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Kesha Baptiste-Roberts, PhD, Tiffany L. Gary, PhD, Gloria L.A. Beckles, MD, MSc, Edward W. Gregg, PhD, Michelle Owens, PhD, Deborah Porterfield, MD and Michael M. Engelgau, MD, MS

Kesha Baptiste-Roberts and Tiffany L. Gary are with the Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Md. Gloria L.A. Beckles, Edward W. Gregg, Michelle Owens, and Michael M. Engelgau are with the Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, Ga. Deborah Porterfield is with the Division of Public Health, North Carolina Department of Health and Human Services, Raleigh.

Correspondence: Requests for reprints should be sent to Tiffany L. Gary, PhD, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Room E6531, Baltimore, MD 21205 (e-mail: tgary{at}jhsph.edu).

	ABSTRACT

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Objectives. We examined the role of family history of diabetes in awareness of diabetes risk factors and engaging in health behaviors.

Methods. We conducted a cross-sectional analysis of 1122 African American adults without diabetes who were participants in Project DIRECT (Diabetes Interventions Reaching and Educating Communities Together).

Results. After adjustment for age, gender, income, education, body mass index, and perceived health status, African Americans with a family history of diabetes were more aware than those without such a history of several diabetes risk factors: having a family member with the disease (relative risk [RR]=1.09; 95% confidence interval [CI]=1.03, 1.15), being overweight (RR=1.12; 95% CI=1.05, 1.18), not exercising (RR=1.17; 95% CI=1.07, 1.27), and consuming energy-dense foods (RR=1.10; 95% CI=1.00, 1.17). Also, they were more likely to consume 5 or more servings of fruits and vegetables per day (RR=1.31; 95% CI=1.02, 1.66) and to have been screened for diabetes (RR=1.21; 95% CI=1.12, 1.29).

Conclusions. African Americans with a family history of diabetes were more aware of diabetes risk factors and more likely to engage in certain health behaviors than were African Americans without a family history of the disease.

	INTRODUCTION

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Diabetes is a major contributor to morbidity and mortality and generates large direct as well as indirect costs.^1–3 The prevalence of diabetes among US adults⁴ has increased substantially over the past several decades and stood at 8.7% in 2002.^2,5 The burden of type 2 diabetes disproportionately affects African Americans. For example, data from nationally representative samples show that White men are one half to one fifth as likely as African American men to have or develop diabetes, and African American women are approximately twice as likely as White women to have or develop the disease.^6,7 It is estimated that 33% to 50% of people with type 2 diabetes are not diagnosed.^8,9 As a result, many patients may already have early complications of the disease at the time of their clinical diagnosis.

In addition to older age and being overweight, family history is a well-known risk factor for type 2 diabetes, with risk estimates (relative risks [RRs]) ranging from 2 to 6 depending on study design and case definition.¹⁰ Family histories reflect both inherited genetic susceptibilities and shared environments, which include cultural factors such as preferences, values, and perceptions and behavioral factors such as diet and physical activity.¹¹ Thus, family history of diabetes may be a useful tool to identify individuals at increased risk of the disease and target behavior modifications that could potentially delay disease onset and improve health outcomes. For example, individuals with impaired glucose tolerance could be encouraged to make lifestyle changes, given that results from randomized clinical trials indicate that losing weight, reducing fat intake, and increasing physical activity can result in a 58% reduction in the incidence of diabetes.¹²

Previous research has focused primarily on examining the role of family history of diabetes in the development of type 2 diabetes, insulin resistance, and obesity.^13–18 One study examined the impact of family history of diabetes on glycemic control,¹⁹ and a few studies have examined whether family history of diabetes influences perceived susceptibility and protective health behaviors.^20,21 However, these studies have been conducted among nonminority populations. To our knowledge, the specific role that family history of diabetes plays among African Americans in terms of their being aware of diabetes risk factors and engaging in protective health behaviors has not yet been explored.

In this study, we conceptualized our data in the context of the Health Belief Model,²² a psychological model that attempts to explain and predict health behaviors by focusing on people’s attitudes and beliefs. We hypothesized that individuals with a family history of diabetes would be more aware of risk factors and more likely to engage in healthy behaviors than would individuals without such a family history.

	METHODS

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Study Population
We conducted a cross-sectional study involving African American adults without diabetes who were participating in Project DIRECT (Diabetes Interventions Reaching and Educating Communities Together) at baseline (i.e., before implementation of any interventions). Project DIRECT, a multiyear community-based project based in North Carolina, is designed to improve diabetes detection, quality of care, self-care services, and risk factors among African Americans; health promotion, outreach, and diabetes care are the 3 main intervention components. The methods used in the project have been described in detail elsewhere.^23–25 Briefly, the target population consisted of civilian, noninstitutionalized adults 18 years or older who resided in selected areas of Raleigh and Greensboro, NC. A multistage area probability sample design was used in which area segments were selected from census files and then sample housing units were selected for screening.

Lead letters were sent to each sampled address to inform the residents of the purpose and legitimacy of the survey. Trained field interviewers visited each sample housing unit and selected eligible participants according to specific criteria. Eligible participants were asked to complete an in-person interview. The overall interview response rate was 87%. The weighted response rate was higher in Greensboro (88.9%) than in Raleigh (84.4%). The final study sample included 2310 participants (2210 African Americans, 65 Whites, and 35 members of other races). In this analysis, we used data from the baseline assessment conducted in 1997 and evaluated the 1585 individuals who identified themselves as African American and reported not having diabetes.

Participants with missing data on socio-demographic (not including income), family history, or dietary variables were excluded, yielding a final study population of 1122. Sample sizes varied slightly for a few variables as a result of missing values. Missing data were most frequent for income (n=1023) and diabetes screenings (n=1078).

Responses regarding attempts at weight loss were included only in analyses involving participants who were overweight or obese (n = 732). Only participants who were not attempting to lose weight (n = 779) were asked whether they were trying to maintain their weight. Participants included in the analyses were similar to those not included because of missing data for variables of interest with respect to all of the variables examined except that higher percentages of those included reported consuming 5 or more servings of fruits and vegetables per day (P= .036), engaging in physical activity (P= .040), and having been screened for diabetes (P= .031). A lower percentage of the included participants had received advice from a doctor to lose weight (P= .004).

Study Variables and Measures
Data on sociodemographic characteristics (age, gender, education, income), health variables (self-rated health status, advice from a doctor to lose weight, family history of diabetes), awareness of risk factors for diabetes (older age, overweight, family members with diabetes, insufficient exercise, minority race/ ethnicity, energy-dense diet, diabetes during pregnancy), and behavioral variables (physical activity, attempting weight loss, and participation in screening for diabetes) were self-reported. Weight was measured, and height was obtained through a self-report. Body mass index (BMI; weight in kilograms divided by height in meters squared) categories, classified according to National Institutes of Health guidelines, were optimal or underweight (less than 25 kg/m²), overweight (25–29.9 kg/m²), and obese (30 kg/m² or above).²⁶

Participants were asked whether any of their immediate family members (mother, father, sisters, brothers) had diabetes. Possible responses were "yes," "no," and "don’t know." Individuals were classified as having a family history of diabetes if they reported that any first-degree relative (parent or sibling) had diabetes and as not having a family history if they answered "no" or "don’t know" to all parts of the question. A modified version of the Block questionnaire was used in assessing fruit, vegetable, and fat intakes.²⁷ We calculated daily servings of fruits and vegetables and total fat intake (in grams) using equations derived by Block et al.²⁷ (as outlined elsewhere²⁸).

As a means of assessing awareness of risk factors for diabetes, participants were asked whether each of a series of 7 factors "definitely does not increase," "probably does not increase," "probably increases," or "definitely increases" a person’s chance of developing diabetes; responses were assigned codes of 1 to 4, respectively (0 was assigned for "don’t know"). We investigated awareness separately for each of the risk factors assessed and, in addition, calculated an overall awareness score as the sum of all of a participant’s responses (range: 0 to 28). Participants were classified as being aware of a risk factor if they indicated that it "probably increases" or "definitely increases" a person’s chance of developing diabetes. For our logistic regression analyses, we created awareness score tertiles and compared those in the second and third tertiles with those in the first tertile. Also, we split scores at the median¹⁹ to classify participants as "not aware" or "aware."

Statistical Analyses
To account for the complex survey design, we conducted all analyses using Stata version 8 (Stata Corp, College Station, Tex) survey commands. We conducted descriptive analyses (i.e., means and frequencies) for sociodemographic, risk factor awareness, and health behavior variables. We used the t test and ² test to determine statistical differences on these variables between participants with and without a family history of diabetes.

We conducted multiple logistic regression analyses to evaluate the relationship between having a family history of diabetes and diabetes risk awareness variables. Initially we adjusted for sociodemographic factors (age, gender, education, and income), and in subsequent models we also adjusted for BMI and perceived health status. In addition, we evaluated the relationship between health behaviors and having a family history of diabetes while adjusting for sociodemographic factors, BMI, and perceived health status. Because of the high prevalence of many of the outcome variables, we used Zhang and Yu’s method²⁹ to estimate relative risks from odds ratios generated by our logistic regression models.

	RESULTS

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The participants were predominantly women (62%), and 35% were 50 years or older. Sixty-three percent had a high school education or less, 63% were employed, and 61% had an annual income below $25000. Fifteen percent rated their health as fair or poor. Overall, 20% of the participants had a mother with diabetes, 11% had a father with diabetes, and 18% had a sibling with diabetes (in total, 36% of the participants had a family history of diabetes). Sixty-five percent were overweight or obese, and 15% had received advice from a doctor to lose weight. Thirty-two percent were attempting to lose weight, and 36% were trying to maintain their weight. Approximately one third (34%) were sedentary.

Participants reported an average of 3.8 daily servings of fruits and vegetables, and 23% reported consuming 5 or more servings a day. Mean total intake of fat per day was 87.8 g. Approximately two thirds of the participants (66%) had been screened for diabetes. Levels of awareness of the risk of diabetes imposed by being overweight and by having family members with the disease both exceeded 75%, but percentages were below 50% with respect to the risks associated with having diabetes during pregnancy and belonging to a minority racial/ethnic group (the percentage was below 25% in the case of diabetes during pregnancy).

The unadjusted analyses showed that women were more likely than men to have a family history of diabetes (Table 1), and those with a family history were more likely than those without a family history to rate their health as fair or poor (19.7% vs 12.8%). Higher proportions of participants with a family history of diabetes were overweight and had received advice from a doctor to lose weight.

In the multivariate analyses, having a family history of diabetes was initially significantly associated with greater awareness of the risks of being overweight, having family members with diabetes, not exercising enough, and consuming a energy-dense diet (Table 2). These associations persisted after adjustment for gender, age, income, and education as well as further adjustment for BMI and perceived health status. Analyses involving awareness score tertiles showed that having a family history was associated with greater awareness among participants in the second (RR = 1.19; 95% confidence interval [CI] = 0.99, 1.41) and third (RR = 1.53; 95% CI = 1.20, 1.90) tertiles than among participants in the first tertile. Having a family history of diabetes was also associated with having a summary awareness score above the median; after all stages of adjustment, the relative risk was 1.20 (95% CI = 1.10, 1.29).

	DISCUSSION

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We found that individuals with a family history of diabetes were more likely than those without a family history to consume 5 or more servings of fruits and vegetables per day. Also, in our univariate analyses, we found that those with a family history were more likely to receive advice from a doctor to lose weight, but we could not determine whether they were counseled specifically on physical activity. Murff et al.³¹ examined such counseling by health care providers and reported no significant differences according to family history.

Finally, we used parents and siblings (i.e., first-degree relatives) to define family history, whereas some studies have included both first- and second-degree relatives (e.g., aunts and uncles) in their definition. Results from studies involving first-degree family members only and those combining first-, second-, and third-degree relatives (e.g., first cousins) have been similar.^32,33

Our univariate analyses showed that women were more likely than men to report having a family history of diabetes. This result was similar to that of Annis et al., who found that more women than men reported having a first-degree relative with diabetes and that women were more likely to report on female than on male relatives with diabetes.³⁴ Furthermore, a recent study showed that, in comparison with men, women were slightly more likely to regard family history as important to their own health and were more likely to collect family medical information.³⁵

Several limitations of this study deserve comment. First, the study was cross-sectional, and thus we are unable to make causal inferences. Second, most of the data were obtained through self-report, which may have resulted in biased estimates of measures of association. Third, the questions used to assess awareness of diabetes risk factors were developed by the Project DIRECT investigative team, and their reliability and validity are not known as of yet.

Fourth, many diabetes cases are undiagnosed,⁴ and people may not know the diabetes status of all members of their family, resulting in misclassification. Most likely, we underestimated the percentage of our participants who had a family history of the disease, and thus the strength of the associations observed was probably attenuated. A study conducted by Bensen et al., however, showed that accuracy of probands’ reporting of diabetes among family members was quite high, with reports of parents’ diabetes status having somewhat greater sensitivity (87%) than those of siblings’ status (72%).³⁶

Fifth, our study population consisted of a sample of African Americans from Raleigh and Greensboro, NC, so our results cannot be extrapolated to all African Americans residing in the United States. Finally, we were not able to distinguish between type 2 diabetes and type 1 diabetes, and thus we were not able to assess any differing effects they had on diabetes-related health behaviors or awareness of diabetes risk factors. We were also unable to evaluate the impact of survival on participant’s knowledge of family diabetes history. We can posit that perhaps individuals who succumbed to diabetes-related complications may have been less knowledgeable about their diabetes and less effective in managing the disease.

Despite these limitations, our study had several strengths. First, the sample was population based. Second, extensive data on diabetes-related health behaviors were available. Third, we are unaware of any other published studies examining the interrelationships between family history of diabetes, health behaviors, and diabetes risk awareness among African Americans, who are disproportionately burdened by this disease.

The results of the Diabetes Prevention Project and the emphasis on prediabetes interventions have raised the important question of whether knowledge of diabetes risk factors influences health behaviors. The present analysis, albeit cross-sectional in design, suggests that a family history of diabetes (but not knowledge of risk factors per se) is associated with awareness of risk factors, consumption of 5 or more servings of fruits and vegetables a day, and increased participation in screening. Although evidence is insufficient to conclude that screening is effective in reducing morbidity and mortality associated with diabetes,³⁷ the rate of screening participation in our study should be considered a positive finding.

We did not observe differences in other health behaviors according to family history status, which may seem surprising. This lack of differences may be explained in substantial measure by the disproportionate burden of diabetes borne by African Americans, which may influence their perceptions of risk and their resulting behaviors. No doubt, many of these individuals believe themselves to be at increased risk, and if they become knowledgeable regarding the health behaviors that may delay onset of the disease or reduce its risk, they may engage in these behaviors.

Other people, however, may have fatalistic attitudes, believing that diabetes is inevitable regardless of what they do. Powe et al. conceptualized fatalism within the context of the African American experience as a complex psychological cycle characterized by feelings of powerlessness, worthlessness, meaninglessness, and social despair.^38,39 Fatalism has been shown to be associated with poor diabetes self-management, and it may be associated with decreased engagement in healthy behaviors.⁴⁰

Nevertheless, our study has implications for behavior change that, as mentioned earlier, can be conceptualized through constructs derived from the Health Belief Model.²² A family history of diabetes may be indicative of perceived susceptibility to the disease, which would in turn influence one’s likelihood of behavior change. Awareness of diabetes risk factors can be considered a cue to action. Although African Americans with a family history of the disease may be more aware of associated risk factors than those without such a history, appropriately designed programs focusing on lifestyle improvements should nevertheless be targeted toward this high-risk group to delay or prevent the development of diabetes.

	Acknowledgments

 
This work was funded by the Division of Diabetes Translation, Centers for Disease Control and Prevention.

We thank the Project DIRECT staff, executive board, and community members for their work on the study. We also thank the study participants for their cooperation.

Human Participant Protection
This study was approved by the Committee on Human Research at Johns Hopkins University. All study procedures were explained to participants, and written informed consent was obtained.

	Footnotes

 
Peer Reviewed

Contributors
K. Baptiste-Roberts and T. L. Gary originated and designed the study. K. Baptiste-Roberts performed the statistical analysis, and T. L. Gary was responsible for supervision. G. L. A. Beckles, E. W. Gregg, M. Owens, D. Porterfield, and M. M. Engelgau contributed to the interpretation and discussion of the findings.

Accepted for publication June 28, 2006.

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This Article Abstract Full Text (PDF) All Versions of this Article: AJPH.2005.077032v1 97/5/907    most recent Submit a response View Shopping Cart Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Web of Science (5) Citing Articles via Google Scholar Google Scholar Articles by Baptiste-Roberts, K. Articles by Engelgau, M. M. Search for Related Content PubMed PubMed Citation Articles by Baptiste-Roberts, K. Articles by Engelgau, M. M. Related Collections Diabetes Family Health African Americans/Blacks