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Despite the lack of randomized clinical trials at this point, it is intuitive to believe that the higher the cultural awareness of any health care provider, the more positive the impact he or she can have on a patient's diabetes care.
Latinos or Hispanics are the largest minority group in the U.S.—approximately 14% of the total population. It is predicted that by 2050, one in four people in this country will be Latino or Hispanic.1
The terms Hispanic and Latino are often used interchangeably in the medical literature but are not identical. Hispanic refers to people born in a country conquered by Spaniards and for whom Spanish is their primary language. Latino is a broader term that refers to people born in a country whose language has evolved from Latin.
DIABETES PREVALENCE: GENES OR ENVIRONMENT?
The prevalence of type 1 diabetes among Hispanics is the same or lower than in non-Hispanic whites, but the prevalence of type 2 diabetes is twice as high.2 Type 2 diabetes is a heterogeneous disease that results from the combination of a genetic predisposition and environmental factors. A common manifestation of this genetic predisposition in Latinos is the presence of insulin resistance in peripheral tissues and the tendency to easily accumulate visceral fat.3
Common environmental elements of "Westernization" that increase the risk for obesity, diabetes, and related diseases include a diet higher in total calories and fat but lower in fiber, and less need to expend energy because of labor-saving devices. Many of these elements are widely present throughout Latin America, although in general, Latinos in the U.S. tend to have higher prevalence of type 2 diabetes than do peers in their countries of origin. Certainly, particular aspects of preferred foods and lifestyle practices among Latinos play a role in the development and treatment of type 2 diabetes.3
In addition, Latinos and other minority groups have lagged in the quality of health care received in our system. In 2002, the Institute of Medicine (IOM) reported that when comparing a large number of outcomes, including some related to diabetes care, clear health care disparities exist between whites and minority groups.4 According to the IOM report, these disparities are not accounted for by different access to care, socioeconomic status, age, stage of presentation, or existing comorbidities, and can be found in multiple heath care settings.
Consistent with this report, recent data from the National Health and Nutrition Examination Survey show that glycated hemoglobin (A1C) levels are higher among Latinos with diabetes than among whites.5
I strongly believe that in the vast majority of cases, health care providers do not intentionally provide a lower quality of health care, but it may result from a combination of patients' intrinsic social and cultural factors, the general lack of cultural awareness of many health care providers, and the limited availability of culturally oriented diabetes care and education programs.
HOW TO ADDRESS THE CHALLENGES
The Patient
As in any medical encounter, the more we get to know our patient, the
higher our chances of having a positive influence on his or her health care.
We generally have little time with our patients, so we concentrate on the most
important medical aspects in each case. However, in routine diabetes care and
education, we often forget to address important social and cultural factors
that may influence the development and course of type 2 diabetes.
Acculturation, body image, cultural values and beliefs, depression, education
level, fears, family integration and support, health literacy, individual and
social interaction, knowledge about the disease, language, myths, nutritional
preferences, alternative medicine, physical activity preferences, quality of
life, religion, faith, and socioeconomic status—all may influence
diabetes care.6
A few years ago, a patient with poorly controlled diabetes was referred to our Latino Diabetes Initiative at Joslin Diabetes Center in Boston. According to medical notes, he supposedly had been taking large amounts of insulin for several years, yet his A1C was constantly >11%. One of my first questions to him was, "Are you taking your insulin injections?" He openly answered in Spanish, "Of course not, doctor! I don't want to get blind from taking insulin."
We shouldn't generalize, but the fear of insulin is highly prevalent among Latinos, as it is in other groups. This fear developed because we tend to delay insulin use for many years. Some time after insulin initiation, patients may learn that they already have developed complications, including vision problems, and they associate these complications with insulin use.7
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My patient accepted insulin therapy after careful review of the benefits, but he already had developed severe complications. Both his legs were amputated within one year, and he died of a cardiovascular event within two years.
I think simple questions to understand our patients' views of the disease process and its treatment can help us identify important aspects to address in diabetes care. At the same time, the patient should work to become integrated in the health care system in the best way possible—by working constantly with the health care team.
The Health Care Provider
Cultural awareness or competence is not a call for white providers to see
Latino patients. It applies to any provider who sees a patient from a
different culture. Numerous organizations, such as the American Diabetes
Association, the National Institutes of Health, the National Diabetes
Education Program, the Association of Clinical Endocrinologists, the American
Nurses Association, and the American Dietetic Association, have strengthened
programs to raise awareness about culturally oriented diabetes care and
education.
Continuing medical education in this area also is very important. New Jersey and California have made it mandatory for physicians to obtain academic credits through programs that address cultural aspects of health care. Many academic institutions and universities also have implemented solid programs to address these issues.
The Health Care System
Yet there remains an increasing need to develop more comprehensive
culturally oriented diabetes care, education, research, and outreach programs
for the U.S. Latino population. Community-based health centers, academic
institutions, public and private practices, managed care organizations, and
the pharmaceutical industry should seriously prioritize the development of
culturally oriented programs that tackle the growth of diabetes among Latinos
and other minority groups.
Fortunately, community-based efforts such as the Starr County Border Health
Initiative on the Texas-Mexico border show that going into the community to
get to know patients and their families better may be an effective way to
influence behavior.8
It is highly motivating to see how groups throughout the country are making
the worthwhile decision to face the challenges of preventing and managing type
2 diabetes in the Latino population. 
Footnotes
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References
2. Burrows NR, Valdez R, Geiss LS, et al., for the Centers for Disease Control and Prevention: Prevalence of diabetes among Hispanics—selected areas, 1998–2002. MMWR 53:941–944, 2004. Available online at www.cdc.gov/mmwr/preview/mmwrhtml/mm5340a3.htm. Accessed November 2, 2006.
3. Caballero AE. Diabetes in the Hispanic or Latino population: Genes, environment, culture and more. Curr Diab Rep 5: 217–225, 2005.[Medline]
4. Board on Health Sciences Policy, Institute of Medicine: Unequal Treatment Confronting Racial and Ethnic Disparities in Health Care. Washington, D.C., The National Academies Press, 2002.
5. Boltri JM, Okosun IS, Davis-Smith M, et al.: Hemoglobin A1C levels in diagnosed and undiagnosed black, Hispanic, and white persons with diabetes: Results from NHANES 1999–2000. Ethn Dis 15: 562–567, 2005.[Medline]
6. Caballero AE: Culturally competent care in diabetes care: An urgent need. Insulin. In press.
7. Caballero AE: Bridging cultural barriers: Understanding ethnicity to improve acceptance of insulin therapy in patients with type 2 diabetes. Ethn Dis 16:559–568, 2006.[Medline]
8. Brown SA, Garcia AA, Kouzekanani K, et al.: Culturally competent
diabetes self-management education for Mexican Americans: The Starr County
border health initiative. Diabetes Care 25: 259–268, 2002.
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