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Leading experts weigh in on important issues in managing diabetes.
Diabetes Roundtable
2008
This Physician’s Weekly monograph provides important information to help practitioners improve their care of patients with diabetes.
Helpful Strategies for Managing Minorities With Diabetes Can Prevention Strategies Work & Be Cost Effective? A Guide to Tackling Cardiometabolic Risk
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Table of Contents 4
Improving the Care & Management of Hispanics With Diabetes —Carlos Campos, MD, MPH
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Managing Lipoproteins in Patients With Cardiometabolic Risk —Peter Sheehan, MD
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Prevention Strategies: A Focus on Cost-Effectiveness —Richard A. Kahn, PhD
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An In-Depth Focus on Diabetes in African Americans —Anthony J. Cannon, MD
Letter from the Editor: About 23.6 million people in the United States currently have diabetes; it is the seventh leading cause of death, and the total direct and indirect costs associated with diabetes have been estimated at $174 billion. What’s worse is millions more are predicted to develop the disease in the future. New data on diabetes and its complications continue to emerge, and providers must stay informed of this growing body of evidence so that diagnoses and management of these patients can be optimized. In this Physician’s Weekly monograph, several key points surrounding the optimization of care for diabetes and disease-related issues are discussed. Anthony J. Cannon, MD, and Carlos Campos, MD, MPH, provide compelling insights on the effect of diabetes on African Americans and Hispanics, respectively. Aggressive application of nationally recommended prevention activities could prevent many coronary artery disease events and strokes, and Richard A. Kahn, PhD, discusses new data on how clinicians are trying to find ways to reduce costs and improve delivery efficiency for prevention activities to achieve their full potential. Lastly, Peter Sheehan, MD, addresses a new consensus statement on lipoprotein management in patients with cardiometabolic risk and discusses the importance of treating lipoprotein abnormalities in an effort to improve outcomes. We at Physician’s Weekly hope that this monograph will serve as a valuable tool to help you and your organization improve upon its current diabetes care practices. Thanks for reading! Sincerely,
Keith D’Oria Managing Editor, Physicain’s Weekly
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Carlos Campos, MD, MPH Associate Clinical Professor Department of Family Medicine University of Texas Health Sciences Center, San Antonio Executive Director Institute for Public Health & Education Research, Inc. Member, National Advocacy Committee Former Member, Sub-Committee on Latino Initiatives American Diabetes Association
Improving the Care & Management of Hispanics With Diabetes Physicians managing Hispanic patients with diabetes need to be aggressive when monitoring and treating the disease. Special considerations are required to address adherence issues and cultural norms.
H
ispanics represent the largest minority population in the United States and will comprise almost 25% of the entire American population by 2050. Diabetes has been reported to occur at higher rates in Hispanics when compared with nonHispanic white patients of similar ages. “About 2.9 million Hispanic adults have diabetes in the U.S.,” says Carlos Campos, MD, MPH, “and the number is expected to increase as the Hispanic population expands in America. Furthermore, Hispanic patients with diabetes have higher mean A1C levels than
non-Hispanic white patients and are more likely to experience diabetes-related complications (eg, severe retinopathy or lower extremity amputations). They also have significantly higher rates of all-cause and cardiovascular mortality. Considering the facts, it’s critical that physicians make efforts to diagnose and treat the disease in these patients as early as possible.”
Seek Out Diabetes at Patient Visits It is estimated that about 25% of Hispanics will have diabetes by age 45, and Dr. Campos says that privisit www.physweekly.com
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mary care physicians (PCPs) need to aggressively diagnose the disease in this population. “PCPs can help reduce the disease burden significantly by checking higher-risk Hispanics, even if they present with simple aches or pains. We need to fish for diabetes in Hispanics, especially if they have one or more characteristics that fit the bill, such as being older, sedentary, overweight, or having elevated blood pressure or lipid levels.” Hispanic patients will often involve their families when they are receiving care for diabetes, and Dr. Campos recommends that PCPs take advantage of this unique opportunity. “The families are there to help patients reach their goals for controlling diabetes,” he says. “But we should also inform the families that they are at risk for the disease as well and let them know the importance of checking their glucose levels over time. We may be able to catch two patients with diabetes for the price of one.”
Table 1
Consider Cultural Barriers Once diabetes is diagnosed in Hispanics, Dr. Campos says PCPs need to consider the effect of certain cultural issues in this population (Table 1). “One of the most important cultural factors among Hispanic populations is the importance of family,” he says. “Hispanics place a high value on their families, so it’s important for PCPs to emphasize that patient efforts to improve health will increase the likelihood that they’ll see their children graduate from school, get married, and/or have children of their own. We need to make this connection with patients so that they’ll do what they need to do to control their diabetes.” Another key cultural issue in Hispanic populations is the initiation of insulin therapy (Table 2). “Insulin is often viewed as punishment among Hispanics,” explains Dr. Campos. “We need to change this misconception and stress that insulin is a natural hormone in the body. The need for insulin therapy
5 Cultural Values Affecting Relationships
Value
1 2
Ways to Demonstrate Respect for the Value
Simpatia: Kindness, politeness, pleasantness, avoidance of hostile confrontation
• Emphasize courtesy, a positive attitude, and social amenities
Personalismo: Formal friendliness, warm, personal relationship, characterized by interactions that occur at close distances (eg, handshakes, placing a hand on the shoulder)
• When interacting with patients, decrease physical distance and increase appropriate physical contact
Respeto: Respect, including targeted communication based on age, gender, social position, and economic status
• Use Spanish terms of respect (eg, usted, the polite form of “you,” instead of the informal tu)
• Whenever possible, involve patients in medical decisions, such as decisions to start insulin
• Use appropriate titles and greetings
• Ask about the patient’s concerns, particularly regarding insulin
Familismo: Collective loyalty to extended family that supersedes the needs of the individual
• Encourage patients to bring family members to visits
• Educate the patient’s family about diabetes
• Provide sufficient time and opportunity for the extended family to discuss important medical decisions
• Encourage the family to support the patient’s treatment efforts
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• Emphasize efficacy of medications for diabetes, including insulin
• Refer to the patient’s beliefs and values
3 4
Fatalismo: Fatalism, belief that individuals can do little to alter fate
• Provide a business card or beeper number
• Show interest in the patient’s life at each visit (eg, starting the visit with a brief conversation about the patient’s family, work, or school)
Source: Adapted from: Campos C. South Med J. 2007;100:812-820.
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shouldn’t represent a failure on the patient’s part; in fact, the proper use of insulin should be seen as a success. We should inform them that diabetes is a progressive disease and that they’re likely to require insulin in the future. Put this information out there early and tell patients why it’s needed. Express to them that your primary goal is to partner with them so that they can achieve the quality of life they want and so they can enjoy their family as they get older.”
Conquer Fatalistic Views & Be Respectful Hispanic patients with diabetes may avoid effective treatment plans because they have a fatalistic view of life; they may feel that they cannot control their illness. Dr. Campos says that emphasizing the efficacy of diabetes medications, including insulin, and considering patient beliefs and values are instrumental to overcoming these views. “To conquer a fatalistic view, it’s helpful to establish trust and show them that you care for their well-being. Once
Table 2
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that trust is established, patients are more likely to adhere to treatments.” In addition, Dr. Campos says that PCPs should be respectful during patient encounters. “For example, shaking hands too firmly with Hispanic patients and looking them directly in the eyes may be perceived by some patients that you are trying to overcome them. Simply putting your hand out and letting them dictate how the handshake should go and lowering your eyes, especially with older patients, shows more respect. Once that respect is gained, your chance of improving adherence to treatments is increased.”
Carlos Campos, MD, MPH, has indicated to Physician’s Weekly that he has worked as a consultant for, as a paid speaker for, and has received grants/research aid from Novartis, Novo Nordisk, AstraZeneca, Merck, Sanofi-Aventis, Amylin, and Eli Lilly.
Overcoming Barriers to Insulin Therapy in Hispanics
Barrier
Strategies to Overcome the Barrier
Practical barriers (eg, financial constraints, limited or no insurance, transportation issues)
• Ask patients about these potential barriers
• Direct patients to available resources
Language barriers
• Involve staff who speak Spanish
• Use translation services as needed
Poor health literacy
• Evaluate patients to determine their level of health literacy
• Use pictorial and audiovisual educational materials
• Use non-clinical language
• Create and maintain a shame-free environment
Cultural values
• Practice culturally competent care by being aware of and respecting cultural values
Lack of adequate knowledge about diabetes
• Educate and enable patients using culturally sensitive and language-appropriate materials
• Direct patients to available diabetes educational programs
Resignation
• Educate patients about diabetes and self-management in a culturally sensitive manner
• Begin insulin therapy with a simple titration regimen using once-daily basal insulin
• Focus on achieving glycemic goals Misconceptions about insulin, especially beliefs that insulin therapy indicates the disease has progressed or that insulin may cause complications (eg, blindness)
• Educate patients about the natural history of diabetes and the role of insulin therapy
• Add insulin to the treatment regimen earlier in the course of therapy
Source: Adapted from: Campos C. South Med J. 2007;100:812-820.
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Peter Sheehan, MD Senior Faculty Mount Sinai School of Medicine Chair, Cardiometabolic Risk Initiative American Diabetes Association
Managing Lipoproteins in Patients With Cardiometabolic Risk A consensus statement on lipoprotein management in patients with cardiometabolic risk sheds light on the importance of treating lipoprotein abnormalities in an effort to improve outcomes in these individuals.
A
ccording to published research, risk factors for diabetes and cardiovascular disease (CVD) often cluster, including obesity, insulin resistance, high glucose levels, abnormal concentrations of lipoproteins in the blood, and high blood pressure. Each of these factors increases the risk of CVD, and the clustering of these conditions is referred to as cardiometabolic risk (CMR). “Historically, physicians
have paid most of their attention to hyperglycemia as the primary cause for complications in diabetes, but clinicians are increasingly focusing on diabetes as a cardiovascular disease,” explains Peter Sheehan, MD. “In fact, we’ve learned that cardiovascular risk is conferred even before the onset of hyperglycemia in prediabetes. One of the features of pre-diabetes and diabetes is the presence of CMR characteristics.” visit www.physweekly.com
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In the April 2008 issue of Diabetes Care and April 15, 2008 Journal of the American College of Cardiology, the American Diabetes Association (ADA) and American College of Cardiology (ACC) co-published a consensus statement on lipoprotein management in patients with CMR. The statement indicates that lipoprotein abnormalities—including elevated triglyceride levels, low HDL-cholesterol levels, and increased numbers of small dense LDL particles—are commonly present in patients with CMR. Specific lipid treatment goals have been established for patients with type 2 diabetes or CVD, but guidelines for treatment of lipoprotein abnormalities in high-risk patients without diabetes or CVD have been less intense and may have underestimated lifetime CVD risk.
cholesterol can reduce the risk of CVD events in patients with diabetes and those without it but with other CVD risk factors. However, Dr. Sheehan says that even with adequate LDL cholesterol lowering, many patients on statins have significant residual CVD risks. “The goal of the ADA/ACC consensus statement was to identify lipoprotein parameters other than LDL or non-HDL cholesterol that can provide additional prognostic information, yield more information about the effectiveness of therapy for lipoprotein abnormalities, and indicate more appropriate treatment targets. Many patients with CMR or diabetes have normal levels of LDL cholesterol, but also have increased numbers of small dense LDL particles and other atherogenic lipoproteins.”
Patients with CVD and those with diabetes and one or more other cardiovascular risk factors are at the highest risk of experiencing a cardiac event. —Peter Sheehan, MD
Considering Residual CVD Risk Clinical trials have demonstrated that directing therapies—most notably statins—at lowering LDL
Table 1
The ADA/ACC consensus statement identifies several lipoproteins and lipoprotein components that appear to be most clinically relevant to CMR. Elevated
Treatment Goals in Patients With CMR & Lipoprotein Abnormalities Goals LDL cholesterol
Non-HDL cholesterol
ApoB
<70 mg/dL
<100 mg/dL
<80 mg/dL
<100 mg/dL
<130 mg/dL
<90 mg/dL
Highest-risk patients, including those with: 1) Known CVD 2) Diabetes plus one or more additional major CVD risk factor High-risk patients, including those with: 1) No diabetes or known clinical CVD but two or more additional major CVD risk factors 2) Diabetes but no other major CVD risk factors Note: Other major risk factors (beyond dyslipoproteinemia) include smoking, hypertension, and family history of premature CAD. Abbreviations: CMR, cardiometabolic risk; CVD, cardiovascular disease. Source: Adapted from: Brunzell JD, et al. Diabetes Care. 2008;31:811-822.
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Therapy Recommendations & Other Considerations Table 2
For abnormal concentrations of lipoproteins or abnormal lipoproteins in the blood, the following is recommended: • Statin therapy should be used for the majority of adult patients with CMR who have an abnormal distribution of lipoproteins in the blood. • For patients with CMR on statin therapy, guiding therapy with measurements of apoB and treatment to apoB goals is recommended, in addition to LDL cholesterol and non-HDL cholesterol assessments. • Treatment goals should address the high lifetime risk of patients with an abnormal distribution of lipoproteins in the blood and CMR. Other needs: • Clinical trials should be performed to determine whether the pharmacologic therapy required to achieve very low levels of atherogenic lipoproteins is safe and cost-effective. • A concerted, multifaceted, public health effort, focused on lifestyle modification, should be performed to reduce mean population levels of atherogenic lipoproteins to values well below current ones. Abbreviations: apoB, apolipoprotein B; CMR, cardiometabolic risk; CVD, cardiovascular disease.
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periencing a cardiac event,” Dr. Sheehan says. “These patients should be treated to specific LDL, non-HDL, and apoB goals in order to optimize outcomes. Patients with neither diabetes nor known clinical CVD but two or more additional major CVD risk factors and those with diabetes but no other major CVD risk factors are considered high-risk patients and have slightly different lipoprotein targets. Physicians should keep these targets in mind and strive to reach these goals to reduce CMR.” The ADA/ACC consensus statement indicates that statins should be used for most patients with CMR who have an abnormal distribution of lipoproteins in their blood (Table 2), but Dr. Sheehan notes that it is important for clinicians to assess lipoprotein parameters besides LDL. “Statins have been shown to lower CVD event rates by 25% to 50% depending on the endpoint, but there’s still a high absolute risk to consider. We can’t just focus on LDL because non-HDL and apoB levels are also significant in patients with CMR. Measuring these lipoproteins is not more costly and can help clinicians ascertain a more accurate measure of risk.”
Source: Adapted from: Brunzell JD, et al. Diabetes Care. 2008;31:811-822.
LDL cholesterol and LDL particle numbers have been well established as major predictors of CVD, including patients with CMR or diabetes, but Dr. Sheehan says other lipoproteins are also important. “Most doctors understand that LDL cholesterol is an important measure for cardiovascular risk, but measuring, assessing, and monitoring non-HDL cholesterol [total cholesterol minus HDL cholesterol] and apolipoprotein B [apoB], which measures the total burden of particles that are considered most atherogenic, are also helpful to gaining a better understanding of CMR.”
Dr. Sheehan emphasizes that 57 million Americans are considered to have pre-diabetes. “Because type 2 diabetes is a largely preventable disease, the potential impact of interventions is significant. Efforts that address lipoprotein abnormalities can have a profound impact on CMR. To be successful, we need to find patients with CMR early and initiate therapy quickly and aggressively. The hope is that the ADA/ACC consensus statement, in addition to efforts like the ADA’s Cardiometabolic Risk Initiative, will further encourage physicians to focus on the prevention, recognition, and treatment of all risk factors for type 2 diabetes and CVD.”
Treatment Goals & Recommendations Several treatment goals have been recommended in the ADA/ACC consensus statement based on the evaluation of available evidence (Table 1). “Patients with CVD and those with diabetes and one or more other CVD risk factors are at the highest risk of ex-
Peter Sheehan, MD, has indicated to Physician’s Weekly that he has received research grants from Tissue Repair Company, PamLab, Genzyme, and Sanofi-Aventis. He is also a director at Greystone Pharmaceuticals and is on the Scientific Advisory Board of Advanced BioHealing. He has served as a consultant for Hypermed and Calretex, and on the speaker’s bureau for EV3, Bristol-Myers Squibb/Sanofi, Merck, and Organogenesis.
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Richard A. Kahn, PhD Chief Scientific and Medical Officer American Diabetes Association
Prevention Strategies: A Focus on Cost-Effectiveness Aggressive application of nationally recommended prevention activities could prevent many coronary artery disease events and strokes, but clinicians must find ways to reduce costs and improve delivery efficiency for these activities to achieve their full potential.
C
ancer, cardiovascular disease (CVD), and diabetes are responsible for most of the morbidity, mortality, and healthcare costs in the United States. To help reduce the toll of these diseases, the American Cancer Society (ACS), American Diabetes Association (ADA), and American
Heart Association (AHA) have recommended a variety of prevention activities. Although supported by good efficacy evidence, there are large gaps in how well these efforts are applied, and research has shown that many Americans are not receiving prevention activities from which they would benefit. visit www.physweekly.com 15
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Richard A. Kahn, PhD, says that it is important to know the answers to several questions in order to promote greater attention to prevention and help physicians implement preventive activities. “We need to determine how many people today are candidates for at least one prevention activity and the extent to which these conditions are potentially preventable,” he says. “For example, how much could the burden of these conditions be reduced if prevention activities were applied with complete performance, compliance, and effectiveness? Additionally, we need to determine what can be realistically accomplished if patients, physicians, and health plans throughout the U.S. pursued prevention with greater vigilance. It’s equally important to determine how various prevention activities compare, which are the most important, and the cost of implementing these activities. Ideally, we want to find the best way to make prevention more attractive in the context of quality of life and financial considerations.”
A Cost-Feasibility Analysis Investigators from the ACS, ADA, and AHA have collaborated to determine the effects of 11 nationally recommended prevention activities on CVD-related morbidity, mortality, and costs, and published findings in the July 29, 2008 issue of Circulation. Using data from the National Health and Nutrition Examination Survey, the investigators determined the number and characteristics of adults in the U.S. who are currently candidates for these CVD prevention strategies. Using the Archimedes mathematical model, a simulated population was created to match the real U.S. population. Archimedes then simulated a series of clinical trials that examined the effects of applying each prevention activity—either individually or altogether—over the next 30 years in appropriate candidates. Health
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Table 1 The Impact of Prevention Activities According to a study published in the July 29, 2008 issue of Circulation, approximately 78% of adults between the ages of 20 and 80 in the United States are candidates for at least one cardiovascular disease prevention activity. • If everyone received the activities for which they are eligible, myocardial infarctions would be reduced by 63%. - If more feasible levels of performance are assumed, myocardial infarctions would be reduced 36%. • If everyone received the activities for which they are eligible, strokes would be reduced by 31%. - If more feasible levels of performance are assumed, strokes would be reduced 20%. • Implementation of all prevention activities would add about 221 million life-years and 244 million quality-adjusted life-years to the U.S. adult population over the coming 30 years, or an average of 1.3 years of life expectancy for all adults. Source: Adapted from: Kahn R, Robertson RM, Smith R, Eddy D. The Impact of Prevention on Reducing the Burden of Cardiovascular Disease. Circulation. 2008;118:576-585.
outcomes, quality of life, and medical costs for each prevention activity were assessed. The study showed that the aggressive application of CVD prevention activities could prevent a high proportion of coronary artery disease (CAD) events and strokes that would otherwise be expected to occur in the U.S. (Table 1). If more feasible levels of performance in delivering these prevention activities were assumed, the number of myocardial infarctions and strokes in patients could still be significantly reduced. “Nearly 80% of American adults meet the indications for at least one of the 11 prevention activities we studied,” says Dr. Kahn. “If every person received the prevention activities for which they are a candidate, heart attacks could be reduced by more than 60%, strokes could be reduced by 30%, and life expectancy could increase by an average of 1.3 years and at a higher quality of life than currently experienced.”
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Identify Cost-Effective Interventions of Benefit
The Benefits Are Too Important
As they are currently delivered, many of the 11 interventions assessed in the study would substantially increase costs, and the activities varied in their effectiveness. Dr. Kahn noted that one cost-saving activity was observed and five other relatively cost-effective measures could produce significant benefits (Table 2). “Our investigation found that smoking cessation proved to be cost-saving over 30
For preventive strategies to achieve their full potential, Dr. Kahn says efforts are needed to find ways to reduce costs and deliver interventions more efficiently. “This will require a deeper analysis on the way the current healthcare system is structured,” he says. “We need more cost-effective ways to deliver preventive care to avoid poor outcomes in cancer, CVD, and diabetes” he says. “We can provide these important interventions if we eliminate waste in
Physicians need to … improve outcomes and quality of life in a cost-effective manner. —Richard Kahn, PhD years,” he says. “A few other preventive services were cost-effective and could save a substantial number of lives. These include providing aspirin to high-risk individuals, controlling pre-diabetes, having obese people lose weight, lowering blood pressure in people with diabetes, and lowering LDL cholesterol in people with existing CAD. Physicians need to focus on these key factors to improve outcomes and quality of life in a cost-effective manner.”
Table 2
other areas of medicine. There are many treatments that are not nearly as cost-effective as the higheryielding services we studied. The bottom line is that the impact of these diseases is substantial and the problems are too big to be ignored.”
Richard A. Kahn, PhD, has indicated to Physician’s Weekly that he has or has had no financial interests to report.
Prevention Activities of Greatest Benefit
As currently delivered and at current prices, most cardiovascular disease prevention activities are expensive when considering the direct medical costs. However, a study published in the July 29, 2008 issue of Circulation indicates that several specific prevention activities appear to be of greatest benefits to the U.S. population: MI total, (NNT)
Stroke total, (NNT)
Life-years gained
Cost/QALY
CAD: LDL cholesterol <100 mg/dL
-39.23% (3)
-3.07% (33)
2.45
$39,130
Diabetes: Blood pressure <130/80 mmHg
-19.32% (5)
-13.45% (7)
1.78
$25,317
BMI <30 kg/m2
-11.94% (8)
-1.81% (55)
0.92
$18,941
Pre-diabetes: Fasting plasma glucose <110 mg/dL
-9.88% (10)
-0.86% (116)
0.68
$17,478
Aspirin to high-risk individuals
-18.5% (5)
1.81% (-55)
0.95
$2,779
Smoking: Stop
-7.82% (13)
-3.28% (31)
0.66
-$1,755
Abbreviations: MI, myocardial infarction; NNT, number needed to treat; QALY, quality-adjusted life-years; CAD, coronary artery disease. Source: Adapted from: Kahn R, Robertson RM, Smith R, Eddy D. The Impact of Prevention on Reducing the Burden of Cardiovascular Disease. Circulation. 2008;118:576-585.
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Anthony J. Cannon, MD Chief, Endocrinology Robert Wood Johnson University Hospital Endocrinologist Robert Wood Johnson Endocrine & Diabetes Associates Member, African American Initiatives Committee American Diabetes Association
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.
P
ublished 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 visit www.physweekly.com 19
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diabetes will increase by 50%. When compared with non-Hispanic white patients, studies have shown that the prevalence and severity of diabetic complications is significantly higher in African Americans (Table 1).
diabetes. It’s suspected that only one-third of these patients know they have it. African Americans are more likely to have poorer control of their blood sugar, blood pressure, and cholesterol levels.”
“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,
Spotting the Barriers The management of diabetes in the U.S. largely takes place in primary care. Dr. Cannon says “there is a shortage of endocrinologists and other diabetes
Tell patients that they’re likely to require insulin, and make efforts to minimize their concerns. —Anthony J. Cannon, MD MD. “Recent data from the CDC show that 14.7% of African Americans aged 20 and older have type 2
African Americans & Diabetes: Facts & Notes
Table 1
When compared with the general population, African Americans are disproportionately affected by diabetes: • 3.7 million (14.7%) of all African Americans age 20 and older have diabetes.
• Death rates for people with diabetes are 27% higher for African Americans compared with nonHispanic whites.
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.”
• African Americans are almost 50% as likely to develop diabetic retinopathy as non-Hispanic whites.
Tailoring Treatment Considerations
• African Americans are 1.6 times more likely to have diabetes as non-Hispanic whites. • 25% of African Americans between the ages of 65 and 74 have diabetes. • One in four African American women over 55 years of age has diabetes.
• African Americans are 2.6 to 5.6 times as likely to suffer from kidney disease each year. • African Americans are 2.7 times as likely to suffer from lower-limb amputations. Source: Adapted from: CDC and American Diabetes Association. Available at: www.diabetes.org/communityprogramsand-localevents/africanamericans.jsp.
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specialists in the U.S. today and it continues 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.”
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
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adjust treatment strategies accordingly. It’s important to initiate insulin therapy early to maximize outcomes. Currently, the average person who is placed on insulin has waited more than 3 years with elevated blood sugars.” Dr. Cannon also says that it is important to be upfront 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 AfricanAmerican 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 complica-
Monitoring Parameters for Control of Complications
Table 2
Every visit
• Blood pressure • Foot exam (only 55% achieve this goal) • A1C (average blood sugar over 3 months)
3 to 6 months
- Every 3 months if the patient’s treatment changes or the patient is not meeting goals. - Every 6 months if the patient is stable. • Dilated eye examination (only 63% achieve this goal)
Annual
tions 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.”
• Lipid levels* • Microalbumin
*These levels should be monitored every 2 years if they fall into lower-risk categories. Source: Adapted from: American Diabetes Association.
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.
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