DIABETES IN URBAN AFRICAN-AMERICANS .3. MANAGEMENT OF TYPE-II DIABETES IN A MUNICIPAL HOSPITAL SETTING

OBJECTIVE: Management of type II diabetes is difficult, particularly i n urban populations with limited resources and access to care. To eval uate the effectiveness of structured care delivered by non-physician p roviders, patients were studied prospectively for 6 months in a munici pal hospital diabetes clinic. DESIGN AND METHODS: The population was a pproximately 90% African American and had median known diabetes durati on of approximately 1 year, 54% had incomes below the Federal Poverty Guideline. Primary management was provided by nurse-practitioners anti dietitians, and primary outcome measures were hemoglobin A1c (HbA1c), fasting plasma glucose, and changes in body weight. RESULTS: Response s were analyzed in 325 new patients returning for visits at 2, 4, 6, a nd 12 months; metabolic profiles at presentation were similar to those of subjects who missed intervening visits. Lean patients largely cont inued on pharmacologic therapy and improved HbA1c from 9.4% to 7.4% at 2 months (P < 0.001), remained stable through 6 months, then rose to 7.9% at 1 year. Obese patients (71%) received dietary instruction. Wea ning of pharmacologic therapy was attempted for the first 2 months, re sulting in a decline of HbA1c from 9.6% to 8.0% (P < 0.001), with 70% treated with diet alone. In the obese, HbA1c continued to decrease thr ough 6 months (7.7%). Thereafter, providers saw patients at their own discretion and intensified therapy as needed. Although by 1 year, HbA1 c had risen to only 8.2%, some patients required reinstitution of phar macologic therapy; 59% were on diet alone. While 52% lost 4 lb or more (mean 9.3) by 2 months, little additional weight was lost. Interestin gly, glycemic control was improved both in those who lost greater than or equal to 8.5 lb in the first 2 months (HbA1c 9.6% to 8.1% at 12 mo nths), and in those who gained weight (HbA1c 10.2% to 8.2%). In the ob ese patients using pharmacologic agents at presentation, 35% were able to discontinue oral agents or insulin by 1 year, with good glycemic c ontrol (HbA1c <8%). For patients who were initially on diet alone, a f asting plasma glucose >177 mg/dL predicted the need for pharmacologic therapy with 97% certainty. CONCLUSIONS: In urban African American pat ients, nonpharmacologic management of type II diabetes substantially i mproves metabolic control; decreases in HbA1c are comparable in those who do and do not lose weight. Therapy managed by nonphysician provide rs can be an effective cornerstone of diabetes care in this socioecono mically disadvantaged population.