Year trärä. White Male White Female

Black Male ■ Black Female

FIGURE 2 Age-adjusted mortality rates for diabetes as underlying cause of death by race and sex, U.S. 1980-1996. Source: From Ref. 1.

accounts for 44% of all new cases of ESRD, 60% to 70% of cases of neuropathy and more than 60% of non-traumatic lower limb amputations in the United States (1,12). Ethnic disparity in the prevalence of type 2 diabetes translates to increased burden of diabetic complications in minority populations. Long-term complications of diabetes can be classified into micro-vascular and macrovascular complications. Diabetes-specific microvascular complications, which include, retinopathy, nephropathy and neuropathy require chronic hyperglycemia to occur. About 25% of patients with type 2 diabetes already have evidence of microvascular complications at the time of diagnosis (3). Data from the third National Health and Nutrition Examination Survey (NHANES III) showed that prevalence of diabetic retinopathy was 46% higher in African Americans and 84% higher in Mexican Americans, compared with non-Hispanic whites. Ethnic minority populations also had more advanced retinopathy and higher levels of putative risk factors compared with Caucasians (7). However, the age-adjusted prevalence of visual impairment is 19.5% for whites, 16.7% for Hispanics and 19.1% for African Americans (1).

The rates of ESRD are approximately threefold higher in African Americans, Latinos and Native Americans compared with Caucasians (13). Between 1984 and 2002, the incidence of treatment for ESRD attributable to diabetes was highest among African-American males (1). Diabetic nephropathy is heralded by microalbuminuria, which can be reversed by tight glycemic control and blood pressure control using angiotensin-converting enzyme-inhibitors or angiotensin-receptor blockers. Moreover, microalbuminuria may precede ESRD by nearly two decades, thus affording a window of opportunity for the prevention of ESRD in diabetic patients (3).

Diabetic neuropathy occurs in nearly 30% of patients with diabetes aged 40 years or more (1). It results in impaired sensation, which manifests as numbness, parasthesia and pain in the feet and hands. Diabetic autonomic neuropathy leads to delayed digestion of food due to gastroparesis. Neuropathy, sometimes acting in concert with peripheral vascular disease is a major contributor to diabetes-related non-traumatic lower extremity amputation. Loss of protective pain sensation predisposes to injury, polymicrobial infection and gangrene, which may require amputation to preserve life. Although the rates of hospitalization for lower extremity ulcers are similar in all ethnic groups, amputation rates are two to three times higher in African Americans and Hispanic patients compared with American whites (14). In 2002, the age-adjusted lower extremity amputation rate per 1000 persons with diabetes was 5.3 in

African-Americans and 4.1 in Caucasians (1). Gangrene and amputation in patients with established diabetic neuropathy can be prevented by screening using 5.07 monofilament, to identify patients at high-risk, who would benefit from diligent foot care (15).

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