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Background: In recent decades, the United States experienced increasing prevalence and incidence of diabetes, accompanied by large disparities in county-level diabetes prevalence and incidence. However, whether these disparities are widening, narrowing, or staying the same has not been studied. We examined changes in disparity among U.S. counties in diagnosed diabetes prevalence and incidence between 2004 and 2012. Methods: We used 2004 and 2012 county-level diabetes (type 1 and type 2) prevalence and incidence data, along with demographic, socio-economic, and risk factor data from various sources. To determine whether disparities widened or narrowed over the time period, we used a regression-based β-convergence approach, accounting for spatial autocorrelation. We calculated diabetes prevalence/incidence percentage point (ppt) changes between 2004 and 2012 and modeled these changes as a function of baseline diabetes prevalence/incidence in 2004. Covariates included county-level demographic and, socio-economic data, and known type 2 diabetes risk factors (obesity and leisure-time physical inactivity). Results: For each county-level ppt increase in diabetes prevalence in 2004 there was an annual average increase of 0.02 ppt (p<0.001) in diabetes prevalence between 2004 and 2012, indicating a widening of disparities. However, after accounting for covariates, diabetes prevalence decreased by an annual average of 0.04 ppt (p<0.001). In contrast, changes in diabetes incidence decreased by an average of 0.04 ppt (unadjusted) and 0.09 ppt (adjusted) for each ppt increase in diabetes incidence in 2004, indicating a narrowing of county-level disparities. Conclusions: County-level disparities in diagnosed diabetes prevalence in the United States widened between 2004 and 2012, while disparities in incidence narrowed. Accounting for demographic and, socio-economic characteristics and risk factors for type 2 diabetes narrowed the disparities, suggesting that these factors are strongly associated with changes in disparities. Public health interventions that target modifiable risk factors, such as obesity and physical inactivity, in high burden counties might further reduce disparities in incidence and, over time, in prevalence. [ABSTRACT FROM AUTHOR]

Objectives. We examined the relationship between socioeconomic position (SEP) and sensory impairment. Methods. We used data from the 2007 to 2010 National Health Interview Surveys (n = 69 845 adults). Multivariable logistic regressions estimated odds ratios (ORs) for associations of educational attainment, occupational class, and poverty-income ratio with impaired vision or hearing. Results. Nearly 20% of respondents reported sensory impairment. Each SEP indicator was negatively associated with sensory impairment. Adjusted odds of vision impairment were significantly higher for farm workers (OR = 1.41; 95% confidence interval [Cl] = 1.01, 2.02), people with some college (OR = 1.29; 95% Cl = 1.16, 1.44) or less than a high school diploma (OR = 1.36; 95% Cl = 1.19, 1.55), and people from poor (OR = 1.35; 95% Cl = 1.20, 1.52), low-income (OR = 1.28; 95% Cl = 1.14, 1.43), or middle-income (OR = 1.19; 95% Cl = 1.07, 1.31) families than for the highest-SEP group. Odds of hearing impairment were significantly higher for people with some college or less education than for those with a college degree or more; for service groups, farmers, and blue-collar workers than for white-collar workers; and for people in poor families. Conclusions. More research is needed to understand the SEP-sensory impairment association. [ABSTRACT FROM AUTHOR]

The article discusses the prevalence of diabetes in the U.S. from 2006-2010. It states that the report aims to discuss and raise awareness about group differences of diabetes diagnosis and to provide actions to reduce these differences. Moreover, it found that significant differences for race and ethnicity occurred among non-Hispanic whites and non-Hispanic blacks or Hispanics.

The article aims to discuss and raise awareness regarding group differences in levels of poverty and noncompletion of high school and poverty, and to motivate actions to reduce health disparities. Topics discussed include the Current Population Survey (CPS), persistence of racial or ethnic socioeconomic and geographic disparities in noncompletion of high school and poverty in the country, and income and educational attainment.

Diabetes (diagnosed or undiagnosed) affects 10.9 million US adults aged 65 years and older. Almost 8 in 10 have some form of dysglycemia, according to tests for fasting glucose or hemoglobin A1c. Among this age group, diagnosed diabetes is projected to reach 26.7 million by 2050, or 55% of all diabetes cases. In 2007, older adults accounted for $64.8 billion (56%) of direct diabetes medical costs, $41.1 billion for institutional care alone. Complications, comorbid conditions, and geriatric syndromes affect diabetes care, and medical guidelines for treating older adults with diabetes are limited. Broad public health programs help, but effective, targeted interventions and expanded surveillance and research and better policies are needed to address the rapidly growing diabetes burden among older adults. [ABSTRACT FROM AUTHOR]

OBJECTIVE--To examine the relationship between access to health care and diabetes control. RESEARCH DESIGN AND METHODS--Using data from the National Health and Nutrition Examination Survey, 1999--2008, we identified 1,221 U.S. adults (age 18--64 years) with self-reported diabetes. Access was measured by current health insurance coverage, number of times health care was received over the past year, and routine place to go for health care. Diabetes control measures included the proportion of people with A1C >9%, blood pressure ≥140/90 mmHg, and non-HDL cholesterol ≥130 mg/dL. RESULTS--An estimated 16.0% of known diabetic adults were uninsured. Diabetes control profiles were worse among uninsured than among insured persons (A1C >9% [34.1 vs. 16.5%, P = 0.002], blood pressure ≥140/90 mmHg [31.8 vs. 22.8%, P < 0.05], and non-HDL cholesterol ≥130 mg/dL [67.1 vs. 65.4%, P = 0.7]). Compared with insured persons, uninsured persons were more likely to have A1C >9% (multivariate-adjusted odds ratio 2.4 [95% CI 1.2--4.7]). Compared with those who reported four or more health care visits in the past year, those who reported no health care visits were more likely to have A1C.9%(5.5 [1.2--26.3]) and blood pressure ≥140/90 mmHg (1.9 [1.1--3.4]). CONCLUSIONS--In people with diabetes, lack of health care coverage is associated with poor glycemic control. In addition, low use of health care service is associated with poor glucose and blood pressure control. [ABSTRACT FROM AUTHOR]

Purpose: To examine whether socioeconomic status, as measured by educational attainment and annual household income, is associated with lifetime risk for workplace eye injury in a large US population. Methods: In analyses of data from the Behavioral Risk Factor Surveillance System (2005-2007, N == 43,510), we used logistic regression analysis and propensity score matching to assess associations between socioeconomic measures and lifetime risk for workplace eye injury among those aged ≥50 years. Results: The lifetime prevalence of self-reported workplace eye injury was significantly higher among men (13.5%) than women (2.6%) ( P < 0.001). After adjusting for age, race/ethnicity, eye care insurance, health status, and risk-taking behaviors, men with less than high school education (adjusted odds ratio [OR] == 2.24, 95% CI: 1.74-2.87) or high school education (adjusted OR == 1.92, 95% CI: 1.57-2.33) were more likely to report having had a lifetime workplace eye injury than those with more than a high school education. Men with an annual household income <$$15,000 were also more likely to report having had a lifetime workplace eye injury than those whose income was >$$50,000 (adjusted OR == 1.44, 95% CI: 1.07-1.95). After adjusting for other factors, no statistically significant associations between education, income, and lifetime workplace eye injury were found among women. Conclusions: Socioeconomic status was associated with lifetime risk for workplace eye injury among men but not women. Greater public awareness of individual and societal impacts of workplace eye injuries, especially among socioeconomically disadvantaged men, could help support efforts to develop a coordinated prevention strategy to minimize avoidable workplace eye injuries. [ABSTRACT FROM AUTHOR]

OBJECTIVE--To assess the cardiovascular risk profile of youths across socioeconomic groups in the U.S. RESEARCH DESIGN AND METHODS--Analysis of 1999-2008 National Health and Nutrition Examination Surveys (NHANES) including 16,085 nonpregnant 6- to 24-year-olds to estimate race/ethnicity-adjusted prevalence of obesity, central obesity, sedentary behaviors, tobacco exposure, elevated systolic blood pressure, glycated hemoglobin, non-HDL cholesterol (non-HDL-C), and high-sensitivity C-reactive protein according to age-group, sex, and poverty-income ratio (PIR) tertiles. RESULTS--Among boys aged 6-11 years, 19.9% in the lowest PIR tertile were obese and 30.0% were centrally obese compared with 13.2 and 21.6%, respectively, in the highest-income tertile households (Pobesity < 0.05 and Pcentral obesity < 0.01). Boys aged 12-17 years in lowest-income households were more likely than their wealthiest family peers to be obese (20.6 vs. 15.6%, P < 0.05), sedentary (14.8 vs. 9.3%, P < 0.05), and exposed to tobacco (19.0 vs. 6.5%, P < 0.01). Compared with girls aged 12-17 years in highest-income households, lowest-income household girls had higher prevalence of obesity (17.9 vs. 13.1%, P < 0.05), central obesity (41.5 vs. 29.2%, P < 0.01), sedentary behaviors (20.4 vs. 9.4%, P < 0.01), and tobacco exposure (14.1 vs. 5.9%, P < 0.01). Apart from higher prevalence of elevated non-HDL-C among low-income women aged 18-24 ),ears (23.4 vs. 15.8%, P < 0.05), no other cardiovascular disease risk factor prevalence differences were observed between lowest- and highest-income background young adults. CONCLUSIONS--independent of race/ethnicity, 6- to 17-year-olds from low-income families have higher prevalence of obesity, central obesity, sedentary behavior, and tobacco exposure. Multifaceted cardiovascular health promotion policies are needed to reduce health disparities between income groups. [ABSTRACT FROM AUTHOR]

The article discusses the prevalence and incidence of diabetes in the U.S. from 2004-2008. Topics include analysis of data from the 2004 and 2008 National Health Interview Survey (NHIS) to determine disparities in medically diagnosed diabetes, prevalence and incidence of diabetes among different demographic groups including whites, Asians, and Hispanics, and correlation between sociodemographic factors and prevalence and incidence of diabetes.

The article discusses the association of education and income with health disparities in the U.S. from 2005 and 2009. Topics include the prevalence of poverty and noncompletion of high school as examined by the U.S. Centers for Disease Control and Prevention (CDC) from the Integrated Public Use Microdata Series - Current Population Survey (IPUMS-CPS) data, the change in disparity during the period, and consistency of disparities with sociodemographic differences.

Objective. To examine the relationship between access to health care and undiagnosed diabetes among the high-risk, vulnerable population in the border region between the United States of America and Mexico. Methods. Using survey and fasting plasma glucose data from Phase I of the U.S.-Mexico Border Diabetes Prevention and Control Project (February 2001 to October 2002), this epidemiological study identified 178 adults 18-64 years old with undiagnosed diabetes, 326 with diagnosed diabetes, and 2 966 without diabetes. Access to health care among that sample (n = 3 470), was assessed by type of health insurance coverage (including "none"), number of health care visits over the past year, routine pattern of health care utilization, and country of residence. Results. People with diabetes who had no insurance and no place to go for routine health care were more likely to be undiagnosed than those with insurance and a place for routine health care (odds ratio [OR] 2.6, 95% confidence interval [CI] 1.0-6.6, and OR 4.5, 95% CI 1.4-14.1, respectively). When stratified by country, the survey data showed that on the U.S. side of the border there were more people with undiagnosed diabetes if they were 1) uninsured versus the insured (28.9%, 95% CI 11.5%-46.3%, versus 9.1%, 95% CI 1.5%-16.7%, respectively) and if they 2) had made no visits or 1-3 visits to a health care facility in the past year versus had made ? 4 visits (40.8%, 95% CI 19.6%-62.0%, and 23.4%, 95% CI 9.9%-36.9%, respectively, versus 2.4%, 95% CI-0.9%-5.7%) (all, P < 0.05). No similar pattern was found in Mexico. Conclusions. Limited access to health care--especially not having health insurance and/or not having a place to receive routine health services--was significantly associated with undiagnosed diabetes in the U.S.-Mexico border region. [ABSTRACT FROM AUTHOR]

OBJECTIVE -- Iron deficiency has been reported to elevate A1C levels apart from glycemia. We examined the influence of iron deficiency on A1C distribution among adults without diabetes. RESEARCH DESIGN AND METHODS-- Participants included adults without self-reported diabetes or chronic kidney disease in the National Health and Nutrition Examination Survey 1999-2006 who were aged ≥18 years of age and had complete blood counts, iron studies, and A1C levels. Iron deficiency was defined as at least two abnormalities including free erythrocyte protoporphyrin >70 µg/dl erythrocytes, transferrin saturation <16%, or serum ferritin ≤15 µg/l. Anemia was defined as hemoglobin <13.5 g/dl in men and <12.0 g/dl in women. RESULTS-- Among women (n = 6,666), 13.7% had iron deficiency and 4.0% had iron deficiency anemia. Whereas 316 women with iron deficiency had A 1C > 5.5 %, only 32 women with iron deficiency had A1C ≥6.5%. Among men (n = 3,869), only 13 had iron deficiency and A1C >5.5%, and only 1 had iron deficiency and A1C ≥6.5%. Among women, iron deficiency was associated with a greater odds of A1C >5.5% (odds ratio 1.39 [95% CI 1.11-1.73]) after adjustment for age, race/ethnicity, and waist circumference but not with a greater odds of A1C ≥6.5% (0.79 [0.33-1.85]). CONCLUSIONS -- Iron deficiency is common among women and is associated with shifts in A1C distribution from <5.5 to ≥5.5%. Further research is needed to examine whether iron deficiency is associated with shifts at higher A1C levels. [ABSTRACT FROM AUTHOR]

Low socioeconomic position (SEP) across the lifecourse is associated with Type 2 diabetes (T2DM). We examined whether these economic disparities differ by race and sex. We included 5448 African American (AA) and white participants aged ≥45 years from the national (United States) REasons for Geographic and Racial Differences in Stroke (REGARDS) cohort without T2DM at baseline (2003-07). Incident T2DM was defined by fasting glucose ≥126 mg/dL, random glucose ≥200 mg/dL, or using T2DM medications at follow-up (2013-16). Derived SEP scores in childhood (CSEP) and adulthood (ASEP) were used to calculate a cumulative (CumSEP) score. Social mobility was defined as change in SEP. We fitted race-stratified logistic regression models to estimate the association between each lifecourse SEP indicator and T2DM, adjusting for covariates; additionally, we tested SEP-sex interactions. Over a median of 9.0 (range 7-14) years of follow-up, T2DM incidence was 167.1 per 1000 persons among AA and 89.9 per 1000 persons among white participants. Low CSEP was associated with T2DM incidence among AA (OR = 1.61; 95%CI 1.05-2.46) but not white (1.06; 0.74-2.33) participants; this was attenuated after adjustment for ASEP. In contrast, low CumSEP was associated with T2DM incidence for both racial groups. T2DM risk was similar for stable low SEP and increased for downward mobility when compared with stable high SEP in both groups, whereas upward mobility increased T2DM risk among AAs only. No differences by sex were observed. Among AAs, low CSEP was not independently associated with T2DM, but CSEP may shape later-life experiences and health risks. [ABSTRACT FROM AUTHOR]

OBJECTIVE -- This study examined the association between access to health care and three classifications of diabetes status: diagnosed, undiagnosed, and no diabetes. RESEARCH DESIGN AND METHODS-- Using data from the 1999-2004 National Health and Nutrition Examination Survey, we identified 110 "missed patients" (fasting plasma glucose >125 mg/dl but without diagnoses of diabetes), 704 patients with diagnosed diabetes, and 4,782 people without diabetes among adults aged 18-64 years. The population percentage undetected among adults with diabetes and the odds ratio of being undetected among adults who reported not having diabetes were compared between groups based on their access to health care. RESULTS-- Among those with diabetes, the percentages having undetected diabetes were 42.2% (95% CI 36.7-47.7) among the uninsured, 25.9% (22.9-28.9) among the insured, 49.3% (43.0-55.6) for those uninsured >1 year, 38.7% (29.2-48.2) for those uninsured ≤1 year, and 24.5% (21.7-27.3) for those continuously insured over the past year. Type of insurance, number of times receiving health care in the past year, and routine patterns of health care utilization were also associated with undetected diabetes. Multivariate adjustment indicated that having undetected diabetes was associated with being uninsured (odds ratio 1.7 [95% CI 1.0-2.9]) and with being uninsured >1 year (2.6 [1.4-5.0]). CONCLUSIONS-- Limited access to health care, especially being uninsured and going without insurance for a long period, was significantly associated with being a "missed patient" with diabetes. Efforts to increase detection of diabetes may need to address issues of access to care. [ABSTRACT FROM AUTHOR]

Objectives. We examined the role of family history of diabetes in awareness of diabetes risk factors and engaging in health behaviors. Methods. We conducted a cross-sectional analysis of 1122 African American adults without diabetes who were participants in Project DIRECT (Diabetes Interventions Reaching and Educating Communities Together). Results. After adjustment for age, gender, income, education, body mass index, and perceived health status, African Americans with a family history of diabetes were more aware than those without such a history of several diabetes risk factors: having a family member with the disease (relative risk [RR]=1.09; 95% confidence interval [CI]=1.03, 1.15), being overweight (RR=1.12; 95% CI=1.05, 1.18), not exercising (RR=1.17; 95% CI=1.07, 1.27), and consuming energy-dense foods (RR=1.10; 95% CI=1.00, 1.17). Also, they were more likely to consume 5 or more servings of fruits and vegetables per day (RR=1.31; 95% CI=1.02, 1.66) and to have been screened for diabetes (RR=1.21; 95% CI=1.12, 1.29). Conclusions. African Americans with a family history of diabetes were more aware of diabetes risk factors and more likely to engage in certain health behaviors than were African Americans without a family history of the disease. [ABSTRACT FROM AUTHOR]

The article examines 31-year trends in cardiovascular disease risk factors by annual income and educational levels among adults in the United States. It shows that not all segments of society are benefiting equally despite the general success in reducing cardiovascular disease risk factors in the U.S. population. The article also shows that education- and income-related disparities have worsened for smoking.

Background: Improving diabetes care in the United States is a topic of concern.Objective: To document the quality of diabetes care during 1988-1995.Design: National population-based cross-sectional surveys.Setting: Third U.S. National Health and Nutrition Examination Survey (NHANES III) (1988-1994) and the Behavioral Risk Factors Surveillance System (BRFSS) (1995).Participants: Participants in NHANES III (n = 1026) or BRFSS (n = 3059) who were 18 to 75 years of age and reported a physician diagnosis of diabetes. Women with gestational diabetes were excluded.Measurements: Glycemic control, blood pressure, low-density lipoprotein (LDL) cholesterol level, biannual cholesterol monitoring, and annual foot and dilated eye examination, as defined by the Diabetes Quality Improvement Project.Results: 18.0% of participants (95% CI, 15.7% to 22.3%) had poor glycemic control (hemoglobin A(1c) level > 9.5%), and 65.7% (CI, 62.0% to 69.4%) had blood pressure less than 140/90 mm Hg. Cholesterol was monitored biannually in 85.3% (CI, 83.1% to 88.6%) of participants, but only 42.0% (CI, 34.9% to 49.1%) had LDL cholesterol levels less than 3.4 mmol/L (<130 mg/dL). During the previous year, 63.3% (CI, 59.6% to 67.0%) had a dilated eye examination and 54.8% (CI, 51.3% to 58.3%) had a foot examination. When researchers controlled for age, sex, ethnicity, education, health insurance, insulin use, and duration of diabetes, insured persons were more likely than uninsured persons to have a dilated eye examination (66.5% [CI, 62.6% to 70.4%]) vs. 43.2% [CI, 29.5% to 56.9%]) and were less likely to have a hemoglobin A(1c)level greater than or equal to 9.5%. Persons taking insulin were more likely than those who were not to have annual dilated eye examination (72.2% [CI, 66.3% to 78.1%] vs. 57.6% [CI, 53.7% to 61.5%]) and foot examination (67.3% [CI, 61.4% to 73.2%] vs. 47.1% [CI, 43.2% to 51.0%]) but were also more likely to have poor glycemic control (24.2% [CI, 18.3% to 30.1%] vs. 15.5% [CI, 11.6% to 19.4%]).Conclusions: According to U.S. data collected during 1988-1995, a gap exists between recommended diabetes care and the care patients actually receive. These data offer a benchmark for monitoring changes in diabetes care. [ABSTRACT FROM AUTHOR]

OBJECTIVE -- We compared inflammatory markers among women with a history of gestational diabetes mellitus (hGDM), women with diagnosed diabetes, and unaffected women in a population-based sample. RESEARCH DESIGN AND METHODS -- We conducted cross-sectional analyses of 6,346 nonpregnant women in the Third National Health and Nutrition Examination Survey (1988-1994). Women were classified as having hGDM (n = 87), diagnosed diabetes (n = 244), or neither condition (n = 6,015). Inflammatory markers included ferritin, leukocyte count, and C-reactive protein levels. RESULTS -- After adjustment, women with diagnosed diabetes had the most marked differences in inflammatory markers compared with unaffected women. Differences between unaffected women and women with hGDM were minimal. CONCLUSIONS -- Women with diagnosed diabetes have less favorable inflammation profiles than unaffected women and greater ferritin levels than women with hGDM. After adjustment, women with hGDM who have not developed diagnosed diabetes have inflammation profiles similar to those of unaffected women. [ABSTRACT FROM AUTHOR]

Diabetic retinopathy is found commonly among African Americans in the U.S. However, very few studies have examined the prevalence of diabetic retinopathy and use of preventive eye care services among African American communities. Project DIRECT (Diabetes Intervention Reaching and Educating Communities Together) is the first community project to attempt a comprehensive approach reducing the burden of diabetes in African American communities. We analyzed data from participants with self-reported diabetes (n=1,366; 646 in 1996-1997 and 720 in 2003-2004) in Raleigh (intervention community) and Greensboro (comparison community), North Carolina. All analyses were weighted to adjust for the complex sample design of pre- and post-cross-sectional surveys and to make prevalence estimates representative of the sample population. Estimates were age-standardized by the direct method to the 2000 U.S. Census population. In Raleigh, the age-standardized prevalence of diabetic retinopathy was 41.6% in 1997 and 38.5% in 2004; in Greensboro, the prevalence was 38.5% and 38.1%. The age-standardized proportion of persons who had a dilated eye exam in the preceding 12 months was 63.9% (1997) and 68.4% (2004) in Raleigh and 58.3% (1997) and 62.3% (2004) in Greensboro. Between 1996-97 and 2003-04, the age-standardized proportion of persons who received eye care education about the need for yearly eye exam increased by 0.3 percentage points in Greensboro, but decreased 1.5 percentage points in Raleigh. We found no evidence of difference between the control and intervention populations (p>0.05). After adjusting for age, gender, race, marital status, education, income, and health insurance, eye care education among African Americans with diabetes was independently associated with the use of dilated eye exam (OR: 1.62 in Raleigh; 2.17 in Greensboro). In conclusion, diabetic retinopathy continues to be a considerable problem among African American communities. Community intervention efforts such as comprehensive eye care education may be needed to specifically target improvement in diabetic retinopathy and use of eye care services. [ABSTRACT FROM AUTHOR]

Diabetes is a serious public health problem in the border region between the United States of America and Mexico, reflecting and by some measures surpassing the extent of national diabetes burden of each country. The U.S.-Mexico Border Diabetes Prevention and Control Project, a two-phase prevalence study on type 2 diabetes and its risk factors, was conceived and developed by culturally diverse groups of people representing more than 100 government agencies and nongovernmental organizations; health care providers; and residents of 10 U.S. and Mexican border states, using a participatory approach, to address this disproportionate incidence of diabetes. This report describes the project's history, conceptualization, participatory approach, implementation, accomplishments, and challenges, and recommends a series of steps for carrying out other binational participatory projects based on lessons learned. [ABSTRACT FROM AUTHOR]

Objective: To assess county-level socioeconomic disparities in medical service usage for infections among Medicare beneficiaries with diabetes (MBWDs) who had fee-for-service health insurance claims during 2012., Design: We used Medicare claims data to calculate percentage of MBWDs with infections., Setting: Medicare beneficiaries., Participants: We estimated the percentage of MBWDs who used medical services for each of 3 groups of infections by sex and quintiles of the prevalence of social factors in the person's county of residence: anatomic site-specific infections; pathogen-specific infections; and HHST infections (human immunodeficiency virus/acquired immunodeficiency syndrome, viral hepatitis, sexually transmitted diseases, and tuberculosis)., Main Outcome Measures: Using quintiles of county-specific socioeconomic determinants, we calculated absolute and relative disparities in each group of infections for male and female MBWDs. We also used regression-based summary measures to estimate the overall average absolute and relative disparities for each infection group., Results: Of the 4.5 million male MBWDs, 15.8%, 25.3%, and 2.7% had 1 or more site-specific, pathogen-specific, and HHST infections, respectively. Results were similar for females (n = 5.2 million). The percentage of MBWDs with 1 or more infections in each group increased as social disadvantage in the MBWDs' county of residence increased. Absolute and relative county-level socioeconomic disparities in receipt of medical services for 1 or more infections (site- or pathogen-specific) were 12.9 or less percentage points and 65.5% or less, respectively. For HHST infections, percentage of MBWDs having 1 or more HHST infections for persons residing in the highest quintile (Q5) was 3- to 4-fold higher (P < .001) than persons residing in the lowest quintile (Q1)., Conclusions: Infection burden among MBWDs is generally associated with county-level contextual socioeconomic disadvantage, and the extent of health disparities varies by infection category, socioeconomic factor, and quintiles of socioeconomic disadvantage. The findings imply ongoing need for efforts to identify effective interventions for reducing county-level social disparities in infections among patients with diabetes.

Purpose: Given the importance of family history in the early detection and prevention of type 2 diabetes, we quantified the public health impact of reported family health history on diagnosed diabetes (DD), undiagnosed diabetes (UD), and prediabetes (PD) in the United States., Methods: We used population data from the National Health and Nutrition Examination Survey 2009-2014 to measure the association of reported family history of diabetes with DD, UD, and PD., Results: Using polytomous logistic regression and multivariable adjustment, family history prevalence ratios were 4.27 (confidence interval (CI): 3.57, 5.12) for DD, 2.03 (CI: 1.56, 2.63) for UD, and 1.26 (CI: 1.09, 1.44) for PD. In the United States, we estimate that 10.1 million DD cases, 1.4 million UD cases, and 3.9 million PD cases can be attributed to having a family history of diabetes., Conclusion: These findings confirm that family history of diabetes has a major public health impact on diabetes in the United States. In spite of the recent interest and focus on genomics and precision medicine, family health history continues to be an integral component of public health campaigns to identify persons at high risk for developing type 2 diabetes and early detection of diabetes to prevent or delay complications.

Purpose: Health and administrative systems are facing spatial clustering in chronic diseases such as diabetes. This study explores how geographic distribution of diabetes in the United States is associated with socioeconomic and built environment characteristics and health-relevant policies., Methods: We compiled nationally representative county-level data from multiple data sources. We standardized characteristics to a mean = 0 and a SD = 1 and modeled county-level age-adjusted diagnosed diabetes incidence in 2013 using 2-level hierarchical linear regression., Results: Incidence of age-standardized diagnosed diabetes in 2013 varied across U.S. counties (n = 3109), ranging from 310 to 2190 new cases/100,000, with an average of 856.4/100,000. Socioeconomic and health-related characteristics explained ∼42% of the variation in diabetes incidence across counties. After accounting for other characteristics, counties with higher unemployment, higher poverty, and longer commutes had higher incidence rates than counties with lower levels. Counties with more exercise opportunities, access to healthy food, and primary care physicians had fewer diabetes cases., Conclusions: Features of the socioeconomic and built environment were associated with diabetes incidence; identifying the salient modifiable features of counties can inform targeted policies to reduce diabetes incidence., (Copyright © 2017 Elsevier Inc. All rights reserved.)

The prevalence of diabetes mellitus has increased rapidly in the United States since the mid-1990s. By 2014, an estimated 29.1 million persons, or 9.3% of the total population, had received a diagnosis of diabetes (1). Recent evidence indicates that the prevalence of diagnosed diabetes among non-Hispanic black (black), Hispanic, and poorly educated adults continues to increase but has leveled off among non-Hispanic whites (whites) and persons with higher education (2). During 2004-2010, CDC reported marked racial/ethnic and socioeconomic position disparities in diabetes prevalence and increases in the magnitude of these disparities over time (3). However, the magnitude and extent of temporal change in socioeconomic position disparities in diagnosed diabetes among racial/ethnic populations are unknown. CDC used data from the National Health Interview Survey (NHIS) for the periods 1999-2002 and 2011-2014 to assess the magnitude of and change in socioeconomic position disparities in the age-standardized prevalence of diagnosed diabetes in the overall population and among blacks, whites, and Hispanics. During each period, significant socioeconomic position disparities existed in the overall population and among the assessed racial/ethnic populations. Disparities in prevalence increased with increasing socioeconomic disadvantage and widened over time among Hispanics and whites but not among blacks. The persistent widening of the socioeconomic position gap in prevalence suggests that interventions to reduce the risk for diabetes might have a different impact according to socioeconomic position.

Importance: Individual-level characteristics are associated with eye care use. The influence of contextual factors on vision and eye health, as well as health behavior, is unknown., Objective: To examine the association between county-level characteristics and eye care use after accounting for individual-level characteristics using a conceptual framework., Design, Setting, and Participants: This investigation was a cross-sectional study of respondents 40 years and older participating in the Behavioral Risk Factor Surveillance System surveys between 2006 and 2010 from 22 states that used the Visual Impairment and Access to Eye Care module. Multilevel regressions were used to examine the association between county-level characteristics and eye care use after adjusting for individual-level characteristics (age, sex, race/ethnicity, educational attainment, annual household income, employment status, health care insurance coverage, eye care insurance coverage, personal established physician, poor vision or eye health, and diabetes status). Data analysis was performed from March 23, 2014, to June 7, 2016., Main Outcomes and Measures: Eye care visit and receipt of a dilated eye examination in the past year., Results: Among 117 295 respondents who resided in 828 counties, individual-level data were obtained from the Behavioral Risk Factor Surveillance System surveys. All county-level variables were aggregated at the county level from the Behavioral Risk Factor Surveillance System surveys except for a high geographic density of eye care professionals, which was obtained from the 2010 Area Health Resource File. After controlling for individual-level characteristics, the odds of reporting an eye care visit in the past year were significantly higher among people living in counties with high percentages of black individuals (adjusted odds ratio [aOR], 1.12; 95% CI, 1.01-1.24; P = .04) or low-income households (aOR, 1.12; 95% CI, 1.00-1.25; P = .045) or with a high density of eye care professionals (aOR, 1.18; 95% CI, 1.07-1.29; P < .001) than among those living in counties with the lowest tertile of each county-level characteristic. The odds of reporting receipt of a dilated eye examination in the past year were also higher among people living in counties with the highest percentages of black individuals (aOR, 1.20; 95% CI, 1.07-1.34; P = .002) or low-income households (aOR, 1.17; 95% CI, 1.04-1.32; P = .01). However, the odds of reported receipt of a dilated eye examination in the past year were lower in counties with the highest percentages of people with poor vision and eye health compared with counties with lower percentages (aOR, 0.85; 95% CI, 0.77-0.94; P = .002)., Conclusions and Relevance: Contextual factors, measured at the county level, were associated with eye care use independent of individual-level characteristics. The findings suggest that, while individual characteristics influence health care use, it is also important to address contextual factors to improve eye care use and ultimately vision health.

Objectives: We examined the relationship between socioeconomic position (SEP) and sensory impairment., Methods: We used data from the 2007 to 2010 National Health Interview Surveys (n = 69 845 adults). Multivariable logistic regressions estimated odds ratios (ORs) for associations of educational attainment, occupational class, and poverty-income ratio with impaired vision or hearing., Results: Nearly 20% of respondents reported sensory impairment. Each SEP indicator was negatively associated with sensory impairment. Adjusted odds of vision impairment were significantly higher for farm workers (OR = 1.41; 95% confidence interval [CI] = 1.01, 2.02), people with some college (OR = 1.29; 95% CI = 1.16, 1.44) or less than a high school diploma (OR = 1.36; 95% CI = 1.19, 1.55), and people from poor (OR = 1.35; 95% CI = 1.20, 1.52), low-income (OR = 1.28; 95% CI = 1.14, 1.43), or middle-income (OR = 1.19; 95% CI = 1.07, 1.31) families than for the highest-SEP group. Odds of hearing impairment were significantly higher for people with some college or less education than for those with a college degree or more; for service groups, farmers, and blue-collar workers than for white-collar workers; and for people in poor families., Conclusions: More research is needed to understand the SEP-sensory impairment association.

Background: Sex-specific prediabetes estimates are not available for older-adult Americans., Purpose: To estimate prediabetes prevalence, using nationally representative data, in civilian, non-institutionalized, older U.S. adults., Methods: Data from 7,995 participants aged ≥50 years from the 1999-2010 National Health and Nutrition Examination Surveys were analyzed in 2013. Prediabetes was defined as hemoglobin A1c=5.7%-6.4% (39-47 mmol/mol [HbA1c5.7]), fasting plasma glucose of 100-125 mg/dL (impaired fasting glucose [IFG]), or both. Crude and age-adjusted prevalences for prediabetes, HbA1c5.7, and IFG by sex and three age groups were calculated, with additional adjustment for sex, age, race/ethnicity, poverty status, education, living alone, and BMI., Results: From 1999 to 2005 and 2006 to 2010, prediabetes increased for adults aged 50-64 years (38.5% [95% CI=35.3, 41.8] to 45.9% [42.3, 49.5], p=0.003) and 65-74 years (41.3% [37.2, 45.5] to 47.9% [44.5, 51.3]; p=0.016), but not significantly for adults aged ≥75 years (45.1% [95% CI=41.1, 49.1] to 48.9% [95% CI=45.2, 52.6]; p>0.05). Prediabetes increased significantly for women in the two youngest age groups, and HbA1c5.7 for both sexes (except men aged ≥75 years), but IFG remained stable for both sexes. Men had higher prevalences than women for prediabetes and IFG among adults aged 50-64 years, and for IFG among adults aged ≥75 years. Across demographic subgroups, adjusted prevalence gains for both sexes were similar and most pronounced for HbA1c5.7, virtually absent for IFG, but greater for women than men for prediabetes., Conclusions: Given the large, growing prediabetes prevalence and its anticipated burden, older adults, especially women, are likely intervention targets., (Published by Elsevier Inc.)

The factors that influence the socioeconomic position of individuals and groups within industrial societies also influence their health. Socioeconomic position has continuous and graded effects on health that are cumulative over a lifetime. The socioeconomic conditions of the places where persons live and work have an even more substantial influence on health than personal socioeconomic position. In the United States, educational attainment and income are the indicators that are most commonly used to measure the effect of socioeconomic position on health. Research indicates that substantial educational and income disparities exist across many measures of health. A previous report described the magnitude and patterns of absolute and relative measures of disparity in noncompletion of high school and poverty in 2005 and 2009. Notable disparities defined by race/ethnicity, socioeconomic factors, disability status, and geographic location were identified for 2005 and 2009, with no evidence of a temporal decrease in racial/ethnic disparities, whereas socioeconomic and disability disparities increased from 2005 to 2009.

In 2011, an estimated 26 million persons aged ≥20 years (11.3% of the U.S. population) had diabetes. Both the prevalence and incidence of diabetes have increased rapidly since the mid-1990s, with minority racial/ethnic groups and socioeconomically disadvantaged groups experiencing the steepest increases and most substantial effects from the disease.

Objective: To examine the relationship between access to health care and diabetes control., Research Design and Methods: Using data from the National Health and Nutrition Examination Survey, 1999-2008, we identified 1,221 U.S. adults (age 18-64 years) with self-reported diabetes. Access was measured by current health insurance coverage, number of times health care was received over the past year, and routine place to go for health care. Diabetes control measures included the proportion of people with A1C >9%, blood pressure ≥140/90 mmHg, and non-HDL cholesterol ≥130 mg/dL., Results: An estimated 16.0% of known diabetic adults were uninsured. Diabetes control profiles were worse among uninsured than among insured persons (A1C >9% [34.1 vs. 16.5%, P = 0.002], blood pressure ≥140/90 mmHg [31.8 vs. 22.8%, P < 0.05], and non-HDL cholesterol ≥130 mg/dL [67.1 vs. 65.4%, P = 0.7]). Compared with insured persons, uninsured persons were more likely to have A1C >9% (multivariate-adjusted odds ratio 2.4 [95% CI 1.2-4.7]). Compared with those who reported four or more health care visits in the past year, those who reported no health care visits were more likely to have A1C >9% (5.5 [1.2-26.3]) and blood pressure ≥140/90 mmHg (1.9 [1.1-3.4])., Conclusions: In people with diabetes, lack of health care coverage is associated with poor glycemic control. In addition, low use of health care service is associated with poor glucose and blood pressure control.

Diabetes is a common and costly disease. In 2007, an estimated 24 million people in the United States had diabetes, with almost half of these being women. Diabetes increases the risk of morbidity and mortality from several conditions, including cardiovascular disease, several types of cancers, influenza and pneumococcal infection, and kidney, eye, and periodontal diseases. The aim of this study was to examine the quality of care that women with diabetes receive and to assess how receipt of some clinical preventive services and screening for common conditions associated with diabetes vary according to socioeconomic factors. Our findings indicate that use of diabetes-specific preventive care among women is low, with the youngest women (< or =45 years) and those with low educational levels being the least likely to receive the recommended services. Women with diabetes were less likely than women without diabetes to receive a Pap smear, with the oldest women (> or =65 years) being the most vulnerable. Women with diabetes who were poor and nonwhite were less likely than more affluent and white women to receive a pneumococcal vaccination. This study's findings suggest that having a chronic disease may serve as a barrier to the receipt of recommended preventive care among women. Effective interventions should be designed to meet the needs of the most vulnerable women with diabetes, in particular, those who are at the extremes of the life cycle, are poor, and have low levels of education. Programs should use a life stage approach to address the unique needs of women with diabetes.

Objective: Recent data suggest that residential environment may influence health behaviors and outcomes. We assessed whether perception of neighborhood problems was associated with diabetes behaviors and outcomes., Research Design and Methods: This cross-sectional analysis included 7,830 diabetic adults enrolled in Translating Research Into Action for Diabetes, a study of diabetes care and outcomes in managed care settings. Perception of neighborhood problems was measured using a summary score of participants' ratings of crime, trash, litter, lighting at night, and access to exercise facilities, transportation, and supermarkets. Outcomes included health behaviors and clinical outcomes. Hierarchical regression models were used to account for clustering of patients within neighborhoods and to adjust for objective neighborhood socioeconomic status (percentage living in poverty) and potential individual-level confounders (age, sex, race/ethnicity, education, income, comorbidity index, and duration of diabetes)., Results: After adjustment, residents of neighborhoods in the lowest tertile (most perceived problems) reported higher rates of current smoking (15 vs. 11%) than those in the highest tertile and had slightly lower participation in any weekly physical activity (95 vs. 96%). In addition, their blood pressure control was worse (25 vs. 31% <130/80 mmHg), and their Short Form 12 scores were slightly lower (44 vs. 46 units for emotional well-being and 43 vs. 44 units for physical well-being); all P < 0.01., Conclusions: Neighborhood problems were most strongly associated with more smoking and higher blood pressure, both of which have significant implications for cardiovascular risk. Potential mechanisms that explain these associations should be further explored in longitudinal studies.

Objectives: We assessed educational disparities in smoking rates among adults with diabetes in managed care settings., Methods: We used a cross-sectional, survey-based (2002-2003) observational study among 6538 diabetic patients older than 25 years across multiple managed care health plans and states. For smoking at each level of self-reported educational attainment, predicted probabilities were estimated by means of hierarchical logistic regression models with random intercepts for health plan, adjusted for potential confounders., Results: Overall, 15% the participants reported current smoking. An educational gradient in smoking was observed that varied significantly (P<.003) across age groups, with the educational gradient being strong in those aged 25 to 44 years, modest in those aged 45 to 64 years, and nonexistent in those aged 65 years or older. Of particular note, the prevalence of smoking observed in adults aged 25-44 years with less than a high school education was 50% (95% confidence interval: 36% to 63%)., Conclusions: Approximately half of poorly educated young adults with diabetes smoke, magnifying the health risk associated with early-onset diabetes. Targeted public health interventions for smoking prevention and cessation among young, poorly educated people with diabetes are needed.

Background: Our understanding of social disparities in diabetes-related health behaviors is incomplete. The purpose of this study was to determine if having less education is associated with poorer diabetes-related health behaviors., Methods: This observational study was based on a cohort of 8,763 survey respondents drawn from ~180,000 patients with diabetes receiving care from 68 provider groups in ten managed care health plans across the United States. Self-reported survey data included individual educational attainment ("education") and five diabetes self-care behaviors among individuals for whom the behavior would clearly be indicated: foot exams (among those with symptoms of peripheral neuropathy or a history of foot ulcers); self-monitoring of blood glucose (SMBG; among insulin users only); smoking; exercise; and certain diabetes-related health seeking behaviors (use of diabetes health education, website, or support group in last 12 months). Predicted probabilities were modeled at each level of self-reported educational attainment using hierarchical logistic regression models with random effects for clustering within health plans., Results: Patients with less education had significantly lower predicted probabilities of being a non-smoker and engaging in regular exercise and health-seeking behaviors, while SMBG and foot self-examination did not vary by education. Extensive adjustment for patient factors revealed no discernable confounding effect on the estimates or their significance, and most education-behavior relationships were similar across sex, race and other patient characteristics. The relationship between education and smoking varied significantly across age, with a strong inverse relationship in those aged 25-44, modest for those ages 45-64, but non-evident for those over 65. Intensity of disease management by the health plan and provider communication did not alter the examined education-behavior relationships. Other measures of socioeconomic position yielded similar findings., Conclusion: The relationship between educational attainment and health behaviors was modest in strength for most behaviors. Over the life course, the cumulative effect of reduced practice of multiple self-care behaviors among less educated patients may play an important part in shaping the social health gradient.

Background: Despite consensus about the importance of measuring quality of diabetes care and the widespread use of self-reports and medical records to assess quality, little is known about the degree of agreement between these data sources., Objectives: To evaluate agreement between self-reported and medical record data on annual eye examinations and to identify factors associated with agreement., Research Design and Subjects: Data from interviews and medical records were available for 8409 adults with diabetes who participated in the baseline round of the Translating Research Into Action for Diabetes (TRIAD) Study., Measures: Agreement between self-reports and medical records was evaluated as concordance and Cohen's kappa coefficient., Results: Self-reports indicated a higher performance of annual dilated eye examinations than did medical records (75.9% vs. 38.8%). Concordance between the data sources was 57.9%. Agreement was only fair (kappa coefficient = 0.25; 95% confidence interval, 0.23-0.26). Nearly two-thirds (64.6%) of discordance was due to lack of evidence in the medical record to support self-reported performance of the procedure. After adjustment, agreement was most strongly related to health plan (chi = 977.9, df = 9; P < 0.0001), and remained significantly better for 3 of the 10 health plans (P < 0.00001) and for persons younger than 45 years of age (P = 0.00002)., Conclusions: The low level of agreement between self-report and medical records suggests that many providers of diabetes care do not have easily available accurate information on the eye examination status of their patients.

Objective: To examine racial/ethnic and socioeconomic variation in diabetes care in managed-care settings., Research Design and Methods: We studied 7,456 adults enrolled in health plans participating in the Translating Research Into Action for Diabetes study, a six-center cohort study of diabetes in managed care. Cross-sectional analyses using hierarchical regression models assessed processes of care (HbA(1c) [A1C], lipid, and proteinuria assessment; foot and dilated eye examinations; use or advice to use aspirin; and influenza vaccination) and intermediate health outcomes (A1C, LDL, and blood pressure control)., Results: Most quality indicators and intermediate outcomes were comparable across race/ethnicity and socioeconomic position (SEP). Latinos and Asians/Pacific Islanders had similar or better processes and intermediate outcomes than whites with the exception of slightly higher A1C levels. Compared with whites, African Americans had lower rates of A1C and LDL measurement and influenza vaccination, higher rates of foot and dilated eye examinations, and the poorest blood pressure and lipid control. The main SEP difference was lower rates of dilated eye examinations among poorer and less educated individuals. In almost all instances, racial/ethnic minorities or low SEP participants with poor glycemic, blood pressure, and lipid control received similar or more appropriate intensification of therapy relative to whites or those with higher SEP., Conclusions: In these managed-care settings, minority race/ethnicity was not consistently associated with worse processes or outcomes, and not all differences favored whites. The only notable SEP disparity was in rates of dilated eye examinations. Social disparities in health may be reduced in managed-care settings.

Objective: To examine racial/ethnic differences in healthcare coverage, utilization, and satisfaction, among US adults with diabetes., Design and Setting: We conducted a cross-sectional analysis among 9443 adults with diabetes who participated in the 1999 Behavioral Risk Factor Surveillance System (BRFSS), a telephone survey of the civilian non-institutionalized US population aged > or = 18 yrs., Main Outcome Measures: We compared healthcare coverage, utilization, and satisfaction across 4 race/ethnicity categories: non-Hispanic Whites (NHW), non-Hispanic Blacks (NHB), Hispanics (HSP), and others, and examined whether these factors were associated with self-rated health status., Results: By self-report, more NHB (14.8%), HSP (20.7%), and members of other races (21.8%) were uninsured, compared to NHW (6.4%). Similarly, cost was a barrier to visiting a doctor for 23.9% of HSP, 19.5% of NHB, and 13.4% of members of other races; however, only 8.2% of non-Hispanic Whites reported cost as a barrier. More NHW (90.1%) and NHB (90.7) reported having had a check-up in the past year, compared to HSP (84.5%) or others (84.1%). All 3 variables exhibited significant differences by race or ethnicity (all P<.01). After adjustment for age, sex, income, education, and insulin use, the association with race/ethnicity persisted for health insurance coverage (P<.001), and for cost as a barrier (P<.003). Reporting cost as a barrier to visiting a doctor (P=.013), and rating one's overall health care as fair or poor (P=.001), were associated with poorer health status., Conclusions: These results suggest that ethnic minorities with diabetes report less healthcare coverage and more cost-related barriers to utilization, compared to non-Hispanic Whites. Persons with fair/poor health status were more likely to report cost barriers and poor satisfaction. Future research should focus on the reasons for such differences and on interventions to improve health care for minority populations.

Objectives: We evaluated whether ethnicity and language are associated with diabetes care for Latinos in managed care., Methods: Using data from 4685 individuals in the Translating Research Into Action for Diabetes (TRIAD) Study, a multicenter study of diabetes care in managed care, we constructed multivariate regression models to compare health behaviors, processes of care, and intermediate outcomes for Whites and English- and Spanish-speaking Latinos., Results: Latinos had lower rates of self-monitoring of blood glucose and worse glycemic control than did Whites, higher rates of foot self-care and dilated-eye examinations, and comparable rates of other processes and intermediate outcomes of care., Conclusions: Although self-management and quality of care are comparable for Latinos and Whites with diabetes, important ethnic disparities persist in the managed care settings studied.