Glucose control in diabetes: the impact of racial differences on monitoring and outcomes

Racial and Economic Disparities in Diabetes in a Large Primary Care Patient Population

OBJECTIVE

We sought to determine if, after adjusting for economic status, race is an independent risk factor for glycemic control among diabetic patients in a large primary care patient population.

DESIGN SETTING PARTICIPANTS

We performed a retrospective chart review of 264,000 primary care patients at our large, urban academic medical center to identify patients with a diagnosis of diabetes (n=25,123). Zip code was used to derive median income levels using US Census Bureau demographic information. Self-reported race was extracted from registration data.

MAIN OUTCOME MEASURES

The prevalence of diabetes, average glycated hemoglobin (A1c), and prevalence of uncontrolled diabetes of White and Black patients at all income levels were determined.

RESULTS

White patients had a lower average A1c level and a lower prevalence of diabetes than Black patients in all income quartiles (P<.001). Among White patients, the prevalence of diabetes (P<.001), uncontrolled diabetes (P<.001), and A1c level (P=.014) were inversely proportional to income level. No significant difference in the prevalence of diabetes (P=.214), A1c level (P=.282), or uncontrolled diabetes related to income was seen in Black patients (P=.094).

CONCLUSIONS

Race had an independent association with diabetes prevalence and glycemic control. Our study does not support two prominent theories that economic and insurance status are the main factors in diabetes disparities, as we attempted to control for economic status and nearly every patient had insurance. It will be important for future analysis to explore how health care system factors affect these observed gaps in quality.

HbA1c After a Short Period of Monotherapy With Metformin Identifies Durable Glycemic Control Among Adolescents With Type 2 Diabetes

OBJECTIVE

To determine whether clinically accessible parameters early in the course of youth-onset type 2 diabetes predict likelihood of durable control on oral therapy.

RESEARCH DESIGN AND METHODS

TODAY was a randomized clinical trial of adolescents with type 2 diabetes. Two groups, including participants from all three treatments, were defined for analysis: (1) those who remained in glycemic control for at least 48 months of follow-up and (2) those who lost glycemic control before 48 months. Outcome group was analyzed in univariate and multivariate models as a function of baseline characteristics (age, sex, race/ethnicity, socioeconomic status, BMI, waist circumference, Tanner stage, disease duration, depressive symptoms) and biochemical measures (HbA1c, C-peptide, lean and fat body mass, insulin inverse, insulinogenic index). Receiver operating characteristic curves were used to analyze HbA1c cut points.

RESULTS

In multivariate models including factors significant in univariate analysis, only HbA1c and insulinogenic index at randomization remained significant (P < 0.0001 and P = 0.0002, respectively). An HbA1c cutoff of 6.3% (45 mmol/mol) (positive likelihood ratio [PLR] 3.7) was identified that optimally distinguished the groups; sex-specific cutoffs were 6.3% (45 mmol/mol) for females (PLR 4.4) and 5.6% (38 mmol/mol) for males (PLR 2.1).

CONCLUSIONS

Identifying youth with type 2 diabetes at risk for rapid loss of glycemic control would allow more targeted therapy. HbA1c is a clinically accessible measure to identify high risk for loss of glycemic control on oral therapy. Adolescents with type 2 diabetes unable to attain a non-diabetes range HbA1c on metformin are at increased risk for rapid loss of glycemic control.

Chronic stress, inflammation, and glucose regulation in U.S. Hispanics from the HCHS/SOL Sociocultural Ancillary Study

Diabetes prevalence is rising rapidly, and diabetes disproportionately affects Hispanics and other underserved groups. Chronic stress may contribute to diabetes risk, but few studies have examined this relationship in U.S. Hispanics. We examined associations of chronic stress with fasting glucose, glucose tolerance, and glycosylated hemoglobin (HbA1c) in Hispanics without diabetes, and also assessed indirect effects of stress through inflammation (CRP). Participants were 3,923 men and women, aged 18-74, without diabetes, from the four U.S. field centers (Bronx, NY; Chicago, IL; Miami, FL; San Diego, CA) of the Hispanic Community Health Study/Study of Latinos (HCHS/SOL) Sociocultural Ancillary study. Participants completed a measure of chronic life stress and a physical exam with oral glucose tolerance test. In a multivariate regression analysis with adjustment for demographic and health covariates, higher chronic stress was related to higher fasting glucose (standardized regression coefficient: β = .09, p < .01), postload glucose (β = .07, p < .05), and HbA1c levels (β = .08, p < .01). However, there was no indirect effect of stress through inflammation. Findings suggest that higher chronic stress is associated with poorer glucose regulation in Hispanics, prior to the onset of a clinical diabetes diagnosis.

Efficacy and safety of the dipeptidyl peptidase-4 inhibitor linagliptin in black/African American patients with type 2 diabetes: Pooled analysis from eight Phase III trials

BACKGROUND

The prevalence of type 2 diabetes in black/African Americans from North and South America is high; yet data evaluating antidiabetic agents in this population is scarce. To address this gap, we pooled data from the clinical development program for linagliptin.

METHODS

A retrospective pooled analysis of eight completed randomized, placebo-controlled Phase III trials of linagliptin identified 336 patients with type 2 diabetes who self-identified their ethnicity as black or African American. Participants received linagliptin (n = 173, 5 mg/day) or placebo (n = 163) as monotherapy, or as add-on to other antidiabetic agents, including insulin. The primary end point was the change in glycated hemoglobin (HbA1c) from baseline to week 18 or 24.

RESULTS

The placebo-adjusted mean change (95% confidence interval [CI]) in HbA1c from baseline was -0.69% (-0.92 to -0.46; p < 0.0001) at week 18 (eight trials), and -0.64% (-0.90 to -0.39; p < 0.0001) at week 24 (six trials). The placebo-adjusted mean change (95% CI) in fasting plasma glucose from baseline was -11.7 mg/dL (-23.1 to -0.3; p = 0.0446) at week 18 and -14.7 mg/dL (-25.7 to -3.8; p = 0.0087) at week 24. Incidence of investigator-defined hypoglycemia was similar between the two groups (linagliptin, 12.1%; placebo, 11.7%). Overall, the safety profile of linagliptin in this patient group was comparable to that of placebo, with comparable incidence of adverse events; linagliptin was weight-neutral in this patient population.

CONCLUSION

Linagliptin provided clinically significant improvements in glycemic control without increased risk of hypoglycemia and without weight gain, representing a useful type 2 diabetes therapy option for the black/African American population.

Effect of perceived racial discrimination on self-care behaviors, glycemic control, and quality of life in adults with type 2 diabetes

OBJECTIVE

This study used a large sample size of black and white patients with type 2 diabetes to investigate the influence of perceived racial discrimination on biologic measures (glycemic control, blood pressure, and LDL cholesterol), the mental component of quality of life (MCS), and health behaviors known to improve diabetes outcomes.

METHODS

602 patients were recruited from two adult primary care clinics in the southeastern United States. Linear regression models were used to assess the associations between perceived racial discrimination, self-care, clinical outcomes, MCS, adjusting for relevant covariates. Race-stratified models were conducted to examine differential associations by race.

RESULTS

The mean age was 61 years, with 64.9 % non-Hispanic black, and 41.6 % earning less than $20,000 annually. Perceived discrimination was significantly negatively associated with MCS (β = -0.56, 95 % CI -0.90, 0.23), general diet (β = -0.37, CI -0.65, -0.08), and specific diet (β = -0.25, CI -0.47, -0.03). In African Americans, perceived discrimination was significantly associated with higher systolic blood pressure (β = 10.17, CI 1.13, -19.22). In Whites, perceived discrimination was significantly associated with lower MCS (β = -0.51, CI -0.89, -0.14), general diet (β = -0.40, CI -0.69, -0.99), specific diet (β = -0.25, CI -0.47, -0.03), and blood glucose testing (β = -0.43, CI -0.80, -0.06).

CONCLUSIONS

While no association was found with biologic measures, perceived discrimination was associated with health behaviors and the MCS. In addition, results showed a difference in influence of perceived discrimination by race.

Diabetes: Christian worldview, medical distrust and self-management

To inform the development of a combined diabetes prevention and self-management intervention in partnership with church communities, this study sampled African American church leaders and members (N = 44) to qualitatively study religious beliefs and practices, diabetes prevention and self-management behaviors, and related community actions. Prior to commencing the study, internal review board approval was obtained. Although not required, community consent was officially provided by the church pastors. Individual consent was subsequently obtained from eligible community members who expressed an interest in participating in the study. Following a participatory action research approach, the inquiry group method was used. Qualitative data were analyzed with content analysis. Findings revealed Christian worldview, medical distrust and self-management as prominent themes. Findings suggest that diabetes providers address religious orientation in the provision of care with attention to rebuilding trust with the African-American community to improve health outcomes.

Racial ethnic differences in type 2 diabetes treatment patterns and glycaemic control in the Boston Area Community Health Survey

OBJECTIVES

Numerous studies continue to report poorer glycaemic control, and a higher incidence of diabetes-related complications among African-Americans and Hispanic-Americans as compared with non-Hispanic Caucasians with type 2 diabetes. We examined racial/ethnic differences in receipt of hypoglycaemic medications and glycaemic control in a highly insured Massachusetts community sample of individuals with type 2 diabetes.

SETTING

Community-based sample from Boston, Massachusetts, USA.

PARTICIPANTS

682 patients with physician-diagnosed diabetes from the third wave of the Boston Area Community Health Survey (2010-2012). The study included approximately equal proportions of African-Americans, Hispanics and Caucasians.

METHODS

We examined racial/ethnic disparities in diabetes treatment by comparing proportions of individuals on mutually exclusive diabetes treatment regimens across racial/ethnic subgroups. Using multivariable linear and logistic regression, we also examined associations between race/ethnicity and glycaemic control in the overall population, and within treatment regimens, adjusting for age, gender, income, education, health insurance, health literacy, disease duration, diet and physical activity.

RESULTS

Among those treated (82%), the most commonly prescribed antidiabetic regimens were biguanides only (31%), insulin only (23%), and biguanides and insulin (16%). No overall racial/ethnic differences in treatment or glycaemic control (per cent difference for African-Americans: 6.18, 95% CI -1.00 to 13.88; for Hispanic-Americans: 1.01, 95% CI -10.42 to 12.75) were observed. Within regimens, we did not observe poorer glycaemic control for African-Americans prescribed biguanides only, insulin only or biguanides combined with insulin/sulfonylureas. However, African-Americans prescribed miscellaneous regimens had higher risk of poorer glycaemic control (per cent difference=23.37, 95% CI 7.25 to 43.33). There were no associations between glycaemic levels and Hispanic ethnicity overall, or within treatment regimens.

CONCLUSIONS

Findings suggest a lack of racial/ethnic disparities in diabetes treatment patterns and glycaemic control in this highly insured Massachusetts study population. Future studies are needed to understand impacts of increasing insurance coverage on racial/ethnic disparities in treatment patterns and related outcomes.

Patient characteristics associated with measurement of routine diabetes care: an observational study

BACKGROUND

Non-modifiable patient characteristics, including age, gender, ethnicity as well as the occurrence of multi-morbidities, are associated with processes and outcomes of diabetes care. Information on these factors can be used in case mix adjustment of performance measures. However, the practical relevance of such adjustment is not clear. The aim of this study was to assess the strength of associations between patient factors and diabetes care processes and outcomes.

METHODS

We performed an observational study based on routinely collected data of 12,498 diabetes patients in 59 Dutch primary care practices. Data were collected on patient age, gender, whether the patient lived in a deprived area, body mass index and the co-occurrence of cardiovascular disease, chronic obstructive pulmonary disease, depression or anxiety. Outcomes included 6 dichotomous measures (3 process and 3 outcome related) regarding glycosylated hemoglobin, systolic blood pressure and low density lipoprotein-cholesterol. We performed separate hierarchical logistic mixed model regression models for each of the outcome measures.

RESULTS

Each of the process measure models showed moderate effect sizes, with pooled areas under the curve that varied between 0.66 and 0.76. The frequency of diabetes related consultations as a measure of patient compliance to treatment showed the strongest association with all process measures (odds ratios between 5.6 and 14.5). The effect sizes of the outcome measure models were considerably smaller than the process measure models, with pooled areas under the curve varying from 0.57 to 0.61.

CONCLUSIONS

Several non-modifiable patient factors could be associated with processes and outcomes of diabetes care. However, associations were small. These results suggest that case-mix correction or stratification in assessing diabetes care has limited practical relevance.

Community Interventions to Improve Glycemic Control in African Americans with Type 2 Diabetes: A Systemic Review

PURPOSE

The purpose of this study was to conduct a systematic review of published community interventions to evaluate different components of community interventions and their ability to positively impact glycemic control in African Americans with T2DM.

METHODS

Medline, PsychInfo, and CINAHL were searched for potentially eligible studies published from January 2000 through January 2012. The following inclusion criteria were established for publications: (1) describe a community intervention, not prevention; (2) specifically indicate, in data analysis and results, the impact of the community intervention on African American adults, 18 years and older; (3) measure glycemic control (HbA1C) as an outcome measure; and (4) involve patients in a community setting, which excludes hospitals and hospital clinics.

RESULTS

Thirteen studies out of 9,233 articles identified in the search met the predetermined inclusion criteria. There were 5 randomized control trials and 3 reported improved glycemic control in the intervention group compared to the control group at the completion of the study. Of the 8 studies that were not randomized control trials, 6 showed a statistically significant change in HbA1C.

CONCLUSION

In general, the community interventions assessed led to significant reductions in HbA1C in African Americans with type 2 diabetes. Community health workers did not have a greater impact on glycemic control in this sample. The findings of this study provides insight for designing community-based interventions in the future, such as including use of multiple delivery methods, consideration of mobile device software, nutritionist educator, and curriculum-based approaches.

Is the Chronic Care Model Integrated Into Research Examining Culturally Competent Interventions for Ethnically Diverse Adults With Type 2 Diabetes Mellitus? A Review

The chronic care model (CCM) concerns both the medical and the cultural and linguistic needs of patients through the inclusion of cultural competence in the delivery system design. This literature review attempted to@@ identify the domains of the CCM culturally competent (CC) interventions that the adults from ethnic minorities suffering from type 2 diabetes mellitus report. We identified the CCM and the CC components in the relevant studies published between 2005 and 2014. Thirty-two studies were included. Thirty-one articles focused on self-management and 20 on community resources. Twenty-three interventions integrated cultural norms from the patients’ backgrounds. CC interventions reported the CCM at the individual level but need to address the organizational level more effectively. The scope of CC interventions should be expanded to transform health care organizations and systems.

Associations of structural and functional social support with diabetes prevalence in U.S. Hispanics/Latinos: results from the HCHS/SOL Sociocultural Ancillary Study

Little research has examined associations of social support with diabetes (or other physical health outcomes) in Hispanics, who are at elevated risk. We examined associations between social support and diabetes prevalence in the Hispanic Community Health Study/Study of Latinos Sociocultural Ancillary Study. Participants were 5,181 adults, 18-74 years old, representing diverse Hispanic backgrounds, who underwent baseline exam with fasting blood draw, oral glucose tolerance test, medication review, sociodemographic assessment, and sociocultural exam with functional and structural social support measures. In adjusted analyses, one standard deviation higher structural and functional social support related to 16 and 15% lower odds, respectively, of having diabetes. Structural and functional support were related to both previously diagnosed diabetes (OR = .84 and .88, respectively) and newly recognized diabetes prevalence (OR = .84 and .83, respectively). Higher functional and structural social support are associated with lower diabetes prevalence in Hispanics/Latinos.

Assessing Diabetes Care Disparities with Ambulatory Care Quality Measures

OBJECTIVE

To identify and describe racial/ethnic disparities in overall diabetes management.

DATA SOURCE/STUDY SETTING

Electronic health record data from calendar year 2010 were obtained from all primary care clinics at one large health system in Minnesota (n = 22,633).

STUDY DESIGN

We used multivariate logistic regression to estimate the odds of achieving the following diabetes management goals: A1C <8 percent, LDL cholesterol <100 mg/dl, blood pressure <140/90 mmHg, tobacco-free, and daily aspirin.

PRINCIPAL FINDINGS

Blacks and American Indians have higher odds of not achieving all goals compared to whites. Disparities in specific goals were also found.

CONCLUSIONS

Although this health system has above-average diabetes care quality, significant disparities by race/ethnicity were identified. This underscores the importance of stratifying quality measures to improve care and outcomes for all.

Ethnic differences in psychological outcomes among people with diabetes: USA results from the second Diabetes Attitudes, Wishes, and Needs (DAWN2) study

OBJECTIVE

To assess differences in psychological outcomes as well as risk and protective factors for these outcomes among several USA ethnic groups and identify correlates of these psychological outcomes among adults with diabetes in the second Diabetes Attitudes, Wishes and Needs (DAWN2 * ) study.

RESEARCH DESIGN AND METHODS

The core USA DAWN2 sample was supplemented by independent samples of specific ethnic minority groups, yielding a total of 447 White non-Hispanics, 241 African Americans, 194 Hispanics, and 173 Chinese Americans (n = 1055). Multivariate analysis examined ethnic differences in psychological outcomes and risk/protective factors (disease, demographic and socioeconomic factors, health status and healthcare access/utilization, subjective burden of diabetes and social support/burden). Separate analyses were performed on each group to determine whether risk/protective factors differed across ethnic groups.

MAIN OUTCOME MEASURES

Psychological outcomes include well-being, quality of life, impact of diabetes on life domains, diabetes distress, and diabetes empowerment.

CLINICAL TRIAL REGISTRATION

NCT01507116.

RESULTS

Ethnic minorities tended to have better psychological outcomes than White non-Hispanics, although their diabetes distress was higher. Levels of most risk and protective factors differed significantly across ethnic groups; adjustment for these factors reduced ethnic group differences in psychological outcomes. Health status and modifiable diabetes-specific risk/protective factors (healthcare access/utilization, subjective diabetes burden, social support/burden) had strong associations with psychological outcomes, especially diabetes distress and empowerment. Numerous interactions between ethnicity and other correlates of psychological outcomes suggest that ethnic groups are differentially sensitive to various risk/protective factors. Potential limitations are the sample sizes and representativeness.

CONCLUSIONS

Ethnic groups differ in their psychological outcomes. The risk/protective factors for psychological outcomes differ across ethnic groups and different ethnic groups are more/less sensitive to their influence. These findings can aid the development of strategies to overcome the most prominent and influential psychosocial barriers to optimal diabetes care within each ethnic group.

Association between visual impairment and sleep duration: analysis of the 2009 National Health Interview Survey (NHIS)

Background

Visual impairment (VI) is associated with increased mortality and health factors such as depression and cardiovascular disease. Epidemiologic studies consistently show associations between sleep duration with adverse health outcomes, but these have not systematically considered the influence of VI. The aim of this study was to ascertain the independent association between VI and sleep duration using the National Health Interview Survey (NHIS) data. We also examined whether race/ethnicity influenced these associations independently of sociodemographic and medical characteristics.

Methods

Our analysis was based on the 2009 NHIS, providing valid sleep and vision data for 29,815 participants. The NHIS is a cross-sectional household interview survey utilizing a multistage area probability design. Trained personnel from the US census bureau gathered data during face-to-face interview and obtained socio-demographic, self-reported habitual sleep duration and physician-diagnosed chronic conditions.

Results

The mean age of the sample was 48 years and 56% were female. Short sleep and long sleep durations were reported by 49% and 23% of the participants, respectively. Visual impairment was observed in 10%. Multivariate-adjusted logistic regression models showed significant associations between VI and short sleep (OR = 1.6, 95% CI = 1.5-1.9 and long sleep durations (OR = 1.6, 95% CI = 1.3-1.9). These associations persisted in multivariate models stratified by race-ethnic groups.

Conclusion

Visual impairment was associated with both short and long sleep durations. Analysis of epidemiologic sleep data should consider visual impairment as an important factor likely to influence the amount of sleep experienced habitually.

Glycemic control among U.S. Hispanics/Latinos with diabetes from the HCHS/SOL Sociocultural Ancillary Study: do structural and functional social support play a role?

Social support is one potential source of health-related resiliency in Hispanics with diabetes. This study examined relationships of structural (i.e., social integration) and functional (i.e., perceived) social support with glycemic control (glycosylated hemoglobin; HbA1c) in the Hispanic Community Health Study/Study of Latinos Sociocultural Ancillary Study. This study included 766 men and women representing multiple Hispanic ethnic backgrounds, aged 18-74 years, with diagnosed diabetes who completed fasting blood draw, medication review, and measures of sociodemographic factors, medical history, structural support (Cohen Social Network Index), and functional support (Interpersonal Support Evaluation List-12). After adjusting for sociodemographic covariates and medication, a one standard deviation increase in functional support was related to an 0.18% higher HbA1c (p = 0.04). A similar trend was observed for structural support; however, this effect was non-significant in adjusted models. Greater functional support was associated with poorer glycemic control in Hispanics.

Race/ethnicity, educational attainment, and pregnancy complications in New York City women with pre-existing diabetes

BACKGROUND

More women are entering pregnancy with pre-existing diabetes. Disease severity, glycaemic control, and predictors of pregnancy complications may differ by race/ethnicity or educational attainment, leading to differences in adverse pregnancy outcomes.

METHODS

We used linked New York City hospital record and birth certificate data for 6291 singleton births among women with pre-existing diabetes between 1995 and 2003. We defined maternal race/ethnicity as non-Hispanic white, non-Hispanic black, Hispanic, South Asian, and East Asian, and education level as <12, 12, and >12 years. Our outcomes were pre-eclampsia, preterm birth (PTB) (<37 weeks gestation and categorised as spontaneous or medically indicated), as well as small-for-gestational age (SGA) and large-for-gestational age (LGA). Using multivariable binomial regression, we estimated the risk ratios for pre-eclampsia, SGA, and LGA. We used multivariable multinomial regression to estimate odds ratios (OR) for PTB.

RESULTS

Compared with non-Hispanic white women with pre-existing diabetes, non-Hispanic black and Hispanic women with pre-existing diabetes had a 1.50-fold increased risk of pre-eclampsia compared with non-Hispanic whites with pre-existing diabetes, after full adjustment. Non-Hispanic black and Hispanic women with pre-existing diabetes had adjusted ORs of 1.72 [adj. 95% confidence interval (CI) 1.38, 2.15] and 1.65 [adj.95% CI 1.32, 2.05], respectively, for medically indicated PTB. South Asian women with pre-existing diabetes had the highest risk for having an SGA infant [adj. OR: 2.29; adj. 95% CI 1.73, 3.03]. East Asian ethnicity was not associated with these pregnancy complications.

CONCLUSIONS

Non-Hispanic black, Hispanic, and South Asian women with pre-existing diabetes may benefit from targeted interventions to improve pregnancy outcomes.

Complementing insulin therapy to achieve glycemic control

INTRODUCTION

Most patients with type 2 diabetes mellitus (T2DM) will need incrementally more complex therapeutic regimens to control hyperglycemia as the disease progresses. Insulin is very effective in reducing hyperglycemia and may improve β-cell function in patients with T2DM. However, insulin therapy is associated with weight gain and increased risk of hypoglycemia. Adding other antidiabetes medications to insulin can improve glycemic control and potentially lower the required insulin dose, resulting in less weight gain and lower risk for hypoglycemia. This article summarizes the advantages and disadvantages of different classes of commonly used antidiabetes agents, with emphasis on newer classes, for use as add-on therapy to insulin in patients with T2DM inadequately controlled on insulin therapy.

METHODS

A PubMed search from July 1, 2003 to April 15, 2013 for peer-reviewed clinical and review articles relevant to insulin combination or add-on therapy in T2DM was conducted. Search terms included "insulin combination therapy," "add-on therapy diabetes," "dipeptidyl peptidase-4 (DPP-4) inhibitors," "glucagon-like peptide-1 (GLP-1) receptor agonist," "sodium-glucose cotransporter 2 (SGLT2) inhibitors", "insulin metformin," "insulin sulfonylurea," and "insulin thiazolidinedione." Bibliographies from retrieved articles were also searched for relevant articles. Study design, clinical relevance, and effect on insulin combination therapy were analyzed.

RESULTS

Therapies used as add-on to insulin include agents associated with weight gain (thiazolidinediones and sulfonylureas) and/or hypoglycemia (sulfonylureas), which, therefore, may exacerbate risks already present with insulin. GLP-1 receptor agonists, DPP-4 inhibitors, and SGLT2 inhibitors improve glycemic control when added to insulin and have a low propensity for hypoglycemia and cause no change (DPP-4 inhibitors) or a reduction (GLP-1 receptor agonists, SGLT2 inhibitors) in body weight.

CONCLUSION

GLP-1 receptor agonists, DPP-4 inhibitors, and SGLT2 inhibitors improve glycemic control when combined with insulin. They also have low propensity for weight gain and hypoglycemia and so may be preferred treatment options for insulin combination when compared with traditional therapies.

Behavioral interventions to improve glycemic control in African Americans with type 2 diabetes: a systematic review

OBJECTIVE

The use of behavioral interventions has been shown to improve glycemic control, however, the effectiveness of different behavioral interventions in one of the most high risk populations, African Americans, remains unclear. Our systematic review identified and examined findings of published behavioral interventions targeted at African Americans to improve glycemic control. The goal of our study was to distinguish which interventions were effective and identify areas for future research.

DESIGN

Medline, PsychInfo, and CINAHL were searched for articles published from January 2000 through January 2012 using a reproducible strategy. Study eligibility criteria included interventions aimed at changing behavior in adult African Americans with type 2 diabetes and measured glycemic control.

RESULTS

Ten studies met the inclusion criteria, of which five showed a statistically significant change in HbA1c in the intervention group when compared to the control group. Summary information and characteristics of the reviewed studies are provided.

CONCLUSIONS

Characteristics of successful interventions included using problem solving with the patient, culturally tailoring the intervention, and using a nurse educator. Limitations include the limited number of intervention studies available using glycemic control as the outcome measure. Clinical trials are needed to determine how best to tailor interventions to this largely underserved population and studies should describe details of cultural tailoring to provide information for future programs.