Joslin Diabetes Center
Primary Care Congress for Cardiometabolic Health 2013
Epidemiology of Diabetes and Cardiovascular Disease in Special Populations
Outline
• Prevalence and health impact to this patient
population
• Racial variances in CVD risk factors
• Social and cultural factors that contribute to ↑
DM and CVD risk
• Effective management strategies to improve
outcomes
Epidemiology of Diabetes and
Cardiovascular Disease in African
Americans
Eyiuche Okeke, MD
Diabetes in African Americans
ARS Q 2
The following risk factors for CVD occur at a higher rate
among AA compared to Whites except?
A.
B.
C.
D.
Hypertension
Dyslipidemia
Obesity
Smoking
National Diabetes Fact Sheet 2011.
http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf
Age-Adjusted Incidence of (ESRD-DM) per 100,000
Challenges for African Americans with
Diabetes
Diabetic Population, United States, 1980–2006.
• Higher Disease Prevalence
• Lower quality of Care
• Poorer glucose control compared to
Caucasians when receiving care in similar
settings
• Higher rates of co-morbid complications
• Higher rates of diabetes-related mortality
CDC.gov
Copyright © 2013 by Joslin Diabetes Center, Inc. All rights reserved. These materials may be used for personal use only. Any
distribution or reuse of this presentation or any part of it in any form for other than personal use without the express written
permission of Joslin Diabetes Center is prohibited.
1
Joslin Diabetes Center
Primary Care Congress for Cardiometabolic Health 2013
Epidemiology of Diabetes and Cardiovascular Disease in Special Populations
Number of Diabetes Deaths per 100,000 Population by Race/Ethnicity, 2009
=low | 51=high)
White
Black
Disparities in A1C levels between African Americans and Caucasians:
Meta-analysis
Other
United States
NA
39.5
18.6
Alabama
18.3
48.6
NSD
Washington
21.8
50.4
28.2
Tennessee
22.8
51.3
NSD
Oklahoma
24.7
53.3
56.1
West Virginia
31.9
54.0
NSD
Mississippi
19.5
55.0
NSD
Oregon
24.5
56.2
27.3
Kentucky
27.4
56.4
NSD
Iowa
18.5
57.8
NSD
Arkansas
22.8
62.7
NSD
New Jersey
18.1
38.7
14.3
Texas
21.2
38.7
11.6
California
18.9
40.4
17.1
South Carolina
17.4
41.6
NSD
Florida
17.8
41.8
10.1
New York
15.2
31.3
12.
http://www.statehealthfacts.org
Kirk et al DC 2006 :29:2130
Disparities in improvement in A1C after 1 year of care in
Diabetes subspecialty care
Multiple Factors contribute to Diabetes Disparities
Patient Factors
Non-Patient Factors
• ↓adherence to medications
and use of SMBG
• ↑ Rates of Poverty
• Cultural attitudes
• ↓ Levels of Health Literacy
• ↑Levels of diabetes related
Distress
• Distrust of the medical system
• ? Biological Factors
• ↑ rates of missed appointments
• Limited access to health care
• Quality of health care provided
• Unconscious bias by
physicians
• Failure to take culture into
account in health care delivery
Adult Diabetes Clinic
Joslin Diabetes Center
CVD in African Americans
CVD in African Americans
• Leading course of death
• Greatest risk factor contributing to CVD in this population is
hypertension
~30% of deaths in AA men
~20% of deaths in AA women
•
•
•
•
↑ prevalence of some risk factors for CVD
They are more likely to have multiple risk factors for CVD
Prevalence of CAD is not higher for AA
AA experience ↑ adverse cardiovascular events and mortality
compared to Whites
JM. Flack et al. J Clin Hypertens. 2003;5(1 suppl 1):5–11,
Copyright © 2013 by Joslin Diabetes Center, Inc. All rights reserved. These materials may be used for personal use only. Any
distribution or reuse of this presentation or any part of it in any form for other than personal use without the express written
permission of Joslin Diabetes Center is prohibited.
2
Joslin Diabetes Center
Primary Care Congress for Cardiometabolic Health 2013
Epidemiology of Diabetes and Cardiovascular Disease in Special Populations
HTN
Age Adjusted Death rates for coronary heart disease by Race/ethnicity
and Sex, U.S. 1999-2008
• More prevalent in AAs Compared with Whites and starts earlier
• More severe, and more often associated with target organ injury





1.5 fold ↑ in death from heart disease
1.7 fold ↑ risk of heart failure
1.3 fold ↑ in non-fatal strokes
1.8 fold ↑ in fatal strokes
4.2 fold ↑ in ESRD
• AAs living with HTN are less likely to be optimally managed
• HTN in this group is salt sensitive- DASH Diet and diuretic therapy are
very effective
J Clin Hypertens. 2003;5(1 suppl 1):5–11
Am J Hypertens 1997;10:804-12.
JNC7. http://www.nhlbi.nih.gov
Chart 3-25. 2012 NHLBI chart Book
Obesity /Inactivity
Obesity /Inactivity in AA
Intra-individual Influences Extra-individual influences
• Genetics
• Gender
• Race/ethnicity/culture
•
•
•
•
Socio economic status
Physical activity resources
Side walk connectivity
Access to Fast food /healthy
food
• Neighborhood safety-crime,
litter, unattended dogs, loud
noise etc.
Jnl urban Health 2009; 86(5) : 696-707
Age Adjusted percent of population currently smoking by
Race and Sex, Ages 18 and older, U.S.,1965-2010
Dyslipidema
• Several studies have reported that African Americans have lower
total low-density lipoprotein (LDL) cholesterol concentrations and a
lower prevalence of hypercholesterolemia.
• This does not appear to be “protective”
Chart 2-21. 2012 NHLBI chart Book
Copyright © 2013 by Joslin Diabetes Center, Inc. All rights reserved. These materials may be used for personal use only. Any
distribution or reuse of this presentation or any part of it in any form for other than personal use without the express written
permission of Joslin Diabetes Center is prohibited.
3
Joslin Diabetes Center
Primary Care Congress for Cardiometabolic Health 2013
Epidemiology of Diabetes and Cardiovascular Disease in Special Populations
Ethnic variances in the Diagnosis and
management of CVD
Diagnostic studies
• ↓ Prevalence of coronary
artery calcifications
independent of CVD risk
factors
• ↑ False positive rate with
current ECG algorithms
defining LVH
• Lipid levels
Effective management strategies
• Aggressive RF modification: Early Screening
Management
• ↓ Rates of revascularization,
coronary angiography and
bypass
• Patient education and empowerment-community based
cultural approach
• ↓ Management of both primary
and secondary CVD
prevention strategies
• Innovative solutions to environmental contributors
NEJM 1999;340:618-626, JAMA 1988;261:253-257, J
AM cardiol 2002;39:408-12, AM J HTN 2002;15:663-71
Copyright © 2013 by Joslin Diabetes Center, Inc. All rights reserved. These materials may be used for personal use only. Any
distribution or reuse of this presentation or any part of it in any form for other than personal use without the express written
permission of Joslin Diabetes Center is prohibited.
4