Understanding Health Disparities in the Progression of Type 2 Diabetes

描述(由申请人提供)：众所周知，吸烟、饮酒、饮食和体育活动等与生活方式相关的可改变行为极大地增加了大多数常见身体健康状况的风险。最近，与这些健康行为有关的疾病，特别是高血压、2型糖尿病、心血管疾病(CVD)的患病率几乎是流行病的增加，这些疾病的负担在不同种族和民族之间的差异越来越大，这突显了制定有效预防战略的紧迫性--然而，很少有干预研究产生生活方式和行为的长期变化。针对现有行为干预模型中的一个疏漏，我们提出，需要在健康行为、慢性应激的来源和应对反应之间的相互关系以及它们对身心健康的影响的背景下检查行为变化。这一建议的动机是一项强有力的文献，该文献表明，美国黑人更有可能从事不良的健康行为(即吸烟、高脂肪和碳水化合物饮食、过度饮酒)，并且与非西班牙裔白人相比，预期会经历与这些行为相关的常见身体健康状况的不成比例的负担，包括心血管疾病和糖尿病-然而，矛盾的是，基于人口和临床的研究一直发现，与白人相比，黑人有相同或更低的大多数精神障碍的发生率，即使经历了更高的心理苦恼。我们的理论是，一套明确的与健康相关的压力应对策略(即吸烟、高脂肪和高碳水化合物的饮食、过量饮酒等)具有双管齐下的效果，有助于解释这种违反直觉的模式。首先，我们认为这些行为作用于下丘脑-垂体-肾上腺(HPA)轴和相关的应激-激素系统，从而影响应激相关精神障碍的主观体验和发展。其次，我们认为，这些不良行为对病理生理学的影响，加上整个生命过程中紧张的生活条件的直接影响，导致黑人慢性身体健康问题的不成比例的负担。简而言之，我们建议黑人和其他来自高压力人群的个人以他们日益恶化的身体健康为代价，“购买”他们相对积极的精神障碍比率。因此，这一框架表明，坚持传统的预防性护理，特别是改变行为生活方式，可能会导致反常的结果：身体健康改善，但精神健康恶化。我们将扩展这一研究范围，并评估传统预防性护理在三类2型糖尿病患者中的效果：1)前期或临界期；2)早期发病；以及3)控制不良。在拟议的加速纵向设计中，我们将在糖尿病进展的三个不同点检查压力、健康行为和身心健康之间的相互关系。 公共卫生相关性：2型糖尿病及其相关危险因素，如高血压和心脏病，继续位居国内和国际公共卫生议程的首位。在诊断出这些情况之后，总是会建议进行广泛的行为调整。在所有情况下，长期坚持建议的健康行为改变的比率充其量也是参差不齐的，无论是在内部还是在个体之间。我们认为，身体和心理健康的差异与缺乏行为改变的坚持有关。这项研究的结果将有助于预测、理解和确定非正式和正式的计划和公共卫生政策，以应对在美国和其他发达国家和发展中国家面临的日益流行的相关心血管和代谢紊乱所面临的身心健康挑战。

DESCRIPTION (provided by applicant): It is well-established that modifiable, lifestyle-related behaviors including smoking, alcohol, diet, and physical activity greatly contribute to the risk of most common physical health conditions. The recent, almost epidemic increase in the prevalence of diseases associated with these health behaviors, especially hypertension, type 2 diabetes, cardiovascular disease (CVD), and growing disparities in the burden of these conditions across racial and ethnic groups, highlights the urgency of developing effective prevention strategies - however, few intervention studies have produced long-term changes in lifestyle and behaviors. Addressing an omission in existing behavioral intervention models, we propose that what is needed is an examination of behavioral change in the context of the interrelationships among health behaviors, sources of and coping responses to chronic stress, and their influence on physical and mental health. This proposal is motivated by a robust literature that indicates blacks in the US are more likely to engage in poor health behaviors (i.e., tobacco smoking, diets high in fat and carbohydrates, excessive alcohol use) and, expectedly, experience disproportionate burdens of common physical health conditions associated with these behaviors, including CVD and diabetes, relative to non-Hispanic whites - paradoxically, however, population-based and clinic studies have consistently found that blacks, in comparison to whites, have the same or lower rates of most mental disorders, even while experiencing higher rates of psychological distress. We theorize that a defined set of health-related stress-coping strategies (i.e., tobacco smoking, diets high in fat and carbohydrates, excessive alcohol use, etc) have a two-pronged effect that helps to account for this counterintuitive patterning. First, we suggest that these behaviors act on the hypothalamic-pituitary-adrenal (HPA) axis and related stress- hormonal systems which influences the subjective experience and development of stress-associated psychiatric disorder. Second, we believe that the effects of these poor behaviors on pathophysiology, combined with direct effects of stressful living conditions over the life-course, contribute to disproportionate burden of chronic physical health problems among blacks. Succinctly, we propose that blacks and other individuals from highly stressed populations "buy" their relative, comparatively positive rates of mental disorders at the expense of their deteriorating physical health. Therefore, this framework suggests that adherence to traditional preventative care, specifically involving changes in behavioral lifestyle, can lead to a perverse result: improvements in physical health but worsening of mental health. We will extend this line of research and assess the effect of traditional preventative care among three categories of type 2 diabetes patients: 1) pre- or borderline; 2) early onset; and, 3) poorly-controlled. In the proposed accelerated longitudinal design we will examine the inter-relationships among stress, health behaviors, and physical and mental health at three distinct points of diabetes progression. PUBLIC HEALTH RELEVANCE: Type 2 diabetes and its associated risk factors such as hypertension and heart disease continue to top the domestic and international public health agendas. The diagnoses of these conditions are invariably followed by recommendations for extensive behavioral modifications. In all cases rates of long-term adherence to recommended healthy behavioral changes are spotty at best, both intra-and inter-individually. We believe that physical and mental health disparities are linked to the lack of behavioral change adherence. The findings of this study will help anticipate, understand, and identify informal and formal programs and public health policies needed to address the physical and mental health challenges facing the growing epidemic of related cardiovascular and metabolic disorders in the U.S. and other developed and developing countries.