Commentary on "Race, socioeconomic status, health-related quality of life, and self-care of type 2 diabetes mellitus among adults in North Carolina".

The Centers for Disease Control and Prevention initiated the Behavioral Risk Factors Surveillance System (BRFSS) in 1984 to supplement their annual series of surveillance surveys to monitor the prevalence of infectious and chronic diseases, as well as risk factors for future disease in the US population. The BRFSS is a telephone survey conducted at the state level to assess the health behaviors of Americans from smoking to the use of preventive services. These surveys provide a basis for understanding population health and targets for control and prevention in the United States. These efforts have tracked the increasing prevalence of chronic diseases, which now account for 7 of the top 10 causes of death in the United States. Of these, diabetes mellitus may pose the greatest cumulative threat to morbidity, resource expenditures, and mortality, given the broad range of its complications and the management of those complications. In this issue of the Southern Medical Journal, Piper and colleagues analyzed BRFSS data from self-reported diabetics in North Carolina to determine predictors of self-care. Respondents were classified as having good self-care if they took a diabetes mellitus management class/course and checked their blood glucose daily; however, diabetes mellitus type and insulin use were not recorded in the BRFSS. The authors found that diabetics without insurance, with less education, and with lower income levels were less likely to report good self-care. These predictors are consistent with known predictors of diabetes mellitus and health in North Carolina. Together, these results describe a potentially viscous pathway of disparity in which those who are poor and with decreased access to health care are more likely to develop disease, are less likely to care for their disease, and then are more likely to suffer from complications of their disease. Understanding predictors of self-care is an important step in identifying targets to reduce this disparity. A strength of this study is that the sample is representative of individuals with diabetes mellitus in North Carolina and is not focused solely on a subsample such as those with access to health care or more advanced disease. The findings of this study are limited by potential misclassification error because some respondents with type 2 diabetes mellitus managed without insulin may have been falsely defined as practicing poor self-care for less frequent glucose monitoring, which is unnecessary in this group. If these individuals also were more likely to have better health, then this would have biased the results. The authors also found that individuals with diabetes mellitus who perceived their health as being poor were more likely to practice good self-care even after adjusting for potential demographic confounders. This is consistent with prior work showing that diabetics with worse disease are more likely to be involved in their care. Johnston and colleagues found that veterans with diabetes were more likely to practice good foot self-care if they had a prior foot ulcer, while Nahin and colleagues found that those with worse disease were more likely to pursue alternative medical strategies. Unfortunately, these findings reflect the opposite of prevention. Understanding what motivates diabetics to care for their disease is the first step to targeting interventions to limit complications. Nearly 1 in 4 individuals with diabetes mellitus in United States has uncontrolled disease with a hemoglobin A1c of 98%, with racial minorities and patients with decreased levels of education predominantly affected. Despite this, the attention of most healthcare providers regarding advances in the management of diabetes mellitus during the last 2 decades was diverted by mega-randomized trials such as the National Institutes of HealthYfunded Action to Control Cardiovascular Risk in Diabetes study and industry-supported Action in Invited Commentary