Health beliefs among individuals at increased familial risk for type 2 diabetes: Implications for prevention,☆☆

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Abstract

Aim

To evaluate perceived risk, control, worry, and severity about diabetes, coronary heart disease (CHD) and stroke among individuals at increased familial risk of diabetes.

Methods

Data analyses were based on the Family Healthware™ Impact Trial. Baseline health beliefs were compared across three groups: (1) no family history of diabetes, CHD or stroke (n = 836), (2) family history of diabetes alone (n = 267), and (3) family history of diabetes and CHD and/or stroke (n = 978).

Results

After adjusting for age, gender, race, education and BMI, scores for perceived risk for diabetes (p < 0.0001), CHD (p < 0.0001) and stroke (p < 0.0001) were lowest in Group 1 and highest in Group 3. Similar results were observed about worry for diabetes (p < 0.0001), CHD (p < 0.0001) and stroke (p < 0.0001). Perceptions of control or severity for diabetes, CHD or stroke did not vary across the three groups.

Conclusions

Among individuals at increased familial risk for diabetes, having family members affected with CHD and/or stroke significantly influenced perceived risk and worry. Tailored lifestyle interventions for this group that assess health beliefs and emphasize approaches for preventing diabetes, as well as its vascular complications, may be an effective strategy for reducing the global burden of these serious but related chronic disorders.

Introduction

During the first decade of the 21st century, the increase in the global burden of diabetes exceeded prior predictions [1]. This was primarily the result of a rise in obesity, and a concomitant increase in the incidence of type 2 diabetes. The most recent estimates indicate that there are now 285 million individuals in the world with diabetes [2]. This number is expected to climb to 439 million adults diagnosed with diabetes by 2030. In North America alone, it is anticipated that the prevalence of diabetes will be 12%, representing a 42% increase from the current rate.

More than three-quarter of individuals with diabetes will die from vascular complications [3]. Myocardial infarction, stroke and peripheral artery disease are common causes of death. In a meta-analysis of individual records from 102 prospective studies, the hazard ratios, after adjusting for age and sex, were 2.06 (95% CI: 1.82–2.34) for coronary heart disease (CHD) and 2.56 (95% CI: 2.15–3.05) for stroke for diabetic compared to non-diabetic individuals [4]. As the global burden of diabetes increases, one can predict that there will be a corresponding rise in the prevalence of CHD and stroke among affected individuals.

Based on evidence from the Diabetes Prevention Program (DPP) in the US [5] and the Diabetes Prevention Study (DPS) in Finland [6] that diabetes and its vascular complications can be prevented through lifestyle modifications [3], [7], [8], [9], the identification of persons at increased risk, and targeting these individuals for interventions is paramount to reducing the global burden of these diseases. High risk individuals include those with impaired fasting glucose or impaired glucose tolerance, as well as persons with a family history of the disease. Family history of diabetes, which reflects the effect of shared genes and environmental risk factors, has been consistently shown to be a significant independent risk factor for developing the disease [10], [11], [12], [13], [14], [15]. Compared to individuals with a negative family history, those with affected relatives have a two- to six-fold increased risk of developing diabetes. In the adult US population, approximately 30% of non-Hispanic whites have a moderate-to-high familial diabetes risk [10]. These proportions are higher for non-Hispanic blacks (37%) and Mexican Americans (36%).

In addition to its effect on diabetes risk, having a family history of diabetes independently increases one's likelihood of developing its vascular complications, particularly CHD and stroke. Scheuner et al. showed that a family history of diabetes was significantly associated with a positive score for coronary artery calcification [16], which is highly predictive of major cardiovascular events. Similar findings were reported from a study of healthy young Caucasian adults [17], as well as an investigation based on a Mexican American cohort [18]. Although the relationship between family history and stroke is less clear, a recent Korean study reported that a positive family history of diabetes doubled the risk of stroke among diabetic adults [19].

Given that obesity, a high-fat diet and physical inactivity increase risk of developing diabetes [5], [6], CHD [3], [7] and stroke [8], [9], interventions that emphasize the importance of these three modifiable risk factors for preventing diabetes and its vascular complications may be more effective long-term than those that focus on diabetes alone. However, it is unclear whether healthy individuals with a family history of diabetes are aware that they at increased risk of developing these co-morbid conditions, or attempt lifestyle modifications to prevent their development. The few studies that have addressed these issues reported that among individuals at increased familial diabetes risk, only about half worried [20], [21], [22], [23], [24] or perceived that they were at increased risk for developing diabetes [22], [23], [24], [25], [26], [27], [28]. A similar proportion thought that diabetes could be prevented [21], [25], [26] or attempted to make lifestyle changes to reduce their risk [26], [29]. Thus, individuals at increased familial risk for diabetes appear to have misconceptions regarding their degree of susceptibility and the risk factors that contribute to the development of diabetes.

Health beliefs, attitudes and knowledge are major constructs of health behavior theories. In particular, perceptions of disease risk, control, and severity are included in social cognitive models such as the Health Belief Model [30] and the Theory of Planned Behavior [31] because they underlie health behaviors, mediate the effects of other risk factors, are amenable to change, and are targets for disease interventions [32]. Therefore, the development of successful interventions for individuals at increased familial risk for diabetes is contingent upon understanding their health beliefs regarding diabetes, CHD and stroke. Moreover, it is important to determine whether these beliefs are influenced by the presence of family members who are also affected CHD and/or stroke. Evidence supporting this premise would further justify the need for multiple risk factor interventions that focus on diabetes, as well as its vascular complications, as an approach for reducing the global burden of these related disorders.

To our knowledge, no study has examined health beliefs regarding these three conditions among individuals stratified by their familial risk for diabetes. We have a unique opportunity to address this issue using data collected for the Family Healthware™ Impact Trial (FHITr), which is the focus of this report.

Section snippets

Study design

The FHITr was designed to determine whether providing tailored prevention messages, based primarily on an individual's family health history for six chronic diseases (CHD, stroke, diabetes, and breast, colon and ovarian cancer) influenced health behaviors and communication about disease risk. Details regarding the study have been previously published [33], [34], [35], [36], [37]. To summarize, 41 primary care practices associated with three academic centers (NorthShore University HealthSystem

Results

The demographic characteristics for the three familial risk groups are illustrated in Table 1. Individuals at increased familial risk for diabetes, CHD and/or stroke (Group 3) were significantly older (p < 0.001), more likely to be female (p = 0.006) and have less education (p = 0.007) than those who were at increased familial risk for diabetes alone (Group 2) or those who were not at increased familial risk for any of the metabolic disorders (Group 1). Individuals in Group 1 were significantly more

Discussion

Although several studies have examined health beliefs among individuals at increased familial risk for diabetes [20], [21], [22], [23], [24], [25], [26], [27], [28], [29], little is known about how such perceptions vary when the family history also consists of individuals with additional metabolic disorders. To our knowledge, these analyses represent the first evaluation of health beliefs regarding diabetes, CHD and stroke among individuals with different familial risk profiles for diabetes.

Conflict of interest

The authors declare that they have no conflict of interest.

Acknowledgements

The FHITr Group extends gratitude to the patients, physicians, and their office staff for participating in this study. Without their time and effort, the study would not have been possible.

The Family Healthware™ Impact Trial (FHITr) Group consists of the collaborators listed below:

  • From the Centers for Disease Control and Prevention: Paula W. Yoon, ScD, MPH; Rodolfo Valdez, PhD; Margie Irizarry-De La Cruz, MPH; Muin J. Khoury, MD, PhD; Cynthia Jorgensen, DrPH

  • From the Veterans Administration

References (49)

  • W.S. Rubinstein et al.

    Components of family history associated with women's disease perceptions for cancer: a report from the Family Healthware™ Impact Trial

    Genet Med

    (2011)
  • G.H. Montgomery et al.

    Family and friends with disease: their impact on perceived risk

    Prev Med

    (2003)
  • H.K. Brekke et al.

    Lifestyle changes can be achieved through counseling and follow-up in first-degree relatives of patients with type 2 diabetes

    J Am Diet Assoc

    (2003)
  • H.K. Brekke et al.

    Long-term (1- and 2-year) effects of lifestyle intervention in type 2 diabetes relatives

    Diabetes Res Clin Pract

    (2005)
  • S. Haffner

    Diabetes and the metabolic syndrome—when is it best to intervene to prevent?

    Atherosclerosis

    (2006)
  • A.F. Amos et al.

    The rising global burden of diabetes and its complications: estimates and projections to the year 2010

    Diabet Med

    (1997)
  • K.G.M.M. Alberti et al.

    International Diabetes Federation: a consensus on type 2 diabetes prevention

    Diabet Med

    (2007)
  • J. Tuomilehto et al.

    Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance

    N Engl J Med

    (2001)
  • W.C. Knowler et al.

    Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin

    N Engl J Med

    (2002)
  • N.M. Maruthur et al.

    Lifestyle interventions reduce coronary heart disease risk: results from the PREMIER Trial

    Circulation

    (2009)
  • A. Galimanis et al.

    Lifestyle and stroke risk: a review

    Curr Opin Neurol

    (2009)
  • Y. Zhang et al.

    Lifestyle factors on the risks of ischemic and hemorrhagic stroke

    Arch Intern Med

    (2011)
  • R. Valdez et al.

    Family history and prevalence of diabetes in the US population: the 6-year results from the National Health and Nutrition Examination Survey (1999–2004)

    Diabetes Care

    (2007)
  • R. Valdez

    Detecting undiagnosed type 2 diabetes: family history as a risk factor and screening tool

    J Diabetes Sci Technol

    (2009)
  • Cited by (0)

    Sources of support: The Family Healthware™ Impact Trial (FHITr) was supported through cooperative agreements between the Centers for Disease Control and the Association for Prevention Teaching and Research (ENH-U50/CCU300860 TS-1216) and the American Association of Medical Colleges (Grants UM-U36/CCU319276 MM-0789 and CWR-U36/CCU319276 MM0630). Drs. Acheson (K07 CA086958) and Wang (K07 CA131103) also received salary support from the National Cancer Institute. Trial Registration: NCT00164658 ‘Evaluating Tools for Health Promotion and Disease Prevention’.

    ☆☆

    The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

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