You are on page 1of 12

Journal of Racial and Ethnic Health Disparities

https://doi.org/10.1007/s40615-018-0477-y

HRQOL in Diverse Ethnic Groups with Diabetes: Findings


from the 2014 BRFSS
Kelley Newlin Lew 1 & Julie Wagner 2 & Omar Braizat 1

Received: 19 June 2017 / Revised: 16 September 2017 / Accepted: 27 February 2018


# W. Montague Cobb-NMA Health Institute 2018

Abstract
Objective The study’s objective is to examine differences in mental and physical health-related quality of life (HRQOL) in non-
Hispanic Whites, non-Hispanic Blacks, and Hispanics adults with diabetes.
Design A secondary analysis of 2014 Behavioral Risk Factor Surveillance System (BRFSS) data was conducted. A total of 26
states participated in the 2014 BRFSS core and optional diabetes models (n = 17,923). HRQOL was measured by the number of
mentally and physically unhealthy days during the past month, respectively. A series of regression models were developed to assess
differences in HRQOL without and with inclusion of demographic (age, marital status, income, gender, and education) and
diabetes-related (depression, sleep time, insulin use, complications, age of diabetes diagnosis, BMI, smoking, and exercise) factors.
Results In the fully adjusted models (inclusion of demographic and diabetes-related factors), non-Hispanic Whites had more
mentally (β = 0.88, p = 0.03) and physically (β = 1.35, p = 0.01) unhealthy days per month compared to Hispanics. Non-Hispanic
Blacks (β = 1.42, p < 0.0001) also had more mentally unhealthy days per month in relation to Hispanics when adjusting for
demographic and diabetes-related factors. Depression emerged as a potent predictor of mentally (β = 8.60; p < 0.0001) and
physically (β = 4.43; p < 0.0001) unhealthy days in the multivariate models.
Conclusion Non-Hispanic Black and White adults with diabetes may be more vulnerable to poor HRQOL compared to their
Hispanic counterparts. Increased, widened application of diabetes interventions targeting depression appears warranted to im-
prove HRQOL outcomes.

Keywords Health-related quality of life . Diabetes . Ethnic minorities

Ethnic minorities are disproportionately burdened by diabetes QOL is a multidimensional construct that captures an indi-
and its secondary complications. Among United States (US) vidual’s subjective perception of physical, emotional, and so-
adults,Hispanics(12.8%)andnon-HispanicBlacks(13.2%)have cial well-being. This global construct also captures specific
higher rates of diabetes relative to non-Hispanic Whites (7.6%) subdomains, such as health, with attention, for example, to
[1]. Whereas diabetes treatment aims to optimize diabetes clinical both subjective mental and physical health-related (HR)QOL
outcomes, such as prevention or amelioration of secondary com- [5].
plications, an associated aim is quality of life (QOL) [2]. Although US health policy has focused on eliminat-
Compelling evidence suggests that QOL uniquely contributes ing health disparities over the last two decades, it re-
to mortality, independent of duration of diabetes, smoking status, mains uncertain which ethnic groups with diabetes are
glycemic control, and diabetes-related complications [3, 4]. disproportionately burdened by poor health-related qual-
Among those burdened by diabetes, addressing QOL may im- ity of life (HRQOL). To more fully understand and,
prove the subjective experience of living with this progressive, thereby, contribute to elimination of HRQOL disparities
chronic disease while also reducing risk for pre-mature mortality. in diverse diabetes populations, additional research is
warranted. Thus, the purpose of this study is to examine
differences in mental and physical HRQOL in non-
* Kelley Newlin Lew Hispanic Whites, non-Hispanic Blacks, and Hispanics
kelley.newlin_lew@uconn.edu
with consideration of demographic and diabetes-related
(depression, sleep time, insulin use, complications, age
1
University of Connecticut, Storrs, CT, USA of diabetes diagnosis, body mass index [BMI], smoking,
2
University of Connecticut Health Center, Farmington, CT, USA and exercise) factors.
J. Racial and Ethnic Health Disparities

Literature Review nocturia, obstructive sleep apnea (OSA), and restless leg syn-
drome (RLS), which, in turn, may diminish HRQOL.
HRQOL Analysis of 2005–2008 NHANES data revealed that adults
with diabetes were at higher risk for sleep problems (particu-
A growing number of studies have examined levels of HRQOL larly nocturia, inadequate sleep, OSA, and symptoms of RLS),
across ethnically diverse US diabetes populations with varied relative to the general population, after adjustment for condi-
findings reported [6–11]. Analysis of 2001–2010 National tions contributing to poor sleep [18]. Additional research sug-
Health and Nutrition Examination Survey (NHANES) data gests that poor sleep quality or problems are related to decre-
(n = 2594), for example, revealed that Hispanics with diabetes ments in mental and physical HRQOL in diabetes populations
had more optimal mental and physical HRQOL compared to [19, 20]. The relationship of OSA and RLS to HRQOL in
their non-Hispanic White counterparts. Differences in mental or diabetes populations is understudied. However, related re-
physical HRQOL between non-Hispanic Whites and Blacks search suggests that both conditions may compromise
were not observed [8]. Another study, sampling older adults HRQOL [21, 22].
with diabetes (N = 6096), reported both Hispanics and Blacks
had more optimal physical, but not mental, HRQOL in relation
Insulin Therapy and HRQOL
to Whites [9]. Additional research (n = 21,504) suggests that
Hispanics may have better HRQOL compared to Blacks and
Insulin therapy, for some with diabetes, may be demanding in
Whites [6]. Yet, the Diabetes Attitudes, Wishes, and Needs
terms of daily self-management and elicit fear, secondary to
study (n = 1055) found that Hispanics with diabetes had poorer
QOL in relation to African Americans but not Whites [11]. risk for hypoglycemia, and thereby potentially affect HRQOL
Mixed findings across the literature may reflect varied mea- [23–25]. Research results are mixed in terms of the relation-
surement of HRQOL, sampling frames, and adjustments for ship of insulin therapy to HRQOL. Analysis of Behavioral
covariates. Across the literature, salient covariates—such as Risk Factor Surveillance System (BRFSS) data revealed,
depression, sleep patterns or quality, insulin use, age of diabe- among older adults with diabetes, that mental and physical
tes diagnosis, diabetes-related complications, BMI, smoking, HRQOL were reduced for those treated with insulin compared
and exercise—are not consistently included in the analyses in to those not treated with insulin in the adjusted models [26].
examining differences in HRQOL across diverse ethnic Findings from the Diabetes Control and Complications Trial
groups [6–10]. Inadequate selection of important background (DCCT), however, indicate that intensive multiple daily injec-
variables affecting the dependent variables, such as mental tion therapy is not associated with decrements in HRQOL in
and physical HRQOL, may lead to omitted variable bias. In patients with type 1 diabetes (T1D) [27]. Yet, among those
multivariate modeling, adequate inclusion of background var- with type 2 diabetes (T2D), a number of reports suggest insu-
iables is critical in order to adjust for differences in the sample lin therapy may contribute to poor HRQOL [28–30].
population and allow for more precise comparisons across
groups, thereby enhancing validity of the study findings. Diabetes-Related Complications and HRQOL

Diabetes-related complications include nephropathy, retinop-


Depression and HRQOL athy with or without visual impairment, stroke, and myocar-
dial infarction, among others. Research findings suggest that
Depression is a well-established co-morbidity of diabetes. diabetes-related complications contribute to reduced HRQOL
Depression is a chronic disease characterized by symptoms that [30–33]. For example, analyzing a longitudinal data set repre-
may include poor mood, loss of interests or pleasure, sleep distur- sentative of diabetes patients from 20 countries in Australasia,
bance, and appetite changes [12]. Among Hispanics, Blacks, and Asia, Europe, and North America, the relationship of HRQOL
Whites with diabetes, data tend to suggest that depression preva- to diabetes-related complications was assessed on four occa-
lence is fairly comparable and often estimated at ~ 30% across sions over a 5-year period. Findings revealed that the presence
groups [13–16]. A body of research suggests that depression is a of having any diabetes-related complication (e.g., stroke,
strong predictor of HRQOL in populations with diabetes. A sys- myocardial infarction, ischemic heart disease, renal failure,
tematic review (N = 14) reported depressive symptoms dimin- and blindness) significantly reduced HRQOL scores while
ished HRQOL, particularly its mental health dimension, across adjusting for baseline age, sex, and economic region [32].
both global and disease-specific measures [17].
BMI and HRQOL
Sleep and HRQOL
BMI is a metric based on height and weight that may be used
Among people with diabetes, sleep patterns or quality may be to assess weight categories for both adult men and women.
disrupted by inadequate sleep (< 7 h per night), insomnia, Standard weight categories are underweight (BMI < 18.5),
J. Racial and Ethnic Health Disparities

normal or healthy weight (BMI = 18.5–24.9), overweight exercise) factors. In so doing, the following research questions
(BMI = 25.0–29.9, and obese (BMI ≥30). It is well established are posed:
that, among populations with diabetes, an elevated BMI, indic-
ative of overweight or obesity, may contribute to poor HRQOL 1. Across Hispanic, non-Hispanic Black, and non-Hispanic
[8, 28, 30, 34, 35]. For example, in the Canadian Community White populations with diabetes, are there significant dif-
Health Survey Cycle 1.1 (n = 5497), determinants of HRQOL ferences in mental and physical HRQOL?
in adults with T2D were examined with multivariate analyses. 2. Across Hispanic, non-Hispanic Black, and non-Hispanic
Results revealed obesity provided significant explanatory pow- White populations with diabetes, are there significant dif-
er in predicting HRQOL [30]. Analyzing 2001–2010 ferences in mental and physical HRQOL following ad-
NHANES data (n = 2594) to investigate predictors of justments for demographics?
HRQOL in diverse ethnic groups with diabetes, another study 3. Across Hispanic, non-Hispanic Black, and non-Hispanic
reported that an increased BMI negatively predicted physical White populations with diabetes, are there significant dif-
HRQOL. Among non-Hispanic Whites, being overweight ferences in mental and physical HRQOL following ad-
contributed to more limited activity days while being obese justments for demographics and diabetes-related factors?
predicted more frequent physically unhealthy days for non-
Hispanic Blacks [8].

Methods
Smoking and HRQOL
Study Design and Data Source
In diabetes populations, several studies report that smoking is
related to poorer HRQOL [8, 2834, 35]. In addition to in-
A secondary quantitative analysis of cross-sectional
creased BMI, the 2001–2010 NHANES study also reported
2014 BRFSS data was conducted. The BRFSS is an ongoing,
current smoking status was a significant predictor of poorer
annual surveillance system designed to measure behavioral risk
mental and physical HRQOL for non-Hispanic Whites and
factors for the non-institutionalized adult population residing in
Blacks, but not Hispanics, with diabetes [8]. Similarly, the
the USA and participating territories (District of Columbia,
Alberta Longitudinal Exercise and Diabetes Research
Puerto Rico, and Guam), referred to as states in this document
Advancement study reported being a non-smoker predicted
consistent with BRFSS terminology. Administered and sup-
more optimal HRQOL in adults with T1D (N = 490) and
ported by the Centers for Disease Control (CDC), the BRFSS
T2D (N = 1147), respectively [34, 35].
consists of a (1) core component (administered across all states)
and (2) optional modules (administered selectively across
Exercise and HRQOL states) (see the BMeasures^ section) [42].

A positive relationship between exercise and HRQOL in pop- Sample


ulations with diabetes is well documented [28, 30, 36–41]. For
example, a study (n = 173), ancillary to the Health Benefits of The BRFSS is a state-based system of telephone surveys
Aerobic and Resistance Training in individuals with type 2 (landline and cellular) that selects adults aged ≥ 18 years with
Diabetes (HART-D), investigated the effect of aerobic random dialing procedures. In conducting the BRFSS landline
training, resistance training, or a combination of resis- telephone survey, data were collected from a randomly select-
tance and aerobic training, versus a non-exercise control ed adult in a household. In conducting the cellular telephone
group, on HRQOL [36]. Improvements in physical version of the BRFSS questionnaire, data were collected from
HRQOL were observed in all treatment conditions in adults with a cellular telephone and residing in a private res-
relation to the non-exercise control group. Another clin- idence or college housing [42].
ical trial (N = 43) similarly reported a combined aerobic- The BRFSS provides no direct method of accounting for
resistance exercise intervention improved HRQOL, both non-telephone coverage. Therefore, the BRFSS uses a weight-
mental and physical, compared to the non-exercise con- ed method, iterative proportional fitting (or raking). Raking
trol group [38]. allows for the incorporation of cellular telephone survey data.
The present study, informed by this body of research, ex- Raking adjusts the data to ensure that underrepresented groups
amines levels of mental and physical HRQOL across diverse are more accurately represented in the final data set with re-
US diabetes populations with consideration of demographic duction of error within estimates [42].
(age, marital status, income, gender, and education) and In our secondary analysis, landline or cellular participants
diabetes-related (depression, sleep time, insulin use, compli- from those states administering the BRFSS’ optional diabetes
cations, age of diabetes diagnosis, BMI, smoking, and module (see the BMeasures^ section) were included. In 2014,
J. Racial and Ethnic Health Disparities

a total of 26 states collected optional diabetes module data: assessed with the following items: (1) Bever told you have
Alaska, Arizona, Connecticut, Delaware, District of Columbia, diabetes?^, (2) Bare you blind or do you have serious difficulty
Florida, Georgia, Guam, Indiana, Iowa, Louisiana, Maine, seeing, even when wearing glasses?^, (3) B ever told you that
Mississippi, Nebraska, New Jersey, New Mexico, North diabetes has affected your eyes or that you had retinopathy?^,
Dakota, Ohio, Puerto Rico, South Carolina, South Dakota, (4)Bever told you had angina or coronary heart disease?^, (5)
Tennessee, Texas, Virginia, West Virginia, and Wyoming [43]. Bever told you had a stroke?^, (6) Bever told you had a heart
attack, also called a myocardial infarction?^, (7) Bever told
Measures you have kidney disease?^ (do not include kidney stones,
bladder infection or incontinence), and (8) Bever told you have
The BRFSS core component is a standard set of questions depressive disorder, including depression, major depression,
administered to participants across all states in English and dysthymia, or minor depression?^ [44] We created a comor-
Spanish, accordingly. Core content includes demographics bidities variable reflecting the presence or absence of the fol-
and items addressing HRQOL, specific health conditions (e.- lowing: (1) blindness or difficulty seeing, (2) diabetes
g., diabetes, blindness, stroke, heart attack, kidney disease, eye disease or retinopathy, (3) angina or coronary heart
and depression), and health behaviors (e.g., smoking and ex- disease, (4) heart attack, (5) stroke, (6) kidney disease,
ercise). Additionally, the core content assesses BMI, age of and (7) depression to assist in describing our sample in
diabetes diagnosis, and hours of sleep in a 24-h period. The the bivariate analyses.
optional diabetes module includes items assessing insulin use Other diabetes-related factors included age of diabetes diag-
and diabetes eye disease or retinopathy [44]. nosis (measured continuously), insulin use (measured dichoto-
In the present study, the following BRFSS demographic mously), and hours of sleep in a 24-h period (measured contin-
variables were included: age, marital status, annual income, uously). Additionally, BMI was assessed with an ordinal calcu-
gender, education, and ethnicity. Age was assessed ordinally lated variable coded to reflect overweight (BMI = 25.0–29.9),
using the BRFSS calculated variable for a six-level imputed obesity (BMI ≥ 30), or not (BMI < 25.0) based on partici-
age category (age 18–24 years, age 25–34 years, age 35– pant self-report of height and weight. Smoking status was
44 years, age 45–54 years, age 55–64 years, age ≥65 years). measured dichotomously with the BRFSS calculated var-
Marital status was assessed nominally (married; divorced, iable assessing the presence or absence of current ciga-
widowed, or separated; never married; or member of rette smoking. Exercise was likewise assessed dichoto-
an unmarried couple). Annual income was assessed mously with the following item: BDuring the past month,
ordinally: < $25,000, $25,000 to $34,999, $35,000 to other than your regular job, did you participate in any
$49,999, $50,000 to $74,999, and ≥$75,000. Gender was physical activities or exercises such as running, calisthen-
assessed dichotomously (male or female). Education was ics, golf, gardening, or walking for exercise?^ [44, 45].
assessed ordinally (never attended school or only attended
kindergarten, grades 1–8 [elementary school], grades 9–11 Data Analysis
[some high school], grade 12 or GED [high school graduate],
college 1–3 years [some college or technical school], SAS version 9.4 was used to analyze all data with the CDC
college ≥ 4 years [college graduate]). Ethnicity was weighting two-part weight methodology (design weight and
assessed nominally using the BRFSS calculated variable raking) to adjust for non-coverage and non-response in admin-
for racial/ethnic categories with specific capture of istering the BRFSS, thereby forcing the total number of cases
White only, non-Hispanic; Black only, non-Hispanic; to equal population estimates for each geographic region.
and Hispanic only [44, 45]. CDC weighting helps to adjust for assumption violations
HRQOL was measured continuously, in terms of the fre- when deviations from assumptions are large enough to affect
quency of suboptimal physical or mental health days over the the results. Use of the two-part weight methodology is neces-
past month, respectively. In terms of physical health, respon- sary to make generalizations from the sampled population to
dents were asked: BNow thinking about your physical health, the general population [42, 43, 46].
which includes physical illness and injury, for how many days All analyses were conducted using SAS SURVEY proce-
during the past 30 days was your physical health not dures. To describe the sample, we calculated percentages,
good?^ With respect to mental health, respondents were standard errors, and 95% confidence intervals with computa-
asked: BNow thinking about your mental health, which tion of Rao-Scott chi-square test statistics for dichotomous
includes stress, depression, and problems with emotions, and ordinal level variables across ethnic groups. We computed
for how many days during the past 30 days was your means and standard errors across ethnic groups for continuous
mental health not good?^ [44]. variables. Additionally, we assessed HRQOL by comorbidi-
Diabetes-related factors included health conditions, which ties. To answer research question no. 1, simple linear regres-
were measured dichotomously. Health conditions were sion models assessed differences in HRQOL, both physical
J. Racial and Ethnic Health Disparities

and mental HRQOL, respectively, with non-Hispanic Whites tended to have 1.8 (SE = 0.22) mentally and 4.5 (SE = 0.22)
and Hispanics as the referent groups in separate models. To physically suboptimal HRQOL days per month.
answer research question no. 2, demographic factors (age, Simple linear regression models revealed that the frequency
marital status, income, gender, and education) were added into of poor mental HRQOL days did not significantly differ across
the regression equations simultaneously. For research ques- ethnic groups with Hispanics and non-Hispanic Whites as ref-
tion no. 3, diabetes-related factors (depression, sleep time, erent categories, respectively. However, adjusting for demo-
insulin use, complications, age of diabetes diagnosis, BMI, graphics (age, marital status, income, gender, and education),
smoking, and exercise) were next added into the multiple re- non-Hispanic Whites had 1.54 (p < 0.0001) and non-Hispanic
gression equations simultaneously. Blacks had 1.02 (p = 0.04) more poor mental HRQOL days per
month, on average, compared to Hispanics. Adjusting for de-
mographics and diabetes-related factors (depression, sleep time,
insulin use, complications, age of diabetes diagnosis, BMI,
Results smoking, and exercise) in the fully adjusted model, these rela-
tionships persisted. Non-Hispanic Whites, on average, had 0.88
The sample (N = 17,923) was composed largely of non- (p = 0.03) more days of poor mental HRQOL days per month in
Hispanic Whites (73.9%), followed by non-Hispanic relation to Hispanics. Likewise, non-Hispanic Blacks tended to
Blacks (13.9%), and then Hispanics (12.2%). In terms have 1.42 (p < 0.01) more days of poor mental HRQOL per
of age, most non-Hispanic Whites (72.8%) and, to a less- month compared to their Hispanic counterparts. Depression
er degree, non-Hispanic Blacks (63.5%) and Hispanics emerged as the most potent predictor of mental HRQOL (β =
(62.3%) were ≥ 55 years of age. A majority of non- 8.60, SE = 0.40, p < 0.0001) (see Table 3).
Hispanic Whites (88.3%), and fewer non-Hispanic In terms of poor physical HRQOL days, simple linear re-
Blacks (79.3%) and Hispanics (59.0%), completed high gression models revealed no significant differences across eth-
school or more. With respect to income, a majority of nic groups. Yet, adjusting for demographics, non-Hispanic
Hispanics (64.8%) and non-Hispanic Blacks (50.8%) Whites (2.04 days, p < 0.0001) tended to have more subopti-
had an annual income of < $25,000 (see Table 1). mal physical HRQOL days per month than Hispanics . This
With respect to diabetes-related factors, non-Hispanic relationship remained in the fully adjusted model, controlling
Whites (26.8%) and Hispanics (26.3%) more frequently re- for demographics and diabetes-related factors. Specifically,
ported depression compared to non-Hispanic Blacks (20.5%). non-Hispanic Whites had, on average, 1.35 more days of poor
Age of diabetes diagnosis was lower for Hispanics (M = 45.9, physical HRQOL per month compared to Hispanics
SE = 0.69) and non-Hispanic Blacks (M = 45.8, SE = 0.51) (p = 0.01). No significant differences in physical HRQOL
compared to non-Hispanic Whites (M = 50.3, SE = 0.26). In were observed between non-Hispanic Blacks and Hispanics.
terms of heart disease and heart attack, non-Hispanic Whites Yet, non-Hispanic Blacks (-1.23 days, p = 0.004) had fewer
(16.3, 15.4%) had the highest rates, followed by non-Hispanic poor physical health days, relative to their White peers, when
Blacks (12.1, 10.7%) and Hispanics (10.5, 10.1%). Rates of adjusting for demographics only. As with mental HRQOL,
self-reported stroke were highest among non-Hispanic Blacks depression provided substantial explanatory power for physi-
(10.4%) compared to non-Hispanic Whites (8.5%) and cal HRQOL (β = 4.43, SE = 0.40, p < 0.0001) (see Table 4).
Hispanics (6.5%). Differences in diabetes eye disease and
blindness were observed with non-Hispanic Blacks (23.0,
12.4%) and Hispanics (20.6, 13.2%) reporting higher rates
in relation to non-Hispanic Whites (16.5, 9.1%), respectively. Discussion
Non-Hispanic Blacks (18.6%) more frequently reported cur-
rent smoking compared to non-Hispanic Whites (15.2%) and This is the first study (N = 17,923), to our knowledge, that has
Hispanics (13.2%) (see Table 2). examined differences in mental and physical HRQOL across
In assessing levels of HRQOL, we observed that non- diverse ethnic groups with diabetes while considering both
Hispanic Blacks, on average, had more suboptimal mental demographic (age, marital status, income, gender, and educa-
(M = 5.3, SE = 0.41) and physical (M = 8.4; SE = 0.46) tion) and several salient diabetes-related (depression, sleep
HRQOL days per month compared to non-Hispanic Whites time, insulin use, complications, age of diabetes diagnosis,
(M = 4.6, SE = 0.16; M = 7.8, SE = 0.19) and Hispanics (M = BMI, smoking, and exercise) factors using a largely nationally
4.4, SE = 0.37; M = 7.9, SE = 0.50), respectively (see Table 2). representative sample of adults with diabetes. Our multivariate
With all ethnic groups combined, results showed that those with modeling included critical demographic and diabetes-related
one or more comorbidities had, on average, 7.0 (SE = 0.15) factors to adjust for differences in the sample population, and
mentally and 10.8 (SE = 0.24) physically poor HRQOL days thereby, allow for increased precision in comparing groups to
per month. In contrast, participants without comorbidities enhance the validity of our findings.
J. Racial and Ethnic Health Disparities

Table 1 Weighted demographic characteristics by ethnic group

Ethnic group Non-Hispanic Whites Non-Hispanic Blacks Hispanics


n = 13,239 n = 2494 n = 2190
Demographic factors % (SE) % (SE) % (SE) p value
95% CI 95% CI 95% CI

Female 45.6 (0.88) 58.3 (2.10) 48.35 (2.37) < 0.0001


43.88–47.32 54.17–62.42 43.71–53.00
Age < 0.0001
18–24 years 1.0 (0.20) 1.0 (0.44) 0.5 (0.23)
0.50–1.30 0.13–1.84 0.06–0.94
25–34 years 2.6 (0.32) 3.1 (0.63) 5.0 (1.09)
1.93–3.18 1.84–4.33 2.83–7.12
35–44 years 7.1 (0.53) 10.9 (1.35) 10.7 (1.47)
6.03–8.10 8.26–13.56 7.84–13.59
45–54 years 16.7 (0.73) 21.5 (1.69) 21.5(1.80)
15.23–18.11 18.19–24.82 17.96–25.03
55–64 years 28.3 (0.83) 34.2 (2.18) 30.3 (2.32)
26.67–29.91 29.96–38.49 25.78–34.90
≥65 years 44.5 (0.81) 29.3 (1.86) 32.0 (2.12)
42.88–46.16 25.64–32.94 27.81–36.13
Education < 0.0001
≤ Kindergarten 0.2 (0.11) <0.1 (0.05) 2.8 (0.74)
0.00–0.41 0.00–0.15 1.40–4.30
Grades 1–8 2.3 (0.21) 4.4 (0.68) 20.7 (1.60)
1.84–2.68 3.04–5.73 17.57–23.86
Grades 9–11 9.2 (0.53) 16.3 (1.72) 17.4 (1.96)
8.21–10.30 12.92–19.67 13.60–21.27
Grade 12 or GED 32.9 (0.78) 34.6 (2.25) 27.9 (2.23)
31.39–34.45 30.19–39.03 23.52–32.28
College (1–3 years) or technical school 34.8 (0.88) 27.6 (1.74) 18.9 (2.00)
33.10–36.56 24.19–31.02 15.01–22.86
College graduate ( ≥4 years) 20.6 (0.68) 17.1 (1.38) 12.2 (1.32)
19.23–21.90 14.36–19.75 9.58–14.74
Marital status < 0.0001
Married 60.9 (0.83) 43.2 (2.11) 56.3 (2.33)
59.29–62.53 39.0–47.30 51.78–60.92
Divorced/separated/widowed 28.9 (0.71) 38.5 (2.21) 29.5 (2.01)
27.54–30.31 34.13–42.78 25.56–33.45
Never married 8.2 (0.49) 17.4 (1.55) 9.1 (1.75)
7.28–9.21 14.32–20.39 5.65–12.51
Member of unmarried couple 1.9 (0.37) 1.0 (0.29) 5.1 (0.95)
1.20–2.64 0.44–1.58 3.19–6.93
Annual income < 0.0001
< $25,000 33.6 (0.80) 50.8 (2.12) 64.8 (2.44)
32.06–35.19 46.67–54.97 60.01–69.56
$25,000–$34,999 12.0 (0.50) 13.7 (1.39) 11.2 (1.77)
11.00–12.95 10.98–16.44 7.78–14.73
$35,000–$49,999 15.9 (0.62) 10.8 (1.0) 7.8 (1.19)
14.69–17.14 8.81–12.72 5.52–10.18
$50,000–$74,999 15.9 (0.73) 11.2 (1.23) 7.0 (1.03)
14.42–17.29 8.82–13.64 5.01–9.07
≥ $75,000 22.6 (0.76) 13.5 (1.50) 9.1 (1.90)
21.13–24.13 10.54–16.40 5.34–12.80

Note: CI confidence interval; p values based on the x2 test


J. Racial and Ethnic Health Disparities

Table 2 Weighted diabetes-related factors and HRQOL by ethnic group

Ethnic group Non-Hispanic Whites Non-Hispanic Blacks Hispanics


n = 13,239 n = 2494 n = 2190
% (SE) % (SE) % (SE) p value
95% CI 95% CI 95% CI

Diabetes-related factors
Insulin use 31.0 (0.86) 38.8 (2.21) 32.3 (2.28) 0.004
29.31–32.67 34.51–43.15 27.79–36.75
Age diabetes diagnosis, years (M), range 1–96 50.3 (0.26) 45.8 (0.51) 45.9 (0.69) < 0.0001
49.77–50.80 44.76–46.76 44.58–47.29
Nightly sleep time, hours (M), range 1–22 7.0 (0.03) 7.0 (0.11) 6.9 (0.06) < 0.0001
6.99–7.10 6.77–7.19 6.82–7.07
Depressiona 26.8 (0.71) 20.5 (1.73) 26.3 (2.16) 0.01
25.38–28.18 17.14–23.94 22.06–30.52
Diabetes eye diseasea 16.5 (0.66) 23.0 (1.65) 20.6 (1.73) < 0.001
15.25–17.85 19.76–26.24 17.21–23.98
Blindnessa 9.1 (0.46) 12.4 (1.36) 13.2 (1.20) 0.001
8.18–9.99 9.74–15.06 10.82–15.54
Chronic kidney diseasea 8.4 (0.38) 8.7 (1.08) 9.9 (1.88) 0.62
7.67–9.18 6.62–10.85 6.24–13.60
Heart diseasea 16.3 (0.70) 12.1 (1.56) 10.5 (1.43) < 0.01
14.90–17.65 9.07–15.21 7.66–13.25
Strokea 8.5 (0.47) 10.4 (1.10) 6.5 (1.11) 0.04
7.54–9.40 8.24–12.55 4.37–8.72
Heart attacka 15.4 (0.69) 10.7 (1.07) 10.1 (1.22) < 0.0001
14.09–16.80 8.55–12.77 7.67–12.45
Comorbiditya 56.3 (0.89) 52.5 (2.20) 54.0 (2.36) 0.27
54.53–58.01 48.24–56.85 49.39–58.65
Obesitya 54.6 (0.89) 57.9 (2.13) 51.4 (2.36) 0.09
52.85–56.33 53.74–62.10 46.74–56.00
Smokinga 15.2 (0.66) 18.6 (1.60) 13.2 (1.72) 0.05
13.89–16.48 15.43–21.71 9.81–16.56
Exercisea 63.2 (0.87) 60.9 (2.25) 57.3 (2.37) 0.06
61.50–64.89 56.55–65.36 52.69–61.98
HRQOL
Poor physical health, days per month (M) range 0–30 7.8 (0.19) 8.4 (0.46) 7.9 (0.50) < 0.0001
7.48–8.22 7.51–9.32 6.97–8.94
Poor mental health, days per month (M), range 0–30 4.6 (0.16) 5.3 (0.41) 4.4 (0.37) < 0.0001
4.25–4.89 4.49–6.08 3.71–5.17

Note: CI confidence interval; p values based on the x2 test


NA not available
a
Presence of disease state or behavior

With respect to research question no. 1, no significant dif- holding demographic and diabetes-related factors constant
ferences in the number of poor mental and physical HRQOL for research question no. 3, results showed that (1) non-
days per month, across ethnic groups, were observed in the Hispanic Whites and Blacks had more poor mental HRQOL
unadjusted models. In terms of research question no. 2, find- days per month compared to Hispanics and (2) non-Hispanic
ings revealed that (1) non-Hispanic Whites and Blacks had Whites had more poor physical HRQOL days per month in
more poor mental HRQOL days per month in relation to relation to Hispanics.
Hispanics; (2) non-Hispanic Whites had a greater number of Overall, our results reveal that non-Hispanic Blacks and
poor physical HRQOL days per month compared to Whites have increased burden of poor HRQOL compared to
Hispanics; and (3) non-Hispanic Blacks had fewer poor phys- Hispanics. To date, differences in mental HRQOL between
ical HRQOL days per month compared to non-Hispanic Blacks and Hispanics remain understudied. In terms of mental
Whites when adjusting for demographic factors. When HRQOL, one study, sampling patients seeking care in general
J. Racial and Ethnic Health Disparities

Table 3 Simple and multiple


linear regression models Intercept Unadjusted Demographics Adjusted Fully Adjusted
predicting poor mental Model Model Model
health days R2 R2 R2
β (SE) p β (SE) p β (SE) p

Ethnic group < 0.001 0.07 0.28


Non-Hispanic White (Hispanic referent) − 0.03 (0.38) 1.54 (0.40) < 0.0001 0.88 (0.40) 0.03
0.94
Non-Hispanic Blacks (Hispanic referent) 0.63 (0.50) 1.02 (0.50) 0.04 1.42 (0.51) < 0.01
0.21
Non-Hispanic Blacks (Non-Hispanic 0.66 (0.40) − 0.52 (0.42) 0.21 0.54 (0.38) 0.15
White referent) 0.10
Demographics
Age − 1.43 (0.14) < 0.0001 − 0.87 (0.17)
< 0.0001
Income − 1.03 (0.11) < 0.0001 − 0.45 (0.10)
< 0.0001
Education − 0.20 (0.13) 0.12 − 0.04 (0.12) 0.72
Gendera 0.98 (0.26) < 0.001 0.23 (0.25) 0.34
Marital status 0.21 (0.21) 0.33 0.13 (0.18) 0.48
Diabetes-related factors
Insulin useb − 0.09 (0.28) 0.76
Age diabetes diagnosis < 0.01 (0.01) 0.94
Nightly sleep time − 0.25 (0.12) .04
Depressionb 8.60 (0.40)
< 0.0001
Diabetes eye diseaseb 0.60 (0.38) 0.12
Blindnessb 2.22 (0.45)
< 0.0001
Chronic kidney diseaseb 0.09 (0.49) 0.86
Heart diseaseb 0.85 (0.39) 0.03
Strokeb 0.07 (0.46) 0.87
Heart attackb 0.52 (0.39) 0.18
BMI 0.43 (0.12)
< 0.001
Exerciseb − 1.31 (0.26)
< 0.0001
Current smokerb − 0.96 (0.23)
< 0.0001
a
Males as reference group
b
Absence of disease state or behavior as reference group

medical settings, suggested that Blacks have comparable counterparts while holding demographics, health behaviors
levels of emotional well-being but marginally poorer role (e.g., smoking and exercise), diabetes complications, and de-
limits due to emotional health in relation to Hispanics [6]. In pression, among other factors constant [9].
terms of mental and physical HRQOL, prior studies, consis- More optimal HRQOL among Hispanics, compared to
tent with our findings, report differences between Whites and Blacks and Whites, may reflect increased social support.
Hispanics with diabetes. Similar to our findings, analysis of Investigating the determinants of HRQOL in diverse ethnic
2001–2010 NHANES data (n = 2594) revealed that Hispanics groups with diabetes, Zang and colleagues reported that,
had more optimal mental and physical HRQOL after adjust- among Hispanics, social support (specifically, being married
ments for age, sex, education, family poverty-income ratio, or living with a partner) was related to more optimal mental
BMI, smoking status, insurance coverage, diabetes duration, and physical HRQOL [8]. Additional research suggests
and marital status [8]. Likewise, another study, sampling older Hispanics, but not Blacks, with diabetes benefit from social
adults with diabetes (N = 6096) reported that Hispanics with support in the setting of stress with maintenance of stable
diabetes had more optimal physical HRQOL than their Whites mental HRQOL across levels [47]. Additional research is
J. Racial and Ethnic Health Disparities

Table 4 Simple and multiple


linear regression models Intercept Unadjusted Demographics-adjusted Fully adjusted
predicting poor physical model model model
health days R2 R2 R2
β (SE) p β (SE) p β (SE) p

Ethnic group < 0.001 0.07 0.20


Non-Hispanic Whites (Hispanics referent) − 0.15 (0.51) 2.04 (0.52) < 0.0001 1.35 (0.53) 0.01
0.78
Non-Hispanic Blacks (Hispanics referent) 0.30 (0.61) 0.81 (0.60) 0.18 1.11 (0.65) 0.85
0.61
Non-Hispanic Blacks (non-Hispanic − 0.16 (0.41) − 1.23 (0.42) 0.004 − 0.23 (0.46) 0.61
Whites referent) 0.70
Demographics
Age − 0.28 (0.14) 0.05 − 0.13 (0.21) 0.52
Income − 1.78 (0.12) < 0.0001 − 1.05 (0.12)
< 0.0001
Education − 0.48 (0.16) 0.003 − 0.30 (0.15) 0.05
Gendera 0.20 (0.31) 0.53 − 0.10 (0.34) 0.77
Marital status − 0.23 (0.23) 0.33 − 0.42 (0.25) 0.08
Diabetes-related factors
Insulin useb 2.20 (0.42)
< 0.0001
Age diabetes diagnosis < 0.01 (0.01) 0.74
Nightly sleep time − 0.34 (0.11)
0.001
Depressionb 4.43 (0.40)
< 0.0001
Diabetes eye diseaseb 1.22 (0.47) < 0.01
Blindnessb 3.00 (0.57)
< 0.0001
Chronic kidney diseaseb 2.53 (0.61)
< 0.0001
Heart diseaseb 2.78 (0.49)
< 0.0001
Strokeb 1.93 (0.62) < 0.01
Heart attackb 0.51 (0.53) 0.33
BMI 0.60 (0.16)
< 0.001
Exerciseb − 3.38 (0.36)
< 0.0001
Current smokerb − 0.62 (0.25) 0.01
a
Males as reference group
b
Absence of disease state or behavior as reference group

needed to better understand why Hispanics with diabetes, culturally sensitive diabetes self-management interventions
compared to their non-Hispanic Black and White counter- improve levels of depression and HRQOL [50, 51].
parts, may have more optimal HRQOL in living with a Increased, widened application of such interventions appears
chronic, progressive disease. warranted to improve HRQOL outcomes, a primary goal of
Further, we identified depression, consistent with previous diabetes care and education [2].
research, as a potent predictor of HRQOL, especially mental The present study uniquely examined differences in mental
HRQOL [17]. Depression is a potentially modifiable predictor and physical HRQOL while holding demographic (age, mar-
of HRQOL through both screening and treatment. However, ital status, income, gender, and education) and diabetes-
in disadvantaged groups, rates of depression screening may be related (depression, sleep time, insulin use, diabetes-related
suboptimal [48, 49]. Interdisciplinary team interventions im- complications, age of diabetes diagnosis, BMI, smoking,
prove rates of depression screening and treatment while and exercise) factors constant. Yet, despite inclusion of
J. Racial and Ethnic Health Disparities

multiple demographic and diabetes-related factors, as in- both mental and physical HRQOL. To advance understanding
formed by the literature, the fully adjusted models for mental of differences in HRQOL across ethnic groups, future studies
and physical HRQOL only accounted for about 30 and 20%, may use path analysis to disentangle the effects of salient
respectively, of the variance in HRQOL. This indicates that background factors. Inclusion of race or ethnic related vari-
additional salient background factors contribute to HRQOL in ables appears particularly warranted in future HRQOL analy-
diverse populations with diabetes. ses as does symptom severity. With diabetes health disparities
Unexamined in the present study, research suggests that race persisting, especially burdening economically disadvantaged
or ethnic related variables may significantly contribute to and diverse ethnic groups, additional research is needed to
HRQOL in diverse ethnic groups, particularly Blacks. With improve HRQOL outcomes in accordance with clinical guide-
respect to mental HRQOL, Blacks have significantly higher lines [2].
race-related stress and ethnic identity, relative to other groups,
with findings indicating that ethnic identity and cultural racism
may account for 16% of the total variance in HRQOL [52]. In
older Blacks, institutional racism has exclusively explained References
18% of the total variance in mental HRQOL [53].
Also, among Whites with or without diabetes, research 1. Centers for Disease Control (CDC). Age-adjusted percentage of
indicates perceived discrimination is negatively related to people with diabetes aged 35 years or older reporting heart disease
or stroke, by race/ethnicity, United States, 1988–2006. 2014.
HRQOL [54, 55]. Further, among Blacks and Hispanics,
2. American Diabetes Association: Standards of medical care in dia-
higher levels of perceived discrimination and racial disadvan- betes–2017. Diabetes Care 2017;(Suppl 1):S1-S129.
tage are associated with decrements in HRQOL, [55, 56]. In 3. Kleefstra N, Landman GW, Houweling ST, Ubink-Veltmaat LJ,
Hispanics, racial discrimination appears to effect mental Logtenberg SJ, Meyboom-de Jong B, et al. Prediction of mortality
and physical HRQOL through anxiety symptoms although in type 2 diabetes from health-related quality of life (ZODIAC-4).
Diabetes Care. 2008;31:932–3.
additional factors may be operative [57].
4. Li T-C, Lee Y-D, Liu C-S, Chen C-C, Li C-I, Lin C-C.
Although largely unexamined in the diabetes literature, be- Disease-specific quality-of-life measures as predictors of mor-
ginning research suggests that symptom severity, in the setting tality in individuals living with type 2 diabetes. J Psychosom
of diabetes complications, may adversely affect HRQOL [58, Res. 2011;70:155–60.
59]. Among Hispanics and Blacks with gastroparesis, for ex- 5. Rubin RR, Peyrot M. Quality of life and diabetes. Diabetes Metab
Res Rev. 1999;15:205–18.
ample, greater symptom severity predicted poorer HRQOL 6. Jackson-Triche ME, Greer Sullivan J, Wells KB, Rogers W, Camp P,
[59]. Mazel R. Depression and health-related quality of life in ethnic mi-
norities seeking care in general medical settings. J Affect Disord.
Limitations 2000;58:89–97.
7. Misra R, Lager J. Ethnic and gender differences in psychosocial
factors, glycemic control, and quality of life among adult type 2
The present study has a number of limitations. We examined diabetic patients. J Diabetes Complicat. 2009;23:54–64.
non-Hispanic Blacks and Hispanics as homogenous sub- 8. Zhang L, Ferguson TF, Simonsen N, Chen L, Tseng TS. Racial/
groups, respectively, despite their ethnic heterogeneity. ethnic disparities in health-related quality of life among participants
HRQOL was studied cross-sectionally, not longitudinally. A with self-reported diabetes from NHANES 2001-2010. Diabetes
Educ. 2014;40:496–506.
longitudinal investigation would allow examination of chang-
9. Laiteerapong N, Karter AJ, John PM, Schillinger D, Moffet HH,
es in HRQOL over time, and thereby, more validly assess Liu JY, et al. Ethnic differences in quality of life in insured older
differences across ethnic groups. In the present study, adults with diabetes mellitus in an integrated delivery system. J Am
operationalization of HRQOL was limited to number of poor Geriatr Soc. 2013;61:1103–10.
mental or physical days over the past month, which did not 10. Quandt SA, Graham CN, Bell RA, Snively BM, Golden SL,
Stafford JM, et al. Ethnic disparities in health-related quality of life
capture the complexity of the concept under study. Lastly, among older rural adults with diabetes. Ethn Dis. 2007;17:471–6.
measures of discrimination, race, or ethnic-related concepts 11. Peyrot M, Egede LE, Campos C, Cannon AJ, Funnell MM, Hsu WC,
were not included in the analyses. et al. Ethnic differences in psychological outcomes among people
with diabetes: USA results from the second diabetes attitudes, wishes,
and needs (DAWN2) study. Curr Med Res Opin. 2014;30:2241–54.
12. American Psychiatric Association. The fifth edition of the diagnos-
Conclusion tic and statistical manual of mental disorders (DSM-5).
Washington: USA; 2013.
Using a largely national representative sample of adults with 13. Gary TL, Crum RM, Cooper-Patrick L, Ford D, Brancati FL.
diabetes, the present study observed that non-Hispanic Black Depressive symptoms and metabolic control in African-
Americans with type 2 diabetes. Diabetes Care. 2000;23:23–9.
and White adults with diabetes, relative to their Hispanic 14. Anderson RJ, Freedland KE, Clouse RE, Lustman PJ. The preva-
counterparts, are disproportionately burdened by poorer lence of comorbid depression in adults with diabetes: a meta-anal-
HRQOL. Depression was found to be a potent predictor of ysis. Diabetes Care. 2001;24:1069–78.
J. Racial and Ethnic Health Disparities

15. Wagner J, Tsimikas J, Abbott G, de Groot M, Heapy A. Racial and related complications on health utilities for patients with type 2
ethnic differences in diabetic patient-reported depression diabetes in Ontario, Canada. Qual Life Res. 2011;20:939–43.
symptoms, diagnosis, and treatment. Diabetes Res Clin Pract. 34. Imayama I, Plotnikoff RC, Courneya KS, Johnson JA.
2007;75:119–22. Determinants of quality of life in adults with type 1 and type 2
16. Ell K, Katon W, Cabassa LJ, Xie B, Lee PJ, Kapetanovic S, et al. diabetes. Health Qual Life Outcomes. 2011;9:115.
Depression and diabetes among low-income Hispanics: design el- 35. Imayama I, Plotnikoff R, Courneya K, Johnson J. Determinants of
ements of a socioculturally adapted collaborative care model ran- quality of life in type 2 diabetes population: the inclusion of per-
domized controlled trial. Int J Psychiatry Med. 2009;39:113–32. sonality. Qual Life Res. 2010;20(4):551–8.
17. Ali S, Stone M, Skinner TC, Robertson N, Davies M, Khunti K. 36. Myers VH, McVay MA, Brashear MM, et al. Exercise training and
The association between depression and health-related quality of quality of life in individuals with type 2 diabetes: a randomized
life in people with type 2 diabetes: a systematic literature review. controlled trial. Diabetes Care. 2013;36(7):1884–90.
Diabetes Metab Res Rev. 2010;26:75–89. 37. Zimbudzi E, Lo C, Ranasinha S, Kerr P, Usherwood T, Cass A,
18. Plantinga L, Rao MN, Schillinger D. Prevalence of self-reported et al. Self-management in patients with diabetes and chronic kidney
sleep problems among people with diabetes in the United States, disease is associated with incremental benefit in HRQOL. J
2005-2008. Prev Chronic Dis. 2012;9:E76. Diabetes Complicat. 2017;31(2):427–32.
19. Chasens ER, Sereika SM, Burke LE, Strollo PJ, Sleep KM. Health- 38. Tomas-Carus P, Ortega-Alonso A, Pietilainen K, Santos V,
related quality of life, and functional outcomes in adults with dia- Goncalves H, Ramos J, et al. Randomized controlled trial on the
betes. Appl Nurs Res. 2014;27:237–41. effects of combined aerobic-resistance exercise on muscle
20. Luyster FS, Dunbar-Jacob J. Sleep quality and quality of life in strength and fatigue, glycemic control and health-related qual-
adults with type 2 diabetes. Diabetes Educ. 2011;37(3):347–55. ity of life of type 2 diabetes patients. J Sports Med Phys
21. Moyer CA, Sonnad SS, Garetz SL, Helman JI, Chervin RD. Quality Fitness. 2015;56(5):572–8.
of life in obstructive sleep apnea: a systematic review of the litera- 39. Kueh YC, Morris T, Borkoles E, Shee H. Modelling of diabetes
ture. Sleep Med. 2001;2(6):477–91. knowledge, attitudes, self-management, and quality of life: a cross-
22. Kushida C, Martin M, Nikam P, Blaisdell B, Wallenstein G, sectional study with an Australian sample. Health Qual Life
Ferini-Strambi L, et al. Burden of restless legs syndrome on Outcomes. 2015;13:129.
health-related quality of life. Qual Life Res. 2007;16(4):617–24. 40. Eckert K. Impact of physical activity and bodyweight on health-
related quality of life in people with type 2 diabetes. Diabetes Metab
23. Wild D, von Maltzahn R, Brohan E, Christensen T, Clauson P,
Syndr Obes. 2012;5:303–11.
Gonder-Frederick L. A critical review of the literature on fear of
41. Wiesinger GF, Pleiner J, Quittan M, Fuchsjäger-Mayrl G,
hypoglycemia in diabetes: implications for diabetes management
Crevenna R, Nuhr MJ, et al. Health related quality of life in
and patient education. Patient Educ Couns. 2007;68(1):10–5.
patients with long-standing insulin dependent (type 1) diabetes
24. Grammes J, Stock W, Mann CG, Flynn EM, Kubiak T. Focus group
mellitus: benefits of regular physical training. Wien Klin
study to identify the central facets of fear of hypoglycaemia in
Wochenschr. 2001;113(17–18):670–5.
people with type 2 diabetes mellitus. Diabet Med. 2017; [Epub
42. CDC. Behavioral Risk Factor Surveillance System (BRFSS):
ahead of print];34:1765–72.
Overview BRFSS 2014. Available at https://www.cdc.gov/brfss/
25. Rombopoulos G, Hatzikou M, Latsou D, Yfantopoulos J. The prev-
annual_data/2014/pdf/overview_2014.pdf. Accessed 16
alence of hypoglycemia and its impact on the quality of life (QoL)
May 2017.
of type 2 diabetes mellitus patients (The HYPO Study). Hormones.
43. CDC. BRFSS 2014 Modules by state by data set & weight.
2013;12(4):550–8.
Available at https://www.cdc.gov/brfss/questionnaires/state2014.
26. Brown DW, Balluz LS, Giles WH, Beckles GL, Moriarty DG, Ford ES, htm. Accessed 16 May 2017.
et al. Diabetes mellitus and health-related quality of life among 44. CDC. BRFSS 2014 Codebook report: landline and cell-phone data.
older adults: findings from the behavioral risk factor surveillance Available at https://www.cdc.gov/brfss/annual_data/2014/pdf/
system (BRFSS). Diabetes Res Clin Pract. 2004;65:105–15. codebook14_llcp.pdf. Accessed 16 May 2017.
27. The Diabetes Control and Complications Trial Research 45. CDC. Calculated variables in the data file of the 2014 behavioral
Group. Influence of intensive diabetes treatment on quality-of-life risk factor surveillance system. Available at https://www.cdc.gov/
outcomes in the Diabetes Control and Complications Trial. brfss/annual_data/2014/pdf/2014calculated_variables_
Diabetes Care. 1996;19:195–203. version8pdf. . Accessed 16 May 2017.
28. Wan EY, Fung CS, Choi EP, Wong CK, Chan AK, Chan KH, et al. 46. CDC. Behavioral risk factor surveillance system module data for
Main predictors in health-related quality of life in Chinese patients analysis for 2014 BRFSS. Available at https://www.cdc.gov/brfss/
with type 2 diabetes mellitus. Qual Life Res. 2016;25(11):2957–65. annual_data/2014/pdf/2014moduleanalysis.pdf. Accessed 16
29. Schunk M, Reitmeir P, Schipf S, Volzke H, Meisinger C, Ladwig May 2017.
KH, et al. Health-related quality of life in women and men with type 47. Shallcross AJ, Ojie MJ, Chaplin W, Levy N, Odedosu T, Ogedegbe G,
2 diabetes: a comparison across treatment groups. J Diabetes et al. Race/ethnicity moderates the relationship between chronic life
Complicat. 2015;29(2):203–11. stress and quality of life in type 2 diabetes. Diabetes Res Clin Pract.
30. Maddigan SL, Feeny DH, Majumdar SR, Farris KB, Johnson JA. 2015;108:150–6.
Understanding the determinants of health for people with type 2 48. Hudson DL, Karter AJ, Fernandez A, Parker M, Adams AS,
diabetes. Am J Public Health. 2006;96(9):1649–55. Schillinger D, et al. Differences in the clinical recognition of de-
31. Lloyd A, Sawyer W, Hopkinson P. Impact of long-term complica- pression in diabetes patients: the diabetes study of northern
tions on quality of life in patients with type 2 diabetes not using California (DISTANCE). Am J Manag Care. 2013;19:344–52.
insulin. Value Health. 2001;4:392–400. 49. Maimone RM, Marhatta A. The rate of depression screening at a
32. Hayes A, Arima H, Woodward M, Chalmers J, Poulter N, Hamet P, federally qualified community health center. Health Serv Res
et al. Changes in quality of life associated with complications Manag Epidemiol. 2015;2:2333392815613057.
of diabetes: results from the ADVANCE study. Value Health. 50. D'Eramo-Melkus G, Spollett G, Jefferson V, Chyun D, Tuohy B,
2016;19:36–41. Robinson T, et al. A culturally competent intervention of education
33. O'Reilly DJ, Xie F, Pullenayegum E, Gerstein HC, Greb J, and care for black women with type 2 diabetes. Appl Nurs Res.
Blackhouse GK, et al. Estimation of the impact of diabetes- 2004;17:10–20.
J. Racial and Ethnic Health Disparities

51. Farrell P, Barnaby S, Galarza T, Simonson JK, Zonszein J, Meara A, 55. Otiniano AD, Gee GC. Self-reported discrimination and health-
et al. Population management of diabetes in a high-need urban com- related quality of life among Whites, Blacks, Mexicans and
munity in the Bronx: the experience of Montefiore Medical Center. Central Americans. J Immigr Minor Health. 2012;14:189–97.
Diabetes Educ. 2013;39:515–22. 56. Fujishiro K. Is perceived racial privilege associated with health?
52. Utsey SO, Chae MH, Brown CF, Kelly D. Effect of ethnic group Findings from the behavioral risk factor surveillance system. Soc
membership on ethnic identity, race-related stress, and quality of Sci Med. 2009;68:840–4.
life. Cult Divers Ethn Minor Psychol. 2002;8:366–77. 57. Howarter AD, Bennett KK. Perceived discrimination and health-
53. Utsey SO, Payne YA, Jackson ES, Jones AM. Race-related related quality of life: testing the reserve capacity model in Hispanic
stress, quality of life indicators, and life satisfaction among Americans. J Soc Psychol. 2013;153:62–79.
elderly African Americans. Cult Divers Ethn Minor Psychol. 58 Suckow BD, Goodney PP, Nolan BW, Veeraswamy RK, Gallagher
2002;8:224–33. P, Cronenwett JL, et al. Domains that determine quality of life in
54. Dawson AZ, Walker RJ, Campbell JA, Egede LE. Effect of per- vascular amputees. Ann Vasc Surg. 2015;29:722–30.
ceived racial discrimination on self-care behaviors, glycemic con- 59 Friedenberg FK, Kowalczyk M, Parkman HP. The influence of race
trol, and quality of life in adults with type 2 diabetes. Endocrine. on symptom severity and quality of life in gastroparesis. J Clin
2015;49:422–8. Gastroenterol. 2013;47:757–61.