certifying Examination
12.  Long-term All-Cause Mortality in Cancer Patients With Preexisting Diabetes Mellitus 
Diabetes mellitus appears to be a risk factor for some cancers, but the effect of preexisting diabetes on all-cause mortality in newly diagnosed cancer patients is less clear.
To perform a systematic review and meta-analysis comparing overall survival in cancer patients with and without preexisting diabetes.
Data Sources
We searched MEDLINE and EMBASE through May 15, 2008, including references of qualifying articles.
Study Selection
English-language, original investigations in humans with at least 3 months of follow-up were included. Titles, abstracts, and articles were reviewed by at least 2 independent readers. Of 7858 titles identified in our original search, 48 articles met our criteria.
Data Extraction
One reviewer performed a full abstraction and other reviewers verified accuracy. We contacted authors and obtained additional information for 3 articles with insufficient reported data.
Studies reporting cumulative survival rates were summarized qualitatively. Studies reporting Cox proportional hazard ratios (HRs) or Poisson relative risks were combined in a meta-analysis. A random-effects model meta-analysis of 23 articles showed that diabetes was associated with an increased mortality HR of 1.41 (95% confidence interval [CI], 1.28-1.55) compared with normoglycemic individuals across all cancer types. Subgroup analyses by type of cancer showed increased risk for cancers of the endometrium (HR, 1.76; 95% CI, 1.34-2.31), breast (HR, 1.61; 95% CI, 1.46-1.78), and colorectum (HR, 1.32; 95% CI, 1.24-1.41).
Patients diagnosed with cancer who have preexisting diabetes are at increased risk for long-term, all-cause mortality compared with those without diabetes.
PMCID: PMC3093051  PMID: 19088353
To summarize the influence of pre-existing diabetes on mortality and morbidity in men with prostate cancer.
We searched MEDLINE and EMBASE from inception through October 1, 2008. Search terms were related to diabetes, cancer, and prognosis. Studies were included if they reported an original data analysis of prostate cancer prognosis, compared outcomes between men with and without diabetes, and were in English. Titles, abstracts, and articles were reviewed independently by two authors. Conflicts were settled by consensus or third review. We abstracted data on study design, analytic methods, outcomes, and quality. We summarized mortality and morbidity outcomes qualitatively and conducted a preliminary meta-analysis to quantify the risk of long-term (>3 months), overall mortality.
11 articles were included in the review. 1/4 studies found increased prostate-cancer mortality, 1/2 studies found increased non-prostate cancer mortality, and 1/1 study found increased 30-day mortality. Data from 4 studies could be included in a preliminary meta-analysis for long-term, overall mortality and produced a pooled hazard ratio of 1.57 (95% CI: 1.12-2.20). Diabetes was also associated with receiving radiation therapy, complication rates, recurrence, and treatment failure.
Our analysis suggests that pre-existing diabetes affects the treatment and outcomes of men with prostate cancer.
PMCID: PMC3085982  PMID: 20145631
diabetes; prostate cancer; prognosis; meta-analysis
14.  Postoperative Mortality in Cancer Patients With Preexisting Diabetes 
Diabetes Care  2010;33(4):931-939.
Diabetes appears to increase risk for some cancers, but the association between preexisting diabetes and postoperative mortality in cancer patients is less clear. Our objective was to systematically review postoperative mortality in cancer patients with and without preexisting diabetes and summarize results using meta-analysis.
We searched the Medical Literature Analysis and Retrieval System Online (MEDLINE) and Excerpta Medica Database (EMBASE) for articles published on or before 1 July 2009, including references of qualifying articles. We included English language investigations of short-term postoperative mortality after initial cancer treatment. Titles, abstracts, and articles were reviewed by at least two independent readers. Study population and design, results, and quality components were abstracted with standard protocols by one reviewer and checked for accuracy by additional reviewers.
Of 8,828 titles identified in our original search, 20 articles met inclusion criteria for qualitative systematic review. Of these, 15 reported sufficient information to be combined in meta-analysis. Preexisting diabetes was associated with increased odds of postoperative mortality across all cancer types (OR = 1.85 [95% CI 1.40–2.45]). The risk associated with preexisting diabetes was attenuated but remained significant when we restricted the meta-analysis to models that controlled for confounders (1.51 [1.13–2.02]) or when we accounted for publication bias using the trim and fill method (1.52 [1.13–2.04]).
Compared with their nondiabetic counterparts, cancer patients with preexisting diabetes are ∼50% more likely to die after surgery. Future research should investigate physiologic pathways to mortality risk and determine whether improvements in perioperative diabetes care can reduce postoperative mortality.
PMCID: PMC2845055  PMID: 20351229
16.  Predictors of HIV Testing Among Latinos in Baltimore City 
To better understand access to HIV testing and prevention services experienced by Latinos, we evaluated data compiled through Baltimore City Health Department HIV outreach efforts in 2008. Of 6,443 clients served, Latinos were more likely male, young, and less-educated than non-Latinos. A greater proportion of Latinos had never been tested for HIV compared to non-Latinos (63% vs. 20%, P < 0.001). Male gender (AOR 1.58, 95% CI 1.04, 2.44), >8th grade education (AOR 2.4, 95% CI 1.60, 3.60) were associated with accessing HIV testing in the past. Increasing age, identifying as gay or bisexual, history of sexually-transmitted disease, and injection drug use were also associated with reporting prior HIV testing. HIV prevention services for Latinos should expand to reach those who are younger, heterosexual, of lower educational level, and female.
PMCID: PMC2896978  PMID: 19830563
HIV; HIV prevention; Latinos; Hispanic Americans
17.  Factors Associated With Intensification of Oral Diabetes Medications in Primary Care Provider-Patient Dyads: A Cohort Study  
Diabetes Care  2009;32(1):25-31.
OBJECTIVE—Although suboptimal glycemic control is known to be common in diabetic adults, few studies have evaluated factors at the level of the physician-patient encounter. Our objective was to identify novel visit-based factors associated with intensification of oral diabetes medications in diabetic adults.
RESEARCH DESIGN AND METHODS—We conducted a nonconcurrent prospective cohort study of 121 patients with type 2 diabetes and hyperglycemia (A1C ≥8%) enrolled in an academically affiliated managed-care program. Over a 24-month interval (1999–2001), we identified 574 hyperglycemic visits. We measured treatment intensification and factors associated with intensification at each visit.
RESULTS—Provider-patient dyads intensified oral diabetes treatment in only 128 (22%) of 574 hyperglycemic visits. As expected, worse glycemia was an important predictor of intensification. Treatment was more likely to be intensified for patients with visits that were “routine” (odds ratio [OR] 2.55 [95% CI 1.49–4.38]), for patients taking two or more oral diabetes drugs (2.82 [1.74–4.56]), or for patients with longer intervals between visits (OR per 30 days 1.05 [1.00–1.10]). In contrast, patients with less recent A1C measurements (OR >30 days before the visit 0.53 [0.34–0.85]), patients with a higher number of prior visits (OR per prior visit 0.94 [0.88–1.00]), and African American patients (0.59 [0.35–1.00]) were less likely to have treatment intensified.
CONCLUSIONS—Failure to intensify oral diabetes treatment is common in diabetes care. Quality improvement measures in type 2 diabetes should focus on overcoming inertia, improving continuity of care, and reducing racial disparities.
PMCID: PMC2606824  PMID: 18931096
18.  HIV Women's Health: A Study of Gynecological Healthcare Service Utilization in a U.S. Urban Clinic Population 
Journal of Women's Health  2008;17(10):1609-1614.
Women infected with HIV have a high rate of many gynecological problems. Adherence to recommended gynecological care among women enrolled in our urban HIV clinics was hypothesized to be low.
We conducted an analysis of data from the Johns Hopkins HIV Clinical Cohort Database examining demographic and clinical predictors of clinic visit adherence by women in the HIV primary care and HIV gynecological clinics.
Between January 2002 and April 2006, 1,086 women had 26,401 scheduled appointments to the two clinics, of which 21,959 were to HIV primary care and 4,442 were to HIV gynecological care. There were 12,097 (55%) completed primary care visits and 1,609 (36.2%) completed HIV gynecological visits (p < 0.001, accounting for clustering). By multivariate analysis, age <40 years (OR 0.81, 95% CI 0.70-0.94) and substance abuse (OR 0.67, 95% CI 0.61-0.73) were associated with a decreased likelihood of attending an HIV primary care appointment. African American race (OR 0.63, 95% CI 0.45-0.90), CD4 count <200 cells/mm3 (OR 0.73, 95% CI 0.56-0.95), and substance abuse (OR 0.57, 95% CI 0.45-0.71) were associated with a decreased likelihood of attending an HIV gynecological appointment.
This analysis determined that the rate of clinic visit adherence is significantly lower for HIV gynecological care than for HIV primary care in the same population of women. Factors associated with HIV gynecological clinic visit noncompliance included African American race/ethnicity, substance use, and more advanced immunosuppression. We have planned additional quantitative and qualitative studies to examine the associations with and barriers to HIV gynecological care, with the goal of creating appropriate interventions toward improving gynecological healthcare utilization among women enrolled in urban HIV clinics.
PMCID: PMC2716001  PMID: 19049355
19.  Cross-Sectional and Prospective Study of Lung Function in Adults with Type 2 Diabetes Mellitus: The Atherosclerosis Risk in Communities (ARIC) Study 
Diabetes care  2007;31(4):741-746.
To test the hypothesis that diabetes is independently associated with reduced lung function, both cross-sectionally and longitudinally.
We conducted cross-sectional and prospective analyses of diabetes status and lung function decline using baseline and 3-year follow-up data on 1,100 diabetic and 10,162 non-diabetic middle-aged adults from the Atherosclerosis Risk in Communities (ARIC) Study. Forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV1) were measured at baseline and 3-year follow-up using standard spirometry.
At baseline, adults with diabetes had significantly lower predicted FVC (96% vs. 103%, p< 0.001) and predicted FEV1 (92% vs. 96%, p < 0.001) than those without diabetes. These differences remained significant after adjustment for demographic characteristics, adiposity, smoking, physical activity index, education, and ARIC field center. Graded, inverse associations were observed between hyperglycemia, diabetes severity (i.e. duration of diabetes and types of anti-diabetes medications) and FVC and FEV1 (all p for trend < 0.001). In prospective analyses, FVC declined faster in diabetic adults than in their non-diabetic counterparts (64 vs. 58 ml/year, p= 0.01). Diabetes severity as indicated by intensity of anti-diabetic treatment also showed graded relationships with rate of FVC decline (p< 0.01).
These data support the notion that the lung is a target organ for diabetic injury. Additional research is required to identify pathophysiologic mechanisms and to determine clinical significance.
PMCID: PMC2773203  PMID: 18056886
Type 2 diabetes mellitus; Spirometry; Cohort study; Risk factors
20.  Cardiovascular Outcomes in Trials of Oral Diabetes Medications: A Systematic Review 
Archives of internal medicine  2008;168(19):2070-2080.
A wide variety of oral diabetes medications are currently available for the treatment of type 2 diabetes, but it is unclear how these agents compare with respect to long-term cardiovascular risk.
To systematically review the peer-reviewed literature on cardiovascular risk associated with oral agents (second-generation sulfonylureas, biguanides, thiazolidinediones, and meglitinides) for treating adults with type 2 diabetes mellitus.
Data Sources
MEDLINE®, EMBASE®, and the Cochrane Central Register of Controlled Trials, from inception through January 2006.
Study Selection
40 publications of controlled trials that reported information on cardiovascular events (primarily myocardial infarction and stroke).
Data Extraction
Using standardized protocols, 2 reviewers serially abstracted data for each article. Trials were first described qualitatively. For comparisons with four or more independent trials, results were quantitatively pooled using the Mantel- Haenszel method. Results were presented as odds ratios and corresponding 95% confidence intervals.
Treatment with metformin was associated with a decreased risk of cardiovascular mortality(pooled odds ratio(OR)=0.74, 95%CI 0.62-0.89) compared with any other oral diabetes agent or placebo; the results for cardiovascular morbidity and all-cause mortality were similar but not statistically significant. No other significant associations of oral diabetes agents with fatal or non-fatal cardiovascular disease or all-cause mortality were observed. When compared to any other agent or placebo, rosiglitazone was the only diabetes agent associated with an increased risk of cardiovascular morbidity or mortality, but this result was not statistically significant(OR 1.68 95%CI 0.92-3.06).
Meta-analysis suggested that compared to other oral diabetes agents and placebo, metformin was moderately protective and rosiglitazone possibly harmful, but lack of power prohibited firmer conclusions. Larger, long-term studies taken to hard endpoints and better reporting of cardiovascular events in short term studies will be required to draw firm conclusions about major clinical benefits and risks related to oral diabetes agents.
PMCID: PMC2765722  PMID: 18955635
21.  Failure to Intensify Antihypertensive Treatment by Primary Care Providers: A Cohort Study in Adults with Diabetes Mellitus and Hypertension 
Although tight blood pressure control is crucial in reducing vascular complications of diabetes, primary care providers often fail to appropriately intensify antihypertensive medications.
To identify novel visit-based factors associated with intensification of antihypertensive medications in adults with diabetes.
Non-concurrent prospective cohort study.
A total of 254 patients with type 2 diabetes and hypertension enrolled in an academically affiliated managed care program. Over a 24-month interval (1999–2001), we identified 1,374 visits at which blood pressure was suboptimally controlled (systolic BP ≥ 140 mmHg or diastolic BP ≥ 90 mmHg).
Measurements and Main Results
Intensification of antihypertensive medications at each visit was the primary outcome. Primary care providers intensified antihypertensive treatment in only 176 (13%) of 1,374 visits at which blood pressure was elevated. As expected, higher mean systolic and mean diastolic blood pressures were important predictors of intensification. Treatment was also more likely to be intensified at visits that were “routine” odds ratio (OR) 2.08; 95% Confidence Interval [95% CI] 1.36–3.18), or that paired patients with their usual primary care provider (OR 1.84; 95% CI 1.11–3.06). In contrast, several factors were associated with failure to intensify treatment, including capillary glucose >150 mg/dL (OR 0.54; 95% CI 0.31–0.94) and the presence of coronary heart disease (OR 0.61; 95% CI 0.38–0.95). Co-management by a cardiologist accounted partly for this failure (OR 0.65; 95% CI 0.41–1.03).
Failure to appropriately intensify antihypertensive treatment is common in diabetes care. Clinical distractions and shortcomings in continuity and coordination of care are possible targets for improvement.
PMCID: PMC2324132  PMID: 18219539
diabetes mellitus; hypertension; health services; cohort study
22.  Blood Viscosity and Hematocrit as Risk Factors for Type 2 Diabetes Mellitus 
American Journal of Epidemiology  2008;168(10):1153-1160.
Several lines of evidence support the notion that elevated blood viscosity may predispose to insulin resistance and type 2 diabetes mellitus by limiting delivery of glucose, insulin, and oxygen to metabolically active tissues. To test this hypothesis, the authors analyzed longitudinal data on 12,881 initially nondiabetic adults, aged 45–64 years, who were participants in the Atherosclerosis Risk in Communities (ARIC) Study (1987–1998). Whole blood viscosity was estimated by using a validated formula based on hematocrit and total plasma proteins at baseline. At baseline, estimated blood viscosity was independently associated with several features of the metabolic syndrome. In models adjusted simultaneously for known predictors of diabetes, estimated whole blood viscosity and hematocrit predicted incident type 2 diabetes mellitus in a graded fashion (Ptrend (linear) < 0.001): Compared with their counterparts in the lowest quartiles, adults in the highest quartile of blood viscosity (hazard ratio = 1.68, 95% confidence interval: 1.53, 1.84) and hematocrit (hazard ratio = 1.63, 95% confidence interval: 1.49, 1.79) were over 60% more likely to develop diabetes. Therefore, elevated blood viscosity and hematocrit deserve attention as emerging risk factors for insulin resistance and type 2 diabetes mellitus.
PMCID: PMC2581671  PMID: 18931370
blood viscosity; diabetes mellitus, type 2; hematocrit; insulin resistance; metabolic syndrome X; oxidative phosphorylation
23.  Computer and internet use among urban African Americans with type 2 diabetes 
Previous studies have identified a “digital divide” between African Americans and whites, with African Americans having substantially lower rates of Internet use. However, use of the Internet to access health information has not been sufficiently evaluated in this population. Therefore, we conducted a telephone survey to determine the prevalence of computer and Internet use among 457 African American adults with type 2 diabetes. Participants were 78% female, with a mean age of 57±11 years, and about one-third had a yearly income ≦$7,500. Forty percent of the participants reported having a computer at home and 46% reported knowing how to use a computer. Most participants (58%) reported that they had, at some point, used a computer, and of those, 40% reported that they used the computer to find health information. In a stratified analysis, participants with lower education levels (
PMCID: PMC3456680  PMID: 16221917
African Americans; Computer; Internet; Survey; Type 2 diabetes
Obesity (Silver Spring, Md.)  2013;21(6):1269-1275.
We compared pre- to post-pregnancy change in weight, body mass index (BMI), waist circumference, diet and physical activity in women with and without gestational diabetes mellitus (GDM).
Using the Coronary Artery Risk Development in Young Adults (CARDIA) study we identified women with at least one pregnancy during 20 years of follow-up (n=1,488 with 3,125 pregnancies). We used linear regression with generalized estimating equations to compare pre- to post-pregnancy changes in health behaviors and anthropometric measurements between 137 GDM pregnancies and 1,637 non GDM pregnancies, adjusted for parity, age at delivery, outcome measure at the pre-pregnancy exam, race, education, mode of delivery, and interval between delivery and post-pregnancy examination.
Compared with women without GDM in pregnancy, women with GDM had higher pre-pregnancy mean weight (158.3 vs. 149.6 lb, p=0.011) and BMI (26.7 vs. 25.1 kg/m2, p=0.002), but non-significantly lower total daily caloric intake and similar levels of physical activity. Both GDM and non GDM groups had higher average postpartum weight of 7–8 lbs and decreased physical activity on average 1.4 years after pregnancy. Both groups similarly increased total caloric intake but reduced fast food frequency. Pre- to post- pregnancy changes in body weight, BMI, waist circumference, physical activity and diet did not differ between women with and without GDM in pregnancy.
Following pregnancy women with and without GDM increased caloric intake, BMI and weight, decreased physical activity, but reduced their frequency of eating fast food. Given these trends, postpartum lifestyle interventions, particularly for women with GDM, are needed to reduce obesity and diabetes risk.
PMCID: PMC3735637  PMID: 23666593
Digestive diseases and sciences  2010;55(7):1839-1851.
Diabetes mellitus increases the risk of incident colorectal cancer, but it is less clear if pre-existing diabetes mellitus influences mortality outcomes, recurrence risk, and/or treatment-related complications in persons with colorectal cancer.
We performed a systematic review and meta-analysis comparing colorectal cancer mortality outcomes, cancer recurrence, and treatment-related complications in persons with and without diabetes mellitus. We searched MEDLINE and EMBASE through October 1, 2008, including hand-searching references of qualifying articles. We included studies in English that evaluated diabetes mellitus and cancer treatment outcomes, prognosis, and/or mortality. The initial search identified 8,208 titles, of which 15 articles met inclusion criteria. Each article was abstracted by one author using a standardized form and re-reviewed by another author for accuracy. Authors graded quality based on pre-determined criteria.
We found significantly increased short-term perioperative mortality in persons with diabetes mellitus. In the meta-analysis of long-term mortality, persons with diabetes mellitus had a 32% increase in all-cause mortality compared to those without diabetes mellitus (95% CI: 1.24, 1.41). Although data on other outcomes are limited, available studies suggest that pre-existing diabetes mellitus predicts increased risk of some post-operative complications as well as 5-year cancer recurrence. In contrast, there is little evidence that diabetes confers increased risk for long-term cancer-specific mortality.
Patients with colorectal cancer and pre-existing diabetes mellitus have an increased risk of short- and long-term mortality. Future research should determine whether improvements in prevention and treatment of diabetes mellitus will improve outcomes for colorectal cancer patients.
PMCID: PMC3093049  PMID: 19731028
Colorectal carcinoma; Diabetes mellitus; Mortality; Treatment outcome; Fatal outcome

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