The best way to bring down the number of Black Americans being diagnosed with diabetes is for the medical community to be on the ground in African American neighborhoods, not through slogans or brochures listing the perils of the chronic disease.

That’s the conclusion of doctors, nurses, and dietitians interviewed for Medscape Medical News who work directly with the Black community on diabetes education and who for years have decried providers’ heavy reliance on medication to address the issue.

“The cornerstone of diabetes care is education,” said Anne Wolf, MS, RDN, director of the Virginia Center for Diabetes Prevention and Education at the University of Virginia, Charlottesville, Virginia. “Before they get to the level of medication, we want to teach about lifestyle and how it impacts their blood sugars.”

That means getting out in the community and taking the message of healthy living directly to Black Americans, they said. Those places include community centers, churches, fraternal organizations, schools, barber shops and beauty salons, nightclubs, and large gatherings such as family reunions.

Getting it right is critical. The Black community has the worst health outcomes in diabetes, despite decades of national and local efforts to reduce the annual number of newly diagnosed cases.

Around 12.1% of Black Americans have diabetes compared with about 6.9% of non-Hispanic White adults, according to the American Diabetes Association. Black Americans also are 1.8 times more likely to be diagnosed with the disease than White Americans, the group said.

The disparity has been rising for more than 30 years, according to the National Institutes of Health.

The main prescription to change those behaviors has often been medicine, the medical professionals interviewed said. Doctors and nurses, their time increasingly shortened because of overwhelming demand, don’t have time to delve deep into patients’ lifestyles to outline detailed actions suited specifically to them. Instead, they propose tried-and-true medicines and leave the room.

“It’s not like one thing will take care of everything,” said Neviana Dimova, MD, a leading physician at Family Health Centers in Louisville, Kentucky. “You have to look at all the angles.”

That includes, Dimova said, finding out the barriers each patient feels stops them from eating healthy and brainstorming ways to reverse that.

“If you’re just getting by, cooking organically is probably not a priority,” she said.

Hurdles to Healthy Living

Many of the issues that contribute to the disparities are long known. Black Americans often struggle with access to healthcare or live in food deserts where fresh fruits and vegetables are harder to find, the medical leaders said. There also are genetic factors that make some Black Americans more susceptible to the disease.

Other Black Americans develop diabetes from eating and health habits that are a result of financial issues, said Vivianne Griffiths, MSN, a retired nurse practitioner who volunteers at a West End clinic in Louisville, Kentucky. Single parents, for instance, may eat unhealthy foods because of budgets that are stretched thin. A person with diabetes could work two or more jobs to make ends meet, which makes it difficult to find time to exercise, a key factor in addressing the disease.

She said knowing the social determinants of a patient’s health helps her set realistic expectations.

“If I want to get their A1c below 7%, I need to know do they have fresh fruits and vegetables and are they able to walk around their neighborhoods,” she said. “Are there multiple family members in the household that affect how much they can spend on food, or is this a single mom who has to pick up her children from school and the easiest thing to do is buy a McDonald’s Happy Meal?”

The effort doesn’t stop at the patient but extends to his or her family, said Davida Kruger, a nurse practitioner at Henry Ford Health in Detroit.

“Sometimes you have to bring the whole family in,” she said. “It may not be enough to bring the person with diabetes in. You need to bring in their support and their family members so they can hear and understand how meals are prepared (for a person with diabetes). Bringing in the person who cooks is another way of helping the family meet their goals.”

Finding the Right Way to Communicate

Significant to making a dent in the fight to bring down the rate of diabetes among Black Americans is often the racial makeup of the communicator and understanding how the disease is viewed in the community, the medical leaders said.

Black patients are often more willing to listen to Black medical staff because the workers better understand cultural references, like the importance of seasoning food, the medical leaders said. They can also relate to misgivings some Black Americans have about historical abuses of African Americans in medicine, such as the Tuskegee Experiment (formally the US Public Health Service Study of Untreated Syphilis in the Negro Male at Tuskegee and Macon County, Alabama). That experiment focused on the effects of untreated syphilis, using Black men as test subjects without their knowledge or consent.

But Kruger said that is not an unsolvable barrier, even if you are not a Black individual. She once had a Black patient who chose her for an examination because he thought her first name, Davida, sounded Black. When she walked in the room, he was not pleased.

“I signed up for a Black sister, and you are not a Black sister,” Kruger, who is White, said he told her. “He said, ‘Your name confused me.’”

Though surprised, he went through with the exam after they had a long talk and he decided she was trustworthy, Kruger said. He later became a regular patient.

“What this gentleman told me was culturally you don’t get me,” she said, adding that she prefers female doctors, so she understands his perspective. “I couldn’t argue with that.” 

And because diabetes, especially type 2, is so prevalent among some African Americans, it is seen as almost inevitable by some in the community.

Many African Americans refer to the disease as the “sugars” or “the sugar,” a shorthand that makes it sound less terrifying and, after universal repetition, appear more like a normal process of life.

The problem is, it isn’t.

“If you don’t have cultural competency, it’s going to be hard for you to reach your patients on a level that’s going to make them believe you and take ownership of their health,” Griffiths said. “We can give patients advice all day long, but if they don’t believe they can do it or understand what you want them to do, it’s not going to happen.”

Understanding this can lead to changing the trajectory of the disease’s impact on Black America. Compared with the total population, Black Americans in 2022 died from diabetes at a 78% higher rate, according to the Office of Minority Health of the US Department of Health and Human Services.

Also, in 2021, African Americans were diagnosed with end stage renal disease due to diabetes 2.19 times more often than the total population, according to the minority health office.

Compared with White Americans, Black Americans also are two to four times more likely to suffer lower-extremity amputations of their toes, feet, or legs because of infections related to diabetes, according to numerous studies.

Dimova said she had a Black male patient who lost a part of a toe because he waited a month to see a podiatrist after she told him he needed to address the issue immediately. Since then, he has been an exemplary patient because he knows the consequences of not heeding medical advice.

“This is a complex problem,” she said.

Wolf said it is not too late to course correct. Hiring more doctors and nurses to help treat diabetes patients and pairing that with free diabetes education for everyone would go a long way to achieving the outcomes the medical profession wants to see.

“That creates a system where the patient has access and doesn’t have to worry about a barrier to cost,” Wolf said. “Also, if you are paying a provider to provide diabetes education, more people will come into the field and that will provide more access.”