Disadvantaged Populations

There are significant racial and ethnic disparities in diabetes prevalence and outcomes.¹

• Hispanics, Blacks, and Native Americans have a 50–100% greater burden of diabetes complications and mortality than whites.²
• At similar BMI levels, diabetes prevalence is higher in Asians compared with whites.³
• Black patients are less likely to achieve treatment goals including glycemic, cholesterol, and blood pressure control.⁴
• Blacks experience worse long-term diabetes-related outcomes than whites, including diabetic retinopathy, lower extremity amputations, and chronic kidney disease.⁴
• Native Americans experiencing disproportionately high rates of lower extremity amputations, chronic kidney disease, and diabetes-related mortality.⁴
• The prevalence of diagnosed diabetes among non-Hispanic black and Hispanic adults continues to increase but has leveled off among non-Hispanic whites.⁵

 

 
While the reasons are not yet completely understood, diabetes disparities likely result from complex interactions between clinical, biophysiological, socioeconomic and behavioral factors.⁷

Contributors to Diabetes Health Disparities^8–13
 

 
In order to improve health inequities related to diabetes, 2019 ADA Guidelines recommend that treatment be tailored for social context.

• Providers should assess social context, including potential food insecurity, housing stability, and financial barriers, and apply that information to treatment decisions.
• Refer patients to local community resources when available.
• Provide patients with self-management support from lay health coaches, navigators, or community health workers when available.¹⁴

References

1. Karter AJ, Schillinger D, Adams AS, et al. Elevated Rates of Diabetes in Pacific Islanders and Asian Subgroups: The Diabetes Study of Northern California (DISTANCE). Diabetes Care. 2013;36(3):574-579. doi:10.2337/dc12-0722
2. Canedo JR, Miller ST, Schlundt D, Fadden MK, Sanderson M. Racial/Ethnic Disparities in Diabetes Quality of Care: the Role of Healthcare Access and Socioeconomic Status. J Racial and Ethnic Health Disparities. 2018;5(1):7-14. doi:10.1007/s40615-016-0335-8
3. Hsu WC, Araneta MRG, Kanaya AM, Chiang JL, Fujimoto W. BMI Cut Points to Identify At-Risk Asian Americans for Type 2 Diabetes Screening. Diabetes Care. 2015;38(1):150-158. doi:10.2337/dc14-2391
4. Sequist TD, Ayanian JZ, Marshall R, Fitzmaurice GM, Safran DG. Primary-care Clinician Perceptions of Racial Disparities in Diabetes Care. J Gen Intern Med. 2008;23(5):678-684. doi:10.1007/s11606-008-0510-7
5. Beckles GL, Chou C-F. Disparities in the Prevalence of Diagnosed Diabetes – United States, 1999-2002 and 2011-2014. MMWR Morb Mortal Wkly Rep. 2016;65(45):1265-1269. doi:10.15585/mmwr.mm6545a4
6. Addressing Health Disparities in Diabetes. Centers for Disease Control and Prevention. https://www.cdc.gov/diabetes/disparities.html. Published October 2, 2018. Accessed May 16, 2019.
7. Dal Canto E, Farukh B, Faconti L. Why are there ethnic differences in cardio-metabolic risk factors and cardiovascular diseases? JRSM Cardiovasc Dis. 2018;7:2048004018818923. doi:10.1177/2048004018818923
8. Peek ME, Cargill A, Huang ES. Diabetes Health Disparities. Med Care Res Rev. 2007;64(5 Suppl):101S-156S. doi:10.1177/1077558707305409
9. White RO, Beech BM, Miller S. Health Care Disparities and Diabetes Care: Practical Considerations for Primary Care Providers. Clinical Diabetes. 2009;27(3):105-112. doi:10.2337/diaclin.27.3.105
10. Cook JP, Morris AP. Multi-ethnic genome-wide association study identifies novel locus for type 2 diabetes susceptibility. Eur J Hum Genet. 2016;24(8):1175-1180. doi:10.1038/ejhg.2016.17
11. Ruiz D, Becerra M, Jagai JS, Ard K, Sargis RM. Disparities in Environmental Exposures to Endocrine-Disrupting Chemicals and Diabetes Risk in Vulnerable Populations. Diabetes Care. 2018;41(1):193-205. doi:10.2337/dc16-2765
12. Chatterjee R, Maruthur NM, Edelman D. Novel Risk Factors for Type 2 Diabetes in African-Americans. Curr Diab Rep. 2015;15(12):103. doi:10.1007/s11892-015-0675-5
13. Golden SH, Brown A, Cauley JA, et al. Health Disparities in Endocrine Disorders: Biological, Clinical, and Nonclinical Factors—An Endocrine Society Scientific Statement. J Clin Endocrinol Metab. 2012;97(9):E1579-E1639. doi:10.1210/jc.2012-2043
14. American Diabetes Association. 1. Improving Care and Promoting Health in Populations: Standards of Medical Care in Diabetes—2019. Diabetes Care. 2019;42(Supplement 1):S7-S12. doi:10.2337/dc19-S001

 

Older Adults

The natural history of diabetes in older adults differs from that in younger patients, due in part to shorter life expectancy, increased comorbidity and a greater risk of treatment-related complications.¹

• 50-80% of adults >65 years of age have diabetes or prediabetes.²
• 61% of all expenditures attributed to diabetes are incurred by patients >65 years. ³
• Older adults with diabetes have higher complication rates than younger cohorts.³
• One-third of all individuals with diabetes are >65 years.⁴

Diabetes management strategies for high-functioning older people with a long life expectancy are similar to those used in younger patients.¹ Life expectancy is an important factor in treatment decisions for older patients near the end of life. As morbidity and functional impairment increase, the anticipated benefit of glycemic control declines.²
 

 
Resources

American Diabetes Association. 12. Older Adults: Standards of Medical Care in Diabetes—2019. Diabetes Care. 2019;42(Supplement 1):S139-S147.

References

1. Strain WD, Hope SV, Green A, Kar P, Valabhji J, Sinclair AJ. Type 2 diabetes mellitus in older people: a brief statement of key principles of modern day management including the assessment of frailty. A national collaborative stakeholder initiative. Diabetic Medicine. 2018;35(7):838-845. doi:10.1111/dme.13644
2. Halter JB, Musi N, Horne FM, et al. Diabetes and Cardiovascular Disease in Older Adults: Current Status and Future Directions. Diabetes. 2014;63(8):2578-2589. doi:10.2337/db14-0020
3. Leung E, Wongrakpanich S, Munshi MN. Diabetes Management in the Elderly. Diabetes Spectrum. 2018;31(3):245-253. doi:10.2337/ds18-0033
4. Schernthaner G, Schernthaner-Reiter MH. Diabetes in the older patient: heterogeneity requires individualisation of therapeutic strategies. Diabetologia. 2018;61(7):1503-1516. doi:10.1007/s00125-018-4547-9
5. American Diabetes Association. 12. Older Adults: Standards of Medical Care in Diabetes—2019. Diabetes Care. 2019;42(Supplement 1):S139-S147. doi:10.2337/dc19-S012

 

Pregnant Women

The annual prevalence of pregestational diabetes is increasing, largely as a result of the obesity epidemic.¹

Adverse maternal and fetal consequences of poor glycemic control include²:

• congenital anomaly
• miscarriage
• pre-eclampsia
• pre-term delivery
• macrosomia
• stillbirth
• neonatal hypoglycemia.

Insulin is the preferred anti-hyperglycemic agent in pregnant women. Insulin requirements may change during pregnancy.³

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References:

1. Sugrue R, Zera C. Pregestational Diabetes in Pregnancy. Obstet Gynecol Clin North Am. 2018;45(2):315-331. doi:10.1016/j.ogc.2018.01.002
2. Etomi O, Banerjee A. The management of pre-existing (type 1 and type 2) diabetes mellitus in pregnancy. Medicine. 2018;46(12):731-737. doi:10.1016/j.mpmed.2018.09.004
3. O’Neill SM, Kenny LC, Khashan AS, West HM, Smyth RM, Kearney PM. Different insulin types and regimens for pregnant women with pre-existing diabetes. Cochrane Database Syst Rev. 2017;2:CD011880. doi:10.1002/14651858.CD011880.pub2
4. American Diabetes Association. 14. Management of Diabetes in Pregnancy: Standards of Medical Care in Diabetes—2019. Diabetes Care. 2019;42(Supplement 1):S165-S172. doi:10.2337/dc19-S014

Resources:

ACOG Practice Bulletin No. 201 Summary: Pregestational Diabetes Mellitus. Obstet Gynecol. 2018;132(6):1514-1516. doi:10.1097/AOG.0000000000002961