MANAGEMENT OF DIABETES IN MINORITIES: A MATTER OF URGENCY

Transcription

1 MANAGEMENT OF DIABETES IN MINORITIES: A MATTER OF URGENCY James R. Gavin III, MD, PhD CEO & Chief Medical Officer Healing Our Village, Inc. Clinical Professor of Medicine Emory University School of Medicine Atlanta, Georgia

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3 Distribution by Race/Ethnicity in the U.S. TOTAL POPULATION 281,421,906 White/Caucasian 211,460, % Hispanic/Latino 35,305, % Black/African American 34,658, % Asian 10,242, % American Indian & Alaska Native 2,475, % Native Hawaiian & Other Pacific Islander 398, % Others 15,359, % Note: Numbers and percentages do not add to 100% due to the way data were collected U.S. Census Bureau Table DP-1 Profile of General Demographic Characteristics for the United States: 2000

4 Prevalence of Diabetes and Prediabetes (IFG) in the U.S million people in the U.S. have diabetes (7.0% of the population) million are diagnosed 6.2 million are undiagnosed About 54 million people in the US have impaired fasting glucose (IFG) 2* *This study did not measure impaired glucose tolerance (IGT). 1 Centers for Disease Control National Diabetes Fact Sheet. Available at 2 Cowie CC, et al. Diabetes Care. 2006;29:

5 U.S. Diabetes Prevalence by Ethnic Group Men and Women, Age Years % with diabetes 0 European Cuban American Japanese American African American Mexican American Puerto Rican Pima Harris, et al. Diabetes. 1987;36:523; Flegal et al. Diabetes Care. 1991;14(suppl 3):628. Knowler, et al. Diabetes Care. 1993;16(suppl 1):216. Fujimoto, et al. Diabetes Res Clin Pract. 1991;13:119. Fujimoto, et al. Diabetes. 1987;36:721.

6 Greatest Impact of Diabetes Epidemic Is in Blacks and Hispanics Age-adjusted Prevalence of Diabetes per 100 Population, Rate (per 100) White males Black males Hispanic males Year CDC. Diabetes Public Health Resources. Data & Trends. Accessed July White females Black females Hispanic females

7 African Americans and Diabetes 13.3 percent of all African Americans have diabetes African Americans are 1.8 times as likely to have diabetes as non-hispanic whites** NIDDK, National Diabetes Statistics fact sheet. HHS, NIH, ** Evidence has been generated to demonstrate differences in Disease outcomes and in the pathophysiologic drivers of DM

8 Type 2 Diabetes Risk Factors Age >45 years Overweight (BMI 25 kg/m 2 )* Physically inactive lifestyle Hypertensive ( 140/90 mm Hg) HDL cholesterol <35 mg/dl and/or a triglyceride >250 mg/dl History of gestational diabetes, vascular disease, PCOS, acanthosis nigricans, schizophrenia, or severe mental illness Prediabetes (patients with IFG and/or IGT) High-risk ethnicity/genetic risk (e.g., African American, Latino, Native American, Asian American, Pacific Islander) Prevalence nearly twice as high in Mexican Americans and non-hispanic blacks than in non-hispanic whites BMI = body mass index; PCOS = polycystic ovary syndrome; IFG = impaired fasting glucose; IGT = impaired glucose tolerance *May not be applicable to all ethnic groups. ADA. Diabetes Care. 2007;30 (suppl 1):S4-S41. Newcomer JW. J Clin Psychiatry. 2006;67:e16.

9 Mortality Rates in Black and White Diabetic Men and Women in a Sample of the U.S. Population, year mortality rate per 1,000 person-years Non-Hispanic Blacks Non-Hispanic Whites Men Age in Women Source: National Diabetes Information Clearinghouse; NIDDK, 2001

10 Ethnic Distribution of Diabetes in Children % of diabetes in children Type 2 diabetes Type 1 diabetes 82% African-American 74% White Other 24% 2% 18% 0% Scott et al. Pediatrics. 1997;100:84.

11 Insulin Resistance: Inherited and Acquired Influences Inherited Acquired Rare Mutations Insulin receptor Glucose transporter Signaling proteins Common forms Largely unidentified Overeating Overweight Inactivity Aging Medications Illness Hyperglycemia / glucose toxicity Elevated FFAs INSULIN RESISTANCE

12 Insulin Sensitivity Differs Among Ethnic Groups in Healthy Subjects Insulin Sensitivity Index (µmol L -1 m -2 min -1 pmol -1 L -1 ) n=34 Non-Hispanic White *P =.002 vs. Caucasians. Data are geometric means. n=9 * African American n=18 Asian American n= Adapted from: Chiu KC, et al. Diabetes Care. 2000;23: * Age: BMI: * Mexican American

13 Natural History of Type 2 Diabetes Obesity IGT * IFG ** Diabetes Uncontrolled Hyperglycemia Plasma Glucose 120 (mg/dl) Post-Meal Glucose Fasting Glucose Relative β-cell Function Insulin Resistance 100 (%) Insulin Secretion *IGT=Impaired Glucose Tolerance **IFG=Impaired Fasting Glucose Years of Diabetes Adapted from International Diabetes Center (Minneapolis, MN).

14 Genes, Environment and Social/Cultural Factors in the Development and Course of Diabetes in Minority Groups Socio-economic and cultural factors Thrifty genes + Inadequate lifestyle Insulin resistance and abdominal obesity Beta cell dysfunction Type 2 diabetes Other defects Incretin function? Socio-economic and Cultural factors Frequent chronic complications Increased mortality rates Biological factors Adapted from Caballero AE. Current Diabetes and Endocrinology Reports 2007;14:

15 MULTIPLE FACTORS ARE RESPONSIBLE FOR THE WHY THERE IS MORE DIABETES IN MINORITY POPULATIONS THESE FACTORS REPRESENT A POWERFUL SYNERGY BETWEEN THE GENETIC AND THE ACQUIRED

16 Prevalence of Obesity Prevalence of Obesity (%)* Non-Hispanic White Non-Hispanic Black Mexican American Men Women * 20 years old, age adjusted; obesity is defined as a body mass index (BMI) of 30 kg/m 2. Ogden CL, et al. JAMA. 2006;295:

17 Ethnic Populations Not at Goal Percent with A1C >7% Non-Hispanic White Non-Hispanic Black * Mexican American *P <.01. Harris MI, et al. Diabetes Care. 2001;24:

18 Premature Death from Coronary Heart Disease Varies Between Ethnicities Percent of Total Deaths 40 Black 35 White 30 Indian 25 Asian 20 Hispanic yrs yrs yrs Centers for Disease Control. Morb Mortal Wkly Rep. 2004; 53:

19 THE SEVERE IMPACT OF THE GROWING TRENDS AND ADVERSE OUTCOMES MEANS THERE IS URGENCY FOR MORE INTENSIVE TREATMENT OF DIABETES IN MINORITY POPULATIONS THE GREATER RISKS OF MINORITIES HEIGHTENS THE NEED TO ASSURE EARLIER AND BETTER CONTROL OF BLOOD SUGAR AND THE OTHER RISK FACTORS IN DIABETES

20 Elevated Incidence of ESRD in Ethnic Minorities* Incidence Rate/ 1000 Person-Years White Asian Latino Black N = 39,683 N = 7540 N = 6202 N = 8364 *Rates adjusted for age and gender. Adapted from Karter AJ et al. JAMA. 2002;287:

21 Amputations in People With Diabetes: Three Ethnic Groups Per 10,000 persons with diabetes Amputation rates 0 White Hispanic African- American Reiber GE, et al. In: Diabetes in America. 2nd ed. 1995;chap 18.

22 Good Glycemic Control (Lower HbA 1c ) Reduces Incidence of Complications DCCT Kumamoto UKPDS HbA 1c 9 7% 9 7% 8 7% Retinopathy 63% 69% 17 21% Nephropathy 54% 70% 24 33% Neuropathy 60% Macrovascular 16% disease DCCT Research Group. N Engl J Med. 1993;329: Ohkubo Y, et al. Diabetes Res Clin Pract. 1995;28: UKPDS 33. Lancet. 1998;352: Slide modified from D. Kendall International Diabetes Center, Minneapolis.

23 The Benefits of Metabolic Memory for High-Risk Minority Groups

24 Distribution of HbA1c in the Former DCCT Intensive and Conventional Groups During EDIC Conventional Intensive Mean HbA 1c throughout EDIC: Conventional 8.2% Intensive 8.0% p =.0019 HbA1c (%) p <.001 <.001 < DCCT Close out EDIC year DCCT/EDIC Research Group. JAMA. 2003;290:

25 EDIC Results: Nephropathy Albuminuria Prevalence (%) DCCT Close out Years 1 2 Intensive therapy Years 3 4 Years 5 6 Years 7 8 Conventional therapy Cumulative Incidence (%) Log-rank p <.001 Years 1 2 Years 3 4 Years 5 6 Years 7 8 EDIC EDIC At DCCT close out, cumulative incidences of albuminuria were 3.8% in the intensive cohort and 6.3% in the conventional cohort DCCT/EDIC Research Group. JAMA. 2003;290:

26 DCCT EDIC: Early Intensive Diabetes Therapy Reduced the Risk of CVD Events in T1DM Conventional Treatment Intensive Treatment 0.12 Any predefined CVD outcome 0.12 Nonfatal MI, stroke, or death from CVD Cumulative Incidence % risk reduction (95% CI, 9% 63%; p = 0.02) % risk reduction (95% CI, 12% 79%; p = 0.02) Time Since Entry (years) Time Since Entry (years) Predefined CVD outcome = nonfatal MI or stroke; death judged to be due to CVD; subclinical MI; angina, confirmed by ischemic changes on exercise tolerance testing or by clinically significant obstruction on coronary angiography; or the need for revascularization with angioplasty or coronary artery bypass. CVD = cardiovascular disease; MI = myocardial infarction. DCCT/EDIC Study Research Group. N Engl J Med. 2005;353:

27 Steno-2 Study: Changes in Risk Factors at 7.8 Years FPG TG TC LDL SBP DBP Percent Change * *p <.001. p =.015. p =.006. * * * Intensive Therapy (n = 67) Conventional Therapy (n = 63) DBP = diastolic blood pressure; FPG = fasting plasma glucose; LDL = low-density lipoprotein; SBP = systolic blood pressure; TC = total cholesterol; TG = triglyceride. Gaede P, et al. N Eng J Med. 2003;348:

28 Steno-2 Study Results 60 Primary Composite Endpoint (%) Conventional Intensive Months of Follow-up 50% risk reduction Gaede P, et al. N Eng J Med. 2003;348:

29 Patients With Diabetic Complications Intensive therapy Conventional therapy No. of patients Neuropathy No. of patients Retinopathy 0 4 yr 8 yr Post-trial 13 yr 0 4 yr 8 yr Post-trial 13 yr No. of patients Autonomic neuropathy No. of patients Peripheral neuropathy 0 4 yr 8 yr Post-trial 13 yr 0 4 yr 8 yr Post-trial 13 yr Gaede P, et al. N Eng J Med. 2008;358:

30 The Benefits of Combination Therapy

31 Cumulative Incidence of the First of Any of the Predefined CVD Outcomes Cumulative Incidence of Any Predefined CV Outcome Conventional treatment Intensive treatment Years Since Entry Number at Risk Intensive treatment Conventional treatment DCCT/EDIC Study Research Group. N Engl J Med. 2005;353:

32 The Basic Triad in Diabetes Care The Patient: Medical, Socio-economic, Cultural factors The Health Care Provider: Lack of Cultural Competence The Health Care System: Insufficient: Culturally Oriented Programs Professional Education Cultural Diversity Health Care Access Time and Support with Patients Caballero AE. Current Diabetes and Endocrinology Reports 2007;14:

33 In Minorities, there is great urgency for Combination Therapy to reduce ALL the risk factors that contribute to increased CVD in diabetes---yet there is far too often too little and too late

34 Clinical Inertia: Failure to advance therapy when required Percentage of Subjects advancing when A1C > 8% % Age of Subjects % 35.3% At Insulin Initiation, the average patient had: 5 years with A1C > 8% 10 years with A1C > 7% 44.6% 18.6% 0 Diet Sulfonylurea Metformin Combination Brown et al. Diabetes Care. 2004;27:

35 * Institute of Medicine. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: The National Academies Press, 2004.

36 Unequal Treatment: Major Findings Racial/ethnic disparities consistently found across a wide range of health care settings (managed care, public/private hospitals, teaching/community, etc.) disease areas, including diabetes care and clinical services even when various confounders are controlled for (i.e. socioeconomic status, insurance, stage of presentation, co-morbidities) Available at:

37 Ethnic Disparities in the Healthcare Experience with Diabetes Non-Hispanic Whites (n = 6,899) Non-Hispanic Blacks (n = 1,163) Hispanic (n = 976) Uninsured 6.4% 14.8% 20.7% Checkup in past year Never had a checkup Poor general health Cost is barrier to healthcare 90.1% 90.7% 84.5% 0.5% 0.2% 3.6% 16.7% 18.7% 26.0% 8.2% 19.5% 23.9% Gary TL, et al. Ethn Dis. 2003;13:47-54.

38 Health Insurance Coverage Non-Latino White African American All Latino U.S. Born Mexican American Foreign Born Mexican American Percentage with health insurance U.S. Census Bureau. Health Insurance Coverage: September, Harris MI. Diabetes Care. 2001;24:

39 Patient Self-Identified Barriers Physicians don t care about me Diabetic complications are inevitable. I need to buy special food in order to lose weight. Physical activity at work is enough. Diabetes disappears when symptoms improve. When you go to the hospital, you die. I don t have control over my life this must be God s Will. Why should I think about living 10, 20 years from now, I m worried about how I m going to get through tomorrow. Fitzgerald et al. Diabetes Educator. 1997,23:

40 Cultural Concerns Language and literacy barriers Concept of fatalism is prevalent in many ethnic groups Can lead to problems with patient adherence Misconceptions regarding diabetes and its treatment Patient-physician ethnic differences can limit effective communication Dagogo-Jack S, et al. Curr Diabetes Rev. 2006;2:

41 Creating a Culturally Sensitive Management Program Determine patient s level of acculturation Involve key family members in education and decision-making Use culturally sensitive, language-appropriate material and educators Identify economic, social, familial, and religious barriers to treatment Identify patients perceptions of diabetes and treatment Determine use of alternative medicines Maintain open communication with patient and family; ask direct questions at follow-up about treatment adherence, barriers to participation, and possible solutions Emphasize seriousness of diabetes and its changing nature over time Oomen JS et al. Diabetes Educ. 1999;25:

42 Culturally Competent Approaches in Clinical Practice Establish trust Improve communication Be sensitive to financial concerns Consider family dynamics Modify office environment Provide nutrition education, including that specific to ethnic food preparation Tucker CM, et al. Med Care. 2003;41:859-70; Dagogo-Jack S, et al. Curr Diabetes Rev. 2006;2:

43 Strategies to Improve Compliance With Drug Therapy for Diabetes Use visual aids (color-code instructions) Write down names of pills and when they should be taken Use simple regimens (fewer pills and fewer daily doses) to improve compliance Discuss potential obstacles to compliance (finances, cost, insurance, family issues, travel difficulties, cultural values, fear) Ask about alternative medicines Utilize tactics to encourage compliance such as follow-up phone calls from pharmacists (it takes a village a team!), drug coupons on refills, electronic pill-dispensers Oomen JS et al. Diabetes Educ. 1999;25:

44 Opportunities for Care: Enhancing Patient Comfort and Adherence (Spanish population) Increase patient comfort level with welcoming atmosphere Employ Spanish speakers in physician s office physician s attempts to speak Spanish appreciated Hispanic-oriented reading material, music and videos provide Spanish-language printed material for various literacy levels that includes illustrations and idiomatic expressions avoid using the word failure (patients apply to themselves, not to failure of treatment) physical contact/body language: building trust shake hands or bow, according to customs make eye contact, according to customs Oomen JS et al. Diabetes Educ. 1999;25:

45 Expert Panel of NMQF Recommendations to Improve Outcomes in Minority Patients Consider the earlier use of combination medications given synergies in mechanisms of action. The panel emphasized that earlier use of insulin a flexible and underutilized treatment tool should be considered as a tool for more effectively reaching goals Engage the Centers for Medicare and Medicaid Services (CMS) to highlight the need for some risk stratification and sensitivity to the clinical benchmarks according to the demographics of the patient population, perhaps including a point or scoring system based on movement toward rather than actually reaching the specified goal Engage minority communities to promote diabetes support and education, particularly as it relates to aggressive management of diabetes ( create buzz, generate excitement, promote hope)

46 IT IS HELPFUL TO DEFINE THE SCOPE AND IMPACT OF THE PROBLEMS AND TO EVEN IDENTIFY PATTERNS AND TRENDS.THIS IS A FOCUS ON WHAT IF WE ARE TO CHANGE OUTCOMES AND MAKE A DIFFERENCE IN THE HEALTH OF UNDERSERVED POPULATIONS.WE MUST EXPAND OUR FOCUS TO INCLUDE HOW

47 Diabetes Self-Management Education (DSME) A key element for improving patient outcomes and quality-of-life Requires behavioral and psychosocial strategies that are culturally-sensitive and age-appropriate Patient self-monitoring of blood glucose (SMBG) is necessary for patients taking insulin Assessment of glycemic targets monitoring for hypoglycemia adjustment of medications accuracy is instrument and user-dependent Racial and ethnic differences in self-monitoring rates are related to poverty and lack of diabetes education ADA Diabetes Care. 2008:31:S12-S54, S97-S104.

48 Health Literacy Mostly a Functional Illiteracy Medical instructions Consent forms Health literature translations Some ethnic populations prefer visual media Less focus on WHAT, more focus on HOW!

49 Knowledge is Key Action is Power

50 African American Materials Available at: Last accessed June 6, 2007.

51 Diabetes Management Challenges in the African American Population Urgency to identify the high-risk and use preventive strategies, especially in the obese Urgency to apply intensive management strategies to reduce impact of risk factors Given the earlier disease onset, attempts to alter natural history of disease warranted More intensive therapy using full spectrum of combination treatments required in African Americans Employ more integrative approach to offset impact of cultural barriers Deliberations of Expert panel of National Minority Quality Forum.