Psychosocial Factors and Ethnic Disparities in Diabetes Diagnosis and Treatment among Older Adults

Bertera, Elizabeth M., Health and Social Work

The prevalence of non--insulin-dependent diabetes mellitus type 2 (NIDDM) increases with age, and more than 50 percent of patients with diabetes are over the age of 65 (U.S. Department of Health and Human Services and Office of Public Health and Science, 1998). It is estimated that 3.6 million people age 65 or older are afflicted with this disease, the majority of whom have type 2, noninsulin-dependent diabetes mellitus (NIDDM) (Rubin, Altman, Altman, & Mendelson, 1994). The prevalence of diabetes at age 60 is 10 percent, and by age 80 it rises to 16 percent to 20 percent for white people. The death rate for cardiovascular disease among elderly diabetic patients is twice that of people without diabetes in the same age range (Harris, 1990a).

Not only is diabetes a heavy burden on older adults, but also is expensive to society in terms of disability, mortality, and health care costs. The majority of health care expenses are for inpatient costs, with most being attributed to the care of cardiovascular complications. Per capita expenditures for confirmed diabetics were more than four times greater than for people without diabetes (Caruso & Silliman, 1999; Rubin et al., 1994). People age 65 or older with diabetes make an average of 3.7 visits per year to physicians specifically for care of their diabetes. These diabetes care visits represented 7.7 percent of visits for all health causes in this age group. About 30 percent of diabetics 65 to 74 years of age are hospitalized each year, a rate almost twice that for nondiabetic elderly people (Harris, 1990a, 1990b).By any measurement, diabetes is a major health concern for older adults in this country (Haan & Weldon, 1996), yet one-third of those affected by the disease are unaware they have it (CDC Diab etes Cost-Effectiveness Study Group, 1998). Information is limited about people who have diabetes but are not yet in treatment. Undiagnosed diabetes in older adults presents a challenge, as this group's elevated blood sugar levels seem to carry an elevated risk of morbidity and mortality compared with those of older adults with a diagnosis of diabetes who are in treatment. In a comparison study of older men and women who were not previously known to have diabetes and older men and women who had diabetes, one-third of undiagnosed people had elevated serum glucose levels compared with those already diagnosed (DECODE Study Group, 1999).

RACIAL AND ETHNIC FACTORS

A number of cross-sectional and prospective studies have found that the risk factors for development of type 2 diabetes among African Americans, Hispanics, and Native Americans are approximately2, 2.5, and 5 times greater, respectively, than for white people (Haffner, 1998; Harris, Eastman, Cowie, Flegal, & Eberhardt, 1999; Harris, Sherman, & Georgopoulos, 1999). Lower socioeconomic status (SES) has been associated with risk of developing the disease (Gaillard, Schuster, Bossetti, Green, & Osei, 1997) as well as with the prognosis for compliance with treatment and achieving control of blood glucose levels (Hooyman & Asuman, 1999; Terpstra & Terpstra, 1998). There is also evidence that racial and ethnic differences may influence the severity of the disease and its complications. For example, one study noted that people of minority racial and ethnic groups had higher glycohemoglobin levels than white people (Delamater et al., 1999). Harris s review indicated that black people experience vision loss, amputations , and renal disease rates one and a half to four times higher than white people (Harris, 1990b). Harris also found that white people with diabetes have approximately 40 percent more visits to office-based physicians each year than people of color (Harris, 1990b), suggesting differences in access to and use of health care services. In a national survey, Mexican American men and African American women had the poorest glycemic control and were least likely to self-monitor blood glucose levels compared with other patient subgroups (Harris, Eastman, et al., 1999). African Americans, Hispanic people, and Native Americans have higher insulin sensitivity than white people. There is also evidence that cultural factors and SES differences contribute to increased obesity in these populations, which may lead to insulin resistance (Haffner, 1998).

PSYCHOSOCIAL FACTORS

Despite some conceptual disagreementwiththeway the term "social support" is defined (Antonucci, Ajrouch, & Janevic, 1999), gerontological researchers are interested in social support mechanisms because of their potential usefulness in the assessment of care, health maintenance, and sustained independent living of older adults. Social support can be given as well as received (Bertera, 1997). Kahn and Antonucci (cited in Sauer & Coward, 1985) suggested that social support networks are in force over the entire life span but that the structure, the participants (for example, central figures), or both may be subject to change. Social support plays a positive role in compliance health behaviors (Belgrave & Lewis, 1994) and is important to health, particularly in older populations (Antonucci et al., 1999). Several studies have documented the importance of social support in glycemic control in noninsulin-dependent diabetes mellitus among white, black, and Hispanic patients (Eriksson & Rosenqvist, 1993; Ford, Tilley, & McDonald, 1998; Fukunishi, Akimoto, Horikawa, Shirasaka, & Yamazaki, 1998; Fukunishi, Horikawa, et al., 1998; Garay-Sevilla et al., 1995; Griffith, Field, & Lustman, 1990; Littlefield, Rodin, Murray, & Craven, 1990; Lyons, Perrotta, & Hancher-Kvam, 1988; Maxwell, Hunt, & Bush, 1992; Mengel, Connis, Gordon, Herman, & Taylor, 1990). These findings are consistent with a substantial body of evidence that indicates that strong and supportive social relationships are associated with the health of individuals who live within such social contexts (L. Berkman, 1995).

For the purposes of this study, social support is defined as informal social participation that occurs as part of natural social interaction. This support includes a network of individuals represented by contacts with friends, family, and neighbors, as well as interactions during attendance at church and as a member of social groups.

Some evidence suggests that social support may be more critical to morbidity and mortality risks in Hispanic versus non-Hispanic people. A two-year follow-up study of postmyocardial infarction patients showed that mortality risk among the individuals with low social support scores was …

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Publication information: Article title: Psychosocial Factors and Ethnic Disparities in Diabetes Diagnosis and Treatment among Older Adults. Contributors: Bertera, Elizabeth M. - Author. Journal title: Health and Social Work. Volume: 28. Issue: 1 Publication date: February 2003. Page number: 33+. © 1999 National Association of Social Workers. COPYRIGHT 2003 Gale Group.

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