Wagner J, Keuky L, Horn I, Schumann K, Scully M, Kuoch T.
Published in the Journal of Endocrinology, Diabetes & Obesity, September 2015.
The full article is available for free at the link below.
Background: Psychological distress is associated with hyperglycemia in persons with diabetes. Preliminary reports suggest that metformin may help buffer the effects of psychological distress on hyperglycemia. Many Cambodians who are currently over age 35 have elevated symptoms of psychological distress from having survived their country's genocide. This study investigated the associations among psychological distress, metformin use, and glucose levels in Cambodians with type 2 diabetes.
Methods: Patients with type 2 diabetes >1 year, aged 35-80, not using insulin, were recruited from a Cambodian Diabetes Association clinic. Participants provided a fasting finger prick blood sample and completed a psychological assessment.
Measures: A MiniMed Ultra-II point of care glucometer was used to determine fasting glucose. Participants completed the valid and reliable Khmer language version of the 25-item Hopkins Symptom Checklist (HSCL) which measures symptoms of depression and anxiety. The HSCL was administered via a computerized spoken format which allowed standardized administration and automated data entry.
Data Analysis: Multiple linear regressions were performed using SPSS v21.
Results: Participants, n=60, were M=55.7 (SD=9.6) years old, 60% female, 68.3 % were using metformin. Fasting glucose values were above target range, M=143.5 mg/dl (SD=48.1). Mean total scores on the HSCL exceeded the clinical cutoff (1.75) for likely psychiatric disorder, M=1.8 (SD=0.5). In linear regression with main effects in the model there was a significant interaction between psychological distress and metformin use on glucose, (beta=-1.47, t=-2.49, *p<.05). Controlling for age, sex, antidepressant use and other oral hypoglycemic agents did not meaningfully change the findings. Conclusion: Metformin may buffer the deleterious association between psychological distress and glucose. These findings add to a small but provocative literature on the potential metabolic benefits of metformin specifically for patients with psychological distress.
Article drawing from Khmer Health Advocates' work in the torture treatment field; notes trends and interventions for diabetic refugees and recommendations for new arrivals.
Link is to abstract; full article is available for purchase from publisher.
Julie Wagner, Lim Keuky, Lorraine Fraser-King, Theanvy Kuoch, and Mary Scully
Published in Journal of Community Medicine & Health Education April 2015.
Click on the link below for full text or .pdf of the article
Objectives: Lifestyle modification can prevent type II diabetes. Rates of diabetes are high in Cambodia. The Cambodian genocide and its aftermath resulted in destruction of the healthcare system and a critical shortage in the Cambodian healthcare workforce. Cambodia has a well-established system of community health workers, or village health support guides (Guides). This study explored opportunities for and challenges to training Guides to deliver diabetes prevention interventions.
Design: In depth interviews were conducted with 12 Guides in Khmer. Guides also completed a 22-item validated Khmer language quiz regarding their knowledge of diabetes.
Results: Participants were 75% female, on average 52 years old, with 8 years of education and 9 years Guides experience. Guides were aware that diabetes is a problem for their communities and were eager to address it. However, they had very low diabetes knowledge (quiz mean=57% correct). Three themes emerged: dedication to being a Guide, current responsibilities and need for additional and high quality training, and striving to do a good job in the face of barriers and insufficient resources. Participants easily identified factors that would support their own training in diabetes, and factors that would promote their teaching diabetes prevention in their villages.
Conclusions: Diabetes prevention is overdue in Cambodia. Guides are poised to be trained to deliver these programs. Such training should be responsive to their perceived needs. Political will must be cultivated to support appropriate resources.
Kinzie JD, Riley C, McFarland B, Hayes M, Boehnlein J, Leung P, Adams G. Published in the Journal of Nervous & Mental Disorders, Feb 2008.
There is increasing evidence that immigrants and traumatized individuals have elevated prevalence of medical disease. This study focuses on 459 Vietnamese, Cambodian, Somali, and Bosnian refugee psychiatric patients to determine the prevalence of hypertension and diabetes. The prevalence of hypertension was 42% and of diabetes was 15.5%. This was significantly higher than the US norms, especially in the groups younger than 65. Diabetes and hypertension were higher in the high-trauma versus low-trauma groups. However, in the subsample with body mass index (BMI) measurements subjected to logistic regression, only BMI was related to diabetes, and BMI and age were related to hypertension. Immigrant status, presence of psychiatric disorder, history of psychological trauma, and obesity probably all contributed to the high prevalence rate. With 2.5 million refugees in the country, there is a strong public health concern for cardiovascular disease in this group.
Singh HK, Scott TE, Henshaw MM, Cote SE, Grodin MA, Piwowarczyk LA. Oral Health Status of Refugee Torture Survivors Seeking Care in the United States. American Journal of Public Health 2008;98(12):2181-2182. doi:10.2105/AJPH.2007.120063.
This study assessed the oral health status of 216 refugee torture survivors seeking care at an urban torture treatment center in the United States. Results showed that patients' dental health ranged from poor to fair; 76% had untreated cavities, and approximately 90% required immediate or near-immediate dental care. Torture treatment centers, in addition to offering safe environments for educating and examining patients, are ideal settings to provide basic oral health services without the risk of retraumatization.
Wagner J, Kong S, Kuoch T, Scully MF, Tan HK, Bermudez-Millan A.
Published inJournal of Health Care for the Poor and Underserved May 2015.
This study investigated a community health worker-delivered lifestyle intervention for prevention of cardiometabolic disease, called Eat, Walk, Sleep. It was designed for traumatized, low-literacy Cambodian American refugees.
We used a single group, pre-post design to evaluate the effects of the program on self-reported health behaviors. As a control for threats to internal validity, we also measured a nonequivalent dependent variable, i.e., perceived discrimination by health care providers.
Of 140 participants enrolled, 114 completed one-year assessments. In intent-to-treat analysis with correction for multiple comparisons, compared with baseline, participants at one year scored higher on cardiometabolic prevention knowledge, self-rated health, physical activity, medication compliance, and preventive screenings, and they reported improved sleep, a modest shift from white to brown rice, and reduced barriers to care. As expected, perceptions of discrimination by health care providers did not change.
Self-reported behavioral risk factors improved. A randomized, controlled study with objective measures is warranted.
It is quite important that health care professionals working in primary care medical settings learn how to identify which patients have survived torture. Once these patients have been identified, it is critical to work with them in a compassionate and competent manner.
This article, by Sandra Crosby, MD, is attached, or available for subscribers through JAMA.
Importance Refugees are a vulnerable class of immigrants who have fled their countries, typically following war, violence, or natural disaster, and who have frequently experienced trauma. In primary care, engaging refugees to develop a positive therapeutic relationship is challenging. Relative to care of other primary care patients, there are important differences in symptom evaluation and developing treatment plans.
Objectives To discuss the importance of and methods for obtaining refugee trauma histories, to recognize the psychological and physical manifestations of trauma characteristic of refugees, and to explore how cultural differences and limited English proficiency affect the refugee patient–clinician relationship and how to best use interpreters.
Evidence Review MEDLINE and the Cochrane Library were searched from 1984 to 2012. Additional citations were obtained from lists of references from select research and review articles on this topic.
Findings Engagement with a refugee patient who has experienced trauma requires an understanding of the trauma history and the trauma-related symptoms. Mental health symptoms and chronic pain are commonly experienced by refugee patients. Successful treatment requires a multidisciplinary approach that is culturally acceptable to the refugee.
Conclusions and Relevance Refugee patients frequently have experienced trauma requiring a directed history and physical examination, facilitated by an interpreter if necessary. Intervention should be sensitive to the refugee’s cultural mores.
Wagner J, Rajan TV, Kuoch T, Scully M.
Published in Journal of Immigrant Minority Health December 2013.
Few studies have explored interrelationships among mental health and health status in refugees using objective, clinical data. Pulse pressure (PP) has recently emerged as an easily obtained, strong, independent determinant of mortality. We conducted a chart review of electronic records for 24 consecutive months to investigate PP among Cambodian refugees receiving services at a community clinic in Connecticut, USA. 301 patients charts were retrieved, 41 contained complete data for all variables. We found high rates of cardiovascular, anthropometric, and mental health problems. Among women, higher weight was related to higher PP. Among men, higher mental health symptom scores were marginally related to higher PP. Findings held after controlling for age.
Adiposity and mental health symptoms, which are known to be related to trauma history, contribute to elevated PP in this resettled refugee population. Given that PP may be modifiable through lifestyle intervention, further investigation of these problems in this needy population is warranted.
American Journal of Preventive Medicine, Volume 14 , Issue 4 , 245 - 258
This study found a strong graded relationship between the breadth of exposure to abuse or household dysfunction during childhood and multiple risk factors for several of the leading causes of death in adults.
Link is to full article available for free.
Published in International Journal of Behavioral Medicine December 2015.
Diabetes, adiposity, and socioeconomic status (SES) are all associated with decreased heart rate variability (HRV), a marker of autonomic function predictive of mortality. Cambodians have high rates of diabetes and low SES. How these factors interact to explain HRV has not been examined.
The aims of this study were to investigate associations among waist-to-hip ratio, socioeconomic status, and HRV among Cambodians with diabetes.
Sixty patients with type 2 diabetes for ≥1 year, not taking insulin, aged 35-80 years were recruited from the Cambodian Diabetes Association. The 2010 Ministry of Health survey regarding household conditions was used to measure SES. Waist-to-hip ratio was measured two times and averaged. For HRV, beat-to-beat intervals were recorded on ambulatory ECG recorders, and short-term HRV was calculated in the time domain and in the frequency domain using spectral analysis. Cross-sectional data were analyzed using a series of multiple linear regressions using SPSS v21.
Participants were of mean age of 56 years old, 60 % female, with National Glycohemoglobin Standardization Program (NGSP) HbA1c mean = 8.4. Participants were poor (e.g., 18 % did not have flush toilets), had high waist-to-hip ratios (mean = 0.91), and had HRV values below published norms. In linear regression, there was a significant interaction between waist-to-hip ratio and SES explaining HRV in the time domain (standard deviation of the R-R interval (SDNN), beta = .33, t = 2.61, p < .05) and the frequency domain (log transformed very low frequency (Ln VLF), LF, and total power; all p < .05). Among those with lower SES only, higher waist-to-hip ratio was associated with lower HRV. Findings remained significant after controlling for age, sex, and HbA1c.
Central adiposity shows a stronger deleterious association with autonomic tone among individuals with more adverse social conditions.
Adiposity; Cambodians; Diabetes; Heart rate variability; Socioeconomic status; Waist-to-hip ratio
Kuoch T, Scully M, Tan HK, Rajan TV, Wagner J.
Published in Progress in Community Health Partnerships: Research, Education, and Action Winter 2014.
The 2009 National Cambodian American Town Hall Meeting was a public-private partnership convened to address long-term health issues related the Cambodian holocaust. Goals for participants were to dispel myths about diabetes; goals for the partnership were to build research capacity and to strengthen relationships.
Partners collaborated on all aspects of the meeting which was held in Khmer by bridged videoconferencing in 10 sites and webinar at 5 sites across the United States over a 3-hour period. EAT, WALK, SLEEP for Health (EWS), the National Cambodian American Diabetes Project program, provided the framework for the meeting.
Pre and post surveys were completed by 323 participants. Modest improvements were seen in participants' belief that they could improve their own and their community's health, although significant barriers remained. Participants and community partners evaluated the meeting positively.
The meeting is a model for other populations, and results inform future work.
Published in International Journal of Behavioral Medicine,April 2016.
Type 2 diabetes is a pressing public health concern in Cambodia, a country with limited human resource capacity due to genocide. Cambodian village health support guides (Guides) promote health at the local level.
The curriculum, called Eat, Walk, Sleep was delivered to Guides in Siem Reap province once over 3 h. Participants completed a pretest and posttest on diabetes knowledge. Guides were offered continuing education through Eat, Walk, Sleep resources and were encouraged to teach Eat, Walk, Sleep in their villages. For each of 6 months following their training, Guides completed a checklist regarding their activities.
One hundred eighty-five Guides attended one of ten trainings. Knowledge scores increased significantly from pretest to posttest. During 6 months of follow-up, n = 159 Guides (85 %) completed at least one monthly checklist. Guides reported high rates of uptake and delivery of the Eat, Walk, Sleep curriculum and moderate rates of continuing education about diabetes.
Diabetes prevention in Cambodia is nascent. Guides show excellent uptake and dissemination of the curriculum. Future research should examine effect of support for Guide activities and the effect of the curriculum on villager health behaviors, and ultimately, on rates of type 2 diabetes.
Wagner J, Burke G, Kuoch T, Scully M, Armeli S, Rajan TV.
Published in Journal of Immigrant and Minority Health December 2013.
Mental health problems among Southeast Asian refugees have been documented. However, longer term health consequences of mass violence as re-settled refugees age are less well described. This study investigated relationships among trauma symptoms, self-reported health outcomes, and barriers to healthcare among Cambodian and Vietnamese persons in Connecticut. An internet phone directory was used to generate a list of names that was compared to 2000 census data to estimate the proportion of the population in each group. From these lists, 190 telephone listings were selected at random. Interviewers telephoned selected listings to screen for eligible participants and obtain an appointment for interview. Surveys were administered through face-to-face interviews during home visits conducted in Khmer or Vietnamese. The Harvard Trauma Questionnaire assessed trauma symptoms. Questions regarding the presence of physician diagnosed heart disease, hypertension, diabetes, and chronic pain were adapted as written from the Health Interview Survey. Healthcare access and occurrence were measured with questions regarding cost and access, patient-provider understanding, and interpretive services. Hierarchical modeling was used to account for respondent nesting within family. Analyses controlled for age, sex, and country of origin. Individuals who reported greater trauma symptoms were more likely to report heart disease by a factor of 1.82, hypertension by a factor of 1.41, and total count of diseases by a factor of 1.22, as well as lower levels of subjective health. Greater trauma symptoms were also associated with greater lack of understanding, cost and access problems, and the need for an interpreter. Although the majority of Southeast Asian immigrants came to the United States as refugees approximately 20-30 years ago, there continues to be high levels of trauma symptoms among this population which are associated with increased risk for disease and decreased access to healthcare services.