Non-Insulin-Dependent Diabetes Mellitus in Minorities in the United States

  1. Janette S. Carter, MD;
  2. Jacqueline A. Pugh, MD; and
  3. Ana Monterrosa, MD
  1. From the University of New Mexico School of Medicine and the Albuquerque Veterans Affairs Medical Center, Albuquerque, New Mexico, and the University of Texas Health Science Center at San Antonio, Audie L. Murphy Memorial Veterans Hospital, the Mexican American Medical Treatment Effectiveness Center, and the Texas Diabetes Institute, San Antonio, Texas. Grant Support: In part by grant DK38392 from the National Institute of Diabetes and Digestive and Kidney Diseases (Dr. Pugh) and grant U01HS07397 from the Agency for Health Care Policy and Research (Drs. Pugh and Monterrosa). Requests for Reprints: Jacqueline A. Pugh, MD, Audie L. Murphy Memorial Veterans Hospital, University of Texas Health Science Center at San Antonio, Ambulatory Care 11C6, 7400 Merton Minter Boulevard, San Antonio, TX 78284. Current Author Addresses: Dr. Carter: Primary Care, 11PC, Veterans Affairs Medical Center, 2100 Ridgecrest, SE, Albuquerque, NM 87108.
     
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    Abstract

    Purpose: To review the available information on prevalence, complications, and mortality of non–insulin-dependent diabetes mellitus and primary and secondary prevention activities in black persons, Hispanic persons, Native Americans, and Asians and Pacific Islanders in the United States.

    Data Source: MEDLINE search from 1976 to 1994 through the PlusNet search system.

    Study Selection: Use of the key words non–insulin-dependent diabetes mellitus, the names of each specific minority group, socioeconomic status, acculturation, genetics, diet, complications, mortality, treatment, and intervention (lifestyle or medication) produced 290 unduplicated articles. Additional articles cited in the original articles were also included.

    Data Extraction: Risk factors, incidence, prevalence, complications, and mortality of non–insulin-dependent diabetes mellitus.

    Data Synthesis: All minorities, except natives of Alaska, have a prevalence of non–insulin-dependent diabetes mellitus that is two to six times greater than that of white persons. Most studies show an increased prevalence of nephropathy that can be as much as six times higher than that of white persons. Retinopathy has variably higher rates in black persons, Hispanic persons, and Native Americans. Amputations are done more frequently among black persons than among white persons (9.0 per 1000 compared with 6.3 per 1000), and Pima Indians have 3.7 times more amputations than do white persons. Diabetes-related mortality is higher for minorities than for white persons, and the rate is increasing. The relative importance of genetic heritage, diet, exercise, socioeconomic status, culture, language, and access to health care in the prevalence, incidence, and mortality of diabetes is not clear. Studies of interventions in minority populations are in progress.

    Conclusion: Diabetes should be treated as a public health problem for minority populations.

    For some time, diabetes specialists have recognized that non–insulin-dependent diabetes mellitus is more prevalent in minority populations [1-12]. Recent information also shows increased complications and mortality from diabetes. We review the available literature on prevalence, incidence, complications, mortality, and interventions in black persons, Hispanic persons, Native Americans, and Asians and Pacific Islanders in the United States.

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    Methods

    In June 1994, we searched the MEDLINE data-base through the PlusNet search system from 1976 to the date of the search. Using the key words “non–insulin-dependent diabetes,” “African Americans,” “blacks,” “Hispanic,” “Mexican Americans,” “Native Americans,” “Asians,” “Pacific Islanders,” “minorities,” “socioeconomic status,” “acculturation,” “genetics,” “diet,” “complications,” “mortality,” “treatment,” and “intervention (lifestyle or medication),” we found 268 unduplicated articles. In February 1996, we repeated the search and added the key words “Asian” and “Pacific Islander”; 22 more articles were identified. Ethnic-specific data were also included from Diabetes in America [13]. Several searches were done using “non–insulin-dependent diabetes mellitus,” a key word for one of the minority groups, and one each of the other key words—for example, “non–insulin-dependent diabetes mellitus and African Americans and socioeconomic status.” Articles cited in the original articles or encountered during the writing of this manuscript were also included. Only articles that discussed incidence, prevalence, complications, mortality, risk factors, or interventions were included. Papers on the basic physiology of obesity or diabetes or articles that did not include minority-specific data were not included.

    Data on diabetes-related complications and mortality, lifestyles, socioeconomic status, acculturation, and access to health care are scarce for some minority groups—particularly Asians and Pacific Islanders, Arab-Americans, and other ethnic subgroups (such as Puerto Ricans, Cubans, and specific Native American tribes). Further, few prospective studies have assessed the incidence of non–insulin-dependent diabetes mellitus and associated risk factors. Finally, few studies have provided data on white persons for comparison.

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    Prevalence and Incidence of Diabetes

    Most minority groups in the United States have higher rates of non–insulin-dependent diabetes mellitus than do white persons [2-47] (Table 1). The 1976-1980 National Health and Nutrition Examination Survey (NHANES II) [12] found the total prevalence of diabetes in black persons (diagnosed and undiagnosed) to be 1.5 times greater than that of white persons. Other estimated prevalences for black persons range from 1.4 to 2.2 times greater than the prevalences for white persons [13, 14]. The 1976 National Health Interview Survey [15] and a recent study of U.S. Army veterans [16] confirm this increased risk for black persons even after controlling for an increased prevalence of obesity.

    View this table:
    Table 1. Prevalence of Diabetes in the United States

    All Hispanic groups studied to date have a greater prevalence of diabetes than do white persons [17-23]. Data from the 1982-1984 Hispanic Health and Nutrition Examination Survey (HHANES) [17] show that, among Hispanic persons living in the United States, the prevalence of non–insulin-dependent diabetes mellitus is greatest for Puerto Ricans and Hispanic persons living in the southwest and is lowest for Cubans (Table 1). Epidemiologic studies in Texas (Laredo [18], Starr County [19], and San Antonio [20]) and in Colorado [21] and New Mexico [22], show a prevalence of diabetes in Hispanic persons that is two to five times higher than that in non-Hispanic persons (Table 1). The excess of diabetes in the Mexican-American population persists even when the greater overall and centralized obesity rates of the Mexican-American population when compared with those of white persons are considered [23].

    Native Americans comprise more than 500 tribal organizations; in the 1990 census, about 1.9 million persons identified themselves as an American Indian or Alaska native [24]. High prevalences of diabetes among most Native American tribes have been reported [25-37]. The Pima tribe in Arizona has one of the highest rates in the world [25]. Variation of rates among tribes may be due to ascertainment methods (many rates are derived from clinical settings) or to true variation caused by genetic differences [8, 24-37]. Indian Health Service data indicate that the overall prevalence is 2.8 times the overall U.S. rate [8]. Only Alaska natives (Eskimo and Indian) have been shown to have prevalences less than or slightly greater than the overall rates of diabetes in the United States, but evidence suggests that the prevalence may be increasing in these groups [35, 37].

    Asian Americans and Pacific Islander Americans are a diverse group with more than 20 population groups [38]. The Seattle Japanese-American Community Diabetes Study [9, 10] found the prevalence of diabetes to be higher than that reported for the U.S. white population [12]. Filipinos had the highest prevalence of diabetes among the four largest ethnic Asian groups in Hawaii (Chinese, Filipino, Japanese, and Korean); all groups had higher prevalences than those of white persons [11]. In one pilot study of Arab Americans [39], the rates were also high.

    Although the prevalence of non–insulin-dependent diabetes mellitus is consistently higher in minorities, it is possible that prolonged duration—and not an increased incidence—of non–insulin-dependent diabetes mellitus could be the explanation. Few incidence studies have been done, but thus far, incidence rates in the United States have been found to be higher in black persons [40], Mexican Americans [41, 42], the Pima tribe [43, 44] and Japanese Americans [45] than in white persons.

    Impaired glucose tolerance and gestational diabetes are recognized risk categories for progression to diabetes. Black persons, Hispanic persons, Native Americans, and Asian Americans have been shown to have higher rates of impaired glucose tolerance than white persons [2, 5-610, 46, 48]. Black persons, Hispanic persons, and Native Americans also have higher rates of gestational diabetes [49-53]. However, rates of gestational diabetes in Asians are similar to those of white persons in the United States [54].

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    Prevalence and Incidence of Complications and Mortality

    Table 2 lists the rates of complications between the primary minority subgroups and white persons.

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    Table 2. Diabetes Complication Rates in Minorities and White Persons*

    Nephropathy

    Diabetic end-stage renal disease rates have been shown to be higher in all U.S. minority groups than in white persons [55-63]. The rate in black persons is 3.2 to 6.6 times higher than that in white persons; this value is reduced to 2.6 after adjustment for the underlying increased prevalence of diabetes [55]. After adjustment for systolic blood pressure, income, age, and other potential risk factors, black persons still had a 63% higher risk for developing end-stage renal disease [59]. Mexican Americans had a rate ratio for end-stage renal disease of 2.9 to 7 compared with white persons [60]. However, after adjustment for prevalence of diabetes, Mexican Americans no longer had an excess risk [64]. According to Medicare and United States Renal Data System data [61, 62], the age-adjusted incidence of diabetic end-stage renal disease is 6.3 times higher for Native Americans than for white persons in the United States; data from specific Native American tribes confirm this finding [65-69]. End-stage renal disease is the leading cause of death among diabetic Pima Indians, with incidence rates similar to those reported among persons with insulin-dependent diabetes mellitus [70]. Asians and Pacific Islanders had the lowest incidence of end-stage renal disease among minority groups, but this rate were still higher than those of white persons [62].

    The mixture of insulin-dependent diabetes mellitus and non–insulin-dependent diabetes mellitus end-stage renal disease substantially differs between minorities and white persons. In a cohort study of diabetic end-stage renal disease in Texas [64], 93% of Mexican Americans with diabetic end-stage renal disease had non–insulin-dependent diabetes mellitus compared with 84% of black persons and 60% of white persons. Similarly, Cowie and colleagues [55] reported that 73% of cases of diabetic end-stage renal disease among black persons and 42% of cases among white persons were secondary to non–insulin-dependent diabetes mellitus.

    Survival among minority persons with diabetic end-stage renal disease who are treated with hemodialysis is better than for white persons [62, 71-73]. The reason of this survival advantage is unclear. Minorities receive transplants less often, leaving minority patients who are eligible for transplantation on dialysis [62, 74]. In addition, black persons have lower rates of voluntary withdrawal from dialysis than white persons [75]. It is not known whether this phenomenon occurs in other minorities.

    With regard to incipient nephropathy, Hispanic persons, black persons, and Native Americans have been found to have higher rates of proteinuria than do white persons [76-82]. Although fewer data are available for microalbuminuria, the available data also generally show higher rates for Pima Indians, Hispanic persons, and black persons [76-7880, 83-85].

    Retinopathy

    Although minorities tend to have higher reported rates of retinopathy, this finding is not as consistent as that for end-stage renal disease. Age-standardized rates of blindness secondary to diabetes for nonwhite persons is double that for white persons [86]. Black adults with diagnosed diabetes have a higher prevalence of retinopathy [87, 88]. Two studies of retinopathy in Hispanic persons have conflicting results: One shows higher rates, and the other shows lower rates [77, 89]. Pima Indians and Native Americans in Oklahoma have also been shown to have excess retinopathy [90-92]. No data are available on Asians or Pacific Islanders.

    Neuropathy, Peripheral Vascular Disease, and Amputations

    Few reports have been published about the prevalence of neuropathy among minorities with diabetes. Increased rates of amputations (see below) suggest a higher incidence of neuropathy, but available data from the San Luis Valley Study [77] and the National Health Interview Survey [93] showed no differences in neuropathy for either Hispanic persons or black persons. Published prevalence rates for three Native American tribes showed rates similar to those for other populations [94, 95]. No data are available for Asians or Pacific Islanders.

    Rates of peripheral vascular disease are higher among black persons than among white persons, but data specifically comparing black and white diabetic persons are not available [96]. Mexican Americans with diabetes have rates of peripheral vascular disease similar to those of white persons (15.8% and 10.0%, respectively [97]). Hopi and Navajo patients with diabetes have a high prevalence (28%) of peripheral vascular disease [94].

    Black persons with diabetes have amputations more frequently than do white persons and Hispanic persons [14, 98-100], and the in-hospital mortality related to amputations is twice as high for black persons than for white persons [101]. Hispanic persons in California have similar rates of nontraumatic amputations related to diabetes as do white persons after controlling for the higher prevalence of diabetes [100]; their in-hospital mortality rates, however, are lower [101]. Pima Indians have a rate of amputation 3.7 times greater than overall rates previously compiled for six states [102]. Indian Health Service data show that amputation rates vary among their service delivery areas, but researchers could not determine the cause of variability with the information available [103, 104]. No data are available for Asians or Pacific Islanders.

    Coronary Artery Disease

    Diabetes is a strong risk factor for coronary artery disease, and the few data available suggest that minorities have a risk similar to that of the white population rather than an increased risk. Black persons have a higher rate of coronary disease than does the general population, but few data are available for the diabetic population [96]. Mexican Americans with diabetes do not have an excess of myocardial infarctions but show a risk elevation similar to that of white persons with diabetes [97]. Pima Indians have been found to have low rates of coronary disease [105]. Other Native American tribes do not appear to be as well protected [106]. The Strong Heart Study [47] recently reported that prevalence of coronary heart disease was lowest among the communities in Arizona; prevalence in Oklahoma, South Dakota, and North Dakota was twofold to threefold higher than that in Arizona. Diabetes was the strongest risk factor. The lower prevalence of coronary heart disease among Native Americans in Arizona may be related to this group's low prevalence of smoking and low concentrations of total and low-density lipoprotein cholesterol [47]. Impaired glucose tolerance and non–insulin-dependent diabetes mellitus were found to be risk factors for coronary artery disease among Japanese Americans in Seattle [48].

    Functional Status

    Given the higher rates of most complications for minorities, it is likely that their functional status is poor compared with that of white persons. Unfortunately, almost no data on functional status exist, except for those on Mexican Americans. The two studies available [107, 108] show that Mexican Americans experience functional status limitations because of diabetes and that they are slightly more likely to describe themselves as functionally impaired than are white persons. More data are needed for other minorities.

    Mortality

    Diabetes-specific mortality rates for black persons, Hispanic persons, and Native Americans are higher than those for white persons [106, 109-120]. In New Mexico, diabetes-related mortality rates were highest for Native Americans, intermediate for Hispanic persons, and lowest for white persons [114]. In this same study, the rates for Native Americans and Hispanic persons increased dramatically during a 30-year period [114]. In studies of Pima Indians, renal disease accounted for nearly all of the excess mortality associated with diabetes [118]. However, cardiovascular mortality was decreased in this population [120]. Recently, the Centers for Disease Control and Prevention [119] reported that among minorities and white persons, Asians and Pacific Islanders had the lowest rate of death from non–insulin-dependent diabetes mellitus. Because most of these minority groups have diabetes prevalence rates higher than those of the general population, it is difficult to conclude whether the higher mortality rate is secondary only to the higher prevalence rates of non–insulin-dependent diabetes mellitus or to other factors. Unfortunately, most studies have not controlled for prevalence of diabetes. The manner in which differences among ethnic or racial groups in smoking, hypertension, cardiovascular disorders, or renal disease rates would affect mortality rates in persons with diabetes is still unknown at this time.

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    Causes of Increased Prevalence of Non-Insulin-Dependent Diabetes in Minorities

    Given the diverse genetic makeup of the minority groups reported here, some common environmental or combined environmental-genetic explanation is likely. Studies comparing migrant populations with native nonmigrant populations have established a consistent theme of elevated prevalence of non–insulin-dependent diabetes mellitus with “westernization.” The common elements of “westernization” include a diet higher in total calories and fat but lower in fiber and less need to expend energy because of labor-saving devices. In addition, some of the minorities mentioned may also have a genotype selected for survival in less plentiful environments, that is, the “thrifty genotype” [121]. Figure 1 shows that all minorities in the United States for which data exist have a higher prevalence of diabetes than do residents of their countries of origin [2, 9-11, 122-132]. Data from other parts of the world also show increased prevalence in urban compared with rural areas and in minority persons who have moved to other “western” nations [128, 133-137]. Further, as Native Americans have changed their diet and exercise patterns over time, diabetes prevalence has also increased [138].

    Figure 1. Rate in country of origin compared with rate in the United States. Compiled from references 2, 11, and 121 to 130.
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    Figure 1. Rate in country of origin compared with rate in the United States. Compiled from references 2, 11, and 121 to 130. Prevalence of diabetes mellitus in minority populations.

    Diet

    Various components of diet have been linked to the prevalence and incidence of non–insulin-dependent diabetes mellitus, but the exact dietary composition that causes the greatest risk is not absolutely clear [139, 140]. Total calories and the percentage of fat calories appear to be the two most consistent risk factors [131, 140-142]. Black persons consume diets higher in fat and sodium and lower in fiber than those consumed by white persons [143], but the link between these dietary differences and the increased prevalence of diabetes in black persons has yet to be established. Mexican Americans have a slightly more atherogenic diet than do white persons [144]. Pima Indians have been found to have diet composition similar to that of the U.S. population in general; however, the Pima diet has changed markedly in the past century [145]. Migration studies of Asian Americans suggest that the diet in the United States is higher in fat and calories and lower in fiber than the diet in the Asian country of origin [146]. The “thrifty genotype” may put these groups at risk for obesity and diabetes even when the diet is the same as that of white persons [147].

    Exercise

    All but one of the few available studies show lower levels of physical activity in minority populations than in the white U.S. population. This is associated with a higher prevalence and incidence of non–insulin-dependent diabetes mellitus that are independent of body fat distribution [12, 40, 48, 138, 148]. In a recent prospective study [148], amount of exercise was inversely predictive of incidence of non–insulin-dependent diabetes mellitus among Mexican-American men but not among Mexican-American women. A similar association with incidence was found among black men and women [40]. Another study [12] found no such association. One study [138] found that obesity and perhaps diabetes were less prevalent among Pima Indians living in Mexico who practiced a traditional lifestyle (greater energy expenditure in physical labor and consumption of less animal fat and more complex carbohydrates) than among Pima Indians living in Arizona. In Japanese Americans, an association between decreasing levels of physical activity and increasing incidence of diabetes has also been found [48]. White men are less likely to have a sedentary lifestyle (56%) than are black persons (63%) or Hispanic persons (62%) but have a lifestyle similar to that of Native Americans (51%) and Asians and Pacific Islanders (57%) [119]. White women are less sedentary than all four minority groups (56% compared with 68%, 62%, 64%, and 65%, respectively) [119].

    Obesity

    Obesity, which is often associated with diabetes, is prevalent in all minority groups discussed. In multiple studies, however, obesity alone does not explain the excess prevalence and incidence of diabetes [15, 16, 148-151]. Not all types of obesity carry the same risk for diabetes; centralized obesity carries a higher risk [152, 153]. Mexican Americans [152], black persons [40], and Native Americans [154, 155] all have higher rates of centralized obesity than do white persons. The duration of obesity increases the incidence of non–insulin-dependent diabetes mellitus in Pima Indians and therefore may be important in prevention efforts [156]. A study [130] comparing Japanese persons living in Hiroshima with Japanese who had emigrated to Hawaii found that the Hawaiian Japanese had a higher frequency of obesity and approximately twice the prevalence of non–insulin-dependent diabetes mellitus.

    Genetics

    The evolution of a “thrifty genotype” is postulated to have resulted in selective survival advantage in times of fluctuating feast and famine by allowing highly efficient storage of calories in times of plenty [121]. However, this thrifty genotype has become detrimental when food supplies are constant and abundant and is postulated to have led to an increased prevalence of obesity and non–insulin-dependent diabetes mellitus in certain populations [157-160]. Many groups with high rates of non–insulin-dependent diabetes mellitus, including Mexican Americans and Pima Indians, have also been shown to have high rates of hyperinsulinemia and insulin resistance among the nondiabetic members of the minority group [23, 161]. Insulin resistance and a low metabolic rate have been identified as prediabetic phenotypes [162]. Further, there is familial aggregation of diabetes [163] and insulin-mediated glucose disposal rates among Pima Indians [161] and Mexican Americans [164]. The increasing evidence on familial aggregation suggests that specific genotypes will be identified in the future [165, 166]. Candidate genes include an autosomal dominant gene associated with 2-hour postchallenge insulin levels [167], a diabetogenic locus near or within D7S527 and DTS527 on chromosome 7q [168], the fatty acid-binding protein (FABP2), glucokinase, the insulin receptor, and the β3-adrenergic receptor [169].

    One confounding factor in studying familial aggregation of diabetes is that the in utero environment itself may be a risk factor independent of genetics. Offspring of Pima Indian mothers who had diabetes during pregnancy have a higher prevalence of obesity [170] and diabetes [171] than do offspring of mothers who did not have diabetes or had impaired glucose tolerance during pregnancy. Because both diabetes and gestational diabetes are more prevalent in minorities, the risk for in utero exposure is also higher.

    Socioeconomic Factors

    Information on the influence of socioeconomic status on diabetes is sparse. In the United States, intragroup comparisons among white persons, black persons, Hispanic persons, and Japanese Americans show an association between lower socioeconomic status or education level and higher prevalence of diabetes [172-177]. Given that large proportions of black and Hispanic populations live in poverty and have less than a high school education, socioeconomic status may strongly influence the prevalence of diabetes in these minority groups [178].

    Paradoxically, increasing levels of acculturation to “mainstream” U.S. society, independent of socioeconomic status, correlate with reduced prevalence of diabetes among Mexican Americans [179]. One explanation of this apparent paradox is a “descending limb” of the curve of modernization [180]. As persons become progressively more affluent, they try to live healthier lifestyles by avoiding the more unhealthy factors associated with the “ascending limb” of modernization—such as increased consumption of total calories, dietary fat, and refined sugars; decreased consumption of dietary fiber and total and complex carbohydrates; and decreased physical activity—that lead to diabetes [180, 181].

    Another interesting socioeconomic link is that persons with low birthweight are more prone to develop diabetes later in life [182, 183]. Minority women (black women, American Indian women, Asian women and Pacific Islander women, and Hispanic women) are less likely to obtain prenatal care [184]. Black persons, Puerto Ricans, Japanese Americans, Hawaiians, and Filipinos are more likely to have infants with low birthweights [185].

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    Risk Factors for Complications

    Few studies have directly compared risk factors for complications among minority groups. Mexican Americans and black persons have been found to have worse glycemic control, even after adjustment for treatment status [186, 187]. Hypertension, which has been linked to increased microvascular complications, is high among black persons with diabetes [188] but not among Mexican Americans [189]. Although familial aggregation of microvascular complications has been described among Pima Indians [190], no data are available for other minorities.

    Access to health care might also be expected to influence the occurrence of complications, but few data are available to confirm this. In the general population, diabetic patients without health insurance are more likely to report high blood glucose levels and less likely to perform diabetes self care or receive screening for complications [191]. However, compared with white persons who have diabetes, only Mexican Americans have a lower rate of health insurance, whereas black persons and persons of other minority groups have similar rates [191, 192]. Lack of outpatient health insurance (but not lack of hospitalization insurance or socioeconomic status) was associated with a higher rate of microvascular complications in Mexican Americans [193, 194]. Further, the lack of differences in health insurance coverage is reflected in a National Health Interview Survey [195] that found little difference in the number of visits to physicians and compliance with screening for complications between white and black persons. However, certain clinical settings in which minorities receive care may not adequately comply with recommended standards [196].

    For minorities whose primary language is not English, language discordance between physician and patient can lead to decreased patient information recall, decreased patient question-asking behavior, and decreased compliance and can result in poor outcomes [197, 198]. In a group of Hispanic patients with diabetes, recall of information was higher in patients seen by bilingual physicians than in patients seen by physicians who spoke only English. The greatest differences were found in categories of laboratory information, treatment, and social and personal aspects [197].

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    Interventions

    Despite the high prevalence of non–insulin-dependent diabetes mellitus and the increased rate of complications and mortality from this disease, few intervention data are available for minorities. Only two primary prevention trials have been reported. One [199] focused on cardiovascular disease prevention in Navajo children, and the second [200] focused on a childhood obesity prevention pilot project with Mexican-American children in San Antonio, Texas. Other projects with minority children are in the design and implementation stages [201, 202], and the National Institutes of Health has funded primary intervention childhood projects to prevent non–insulin-dependent diabetes mellitus in high-risk children. The Diabetes Prevention Trial, which targets high-risk adults (many of whom are from minority communities) with impaired glucose tolerance or gestational diabetes, has also been initiated by the National Institutes of Health. Other studies are being conducted for black persons through churches in Baltimore [202] and for Hispanic adults through community college English classes in San Diego [202].

    Secondary prevention studies have been done in minority populations. Three examples are the Zuni Diabetes Project [203], which entails a community and individual exercise intervention; a behavior-oriented program for obese black women with non–insulin-dependent diabetes mellitus in Chicago [204]; and a videotape pilot project in the Mexican-American population [205]. The American Diabetes Association is sponsoring programs for black persons through churches and a program that targets the Hispanic population. All projects have emphasized culture-specific approaches. The National Institutes of Health has funded secondary intervention projects targeting non–insulin-dependent diabetes mellitus and minority populations, and the Texas Diabetes Council is funding a Hispanic diabetes awareness and screening project.

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    Discussion

    Although it has been shown that diabetes prevalence, complications, and mortality are higher in minority populations than in the white population, the relative contributions of genetics, environmental changes in diet and exercise, and socioeconomic factors are not well defined. Further research is needed. However, because each factor potentially contributes a portion of the increased morbidity and mortality from non–insulin-dependent diabetes mellitus, intervention should proceed. The planned studies mentioned here will teach us important lessons in the future, but some recommendations can now be made for primary and secondary prevention activities for high-risk individuals and communities.

    1. Screen High-Risk Persons

    About 50% of patients with diabetes identified in community surveys do not know that they have diabetes [206]. They often already have complications at the time of diagnosis; the estimated duration of non–insulin-dependent diabetes mellitus from onset to diagnosis is 7 years [206]. Screening in the general population is still not recommended, but attempts have been made to identify high-risk characteristics that should prompt screening. The Centers for Disease Control and Prevention [207] and the American Diabetes Association [208] have slightly different recommendations about who is at high risk and in need of screening. Researchers at the Centers for Disease Control and Prevention have developed a screening questionnaire that uses age, percentage of ideal body weight, sedentary lifestyle, first-degree relative with diabetes, and history of delivery of a baby weighing more than 4 kg as determinants of high risk. The questionnaire has a sensitivity of 73% and is meant to be followed by blood screening [207]. The American Diabetes Association recommends blood screening for persons with any single high-risk characteristic—including the ones listed above (except sedentary lifestyle)—as well as for persons older than 45 years of age; members of racial or ethnic groups with high prevalences of diabetes (Native American, Hispanic, or black persons); persons with previously identified impaired glucose tolerance, hypertension, or significant hyperlipidemia (total cholesterol level more than equals 6.21 mmol/L or triglyceride level more than equals 2.82 mmol/L); and persons with a history of gestational diabetes [208]. It currently seems prudent to screen the members of minority populations discussed here, especially if they are overweight or have other risk factors.

    2. Develop Education Programs

    Previous reviews of available diabetes education materials suggest that most literature is at a high reading level or is not culturally sensitive [209]. Low literacy rates complicate diabetes care and education for many persons, including minorities [210]; however, methods are available to present information in an interesting and appealing manner using skills-based workshops with practice, implementation, and positive reinforcement [211, 212]. Traditional foods and medicines may decrease blood sugar levels [213-215] and can be used to enhance acceptance of diabetes care [216-218]. Cookbooks have been developed for some ethnic populations by the American Diabetes Association and the National Institutes of Health, but these must be distributed more widely. In addition, cookbooks and cooking classes should be developed at the local level for specific populations, using traditional flavors and forms but with reduced calorie and fat content.

    Cultural attitudes toward obesity may also need to be addressed. Obesity is considered normal in many minority communities; in fact, it is often seen as not only acceptable but, in some instances, preferable [219, 220]. Use of culturally and socioeconomically appropriate diet and exercise interventions may enhance compliance [221, 222].

    3. Train More Minority Physicians, Educators, and Translators

    Statistics show that most health care providers often do not share the same racial and ethnic background as persons who most often have diabetes [223]. When health care professionals of the same ethnic or racial background are not available, bilingual professionals or translation services should be used [197]. Health care professionals would also benefit from cultural sensitivity and competency training [224].

    4. Develop Low-Cost Models of Diabetic Care

    Among minority populations, diabetes needs to be treated as an important public health problem. Public health approaches can feature standardized secondary prevention strategies of clinic-based education and complication screening, including use of chart audits to determine clinic or professional compliance with locally set guidelines [225]. The use of low-cost medications and reuse of insulin syringes [226, 227] are other ways to decrease costs and increase their purchase and use by patients.

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    Summary

    Minority populations in the United States have higher prevalences of non–insulin-dependent diabetes mellitus and its complications, and more persons in these minority populations die of the disease than do persons in the general population. The reasons for the increased morbidity and mortality include prevalence of the disease, genetics, environmental change in diet and exercise, and socioeconomic factors. Few interventions have been completed, but primary and secondary prevention strategies are currently being studied. In the meantime, diabetes should be treated as a public health problem for minority populations. Time and resources should be expended to control this disease and its associated high morbidity and mortality.

    Drs. Pugh and Monterrosa: Audie L. Murphy Memorial Veterans Hospital, Ambulatory Care 11C6, 7400 Merton Minter Boulevard, San Antonio, TX 78284.

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