An Overview of Body Size Preference, Perception and Dissatisfaction in Sub-Saharan Africans Living in the United States.

Purpose: Body image affects health practices. With acculturation superimposed on globalization, 21st century body size preferences of African immigrants, one of the fasting growing populations in the United States, are unknown. Therefore, in African immigrants living in America we assessed: 1) body size preference; and 2) body size dissatisfaction. Methods: Participants chose two silhouettes from the Stunkard Figure Rating Scale: one for body size preference and one for perceived body size. Each silhouette corresponds to a BMI category: (a) Underweight: 1 and 2; (b) Normal weight: 3 and 4; (c) Overweight: 5, 6 and 7; (d) Obesity: 8 and 9. Dissatisfaction was defined as the difference between silhouette numbers for perceived and preferred body size. Results: Characteristics of the 412 participants were: women: 42% (174/412), age 40±11y (mean±SD), range 20-69 y, BMI 27.9±4.6, range 19.5-47.3 kg/m2. As a body size of preference, no one (0/412) chose obese silhouettes. Normal weight silhouettes were chosen as their body size of preference by 75% (131/174) of women and 60% (143/238) of men. Overweight silhouettes were chosen as their preferred body size by 11% (19/174) of women and 26% (62/238) of men. Combining normal and overweight silhouettes into one group, 86% (150/174) of women and 86% (205/238) of men preferred to be either normal or overweight. Underweight silhouettes were preferred by 14% (24/174) of women and 14% (33/238) of men. Dissatisfaction because body size was too large occurred in 78% (135/174) of women and 53% (126/238) of men. Dissatisfaction because body size was too small occurred in 6% (11/174) of women and 16% (38/238) of men. Conclusion: African immigrants prefer body sizes which are normal or overweight. However, and presumably attributable to the combined influence of globalization and acculturation, a worrisome fraction of African immigrants favor an underweight silhouette.

Understanding the attitudes of Africans towards body size is important because these attitudes affect health behaviors. The 20th century consensus was that Africans viewed large body sizes as a sign of the health, beauty, fertility, and prosperity. In addition, underweight silhouettes were viewed with fear and considered to be a sign of poverty, malnutrition, and HIV infection. In the 21st century, African attitudes towards body size are unknown. African immigrants are a rapidly growing segment of the American population. Their attitudes toward body size are influenced by both globalization and acculturation. In our cohort, we found 86% of the Africans living in America wanted to be either normal or low range overweight. However, and very concerning, 14% of African immigrants chose underweight silhouettes to represent their body size of preference. As weight loss programs are brought forward in and by African communities living in the United States, the emphasis must be on achieving a healthy weight and not glorification of underweight silhouettes.

Determining the 1-hour post-load glucose which identifies diabetes in Africans: Insight from the Africans in America study.

Diagnosing diabetes by shortening the OGTT to 1-h and substituting 1-h post-load glucose (PG) ≥ 209 mg/dL for 2-h PG≥200 mg/dL has been proposed. One-hour PG≥209 mg/dL is from a meta-analysis without any African-descent populations. Our data suggest 1-h PG≥183 mg/dL maybe more optimal for Africans. As with waist circumference guidelines, population-specific thresholds may be appropriate.

Fructosamine is Not a Reliable Test for the Detection of Hyperglycemia: Insight from the Africans in America Study.

Objective: To improve detection of abnormal glucose tolerance (Abnl-GT), attention has moved beyond the oral glucose tolerance test (OGTT), to non-fasting markers of glycemia, specifically, HbA1c, fructosamine (FA) and glycated albumin (GA). Emerging data suggest that in African descent populations, the combination of HbA1c and GA is superior to the combination of HbA1c and FA. However, the diagnosis of Abnl-GT is usually based on tests which are performed only once. As reproducibility of Abnl-GT diagnosis by HbA1c, fructosamine (FA) and glycated albumin (GA) is unknown, reproducibility of Abnl-GT diagnosis by HbA1c, FA and GA were assessed in 209 African-born Blacks living in America. Methods: At Visits 1 and 2 (9 ± 4 days apart), samples were obtained for HbA1c, FA and GA levels. Glucose tolerance status was determined at Visit 1 by OGTT. Reproducibility was based on the К-statistic and paired t-tests. Thresholds for the diagnosis of Abnl-GT by FA and GA which corresponded to an HbA1c of 5.7% were 235umol/L and 14.6%, respectively. Results: Abnl-GT occurred in 38% (80/209). Diagnostic reproducibility was excellent for HbA1c (К≥0.86) and GA (К≥0.89), but only moderate for FA (К=0.59). Neither HbA1c nor GA levels varied between visits (both P≥0.3). In contrast, FA was significantly lower at Visit 2 than Visit 1(P<0.01). Conclusion: As HbA1c and GA provided similar diagnostic results on different days and FA did not, HbA1C and GA are superior to FA in both clinical care settings and epidemiologic studies.

The Africans in America study demonstrates that subclinical cardiovascular risk differs by etiology of abnormal glucose tolerance.

Abnormal-glucose tolerance (Abnl-GT) is due to an imbalance between ß-cell function and insulin resistance (IR) and is a major risk factor in cardiovascular disease (CVD). In sub-Saharan Africa, ß-cell failure is emerging as an important cause of Abnl-GT (Abnl-GT-ß-cell-failure). Visceral adipose tissue (VAT) volume and hyperlipidemia are major contributors to CVD risk when Abnl-GT is due to IR (Abnl-GT-IR). Yet, the CVD profile associated with Abnl-GT-ß-cell failure is unknown. Therefore, our goals in 450 African-born Blacks (Male: 65%; Age: 39 ± 10 years; BMI 28 ± 5 kg/m2), living in America were to: (1) determine Abnl-GT prevalence and etiology; (2) assess by Abnl-GT etiology, associations between four understudied subclinical CVD risk factors in Africans: (a) subclinical myocardial damage (high-sensitivity troponin T (hs-cTnT)); (b) neurohormonal regulation (N-terminal pro-Brain-natriuretic peptide (NT-proBNP)); (c) coagulability (fibrinogen); (d) inflammation (high-sensitivity C-reactive protein (hsCRP)), as well as HbA1c, Cholesterol/HDL ratio and VAT. Glucose tolerance status was determined by the OGTT. IR was defined by the threshold at the lowest quartile for the Matsuda Index (≤ 2.97). Abnl-GT-IR required both Abnl-GT and IR. Abnl-GT-ß-cell-failure was defined as Abnl-GT without IR. VAT was assessed by CT-scan. For both the Abnl-GT-ß-cell-failure and Abnl-GT-IR groups, four multiple regression models were performed for hs-cTnT; NT-proBNP; fibrinogen and hsCRP, as dependent variables, with the remaining three biomarkers and HbA1c, Cholesterol/HDL and VAT as independent variables. Abnl-GT occurred in 38% (170/450). In the Abnl-GT group, ß-cell failure occurred in 58% (98/170) and IR in 42% (72/170). VAT and Cholesterol/HDL were significantly lower in Abnl-GT-ß-cell-failure group vs the Abnl-GT-IR group (both P < 0.001). In the Abnl-GT-ß-cell-failure group: significant associations existed between hscTnT, fibrinogen, hs-CRP, and HbA1c (all P < 0.05), and none with Cholesterol/HDL or VAT. In Abnl-GT-IR: hs-cTnT, fibrinogen and hsCRP significantly associated with Cholesterol/HDL (all P < 0.05) and NT-proBNP inversely related to fibrinogen, hsCRP, HbA1c, Cholesterol/HDL, and VAT (all P < 0.05). The subclinical CVD risk profile differed between Abnl-GT-ß-cell failure and Abnl-GT-IR. In Abnl-GT-ß-cell failure subclinical CVD risk involved subclinical-myocardial damage, hypercoagulability and increased inflammation, but not hyperlipidemia or visceral adiposity. For Abnl-GT-IR, subclinical CVD risk related to subclinical myocardial damage, neurohormonal dysregulation, inflammation associated with hyperlipidemia and visceral adiposity. ClinicalTrials.gov Identifier: NCT00001853.

Non-invasive type 2 diabetes risk scores do not identify diabetes when the cause is ß-cell failure: The Africans in America study.

Background: Emerging data suggests that in sub-Saharan Africa ß-cell-failure in the absence of obesity is a frequent cause of type 2 diabetes (diabetes). Traditional diabetes risk scores assume that obesity-linked insulin resistance is the primary cause of diabetes. Hence, it is unknown whether diabetes risk scores detect undiagnosed diabetes when the cause is ß-cell-failure. Aims: In 528 African-born Blacks living in the United States [age 38 ± 10 (Mean ± SE); 64% male; BMI 28 ± 5 kg/m2] we determined the: (1) prevalence of previously undiagnosed diabetes, (2) prevalence of diabetes due to ß-cell-failure vs. insulin resistance; and (3) the ability of six diabetes risk scores [Cambridge, Finnish Diabetes Risk Score (FINDRISC), Kuwaiti, Omani, Rotterdam, and SUNSET] to detect previously undiagnosed diabetes due to either ß-cell-failure or insulin resistance. Methods: Diabetes was diagnosed by glucose criteria of the OGTT and/or HbA1c ≥ 6.5%. Insulin resistance was defined by the lowest quartile of the Matsuda index (≤ 2.04). Diabetes due to ß-cell-failure required diagnosis of diabetes in the absence of insulin resistance. Demographics, body mass index (BMI), waist circumference, visceral adipose tissue (VAT), family medical history, smoking status, blood pressure, antihypertensive medication, and blood lipid profiles were obtained. Area under the Receiver Operator Characteristics Curve (AROC) estimated sensitivity and specificity of each continuous score. AROC criteria were: Outstanding: >0.90; Excellent: 0.80-0.89; Acceptable: 0.70-0.79; Poor: 0.50-0.69; and No Discrimination: 0.50. Results: Prevalence of diabetes was 9% (46/528). Of the diabetes cases, ß-cell-failure occurred in 43% (20/46) and insulin resistance in 57% (26/46). The ß-cell-failure group had lower BMI (27 ± 4 vs. 31 ± 5 kg/m2 P < 0.001), lower waist circumference (91 ± 10 vs. 101 ± 10cm P < 0.001) and lower VAT (119 ± 65 vs. 183 ± 63 cm3, P < 0.001). Scores had indiscriminate or poor detection of diabetes due to ß-cell-failure (FINDRISC AROC = 0.49 to Cambridge AROC = 0.62). Scores showed poor to excellent detection of diabetes due to insulin resistance, (Cambridge AROC = 0.69, to Kuwaiti AROC = 0.81). Conclusions: At a prevalence of 43%, ß-cell-failure accounted for nearly half of the cases of diabetes. All six diabetes risk scores failed to detect previously undiagnosed diabetes due to ß-cell-failure while effectively identifying diabetes when the etiology was insulin resistance. Diabetes risk scores which correctly classify diabetes due to ß-cell-failure are urgently needed.

Sleep and Economic Status Are Linked to Daily Life Stress in African-Born Blacks Living in America.

To identify determinants of daily life stress in Africans in America, 156 African-born Blacks (Age: 40 ± 10 years (mean ± SD), range 22-65 years) who came to the United States as adults (age ≥ 18 years) were asked about stress, sleep, behavior and socioeconomic status. Daily life stress and sleep quality were assessed with the Perceived Stress Scale (PSS) and Pittsburgh Sleep Quality Index (PSQI), respectively. High-stress was defined by the threshold of the upper quartile of population distribution of PSS (≥16) and low-stress as PSS < 16. Poor sleep quality required PSQI > 5. Low income was defined as <40 k yearly. In the high and low-stress groups, PSS were: 21 ± 4 versus 9 ± 4, p < 0.001 and PSQI were: 6 ± 3 versus 4 ± 3, p < 0.001, respectively. PSS and PSQI were correlated (r = 0.38, p < 0.001). The odds of high-stress were higher among those with poor sleep quality (OR 5.11, 95% CI: 2.07, 12.62), low income (OR 5.03, 95% CI: 1.75, 14.47), and no health insurance (OR 3.01, 95% CI: 1.19, 8.56). Overall, in African-born Blacks living in America, daily life stress appears to be linked to poor quality sleep and exacerbated by low income and lack of health insurance.

Beta-cell failure rather than insulin resistance is the major cause of abnormal glucose tolerance in Africans: insight from the Africans in America study.

INTRODUCTION: Uncertainties exist on whether the main determinant of abnormal glucose tolerance (Abnl-GT) in Africans is ß-cell failure or insulin resistance (IR). Therefore, we determined the prevalence, phenotype and characteristics of Abnl-GT due to ß-cell failure versus IR in 486 African-born blacks (male: 64%, age: 38±10 years (mean±SD)) living in America. RESEARCH DESIGN AND METHODS: Oral glucose tolerance test were performed. Abnl-GT is a term which includes both diabetes and prediabetes and was defined as fasting plasma glucose (FPG) ≥5.6 mmol/L and/or 2-hour glucose ≥7.8 mmol/L. IR was defined by the lowest quartile of the Matsuda Index (≤2.98) and retested using the upper quartile of homeostatic model assessment of insulin resistance (HOMA-IR) (≥2.07). Abnl-GT-IR required both Abnl-GT and IR. Abnl-GT-ß-cell failure was defined as Abnl-GT without IR. Beta-cell compensation was assessed by the Disposition Index (DI). Fasting lipids were measured. Visceral adipose tissue (VAT) volume was obtained with abdominal CT scan. RESULTS: The prevalence of Abnl-GT was 37% (182/486). For participants with Abnl-GT, IR occurred in 38% (69/182) and ß-cell failure in 62% (113/182). Compared with Africans with Abnl-GT-IR, Africans with Abnl-GT-ß-cell failure had lower body mass index (BMI) (30.8±4.3 vs 27.4±4.0 kg/m2), a lower prevalence of obesity (52% vs 19%), less VAT (163±72 vs 107±63 cm2), lower triglyceride (1.21±0.60 vs 0.85±0.42 mmol/L) and lower FPG (5.9±1.4 vs 5.3±0.6 mmol/L) and 2-hour glucose concentrations (10.0±3.1 vs 9.0±1.9 mmol/L) (all p<0.001) and higher DI, high-density lipoprotein (HDL), low-density lipoprotein particle size and HDL particle size (all p<0.01). Analyses with Matsuda Index and HOMA-IR yielded similar results. Potential confounders such as income, education, alcohol and fiber intake did not differ by group. CONCLUSIONS: Beta-cell failure occurred in two-thirds of participants with Abnl-GT and may be a more frequent determinant of Abnl-GT in Africans than IR. As BMI category, degree of glycemia and lipid profile appeared more favorable when Abnl-GT was due to ß-cell failure rather than IR, the clinical course and optimal interventions may differ. TRIAL REGISTRATION NUMBER: NCT00001853.

Africans Who Arrive in the United States before 20 Years of Age Maintain Both Cardiometabolic Health and Cultural Identity: Insight from the Africans in America Study.

The overall consensus is that foreign-born adults who come to America age < 20 y achieve economic success but develop adverse behaviors (smoking and drinking) that lead to worse cardiometabolic health than immigrants who arrive age ≥ 20 y. Whether age of immigration affects the health of African-born Blacks living in America is unknown. Our goals were to examine cultural identity, behavior, and socioeconomic factors and determine if differences exist in the cardiometabolic health of Africans who immigrated to America before and after age 20 y. Of the 482 enrollees (age: 38 ± 1 (mean ± SE), range: 20-65 y) in the Africans in America cohort, 23% (111/482) arrived age < 20 y, and 77% (371/482) arrived age ≥ 20 y. Independent of francophone status or African region of origin, Africans who immigrated age < 20 y had similar or better cardiometabolic health than Africans who immigrated age ≥ 20 y. The majority of Africans who immigrated age < 20 y identified as African, had African-born spouses, exercised, did not adopt adverse health behaviors, and actualized early life migration advantages, such as an American university education. Due to maintenance of cultural identity and actualization of opportunities in America, cardiometabolic health may be protected in Africans who immigrate before age 20. In short, immigrant health research must be cognizant of the diversity within the foreign-born community and age of immigration.

The OGTT is highly reproducible in Africans for the diagnosis of diabetes: Implications for treatment and protocol design.

Whether an OGTT reproducibly detects either type 2 diabetes (T2D) or prediabetes in Africans in unknown. Therefore, 131 Africans had two OGTT. Diagnostic reproducibility for T2D was excellent (κ = 0.84), but only moderate for prediabetes (κ = 0.51). A single OGTT positive for T2D may be sufficient to guide clinical care and inform epidemiologic study design. ClinicalTrials.gov Identifier: NCT00001853.

Improved Detection of Abnormal Glucose Tolerance in Africans: The Value of Combining Hemoglobin A1c With Glycated Albumin.

OBJECTIVE: In African-born Blacks living in America, we determined by BMI category 1) prevalence of abnormal glucose tolerance (Abnl-GT) and 2) diagnostic value and reproducibility of hemoglobin A1c (HbA1c), fructosamine, and glycated albumin (GA). RESEARCH DESIGN AND METHODS: Participants (n = 416; male, 66%; BMI 27.7 ± 4.5 kg/m2 [mean ± SD]) had an oral glucose tolerance test with HbA1c, GA, and fructosamine assayed. These glycemic markers were repeated 11 ± 7 days later. Abnl-GT diagnosis required 0 h ≥5.6 mmol/L (≥100 mg/dL) and/or 2 h ≥7.8 mmol/L (≥140 mg/dL). Thresholds for HbA1c, GA, and fructosamine were the values at the 75th percentile for the population (39 mmol/mol [5.7%], 14.2%, and 234 µmol/L, respectively). RESULTS: Abnl-GT prevalence in the nonobese was 34% versus 42% in the obese (P = 0.124). Reproducibility was excellent for HbA1c and GA (both κ ≥ 0.8), but moderate for fructosamine (κ = 0.6). Focusing on HbA1c and GA in the nonobese, we found as single tests the sensitivities of HbA1c and GA were 36% versus 37% (P = 0.529). Combining HbA1c and GA, sensitivity increased to 58% because GA identified 37% of Africans with Abnl-GT not detected by HbA1c (P value for both tests vs. HbA1c alone was <0.001). For the obese, sensitivities for HbA1c, GA, and the combined tests were 60%, 27%, and 67%, respectively. Combined test sensitivity did not differ from HbA1c alone (P = 0.25) because GA detected only 10% of obese Africans with Abnl-GT not detected by HbA1c. CONCLUSIONS: Adding GA to HbA1c improves detection of Abnl-GT in nonobese Africans.

Stress Measured by Allostatic Load Varies by Reason for Immigration, Age at Immigration, and Number of Children: The Africans in America Study.

Stress leads to physiologic dysfunction and cardiometabolic disease. Allostatic load score (ALS) measures stress-induced cardiovascular, metabolic, and inflammatory biomarkers. We estimated the odds of high ALS by reason for and age at immigration, duration of American residence, number of children, and socioeconomic status in 193 African immigrants (male: 65%, age 41 ± 10 y (mean ± Standard Deviation (SD)), range 22-65 y). ALS was calculated with High-ALS defined as ALS ≥ 3.0 and Low-ALS defined as ALS < 3.0. Oral glucose tolerance tests (OGTT) were performed, the cardiovascular disease (CVD) risk estimated, and TNF-α, an inflammatory cytokine, measured. Logistic regression was used to estimate odds of High-ALS. In the High- and Low-ALS groups, ALS were 4.0 ± 1.2 vs. 1.3 ± 0.7, diabetes prevalence: 14% vs. 4%, CVD risk: 23% vs. 8%, TNF-α levels: 15 ± 9 vs. 11 ± 6 pg/mL, respectively (all p ≤ 0.01). Immigrants were more likely to be in the High-ALS group if their reason for immigration was work or asylum/refugee (OR 2.18, p = 0.013), their age at immigration was ≥30 y (OR 3.28, p < 0.001), their duration of residence in United States was ≥10 y (OR 3.16, p = 0.001), or their number of children was ≥3 (OR 2.67, p = 0.019). Education, income, health insurance, marital status, and gender did not affect High-ALS odds. Factors adversely influencing allostatic load and cardiometabolic health in African immigrants were age at and reason for immigration, duration of residence in America, and number of children.

Identifying Africans with undiagnosed diabetes: Fasting plasma glucose is similar to the hemoglobin A1C updated Atherosclerosis Risk in Communities diabetes prediction equation.

AIMS: Seventy percent of Africans living with diabetes are undiagnosed. Identifying who should be referred for testing is critical. Therefore we evaluated the ability of the Atherosclerosis Risk in Communities (ARIC) diabetes prediction equation with A1C added (ARIC + A1C) to identify diabetes in 451 African-born blacks living in America (66% male; age 38 ± 10y (mean ± SD); BMI 27.5 ± 4.4 kg/m2). METHODS: All participants denied a history of diabetes. OGTTs were performed. Diabetes diagnosis required 2-h glucose ≥200 mg/dL. The five non-invasive (Age, parent history of diabetes, waist circumference, height, systolic blood pressure) and four invasive variables (Fasting glucose (FPG), A1C, triglycerides (TG), HDL) were obtained. Four models were tested: Model-1: Full ARIC + A1C equation; Model-2: All five non-invasive variables with one invasive variable excluded at a time; Model-3: All five non-invasive variables with one invasive variable included at a time; Model-4: Each invasive variable singly. Area under the receiver operator characteristic curve (AROC) predicted diabetes. Youden Index identified optimal cut-points. RESULTS: Diabetes occurred in 7% (30/451). Model-1, the full ARIC + A1C equation, AROC = 0.83. Model-2: With FPG excluded, AROC = 0.77 (P = 0.038), but when A1C, HDL or TG were excluded AROC remained unchanged. Model-3 with all non-invasive variables and FPG alone, AROC=0.87; but with A1C, TG or HDL included AROC declined to ≤0.76. Model-4: FPG as a single predictor, AROC = 0.87. A1C, TG, or HDL as single predictors all had AROC ≤ 0.74. Optimal cut-point for FPG was 100 mg/dL. CONCLUSIONS: To detect diabetes, FPG performed as well as the nine-variable updated ARIC + A1C equation.

Metabolic characteristics of Africans with normal glucose tolerance and elevated 1-hour glucose: insight from the Africans in America study.

INTRODUCTION: Risk of insulin resistance, dyslipidemia, diabetes and cardiac death is increased in Asians and Europeans with normal glucose tolerance (NGT) and 1-hour glucose ≥8.6 mmol/L. As African descent populations often have insulin resistance but a normal lipid profile, the implications for Africans with NGT and glucose ≥8.6 mmol/L (NGT-1-hour-high) are unknown. OBJECTIVE: We performed oral glucose tolerance tests (OGTTs) in 434 African born-blacks living in Washington, DC (male: 66%, age 38±10 years (mean±SD)) and determined in the NGT group if either glucometabolic or lipid profiles varied according to a 1-hour-glucose threshold of 8.6 mmol/L. METHODS: Glucose tolerance category was defined by OGTT criteria. NGT was subdivided into NGT-1-hour-high (glucose ≥8.6 mmol/L) and NGT-1-hour-normal (glucose <8.6 mmol/L). Second OGTT were performed in 27% (119/434) of participants 10±7 days after the first. Matsuda Index and Oral Disposition Index measured insulin resistance and beta-cell function, respectively. Lipid profiles were obtained. Comparisons were by one-way analysis of variance with Bonferonni corrections for multiple comparisons. Duplicate tests were assessed by к-statistic. RESULTS: One-hour-glucose ≥8.6 mmol/L occurred in 17% (47/272) with NGT, 72% (97/134) with pre-diabetes and in 96% (27/28) with diabetes. Both insulin resistance and beta-cell function were worse in NGT-1-hour-high than in NGT-1-hour-normal. Dyslipidemia occurred in both the diabetes and pre-diabetes groups but not in either NGT group. One-hour glucose concentration ≥8.6 mmol/L showed substantial agreement for the two OGTTs (к=0.628). CONCLUSIONS: Although dyslipidemia did not occur in either NGT group, insulin resistance and beta-cell compromise were worse in NGT-1 hour-high. Subdividing the NGT group at a 1-hour glucose threshold of 8.6 mmol/L may stratify risk for diabetes in Africans.

A1C Underperforms as a Diagnostic Test in Africans Even in the Absence of Nutritional Deficiencies, Anemia and Hemoglobinopathies: Insight From the Africans in America Study.

Introduction: To improve detection of undiagnosed diabetes in Africa, there is movement to replace the OGTT with A1C. The performance of A1C in the absence of hemoglobin-related micronutrient deficiencies, anemia and heterozygous hemoglobinopathies is unknown. Therefore, we determined in 441 African-born blacks living in America [male: 65% (281/441), age: 38 ± 10 y (mean ± SD), BMI: 27.5 ± 4.4 kg/m2] (1) nutritional and hematologic profiles and (2) glucose tolerance categorization by OGTT and A1C. Methods: Hematologic and nutritional status were assessed. Hemoglobin <11 g/dL occurred in 3% (11/441) of patients and led to exclusion. A1C and OGTT were performed in the remaining 430 participants. ADA thresholds for A1C and OGTT were used. Diagnosis by A1C required meeting either A1C-alone or A1C&OGTT criteria. Diagnosis by OGTT-alone required detection by OGTT and not A1C. Results: Hemoglobin, mean corpuscular volume and red blood cell distribution width were 14.0 ± 1.3 g/dL, 85.5 ± 5.3 fL, and 13.2 ± 1.2% respectively. B12, folate, and iron deficiency occurred in 1% (5/430), 0% (0/430), and 4% (12/310), respectively. Heterozygous hemoglobinopathy prevalence was 18% (78/430). Overall, diabetes prevalence was 7% (32/430). A1C detected diabetes in 32% (10/32) but OGTT-alone detected 68% (22/32). Overall prediabetes prevalence was 41% (178/430). A1C detected 57% (102/178) but OGTT-alone identified 43% (76/178). After excluding individuals with heterozygous hemoglobinopathies, the rate of missed diagnosis by A1C of abnormal glucose tolerance did not change (OR: 0.99, 95% CI: 0.61, 1.62). Conclusions: In nutritionally replete Africans without anemia or heterozygous hemoglobinopathy, if only A1C is used, ~60% with diabetes and ~40% with prediabetes would be undiagnosed. Clinical Trial Registration:: www.ClinicalTrials.gov, Identifier: NCT00001853.

Postprandial Insulin Response and Clearance Among Black and White Women: The Federal Women's Study.

Context: Postprandial hyperinsulinemia might be an important cardiometabolic risk determinant in black compared with white women. However, the contributions of insulin clearance and ß-cell function to racial differences in postprandial insulin response are unknown. Objective: To compare, by race and menopause, early insulin response to oral and intravenous glucose and to measure postprandial intact glucagon-like peptide 1 (GLP-1) concentrations, insulin clearance, and ß-cell function. Design and Participants: 119 federally employed women without diabetes [87 premenopausal (52 black, 35 white) and 32 postmenopausal (19 black, 13 white)] underwent an oral glucose tolerance test, insulin-modified frequently sampled intravenous glucose test (IM-FSIGT), and mixed meal tolerance test (MMTT). Outcome Measures: Early insulin response was measured as follows: (i) insulinogenic index (oral glucose tolerance test); (ii) acute insulin response to glucose (IM-FSIGT); and (iii) ratio of incremental insulin/glucose area under the curve in the first 30 minutes of the MMTT. Insulin clearance was assessed during the IM-FSIGT and MMTT. During the MMTT, intact GLP-1 was measured and ß-cell function assessed using the insulin secretion rate and ß-cell responsivity indexes. Results: Black pre-menopausal and postmenopausal women had a greater insulin response and lower insulin clearance and greater dynamic ß-cell responsivity (P ≤ 0.05 for all). No differences were found in the total insulin secretion rates or intact GLP-1 concentrations. Conclusions: Greater postprandial hyperinsulinemia in black pre-menopausal and postmenopausal women was associated with lower hepatic insulin clearance and heightened ß-cell capacity to rapid changes in glucose, but not to higher insulin secretion. The relationship of increased ß-cell secretory capacity, reduced insulin clearance, and ambient hyperinsulinemia to the development of cardiometabolic disease requires further investigation.

Do current guidelines for waist circumference apply to black Africans? Prediction of insulin resistance by waist circumference among Africans living in America.

BACKGROUND: To lower the risk of diabetes and heart disease in Africa, identification of African-centred thresholds for inexpensive biomarkers of insulin resistance (IR) is essential. The waist circumference (WC) thresholds that predicts IR in African men and women have not been established, but investigations recently conducted in Africa using indirect measures of IR suggest IR is predicted by WC of 80-95 cm in men and 90-99 cm in women. These WC cannot be used for guidelines until validated by direct measurements of IR and visceral adipose tissue (VAT). Therefore, we determined in a group of African-born black people living in America (A) the WC, which predicts IR and (B) the influence of abdominal fat distribution on IR. METHODS: The 375 participants (age 38±10 years (mean±SD), 67% men) had IR determined by HOMA-IR and Matsuda index. VAT and subcutaneous adipose tissue (SAT) were measured by abdominal CT scans. Optimal WC for the prediction of IR was determined in sex-specific analyses by area under the receiver operating characteristic (AUC-ROC) and Youden index. RESULTS: Women had more SAT (203±114 vs 128±74 cm2) and less VAT than men (63±48 vs 117±72 cm2, p<0.001). Optimal WC for prediction of IR in men and women were: 91 cm (AUC-ROC: 0.80±0.03 (mean±SE)) and 96 cm (AUC-ROC: 0.81±0.08), respectively. Regression analyses revealed a significant sex-VAT interaction (p<0.001). Therefore, for every unit increase in VAT, women had a 0.94 higher unit increase in SAT and 0.07 higher unit increase in WC than men. CONCLUSION: Working with a group of African-born black people living in America, we accessed technology, which validated observations made in Africa. Higher SAT at every level of VAT explained why the WC that predicted IR was higher in women (96 cm) than men (91 cm). For Africans to benefit from WC measurements, convening a panel of experts to develop evidence-based African-centred WC guidelines may be the way forward.

Gluconeogenesis and risk for fasting hyperglycemia in Black and White women.

Black women, compared with White women, have high rates of whole-body insulin resistance but a lower prevalence of fasting hyperglycemia and hepatic steatosis. This dissociation of whole-body insulin resistance from fasting hyperglycemia may be explained by racial differences in gluconeogenesis, hepatic fat, or tissue-specific insulin sensitivity. Two groups of premenopausal federally employed women, without diabetes were studied. Using stable isotope tracers, [2H2O] and [6,62-H2]glucose, basal glucose production was partitioned into its components (gluconeogenesis and glycogenolysis) and basal whole-body lipolysis ([2H5]glycerol) was measured. Indices of insulin sensitivity, whole-body (SI), hepatic (HISIGPR), and adipose tissue, were calculated. Hepatic fat was measured by proton magnetic resonance spectroscopy. Black women had less hepatic fat and lower fractional and absolute gluconeogenesis. Whole-body SI, HISIGPR, and adipose tissue sensitivity were similar by race, but at any given level of whole-body SI, Black women had higher HISIGPR. Therefore, fasting hyperglycemia may be a less common early pathological feature of prediabetes in Black women compared with White women, because gluconeogenesis remains lower despite similar whole-body SI.