A disparate burden  pg. 4

But food can be more than mere sustenance. Holidays, reunions, weddings, funerals. Saturday picnics and Sunday dinners. Gatherings of family and friends often revolve around special meals, rich with tradition and steeped in cultural meaning.

“A meal is often a cultural event,” says Marilyn Skaff, Ph.D., associate adjunct professor of Family and Community Medicine at the University of California, San Francisco. “Within the Chinese American population, for instance, the family gathers and eats from one big pot, making it very difficult to measure amounts eaten and calories consumed.”

African Americans in her community also talk of how tough it is to stick to a diet when they go to family gatherings, she says. “Convincing people to change this part of their life is very difficult.”

“It is a tough, tough disease to live with,” says nurse practitioner Anne Brown. “I can’t think of any other disease where we ask people to do so much to take care of themselves.”

Brown sees referral patients in her endocrinology practice as part of the Diabetes Improvement Program, part of the Vanderbilt-Eskind Diabetes Clinic. The nurse practitioner-run program aims to help patients fine-tune their glucose control.

With the help of dietitians, the advanced care nurses intensively counsel patients over a three-month period, meeting weekly to adjust medication regimens and facilitate lifestyle changes. Once glycemic targets are achieved, patients return to the care of their primary physicians.

A similar program, conceived through an alliance between Nashville’s historically black Meharry Medical College and Vanderbilt, exists at local “safety net” clinics to ensure that every diabetic patient receives a recommended standard of care, which includes annual measurement of hemoglobin A1c, cholesterol, weight, and blood pressure, in addition to a kidney function test and eye and foot exams.

“There is no aspect of these patients’ lives that diabetes does not touch and that they don’t have to make adjustments for,” says Brown.

The demands of the disease can cause frustration and anxiety in patient and family, leading to marital strife and other stresses. Feelings of helplessness can overwhelm, and depression is common, especially at diagnosis and later, at the onset of long-term complications.

Addressing patient's perceptions of mastery and control of their diabetes affect their self-care and outcomes of the disease is the research focus of M. Kathleen Figaro, M.D., assistant professor of Medicine at Vanderbilt.

She is interested on how psychological states can be measured and how interventions can increase self-perception of mastery and can improve previous feelings of learned helplessness. “Empowered patients do better with diabetes management,” Figaro says.

Both physical and psychological variables can influence disease outcomes. Without sufficient knowledge, positive attitudes and active behaviors, patients may receive adequate care but still fail to experience the best outcomes. Perhaps this accounts for some of the racial disparities seen in diabetes outcomes, she says.

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