www.alliancefordiabetes.org

A national report released in

2000 by the U.S. Department of

Health and Human Services found that African-Americans, Mexican Americans

and American Indians in

particular were experiencing a

sharp rise in the prevalence of

type 2 diabetes.

Disparities in Diabetes Prevention and CarewHat is diabetes?Diabetes is a group of diseases marked by high levels of blood glucose, also called blood sugar, resulting from defects in insulin production, insulin action or both. Diabetes can lead to serious complications and premature death, but people with diabetes can take steps to control the disease and lower the risk of complications.1

As the American population ages and becomes increasingly diverse, the consequences of inadequate health care to low-income, underserved, uninsured and underinsured groups are becoming progressively serious, particularly for those who have or are at risk for developing diabetes. With nearly 24 million people (about 8 percent of the U.S. population2) already diagnosed with diabetes and the costs associated with this disease skyrocketing, it is critical not only to understand how and why disparities exist, but also to invest in prevention and management initiatives that can address the special needs of underserved communities.

Disparities in health care are often a result of environmental conditions, social and economic factors, insufficient health resources and poor disease management. With many causes for these critical gaps in care, success in reducing disparities can only come by addressing these factors together. That’s why The Merck Company Foundation is launching the Alliance to Reduce Disparities in Diabetes (the Alliance) to employ a multi-pronged approach to addressing this critical issue.

Type 2 diabetes disproportionately affects people of certain racial and ethnic groups, including African-Americans, American Indians, Asian Americans, Hispanics/Latinos and Pacific Islanders.3 These groups also make up a disproportionate share of the poor and uninsured. They may live in substandard housing or in low-income neighborhoods with plentiful fast-food restaurants but lacking in grocery stores that carry healthy foods, resulting in higher rates of overweight and obesity. In urban neighborhoods, a lack of sidewalks and crime-free parks also may discourage the daily physical activity needed to maintain a healthy lifestyle.

However, even when minority populations do have access to good food and physical activity, many continue to receive a lower quality of care than non-minorities. A 2003 Institute of Medicine report cited stereotyping, biases, language and geographical and cultural barriers as possible explanations.4

The consequences of disparate care can be dire. According to the U.S. Departement of Health and Human Services’ Centers for Disease Control and Prevention, chronic conditions such as diabetes and its numerous complications (including nerve, heart and kidney disease) are the leading cause of death, disability and illness in the United States.

But it needn’t be so. Research has shown that lifestyle changes (such as being physically active, eating healthy and losing weight) can prevent or delay diabetes. Likewise, proper management of diabetes once diagnosed (e.g., maintaining glucose, cholesterol and blood pressure control) can significantly delay or prevent its numerous complications.5 Disparities in routine preventive care and treatment among racial and ethnic groups may therefore contribute to the higher prevalence of diabetes and its complications among these populations.

wHo Has diabetes??Of those aged 20 years or older, data adjusted by population age6 finds:

• 6.6 percent of non-Hispanic whites have diabetes

• 7.5percentofAsianAmericansandPacificIslanders have diabetes

• 10.4 percent of Hispanics have diabetes (12.6 percent of Puerto Ricans have diabetes, 11.9 percent of Mexican Americans have diabetes)

• 11.8 percent of African-Americans have diabetes

• 16.5 percent of American Indians and Alaska Natives have diabetes,7 though rates are higher in some tribes. Native Americans have the highest diabetes prevalence rates in the world.

A national report released in 2000 by the U.S. Department of Health and Human Services found that African-Americans, Mexican Americans and American Indians in particular were experiencing a sharp rise in the prevalence of type 2 diabetes.8

wHo ProVides coVerage for tHeir HealtH care?Of the U.S. population, those with diabetes (both diagnosed and undiagnosed) represent:

• 5.9 percent of those with private insurance

• 13 percent of those with government insurance (including Medicaid and Medicare)

• 5.4 percent of the uninsured9

wHo are tHe UninsUred?Members of racial and ethnic groups likewise make up a disproportionate share of the non-elderly uninsured population.

• 22.8 percent of African-Americans are uninsured.

• 35.7 percent of Hispanics are uninsured.

• 12.6 percent of non-Hispanic whites are uninsured.10

Compared to insured adults, uninsured adults with diabetes are less likely to receive the proper standard of care, including regular glucose monitoring and preventive check-ups for their eyes and feet. This can lead to a greater risk of hospitalization and an increased risk of chronic disease and disability.11

Poverty is a major factor in access to health care. Families earning less than $10,000 per year make up the greatest percentage of the uninsured (35.7 percent), compared to just 7.1 percent of those who earn more than $75,000 per year.12

Poverty rates in the United States are:

• 25.9 percent for American Indians

• 22.1 percent for African-Americans

• 21.2 percent for Hispanics

• 7.5 percent for non-Hispanic whites13

American Indians and Alaska Natives have among the highest poverty rates of all ethnic groups in the United States, earning about half of what the average American earns. Poverty rates are highest on Indian reservations, where substandard housing also contributes to poor health outcomes.14

The Indian Health Service (IHS) provides health care services to those eligible American Indians and Alaska Natives from federally recognized tribes, however, American Indians and Alaska Natives still suffer with diabetes at rates higher than most other Americans.

• Native Americans are 420 percent more likely to die from diabetes-related causes than other Americans.15

• It is estimated that 30 percent of American Indians and Alaska Natives have pre-diabetes.16

• American Indians and Alaska Natives have a death rate due to diabetes that is three times higher than the general U.S. population (2004).17

• There was a 68 percent increase in diabetes from 1994 to 2004 in American Indian and Alaska Native youth aged 15-19 years.18

• American Indians and Alaska Natives have a rate of diabetes-related kidney failure that is 3.5 times higher than the general U.S. population (2004).19

Many studies have shown that a gap exists between the tests recommended for proper management of diabetes — such as the hemoglobin A1C (a measure of blood glucose levels over time) — and the care patients actually receive. These gaps are greater among African-Americans than they are among non-Hispanic whites.

• Some studies find African-Americans in private managed care settings and those on Medicaid are less likely than non-Hispanic whites to receive annual A1C tests or eye screenings.20

• A 2003 study found African-Americans in Veterans Affairs facilities were less likely than non-Hispanic whites to have a cholesterol check in the past two years, and had poorer control of cholesterol and blood pressure. Once detected, however, poor control was treated equally as intensively as it was for non-Hispanic white patients.21

• A 2008 study by the National Kidney Foundation showed that diabetes-related end-stage renal disease among African-Americans increased between 1995 and 1998, and then leveled off between 1998 and 2005.22

• Racial differences in glycemic control are associated with disease severity, health status and poorer quality of care. However, these factors alone do not fully explain the significant gap in control between non-Hispanic whites and African-Americans, which researchers are still exploring.23

• There are four times more supermarkets located in non-Hispanic white neighborhoods than in African-American neighborhoods. The presence of supermarkets is associated with lower prevalence of obesity and overweight, which are major risk factors for diabetes.24

• Hispanics/Latinos have more complications and worse outcomes from diabetes-related complications than non-Hispanic whites.25

• A 2007 nationwide study found Hispanics/Latinos with previously diagnosed diabetes were less likely than non-Hispanic whites to have a regular health care provider. They were also less likely to have had their A1C checked in the past year, or to have had a foot exam — even after controlling for access to care.26

• Hispanics/Latinos previously diagnosed with diabetes but lacking a usual health care provider are less likely to self-monitor blood glucose levels on a regular basis, an important indicator of how well their diabetes is being controlled and a major predictor of developing complications.27

• A 2008 study by the National Kidney Foundation showed that diabetes-related end-stage renal disease among Hispanics/Latinos increased in the 1990s and is now decreasing, although not significantly in the 2000s.28

• A 2007 national study of women with a history of gestational diabetes (a predictor of type 2 diabetes) found Hispanic/Latina women were substantially less likely than non-Hispanic white women with this history to have health insurance or access to a primary care physician.29

American Indians and Alaska Natives African-Americans Hispanics/Latinos

1. National Diabetes Information Clearinghouse, National Diabetes Statistics, 2007 Factsheet, http://diabetes.niddk.nih.gov/dm/pubs/statistics/index.htm#what

2. Centers for Disease Control and Prevention. National Diabetes Factsheet, 2007. Atlanta, GA: U.S. Department of Health and Human Services, 2008. http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2007.pdf

3. Ibid.

4. Institute of Medicine of the National Academies. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. 2003. The National Academies Press.

5. See 2.

6. The American Diabetes Association (ADA) strongly encourages controlling for population age differences when making racial and ethnic comparisons in the prevalence of diabetes, because most minority populations are younger and tend to develop diabetes at earlier ages than the non-Hispanic white population. This is important because the longer you live with diabetes, the more damage it can do to your body.

7. See 2.

8. Centers for Disease Control and Prevention and the National Institutes of Health, HealthyPeople 2010. Chapter 5. 2000. www.healthypeople.gov/Document/HTML/Volume1/05Diabetes.htm

9. “Economic Costs of Diabetes in the U.S. in 2007,” Diabetes Care, 2008; Vol. 31: pp. 1-20.

10. Employee Benefit Research Institute estimates from the March Current Population Survey, 2007 Supplement.

11. “Coverage Matters for Individuals,” Covering the Uninsured, www.CoverTheUnisured.org. 12. Ibid.

13. Ibid.

14. “Broken Promises: Evaluating the Native American Health Care System,” U.S. Commission on Civil Rights, September 2004. www.usccr.gov/pubs/nahealth/nabroken.pdf

15. Ibid. 16. Indian Health Service, Division of Diabetes Treatment and Prevention. Diabetes in

American Indians and Alaska Natives: Facts At-a-Glance, June 2008. www.ihs.gov/MedicalPrograms/Diabetes/index.cfm?module=resourcesFactSheets_AIANs08

17. Ibid.

18. Ibid.

19. Ibid.

20. LeMaster, J.W. et al., “Racial Disparities in Diabetes-Related Preventive Care: Results from the Missouri Behavioral Risk Factor Surveillance System,” Preventing Chronic Disease, July 2006; Vol. 3, No. 3: pp. A86.

21. Heisler, M. et al. “Racial Disparities in Diabetes Care Processes, Outcome, and Treatment Intensity,” Medical Care, November 2003; Vol. 41, No. 11: pp. 1221-32.

22. Burrows, N.R., Li, Y. and Williams, D.E. “Racial and Ethnic Differences in Trends of End-Stage Renal Disease: United States, 1995 to 2005. Advances in Chronic Kidney Disease, April 2008; Vol. 15, No. 2: pp. 147-152.

23. de Rekeneire, N. et al. “Racial Differences in Glycemic Control in a Well-Functioning Older Diabetic Population,” Diabetes Care 26: 1986-1992, 2003.

24. Presentation by Michelle Gourdine at the American Diabetes Association’s 2008 Annual Partnership Forum. See www.diabetes.org.

25. Mainous III, A.G. et al., “Quality of Care for Hispanic Adults with Diabetes,” Family Medicine, 2007; Vol. 39, No. 5: pp. 351-6.

26. Ibid.

27. Ibid.

28. See 22.

29. Kim, C. et al., “Racial and Ethnic Variation in Access to Health Care, Provision of Health Care Services, and Ratings of Health Among Women with Histories of Gestational Diabetes Mellitus,” Diabetes Care, 2007, Vol. 30: pp. 1459-65.

endnotes

Compared to insured adults,

uninsured adults with diabetes

are less likely to receive the proper

standard of care, including regular

glucose monitoring and preventive

check-ups for their eyes and feet.

This can lead to a greater risk of

hospitalization and an increased risk of chronic disease and

disability.