Separate but Unequal: The Disparities of Diabetes

The statistics prove the differences. The Centers for Disease Control and Prevention (CDC) recently reported that an estimated 26 million U.S. adults (11% of the population) had diabetes in 2011. The prevalence of the disease, however, is far from equal among the races.

According to the CDC, 6% of whites have diabetes compared with 11.5% of Latinos, 11.3% of blacks, and nearly 8% of Asians. Blacks are 77% more likely to have diagnosed diabetes, and Latinos are 66% more likely than whites, reports the American Diabetes Association. And, what’s more, minorities with the disease suffer far worse health outcomes. The long list of racial and ethnic disparities include:
• Mexican Americans are 50% more likely to die from diabetes than whites.
• Blacks are almost 50% more likely to develop diabetic retinopathy.
• Blacks are two to five times more likely to suffer from kidney disease.

The good news, though, is that many in the healthcare community who treat diabetes are searching for solutions to close the disparity gap. Marshall Chin, MD, in the Department of Medicine at the University of Chicago and director of Robert Wood Johnson Foundation’s Finding Answers: Disparities Research for Change, says making more providers aware of the problem is a crucial step.

“It’s important for providers who care for diabetes patients to report clinical performance data stratified by race, ethnicity, and socio-economic status,” Chin explains.

“We know most providers are well-meaning, but many do not believe there are disparities in their own practice because they are good moral people and wouldn’t discriminate,” he says. “But, by and large, when providers look at these stratified data and see the disparities, people then are motivated to make changes.”

To have the most impact on reducing disparities in diabetes care and outcomes, there needs to be broad, targeted approaches, Chin says.

“Doctors and nurses need to be able to provide care that is closely tailored to patients so it’s more likely to work,” he continues. “And we need interventions in the community because diabetes is largely a chronic disease of self-management, and 99% of the time the patient is managing his or her condition at home as opposed to in my office, so we need to work with community partners to make it more likely these patients can live healthy lifestyles.”

Community Solutions

Chin and Monica Peek, MD, are co-founders of the Improving Diabetes Care and Outcomes on the South Side of Chicago project that partners clinics, community-based organizations, and private businesses to help Blacks better cope with the challenges of the disease.

One partnership connects clinics, a local farmers’ market, and a major national pharmacy chain to create “food prescriptions” that offer free or discounted healthy food. Physician partners can also prescribe six months of free use of city gym facilities to patients with chronic diseases.

At the Joslin Diabetes Center in Boston, endocrinologist A. Enrique Caballero, MD, is the director of the Latino Diabetes Initiative and agrees community outreach is key to reducing the disparity gap. Caballero developed four components by which to improve the lives of Latinos with diabetes: clinical care and education, research, outreach, and professional education programs.

“I think it is important to know that in the Hispanic community there are a lot of traditions and cultural factors that may delay the diagnosis of diabetes and perhaps decrease adherence to therapies,” says Caballero. “What we’ve found that has been very successful is not only to have a clinical program and an education program that is culturally and linguistically oriented, but also to develop activities in the community that I think is very appropriate for this population and perhaps for others.”

As part of the patient education effort, Joslin recently developed two Spanish language audio-novellas (soap operas) that Caballero says have become very popular.

“We did some studies with our population and found that people like to listen to stories,” says Caballero. “They find it more interesting and more practical than reading.”

“La Historia de Rosa” (Rosa’s Story), for example, features a woman with type 2 diabetes who tells how she dealt with her diagnosis. And “La Historia de José” focuses on all diabetes-related complications. The novellas include practical information about goals, tests, nutrition, exercise, and medications in a culturally oriented manner. The audio CDs and accompanying materials are available from Joslin’s online store.

“These novellas are just an example of some culturally oriented materials that can be identified to really help educate a lot of patients with diabetes in this community,” Caballero adds.

To reach her at-risk population, Kate Lorig, DrPH, director of the Stanford University Patient Education Research Center, developed the Chronic Disease Self-Management Program (CDSMP) as well as the Diabetes Self-Management Program, which is now offered in both English and Spanish in more than 400 sites across the country.

The workshops are given to small groups of 12 to16 patients for 2½ hours once a week for six weeks in settings such as community centers, libraries, and hospitals. They are led by other peers with diabetes and cover a wide range of subjects, including how to deal with symptoms, appropriate exercise, healthy eating, and working more effectively with healthcare providers.

In a study published in 2013’s September/October issue of The Diabetes Educator, 114 adults with diabetes participated in Lorig’s CDSMP workshop. Half of the patients started with A1C values of 7% or more, and all had reductions at six and 12 months.

Lorig believes a chief reason for her programs’ success is that they help people “self-tailor.” “Instead of telling people you have to do this, we tell them ‘this is what we know about eating and diabetes,’” she says. “We really work with them on doing what they can do now and not worry about the ideal.”

“Many people with diabetes are overwhelmed,” she continues. “A typical diabetes program will give people something like 250 different messages.”

“If somebody’s faced with 250 things they are supposed to do, they throw up their hands and do nothing. So, what we do in our courses is have only about 80 messages and we make it very clear: ‘We don’t expect you to do all 80 of these things, but we want to help you do the things that you think would be most helpful and relevant to your life now.’”

In North Carolina, Nicolle Miller of the Division of Aging and Adult Services works with the Living Healthy program that implements both of Lorig’s CDSMP and Diabetes Self-Management programs. Since 2010, 2,100 individuals have taken the diabetes workshop, and Miller says participants have benefited from the intervention.

“We examined changes in the four domains of general health, physician communication, symptom management, and interference of daily activities,” explains Miller. “We saw significant pre-post improvements in all four of those categories one year after participants completed the program, which is consistent with what Kate [Lorig] and others have found nationally.”

“What Can We Do Better?”

When asked his advice for fellow endocrinologists, Caballero delivers a plain message.

“We all have an opportunity to do a better job in treating our minority patients,” he says. “I say this respectfully, but we often blame the patients for not following the recommendations but I think we must ask ourselves, “What can we do better?”

“Getting more familiar with the culture with some of the misconceptions and myths, with some of the self-care behaviors and working together with a patient and the family to address cultural and linguistic issues would be something important for healthcare providers,” he continues.

Caballero adds that several states have mandated that physicians get their continuing medical education by participating in programs that address cultural and social issues, which illustrates a step in the right direction.

Chin is also optimistic about eliminating diabetes disparities.

“As long as we do some of the interventions and make some of the changes we know can reduce disparities, things will improve over time,” he says. “We know a lot more now than 10 years ago, and the usual way of doing things is not working. So we need to step back and learn from the good work of many others over the past 10 years.”

— Fauntleroy is a freelance writer in Carmel, Ind. She wrote about new practice apps in the January issue of Endocrine News.

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