Diabetes in the Latino population Enrique Caballero MD Endocrinologist/Clinical Investigator Director of the Latino Diabetes Initiative Director, International Professional Education Joslin Diabetes Center Harvard Medical School Boston, MA Challenges The Latino/Hispanic population is the largest minority group in the country ( 5.5 million 16% of total population - 21 census ) The prevalence of type 2 diabetes is at least twice as high as that in the White population Diabetes care disparities worse glycemic control, high rates of chronic complications Social and cultural barriers Limited cultural awareness and skills among providers Significant limitations in clinical practice time, resources, support Limited comprehensive culturally oriented programs that address patient, provider and health system issues Race and Ethnicity: Definitions Race Usually biological White, Black, American Indian (Native American)/ Alaska Native (Eskimo, Aleut), Asian/Pacific Islander Often overlapping Ethnicity Primarily social Independent of race Hispanic or Latino? Caballero AE. Diabetes in minority populations. In: Joslin s Diabetes Mellitus. LW & W; 25. 14 th Ed. p 55-524. 1
The US Hispanic/Latino Population Puerto Ricans 9.2% Central Americans 7.9% Mexicans 63% South Americans 7.9% Cubans 3.5% Dominicans 2.8% Spaniards 1.3% Others 6.8% US Census Bureau 21. The Hispanic Population in the United States. Available at: www.census.gov. Accessed Sept 13th, 213 *Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Institute of Medicine. The National Academies Press. Washington, D.C. 24. Genes, Environment and Social/Cultural Factors in Type 2 Diabetes in Racial/Ethnic Minorities Appetite and Satiety? Thrifty Genes + Lifestyle Insulin Resistance and Abdominal Obesity Beta and Alpha Cell Dysfunction Type 2 Diabetes Incretin dysfunction? Socio-economic and Cultural factors Renal glucose handling? Frequent Chronic Complications Increased Mortality rates Caballero AE. Modified from Curr Diab and Endocrinology Reports 27. 14:151-157 2
Type 2 Diabetes and its Complications in Minorities Disparate and Disproportionate prevalence of long-term complications of type 2 diabetes in minorities Vs NH Whites lower leg amputations 2-4x retinopathy and blindness 2-4x stroke 2x ESRD 4-6x Caballero AE. Diabetes in minority populations. In: Joslin s Diabetes Mellitus. LW & W; 25. 14 th Ed. p 55-524. Metabolic control in the US Percentage of patients achieving an A1c<7% NHANES 1999-2 NHANES 21-22 NHANES 23-24 75 P=.1 P=.8 63.5 Patients (%) 5 25 56.8 49.7 37. 53.6 41.8 28.1 P=.21 44.2 43.5 P=.388 42.4 34. 28.9 N=1334 Total White African American Mexican American Ford E et al. Diabetes Care. 28;31:12-14. A1c levels by ethnicity/race NHANES 1999-2 % 8.2 8.1 8 7.9 7.8 7.7 7.6 7.5 7.4 7.3 NH White NH Black Hispanics NH White NH Black Hispanics Boltri JM, et al. Ethn Dis 25; 15 (4): 562-7 3
Percentage of participants with diagnosed diabetes with an A1c 11% by ethnicity/race NHANES 1999-2 % 12 1 8 6 4 2 1.7 11.1 1.4 NH White NH Black Hispanics NH White NH Black Hispanics Boltri JM, et al. Ethn Dis 25; 15 (4): 562-7 Prevalence of major CVRF in Latinos Daviglus ML, et al. JAMA 212: 38(17):1775-84 Prevalence of major CVRF in Latinos Daviglus ML, et al. JAMA 212: 38(17):1775-84 4
Prevalence of major CVRF in Latinos Daviglus ML, et al. JAMA 212: 38(17):1775-84 Estimated lifetime risk of developing diabetes for individuals born in the United States in 2 Percent 6 5 4 3 2 1 Total Non-Hispanic Black Men Non-Hispanic White Hispanic Women Narayan et al, JAMA, 23 Obesity and Endothelial Dysfunction in Hispanic Children Variable Controls (n=17) At risk (n=21) P value Age 14.18+2.3 13.33+2.7.31 Waist/hip ratio.79+.8.88+.11.3 Total % fat 24+6 42+9 <.1 Trunk fat 19+5 42+9 <.1 Systolic BP 11.5+7 116.6+12 <.1 Diastolic BP 68.6+6 7.9+6.23 Total cholesterol 142.6 149.76.318 Triglycerides 58.82 18.29.4 HDL 42. 37.52.162 LDL 89.24 93.5.484 Demographic and clinical characteristics between both groups, comparisons were Done with t test in case of continuous variables and x 2 in case of dichotomous variables 5
Obesity and Endothelial Dysfunction in Hispanic Children Caballero AE. Diabetes Care. 28; 31:576-82 ng/ml 1, 8 6 4 2 svcam 4 3 2 1 ng/ml sicam * μg/ml 2 1 51 5 Adiponectin * pg/ml 4 3 2 1 TNF-α * 1 PAI-1 1 tpa * 8 8 6 6 4 4 2 2 ng/ml ng/ml * mg/ml 8 6 4 2-2 hs-crp * * White Cells (zx1-3) 12 1 86 White Blood Cell Count * 4 2 pg/ml 4.5 3.5 2.5 1.5.5 IL-6 Control Group Overweight Group Caballero AE. Diabetes Care. 28; 31:576-82 System Dynamics Modeling Population Flow Map People with normal blood sugar levels Obesity in general population Prediabetes onset Recovery People with prediabete s Diabetes Onset Pre-diabetes detection and management People with undiagnosed diabetes Deaths Total Prevalence (People with diabetes) Diagnosis Diabetes detection Burden of diabetes Unhealthy days per person with diabetes People with diagnosed diabetes Costs per person with diabetes Deaths Diabetes management Children Adults 6
Control metabólico en los EUA Porcentaje de pacientes con A1c<7% NHANES 1999-2 NHANES 21-22 NHANES 23-24 75 P=.1 P=.8 63.5 Pacientes (%) 5 25 56.8 49.7 37. 53.6 41.8 28.1 P=.21 44.2 43.5 P=.388 42.4 34. 28.9 N=1334 Total Blancos Afro-Americanos México-Americanos Ford E et al. Diabetes Care. 28;31:12-14. Expenditures in the Medicare Population with diabetes Classification of Medicare Consumers based on aggregate payments Crisis - Top 1% Heavy - 9 to 99 percentile Moderate - 75 to 89 percentile Light - 5 to 74 percentile Low - Under 49 percentile Caballero AE. et al. Am J Manag Care 213; 19 (7): 541-548 Expenditures in the Medicare Population with diabetes Caballero AE. et al. Am J Manag Care 213; 19 (7): 541-548 7
Expenditures in the Medicare Population with diabetes Caballero AE. et al. Am J Manag Care 213; 19 (7): 541-548 The Latino Diabetes Initiative at Joslin A comprehensive strategy that involves clinical care, patient education, community outreach, research and provider education www.joslin.org/latino Current structure of LDI Clinical Program Research Program Community Based Activities Professional Education 8
What Causes Disparities in Healthcare? Patient Socio-economic status Education/Health literacy Health seeking behavior Cultural factors Mistrust Provider System Lack of cultural awareness Stereotyping or biases Language barrier Lack of resources Lack of culturally oriented programs Inadequate interpreter services Time pressures and resource constraints Lack of adequate training Limited Access Ecological Model Community and policy System, group, culture Family, friends, small group Individual The health of individuals is inseparable from the health of communities (Healthy People 21) Primary Factors That May Influence Diabetes Development and Care in Culturally Diverse Populations Acculturation Body image Cultural competence Depression Educational level Fears General family integration and support Health literacy Individual and social interaction Judgment about disease Caballero AE. Am J Med 211; 124, S1-S15 9
Primary Factors That May Influence Diabetes Development and Care in Culturally Diverse Populations Knowledge about the disease Language Myths Nutritional preferences Other forms of medicine (alternative) Physical activity preferences Quality of life Religion Socioeconomic status Caballero AE. Am J Med 211; 124, S1-S15 A true story: Language Barrier 64 y/o Hispanic woman Patient does not speak English Treated for Hypertension Received a prescription for : Lisinopril 1 mg. Once/d. Patient rushed to the ER due to severe hypotension Prevalent Racial/Ethnic Differences Related to Diabetes Medications Caucasian (n=23) If my doctor told me that I would benefit from taking more medications, I would be willing to take more If my doctor asked me to change my medication regimen, it would make me worry more about my health I worry about the expense of my medications or glucosemonitoring supplies I worry about becoming dependent on my medications I worry about side effects from my medications African American (n=279) } P=.8 Latino (n=167) } } } } P<.1 1 2 3 4 5 6 7 8 Patients responding affirmatively (%) P<.1 P<.1 P<.1 Huang ES et al. Diabetes Care. 29;32:311-316. 1
Education Level by Race/Ethnicity, 21 18 and older only 1% 8% 6% 4% 2% % White, NH Black, NH Hispanic Asian, NH Less than high school College graduate US Census 21 Data How common is Low Health Literacy? 3 million Americans (14%) scored below basic on health literacy Grasp of no more than the simplest, most concrete literacy skills 47 million (22% or 1 in 5) of the population at basic health literacy Basic is defined as skills needed to perform simplest everyday literacy activities White S. Assessing the Nation s Health Literacy. Accessed at http://www.ama-assn.org/ama1/pub/upload/mm/367/hl_report_28.pdf on August 28, 29: p. 45. Assessing Literacy: The Newest Vital Sign Validated tool Correlates with TOFHLA English and Spanish version Screening tool Score 1: High likelihood of limited literacy Score 2 3: Possible limited literacy Score 4 6: Almost always adequate http://www.pfizerhealthliteracy.com/physiciansproviders/newestvitalsign.aspx Weiss BD, Mays MZ, Martz W, et al. Ann Fam Med. 25;(6):514-552. 11
Evaluation of health literacy can guide education efforts 5 A1C < 7% 4 3 2 1 Intervention Control Rothman et al. JAMA. 24;292(14):1711-6. Rosa s Story Provider Manual English Patient Booklet Spanish Culturally Appropriate Translations 12
Practice Listening! And observing! Patients are interrupted by the healthcare provider after an average of 23 seconds In only 28% of visits did patients completely express concerns In 25% of visits, the healthcare provider never asked about patient s concerns Marvel MK et al. JAMA. 1999;281:283-287. Goal setting S - Specific M - Measurable A - Attainable R - Realistic T Time 13
Current structure of LDI Clinical Program Research Program Community Based Activities Professional Education Time spent for a patient with diabetes Health Care Team 1.3 Work 8 Family 285 Person with diabetes 365 Incidence of Diabetes Placebo (n=182) Metformin (n=173, p<.1 vs Placebo) Lifestyle (n=179, p<.1 vs Metformin, p<.1 vs Placebo) Risk reduction 31% by metformin 58% by lifestyle Knowler W. The DPP Research Group. N Engl J Med 22; 346: 393-43. 14
Ideal Body Image in Latinas with type 2 diabetes 3 or 4 ideal shape for White women 5 ideal shape for Latino women Weitzman PF, Caballero AE, Millan A. The Diabetes Educator ; Sept-Oct 213 Esto es mejor: Improving food purchasing selection among low-income Spanish-speaking Latinos through social marketing messages Baseline Evaluation: Analysis of the Grocery Receipt: 93 Calories per dollar 29 gr of Fat per dollar 15 gr of Carbs per dollar 5 gr of Fiber per dollar 21 gr of Protein per dollar 465 cal 5 USD Other activities: Home Visits Supermarket tours Photovoice Rosa s Story Salud America - RWJ Foundation Cortés D. et al. Am J Prev Med April 213. Esto es mejor: Improving Food Purchasing Selection Among Low-income Spanish-speaking Latinos 7 6 5 4 3 2 1 Calories per receipt 1st supermarket 2nd supermarket 8 7 6 5 4 3 2 1 Total Fat - gr Total Carbs - gr Each dollar bought: 1 st Supermarket 2 nd Supermarket 132 Calories 583 Calories 84 grams of fat 28 grams of fat 135 grams of carbs 56 grams of carbs 1 grams of fiber 4 grams of fiber 9 grams of protein 18 grams of protein 1st supermarket Fiber - gr 2nd supermarket Protein - gr 15
Esto es mejor: Improving Food Purchasing Selection Among Low-income Spanish-speaking Latinos - RWJ Project Before After Patient Care and Education Health Care Professionals Education Joslin CME programs Community Health Centers Medical Students Visitors Program National and International Meetings Publications Health Coach training program 16
What is Cultural Competence? The knowledge and interpersonal skills that allow providers to understand, appreciate, and work with individuals from cultures other than their own. It involves an awareness and acceptance of cultural differences; self-awareness; knowledge of patient s culture; and adaptation of skills. American Medical Association Cultural Competence Purnell s Model: Person, Family, Community, Society Unconsciously incompetent Consciously incompetent Consciously competent Unconsciously competent The ESFT Model Explanatory Model Social Risk for Noncompliance Fears/Concerns about the Medication Therapeutic Contracting/Playback 17
Model for Cross-Cultural Care: A Patient-Based Approach Awareness of Cultural and Social Factors Elicit Factors Negotiate Models Implement Management Strategies Tools and skills necessary to provide quality care to any patient we see, regardless of race, ethnicity, culture, class or language proficiency. Resources Cultural Awareness http://medweb.med.harvard.edu www.diversity.org www.healthcarecommunities.org www.nimhd.nih.gov www.hispanichealth.org Resources Latinos with Diabetes www.joslin.org/latino diabetes.org/espanol www.cdc.gov/minorityhealth ndep.nih.gov diabetes.niddk.nih.gov 18
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