Etiology Of Disparity In The Complications Of Diabetes

The reasons for high prevalence of diabetic complications in the high-risk ethnic populations may be attributable to genetic and acquired factors. The observation of familial clustering of diabetic microvascular complications, particularly nephropathy, has raised the possibility of a heritable genetic predisposition in the minority patients as the underlying cause of disparity in diabetic complications. However, the Diabetes Control and Complications Trial showed conclusively that proper glycemic control (hemoglobin A1c <7%) resulted in 50% to 70% reduction in the risk of microvascular complications (39). Similarly, the United Kingdom Prospective Diabetes Study (UKDPS) demonstrated that good glycemic control diminished the risk of doubling of serum creatinine by 74% (40). These findings were further substantiated in Japan by the Kumamoto study (41). The robust effect of glycemic control on the incidence of target organ damage in diabetes clearly indicates that genetic predisposition may be permissive, but not an obligate determinant of the risk for developing microvascular complications. In the NHANES III retinopathy data (7), the disparity in the prevalence of retinopathy became insignificant after adjusting for risk factors for retinopathy such as chronicity of diabetes, hemoglobin A1c level and blood pressure.

Acquired factors that may contribute to the excess burden of diabetic complications in minority populations include non-adherence to therapeutic recommendations, low socioeconomic status and suboptimal quality of care. It may appear plausible that poor compliance with therapeutic recommendations would account for the excess burden of diabetic complications in high-risk groups, but studies have not shown any evidence of racial differences in adherence to medications and lifestyle modification (42), or compliance with

TABLE 2 Diabetes Management: Patient Compliance and Practices by Ethnicity3

African American (%)

Missed clinic

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