As with other minorities, distrust in healthcare professionals of other ethnicities may be a barrier to successful diabetes care. In clinic visits, physicians with Latinx/Hispanic patients should understand the cultural importance of a handshake and maintaining proper eye contact. Clinicians should learn basic Spanish phrases if they do not speak the language, and if necessary, a translator should be present.
Lower adherence to insulin and other diabetes medications has also been reported in Latinx/Hispanics. This may be related to uncertainty or fear about the treatment itself or lack of insurance coverage; in 2017, 16.1% of Latinx/Hispanics were uninsured compared with 6.3% of non-Hispanic whites.
Diabetes care for Latinx/Hispanics may benefit from incorporation of midlevel healthcare professionals or community health workers. Language concordance and maintaining familiarity and empathy are key parts of the patient-provider relationship for this population. The AACE recommends having a clinician-driven agenda during visits while also prioritizing individual patient-driven problems, rather than a visit that is oriented solely toward formulaic disease prevention or treatment.
The Asian American population encompasses people from at least 23 countries; healthcare professionals should be familiar with basic geography as part of understanding Asian culture. Even with this considerable diversity with regard to language, religion, and education and income levels, assimilation into American culture and lifestyle has considerably increased cardiometabolic disease risk among most Asian American populations.
Anthropometrics differ significantly between Asian Americans and other ethnic groups, with people of Asian ancestry tending toward higher percentages of intra-abdominal fat. As such, standardized cutoffs to determine central adiposity are lower for Asian Americans, and measuring waist circumference is particularly important in this population.
As a result of a population-specific gene variant, Asian patients are more susceptible to developing diabetes, and have demonstrated novel variants of the condition. For example, because of decreased β-cell mass, Asians with T2D are more prone to postprandial hyperglycemia and may benefit from diets that include foods with lower glycemic indices. Further, studies have shown that in patients of Asian ancestry with T2D who require insulin, a higher basal dosage is necessary. In some cases, encouraging a reversion to a traditional Asian diet (vegetables and fruits, spices, fish and seafood, low red meat consumption, soy consumption, green tea, smaller portion sizes, etc) and avoidance of refined grains, the use of animal fat and palm oil, and excessive consumption of salt and cured meats may help prevent progression of prediabetes to diabetes, as well as all-cause and cardiovascular mortality.
Exercise can present as a unique challenge in some Asian American populations. Cultural beliefs in South Asian people may endorse a neutral or negative perspective toward exercise (eg, it is healthier/safer for the elderly to rest; it is unsafe for women to exercise outside), and in some Islamic communities, there may be stigma against sweating prior to prayer. Culturally appropriate forms of dance, mosque-based physical activity, and culturally sensitive lifestyle intervention programs may be helpful.
Holidays and social events can disrupt healthy diet and lifestyle patterns, including missed appointments and poor adherence to medication. As a result, flexible clinic appointments may benefit these patients. For patients who observe Ramadan, avoidance of hypoglycemia and hyperglycemia is key. Clinicians should modify pharmacotherapy accordingly during Ramadan, and strenuous physical activity should be avoided during fasting.
In addition, Asian Americans may have belief systems deeply rooted in non-Western or alternative medicine that can disrupt care for patients with diabetes. Despite some evidence indicating that Asian patients trust and view their physicians as the best authority for advice, medication nonadherence or use of alternative therapies can remain unreported to healthcare professionals.
Drivers of diabetes may be unique for Native Americans compared with other ethnic groups, particularly with regard to genetic traits in the Pima people. Approximately 30% of Native Americans will develop prediabetes and, historically, mortality rates in diabetes were significantly higher for Native Americans compared with non-Hispanic whites. However, mortality rates differ between Native American regions and are lower among Pacific Northwest and Alaskan populations, “invalidating the perception that diabetes is severely endemic across all Native American entities.” Research has indicated that obesity prevalence rates for Native Americans are comparable to those for Latinx/Hispanics, blacks, and non-Hispanic whites.
A variety of dietary changes from natural, unprocessed foods to less healthy options, in conjunction with food insecurity and subsequent dependence on government provisions, has shown a direct correlation with the emergence of diabetes in the Native American population. Further, as a result of forced displacement, Native American culture has transitioned from an active to a sedentary lifestyle in reservation-based communities. These communities often lack adequate exercise programs, facilities, equipment, trained staff, and culturally appropriate, family-oriented resources for physical activity. In addition, disruption of tribal structure and geographic isolation due to government control has led to changes in culture and subsequent feelings of fear, fatalism, and denial with regard to diabetes among some Native Americans.
However, there have been advances in diabetes care for this population, with funding allocated to special diabetes programs coordinated by the Indian Health Service. These programs are focused on primary prevention of T2D and cardiovascular disease reduction.
Education for diabetes management is best received from within Native American communities rather than from outsiders. When communicating with Native American patients, whose people continue to experience social injustices and intergenerational trauma, emphasizing that Native Americans and their traditions “matter” can be an important message for clinicians to convey.
For CME training and other resources, see the Federal Health Program for American Indians and Alaska Natives Division of Diabetes Treatment and Prevention website.
Overall, attempted transculturalization in diabetes care should be approached as a modification to existing evidence-based guidelines. The key takeaway points are founded on recommendations for lifestyle changes with respect to patients’ culture, targeted pharmacologic interventions based on knowledge of potential ethnicity-specific efficacy, and improvements in clinician-patient communication.
*Editor’s note: The guideline authors use the term Latino to refer to all people with ancestry in Latin America. The term Latinx has been used to remain gender neutral.
Disclosure: Several authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.
Mechanick JI, Adams S, Davidson JA, et al. Transcultural diabetes care in the United States – a position statement by the American Association of Clinical Endocrinologists. Endocr Pract. 2019;25(7):729-765.