Ameena T. Ahmed

Objective: Bariatric surgery is the most effective therapy for severe obesity. People with bipolar disorder have increased risk of obesity, yet are sometimes considered ineligible for bariatric surgery due to their bipolar disorder diagnosis. This study aimed to determine if bariatric surgery alters psychiatric course among stable patients with bipolar disorder.Methods: A matched cohort study (2006–2009) with mean follow‐up of 2.17 years was conducted within Kaiser Permanente Northern California, a group practice integrated health services delivery organization that provides medical and psychiatric care to 3.3 million people. Participants were 144 severely obese patients with bipolar disorder who underwent bariatric surgery, and 1,440 control patients with bipolar disorder, matched for gender, medical center, and contemporaneous health plan membership. Controls met referral criteria for bariatric surgery. Hazard ratio for psychiatric hospitalization, and change in rate of outpatient psychiatric utilization from baseline to Years 1 and 2, were compared between groups.Results: A total of 13 bariatric surgery patients (9.0%) and 153 unexposed to surgery (10.6%) had psychiatric hospitalization during follow‐up. In multivariate Cox models adjusting for potential confounding factors, the hazard ratio of psychiatric hospitalization associated with bariatric surgery was 1.03 [95% confidence interval (CI): 0.83–1.23]. In fully saturated multivariate general linear models, change in outpatient psychiatric utilization was not significantly different for surgery patients versus controls, from baseline to Year 1 (−0.4 visits/year, 95% CI: −0.5 to 0.4) or baseline to Year 2 (0.4 visits/year, 95% CI: −0.1 to 1.0).Conclusions: Bariatric surgery did not affect psychiatric course among stable patients with bipolar disorder. The results of this study suggest that patients with bipolar disorder who have been evaluated as stable can be considered for bariatric surgery.

Childhood obesity prevention is a national priority. School-based gardening has been proposed as an innovative obesity prevention intervention. Little is known about the perceptions of educators about school-based gardening for child health. As the success of a school-based intervention depends on the support of educators, we investigated perceptions of educators about the benefits of gardening programs to child health. Semi-structured interviews of 9 middle school educators at a school with a garden program in rural Hawai'i were conducted. Data were analyzed using a grounded theory approach. Perceived benefits of school-based gardening included improving children's diet, engaging children in physical activity, creating a link to local tradition, mitigating hunger, and improving social skills. Poverty was cited as a barrier to adoption of healthy eating habits. Opinions about obesity were contradictory; obesity was considered both a health risk, as well as a cultural standard of beauty and strength. Few respondents framed benefits of gardening in terms of health. In order to be effective at obesity prevention, school-based gardening programs in Hawai'i should be framed as improving diet, addressing hunger, and teaching local tradition. Explicit messages about obesity prevention are likely to alienate the population, as these are in conflict with local standards of beauty. Health researchers and advocates need to further inform educators regarding the potential connections between gardening and health.

Persons with bipolar disorder (BD) have an increased risk of obesity and associated diseases. Success of current behavioral treatment for obesity in patients with BD is inadequate. Existing literature on bariatric surgery outcomes in populations with BD were reviewed, and needed areas of research were identified. Knowledge about bariatric surgery outcomes among patients with BD is limited. Available evidence indicates that bariatric surgery is a uniquely effective intervention for achieving and sustaining significant weight loss and improving metabolic parameters. Notwithstanding the benefits of bariatric surgery in nonpsychiatric samples, individuals with BD (and other serious and persistent mental illnesses) have decreased access to this intervention. Areas of needed research include: (1) current practice patterns; (2) metabolic course after bariatric surgery; (3) psychiatric course after bariatric surgery; and (4) mechanisms of psychiatric effect. The considerable hazards posed by obesity in BD, as measured by illness complexity and premature mortality, provide the basis for hypothesizing that bariatric surgery may prevent and improve morbidity in this patient population. In addition to physical health benefits, bariatric surgery may exert a robust and favorable effect on the course and outcome of BD and reduce obesity-associated morbidity, the most frequent cause of premature mortality in this patient population.

To examine the patient and provider characteristics associated with utilization of mental health services (MHS) among women experiencing intimate partner violence (IPV). Cross-sectional study among 6870 women aged 18 to 65 years with first IPV identification between May 2004 and December 2009 in Kaiser Permanente Northern California. Utilization of MHS within 60 days after first IPV identification was determined. Multivariate generalized estimating equation logistic regression models that controlled for patient and provider characteristics were used to determine predictors of utilization. Thirty-seven percent of women utilized MHS. In multivariate generalized estimating equation models, the strongest predictor of utilization was electronic referral (odds ratio [OR], 4.40; 95% confidence interval [CI], 3.66-5.28). Odds of utilization were lower among black (OR, 0.71; 95% CI, 0.57-0.89), Latina (OR, 0.62; 95% CI, 0.41-0.95), and Spanish-speaking (OR, 0.71; 95% CI, 0.57-0.89) patients and were higher among those with prior posttraumatic stress disorder (OR, 2.38; 95% CI, 1.17-3.44) or depression (OR, 1.35; 95% CI, 1.17-1.57). Emergency department identification of IPV was associated with lower odds of MHS utilization (OR, 0.46; 95% CI, 0.37-0.59), while older provider identification of IPV was associated with higher odds of MHS utilization (OR, 1.33; 95% CI, 1.07-1.65). Additional training for providers, particularly those who are younger or are practicing in emergency departments, may be needed to increase rates of MHS utilization among patients affected by IPV. Addressing language barriers to care and cultural appropriateness may improve MHS utilization.

To examine ethnic differences in hemoglobin testing practices and to test the hypothesis that ethnicity is an independent predictor of anemia among patients with diabetes mellitus. We conducted a panel study to assess the rate of hemoglobin testing during 1999–2001 and the period prevalence and incidence of anemia among 79,985 adults with diabetes mellitus receiving care within Kaiser Permanente of Northern California. Anemia was defined as hemoglobin P < 0.0001). Fifteen percent of the cohort had prevalent anemia at baseline, and an additional 22% of those tested developed anemia during the study period. Anemia was more prevalent among blacks and mixed ethnicity persons compared with other racial/ethnic groups. Anemia was also more prevalent among those ≥70 years of age or with estimated glomerular filtration rate 2. In multivariable models, blacks had higher and Asians had lower odds of prevalent anemia and hazard ratios of incident anemia compared with whites. Within a large, diverse cohort with diabetes, ethnicity was predictive of anemia, even after adjustment for age, level of kidney function, and other potential confounders. Blacks with diabetes are at increased risk of anemia relative to whites. These differences may account for some of the observed ethnic disparities in diabetes complications. Am. J. Hematol., 2010.

Diabetes disproportionately affects Latinos. However, examining Latinos as one group obscures important intra-group differences. This study examined how generational status, duration of US residence, and language preference are associated with diabetes prevalence and to what extent these explain the higher prevalence among Latinos.

BACKGROUND Alcohol consumption is a common behavior. Little is known about the relationship between alcohol consumption and glycemic control among people with diabetes. OBJECTIVE To evaluate the association between alcohol consumption and glycemic control. DESIGN Survey follow-up study, 1994–1997, among Kaiser Permanente Northern California members. PATIENTS 38,564 adult diabetes patients. MEASUREMENTS Self-reported alcohol consumption, and hemoglobin A1C (A1C), assessed within 1 year of survey date. Linear regression of A1C by alcohol consumption was performed, adjusted for sociodemographic variables, clinical variables, and diabetes disease severity. Least squares means estimates were derived. RESULTS In multivariate-adjusted models, A1C values were 8.88 (lifetime abstainers), 8.79 (former drinkers), 8.90 (p < 0.001) and inversely (p = 0.001) associated with A1C among diabetes patients. CONCLUSIONS Alcohol consumption is inversely associated with glycemic control among diabetes patients. This supports current clinical guidelines for moderate levels of alcohol consumption among diabetes patients. As glycemic control affects incidence of complications of diabetes, the lower A1C levels associated with moderate alcohol consumption may translate into lower risk for complications.

This review provides an overview of the existing empirical research of the multiple ways by which discrimination can affect health. Institutional mechanisms of discrimination such as restricting marginalized groups to live in undesirable residential areas can have deleterious health consequences by limiting socio-economic status (SES) and creating health-damaging conditions in residential environments. Discrimination can also adversely affect health through restricting access to desirable services such as medical care and creating elevated exposure to traditional stressors such as unemployment and financial strain. Central to racism is an ideology of inferiority that can adversely affect non-dominant groups because some members of marginalized populations will accept as true the dominant society's ideology of their group's inferiority. Limited empirical research indicates that internalized racism is inversely related to health. In addition, the existence of these negative stereotypes can lead dominant group members to consciously and unconsciously discriminate against the stigmatized. An overview of the growing body of research examining the ways in which psychosocial stress generated by subjective experiences of discrimination can affect health is also provided. We review the evidence from the United States and other societies that suggest that the subjective experience of discrimination can adversely affect health and health enhancing behaviours. Advancing our understanding of the relationship between discrimination and health requires improved assessment of the phenomenon of discrimination and increased attention to identifying the psychosocial and biological pathways that may link exposure to discrimination to health status.

Aims  Our aim was to examine the associations of alcohol consumption with six diabetes self‐care behaviours.Methods  We determined levels of alcohol consumption and examined associations between alcohol consumption and six self‐care behaviours in 65 996 adults with diabetes who received care through Kaiser Permanente Northern California and who responded to a 1994–1997 survey. Adherence with recommendations for self monitoring of blood glucose, HbA_1c testing, and diabetes medications were determined from electronic records; smoking and use of diet and exercise to treat diabetes were self reported. Multiple logistic regression models were used to determine the associations between alcohol consumption (average number of drinks/day in the past year) and the probability of adherence to each self‐care behaviour.Results  Current alcohol consumption was reported by 50.8% of adults with diabetes. In adjusted models, we observed a gradient of increasing risk for poor adherence to diabetes self‐care behaviours with increasing alcohol consumption, starting with those who consume even one drink a day. Former drinkers had the greatest compliance with each self‐care behaviour, except for current smoking.Conclusions  Alcohol consumption is a marker for poorer adherence to diabetes self‐care behaviours. These findings highlight the importance of routine assessment of alcohol intake in people with diabetes, particularly as half of adults with diabetes consume alcohol. Given extant evidence that moderate alcohol intake may have cardiovascular benefits for patients with diabetes, examination of the trade‐offs between cardiovascular benefits vs. potential risk of lower adherence with self‐care behaviours deserves study.

Kaiser Permanente Northern California dialysis registry. To examine the incidence of tuberculosis disease (TB) in a large, insured population of dialysis patients and to describe the disease characteristics and outcomes of these cases. Cohort study of all Kaiser patients who initiated dialysis between 1 January 1995 and 31 December 1999. TB incidence in our cohort between 1 January 1995 and 31 December 2000 was determined through electronic databases of out-patient diagnoses, laboratory results, and pharmacy records. The incidence of TB in the general population was determined from mandatory reporting of TB cases compiled by the California Department of Health Services. During the 6-year period of observation, 13 cases of TB occurred among 2806 dialysis initiators. The incidence of TB in the dialysis cohort was 134 per 100,000 person-years, compared to an incidence of 11.9/100,000 in the California population, yielding a relative risk of 11.3. Extra-pulmonary disease occurred in eight of 11 patients for whom site of disease was recorded. Five of 13 patients died within 3 months of TB diagnosis. The dialysis population is at high risk of TB. Physicians caring for dialysis patients must remain vigilant for signs of TB in this vulnerable population.