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Despite substantial progress in type 2 diabetes management in recent years, significant racial and ethnic disparities persist in terms of the disease’s prevalence and outcomes. In Hispanic and Latino communities, rates of type 2 diabetes are more than twice as high compared with Whites, at 17% and 8%, respectively. Complications such as diabetes-related nephropathy and eye disease are also more common among Hispanics and Latinos as a result.1,2
Additionally, rates of mortality and hospitalizations are higher among Hispanics and Latinos compared with Whites.3 These disparities may be the result of a combination of biological, genetic, sociocultural, and environmental factors.
Endocrinology Advisor explored these issues and potential solutions in an in-depth interview with endocrinologist and researcher A. Enrique Caballero, MD, director of Latino Diabetes Health in the Division of Endocrinology, Diabetes, and Hypertension at Brigham and Women’s Hospital at Harvard Medical School in Boston. Dr Caballero is also chair of the Health Care Disparities Committee at the American Diabetes Association.
In addition to the higher prevalence of type 2 diabetes, what are the most notable diabetes-related health disparities affecting Latino and Hispanic communities compared with other populations?
The proportion of people with undiagnosed diabetes is higher among Hispanics and Latinos compared with the White population. While roughly two-thirds of people with diabetes in the White population know they have the disease, in the Hispanic community only close to 50% of the people are aware they have the disease.4 Glycated hemoglobin (HbA1c) levels are usually higher at the time of diagnosis and during routine diabetes care among Hispanics and Latinos than in the White population. There are also higher rates of gestational diabetes and prediabetes [among Hispanics and Latinos].
Additionally, almost every complication associated with diabetes is reported to be more common in people from the Hispanic and Latino communities vs people with diabetes in the White community.
Notably, disparities in the quality of diabetes care have been well identified. Hispanics and Latinos are less likely to receive proper diabetes care compared to the White population. For example, the proportion of people who have a yearly full eye exam and a routine foot examination is lower among Hispanics and Latinos than in Whites.
Of great concern is that all of these disparities occur even when people have access to regular health care – this is not because they don’t have insurance or they don’t go to the hospital or clinic. Even when they do, they’re not receiving the same quality of care as other populations. That’s obviously a sensitive issue because it involves structural discrimination in our health care system and biases among health care providers. This is a difficult fact to accept, but the data are compelling and irrefutable.
More recently, it has also been documented that some of the new medications for type 2 diabetes, such as sodium-glucose cotransporter-2 (SGLT2) inhibitors and glucagon-like peptide-1 receptor agonists (GLP-1RA), are less frequently prescribed to Latinos and Hispanics.5 Certainly, limitations in health care coverage play a role, but the key question is whether clinicians are not offering these options equally to their patients.
What are thought to be the main factors driving the disparities you described?
These disparities are related to inequities in health care – that is, not everyone has the same opportunity for optimal health care. I always think about a triad that includes the patient, the health care system, and health care provider, and there are factors in all 3 domains that contribute to health care disparities and inequities.6
Clearly there are cultural, social, economic, and psychological factors on the patient side that may be present in many members of the community which influence diabetes self-care behaviors. That’s obviously something we need to better address.
The health care system is not usually conducive to providing culturally- and socially-oriented care. Our health care system usually focuses the biomedical side of medicine, but we don’t usually address social determinants to health.
There are no team members to address these issues in most clinical practices within endocrinology, internal medicine, family medicine, or primary care, and physicians are often alone trying to do a lot of things. They don’t usually have time to see patients and encounters are brief. There are so many things to pay attention to that these factors are often left on the side, and no one really addresses them. Our system is not developed and supported to address all of these important factors, so that’s hopefully something that can be changed in the future. I think having teams that could address these elements, along with the physician, is important.
The third component is the health care provider, and this is also a sensitive issue. Whereas we all are well-intended people and professionals, we truly fall short by not properly understanding people’s backgrounds, culture, and needs. I like the term “cultural humility,” which is really a call for all of us as clinicians to become more aware of our cultural differences with our patients and not try to impose our own beliefs and points-of-view on them. We need to listen more attentively to their needs to better understand their preferences, [viewpoints], perceptions, health beliefs, and expectations. It is then easier to establish better communication with patients and to develop treatment plans that are more likely to be effective.
I think all of these factors are important in health care disparities, but I would say these all happen within an umbrella that is much bigger than just the health care system, patients, and providers: Our society unfortunately promotes structural racism and discrimination. It’s important to say that because systems and policies often prevent some people from following or implementing the recommendations that we as clinicians provide. Patients may not be able to fully engage in regular exercise practices if they live in a dangerous neighborhood. They may not be able to follow a healthier meal plan as we often recommend if they have food insecurity or if healthy foods are not available and accessible to them.
These are crucial factors that we as health care providers should be fully aware of, and although we can’t totally address them we must identify and try to do something in order to eliminate health care disparities.
What are some ways clinicians can address these issues in practice?
I think health care providers need to embrace the need to become more culturally aware of our patients’ realities, and that includes not necessarily speaking the same language that our patients speak. I think it’s about really being able to develop better communication with our patients within the limited time that we have.7
We must find ways, and time, to listen to our patients. A lot of the talking in clinical encounters typically comes from the health care provider – our patients come and just listen to the recommendations we provide to them. Even though we’re busy and need to accomplish a lot of tasks within a few minutes, we should try to better identify the needs and concerns of our patients.
In addition, we all need to embrace going through training programs to become more aware of our own unconscious or hidden biases in how we approach encounters with patients. As I said, all of us may be very well-intended, but we are most likely doing things in a suboptimal way because we’re not aware of our own biases. Being aware of these important aspects can help us improve the way in which we interact with our patients.
For example, there are training programs on cross-cultural care, unconscious biases, ways to improve patient-provider communication, and how to best address social determinants of health. Even though these may not be the typical areas clinicians are interested in, we as endocrinologists need to really think outside the box and consider better preparing ourselves in these areas, which are often neglected in clinical practice.
We should also consider surrounding ourselves with people who believe in this new focus on diabetes care and are ready to act. That means integrating teams in our clinical practices or hospitals that include social workers, psychologists, educators, pharmacists, behavioral health specialists, community health workers, patient system navigators, and all these amazing health care professionals who can provide extra help to the management of chronic conditions like diabetes. Despite great advances in the field of diabetes in the last few years and decades with technology, medications, and knowledge, most patients with diabetes are not well-controlled. I truly believe this is because it’s not just about science and technology; it is about addressing all of these factors that we often overlook. In my mind, effective care requires the combination of great science with the art of medicine.
What efforts are needed to address these disparities on a broader level?
We all need to do whatever we can at the local, regional, and national level if possible. I am fortunate to work very closely with the American Diabetes Association. I am currently the Chair of the Health Care Disparities Committee, where we discuss a lot of these issues regularly. We believe community-based interventions should be widely developed and supported. Programs that make healthy foods more affordable and available to underserved communities, including the Hispanic and Latino populations, are urgently needed. Strategies within our society that address common problems like housing, transportation, and safety in neighborhoods are crucial so that people can truly implement the health-related recommendations we provide.
If patients lack transportation, for example, obviously they’re not going to go to the hospital or the clinic for their appointments. If they don’t have stable housing, they may not be able to follow recommendations. For instance, if they are on insulin therapy and they don’t have a place where they can store their insulin under proper conditions, they won’t be able to adhere to this treatment strategy. We all need to aim for our system to provide equal opportunity to every patient so they can access optimal health care and not allow all these barriers to limit their ability to improve their diabetes self-care behaviors.
What are some additional key points for endocrinologists regarding this topic?
As endocrinologists, we are witnessing so many wonderful advances in diabetes care. This is the best time in history in terms of technology, with continuous glucose monitors that allow us to accurately and regularly assess patients’ blood glucose levels and insulin pumps along with the use of telemedicine. We also have more medications for type 2 diabetes than ever before.
We actually have 12 different classes of medications to treat type 2 diabetes. We also have better knowledge about diabetes pathophysiology and its complications. However, we need to accept that most people living with diabetes have not achieved usual treatment targets and that we are not helping everybody to the same extent.
Data from the National Health and Nutrition Examination Survey shows only 1 in 5 patients with diabetes have achieved common targets for diabetes, blood pressure, cholesterol control, as well as smoking cessation.8 We definitely have the knowledge and treatment tools to help people achieve these goals, but we’re not being very effective in doing so. It is imperative for all of us to reflect on why we are falling short.
We have historically blamed the patients – we may say, “I recommend to my patients what they should do, and if they don’t do it, that’s not my fault.” A much better sentence would be: “I don’t really know how to better help my patients achieve their goals despite providing them with all treatment recommendations.” That would be a great way to start.
There are huge challenges in our health care system, and certainly patients need to better engage in health care. But we as health care providers have an important role to play in improving diabetes care for all. Let’s also not forget that some populations like the Latino and Hispanic subgroups need an extra hand. Ultimately, true equity can only be achieved when we provide what is needed to each group–and individual–in order to succeed.
1. Centers for Disease Control and Prevention. Hispanic/Latino Americans and type 2 diabetes. Accessed September 30, 2021. https://www.cdc.gov/diabetes/library/features/hispanic-diabetes.html
2. Aguayo-Mazzucato C, Diaque P, Hernandez S, Rosas S, Kostic A, Caballero AE. Understanding the growing epidemic of type 2 diabetes in the Hispanic population living in the United States. Diabetes Metab Res Rev. 2019;35(2):e3097. doi:10.1002/dmrr.3097
3. US Department of Health and Human Services, Office of Minority Health. Diabetes and Hispanic Americans. Accessed September 30, 2021. https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=4&lvlid=63
4. Menke A, Casagrande S, Geiss L, Cowie CC. Prevalence of and trends in diabetes among adults in the United States, 1988-2012. JAMA. 2015;314(10):1021-1029. doi:10.1001/jama.2015.10029
5. McCoy RG, Van Houten HK, Deng Y, et al. Comparison of diabetes medications used by adults with commercial insurance vs Medicare Advantage, 2016 to 2019. JAMA Netw Open. 2021;4(2):e2035792. doi:10.1001/jamanetworkopen.2020.35792
6. Caballero AE. Transcultural diabetes care: a call for addressing the patient as a whole. Endocr Pract. 2019;25(7):766-768. doi:10.4158/EP-2019-0281
7. Caballero AE. The “A to Z” of managing type 2 diabetes in culturally diverse populations. Front Endocrinol (Lausanne). 2018;9:479. doi:10.3389/fendo.2018.00479.
8. Wang L, Li X, Wang Z, et al. Trends in prevalence of diabetes and control of risk factors in diabetes among US adults, 1999-2018. JAMA. 2021;326(8):704-716.. doi:10.1001/jama.2021.9883