Complications hit the black community hard

Black women have higher prevalence than men

One would think that in her 45 years of practicing medicine in the poor neighborhoods of Houston, Edith Irby Jones, MD, has seen just about all there is to see with urban health issues.

But the sudden rise in diabetes among her fellow African Americans has stunned her.

"It’s frightening. Very frightening," says Jones, a family practitioner, clinical assistant professor at both Baylor University and the University of Texas at Houston, and former president of the National Medical Association.

Like other health care professionals treating members of minority groups, Jones says obesity and a sedentary lifestyle must carry a big part of the blame for the escalation. But she points a finger at another culprit: poverty and the complex web of disease and death it weaves in the lives of its victims.

Medicaid helps the poor with receiving health care, she says. But in considering how much Medicaid helps, Jones asks the following questions:

• What if patients can’t get to the clinic?
• What if they have no transportation?
• What if the clinic is only open 9 a.m. to 5 p.m. and patients will lose their jobs if they take time off from work?
• Who will take care of the children while patients go to the clinic?
• What if they’re too sick to get to the clinic?
• If they do get there, what if they can’t get back for follow-up?

It sounds like a myriad of problems, but Jones has found answers at least to some of them. First of all, she says, her clinics are in the neighborhoods where people live, not downtown or three bus rides away.

They are open early in the morning and in the evenings so people who work can get there. "We can’t expect them to come to us. We have to go to them," Jones says.

She has arranged for podiatrists to go to the homes of her diabetic patients to provide foot care services.

Sometimes she even piles patients into her car and takes them where they need to go.

In addition, her clinics provide little "perks" to entice patients there and to persuade them to stay.

"We give breakfast and lunch. We give education classes and particularly teach them about nutrition. We get the drug companies to donate glucose monitors, and we teach them how to use them. We even get nutritionists out to their homes to teach them how to cook meals."

It may take a community-by-community approach to reverse the toll diabetes is taking on African Americans.

According to the National Institutes of Health (NIH) and the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), both in Bethesda, MD, the rate of diabetes among African Americans has skyrocketed by 400% in the past 30 years.

• Of 35 million black Americans, 1.5 million have been diagnosed with diabetes and about half of them are unaware they have the disease.

• Among African Americans age 50 and older, 19% of men and 28% of women have diabetes.

• African American diabetics have three times the likelihood of end-stage renal disease (ESRD) as whites. (See graph, p. 17.)

• Blacks are 2½ times as likely to have a lower extremity amputation, and they are about 20% more likely to die as a result of the amputation. (See graph on amputations, at left.)

• The frequency of diabetic retinopathy is 40% to 50% higher in blacks than whites.

• African-Americans die from diabetes at a far higher rate than whites. The death rate is 40% higher for women and 20% higher for men. Diabetes is the fifth leading cause of death in blacks.

Not only do blacks suffer complications at a far greater rate than whites, say the NIH and the NIDDK; greater disability results from those complications.

"The denominator is still poverty," Jones says. "It’s lack of education, lack of time, lack of family support, lack of proper foods."

She says it is important for health care professionals to invest the time to be sure patients understand what a diagnosis of diabetes means.

"When you get into a one-on-one situation, they can ask questions and I can take the time to be sure they understand," says Jones. "I tell them how to take what little money they have and buy proper foods and to get a right combination of rest, work, play, exercise, and diet."

Of course, compliance is a major issue and always will be, Jones says, but explaining to her patients why they should be compliant is worth the effort: "They’re noncompliant when they don’t understand why they should comply."

The illiteracy and functional illiteracy that are so prevalent in poor black communities are also a big barrier to compliance, Jones says. "You can’t just hand them a pamphlet to read. You have to take the time to sit down and explain it to them."

Black women have a particular risk of diabetic complications, at least in part, because of a cultural behavior pattern in which "they take care of everybody but themselves," she explains. And they are far less likely to exercise, with fewer than one-third of all black women reporting they participated in any form of exercise. (See graph, at left.)

Add to that the complications of diabetes associated with pregnancy and the higher risk of gestational diabetes among black women (50% to 80% higher than in whites) and Jones says that explains why black women are at greater risk than black men.

The high rate of hypertension among African Americans, diabetic and nondiabetic, is a factor in developing ESRD. Diabetes is the cause of 43% of ESRD in black patients. Hypertension is blamed for 42% of cases. (The remaining cases are due to other causes.)