Most older Americans struggle to keep their diabetes under control, and serious racial disparities remain in hitting targets, according to a new study. Most of the more than 5,000 patients in the study met targets for hemoglobin A1c levels (72%), for LDL cholesterol levels (63%), and for blood pressure (73%), but only 35% met all three, reported Christina Parrinello, MPH, a PhD candidate at Johns Hopkins Bloomberg School of Public Health in Baltimore, and colleagues. In addition, a higher proportion of whites than blacks met the targets, and among patients treated for risk factors, there were disparities in terms of race (strong but nonsignificant trends in some cases): Prevalence ratios were 1.03 for HbA1c (95% CI 0.91-1.17), 1.21 for LDL cholesterol (95% CI 1.09-1.35), 1.10 for blood pressure (95% CI 1.00-1.21), and 1.28 for all three (95% CI 0.99-1.66).
The findings appeared in the July issue of Diabetes Care. “Many older adults with diabetes are not meeting recommended treatment targets for hemoglobin A1c, blood pressure, and cholesterol,” according to Parrinello.
“However, a one-size-fits-all approach may not be ideal for this heterogeneous population,” she added. “We need to think about whether older adults are currently being over- or under-treated, and whether individualized targets may be more appropriate.” The targets for risk factor control among older adults have been controversial, noted the authors, partly because the evidence for the targets comes from trials of middle-aged adults. “These findings may not apply to older adults with diabetes who may not live long enough to experience the full microvascular benefits of tight glycemic control,” wrote the authors. Alternative, less stringent targets have been proposed. For those, 90% of patients met the target for HbA1c, 86% for LDL cholesterol, 87% for blood pressure, and 68% for all three.
The racial disparities remained with the relaxed targets, however. Data were taken for the Atherosclerosis Risk in Communities Study, which began in 1987. About a third of the patients had diagnosed diabetes, of which the mean age was 75; 44% were male, and 29% were black. In addition, among those with diabetes, those who were taking glucose-lowering medication were more likely to be black, male, and obese and have lower education and income than those not taking medication. About a quarter of those with diabetes were taking insulin. The American Diabetes Associations has established risk factor targets for people with diabetes: HbA1c at <7% (or <53 mmol/mol), LDL cholesterol at <100 mg/dL, systolic blood pressure at <140 mm Hg, and diastolic blood pressure at <90 mm Hg.
The alternative guidelines are less stringent: HbA1c <8% (<64 mmol/mol), LDL cholesterol <130 mg/dL, systolic blood pressure <150 mm Hg, and diastolic blood pressure <90 mm Hg. (These blood pressure targets are those recommended — controversially — by the experts appointed to the Eighth Joint National Committee.) In the study, HbA1c and cholesterol were measured in the laboratory during visits.The authors found that black women were the least likely of the group divided by race and sex to have risk factors that were at or below the treatment targets. Those with diabetes for more than 15 years were less likely to hit the HbA1c and blood pressure targets compared to those who had diabetes for a shorter period.
White and black men had similar rates of hitting all three of the targets (prevalence ratio 0.95, 95% CI 0.69-1.32) but white women were more likely than black women to meet all three (1.58, 95% CI 1.08-2.32). Similarly, there was no significant difference by race in who met the blood pressure targets, but there was in women.
When the less stringent targets were taken into account, many of the same patterns held. The authors noted that educational differences could not entirely explain the racial disparities in controlling of risk factors. “There could be racial differences in access to health care or treatment approaches, as well as medication adherence, which could contribute to the observed racial disparities in risk factor control,” they wrote. They added that it’s still not clear whether alternative, less strict targets should be considered. “There is growing emphasis on the need for individualized treatment targets but it is unclear how to optimize treatment in older adults to maximize health benefits and minimize adverse outcomes,” they said.
Elizabeth Selvin, MPH, PhD, of Johns Hopkins University and senior author of the study, added in a press release that more research needs to be done. “Are some older adults being over-treated? Are some being undertreated? These are questions for which we don’t have answers,” she said. Researchers noted that the blood pressure guidelines have changed over time, and they were different at the time the data began to be collected, which may be an important limitation to the study. Another limitation is that most of the black patients were recruited from only two sites. In addition, those with poorly controlled diabetes may have been less likely to make an appointment, thus eliminating themselves from the data pool.
Tip of the Day
Foods to eat more often. Eat more vegetables, fruits, whole grains, and fat-free or 1% milk and dairy products. These foods have the nutrients you need for health including potassium, calcium, vitamin D, and fiber. Make them the basis for meals and snacks.