Introduction and Overview

Diabetes affects about 7% of the US population¹ with more than 90% of cases being type 2 diabetes mellitus (T2DM). In 2005, this translated into nearly 21 million Americans with diabetes.¹ Whereas Americans from all ethnic and cultural groups are affected, minority populations are disproportionately affected.¹ In fact, diabetes prevalence is 2 to 6 times higher among Latino Americans, African Americans, Native Americans (American Indians and Native Alaskans), and Asian Americans than among white Americans.² The National Institutes of Health reports that American Indians and Native Alaskans are 2.2 times more likely to have the disease than are non-Hispanic whites.³ Furthermore, studies using glycosylated hemoglobin (A1C) as a marker have shown that Latino Americans, African Americans, and Asian Americans have poorer control of their diabetes. In a study by Brown and colleagues, mean A1C levels were higher among Latino Americans, African Americans, and Asian Americans/Pacific Islanders than among white Americans (FIGURE).⁴

Perhaps as a direct consequence, diabetes complication rates are higher among patients from ethnic minorities,⁵ and the mortality rates in these populations are 2 to 5 times higher than the rates among white patients.² End-stage renal disease is higher among Latino Americans and African Americans than among whites. At least 4 studies have shown higher risks of lower extremity amputations among ethnic minorities.⁵ Thus, all patients with diabetes— but especially patients from ethnic minorities—need more assistance in controlling this chronic and progressive disease. A more culturally appropriate approach to these patients will increase the effectiveness of available treatments.

The trends of immigration suggest that the number of Americans of Latino, African, and Asian ethnicities will rise over time. Currently, Latino Americans make up 12.5% of the population, followed by African Americans at 12.3%, and Asian Americans at 3.6%.⁶ It is estimated that by the year 2050, minority populations will comprise 47% of the total US population,⁶ with projected increases in diabetes diagnoses of 165% in the overall population and at least this high in minority subpopulations.⁷ Many health care initiatives, including Healthy People 2010, have acknowledged the importance of improving care across America and have set goals to eliminate racial disparities in health and health care.⁸ However, barriers abound in the current health care environment even as we attempt to improve care.

 

Cultural Obstacles

Minority populations face many cultural obstacles to the acquisition of health care. Although some assume that the American system of health care is universally accepted and accessible, for a variety of reasons, many ethnic minorities receive suboptimal care in the United States. Barriers to care include patients’ and providers’ cultural beliefs and misalignment between the American health care system and ethnic health assumptions. Furthermore, our approach to treating medical conditions in the United States, combined with the lack of health insurance for many individuals, contributes to these barriers and disparities. In addition, immigration is adding more diversity to socioeconomic groups. Therefore, diversity within various cultural groups, as well as the cultural obstacles described here, must be understood and overcome to achieve superior cross-cultural health care.

In some cultures, seeking health care may be considered a “self-indulgent luxury.”² To seek care before the emergence of evident physical impairment may suggest egocentric conduct. Because diabetes, particularly T2DM, is a disease with a typically prolonged asymptomatic period, patients who wait for physical impairment may lose years of potential treatment for the disease. Without early treatment, residual pancreatic beta-islet cells diminish and complication rates rise. Patients with T2DM often present with complications such as neuropathy, vision changes, or nephropathy at the time of diagnosis.

Many patients fail to seek medical care because they believe there is an association between illness and an imbalance of excess and deficiency.² Some cultures believe that diabetes indicates a failure to live properly, represents a lack of spiritual strength, or is a punishment for immoral behavior.² Again, patients who resist seeking health care because they associate illness with a morally inferior lifestyle deny themselves timely access to care.

For some groups, cultural ideals may be violated by American health care attitudes. In diabetes care, much emphasis is placed on healthy diet and lifestyle as well as on limiting a patient’s weight to achieve glycemic control. For some cultures, however, a heavier physique is indicative of health.² Although much evidence links obesity and T2DM, patients who consider weight control measures to be contrary to their cultural ideals may devalue the advice of their physician. Thus, US providers must exercise care in offering health care advice to their patients to avoid conflicts between their patients’ cultural beliefs and any pre-existing notions of the superiority of the traditional American approach to medical care. Refuting engrained cultural health care standards before a relationship of mutual trust and respect between patient and health care provider has been developed will likely lead to rejection of any plan for treatment.

With these and other cultural factors in mind, American health care providers might easily consider patients from unfamiliar cultures and ethnicities to be “problem patients.”² But American health care providers and the American health care system may be at least partly responsible for the barriers to caring for our ethnically diverse population. Instead of viewing beliefs that are different as foreign, we need to educate ourselves and modernize our health care system to accommodate these different approaches to illness. In order to lessen the burden of disease, we need to recognize the differing opinions about provision of care and treatments. To optimally care for Americans across ethnic and cultural boundaries, a cross- cultural understanding of medicine is paramount.

 

Cultural Competency

Cultural competency is “awareness of and sensitivity to cultural differences; knowledge of cultural values, beliefs, and behaviors; and skill in working with culturally diverse populations.”² Although the definition is succinct, the challenge is to identify an individual patient’s culture. It is vital for providers to comprehend the distinction between race (populations characterized by physical traits), ethnicity (social groups with shared history and cultural roots regardless of race), and culture (members of a society with shared beliefs, values, customs, and behaviors).

Instead of stereotyping, culturally competent providers can first gain a general awareness of a culture’s norms; they can then explore a patient’s beliefs and values, remembering that each patient is different, even within his or her own cultural context.⁶ Whether the issue is achieving an understanding of the Latino or Asian belief that a balance of hot and cold is necessary for health,⁶ or the African American belief that the use of bitter foods and herbs can neutralize the blood,² an appreciation of varied cultural convictions is critical to caring for the individual patient.

Nonjudgmental Questions for Patients With Diabetes

Although achieving cultural competency can be time-consuming and challenging, it has the potential to lead to greatly improved outcomes. The history-taking interview is the best opportunity to establish open communication with the patient. From this history taking, the physician will be able to establish a solid basis for appropriate management of the patient. Throughout the patient cases discussed here, there are a number of recommended questions and techniques that physicians can use with patients. Interview questions must be tailored to elicit the patient’s perceived cause of illness, information about complications related to the illness, the severity of the illness, and the patient’s fears about the illness.⁶ Questions must also be nonjudgmental (TABLE 1).⁹

Health care providers must be skilled in intercultural communication, understanding the various perceptions and attitudes toward personal space, the appropriateness of certain gestures, and the meaning of direct and indirect communication.^2,6 For example, some Asian American populations consider indirect eye contact a sign of respect and so will avoid direct eye contact with a physician. Interpreters can be helpful in reducing language barriers, but they must also be chosen carefully to ensure proficient translation of sensitive topics. To provide culturally competent care, providers must compile a new knowledge set, including cultural awareness (to appreciate and accept differences), cultural knowledge (to comprehend different world views of illness), and cultural skill (to assess and explain issues to a person who has different beliefs), and then providers must amass an abundance of cultural encounters.⁹ Cultural competency enables a provider to tailor care to the individual needs of the patient, and it has the potential to revolutionize diabetes care in America.

As important as cultural competency is, we must also remember to focus on what so many patients with diabetes share—the inability to achieve target glycemic goals. All patients with diabetes face long-term challenges that will affect their lifestyle. Diabetes is a progressive disease, and the treatment modality must match not only the patient’s lifestyle but also the amount of endogenous insulin being produced by the body at any one time. All glucose-lowering agents are limited in their ability to lower A1C levels; therefore, it is unrealistic to expect any one medication to be successful, particularly if that medication’s effects may be limited by the amount of endogenous insulin available.

 

Case Studies

To further explore the similarities and differences in treating Americans with diabetes, case-based scenarios are presented for Asian American, African American, and Latino American patients with T2DM. These 3 cases describe a variety of patients: one who is newly diagnosed, one who must now initiate insulin therapy, and one who has had the disease for a few years and now needs the treatment plan to be intensified (TABLE 2). Each patient is treated as an individual, with his or her own ethnic and cultural beliefs. However, because many of the challenges are similar, each case highlights a different cultural competency issue and management discussion.

Diabetes is a disease with a variety of presentations, treatment options, and complications. By better understanding the patient as an individual, within the context of his or her cultural beliefs, the health care provider can better tailor the patient’s overall care and, particularly, his or her diabetes care. The implications are of great consequence. A culturally competent physician can not only identify the disease but also recognize the challenges to incorporating treatment into a life filled with family and cultural influence. Failing to understand the importance of cultural beliefs, lifestyle, family responsibilities, or the way the patient expresses himself or herself fails the patient. Therefore, providers are now charged with a new task: the implementation of culturally competent care. In the case of diabetes, the provider and all members of the health care team are responsible for understanding the disease beyond pancreatic dysfunction and treatment options. Understanding not only the disease of T2DM but also the patient with the disease is paramount in achieving optimal outcomes. Cultural competence is an ongoing journey and a lifelong learning process.

Case-based Scenarios Presented

References

1.  National Diabetes Fact Sheet. United States 2005. http://www.cdc.gov/diabetes/pubs/pdf /ndfs_2005.pdf. Accessed July 17, 2007.
2. Tripp-Reimer T, Choi E, Skemp Kelley L, et al. Cultural barriers to care: inverting the problem. Diabetes Spectrum. 2001;14:13–22.
3.  National Institutes of Health. The diabetes epidemic among American Indians and Native Alaskans. http://ndep.nih.gov/diabetes/pubs/FS_AmIndian.pdf. Accessed June 13, 2007.
4. Brown AF, Gregg EW, Stevens MR, et al. Race, ethnicity, socioeconomic position, and quality of care for adults with diabetes enrolled in managed care. Diabetes Care. 2005;28:2864–2870.
5. Lanting LC, Joung IMA, Mackenbach JP, et al. Ethnic differences in mortality, end-stage complications, and quality of care among diabetic patients. Diabetes Care. 2005;28:2280–2288.
6. Juckett G. Cross-cultural medicine. Am Fam Physician. 2005;72:2267–2274.
7. Venkat Narayan KM, Boyle JP, Thompson TJ, et al. Lifetime risk for diabetes mellitus in the United States. JAMA. 2003;290:1884–1890.
8. Virnig BA, Hudson Scholle S, Chou AF, et al. Efforts to reduce racial disparities in Medicare managed care must consider the disproportionate effects of geography. Am J Manag Care. 2007;13:51–56.
9.  American Medical Student Association. Cultural competence in medicine. http://www.amsa.org/programs/gpit/cultural.cfm. Accessed May 14, 2007.