Depressive Symptoms, Cardiovascular Risk, and Diabetes Self-Care Strategies in African American Women With Type 2 Diabetes

Depressive Symptoms, Cardiovascular Risk, and Diabetes Self-Care Strategies in African American Women With Type 2 Diabetes Jan Collins-McNeil, Ezra C. Holston, Christopher L. Edwards, Judy Carbage-Martin, Debra L. Benbow, and Tanya D. Dixon This descriptive study examined depressive symptoms, cardiovascular risk, and diabetes self-care strategies in African American women (N = 45) with type 2 diabetes (T2D). All completed a questionnaire packet during structured interviews. Significant associations were found between two individual depressive symptoms and mean cardiovascular disease (CVD) risk scores, which suggest that in African American women withT2D, depressive symptoms may be correlated with a specific CVD profile and/or are unrecognized and/or unexpressed. Further analysis is warranted to determine the extent of this relationship in African American women withT2D. D 2007 Elsevier Inc. All rights reserved.

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IABETES MELLITUS IS one of the most prevalent chronic diseases in the United States with 798,000 new cases diagnosed every year (Harris et al., 1998). Approximately 17 million people in the United States have diabetes. Compared with White Americans, individuals from minority ethnic groups suffer disproportionately from type 2 diabetes (T2D) and its long-term complications (Dagogo-Jack, 2003). African Americans with T2D have been shown to have an increased risk of developing micro- or macrovascular disease complications (Ferdinand, 2005). Consequently, African Americans with diabetes have a higher rate of cardiovascular disease (CVD), retinopathy, microalbuminuria, end-stage renal disease, lower extremity amputation, and mortality compared with White Americans (Marshall, 2005; Ness, Nassimiha, Feria, & Aronow, 1999). Notably, the relationship between these comorbidities and T2D is not well understood. The prevalence of one particular psychiatric morbidity, major depression, is approximately twofold higher in individuals with diabetes than

in those without diabetes (Katon et al., 2005; U.S. Department of Health and Human Services [USDHHS], National Institutes of Health, National Institute of Mental Health, 2000). Unfortunately, African American women with T2D represent one of the highest risk groups in terms of prevalence and diabetes disease burden (Samuel-Hodge et al., 2000). Compared to women without diabetes, From the Department of Nursing, Duke University School of Nursing, Duke University, Durham, NC; Hythiam, Inc., Los Angeles, CA; Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC; Pain and Palliative Care Center, Duke University Medical Center, Durham, NC; Department of Medicine, Division of Hematology, Duke University Medical Center Durham, NC; MemphisShelby County Health Department, Memphis, TN; Winston Salem State University, Winston-Salem, NC; and North Carolina Central University, Durham, NC. Address reprint requests to Jan Collins-McNeil, PhD, APRN, BC, Duke University School of Nursing, Durham, NC. E-mail address: [email protected] n 2007 Elsevier Inc. All rights reserved. 0883-9417/1801-0005$30.00/0 doi: 10.1016/j.apnu.2007.03.002

Archives of Psychiatric Nursing, Vol. 21, No. 4 (August), 2007: pp 201–209

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women with diabetes have from two to six times the risk of heart disease and heart attack and are at much greater risk of having a stroke (American Heart Association, 2006). Yet, depressive symptoms in this population are largely unexplored. Depression, CVD, and T2D impose a particularly high burden on African Americans (Braithwaite & Taylor, 2001; Burt et al., 1995; Gavin, Peterson, & Warren-Boulton, 2003). These diseases are found in higher prevalence among African Americans and are associated with reduced quality of life, increased morbidity and disability, and even death (Braithwaite & Taylor, 2001; Gavin et al., 2003). African American women suffer with higher mortality rates (187.5 per 100,000) from CVD than White women (145.3 per 100,000) (American Heart Association, 2006), but a comorbidity of T2D escalates the mortality rate so that together, CVD and T2D produce the highest mortality rate of all groups of women in the United States (American Heart Association, 2004; USDHHS, Office on Women's Health, National Women's Health Information Center, 2003). Clearly, an association exists between T2D and increased risk of CVD. Diabetes is also associated with depressive symptoms and major depression (de Groot, Pinkerman, Wagner, & Hockman, 2006; Lustman et al., 2000). Depression rates double with a comorbidity of diabetes and are considerably higher in women with diabetes than in men with diabetes (Clouse et al., 2003). Among individuals with diabetes, depressive symptoms are associated with poor selfcare behaviors including poor adherence to medication and glucose-monitoring regimens, unhealthy diet, and less exercise (Husaini et al., 2004). Few studies have examined the association of CVD risk with depressive symptoms and self-care behaviors in African American women with T2D (de Groot, Auslander, Williams, Sherraden, & Haire-Joshu, 2003; Everson-Rose et al., 2004; Husaini et al., 2004; USDHHS, Office on Women's Health, National Women's Health Information Center, 2003). Therefore, the specific aims of this study are to describe the prevalence of depressive symptoms, CVD risks, and self-care strategies in African American women with T2D; and examine relationships among depressive symptoms and CVD risk estimates. Findings from this study will enhance our understanding of the relationship of diabetes self-care behaviors and glycemic

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control, expand the conceptualization of risk for CVD in African American women to include T2D, and simultaneously add to the base of scientific knowledge in the areas of depression, diabetes, and CVD. LITERATURE REVIEW

The association among depression, CVD, and diabetes in general populations is well established. The presence of major depression in individuals with diabetes results in symptom amplification (Musselman, Evans, & Nemeroff, 1998). That is, even when controlling for severity of diabetes, individuals with diabetes and comorbid depression experience more diabetic symptoms than their nondepressed counterparts. However, little is known about the prevalence and correlates of depressive symptoms and CVD risk among African American women with T2D (de Groot et al., 2006). Currently, research has established that women with diabetes experience more psychological distress than men, and, rather than merely being a secondary emotional response to diabetic complications, depression may be an independent risk factor in initiating T2D (Musselman et al., 1998). Depression has also been positively associated with the metabolic syndrome among women (but not men) younger than 40 years, suggesting that early detection and treatment of depression might forestall the risk of CVD among women (Chapman, Perry, & Strine, 2005). African American women have long been identified as a group at high risk for depression (Barbee, 1992), although the evidence is conflicting. African American women are less likely to have a depressive disorder than White women (USDHHS, Office on Women's Health, National Women's Health Information Center, 2003). However, of those African American women suffering from depression, almost half (47%) are afflicted with severe depression (USDHHS, Office on Women's Health, National Women's Health Information Center, 2003). Individuals with major depression and diabetes with or without evidence of CVD have a higher number of CVD risk factors (Katon et al., 2004). Furthermore, depression is a major risk factor for the development of CVD, stroke, and death after an index myocardial infarction (Jonas & Mussolino, 2000; Musselman et al., 1998).

DEPRESSIVE SYMPTOMS, CARDIOVASCULAR RISK, AND DIABETES SELF-CARE STRATEGIES

CVD is the major cause of mortality for persons with diabetes (American Diabetes Association, 2004). CVD is a major contributor to morbidity and direct and indirect costs of diabetes (USDHHS, Centers for Disease Control and Prevention. Coordinating Center for Health Promotion, 2005). T2D is also an independent risk factor for macrovascular disease, and its common coexisting conditions (e.g., hypertension and dyslipidemia) are also risk factors (American Diabetes Association, 2006). CVD is the leading cause of death of women in the United States (Finkelstein, Khavjou, Mobley, Haney, & Will, 2004). More specifically, CVD is a particularly important problem among minority women (Mosca et al., 1997) because it accounted for 40.6% of deaths among African American women in 2000 (Chapman et al., 2005). African American women tend to develop CVD at an earlier age (American Heart Association, 2006) than White women while also having the highest incidence and prevalence of T2D (Samuel-Hodge et al., 2000; USDHHS, Office on Women's Health, National Women's Health Information Center, 2003). Clearly, evidence exists that African American women with diabetes are at increased risk for CVD, and to effectively impact these health disparities in this population, care must target the specific diabetes self-management behaviors that influence CVD risk and glycemic control. Diabetes self-management is the cornerstone of care for all individuals with diabetes (American Diabetes Association, 2006). Self-management has emerged as a vital component of health maintenance, prevention, and illness management in recent decades; the cultural components of self-management and their relevance for illness management have been underemphasized (Becker, Knez, Leber, Boekstegers, & Steinbeck, 2004). Managing diabetes is a major health challenge that requires individuals to have a complex treatment regimen— including integration of diet, medications, weight control, blood glucose monitoring, medication adjustments, exercise, and stress management into one's daily routine over long periods (Montague, Nichols, & Dutta, 2005). African American women face a number of issues that include spirituality, emotional and physical well-being, coping, perceived competition between their own self-care needs and their multiple caregiving responsibilities that further influence their ability to adopt appropriate self-management behaviors that could poten-

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tially reduce the burden of suffering and death caused by diabetes (Carter-Edwards, Skelly, Cagle, & Appel, 2004; Chin, Polonsky, Thomas, & Nerney, 2000; Martin, 1996; Montague, 2002; SamuelHodge et al., 2000). These daily life issues added to the complexity of the diabetes care regimen present a critical challenge to self-care capability of African American women with diabetes and that can manifest in a number of behaviors (Montauge, 2002). There has been substantial evidence linking poor health and disease management to depressive symptoms and a variety of other negative emotions, such as hostility, anger, stress, and anxiety (Fisher et al., 2005). Among individuals with diabetes, depressive symptoms have been associated with poor adherence to medication regimens, inadequate monitoring of blood glucose, greater than normal glycosylated hemoglobin level, unhealthy diet, and less frequent physical exercise (Clouse et al., 2003; Husaini et al., 2004). More importantly, individuals with depression and diabetes are significantly more likely to have three or more cardiac risk factors (i.e., smoking, obesity, sedentary lifestyle, hemoglobin A1c (HbA1c)N8.0%) compared with those with diabetes alone (Katon et al., 2005). Although not yet studied, the co-occurrence of depressive symptoms in African American women with diabetes may also contribute to poor diabetes self-care and an exacerbation of CVD risk. In the current study, we examined the relationship between depressive symptoms and CVD risk in African American women. We further examined the diabetes self-care strategies of this high-risk population. METHODS

This institutional review board-approved study utilized a descriptive, cross-sectional, correlational design to examine relationships between depressive symptoms and CVD risk, and to describe diabetes self-management behaviors in middle-aged and older African American women with T2D in the southeast United States. Sample and Setting The sample consisted of 45 African American women (mean age, 55.94 ± 11.95 years; range, 35–73 years) in a nonrandomized convenience sample. Most participants (57%, n = 26) reported being high school graduates and 22% (n = 10) reported graduation from college. Most participants were unmarried (76%, n = 34) and reported annual household incomes of less

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Table 1. Sociodemographic Characteristics of Study Participants (N = 45) Variable

Marital status Married Divorced Widowed Single Education level Elementary Some high school High school graduate Some college College graduate Income status b$10,000 b$15,000 b$20,000 b$25,000 b$35,000 b$50,000 b$75,000 ≥$75,000 Not sure Refused

n

%

11 7 9 18

24.4 15.6 20.0 40.0

4 5 15 11 10

8.9 11.1 33.3 24.4 22.2

17 5 5 7 4 3 0 2 1 1

38.8 11.1 11.1 15.6 8.9 6.7 0 4.4 2.2 2.2

than $25,000 (76%, n = 34) (Table 1). The mean duration of T2D reported by participants was 8 ± 10 years. All participants signed the informed consent form during a structured interview with the principal investigator or trained nurse research assistant. Participants were required to demonstrate written or verbal comprehension by signing or making a witnessed mark indicating consent. Individuals excluded from participation were outside the targeted age range (b35 and N74 years of age), legally blind, profoundly deaf, unable to read or write English, or cognitively impaired (confirmed by medical record), which would prevent any comprehension of verbal instructions or the ability to complete the interview. In addition, participants were excluded if they had a medical history of coronary heart disease (myocardial infarction [MI], angina pectoris, or risk of coronary disease death), cerebrovascular disease (stroke), or any physical conditions restricting the ability to complete the study questionnaire. Measurements Four instruments were used to measure the study variables. The Personal, Health and Sociodemographic Form was used to collect sociodemographic and personal health information. The 20-item Center for Epidemiological Studies Depression Scale (CES-D) (Radloff, 1977) was

used to assess depressive symptoms. This measure was selected because it identifies more affective symptoms of mental health disorders and fewer somatic symptoms than some symptom checklists, making it more culturally sensitive for Americans who frequently present with somatic symptoms secondary to chronic illness (Fonda & Herzog, 2001; Gary & Yarandi, 2004; USDHHS, Centers for Disease Control and Prevention, 1994). Scores ranged from 0 to 60. For the purposes of this study, the clinical depression cutoff score of 16 was utilized (Jiang et al., 2003). Alpha coefficients of .85 and .90 have been documented for general population samples (Radloff, 1977). The National Heart, Lung, and Blood Institute Framingham Coronary Heart Disease (CHD) Risk Prediction Score (Wilson et al., 1998) was used to estimate CVD risk over the course of 10 years. Gender-specific score sheets were used; the factors used to estimate CVD risk included age, blood cholesterol (low-density lipoprotein cholesterol [LDL-C]) and high-density lipoprotein cholesterol [HDL-C], blood pressure, cigarette smoking, and diabetes or glucose intolerance. The Diabetes Self-Care Practices Measure (DSCPM); (Skelly, Marshall, Haughey, Davis, & Dunford, 1995) was used to measure adherence to a self-management program; response options ranged from “all the time” (100%) to “none of the time” (0%). The responses measured if the self-management activities were performed and how long they were performed. This instrument measures adherence to diet, exercise, insulin/oral hypoglycemic medications, foot care, and home glucose monitoring. The DSCPM has a Cronbach's alpha of .88 and test–retest reliability of 95% measured at a 2-week interval (Skelly et al., 1995).

Table 2. Physical Health Characteristics of Participants (N = 45): T2D and CVD Data Variable

Duration of T2D (months) HbA1c (%) Total cholesterol (mg/dl) High-density lipids (mg/dl) Low-density lipids (mg/dl) Systolic blood pressure (mmHg) Diastolic blood pressure (mmHg) BMI (kg/m2)

M ± SD

96.62 8.5 191.73 47.2 116.07 134.35

± ± ± ± ± ±

117.93 2.65 39.07 11.54 33.18 20.93

Range

1–636 5.3–15.9 118–303 26–80 59–210 100–198

77.00 ± 14.19

49–100

33.6 ± 6.66

23–48

DEPRESSIVE SYMPTOMS, CARDIOVASCULAR RISK, AND DIABETES SELF-CARE STRATEGIES

Medical records were reviewed to obtain and validate data on physiological variables required for cardiovascular risk estimation and sample description, including past medical history or family history of CHD or cerebrovascular disease, age, total cholesterol (TC) (or LDL-C), HDL-C, HbA1c, blood pressure, smoking status, and diabetes diagnosis. Duration of diabetes as well as height and weight data were validated by review of medical records. Data were recorded on the Personal, Health and Sociodemographic Form and the Framingham CHD Risk Prediction Score sheets. Potential participants were approached by their health care providers about interest in participating in the study. After potential participants volunteered to the clinic or their health care provider and signed an informed consent form, face-to-face interviews were conducted in a designated private area at each clinic. At the end of the interview, each participant received a Wal-Mart gift card valued at $25 as a token of appreciation of his or her participation. RESULTS

In general, HbA1c levels were elevated (8.5 ± 2.65), indicating poor glycemic control (Table 2). Study participants had total cholesterol levels at the upper limits of the normal range (191.7 ± 39. 06 mg/dl), HDL-C levels within the recommended goal range (47.20 ± 11.54 mg/dl), and elevated LDL-C levels (116.07 ± 33.18 mg/dl) that exceeded the recommended goal range of b100 mg/dl. Study participants had body mass indexes (BMIs) (33.2 ± 6.9 kg/m2) that exceeded national diagnostic criteria (BMI ≥27 kg/m2) for obesity. Thirty-one percent (n = 14) of the participants reported a family history of heart disease, and 27% (n = 12) reported-first degree relatives who had experienced heart attacks. Table 3. Descriptive Data for Depressive Symptoms, Cardiovascular Risk Estimates, and Diabetes Self-Care (N = 45) Variable

CES-D depression score Framingham CHD 10-year risk estimate Diabetes self-care behaviors Oral medication adherence Dietary adherence Self-monitored blood glucose adherence Exercise adherence Foot care adherence

M ± SD or % adherence

Range

9.5 ± 9.5 13.32 ± 8.08

0–35 2–27

73% 29% 49% 40% 80%

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Depressive Symptoms Sixty-seven percent (n = 30) of participants reported normal CES-D scores (b16) and 33% (n = 15) reported high CES-D scores (≥16). The mean CES-D score was 9.5 ± 9.5; the median was 6 and the range was 45 (instrument score range, 0– 60) (Table 3). Cardiovascular Risk The mean CVD score (risk estimate) was 13.32 ± 8.08% and the median CVD risk score was 13% (in a potential instrument score range from ≤2% to ≥32%), in which higher risk estimates indicate higher risk for death associated with a cardiovascular event. Thirty-nine percent (n = 17) of participants reported CVD risk scores that were b10%, 39% (n = 17) reported CVD scores of b20%, and 22% (n = 10) reported CVD scores of N20%. Higher risk estimates indicate higher risk for death associated with a cardiovascular event. Risk categories have been defined by the National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) as (1) “high risk” (CHD or CHD risk equivalents [10-year risk for hard CHD N20%]); (2) “moderately high risk” (2+ risk factors [10-year risk 10%–20%]); (3) “moderate risk” (2 risk factors [10-year risk b10%]); and (4) “low risk” (0–1 risk factors) (Grundy et al., 2004; Linton & Fazio, 2003). This sample's mean score indicates that study participants were at moderately high risk for a CVD event (defined as MI, angina, coronary insufficiency, sudden and nonsudden coronary death, stroke, transient ischemic attack (TIA), peripheral vascular disease (PVD) [claudication], and left ventricular failure (LVF) [symptomatic]) over any period of 2 to 10 years. However, the NCEP ATP III has mandated that individuals with medical diagnoses of diabetes be assigned to the high-risk category (Grundy et al., 2004; Linton & Fazio, 2003). Thus, these participants had a greater than 20% risk for the occurrence of CVD event over any period of 2 to 10 years based on diabetes status alone. Diabetes Self-Care Behaviors Seventy-three percent (n = 33) of the participants reported oral medication compliance. Conversely, only 29% (n = 13) reported dietary compliance. Sixty-four percent (n = 29) of the participants reported consumption of a low- or reduced-cholesterol diet and 51% (n = 23) reported consumption of a low- or reduced-sodium diet.

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Table 4. Associations Among Depressive Symptoms and Cardiovascular Disease Risk and Selected Sociodemographic Variables (N = 45) Association with cardiovascular disease risk Variable

Δ (P)

Age (N = 45) Education (n = 44) Marital status (N = 45) CES-D total score (n = 44) CES-D Item 1 (n = 44) CES-D Item 16 (n = 44)

.62 (.01) * −0.01 (.99)

*

χ2 (P)

6.11 (.10) −0.05 (.76) .32 (.03) * −.37 (.01) *

P ≤ .05.

Approximately 49% (n = 22) indicated adherence to self-managed glucose monitoring. Approximately 80% (n = 36) reported adherence to foot care. Forty percent (n = 18 ) of participants reported engagement and adherence to exercise recommendations (moving large muscle groups for at least 20 min a day) for an average of 2.53 ± 2.54 days a week. Spearman rho correlations were used to examine the relationships between depressive symptoms and CVD risk (Table 4). There were no significant associations between CES-D total scores and CVD risk scores. However, specific depressive symptoms were significantly correlated with CVD risk scores. CES-D item 1, “I was bothered by things that don't usually bother me” (n = 44, Δ = .32, P = .03), and CES-D item 16, “I did not enjoy life” (n = 44, Δ = −.37, P = .01), were significantly related to CVD risk scores within this sample. DISCUSSION

Depression, CVD, and diabetes are major health problems, both because of their high prevalence and because of their adverse outcomes. In this study, a substantial minority of our sample (30%) experienced significant depressive symptoms. Total depressive symptom scores were not found to be related to CVD risk scores. However, two of the depressive symptoms were significantly associated with the elevated CVD risk. Anhedonia (“I don't enjoy life”) and lowered frustration tolerance (“I am bothered by things that usually don't bother me”) were directly associated with increased risk of CVD. These findings clearly indicate that the participants in this study experienced depressive symptoms even though they might have been embedded in the CVD risk profile.

The current finding is consistent with previous reports of high prevalence of CES-D scores of 16 or higher in African American women (Bromberger et al., 2005). Furthermore, it echoes the fact that historically, the mental health needs of African American women have been underdiagnosed, misdiagnosed, and undertreated in investigations of psychiatric disorders (Carrington, 2006; Gary & Yarandi, 2004) and comorbid illness. Depressive symptoms can be undetected in African American women because of differences in symptom presentations that may be culturally determined or related to mood state as compared to symptoms that might be more manifest in the cognitive dimension (Carrington, 2006; Gary & Yarandi, 2004). This is especially disconcerting because the lack of a cognitively based depressive symptom will go misdiagnosed or underdiagnosed in African American women. Yet, evidence indicates that women with diabetes and depressive symptoms are clearly at risk for severe complications such as obesity, nonadherence, substance abuse, smoking, inactivity, and glucose deregulation that result in poor outcomes (Clouse et al., 2003; Gallo et al., 2005). In the current study, most participants had poor diabetes self-management, which is manifested as obesity, poor glycemic control, elevated LDL-C, and poor dietary adherence. Although this study did not examine the relationship between the above factors and depressive symptoms, previous research has reported a marginal association (Gary, Crum, Cooper-Patrick, Ford, & Brancati, 2000). In addition, it has been suggested that this association contributes to poorer self-management and higher mortality risk, especially in the presence of CVD and diabetes (Gallo et al., 2005; Katon et al., 2004). Therefore, further examination of this relationship is warranted. Given the challenging nature of the daily selfcare regimen and the high level of nonadherence clinicians should understand the psychological factors that impact or predict better self-care and physiological outcomes related to diabetes management (Johnston-Brooks, Lewis, & Garg, 2002). An important consideration for clinicians and researchers in diagnosing and assessing depressive symptoms in African American women with T2D is an awareness of potentially unexpressed and/or unrecognized depressive symptoms in this population. This study contributes valuable information about African American women with T2D and

DEPRESSIVE SYMPTOMS, CARDIOVASCULAR RISK, AND DIABETES SELF-CARE STRATEGIES

the impact that depressive symptoms and CVD risk may have on their diabetes self-management strategies. These findings are unique in that few studies have attempted to identify, in a sample of middle-aged and older African American women with T2D, the specific depressive symptoms that would serve as indicators of psychological dimensions of cardiovascular health and their diabetes self-management strategies. Limitations Limitations of this study include small sample size and the limited range of demographics of the sample and the consequential impact on reduced generalizability. Furthermore, this sample was a convenience sample and may not be representative of this primary care population. In addition, selfreport measures of depressive symptoms may not have been sufficiently sensitive to detect culturally defined differences in depressive symptom recognition and reporting among middle-aged and older African American women. Conclusions and Implications This study found relationships between specific depressive symptoms and CVD risk scores among middle-aged and older African Americans with T2D. However, there was no statistically significant correlation between total depressive symptom scores and CVD risk scores among these African American women with T2D. The relationships among specific depressive symptoms and CVD risk scores were also associated with higher years of age in this sample of African American women with T2D. The moderately high CVD risk estimates observed in this sample indicates that CVD risk factors are more difficult to control clinically and may be influenced by specific depressive symptoms or unrecognized and/or unexpressed depressive symptoms. Behavior-related risk factors (e.g., high glycemic indexes, high blood cholesterol, and obesity) even in the presence of few depressive symptoms (low levels of affective disturbance) may yield significant risk of CVD in African American women with T2D and warrant further investigation. Recommendations Future prospective studies with a randomized design focusing on independent depressive symptoms and their potential to affect CVD risk in middle-aged and older African Americans with

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T2D are needed. There is also a need for prospective and interventional studies with substantial African American representation for the development of ethnically or culturally specific measures of depressive symptoms. Multidisciplinary collaboration among primary health care providers, mental health care providers and diabetes educators may be indicated in the treatment of normal depressive symptoms or specific depressive symptoms and CVD risk reduction in African American women with T2D. Aggressive treatment, education, and prevention interventions should target depressive symptom recognition, dietary adherence, glycemic control and correction of dyslipidemia, weight reduction measures, and hypertension for African American women with T2D to lower CVD risk estimates. This study provides support for investigation of depressive symptoms, CVD risk reduction, and diabetes self-care strategies to decrease health care disparities and improve physical and mental health outcomes in middle-aged and older African American women with T2D. ACKNOWLEDGMENT

This study was funded by the American Nurses Association, Ethnic Minority Fellowship Program, and the Substance Abuse and Mental Health Services Administration Grant 1-T06-SM 5657201; the University of North Carolina Center for Innovation in Health Disparities Research, National Institutes of Health Research Grant 5P20NR8369; National Institute of Nursing Research; and the National Center for Minority Health and Health Disparities. Acknowledgements are given to Diane Holditch-Davis, PhD, RN, for her guidance and critique of this work. REFERENCES American Diabetes Association. (2004). Standards of medical care in diabetes. Diabetes Care, 27(Suppl 1), S15–S35. American Diabetes Association. (2006). Standards of medical care in diabetes—2006. Diabetes Care, 29(Suppl 1), S4–S42. American Heart Association. (2004). Heart disease and stroke statistics 2004. Retrieved from: http://www.americanheart.org/downloadable/heart/1079736729696HDSStats 2004UpdateREV3-19-04.pdf. American Heart Association. (2006). Women, heart disease and stroke. Retrieved August 17, 2006, from: http://www. americanheart.org/presenter.jhtml?identifier=4786.

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