• African Americans and Diabetes

The National Health and Nutrition Examination Survey (NHANES III) conducted from 1988 to 1994 revealed that the proportion of the African-American population that had diabetes ranged from less than 1% for those younger than 20 years to as high as 32% for women age 65 years to 74 years.8 Overall, among those age 20 or older, the rate was 11.8% for women and 8.5% for men. About one-third of total diabetes cases were undiagnosed among African-Americans.

According to the NHANES III data for diabetes-related complications, the frequency of diabetic retinopathy is 40% to 50% higher in African-Americans than in Caucasian-Americans. African-Americans with diabetes experience kidney failure about four times more often than Caucasian-Americans with diabetes.8 The first and second leading causes of kidney failure are diabetes and hypertension, respectively. Diabetes accounted for 43% of the new cases of end-state renal disease (ESRD) among African-Americans between 1992 and 1996 and hypertension accounted for 42% of cases. Diabetic neuropathy and vascular disease often lead to foot or limb amputation. The hospitalization rate of amputations for African-Americans was 9.3 per 1,000 patients in 1994, compared with 5.8 per 1,000 Caucasian patients with diabetes.8

Providing culturally competent careto African-Americans

African-Americans draw upon a wealth of spiritual connections and strength when faced with an illness. A strong spiritual connection is evident in church membership and attendance, a sense of right and wrong, teaching moral values and a shared religious core. For many, the church serves as the center of community life.24 African-American churches not only provide strong leadership, they often are concerned with the health of their members, as well. In fact, the ADA has recognized the important link between church and community and has launched a program called Diabetes Sunday. A pastor or designated person shares information with the church about the risk factors for diabetes, importance of screening for diabetes and good glycemic control. The ADA can provide a variety of additional activities as follow-up for churches interested in year-round diabetes education programs.25

Impact of lifestyle factors

Dietary habits continue to be a problem area for African-Americans who are at risk for diabetes or who have diabetes. In general, African-Americans tend to follow diets high in fat and sodium and low in fiber. The use of focus groups with urban-dwelling African-American women with diabetes yielded helpful insights towards barriers to dietary therapy in this population.4 Study subjects found it hard to give up the habit of adding butter, pork, ham and bacon to cooked food. These added fats were considered indispensable in preserving the flavor of the food. Economic factors related to dietary therapy also were identified as barriers. Participants felt that they could not afford low-sugar or low-fat foods for themselves in addition to traditional foods for the rest of the family. The use of the Diabetes Exchange Lists for Meal Planning (publication of the American Diabetes Association and the American Dietetic Association and commonly used by diabetes educators) was felt to be difficult to understand and too time-consuming to follow.26 Health care professionals can link African-American patients with diabetes to nutritionists who adapt cultural aspects to meal planning or utilize culturally acceptable African-American dietary education materials (illustrated in Table 3). The ADA offers meal planning materials for African-Americans.25 African-American focus groups have conducted grocery shopping trips focused on identifying diabetes friendly foods as an interactive method of learning. Perceptions of preferred body size among African-American women also may play a role in weight control. In a sample of African-American women of low income, two-thirds of them understood the importance of weight control and expressed a desire to lose weight to help control their diabetes. However, after watching images of thin, mid-sized and large bodies, they rejected thin bodies as unhealthy and perceived mid- to large-sized bodies as signs of good health.26 Therefore, personal perceptions of body image should be discussed in relation to glycemic control during initial interviews with African-American in a diabetes education program.

In addition, the NHANES III survey reported that 50% of African-American men and 67% of African-American women reported that they participated in little or no leisure time physical activity.8 Women from low-income areas reported difficulties in finding a safe and affordable place with affordable childcare to exercise.26 Other cultural characteristics related to healthcare are listed in Table 2. An important resource that the healthcare professionals interested in providing diabetes education should know about is the location and expense of exercise programs. For some patients, the availability of child care at such programs may also be important. Being as African-Americans have a strong sense of community, community centers offering such programs may be preferable. When queried about desirable exercise activities, African-American women focus groups identified mall walking or walking clubs as a desirable way to exercise and socialize at the same time.

Another attribute that may influence the health decisions of African-American patients is time orientation. In general, African-Americans are oriented toward the present, having a tendency to take one day at a time and place less emphasis on looking into the future. This focus on the present may correspond to a fatalistic attitude toward diabetes.23 Indeed, one small study showed fatalism to be a factor in not achieving glycemic control in a sample of low income African-Americans.16 Some study participants believed that their diabetes was given to them by God, and they were powerless to control it on their own. Healthcare professionals wishing to initiate diabetes education programs may want to consider eliciting the help and involvement of area church leaders to address issues of fatalism in the African-American community.