Type 2 Diabetes and Black Women - Today's Dietitian Magazine

July 2019 Issue

Diabetes Management & Nutrition Guide: Type 2 Diabetes and Black Women
By Constance Brown-Riggs, MSEd, RD, CDE, CDN
Today’s Dietitian
Vol. 21, No. 7, P. 40

An understanding of their unique cultural differences can help reduce disparities and lead to better health outcomes.

Of the 23.1 million adults who have been diagnosed with diabetes in the United States, 3 million are black. One-quarter of black women older than age 55 have diabetes, and nearly 12% of all black women aged 20 and older have the disease. What’s more, black people suffer greater consequences from the complications of diabetes. For example, they experience kidney failure four times more often than white Americans with diabetes. They’re twice as likely to suffer from diabetes-related blindness and more likely to experience amputations.1 Black women are especially at risk of diabetes due to the high prevalence of overweight and obesity, lack of physical activity, high blood pressure, and high cholesterol among this population.2

Diabetes not only affects black women in different ways genetically and physiologically, but they also cope with the disease within a distinct cultural context. Their relationships with health care providers, their approach to diet and exercise, their eating habits, even their spirituality and behavior patterns are unique—and all of this has an impact on how they approach a diabetes diagnosis and manage their health. So it’s essential for diabetes educators to recognize and understand the cultural context in which black women cope with diabetes.

This article will discuss the diabetes disparities in black women, highlight the unique cultural differences that may influence disparities, and provide strategies for diabetes educators to help reduce the prevalence of diabetes disparities in this population.

Relationship With Health Care Providers
Many factors contribute to health disparities in black women. One explanation is a longstanding mistrust of the medical community—and understandably so. For example, there was the notorious Tuskegee experiment, in which poor black men were unknowingly infected with syphilis and allowed to live with the deadly infection so doctors could track the life history of the disease. Black Americans who know of the study report a greater mistrust of medicine and research.3

“The African American community has historically had very unique negative experiences with health care providers,” says Tamara Melton, MS, RDN, cofounder of Diversify Dietetics, Inc, a group dedicated to increasing ethnic and racial diversity in the dietetics field. “Nutrition professionals who aren’t knowledgeable and sensitive to these experiences and beliefs may have a hard time gaining the trust and confidence of their clients and patients.”

Another disturbing explanation for health disparities in black women is implicit or unconscious bias on the part of health care providers. Even when there’s a desire to provide equitable care, nutrition professionals may unintentionally interact with their black patients less effectively than with white patients.3

“Implicit bias can manifest as a provider brushing off a patient, making negative assumptions that affect the quality of care they receive, or not seeing any value in integrating black/ethnic cultural foods into a healthy meal plan,” says Ariel Lawrence, creator of Just a Little Suga (www.justalittlesuga.com), a blog created to shed light on the experiences of individuals of color and marginalized communities affected by diabetes.

The most successful diabetes self-management programs often include practitioners who culturally identify with the population they serve.4 Yet, the nutrition and dietetics professionals in the Academy of Nutrition and Dietetics don’t resemble the black community. According to 2019 demographic information from the Commission on Dietetic Registration, 81% of RDs are white, and only 4% of RDs identify themselves as black or African American. The American Association of Diabetes Educators 2017 member survey reflects a similar demographic: 85% of its members are white, and only 4% identify as black or African American.

These statistics don’t preclude RDs from working effectively with black women. However, it does require an acknowledgment that everyone has implicit biases and that those biases may affect day-to-day decision making and interactions with patients. Admittedly, this is difficult for most practitioners to accept, but numerous studies show that health care provider bias contributes to health care disparities.5 “By definition, there has to be implicit bias in health care,” says Tracey D. Brown, CEO of the American Diabetes Association. “But the more you are aware of implicit bias, the more opportunity you have to disrupt it,” Brown says. Therefore, RDs and diabetes educators must carefully assess their biases and beliefs.

Mindset and Spirituality
Black Americans tend to be a community of believers in God—and this spiritual foundation that sets the tone for their lives has an impact on how they feel about physical afflictions, healing, and the relationship between faith and medicine.6

Many black women approach health challenges as a test of their faith or spiritual beliefs. Many believe they can rely on their faith to bring blessings into their lives or push unwanted circumstances away, and use the colloquial phrase “I’m not claiming it” to mentally dismiss an illness. The phrase is designed to help fortify oneself mentally and spiritually when fighting a disease. However, using the phrase “I’m not claiming it” to dismiss or ignore the illness may result in failure to seek care.6

“Some in the African American community may choose to forgo or delay traditional medical treatments for conditions such as diabetes in favor of spiritually focused treatments such as prayer,” Melton says. Therefore, it’s imperative for the diabetes educator to assess the patient’s beliefs about diabetes, its cause, and how the patient believes it should be treated.

Phyllisa Deroze, PhD, a global diabetes patient advocate, says her initial perception of diabetes was that it happened to seniors and, like all illnesses, could be cured by God. “I didn’t know that once a person was diagnosed with diabetes that they would have it until death because I grew up in a Pentecostal church where we rebuked everything. The churchgoers that rebuked cancer and came back to tell their testimonies were no different to me than those that ‘didn’t claim’ having diabetes,” says Deroze, who has type 2 diabetes.

What’s important to note among black women of faith or those who don’t rely on faith to deal with an illness is that people with diabetes are at increased risk of depression and other psychosocial difficulties such as anxiety compared with the general population.7 Studies show that significant depressive symptoms affect approximately 1 in 4 adults with type 1 and type 2 diabetes.8 Women are almost twice as likely as men to have depression, and black women experience higher rates of depression than white women.9 Depression impairs quality of life, adds to the difficulties experienced in diabetes self-management, and is a known risk factor for noncompliance with medical treatment.8,10

Lawrence, who was diagnosed with type 1 diabetes one month shy of her 16th birthday, had experienced episodes of anxiety and depression. Her first episode of depression occurred during her freshman year of college. “I registered for a therapy session, where I hesitantly identified with many of the feelings associated with depression,” Lawrence says.

The myths and stigma that surround depression in the black community along with faith can keep black women from getting proper treatment. One common misconception is that when a black woman suffers from a mental disorder, she’s weak, and weakness in black women is intolerable.11 Cultural habits and historical experiences can cause depression to be expressed and addressed differently among black women.12

However, Lawrence wasn’t concerned about stigma when she entered therapy. “Ever since I was a child, I’ve known family members who benefited from therapy,” Lawrence says. So when she found herself in “a debilitating quarter-life crisis,” she didn’t hesitate to start therapy again. “While I’m currently in a much better mental-emotional state, I’ve still kept up with my therapy sessions, as it’s been instrumental in teaching me to be more kind and forgiving to myself.”

Black Americans also may use the church, family, friends, neighbors, and coworkers to cope with mental health problems.13 In many cases, they seek treatment from ministers and physicians as opposed to mental health professionals.12

“I attended a church that preached about God’s ‘healing hand’ but also openly discussed … that sometimes God isn’t enough. Therapy and medicine were welcome resources,” Lawrence says.

But perhaps a more balanced view for black women who are spiritually minded and have a strong faith is that they must realize that the God they serve often works through medical personnel, such as doctors and mental health professionals, whose services can lead to their healing.

Weight Management, Nutrition, and Exercise
Another hindrance that contributes to diabetes disparities is the obesity epidemic, which continues to worsen nationally, and black women are the hardest hit. According to the 2017 National Center for Health Statistics report, the prevalence of obesity in black women is 54.8% and is expected to increase to 70% by 2020.14

Genetics, diet, physical activity, psychological factors, stress, income, and discrimination, are associated with higher rates of obesity among black Americans.15 Moreover, the Black Women’s Health Study suggests that black women experience racism more than whites, which also may contribute to the increased prevalence of obesity in black women.14

Perception of overweight and obesity among black women is another factor. “African American women have different standards of beauty than the mainstream white standard,” Melton says. “Being curvy and ‘thick’ is celebrated in the African American community, even if that means being at a weight that is considered clinically overweight or even obese,” Melton says.

These cultural definitions of overweight and obesity may prevent awareness among black women about the potential health benefits of weight loss.16

RDs should work to uncover the clients’ motivations, then explain how losing weight will improve diabetes management.

Nutrition
One of the ways to help lose and manage weight is through healthful eating, or proper nutrition, as nutrition is the cornerstone of diabetes self-management and, for many individuals with diabetes, the most challenging part of the treatment plan—particularly when the RD lacks knowledge of cultural foodways. Deroze suggests that, when counseling black women, RDs should spend time asking questions about their foodways and not just their food choices. “I’ve probably been to see an RDN three to four times in my life and only one knew what grits were, and none of them knew that collards are eaten together with cornbread using your fingers. To suggest that one only eats collards isn’t understanding the cultural foodways,” Deroze says.

“RDs should focus on learning as much as they can about their clients’ and patients’ preferences, beliefs, motivations, and barriers around food, nutrition, and physical activity,” Melton says.

Physical Activity
Regular activity is essential for overall fitness, weight management, and blood glucose control. However, only one-third of black women meet the national guidelines for exercise.17

Studies show that barriers to engaging in physical activity among black women include lack of time or knowledge, tiredness, health concerns, physical appearance, maintaining their hairstyle, and the cost of using exercise facilities.17 “The desire to maintain a hairstyle as long as possible may mean avoiding sweat-inducing physical activity for days or weeks at a time. Barriers such as these are why understanding cultural beliefs is so important when working with African American women,” Melton says. “RDNs may do well to reach out to African American colleagues if they need assistance providing adequate care to their clients and patients,” Melton adds.

The Diabetes Online Community
In addition to weight management, proper nutrition, and physical activity, online or in-person peer support is a valuable part of diabetes self-management. “No one can do this [manage diabetes] alone,” says Brown, who’s been living with type 2 diabetes for 15 years. “As important as health care providers are, it’s equally as important to have a support system that’s there for you. Among the pricks, sticks, and stigma associated with diabetes, there are good days and bad days. Support is critical, not only for encouragement and accountability, but sometimes just for an ear to listen.” A review of the literature found that diabetes online communities (DOC) were associated with neutral or lower A1c measurements; positive psychosocial support by way of shared experience, social support, and empowerment; and behavior change such as increasing self-care activities and feeling motivated and accountable. Surprisingly, the review also found misinformation in DOCs occurred only 0% to 9% of the time.18

Although DOCs may be valuable for people with diabetes, most don’t meet the cultural needs of black women. To remedy the situation, there’s a growing community of black women and other women of color supporting one another in the DOC.

In her pursuit of a “diabetes tribe and as a black woman,” Lawrence seldom found individuals who looked like her. She found it hard to understand why the voices of people of color were few and far between. So Lawrence started the online project “Diabetics on the Margin: Celebrating Diversity Within the Diabetes Community” to elevate the narrative of women of color with diabetes. You can find Lawrence on Facebook, Twitter, or Instagram @justalittlesuga.

Deroze also is active in the DOC. When she realized her health care providers weren’t culturally sensitive to her needs—or those of others with diabetes—she created “Black Diabetic Info” to provide accurate, culturally competent information about diabetes in black communities. “I wanted to fill in the gaps that I saw. There were questions I had and couldn’t find answers online easily, and I wanted to make sure that the next person [diagnosed with diabetes] didn’t fall into the same situation,” Deroze says. You’ll find Deroze on Twitter @not_defeated and Instagram, Facebook, and YouTube @BlackDiabeticInfo.

Cherise Shockley, a pioneer in the DOC, is a well-known social media advocate for people with diabetes. She’s the founder of Diabetes Social Media Advocacy, an online platform whose mission is to promote social media networking in all its forms such as Facebook, Twitter, Instagram, and YouTube. “WOC Diabetes” is one of her latest projects. “I started WOC Diabetes to highlight women of color who live with diabetes, change the narrative, and to help them advocate for themselves and their family members. My hope is sharing stories will empower women and make sure WOC has a seat at the table,” Shockley says. Dietitians can find Shockley on Instagram @SweeterCherise or @wocdiabetes, and Twitter @SweeterCherise, @wocdiabetes, and @diabetessocmed where she runs a Twitter chat every Wednesday at 9 pm EST.

Diabetes Realities
Diabetes can cause serious complications and premature death and is one of the leading causes of death and disability in the United States, especially among black women. Many factors contribute to diabetes disparities in black women, including mistrust of the medical community and health care provider bias. Mindset and spirituality can have a significant impact on black women’s approaches to diabetes self-management. To decrease diabetes disparities in these women and improve outcomes, diabetes educators and RDs must understand the cultural context in which black women cope with diabetes. “See us, listen to us, and affirm us,” Lawrence says.

— Constance Brown-Riggs, MSEd, RD, CDE, CDN, is chair of the Diabetes Care and Education Dietetic Practice Group of the Academy of Nutrition and Dietetics and author of the award-winning Diabetes Guide to Enjoying Foods of the World, a convenient guide to help people with diabetes enjoy all the flavors of the world while still following a healthful meal plan.

References
1. Centers for Disease Control and Prevention. National Diabetes Statistics Report, 2017: estimates of diabetes and its burden in the United States. http://www.diabetes.org/assets/pdfs/basics/cdc-statistics-report-2017.pdf. Accessed May 10, 2019.

2. Black women & diabetes — more than a little sugar. Black Women’s Health Imperative website. http://www.blackwomenshealth.org/issues-and-resources/black-women-diabetes-more-than-a-little-sugar/_print_y.html. Accessed May 10, 2019.

3. Zestcott CA, Blair IV, Stone J. Examining the presence, consequences, and reduction of implicit bias in health care: a narrative review. Group Process Intergroup Relat. 2016;19(4):528-542.

4. Goode P, Bartlett R, Wallace D. The value of diabetes self-management programs for African Americans in community-based settings: a review of the literature. Int J Faith Community Nurs. 2017;3(1):20-34.

5. Confronting bias. Georgetown University National Center for Cultural Competence website. https://nccc.georgetown.edu/bias/module-4/1.php. Accessed May 10, 2019.

6. Spruill IJ, Magwood GS, Nemeth LS, Williams TH. African Americans’ culturally specific approaches to the management of diabetes. Glob Qual Nurs Res. 2015;2:2333393614565183.

7. Gonzalvo JD, Hamm J, Eaves S, et al. AADE Practice Paper: a practical approach to mental health for the diabetes educator. https://www.diabeteseducator.org/docs/default-source/practice/practice-documents/practice-papers/a-practical-approach-to-mental-health-for-the-diabetes-educator.pdf?sfvrsn=2. Published 2018. Accessed May 10, 2019.

8. Holt RIG, de Groot M, Golden SH. Diabetes and depression. Curr Diab Rep. 2014;14(6):491.

9. Brody DJ, Pratt LA, Hughes JP; Centers for Disease Control and Prevention. NCHS Data Brief: prevalence of depression among adults aged 20 and over: United States, 2013–2016. https://www.cdc.gov/nchs/products/databriefs/db303.htm. Published February 2018. Accessed May 10, 2019.

10. Naicker K, Johnson JA, Skogen JC, et al. Type 2 diabetes and comorbid symptoms of depression and anxiety: longitudinal associations with mortality risk. Diabetes Care. 2017;40(3):352-358.

11. Depression and African Americans. Mental Health America website. https://www.mentalhealthamerica.net/conditions/depression-and-african-americans. Accessed May 10, 2019.

12. African-American women and depression. PsychCentral website. https://psychcentral.com/lib/african-american-women-and-depression/. Updated October 8, 2018. Accessed May 10, 2019.

13. Ward EC, Clark le O, Heidrich S. African American women’s beliefs, coping behaviors, and barriers to seeking mental health services. Qual Health Res. 2009;19(11):1589-1601.

14. Cozier YC, Yu J, Coogan PF, Bethea TN, Rosenberg L, Palmer JR. Racism, segregation, and risk of obesity in the Black Women’s Health Study. Am J Epidemiol. 2014;179(7):875-883.

15. Byrd AS, Toth AT, Stanford FC. Racial disparities in obesity treatment. Curr Obes Rep. 2018;7(2):130-138.

16. Lynch EB, Kane J. Body size perception among African American women. J Nutr Educ Behav. 2014;46(5):412-417.

17. Arizona State University Southwest Interdisciplinary Research Center. Research in action: recognizing barriers to exercise among African American women. https://sirc.asu.edu/sites/default/files/sirc_research_in_action_exercise_among_africanamerican_women.pdf. Accessed May 10, 2019.

18. Litchman ML, Walker HR, Ng AH, et al. State of the science: a scoping review and gap analysis of diabetes online communities. J Diabetes Sci Technol. 2019;13(3):466-492.