AACE recently created a statement called “Policy for the Elimination of Healthcare Disparities in the USA.” This statement asserts:
AACE actively opposes the continued existence of endocrine healthcare disparities in the USA, and will devote its resources to diminish these disparities. AACE members, staff, partners and others with whom AACE interacts will continue to advocate for understanding, prevention and elimination of endocrine healthcare disparities.
(To read the full position statement, visit www.aace.com/publications/position-statements.)
But why does AACE have a statement on healthcare disparities? Why make this a focus for members of AACE? The answer is because AACE believes that to best treat people with endocrine diseases all medical professionals must be aware of the many differences that make one person different from the next. This includes:
- The different risks and impact certain diseases may have on them
- What the best choice of therapy is
- Access to care
- The ability to afford medical care.
So what does this really mean?
Let’s take a look at diabetes.
In the US, there is a higher incidence of type 2 diabetes [dye-uh-BEE-teez] (the most common form of diabetes) in Latino, Asian, and African American people compared with white people. The reasons for this are not known. Some people might be more likely to get diabetes, partly, because of how well the insulin made in their body works.
In 2009 more than 14% of American Indians and Alaska natives over 19 years old who received care from the Indian Health Service had diabetes. Rates varied a great deal depending on the region of the country that they came from. For example, about 5% of Alaska native adults had diabetes. Yet more than 33% of American Indian adults living in southern Arizona had diabetes. See below for the big difference in diabetes between ethnic groups and subgroups.
Risk of Developing Diabetes Compared to Non-Latino Whites
- Asian Americans: 18% higher
- Latinos: 66% higher
- African Americans: 77% higher
Risk of Developing Diabetes Among Latino Compared With Non-Latino Whites:
- Mexican Americans: 87% higher
- Puerto Ricans: 94% higher
- Cubans: Equal
- Central Americans: Equal
- South Americans: Equal
Clearly, there are different rates of diabetes in different populations.
What about prediabetes progressing to diabetes?
About 60 million Americans have prediabetes [PREEdye-uh-BEE-teez]. People with prediabetes have blood sugar levels that are higher than normal but not high enough to be diagnosed as diabetes. People with prediabetes are more likely to end up with diabetes than those with normal blood sugars. It is not known if ethnicity is a risk factor for going from prediabetes to diabetes. The Diabetes Prevention Program looked at whether people at very high risk of diabetes that
exercised and made changes to their diet and lost weight could avoid getting diabetes. People with a high fasting blood sugar level, whether of white, African American, Latino, American Indian or Asian ethnicity, all got diabetes at an equal rate. But this finding was very different from earlier studies done in San Antonio and Colorado. The earlier studies found that Latino people in a prediabetes state had a higher risk of developing diabetes than non-Latino whites. More studies are needed for us to know whether one group is more likely than another to develop diabetes.
We also do not know if diabetes drugs might lower the risk of developing diabetes. In the Diabetes Prevention Program taking metformin [met-FOR-min] (a common diabetes treatment) lowered the risk of developing diabetes. But there was no difference in risk reduction due to ethnicity. Yet other studies have shown very different results. In a study called the DREAM study (in which people took rosiglitazone [ROE-zi-GLI-ta-zone]), progression to diabetes in those with prediabetes went down by more than 40% in all ethnic groups. But the reduction was smaller in South Asians and greater in Latinos. Differences in age, sex, body mass index (a measure of weight, taking into account also height or a measurement of waist–hip ratio) did not explain the difference seen by ethnicity.
So prevention of diabetes in different ethnic populations remains confusing as to what might or might not work. More research is clearly needed!
What about diabetes complications?
African Americans and Latinos in the US have a higher risk of end-stage kidney disease and diabetes eye disease. Although eye exams find effects of diabetes on the eye, African Americans have fewer eye exams than others for diabetes eye disease. On the other hand, Asians with diabetes have a lower risk of heart attack and foot amputation compared with whites.
Should treatment of diabetes and/or diabetes complications be different in different ethnicities?
People with diabetes are at greater risk for heart disease and heart attacks than the general population. African Americans with diabetes are more likely than whites to have a bad lipid profile, which puts them at high risk for heart disease. African Americans generally need to focus on improving LDL and HDL levels, and whites generally need to pay more attention to triglycerides [try-GLIS-er-ides].
We just reviewed differences in only one disease. There are differences seen in race, sex, economic status, and country of origin that relate to many conditions, such as bone disease, obesity, high blood pressure, and other conditions that have not even been studied as much as diabetes. Education and research needs to be supported so that we can prevent or at least better manage these conditions among different groups. To do this we need to address the issues of access to care as well as its cost, which contributes to healthcare disparities in the US.
Dr. Trence is Director of the Diabetes Care Center and Associate Professor of Medicine at the University of Washington Medical Center in Seattle. She is also the University of Washington Endocrine Fellowship Program Director and Director of Endocrine Days, a medical education program for endocrinologists practicing in the Pacific Northwest. She is on the Board of Trustees for the American College of Endocrinology, chairs the AACE CME committee and is co-editor of EmPower Magazine.