Diabetes Care for African Americans: Navigating the Healthcare System

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.