Clinical Therapeutics features a special report in its April issue focusing primarily on the behavioral issues associated with patients' self-management of type 2 diabetes. "Diabetes, perhaps more so than any other chronic disease, requires people to significantly modify their behaviors - sometimes in ways that are contrary to their cultural norms and backgrounds - even when they don't 'feel' sick or experience symptoms of the disease," said John G. Ryan, Dr.PH., Topic Editor for Endocrinology and Diabetes, and guest editor for the April 2014 Diabetes Update, entitled Race, Risk and Behaviors. Publication of the Diabetes Update coincided with the recent approval from the US Food and Drug Administration of a new dapagliflozin from AstraZeneca and Bristol-Myers Squibb for the treatment of adults with type 2 diabetes.
Type 2 diabetes is a metabolic disorder affecting about 24 million people in the United States. An asymptomatic period that occurs between the onset of diabetic hyperglycemia, the elevated blood sugar levels that are a hallmark sign of type 2 diabetes, and clinical diagnosis is estimated to last from four to seven years, and many people are estimated to have had the condition for an average of ten years prior to diagnosis and treatment. During this time, irreversible damage can occur, often resulting in a high prevalence of retinopathy and an increased risk for cardiovascular disease. The delay in diagnosis also prevents pharmacological interventions from being initiated, and non-pharmacological activities from being started, such as engaging in diabetes education, discontinuing tobacco use, modifying dietary behaviors and increasing physical activity for improving cardiovascular health and stimulating weight loss. The risk of developing type 2 diabetes is associated with multiple factors, including race. African Americans have a 77% greater risk of being diagnosed with diabetes compared to Caucasians in the US. Furthermore, 18.7% of African Americans aged 20 and older have diagnosed or undiagnosed diabetes compared to 10.2% of Caucasians. The causes of this disparity are from multiple risk factors including genetics, diet and cultural norms associated with the condition.
The process of managing type 2 diabetes consists of pharmacological and behavioral interventions and includes both provider and patient responsibilities. Providers decide upon pharmacological approaches based on numerous factors, the foremost of which is the extent to which the patient's diabetes is controlled. "New pharmacologic options are welcomed by practicing clinicians like me who struggle to work with our patients who have diabetes - each of whom have unique circumstances that require customized approaches," says Dr. Vivian Fonseca, M.D., Chief, Section of Endocrinology, Tulane University Medical Center, New Orleans, Louisiana, and author of a paperdescribing new pharmacological advances in the management of type 2 diabetes. According to Dr. Fonseca, who studies the efficacy of new diabetes agents as the principal investigator of numerous clinical trials, "New medications offer more options for us and our patients. However, we need outcome trials to determine the long-term efficacy and safety of new therapies and their impact on diabetes complications. They also need to be studied in a variety of patients with diabetes, including people with high risk for poor diabetes outcomes and in ethnic minorities."
Patient responsibilities include taking medication as recommended, testing blood sugar levels daily using a glucometer, modifying diet and increasing physical activity, among many others. To benefit from the types of medications Dr. Fonseca describes, patients must fill their prescriptions and take their medications as recommended. In the paper "Having their say: Patients' Perspectives and the Clinical Management of Diabetes," Dr. Leonard Jack, Jr., Ph.D., M.Sc., Director of the Division of Community Health at the National Center for Chronic Disease and Health Promotion, and his co-authors Dr. Leandris C. Liburd, Ph.D., M.P.H., M.A. and Dr. Pattie Tucker, Dr.P.H., M.P.H. and R.N., propose that healthcare providers can offer more effective diabetes support to their patients by understanding the cultural perspectives that explain their health behavior, to promote adherence and improve health outcomes. The authors include in their paper a set of recommended resources to assist healthcare providers, and examples of culturally tailored, community-based public health initiatives that have been effective in improving diabetes outcomes among African-Americans, who represent a critical population for effective and culturally appropriate diabetes healthcare because they are disproportionately burdened by type 2 diabetes in the United States.
Glucometers are meant to help patients self-monitor their blood sugar and understand the impact of diet and exercise on blood sugar levels. Like taking medications, effective use of glucometers falls within the responsibility of the patient. Dr. Sonjia Kenya, Ed.D. and her colleagues at the University of Miami Miller School of Medicine examined the extent to which Hispanic patients with diabetes understood how to use their glucometers by querying community health workers. The community health workers in the study felt their Hispanic patients had only a limited understanding for how to use glucometers, prompting Dr. Kenya to state, "Glucometers, which add a costly expense to many patients, were not used effectively by the low-income Hispanics we were studying, suggesting that tools such as these are futile if users are not equipped with the knowledge to use them to their full capacity." Kenya suggests that an important mechanism for improving this disconnect is to make diabetes self-management education more widely available to this patient population.
Race, Risk and Behaviors also includes papers authored by Dr. Janice M.S. Lopez, Pharm.D and Dr. Marcus Hompesch, M.D. Dr. Janice M.S. Lopez, Pharm.D., a health economics and outcomes researcher at Janssen Scientific Affairs, suggests that individualized diabetes therapies "may need to start with consideration of factors that are associated with poor medication adherence, such as race, ethnicity and age." Dr. Lopez summarizes the results of an Internet survey designed to understand patients' perspectives of type 2 diabetes. "According to [type 2 diabetes] patients' responses to this nationwide survey, cultural adaptations need to be incorporated into diabetes management plans with respect to HbA1C awareness, hypoglycemia, weight, and medication adherence," says Dr. Lopez. A subgroup analysis of patients with diabetes by Dr. Marcus Hompesch, M.D., of the Profil Institute of Clinical Research in Chula Vista, CA, along with co-authors Linda Morrow, M.D., Elaine Watkins, D.O., M.S. and Henrik F. Thomsen, Ph.D., also from the Prolif Institute, and Carsten Roepstorff, Ph.D. and Hanne Haahr, Ph.D., from Novo Nordkisk, Soborg, Denmark suggests that pharmacokinetic and pharmacodynamic responses to insulin degludec (IDeg), an "ultra-long-acting" basal insulin, are similar among patients with diabetes regardless of race or ethnicity. Dr. Ryan, Associate Professor and Director, Division of Primary Care/Health Services Research and Development in the Department of Family Medicine and Community Health at the University of Miami Miller School of Medicine, and Clinical Therapeutics Topic Editor for Endocrinology, Diabetes and Other Endocrine Disorders, summarizes the issues in his editorial, Race, Risk and Behaviors.