Physician's Weekly Article - An In-Depth Focus on Diabetes in African Americans

       African Americans are at greater risk of diabetes and its complications. Physicians need to make greater efforts to appropriately diagnose the disease and tailor therapies.

      Published data have shown that African Americans are disproportionately affected by diabetes and its related complications. According to the American Diabetes Association (ADA), the number of racial and ethnic minority patients in the United States who will be diagnosed with diabetes will increase significantly in the coming years. By 2020, it is projected that the number of African Americans developing diabetes will increase by 50%. When compared with non-Hispanic whites, studies have shown that the prevalence and severity of diabetic complications are significantly higher in African Americans (Table 1).

      “Diabetes has a major adverse impact on mortality, morbidity, and quality-of-life in all populations, but the impact of the disease burden is even greater among African Americans,” says Anthony J. Cannon, MD. “Recent data from the CDC show that 14.7% of African Americans aged 20 and older have type 2 diabetes. It’s suspected that only a third of these patients know they have it. African Americans are more likely to have poorer control of their blood sugars, blood pressure, and cholesterol levels.”

      Spotting the Barriers

      The management of diabetes in the U.S. primarily takes place in primary care. Dr. Cannon says “there is a shortage of endocrinologists and other diabetes specialists in the U.S. today and it’s continuing to worsen. Considering this shortage, many primary care physicians (PCPs) will be managing people with type 2 diabetes instead of endocrinologists. However, PCPs have an average of just 7-to-8 minutes to spend with patients. This can delay or postpone evaluations of abnormal blood sugars, blood pressure, and cholesterol levels.”

      Several factors have been identified as drivers of the observed differences in diabetes control in African Americans, including biological, socioeconomic, and quality-of-care factors. “Lack of access to healthcare and lower rates of health insurance and prescription drug coverage can lead to delayed diagnoses,” explains Dr. Cannon. “It can also increase the number of years of exposure to untreated diabetes. A confounding variable is a lack of exposure to diabetes education.”

      Tailoring Treatment Considerations

      In the African American community, initiation of insulin therapy can be particularly challenging, says Dr. Cannon. “Insulin is often considered the end of life for African Americans because they may have seen or heard about relatives or friends who experienced poor outcomes after starting it. PCPs and providers need to be aware of this viewpoint and adjust treatment strategies accordingly. It’s important to initiate insulin therapy early to maximize outcomes. Currently, the average person that is placed on insulin has waited more than 3 years with elevated blood sugars.”

      Dr. Cannon also says that it is important to be up front and honest with patients when considering insulin therapy. “Tell patients that they’re likely to require insulin, and make efforts to minimize their concerns. For example, take a few extra minutes to inform them about newer insulin delivery devices if these options are appropriate alternatives.” Additionally, he recommends that providers teach African American patients about their diabetes, blood pressure, and cholesterol medications, and why they are required. “The association between diabetes and cardiovascular risk is obvious to PCPs, but not necessarily for patients. Taking the time to explain what specific medications do, how they work, and the benefits associated with them may empower patients to better adhere to treatments.”

      Continuing Follow-Up

      The ADA recommends several important monitoring parameters to control diabetes-related complications throughout follow up (Table 2). Dr. Cannon says “regardless of race, creed, or color, all patients should be treated to national diabetes goals. It’s critical to get blood glucose levels as close to normal as possible, blood pressure levels to 120/80 mm Hg, LDL cholesterol levels to less than 100 mg/dL, and HDL cholesterol levels as high as possible. This requires close monitoring and continued follow up with patients. In addition, using all available resources—including dieticians, certified diabetes educators, and other providers—is paramount to reducing the burden of diabetes in African Americans. PCPs should look beyond their immediate staff to optimize outcomes and take advantage of educational opportunities for patients.”

      Anthony J. Cannon, MD has indicated to Physician’s Weekly that he has worked as a paid speaker for the following corporations: GlaxoSmithKline, Novo Nordisk, Eli Lilly, Amylin Pharmaceuticals, Merck, Schering Plough, Sanofi-Aventis, and Bristol-Myers Squibb.