diabetes roundtable: 2008

visit www.physweekly.com

Leading experts weigh in on important issues in managing diabetes.

Helpful Strategies for Managing Minorities

With Diabetes

Can Prevention Strategies Work & Be Cost Effective?

A Guide to Tackling Cardiometabolic Risk

This Physician’s Weekly monograph provides important information to help practitioners improve their care of patients with diabetes.

Brought to you, in cooperation with:

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The Basics

Physician’s Weekly (ISSN 1047-3793)is published by Physician’s Weekly,LLC. Copyright ©2008. Physician’sWeekly™ is a trademark of Physician’sWeekly, LLC. Reproduction withoutwritten permission from the publisheris prohibited. Offices: 490 State Route33, Bldg. 2-6, Millstone Twp, N.J.,08535; 732-792-1558; and 75 Clare-mont Road, Suite 205, Bernardsville,N.J., 07924; 908-204-0010; E-mail:[email protected]

Improving the Care & Management of Hispanics With Diabetes —Carlos Campos, MD, MPH

Managing Lipoproteins in Patients With Cardiometabolic Risk—Peter Sheehan, MD

Prevention Strategies: A Focus on Cost-Effectiveness—Richard A. Kahn, PhD

An In-Depth Focus on Diabetes in African Americans —Anthony J. Cannon, MD

About 23.6 million people in the United States currently have diabetes; it is the seventh leading cause of death, and thetotal direct and indirect costs associated with diabetes have been estimated at $174 billion. What’s worse is millions moreare predicted to develop the disease in the future. New data on diabetes and its complications continue to emerge, andproviders must stay informed of this growing body of evidence so that diagnoses and management of these patients canbe optimized.

In this Physician’s Weekly monograph, several key points surrounding the optimization of care for diabetes and disease-re-lated issues are discussed. Anthony J. Cannon, MD, and Carlos Campos, MD, MPH, provide compelling insights on theeffect of diabetes on African Americans and Hispanics, respectively. Aggressive application of nationally recommended pre-vention activities could prevent many coronary artery disease events and strokes, and Richard A. Kahn, PhD, discussesnew data on how clinicians are trying to find ways to reduce costs and improve delivery efficiency for prevention activi-ties to achieve their full potential. Lastly, Peter Sheehan, MD, addresses a new consensus statement on lipoprotein man-agement in patients with cardiometabolic risk and discusses the importance of treating lipoprotein abnormalities in an effortto improve outcomes.

We at Physician’s Weekly hope that this monograph will serve as a valuable tool to help you and your organization improveupon its current diabetes care practices. Thanks for reading!

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Table of Contents

Sincerely,

Keith D’OriaManaging Editor, Physicain’s Weekly

Letter from the Editor:

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5visit www.physweekly.com

ispanics represent the largest minority popu-lation in the United States and will comprisealmost 25% of the entire American popula-

tion by 2050. Diabetes has been reported to occur athigher rates in Hispanics when compared with non-Hispanic white patients of similar ages. “About 2.9million Hispanic adults have diabetes in the U.S.,”says Carlos Campos, MD, MPH, “and the number isexpected to increase as the Hispanic population ex-pands in America. Furthermore, Hispanic patientswith diabetes have higher mean A1C levels than

non-Hispanic white patients and are more likely toexperience diabetes-related complications (eg, severeretinopathy or lower extremity amputations). Theyalso have significantly higher rates of all-cause and cardiovascular mortality. Considering the facts, it’scritical that physicians make efforts to diagnose andtreat the disease in these patients as early as possible.”

Seek Out Diabetes at Patient VisitsIt is estimated that about 25% of Hispanics will havediabetes by age 45, and Dr. Campos says that pri-

H

Physicians managing Hispanic patients with diabetes need to be aggressivewhen monitoring and treating the disease. Special considerations arerequired to address adherence issues and cultural norms.

Improving the Care & Management of Hispanics With Diabetes

Carlos Campos, MD, MPHAssociate Clinical Professor

Department of Family Medicine

University of Texas Health Sciences Center, San Antonio

Executive Director

Institute for Public Health & Education Research, Inc.

Member, National Advocacy Committee

Former Member, Sub-Committee onLatino Initiatives

American Diabetes Association


6

mary care physicians (PCPs) need to aggressively diagnose the disease in this population. “PCPs canhelp reduce the disease burden significantly by check-ing higher-risk Hispanics, even if they present withsimple aches or pains. We need to fish for diabetes in Hispanics, especially if they have one or morecharacteristics that fit the bill, such as being older,sedentary, overweight, or having elevated blood pres-sure or lipid levels.”

Hispanic patients will often involve their familieswhen they are receiving care for diabetes, and Dr.Campos recommends that PCPs take advantage ofthis unique opportunity. “The families are there tohelp patients reach their goals for controlling diabetes,” he says. “But we should also inform thefamilies that they are at risk for the disease as welland let them know the importance of checking theirglucose levels over time. We may be able to catch twopatients with diabetes for the price of one.”

Consider Cultural BarriersOnce diabetes is diagnosed in Hispanics, Dr. Cam-pos says PCPs need to consider the effect of certaincultural issues in this population (Table 1). “One ofthe most important cultural factors among Hispanicpopulations is the importance of family,” he says.“Hispanics place a high value on their families, so it’simportant for PCPs to emphasize that patient effortsto improve health will increase the likelihood thatthey’ll see their children graduate from school, getmarried, and/or have children of their own. We needto make this connection with patients so that they’lldo what they need to do to control their diabetes.”

Another key cultural issue in Hispanic populationsis the initiation of insulin therapy (Table 2). “Insulinis often viewed as punishment among Hispanics,” explains Dr. Campos. “We need to change this misconception and stress that insulin is a natural hormone in the body. The need for insulin therapy

5

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Table 1 5 Cultural Values Affecting RelationshipsValue

Simpatia: Kindness, politeness, pleasant-ness, avoidance of hostile confrontation

Personalismo: Formal friendliness, warm,personal relationship, characterized by interactions that occur at close distances(eg, handshakes, placing a hand on theshoulder)

Respeto: Respect, including targetedcommunication based on age, gender, social position, and economic status

Familismo: Collective loyalty to extendedfamily that supersedes the needs of theindividual

Fatalismo: Fatalism, belief that individuals can do little to alter fate

Ways to Demonstrate Respect for the Value

• Emphasize courtesy, a positive attitude, and social amenities

• When interacting with patients, decrease physical distance and increase appropriate physical contact

• Provide a business card or beepernumber

• Use Spanish terms of respect (eg,usted, the polite form of “you,” instead of the informal tu)

• Use appropriate titles and greetings

• Encourage patients to bring familymembers to visits

• Provide sufficient time and opportu-nity for the extended family to dis-cuss important medical decisions

• Emphasize efficacy of medicationsfor diabetes, including insulin

• Show interest in the patient’s life at each visit (eg, starting the visit with a brief conver-sation about the patient’s family, work, or school)

• Whenever possible, involve pa-tients in medical decisions, suchas decisions to start insulin

• Ask about the patient’s concerns,particularly regarding insulin

• Educate the patient’s familyabout diabetes

• Encourage the family to supportthe patient’s treatment efforts

• Refer to the patient’s beliefs and values

Source: Adapted from: Campos C. South Med J. 2007;100:812-820.



shouldn’t represent a failure on the patient’s part; infact, the proper use of insulin should be seen as a suc-cess. We should inform them that diabetes is a pro-gressive disease and that they’re likely to requireinsulin in the future. Put this information out thereearly and tell patients why it’s needed. Express tothem that your primary goal is to partner with themso that they can achieve the quality of life they wantand so they can enjoy their family as they get older.”

Conquer Fatalistic Views & Be RespectfulHispanic patients with diabetes may avoid effectivetreatment plans because they have a fatalistic viewof life; they may feel that they cannot control their illness. Dr. Campos says that emphasizing the efficacy of diabetes medications, including insulin,and considering patient beliefs and values are in-strumental to overcoming these views. “To conquera fatalistic view, it’s helpful to establish trust andshow them that you care for their well-being. Once

that trust is established, patients are more likely to adhere to treatments.”

In addition, Dr. Campos says that PCPs should be respectful during patient encounters. “For example,shaking hands too firmly with Hispanic patients andlooking them directly in the eyes may be perceived bysome patients that you are trying to overcome them.Simply putting your hand out and letting them dictate how the handshake should go and loweringyour eyes, especially with older patients, shows morerespect. Once that respect is gained, your chance ofimproving adherence to treatments is increased.”

Carlos Campos, MD, MPH, has indicated to Physi cian’s Weeklythat he has worked as a consultant for, as a paid speaker for, and has received grants/research aid from Novartis, Novo Nordisk,AstraZeneca, Merck, Sanofi-Aventis, Amylin, and Eli Lilly.

Table 2 Overcoming Barriers to Insulin Therapy in HispanicsBarrier

Practical barriers (eg, financial constraints,limited or no insurance, transportation issues)

Language barriers

Poor health literacy

Cultural values

Lack of adequate knowledge about diabetes

Resignation

Misconceptions about insulin, especially beliefs that insulin therapy indicates the disease has progressed or that insulin may cause complications (eg, blindness)

Strategies to Overcome the Barrier

• Ask patients about these potential barriers

• Involve staff who speak Spanish

• Evaluate patients to determine their level of health literacy

• Use non-clinical language

• Practice culturally competent care by being aware of and respectingcultural values

• Educate and enable patientsusing culturally sensitive andlanguage-appropriate materials

• Educate patients about diabetesand self-management in a culturally sensitive manner

• Focus on achieving glycemic goals

• Educate patients about the natural history of diabetes and the role of insulin therapy

Source: Adapted from: Campos C. South Med J. 2007;100:812-820.

• Direct patients to available resources

• Use translation services as needed

• Use pictorial and audiovisualeducational materials

• Create and maintain a shame-free environment

• Direct patients to available diabetes educational programs

• Begin insulin therapy with asimple titration regimen usingonce-daily basal insulin

• Add insulin to the treatmentregimen earlier in the course of therapy


8



Managing Lipoproteinsin Patients With

Cardiometabolic RiskA consensus statement on lipo protein management in patients with cardio -metabolic risk sheds light on the importance of treating lipoproteinabnormalities in an effort to improve outcomes in these individuals.

ccording to published research, risk factors for diabetes and cardiovascular disease (CVD)often cluster, including obesity, insulin resist-

ance, high glucose levels, abnormal concentrations oflipoproteins in the blood, and high blood pressure.Each of these factors increases the risk of CVD, andthe clustering of these conditions is referred to as car-diometabolic risk (CMR). “Historically, physicians

have paid most of their attention to hyperglycemia asthe primary cause for complications in diabetes, butclinicians are increasingly focusing on diabetes as acardiovascular disease,” explains Peter Sheehan, MD.“In fact, we’ve learned that cardiovascular risk is con-ferred even before the onset of hyperglycemia in pre-diabetes. One of the features of pre-diabetes anddiabetes is the presence of CMR characteristics.”

A

Peter Sheehan, MDSenior Faculty

Mount Sinai School of Medicine

Chair, Cardiometabolic Risk Initiative



10

In the April 2008 issue of Diabetes Care and April 15,2008 Journal of the American College of Cardiology, theAmerican Diabetes Association (ADA) and AmericanCollege of Cardiology (ACC) co-published a consen-sus statement on lipoprotein management in patientswith CMR. The statement indicates that lipoproteinabnormalities—including elevated triglyceride levels,low HDL-cholesterol levels, and increased numbersof small dense LDL particles—are commonly presentin patients with CMR. Specific lipid treatment goalshave been established for patients with type 2 diabetesor CVD, but guidelines for treatment of lipoproteinabnormalities in high-risk patients without diabetesor CVD have been less intense and may have under-estimated lifetime CVD risk.

Considering Residual CVD RiskClinical trials have demonstrated that directing therapies—most notably statins—at lowering LDL

cholesterol can reduce the risk of CVD events in pa-tients with diabetes and those without it but withother CVD risk factors. However, Dr. Sheehan saysthat even with adequate LDL cholesterol lowering,many patients on statins have significant residualCVD risks. “The goal of the ADA/ACC consensusstatement was to identify lipoprotein parameters otherthan LDL or non-HDL cholesterol that can provideadditional prognostic information, yield more infor-mation about the effectiveness of therapy for lipopro-tein abnormalities, and indicate more appropriatetreatment targets. Many patients with CMR or dia-betes have normal levels of LDL cholesterol, but alsohave increased numbers of small dense LDL particlesand other atherogenic lipoproteins.”

The ADA/ACC consensus statement identifies sev-eral lipoproteins and lipoprotein components that ap-pear to be most clinically relevant to CMR. Elevated

Table 1 Treatment Goals in Patients With CMR & Lipoprotein Abnormalities

Highest-risk patients, including those with:

1) Known CVD

2) Diabetes plus one or more additional majorCVD risk factor

High-risk patients, including those with:

1) No diabetes or known clinical CVD but two ormore additional major CVD risk factors

2) Diabetes but no other major CVD risk factors

Goals

LDL cholesterol Non-HDL cholesterol ApoB

<70 mg/dL <100 mg/dL <80 mg/dL

<100 mg/dL <130 mg/dL <90 mg/dL

Note: Other major risk factors (beyond dyslipoproteinemia) include smoking, hypertension, and family history of premature CAD.

Abbreviations: CMR, cardiometabolic risk; CVD, cardiovascular disease.

Source: Adapted from: Brunzell JD, et al. Diabetes Care. 2008;31:811-822.

Patients with CVD and those with diabetes and one or more other cardiovascular risk factors are

at the highest risk of experiencing a cardiac event.—Peter Sheehan, MD



LDL cholesterol and LDL particle numbers have beenwell established as major predictors of CVD, includ-ing patients with CMR or diabetes, but Dr. Sheehansays other lipoproteins are also important. “Most doc-tors understand that LDL cholesterol is an importantmeasure for cardiovascular risk, but measuring, as-sessing, and monitoring non-HDL cholesterol [totalcholesterol minus HDL cholesterol] and apolipopro-tein B [apoB], which measures the total burden ofparticles that are considered most atherogenic, are alsohelpful to gaining a better understanding of CMR.”

Treatment Goals & RecommendationsSeveral treatment goals have been recommended inthe ADA/ACC consensus statement based on theevaluation of available evidence (Table 1). “Patientswith CVD and those with diabetes and one or moreother CVD risk factors are at the highest risk of ex-

periencing a cardiac event,” Dr. Sheehan says. “Thesepatients should be treated to specific LDL, non-HDL,and apoB goals in order to optimize outcomes. Pa-tients with neither diabetes nor known clinical CVDbut two or more additional major CVD risk factorsand those with diabetes but no other major CVD riskfactors are considered high-risk patients and haveslightly different lipoprotein targets. Physicians shouldkeep these targets in mind and strive to reach thesegoals to reduce CMR.”

The ADA/ACC consensus statement indicates thatstatins should be used for most patients with CMRwho have an abnormal distribution of lipoproteins intheir blood (Table 2), but Dr. Sheehan notes that it isimportant for clinicians to assess lipoprotein param-eters besides LDL. “Statins have been shown to lowerCVD event rates by 25% to 50% depending on theendpoint, but there’s still a high absolute risk to con-sider. We can’t just focus on LDL because non-HDLand apoB levels are also significant in patients withCMR. Measuring these lipoproteins is not morecostly and can help clinicians ascertain a more accu-rate measure of risk.”

Dr. Sheehan emphasizes that 57 million Americansare considered to have pre-diabetes. “Because type 2diabetes is a largely preventable disease, the potentialimpact of interventions is significant. Efforts that ad-dress lipoprotein abnormalities can have a profoundimpact on CMR. To be successful, we need to findpatients with CMR early and initiate therapy quicklyand aggressively. The hope is that the ADA/ACC con-sensus statement, in addition to efforts like the ADA’sCardiometabolic Risk Initiative, will further encour-age physicians to focus on the prevention, recogni-tion, and treatment of all risk factors for type 2diabetes and CVD.”

Peter Sheehan, MD, has indicated to Physician’s Weekly that he has received research grants from Tissue Repair Company, PamLab,Genzyme, and Sanofi-Aventis. He is also a director at GreystonePharmaceuticals and is on the Scientific Advisory Board of AdvancedBioHealing. He has served as a consultant for Hypermed andCalretex, and on the speaker’s bureau for EV3, Bristol-MyersSquibb/Sanofi, Merck, and Organogenesis.

Table 2 Therapy Recommendations & Other ConsiderationsFor abnormal concentrations of lipoproteins or abnormallipoproteins in the blood, the following is recommended:

• Statin therapy should be used for the majority ofadult patients with CMR who have an abnormaldistribution of lipoproteins in the blood.

• For patients with CMR on statin therapy, guiding therapy with measurements of apoB and treatment to apoB goals is recommended, in addition to LDL cholesterol and non-HDL cholesterol assessments.

• Treatment goals should address the high lifetime risk of patients with an abnormal distribution oflipoproteins in the blood and CMR.

Other needs:

• Clinical trials should be performed to determinewhether the pharmacologic therapy required toachieve very low levels of atherogenic lipoproteins is safe and cost-effective.

• A concerted, multifaceted, public health effort, focused on lifestyle modification, should be per-formed to reduce mean population levels of athero-genic lipoproteins to values well below current ones.

Abbreviations: apoB, apolipoprotein B; CMR, cardiometabolic risk; CVD, cardiovascular disease.

Source: Adapted from: Brunzell JD, et al. Diabetes Care. 2008;31:811-822.


14


ancer, cardiovascular disease (CVD), and diabetes are responsible for most of the morbidity, mortality, and healthcare costs in

the United States. To help reduce the toll of thesediseases, the American Cancer Society (ACS), Amer-ican Diabetes Association (ADA), and American

Heart Association (AHA) have recommended a variety of prevention activities. Although supportedby good efficacy evidence, there are large gaps inhow well these efforts are applied, and research hasshown that many Americans are not receiving pre-vention activities from which they would benefit.


Prevention Strategies: A Focus on Cost-Effectiveness

C

Aggressive application of nationally recommended prevention activitiescould prevent many coronary artery disease events and strokes, butclinicians must find ways to reduce costs and improve delivery efficiency for these activities to achieve their full potential.

Richard A. Kahn, PhDChief Scientific and Medical Officer



16

Richard A. Kahn, PhD, says that it is important toknow the answers to several questions in order to promote greater attention to prevention and helpphysicians implement preventive activities. “Weneed to determine how many people today are candidates for at least one prevention activity andthe extent to which these conditions are potentiallypreventable,” he says. “For example, how muchcould the burden of these conditions be reduced ifprevention activities were applied with complete per-formance, compliance, and effectiveness? Addition-ally, we need to determine what can be realisticallyaccomplished if patients, physicians, and healthplans throughout the U.S. pursued prevention withgreater vigilance. It’s equally important to determinehow various prevention activities compare, which arethe most important, and the cost of implementingthese activities. Ideally, we want to find the best wayto make prevention more attractive in the context ofquality of life and financial considerations.”

A Cost-Feasibility AnalysisInvestigators from the ACS, ADA, and AHA havecollaborated to determine the effects of 11 nationallyrecommended prevention activities on CVD-relatedmorbidity, mortality, and costs, and published find-ings in the July 29, 2008 issue of Circulation.

Using data from the National Health and NutritionExamination Survey, the investigators determined thenumber and characteristics of adults in the U.S. whoare currently candidates for these CVD preventionstrategies. Using the Archimedes mathematical model,a simulated population was created to match the real

U.S. population. Archimedes then simulated aseries of clinical trials that examined the

effects of applying each prevention activity—either indi vidually or altogether—over the next 30 yearsin appropriate candidates. Health

outcomes, quality of life, and medical costs for eachprevention activity were assessed.

The study showed that the aggressive application ofCVD prevention activities could prevent a highproportion of coronary artery disease (CAD) eventsand strokes that would otherwise be expected tooccur in the U.S. (Table 1). If more feasible levels ofperformance in delivering these prevention activi-ties were assumed, the number of myocardial in-farctions and strokes in patients could still besignificantly reduced. “Nearly 80% of Americanadults meet the indications for at least one of the11 prevention activities we studied,” says Dr. Kahn.“If every person received the prevention activitiesfor which they are a candidate, heart attacks couldbe reduced by more than 60%, strokes could be re-duced by 30%, and life expectancy could increaseby an average of 1.3 years and at a higher quality oflife than currently experienced.”

Table 1 The Impact of PreventionActivitiesAccording to a study published in the July 29, 2008issue of Circulation, approximately 78% of adults between the ages of 20 and 80 in the United States are candidates for at least one cardiovascular diseaseprevention activity.

• If everyone received the activities for which they are eligible, myocardial infarctions would be reduced by 63%.

- If more feasible levels of performance are assumed, myocardial infarctions would be reduced 36%.

• If everyone received the activities for which they are eligible, strokes would be reduced by 31%.

- If more feasible levels of performance are as-sumed, strokes would be reduced 20%.

• Implementation of all prevention activities wouldadd about 221 million life-years and 244 millionquality-adjusted life-years to the U.S. adult popula-tion over the coming 30 years, or an average of 1.3years of life expectancy for all adults.

Source: Adapted from: Kahn R, Robertson RM, Smith R, Eddy D. The Impact of Prevention on Reducing the Burden of

Cardiovascular Disease. Circulation. 2008;118:576-585.



Identify Cost-Effective Interventions of BenefitAs they are currently delivered, many of the 11 interventions assessed in the study would substan-tially increase costs, and the activities varied in theireffectiveness. Dr. Kahn noted that one cost-savingactivity was observed and five other relatively cost-effective measures could produce significantbenefits (Table 2). “Our investigation found thatsmoking cessation proved to be cost-saving over 30

years,” he says. “A few other preventive services werecost-effective and could save a substantial number oflives. These include providing aspirin to high-riskindividuals, controlling pre-diabetes, having obesepeople lose weight, lowering blood pressure in people with diabetes, and lowering LDL cholesterolin people with existing CAD. Physicians need tofocus on these key factors to improve outcomes andquality of life in a cost-effective manner.”

The Benefits Are Too ImportantFor preventive strategies to achieve their full poten-tial, Dr. Kahn says efforts are needed to find ways toreduce costs and deliver interventions more effi-ciently. “This will require a deeper analysis on theway the current healthcare system is structured,” hesays. “We need more cost-effective ways to deliverpreventive care to avoid poor outcomes in cancer,CVD, and diabetes” he says. “We can provide theseimportant interventions if we eliminate waste in

other areas of medicine. There are many treatmentsthat are not nearly as cost-effective as the higher-yielding services we studied. The bottom line is thatthe impact of these diseases is substantial and theproblems are too big to be ignored.”

Richard A. Kahn, PhD, has indicated to Physician’s Weekly thathe has or has had no financial interests to report.

Table 2 Prevention Activities of Greatest BenefitAs currently delivered and at current prices, most cardiovascular disease prevention activities are expensive when consider-ing the direct medical costs. However, a study published in the July 29, 2008 issue of Circulation indicates that several specific prevention activities appear to be of greatest benefits to the U.S. population:

CAD: LDL cholesterol <100 mg/dL

Diabetes: Blood pressure <130/80 mmHg

BMI <30 kg/m2

Pre-diabetes: Fasting plasma glucose <110 mg/dL

Aspirin to high-risk individuals

Smoking: Stop

Abbreviations: MI, myocardial infarction; NNT, number needed to treat; QALY, quality-adjusted life-years; CAD, coronary artery disease.

Source: Adapted from: Kahn R, Robertson RM, Smith R, Eddy D. The Impact of Prevention on Reducing the Burden of Cardiovascular Disease. Circulation. 2008;118:576-585.

MI total, (NNT)

-39.23% (3)

-19.32% (5)

-11.94% (8)

-9.88% (10)

-18.5% (5)

-7.82% (13)

Stroke total, (NNT)

-3.07% (33)

-13.45% (7)

-1.81% (55)

-0.86% (116)

1.81% (-55)

-3.28% (31)

Cost/QALY

$39,130

$25,317

$18,941

$17,478

$2,779

-$1,755

Life-years gained

2.45

1.78

0.92

0.68

0.95

0.66

Physicians need to … improve outcomes and quality of life in a cost-effective manner.

—Richard Kahn, PhD


18


ublished data have shown that African Ameri-cans are disproportionately affected by diabetes

and its related complications. According to theAmerican Diabetes Association (ADA), the number ofracial and ethnic minority patients in the United Stateswho will be diagnosed with diabetes will increase sig-nificantly in the coming years. By 2020, it is projectedthat the number of African Americans developing


An In-Depth Focus on Diabetes in

African AmericansAfrican Americans are at greater riskof diabetes and its complications.Physicians need to make greaterefforts to appropriately diagnose thedisease and tailor therapies.

P

Anthony J. Cannon, MDChief, Endocrinology

Robert Wood Johnson University Hospital

Endocrinologist

Robert Wood Johnson Endocrine & Diabetes Associates

Member, African American InitiativesCommittee



20

diabetes will increase by 50%. When compared withnon-Hispanic white patients, studies have shown thatthe prevalence and severity of diabetic complications issignificantly higher in African Americans (Table 1).

“Diabetes has a major adverse impact on mortality,morbidity, and quality of life in all populations, butthe impact of the disease burden is even greateramong African Americans,” says Anthony J. Cannon,

MD. “Recent data from the CDC show that 14.7%of African Americans aged 20 and older have type 2

diabetes. It’s suspected that only one-third of thesepatients know they have it. African Americans aremore likely to have poorer control of their bloodsugar, blood pressure, and cholesterol levels.”

Spotting the BarriersThe management of diabetes in the U.S. largelytakes place in primary care. Dr. Cannon says “thereis a shortage of endocrinologists and other diabetes

specialists in the U.S. today and it continues toworsen. Considering this shortage, many primarycare physicians (PCPs) will be managing people withtype 2 diabetes instead of endocrinologists. How-ever, PCPs have an average of just 7 to 8 minutes tospend with patients. This can delay or postpone eval-uations of abnormal blood sugars, blood pressure,and cholesterol levels.”

Several factors have been identified as drivers of theobserved differences in diabetes control in AfricanAmericans, including biological, socioeconomic, andquality-of-care factors. “Lack of access to healthcareand lower rates of health insurance and prescriptiondrug coverage can lead to delayed diagnoses,” explainsDr. Cannon. “It can also increase the number of yearsof exposure to untreated diabetes. A confoundingvariable is a lack of exposure to diabetes education.”

Tailoring Treatment ConsiderationsIn the African-American community, initiation of insulin therapy can be particularly challenging,says Dr. Cannon. “Insulin is often considered theend of life for African Americans because they mayhave seen or heard about relatives or friends who experienced poor outcomes after starting it. PCPsand providers need to be aware of this viewpoint and

Table 1 African Americans & Diabetes: Facts & NotesWhen compared with the general population, AfricanAmericans are disproportionately affected by diabetes:

• 3.7 million (14.7%) of all African Americans age20 and older have diabetes.

• African Americans are 1.6 times more likely to have diabetes as non-Hispanic whites.

• 25% of African Americans between the ages of 65 and 74 have diabetes.

• One in four African American women over 55 years of age has diabetes.

• Death rates for people with diabetes are 27%higher for African Americans compared with non-Hispanic whites.

• African Americans are almost 50% as likely to de-velop diabetic retinopathy as non-Hispanic whites.

• African Americans are 2.6 to 5.6 times as likely to suffer from kidney disease each year.

• African Americans are 2.7 times as likely to suffer from lower-limb amputations.

Source: Adapted from: CDC and American Diabetes Association. Available at: www.diabetes.org/communityprograms-

and-localevents/africanamericans.jsp.

Tell patients that they’re likely to require insulin, and make efforts to minimize their concerns.

—Anthony J. Cannon, MD



adjust treatment strategies accordingly. It’s impor-tant to initiate insulin therapy early to maximizeoutcomes. Currently, the average person who isplaced on insulin has waited more than 3 years with elevated blood sugars.”

Dr. Cannon also says that it is important to be up-front and honest with patients when considering insulin therapy. “Tell patients that they’re likely to require insulin, and make efforts to minimize theirconcerns. For example, take a few extra minutes toinform them about newer insulin delivery devices ifthese options are appropriate alternatives.” Addi-tionally, he recommends that providers teach African-American patients about their diabetes, bloodpressure, and cholesterol medications, and why theyare required. “The association between diabetes and cardiovascular risk is obvious to PCPs, but not necessarily for patients. Taking the time to explainwhat specific medications do, how they work, andthe benefits associated with them may empower patients to better adhere to treatments.”

Continuing Follow-UpThe ADA recommends several important monitor-ing parameters to control diabetes-related complica-

tions throughout follow-up (Table 2). Dr. Cannonsays “regardless of race, creed, or color, all patientsshould be treated to national diabetes goals. It’s critical to get blood glucose levels as close to normalas possible, blood pressure levels to 120/80 mm Hg,LDL cholesterol levels to less than 100 mg/dL, andHDL cholesterol levels as high as possible. This requires close monitoring and continued follow-upwith patients. In addition, using all available resources—including dieticians, certified diabeteseducators, and other providers—is paramount to reducing the burden of diabetes in African Ameri-cans. PCPs should look beyond their immediate staffto optimize outcomes and take advantage of edu cational opportunities for patients.”

Anthony J. Cannon, MD, has indicated to Physician’s Weekly thathe has worked as a paid speaker for the following corporations:GlaxoSmithKline, Novo Nordisk, Eli Lilly, Amylin Pharma ceuticals,Merck, Schering Plough, Sanofi-Aventis, and Bristol-Myers Squibb.

*These levels should be monitored every 2 years if they fall into lower-risk categories.

Source: Adapted from: American Diabetes Association.

Table 2 Monitoring Parameters for Control of Complications

Everyvisit

3 to 6months

Annual

• Blood pressure

• Foot exam (only 55% achieve this goal)

• A1C (average blood sugar over 3 months)

- Every 3 months if the patient’s treatment changes or the patient is not meeting goals.

- Every 6 months if the patient is stable.

• Dilated eye examination (only 63% achieve this goal)

• Lipid levels*

• Microalbumin


diabetes roundtable: 2008

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