The classification of specific populations is defined by the dominant culture in the United States and our federal government. It is important to recognize that the arbitrary groupings into African Americans, Hispanic/Latinos, American Indians/Alaska Natives, and Asian Americans/Pacific Islanders/Native Hawaiians lump diverse groups and cultures into somewhat artificial groups. American Indians/Alaska Natives have a common bond only because their ancestors predate the European settlers. The culture, language, and traditions of East Coast American Indians are distinctly different from those in California or Alaska. Similarly, the Hispanic/Latino population can be identified only by a common language, and the African American population by their origin from the African continent. Asian Americans and Pacific Islanders are more defined by geography of origin than by any cultural or linguistic ties.
Health care professionals should be careful when attributing cultural characteristics to these specific populations and in working with the smaller populations. It is also important to be aware that additional research is required to gain insight into more specific cultural practices and beliefs. The same is true for the older adult population and those who live with depression, distress, and/or mental illness. For instance, some older adults may have good physical and mental health, while others in this group may have a range of chronic conditions and mental disabilities. To add to the complexity, a patient may be included in one or more of the other specific populations.
The common thread connecting these specific populations is an increase in the prevalence of diabetes.1 For instance, Native Americans and Alaska natives are reported to have the highest rates of diagnosed diabetes (15.1%), followed by blacks (12.7%) and Hispanics (12.1%), while rates are lower among Asians (8%) and whites (7.4%).2
1) Older Adults
Diabetes management for the population older than 65 requires special consideration on an individual level. The diversity within this population prevents a broad management strategy. Following are factors to consider when developing a treatment plan for older adults:
- 10-year survival risk should be estimated. Treatment directed at reducing long-term complications may not be appropriate or necessary.
- Progressive decrease in renal function, cardiac and pulmonary reserve, metabolism, and mobility require periodic assessments. Medication doses may need to be adjusted based on physiologic parameters.
- Progressive deterioration of sensory function should be periodically assessed and treated if possible.
- Cognitive function deteriorates with age. Alzheimer’s and multi-infarct dementia prevalence increase with age.
- Depression often occurs with decreased functional ability and changing living situations.
- Social isolation and loss of friends and loved ones has significant impact on overall health.
- Adjust A1C goals and avoid hypoglycemia. Hypoglycemia impacts cognitive function and increases fall risk.
- Check for orthostatic hypotension prior to starting or adjusting hypertensive medication. Effects of autonomic nerve dysfunction in patients with diabetes causes orthostatic hypotension and increases fall risk.
- Avoid benzodiazepines and opioid pain medication. Use other psychoactive medications with caution and check if reduced dosage is required in older adults. The American Geriatrics Society provides the Beers Criteria (PDF, 561 KB) to identify medications, including some common diabetes medications, which may be potentially inappropriate in older adults.
Resources for Working With Older Adults with Diabetes:
- American Diabetes Association: Recommendations for Older Adults
- American Diabetes Association and the American Geriatrics Society: Diabetes in Older Adults (PDF, 152 KB)
2) African Americans
African Americans have a higher prevalence of diabetes than the non-Hispanic white population and worse health outcomes.3 Obesity is common in the African American community and may be more culturally accepted. A higher percentage of African Americans fall below the poverty line, have lower education levels, and less access to culturally appropriate care: all components of the social determinants of health care outcomes. Faith is strong in many African American communities; churches and other faith-based organizations may be effective partners in establishing creative approaches to diabetes management.
Standard office-based medical care has been less effective in achieving effective diabetes management in African American communities. Clearly, poverty and limited access to care accounts for some of the disparity, but alternative approaches—such as partnering with churches and using lay educators and community health workers—have shown promise in building better rapport with the individual patient and the community.
- Centers for Disease Control and Prevention: Resources for African Americans and People of African Ancestry
- Office of Minority Health: Prevalence and rates of complications in African Americans
- American Diabetes Association: Treatment and Care for African Americans
3) American Indians/Alaska Natives
The designation of American Indian/Alaska Native encompasses broad and diverse populations. There are 5.2 million people who maintain tribal affiliation or community attachment and thus are classified as American Indians.4 Twenty-two percent of the population lives on reservations or other trust lands. There are 566 federally recognized American Indian/Alaska Native tribes. The populations residing on tribal lands are eligible to receive care through the Indian Health Service (IHS) or tribal-run health care. In addition, the Office of Urban Indian Health Programs provides access to care outside of the IHS service areas. One in three American Indians/Alaska Natives is uninsured, which continues to be a barrier to care, even with the introduction of the 2010 Patient Protection and Affordable Care Act.
The challenges in managing diabetes in the American Indian/Alaska Native population include working with small populations with distinct cultural practices, poverty, the limited resources within the IHS/Tribal structure, and reaching a large percentage of the population that live in rural settings. There is a high rate of co-morbid conditions in this population, including alcoholism and depression.5 The effect treatment often requires a team that has community health workers or other peer educators, access to alcohol and substance abuse counseling, and a strong behavioral health component.
- Office of Minority Health: Data on prevalence and complications of diabetes in American Indians/Alaska Natives
- Centers for Disease Control and Prevention: Diabetes Among American Indians and Alaska Natives (PDF, 304 KB)
- American Diabetes Association: American Indian/Alaska Native Programs
- Indian Health Service: Special Diabetes Program for Indians
4) Asian Americans/Pacific Islanders/Native Hawaiians
Asian Americans/Pacific Islanders/Native Hawaiians are grouped based on geography and have a wide range of cultural beliefs, as well as many distinct languages and dialects.6 The 2010 census reported approximately 18 million Americans of Asian descent and 1.2 million Native Hawaiians and Pacific Islanders. Not unexpected, the prevalence of diabetes varies considerably within this classification, with the highest rates in the Pacific Islanders (18.3%), South Asians (15.9%), and Filipinos (16.1%).7 Average statistics fail to define the diversity in this population. Notably, the estimated prevalence of diabetes is higher in Asian Americans than non-Hispanic Whites, and half of Asian Americans with diabetes are undiagnosed.8 Asians as a group are more economically prosperous than other minority groups in the United States, but a significant percentage are below the poverty level and have limited access to culturally tailored health care.
Asian Americans/Pacific Islanders/Native Hawaiians have a rich history in traditional health care.9 The common practice of acupuncture dates back 2,000 years as a chapter in The Yellow Emperor’s Classic of Internal Medicine (Huangdi Neijing), the writing that established traditional Chinese medicine.10 Some Asian American and Pacific Islanders continue to rely on traditional and alternative medicines, often in combination with western medicine. An additional challenge in diabetes management is the ability to tailor diabetes education to the traditional diets from Asia and the Pacific Islands.11 Unlike the Hispanic/Latino population with a common language, limited English proficiency is a barrier to diabetes care for many providers and patients. Health literacy is difficult to access and manage. For the lesser spoken languages, translated material is very limited, and a sizable population have limited education from their country of origin and are not able to read in their own language.
- Office of Minority Health: Data on prevalence and complications of diabetes in Asians and Pacific Islanders
- Centers for Disease Control and Prevention: Diabetes Resources for Asian Americans, Native Hawaiians, and Pacific Islanders
- American Diabetes Association: Resource for Asian Americans, Native Hawaiians and Pacific Islanders
- National Council of Asian Pacific Islander Physicians: Asian American, Native Hawaiian, and Pacific Islander Diabetes Coalition resources
- Harvard School of Public Health: Asian Diabetes Prevention Initiative
The Hispanic/Latino population is a diverse set of cultures. This population may have a common language, but they come from a number of Spanish-speaking countries from both American continents and the Caribbean Islands. Historically, the Spanish intermarried with the American Indians and thus, both genetically and morphologically, some Hispanic/Latinos are similar to American Indians. Access to care is significantly affected in the sub-group who are undocumented aliens, in addition to the language and cultural barriers. Even though the largest populations of Hispanic/Latinos are in the traditional border states, the Hispanic/Latino population is distributed throughout the United States.12
Many first generation Hispanic/Latinos have limited English language skills and do not typically seek medical care unless acutely ill. The traditional strong family structure is at times disrupted by migration and other factors. A relatively high percentage of the population is uninsured, either due to their immigrant status or employment in agricultural or services jobs. Diabetes education and management is a challenge for many patients because they have conflicting priorities related to family and employment. Many who do have substantial income send remittance back to the country of origin to support their families and others. Second generation and third generation Hispanic/Latinos tend to be more acculturated with the American lifestyle, but much depends on whether they come from a large Hispanic/Latino community and their cultural upbringing. Effective diabetes programs focus on being linguistically and culturally appropriate and building strong ties to the Hispanic/Latino communities. Culturally tailored diabetes educational and self-management material has significantly increased over the last 15 years.
There are a significant number of resources available focused on managing diabetes in the Hispanic/Latino community. The use of community health works or peer educators as team members has been successful in improving self-management skills.13 Most Hispanic/Latinos appreciate providers that communicate in Spanish even if their language skills are limited and does not replace medical translation complements it. Social barriers to care are common, and exploring life situations and the stresses associated with daily living may provide insight in developing a care plan.
Resources and Model Programs for Hispanic/Latino Populations:
- Centers for Disease Control and Prevention: Resources for Hispanic and Latino Americans
- American Diabetes Association: Diabetes Among Hispanics: All Are Not Equal
- Office of Minority Health: Diabetes and Hispanic Americans
- American Diabetes Association: Latino Programs
6) People with Depression, Distress, and Mental Illness
The incidence of depression is higher in patients with diabetes and is associated with poor diabetes care. Estimates of the number of patients with diabetes that have depression varies wildly; approximately one third likely have depression symptoms.14 Less research has been done with other mental illness, but the combination of these conditions clearly impacts long-term outcomes and management. The diagnosis and daily demands of diabetes management also often exacerbates anxiety. Diabetes distress, defined as patient concerns about disease management, support, emotional burden, and access to care, is an important condition distinct from depression.15 The second Diabetes, Attitudes, Wishes and Needs (DAWN2) study found that diabetes distress was higher among ethnic minorities than White non-Hispanics in the United States.16
Depression, distress, and mental illness can be chronic or relapsing conditions. Clinicians need to be aware of the dynamic aspect of depression, distress, and mental illness and assess patients periodically, particularly when diabetes control worsens. In addition, patients with depression and mental illness have a higher incidence of alcoholism and substance abuse. Treatment plans must be comprehensive and not focus on a single condition. Effective management requires a team approach that integrates behavioral health into primary care. The 2010 Patient Protection and Affordable Care Act provides annual screening for prevention at no cost to the beneficiary.
- Patients should be screened for depression and substance abuse periodically and when there is deterioration in diabetes control using one of the standard validated screening tools. A commonly used screening tool for depression is the Patient Health Questionnaire (PHQ-9) and the short form, the PHQ-2 (PDF, 37.7 KB) . Substance Abuse and Mental Health Services Administration-Health Resources and Services Administration (SAMHSA-HRSA) provides resources for screening for mental health conditions and alcohol and substance abuse.
- If alcohol or substance abuse is present, the patient needs effective treatment prior to managing either the mental illness or diabetes. Additive drugs have significant effect on both mental status and metabolism.
- Psychoactive medications used in the treatment of depression and other mental illness affect appetite, sleep, energy levels, and emotion. Side effects should be reviewed periodically, including weight gain or loss, which may impact diabetes management.
- Counseling in lifestyle changes may be handled by the behavioral health specialist on the team, combining diabetes management with the treatment of depression or other mental illness.
- National Institute of Mental Health: Chronic Illness and Mental Health
- American Diabetes Association: Does Diabetes Cause Depression?
- DAWN2: Information about the DAWN2 Study
- SAMHSA-HRSA Center for Integrated Health Solutions: Screening Tools