Fighting ‘inevitability’ of developing type 2 diabetes in Mexican-Americans

Targeting a population unlikely to seek medical care takes frankness, inventiveness for educators and physicians.

It is something they strive for, and is the likely reason they — or previous generations — came to this country. However, for many Mexican-Americans, the pursuit of an improved standard of living has resulted in a growing risk for developing type 2 diabetes.

“When people know they can buy more and eat more, they may adopt a sedentary lifestyle,” said Enrique Caballero, MD, director of the Joslin Latino Diabetes Initiative. “As people move up in socioeconomic strata, they tend to adopt elements of a better lifestyle.”

Better does not necessarily mean healthier, Caballero added.

Diabetes is also a problem for Mexican-Americans who can’t yet claim an improved standard of living. According to Teresa Rodriguez Jacobson, LICSW, also from the Joslin initiative, economically disadvantaged patients are more concerned about obtaining food and shelter.

“Health is way up in terms of unmet needs,” she said.

Twice the risk

Mexican-Americans are the largest Hispanic population in the United States. According to the U.S. Census Bureau report from 2002, the most recent year statistics were available, 66.9% of the 37.4 million Hispanic Americans in the civilian, noninstitutional population were of Mexican heritage. Those of Central and South American heritage comprise the next largest group at 14.3%, Puerto Ricans comprise 8.6% and those of other heritages comprise 6.5%.

The U.S. Department of Health and Human Services Office of Minority Health reports that the Hispanic population has the highest uninsured rate of any ethnic group in the country. Within the Hispanic population, Mexican-Americans have the highest uninsured rate at 37%.

According to the National Diabetes Education program, approximately 10.2% of Hispanic Americans have diabetes; approximately 2 million Hispanic Americans have been diagnosed with diabetes. In addition, they are 1.9 times more likely to have diabetes than the non-Hispanic white population.

Their elevated risk for type 2 diabetes is based on genetics, said Caballero. Mexican-Americans are more insulin resistant than those of other heritages. The process of insulin binding to insulin receptors is a normal process in most people with diabetes. However, after that happens, the series of events that follows can cause problems for some populations. In Mexican-Americans, compared with Caucasians, “it is the intracellular insulin signaling cascade that seems to be abnormal,” Caballero said.

An accepted disease

Mexican-Americans in some parts of the country see type 2 diabetes as inevitable. This is the case in the Rio Grande Valley, said Alan J. Garber, MD, PhD, professor of medicine, biochemistry, molecular biology and molecular and cellular biology at Baylor College of Medicine. Mexican-Americans in that area are likely to view diabetes as simply part of the life cycle.

“We’re trying to change that by education,” said Garber, whose patient population is between 20% and 25% Mexican-American. “You don’t have to become diabetic.”

Although he contends that awareness of type 2 diabetes within the Mexican-American population is better than it was 10 years ago, Garber said massive efforts are still needed in the area of public health.

“The current health care system does not focus on prevention of chronic disease,” Garber noted. “When you only deal with the consequences, you cannot get superb results.”

Educating physicians who treat Hispanic American patients is one way the American Association of Clinical Endocrinologists (AACE) is trying to improve public awareness.

At the 2005 Annual Meeting and Clinical Congress in Washington, D.C., AACE held a special session on Hispanic and Latino health. Diabetes, insulin resistance and the resulting cardiovascular burden were just a few of the topics covered at the meeting.

Caballero agreed that cultural competence is becoming more important for doctors. He noted that two states, California and New Jersey, have made it mandatory for physicians to obtain continuing medical education credits through programs that address cultural issues.

Invincible first, fearful later

In the Mexican-American population, a person’s upbringing and financial situation frames a tendency to avoid seeking medical care.

Pam Sheffield, RN, CDE, of the Medical Clinic of North Texas in Plano, told Endocrine Today that a focus on preventive medicine does not often play a role for her Mexican-American patients, who account for 35% of her patients.

“Health and being health-conscious is not something they’re brought up with,” Sheffield said. “Economics plays a role because a good percent of these people may not have health insurance.”

Sheffield has observed a feeling of invincibility among some in this population.

“‘As long as something is not hurting or broken, why fix it?’” is the philosophy of some Mexican-American patients, said Sheffield.

Faced with headstrong patients, Sheffield said it is better to be up front about the disease itself rather than immediately press the issue of lifestyle change.

“If you’re frank with them, they turn around,” she said.

Moving past patient fear of insulin is another challenge for those working with the Mexican-American population.

According to Garber, insulin is seen as a “death knell” among Mexican-Americans. “People are fearful because it means bad things are around the corner,” he said.

In reality, patients are seeing evidence that their diabetes has not been treated early enough.

It is important to teach patients that insulin use can be positive when compared with the potential complications that can result from untreated diabetes, Garber said. Patients with type 2 diabetes additionally must learn that insulin use does not denote a lifestyle failure, but is rather due to the progressive nature of the disease.

The diet followed by many Mexican-Americans increases their risk for type 2 diabetes.

Sheffield told Endocrine Today that her patients tend to choose high-fat meat and flour tortillas instead of low-fat corn tortillas. When those meals include rice, they are also too high in carbohydrates, she added. But type of food is just one part of the problem.

“No one seems to address portion control,” Sheffield said.

Carbohydrates count

When it comes to diet, not all Hispanic diets can be viewed alike. For example, a Cuban diet differs from a Tex-Mex diet, and they each differ from a Mexican one.

Garber noted that most Hispanic diets could reduce the high use of pork; however, it is generally better to work with the dietary preferences of different Hispanic American populations.

“The challenge is not to change their complete diet,” Garber said. “The likelihood of being able to adhere to that long-term is rather low.”

Making dietary changes can be challenging for parents who have type 2 diabetes, but it can be a positive experience, Rodriguez Jacobson said.

“I say to parents, ‘what a unique opportunity now to do a lot of education with your kids.’”

Starting earlier than adolescence is key to educating children about the risk of type 2 diabetes, Rodriguez Jacobson said. However, as parents or caregivers who have children with type 2 diabetes learn, the situation can be difficult.

“For disorganized, poor families, it’s another stressor,” Rodriguez Jacobson said.

In an effort to offer support and education to patients with type 2 diabetes, their families and those who support them in their diabetes care, the Joslin Latino center is starting a once-a-month drop-in program in May.

The program is centered on Joslin-produced television novellas, Spanish language made-for-TV shows similar to soap operas. The series revolves around a protagonist named Rosa, and viewers follow her steps from diagnosis to treatment.

“It can be a unifying thing,” Rodriguez Jacobson said, “where several generations come and watch one.” – by Rachel Eskenazi

For more information:

• Visit the Joslin Latino Diabetes Initiative at joslindiabetescenter.org.