Lipids and psychosocial status in aboriginal persons with and at risk for Type 2 diabetes: implications for tertiary prevention
Introduction
Diabetes mellitus (DM), mostly Type 2 DM, has become a serious public health problem in the Canadian aboriginal population [1]. In Canada, age-adjusted prevalence rates range from 5 to 10% for aboriginal people. These rates exceed by two to four times those for all other Canadians, for whom diabetes prevalence is close to 2.5%. The risk of death from diabetes for aboriginal Canadians is twice as high for men, and four times higher for women, than the risk for their counterparts in the general Canadian population [2]. Given continuing increases in prevalence rates, diabetes in the Canadian aboriginal population is considered to have reached “epidemic” proportions, such that all aboriginal people are at high risk for the disease [3].
Diabetes coexists with other conditions that contribute to morbidity and mortality. The objective in the management of diabetes is to control hyperglycemia. The fundamental rationale for glucose control is to prevent macrovascular and microvascular complications [4]. Rates of complications are greater for aboriginal than for non-aboriginal populations, and rates per case of outpatient visits and hospital admissions for diabetic aboriginal people are more than twice those of non-diabetic aboriginal people [5].
Coronary heart disease (CHD) is the leading cause of death for people with diabetes, and the risk of mortality due to CHD is two to four times greater for diabetic than for non-diabetic persons [6]. Dyslipidemias such as low high-density lipoprotein cholesterol (HDL-C) and high triglyceride concentration are the major risk factors for CHD related to diabetes [7], [8]. Given a need for community-level preventive strategies against diabetes [9], the substantial impact of diabetes in aboriginal populations warrants a shared focus on promotive and rehabilitative aspects of the disease. Hyperglycemia may be controlled, but low HDL-C and high triglyceride levels may persist despite therapy [10]. Behavioral and psychosocial aspects of tertiary prevention of macrovascular complications of diabetes have earned little attention [11].
Behavioral treatment is informed by an understanding of relations between psychosocial factors and effective therapy. Locus of control is important for achieving effective control of diabetes [12]. For persons with Type 1 DM, treatment compliance is positively associated with perceived benefit, emotional stability, and supportive structure, and negatively associated with perceived barriers and negative social environment [13]. Individuals with Type 2 DM are more likely to comply with treatment regimens, given positive relationships with health care providers [14]. Low mastery, the extent to which people feel control of the forces affecting their lives, is associated with Type 2 DM and inversely related to fasting glucose concentration in aboriginal people with and at risk for the disease [15]. Depression has been linked to an elevated risk of Type 2 DM [16], and positive mood is associated with effective diabetes control [17].
Further research on persons without diabetes has implicated depression in the development and progression of CHD [18], [19]. The possibility that positive psychosocial status is negatively related to risk factors for CHD in people with or at risk for diabetes has not been studied, however. The psychosocial aspect of diabetes among aboriginal people has been widely overlooked, and research on psychosocial factors in diabetic dyslipidemia has not been published. This study tested the hypotheses that positive psychosocial status is related to healthful HDL-C and triglyceride concentrations, and that relationships between psychosocial factors and lipids are similar across glycemic status classifications, in aboriginal persons with and at risk for diabetes. Our results have implications for health professionals concerned with the tertiary prevention of diabetic dyslipidemia in aboriginal and other under-served populations.
Section snippets
Population and setting
Data analyzed in this report are from a diabetes screening program among on-reserve registered Indians in British Columbia’s rural Okanagan region. Persons indigenous to this area are of the Interior Salishan linguistic group and the Plateau area culture. The Okanagan region falls into the South Mainland Zone quadrant defined by the Medical Services Branch, Health Canada. Registered Indians in this region are of limited educational attainment and low socio-economic status, relative to the
Participant characteristics
Individuals with diabetes and IGT did not differ in terms of the distribution of gender, age, education, BMI, dietary behavior, or physical activity (Table 1). Relative to persons with diabetes and IGT, normoglycemic persons were younger (by 16 years) (t196=7.1, P=0.0001), had more years of education (χ2=19.9 with 2 d.f., P=0.0001), were less likely to be married (χ2=12.5 with 2 d.f., P=0.002), and had lower BMI (t196=2.9, P=0.004). The difference in age was of greatest magnitude, and in
Discussion
In our study population, relationships between HDL-C and psychosocial measures were associated with glycemic status, differing significantly across glycemic status classifications. For persons with diabetes and IGT, HDL-C was positively related to mastery, and inversely related to depression. These relations are in the expected direction; however, this was not the case for normoglycemic persons, for whom HDL-C was inversely associated with mastery but not associated with depression.
Acknowledgements
This research was supported by grants from the National Health Research and Development Program of Health Canada (grant #6610–2022-ND), and the Medical Research Council of Canada (grant #9704H5N-1005–55102). The authors are indebted to their colleague, Margaret Çargo, PhD, Groupe de recherche interdisciplinaire en sante, Faculté de medécine, Université de Montréal, for helpful comments and critical questions on an earlier version of this paper. The authors extend appreciation to the Salishan
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