Wellness vs Illness
Health care costs can be lowered by PREVENTION, not medication!
When a nation seeks to have universal healthcare and its citizens have unrestricted descretion to engage and indulge in unhealthy practices, and it has industries that profit from illness, universal healthcare then is a elusive fantasy and cost prohibitive. . – Gregory Cheadle
Diabetes - The Modern Plague!
Blacks and people of color have significantly higher rates of diabetes-related complications. Blacks have 2-4 times the rate of renal disease, blindness, amputations, and amputation-related mortality of non-Hispanic whites.5,6,7 Diabetes age-adjusted mortality rates (per 100,000) in California in 1998 were nearly three times greater for Blacks, 98, than non-Hispanic Whites, 38. The higher rates of complications may be due to disproportionately poor control of diabetes as well as associated cardiovascular risk factors such as blood pressure and cholesterol.8 One national data set reported average glycosylated hemoglobin (HbA1c) levels of 7.6% among non-Hispanic white women compared 8.3% among African American women.9 Furthermore, Blacks and people of color have higher rates, and worse control, of dyslipidemia and hypertension.10,11
Diabetes is a gateway disease that results in a number of medical maladies. Type 2 diabetes is more common in adults and accounts for around 90% of all cases of diabetes. For brevity, this policy brief will focus on seven major complications of diabetes: heart disease, hypertension, neuropathy, blindness, Alzheimer’s disease, cerebral vascular accidents (strokes), and kidney disease, their pathophysiology and their relationship to diabetes.
Diabetes is a chronic disease that occurs when the pancreas is no longer able to make insulin, or when the body cannot utilize the insulin it produces. Insulin is a hormone made by the pancreas, that acts to let glucose from blood enter the cells of the body to produce energy. All carbohydrates from foods and drinks are broken down into glucose in the blood. The inability to produce insulin or use it effectively leads to increased glucose levels in the blood. Long-term high glucose levels are associated with damage to the body and failure of various organs and tissues. In type 2 diabetes, the body does not make good use of the insulin that it produces. In tandem with type 2 diabetes is a condition known as insulin resistance. Insulin resistance occurs when cells in the muscles, fat, and liver don't respond well to insulin due to a decreased number of receptors on the cell surface and can't use glucose from the blood for energy. To counter this, the pancreas makes more insulin. Over time this leads to an increase in blood sugar levels.
Diabesity = Diabetes + Obesity
There are several drivers that lend themselves to the glorification and acceptance of obesity in Blacks. The term fat has been replaced with a more clinical sounding word, obese. Moreover, terms like thick, curvy, voluptuous, and BBW have served to take the sting out of being overweight and made it a thing to be celebrated and embraced. Moreover, Black men claiming to have a penchant for women who have “meat on their bones” is a factor that cannot be discounted.
The media is replete with images of obese Black women. Of the few obese female actors being cast in prominent roles or who have sustained their careers despite their weight, an overwhelming majority are Black: Amber Riley, Gabourey Sidibe, Mo’Nique, Queen Latifah, and, of course, Oprah Winfrey. Comedian/actress Mo’Nique is known for promoting heavier women on shows like “Mo’Nique’s Fat Chance. Such glorification comes with a cost. African American women have the highest rates of obesity or being overweight compared to other groups in the United States. About 4 out of 5 African American women are overweight or obese. From 2013-2016, non-Hispanic black females were 2.3 times more likely to be overweight as compared to non-Hispanic white females.25
Lower Extremity Amputation
Between the years 2011 to 2017 doctors in California performed more than 82,000 amputations related to complications of diabetes. Unfortunately, those who were Black or Latino were more than twice as likely as non-Hispanic Whites to undergo amputations related to diabetes. The legedary Dr. Dre, pictured here, had his lower leg amputated due to complications of diabetes. Tragically, this pattern is not unique to California.
Across the country, studies have shown that diabetic amputations vary significantly not just by race and ethnicity but also by income and geography. Diabetic patients living in communities that rank in the nation's bottom quartile by income were nearly 39% more likely to undergo major amputations compared with people living in the highest-income communities, according to one 2015 study.
A 2014 study by UCLA researchers found that people with diabetes in poorer neighborhoods in Los Angeles County were twice as likely to have a foot or leg amputated than those in wealthier areas. The difference was more than tenfold in some parts of the county.
Heart Disease
Atherosclerosis, the formation of plaque along the arterial wall, is the major threat to the macrovasculature for patients with and without diabetes. Dyslipidemia, an abnormal amount of fat in the blood, is highly correlated with atherosclerosis, and up to 97% of patients with diabetes
are dyslipidemic.12 In addition to the characteristic pattern of increased triglycerides and decreased HDL cholesterol found in the plasma of the blood of patients with diabetes, abnormalities are also seen in the physical structure of the lipoprotein particles. In diabetes, the
major form of LDL, (low-density lipoprotein), cholesterol is the small, dense form. Small LDL particles are more prone to cause atherosclerosis than large LDL particles due to their ability to penetrate and form stronger attachments to the arterial wall.
On the microvasculature level- small vessels throughout the body are affected by diabetes, including those in the brain, heart, and extremities. This small vessel damage is typically not related to atherosclerosis and is not a factor with lipid levels. Diabetic autonomic neuropathy (DAN) is one factor associated with impaired autoregulation of blood flow in a variety of vascular beds, including the skin and the heart.13,14 Patients with DAN have increased rates of sudden cardiac death as well as a higher overall cardiovascular mortality rate. These patients have been found to lack the normal cardiac flow reserve that is activated under conditions of increased demand for myocardial perfusion.15 Inflammation, another factor in heart disease, is a normal response to tissue injury or pathogen exposure and is a critical factor in the body's ability to heal itself or to fight off infection. The inflammatory response involves the activation of leukocytes (white blood cells) and in conjunction with cytokines and chemokines.
Diabetes has long been considered a state of chronic, low-level inflammation.16 Heart failure in a patient with diabetes may arise from myocardial damage resulting from an ischemic, lack of blood flow, or thrombotic, blockage event. In the case of inflammation, endothelial dysfunction, oxidation and glycation of atherogenic lipids, and the hypercoagulability of the blood are major contributors to the patient's resulting heart failure.
DIABETES CAN BE PREVENTED even cured by a change in lifestyle!
According to the Centers for Disease Control, the United States has 34.2 million people, or just over 10% of the population, with diabetes. There are approximately 5.2 million Blacks with diabetes in the U.S. More problematic though, is the number of Americans who are prediabetic, 88 million American adults. Fully one out of every three adults in the U.S. population are diabetic or prediabetic. Diabetes was the seventh leading cause of death in the United States in 2017 based on the 83,564 death certificates in which diabetes was listed as the underlying cause of death. In 2017, diabetes was mentioned as a cause of death in a total of 270,702 certificates. (Diabetes, 2018)
Given the ever-increasing costs associated with health care, e.g., in 2019 health care expenditures were $3.8 trillion with no end of increases in sight. (CMS, 2020) In addition to the astronomical health care expenditures, there is also a shortage of doctors as well as nurses in the US. Given these shortages and the ballooning of cases of lifestyle induced diseases, such as diabetes one can readily conclude that the answer to decreasing these expenditures lies in prevention, not medication.
Type II diabetes in many cases is not only preventable, but curable. A disproportionate percentage of African Americans have diabetes or are pre-diabetic. As such, an unnecessary burden is placed on healthcare and the Black community. However, the challenge is for African Americans to engage in activities that will prevent them from acquiring diabetes, and for those who do have diabetes, to encourage them to engage in behaviors that will mitigate, if not reverse, their diabetes. (CDC, 2020)
Only ten percent of the cases of diabetes are Type I in nature, the rest of the cases, 90 percent, are Type II diabetic cases. The percentage of those with diabetes increases markedly after the age of 45. Though Whites have Type I diabetes at a rate that is four times that of Blacks, Blacks have Type II diabetes at a rate that is 1.4 to 2.3 times that of Whites. (ADA, 2020) New cases of diabetes were highest in Blacks compared to other groups. Moreover, the incidence of diabetes in young people, those aged from 10 to 19, increased more for Blacks than any other group. One of the complications of diabetes is kidney disease. Diabetics with stages 1 through 4 chronic kidney disease comprise 37 percent of the cases. (CDC, 2020) With respect to risk factors, 89 percent of diabetics are overweight, and 38 percent were physically inactive. (CDC, 2020) The prevalence of diabetes among African Americans is more than one and a half times greater than that of White Americans. (Signorello, 2007) The higher rate of diabetes among Blacks transcends occupation and age. The rates are higher among Black in U.S. military personnel. (Paris, 2001)
The prevalence of diabetes among African Americans is of great concern, however, what is of greater concern is the outcomes African Americans face when compared to White Americans and other groups. This is of concern because of the social and financial costs associated with these outcomes. For instance, consider the following: in 2018, non-Hispanic Blacks were twice as likely as non-Hispanic Whites to die from diabetes even though African American adults are 60 percent more likely than non-Hispanic White adults to be diagnosed with diabetes by a physician. In 2017, non-Hispanic Blacks were 3.2 times more likely to be diagnosed with end stage renal disease as compared to non-Hispanic Whites. (OMH, 2020) Data from 2017 shows that non-Hispanic Blacks were 2.3 times more likely to be hospitalized for lower limb amputations as compared to non-Hispanic Whites. (NationalHealthcare, 2018) Vision impairment for African Americans with diabetes was 30 percent higher than Whites with diabetes. (CDC 2021) Hospital admissions per 100,000 for uncontrolled diabetes without complications, age 18 and over, in 2017 were more than three times greater for African Americans than Whites. (CDC, 2021) Hospital admissions per 100,000 for lower extremity amputations, age 18 and over with diabetes, in 2017 for African Americans was more than double that of Whites. (NHQ, 2018) Age-adjusted incidence rate per million of end stage renal disease (ESRD) due to diabetes, and related to diabetes, for African Americans was more than three times that of Whites. (NHQ, 2018)
