Adoption of pharmacogenomic testing by US physicians: results of a nationwide survey.

To develop a benchmark measure of US physicians' level of knowledge and extent of use of pharmacogenomic testing, we conducted an anonymous, cross-sectional, fax-based, national survey. Of 397,832 physicians receiving the survey questionnaire, 10,303 (3%) completed and returned it; the respondents were representative of the overall US physician population. The factors associated with the decision to test were evaluated using χ(2) and multivariate logistic regression. Overall, 97.6% of responding physicians agreed that genetic variations may influence drug response, but only 10.3% felt adequately informed about pharmacogenomic testing. Only 12.9% of physicians had ordered a test in the previous 6 months, and 26.4% anticipated ordering a test in the next 6 months. Early and future adopters of testing were more likely to have received training in pharmacogenomics, but only 29.0% of physicians overall had received any education in the field. Our findings highlight the need for more effective physician education on the clinical value, availability, and interpretation of pharmacogenomic tests.

Rosiglitazone and pioglitazone increase fracture risk in women and men with type 2 diabetes.

AIM: The objectives of the study were to determine whether thiazolidinedione (TZD) use is associated with an increased risk of fracture in men and women with type 2 diabetes mellitus and to compare the effects of pioglitazone and rosiglitazone. MATERIALS AND METHODS: A research database of integrated pharmacy and medical claims was analysed using Cox models adjusted for age, gender, chronic obstructive pulmonary disease, asthma, osteoporosis, stroke, prior fracture and chronic disease score. Patients were followed for 540 days. RESULTS: There was a 39% higher [adjusted hazard ratio (HR), 1.39; 95% confidence interval (CI), 1.32-1.46] incidence of fractures in men and women exposed to a TZD (n = 69047; age = 56 +/- 5 years; 59% men; 48% rosiglitazone) compared with that in control patients (n = 75352; age = 56 +/- 5 years; 51% men). Men treated with a TZD had a higher likelihood of fracture than control patients (adjusted HR rosiglitazone, 1.47; 95% CI, 1.38-1.56; adjusted HR pioglitazone, 1.43; 95% CI, 1.34-1.52). The HRs associated with pioglitazone (adjusted HR, 1.43; 95% CI, 1.34-1.52) and rosiglitazone (adjusted HR, 1.47; 95% CI, 1.38-1.56) were almost identical. TZD use was associated with a higher fracture risk in women aged above and below 50 years and in men aged above 50 years. CONCLUSIONS: Our findings add support to the growing literature that TZD treatment is associated with an increased risk of fractures in both men and women, that effects of rosiglitazone and pioglitazone are similar and that fracture risk is increased even in younger women.

The relationship among John Henryism, hostility, perceived stress, social support, and blood pressure in African-American college students.

African Americans' rates of hypertension-related morbidity and mortality are several times that of white Americans. A number of behavioral and psychological variables may influence these differences. John Henryism, characterized by active coping to overcome obstacles, is one such variable. Prior research indicates that among highly educated individuals, high levels of John Henryism may be associated with decreased hypertension risk. The purpose of this study was to identify a cohort of well-educated African Americans to establish a baseline examination of the relationships between John Henryism, hostility, perceived stress, social support and resting systolic and diastolic blood pressures (SBP and DBP, respectively). Participants completed measures of study variables and resting blood pressures were taken. Results indicated that high family and friendship support were related to reports of lowered levels of stress (P<.001). Family support was associated with decreased risk for elevated DBP (P<.05). A positive association between hostility and DBP was found (P<.01). Perceived stress was negatively associated with SBP (P<.05), but did not have an independent effect on DBP. Similarly, no interactive effects of John Henryism and perceived stress were found on blood pressure. Examination of this cohort over time will reveal the impact of John Henryism and other variables on blood pressure elevations and hypertension.

Prevalence of self-rated visual impairment among adults with diabetes.

OBJECTIVES: This study estimated the prevalence of self-rated visual impairment among US adults with diabetes and identified correlates of such impairment. METHODS: Self-reported data from the 1995 Behavioral Risk Factor Surveillance System survey of adults 18 years and older with diabetes were analyzed. Correlates of visual impairment were examined by multiple logistic regression analysis. RESULTS: The prevalence of self-rated visual impairment was 24.8% (95% confidence interval [CI] = 22.3%, 27.3%). Among insulin users, multivariable-adjusted odds ratios were 4.9 (95% CI = 2.6, 9.2) for those who had not completed high school and 1.8 (95% CI = 1.0, 2.8) for those who had completed high school compared with those with higher levels of education. Comparable estimates of odds ratios for nonusers of insulin were 2.2 (95% CI = 1.4, 3.4) and 1.3 (95% CI = 0.9, 2.0), respectively. Among nonusers, the adjusted odds for minority adults were 2.4 (95% CI = 1.0, 3.7) times the odds for non-Hispanic Whites. CONCLUSIONS: By these data, 1.6 million US adults with diabetes reported having some degree of visual impairment. Future research on the specific causes of visual impairment may help in estimating the avoidable public health burden.

Renal assessment practices and the effect of nurse case management of health maintenance organization patients with diabetes.

OBJECTIVE: To examine baseline renal screening practices and the effect of nurse case management of patients with diabetes in a group model health maintenance organization (HMO). RESEARCH DESIGN AND METHODS: We performed both 1-year retrospective and 1-year prospective studies of renal assessment practices and ACE inhibitor usage in a cohort of 133 diabetic patients enrolled in a randomized controlled trial of a diabetes nurse case management program in a group model HMO. In accordance with American Diabetes Association recommendations, urine dipstick and quantitative protein and microalbuminuria testing rates were calculated. RESULTS: At baseline, 77% of patients were screened for proteinuria with dipsticks or had quantitative urine testing. Of patients with negative dipstick findings, 30% had appropriate quantitative protein or microalbumin follow-up at baseline. Baseline ACE inhibitor usage was associated with decreased follow-up testing (relative risk = 0.47). Nurse case management was associated with increased quantitative protein or or microalbumin testing and increased follow-up testing (relative risk = 1.65 and 1.60, respectively). CONCLUSIONS: We found a higher degree of adherence to recommendations for renal testing than has been reported previously. Nurse case management intervention further increased renal screening rates. The inverse association between ACE inhibitor usage and microalbumin testing highlights a potentially ambiguous area of current clinical pathways.

Diabetes mellitus in Egypt: glycaemic control and microvascular and neuropathic complications.

We performed a cross-sectional, population-based survey of persons 20 years of age and older living in Cairo and surrounding rural villages. The purpose was to describe glycaemic control and the prevalence of microvascular and neuropathic complications among Egyptians with diagnosed diabetes, previously undiagnosed diabetes, impaired glucose tolerance, and normal glucose tolerance. A total of 6052 households were surveyed. The response rate was 76% for the household survey and 72% for the medical examination. Among people with previously diagnosed diabetes, mean haemoglobin A1c, was 9.0%. Forty-two per cent had retinopathy, 21% albuminuria, and 22% neuropathy. Legal blindness was prevalent (5%) but clinical nephropathy (7%) and foot ulcers (1%) were uncommon in persons with diagnosed diabetes. Among people with diagnosed diabetes, microvascular and neuropathic complications were associated with hyperglycaemia. Retinopathy was also associated with duration of diabetes; albuminuria with hypertension and hypercholesterolaemia; and neuropathy with age, female sex, and hypercholesterolaemia. Albuminuria was as common in people with previously undiagnosed diabetes (22%) as those with diagnosed disease (21%). Mean haemoglobin A1c was lower (7.8%) and retinopathy (16%) and neuropathy (14%) were less prevalent in people with previously undiagnosed disease. Ocular conditions, blindness, and neuropathy were prevalent in the non-diabetic population. The microvascular and neuropathic complications of diabetes are a major clinical and public health problem in Egypt.

Nurse case management to improve glycemic control in diabetic patients in a health maintenance organization. A randomized, controlled trial.

BACKGROUND: Control of hyperglycemia delays or prevents complications of diabetes, but many persons with diabetes do not achieve optimal control. OBJECTIVE: To compare diabetes control in patients receiving nurse case management and patients receiving usual care. DESIGN: Randomized, controlled trial. SETTING: Primary care clinics in a group-model health maintenance organization (HMO). PATIENTS: 17 patients with type 1 diabetes mellitus and 121 patients with type 2 diabetes mellitus. INTERVENTION: The nurse case manager followed written management algorithms under the direction of a family physician and an endocrinologist. Changes in therapy were communicated to primary care physicians. All patients received ongoing care through their primary care physicians. MEASUREMENTS: The primary outcome, hemoglobin A1c (HbA1c) value, was measured at baseline and at 12 months. Fasting blood glucose levels, medication type and dose, body weight, blood pressure, lipid levels, patient-perceived health status, episodes of severe hypoglycemia, and emergency department and hospital admissions were also assessed. RESULTS: 72% of patients completed follow-up. Patients in the nurse case management group had mean decreases of 1.7 percentage points in HbA1c values and 43 mg/dL (2.38 mmol/L) in fasting glucose levels; patients in the usual care group had decreases of 0.6 percentage points in HbA1c values and 15 mg/dL (0.83 mmol/L) in fasting glucose levels (P < 0.01). Self-reported health status improved in the nurse case management group (P = 0.02). The nurse case management intervention was not associated with statistically significant changes in medication type or dose, body weight, blood pressure, or lipids or with adverse events. CONCLUSIONS: A nurse case manager with considerable management responsibility can, in association with primary care physicians and an endocrinologist, help improve glycemic control in diabetic patients in a group-model HMO.

Global burden of diabetes, 1995-2025: prevalence, numerical estimates, and projections.

OBJECTIVE: To estimate the prevalence of diabetes and the number of people with diabetes who are > or =20 years of age in all countries of the world for three points in time, i.e., the years 1995, 2000, and 2025, and to calculate additional parameters, such as sex ratio, urban-rural ratio, and the age structure of the diabetic population. RESEARCH DESIGN AND METHODS: Age-specific diabetes prevalence estimates were applied to United Nations population estimates and projections for the number of adults aged > or =20 years in all countries of the world. For developing countries, urban and rural populations were considered separately RESULTS: Prevalence of diabetes in adults worldwide was estimated to be 4.0% in 1995 and to rise to 5.4% by the year 2025. It is higher in developed than in developing countries. The number of adults with diabetes in the world will rise from 135 million in 1995 to 300 million in the year 2025. The major part of this numerical increase will occur in developing countries. There will be a 42% increase, from 51 to 72 million, in the developed countries and a 170% increase, from 84 to 228 million, in the developing countries. Thus, by the year 2025, >75% of people with diabetes will reside in developing countries, as compared with 62% in 1995. The countries with the largest number of people with diabetes are, and will be in the year 2025, India, China, and the U.S. In developing countries, the majority of people with diabetes are in the age range of 45-64 years. In the developed countries, the majority of people with diabetes are aged > or =65 years. This pattern will be accentuated by the year 2025. There are more women than men with diabetes, especially in developed countries. In the future, diabetes will be increasingly concentrated in urban areas. CONCLUSIONS: This report supports earlier predictions of the epidemic nature of diabetes in the world during the first quarter of the 21st century. It also provides a provisional picture of the characteristics of the epidemic. Worldwide surveillance of diabetes is a necessary first step toward its prevention and control, which is now recognized as an urgent priority.

Population-based assessment of the level of care among adults with diabetes in the U.S.

OBJECTIVE: To estimate the levels of use of preventive care and to identify correlates of such care among people with diabetes in the U.S. RESEARCH DESIGN AND METHODS: A cross-sectional study was conducted using a sample of 2,118 adults, age > or =18 years, with self-reported diabetes in 22 states that participated in the 1994 Behavioral Risk Factor Surveillance System. Most subjects were age > or =45 years (83%), women (51%), and white (75%) and were diagnosed at ages > or =30 years (83%), had type 2 diabetes (89%), and were not using insulin (66%). RESULTS: Among all people with diabetes, 78% practiced self-monitoring of blood glucose, and 25% were aware of the term "glycosylated hemoglobin" or "hemoglobin A one C" (HbA1c). In the last year, 72% of the subjects visited a health care provider for diabetes care at least once, 61% had their feet inspected at least once, and 61% received a dilated eye examination. Controlled for age and sex, the odds ratios (ORs) for insulin use were for self-monitoring (OR [95% CI]; 4.0 [2.6-6.1]); having heard of HbA1c or receipt of a dilated eye examination (1.9 [1.4-2.5]); at least one visit to a provider (3.4 [1.9-7.2]); and feet inspected at least once (2.1 [1.5-2.9]). In addition, people <45 years, those who did not complete high school, and those without insurance coverage were high-risk groups for underuse of preventive care. Only 3% of insulin users and 1% of nonusers met all five of the American Diabetes Association standards in the previous year. CONCLUSIONS: Underuse of recommended preventive care practices is common among people with diabetes.

Diabetes mellitus and its complications in an African-American community: project DIRECT.

Project DIRECT (Diabetes Intervention Reaching and Educating Communities Together) is a multilevel community-based intervention project designed to address diabetes and its complications in an African-American community. This article presents results of the Project DIRECT pilot study and describes risk factors for diabetes, diabetes prevalence, complications, and care practices. During 1993, a pilot study was conducted among persons 20 to 74 years of age in Wake County, North Carolina. The study involved household interviews and examinations, and more extensive health center interviews and examinations based on the race of the head of the household, previous diagnosis of diabetes, and results of capillary glucose tests done in the household. Of the black population aged 20 to 74 years, 52 +/- 3% reported being inactive and 51 +/- 3% were overweight; the prevalence of diagnosed diabetes was 5.2 +/- 0.9%; the prevalence of undiagnosed diabetes was 5.7 +/- 2.7%; and the prevalence of impaired glucose tolerance was 11.4 +/- 7.5%. Blacks with diabetes were significantly more likely than nonblacks with diabetes to have uncontrolled hypertension and to smoke cigarettes. Blacks with diabetes were significantly less likely to report having health insurance or to have a private health-care provider. Diabetes mellitus is a major public health problem in the African-American community of Wake County. Modifiable risk factors for diabetes and undiagnosed diabetes are common. Project DIRECT is attempting to improve the health-related quality of life of this population by reducing the burden of diabetes and its complications through a multilevel, community-based intervention.

Comparison of fasting and 2-hour glucose and HbA1c levels for diagnosing diabetes. Diagnostic criteria and performance revisited.

OBJECTIVE: Nearly two decades ago, the National Diabetes Data Group (NDDG) and the World Health Organization (WHO) Expert Committee on Diabetes Mellitus published diagnostic criteria for diabetes. We undertook this study to compare the performance of three glycemic measures for diagnosing diabetes and to evaluate the performance of the WHO criteria. RESEARCH DESIGN AND METHODS: In a cross-sectional population-based sample of 1,018 Egyptians > or = 20 years of age, fasting and 2-h glucose and HbA1c levels were measured, and diabetic retinopathy was assessed by retinal photograph. Evidence for bimodal distributions was examined for each glycemic measure by fitting models for the mixture of two distributions using maximum likelihood estimates. Sensitivity and specificity for cutpoints of each glycemic measure were calculated by defining the true diabetes state (gold standard) as 1) the upper (diabetic) component of the fitted bimodal distribution for each glycemic measure, and 2) the presence of diabetic retinopathy. Receiver operating characteristic (ROC) curves were constructed to determine the performance of the glycemic measures in detecting diabetes as defined by diabetic retinopathy. RESULTS: In the total population, the point of intersection of the lower and upper components that minimized misclassification for the fasting and 2-h glucose and HbA1c were 7.2 mmol/l (129 mg/dl), 11.5 mmol/l (207 mg/dl), and 6.7%, respectively. When diabetic retinopathy was used to define diabetes, ROC curve analyses found that fasting and 2-h glucose values were superior to HbA1c (P < 0.01). The performance of a fasting glucose of 7.8 mmol/l (140 mg/dl) was similar to a 2-h glucose of 12.2-12.8 mmol/l (220-230 mg/dl), and the performance of a 11.1 mmol/l (200 mg/dl) 2-h glucose was similar to a fasting glucose of 6.9-7.2 mmol/l (125-130 mg/dl). CONCLUSIONS: Optimal cutpoints for defining diabetes differ according to how diabetes itself is defined. When diabetes is defined as the upper component of the bimodal population distribution, a fasting glucose level somewhat lower than the current WHO cutpoint and a 2-h glucose level somewhat higher than the current WHO cutpoint minimized misclassification. When diabetic retinopathy defines diabetes, we found that the current fasting diagnostic criterion favors specificity and the current 2-h criterion favors sensitivity. These results should prove valuable for defining the optimal tests and cutpoint values for diagnosing diabetes.

Strategies to improve the reporting of legal blindness in Massachusetts.

OBJECTIVES: Registration practices were evaluated as the initial phase of a validation study of the Register of the Massachusetts Commission for the Blind. METHODS: Massachusetts eye care providers were surveyed to determine factors associated with nonreporting of legal blindness to the commission. RESULTS: Among ophthalmologists, factors associated with nonreporting were small practice size and practicing for 5 years or less in Massachusetts. Among optometrists, factors included small practice size and unawareness of the Massachusetts reporting law. CONCLUSIONS: Information should be disseminated to eye care providers, legally blind patients, and the public to ensure registration and sustain it.

Screening for NIDDM in nonpregnant adults. A review of principles, screening tests, and recommendations.

The economic burden of diabetes in the U.S. is now more than 90 billion dollars per year (113-115). In the diabetes community, there is a feeling that aggressive measures to detect diabetes in earlier stages may be warranted. Regardless of whether evidence is convincing that there are benefits from early detection of diabetes (3,116,117), screening activities have been sanctioned by many organizations and are now taking place. Operational research is needed to define more clearly the who, when, where, and how of screening and the effectiveness of screening programs (4,118). Diabetes screening programs should be comprehensive and should educate about diabetes and provide appropriate interpretation of both positive and negative screening results. It is essential that programs have diagnostic follow-up and refer those with newly diagnosed diabetes for treatment. In addition, individuals with previously diagnosed diabetes encountered during screening activities should be made aware of the importance of glycemic control and follow-up with their health care providers.

Diabetes mellitus in Egypt: risk factors and prevalence.

Major sociodemographic changes have occurred in Egypt to promote the development of noncommunicable diseases. We have performed a cross-sectional, population-based survey of persons > or = 20 years of age in Cairo and surrounding rural villages to describe the prevalence of diabetes risk factors, diagnosed diabetes, previously undiagnosed diabetes, and impaired glucose tolerance by age, sex, rural and urban residence, and socioeconomic status (SES). In the survey, we identified 6052 eligible households: 76% of household respondents completed a household examination and 72% of selected household respondents subsequently completed a medical examination. Exercise was assessed by questionnaire; adiposity by measurement of height, weight, and girths; and diabetes by history and 2-h 75 g oral glucose tolerance test. In rural areas, 52% of persons > or = 20 years of age were sedentary, 16% were obese, and 4.9% had diabetes. In lower SES urban areas, 73% were sedentary, 37% were obese, and 13.5% had diabetes. In higher SES urban areas, 89% were sedentary, 49% were obese, and 20% had diabetes. The combined prevalence of diagnosed and undiagnosed diabetes in the Egyptian population > or = 20 years of age was estimated to be 9.3%. Approximately half the diabetes was diagnosed and the other half was previously undiagnosed. The prevalence of diabetes in Egypt is high, and the gradient in risk factors and disease from rural to urban areas and in urban areas from lower to higher SES suggest that diabetes is a major, emerging clinical and public health problem in Egypt.

The epidemiology of diabetes and pregnancy in the U.S., 1988.

OBJECTIVE: To determine the prevalence of pregnancy complicated by diabetes in a representative sample of the U.S. population. RESEARCH DESIGN AND METHODS: We analyzed data from a multistaged cross-sectional probability sample of live births recorded in the U.S. in 1988 for women 15-49 years of age. The main outcome measure was pregnancy complicated by diabetes. RESULTS: Diabetes was present in congruent to 154,000 (4%) of all pregnancies in the U.S. Gestational diabetes mellitus (GDM) accounted for 135,000 of such pregnancies (88%), non-insulin-dependent diabetes mellitus (NIDDM) for 12,000 (8%), and insulin-dependent diabetes mellitus for 7,000 (4%). On average, the mothers with NIDDM (29.6 years) and GDM (29.3 years) were older than mothers whose pregnancies were not complicated by diabetes (26.2 years; P < 0.05). In multivariate analyses, the odds of having a pregnancy complicated by GDM increased significantly with maternal age and body mass index. CONCLUSIONS: Pregnancy is complicated by diabetes more often than was previously believed. More frequent testing may further increase the apparent prevalence of GDM.

Screening for diabetes mellitus in adults. The utility of random capillary blood glucose measurements.

OBJECTIVE: Because half of the people with non-insulin-dependent diabetes mellitus (NIDDM) are undiagnosed and because near-normal glycemic control can prevent diabetic complications, we evaluated the use of field-based random capillary blood glucose measurement as a screening test for NIDDM. RESEARCH DESIGN AND METHODS: A cross-sectional sample of 828 Egyptians > or = 20 years of age underwent both a random capillary blood glucose measurement performed with a portable reflectance meter in the field and an oral glucose tolerance test in the laboratory. The sensitivity and specificity of random capillary blood glucose measurements in predicting the presence of NIDDM were evaluated. RESULTS: Multivariate analyses showed that the screening test performed better when subjects had eaten shortly before the test (area under receiver operating characteristic curve, 0.87 for a 1-h postprandial period compared with 0.69 for an 8-h postprandial period) and that the optimal capillary blood glucose cutoff points to define a positive test increased with age. For a postprandial period of 1 h, cutoff points of 115 mg/dl for individuals 30 years of age and 140 mg/dl for those 75 years of age yielded similar performance characteristics (sensitivity 82% and specificity 78% for those 30 years old; sensitivity 81% and specificity 80% for those 75 years old). CONCLUSIONS: Adjusting random capillary blood glucose measurements for the postprandial period and using age-specific cutoff point values can improve performance of the screening test.

A new and simple questionnaire to identify people at increased risk for undiagnosed diabetes.

OBJECTIVE: To develop a simple questionnaire to prospectively identify individuals at increased risk for undiagnosed diabetes. RESEARCH DESIGN AND METHODS: People with newly diagnosed diabetes (n = 164) identified in the Second National Health and Nutrition Examination Survey and those with neither newly diagnosed diabetes nor a history of physician-diagnosed diabetes (n = 3,220) were studied. Major historical risk factors for undiagnosed non-insulin-dependent diabetes were defined, and classification trees were developed to identify people at higher risk for previously undiagnosed diabetes. The sensitivity, specificity, and predictive value of the classification trees were described and compared with those of an existing questionnaire. RESULTS: The selected classification tree incorporated age, sex, history of delivery of a macrosomic infant, obesity, sedentary lifestyle, and family history of diabetes. In a representative sample of the U.S. population, the sensitivity of the tree was 79%, the specificity was 65%, and the predictive value positive was 10%. CONCLUSIONS: This classification tree performed significantly better than an existing questionnaire and should serve as a simple, noninvasive, and potentially cost-effective tool for diagnosing diabetes in the U.S.

Diabetes mellitus and cigarette smoking. Findings from the 1989 National Health Interview Survey.

OBJECTIVE: To compare the prevalence of current smoking in the U.S. diabetic population with that of the nondiabetic population. RESEARCH DESIGN AND METHODS: Using data from the 1989 National Health Interview Survey--a nationally representative sample--we calculated the prevalence of current smoking for 2,405 people with self-reported diabetes and 20,131 people without this condition. RESULTS: Overall, the age-adjusted prevalence of smoking was 27.3% among people with diabetes and 25.9% among people without diabetes. The prevalence of smoking did not differ significantly between participants with and without diabetes when they were stratified by age, sex, race, or education. Black and Hispanic men with diabetes had a higher prevalence of smoking than did white men with diabetes and black and Hispanic men without diabetes, but none of these differences were statistically significant. Among people with diabetes, age, race, sex, and educational status were independent predictors of current smoking in a multiple-logistic regression model. Duration of diabetes was not related to smoking. CONCLUSIONS: These data again emphasize the need to prevent and reduce smoking in the diabetic population. Smoking cessation programs should particularly target people with diabetes who are < or = 44 years of age. Black and Hispanic men are also prime targets for intervention efforts.

Education, race, and high-density lipoprotein cholesterol among US adults.

OBJECTIVES: Although educational achievement is positively related to levels of high-density lipoprotein cholesterol (HDL-C) among White adults, there is an inverse association among Blacks. We assessed whether this interaction could be attributed to differences in the relation of education to correlates of HDL-C. METHODS: Cross-sectional analyses were based on data from 8391 White and 995 Black adults who participated in the Second National Health and Nutrition Examination Survey. RESULTS: Associations between education and HDL-C levels varied from negative (Black men), to nearly nonexistent (White men and Black women), to positive (White women). Mean HDL-C levels were higher among Blacks than among Whites, but differences varied according to educational achievement. Among adults with less than 9 years of education, mean levels were 6 to 10 mg/dL higher among Blacks, but the radical difference was less than 1 mg/dL among adults with at least 16 years of education. About 20% to 40% of these differences could be accounted for by obesity, alcohol consumption, and other characteristics. CONCLUSIONS: Because of the implications for coronary heart disease risk, consideration should be given to behavioral characteristics associated with the interaction between race and educational achievement.