Better diabetes control needed among Haitian patients, study finds

Vimalananda VG. Diabetes Care. 2010;doi:10.2337/dc10-1387.

Issue: January 2011

Haitians with diabetes not only exhibit worse glycemic control but also appear to be less likely to have control of their blood pressure and LDL levels, as compared with black and white patients with the disease.

"Haitians appear to be a culturally distinct group with respect to diabetes control," Varsha Vimalananda, MD, a fellow in endocrinology at Boston Medical Center, told Endocrine Today. "Data collection and intervention design should account for ethnicity in addition to race so that programs to improve diabetes care can be culturally tailored."

To explore these cultural differences, researchers conducted an observational study that examined adults aged 20 years and older who had been diagnosed with diabetes. All participants had at least one annual primary care visit between 2007 and 2009 at the Boston Medical Center. Of 2,653 patients, 715 self-identified as Haitian, 1,472 as black and 466 as white.

Diabetes in Haitians

At 8.2%, Haitian patients experienced a higher mean HbA1c compared with black (7.7%) and white patients (7.7%; P<.0001).

Results of an unadjusted analysis indicated that Haitian patients had a higher risk for poor BP control compared with those in the comparison groups, and a higher risk for elevated LDL levels compared with white patients only.

The study also revealed positive findings for Haitians with diabetes as compared with the other groups:

Haitian patients had a lower mean BMI (30.8) vs. the black (33.8) and white patients (33.4; P<.05);
were less likely to report a history of smoking;
had fewer primary care visits; and
had a lower likelihood of visiting an endocrinologist.

The researchers noted, however, that, with the exception of retinopathy, Haitian patients experienced complications less often than black and white patients. Compared with black patients only, Haitians had a lower adjusted OR of 0.35 (95% CI, 0.23-0.55) for macrovascular complications and a lower adjusted OR of 0.56 (95% CI, 0.41-0.76) for microvascular complications. Similarly, when compared with white patients, Haitians had an adjusted OR of 0.32 (95% CI, 0.2-0.5) for macrovascular complications and 0.55 (95% CI, 0.39-0.79) for microvascular complications.

"We were surprised to find lower rates of diabetes-related complications among Haitians, in light of higher rates of uncontrolled risk factors," Vimalananda said, noting that this may be due to ascertainment bias. However, she also pointed out that nephropathy was based on laboratory values rather than ICD-9 codes, suggesting a genuine difference in that particular complication.

Vimalananda also noted that BMI may be responsible for lower rates of complications.

"Haitians have a lower mean BMI than either comparison group, so perhaps they experience a later onset of disease and hence a shorter exposure time to risk factors," she said.

Interpretations, implications

Worse glycemic control among Haitians persisted despite adjustment for age or language, Vimalananda said, therefore indicating the unique problem of diabetes control in this population.

Traditional high-carbohydrate Haitian diets or a lack of cultural understanding may be to blame for poor glycemic control in this population, the researchers said. They pointed out that this problem may progress as cultural adjustment, obesity and diabetes prevalence increases.

"Physicians should continue to enlist the help of their care teams in assessing and addressing culture-specific barriers to adequate diabetes care and, when possible, advocate for research and interventions that address ethnicity as well as race," said Vimalananda. - by Melissa Foster.

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