Fact Sheet
The burden of diabetes is much higher for racial/ethnic minorities than for whites. Minorities have a higher prevalence of diabetes than whites, and some minorities have higher rates of diabetes-related complications and death. Research results help in understanding these disparities and ways to reduce them.
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Contents
Overview
High Diabetes Rates for Minorities
High Complication Rates for Minorities
Mortality
Cultural Variations and Economic Barriers
Reducing Disparities
Current Research
References
Diabetes, the sixth leading cause of death in the United States, is a chronic
disease characterized by persistent hyperglycemia (high blood glucose levels).
As of 1999, approximately 16 million Americans—5.9 percent of the total
population—had been diagnosed with diabetes, and that number is increasing
rapidly.
In a healthy person, blood sugar levels, which fluctuate based on food intake,
exercise, and other factors, are kept within an acceptable range by insulin.
Insulin, a hormone produced by the pancreas, helps the body absorb excess sugar
from the bloodstream. In a person with diabetes, blood sugar levels are not
adequately controlled by insulin.
From 1990 to 1998, the prevalence of type 2 diabetes increased by one-third—from
4.9 percent to 6.5 percent of the adult population. In type 2 diabetes, the
pancreas produces some insulin, sometimes even large amounts; however, either
the pancreas does not produce enough insulin or the body's cells are resistant
to the action of insulin. Almost 800,000 people are expected to be newly diagnosed
with the disease in 2001, and close to 200,000 will die from its complications.
The burden of diabetes is much greater for minority populations than the white
population. For example, 10.8 percent of non-Hispanic blacks, 10.6 percent of
Mexican Americans, and 9.0 percent of American Indians have diabetes, compared
with 6.2 percent of whites.1 Certain minorities
also have much higher rates of diabetes-related complications and death, in
some instances by as much as 50 percent more than the total population.2
Overview
The Agency for Healthcare Research and Quality (AHRQ) sponsors research that
focuses, among other issues, on identifying disparities in health care quality
and outcomes that might result from variations in how health care is provided
to people of different racial and ethnic backgrounds.
Results of this research have contributed to a better understanding of the
disparities in the prevalence of diabetes and related complications among different
racial and ethnic groups, identification of some of the barriers to health care
that contribute to these disparities, and identification of changes that could
be made to eliminate the barriers and reduce the disparities.
Research on diabetes in minorities published from 1976 to 1994 was identified
through a MEDLINE® search.2 This comprehensive
AHRQ-funded literature review of 290 articles revealed that:
- All minorities, except Alaska Natives, have a prevalence of type 2 diabetes
that is two to six times greater than that of the white population.
- Improving the lipid profile of African Americans with diabetes could help
to lower their risk of diabetes-related cardiovascular disease.
- Health care interventions that take into consideration cultural and population-specific
characteristics can reduce the prevalence and severity of diabetes and its
resulting complications.
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High Diabetes Rates for Minorities
Identifying disparities is a first step toward understanding what causes them
and what can be done to reduce them.
- Different studies found that African Americans are from 1.4 to 2.2 times
more likely to have diabetes than white persons.
- Hispanic Americans have a higher prevalence of diabetes than non-Hispanic
people, with the highest rates for type 2 diabetes among Puerto Ricans and
Hispanic people living in the Southwest and the lowest rate among Cubans.
- The prevalence of diabetes among American Indians is 2.8 times the overall
rate.
- Major groups within the Asian and Pacific Islander communities (Japanese
Americans, Chinese Americans, Filipino Americans, and Korean Americans) all
had higher prevalences than those of whites.
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High Complication Rates for Minorities
Although minorities are more likely than whites to be diagnosed with diabetes,
the rates of complications vary by disease and minority group.2
Kidney Disease
Diabetes is the most frequently reported cause of kidney failure in the United
States. In 1990, it was the underlying cause of kidney failure in 34 percent
of patients starting treatment for end stage renal disease (ESRD). Diabetes-related
kidney failure affects a much higher percentage of African Americans than whites.3
An AHRQ-funded study of renal disease found that:
- The rate of diabetic ESRD is 2.6 times higher among African Americans than
among whites.3
- From 1988 to 1990, the annual incidence of new cases of diabetes-related
ESRD was 137 per million African Americans, compared to 38 cases per million
whites.3
- ESRD is more likely to be related to type 2 diabetes among African Americans
than it is among whites.3
- Rates of early stage kidney disease (proteinuria) are higher among Hispanic
Americans, African Americans, and American Indians than among the white population.2
The AHRQ-funded study also found that the proportion of ESRD attributable to
diabetes was similar in whites (44 percent) and blacks (41 percent).
The reasons that African Americans have more diabetes-related ESRD are unclear.
African Americans have much higher rates of hypertension than whites. The interaction
between hypertension and type 2 diabetes, which occur together more frequently
in African Americans than in whites, may account for the higher rate of ESRD.
Another factor could be a difference in the quality of care furnished to African-American
patients with type 2 diabetes.3
Eye Disease
Another serious complication of diabetes is retinopathy, which, if untreated,
can cause blindness.
Diabetic retinopathy is the major cause of blindness among adults ages 20 to
74.
- Rates of blindness due to diabetes are only half as high for whites as they
are for rest of the population.
- Two studies of retinopathy in Hispanic Americans showed conflicting results,
with one showing higher rates and the other showing lower rates than whites.
- Pima Indians in Arizona and Native Americans in Oklahoma have both been
shown to have higher rates of retinopathy than whites.2
Coronary Artery Disease
People with diabetes are at greater risk for heart disease than the general
population. Although there do not appear to be consistent disparities in diabetes-related
coronary artery disease between minorities and white persons, an AHRQ-funded
study has found that African-American diabetic patients are more likely than
whites to have a particular lipid profile: low HDLs (high-density lipoproteins),
high LDLs (low-density lipoproteins), but lower triglycerides than among whites.
This is important because having too few HDLs, too many LDLs, or too many triglycerides
are all risk factors for heart disease. Therefore, the researchers recommend
that, in treating dyslipidemia (imbalances among HDLs, LDLs, and triglycerides)
among African Americans, clinicians should focus primarily on improving LDLs
and HDLs.4
Other Conditions
No consistent evidence exists that shows disparities between minorities and
whites for diabetes-related neuropathy and peripheral vascular disease. However,
African Americans and American Indians have higher rates of lower-extremity
amputations than white persons.2
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Mortality
Diabetes-related mortality rates for African Americans, Hispanic Americans,
and American Indians are higher than those for white people. Asians and Pacific
Islanders have the lowest diabetes-related mortality of any racial/ethnic group
in America.2
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Cultural Variations and Economic Barriers
AHRQ-funded research has shown that Hispanics with diabetes often face economic
barriers to treatment and are reluctant to place their own medical needs over
needs of family members. Other common barriers include:
- A distrust of insulin therapy.
- A preference for more familiar traditional remedies.
- A fatalistic acceptance of the course of the disease.5,6
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Reducing Disparities
AHRQ-funded research has demonstrated ways in which racial/ethnic disparities
can be reduced. Strategies to prevent the onset of diabetes through diet and
lifestyle changes require interventions that are culturally sensitive and population
specific.5,6 Designing strategies for managing the disease and its complications
to be culturally sensitive and targeted to specific populations may also be
helpful.
Diet, Exercise, and Primary Prevention
In studies comparing migrant populations with native nonmigrant populations,
a consistent linkage of type 2 diabetes with the American lifestyle was found.
According to AHRQ-funded researchers, this lifestyle includes a diet higher
in total calories and fat but lower in fiber, as well as the tendency to expend
less energy because of laborsaving devices. All minorities in the United States
for which data exist have a higher prevalence of diabetes than do residents
of their countries of origin.2
To learn more about how to prevent diabetes from occurring in the Mexican-American
population, AHRQ funded a pilot study of an intervention program for children
at risk for type 2 diabetes. The 3 1/2-month program had a threefold emphasis
on understanding of diabetes, diet, and exercise and was designed to be culturally
and age-appropriate for Mexican-American children. Thirty-seven at-risk children
7-12 years of age (those with at least one diabetic parent or grandparent) and
their parents were enrolled in an eight-session educational program intended
to inform them about diabetes and its complications and to teach the essentials
of a healthy lifestyle. The children received health screenings before and after
the program. Post-program analysis of individual risk factors showed a trend
toward more normal values. For example, the percentage of children whose consumption
of protein, total fat, saturated fat, and cholesterol fell within the recommended
daily requirement increased.
Also, 94 percent of parents and 67 percent of children began reading food labels,
83 percent of parents began to use fat-modified recipes, and 83 percent of children
began exercising regularly. Parental involvement also resulted in parents making
progress toward adopting healthier lifestyles.7
Chronic Disease Self-Management Program
The Chronic Disease Self-Management Program (CDSMP) is now being used by health
organizations in 31 States and 9 countries (including diabetes treatment facilities).8
The CDSMP could eventually have a significant impact on the health status and
health care use of minority persons with diabetes.
The program originated in an AHRQ-funded study that tested a 7-week community-based
patient education program for people with heart disease, lung disease, stroke,
and arthritis. A premise of the program is that many chronic diseases, such
as diabetes, heart disease, lung disease, arthritis, and high blood pressure,
pose similar problems in patient self-management. The CDSMP focuses on improving
people's self-efficacy in taking care of their own health. In the initial 6-month
followup, the study found positive results for self-reported health, disability,
fatigue, and hospital use indicators.
The CDSMP consists of seven weekly 2 1/2-hour sessions (later changed to six
weekly sessions) focusing on:
- Nutritional change.
- Adoption of exercise programs.
- Use of medications and community resources.
- Health-related problem solving.
- Decisionmaking.
Preliminary followup studies (covering a 2-year period) indicate that participants
have improved health, more energy, and fewer hospitalizations and doctor visits.8
Family Support
An AHRQ-funded study, a literature review of studies reporting on the effects
of social support among African-American adults with diabetes, found that African
Americans relied more heavily than whites on informal social networks to meet
their disease management needs. The social support consisted of help with the
day-to-day management of diabetes including:
- Help with diet supervision.
- Medication assistance.
- General support.
- Blood sugar monitoring.
The review found that social support is significantly associated with improved
diabetes management among this population.9 Although
research has not been done to show that this practice leads to better outcomes,
it appears to be a promising practice.
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Current Research
Current AHRQ studies continue to address the need for better disease management
and improved quality of life for diabetics in minority populations. The principal
investigator, name of project, and grant number (if applicable) for each study
are shown.
Current AHRQ Projects
Phillips L. Improving primary care of African-Americans with NIDDM (HS09722).
McCabe M. The impact of Navajo interpreters on diabetes outcomes (HS10637).
Piette JD. Automated assessments and the quality of diabetes care (HS10281).
Gerber B. A multi-media computer education program for minority populations
(HS11092).
Taylor A, Taliaferro G. Medical care use and expenditures for people with diabetes:
Are there racial and ethnic disparities?
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A summary of the projects follows:
- Primary care providers are collaborating with endocrinologists in Atlanta
to see if they can improve care and prevent complications in indigent urban
African Americans with type 2 disease who are in poor control of their blood
sugar (Phillips).
- The effects of interpreters on diabetes outcomes for Navajo patients are
being studied. Researchers are evaluating how the training of interpreters
affects their impact and the effects that the interpreters have on diabetes
outcomes and cost of ambulatory care of Navajo diabetic patients (McCabe).
- Researchers are examining the variation in outcomes for diabetic patients
using an automated telephone disease management system (ATDM) and extending
the use of ATDM to Spanish-speaking patients (Piette).
- A culturally sensitive multimedia computer education program is being tested
in a clinical setting. Researchers are evaluating its impact on diabetes-related
knowledge, attitudes, self-efficacy (the belief that what you do makes a difference),
and self-care for African-American and Latino populations (Gerber).
- An AHRQ study of racial and ethnic disparities in medical care use and expenditures
for people with diabetes is underway. Using 1997 survey data, it will present
national estimates of medical visits, individual expenses, and sources of
payment for people with diabetes, including racial and ethnic minorities.
This study is expected to be completed during 2002 (Taylor and Taliaferro).
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References
1. Mokdad AH, Ford ES, Bowman BA, et al. Diabetes trends in
the U.S.: 1990-1998. Diabetes Care 2000;23(9):1278-83.
*2. Carter JS, Pugh JA, Monterrosa A.
Non-insulin-dependent diabetes mellitus in minorities in the United States.
Ann Intern Med 1996;125(3):221-32. (AHRQ Grant HS07397).
*3. Perneger TV, Brancati FL, Whelton
PK, Kiag M. End-stage renal disease attributable to diabetes mellitus. Ann
Intern Medicine 1994;121:912-8. (AHRQ Grant HS06978).
*4. Cook CB, Erdman DM, Ryan GJ, et al.
The pattern of dyslipidemia among urban African-Americans with Type 2 diabetes.
Diabetes Care 2000;23(3):319-24. (AHRQ Grant HS09722).
*5. Noel PH, Larme AC, Meyer I, et al.
Patient choice in diabetes education curriculum. Diabetes Care 1998;21(6):896-901.
(AHRQ Grant HS07397).
*6. Lipton RB, Losey LM, Giachello A,
et al. Attitudes and issues in treating Latino patients with Type 2 diabetes:
views of healthcare providers. Diabetes Educ 1998;24(1);67-71. (AHRQ
Grant HS07376-03).
*7. McKenzie SB, O'Connell J, Smith LA,
et al. A primary intervention program (pilot study) for Mexican American children
at risk for Type 2 diabetes. Diabetes Educ 1998;24(2):180-7. (AHRQ Grant
HS07397-02).
*8. Lorig KR, Sobel DS, Stewart AL, et
al. Evidence suggesting that a chronic disease self-management program can improve
health status while reducing hospitalization. Med Care 1999;37(1):5-14.
(AHRQ Grant HS06680). For sites using the program for diabetes and other conditions,
go to http://patienteducation.stanford.edu/.
*9. Ford ME, Tilley BC, McDonald PE.
Social support among African-American adults with diabetes, part 2: a review.
J Nat Med Assoc 1998;90(7):425-32. (AHRQ Grant HS07386).
*AHRQ-funded sponsored research.
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AHRQ Publication No. 02-P007
Current as of November 2001
Internet Citation:
Diabetes Disparities Among Racial and Ethnic Minorities. November 2001. AHRQ Publication No. 02-P007. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/diabdisp.htm