Recognizing and Addressing Healthcare Disparities Among Racial and Ethnic Minorities With DiabetesEnrique Caballero, MD
Suboptimal pharmacologic treatment of diabetes mellitus in ethnic minorities and socioeconomically disadvantaged persons is a major contributor to healthcare disparities and unequal treatment in the United States. Michael Blaze, PhD, Scientific Director, Medscape, LLC, interviewed Enrique Caballero, MD, to discuss some cultural differences and socioeconomic factors that are among the many challenges that both patients and providers face when attempting to improve the clinical outcomes in diabetes management of minority and low-income populations. Dr. Caballero is Assistant Professor of Medicine, Harvard Medical School, Boston, Massachusetts, and Director, Latino Diabetes Initiative, Joslin Diabetes Center, Boston, Massachusetts.
Medscape: In diverse populations, what is the demography and epidemiology of diabetes?
Dr. Caballero: Unfortunately, we are now facing a diabetes epidemic in the United States and around the world. Diabetes is one of the major contributing factors for cardiovascular disease (CVD), the number one cause of death in the adult population. It is estimated that there are 21.6 million people with diabetes in the United States and a greater number of people with what is referred to as prediabetes, ie, the presence of either impaired fasting glucose or impaired glucose tolerance. The prevalence of type 2 diabetes is definitely higher among most minority populations in the United States when compared with the mainstream white population, including Latinos or Hispanics, African Americans, Asian Americans, American Indian and Alaska Native populations, Arab Americans, and Southeast Asians. On the other hand, the incidence of type 1 diabetes in these culturally diverse groups may be equal or lower than that in the white population.
The next question is whether these numbers are similar in the countries of origin for these groups. In general, the prevalence of diabetes in people according to country of origin is lower than the one observed here in the United States for the same group. For instance, the prevalence of type 2 diabetes for Mexican Americans in San Antonio, Texas, is almost twice as high as the prevalence for Mexicans living in Mexico City. The prevalence of diabetes is higher in Japanese Americans living in Seattle, Washington, than that in the Tokyo population. This is most likely the result of the combination of a genetic predisposition along with significant lifestyle changes that usually occur in people who come to the United States. In fact, there may be some specific trends in a population that has just migrated to the United States. The first few years don't demonstrate any significant changes in prevalence rates. However, once people have been in the United States for more than 3-5 years, the prevalence of diabetes usually increases in most of these groups. Again, the increase in prevalence most likely occurs because these individuals have adopted some of the Westernized lifestyle patterns, such as becoming more sedentary and increasing the amounts of saturated fats and carbohydrates in their meal plans. Most importantly, increased portion sizes in food intake are related to higher type 2 diabetes figures.
Medscape: Would you say that second-generation immigrants have similar rates to those who have been in the United States their entire lives (ie, nonimmigrants)?
Dr. Caballero: It all depends on the lifestyle that these groups have adopted. Generally speaking, the highest rates for type 2 diabetes are seen in those individuals with a strong genetic predisposition and a sedentary lifestyle with increased consumption of calories, saturated fats, and carbohydrates. This fact applies to many of these groups whether they are second- or third-generation minority populations. Lifestyle issues [as described] above are driving the diabetes epidemic that we are seeing in these groups.
The genetic factors influencing the development of type 2 diabetes in these groups are not clearly known. (They have not been fully identified.) However, most of the genetic factors that have been identified point to a few abnormalities in how the body may work in these populations. First, there is a higher prevalence of what we call insulin resistance: the inability of insulin to promote glucose uptake in peripheral tissues. This seems to be more frequently present among some of these populations. The other factor is the tendency to develop abdominal obesity, which we now know is closely related to the development of type 2 diabetes and CVD. Some individuals in these populations have demonstrated the tendency to accumulate fat in the abdomen, particularly what we call visceral or intra-abdominal fat. The third element is that the beta cells in the pancreas that produce insulin may get tired more quickly. This may lead to a premature beta-cell exhaustion that, in combination with all the other elements, may increase the risk for type 2 diabetes, although the specific genes that trigger all of these problems have not been completely identified and may actually differ from population to population. However, those are the most common elements from the genetic perspective that may increase the risk for type 2 diabetes.
Medscape: Are there differences in the types of complications that are often associated with diabetes -- ie, macrovascular, cardiovascular, renal, ophthalmologic, or urologic -- among these diverse populations?
Dr. Caballero: In most of the studies, there is information suggesting that most of these populations do develop higher rates of diabetes-related complications. We usually divide the complications into microvascular and macrovascular. Data for higher microvascular complications in these groups are usually consistent, ie, higher rates of retinopathy, neuropathy, and nephropathy, particularly among African Americans, Latinos, and Asian Americans. In regard to macrovascular complications, the rates for CVD are rapidly increasing in these groups, sometimes at a faster pace that in the white population. This has been shown in African Americans and in American Indians. Other populations, such as the Pima Indians and others, have very high rates for CVD.[1] In past years, a controversy with the Latino population existed due to data from some of the initial studies that reported lower rates of coronary artery disease and myocardial infarction. This was known as the Hispanic paradox: Latinos have more diabetes, more insulin resistance, and more obesity; however, some of the initial studies suggested less CVD. The current concept suggests that there may not actually be such a paradox; most likely some of the appreciated differences in cardiovascular rates were due to the methodology used to define CVD, some confounding factors as well as some migration issues that affected the ability to capture all data in study participants.[2] In fact, some of the newer studies have suggested that the rates for CVD are also increasing in Latinos, which then puts us at the conclusion that there is no clear evidence that there is any protective mechanism for CVD in any of these populations, and the rates for CVD seem to be higher in most of them.
Medscape: Are there any ethnic or cultural factors that clinicians should consider when choosing among the various therapeutic options for type 2 diabetes?
Dr. Caballero: I would like to divide this into the nonpharmacologic and the pharmacologic interventions. Treatment of diabetes should be based primarily on lifestyle modification, and that involves improving a meal plan and engaging in regular physical activity aiming at weight control when appropriate. There is no question that interventions and strategies that allow people to improve their lifestyle need to be culturally and linguistically oriented. This is crucial because one of the reasons we often fail in engaging patients in better diabetes care plans is our lack of information and resources to implement effective strategies to improve their self-care behaviors. Therefore, there is no question that this has become a very important element in the treatment of diabetes, the possibility of providing tools and strategies to populations that are close to their culture, social status, and their belief system. In regard to the use of diabetes medications, unfortunately there is very limited information out there as to whether a particular class of medications for type 2 diabetes would work better in one ethnic group vs another. This is just a general deficiency in our research system. Clinical trials are not often developed in a way that allows us to answer this common question. The encouragement should really be to develop either specific clinical trials in these groups or to incorporate a higher proportion of racial/ethnic minorities in pharmacologic clinical trials.
Medscape: Do you believe that the lack of information and resources guiding physicians concerning nonpharmacologic factors are barriers in treating diverse populations?
Dr. Caballero: This is probably one of the best times that we've had in the understanding of how type 2 diabetes develops, how it leads to the development of complications, and how different therapeutic options may help our patients. We currently have 10 different classes of medications that can be used in the treatment of type 2 diabetes. Yet, many of our patients continue to have uncontrolled diabetes, blood pressure, dyslipidemia, obesity, and still a high CVD risk. I believe that part of the disconnect between what we know and what we do in clinical practice is related to the fact that we usually don't pay attention to many of the factors in patients with diabetes that influence the course of the disease and perhaps the decreased adherence to treatment that many of these populations do have (social, cultural, financial, emotional, and spiritual factors). We healthcare professionals are often not well equipped to deal with these factors. This gap is something that needs to be [addressed] more carefully because I think there is an opportunity to improve diabetes care in a way that can really produce and make significant changes.
One of the deficiencies and problems in our system is that we have very limited time to interact with patients. This limits our ability to truly evaluate and address these specific population factors. Instead, we continue to repeat unsuccessful approaches. Covering the standards of care is a high priority. However, we do need to pay closer attention to how to implement them. A particular strategy that may prove to be highly beneficial is to improve the quality of the healthcare professional -- patient interaction by addressing some of these factors. Since we have limited time in our clinical practice to go beyond the usual activities, involving our healthcare team may allow us to think and act outside the traditional box.
Medscape: Do you believe the current diabetes treatment guidelines adequately support treatment of these diverse groups, or do you believe that they need to do more to pay attention to the social, cultural, spiritual, and financial issues in order to assist in treating these diverse populations?
Dr. Caballero: I think that current guidelines are appropriate in the sense that they provide directions for most healthcare professionals for what needs to be done with any patient with type 2 diabetes. However, they don't usually go beyond the standards of care and suggest how to address the issues of minority populations. One of the reasons is that we are not completely sure about the best strategies that would work with these populations and how to effectively address their social, emotional, and cultural issues. This is an evolving field. There are interesting data being generated, and I think that down the road most guidelines will need to include strategies to address some of these factors that may favorably influence diabetes care.
Medscape: Can clinicians do anything, in your opinion, to better integrate preventive and clinical care guidelines in helping to serve these multicultural communities?
Dr. Caballero: We can consider 3 elements that [contribute to] the challenge of improving diabetes care in minority populations -- what we know as healthcare disparities. The first one relates to personal, medical, social, and cultural factors in our patients; the second is related to how we as healthcare professionals perceive ourselves and interact with others, the skills and resources that we may acquire to help these groups; and the third is the healthcare system as a whole. Certainly healthcare professionals need to be more aware and cognizant about the challenges that patients have to improve their diabetes care, not just the biological components, but also family situation, social support or lack thereof, financial challenges, emotional and psychological issues, etc, otherwise we will continue to perform an incomplete job in diabetes care. I am not saying necessarily that we, as healthcare providers, need to solve all of these problems, but we need to be at least aware that they exist and help the patients navigate the system in a way that allows them to get the proper care. As healthcare professionals we need to be aware that the healthcare disparities phenomenon that we are seeing is somehow related to our inabilities to implement effective strategies in these populations [which is the second element]. I think the first step is to be aware that there is more that we can do and that is not just the patients' fault, as we usually say. I think we can do a lot more, and the first step is to recognize that we can do a better job, that we are probably not implementing effective strategies from the cultural and social perspective. There is no easy solution, although I think that medical education is very important; the development of programs that may help particular populations should also be welcome. It is true that time is limited, and we are already very busy, but wouldn't it make sense to try something that sounds reasonable and necessary when we are already wasting a lot of our time with strategies that don't work?
The third element, which is the most difficult to change, is the healthcare system. Clinicians have very tight schedules, can't dedicate too much time to patients, and have little support and resources to implement effective strategies. Reimbursement rates may not be appropriate; there are limited education opportunities for some patients; and that continues to be our struggle. In addition, there is [minimal] emphasis on prevention, a huge limitation in our system. The healthcare system spends approximately $174 billion per year in treating diabetes. Unfortunately, most of that money is dedicated to treat the complications of the disease. We are acting late in the natural history of the disease. We must start by recognizing the problems and think about some potential solutions that could be effectively implemented in clinical practice.
Medscape: There seems to be a lot of difficulties in guaranteeing that these patients are treated with care and respect for their social, cultural, spiritual, financial, and emotional factors. Are you aware of any disparities that exist with individual medications or types of medications for treating patients of diverse populations?
Dr. Caballero: Some studies suggest that due to social and financial difficulties, some of these groups are less likely to follow their pharmacologic treatments. Sometimes cultural factors may influence the hesitance of some patients to go on specific therapies. For instance, insulin is often underutilized in some of these groups. There is a general fear of going on insulin, which may occur in individuals from all racial/ethnic groups. However, our experience with the Latino population, for example, suggests that many people in this group associated insulin with the development of blindness, a myth that has been transmitted from generations. Starting insulin gives a sense of tremendous failure to patients; it is sometimes like a death sentence because there is not much else to do. Obviously, these misconceptions must be overcome with proper and early patient and family education. In addition, some ethnic minorities may be diagnosed at a later time in the natural course of the disease, and that is partly due to lower access to healthcare, but also because of cultural beliefs and myths surrounding diabetes (about not being able to be proactive in going to the doctor on time to be diagnosed with the disease). So many of these people are diagnosed when they already have significant complications of the disease, and many diabetes medications are used late in the course of the disease.
Medscape: Do you see a lot of issues, either social or emotional, with having these patients pull out their [glucose] monitors 2 or 3 times a day?
Dr. Caballero: An important point before we continue. Everything that we are talking about cannot be generalized to everyone in a given minority population because that may not be true and appropriate. I don't want to create stereotypes. That would be very dangerous, probably as dangerous as not recognizing that there may be cultural and social differences among different people. I cannot say that all people in a particular group are afraid of insulin or are reluctant to test their blood sugars, but some studies have demonstrated that some minority populations, particularly Latinos and some African Americans, may be less inclined to test their blood sugars. Part of the reason is that it may be cultural, but it may also be financially driven because, unfortunately, sometimes test strips are cost-prohibitive and may not be completely covered by their insurance. Additionally, the proportion of people with no insurance is higher among some minority populations; therefore, there is an impact in what they can do in regard to diabetes care.
Medscape: You make an excellent point: These issues are not generalized to one specific minority; you see them all over in all different cultural groups.
Dr. Caballero: The point I was making is even within a particular group we cannot generalize, so we cannot say that all Latinos behave in the same way because that may not be true. In fact, we know the Latino population is a very heterogeneous group. We tend to put them all together, but a patient may be very different if he or she comes from Puerto Rico, the Dominican Republic, Mexico, or Central or South America. Individuals behave differently, particularly when it comes to food preferences and food habits. Not all Latinos eat rice and beans every day. The way we eat and the way we name foods is quite different in different countries. Sometimes it's difficult to come up with a unified way to refer to issues in diabetes education that are applicable to all groups. Even within populations there is a wide variety of different preferences and linguistic terms.
Medscape: What about alternative therapies? Are you aware of any that patients with diabetes may be following up with, and if so, do you know anything about the efficacy and risks associated with their use?
Dr. Caballero: This is a growing field, but in general, it is recognized that most patients with type 2 diabetes -- regardless of race and ethnicity -- tend to use in combination what we call alternative medicine, whether that is in the form of natural products, herbs, acupuncture, meditation, or any other way in which people may believe that they can get a benefit. There is the need to have more specific and scientifically driven evaluations of the impact of these therapies in diabetes care in order to be able to guide people more effectively as to whether they can and should continue with these therapies. The general belief [of professionals] is that at least they don't harm the patient, but unless we have more specific information, we may not be in a position to really widely recommend the use of these therapies or at least allow patients to continue with them.
Fortunately, the National Institutes of Health (NIH) has now decided to sponsor more research trials to address some of these issues. Therefore, the answer is that we don't know to what extent these practices may either improve or negatively affect diabetes treatment plans and outcomes. We do need the studies to really address this more effectively, but it is unquestionable that many patients in minority populations use alternative medicine as part of their treatment plan. We, as healthcare professionals, don't usually ask questions about their use, and I think we should inquire about these issues more often.
Medscape: What is the role of faith-based organizations in fostering trust and improving communication about diabetes to minority populations?
Dr. Caballero: In a general sense, religion is a very important factor in our lives, and among some minority populations it may even have a more significant role. I think that there is an opportunity to work more closely with some of these organizations to try to raise awareness about not only what diabetes and chronic care conditions are about, but also that we can do something about them. Sometimes when any religion is taken to an extreme, there is the unfortunate belief that there is not much that we can do as individuals and that everything is just part of our destiny or it's God's decision, but I think that God has given us the right and opportunity to be proactive and help ourselves. This may be the foundation to work together with some of these organizations. In addition, religious organizations may allow us to get closer to a lot of people and be able to provide health-related information that may be highly appreciated. That may include basic information about the disease, inviting them to participate in studies, guiding them on how to access and navigate the healthcare system, and promoting diabetes care in a more affective way. Therefore, I do think that these are very valuable collaborations in the community.
Medscape: Are you aware of any specific partnerships currently between multicultural communities, faith-based organizations, and clinicians or hospitals that are working in this route?
Dr. Caballero: I know that organizations, such as the American Diabetes Association (ADA), the National Diabetes Education Program (NDEP) sponsored by the US Centers for Disease Control and Prevention (CDC) and the NIH, and many other groups working in the area of diabetes, including our own (Joslin Diabetes Center) have gotten a lot closer to the community to raise awareness and provide valuable information to various groups. Going into the community rather than waiting for people to access the healthcare system seems to be a difficult but important step in the fight against diabetes.
Medscape: Dr. Caballero, can you suggest to our audience any additional health disparities or culture competency resources that may assist physicians or other healthcare professionals in caring for patients with diabetes?
Dr. Caballero: As previously mentioned, the ADA and the NDEP have updated information on diabetes in minority populations. The Massachusetts General Hospital here in Boston, Massachusetts, has a great program on healthcare disparities. Our own Joslin Diabetes Center is an institution fully dedicated to diabetes that has extended the reach into various communities. We currently have a Latino Diabetes Initiative that I have the privilege of directing and a great Asian American Diabetes Initiative, directed by Dr. Will Hsu and Dr. George King.
A must read publication is the one by the National Institute of Medicine that has evaluated and reported on the presence of healthcare disparities among different groups in the United States.
Medscape: Dr. Caballero, do you have any final thoughts or recommendations to the healthcare community concerning recognition and/or addressing these disparities?
Dr. Caballero: I would like to point out that this is a process. We cannot eliminate healthcare disparities in just 1 day. It requires a combined effort from us, as healthcare professionals; obviously patients and their families; the healthcare system; the government; and society in general. I am very hopeful that over the next few years we will be able to see more significant efforts trying to improve diabetes care, specifically among some of these groups, at the same time that we continue to work to improve the lives of all people with diabetes. However, we should not forget those that are lagging behind. The recognition of patients' challenges and their transformation into opportunities is the road to follow. We need to work more closely with these groups and understand and respect their culture, their belief system, and their ideas. We must listen to our patients more carefully, that is, go back to the roots of medicine and have the curiosity and willingness to know our patients better. We must not impose a treatment plan, but rather discuss and create an agreement to work together so that our strategies are feasible, realistic, and culturally and socially appropriate.
It is great to see that many groups around the country are working on developing culturally oriented programs. The Joslin Diabetes Center is steadily moving ahead with our culturally oriented initiatives. We currently incorporate clinical care, education, outreach, research, and professional education activities. Through the Joslin's Professional Education Department, we have been able to disseminate our own experience and that of other groups to many clinicians around the country. However, this is just the beginning of an era in diabetes in which we need to challenge old paradigms and creatively think about working more closely with our communities, particularly those that suffer from high rates of diabetes and its consequences.
Medscape: Dr. Caballero, thank you so much for taking the time today to address these very important issues related to healthcare disparities in minority populations.
Dr. Caballero: Thank you very much for inviting me. This is a wonderful area to work in; this is one that I'm not only very passionate about, but I do think that there's a huge need out there to implement effective strategies to help these populations. I hope that this program as well as many others to come, will be very influential in raising that awareness and affecting clinical practice.
This activity is supported by an independent educational grant from Eli Lilly and Company.
