African-Americans have increased prevalence of both diabetes and diabetic complications. Since many patients have poor metabolic control, novel interventions are needed, especially for urban patients with limited resources and literacy. Recent critical findings in - 1500 new patients in the Grady Diabetes Unit: (1) At presentation, HbA1c average 9.1% - similar to DCCT """"""""standard therapy"""""""" patients. (2) 3% of patients have renal insufficiency, 5% have urine protein > 300 mg/24 hr, and 26% have > 30 mg.24hr - early evidence of complications. (3) 62% of obese patients are using pharmacologic agents at presentation, vs. only 30% after 6 months. (4) Patients managed with diet alone exhibit mean HbA1c 6.7% and FPG <150 after 6 months, and patients requiring drug therapy improve with both oral agents and insulin. (5) Improvement in control is comparable in patients who lose weight and those who do not. These outcomes contrast with care in -1400 patients in our primary care centers - where HbA1c is ordered on only 50% of patients, and averages 9%. We question whether an emphasis on weight loss is essential in our population, and we hypothesize that successful Diabetes Units approaches can be translated into effective interventions in the primary care setting. 1. To determine if an emphasis on weight loss is necessary, we will compare regimens stressing nonquantitative reduction in simple sugars, saturated fats, and cholesterol with and without emphasis on weight loss, and assess outcomes related to both metabolic control (HbA1c) and compliance (follow-up, satisfaction, quality of life). 2. To improve primary care of diabetes, we will focus on both providers and patients, using a systems model. a) We will assess structural and process variables, as well as environment, in Diabetes Unit and primary care settings, to identify factors that will be targeted to enhance provider organization, attitudes, and adherence. b) We will also develop culturally sensitive, low literacy level educational materials to facilitate glucose monitoring and diet critical to patient involvement. Before and after these interventions, we will test outcomes related to both microvascular disease (HbA1c) and macrovascular disease (BP, lipid levels), assess proteinuria as a complication, and evaluate patients adherence and quality of life in both the Diabetes Unit, and two a complication, and evaluate patient adherence and quality of life in both the Diabetes Unit, and two primary care sites - a hospital-based clinic and a neighborhood health center. These studies should delineate approaches effective in primary care settings, together with specific management strategies, as needed to improve care and prevent complications in urban African-Americans with NIDDM.
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