Hispanic Health Disparities in Diabetes: Implications for CVD Prevention Neil Schneiderman University of Miami Baptist Health South Florida 12 th Annual CVD Prevention Symposium Miami Beach, Florida February 8, 2014 2 Disclosures No Relevant Financial Relationship No Off Label Usage Acknowledgements Hispanic Community Health Study-Miami Field Center NIH/NHLBI Multi-Center Epidemiological Study 2007-20192019 N. Schneiderman, PI N01-HC-65234/HHSN28 Biobehavioral Bases of CHD Risk and Management NIH/NHLBI Program Project 1986-2013 N. Schneiderman, PI P01 HL036588-26 Why Study Hispanic/Latino Health in US? Largest minority group in US According to 2010 US census H/L were 16% of US population (n= 50.5 million) We know that H/L are understudied and underserved We know very little about H/L health as a function of diversity in H/L background 3 1
Why Study Hispanic/Latino Health in Miami-Dade County? According to the 2010 US Census we are: 65% Hispanic/Latino (n = 1,622,708) 18.9% Blacks (n = 474,323) 15.4% White Non-Hispanics (n = 384,451) Three quarters of Miami-Dade County residents speak a language other than English at home. 4 Diabetes and Cardiovascular Disease Diabetes carries 2x risk for CHD or stroke 2 of 3 people with diabetes die of CVD In Hispanic Community Health Study/Study of Latinos (HCHS/SOL) diabetes associated with increased prevalence of CHD and stroke (Daviglus et al, 2012, JAMA) 5 HCHS/SOL examined differences in prevalence of diabetes and rates of awareness and control among adults in US from diverse H/L backgrounds Central American Cuban Dominican Mexican Puerto Rican South American 6 2
HCHS/SOL Design Sample Size 16,415 Hispanics/Latinos > 4,000 at each of 4 Field Centers Ages: 18-74 years 9,714 participants 45-74 years (59%) 6,701 participants 18-44 years (41%) Longitudinal Study 3 years baseline collection (2008-2011) Up to 4.5 years of follow-up (now 6 more years) Longitudinal Study Census blocks in neighborhoods 7 Participants recruited as a multi- stage stratified probability sample in 4 communities (Bronx, Chicago, Miami-Dade, San Diego) representing 4 of 11 urban metropolitan areas with largest number of Hispanics/Latinos in US 8 Results are weighted and age standardized taking into account age, gender and Hispanic background distribution using the US Census 2010 standard population Weighted estimates almost identical to Census 2010 target population 9 3
Definition of Diabetes Mellitus (DM) FPG 126 mg/dl or 2h OGTT 200 mg/dl or A1c 6.5% or documented use of hypoglycemic agents or for specified analyses, self-reported DM 10 Prevalence of Diabetes in SOL in Terms of Hispanic Background Objectively Recognized Sample Size 95% CI Central American 1,731 17.7 (15.36, 20.22) Cuban 2,347 13.4 (12.03, 14.91) Dominican 1,472 18.0 (16.17, 20.09) Mexican 6,468 18.3 (16.83, 19.86) Puerto Rican 2,727 18.0 (16.24, 19.99) South American 1,071 10.2 (8.35, 12.29) Other/Mixed 503 -- -- Values (except sample size) weighted and age standardized to Census 2010 US population. 11 Differences in prevalence as a function of Hispanic background remain significant after controlling for age, sex, BMI, field center and years lived in the US (p <.0001) 12 4
Using slightly different metrics the CDC (standardized to 2000 US Census) and HCHS/SOL (standardized to 2010 US Census) found similar ranges for Non-Hispanic Blacks vs Whites (CDC) and different Hispanic Backgrounds (HCHS/SOL) C.D.C. (2007-2009) 2009) Prevalence - Non-Hispanic Whites 10.2 - Non-Hispanic Blacks 18.7 HCHS/SOL (2008-2011) 2011) - South Americans 10.2 - Mexicans 18.3 - All Hispanics/Latinos 16.9 13 Prevalence of Diabetes in SOL among Men and Women Objectively Recognized Sample Size 95% CI Overall 16,406 16.9 (16.09, 17.66) Sex Women 9,829 16.5 (15.38, 17.67) Men 6,577 17.1 (16.14, 18.17) Men and women in SOL do not differ reliably in terms of diabetes prevalence Values (except sample size) weighted and age standardized 14 60 Prevalence of Diabetes Related to Age (%, Standard Error; weighted and age-standardized) 50 40 30 20 25.0 38.7 48.6 15 10 0 2.6 6.7 14.1 18-29 30-3939 40-4949 50-5959 60-6969 70-7474 Age 5
Prevalence of Diabetes Related to BMI (%, Standard Error) Weighted and age standardized 30 25 Men and Women Women Men 20 15 10 5 9.8 9.5 10.2 14.2 13.5 15.0 22.4 23.1 21.4 0 < 25 25-29.9 30+ 16 Body Mass Index (BMI) in kg/m 2 Prevalence of Diabetes Related to Age and Years Living in 50 US (weighted and age standardized) 60.0 10 Years 50.0 40.0 30.0 34.4 47.1 17 20.0 10.0 0.0 5.0 7.2 19.4 25.9 18-44 45-64 65-74 Age in Years Prevalence of diabetes in participants living in US longer than 10 years including those born in the US was higher than among those living in the US 10 years or less after adjusting for age, sex, BMI, Hispanic heritage and field center (p < 0.02) 18 6
Prevalence of Diabetes Related to Household Income (weighted and age standardized) 25 20 Men Women 15 10 18.5 16.9 17.1 16.5 16.2 13.9 12.8 5 8.3 19 0 <20 21-40 41-75 >75 Household Income in Thousands of Dollars 25.0 Prevalence of Diabetes Related to Education (weighted and age standardized) Men Women 20.0 15.0 10.0 18.6 20.1 19.0 15.0 15.4 12.9 5.0 0.0 < High School High School > High School 20 The associations of diabetes prevalence with education (p=0.0005) and household income (p=0.0004) were significant; the interaction for household income and sex was not (p=0.44). 21 7
Prevalence of Self-Reported Diabetes and Diabetes Detected at the Baseline Exam Self-Reported Detected at Exam % ( % CI) % ( % CI) Women and Men 11.9 (11.19, 12.59) 6.2 (5.69, 6.68) Women 11.8 (10.87, 12.74) 6.5 (5.82, 7.15) Men 12.0 (11.06, 12.96) 5.8 (5.12, 6.56) 34% of those with diabetes were first recognized at the baseline exam. 22 Among SOL participants at Baseline who had diabetes by objective criteria: 59% aware they had diabetes 48% adequate glycemic control (A1c<7%; 53 mmol/mol) 52% had health insurance 23 Prevalence of Diabetes Awareness, Diabetes Control and Health Insurance 24 90 80 70 60 50 40 30 20 10 0 Diabetes Awareness 73.0 63.9 58.2 Diabetes Control (A1c<7%) 54.1 56.4 54.1 48.0 43.4 Age in Years Health Insurance 82.2 18-44 45-64 65-74 18-44 45-64 65-74 18-44 45-64 65-74 8
of participants with health insurance (p=0.0001), diabetes awareness (p=0.0001) and glycemic control (p=0.0299) increased significantly with age after controlling for sex, Hispanic background, BMI, field center, education and years living in the US. Those 65 years had greater rates of diabetes awareness (p=0.0001), control (p=0.0106) and insurance coverage (p=0.0001) than those < 65 years Individuals with health insurance were less likely to present at baseline exam with unrecognized diabetes (p=0.003) 25 Summary Prevalence of diabetes in HCHS/SOL: Positively related to age Positively related to BMI Positively related to years living in US Negatively related to education and income Related to ethnic background Not related to sex 26 Summary for Diabetes Participants Rate of diabetes awareness was 59% Rate of adequate glycemic control (A1c < 7%, 53 mmol/mol) was 48% Rate of having health insurance among those with diabetes was 52% 27 9
Conclusions HCHS/SOL has found a high prevalence of diabetes but considerable diversity related to Hispanic background Prevalence of diabetes appears to be considerably higher in Hispanics/Latinos than in Non- Hispanic Whites. 28 Conclusions Low rates of diabetes awareness, glycemic control and health insurance in conjunction with negative associations between diabetes prevalence and both household income and education among Hispanics/Latinos in the US have important public health implications. 29 Public Health Comment Since persons 65 yrs + were more likely to have health insurance, DM awareness, and if DM, glycemic control, it appears likely that improving health care access would: flatten the gradient relating DM prevalence and household income decrease incidence of DM complications 30 10
Health Provider Comment We conducted an RCT in Miami-Dade County comparing lifestyle intervention with usual care in 111 relatively poor (mean household income < $15,000), minority (85% H/L; 10% Non-Hispanic Black), overweight/obese (Mean BDI = 85kg) people with DM and depressive symptoms (BDI-II > 10) with few exclusions for co-morbidities. 31 Community Approach to Lifestyle Modification for Diabetes (CALM-D) 32 The intervention included 17 sessions across one year to counsel intervention participants on diet, physical activity and stress management Using an intent-to-treat treat analysis we found decreased weight (p.001), HbA1c (p =.017) and depressed affect (p <.001) and improved egfr (p =.020). Implication Multi-component intervention targeting weight loss (via diet, physical activity, and stress management) may be efficacious in management of type 2 diabetes in a disadvantaged, minority population. 33 11