Racial differences in lipid and lipoprotein levels in diabetes.

Racial differences in plasma lipid and lipoprotein levels were investigated in 145 patients with non-insulin-dependent diabetes mellitus (NIDDM). Black men had higher high-density lipoprotein (HDL) cholesterol levels, lower triglyceride levels, and an improved atherogenic index compared with white men. Premenopausal black women were also found to have higher HDL cholesterol levels, lower triglyceride levels, and a lower atherogenic index than their white counterparts. Adjustment for age, waist to hip ratio (WHR), hemoglobin A1c (HbA1c), and physical activity did not eliminate the significant differences found. There were no racial differences found regarding total and low-density lipoprotein (LDL) cholesterol. Metabolic control as measured by HbA1c was significantly correlated with the triglyceride level in black women. These data confirm that racial differences exist in plasma lipid levels among patients with NIDDM.

Quality of diabetes care among low-income patients in North Carolina.

BACKGROUND: Diabetes is a leading cause of death and disability, disproportionately affecting most ethnic minority groups, people of low socioeconomic status, the elderly, and people in rural areas. Despite the availability of evidence-based clinical recommendations, barriers exist in the delivery of appropriate diabetes care. The purpose of this study is to examine the level of diabetes care among low-income populations in North Carolina. METHODS: Baseline medical record abstractions were performed (N=429) on diabetic patients at 11 agencies serving low-income populations (community health centers, free clinics, primary care clinics, and public health clinics) across the state participating in a quality-of-diabetes-care initiative. Data were collected for four process (measurement of glycosylated hemoglobin and lipids, dilated eye examination, nephropathy assessment) and two outcome (glycemic and lipid control) measures based on the Diabetes Quality Improvement Project (DQIP) and the Health Plan Employer Data and Information Set (HEDIS), and three additional indicators (blood pressure measurement and control, and lower limb assessment). Compliance rates to individual measures were calculated overall and by demographic and health characteristics. RESULTS: Diabetes care compliance rates ranged from 77.9% for blood pressure testing to 3.3% for complete foot examinations. Differences in care were observed by age, insulin use, and prevalent disease. CONCLUSIONS: This study indicates low compliance with diabetes care guidelines in underserved North Carolinians, and inconsistency of care according to some demographic and health characteristics. These results stress the need for quality improvement initiatives that enhance the level of care received by patients with diabetes, particularly those most vulnerable to diabetes and its complications.

Four factors of clinical decision making: a teaching model.

For more than 25 years, Bowman Gray has been placing fourth-year students in community-based primary care settings. Upon their return to campus, the students participate in a seminar in which they discuss issues raised by their primary care experiences. In these seminars, the students have consistently identified four key factors of clinical decision making that reflect current trends in medicine: quality, cost, ethics, and legal concerns. These factors influence the practice of medicine and affect the health care of individuals and communities. The authors discuss the nature of these factors and the physician's role and obligation in clinical decision making. Physicians have two responsibilities in this decision-making model: to be the primary advocates for quality health care and to ensure that there be a balance among the weights given the four factors. While physicians must take the lead in ensuring quality care, they must work in partnership with patients, payers, lawyers, ethicists, and the government. It is up to those responsible for the education of future physicians to see that students understand all the factors of clinical decision making and how best to balance them to fulfill their future obligations to patients.

Evaluations by three graduating classes of a required community health project.

The authors analyzed seniors' evaluations of the first three years of an intensive community health project at the Bowman Gray School of Medicine of Wake Forest University in 1988-89, 1989-90, and 1990-91. The project was designed to provide a public health perspective by having the students select, study, and propose solutions to a community health problem. Of 285 seniors, 240 (84%) completed evaluation questionnaires, using a five-point scale. The students' perceptions of the value of the project became steadily more favorable with each subsequent class; the classes of 1990 and 1991 rated the value of the project as being greater than that of most other experiences in their medical education. The project was more positively evaluated by the 106 responding students (44%) who planned to enter primary care specialties. The students who invested more time in the project also perceived its value to be greater.

Effects of Terazosin on Glycemic Control, Cholesterol, and Microalbuminuria in Patients with Non--Insulin-Dependent Diabetes Mellitus and Hypertension.

The use of antihypertensive agents that have positive or neutral effects on blood sugar, lipid profiles, and microalbuminuria can be important clinical treatment for patients with diabetes. We evaluated the effects of both terazosin, a selective alpha-one-adrenergic blocker, and hydrochlorothiazide (HCTZ), a standard mild antihypertensive agent, on glycemic control, urinary albumin excretion rate overnight total cholesterol, and other parameters in non--insulin-dependent diabetes mellitus (NIDDM) patients. A randomized, placebo-controlled, cross-over design was implemented in 25 patients. Over an 8-week treatment period fasting plasma glucose (FPG) and glycosylated hemoglobin (GHgb) improved in the terazosin group. Post-treatment FPG was 200 plus minus 85 and 187 plus minus 71 for patients who received HCTZ and terazosin, respectively. Although the GHgb improved significantly for terazosin patients (12.2 plus minus 5.8 for HCTZ versus 10.7 plus minus 4.6 for terazosin, p = 0.03), microalbuminuria did not improve in terazosin patients in this pilot study. A larger randomized study with tighter blood pressure end points are needed to assess fully the impact of terazosin on micoroalbuminuria and overall glycemic control in the NIDDM patient.

Changes in diabetic urinary transferrin excretion after moderate exercise.

Microalbuminuria following submaximal exercise testing has been proposed for detecting renal abnormalities in diabetic patients. We compared urinary transferrin and albumin excretion between eight adults with insulin dependent diabetes mellitus and eight nondiabetic controls without microalbuminuria before and after a standardized exercise challenge of only moderate intensity for 20 min. Both groups were similar for age, sex, and METs expended during treadmill walking. Urinary excretion ratios of transferrin (UTER) and albumin (UAER) did not significantly increase for nondiabetic subjects. After exercise, UTER increased on average 207% in diabetic subjects (P = 0.009) and UAER increased 209% (P = 0.046). The percent increase in UTER appears to be a function of workload intensity, while the percent increase in UAER appears less dependent on the duration of exercise. A standardized treadmill challenge of moderate intensity easily differentiated changes in urinary transferrin excretion ratios between diabetic and nondiabetic subjects. Measuring transferrin excretion may be a more sensitive parameter than albumin in studies using urinary protein excretion as a response to a provocative exercise challenge.

Association of gender with symptoms and complications in type II diabetes mellitus.

Females with Type II diabetes appear more likely than males to experience symptoms and vascular complications related to their disease.

Association between exercise and other preventive health behaviors among diabetics.

Two hundred and seventy patients were studied to investigate the cross sectional association between exercise and other preventive health behaviors in a diabetic population. Patients included both insulin and noninsulin dependent diabetics and were recruited from the Family Practice and Pediatrics Clinics at Bowman Gray School of Medicine. During screening, patients underwent a physical examination as well as completing a survey to assess exercise and health behavior habits. Three exercise groups were compared: (a) patients who expended more than 600 kilocalories per week during exercise, (b) patients who expended 600 kilocalories or less, and (c) patients who did not exercise. The mean body weights of both exercise groups were found to be less than the nonexercise group, and the heavy exercise group also had a lower mean body mass index. Heavy exercisers reported greater caloric intakes than both moderate and nonexercisers. There were no differences found concerning the composition of their diets among groups. The heavy exercise group reported wearing their seatbelts a greater percentage of the time and visited the dentist more often compared with the sedentary group. There were no significant differences found among exercise groups concerning blood sugar monitoring, alcohol consumption, smoking, or in obtaining periodic health examinations. It was concluded that exercise was associated with several, but not a majority, of other healthful behaviors in a population of diabetics.

Microtransferrinuria and microalbuminuria: enhanced immunoassay.

An enhanced-sensitivity immunoassay for urinary microtransferrin and microalbumin was devised based on protein precipitation with cold trichloroacetic acid followed by dissolution of the precipitate in a small volume of phosphate buffer. Samples can be concentrated 10-fold by this method while at the same time removing many of the chromogens present in urine. Concentrated samples were assayed by immunoturbidity and radial immunodiffusion. The average recovery for urinary microtransferrin was 82 percent and for microalbumin 91 percent. The reference range for 80 normal adults for microtransferrinuria and microalbuminuria is 0 to 0.9 and 5 to 32 mg per g creatinine, respectively. The same method can be used for the assay of other proteins such as B2-microglobulin in the urine or the cerebrospinal fluid.

Measurement feasability of advanced glycated end-products from skin samples after antioxidant vitamin supplementation in patients with type 2 diabetes.

PURPOSE: To determine the feasibility of measuring advanced glycated end-products (AGEs)from skin samples and to evaluate the effects of a combination of vitamins E and C on measures of glycemic control and AGEs in patients with type 2 diabetes mellitus. METHODS: Twenty-two patients with type 2 diabetes from a Family Medicine clinic were randomly assigned to receive a daily dietary supplement containing either a combination of 400 mg of vitamin E and 500 mg of vitamin C or matching placebo for a period of one year. AGEs were measured from skin samples taken from the buttock. RESULTS: Nineteen subjects completed this one-year pilot study. There were no major problems found in measuring AGEs from skin samples taken from the butttock. Neither the treatment or placebo group had significant changes in glycemic control, protein glycosylation or AGEs. DISCUSSION: Skin samples taken from the buttock area may be an appropriate site for the determination of AGE levels as this procedure appeared to be well-tolerated. Daily vitamin E and C supplementation did not improve measures of glycemic control or AGE levels in this small sample of patients with type 2 diabetes. Because antioxidant vitamins are inexpensive and free of side effects, additional research using a variety of antioxidant vitamin combinations and dosing regimens is needed.

Smoking status and psychosocial variables in type 1 diabetes mellitus.

While depression, anxiety, and negative affect are associated with smoking and smoking cessation outcomes in healthy individuals, these associations have not been established in smokers with chronic diseases such as diabetes mellitus, a condition which greatly increases cardiovascular disease risk. Other psychosocial variables such as stress and locus of control may also be associated with smoking but are seldom reported. We examined stress, affect, and locus of control by smoking status in patients with type 1 diabetes mellitus. Results indicated that current smokers reported significantly higher levels of perceived stress, a more negative affect, and higher powerful others locus of control compared with nonsmokers. These findings indicate that those patients who have diabetes and who smoke are at greater risk for depressive symptoms. This knowledge may aid clinicians in their attempts to help these patients quit smoking.

Abnormal urinary protein excretion in African Americans with type 2 diabetes mellitus.

The purpose of this investigation was to determine the prevalence and correlates of abnormal urinary albumin excretion and to examine the possible additive effects of cardiovascular risk factors on urinary albumin excretion in African Americans with type 2 diabetes mellitus. One hundred fifty-one African-American subjects who met WHO criteria for type 2 diabetes were included in this cross-sectional analysis. Subjects were identified through computerized medical records from a family medicine clinic and a community health center. Urinary albumin excretion ratios (UAER) were determined from overnight samples. The prevalence of abnormal urinary protein excretion was 51%. Of those with abnormal protein excretion, 36% had microalbuminuria and 15% had macroalbuminuria. Diabetes duration, waist to hip ratio, blood pressure, and total- and LDL cholesterol were significantly higher in subjects with macroalbuminuria. Regression analysis indicated that mean arterial blood pressure, diabetes duration and total cholesterol were independently associated with UAER. Mean UAER significantly increased with the addition of one or more syndrome X risk factors to pure diabetes. Our results indicate that African Americans with type 2 diabetes mellitus have a high prevalence of abnormal urinary protein excretion, which is associated with a clustering of additional cardiovascular risk factors. The fact that this increased risk was associated with hypertension indicates that screening for albuminuria in this population is essential and that a majority of African Americans with diabetes may be at risk for developing cardiovascular complications.

Using a family practice preceptorship to teach clinical epidemiology.

Because physicians in training can benefit from an epidemiological approach to primary care practice, research, and education, educators are turning their attention to better methods and settings to teach preventive and epidemiological principles while cultivating an attitude for clinical research. This report describes the development of a clinical epidemiological problem studied in the context of a one-week family practice preceptorship. The project was designed to study the possible association between obesity and hypertension and to familiarize students with a common study design. Data from 393 case control pairs produced results of the same magnitude as that documented by formal, carefully controlled research studies. Students participated with dedication and excitement in the clinical application of relevant and practical epidemiologic and biostatistical tools in a clinical setting. Often difficult to comprehend concepts of interaction and confounding were clearly demonstrated using data derived from actual patients encountered during the preceptorship experience.

A family practice residency curriculum in critical appraisal of the medical literature.

This paper reports a five-year experience with a comprehensive curriculum for teaching critical appraisal and practical research skills to family practice residents. The curriculum includes a seminar series in research and medical practice and simulated research projects. Rationale, methods, format, and evaluations of the curriculum are presented. The curriculum prepared graduates to critically review research studies in the professional literature and translate valid conclusions into medical practice. Residents were able to identify potential areas of research interest and acquired additional skills that encouraged continuing education and professional growth.

Using standardized patient instructors to teach health promotion interviewing skills.

BACKGROUND: Medical students report knowledge, but inadequate skills, in health promotion and disease prevention (HPDP) technology. An established methodology using standardized patient instructors (SPIs) was adapted and tested for effectiveness in teaching HPDP. METHODS: Thirteen lay persons were trained and given profiles showing high cardiovascular risks. During their family medicine clerkship, 104 students engaged in one-to-one exercises with the SPIs. Half of these sessions were spent in the doctor-patient interview; in the other half, the SPI gave specific feedback using a validated scale. Encounters were videotaped. RESULTS: The students rated the SPI feedback as the program's most valuable aspect and the videotaping as the least valuable. The SPI feedback was rated valuable by 90%-96% of the students. The students also reported that the skills acquired were likely to be used, and they had learned "much" or "very much." As a group, students' self-assessments did not differ from the SPIs' assessments of the students. CONCLUSION: Lay SPIs are a powerful educational tool.

Women's cardiovascular health.

Significant coronary artery disease is uncommon in premenopausal women, but it is the leading cause of death among postmenopausal women. This article briefly discusses atherosclerotic disease in women, including the effects of menopause and estrogen, the role of cholesterol, hypertension, exercise and weight control, smoking cessation, and diabetes mellitus. The role of screening and testing for coronary artery disease and carotid artery stenosis is discussed. Recommendations for prevention and patient education are included in each section.

Racial differences in psychosocial variables among adults with non-insulin-dependent diabetes mellitus.

To determine whether racial differences exist in psychosocial variables among patients with non-insulin-dependent diabetes mellitus (NIDDM), the authors administered a series of questionnaires to 211 Black and White patients of the Wake Forest Family Medicine ambulatory care unit and the Reynolds Health Center, a community health center. In general, Blacks in the study population had higher levels of external locus of control, higher levels of stress, and lower levels of family functioning compared with Whites. These differences may account partially for the disparity of diabetes control and the consequences of diabetes among Blacks. Health professionals may benefit from understanding and addressing these psychosocial variables and may be more successful in implementing intervention programs in this population by tailoring programs to the psychosocial orientation of their population.

Body fat, fat distribution, and psychosocial factors among patients with Type 2 diabetes mellitus.

Diabetes, a risk factor for cardiovascular disease, requires lifestyle modifications (diet, exercise, weight loss). The relations between body mass index, waist-hip ratio (WHR), and psychosocial indicators, such as affect and stress, among 302 diabetic patients from a clinic and a neighborhood health center were analyzed. Data included stress and mood scale responses, body size (height, weight, and WHR) and potential confounders (physical activity, energy intake, and diabetes duration). In univariate analyses, body mass index was positively associated with stress and inversely associated with positive affect only in women. Multiple regression analyses indicated that stress was associated with body mass index and negative mood was associated with the WHR. The findings suggested that stress and affect may be important correlates of body fat among women with Type 2 diabetes, leading to more complications. Healthcare providers can help women with Type 2 diabetes lose weight and lower the risk of cardiovascular disease by recognizing and helping them deal with these psychosocial issues.

Prevalence and predictors of problem drinking among primary care diabetic patients.

BACKGROUND: Alcohol abuse among patients with diabetes mellitus is dangerous and complicates therapy, but its prevalence and the factors that predict it are unknown. This study examined the prevalence of problem drinking among a large number of primary care diabetic patients, exploring its relation to age, race, sex, psychological factors, and other health behaviors. METHODS: Volunteers with insulin-dependent diabetes mellitus and non-insulin-dependent diabetes mellitus were surveyed at three primary care practice sites. Patients completed a health risk appraisal designed to elicit alcohol use and other health practices, and two psychometric instruments: the Brief Encounter Psychosocial Instrument and the Affect Balance Scale. Fasting blood glucose and hemoglobin A1C levels were also determined. RESULTS: Of 395 diabetic patients, 32 (8.1%) had a drinking problem as defined by answering yes to the question "Have you ever had a drinking problem?" or reporting their last drink to be within 24 hours, or both. Patients with a drinking problem coped less well with psychological stress and had a more highly negative affect than those without a drinking problem. Depression, black race, and male sex were significantly associated with problem drinking (odds ratios = 8.42, 2.70, and 3.80, respectively). Problem drinking did not predict glycemic control but was associated with smoking and less frequent glucose monitoring. CONCLUSIONS: The prevalence of problem drinking among patients with diabetes mellitus appears lower than among other medical outpatient populations and is in keeping with the prevalence found in community surveys. While the lack of association between problem drinking and glycemic control in diabetic patients may be surprising, these data help define the characteristics of this subgroup of diabetic patients and highlight the need for family physicians to intensify alcohol screening efforts in this population.

Screening diabetic patients for microalbuminuria.

Abnormal rates of urinary albumin excretion have been shown to predict the development of nephropathy and may signal atherosclerotic disease in diabetic patients. This study demonstrated the feasibility of measuring microalbuminuria in diabetic patients from a large family practice population. Although only one half of the 473 diabetic patients offered free screening took advantage of the testing, those participating did not differ in terms of sex, race, type of diabetes, mean age, systolic blood pressure, and fasting blood glucose levels from those not electing to participate. Over 40% of those screened had abnormally elevated albumin excretion rates as defined as greater than 0.02 g of albumin per gram of creatinine. Those participating in the screening perceived the process as useful and were able to comply with directions for overnight urine collection. Results show that screening for microalbuminuria in diabetic patients cared for by family physicians is feasible, simple, and inexpensive. Interventions to slow or reverse the progression of abnormal microalbuminuria and future risk for nephropathy in those with diabetes are underway.