Diabetes in the African American Community

Background

Among African-Americans diabetes, a disease associated with being overweight or obese, is twice as likely to be diagnosed compared to the general population. African-Americans also suffer more from comorbidities of diabetes, such as high blood pressure (hypertension) and high cholesterol (hyperlipidemia). It has been suggested that the higher rate of diabetes in the community is due to the fact that most African-Americans see diabetes as a genetic disorder over which they have no control and remain noncompliant in their own treatment. Economic disadvantage, lack of access to medical care and cultural behavior are some factors that contribute to the higher rate of diabetes in this community. However, it is not clear whether these factors are responsible or explain all of the differences between African-Americans and others in the US population. Moreover, we can conclude that there are genetic factors at play.

The medical conditions most commonly associated with diabetes are high blood pressure and high cholesterol. African-Americans have a higher risk to these ailments because of the high rate of obesity.5 Metabolic Syndrome is also a component to all of these health issues. The syndrome is described as a group of factors that occur together, which can contribute to a higher chance of heart disease, stroke and Type 2 diabetes. Several factors, environment, diet, availability of quality health care, as well as genetics, contribute to the higher rate of diabetes in the community. In the following sections we examine risk factors for diabetes as well as comorbidities that are predominant among African-Americans.

Risk Factors for Diabetes

African-Americans tend to blame genetics and family history to the nature of diabetes in the community. Family history can be described as sharing “genes, behaviors, lifestyles and environments that may increase may influence their health and their risk of chronic disease” (CDC.) Along with genetics, obesity is the major risk factors for diabetes as it affects the African-American community. Table 1 below shows the major and secondary risk factors associated with diabetes in the general American population.

Complications of untreated and treated diabetes in the African-American community

Several studies found that African-Americans are 1.4 to 2.2 times more likely to have diabetes than white persons. The rates of disease complications caused by diabetes vary by disease and minority group.1,8 Kidney, eye, and cardiovascular diseases are the most common comorbidities of diabetes in African-Americans. Native Americans are prone to these same illnesses due to the prevalence of smoking in their community, while obesity also plays a role. Moreover, statistics show the rate of disease amongst African-Americans is higher than any other race.

Kidney Disease

End stage renal disease (ESRD) is a complication of diabetes that affects 34% of patients with the disease. A recent study at Wake Forest University demonstrates that “African-Americans have higher overall incidence rates of end-stage renal disease (ESRD) compared with American whites” and “... diabetes mellitus types I and II, and chronic glomerulonephritis (CGN) all occur more frequently in African-Americans. To explore the possibility that hereditary factors may play a role in the increased risk of ESRD in African-Americans...” 9 Among African-Americans, ESRD is higher than those of the white population at the rate of 2.6 times.9 There were 137 new cases of diabetes-related ESRD per million among African-Americans and 38 cases per million among whites from 1988 to 1990.8 ESRD among African-Americans is more likely related to diabetes that in other races and Hispanic Americans, African-Americans, and American Indians also have higher rates of early stage kidney disease (proteinuria).8 It is unclear why African-Americans have more diabetes-related ESRD and higher rates of hypertension than whites. It has been suggested that the co-occurrence of both hypertension and Type 2 diabetes may account for the higher rate of ESRD in the African-American community.

Eye Disease

Retinopathy is another comorbidity of obesity that disproportionately affects non-whites. Untreated retinopathy can cause blindness, and diabetic retinopathy is the major cause of blindness among adults ages 20 to 74 in the US. Risk factors for diabetic retinopathy include Type 1 or Type 2 diabetes. A study done by the American Medical Association found “Among patients with diabetes, African-Americans have higher prevalence rates of high blood pressure and are 2.6 to 5.6 times more likely to have diabetic nephropathy, including diabetic end-stage renal disease, than white patients.”10 African-Americans are at a greater risk for retinopathy because of the high incidence of diabetics in the population. A survey done on the city of Boston found “causes of blindness and visual impairment in persons 40 years or older, there was a greater proportion of African-Americans than of whites who were visually impaired from diabetic retinopathy.”10

Coronary Artery Disease

Diabetes predisposes those people with it to have heart disease more compared to the general population. Minorities and white persons do not exhibit consistent disparities in coronary artery disease due to diabetes. A study funded by AHRQ found that African-American diabetic patients exhibit a particular lipid profile that is different from the rest of the population: low HDLs (high-density lipoproteins), high LDLs (low-density lipoproteins), and lower triglycerides. The lipid profile is important “… because having too few HDLs, too many LDLs, or too many triglycerides are all risk factors for heart disease.”11 For this reason, it has been recommended that in treating dyslipidemia (an abnormal amount of lipids) in the blood) among African-Americans, clinicians’ should focus largely on improving LDLs and HDLs.11

Diabetes: Gender and Ethnicity

Another study funded by AHRQ found that Type 2 diabetes is more common in African-American women than men.10 The higher rate of Type 2 diabetes among African-American women is explained by differences in income and body size. The Robbins, Vaccarino, Zhan and Kasl’s study on socioeconomic status and the prevalence of diabetes found gender differences in the associations between race/ethnicity and body size. 12

Cultural Variations and Economic Barriers

Minorities with diabetes often face economic barriers due to lack of insurance and are reluctant to place their own medical needs over the needs of economics priorities. 12 Minorities, especially African-Americans, also distrust insulin therapy; they prefer more familiar traditional remedies and have a fatalistic acceptance of the course of the disease. 13,14 How do you bridge the ethnic disparities in diabetes and its comorbidities? Recent research by Noel, et al. and Lipton, et al. has demonstrated racial/ethnic disparities can be lowered by having strategies that are sensitive to culture and specific to the population that is targeted. 13,14 Their studies show that the onset of diabetes can be prevented through diet and lifestyle changes.

Diet, Exercise, and Primary Prevention

In Carter, Pugh, and Monterossa’s8 comparison of migrant populations with native nonimmigrant populations in their country of origin found that there is a relationship between Type 2 diabetes and the American lifestyle, namely that a diet higher in total calories and fat, a diet lower in fiber, and laborsaving devices that causes Americans not to move around has a direct link to obesity. The data on minorities that are not native African-American in the United States shows that they have a higher prevalence of diabetes than do residents of their countries of origin, for example, Mexico, Nigeria, etc. 8 A program that educated children at risk for diabetes showed that post-program, the percentage of children whose consumption of protein, total fat, saturated fat, and cholesterol fell within the recommended daily requirement increased. 15

Chronic Disease Self-Management Program

Health organizations are finding means to significantly impact the health status and health care of minority persons with diabetes with programs such as the Chronic Disease Self-Management Program (CDSMP). Many chronic diseases, such as diabetes, heart disease, lung disease, arthritis, and high blood pressure, are similar in the problems they pose for health care institutions because patients have to self-manage the disease. The CDSMP emphasis on educating patients’ on self-management of their health resulted in positive results for “… self-reported health, disability, fatigue, and hospital use indicators.”16 Participants improved their health, had more energy, and fewer hospitalizations and doctor visits.

Family Support

A literature review of studies on African-Americans with diabetes found that African-Americans relied more heavily than other groups on informal social networks to meet their need to manage the disease and that such social support significantly improves the management of diabetes. Such social support consisted of help with “…help with diet supervision, medication assistance, general support and blood sugar monitoring.” 17 Although research has not been done to show that this practice leads to better outcomes, it appears to be a promising practice.

Current state of quality care to prevent diabetes, diagnose diabetes, and its comorbidities in the African-American community

A person with diabetes has to take responsibility to manage the disease because it is a self-managed disease. Keeping blood glucose (blood sugar), blood pressure, and cholesterol levels in the recommended target range are the keys to prevent, reduce or significantly delay the chance of getting diabetes and keeping its comorbidities at bay. The National Diabetes Education Program (NDEP) recommends that diabetes can be managed by eating healthy foods, being physically active, taking diabetes medicine as prescribed, and testing blood glucose levels. Community education and support programs can help people with diabetes and their families to manage their diabetes.

Conclusion

There are programs in place are inadequate to stem the prevalence of diabetics in the African-Americans community: Project DIRECT (Diabetes Interventions Reaching and Educating Communities Together) is the first comprehensive community diabetes demonstration project in the United States in an African-American community. 18 The Racial and Ethnic Approaches to Community Health (REACH) study in Detroit on diabetes lifestyle intervention, intervention, dietary, behaviors and physical activity knowledge concludes that “… culturally tailored diabetes lifestyle intervention delivered by trained community residents produced significant improvement in dietary and diabetes self-care related knowledge and behaviors as well as important metabolic improvements.” 18 Another intervention program, Lotrel and Enalapril in African-Americans with Diabetes, or LEAAD, demonstrates that providing patients with a combination of two highly effective medications in one capsule helps them reach the rigorous blood pressure goal of less than 130/80 mm Hg. 19

Despite these interventions, the research and news on diabetes is disheartening. Researchers are predicting this generation and the next generation of Americans will have a shortened lifespan compared to their parents due of diabetes. 20 It is crucial that the government develop a public health campaign targeting all Americans about the risks associated with being overweight and obese. It seems that success within the African-Americans community to combat diabetes will be a community-based programs targeting African-Americans institutions such as churches to fight the epidemic of obesity. Community based church collaborations have usually worked in the African-American to stem the spread of disease. 21,22

A new potential to aid in treatment to reduce complications from diabetes especially in the African-American community is clinical decision support.

References

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Submitted by (Yetunde Laniran)