Type 2 Diabetes Disparities in Ethnic Minorities

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Type 2 Diabetes Disparities in Ethnic Minorities

Tuesday, September 15, 2009

The New York Academy of Sciences

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Type 2 diabetes accounts for at least 90% of diabetes worldwide, affecting more than 23 million of Americans and over 7% of the US population. Type 2 diabetes is disproportionately more common in ethnic minority groups in developed countries including African, Native Americans, Hispano/Latino, Asian, and Pacific Islanders. These groups are 1.5 to 20 times more likely to develop diabetes than their non-Hispanic, white peers, and present worse diabetes control and higher rates of complications, such as coronary artery disease or stroke. In addition, individuals with Type 2 diabetes tend to be treated differently depending on ethnicity.

This afternoon meeting will convene physicians, endocrinologists, cardiologists, nutritionists, care-givers, sociologists, public heath experts, policy-makers, epidemiologists, patient-advocacy groups and community leaders, among others, to discuss the origin of Type 2 diabetes disparities in minority populations, associated cardiovascular complications, and the public health approaches to control and prevent the disease epidemic. This symposium is anticipated to help develop culturally sensitive prevention, diagnosis, treatment, and disease management programs for patients and healthcare providers.

Presented by

Takeda

This program is supported by an educational grant from Takeda Pharmaceuticals North America, Inc.

For a complete list of sponsors, please click the Sponsorship tab.

Childhood Risk Factors for Obesity


Robert Whitaker (Temple University)

Neonatal Nutrition and Risk of Obesity


Andreas Plagemann (University of Medicine Berlin)

The Early Environment Sets the Stage for Adult Obesity


Barry Levin (University of Medicine and Dentistry of New Jersey)

The Role of Leptin in Signaling Body Fat Content


Rudolph Leibel (Columbia University)

Agenda


12:00 pm

Registration

12:30 pm

Opening Remarks and Introduction
Gabrielle Rieckhof, PhD, The New York Academy of Sciences

SESSION I: Origins of Type 2 Diabetes Ethnic Discrepancies

12:45 pm

Origins of Type 2 Diabetes Ethnic Discrepancies
Enrique Caballero, MD, Harvard Medical School

SESSION II: Comorbidity of Diabetes with Cardiovascular Syndromes

Chair: Cary S. Pollack, MD

1:15 pm

Introduction
Cary S. Pollack, MD, The Mount Sinai School of Medicine

1:30 pm

Cardiovascular Risks/Complications in Patients with Type 2 Diabetes: Genetic and Ethnic Considerations
Harold E. Lebovitz, MD, State University of New York

2:00 pm

Cardiovascular Risks/Complications Associated with Type 2 Diabetes with a Special Focus Ethnic Minorities
Guillermo E. Umpierrez, MD, Emory University School of Medicine

2:30 pm

Screening for Coronary Artery Disease in Type 2 Diabetes
Lawrence H. Young, MD, Yale University

3:00 pm

Coffee Break

SESSION III: Public Health and Educational Initiatives

Chair: Diana Berger, MD, MSc

3:30 pm

Introduction
Diana Berger, MD, MSc, NYC Department of Health and Mental Hygiene

3:45 pm

Testing a Telephonic Behavioral Intervention in the Context of the NYC HbA1c Registry
Elizabeth Walker, PhD, RN, Albert Einstein College of Medicine

4:15 pm

A Public Health Approach to Diabetes Health Disparities
Ann Albright, PhD, RD, Centers for Disease Control and Prevention

4:45 pm

Panel Discussion (all speakers)
Moderator: Mary Ann Banerji, MD, SUNY Downstate Medical Center

6:00 pm

Networking Reception

Speakers

Organizer

Mary Ann Banerji, MD

SUNY Downstate Medical Center

Mary Ann Banerji, M.D., F.A.C.P. is Professor of Medicine at SUNY Downstate Medical Center in Brooklyn. With an expertise in diabetes, she directs the Kings County Hospital Diabetes Clinic and SUNY Diabetes Treatment Center. She received her medical degree from Temple University School of Medicine in Philadelphia. She completed her residency in internal medicine and a fellowship in Endocrinology and Metabolism at SUNY Downstate Medical Center. Dr Banerji’s research interests are in type 2 diabetes among minorities, in particular African-American and South Asians. She described Flatbush Diabetes, an atypical form with features of both type 1 and type 2 diabetes among African Americans and is an expert in body composition. She pioneered the concept of long-term remission in type 2 diabetes induced by intensive treatment. In addition, she is actively involved in developing interventions to prevent diabetes and its complications at a community level. Dr. Banerji publishes and is actively involved in post graduate and graduate medical education.

Speakers

Ann Albright, PhD, RD

Centers for Disease Control and Prevention

Dr. Ann Albright assumed the post of Director, Division of Diabetes Translation (DDT) in January 2007. As director, Dr. Albright leads a team of more than 100 who strive to eliminate the preventable burden of diabetes through leadership, research, programs, and policies that translate science into practice. Dr. Albright received her doctoral degree in Exercise Physiology from the Ohio State University. She completed a National Institutes of Health postdoctoral fellowship in nutrition at the University of California, Davis and a clinical internship in nutrition at University of California, San Francisco (UCSF). Prior to commencing her post at the CDC, Dr. Albright served as Chief of the California Diabetes Program for the California Department of Health Services, a position she held since 1995. Dr. Albright also held an academic appointment in the Institute for Health and Aging at UCSF. From 2003-2004, Dr. Albright served as the Senior Health Policy Advisor in the Office of the United States Surgeon General and led the Secretary of Health’s Diabetes Detection Initiative. Dr. Albright is well known for her work in diabetes including the implementation of evidence-based diabetes care guidelines, work on models of care in community clinics, and development of public awareness campaigns to increase the understanding of diabetes and importance of blood glucose, blood pressure, and lipid control. Dr. Albright is published in the areas of exercise, nutrition, body composition, diabetic nephropathy, the role of tissue glycosylation in diabetic complications, the feasibility of enhanced care among Medicaid recipients with type 2 diabetes, and public health practice in diabetes prevention and control. Dr. Albright has served in key leadership roles with the American Diabetes Association including her role as immediate-past President for Health Care and Education, the American College of Sports Medicine, the American Association of Diabetes Educators, and the American Dietetic Association.

Diana Berger, MD, MSc

NYC Department of Health and Mental Hygiene

Diana Berger, MD, MSc, is the Diabetes Medical Speciaist and founder of the Diabetes Prevention and Control Program, at NYC Department of Health and Mental Hygiene. She is on the faculty at the Mount Sinai School of Medicine. Dr. Berger’s interests in diabetes include the emerging epidemic of type 2 diabetes in children, coaching school nurses about diabetes in youth, and using physical activity and healthy eating for diabetes prevention. She attended Dartmouth Medical School and completed her Preventive Medicine residency at Mount Sinai. She was a research fellow at the Joslin Diabetes Center in Boston. She also has a Masters of Science in Community Medicine from Mount Sinai. She is a member of the NYS Diabetes Task Force.

Enrique Caballero, MD

Harvard Medical School

Dr Caballero is the Director of the Latino Diabetes Initiative, Director of Medical Affairs of Professional Education, Staff Endocrinologist and Clinical Investigator at Joslin Diabetes Center. He is Assistant Professor of Medicine at Harvard Medical School. Dr. Caballero developed the Joslin Latino Diabetes Initiative that was launched in the summer of 2002 and that integrates culturally oriented activities in the areas of patient care and education, community outreach, research and professional education. His research interests include type 2 diabetes and cardiovascular disease prevention, endothelial dysfunction and diabetes in minority populations. He is a co-investigator of the National Diabetes Prevention Program, the LookAhead Program and the Diabetes Education Study, all sponsored by the National Institutes of Health. He is the principal investigator in studies assessing vascular abnormalities in obese Hispanic children, adolescents and young adults. He is also principal investigator in a study assessing biological, psychological, social and cultural factors influencing adherence to treatment in Latinos with diabetes. Dr. Caballero has written various publications on pre-diabetes, obesity and endothelial dysfunction, diabetes in Latinos and the chapter of Diabetes in Minorities in the prestigious Joslin’s Diabetes Mellitus textbook. He is also a reviewer for multiple prestigious medical journals. Dr. Caballero frequently lectures nationally and internationally in the areas of diabetes, cardiovascular disease and diabetes in minorities. He has been appointed as the chair for the Latino Diabetes Education Program at the American Diabetes Association. He is also of the first tutors of the recently created Culturally Competent Care Curriculum at Harvard Medical School. Dr. Caballero graduated from the National University of Mexico Medical School where he was awarded with the “Gabino Barreda” medal for being the top student in his class. He then completed his residency in Internal medicine and fellowship in Endocrinology at the National Institute of Nutrition in Mexico, and went on to complete a master’s degree in Clinical Epidemiology in Mexico. In addition, he completed a fellowship program in Endocrinology and Metabolism at the Lahey Clinic/Deaconess Hospital/Joslin Diabetes Center and the Program on Clinical Effectiveness at the Harvard School of Public Health. Dr. Caballero is the 2009 recipient of the Alberto Houssay award by the National Minority Quality Forum for his work on health care disparities.

Harold E. Lebovitz, MD

State University of New York

Harold E. Lebovitz, MD, FACE, is a professor of Medicine at the Division of Endocrinology and Metabolism/Diabetes at the State University of New York, Health Sciences Center at Brooklyn. Dr. Lebovitz is an internationally recognized authority in the field of diabetes. He and his colleagues have contributed to the understanding of the pathogenesis of type 2 diabetes, particularly as it relates to ethic and racial differences, to mechanism of action and clinical utility of therapeutic agents used in the treatment of type 2 diabetes, and to the effects of body composition on insulin resistance and its associated abnormalities. He has published approximately 200 articles in peer-reviewed journals and 75 book chapters or books. Dr. Lebovitz has served on review committees for the American diabetes Association, the National Institutes of Health, and Veterans Administration and currently serves on several editorial boards. He has been the recipient of many awards, including the Albert E. Renold Medal of the American Diabetes Association in 1994, the Samuel Moses Oration Award of the Research society for study of diabetes in India in 1993, and the Servier Medal of the Philippine Diabetes Association in 1999.

Cary S. Pollack, MD

Mount Sinai School of Medicine

Cary S. Pollack, MD, is a cardiologist and internal medicine physician. He is Cardiologist at Mount Sinai Medical Center and Assistant Clinical Professor at Mount Sinai School with vast experience in treating type 2 diabetes patients with cardiovascular complications. He has lectured nationally and internationally on Hypertension, Diabetes, and Hyperlipidemia. He also hold the distinction as being the first American Cardiologist to lecture at the University of Bagdad School of Medicine, in 2004, while being the Brigade Surgeon for the 800 MP and the 16 MP (Airborne) Brigades, Colonel in the U.S. Army.

Guillermo E. Umpierrez, MD

Emory University School of Medicine

Guillermo E. Umpierrez, MD, is Professor of Medicine in the Division of Endocrinology, Metabolism, and Diabetes and Associate Director of the General Clinical Research Center at Emory University School of Medicine in Atlanta, Georgia. He is also Director of the Diabetes Clinic and the Diabetes and Endocrinology Section of Grady Health Systems, also in Atlanta. Dr. Umpierrez received his medical degree in Ecuador and completed his internal medicine residency and endocrinology fellowship at Emory University School of Medicine. Dr. Umpierrez is the recipient of numerous teaching awards, including 4 Best Clinical Science Professor Awards, 3 Golden Apple Awards for Best Clinical Teacher, and the Silver Pear Award for Best Clinical Junior Faculty Mentor in the Department of Medicine at Emory University; the J. Willis Hurst Outstanding Bedside Teacher Award, from the Georgia ACP, and the AACE Outstanding Service Award for the Promotion of Endocrine Health of an Underserved Population. He has published more than 100 scientific papers and book chapters, and has presented over 100 research abstracts at national and international scientific meetings. Dr. Umpierrez’s current research interest includes mechanisms for β-cell dysfunction in African Americans; the effects of free fatty acids on insulin secretion, inflammation, and hypertension in obese patients; and management of hyperglycemia in critical and noncritical inpatients. His research program at Grady Hospital and Emory University is funded by the National Institutes of Health and the American Diabetes Association. Dr. Umpierrez also oversees funding of a bilingual diabetes education program for Latino patients in Georgia, and serves as the principal investigator for several multicenter research studies in the area of inpatient glycemic control.

Elizabeth Walker, PhD, RN

Albert Einstein College of Medicine

Elizabeth A. Walker, PhD, RN, CDE is a Professor of Medicine and Professor of Epidemiology & Population Health, and the Director of the Prevention and Control Core for the Diabetes Research and Training Center (DRTC) at the Albert Einstein College of Medicine, Bronx, New York. Dr. Walker is principal investigator of a large NIH-funded behavioral intervention study in minority diabetes populations, using telephonic interventions in Spanish and English to promote medication adherence, lifestyle change and other self-management behaviors. Since its inception, she has also been a behavioral scientist and co-investigator for the multi-center Diabetes Prevention Program (DPP) and Outcomes Study and she co-chairs the DPP Medication Adherence Workgroup. Through the Prevention and Control Core of the DRTC she provides or facilitates various intervention and evaluation services to multiple health disparities projects in academic centers and in the community. Elizabeth is also a diabetes nurse specialist and she has been a certified diabetes educator since 1986. In 2000, she served as the national President, Health Care & Education, of the American Diabetes Association. In 2008, she was named a Fellow of the American Association of Diabetes Educators (FAADE).

Lawrence H. Young, MD

Yale University

Dr. Young is Professor of Medicine in the Section of Cardiology at Yale University School of Medicine in New Haven, Connecticut, USA. He is a board-certified clinical cardiologist and a Fellow of the American Heart Association and American College of Cardiology. His interests center on cardiovascular disease in patients with insulin-resistance and diabetes and he has basic research interests on cardiac metabolism and the fundamental mechanisms by which cardiac cells adapt to stress and ischemia. Dr. Young has been the recipient of numerous research grants, including support from the National Institutes of Health, American Heart Association, American Diabetes Association and Juvenile Diabetes Foundation. He is co-principal investigator of the DIAD (Detection of Ischemia in Asymptomatic Patients with Diabetes) Study, which is developing new approaches to identifying and treating heart disease in patients with diabetes. He is the Cardiology Principal Investigator for the Insulin Resistance Intervention After Stroke Trial (IRIS), which is testing whether treating insulin resistance prevents stroke and myocardial infarction in non-diabetic patients. Dr.Young has held several leadership positions within the American Heart Association.

Sponsors

For sponsorship opportunities please contact Cristine Barreto at cbarreto@nyas.org or 212.298.8652.

Presented by

Takeda

    This program is supported by an educational grant from Takeda Pharmaceuticals North America, Inc.

    This activity is supported by an educational grant from Lilly USA, LLC. For further information concerning Lilly grant funding visit the Lilly Grant Office.

    This event is funded in part by the Life Technologies™ Foundation and by educational grants from Bayer HealthCare Diabetes Care and sanofi-aventis U.S.

    Academy Friends

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    Abstracts

    Origins of Type 2 Diabetes Ethnic Discrepancies

    Enrique Caballero, MD, Harvard Medical School

    This lecture will highlight the main biological, medical, social and cultural factors that influence the disproportionate rates of diabetes and complications in ethnic/racial minorities in the U.S. Some potential strategies to overcome these challenges will be discussed.

    Cardiovascular Risks/Complications in Patients with Type 2 Diabetes: Genetic and Ethnic Considerations

    Harold E. Lebovitz, MD, State University of New York

    Minority diabetic populations have different outcomes than Caucasian diabetic populations. African American and Hispanic type 2 diabetic populations have more visual problems and more end stage renal disease. Mortality from cardiovascular disease is higher in minority diabetic populations than Caucasian populations. It is important to determine the extent to which the cause of ethnic and racial disparities in the prevalence, treatment and clinical outcomes are related to social factors versus differences in the genetic background and the pathophysiology. This presentation will focus on potential influences of different pathophysiology and genetic background. Type 2 diabetes is the consequence of factors which lead to insulin resistance and factors which control beta cell function. The complications of diabetes are related to the chronic metabolic control and the genetic background of the end organs. Insulin resistance in the metabolic syndrome and type 2 diabetes appears to be related to adiposity in general and visceral adiposity specifically. Excessive or diminished products from visceral adipose tissue are taken up by muscle, liver and other tissues. In insulin-sensitive tissues this results in interference with the intracellular transmission of the insulin signal at the level of IRS (insulin receptor substrate) interaction with PI-3 kinase (phosphoinositide 3-kinase). The increased in free fatty acids coming from the adipose tissue causes excessive deposits of triglyceride in the liver (hepatic steatosis)and the muscle intramyocellular compartment. In response to insulin resistance, the beta cell must increase insulin secretion in the basal state and must be able to increase insulin secretion appropriate to meals to maintain normal fasting and postprandial glucose levels. The failure of the beta cell to compensate for insulin resistance results in hyperglycemia. Increases in the delivery of the metabolic products of the metabolic syndrome to the liver leads to dyslipidemia and implements other components of the metabolic syndrome. The increase in cardiovascular disease is associated with the increase in cardiovascular risk factors associated with the metabolic syndrome. There are clinically significant differences in the pathophysiology in different ethnic groups. These differences in ethnic minorities are confounded by the fact that the ethnic minorities are heterogeneous. For example people of African descent have their origins from different parts and tribes of Africa. Hispanic Americans are composed of individuals from Cuban, Mexican, Puerto Rican and other Caribbean and South American populations. Asians are from Oriental or South Asian Indian origins. Consequently the results of studies will depend on the origins of the ethnic population recruited. African Americans of the same BMI and body fat as Caucasians have smaller visceral adipose tissue pools, lower hepatic triglyceride content, and a less atherogenic lipid profile (lower LDL-cholesterol, lower plasma triglyceride, and higher HDL-cholesterol ). They are more insulin resistant and have greater basal hyperinsulinemia than Caucasians. However they are not able to increase insulin secretion in response to increases in glucose as Caucasians and therefore appear to have greater insulin insufficiency than Caucasians. African Americans have lower basal hepatic glucose production than Caucasians. Past studies have shown a lower prevalence of coronary heart disease in African Americans as compared to Caucasians. Hispanic Americans as well as Caucasians with type 2 diabetes have increased visceral adipose tissue pools, increased hepatic steatosis and dyslipidemia compared to their non-diabetic controls. Asian Indians have greater body fat and visceral fat than Caucasians of comparable BMI. Asian Indians are more insulin resistant than comparable other ethnic populations. They have higher plasma free fatty acids, lower adiponectin levels and more hepatic steatosis. The prevalence of coronary artery disease is higher in Asian Indian diabetic populations than in Caucasian diabetic populations. These metabolic differences in ethnic populations need to be considered in developing treatment strategies.

    Cardiovascular Risks/Complications Associated with Type 2 Diabetes with a Special Focus Ethnic Minorities

    Guillermo E. Umpierrez, MD, Emory University School of Medicine

    A recent report from the Centers for Disease Control and Prevention (CDC) indicated that in 2007 about 23.6 million Americans live with diabetes. Diabetes disproportionately affects racial and ethnic minority populations in the U.S. After adjusting for population age, the rate of diabetes is higher in minority populations [Native Americans (16.5%), blacks (11.8%), Hispanics (10.4%), Asian Americans (7.5 percent)] than in non-Hispanic whites (6.6%). The prevalence of diabetes during the past decade was increased by 26% and 37% in Blacks and Hispanics, respectively. There are several factors accounting for the diabetes epidemic in the U.S., including demographic changes (aging, increased growth of at-risk populations); behavioral elements (improper nutrition, decreasing physical activity, obesity); improved surveillance systems that more completely capture the extant burden of diabetes; and our present limited ability to change behaviors. Given the diverse genetic makeup of the different minority groups, some common environmental or combined environmental-genetic factors are likely involved. To date, more than 50 candidate genes for T2DM have been studied in various populations worldwide. “Westernization” including a diet higher in total calories and fat and lower in fibers associated with less need to expend energy is an important risk factor for diabetes. The frequency of chronic complications is increased in minority groups when compared with Caucasians. Many racial/ethnic minorities also demonstrate worse control of their diabetes than whites and poorer control of other cardiovascular risk factors such as hypertension and hyperlipidemia that are often present in individuals with diabetes. Compared with whites, nonwhites often have poorer glycemic control (higher A1C), poorer blood pressure control, poorer LDL control, and higher rates of end-stage renal disease. In the USA, the death rate for people with diabetes is higher for minority populations than for whites. The overall mortality rate is ~20% higher for black men and 40% higher for black women, compared with their white counterparts. The increasing rate of overweight (64%) and obesity (15%) in adults and children currently affecting >120 million people in the U.S. is a major health problem and an important cardiovascular risk factor. The rate of overweight and obesity are higher in minority groups than Caucasians. Based on the NHANES III, the proportion of black women who were overweight or obese was 77% compared with 57% of white women. The prevalence of being overweight or obese in Mexican American men and women is approximately 73%. Of great concern is the increasing prevalence of obesity in minority children and adolescents in the U.S. Data from the National Longitudinal Survey of Youth indicate that the prevalence of overweight has increased by 21.5% among black children, 22% among Hispanic children, and 12% among white children. National health statistics suggest that African Americans with diabetes may be receiving similar access to basic medical services as Caucasians; however the incidence of diabetic complications and mortality rate continues to increase at a rate that exceeds that of Caucasians. Racial disparities in medication adherence across racial and ethnic groups, utilization of health care resources, lack of access to care in Hispanics, lack of insurance coverage, and cultural barriers can explain health disparities in healthcare.

    Screening for Coronary Artery Disease in Type 2 Diabetes

    Lawrence H. Young, MD, Yale University

    Coronary artery disease is a major cause of morbidity and the primary cause of mortality in patients with type 2 diabetes. Screening for asymptomatic coronary artery disease indicates its presence in 20% of asymptomatic patients. Specialized testing stratifies patients according to the extent of inducible ischemia. However, cardiac screening does not impact on the incidence of myocardial infarction or cardiac death over a five year follow-up period and should not be recommended in the general population of asymptomatic patients with type 2 diabetes.

    Testing a Telephonic Behavioral Intervention in the Context of the HbA1c Registry

    Elizabeth Walker, PhD, RN, Albert Einstein College of Medicine

    The New York City DOHMH has developed and implemented an HbA1c registry and the Bronx is the pilot site for the multi-component intervention. The Einstein Diabetes Research & Training Center partnered with investigators at the NYC DOHMH to test in a randomized controlled trial a tailored telephonic intervention compared to a print intervention to improve glycemic control among South Bronx adults with diabetes. This presentation will briefly outline the registry and the NIDDK-funded intervention study, and Dr. Walker will provide some baseline data on over 400 subjects in the study thus far.

    A Public Health Approach to Diabetes Health Disparities

    Ann Albright, PhD, RD, Centers for Disease Control and Prevention

    Efforts over the last decade have resulted in some improvements in diabetes outcomes, but these improvements have not been experienced by everyone. Advances in the clinical care provided to those with diabetes are certainly necessary, but those alone will not yield improvements needed by populations hardest hit. Approaching diabetes prevention and control using a socioecological framework and a focus on social determinants of health will also be required. This presentation will share some of the data and approaches being used by CDC and our partners to address diabetes health disparities.

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