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Managing Type II Diabetes within the Hispanic Community

Submitted by Kathy Nobles

Tags: culture diabetes disease health patient education

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Introduction

Diabetes is termed the life style disease for good reason.  It is a progressive and chronic illness largely caused by obesity and lack of exercise.  If left untreated or poorly controlled, this disease can lead to debilitating complications and premature death.  However, Type II diabetes can be controlled and complications prevented using good management and treatment techniques.  The fundamentals of treatment and management include monitoring glucose levels, diet, exercise, insulin, and oral medication.

Proper management of Type II diabetes requires lifestyle changes and continuing coordination between the patient and healthcare provider.  Encouraging patient involvement to play a more active role in their healthcare behaviors outside of the clinical setting, also known as self-management practice, is a key component for successful disease treatment.  Failure to recognize and support self-care efforts encourages unnecessary dependency on professionals.  Patients must be given appropriate disease education and support to enhance their self-management skills.

Lifestyle and culture can greatly impact the success of self-managed diabetic treatment plans.  To increase self-management success and sustain health behavior change, any recommended lifestyle changes must not only consider the associated health risks, but the connections between demographic, psychosocial, and social-environment variables (King et al., 2010).  According to American Diabetes Association (2009), certain ethnic groups are more likely to develop diabetes.

Hispanics are among the high risk ethnic groups.  They have a disproportionate burden of obesity and its related comorbidities (Center for Disease Control, 2011).  They also have lower levels of education and higher average glucose levels (Bertera, 2003).  Hispanic demographics clearly imply a critical need of strategies for preventing the complications of diabetes (Hatcher & Whittemore, 2007).  The Hispanic population is the largest and fasting growing minority group in America.  An estimated 37.3 million people of Hispanic descent live in the United States, constituting about 13.7% of the total population (Idrogo & Mazze, 2004).

As the Hispanic population in the United States increases, healthcare providers are faced with new challenges in educating the Hispanic community on the risks and management of diabetes.  To create the most effective education opportunities healthcare providers must have a good understanding of Hispanic adults’ unique ethnic beliefs, customs, food patterns, and healthcare practices.  Overcoming language, communication, and health literacy barriers will improve self-management of diabetes among the Hispanic population.

Background

Before discussing specific self-management improvement techniques a brief discussion about diabetes must occur.  Diabetes mellitus, commonly referred to as “Diabetes,” is a long-term metabolic disease that disrupts normal metabolism by deficiencies in insulin secretion or insulin action, or both.  Insulin deficiency results in an increase in blood glucose concentration also known as hyperglycemia (American Diabetes Association [ADA], 2009).  There are three main forms of diabetes, Type I, Type II, and Gestational.  Type I was previously called insulin-dependent diabetes mellitus (IDDM) or juvenile-onset diabetes.  Type II was previously called non-insulin-dependent diabetes mellitus (NIDDM) or maturity-onset diabetes.  Type II is also the most common of the 3, accounting for 90 - 95% of diabetic cases (http://www.cdc.gov).

According to the Mayo Clinic, poorly controlled diabetes opens a pathway for many other major medical complications including retinopathy, nephropathy peripheral neuropathy, and an increased risk of cardiovascular disease (http://www.mayoclinic.com).  The length of time a person has diabetes increases probabilities of complications associated with the disease (Hewitt, Smeeth, Chaturvedi, Bulpitt, & Fletcher, 2011).  Some scientists believe weight gain or obesity can trigger the disease because about 80 percent of diabetics with type 2 diabetes are overweight.  Because symptoms develop slowly, individuals with the disease may not immediately recognize that they are sick.

The National Diabetes Fact Sheet (2011) from The Center for Disease Control and Prevention (CDC) clearly shows that the occurrence of diabetes is on the rise.  1.9 million new cases were diagnosed in people over 20 in the year 2010.  It is now the seventh leading cause of all deaths in the United States and the sixth leading cause of all deaths caused by any disease.  The 2011 report also states that 18.8 million people are currently diagnosed with diabetes and 7.0 million are undiagnosed.  More men than women have been diagnosed with the disease and it is most common in adults over 45 years of age; in people who are overweight or physically inactive; and in individuals who have an immediate family member with the disease.  Diabetes is a universal problem that affects every population; however certain ethnic groups are more likely to develop it.

Hispanics are among these high risk ethnic groups.  The prevalence of Type II diabetes in Hispanics in the United States is approximately twice that of whites, compared to white individuals of similar age (Aguirre-Molina, Molina, & Zambrana, 2001, p. 277).  After adjusting for population age differences, 2008–2010 national survey data for people ages 20 years or older indicate that 7.1 percent of non-Hispanic whites, 8.4 percent of Asian Americans, 11.8 percent of Hispanics/ Latinos, and 12.6 percent of non-Hispanic blacks had diagnosed diabetes.  Even though nationally more men than women have been diagnosed with the disease, women in the Hispanic community have a higher diagnosis rate than Hispanic men.

Table 1.  (National diabetes statistics, 2011) Diagnosed and Undiagnosed Diabetes among People Ages
20 Years or Older, United States, 2010
Group	Number or percentage who have diabetes
Ages 20 years or older	25.6 million, or 11.3 percent, of all people in this age group
Ages 65 years or older	10.9 million, or 26.9 percent, of all people in this age group
Men	13.0 million, or 11.8 percent, of all men ages 20 years or older
Women	12.6 million, or 10.8 percent, of all women ages 20 years or older
Non-Hispanic whites	15.7 million, or 10.2 percent, of all non-Hispanic whites ages 20 years or older
Non-Hispanic blacks	4.9 million, or 18.7 percent, of all non-Hispanic blacks ages 20 years or older

 

 

 

Obesity is a major contributor to the onset of type 2 diabetes.  According to the National Diabetes Information Clearinghouse (NDIC) minority ethnic groups in the United States that have high rates of obesity are on the rise, especially Hispanic Americans.  The NDIC reports that Mexican Americans make up the largest percentage of the Hispanic population in the United States; they also represent the largest percentage of Hispanic Americans with diabetes.  The increase of diagnosed Hispanics was not held to adults as the increase also occurred with children.  A number of risk factors apart from obesity, such as genetics, can push the number of diabetes incidents higher.

Overall lifestyle habits and genetics appear to be the largest contributing factors.  According to the NDIC, "The prevalence of diabetes among Mexican Americans who have first degree relatives (e.g., parents) with diabetes was twice as great as for those with no family history of diabetes."  Demographic factors such as ethnic minority have been associated with lower regimen adherence and greater diabetes-related morbidity (Delamater et al., 2001).

Argument

There is a significant knowledge gap related to the factors that influence the achievement of glycemic control and self-management practices in the Hispanic population.  These individuals usually have language barriers, low health literacy, financial challenges, cultural and demographic considerations which all play a role in low self-management success of diabetes.  Ever increasing evidence suggests that the health of a population is greatly determined by the social and economic circumstances of that population (Morales, Lara, Kington, Valdez, & Escarce, 2002).  Socioeconomic factors such as income, reduced access to health care services, ethnic factors, and influences of cultural values and level of education play a role in the increasing prevalence of diabetes and diabetes related complications.  “Health in the United States is often, though not invariably, patterned strongly along both socioeconomic and racial/ethnic lines, suggesting links between hierarchies of social advantage and health (Bravemen, Cubbin, Egerter, Williams, & Pamuk, 2010).”  It is significant to note that Hispanics have the highest uninsured rates of any racial or ethnic group within the United States.

Many Hispanics are motivated to achieve favorable lifestyle modifications in the short term (Stein, 2011); but diabetes is a long term disease and requires long term treatment to minimize the associated health complications.  Stein’s (2011) study showed that clients have the knowledge that obesity can contribute to the onset and exacerbate confirmed diabetes.  However, it was shown that only 70% of respondents stated that they had tried to lose weight, and only 34% had maintained their goal weight for more than six months.  Even though these clients had been advised to increase physical activity only 13% added to their physical activity.  An alarming 20% of clients stated they would rather take medication for diabetes rather than alter their lifestyle.  This study was not broken down into ethnic groups, but the numbers and attitudes are disturbing nonetheless.  Non-adherence becomes further complicated when cultural and religion factors are computed with the Hispanic community (Stein, 2011).

In order to assist the Hispanic community with management of diabetes we need to understand why the Hispanic population has a higher incidence of diabetes.  One factor that plays an enormous role is culture.  It is critical to identify and respect a patient’s cultural beliefs; this will ensure an effective relationship between patient and practitioner.  Table 4 defines key cultural principals in the Hispanic community, including simpatia, personalismo, respeto, familismo, and fatalismo, and includes suggestions for addressing these values when they hinder the relationship between clinician and patient (Campos, 2007).

Table 4. (Campos, 2007)
	Hispanic cultural values that can affect the patient-provider relationship
Term	Definition	How cultural values can serve as barriers to treatment	Ways to demonstrate respect for cultural values
Simpatia	Kindness, politeness, pleasantness, avoidance of hostile confrontation	• Neutral attitude of many • American physicians may be perceived as negative, resulting in inaccurate history, decreased satisfaction with care, treatment nonadherence and poor follow-up	• Emphasize courtesy, a positive attitude, and social amenities
Personalismo	Formal friendliness, warm, personal relationship, characterized by interactions that occur at close distances (eg, handshakes, placing a hand on the shoulder	• When lacking, patients may believe that the physician does not care about them and may be reluctant to share crucial details about their diabetic status, may become nonadherence to medications, may be reluctant to consider starting insulin, and may be dissatisfied with their care	• When interacting with patients, decrease physical distance and increase appropriate physical contact • Show interest in the patient's life at each visit (eg, starting the visit with a brief conversation about the patient's family, work, or school) • Provide a business card or beeper number
Respeto	Respect, including targeted communication based on age, gender, social position, and economic status	• Patients may be hesitant to ask questions because questioning an authority figure (eg, a physician) is viewed as disrespectful • Patients may nod in response to physician's instructions as a sign of respect even when they do not understand • When respeto is perceived as lacking, patients may become resentful and distant	• Use Spanish terms of respect (eg, usted, the polite form of "you," instead of the informal tu) • Use appropriate titles and greetings • Whenever possible, involve patients in medical decisions, such as decisions to start insulin • Ask about the patient's concerns, particularly regarding insulin
Familismo	Collective loyalty to extended family that supersedes the needs of the individual	• Patients may delay or defer important treatment decisions to permit consultation with their family • Failure to recognize this cultural value may result in unnecessary conflict, dissatisfaction with care, nonadherence to treatment, delays in initiating insulin therapy and poor continuity of care	• Encourage patients to bring family members to visits • Provide sufficient time and opportunity for the extended family to discuss important medical decisions • Educate the patient's family about diabetes • Encourage the family to support the patient's treatment efforts
Fatalismo	Fatalism, belief that individuals can do little to alter fate	• Patients may avoid effective treatment pians because they feel that they cannot control their illness	• Emphasize efficacy of medications, including insulin, for diabetes • Refer to the patient's beliefs and values

 

Healthcare providers need not only to educate the Hispanic community on resources that might support early entry into the healthcare system, but provide culturally competent interventions to encourage health and promote disease prevention.  It is critical that healthcare providers learn how to support and enhance self-management of those Hispanics that are affected with diabetes.  In return this will reduce disability and improve quality of life.  Healthcare provider knowledge needs to include understanding of the cultural and ethnic differences that could impact how Hispanics self-manage this disease.

One significant barrier that the Hispanic population face when seeking medical and social services is limited English proficiency.  Some may ask ‘why don’t they just learn to speak English?’  Although many Hispanics do speak English, the Spanish language is a core part of the Hispanic culture.  Speaking the language is important to the Hispanic community, and one way to preserve the sense of ethnic identity.  Self-awareness of unintentional bias in health care is crucial (Arnold & Boggs, 2011).  The Department of Health and Human Services (DHHS) Office for Civil Rights considers inadequate interpretation as a form of discrimination (Woloshin, Bickell, Schwartz, Gary, & Welch, 1995).  Reciprocal communications is vital when it comes to providing or receiving healthcare.

If the clinician and the patient do not speak the same language, there may be clinical consequences as a result of inadequate interpretation, such as gaps in the information obtained from the patient, gaps in information relayed to the patient from the health care provider, or inadequate or incomplete patient education (Talamantes, Lindeman, & Mouton, n.d.).

Depending on where the interview or teaching is taking place may determine what type of interpretation services is available.  Many larger facilities such as hospitals or organizations offer full time onsite interpreters or have access to trained telephone interpreters.  These are the best solution when available.  Although family member involvement is common in the Hispanic community, family member, or friends should only be used for interpreting as a last resort.  Today’s technologies offer many low or low cost translation alternatives as well.  Voice activated applications can translate phrases from English into Spanish and vice versa.  Several cellular phones offer free software applications for interpretation services in the field when there is no access to other services.  Written materials such as brochures or pamphlets should also be provided in Spanish.

In addition to addressing language barriers healthcare providers should form a good communication relationship with the mature Hispanic client.  Helpful recommendations include, addressing clients by their last name, this is a demonstration of respect.  The use of gestures should be avoided; gestures have different meanings in other cultures.  Comprehension of questions and instructions need to be carefully evaluated, people will nod “yes” but may not understand.  Encourage clients to voice their concerns; some cultures feel that questioning authority such healthcare providers are taboo.  Assure client that you understand certain issues may be uncomfortable to discuss, but are necessary so they can receive the best care possible (Talamantes, Lindeman, & Mouton, n.d.).  Understanding and eliminating the commination barrier allows health care providers the ability to provide positive and culturally respectful care to the Hispanic community.

Health literacy is the degree in which the client has the ability to acquire, process and understand basic health information needed to make appropriate health decisions.  Low health literacy is an example of a significant barrier to self-management of diabetes.  If a client has no or low reading skills they face many problems reading labels on pill bottles, interpreting blood sugar values, or educational brochures.  These clients may face challenges with oral communication and conceptualizing risks.  When placing greater technical and self-management demands on clients, low health literacy becomes an important barrier to recognize for chronic-disease care.  Despite increasing concern about the impact of low health literacy on diabetes care, there are few proven interventions available that address low health literacy.  Health care providers need to use any skill sets necessary in order to provide culturally competent diabetes care.  This should start by performing a targeted cultural assessment which includes defining problems, modifying interventions, and establishing goals with the client.  After determining the client’s health literacy and learning style, education materials should be structured to fit the specific needs of the client.  Ask clients about personal views on noncompliance and include their input when devising strategies to address these issues.  Health care providers may indicate that using these skills are not practical due to lack of time, resources, and information or motivation of clients to comply with these instructions.  Yet it should be shown that these are the same excuses often offered by the clients that have problems managing the recommended therapeutic regimen (Tripp-Reimer, Choi, Kelley, & Enslein, 2001).

Counter Argument

Although educating healthcare personnel on specific culture consideration can provide many positive benefits with self-management of diabetes, it is a greater significance that all health care providers be educated on the most current diabetic management information.  A thorough understanding of diabetes and the major complications associated with the disease is paramount.  In the United States every culture is affected by diabetes.  Although patients affected by diabetes are differentiated by culture they share many similarities of the disease and its processes.  The model for treatment of diabetes is to treat the disease as a multicultural syndrome.

Diabetes is a complex disease that requires long-term interventions to facilitate self-management care.  According to a study by Torres, Rozemberg, Amaral & Bodstein (2010), many health professionals feel insufficiently prepared to educate patients about diabetes.  This is due to the significance of diabetes management, gaps in their own knowledge about diabetes, and problems with teaching methods.

The American Diabetes Association (ADA) has standards of care in place.  These standards can provide individuals a basic guide of diabetes care, general treatment goals, and tools to evaluate the quality of care.  There are many recommendations such as screening, diagnostic, and therapies which are known or believed to affect a patient with diabetes positively.  The ADA suggests that assessments of risk in asymptomatic patients for future diabetes should be considered for any overweight or obese patients (BMI ≥ 25 kg/m²) with one or more additional diabetes risk factors.  There are 18.8 million people diagnosed with diabetes.  That number is alarming but when you take into consideration that there are 7.0 million people who are undiagnosed and 79 million people who have pre-diabetes it clearly becomes epidemic.  Some analysis suggests by the year 2020 nearly half of all Americans may develop diabetes unless prevention strategies are widely implemented.

Unfortunately diagnosed, undiagnosed, and pre-diabetic patients are at increased risk for life threating acute and chronic complications.  Acute problems such as hyperglycemia, diabetic ketoacidosis (DKA), hyperosmolar hyperglycemia non- ketotic syndrome (HHNS), and hypoglycemia are equally relevant and can become a medical emergency without warning.  Studies have shown direct association between poor glycemic control and diabetic micro vascular disease such as neuropathies, nephropathy, retinopathy, and encephalopathy’s.  The macro vascular complications include cardiovascular disease, stroke, and peripheral vascular disease.  Many times the patient dies from the macro vascular disease such as heart disease or stroke before the micro vascular disease is identified (Forth & Jude, 2011).

Cardiovascular disease carries the highest risk of morbidity and mortality.  Patients die from heart disease and stroke at the rate of 2 to 4 times higher than those without diabetes.  Diabetes is the leading cause of kidney failure and blindness in adults in the United States (ADA, 2009).  About 60% to 70% of people with diabetes suffer from some form of nerve damage.  This can be identified as impaired sensation of feet or hands, slowed digestion, carpal tunnel syndrome, erectile dysfunction, or other nerve problems. This disease demands urgency, something must be done to bring awareness to all health care personnel on the importance of prevention, early detection and management of diabetes.  Health care personnel being educated and conscientious about diabetes can significantly reduce the complications of the disease in all cultures.

Conclusion

Diabetes is a progressive disease that can lead to debilitating complications and premature death if not well controlled.  However a diagnosis of diabetes is not necessarily a sentence of premature death, as it often used to be.  Diabetes has become an epidemic in the United States and some data analysis suggests by the year 2020 nearly half of all Americans may develop diabetes.  Certain ethnic groups such as Asians, Blacks, and Hispanics pose a greater risk for developing this disease.

Misconceptions about diabetes and diabetic management in the Hispanic community are common.  However, a significant knowledge gap does exist regarding the factors that influence the achievement of glycemic control and self-management practices in the Hispanic population.  Many factors can contribute to health disparities such as reduced access to health care, increased risk due to underlying biological, socioeconomic, ethnic factors; influences of cultural values and level of education.

Maintaining good self-care behaviors allows for excellent glycemic control.  Empowering people to manage their own health care while away from the clinical environment is crucial.  Providing effective long-term education and support can effectively reduce a patient’s risk of complications including renal disease, amputations, and blindness.  Unfortunately, very few patients currently achieve the control needed for preventing complications (National Institutes of Health, 2010).

Due to the diabetes epidemic in the United States governmental agencies are assembling programs to educate health care personnel on culture considerations and treatment of diabetes.  These programs aim the close the gap in diabetes related health disparities in various racial and ethnic populations and strengthen communication between health care providers and the community members they serve (Roe & Thomas, 2002).  Disease knowledge and access to health care are not the primary cause for poor self-management for the Hispanic community.  It is often assumed that if people are aware a specific behavior that causes adverse health effects, they would change their behavior, but this is not always the case.

Managing diabetes is challenging for both the healthcare provider and the patient.  The lack of disease awareness and proper blood glucose levels further complicates the problem.  Advances in technology and improved medical research bring improved methods of diabetes control, new medications, and easier ways to take insulin.  People who have Type I or Type II diabetes can utilize these medical advancements to help live a long and healthy life.

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