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Race, Risk, and Behaviors: Race and Disproportionate Burdens of Chronic Disease

      Chronic disease and race are intimately bound, generating persistent and sometimes hard-to-explain health care disparities. Race is a superficial and most often a misleading explanatory variable for a category of people. This concept was vividly demonstrated when Chris Hayes, host of MSNBC’s All In, used a segment of his television show to ask, “What Will the White Community Do About ‘White Criminal Culture’’? (http://www.huffingtonpost.com/2013/07/31/cord-jefferson-chris-hayes-white-community_n_3680067.html). Although Hayes’ segment turned out to be somewhat tongue-in-cheek, his message—that race is a disingenuous generalization to a population group—was not. However, in the field of epidemiology and health sciences, when we are often lacking access to more discrete measures that place individuals within the context of society and their communities, race is often our go-to variable, for better or worse. Furthermore, we are often left to use proxy measures, such as income, educational attainment, or zip code, for how people perceive disease and their subsequent behaviors. What we really need to know, however, is how particular groups of people think about their disease, think about their health, think about their risks for complications, and think about their future and what is possible for them.
      Left with such proxy measures, the Centers for Disease Control and Prevention (CDC) describes health disparities and inequalities as representing differences in education and income, inadequate and unhealthy housing, exposure to unhealthy air quality, access to health care and preventive health services, and health outcomes (including both mortality and disease burden).
      Centers for Disease Control and Prevention
      CDC health disparities and inequalities report—United States, 2013.
      One framework for understanding health care disparities is the social determinants of health model. The characteristics that comprise this model include factors associated with socioeconomic status, including education, income, health practices, and stress; factors associated with residential segregation, including impact on income, violence, and links to disease; and factors associated with medical care, including links to homicide, links to cancer mortality, and impact of segregation.
      • Williams D.R.
      • Jackson P.B.
      Social sources of racial disparities in health.
      Although these characteristics are somewhat closer to the mark, they still are dissatisfying because we run the risk of inaccurately assigning risk to a generic group of people based on a superficial feature such as race or income; however, delving deeper into how these characteristics may be quantified begins to help us think in terms of peoples’ lives and their unique experiences that increase their risk for poor health care outcomes.

      Social Explanations for Poor Health Care Outcomes

      Hanke and Gundlach
      • Hanke P.J.
      • Gundlach J.H.
      Damned on arrival: a preliminary study of the relationship between homicide, emergency medical care, and race.
      described the relationship between medical care and homicide as disparate access to timely emergency transportation and subsequent high-quality medical care. The federal government summarized the linkages between medical care and cancer as disparate access to preventive, screening, diagnostic, treatment, and rehabilitation services for cancer.

      Department of Health and Human Services. Trans-HHS Cancer Health Disparities Progress Review Group, Making Cancer Health Disparities History. Washington, DC: Department of Health and Human Services; 2004.

      Baicker et al
      • Baicker K.
      • Chandra A.
      • Skinner J.S.
      • Wennberg J.E.
      Who you are and where you live: how race and geography affect the treatment of Medicare beneficiaries.
      linked medical care and social segregation by suggesting that, compared with white Medicare patients, black Medicare patients are more likely to live in areas in which medical procedure rates and the quality of care are lower. A recent analysis of exposure to various social determinants of health suggested that urban black men are 2.6 times as likely to have >2 of these risk factors for poor health care outcomes than white men.
      • Quarells R.C.
      • Liu J.
      • Davis S.K.
      Social determinants of cardiovascular disease risk factor presence among rural and urban black and white men.

      Intrinsic Risk Factors That Emerge from Social Explanations for Poor Health Care Outcomes

      Health care disparities seem to persist, despite attention on a grand scale from funders, investigators, and, to some extent, legislators. The Agency for Healthcare Research and Quality ascribes other causes to continuing health care disparities, including physician decision making and cultural and communication barriers. In describing the American-Indian community, Mitchell suggests that patient-level strategies for preventing and managing diabetes fail to address the fundamental causes and complexity of the disease.
      • Mitchell F.M.
      Reframing diabetes in American Indian communities: a social determinants of health perspective.
      Although she writes about an effort to reframe diabetes to understand it within the context of the American-Indian experience as “a product of and a response to unjust conditions and environments, rather than as a disease rooted solely in individual pathology and responsibility,” she could just as easily be describing the complexity of diabetes as a universal sociomedical condition.
      Intrinsic, patient-centric factors have been suggested as militating against patient capabilities to incorporate diabetes prevention and management activities into individuals’ daily lives. These factors emerge from the context in which people live and may contribute to our understanding of persistent health care disparities. They include such factors as health literacy, health care fatalism, cognitive impairment, and depression. For example, a cross-sectional study of the most recent glycosylated hemoglobin level among 408 English- and Spanish-speaking adult patients with type 2 diabetes mellitus (T2DM) suggested that those patients with inadequate health literacy (on the basis of the short-form Test of Functional Health Literacy in Adults) were more likely to have poor glycemic control (adjusted odds ratio [OR], 2.03 [95% CI, 1.11–3.73]; P = 0.05) and to report having retinopathy (adjusted OR, 2.33 [95% CI, 1.19–4.57]; P = 0.01). Health literacy goes beyond a capability to describe health concepts to also include understanding these concepts.
      Fatalism represents “a complex psychological cycle characterized by perceptions of hopelessness, worthlessness, meaninglessness, and social despair.”
      • Powe B.D.
      • Weinrich S.
      An intervention to decrease cancer fatalism among rural elders.
      Egede and Bonadonna explored the concept of fatalism in relation to diabetes self-management behavior in the United States, describing it as particularly relevant to African-American subjects and the African-American experience, linking the concept to existential angst as the universal experience of dread and despair from years of enslavement, economic impoverishment, and disenfranchisement, accompanied by nihilism. Using a validated instrument (the 12-item Diabetes Fatalism Scale
      • Garcia A.A.
      • Villagomez E.T.
      • Brown S.A.
      • et al.
      The Starr County Diabetes Education Study Development of the Spanish-language diabetes knowledge questionnaire.
      ), Walker et al
      • Walker R.J.
      • Smalls B.L.
      • Hernandez-Tejada M.A.
      • et al.
      Effect of diabetes fatalism on medication adherence and self-care behaviors in adults with diabetes.
      discerned significant correlations between fatalism and medication adherence (r = 0.24, P < 0.001), diet (r = 0.26, P < 0.001), exercise (r = –0.20, P < 0.001), and blood sugar testing (r = –0.19, P < 0.001).
      Poverty and depression are closely correlated. The chronic stress that develops after long-term economic hardship and perceptions of bias and experiences of being socially disadvantaged is a mediator for depression among low-income populations,
      • Mezuk B.
      • Rafferty J.A.
      • Kershaw K.N.
      • et al.
      Reconsidering the role of social disadvantage in physical and mental health: stressful life events, health behaviors, race, and depression.
      • Everson S.A.
      • Maty S.C.
      • Lynch J.W.
      • Kaplan G.A.
      Epidemiologic evidence for the relation between socioeconomic status and depression, obesity, and diabetes.
      • Delahanty L.M.
      • Conroy M.B.
      • Nathan D.M.
      Psychological predictors of physical activity in the diabetes prevention program.
      contributing to an increased number of depressive symptoms
      • Grote N.K.
      • Bledsoe S.E.
      • Wellman J.
      • Brown C.
      Depression in African American and white women with low incomes: the role of chronic stress.
      and reduced cognitive functioning.
      • Evans G.W.
      • Schamberg M.A.
      Childhood poverty, chronic stress, and adult working memory.
      • Crowe M.
      • Sartori A.
      • Clay O.J.
      • et al.
      Diabetes and cognitive decline: investigating the potential influence of factors related to health disparities.
      Poverty represents an important risk factor in the social determinants framework for chronic disease, including obesity, diabetes, and cardiovascular disease. Depression commonly accompanies diabetes, resulting in reduced adherence to medications and increased risk for morbidity and mortality.
      • Bogner H.R.
      • Morales K.H.
      • de Vries H.F.
      • Cappola A.R.
      Integrated management of type 2 diabetes mellitus and depression treatment to improve medication adherence: a randomized controlled trial.
      Major depression among people with T2DM has been linked to a greater likelihood for initial hospitalization for ambulatory care–sensitive conditions (hazard ratio [HR], 1.41 [95% CI, 1.15–1.72]) and number of hospitalizations for ambulatory care–sensitive conditions (HR, 1.37 [95% CI, 1.12–1.68]).
      • Davydow D.S.
      • Katon W.J.
      • Lin E.H.
      • et al.
      Depression and risk of hospitalizations for ambulatory care-sensitive conditions in patients with diabetes.
      Depressed patients with T2DM have a significantly higher risk of a severe hypoglycemic episode compared with nondepressed patients with T2DM (hazard ratio, 1.42 [95% CI, 1.03–1.96]) and a greater number of hypoglycemic episodes (OR, 1.34 [95% CI, 1.03–1.74]).
      • Katon W.J.
      • Young B.A.
      • Russo J.
      • et al.
      Association of depression with increased risk of severe hypoglycemic episodes in patients with diabetes.
      With data from the National Social Life, Health and Aging Project, Wexler et al
      • Wexler D.J.
      • Porneala B.
      • Chang Y.
      • et al.
      Diabetes differentially affects depression and self-rated health by age in the US.
      identified a higher rate of depression among the youngest cohort of respondents with diabetes compared with those without diabetes.
      We are learning more about the complex interplay between diabetes and depression, with a dysfunction in the hypothalamus-pituitary-adrenal axis, neurotrophins, and inflammatory mediators contributing to the development of a bidirectional relationship between depression and diabetes.
      • Stuart M.J.
      • Baune B.T.
      Depression and type 2 diabetes: inflammatory mechanisms of a psychoneuroendocrine co-morbidity.
      If, indeed, evidence from the molecular sciences continues to mount, signifying a key biological link between diabetes and depression, as suggested by Stuart and Baune in Neuroscience & Biobehavioral Reviews, we might eventually acquire the pharmacologic therapy with which to more efficiently manage this complex comorbidity. Until we move our understanding of the overlay between behavior and disease further, we are left with the very real problem of positively motivating people who are depressed to engage in healthy lifestyle behaviors that prevent or delay the diagnosis of diabetes, and reduce the risk for complications among people with diabetes. Similarly, we must also rely on our somewhat limited understanding of how to motivate and encourage patients with diabetes, regardless of whether they are also depressed, to engage in diabetes self-management activities by also considering the social context of their experiences.

      In this DIABETES Update

      The social context of disease and the intrinsic risk factors that contribute to health care disparities is the prism through which we examine T2DM in this Diabetes Update, entitled “Race, Risk, and Behaviors.” Clinicians in practice, health services researchers, clinical researchers, and pharmacotherapy researchers can benefit from this review, which includes an examination of a high-risk population and their perceptions of T2DM. This Diabetes Update includes papers by the lead authors which I have presented a quick overview of below.
      Leonard Jack, Jr., PhD, MSC, director of the CDC’s Division of Community Health in the National Center for Chronic Disease Prevention and Health Promotion, and Leandris C. Liburd, PhD, MPH, MA, associate director for Minority Health and Health Equity at the CDC, are coauthors on an article describing how African-American subjects perceive T2DM. Their article, entitled, “Having Their Say: Patients’ Perspectives and the Clinical Management of Diabetes,”
      • Jack Jr, L.
      • Liburd L.C.
      • Tucker P.
      • Cockrell T.
      Having their say: patients’ perspectives and the clinical management of diabetes.
      has important implications for how clinicians can effectively engage with patients to increase the extent to which they participate in diabetes prevention behaviors and diabetes self-management activities. Sonjia Kenya, EdD, assistant professor of Family Medicine at the University of Miami Miller School of Medicine, reports on the observations from a team of community health workers regarding perceptions toward self-monitoring of blood glucose among Latino community members with T2DM. In “Glucometer Use and Glycemic Control Among Hispanics in South Florida,”
      • Kenya S.
      • Lebron C.
      • Arrechea E.R.
      • Li H.
      Glucometer use and glycemic control among Hispanics in south Florida.
      Dr. Kenya suggests that Latinos with T2DM in a particular geographical area have a limited understanding regarding the purpose of self-monitoring of blood glucose, which may be partially due to the limited availability of diabetes self-management education for low-income, minority patients. Janice M. Lopez, PharmD, at Bristol-Myers Squibb, uses data collected from a Web-based survey to describe the manner in which diabetes is conceptualized by subjects with diabetes, based on their ethnic group and how this concept changes with age. Despite the potential for response bias that comes with a survey conducted on the Web, in her article entitled “Characterization of Type 2 Diabetes Mellitus Burden by Age and Ethnic Groups Based on a Nationwide Survey,”
      • Lopez J.M.
      • Bailey R.A.
      • Rupnow M.F.
      • Annunziata K.
      Characterization of type 2 diabetes mellitus burden by age and ethnic groups based on a nationwide survey.
      Dr. Lopez offers a provocative conclusion that merits review—and understanding—by investigators and clinicians alike. This Diabetes Update also includes articles from Marcus Hompesch, MD (“Insulin Degludec Provides Similar Pharmacokinetic and Pharmacodynamic Responses in African American, Caucasian, and Hispanic/Latino Subjects With Type 2 Diabetes”
      • Hompesch M.
      • Morrow L.
      • Watkins E.
      • et al.
      Insulin degludec provides similar pharmacokinetic and pharmacodynamic responses in African American, Caucasian, and Hispanic/Latino subjects with type 2 diabetes.
      ), and Vivien Fonseca, MD, chief, Section of Endocrinology at the Tulane University School of Medicine, who provides an overview of new pharmacologic tools for managing T2DM (“New Developments in Diabetes Management: Medications of the 21st Century”
      • Fonseca V.A.
      New developments in diabetes management: medications of the 21st century.
      ).

      Express Yourself and Communicate With Us

      As we strive to offer novel and useful perspectives regarding the treatment and management of T2DM, we invite our readers to communicate their interests to us. Is there a general interest in focusing more on pharmacologic innovations, such as that offered by Dr. Fonseca in this Diabetes Update? Is there an interest in exploring various complications from T2DM in greater detail through these updates, or would readers like more content describing the sociological perspectives of T2DM, such as those provided by Drs. Jack and Liburd? We invite your opinions and suggest that you Tweet them to us (@clinthe), thereby potentially engaging other readers of Clinical Therapeutics in a dialogue about reader preferences. We also invite Letters to the Editor (see http://www.clinicaltherapeutics.com/content/guide) or e-mailed responses ([email protected]). Whatever mode of communication you choose, let us know what types of diabetes content interests you, and we will endeavor to tailor our content in future updates accordingly.

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