Among their findings, researchers observed that black and Asian people with diabetes tended to have higher average blood sugar levels than white individuals; that Asian people were less likely to be prescribed insulin and two relatively new diabetes drugs, SGLT-2 inhibitors and GLP-1 agonists, compared to white people; and that black people were less likely to be prescribed those two new drug classes than white people. “We have long known that racial disparities and many other social determinants of health influence diabetes care and outcomes,” says Kevin Pantalone, DO, director of diabetes initiatives at the Cleveland Clinic in Ohio. Dr. Pantalone wasn’t involved in the study. Indeed, past research supports the current study conclusions. For example, a study published in December 2017 in JAMA concluded that factors including obesity, neighborhood segregation, poverty, depression, unemployment, and limited education may contribute to a higher diabetes risk in black people. And an April 2017 study in the Journal of General Internal Medicine found that Asian-Americans are far less likely than other racial and ethnic groups to be screened for diabetes even when they got other preventive health screenings. “The current study findings highlight from a large data set the scope of this issue in primary care in England,” Pantalone continues. “If this study were reproduced from another large data set from another country, it would likely yield similar results. These results add to the growing body of evidence that these variables must be recognized and addressed in order to improve the quality of care that we render to patients with diabetes.” RELATED: How Ethnicity Affects Type 2 Diabetes Risk
How Researchers Studied Racial Disparities in Diabetes Care
For the current U.K. study, researchers examined national health records from 2012 to 2016 for 84,452 adults with type 2 diabetes. Type 2 diabetes is the most common form of the disease, and it is associated with aging and obesity, the Centers for Disease Control and Prevention (CDC) notes. Authors sorted participants into five groups based on how well their blood sugar was controlled, how often they got routine monitoring and screening for complications, and how often they received prescriptions for insulin and other diabetes drugs. During the five-year study period, the proportion of participants who got annual blood sugar monitoring increased from about 83 percent to 93 percent, suggesting that access to care improved overall. But black and Asian subjects still had higher-than-average blood sugar levels than their white counterparts. Healthcare providers estimate average blood sugar levels by measuring the percentage of hemoglobin that binds to glucose in blood, according to Diabetes.co.uk. This percentage, called A1C, reveals a person’s average blood sugar levels over the past two to three months. An A1C of 6.5 percent or higher signals diabetes. That is equivalent to 140 milligrams per deciliter (mg/dL), or 7.8 millimoles per mole (mmol/l). RELATED: 5 Ways to Help Lower Your A1C Researchers measured blood sugar in mmol/l. Compared with white study participants, black individuals had average A1C readings 2.36 mmol/mol higher, and Asian individuals had A1C readings that were 1.10 mmol/mol higher. And the poorest people in the study had average A1C readings 1.86 mmol/mol higher than the most affluent participants. Over time, these disparities in blood sugar control can lead to an increased risk of diabetes complications, says lead study author Martin Whyte, PhD, a clinical senior lecturer at the University of Surrey and a diabetes consultant at King’s College Hospital in London. “The difficulty with type 2 diabetes is that very often the individual has the condition for a long time before it is diagnosed, as often there are few symptoms other than feeling more tired than usual or a bit more thirsty," Dr. Whyte continues. This makes lowering blood sugar urgent once a person receives a diabetes diagnosis, Whyte says. “In type 2 diabetes, high [blood] sugar levels often coexist with ‘bad’ (LDL) cholesterol and low levels of ‘good’ (HDL) cholesterol as well as with high blood pressure,” Whyte adds. “You can imagine that after months or years of living with this, leading to hardening (of the arteries), no more delay should be tolerated.” RELATED: 8 Ways to Manage Diabetes and Heart Health
Differences in Monitoring, Screening, and Drug Prescriptions
Black people were 11 percent less likely to get complete annual monitoring for blood sugar, the study found. Yet Asian participants were 10 percent more likely to get complete monitoring than white people with diabetes were. In addition, Asians were 12 percent less likely to get screened for eye complications related to diabetes than whites with diabetes, and blacks were 18 percent less likely to get eye checks. Asians were also 12 percent less likely to undergo screenings for diabetes-related nerve damage (diabetic neuropathy) than whites were. Nonwhite participants were also less likely to get prescribed two new medicines known as GLP-1 agonists and SGLT-2 inhibitors, which can help reduce the risk that someone with diabetes will have or die from an event like a heart attack or stroke, notes an article published in May 2019 in JAMA. Compared with whites, Asians were 63 percent less likely to receive GLP-1 agonists, while blacks had a 55 percent lower chance of getting these drugs. And Asians were 32 percent less likely to be prescribed SGLT-2 inhibitors than whites, while blacks had a 50 percent lower chance of getting these drugs. RELATED: What Are the Pros and Cons of SGLT2 Inhibitors for Type 2 Diabetes?
BMI May Have Affected Drug Prescriptions in Asian Participants
It’s possible these prescribing decisions are driven in part by patients’ body mass index (BMI) rather than racial bias, Whyte says. That’s because these new medicines are associated with weight loss, and doctors may use them more for this purpose than for the potential to prevent heart problems, Whyte says. “For instance, it may be that because Asian individuals tend to have lower BMI, they are not prescribed GLP-1 drugs, which are usually prescribed only if BMI is over 35,” Whyte says. “This would, however, be a mistake, as Asians have equivalent cardiovascular risk even if they have a lower BMI than whites.” RELATED: What Are the Flaws of Body Mass Index (BMI)?
Where the Study Fell Short and What to Take Away From the Findings
The study wasn’t a controlled experiment designed to prove whether or how race or class may impact diabetes care in the United Kingdom, and it didn’t follow patients long enough to see how disparities in care might influence the potential for serious complications from diabetes or cardiovascular disease. Even so, the results suggest there’s room for improvement in access to diabetes care, says Pantalone. “These findings support the notion that a disparity in glycemic control, diabetes-related monitoring, and prescription patterns of newer therapies remain a challenge in diabetes care, and that both socioeconomic status and ethnicity are important determinants of inequality,” says Pantalone. “These disparities need to be acknowledged and solutions developed to correct the observed disparities so that all patients with diabetes have adequate glycemic control, thereby reducing their risk of developing diabetes-related complications and other adverse outcomes,” Pantalone adds. People with diabetes can also advocate for themselves when they see the doctor, Whyte says. “I think the message to patients would be to keep as well informed about their diabetes as possible — attend structured self-education, consider joining a diabetes patient group (such as Diabetes U.K.), and ensure they are getting their annual reviews,” Whyte advises. “And ask their doctor about the latest evidence for diabetes treatments and whether any additions or changes to their medication would be suitable for them.” Finally, Whyte says, “If people feel that they are not getting quality diabetes care, they are entitled to ask for a second opinion.” RELATED: The 11 Best Blogs About Living With Type 2 Diabetes
