Diabetes Care
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

This Article
Right arrow Extract Freely available
Right arrow Full Text (PDF)
Right arrow Purchase Article
Right arrow View Shopping Cart
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow Request Permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Carnethon, M. R.
Right arrow Articles by Liu, K.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Carnethon, M. R.
Right arrow Articles by Liu, K.
Social Bookmarking
Add to CiteULike   Add to Del.icio.us   Add to Digg   Add to Reddit   Add to Technorati  
What's this?
Diabetes Care 28:2768-2770, 2005
© 2005 by the American Diabetes Association, Inc.

Epidemiology/Health Services/Psychosocial Research
Brief Report

Racial/Ethnic Differences in Subclinical Atherosclerosis Among Adults With Diabetes

The Multiethnic Study of Atherosclerosis

Mercedes R. Carnethon, PHD1, Alain G. Bertoni, MD, MPH2, Steven Shea, MD3,4, Philip Greenland, MD1, Hanyu Ni, PHD5, David R. Jacobs, Jr, PHD6,7, Mohammed Saad, MD8 and Kiang Liu, PHD1

1 Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
2 Department of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, North Carolina
3 Department of Epidemiology Mailman School of Public Health, Columbia University, New York, New York
4 Department of General Medicine, Columbia University Medical Center, Columbia University, New York, New York
5 National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
6 Division of Epidemiology, University of Minnesota School of Public Health, Minneapolis, Minnesota
7 Department of Nutrition, University of Oslo, Oslo, Norway
8 Division of Endocrinology, University of California, Los Angeles, California

Address correspondence and reprint requests to Mercedes R. Carnethon, Department of Preventive Medicine, 680 N. Lake Shore Dr., Suite 1102, Chicago, IL 60611. E-mail:carnethon{at}northwestern.edu

Abbreviations: ABI, ankle brachial index • CAC, coronary artery calcium • CVD, cardiovascular disease • IMT, intimal medial thickness • MESA, Multiethnic Study of Atherosclerosis • PAD, peripheral artery disease


   INTRODUCTION
TOP
 INTRODUCTION
RESEARCH DESIGN AND METHODS
 RESULTS
 CONCLUSIONS
 References
 
Recent findings from the Multi-ethnic Study of Atherosclerosis (MESA) (1) are consistent with previous reports that non-Hispanic white (white) adults have a greater presence and quantity of coronary artery calcium (CAC) than non-Hispanic black (black), Hispanic, and Chinese-American (Chinese) adults (2,3,4,5). It is not known whether previously reported racial/ethnic differences in atherosclerosis persist in the presence of type 1 or type 2 diabetes, an established risk factor for cardiovascular disease (CVD). Further, it is not known whether previously reported racial/ethnic differences in markers of atherosclerosis in the carotid and peripheral arteries (6,7) are also present among persons with diabetes. We assessed whether racial/ethnic differences in CAC, common and internal carotid intimal medial thickness (IMT), and the ankle brachial index (ABI) were evident in persons with diabetes in the MESA cohort and whether these differences persisted following adjustment for measured cardiovascular disease risk factors.


   RESEARCH DESIGN AND METHODS
TOP
 INTRODUCTION
 RESEARCH DESIGN AND METHODS
RESULTS
 CONCLUSIONS
 References
 
MESA is a multicenter study of 6,814 men and women aged 45–84 who were free from clinical CVD in 2000–2002 (8). From the cohort of 6,814 participants, we excluded 25 participants without glucose measurements and 5,761 without diabetes. Our final analysis sample included 204 whites, 387 blacks, 311 Hispanics, and 126 Chinese with diabetes. The prevalence of diabetes in the cohort by race/ethnicity is comparable to that reported in a general U.S. population survey (9).

Demographics, clinical characteristics, and health behavior data were collected in a standardized manner at all study sites by trained personnel; blood assays were processed at central laboratories (10,11). Diabetes was defined according to measured fasting glucose of at least 7.0 mmol/l (126 mg/dl), self-reported previous physician diagnosis, or use of diabetes medication. Computed tomography was performed using a cardiac-gated electron-beam computed tomography scanner or a prospectively electrocardiogram-triggered scan acquisition multidetector computed tomography system over phantoms of known physical calcium concentrations. High-resolution B-mode ultrasonography was used to capture images of the bilateral common carotid and internal carotid arteries using a Logiq 700 ultrasound machine (General Electric Medical Systems) at all centers (10). ABI, the ratio of ankle to arm blood pressure, was computed separately for each leg using a Doppler probe (12). Peripheral artery disease (PAD) was defined as ABI <0.90 in either ankle (13). All analyses were conducted using SAS version 9.0 (SAS Institute, Cary, NC).


   RESULTS
TOP
 INTRODUCTION
 RESEARCH DESIGN AND METHODS
 RESULTS
CONCLUSIONS
 References
 
The mean age and BMI of the sample were 67 years and 30.6 kg/m2, respectively; 65% of participants were using diabetes control medications, ranging from a high of 68% in black and Hispanic participants to 55% in whites. Hypertension and treated hypercholesterolemia were present in 66 and 26% of the sample, respectively.

The highest prevalence of measurable CAC was in whites (78%), followed by Chinese (68%), Hispanics (58%), and blacks (54%) (overall 62%). CAC >400 (17% of the total) followed a similar pattern of prevalence with 24, 20, 15, and 14% of white, Chinese, Hispanic, and black participants, respectively, affected. Following adjustment for age, sex, high school education, health insurance, current alcohol intake, cigarette smoking, physical activity, hypertension, total and HDL cholesterol, cholesterol medication use, and BMI in a multivariable logistic regression model, the odds of having any CAC were lower in blacks (OR [95% CI] 0.32 [0.2–0.51]; P < 0.0001) and Hispanics (0.37 [0.23–0.60]; P < 0.0001) compared with whites with diabetes, but did not differ between Chinese and whites (0.66 [0.36–1.22]; P = 0.18). Similar patterns were present for CAC >400. Although prevalence of PAD varied by ethnicity (9.5, 8.5, 6.4, and 5% of black, white, Chinese, and Hispanic participants, respectively), the age- and sex-adjusted odds of having PAD comparing blacks (1.26 [0.67–2.37]; P = 0.68), Hispanics (0.59 [0.28–1.23]; P = 0.13), and Chinese (0.65 [0.26–1.59]; P = 0.29) to whites did not differ significantly from 1.0. Results were unchanged following adjustment for duration of diabetes control medications (a surrogate for diabetes duration).

Among participants with any measurable CAC, geometric mean scores calculated from linear regression models and compared using ANOVA did not differ significantly across ethnicities. Lower IMT scores were noted among Chinese compared with whites, and ABI values were lower among blacks compared with whites and other ethnicities (Table 1).


View this table:
[in this window]
[in a new window]
  		Table 1— Means (95% CIs) of measures of subclinical atherosclerosis by race/ethnicity among persons with diabetes

 

   CONCLUSIONS
TOP
 INTRODUCTION
 RESEARCH DESIGN AND METHODS
 RESULTS
 CONCLUSIONS
References
 
In this study of asymptomatic men and women without a prior diagnosis of atherosclerotic disease, we found excess atherosclerosis in whites with diabetes compared with blacks and Hispanics that was restricted to calcification in the coronary arteries. However, among those participants with measurable CAC, the levels did not differ significantly by ethnicity, which suggests that the burden among those with some calcification was similar. Our finding of smaller IMT among Chinese compared with other ethnicities is consistent with studies of clinical outcomes of persons with diabetes that demonstrate lower risks of myocardial infarction in Asians with diabetes versus whites (14). Conflicting results in Chinese for IMT and CAC indicate that further research is needed in this ethnic group.

The finding that blacks with diabetes have lower ABI than whites and Hispanics is consistent with findings in this population that were not restricted to persons with diabetes (7) and reports of PAD prevalence in other samples (6,7,11,15). One explanation for the absence of a statistically significant finding between ethnicity and PAD is that clinical PAD is often present with CVD (6). Although the mean age in this sample is similar to the age of onset of PAD, participants in this study were chosen specifically because they did not have clinical CVD. Consequently, the overall prevalence of PAD in this sample is low, and those with PAD did not have CVD comorbidities, which may contribute to ethnic disparities in PAD in other population samples.

This population-based study of adults with diabetes who are free from clinical CVD describes racial/ethnic variations in the presence of atherosclerosis across different vascular beds that are consistent with previous reports in this sample (1) and most others (2,3,4,5) that are not restricted to persons with diabetes. Further research to explore how these ethnic differences in subclinical atherosclerosis relate to clinical outcomes in persons with diabetes is warranted.


   Acknowledgments
 
This research was supported by contracts N01-HC-95159 through N01-HC-95166 and N01-HC-95169 from the National Heart, Lung, and Blood Institute. M.R.C. was supported in part by a career development award from the National Heart Lung and Blood Institute (1K01 HL73249-01).


   Footnotes
 
A table elsewhere in this issue shows conventional and Système International (SI) units and conversion factors for many substances.

Received for publication May 9, 2005. Accepted for publication July 21, 2005.


   References
TOP
 INTRODUCTION
 RESEARCH DESIGN AND METHODS
 RESULTS
 CONCLUSIONS
 References
 

  1. Bild DE, Detrano R, Peterson D, Guerci A, Liu K, Shahar E, Ouyang P, Jackson S, Saad MF: Ethnic differences in coronary calcification: the Multi-Ethnic Study of Atherosclerosis (MESA). Circulation 111:1313–1320, 2005[Abstract/Free Full Text]
  2. Lee TC, O’Malley PG, Feuerstein I, Taylor AJ: The prevalence and severity of coronary artery calcification on coronary artery computed tomography in black and white subjects. J Am Coll Cardiol 41:39–44, 2003[Abstract/Free Full Text]
  3. Reaven PD, Thurmond D, Domb A, Gerkin R, Budoff MJ, Goldman S: Comparison of frequency of coronary artery calcium in healthy Hispanic versus non-Hispanic white men by electron beam computed tomography. Am J Cardiol 92:1198–1200, 2003[Medline]
  4. Sacco RL, Roberts JK, Boden-Albala B, Gu Q, Lin IF, Kargman DE, Berglund L, Hauser WA, Shea S, Paik MC: Race-ethnicity and determinants of carotid atherosclerosis in a multiethnic population: the Northern Manhattan Stroke Study. Stroke 28:929–935, 1997[Abstract/Free Full Text]
  5. Doherty TM, Tang W, Detrano RC: Racial differences in the significance of coronary calcium in asymptomatic black and white subjects with coronary risk factors. J Am Coll Cardiol 34:787–794, 1999[Abstract/Free Full Text]
  6. Selvin E, Erlinger TP: Prevalence of and risk factors for peripheral arterial disease in the United States: results from the National Health and Nutrition Examination Survey, 1999–2000. Circulation110:738–743, 2004
  7. McDermott MM, Liu K, Criqui MH, Ruth K, Goff D, Saad MF, Wu C, Homma S, Sharrett AR: Ankle brachial index and subclinical cardiac and carotid disease: the Multi-Ethnic Study of Atherosclerosis. Am J Epidemiol 162:33–41, 2005[Abstract/Free Full Text]
  8. Bild DE, Bluemke DA, Burke GL, Detrano R, Diez Roux AV, Folsom AR, Greenland P, Jacob DR Jr, Kronmal R, Liu K, Nelson JC, O’Leary D, Saad MF, Shea S, Szklo M, Tracy RP: Multi-ethnic study of atherosclerosis: objectives and design. Am J Epidemiol 156:871–881, 2002[Abstract/Free Full Text]
  9. Prevalence of diabetes and impaired fasting glucose in adults: United States, 1999–2000. JAMA290:1702–1703, 2003
  10. O’Leary DH, Polak JF, Kronmal RA, Manolio TA, Burke GL, Wolfson SK Jr: Carotid-artery intima and media thickness as a risk factor for myocardial infarction and stroke in older adults: Cardiovascular Health Study Collaborative Research Group. N Engl J Med 340:14–22, 1999[Abstract/Free Full Text]
  11. Newman A, Siscovick D, Manolio T, Polak J, Fried L, Borhani N, Wolfson S: Ankle-arm index as a marker of atherosclerosis in the Cardiovascular Health Study: Cardiovascular Heart Study (CHS) Collaborative Research Group. Circulation 88:837–845, 1993[Abstract/Free Full Text]
  12. McDermott MM, Criqui MH, Liu K, Guralnik JM, Greenland P, Martin GJ, Pearce W: Lower ankle/brachial index, as calculated by averaging the dorsalis pedis and posterior tibial arterial pressures, and association with leg functioning in peripheral arterial disease. J Vasc Surg 32:1164–1171, 2000[Medline]
  13. Olin JW: The clinical evaluation and office based detection of peripheral arterial disease. In An Office-Based Approach to the Diagnosis and Treatment of Peripheral Arterial Disease. Am J Med Continuing Education Series, Part I. Hillsborough, NJ, Excerpta Medica, 2001
  14. Karter AJ, Ferrara A, Liu JY, Moffet HH, Ackerson LM, Selby JV: Ethnic disparities in diabetic complications in an insured population. JAMA 287:2519–2527,2002
  15. Collins TC, Petersen NJ, Suarez-Almazor M, Ashton CM: The prevalence of peripheral arterial disease in a racially diverse population. Arch Intern Med 163:1469–1474, 2003[Abstract/Free Full Text]

Add to CiteULike CiteULike   Add to Del.icio.us Del.icio.us   Add to Digg Digg   Add to Reddit Reddit   Add to Technorati Technorati    What's this?


This article has been cited by other articles:


Home page
 Diabetes CareHome page
T. T. Nguyen, J. J. Wang, A. R. Sharrett, F.M. A. Islam, R. Klein, B. E.K. Klein, M. F. Cotch, and T. Y. Wong
Relationship of Retinal Vascular Caliber With Diabetes and Retinopathy: The Multi-Ethnic Study of Atherosclerosis (MESA)
Diabetes Care, March 1, 2008; 31(3): 544 - 549.
[Abstract] [Full Text] [PDF]

Home page
 Med Care Res RevHome page
A. M. Davis, L. M. Vinci, T. M. Okwuosa, A. R. Chase, and E. S. Huang
Cardiovascular Health Disparities: A Systematic Review of Health Care Interventions
Med Care Res Rev, October 1, 2007; 64(5_suppl): 29S - 100S.
[Abstract] [PDF]

Home page
 DiabetesHome page
T. Mazzone, P. M. Meyer, G. T. Kondos, M. H. Davidson, S. B. Feinstein, R. B. D'Agostino Sr., A. Perez, and S. M. Haffner
Relationship of Traditional and Nontraditional Cardiovascular Risk Factors to Coronary Artery Calcium in Type 2 Diabetes
Diabetes, March 1, 2007; 56(3): 849 - 855.
[Abstract] [Full Text] [PDF]

Home page
 HypertensionHome page
B. I. Freedman, D. W. Bowden, M. M. Sale, C. D. Langefeld, and S. S. Rich
Genetic Susceptibility Contributes to Renal and Cardiovascular Complications of Type 2 Diabetes Mellitus
Hypertension, July 1, 2006; 48(1): 8 - 13.
[Full Text] [PDF]

Home page
 Diabetes CareHome page
A. G. Bertoni, D. C. Goff Jr, R. B. D'Agostino Jr, K. Liu, W. G. Hundley, J. A. Lima, J. F. Polak, M. F. Saad, M. Szklo, R. P. Tracy, et al.
Diabetic Cardiomyopathy and Subclinical Cardiovascular Disease: The Multi-Ethnic Study of Atherosclerosis (MESA).
Diabetes Care, March 1, 2006; 29(3): 588 - 594.
[Abstract] [Full Text] [PDF]

This Article
Right arrow Extract Freely available
Right arrow Full Text (PDF)
Right arrow Purchase Article
Right arrow View Shopping Cart
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow Request Permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Carnethon, M. R.
Right arrow Articles by Liu, K.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Carnethon, M. R.
Right arrow Articles by Liu, K.
Social Bookmarking
Add to CiteULike   Add to Del.icio.us   Add to Digg   Add to Reddit   Add to Technorati  
What's this?

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
Diabetes Diabetes Care Clinical Diabetes Diabetes Spectrum