title: Risk of Developing Diabetes Among Refugees and Immigrants: A Longitudinal Analysis.
abstract: To determine the difference in risk of developing diabetes for refugees, immigrants, and American-born participants living in the same communities, and to explore potential mediators of that difference. Retrospective longitudinal cohort from January 1, 2003 and December 31, 2013. Refugees aged ≥18 years were matched in a 1:3 ratio by age, gender, and date of care initiation to (1) Spanish-speaking non-refugee immigrants, and (2) English-speaking controls receiving care in the same community health center. We used proportional hazards regression to estimate the risk of incident diabetes. We tested whether differences in education or baseline obesity mediated diabetes risk using counterfactual mediation analysis. We included 3174 participants. Among refugee participants, the most common countries of origin were Somalia (17.8 %), Iraq (16.7 %) and Bhutan (8.8 %). Diabetes incidence rate was 1.94, 1.91, and 1.22 cases per 100 person-years follow-up for refugees, immigrants, and controls, respectively. In adjusted models, both refugee (HR 2.08 95 % CI 1.32-3.30) and immigrant (HR 1.51 95 % CI 1.01-2.24) statuses were associated with increased diabetes risk compared with controls. Risk between refugees and immigrants did not differ (adjusted HR for refugees 1.37 95 % CI 0.91-2.06). In mediation analyses, educational attainment mediated 36 % (p = 0.007) of the difference in diabetes risk between refugees/immigrants and controls. Baseline obesity did not mediate difference in diabetes risk (proportion mediated 1 %, p = 0.84). Refugees and immigrants had significantly increased risk for diabetes, partially mediated by education. Education-based lifestyle interventions may be a promising strategy to prevent diabetes for these vulnerable patients.
authors.affiliation: Division of General Internal Medicine, Massachusetts General Hospital, 50 Staniford St, 9th Floor, Boston, MA, 02114, USA. SABerkowitz@partners.org.|Diabetes Population Health Unit, Massachusetts General Hospital, Boston, MA, USA. SABerkowitz@partners.org.|Harvard Medical School, Boston, MA, USA. SABerkowitz@partners.org.
authors.forename: Seth A
authors.identifier: http://orcid.org/0000-0003-1030-4297
authors.initials: SA
authors.lastname: Berkowitz
authors.affiliation: Division of General Internal Medicine, Faculty of Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
authors.forename: Gabriel E
authors.initials: GE
authors.lastname: Fabreau
authors.affiliation: Division of General Internal Medicine, Massachusetts General Hospital, 50 Staniford St, 9th Floor, Boston, MA, 02114, USA.|Harvard Medical School, Boston, MA, USA.
authors.forename: Sridharan
authors.initials: S
authors.lastname: Raghavan
authors.affiliation: Harvard Medical School, Boston, MA, USA.
authors.forename: Katherine
authors.initials: K
authors.lastname: Kentoffio
authors.affiliation: Division of General Internal Medicine, Massachusetts General Hospital, 50 Staniford St, 9th Floor, Boston, MA, 02114, USA.|Harvard Medical School, Boston, MA, USA.
authors.forename: Yuchiao
authors.initials: Y
authors.lastname: Chang
authors.affiliation: Division of General Internal Medicine, Massachusetts General Hospital, 50 Staniford St, 9th Floor, Boston, MA, 02114, USA.
authors.forename: Wei
authors.initials: W
authors.lastname: He
authors.affiliation: Division of General Internal Medicine, Massachusetts General Hospital, 50 Staniford St, 9th Floor, Boston, MA, 02114, USA.|Harvard Medical School, Boston, MA, USA.
authors.forename: Steven J
authors.initials: SJ
authors.lastname: Atlas
authors.affiliation: Division of General Internal Medicine, Massachusetts General Hospital, 50 Staniford St, 9th Floor, Boston, MA, 02114, USA.|Harvard Medical School, Boston, MA, USA.
authors.forename: Sanja
authors.initials: S
authors.lastname: Percac-Lima
mesh_terms: D000328:Adult; D003920:Diabetes Mellitus / Q000209:etiology* / Q000517:prevention & control*; D057286:Electronic Health Records; D054242:Emigrants and Immigrants; D005260:Female; D006801:Humans; D015994:Incidence; D008297:Male; D008404:Massachusetts; D008875:Middle Aged; D016016:Proportional Hazards Models; D012036:Refugees; D012042:Registries; D012189:Retrospective Studies; D012307:Risk Factors; D055815:Young Adult
keywords: Diabetes incidence; Diabetes prevention; Immigration; Refugees