A Note from the Editor

In this issue of JHCPU, we see researchers, policymakers, and clinicians grappling with some of the gritty issues that underlie addressing the health needs of the medically underserved in the 21st century. Part 1 is titled Diabetes, Part 2 is titled Health Policy and Epidemiology, and Part 3 is Clinical Care. Much of what is covered in Parts 2 and 3 also has some relevance to the challenges posed by diabetes and the metabolic syndrome generally, especially for minority populations.

Diabetes

“There are 57 million Americans who have pre-diabetes, in addition to the 23.6 million with diabetes,”^{1, p. 1} reports the American Diabetes Association, most of them with type 2 diabetes, and disproportionate numbers of them in low-income and minority groups.^2,3 Approximately 15% of people receiving care at Indian Health Services clinics have diabetes (and over 30% of some American Indian groups in Arizona), as do approximately 12% of non-Hispanic Blacks, Puerto Ricans, and Mexican Americans, in comparison with 6.6% of non-Hispanic Whites.^2,4 Furthermore, minority women tend to be at even further increased risk than minority group members in general.⁵ The rate of diabetes in the entire U.S. population age 60 years and older is above 18%. Notably, the total prevalence of this chronic condition in the U.S. and other developed countries greatly outstrips its prevalence world wide (∼2.8% of the world population), as rates rise with urbanization and associated changes in diet and exercise. In fact, the disease is now so widespread in the U.S. that it is widely considered an epidemic.⁵ Diabetes is financially costly (estimated total annual economic cost of diabetes in 2007: $174 billion)² and can be personally devastating due to associated complications and outcomes (including cardiovascular disease, limb amputation, kidney disease, and blindness) and premature mortality.¹

With other conditions encompassed by the so-called metabolic syndrome (including obesity, blood fat disorders, and hypertension) diabetes poses a central threat to public health in the U.S. and is likely to do so for the foreseeable future.

Two papers in the Diabetes section of the present issue inquire about patients’ views of the disease and using the Community Health Worker model in planning long-term care. Cavanaugh et al. conducted in-depth interviews with Native American men at tribal clinics to understand better their views of health and diabetes, and report on that work here. Cherrington et al. brought front and center the Community Health Worker (CHW) model as a tool for reaching vulnerable populations with diabetes. The research team reviewed the literature to identify existing programs and then conducted in-depth interviews with the directors of the eight programs that appeared relevant. The authors found that CHW roles, responsibilities, and training, and patient outcomes, varied greatly across the programs. They conclude that work must be conducted to determine how best to integrate the promising CHW model into chronic disease management. Culica et al.’s paper makes a start: they report that a CHW-based diabetes education program in a low-income Hispanic community appears feasible. The authors argue that the significant improvements in hemoglobin A1c scores in patients who completed one year of the program suggest that a CHW can serve as the primary diabetes educator in the absence of more highly trained personnel.

The other three papers in the Diabetes section help to establish risk factors and target particular sub-populations for future interventions. Chew et al., in an important national comparative study of diabetes outcomes in six public hospitals serving vulnerable populations, identify disparities along both racial/ethnic and insurance status lines: non-White patients and patients who had never been insured were most at risk for poorer glycemic and lipid control. Smith et al. took a different approach, comparing early-onset (n=417, diagnosed before age 30) and later-onset (n=968, diagnosed at ages 50–58) type 2 diabetes patients in an urban setting on clinical and social measures. They found the bigger problems in the early-onset group: higher levels of hemoglobin A1c, more likely to smoke, more likely...