Diabetes prevention should include minorities

Shift in focus should offer tailor-made treatment

A troubling trend is forcing many providers — and ultimately ethicists — to determine how to reach patient groups most affected by diseases with severe complications.

Minorities bear a disproportionate share of chronic disease in American society. Health care professionals know that most of these diseases are treatable and manageable, but they have yet to find a way to get more people at the highest risk to comply with a more health-conscious lifestyle.

Hispanic Americans, for example, are currently diagnosed with diabetes at twice the rate of white Americans, with 6% of Hispanic adults in the United States and Puerto Rico having been diagnosed with the disease, according to a report released Jan. 15 by the Centers for Disease Control and Prevention (CDC) in Atlanta.

The data indicate a need to shift the focus of major diabetes education and treatment initiatives and to offer diabetes education that is tailored to specific patient groups, says Frank Vinicor, director of the CDC’s Division of Diabetes Translation.

For hospital ethics committees, that could mean ensuring that your diabetes education efforts are reaching all patient groups within the community.

"Diabetes is a serious disease affecting 16 million people in this country. These data tell us that efforts to reduce the burden of diabetes must focus on people who are disproportionately affected," he notes in a statement following the report’s release.

The CDC study included nationwide data from 1994 through 1997 and is the first to show diabetes prevalence among all Hispanics in the United States and Puerto Rico. Most previous studies had focused solely on Mexican Americans. (For a breakdown of diabetes by race, see the chart, p. 42.)

The new study also found that the prevalence of diabetes among Hispanics increases with age: approximately 2.3% of Hispanics between ages 18-44 have been diagnosed with diabetes; vs. 12% of those ages 45-64; and 21.4% of those ages 65 and older.

Although the study found that 6% of Hispanic adults were currently diagnosed with diabetes, the authors estimate that another 6% may have the disease and not be aware of it.

Education must take culture into account

The new data are merely reinforcing what many experts have known for some time, says Robert Stone, executive vice president of Nashville, TN-based Diabetes Treatment Centers of America, a company that contracts with hospitals and health plans to operate and design diabetes treatment and prevention programs and to offer disease management services.

"We have always known that the ethnic minority populations — black, Hispanic, American Indian, Pacific Islanders — have disproportionately high representation in the diabetes population as a percent of that ethnic population," says Stone. (For a breakdown on the rate of amputations among three ethnic groups with diabetes, see the chart, p. 43.)

The challenge, he contends, is eliminating both barriers to access to care and cultural barriers such as language and perception of disease.

"With very urban, inner-city populations, a large issue is access to care or access to insurance for care," he says. "But, in some cases, cultural identities present some different issues in terms of helping physicians and patients effectively deal with managing diabetes."

(For more on eliminating racial and ethnic disparities in care, see the related story, p. 43.)

For example, Diabetes Treatment Centers has, over several years, translated its educational material into Spanish three separate times.

"The reason for that is we have centers in southern California, where you have Mexican Spanish spoken or Chicano Spanish, centers in Texas where Mexican Spanish is spoken, and centers in Florida where the Spanish is Cuban," he notes.

"It’s still Spanish, but it’s different. The way you phrase things, the words you actually use, need to be translated by someone who is familiar with that particular region and type of Spanish, so that you don’t find yourself saying anything particularly inconsiderate, or incomprehensible," explains Stone.

Dietary advice must be culturally specific

Care must also be taken to offer a diet that is sensitive to a particular population’s traditions, says Stone. "I don’t like to make generalizations. But, for the most part, the Hispanic population in south Florida eats differently from the white population, and the Hispanic population in Texas, and the Hispanic population in California."

You cannot give diabetics of a certain population a strict diet that they will have a very difficult time following, says Stone. "You can’t just say, Have a salad, instead.’ Because they won’t eat that way. You have to tailor your diet recommendations to their cultural reality."

For example, the American Dietetic Association and the American Diabetes Association offer a free brochure titled "Meal Planning with Mexican American Foods" that offers advice on converting traditional recipes to healthier alternatives, and offers alternative healthy recipes for chicken soup, refried beans, tortilla chips, and chilaquiles. (See list of resources on p. 44.)

For most of the minority populations, the most prevalent form of diabetes is diabetes mellitus type II, says Stone.

"One of the many issues with type II diabetes is it begins very slowly and, frequently — perhaps too frequently — it is diagnosed only as a result of some acute illness that may or may not be related to the diabetes," he emphasizes. "In the course of interacting with the patient to treat the acute condition, the physician discovers that the patient has diabetes, and the patient may have had the disease for years at that point."

If diabetes type II is detected early, it can be successfully managed and most of the most severe complications can be avoided. (For more on ensuring all patients are screened for diabetes, see the related story, p. 44.)

Hospitalization ideal time to screen

The CDC currently recommends active screening for any person over the age of 25 and Diabetes Treatment Centers of America has guidelines that recommend screening every admitted patient over the age of 18. (For a breakdown of prevalence of diabetes among women, see the chart, p. 43.)

"For our [hospital] clients, the patient already is in the medical system, and the cost of doing the additional screen would be a small to nonexistent incremental cost," Stone points out.

If institutions don’t feel that they can bear that additional cost, then it would at least make sense for them to screen members of at-risk populations over the age of 18, he adds.

"The earlier you get the diabetic patient effectively self-managing their disease, the better outcome of their health or quality of life, and the lower the ultimate cost for society."

[Editor’s note: Copies of the DTCA Inpatient Management Guidelines for People With Diabetes can be ordered from: Diabetes Treatment Centers of America, 1 Burton Hills Blvd., Suite 300, Nashville, TN 37215. Attention: Teresa Mabry. Fax: (615) 665-7697.]