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. Author manuscript; available in PMC: 2012 Dec 12.
Published in final edited form as: J Diabetes Complications. 2012 Apr 18;26(3):181–186. doi: 10.1016/j.jdiacomp.2012.03.010

FACTORS ASSOCIATED WITH POOR GLYCEMIC CONTROL IN OLDER MEXICAN AMERICAN DIABETICS AGED 75 YEARS AND OLDER

Max E Otiniano 1, Soham Al Snih 2,3, James S Goodwin 3, Laura Ray 4, Majd Al Ghatrif 5, Kyriakos S Markides 4
PMCID: PMC3521032  NIHMSID: NIHMS426473  PMID: 22520403

Abstract

Objective

This study examines the prevalence and correlates of poor glycemic control in Mexican Americans aged 75 years and older with diabetes.

Methods

Data are from the 5th wave (2004–05) of the Hispanic Established Population for the Epidemiological Study of the Elderly (H-EPESE). A total of 2,069 Mexican Americans aged 75 and over were interviewed. Six hundred eighty nine subjects (33.5%) reported having been diagnosed with diabetes and 209 (30.3%) subjects agreed to a blood test of their HbA1c level.

Results

Of the 209 diabetic subjects with an HbA1c test, 73 (34.9%) had good glycemic control (HbA1c <7%) and 136 (65.1%) had poor glycemic control (HbA1c >7%). Bivariate analysis revealed that subjects with poor control had longer disease duration, had lower education, used the glucometer more frequently, and had more diabetes-complications when compared to those in the good glycemic control group. Multivariable logistic regression analysis found the following factors associated with poor glycemic control: < 8 years of education, foreign-born, smoking, obesity, longer disease duration, daily glucometer use, and having macro-complications.

Discussion

Prevalence of poor glycemic control is very high in this population with very high and rising prevalence of diabetes. Further studies are needed to explore the effect of these and other characteristics on glycemic control among older Mexican Americans and to develop appropriate interventions to improve diabetes outcomes and increase life-expectancy.

Keywords: glycemic control, Mexican American elders, diabetes

INTRODUCTION

Diabetes is an age related disease with almost 26.9 percent of Americans 65 years and older being affected in 2010, putting older people at a higher risk of diabetes related complications (Centers for Disease Control and Prevention, 2011). With a total estimated cost in 2007 of about $174 billion, diabetes is associated with high cost as well as other disease burdens; further, it was the seven leading cause of death in the United States in 2010 (Centers for Disease Control and Prevention, 2011; 2007).

In addition, diabetes is recognized as a significant threat to the health of the growing Hispanic population in the United States (Harris, 1998). Several epidemiological studies have demonstrated that Hispanics have significantly higher prevalence of Type 2 diabetes than Non-Hispanic Whites (Link & McKinlay, 2009; Cowie et al., 2006; Zhang et al., 2009; Flegal et al., 1991; Lindeman et al., 1998). Hispanics also have worse glycemic control when compared to non-Hispanic whites (Egede et al., 2011; Kirk et al., 2008; Weinstock et al., 2011; Boltri et al., 2005; Suh et al., 2008; Chiu & Wray, 2010; Harris et al., 1999; Wendel et al., 2006).

Hispanics are also more likely to suffer from diabetes-related complications, such as diabetic retinopathy and nephropathy, and to have higher age-adjusted mortality due to diabetes when compared to non-Hispanic Whites (Diehl & Stern, 1989; Hanis et al., 1993; Karter et al., 2002; Lanting et al., 2005; Zhang et al., 2010; Otiniano et al., 2003). This increase in diabetes related morbidity and mortality may be partially explained by higher rates of inadequate glycemic control (Tucker et al., 2000), delays in diagnosis, poor treatment compliance, communication problems between health care providers and patients, and a general lack of knowledge about the disease, its complications, and available treatments (Espino et al., 1993). It is uncertain whether Hispanics face greater challenges in succeeding with behavioral and self management strategies than Non-Hispanic Whites (von Goeler et al., 2003).

A number of studies have addressed factors associated with poor glycemic control in the general population (Kell et al., 1999; Lustman et al., 2000; Nichols et al., 2000; Shorr et al., 2000). Some studies found that older age was not associated with worse glycemic control (Shorr et al., 2000) while others did find it a predictor of good control (Nichols et al., 2000). These reports contradict previous ones that older diabetics are more likely to have worse glycemic control (Kell et al., 1999; Smith et al., 1999). Diabetic subjects receiving insulin or an oral hypoglycemic treatment were found to have worse glycemic control when compared to those without treatment (Smith et al., 1999; Meneilly & Tessier, 2001). Depression has been frequently found to worsen glycemic control (Lustman et al., 2000; Nichols et al., 2000). Some studies have examined these factors among Hispanics (Benoit et al., 2005; Tucker et al., 2000; Meneilly & Tessier, 2001; Lasater et al., 2001). Few studies have addressed glycemic control among older Mexican Americans, a group at a very high risk of diabetes and its complications. Below we examined correlates of poor glycemic control among older Mexican American diabetics aged 75 and older, a group that has experienced a significant increase in the prevalence of diabetes in recent years (Beard et al., 2009).

METHODS

Sample

Data were from the Hispanic Established Populations for Epidemiologic Study of the Elderly (H-EPESE), an ongoing longitudinal study of Mexican Americans aged 65 and over at baseline residing in Texas, New Mexico, Colorado, Arizona and California. Participants in the original sample were selected by area probability sampling procedures that involved selecting counties, census tracts, and households within selected census tracts. Sampling procedures and sample characteristics have been reported previously (Markides et al., 1996; Markides KS et al., 1997). The original H-EPESE sample consisted of 3050 participants who were interviewed in 1993–1994 at baseline and continue to be followed. In 2004–2005, 1167 participants 75 years and older from the original cohort were re-interviewed. A new cohort of 902 respondents aged 75 years and older was added in 2004–2005, using sampling procedures similar to those used in 1993–1994. Both cohorts received identical evaluations at baseline and follow-up (sociodemographics, health conditions, psychosocial characteristics of the subject, blood pressure, anthropometric measures, and physical function measures) (Beard et al., 2009).

In-home interviews were conducted in Spanish (n=1661) or English (n=408) depending on the respondent's preference. The present study used data from the fifth wave. A total of 2,069 Mexican Americans aged 75 years old and over were interviewed. Six-hundred eighty-nine subjects, about 33.5% of sample, reported having been diagnosed with diabetes and 209 subjects, about 30.3% of the diabetics, agreed to perform a finger prick and supply a dry blood sample to test their HbA1c level. The below analysis included participants with self-reported diagnosis of diabetes who also had the HbA1c test (N=209). Characteristics of included and excluded participants are given in Table I. Ninety seven of all participants had insurance coverage.

Table I.

Descriptive characteristics of participants with diabetes with and without HbA1c test (N=690).

Variables N With HbA1c
N=209		 Without HbA1c
N=481
Total 690 209 (30.3) 481 (69.7)
Age, Mean (SD) 690 81.1 (4.1) 81.0 (4.5)
Gender (female) 690 130 (60.8) 312 (63.8)
Education
 < 8 years
 ≥ 8 years
453
170
133 (67.2)
57 (32.8)
320 (70.0)
113 (30.0)
 Language of interview
  English
  Spanish
138
225
54 (28.1)
155 (71.9)
84 (23.9)
397 (76.1)
Marital status
 Married
 Unmarried
304
385
96 (44.7)
113 (55.3)
208 (43.7)
272 (56.3)
Nativity
 US-born
 Foreign-born
401
289
123 (59.9)
86 (40.1)
278 (60.1)
203 (39.9)
 Income
  < 15,000
   15,000 < 30,000
  ≥ 30,000
270
259
79
80 (36.9)
86 (43.2)
30 (19.9)
190 (44.7)
173 (39.8)
49 (15.5)
Current smokes
 Yes
 No
309
381
103 (46.3)
106 (53.7)
206 (45.7)
275 (54.3)
Current drinker
 Yes
 No
361
329
124 (60.4)
85 (39.6)
237 (52.2)
244 (47.8)
Hypertension
 Yes
 No
519
162
156 (76.5)
50 (23.5)
363 (74.1)
112 (25.9)
Heart attack
 Yes
 No
132
553
50 (23.8)
156 (76.2)
82 (19.7)
397 (80.3)
Stroke
 Yes
 No
119
567
45 (21.3)
162 (78.7)
74 (18.1)
405 (81.9)
High depressive symptoms (CES-D ≥ 16)
 Yes
 No
136
502
48 (23.5)
156 (76.5)
88 (21.1)
346 (78.9)
BMI (Kg/m2)
 18.5 – < 25
 25 – 30
 ≥ 30
 Missing or < 18.5
 Mean (SD)
127
212
190
161
533
45 (18.3)
74 (31.3)
55 (32.5)
35 (17.9)
28.8 (4.6)
82 (15.8)
138 (31.5)
135 (21.1)
126 (25.6)
28.8 (5.3)
Hospitalization in the past year
 Yes
 No
218
467
68 (33.3)
140 (66.7)
150 (31.2)
327 (88.8)
Physician visits in the past year
 0 – 1
 ≥ 2
58
622
18 (9.4)
190 (90.6)
40 (10.1)
432 (89.9)
Duration of diabetes (years)
 < 15
 ≥ 15
Mean (SE)
329
361
690
103 (48.8)
106 (51.2)
18.1 (0.8)
226 (47.3)
255 (52.7)
17.7 (0.8)
Use of Glucometer
 > 1 time/day
 All others
290
400
89 (45.8)
120 (54.2)
201 (43.9)
280 (56.1)
Prior HbA1c testing **
 Never
 >1 per year
524
155
142 (62.0)
65 (38.0)
382 (74.3)
90 (25.7)
Current diabetes treatment
 Unknown
 Oral hypoglycemic
 Insulin or/and oral hypoglycemic
87
448
155
22 (11.5)
145 (67.4)
42 (21.0)
65 (16.4)
303 (61.5)
113 (22.1)
Diabetes complications
Mean (SE)		 690 0.9 (0.) 1.0 (0.1)
Kidney
 Yes
 No
89
590
28 (13.4)
179 (86.6)
61 (13.6)
411 (86.4)
Eyes
 Yes
 No
290
400
89 (45.8)
120 (54.2)
201 (43.9)
280 (56.1)
Circulation
 Yes
 No
246
427
80 (40.0)
127 (60.0)
166 (35.4)
300 (64.6)
Amputation
 Yes
 No
266
400
90 (42.0)
114 (57.9)
176 (36.7)
286 (63.3)
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Note: “N” varies due missing data

*

p-value <0.01

**

p-value <0.001

***

p-value <0.0001

Measures

Diabetes

Diabetes was assessed by asking subjects, "Have you ever been told by a doctor that you have diabetes, sugar in your urine or high blood sugar?" Participants who reported a diabetes diagnosis were asked about disease duration (categorized as < 15 years=0, and ≥ 15 years=1) and treatment received (categorized as unknown, oral hypoglycemic, insulin, or oral hypoglycemic/ insulin combination). Participants were asked if as a result of their diabetes, they have ever had any problems with their kidneys or eyes (micro-complications), or circulation or any amputations (macro-complications) (No=0, Yes=1).

Glucometer use and HbA1c test

Information about glucometer use was obtained by asking the subjects about how often the participant or his/her family members check his/her blood glucose. Participants were categorized into those who used a glucometer on a daily basis versus those who did not (No=0, Yes=1). Participants were also asked about the frequency of having HbA1c test performed by a health-care professional and were categorized into those who had a yearly HbA1c versus those who did not (No=0, Yes=1).

Socio-demographics

Included age, gender (male=0, female=1), marital status (married=1, unmarried=0), education (< 8 years=1, ≥ 8 years=0), nativity (U.S born=0, foreign-born=1), language of interview (English=0, Spanish=1), and household income (<15,000=1, 15,000 to < 30,000=2, ≥ 30,000=3).

Smoking and alcohol consumption

Participants were asked if they currently smoke cigarettes now (Yes=1, No=0) and consumption in the past month of any beer, wine or liquor (Yes=1, No=0).

Medical conditions

Medical conditions were assessed with series of questions asking participants if they ever been told by a doctor that they had hypertension, heart attack, or stroke.

Depressive symptomatology

Assessed using the Center for Epidemiologic Studies Depression Scale (CES-D) (Radloff LS, 1977). This scale consists of 20 items that ask how often specific symptoms were experienced during the past week; responses were scored on a 4-point scale (ranging from 0: rarely or none of the time to 3: most or all of the time) with potential total scores ranging 0–60. Alpha reliability with these data was 0.89. As is common in the literature, we consider persons scoring 16 or over to experience high depressive symptomatology (Radloff LS, 1977).

Body Mass Index (BMI)

BMI was computed as weight in kilograms divided by height in meters squared. Participants with BMI ≥ 30 Kg/m2 were considered obese (National Heart & North American Association for the Study of Obesity (NAASO), 2000).

Health Care utilization

Physician utilization was assessed by the following question: “How many times in the past 12 months have you visited with a medical doctor” (0–1 visits=0, ≥ 2 visits=1). Hospital utilization was assessed by the following questions: “Did you experience an illness or injury that required staying overnight or longer in a hospital in the last year” (Yes=1, No=0).

Outcome

Poor glycemic control defined as a HbA1c ≥ 7 % according to the American Diabetes Association for medical care standard (American Diabetes Association, 2004; American Diabetes Association, 2011). Participants who responded positive for the diabetes question were given the option of receiving the HbA1c kit to perform a finger prick test, placing two drops of blood on the test paper. After performing the test, participants were instructed to place the kit in a self-addressed envelope and mail it to Flex Site Diagnostics in Palm City, FL for processing.

Statistical Analysis

Chi-square and t-test statistics were used to examine the association between sociodemographics, smoking and alcohol consumption, medical condition, high depressive symptoms, BMI, and diabetes-related characteristics by HbA1c (<7%=good control, >7%=poor control). Multivariate logistic regression analysis was used to examine the factors (demographics, smoking and alcohol consumption, medical conditions, high depressive symptoms, obesity, health care utilization, disease duration, treatment, and disease complications) associated with poor glycemic control (HbA1c >7%). Language of interview and household income were not included in the multivariate analysis due to the high correlation with education. Also, we repeated the analysis using HbA1c as a continuous variable. Significance was set at p-value < 0.05. PROC SURVEYMEANS PROC SURVEYFREQ, PROC SURVEYLOGISTIC and PROC SURVEYREG were used to account for design effects and sampling weight. All analyses were performed using the SAS System for Windows, version 9.2 (SAS Institute, Inc., Cary, NC).

RESULTS

Table I shows the descriptive characteristics of participants with diabetes who did and did not conduct the HbA1c test. Of the 690 participants with diabetes, 30.3% had their HbA1c level tested and 67.7% did not. There were no significant differences by socio-demographics, smoking and alcohol consumption, hypertension, heart attack, stroke, high depressive symptoms, BMI, physician visits, hospitalization, disease duration, disease treatment or disease complications. Participants who conduct the HbA1c test were significantly more likely for not having a prior HbA1c testing.

Table II presents the descriptive characteristics of participants with diabetes by glycemic control (HbA1c<7%=good control and HbA1c ≥7%=good control). Of the 290 participants with diabetes who took the HbA1c test, 34.9 % had good glycemic control and 65.1% had poor glycemic control. Participants with poor glycemic control were significantly more likely to have < 8 years of education, to have the interview in Spanish, and been US-born compared with those with good glycemic control. Participants with poor glycemic control were significantly more likely to have longer disease duration (≥ 15 years), to report daily glucometer use and have more complications (Table III).

Table II.

Descriptive characteristics of participants with diabetes by glycemic control (N=209).

Variables N Good control
HbA1c < 7%
N (%)		 Poor control
HbA1c ≥ 7%
N (%)
Total 209 73 (34.9) 136 (65.1)
HbA1c level 209 6.4 (0.02) 8.6 (0.1)
Age, Mean (SD) 209 80.7 (3.9) 81.2 (4.2)
Gender (female) 130 43 (60.2) 87 (61.1)
Education **
 < 8 years
 ≥ 8 years
133
57
40 (59.3)
28 (43.7)
93 (73.8)
29 (26.2)
 Language of interview **
  English
  Spanish
54
155
24 (40.5)
49 (59.5)
30 (20.9)
106 (79.1)
Marital status
 Married
 Unmarried
96
113
32 (43.5)
41 (56.5)
64 (45.4)
72 (54.6)
Nativity **
 US-born
 Foreign-born
123
86
49 (72.7)
24 (27.3)
74 (52.6)
62 (47.4)
 Income
  < 15,000
   15,000 < 30,000
  ≥ 30,000
80
86
30
20 (30.1)
33 (46.6)
13 (23.3)
60 (40.7)
53 (41.3)
17 (18.0)
Current smokers
 Yes
 No
106
103
38 (59.6)
35 (40.4)
68 (50.3)
68 (49.7)
Current drinker
 Yes
 No
85
124
24 (33.3)
49 (66.7)
61 (43.3)
75 (56.7)
Hypertension
 Yes
 No
156
50
58 (80.6)
14 (19.4)
98 (74.2)
36 (25.8)
Heart attack
 Yes
 No
50
156
18 (22.9)
53 (77.1)
32 (24.3)
103 (75.7)
Stroke
 Yes
 No
45
162
19 (23.9)
53 (76.1)
26 (19.8)
109 (80.2)
High depressive symptoms (CES-D ≥ 16)
 Yes
 No
48
156
13 (19.1)
60 (80.9)
35 (26.1)
96 (73.9)
BMI (Kg/m2)
 18.5 – < 25
 25 – 30
 ≥ 30
 Missing or < 18.5
 Mean (SD) **
45
74
55
35
209
13 (13.2)
27 (35.4)
20 (31.3)
13 (20.3)
28.4 (4.9)
32 (21.2)
47 (28.9)
35 (33.3)
22 (16.6)
29.1 (4.2)
Hospitalization in the past year
 Yes
 No
68
140
22 (31.8)
50 (68.2)
46 (34.2)
90 (65.8)
Physician visits in the past year
 0 – 1
 ≥ 2
18
190
11 (7.5)
124 (92.5)
7 (12.7)
66 (87.3)
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Note: “N” varies due missing data

*

p-value <0.01

**

p-value <0.001

***

p-value <0.0001

CES-D= Center for Epidemiological Studies Depression Scale, BMI=Body Mass Index

Table III.

HbA1c measurements and diabetes-care related characteristics of older Mexican Americans with diabetes (N=209).

Variables N Good control
HbA1c < 7%
N (%)		 Poor control
HbA1c ≥ 7%
N (%)
Total 73 (36.5) 136 (63.5)
Duration of diabetes (years) **
 < 15
 ≥ 15
Mean (SE)
103
106
209
48 (64.4)
25 (35.6)
18.1 (0.8)
55 (39.8)
81 (60.2)
17.7 (0.8)
Use of Glucometer *
 > 1 time/day
 All others
89
120
23 (35.2)
50 (64.8)
70 (48.0)
66 (52.0)
Prior HbA1c testing
 Never
 >1 per year
142
65
50 (63.1)
22 (36.9)
83.1 (61.4)
43 (38.6)
Current diabetes treatment
 Unknown
 Oral hypoglycemic
 Insulin or/and oral Hypoglycemic
22
145
42
12 (16.5)
50 (68.7)
11 (14.7)
10 (8.6)
95 (66.7)
31 (24.6)
Diabetes complications ***
Median (range)
209
0.5 (0 – 3)
1.0 (0 – 3)
Kidney
 Yes
 No
28
179
10 (10.9)
61 (89.1)
18 (14.8)
118 (85.2)
Eyes
 Yes
 No
80
127
28 (41.6)
45 (58.4
52 (39.0)
82 (61.00)
Circulation **
 Yes
 No
90
114
24 (30.3)
47 (69.7)
66 (51.3)
67 (48.7)
Amputation
 Yes
 No
6
202
2 (1.4)
71 (98.6)
4 (1.4)
131 (98.6)
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Note: “N” varies due missing data

*

p-value <0.01

**

p-value <0.001

***

p-value <0.0001

Table IV shows the multivariate logistic regression analysis for poor glycemic control (HbA1c<7%). Education < 8 years, foreign-born, current smokers, obesity (BMI ≥ 30 Kg/m2), longer disease duration (≥ 15 years), daily glucometer use, and macrocomplications (circulation or amputations) were factors significantly associated with poor glycemic control. When we repeated the analysis using HbA1c as a continuous variable, we found foreign-born, current smokers, obesity, longer disease duration, and macrocomplications significantly associated with high levels of HbA1c (R2=32%).

Table IV.

Logistic regression of factors associated with poor glycemic control (HbA1c ≥ 7%) in older Mexican Americans with diabetes.

Variables OR 95 % CI
N=185*
Age (each year increase) 1.00 (0.89 – 1.12)
Gender (female) 1.35 (0.42 – 4.30)
Education (< 8 years) 3.08 (1.20 – 7.92)
Marital status (married) 1.84 (0.71 – 4.76)
Nativity (foreign-born) 3.01 (1.09 – 8.32)
Current smoker 3.12 (1.16 – 8.38)
Current drinker 0.54 (0.22 – 1.30)
Hypertension or heart attack or stroke 0.69 (0.23 – 2.11)
High depressive symptoms (CES-D ≥ 16) 1.98 (0.52 – 7.51)
Obesity (BMI ≥ 30 Kg/m2) 3.65 (1.08 – 12.36)
Hospitalization in the past year 0.87 (0.36 – 2.08)
Physician visits in the past year (<2) 1.42 (0.43 – 4.73)
Disease duration (≥ 15 years) 3.34 (1.15 – 9.76)
Daily glucometer use 3.13 (1.12 – 8.76)
Prior HbA1c testing 1.37 (0.52 – 3.59)
Current diabetes treatment
 Unknown
 Oral hypoglycemic
 Insulin or/and oral hypoglycemic
1.00
1.19 (0.32 – 4.47)
0.48 (0.06 – 3.68)
Diabetes complications
 Macro (circulation or amputation)
 Micro (eyes or kidney)
5.28 (1.75 – 15.87)
0.29 (0.08 – 1.05)
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Note: Participants with missing data on BMI were included into the equation

“N” varies due missing data

OR=Odds Ratio

CI=Confidence Interval

CES-D= Center for Epidemiological Studies Depression Scale

BMI=Body Mass Index

DISCUSSION

This study examined the factors associated with poor glycemic control (HbA1c >7%) among older Mexican American with diabetes, a population known to be at a higher risk of diabetes and its complications. We found that 65.1% of participants had poor glycemic control. Education, nativity, smoking, obesity, disease duration, daily glucometer use, and macrocomplications were factors associated with poor glycemic control.

Our findings on education are similar to those reported by Goudswaard and colleagues in which lower level of education was associated with poor glycemic control (Goudswaard et al., 2004) but different from those of Ross and colleagues who did not find an association of education with glycemic control among Mexicans and Mexican Americans with type 2 diabetes or Blaum and colleagues, who looked at mostly Non-Hispanic whites (Suh et al., 2008; Ross et al., 2011; Blaum et al., 1997). A pilot study has shown that applying culturally tailored diabetes-self management programs among less educated Mexican Americans may improve glycemic control and diabetes outcomes (Rosal et al., 2005). Previous findings from the H-EPESE showed that foreign-born Mexican Americans were at higher risk for incidence of macro and micro vascular complications that would explain the association with poor glycemic control (Kaushik et al., 2007). Another previous study showed an association between smoking and poor glycemic control (Gunton et al., 2002).

Our analysis showed an association between obesity and poor glycemic control. These findings are different from those reported by Suh and colleagues using the National Health and Nutrition Examination Surveys (NHANES) (1988–1994 and 1999–2004), as well as those of Harris and colleagues using the NHANES 1988–1994, and those reported by Blaum and colleagues, none of whom found an association between obesity and glycemic control (Suh et al., 2008; Harris et al., 1999; Blaum et al., 1997). Furthermore, other have found higher BMI associated with better glycemic control (Nichols et al., 2000; Koro et al., 2004). One explanation for this observation may be that improvement in diabetes control causes weight gain, rather than that weight gain improves diabetes control (U.K.Prospesctive Diabetes Study Group, 1998).

Our finding of longer disease duration associated with poor glycemic control contrast with previous studies in older adults which found no association between longer disease duration and poor glycemic control, suggesting that patients with diabetes may become more skilled in diabetes care the longer they have diabetes (Suh et al., 2008; Chiu & Wray, 2010; Nichols et al., 2000; Goudswaard et al., 2004; Koro et al., 2004). However, in this group of older Mexican Americans, a longer duration of diabetes makes glycemic control more difficult because of the increased burden of comorbidities, drug resistance, and drug disease interactions.

In contrast to other reports showing better glycemic control with more frequent self measurement of blood glucose our analysis showed that those with HbA1c of > 7% were more likely to check their blood glucose daily when compared to those with HbA1c of < 7%. This fact may reflect not so much that poor glycemic control is a result of inadequate measurement of blood sugar levels, but rather the difficulty of achieving good glycemic control in this advanced age group, which demands closer monitoring. Our findings on diabetes complications are consistent with previous research that poor glycemic control is associated with risk of macrovascular complications (Stratton et al., 2000; Imran et al., 2006; Nather et al., 2008).

Our study has several limitations. First, the assessment of diabetes mellitus was based on self-reported data with no clinical evaluation or pathological proof of complications due to diabetes, and no information of previous HbA1c levels or glucose levels. Clinical observation may provide a different and more precise diagnosis. However, the self report approach has been documented to provide reliable information and a good agreement between self-reported diabetes mellitus and diabetes mellitus diagnosed by blood tests (Mokdad et al., 2001; Okura et al., 2004). Second, only one third of respondents agreed to perform a finger prick and supply a dry blood sample to test their HbA1c level. Analysis of excluded and included participants showed no significant differences by socio-demographics, health behaviors, medical conditions, high depressive symptoms, BMI, health care utilization or disease characteristics. Third, because this was a cross-sectional analysis it was not possible to determine the temporal sequence of associated factors and glycemic control. Fourth, in 32 participants information of diabetes treatment was not available and this could underestimate the effect of diabetes treatment on glycemic control.

Despite the limitations identified above, the study yielded important results with implications for future programs addressed to older Mexican American diabetics. Our results show the importance of identifying factors associated with poor glycemic control in older Mexican Americans who have high prevalence and incidence of diabetes. Moreover, our results suggest a very high level of poor glycemic control in a population that has experienced a significant increase in diabetes prevalence in recent years.

In summary, education level, nativity, smoking, obesity, disease duration, daily glucometer use, and macrocomplications were factors associated with poor glycemic control in older Mexican Americans, even if they follow the appropriate diabetes care. A recent report showed that diabetes-free life expectancy has decreased in the US for both men and women, a decrease attributed to an increase in the incidence of diabetes among obese persons (Cunningham SA et al., 2011). As older Mexican American are characterized as having high prevalence of diabetes and obesity, further studies are needed to explore the effect of these and other characteristics on glycemic control with larger samples of older Mexican Americans over time and to develop appropriate interventions to improve diabetes outcomes and increase life-expectancy.

Acknowledgments

Grants and/or financial support:

This study was supported by grants R03-AG029959 and R01-AG017638 from the National Institute on Aging.

Reference List

  1. American Diabetes Association. Standard of medical care in diabetes. 2004. pp. S15–S35. [DOI] [PubMed] [Google Scholar]
  2. American Diabetes Association. Standards of medical care in diabetes -2011. 2011. pp. S11–S61. [DOI] [PMC free article] [PubMed] [Google Scholar]
  3. Beard HA, Al GM, Samper-Ternent R, Gerst K, Markides KS. Trends in diabetes prevalence and diabetes-related complications in older Mexican Americans from 1993–1994 to 2004–2005. Diabetes Care. 2009;32:2212–2217. doi: 10.2337/dc09-0938. [DOI] [PMC free article] [PubMed] [Google Scholar]
  4. Benoit SR, Fleming R, Philis-Tsimikas A, Ji M. Predictors of glycemic control among patients with Type 2 diabetes: a longitudinal study. BMC Public Health. 2005;5:36. doi: 10.1186/1471-2458-5-36. [DOI] [PMC free article] [PubMed] [Google Scholar]
  5. Blaum CS, Velez L, Hiss RG, Halter JB. Characteristics related to poor glycemic control in NIDDM patients in community practice. Diabetes Care. 1997;20:7–11. doi: 10.2337/diacare.20.1.7. [DOI] [PubMed] [Google Scholar]
  6. Boltri JM, Okosun IS, Davis-Smith M, Vogel RL. Hemoglobin A1c levels in diagnosed and undiagnosed black, Hispanic, and white persons with diabetes: results from NHANES 1999–2000. Ethn Dis. 2005;15:562–567. [PubMed] [Google Scholar]
  7. Centers for Disease Control and Prevention. National Diabetes Fact Sheet. Atlanta, GA: U.S. Department of Health and Human Services; 2007. [Google Scholar]
  8. Centers for Disease Control and Prevention. National Diabetes Fact Sheet: national estimates and general information on diabetes and prediabetes in the United States, 2011. Atlanta, GA: U.S. Department of Health and Human Services, Center for Disease Control and Prevention; 2011. 2011. [Google Scholar]
  9. Chiu CJ, Wray LA. Factors predicting glycemic control in middle-aged and older adults with type 2 diabetes. Prev Chronic Dis. 2010;7:A08. [PMC free article] [PubMed] [Google Scholar]
  10. Cowie CC, Rust KF, Byrd-Holt DD, Eberhardt MS, Flegal KM, Engelgau MM, Saydah SH, Williams DE, Geiss LS, Gregg EW. Prevalence of diabetes and impaired fasting glucose in adults in the U.S. population: National Health And Nutrition Examination Survey 1999–2002. Diabetes Care. 2006;29:1263–1268. doi: 10.2337/dc06-0062. [DOI] [PubMed] [Google Scholar]
  11. Cunningham SA, Riosmena F, Wang J, Boyle JP, Rolka DR, Geiss LS. Decreases in diabetes-free life expectancy in the U.S. and the role of obesity. 2011. pp. 2225–2230. [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. Diehl AK, Stern MP. Special health problems of Mexican-Americans: obesity, gallbladder disease, diabetes mellitus, and cardiovascular disease. Adv Intern Med. 1989;34:73–96. [PubMed] [Google Scholar]
  13. Egede LE, Gebregziabher M, Hunt KJ, Axon RN, Echols C, Gilbert GE, Mauldin PD. Regional, geographic, and racial/ethnic variation in glycemic control in a national sample of veterans with diabetes. Diabetes Care. 2011;34:938–943. doi: 10.2337/dc10-1504. [DOI] [PMC free article] [PubMed] [Google Scholar]
  14. Espino DV, Moreno CA, Talamantes M. Hispanic elders in Texas: implications for health care. Tex Med. 1993;89:58–61. [PubMed] [Google Scholar]
  15. Flegal KM, Ezzati TM, Harris MI, Haynes SG, Juarez RZ, Knowler WC, Perez-Stable EJ, Stern MP. Prevalence of diabetes in Mexican Americans, Cubans, and Puerto Ricans from the Hispanic Health and Nutrition Examination Survey, 1982–1984. Diabetes Care. 1991;14:628–638. doi: 10.2337/diacare.14.7.628. [DOI] [PubMed] [Google Scholar]
  16. Goudswaard AN, Stolk RP, Zuithoff P, Rutten GE. Patient characteristics do not predict poor glycaemic control in type 2 diabetes patients treated in primary care. Eur J Epidemiol. 2004;19:541–545. doi: 10.1023/b:ejep.0000032351.42772.e7. [DOI] [PubMed] [Google Scholar]
  17. Gunton JE, Davies L, Wilmshurst E, Fulcher G, McElduff A. Cigarette smoking affects glycemic control in diabetes. Diabetes Care. 2002;25:796–797. doi: 10.2337/diacare.25.4.796-a. [DOI] [PubMed] [Google Scholar]
  18. Hanis CL, Chu HH, Lawson K, Hewett-Emmett D, Barton SA, Schull WJ, Garcia CA. Mortality of Mexican Americans with NIDDM. Retinopathy and other predictors in Starr County, Texas. Diabetes Care. 1993;16:82–89. doi: 10.2337/diacare.16.1.82. [DOI] [PubMed] [Google Scholar]
  19. Harris MI. Diabetes in America: epidemiology and scope of the problem. Diabetes Care. 1998;21(Suppl 3):C11–C14. doi: 10.2337/diacare.21.3.c11. [DOI] [PubMed] [Google Scholar]
  20. Harris MI, Eastman RC, Cowie CC, Flegal KM, Eberhardt MS. Racial and ethnic differences in glycemic control of adults with type 2 diabetes. Diabetes Care. 1999;22:403–408. doi: 10.2337/diacare.22.3.403. [DOI] [PubMed] [Google Scholar]
  21. Imran S, Ali R, Mahboob G. Frequency of lower extremity amputation in diabetics with reference to glycemic control and Wagner's grades. J Coll Physicians Surg Pak. 2006;16:124–127. [PubMed] [Google Scholar]
  22. Karter AJ, Ferrara A, Liu JY, Moffet HH, Ackerson LM, Selby JV. Ethnic disparities in diabetic complications in an insured population. JAMA. 2002;287:2519–2527. doi: 10.1001/jama.287.19.2519. [DOI] [PubMed] [Google Scholar]
  23. Kaushik VP, Al Snih S, Ray LA, Raji MA, Markides KS, Goodwin JS. Factors associated with seven-year incidence of diabetes complications among older Mexican Americans. Gerontology. 2007;53:194–199. doi: 10.1159/000100443. [DOI] [PubMed] [Google Scholar]
  24. Kell SH, Drass J, Bausell RB, Thomas KA, Osborn MA, Gohdes D. Measures of disease control in Medicare beneficiaries with diabetes mellitus. J Am Geriatr Soc. 1999;47:417–422. doi: 10.1111/j.1532-5415.1999.tb07233.x. [DOI] [PubMed] [Google Scholar]
  25. Kirk JK, Passmore LV, Bell RA, Narayan KM, D'Agostino RB, Jr, Arcury TA, Quandt SA. Disparities in A1C levels between Hispanic and non-Hispanic white adults with diabetes: a meta-analysis. Diabetes Care. 2008;31:240–246. doi: 10.2337/dc07-0382. [DOI] [PubMed] [Google Scholar]
  26. Koro CE, Bowlin SJ, Bourgeois N, Fedder DO. Glycemic control from 1988 to 2000 among U.S. adults diagnosed with type 2 diabetes: a preliminary report. Diabetes Care. 2004;27:17–20. doi: 10.2337/diacare.27.1.17. [DOI] [PubMed] [Google Scholar]
  27. Lanting LC, Joung IM, Mackenbach JP, Lamberts SW, Bootsma AH. Ethnic differences in mortality, end-stage complications, and quality of care among diabetic patients: a review. Diabetes Care. 2005;28:2280–2288. doi: 10.2337/diacare.28.9.2280. [DOI] [PubMed] [Google Scholar]
  28. Lasater LM, Davidson AJ, Steiner JF, Mehler PS. Glycemic control in English- vs Spanish-speaking Hispanic patients with type 2 diabetes mellitus. Arch Intern Med. 2001;161:77–82. doi: 10.1001/archinte.161.1.77. [DOI] [PubMed] [Google Scholar]
  29. Lindeman RD, Romero LJ, Hundley R, Allen AS, Liang HC, Baumgartner RN, Koehler KM, Schade DS, Garry PJ. Prevalences of type 2 diabetes, the insulin resistance syndrome, and coronary heart disease in an elderly, biethnic population. Diabetes Care. 1998;21:959–966. doi: 10.2337/diacare.21.6.959. [DOI] [PubMed] [Google Scholar]
  30. Link CL, McKinlay JB. Disparities in the prevalence of diabetes: is it race/ethnicity or socioeconomic status? Results from the Boston Area Community Health (BACH) survey. Ethn Dis. 2009;19:288–292. [PMC free article] [PubMed] [Google Scholar]
  31. Lustman PJ, Freedland KE, Griffith LS, Clouse RE. Fluoxetine for depression in diabetes: a randomized double-blind placebo-controlled trial. Diabetes Care. 2000;23:618–623. doi: 10.2337/diacare.23.5.618. [DOI] [PubMed] [Google Scholar]
  32. Markides KS, Rudkin LL, Angel RJ, Espino DV. Health Status of Hispanic Elderly in the United States. In: Martin LG, Soldo BJ, editors. Racial and Ethnic Differences in the Health of Older Americans. Washington: National Academy Press; 1997. pp. 285–300. [Google Scholar]
  33. Markides KS, Stroup-Benham CA, Goodwin JS, Perkowski LC, Lichtenstein M, Ray LA. The effect of medical conditions on the functional limitations of Mexican-American elderly. Ann Epidemiol. 1996;6:386–391. doi: 10.1016/s1047-2797(96)00061-0. [DOI] [PubMed] [Google Scholar]
  34. Meneilly GS, Tessier D. Diabetes in elderly adults. J Gerontol A Biol Sci Med Sci. 2001;56:M5–M13. doi: 10.1093/gerona/56.1.m5. [DOI] [PubMed] [Google Scholar]
  35. Mokdad AH, Bowman BA, Ford ES, Vinicor F, Marks JS, Koplan JP. The continuing epidemics of obesity and diabetes in the United States. JAMA. 2001;286:1195–1200. doi: 10.1001/jama.286.10.1195. [DOI] [PubMed] [Google Scholar]
  36. Nather A, Bee CS, Huak CY, Chew JL, Lin CB, Neo S, Sim EY. Epidemiology of diabetic foot problems and predictive factors for limb loss. J Diabetes Complications. 2008;22:77–82. doi: 10.1016/j.jdiacomp.2007.04.004. [DOI] [PubMed] [Google Scholar]
  37. National Heart, L.a.B.I.N. and North American Association for the Study of Obesity (NAASO) The practical guide: identification, evaluation, and treatment of overweight and obesity in adults. Report 00-4084. Rockville, MD: 2000. [Google Scholar]
  38. Nichols GA, Hillier TA, Javor K, Brown JB. Predictors of glycemic control in insulin-using adults with type 2 diabetes. Diabetes Care. 2000;23:273–277. doi: 10.2337/diacare.23.3.273. [DOI] [PubMed] [Google Scholar]
  39. Okura Y, Urban LH, Mahoney DW, Jacobsen SJ, Rodeheffer RJ. Agreement between self-report questionnaires and medical record data was substantial for diabetes, hypertension, myocardial infarction and stroke but not for heart failure. J Clin Epidemiol. 2004;57:1096–1103. doi: 10.1016/j.jclinepi.2004.04.005. [DOI] [PubMed] [Google Scholar]
  40. Otiniano ME, Markides KS, Ottenbacher K, Ray LA, Du XL. Self-reported diabetic complications and 7-year mortality in Mexican American elders. Findings from a community-based study of five Southwestern states. J Diabetes Complications. 2003;17:243–248. doi: 10.1016/s1056-8727(02)00260-x. [DOI] [PubMed] [Google Scholar]
  41. Radloff LS. The CED-S Scale: A self-report depression scale for research in the general population. J Appl Psychol Meas. 1977;1:385–401. [Google Scholar]
  42. Rosal MC, Olendzki B, Reed GW, Gumieniak O, Scavron J, Ockene I. Diabetes self-management among low-income Spanish-speaking patients: a pilot study. Ann Behav Med. 2005;29:225–235. doi: 10.1207/s15324796abm2903_9. [DOI] [PubMed] [Google Scholar]
  43. Ross SE, Franks SF, Hall J, Young R, Cardarelli R. Levels of acculturation and effect on glycemic control in Mexicans and Mexican Americans with type 2 diabetes. Postgrad Med. 2011;123:66–72. doi: 10.3810/pgm.2011.01.2246. [DOI] [PubMed] [Google Scholar]
  44. Shorr RI, Franse LV, Resnick HE, Di BM, Johnson KC, Pahor M. Glycemic control of older adults with type 2 diabetes: findings from the Third National Health and Nutrition Examination Survey, 1988–1994. J Am Geriatr Soc. 2000;48:264–267. doi: 10.1111/j.1532-5415.2000.tb02644.x. [DOI] [PubMed] [Google Scholar]
  45. Smith NL, Heckbert SR, Bittner VA, Savage PJ, Barzilay JI, Dobs AS, Psaty BM. Antidiabetic treatment trends in a cohort of elderly people with diabetes. The cardiovascular health study, 1989–1997. Diabetes Care. 1999;22:736–742. doi: 10.2337/diacare.22.5.736. [DOI] [PubMed] [Google Scholar]
  46. Stratton IM, Adler AI, Neil HA, Matthews DR, Manley SE, Cull CA, Hadden D, Turner RC, Holman RR. Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): prospective observational study. BMJ. 2000;321:405–412. doi: 10.1136/bmj.321.7258.405. [DOI] [PMC free article] [PubMed] [Google Scholar]
  47. Suh DC, Kim CM, Choi IS, Plauschinat CA. Comorbid conditions and glycemic control in elderly patients with type 2 diabetes mellitus, 1988 to 1994 to 1999 to 2004. J Am Geriatr Soc. 2008;56:484–492. doi: 10.1111/j.1532-5415.2007.01563.x. [DOI] [PubMed] [Google Scholar]
  48. Tucker KL, Bermudez OI, Castaneda C. Type 2 diabetes is prevalent and poorly controlled among Hispanic elders of Caribbean origin. Am J Public Health. 2000;90:1288–1293. doi: 10.2105/ajph.90.8.1288. [DOI] [PMC free article] [PubMed] [Google Scholar]
  49. U.K. Prospesctive Diabetes Study Group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes. 1998. pp. 837–853. [PubMed] [Google Scholar]
  50. von Goeler DS, Rosal MC, Ockene JK, Scavron J, De TF. Self-management of type 2 diabetes: a survey of low-income urban Puerto Ricans. Diabetes Educ. 2003;29:663–672. doi: 10.1177/014572170302900412. [DOI] [PubMed] [Google Scholar]
  51. Weinstock RS, Teresi JA, Goland R, Izquierdo R, Palmas W, Eimicke JP, Ebner S, Shea S. Glycemic control and health disparities in older ethnically diverse underserved adults with diabetes: five-year results from the Informatics for Diabetes Education and Telemedicine (IDEATel) study. Diabetes Care. 2011;34:274–279. doi: 10.2337/dc10-1346. [DOI] [PMC free article] [PubMed] [Google Scholar]
  52. Wendel CS, Shah JH, Duckworth WC, Hoffman RM, Mohler MJ, Murata GH. Racial and ethnic disparities in the control of cardiovascular disease risk factors in Southwest American veterans with type 2 diabetes: the Diabetes Outcomes in Veterans Study. BMC Health Serv Res. 2006;6:58. doi: 10.1186/1472-6963-6-58. [DOI] [PMC free article] [PubMed] [Google Scholar]
  53. Zhang Q, Wang Y, Huang ES. Changes in racial/ethnic disparities in the prevalence of Type 2 diabetes by obesity level among US adults. Ethn Health. 2009;14:439–457. doi: 10.1080/13557850802699155. [DOI] [PMC free article] [PubMed] [Google Scholar]
  54. Zhang X, Saaddine JB, Chou CF, Cotch MF, Cheng YJ, Geiss LS, Gregg EW, Albright AL, Klein BE, Klein R. Prevalence of diabetic retinopathy in the United States, 2005–2008. JAMA. 2010;304:649–656. doi: 10.1001/jama.2010.1111. [DOI] [PMC free article] [PubMed] [Google Scholar]

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