Racial and Ethnic Disparities in Diabetes

It is not new knowledge that diabetes disproportionately affects racial/ethnic minorities, but it helps to have a reminder about the extent of the problem.

Recent data from the CDC indicates that diabetes affects 9.0% of Asian Americans, 12.8% of Hispanics, 13.2% of non-Hispanic Blacks, and 15.9% of American Indians, compared to 7.6% of non-Hispanic Whites.¹

Once affected, racial/ethnic minorities are also less likely to meet HbA1c targets than non-Hispanic Whites. For example, the Atherosclerosis Risk in Communities (ARIC) study has shown that fewer Blacks than Whites are able to meet diabetes goals.²

Moreover, healthcare disparities exist within racial/ethnic groups. The ARIC study also showed that Black women, as compared to White women, were less likely to meet the “ABC” goals (HbAc1 <7%, BP <140/90 mmHg, LDL <100 mg/dL) set out by the American Diabetes Association, a disparity that was not observed in men.²

And, a recent New York City study of diabetes management practices among Hispanics, Blacks and three Asian subgroups (Chinese, Korean, and Asian Indians), found that Asian Americans in all three subgroups had lower average rates of diabetes management practices than other ethnic/racial groups.³

Racial/ethnic disparities also extend to diabetic complications. A recent study of national trends in the care of high risk peripheral arterial disease in patients with diabetes found that rates of major amputation were significantly higher among Black patients compared to non-Black patients. Blacks also had lower rates of amputation-free survival compared to non-Black patients: 68.4% vs 75.4%, respectively.⁴

Socioeconomic status is a major factor that contributes to such disparities: Blacks are four times more likely than Whites to live in areas of low socioeconomic status.⁵ Neighborhood issues such as social cohesion, crime rates, shared ideas about health promotion, access to healthcare services, healthy foods, and safe places to exercise all play important roles in promoting healthy behaviors and improving diabetes management.⁵

Psychosocial factors, such as social support, chronic stress, discrimination, depression, and feelings of poor self-efficacy, impact diabetes management, and may differ by community and gender. A recent study among 248 low socioeconomic status Hispanic female and male participants in a culturally targeted diabetes management intervention found that women were less likely to receive support, faced more barriers, and reported less self-efficacy and lower amounts of self-care adherence than Hispanic men. The study concluded that not receiving adequate support is a “fundamental barrier” for Hispanic women with diabetes.⁶

Creating a better understanding of how race and ethnicity impact social determinants of health can improve culturally tailored diabetes interventions.⁷

Examples of such programs include Pasos hacia la salud, an internet-based physical activity program delivered in Spanish and targeted toward inactive Latinas in San Diego, California. A randomized study of the intervention found that Latinas who received the culturally tailored intervention were three times more likely to meet national physical activity guidelines at six months than controls (OR = 3.12, 95% CI 1.46-6.66, P<0.05).⁸

Likewise, diabetes prevention efforts among American Indian and Alaska Native communities are focusing on culturally-tailored solutions. The Traditional Foods Project is one example. It is focused on using tribal knowledge and respect for ecology, local tradition, history, and culture to rebuild traditional food systems. The project also emphasizes the role of elders, education, and community.⁹   

Among Blacks, some researchers are focusing on peer-led empowerment. In the PLEASED study, researchers compared three months of diabetes self-management education to 12 months of peer support delivered via phone added to three months of diabetes self-management education among Black adults with T2DM. Results showed that, while neither group showed changes in HbA1c, the peer support group showed significantly lower LDL, systolic blood pressure, diastolic blood pressure, and body mass index. In contrast, these factors worsened in the control group. 

Other studies support the importance of culturally-tailored diabetes interventions. A recent Cochrane review of 33 trials found that culturally appropriate T2DM health education in racial/ethnic minority communities can and does improve HbA1c and diabetes knowledge.¹¹

The review concluded “Culturally appropriate diabetes education [shows] consistent benefits over conventional care in terms of glycaemic control and diabetes knowledge, sustained in the short- to mid-term.”¹¹

All this can serve as a reminder not to forget prior work aimed at dismantling racial and ethnic disparities in healthcare. Let’s continue that work, to ensure that progress endures so that we can all stand together, proud and healthy.

References:

1. Beckles GL, Chou C. Centers for Disease Control and Prevention. Diabetes-United States, 2006 and 2010. MMWR Suppl. 2013 Nov 22;62(3):99-104.

2. Parrinello CM, et al. Prevalence of and racial disparities in risk factor control in older adults with diabetes: the Atherosclerosis Risk in Communities Study. Diabetes Care. 2015 Jul;38(7):1290-1298.

3. Islam NS, et al. Disparities in diabetes management in Asian Americans in New York City compared with other racial/ethnic minority groups. Am J Public Health. 2015 Jul;105 Suppl 3:S443-446.

4. Newhall K, et al. Amputation rates for patients with diabetes and peripheral arterial disease: the effects of race and region. Ann Vasc Surg. 2016 Jan;30:292-298.e1.

5. Puckrein GA, et al. Social and medical determinants of cardiometabolic health: the big picture. Ethn Dis. 2015 Nov 5;25(4):521-524.

6. Mansyur CL, et al. Social factors and barriers to self-care adherence in Hispanic men and women with diabetes. Patient Educ Couns. 2015 Jun;98(6):805-810.

7. Walker RJ, et al. Influence of race, ethnicity and social determinants of health on diabetes outcomes. Am J Med Sci. 2016;351(4):366-373.

8. Marcus BH, et al. Pasos Hacia La Salud: a randomized controlled trial of an internet-delivered physical activity intervention for Latinas. Int J Behav Nutr Phys Act. 2016 May 28;13:62.

9. Satterfield D, et al. Health promotion and diabetes prevention in American Indian and Alaska Native communities--Traditional Foods Project, 2008-2014. MMWR Suppl. 2016 Feb 12;65(1):4-10.

10. Tang TS, et al. Peer-Led, Empowerment-Based Approach to Self-Management Efforts in Diabetes (PLEASED): a randomized controlled trial in an African American community. Ann Fam Med. 2015 Aug;13 Suppl 1:S27-35.

11. Creamer J, et al. Culturally appropriate health education for type 2 diabetes in ethnic minority groups: an updated Cochrane Review of randomized controlled trials. Diabet Med. 2016 Feb;33(2):169-183.