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Senior Citizen Health & Medicine
Older Blacks and Latinos Still Lag Behind Whites in
Controlling Diabetes
Improvement possible by targeting factors such as
medication use and emotional distress, for which the racial and ethnic
gap is wide
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Watch video - Michele Heisler, M.D., MPA,
University of Michigan Medical School, about a new national
study documenting major differences in blood-sugar control among
African Americans, Latinos and whites with diabetes.
CLICK HERE |
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Sept. 27, 2007 - Despite decades of advances in
diabetes care, African Americans and Latinos are still far less likely
than whites to have their blood sugar under control, even with the help
of medications, a new nationally representative study finds. That puts
them at a much higher risk of blindness, heart attack, kidney failure,
foot amputation and other long-term diabetes complications.
The comprehensive new national study of middle-aged
and older adults, published in the Sept. 24 issue of the Archives of
Internal Medicine, was performed by a team from the University of
Michigan and the VA Ann Arbor Healthcare System.
The study documents the persistence of strong
racial and ethnic disparities in diabetes control, which have been
observed for decades and contribute to the much greater impact of
diabetes on those two ethnic groups. The results suggest that diabetes
will continue to kill and disable black and Latino adults
disproportionately for decades to come.
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But the study delves deeper into the reasons behind
this difference in blood sugar levels, using complex statistical
analysis to find factors that do -- and don’t -- play a role. For
instance, diabetes control was worse among black and Latinos under age
65.
Most notably, two factors were found to account for
a sizable portion of the racial and ethnic difference in glucose
control: how well patients persist in taking their diabetes medicines
regularly, and how they respond emotionally to having diabetes.
Fortunately, these factors are likely to change in response to specific
outreach efforts — including some now underway by the U-M researchers.
The study also hints that more factors are at work.
“While we were taken aback to see that diabetes
control still varies so much by race and ethnicity, we’re encouraged
that two of the crucial factors are modifiable,” says Michele Heisler,
M.D., MPA, an assistant professor of Internal Medicine at the U-M
Medical School and a research scientist at the VA Ann Arbor’s Center for
Clinical Practice Management Research. “To improve diabetes outcomes, we
must do better at supporting all patients in managing their disease
through treatment and lifestyle change. But we need to tailor specific
interventions to address the barriers to achieving good diabetes control
that African American and Latino adults with diabetes disproportionately
face.”
The study is based on very recent data from the
Health and Retirement Study, a decades-long national effort to assess
the health of adults over age 50 through regular completion of intensive
questionnaires and health examinations.
Funded by the National Institute on Aging, and
based at the U-M Institute for Social Research, the HRS began assessing
the blood sugar levels of participants in 2003. In the older age groups
where Type II diabetes is mostly found, the new study is larger than the
other major source of population-wide data on this issue, the National
Health and Nutrition Examination Survey (NHANES) run by the Centers for
Disease Control and Prevention.
In all, 1,199 people over age 55 with diabetes were
included in the new study. Their blood sugar was measured using the A1C
test, which gives an average blood glucose level over the last three
months and is considered a more accurate gauge of glycemic control than
a simple glucose test.
“The ability to obtain such an important clinical
marker on a large national sample is a major step forward in using
population surveys to understand health disparities in the older
population,” said David Weir, Ph.D., director of the Health and
Retirement Study and a research professor at ISR.
Current guidelines call for people with diabetes to
maintain an A1C level of under 7 percentage points, to slow the rate of
damage to nerves, blood vessels and organs that can lead to deadly and
debilitating diabetes complications. People without diabetes typically
have an A1C under 6 points.
But when the researchers analyzed data from study
participants who were taking medications to control their blood sugar,
the difference between the mean A1C for whites and the means for the
other ethnic groups was large. White people had a mean A1C of 7.22
points, while the levels for blacks and Latinos were 8.07 and 8.14,
respectively. People with diabetes are typically prescribed medications
for glucose control only when diet and exercise no longer keep their
levels in check.
An even bigger difference was seen when the
researchers looked at the 286 participants on medications who were
between ages 55 and 64 – too young for Medicare coverage. Whites had an
average A1C of 7.46, but blacks were at 8.96 and Latinos were at 8.91.
Less of a difference among senior citizens
By contrast, there was a much smaller difference in
average A1C among members of the three groups over age 65.
The researchers then performed a statistical
analysis that took into account all of the available information about
all the participants who were taking medication — everything from their
education level and annual household income to their mental health,
insurance coverage status, quality of health care, medication regimens,
exercise, diet, as well as their attitudes and behaviors about taking
medications, monitoring blood sugar levels, and other key diabetes
self-care tasks.
The data also included participants’ answers to a
questionnaire that assesses a person’s emotional response to living with
diabetes, and a questionnaire about how they were managing their disease
– including how well they adhered to the diabetes medications prescribed
by their doctors.
A multvariate statistical analysis then allowed the
researchers to separate out factors associated with higher A1C levels,
and to assess how those factors in turn were associated with ethnicity.
It also allowed them to adjust for differences in income, education, and
all the other factors.
In the end, the factors that showed the strongest
influence on racial and ethnic differences in A1C levels were medication
adherence (especially among African Americans) and emotional distress
related to diabetes (especially among Latinos). African Americans
reported more barriers to taking their medications, and less adherence
to their medication, than the other groups. Meanwhile, Latinos reported
much higher levels of distress related to their diabetes than other
groups.
Even so, all the factors examined in the analyses
that might account for the observed racial and ethnic disparities in
glycemic control accounted for only 14 percent of the African
American-white disparity, and 19 percent of the Latino-white disparity,
in blood sugar control.
Meanwhile, differences in income and education
level – two factors long hypothesized to be key determinants of worse
diabetes outcomes – did not explain the glucose control differences,
once the other factors were included in the analyses.
The authors conclude that additional factors not
assessed in the study, such as genetics, stress levels and other
environmental factors, intensity of medication regimens, and the
generosity of patients’ prescription drug insurance coverage must
account for a large part of the picture.
Medication Adherence
“Medication adherence was one of the strongest
predictors of glucose control across the board,” says Heisler. “This
reinforces that by targeting barriers to medication adherence — such as
patient-doctor communication about medications, patient trust in health
systems, patient confidence that medication actually helps, cost
barriers, and other barriers that African Americans disproportionately
face — we can make a difference.”
"Diabetes is one of the most important health
challenges faced by Americans and American society today," notes Richard
Suzman, Ph.D., director of behavioral and social research at the
National Institute on Aging. "These results illuminate some of the
behavioral and other issues associated with glycemic control that can be
useful in designing strategies and interventions to reach diverse
populations."
Heisler and her colleagues are currently conducting
two randomized controlled trials of such interventions in people with
diabetes who have high A1C levels, blood pressures, and lipid
(cholesterol) levels.
One, supported by the National Institutes of Health
and the VA, includes nurse-led group sessions where patients can break
their longer-term diabetes self-care goals into short-term specific
steps, and chance for patients to link up with a diabetes peer “buddy”
who faces similar self-care challenges, to provide mutual coaching and
support during weekly telephone calls.
The other, funded by the National Institute for
Diabetes and Digestive and Kidney Diseases and VA, is training VA
pharmacists to reach out to diabetes patients with poor risk factor
control and pharmacy data that shows difficulties refilling medications.
The clinical pharmacists will provide “motivational-interviewing-based”
adherence assessment and counseling.
This proactive outreach will specifically target
blood pressure, which like glucose is a crucial factor in the
development and progression of diabetes complications. The pharmacists
will also have the ability to increase patients’ dosages of blood
pressure medications, within a framework pre-approved by physicians.
In addition to Heisler and Weir, the newly
published study is co-authored by U-M and VA researchers Jessica Faul,
MPH, Rodney Hayward, M.D., Kenneth Langa, M.D., Ph.D., and Caroline
Blaum, M.D. It was supported by NIA, VA, and the Michigan Diabetes
Research and Training Center. Reference: Archives of Internal Medicine,
Vol. 167 No. 17, Sept. 24, 2007.
Written by Kara Gavin
A University of Michigan Health Minute update on
important health issues.
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