Diabetes

AACE recently created a statement called “Policy for the Elimination of Healthcare Disparities in the USA.” This statement asserts:

AACE actively opposes the continued existence of endocrine healthcare disparities in the USA, and will devote its resources to diminish these disparities. AACE members, staff, partners and others with whom AACE interacts will continue to advocate for understanding, prevention and elimination of endocrine healthcare disparities.

(To read the full position statement, visit www.aace.com/publications/position-statements.)

But why does AACE have a statement on healthcare disparities? Why make this a focus for members of AACE? The answer is because AACE believes that to best treat people with endocrine diseases all medical professionals must be aware of the many differences that make one person different from the next. This includes:

• The different risks and impact certain diseases may have on them
• What the best choice of therapy is
• Access to care
• The ability to afford medical care.

So what does this really mean?

Let’s take a look at diabetes.

In the US, there is a higher incidence of type 2 diabetes [dye-uh-BEE-teez] (the most common form of diabetes) in Latino, Asian, and African American people compared with white people. The reasons for this are not known. Some people might be more likely to get diabetes, partly, because of how well the insulin made in their body works.

In 2009 more than 14% of American Indians and Alaska natives over 19 years old who received care from the Indian Health Service had diabetes. Rates varied a great deal depending on the region of the country that they came from. For example, about 5% of Alaska native adults had diabetes. Yet more than 33% of American Indian adults living in southern Arizona had diabetes. See below for the big difference in diabetes between ethnic groups and subgroups.

Risk of Developing Diabetes Compared to Non-Latino Whites

• Asian Americans: 18% higher
• Latinos: 66% higher
• African Americans: 77% higher

Risk of Developing Diabetes Among Latino Compared With Non-Latino Whites:

• Mexican Americans: 87% higher
• Puerto Ricans: 94% higher
• Cubans: Equal
• Central Americans: Equal
• South Americans: Equal

Clearly, there are different rates of diabetes in different populations.

What about prediabetes progressing to diabetes?

About 60 million Americans have prediabetes [PREEdye-uh-BEE-teez]. People with prediabetes have blood sugar levels that are higher than normal but not high enough to be diagnosed as diabetes. People with prediabetes are more likely to end up with diabetes than those with normal blood sugars. It is not known if ethnicity is a risk factor for going from prediabetes to diabetes. The Diabetes Prevention Program looked at whether people at very high risk of diabetes that
exercised and made changes to their diet and lost weight could avoid getting diabetes. People with a high fasting blood sugar level, whether of white, African American, Latino, American Indian or Asian ethnicity, all got diabetes at an equal rate. But this finding was very different from earlier studies done in San Antonio and Colorado. The earlier studies found that Latino people in a prediabetes state had a higher risk of developing diabetes than non-Latino whites. More studies are needed for us to know whether one group is more likely than another to develop diabetes.

We also do not know if diabetes drugs might lower the risk of developing diabetes. In the Diabetes Prevention Program taking metformin [met-FOR-min] (a common diabetes treatment) lowered the risk of developing diabetes. But there was no difference in risk reduction due to ethnicity. Yet other studies have shown very different results. In a study called the DREAM study (in which people took rosiglitazone [ROE-zi-GLI-ta-zone]), progression to diabetes in those with prediabetes went down by more than 40% in all ethnic groups. But the reduction was smaller in South Asians and greater in Latinos. Differences in age, sex, body mass index (a measure of weight, taking into account also height or a measurement of waist–hip ratio) did not explain the difference seen by ethnicity.

So prevention of diabetes in different ethnic populations remains confusing as to what might or might not work. More research is clearly needed!

What about diabetes complications?

African Americans and Latinos in the US have a higher risk of end-stage kidney disease and diabetes eye disease. Although eye exams find effects of diabetes on the eye, African Americans have fewer eye exams than others for diabetes eye disease. On the other hand, Asians with diabetes have a lower risk of heart attack and foot amputation compared with whites.

Should treatment of diabetes and/or diabetes complications be different in different ethnicities?

People with diabetes are at greater risk for heart disease and heart attacks than the general population. African Americans with diabetes are more likely than whites to have a bad lipid profile, which puts them at high risk for heart disease. African Americans generally need to focus on improving LDL and HDL levels, and whites generally need to pay more attention to triglycerides [try-GLIS-er-ides].

In perspective

We just reviewed differences in only one disease. There are differences seen in race, sex, economic status, and country of origin that relate to many conditions, such as bone disease, obesity, high blood pressure, and other conditions that have not even been studied as much as diabetes. Education and research needs to be supported so that we can prevent or at least better manage these conditions among different groups. To do this we need to address the issues of access to care as well as its cost, which contributes to healthcare disparities in the US.

Dr. Trence is Director of the Diabetes Care Center and Associate Professor of Medicine at the University of Washington Medical Center in Seattle. She is also the University of Washington Endocrine Fellowship Program Director and Director of Endocrine Days, a medical education program for endocrinologists practicing in the Pacific Northwest. She is on the Board of Trustees for the American College of Endocrinology, chairs the AACE CME committee and is co-editor of EmPower Magazine.

Moving from teenage years to adulthood can be stressful for teens with diabetes and their families. Teens and young adults need to take on more diabetes tasks and make more judgments about their health care needs. At the same time, young adults face more pressure in their social lives and at school or work. Young adults living away from home for the first time may have a new doctor and health care team—or no doctor at all.

These challenges can result in poor diabetes care and medical problems that young adults will need to handle on their own. As more young people develop diabetes, their ongoing health care needs will need to be addressed by the adult health care team.

There is good news. New tools can help young adults with diabetes manage their diabetes and health care. The National Diabetes Education Program (NDEP)—a program of the National Institutes of Health, the Centers for Disease Control and revention, and more than 200 public and private partners—has created an online tool, “Transitions from Pediatric to Adult Heath Care,” with resources to help the young adult, their family, and their health care team who provide them with health care.

Tips for Success

How can parents prepare their teenagers to manage their diabetes care as they go off on their own? Here are several tips for success:

1. Start getting ready at least one to two years in advance. The NDEP tool has a “Transition Planning Checklist” that helps the health care team, the young adult, and the family prepare.

2. Help young people become active partners in their health. As young adults take on a bigger role when it comes to their health and wellbeing, they need to be prepared to manage their diabetes in many types of situations such as when they travel or during an illness. They must know how to prevent and/or manage any diabetes crises.

3. Prepare a summary of the teen’s health status. NDEP provides a “Clinical Summary” resource that their current health care team and the family can fill out and provide to the new health care team.

4. Encourage your child to seek support from other young people with diabetes. NDEP’s online tool provides a list of online discussion groups, forums, and message boards.

5. Find support for yourself. Parent support groups and resources can help you cope with the changes while you learn to support your child.

6. Locate adult health care professionals and insurance options. NDEP’s tool contains information on how to find a doctor, dietitian, or education program. In addition, you can find local health clinics that are either free or not costly.

Parents play a key role in helping their older teenagers get ready for life as adults. With thoughtful planning, your child can live independently with diabetes—and thrive.

For more information, visit the National Diabetes Education Program (NDEP) website, www.YourDiabetesInfo.org/Transitions.

Rates of new cases of diabetes (mainly type 2) have soared in the United States over the last 20 years. One of the ethnic groups with the greatest rise is the African American population. Over 12% of African Americans have diabetes. Women and the elderly have the highest rates. One in four African-American women over age 55 has diabetes and 25% of African Americans between the ages of 65 and 74 are affected. African Americans are almost two times more likely to have diabetes than non-Latino whites.

Why are some people more prone to diabetes than others?

We don’t know exactly why. Some scientists believe that African Americans inherited a “thrifty gene” from their African ancestors. This gene helped Africans “store up” food in their bodies during abundant times and use food energy efficiently during periods of famine. But now that food is abundant for many Americans, this thrifty gene is making many African Americans get diabetes because they are becoming obese. Some studies show that there is a problem in how insulin is put into the blood stream (secreted) and how well it works (sensitivity or resistance) in African Americans compared with non-Latino white people. This may explain why they are more likely to develop diabetes. The number of African Americans that are overweight and/or obese has risen significantly in the last 50 years. This is partly because people tend to have jobs that aren’t as physical as they used to be. Also, the diet has changed to eating more high-calorie cheap foods that are rich in carbohydrates and saturated fats but low in fiber.

What other factors affect diabetes care for African Americans?

In the US, African Americans with diabetes are less likely to get routine diabetes care and services to prevent complications. They also have higher blood sugar levels than non-Latino whites. Major health care barriers include less access to health services and low income and education. Compared with non-Latino whites, African Americans have more joblessness, lower income, and are more likely to be uninsured or on programs like Medicaid. Many African Americans receive medical care from community health centers in their neighborhood. However, these facilities are usually subsidized by the government and have much less resources than private health clinics. More and more doctors no longer see patients with Medicaid because they don’t get proper reimbursement. This further limits access to quality health services.

Many African American patients with insurance cannot afford out-of-pocket health expenses for their drugs, diabetes testing supplies, and healthier foods that they should be eating. Thus, these patients are not able to stick to their treatment plan. Many live in areas that are unsafe for outdoor exercise and have very few sources for fresh fruits and vegetables. It is important to note that differences in social status and access to care do not fully explain why African Americans have poorer control of diabetes. African American patients with diabetes tend to receive lower quality of diabetes care even when they have the same health insurance and receive care in the same setting as non-Latino whites. The cause of health care differences among insured populations is an active area of research. Studies suggest that diabetes care is better when health care providers understand African American culture and design therapy taking this into account.

Other factors are associated with poor diabetes outcomes in African Americans. African Americans are less likely to take their medications or monitor their blood sugar every day. They are more likely to miss medical appointments. They may not have the money to take their medications as directed. African American patients often report that they don’t understand instructions about their medical treatment and don’t know their target blood glucose. Many African Americans with diabetes often feel that there is nothing they can do to change things about their disease, so they stop trying. Men especially distrust the medical system because of past racial injustice. African Americans also have a more relaxed attitude towards overweight body image. This may also result in a tendency toward diabetes. Overweight has been seen as a sign of good health while being thin is associated with stigma of disease or drug use.

How can diabetes complications be prevented ?

Despite the higher prevalence and complications from diabetes, African Americans can prevent many complications by improving their diabetes control. Diabetes can also be prevented in this ethnic group by adopting a healthier lifestyle. In the Diabetes Prevention program study, which was a multi-ethnic study, healthy diet and exercise reduced the incidence of diabetes by 58%, and was better than taking medication. The lifestyle group achieved this significant reduction in risk of diabetes by losing just 5%– 7% of their body weight. A recent 10-year study of more than 200,000 men and women over age 50 found that the risk of diabetes was lowest among those with five healthy behaviors:

• Maintaining a normal body weight (BMI below 25)
• Never smoking or smoke-free for over 10 years
• Doing at least 20 minutes of intense activity more than three days a week
• Consuming a healthy diet
• Drinking very little alcohol.

A person’s risk of diabetes was lower the more healthy behaviors they had. These five healthy behaviors lowered diabetes risk even in those with a family history of diabetes.

If you are at risk for diabetes you must adopt healthy lifestyle habits and make sure that you are routinely screened for diabetes. One way to do this would be to make sure it is part of your annual physical exam with your health care provider.

If you are currently living with diabetes, there are many things you can do to improve your care and help your medical team provide better care to you. In most instances, this team will consist of a variety of health care providers like doctors, nurses, dietitians and diabetes educators. The more active part you play in managing your diabetes, the better your blood sugar control will be.

Healthy habits that positively impact your diabetes control include:

• Taking your medications as directed
• Checking blood sugar levels on a regular basis
• Taking good care of your feet
• Keeping your medical appointments
• Doing regular physical activity
• Eating a healthy diet rich in complex carbohydrates and low in simple sugars and saturated fat
• Medical visits:
  • Routine visits with your medical team
  • Yearly eye exam to screen for changes related to diabetes
  • Foot check-ups with the podiatrist.

What to do to prepare for your medical appointments

• Bring a list of your medications, blood glucose log and meter.
• Ask questions about things you do not understand.
• Learn about how the medications you take for your diabetes work to keep your blood sugar levels normal.
• Make a list of questions and bring them with you.
• Speak to your team about any concerns you have about side effects of medications you are taking. We now have a variety of medications for diabetes so your doctor may be able to switch you to something else.
• Let your team know if you cannot afford your medications or testing supplies so that they can design a more affordable diabetes treatment plan.
• Know what an A1C level is and know your target A1C (estimate your average blood sugar level in the last three months). The goal A1C according to the American Association of Clinical Endocrinologists (AACE) is 6.5%, which equals an average blood sugar level of 126 mg/dL, but may be higher for some people with diabetes who have other medical conditions.

Other Related Conditions

Heart disease remains the number one cause of death for people with diabetes in this country. So, in addition to controlling your blood sugar levels, you have to take care of the other risk factors for heart disease like high cholesterol, hypertension, and smoking. Your blood pressure should be less than 130/80 mm Hg and target for LDL (bad cholesterol) is under 100mg/dL, or under 70mg/dL if you already have heart disease. Create a chart to keep track of your A1C, LDL,
and blood pressure levels. If your blood pressure, A1C, or LDL levels are higher than desired, find out from your doctor how your treatment plan will be changed to achieve this.

In managing a chronic condition like diabetes, a positive outlook is essential. There will be times when you feel tired of testing the blood sugar or exercising or paying very close attention to your diet. Some people feel very guilty about this and stop coming to medical appointments. This is the wrong approach to take. This is the time to lean on your diabetes team. Let them know where you are struggling so they can help you get back on track.

Dr. Okeke is an endocrinologist at Joslin Diabetes Center. She is interested in multicultural diabetes care, specifically the disparities in diabetes care that exist for patients from minority ethnic groups, and ways to develop culturally competent diabetes programs for minority patients. Dr. Okeke is also a staff endocrinologist at Harvard Vanguard Medical Associates.

*We would like to thank Tarin Jackson for her role in developing this article.

EmPower Diabetes Emergency Plan

Prepare a portable, insulated and waterproof diabetes emergency kit that contains the following items:

• List of the following information:
  • Type of diabetes
  • All of your medical conditions, allergies and prior surgeries
  • All of your medical conditions, allergies and prior surgeries
  • All medications (include pharmacy contact information, active prescription information and eligible refills)
  • Previous diabetes medications and reason for discontinuation
  • Contact information for all your healthcare providers
• Letter from your diabetes healthcare providers with most recent diabetes medication regimen (especially if taking insulin)
• Most recent laboratory results (especially A1C, kidney and liver tests)
• As possible, a 30-day supply of all medications taken by mouth or injection for diabetes as well as all other medical conditions
  • Include insulin and a severe hypoglycemia emergency kit–if prescribed (always check expiration date)
• Blood glucose testing supplies and, if possible, 2 glucose meters with extra batteries
• A cooler for 4 refreezable gel packs, insulin and unused injectable medications to be added when ready to go
  • Note: Do not use dry ice and avoid freezing the medication
• Empty plastic bottles or sharps containers for syringes, needles and lancets
• Source of carbohydrate to treat hypoglycemic reactions (For example, glucose tablets, 6 oz juice boxes, glucose gel, regular soda, sugar, honey or hard candy)
• A 2-day supply of nonperishable food (For example, peanut butter or cheese crackers, meal replacement shakes or bars, etc.)
• At least a 3-day supply of bottled water
• Pen/pencil and notepad to record blood sugar, other test results and any new signs/symptoms suggesting medical problems
• First aid supplies like bandages, cotton swabs, dressings and topical medications (antibiotic ointments or creams)

Other recommendations:

• Wear shoes at all times and examine your feet often for cuts, sores, red spots, swelling, blisters, calluses and infected toenails or any unusual condition
• Make sure that all vaccinations, including tetanus, are up-to-date
• Pack extra comfortable clothing, including undergarments
• Take a mobile phone with an extra charger or extra batteries for you and family members
• Choose a designated meeting place in case you are separated from your family and are unable to reach them by phone

This 39-foot, custom-built bus may look like an average motor home on the outside, but it is actually a healthcare unit on wheels. Equipped with a waiting room, three screening areas, and a restroom, this mobile center provides preventive health screenings and other services in six different locations around the city of Boston. With only five people on staff, the unit relies upon the assistance of countless volunteers, including medical residents and students, to serve the community.

The Family Van was founded in 1992 by Dr. Nancy Oriol, Dean of Students at Harvard Medical School. Dr. Oriol describes the van as the “knowledgeable neighbor.” Inspired, in part, by the Bridge Over Troubled Waters van, which has provided free medical services to run-away teens in Harvard Square since the 60’s, Dr. Oriol created The Family Van to address the specific healthcare needs of the urban community. The program started in a rented van, which operated only four mornings per week. Within two years the program was firmly rooted in the community and had gained the trust of people all across the city.

In order to maintain relationships in the community, the program operates on a regular schedule, Monday through Friday, 50 weeks per year. Individuals may come to the same areas of town at the same time each week and expect to see familiar faces. There is no appointment or insurance required and all services are offered anonymously. Every person who comes to The Family Van is considered a neighbor rather than a patient. This type of environment has allowed The Family Van to build trusting relationships in the community while providing a safe haven for people to discuss their health concerns. The large majority of its visitors are minorities, 30 percent of which consider English as a second language.

“Our goal is to be a bridge to healthcare,” explains Jennifer Bennet, Executive Director of The Family Van. “We like to meet people where they are.”

Bennet has been working with the program since 2005 and has seen the positive results of its presence in the community. As Executive Director, she works to ensure that every person who comes to The Family Van receives quality care that examines the physical, social and economic factors that can affect one’s health.

While The Family Van cannot diagnose or treat medical conditions, the program has been instrumental in the prevention and management of chronic illnesses such as diabetes and cardiovascular disease. To assess the risk factors for these conditions, The Family Van provides screenings such as blood glucose and hemoglobin A1c levels - which are determining factors in the diagnosis of diabetes, as well as blood pressure and cholesterol. Based on the results of such screening tests, The Family Van helps each individual to set up an appointment with a primary care physician who can diagnose and treat chronic illness. The program has been successful in identifying new cases of undiagnosed diabetes. Out of the past 31,000 visits, one-third were screened for diabetes. Forty percent of those screened for diabetes had abnormal levels of blood glucose. To assist the community in making lifestyle modifications, a registered dietician is on board to educate people in the community about how to prevent such conditions through diet and exercise. Staff and volunteers are also available to show those people with diabetes how to use their testing supplies.

The Family Van is just one of roughly 2,000 mobile healthcare programs across the United States. From California to Florida to Massachusetts, these programs provide preventive health services to those who do not have access to primary care. Programs such as The Family Van are funded through a patchwork of grants and charitable donations, which limits the services such programs can provide. It took nearly a year and a half to establish an A1c level screening program on The Family Van. Supporters of The Family Van and other similar programs stress the value that these healthcare units can impart to the community.

“Mobile healthcare has the flexibility to be responsive to community needs,” says Bennet.

In its 17 years of operation, the Family Van has consistently provided care to people across the city of Boston. Dr. Oriol attributes its success to the development of strong, trusting relationships with the community and the program’s ability to adapt to people’s needs. However, she understands that while The Family Van has reached numerous people and had tremendous success, there are still many who do not understand the importance of preventive healthcare.

“We are here to help people understand why lifestyle changes make a difference,” Dr. Oriol concludes.

To learn more about mobile healthcare programs like The Family Van in your area, visit www.mobilehealthclinicsnetwork.org.

Click to Print This Page

The results of a study called the NICE-SUGAR study were recently released in the New England Journal of Medicine. Some have interpreted the study to mean that tight glucose (blood sugar) control for hospitalized patients can actually have a negative impact. Several months earlier, results of the ACCORD study were released, which also brought into question the value of tight glucose control, this time in the outpatient setting.

The American Association of Clinical Endocrinologists (AACE) and the American Diabetes Association (ADA) caution against letting these studies swing the pendulum of glucose control too far in the other direction where providers in hospitals are complacent about uncontrolled hyperglycemia.

However, recognizing the importance of glycemic control across the continuum of care, AACE and the ADA joined forces to develop an updated consensus statement on inpatient glycemic management. After a thorough analysis of all the data from clinical published trials, including the NICE-SUGAR study, AACE and the ADA believe that patients with elevations in blood glucose should continue to be treated, but to less intensive blood glucose targets. The Associations recommend revised glucose targets of 140-180 mg/dL.

The updated recommendations can be found on the AACE Web Site at www.aace.com.

What is Gestational diabetes?

This common condition refers to an inability to “handle” food properly, as a result of the hormones of pregnancy working against the normal effect of insulin, and allowing the sugar in the blood to rise to dangerous levels. It occurs more commonly in women with a family history of diabetes, as well as women from certain ethnic groups, and is worsened by obesity. Often it can be treated by careful diet alone; but, in many cases, treatment with insulin injections will be necessary to protect the baby from the bad effects of the mom’s high blood sugar. These include high birth weights and the need for Cesarean sections, as well as low blood sugar in the baby at birth (hypoglycemia), which can cause seizures. Expectant mothers may be asked to check their own blood sugars after meals with a finger-prick to make sure that therapy is working correctly.

Gestational diabetes is also a strong predictor of type 2 diabetes later in life. This gives a woman a “heads-up” to engage in healthy eating, regular exercise and keeping her weight in the normal range, since all of these things have been shown to actually prevent or delay the onset of diabetes and all of its complications.

Click to Print This Page