Lupine Publishers| Inequalities in Diabetes in the USA

 Lupine Publishers| Archives of Diabetes & Obesity (ADO)

Abstract

Background: Diabetes disproportionably impacts minorities in the USA.

Objective: To review the latest data regarding diabetes epidemiology and management among different ethnic groups in the USA.

Methods: PubMed research of all pertinent articles up to June 29, 2020. Search terms included diabetes, ethnicity, African Americans, Blacks, Hispanics, Latinos, Asians, minorities, glycemic control, obesity, lifestyle changes, treatment, metformin, sodiumglucose co-transporter 2 inhibitors. Type of studies included are randomized, observational, epidemiological, consensus guidelines, and review articles.

Results: Diabetes prevalence and incidence in adults continue to increase among African Americans and Hispanics. In youths, the fastest increase in type 1 and type 2 diabetes occurs among Asians/Pacific Islanders followed by Hispanics and African Americans. The gap in glycemic control between Whites and minorities is widening. Whereas mortality rates decreased in patients with diabetes overall, the least mortality reduction was observed among Hispanics and non-Hispanic blacks. The diabetes epidemic among nonwhites patients is mainly due to obesity and physical inactivity. Lifestyle changes are generally effective for both prevention and treatment of diabetes among minorities. Metformin may be particularly effective among African Americans. Metformin and sodiumglucose co-transporter 2 (SGLT2) inhibitors are the most convenient drugs for treatment of diabetes in minorities.

Conclusion: Substantial disparities still exist in the USA with respect to diabetes incidence, glycemic control, and mortality.

Keywords: Ethnicity; Disparities; Diabetes; Obesity; Prevention; Treatment; Lifestyle changes

Introduction

According to the World Health Organization, equity is the absence of avoidable, unfair, or remediable differences among groups of people, whether those groups are defined socially, economically, demographically or by other means of stratification [1]. Therefore, health equity implies that everyone should have a fair opportunity to attain his/her full health, and that no one should be disadvantaged from achieving this potential [1]. Unfortunately, marked ethnic/racial disparities in the USA exist with respect to almost all aspects of diabetes and its care. Thus, minority groups are disproportionately affected in terms of diabetes incidence and prevalence, metabolic control, complications, prevention, and treatment. The causes of these disparities are complex but obesity among minorities play a major role. The main purpose of this article is to provide an update on ethnic/racial disparities in diabetes in the USA and to discuss the most effective ways of diabetes prevention and treatment among minorities. We used the same terminology for the racial/ethnic group (e.g. Hispanics versus Latinos) as it appears in the corresponding reference.

Disparities in Diabetes Prevalence

According to 3 surveys conducted by the National Health and Nutrition Examination Surveys (NHANES) between 2011 and 2016, weighted age and sex-adjusted prevalence of total diabetes i.e. diagnosed and undiagnosed was 12.1% for non-Hispanic white, 20.4% for non-Hispanic black, 22.1% for Hispanic and 19.1% for non-Hispanic Asian adults (overall P<0.001) [2]. The prevalence of undiagnosed diabetes generally followed similar pattern: 3.9% for non-Hispanic white, 5.2% for non-Hispanic black, 7.5% for Hispanic, and 7.5% for non-Hispanic Asian adults (overall P < 0.001) [2]. Marked heterogeneity in diabetes prevalence are present within the same ethnic group (Table 1).

Table 1: Estimated prevalence of diabetes, diagnosed and undiagnosed, in the USA among persons 20 years or older among different ethnic groups [adapted from reference 2].

*Weighted age- and sex-adjusted (95% confidence interval).
** Central America: Costa Rica, Guatemala, Honduras, Nicaragua, Panama, Salvador.
*** South America: Argentina, Chile, Columbia, Ecuador, Paraguay, Peru, Uruguay, Venezuela.
■East Asia: China, Japan, Korea.
●South Asian: India, Pakistan, Sri Lanka, Bangladesh, Nepal, Bhutan.
■●Southeast Asia: Philippines, Vietnam, Cambodia, Thailand, Indonesia, Malaysia, Singapore.

Disparities and Trends in Diabetes Incidence

Following a steady increase in diabetes incidence in adults from 1990 to 2007, it started to decrease from 2008 through the last National Health Interview Survey (NHIS) conducted in 2017 [3]. However, this decrease in incidence was driven primarily by non- Hispanic whites (annual percentage change of -5.1% (P=0.002) followed by Asians (annual percentage change -3.4% (P=0.06), whereas incidence rates among Hispanics and non-Hispanic blacks did not decrease [3]. In fact, the latest age-adjusted data for 2017- 2018 indicated that incidence of diagnosed diabetes in adults were highest in Hispanics (9.7 per 1,000 persons), followed by non- Hispanic blacks (8.2 per 1,000 persons), and Asians (7.4 per 1,000 persons), whereas non-Hispanic whites had the lowest incidence (5.0 per 1,000 persons) [4].

Prevalence of Pre-Diabetes

The most recent National Diabetes Statistics Report showed that 34.5% of all US adults had prediabetes (defined as HbA1c 5.7% to less than 6.5%, or fasting plasma glucose 100 to less than 126 mg/dl, or 2-hr postprandial plasma glucose 140 to less than 200 mg/dl) [4]. The prevalence of prediabetes was stable from 2005-8 to 2013-2016 [4], and not statistically significant between racial/ ethnic groups and various education levels: 31.0 % among Whites, 36.8% among non-Hispanic blacks, 36.1% among Hispanics and 33.0% among Asians [4].

Disparities in Diabetes in Youths

According to the SEARCH for Diabetes in Youth Study, a population-based registry study covering 5 states in the USA, incidence of both type 1 and type 2 diabetes is increasing in youths (defined as persons aged < 20 years) [5]. From 2002 to 2015, the annual relative percent increase was 1.9% and 4.8% in type 1 and type 2 diabetes, respectively [5]. Like the adult population, there were clear ethnic/racial differences in the rate of increase of diabetes in youths [5]. In type 1 diabetes, the steepest increase in incidence was among Asians/Pacific Islanders (4.4% per year), followed by Hispanics (4.0% per year), then Blacks (2.7%/year), and finally Whites 0.7% per year [5]. In type 2 diabetes, similar order was observed. Thus, the fastest increase was among Asians/ Pacific Islanders (7.7% per year), followed by Hispanics (6.5% per year), Blacks (6.0%/year), American Indians (3.7% per year), and finally Whites (0.7% per year). The latter increase among Whites was not statistically significant (95% CI, -1.35 to 2.94) [5]. Reasons of increase in type 1 diabetes are unclear. Meanwhile, the increased incidence in type 2 diabetes is likely due to the increase in obesity in US youths, particularly among minorities [6].

Disparities in Prevalence of Gestational Diabetes

In 2016, the crude (unadjusted) national prevalence of gestational diabetes was 6% [7]. In terms of ethnicity, prevalence of gestational diabetes follows a characteristic pattern. The lowest prevalence exists among non-Hispanic blacks 4.8%, followed by Whites 5.3%, then Hispanics 6.6%, then American Indians/Native Alaskans, and highest in Asians 11.1% [7]. However, despite the fact that prevalence of gestational diabetes is lowest among black women, their risk of developing subsequent type 2 diabetes was the highest compared with other racial/ethnic/groups [8]. For instance, the adjusted hazard ratio of developing diabetes after gestational diabetes was 7.6 and 4.4, among Black and White women, respectively, P=0.028) [8].

Diabetes Prevalence Among African Immigrant Population

The African immigrant (African-born) is one of the fastest growing immigrant groups in the USA [9]. Using data from the NHIS, Alma-Ruth et al [10] reported that age-standardized diabetes prevalence was significantly lower in African immigrants than in African- Americans (US-born), 7% and 10%, respectively (P< 0.01) [9]. Furthermore, African immigrants who had lived in the USA for ≥ 10 years were significantly less likely to have diabetes with a prevalence ratio (PR) of 0.61; 95% CI 0.43-0.79), less likely to have overweight/obesity (PR 0.87; 95% CI 0.77-0.96), hypertension (PR 0.69; 95% 0.61-0.78), and to be physically inactive (PR 0.21, 95% 0.15-0.28) [9]. Hence, African immigrants seem to have a more healthy and distinct metabolic profile compared with African Americans.

Disparities in Glycemic Control

Studies have consistently shown that diabetes control, as reflected by hemoglobin A1c (HbA1c) concentrations, is worse in Blacks and Hispanics compared with White race. In a national cohort of persons older than 65 years enrolled in Medicare Advantage Health plans in 2011, Ayanian et al [11] examined the proportions of patients with HbA1c levels ≤ 9.0%. They found this goal was achieved by 84.0%, 80.6%, and 74.6% among White, Hispanic, and Black enrollees, respectively (P<0.001 for the difference between any 2 groups) [11]. Furthermore, available data suggest that the ethnic/racial gap in HbA1c continues to widen. In fact, analysis of NHANES conducted between 2003 and 2014 showed that HbA1c values tend to worsen among African American and Mexican American patients with type 2 diabetes, whereas corresponding values tend to improve among White patients [12]. It should be emphasized, however, that the difference in HbA1c levels between Black and White persons may be attributed in part to racial factors possibly due to difference in glycation of hemoglobin [13]. Thus, on average, HbA1c levels are 0.4 percentage points (95% CI, 0.2-0.6% percentage points) higher among Blacks compared with White individuals for a given mean blood glucose concentrations [13].

Trends and Disparities in Diabetes Care in the US

Serial analysis of the NHANES data between 2005 and 2016 suggests that diabetes care cascade has not significantly improved during that period [14]. Indeed, only 23-25% of patients met the composite goal of targets of HbA1c (<7-8.5%, depending on age and complications), blood pressure (<140/90 mmHg), low-density lipoprotein cholesterol (<100 mg/dl), and no smoking [14]. These proportions of patients did not change between 2005 and 2016 [14]. Furthermore, there were obvious ethnic disparities in achieving this goal [14]. For example, in 2013-2016, 25% of non-Hispanic white patients attained he previous composite goal, compared with only 14% of non-Hispanic blacks, and 18% of Hispanic patients [14].

Disparities in Diabetes-Related Complications

In general, ethnic/racial minorities have more frequent macrovascular and microvascular diabetes complications compared with Whites [10,15]. The largest available National data showed that in 2010, incidence (cases per 10,000) of end-stage renal disease (ESRD) were more than double in Blacks versus Whites 36.6 versus 16.0 [10]. Corresponding rates for lower-extremity amputation were 40.0 versus 20.4, for stroke 63.1 versus 39.0, and for hyperglycemic death 2.2 versus 1.4. A notable exception was the incidence of acute myocardial infarction, which was lower in Blacks compared with Whites, 32.5 versus 37.5, respectively [10]. No corresponding data regarding the Hispanic patients were reported [10].

Disparities in Diabetes-Related Mortality

Mansour et al [16] reported significant ethnic disparities in mortality rates in patients with diabetes who participated in the NHANES surveys during 1999-2010. Follow-up of this cohort revealed that all-cause and cardiovascular (CV) mortality decreased in all ethnic groups with diabetes. However, the magnitude of reduction in CV mortality significantly differed between various ethnic groups [16]. Thus, Whites experienced the largest reduction in CV mortality from 20.4% down to 14.5%, followed by Non- Hispanic Blacks from 20.6% to 16.3%, whereas Hispanics had only a marginal reduction from 18.4% to 17.5% [16]. Similarly, recent analysis of NHIS conducted from 1997 to 2017 showed a significant decline in CV complications among White patients only, whereas no significant decline was observed among Black or Hispanic patients [17]. Taken together, while mortality rates decreased in patients with diabetes overall, the least mortality reduction was observed among Hispanics and non-Hispanic blacks. This finding is in accord with NHANES data mentioned above showing that diabetes care during 2005-2016 was worst among minorities [14].

Causes of Ethnic/Racial Diabetes Disparities: Role of Obesity

Causes of high prevalence of diabetes in minorities are multi-factorial [18]. The growing obesity epidemic is likely the main driver of diabetes among minorities. In fact, non-Hispanic blacks have the highest prevalence of obesity, whereas Mexican Americans have the highest annual increase in obesity and in waist circumference [6]. Likewise, there is steady increase in obesity in US youths (2-19 years) among non-Hispanic blacks and Mexican Americans, but recent decline among non-Hispanic whites [6]. In 2030, it is predicted that severe obesity defined as body mass index (BMI) ≥ 35 kg/m2 will be highest among non-Hispanic blacks 31.7% (95% CI, 29.9-33.4), followed by Hispanics 24.5% (95% CI, 22.8-26.2), and non-Hispanic whites 23.4% (95% CI 22.1-24.8) [19]. Other causes of diabetes disparities include high-sugar diet, food insecurity [20], physical inactivity, increase insulin resistance independent of adiposity [18], health illiteracy, low education and socio-economic levels [4], lack of health insurance, decrease adherence to medications [21], and communication/language barriers. Genetic factors for diabetes susceptibility contribute similarly to diabetes risk across race/ethnicities [18]. Therefore, genetic differences are unlikely to play a major role in ethnic/racial diabetes disparities

Guidelines for Diagnosis of Diabetes Among Minorities

In subjects pertaining to minority groups, the American Diabetes Association (ADA) recommends screening for diabetes and prediabetes by fasting plasma glucose, HbA1c, or oral glucose tolerance test if they have a BMI ≥ 25 kg/m2 (or ≥ 23 kg/m2 in Asian Americans) [22]. If results are normal, testing should be repeated at a minimum of 3 year-intervals [22]. Patients with prediabetes should be tested yearly [22].

Prevention of Diabetes Among Minority Groups

Lifestyle changes

Since obesity is the main cause of high incidence of type 2 diabetes in general, and among minorities in particular, weight loss strategies including diet and exercise are essential to prevent or at least to delay onset of diabetes. In the landmark trial of Diabetes Prevention Program (DPP) that included 3234 multiethnic individuals at high risk for diabetes, participants were randomized to a lifestyle modification program, metformin 850 mg bid, or placebo [23]. After an average follow-up of 2.8 years, incidence of diabetes was reduced by 58% and 31 % by lifestyle changes and metformin, respectively compared to placebo [23]. It was encouraging that sub-group analysis of the DPP showed that lifestyle intervention tended to be more effective among minority groups with 61-71% reduction in incidence of diabetes compared with 51% reduction among white subjects [24]. Due its success, the DPP approach was implemented in several studies including Hispanics [24] American Indians/Alaska Natives [25], African American [26] and as part of faith-based lifestyle intervention in African American churches [27]. In addition, culturally adapted lifestyle intervention was attempted for prevention of diabetes among Hispanics [28]. In general, the previous studies were met with limited or partial success because of short duration of followup, high attrition rates, and female preponderance [24-28].

Metformin

Although metformin, was inferior to lifestyle changes in prevention of diabetes in the DPP [23], its use in this setting may be considered when lifestyle changes are not feasible or successful. In fact, in the DPP, metformin appears more effective in reduction of new-onset diabetes among minorities than among Whites [23]. Thus, African Americans had 44% reduction, followed by Hispanics 31% reduction, then finally Whites 24% reduction (statistical significance between the 3 groups was not reported) [23]. Moreover, studies showed that metformin is particularly effective with respect to diabetes prevention in women with prior history of gestational diabetes, subjects younger than 60 years, and those with higher baseline fasting glucose (≥ 110mg/dl versus 95- 109mg/dl), or HbA1c (6-6.4% versus < 6.0%) [29]. In addition, the ADA recommends consideration of metformin for patients with prediabetes and BMI ≥ 35kg/m2 [29].

Management of diabetes among minorities

Lifestyle intervention: In ‘The Action for Health in Diabetes (Look Ahead)” trial, 5,145 (36% minorities, 40% men) overweight/ obese subjects with type 2 diabetes were randomized to intensive lifestyle intervention and a control group of diabetes support and education [30]. The objective of the lifestyle intervention is a weight loss of 10% by decreased caloric and fat intake and increased physical activity [30]. After 8 years of intervention, all female patients from different ethnic groups lost weight similarly [30]. Among men, there was a trend toward less weight loss among African American and Hispanic men compared with Whites [30]. A more recent randomized trial conducted in Illinois evaluated culturally tailored diet changes and increase physical activity in low-income African American patients with type 2 diabetes [31]. Compared to standard care group, HbA1c levels were significantly lower at 6 months, but the difference was no longer significant at 12 and18 months [31].
The ADA recommends diabetes self-management education (DSME) in all patients with diabetes. The goal of DSME is to increase the patient’s self-efficacy to manage diet, physical activity, glucose monitoring, and stress management [32]. In one meta-analysis of 20 randomized trials of African Americans and Hispanics, DSME programs resulted in modest but significant HbA1c reduction of 0.31% (95% CI, -0.48 to -0.14%) compared with standard care [33]. However, another meta-analysis of 8 African American studies did not find any significant impact of DSME in improving HbA1c values [34]. Overall, data suggest that long-term lifestyle intervention adopted in the Look Ahead trial is generally effective in all ethnic groups [30]. However, culturally adapted diet and DSME strategies had limited or no benefit in terms of glycemic control.

Drug therapy for treatment of diabetes among minorities

Metformin: Data derived from electronic health records suggest that African-Americans (n=7,429) with type 2 diabetes have better glycemic response to metformin compared with European Americans (n=8,783), reduction in HbA1c levels being 0.9% and 0.4%, respectively (P<0.001 for the interaction between metformin exposure and race) [35]. These results are generally in agreement with those of the DPP showing superior efficacy of metformin in prevention of diabetes among African Americans (44% reduction of new-onset diabetes versus placebo) [23]. In addition, a subgroup analysis from the DPP showed that African American subjects with prediabetes treated with metformin have significantly greater decrease in fasting plasma glucose concentrations versus Whites up to 2 years after intervention [36].

Sodium-Glucose Co-Transporters Type 2 Inhibitors

Sodium-glucose co-transporters 2 (SGLT2) inhibitors are effective, safe, and easy to administer (once a day orally). In addition, they reduce systolic blood pressure and body weight. Furthermore, they significantly decrease CV and renal events in patients with type 2 diabetes and high cardiovascular risk [37,38]. Therefore, these agents are well-suited for treatment of type 2 diabetes in minorities. Unfortunately, ethnic minorities remain underrepresented in the major CV trials of SGLT2 inhibitors [39]. Nevertheless, it is reassuring that the 2 SGLT2 inhibitors empagliflozin and dapagliflozin decreased incidence of CV events in all ethnic groups, including the black patients that constituted approximately 5% of the study populations [37,38]. In a recent randomized trial formed exclusively of African Americans with type 2 diabetes and hypertension, empagliflozin reduced HbA1c levels by 0.78%, mean ambulatory systolic blood pressure by 8.4 mmHg, and body weight by 1.2 kg compared with placebo after 6 months [40].

Glucagon-Like Peptide-1 Receptor Agonists

Like SGLT2 inhibitors, glucagon-like peptide-1 receptor (GLP- 1) agonists decreased weight, systolic blood pressure, and CV events in patients with type 2 diabetes and established CV disease [41]. Main limitations of these agents are the subcutaneous way of administration (once daily or weekly) and high cost. Secondary analysis of phase III trials showed that glycemic efficacy, weight reduction, and safety of the GLP-1 agonist liraglutide are generally similar between African American, Latino/Hispanic, and White patients [42,43]. In the LEADER trial in which Blacks constituted 8.3% of the study population, CV benefits of liraglutide were similar irrespective of the race [41].

Amelioration of Patient-Provider Communication

Patient-provider communication is a critical element in health care provision. In one study, Latino patients who switched from language-discordant to language-concordant primary care physician had significant improvement in their glycemic control [44]. Current efforts aiming at standardization of Medical Spanish in Medical Schools represent a step forward to enhance communication and trust between physicians and Hispanic patients with limited English proficiency [45].

Summary and Current Needs

In the last decade, ethnic/racial disparities in diabetes incidence, prevalence, metabolic control, complications, and mortality continue to worsen. With respect to incidence of type 2 diabetes, the gap between Whites and minorities has widened in both adults and youths [2-5]. The latter observation is largely due to the steady increase in prevalence of obesity among minorities [6]. The DPP showed that weight loss and increased physical activity were effective in preventing diabetes among all racial groups [23]. Therefore, targeting obesity should be an absolute priority to diminish diabetes incidence in general and among minorities in particular. It is the time to take serious actions nationwide to change the pattern of current diet in the US. Specifically, sweetened beverages, refined carbohydrates, red and processed meats should be minimized as far as possible, and replaced by non-sweetened beverages, whole grain, and fibers [46]. Government should provide incentives for production and promotion of affordable healthy food. Any economic or political barriers that interfere with implementation of these diet changes should be removed. Intensive efforts are urgently needed from Federal and local authorities to reduce socioeconomic and educational discrepancies between Whites and disadvantaged minorities. Unfortunately, the recently recorded disproportionate high rates of infection and mortality caused by COVID 19 among African Americans have uncovered the deep and chronic wounds of health inequities that long existed and still persist in this country [47].

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Lupine Publishers| Inequalities in Diabetes in the USA

 Lupine Publishers| Archives of Diabetes & Obesity (ADO)

Abstract

Background: Diabetes disproportionably impacts minorities in the USA.

Objective: To review the latest data regarding diabetes epidemiology and management among different ethnic groups in the USA.

Methods: PubMed research of all pertinent articles up to June 29, 2020. Search terms included diabetes, ethnicity, African Americans, Blacks, Hispanics, Latinos, Asians, minorities, glycemic control, obesity, lifestyle changes, treatment, metformin, sodiumglucose co-transporter 2 inhibitors. Type of studies included are randomized, observational, epidemiological, consensus guidelines, and review articles.

Results: Diabetes prevalence and incidence in adults continue to increase among African Americans and Hispanics. In youths, the fastest increase in type 1 and type 2 diabetes occurs among Asians/Pacific Islanders followed by Hispanics and African Americans. The gap in glycemic control between Whites and minorities is widening. Whereas mortality rates decreased in patients with diabetes overall, the least mortality reduction was observed among Hispanics and non-Hispanic blacks. The diabetes epidemic among nonwhites patients is mainly due to obesity and physical inactivity. Lifestyle changes are generally effective for both prevention and treatment of diabetes among minorities. Metformin may be particularly effective among African Americans. Metformin and sodiumglucose co-transporter 2 (SGLT2) inhibitors are the most convenient drugs for treatment of diabetes in minorities.

Conclusion: Substantial disparities still exist in the USA with respect to diabetes incidence, glycemic control, and mortality.

Keywords: Ethnicity; Disparities; Diabetes; Obesity; Prevention; Treatment; Lifestyle changes

Introduction

According to the World Health Organization, equity is the absence of avoidable, unfair, or remediable differences among groups of people, whether those groups are defined socially, economically, demographically or by other means of stratification [1]. Therefore, health equity implies that everyone should have a fair opportunity to attain his/her full health, and that no one should be disadvantaged from achieving this potential [1]. Unfortunately, marked ethnic/racial disparities in the USA exist with respect to almost all aspects of diabetes and its care. Thus, minority groups are disproportionately affected in terms of diabetes incidence and prevalence, metabolic control, complications, prevention, and treatment. The causes of these disparities are complex but obesity among minorities play a major role. The main purpose of this article is to provide an update on ethnic/racial disparities in diabetes in the USA and to discuss the most effective ways of diabetes prevention and treatment among minorities. We used the same terminology for the racial/ethnic group (e.g. Hispanics versus Latinos) as it appears in the corresponding reference.

Disparities in Diabetes Prevalence

According to 3 surveys conducted by the National Health and Nutrition Examination Surveys (NHANES) between 2011 and 2016, weighted age and sex-adjusted prevalence of total diabetes i.e. diagnosed and undiagnosed was 12.1% for non-Hispanic white, 20.4% for non-Hispanic black, 22.1% for Hispanic and 19.1% for non-Hispanic Asian adults (overall P<0.001) [2]. The prevalence of undiagnosed diabetes generally followed similar pattern: 3.9% for non-Hispanic white, 5.2% for non-Hispanic black, 7.5% for Hispanic, and 7.5% for non-Hispanic Asian adults (overall P < 0.001) [2]. Marked heterogeneity in diabetes prevalence are present within the same ethnic group (Table 1).

Table 1: Estimated prevalence of diabetes, diagnosed and undiagnosed, in the USA among persons 20 years or older among different ethnic groups [adapted from reference 2].

*Weighted age- and sex-adjusted (95% confidence interval).
** Central America: Costa Rica, Guatemala, Honduras, Nicaragua, Panama, Salvador.
*** South America: Argentina, Chile, Columbia, Ecuador, Paraguay, Peru, Uruguay, Venezuela.
■East Asia: China, Japan, Korea.
●South Asian: India, Pakistan, Sri Lanka, Bangladesh, Nepal, Bhutan.
■●Southeast Asia: Philippines, Vietnam, Cambodia, Thailand, Indonesia, Malaysia, Singapore.

Disparities and Trends in Diabetes Incidence

Following a steady increase in diabetes incidence in adults from 1990 to 2007, it started to decrease from 2008 through the last National Health Interview Survey (NHIS) conducted in 2017 [3]. However, this decrease in incidence was driven primarily by non- Hispanic whites (annual percentage change of -5.1% (P=0.002) followed by Asians (annual percentage change -3.4% (P=0.06), whereas incidence rates among Hispanics and non-Hispanic blacks did not decrease [3]. In fact, the latest age-adjusted data for 2017- 2018 indicated that incidence of diagnosed diabetes in adults were highest in Hispanics (9.7 per 1,000 persons), followed by non- Hispanic blacks (8.2 per 1,000 persons), and Asians (7.4 per 1,000 persons), whereas non-Hispanic whites had the lowest incidence (5.0 per 1,000 persons) [4].

Prevalence of Pre-Diabetes

The most recent National Diabetes Statistics Report showed that 34.5% of all US adults had prediabetes (defined as HbA1c 5.7% to less than 6.5%, or fasting plasma glucose 100 to less than 126 mg/dl, or 2-hr postprandial plasma glucose 140 to less than 200 mg/dl) [4]. The prevalence of prediabetes was stable from 2005-8 to 2013-2016 [4], and not statistically significant between racial/ ethnic groups and various education levels: 31.0 % among Whites, 36.8% among non-Hispanic blacks, 36.1% among Hispanics and 33.0% among Asians [4].

Disparities in Diabetes in Youths

According to the SEARCH for Diabetes in Youth Study, a population-based registry study covering 5 states in the USA, incidence of both type 1 and type 2 diabetes is increasing in youths (defined as persons aged < 20 years) [5]. From 2002 to 2015, the annual relative percent increase was 1.9% and 4.8% in type 1 and type 2 diabetes, respectively [5]. Like the adult population, there were clear ethnic/racial differences in the rate of increase of diabetes in youths [5]. In type 1 diabetes, the steepest increase in incidence was among Asians/Pacific Islanders (4.4% per year), followed by Hispanics (4.0% per year), then Blacks (2.7%/year), and finally Whites 0.7% per year [5]. In type 2 diabetes, similar order was observed. Thus, the fastest increase was among Asians/ Pacific Islanders (7.7% per year), followed by Hispanics (6.5% per year), Blacks (6.0%/year), American Indians (3.7% per year), and finally Whites (0.7% per year). The latter increase among Whites was not statistically significant (95% CI, -1.35 to 2.94) [5]. Reasons of increase in type 1 diabetes are unclear. Meanwhile, the increased incidence in type 2 diabetes is likely due to the increase in obesity in US youths, particularly among minorities [6].

Disparities in Prevalence of Gestational Diabetes

In 2016, the crude (unadjusted) national prevalence of gestational diabetes was 6% [7]. In terms of ethnicity, prevalence of gestational diabetes follows a characteristic pattern. The lowest prevalence exists among non-Hispanic blacks 4.8%, followed by Whites 5.3%, then Hispanics 6.6%, then American Indians/Native Alaskans, and highest in Asians 11.1% [7]. However, despite the fact that prevalence of gestational diabetes is lowest among black women, their risk of developing subsequent type 2 diabetes was the highest compared with other racial/ethnic/groups [8]. For instance, the adjusted hazard ratio of developing diabetes after gestational diabetes was 7.6 and 4.4, among Black and White women, respectively, P=0.028) [8].

Diabetes Prevalence Among African Immigrant Population

The African immigrant (African-born) is one of the fastest growing immigrant groups in the USA [9]. Using data from the NHIS, Alma-Ruth et al [10] reported that age-standardized diabetes prevalence was significantly lower in African immigrants than in African- Americans (US-born), 7% and 10%, respectively (P< 0.01) [9]. Furthermore, African immigrants who had lived in the USA for ≥ 10 years were significantly less likely to have diabetes with a prevalence ratio (PR) of 0.61; 95% CI 0.43-0.79), less likely to have overweight/obesity (PR 0.87; 95% CI 0.77-0.96), hypertension (PR 0.69; 95% 0.61-0.78), and to be physically inactive (PR 0.21, 95% 0.15-0.28) [9]. Hence, African immigrants seem to have a more healthy and distinct metabolic profile compared with African Americans.

Disparities in Glycemic Control

Studies have consistently shown that diabetes control, as reflected by hemoglobin A1c (HbA1c) concentrations, is worse in Blacks and Hispanics compared with White race. In a national cohort of persons older than 65 years enrolled in Medicare Advantage Health plans in 2011, Ayanian et al [11] examined the proportions of patients with HbA1c levels ≤ 9.0%. They found this goal was achieved by 84.0%, 80.6%, and 74.6% among White, Hispanic, and Black enrollees, respectively (P<0.001 for the difference between any 2 groups) [11]. Furthermore, available data suggest that the ethnic/racial gap in HbA1c continues to widen. In fact, analysis of NHANES conducted between 2003 and 2014 showed that HbA1c values tend to worsen among African American and Mexican American patients with type 2 diabetes, whereas corresponding values tend to improve among White patients [12]. It should be emphasized, however, that the difference in HbA1c levels between Black and White persons may be attributed in part to racial factors possibly due to difference in glycation of hemoglobin [13]. Thus, on average, HbA1c levels are 0.4 percentage points (95% CI, 0.2-0.6% percentage points) higher among Blacks compared with White individuals for a given mean blood glucose concentrations [13].

Trends and Disparities in Diabetes Care in the US

Serial analysis of the NHANES data between 2005 and 2016 suggests that diabetes care cascade has not significantly improved during that period [14]. Indeed, only 23-25% of patients met the composite goal of targets of HbA1c (<7-8.5%, depending on age and complications), blood pressure (<140/90 mmHg), low-density lipoprotein cholesterol (<100 mg/dl), and no smoking [14]. These proportions of patients did not change between 2005 and 2016 [14]. Furthermore, there were obvious ethnic disparities in achieving this goal [14]. For example, in 2013-2016, 25% of non-Hispanic white patients attained he previous composite goal, compared with only 14% of non-Hispanic blacks, and 18% of Hispanic patients [14].

Disparities in Diabetes-Related Complications

In general, ethnic/racial minorities have more frequent macrovascular and microvascular diabetes complications compared with Whites [10,15]. The largest available National data showed that in 2010, incidence (cases per 10,000) of end-stage renal disease (ESRD) were more than double in Blacks versus Whites 36.6 versus 16.0 [10]. Corresponding rates for lower-extremity amputation were 40.0 versus 20.4, for stroke 63.1 versus 39.0, and for hyperglycemic death 2.2 versus 1.4. A notable exception was the incidence of acute myocardial infarction, which was lower in Blacks compared with Whites, 32.5 versus 37.5, respectively [10]. No corresponding data regarding the Hispanic patients were reported [10].

Disparities in Diabetes-Related Mortality

Mansour et al [16] reported significant ethnic disparities in mortality rates in patients with diabetes who participated in the NHANES surveys during 1999-2010. Follow-up of this cohort revealed that all-cause and cardiovascular (CV) mortality decreased in all ethnic groups with diabetes. However, the magnitude of reduction in CV mortality significantly differed between various ethnic groups [16]. Thus, Whites experienced the largest reduction in CV mortality from 20.4% down to 14.5%, followed by Non- Hispanic Blacks from 20.6% to 16.3%, whereas Hispanics had only a marginal reduction from 18.4% to 17.5% [16]. Similarly, recent analysis of NHIS conducted from 1997 to 2017 showed a significant decline in CV complications among White patients only, whereas no significant decline was observed among Black or Hispanic patients [17]. Taken together, while mortality rates decreased in patients with diabetes overall, the least mortality reduction was observed among Hispanics and non-Hispanic blacks. This finding is in accord with NHANES data mentioned above showing that diabetes care during 2005-2016 was worst among minorities [14].

Causes of Ethnic/Racial Diabetes Disparities: Role of Obesity

Causes of high prevalence of diabetes in minorities are multi-factorial [18]. The growing obesity epidemic is likely the main driver of diabetes among minorities. In fact, non-Hispanic blacks have the highest prevalence of obesity, whereas Mexican Americans have the highest annual increase in obesity and in waist circumference [6]. Likewise, there is steady increase in obesity in US youths (2-19 years) among non-Hispanic blacks and Mexican Americans, but recent decline among non-Hispanic whites [6]. In 2030, it is predicted that severe obesity defined as body mass index (BMI) ≥ 35 kg/m2 will be highest among non-Hispanic blacks 31.7% (95% CI, 29.9-33.4), followed by Hispanics 24.5% (95% CI, 22.8-26.2), and non-Hispanic whites 23.4% (95% CI 22.1-24.8) [19]. Other causes of diabetes disparities include high-sugar diet, food insecurity [20], physical inactivity, increase insulin resistance independent of adiposity [18], health illiteracy, low education and socio-economic levels [4], lack of health insurance, decrease adherence to medications [21], and communication/language barriers. Genetic factors for diabetes susceptibility contribute similarly to diabetes risk across race/ethnicities [18]. Therefore, genetic differences are unlikely to play a major role in ethnic/racial diabetes disparities

Guidelines for Diagnosis of Diabetes Among Minorities

In subjects pertaining to minority groups, the American Diabetes Association (ADA) recommends screening for diabetes and prediabetes by fasting plasma glucose, HbA1c, or oral glucose tolerance test if they have a BMI ≥ 25 kg/m2 (or ≥ 23 kg/m2 in Asian Americans) [22]. If results are normal, testing should be repeated at a minimum of 3 year-intervals [22]. Patients with prediabetes should be tested yearly [22].

Prevention of Diabetes Among Minority Groups

Lifestyle changes

Since obesity is the main cause of high incidence of type 2 diabetes in general, and among minorities in particular, weight loss strategies including diet and exercise are essential to prevent or at least to delay onset of diabetes. In the landmark trial of Diabetes Prevention Program (DPP) that included 3234 multiethnic individuals at high risk for diabetes, participants were randomized to a lifestyle modification program, metformin 850 mg bid, or placebo [23]. After an average follow-up of 2.8 years, incidence of diabetes was reduced by 58% and 31 % by lifestyle changes and metformin, respectively compared to placebo [23]. It was encouraging that sub-group analysis of the DPP showed that lifestyle intervention tended to be more effective among minority groups with 61-71% reduction in incidence of diabetes compared with 51% reduction among white subjects [24]. Due its success, the DPP approach was implemented in several studies including Hispanics [24] American Indians/Alaska Natives [25], African American [26] and as part of faith-based lifestyle intervention in African American churches [27]. In addition, culturally adapted lifestyle intervention was attempted for prevention of diabetes among Hispanics [28]. In general, the previous studies were met with limited or partial success because of short duration of followup, high attrition rates, and female preponderance [24-28].

Metformin

Although metformin, was inferior to lifestyle changes in prevention of diabetes in the DPP [23], its use in this setting may be considered when lifestyle changes are not feasible or successful. In fact, in the DPP, metformin appears more effective in reduction of new-onset diabetes among minorities than among Whites [23]. Thus, African Americans had 44% reduction, followed by Hispanics 31% reduction, then finally Whites 24% reduction (statistical significance between the 3 groups was not reported) [23]. Moreover, studies showed that metformin is particularly effective with respect to diabetes prevention in women with prior history of gestational diabetes, subjects younger than 60 years, and those with higher baseline fasting glucose (≥ 110mg/dl versus 95- 109mg/dl), or HbA1c (6-6.4% versus < 6.0%) [29]. In addition, the ADA recommends consideration of metformin for patients with prediabetes and BMI ≥ 35kg/m2 [29].

Management of diabetes among minorities

Lifestyle intervention: In ‘The Action for Health in Diabetes (Look Ahead)” trial, 5,145 (36% minorities, 40% men) overweight/ obese subjects with type 2 diabetes were randomized to intensive lifestyle intervention and a control group of diabetes support and education [30]. The objective of the lifestyle intervention is a weight loss of 10% by decreased caloric and fat intake and increased physical activity [30]. After 8 years of intervention, all female patients from different ethnic groups lost weight similarly [30]. Among men, there was a trend toward less weight loss among African American and Hispanic men compared with Whites [30]. A more recent randomized trial conducted in Illinois evaluated culturally tailored diet changes and increase physical activity in low-income African American patients with type 2 diabetes [31]. Compared to standard care group, HbA1c levels were significantly lower at 6 months, but the difference was no longer significant at 12 and18 months [31].
The ADA recommends diabetes self-management education (DSME) in all patients with diabetes. The goal of DSME is to increase the patient’s self-efficacy to manage diet, physical activity, glucose monitoring, and stress management [32]. In one meta-analysis of 20 randomized trials of African Americans and Hispanics, DSME programs resulted in modest but significant HbA1c reduction of 0.31% (95% CI, -0.48 to -0.14%) compared with standard care [33]. However, another meta-analysis of 8 African American studies did not find any significant impact of DSME in improving HbA1c values [34]. Overall, data suggest that long-term lifestyle intervention adopted in the Look Ahead trial is generally effective in all ethnic groups [30]. However, culturally adapted diet and DSME strategies had limited or no benefit in terms of glycemic control.

Drug therapy for treatment of diabetes among minorities

Metformin: Data derived from electronic health records suggest that African-Americans (n=7,429) with type 2 diabetes have better glycemic response to metformin compared with European Americans (n=8,783), reduction in HbA1c levels being 0.9% and 0.4%, respectively (P<0.001 for the interaction between metformin exposure and race) [35]. These results are generally in agreement with those of the DPP showing superior efficacy of metformin in prevention of diabetes among African Americans (44% reduction of new-onset diabetes versus placebo) [23]. In addition, a subgroup analysis from the DPP showed that African American subjects with prediabetes treated with metformin have significantly greater decrease in fasting plasma glucose concentrations versus Whites up to 2 years after intervention [36].

Sodium-Glucose Co-Transporters Type 2 Inhibitors

Sodium-glucose co-transporters 2 (SGLT2) inhibitors are effective, safe, and easy to administer (once a day orally). In addition, they reduce systolic blood pressure and body weight. Furthermore, they significantly decrease CV and renal events in patients with type 2 diabetes and high cardiovascular risk [37,38]. Therefore, these agents are well-suited for treatment of type 2 diabetes in minorities. Unfortunately, ethnic minorities remain underrepresented in the major CV trials of SGLT2 inhibitors [39]. Nevertheless, it is reassuring that the 2 SGLT2 inhibitors empagliflozin and dapagliflozin decreased incidence of CV events in all ethnic groups, including the black patients that constituted approximately 5% of the study populations [37,38]. In a recent randomized trial formed exclusively of African Americans with type 2 diabetes and hypertension, empagliflozin reduced HbA1c levels by 0.78%, mean ambulatory systolic blood pressure by 8.4 mmHg, and body weight by 1.2 kg compared with placebo after 6 months [40].

Glucagon-Like Peptide-1 Receptor Agonists

Like SGLT2 inhibitors, glucagon-like peptide-1 receptor (GLP- 1) agonists decreased weight, systolic blood pressure, and CV events in patients with type 2 diabetes and established CV disease [41]. Main limitations of these agents are the subcutaneous way of administration (once daily or weekly) and high cost. Secondary analysis of phase III trials showed that glycemic efficacy, weight reduction, and safety of the GLP-1 agonist liraglutide are generally similar between African American, Latino/Hispanic, and White patients [42,43]. In the LEADER trial in which Blacks constituted 8.3% of the study population, CV benefits of liraglutide were similar irrespective of the race [41].

Amelioration of Patient-Provider Communication

Patient-provider communication is a critical element in health care provision. In one study, Latino patients who switched from language-discordant to language-concordant primary care physician had significant improvement in their glycemic control [44]. Current efforts aiming at standardization of Medical Spanish in Medical Schools represent a step forward to enhance communication and trust between physicians and Hispanic patients with limited English proficiency [45].

Summary and Current Needs

In the last decade, ethnic/racial disparities in diabetes incidence, prevalence, metabolic control, complications, and mortality continue to worsen. With respect to incidence of type 2 diabetes, the gap between Whites and minorities has widened in both adults and youths [2-5]. The latter observation is largely due to the steady increase in prevalence of obesity among minorities [6]. The DPP showed that weight loss and increased physical activity were effective in preventing diabetes among all racial groups [23]. Therefore, targeting obesity should be an absolute priority to diminish diabetes incidence in general and among minorities in particular. It is the time to take serious actions nationwide to change the pattern of current diet in the US. Specifically, sweetened beverages, refined carbohydrates, red and processed meats should be minimized as far as possible, and replaced by non-sweetened beverages, whole grain, and fibers [46]. Government should provide incentives for production and promotion of affordable healthy food. Any economic or political barriers that interfere with implementation of these diet changes should be removed. Intensive efforts are urgently needed from Federal and local authorities to reduce socioeconomic and educational discrepancies between Whites and disadvantaged minorities. Unfortunately, the recently recorded disproportionate high rates of infection and mortality caused by COVID 19 among African Americans have uncovered the deep and chronic wounds of health inequities that long existed and still persist in this country [47].

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Lupine Publishers| Is there Association Between Dislipidemia and Diabetes Type 2 in the Population of Castilla-La Mancha?

 Lupine Publishers| Archives of Diabetes & Obesity (ADO)

Summary

Background and objective: The dislipidemia are one of the main factors of risk of cardiovascular illness in patients with diabetes mellitus type 2 (DM2). The aim of this study is to evaluate the prevalence and factors of risk associated to the dislipidemia in the population with DM2 of the Community of Castile-La Mancha.

Material and methods: It are a longitudinal study made in centers of Attention Primaria of the Service of Health of Castilla- La Mancha (n=70). It selected a representative sample of the population with DM2 of 18 to 85 years by means of a procedure polyetapic. They obtained the clinical history and by means of interview the data of the factors of risk to study. It analyzed the association with the dislipidemia by means of linear regression.

Results: 52.1% were men, the half age was of 69-84 years, the evolution of the diabetes of 999 years, 84.3% had HTA, 76.6% sobrepeso/obesigive and the HbA1c half was of 69.6%. The prevalence of dislipidemia was of 85.3% and in the analysis bivariado associated with antecedent of peripheral vascular illness, diabetes controlled, treatment antihypertensive, filtered glomerular, HbA1c>7%, grasto corporal estimated in sobrepeso and obesity, antecedent of cardiovascular illness, age and HbA1c. In the univariant analysis the independent factors were the feminine sex and the antecedent of cardiovascular illness.

Conclusion: The prevalence of dislipidemia in our study was of 85.3%. The factors of risk associated of independent form were the feminine sex and the personal antecedent of cardiovascular illness.

Keywords: Dislipidemia; Diabetes mellitus Type 2; Prevalence; Factors of risk

Introduction

The diabetes mellitus type 2 (DM2) is an illness that has purchased a character pandemic because of the increase of the hope of life, that supposes an increase of the aging of the population, to the increase of the obesity and to the change in the lifestyles to some habits no cardiosaludables (sedentarism and bad feeding) [1].
The prevalence of DM2, according to the study diabetes, emplaza in 13.79% of the Spanish population elder of age. According to data of the Organization Mundial of the Health (2016), in Spain the DM finds between the causes of death more frequent. The proportional mortality that attributes to this illness is of 3% of the total of deaths for all the groups etarios. The DM comports notable costs socioeconomics. Crespo Et al. They signaled that, in 2013, the annual cost of the DM was of 5. 890 million euros: 8.2% of the sanitary cost total [2].
In the patients with diabetes, the complications microvascular are the main cause of morbimortalidad to level mundial. Near of 3/4 parts die by cardiac illness or cerebrovascular. Likewise, the frequency of deaths by cardiovascular reasons in adult’s diabetes in comparison with the no diabetes is of 2 to 4 greater times [3]. The importance of the quilomicrones for the reduction of the cardiovascular risk in the DM2 has been showed in different studies and metanalysis [4]. The association between dislipidemia and cardiovascular illness (ECV) remained showed in the “United Kingdom Prospective Diabetes Study (UKPDS 23)”, where observed that an increase of 38.5 mg/dl in the concentration of quilomicrones associates to an increase of 15.7% to present coronary arterial illness and that an increase of 4 mg/dl of the cHDL associates to a descent of 15% of events cardiovascular [3]; like this then , the factor of risk of greater weight to develop coronary illness were the quilomicrones, followed of the levels of cHDL. It is necessary to diagnose and treat temperamental the dislipidemia of effective form for like this reduce the risk of cardiovascular events futures [1].
In Spain, diverse studies epidemiological have analyzed the prevalence of the alterations lipidic, that oscillate between 56.2% in the one of Domínguez and 92.6% in the study OBEDIA8; however, it is scarce the information on the prevalence and the factors associated to the dislipidemia in patients with DM2 in Castile-La Mancha [5].

The present study has like aims:
a. Estimate the prevalence of the dislipidemia.
b. Investigate the factors of risk associated to the dislipidemia and
c. Investigate the factors of risk associated of independent form to the dislipidemia.

Material and Methods

Longitudinal study of populational base on a sample of 70 patients with DM2, between November of the 2019 and February of the 2020. It made a procedure polyetapic by means of the employment of a sample of the conglomerates of some centers of health. Of the 60 centers of health registered in the Service of Castile-La Mancha of Health, selected 30. The greater part of this in the province of Albacete (where selected 20), in Cuenca selected 4, in Ciudad Real 3 and in Toledo other 3. Later there was a second selection of a submaster of the contingents of patients of the doctors of each center of health elegido. If any of the centers of health rejected to participate in the study, was replaced by another inside the same stratum.
Of each included patient in the study collected information of the following variables: age, sex, year of diagnostic of DM2, habitat, level of education, familiar economic level, labor situation, habit tobacco, weight, size, perimeter abdominal waist, corporal fat estimated, index of corporal mass (IMC), arterial systolic pressure, arterial diastolic pressure, abdominal obesity, antecedents of ECV, arterial hypertension (HTA), antihypertensive treatment, dislipidemia, hypolipidemia treatment, renal insufficiency and retinopathy.
Besides, they collected the analytical parameters of quotient albumin/creatinine, filtered glomerular (FG), hemoglobin glycosylate (HbA1c), plasmatic glycemia, total cholesterol (CT), cLDL, cHDL, triglycerides (TG) and creatinine. For the register of the periarterial ion made 2 measurements of arterial pressure systolic and diastolic in 2 successive visits and with monitor of validated arterial pressure. For the analysis, the average of the two measurements is used.

For the analysis of data used the program statistician SPSS V23.0.0.0. The qualitative variables expressed like absolute value and percentage, with the estimate of the interval of confidence to 90% (IC 90%). The quantitative variables expressed like half ± typical deviation and IC 90%. For the relation of the quantitative and qualitative variables between himself employed an analysis bivariado with t of Student. It made the analysis multivariate of binary linear regression no conditional with the dislipidemia like dependent variable, having in unit the variables that in the analysis bivariado associated with the presence of the dislipidemia or were clinically notable, that were the following: age, sex, HTA, personal antecedent of peripheral vascular illness, diabetes controlled, antidiabetic treatment, HbA1c≥7%, quotient albumin/creatinine, FG, personal antecedent of ECV, years of evolution of DM, glycemia basal, creatinine and retinopathy. All the statistical analyses were of 1 tail and considered estimated signification a value of < p 0.05.

Results

Of the 70 patients, 68.9% were 65 years old or more, with average of age of 69-84 years and average of years of evolution of the diabetes of 999 years. 68.2% of the participants were of urban habitat, 50% had primary studies, 74% were jubilates and 75% had annual income <18.000 D. There was a light predominance of men (52.1%) and the women were of greater age (70.8 years). The tabaquismo active and the obesity according to the IMC was significantly greater in men; the abdominal obesity was significant and greater in women. The prevalence of dislipidemia was of 85.3%; the one of HTA, of 84.3%; renal insufficiency, of 22.9%; sedentarism, of 48.2%; logo albuminuria and proteinuria, 31.3%; sobrepeso and obesity according to IMC, of 76.6%; obesity according to the corporal fat estimated by means of CUN-BAE, of 93%; abdominal obesity, of 67.6% and the retinopathy was of 29.3%. The prevalence of dislipidemia was similar in women and men (87.7% in women in front of 83.1% in men; p = 0.085). Of the subjects dilapidations, 79.5% were dilapidations for receiving hypolipidemic treatment and 20.5%, dilapidations that did not receive hypolipidemic treatment and that presented values of cLDL>160mg/dl, cHDL < 40mg/dl in men or <50mg/dl in women, or TG≥150mg/dl. The 75.3% received hypolipidemic treatment; 71.1%, statins; 5.4%, ezetimibe; 3.3%, fibrates; 0.8%, resins of ionic exchange and 0.5%, esters etarios of sour grass omega 3. 69.6% received treatment in monotherapy and 5.7% in bitherapy. In the subject’s dilapidations for receiving hypolipidemic treatment, 96.5% received statins or ezetimibe; 4.3%, fibrates and 2%, statins and fibrates. In the subjects with diagnostic of dislipidemia and without hypolipidemic treatment, the 14.3% had the cLDL > 160mg/dl; 79%, cHDL < 40mg/ dl in men or <50mg/dl in women and 51.3% had TG>150mg/dl. The average of glycemia plasmatic basal was of 137.85 ± 46.59mg/ dl, of CT 178.17±38.18mg/dl, of cHDL. 47.09±12.10mg/dl, of cLDL 108,10±36.44mg/dl, of TG 136.6±66.3mg/dl and of creatinine 0.96±0.55mg/dl.

68.7% of the patients had normoalbuminuric; 23.8%, logo albuminuria and 7.5%, self-evident proteinuria. 77.1% of the patients had a tax of filtered glomerular (MDRD) TFGe>60ml/ min/1.73m2 and 22.9%, renal insufficiency (TFGe<60ml/ min/1.73m2). Of the patients with renal insufficiency, 19.1% had TFGe of 30-59 ml/min/1.73m2; 2.9%, of 15-29ml/min/1.73m2 and 0.9%, <15ml/min/1.73m2. The average of leukemia plasmatic basal, TG and creatinine was significantly greater in men and, the average of CT, cHDL and cLDL was significantly greater in the women. To his time, the logo albuminuria and proteinuria was significantly more prevalent in the men. They obtained the parameters lipidic complete of 70 patients that had registered one or more parameters. Of them, 26.6% did not reach the aims of CT (<200mg/ dl) neither 54.9% the ones of cLDL (<100mg/dl). They documented TG high (≥150mg/dl) in 33.7% and cHDL low (<40mg/dl in men and <50mg/dl in women) in 46%. With regard to the alterations combined, cLDL out of aims and cHDL low detected in 23.7%; cLDL out of aims, cHDL low or TG elevated in 14% and cLDL and CT future of aims, cHDL low or TG elevated in 6.6%. In the analysis bivariado, the variables associated to the presence of dislipidemia are: antecedent of peripheral vascular illness, diabetes controlled, pharmacological treatment for HTA, HbA1c ≥ 7%, FG, corporal fat estimated in sobrepeso and obesity, personal antecedent of ECV, age and HbA1c (Table 1). The antecedent of peripheral vascular illness is included in the variable antecedent of ECV.

Clinical diagnostic of dislipidemia*

*Dislipidemia: In treatment of hypolipidemia or those that do not follow treatment hypolipidemia and present figures of cLDL > 160 mg/dl; cHDL < 40 mg/dl in men and <50 mg/dl in women or TG > 150 mg/dl. cHDL: Cholesterol joined to lipoproteins of high density; cLDL: cholesterol joined to lipoproteins of low density; CT: total cholesterol; DM: diabetes mellitus; HbA1c: hemoglobin glycosylate; IC: interval of confidence; OR: odds ratio; TG: triglycerides.

We have not found significant differences in the presence of dislipidemia with the following variables: sex, familiar economic level, level of education, labor situation, habitat, habit tobacco, HTA, HTA controlled, pharmacological treatment DM, quotient albumin/ creatinine, IMC, obesity abdominal, retinopathy diabetic, years of evolution, glycemia basal neither creatinine. In spite of have not found significant differences, objectives that the subjects with dislipidemia had greater time of evolution of his DM, greater levels of glycemia basal and creatinine and greater values of IMC. To his time, the feminine sex, the black race, the familiar economic level “annual incomes < 18.000 D”, the low level of education (without studies and primary studies), the labor situation “retired” and the urban habitat were more prevalent in the subjects dyslipidemias. Likewise, the habit tobacco (smoker and exfumador), the HTA, the oligoalbuminuria, the proteinuria and the retinopathy diabetic were more prevalent in dislipidemic patients that in no dislipidemic. He also objectified that the prevalence of the dislipidemia was elder to measure that increased the oligoalbuminuria and the degree of retinopathy diabetic, as well as, when the TFGe diminished.

The model contains the following variables: sex (woman vs. man), personal antecedents of ECV (ictus, cardiopathy ischemic and peripheral arteriopathy), HbA1c>7% and age (continuous, by every year of more).

B: Coefficient of regression; ECV: cardiovascular illness; EE: standard error of B; H: men; HbA1c: glycosylated hemoglobin; IC: interval of confidence; M: women; OR: odds ratio.

In the analysis multivariable, identify that the variables that associate of independent form with the dislipidemia are the feminine sex and the personal antecedent of ECV (Table 2).

Discussion

The results indicate that the prevalence of dislipidemia in patients with DM2 of Castile-La Mancha is elevated and that less than 15% of the patients show the lipidic values normal or recommended by the main guides of clinical practice. Said findings of prevalence are consistent with the found in other works so much in Spain as in the international field. When we compare these results with different publications, observe that it exists a big variability. In the majority of the studies the prevalence of dislipidemia finds above 50%, with a rank that oscillates between 56.2% in the one of Dominguez and 92.6% in the study OBEDIA. On the other hand, the variability found in the prevalence of dislipidemia can be due to the heterogeneity in the form to diagnose it and to that is in relation with the different criteria diagnostics. In this context, the greater prevalence observed in the study OBEDIA could be in relation with the point of court of the cLDL considered in the definition of dislipidemia, that is lower that the used in the present study. These discrepancies are something usual in the medical bibliography, since the methodologies used to the hour to carry out the studies (is possible that other studies use distinct criteria diagnostics, methods of laboratory or different points of cut to determine the diverse factors lipidemic and his cardiovascular risk), as well as the populational diversity, affect to the results ends of the studies. Also it is important emphasize that the studies from populational samples can have the inconvenient that, in spite of his randomness in the selection of the subjects, the sample do not represent the population of reference or that this find very delimited in the space and the time and, therefore, was not comparable with other studies. This prevalence so high could be related with the profile of the patients studied (high taxes of obesity, sick age, bad metabolic control of the diabetes, etc.), since in the sample studied 69% were greater of 65 years. These analytical values do not depend of the register made by the professionals and are a faithful reflection of the reality. Although in multiple studies epidemiological longitudinal has analyzed the prevalency of dislipidemia in populations diabetics with distinct levels of cardiovascular risk, east is the first study in Spain that analyses the characteristics, prevalence and factors associated to the dislipidemia of a representative sample of patients with DM2 of Castile-La Mancha. Besides, the previous studies to the moment to value the prevalence of dislipidemia center usually in the isolated alteration of the CT or cLDL according to the recommendations of the NCEP ATP III, without a complete analysis of the lipid profile and without taking into account to patients in treatment lipid lowering.
In the subjects with diagnostic of dislipidemia and without treatment lipid lowering we objectify that the low values of cHDL is the alteration lipidic more frequent (79%). Of the same way, observe a considerable increase of the levels of TG (51.3%) beside a discreet increase of the values of cLDL (14.3%). These results are concordant with the quantitative alterations described in the dislipidemia in the patient with DM “dislipidemia atherogenic”. The dislipidemia atherogenic is a characteristic element of the vascular residual risk of origin lipidic no associated to changes in the neither of them of cLDL and is a dislipidemia very prevalent in the people with DM2, in the patients with high risk or very high risk, with visceral obesity or metabolic syndrome.

In the sample studied observes that a high proportion of patients do not reach the aims of cLDL. Also, objectives that an important proportion of cases has TG high and cHDL low, which saves concordance with the described in the bibliography, where finds elevation of the TG and decrease of the cHDL in approximate mind the half of the patients with DM2. These data signal an important residual risk (levels of cLDL, cHDL and TG suboptimal) that probably have to be controlled with more intensity of what does in the daily clinical practice and that perhaps was in relation with the inertia and therapeutic fulfillment; in patients with DM2, the percentage of breach therapeutic is very high, and is of the 32, 36 and 38% for the lipid lowering, antidiabetics and antihypertensives. If we examine the fulfillment of objectives according to the recommendations of the guides of clinical practice, objectives that the 2/3 parts of the subjects have suitable levels of TG (67.2%) and less than the half do not reach the optimum levels of cLDL (45.1%) and cHDL (46%).

If we compare these results with the obtained in a transversal study made in the 17 autonomous communities of Spain, observe that the subjects studied attain more frequently the aims lipidics recommended. In patients with DM2 and dislipidemia the approach global therapeutic has to consider, in addition to cLDL, the control of the levels of cHDL and of TG like secondary therapeutic aims, what can involve a change in our therapeutic attitude to achieve such aims. The main contribution of this work is the knowledge of the high prevalence of dislipidemia (85.3%) in patients with DM2 of the Community of Castile-La Mancha and that the factors associated of independent form to the dislipidemia were the feminine sex and the antecedent of ECV. This knowledge is the first stair to implant the necessary means that make possible to improve the group of the profile lipidic, and, therefore, would have to be useful to establish strategies of continuous improvement that involve to all the agents involves (medical personnel, personnel of infirmary and sanitary authorities) in the implementation of the clinical guides and in improving the adherence of the patients. Our results indicate that frequently it exists more than an alteration of the values of plasmatic lipids. Like this, 23.7% showed conjoint alterations of cLDL and cHDL; 14.7%, of cLDL, cHDL and TG and, 6.6%, of the 4 parameters. On the other hand, the CT, cHDL and cLDL were significantly greater in women and the TG were significantly Minimal in men; these findings are similar to the described in a study made in Catalonia. In the Or.K. Prospective Diabetes Study 27, observed that the CT, cHDL and the cLDL were significantly greater in women, what saves relation with encountered in our study.

By means of the analysis multivariable, identify that the feminine sex and the personal antecedent of ECV associate of independent way with the dislipidemia, above the age and of the HbA1c. The prevalence of dislipidemia sand associated with the feminine sex, what was consistent with other studies [4]. Regarding the association between sex and dislipidemia, in the current investigation the feminine sex was the most affected by dislipidemia, although 52.1% of the participants were of masculine sex. The association of both categorical variables by means of the analysis multivariant allowed to estimate that belong to the feminine sex in this group of patients increased in almost 3 times the relative risk to present dislipidemia. The lipid profile altered is a characteristic of the DM and confers greater risk to present ECV, especially EAC. The relative risk of coronary cardiac illness fatal associated with the DM is 50% higher in the women that in the men. The caused the greater risk of coronary cardiopathy in women with DM still does not know completely. However, the changes induced by the DM2 in some factors of cardiovascular risk, like the cLDL, cHDL, TG and the PA, have found more pronounced in the women that in the men, and this can explain the greater increase in the risk of arteriosclerosis in women diabetics. Besides, the differences between the sexes in the lipid profile could exert a paper in the most negative impact that has gave diabetes on the cardiovascular risk in the women in comparison with the men. Likewise, it has posited that the increase of the prevalence of the dislipidemia in the women of age advanced can be related with the hormonal changes in the pre- and post-menopausal. The prevalence of dislipidemia associated with the personal antecedent of ECV [6]. In the current investigation, the antecedent of ECV was significantly more prevalent in the masculine sex (39.5%) and almost 4 of each 10 of patients with dislipidemia had the antecedent of ECV (35.8%). The association of both categorical variables by means of the analysis multivariant allowed to estimate that have the personal antecedent of ECV in this group of patients increased in 3.5 times the risk to present says lipidemia [7]. In this sense, is important to emphasize that the hypercholesterolemia is a factor of risk very prevalent in patients with ECV and confers special risk to suffer it, especially ischemic cardiopathy. Likewise, the high levels of CT and cLDL are between the most important factors of risk of ECV, the cHDL low and the TG high are independent factors of risk of ECV and the treatment with statins has a beneficial effect in the incidence of the ECV atherosclerotic [8]. Our studies presents diverse limitations and fortresses. Between the main limitations find the inherent to the type of study (longitudinal) and of analysis of the information; in this sense has to recognize the presence of the bias of survival, the impossibility to generalize the results to populations with different characteristics to the described; to his time, is necessary to make studies perspectives that can confirm these results and analyze with greater precision the variables associated tool to prevalence of dislipidemia.

Of the present study fits to stand out the sampling in which it is based, that is a representative sample of Castile-La Mancha, as well as the fact that it have been objective by several observers, what does it more damtativo in the recollection of data. In comparison of our results with the studies published to national and international level allows us to see the consistency of the data. Besides, other variables could be predictors valid of dislipidemia. Our study did not take into account the possible modifications of the therapy lipid lowering and the therapeutic fulfillment of the patients. Finally, the longitudinal design is very used, since his cost is relative inferior body to the of other epidemiological designs, like the transversal studies, and provide notable information and of fast form for the management of the services of health. Because of the importance of the object of analysis that occupies us, believe necessary emphasize the importance to follow investigating in this line.

Conclusion

This investigation shows that in the patients with DM2 of Castile- La Mancha there is a high prevalence of dislipidemia. The factors of risk associated of form independent were the feminine sex and the personal antecedent of ECV. In sight of these results, exists the need of a handle integral and intensive of the dislipidemia, for which has to try improve the metabolic control of the diabetes, decrease the obesity and promote changes in the lifestyles (cessation of the habit tobacco, physical exercise and decrease of the consumption of saturated fats and of alcohol), with the end to diminish the ECV and to improve the quality of individual and collective life of the population.

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