Review Article
Addressing Cultural Barriers to the Successful Use of Insulin in Hispanics with Type 2 Diabetes
Abstract
Hispanics experience a higher rate of diabetes than non-Hispanic whites and tend to have worse glycemic control and a greater risk of diabetes-related complications. Once oral antidiabetic agents become insufficient, insulin plays an important role in achieving glycemic goals. However, many Hispanic patients are resistant to initiating insulin therapy or hesitant to increase doses, as necessary, to control their glucose levels. Barriers to insulin therapy include socioeconomic issues (eg, cost, insurance status), language difficulties, poor health literacy, and cultural beliefs that impact the patient-provider relationship and negatively affect patients' perceptions of diabetes and insulin. Healthcare providers can help overcome these issues and improve patient-provider communication by practicing culturally competent care. Implementation of a simple titration regimen using once-daily basal insulin may enable Hispanic patients to maintain glycemic control and improve outcomes.
Key Points
* Compared with non-Hispanic whites, Hispanics experience a higher rate of diabetes and tend to have worse glycemic control and a greater risk of diabetes-related complications.
* Hispanics often resist insulin therapy initiation and hesitate to increase doses to control glucose levels due to language barriers, poor health literacy, and cultural issues.
* Healthcare providers can help overcome these barriers to insulin therapy through culturally competent care.
This content is limited to qualifying members.
Existing members, please login first
If you have an existing account please login now to access this article or view purchase options.
Purchase only this article ($25)
Create a free account, then purchase this article to download or access it online for 24 hours.
Purchase an SMJ online subscription ($75)
Create a free account, then purchase a subscription to get complete access to all articles for a full year.
Purchase a membership plan (fees vary)
Premium members can access all articles plus recieve many more benefits. View all membership plans and benefit packages.
References
1. US Census Bureau. Annual estimates of the population by sex, race and Hispanic or Latino origin for the United States: April 1, 2000, to July 1, 2005. Available at: http://www.census.gov/popest/estimates.php. Accessed May 24, 2006.
2. US Census Bureau. Projected population of the United States, by race and Hispanic origin: 2000 to 2050. Available at: http://www.census.gov/ipc/www/usinterimproj/. Accessed May 24, 2006.
3. Centers for Disease Control and Prevention. National diabetes fact sheet: general information and national estimates on diabetes in the United States, 2005. Atlanta, Ga: US Dept of Health and Human Services, Centers for Disease Control and Prevention, 2005.
4. Boltri JM, Okosun IS, Davis-Smith M, et al. Hemoglobin A1c levels in diagnosed and undiagnosed black, Hispanic, and white persons with diabetes: results from NHANES 1999-2000. Ethn Dis2005;15:562–567.
5. Emanuele N, Sacks J, Klein R, et al, for the Veterans Affairs Diabetes Trial Group. Ethnicity, race, and baseline retinopathy correlates in the Veterans Affairs Diabetes Trial. Diabetes Care 2005;28:1954–1958.
6. Lavery LA, Armstrong DG, Wunderlich RP, et al. Diabetic foot syndrome: evaluating the prevalence and incidence of foot pathology in Mexican Americans and non-Hispanic whites from a diabetes disease management cohort. Diabetes Care 2003;26:1435–1438.
7. Hunt KJ, Williams K, Resendez RG, et al. All-cause and cardiovascular mortality among diabetic participants in the San Antonio Heart Study: evidence against the ‘Hispanic Paradox.' Diabetes Care2002;25:1557–1563.
8. American Diabetes Association. Standards of medical care in diabetes: 2006. Diabetes Care2006;29(suppl 1):S4–S42.
9. UK Prospective Diabetes Study (UKPDS) Group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet 1998;352:837–853.
10. Nathan DM. Initial management of glycemia in type 2 diabetes mellitus. N Engl J Med 2002;347:1342–1349.
11. Monnier L, Lapinski H, Colette C. Contributions of fasting and postprandial plasma glucose increments to the overall diurnal hyperglycemia of type 2 diabetic patients: variations with increasing levels of HbA1c. Diabetes Care 2003;26:881–885.
12. U.K. Prospective Diabetes Study Group. U.K. Prospective Diabetes Study 16: overview of 6 years' therapy of type II diabetes: a progressive disease. Diabetes 1995;44:1249–1258.
13. DeFronzo RA. Pharmacologic therapy for type 2 diabetes mellitus. Ann Intern Med 1999;131:281–303.
14. Wright A, Burden AC, Paisey RB, et al, for the U.K. Prospective Diabetes Study Group. Sulfonylurea inadequacy: efficacy of addition of insulin over 6 years in patients with type 2 diabetes in the U.K. Prospective Diabetes Study (UKPDS 57). Diabetes Care 2002;25:330–336.
15. Polonsky WH, Jackson RA. What's so tough about taking insulin? Addressing the problem of psychological insulin resistance in type 2 diabetes. Clin Diabetes 2004;22:147–150.
16. Hunt LM, Valenzuela MA, Pugh JA. NIDDM patients' fears and hopes about insulin therapy: the basis of patient reluctance. Diabetes Care 1997;20:292–298.
17. Thackeray R, Merrill RM, Neiger BL. Disparities in diabetes management practice between racial and ethnic groups in the United States. Diabetes Educ 2004;30:665–675.
18. Polonsky WH, Fisher L, Dowe SK, et al. Why do patients resist insulin therapy [abstract]?Diabetes 2003;52:A417.
19. Gary TL, Venkat Narayan KM, Gregg EW, et al. Racial/ethnic differences in the healthcare experience (coverage, utilization, and satisfaction) of US adults with diabetes. Ethn Dis 2003;13:47–54.
20. Smedley BD, Stith AY, Nelson AR. eds. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC, National Academy of Sciences, 2003.
21. Brown AF, Gerzoff RB, Karter AJ, et al, for the TRIAD Study Group. Health behaviors and quality of care among Latinos with diabetes in managed care. Am J Public Health 2003;93:1694–1698.
22. Coleman LT. Delivering culturally competent care. In: Koda-Kimble MA, ed. Applied Therapeutics: The Clinical Use of Drugs. 8th ed. Philadelphia, Lippincott Williams & Wilkins, 2005.
23. Mainous AG III, Majeed A, Koopman RJ, et al. Acculturation and diabetes among Hispanics: evidence from the 1999-2002 National Health and Nutrition Examination Survey. Public Health Rep 2006;121:60–66.
24. Weiss BD. Health Literacy: A Manual for Clinicians. American Medical Association Foundation and American Medical Association, 2003.
25. Schillinger D, Grumbach K, Piette J, et al. Association of health literacy with diabetes outcomes. JAMA 2002;288:475–482.
26. Vincent D, Clark L, Zimmer LM, et al. Using focus groups to develop a culturally competent diabetes self-management program for Mexican Americans. Diabetes Educ 2006;32:89–97.
27. Oomen JS, Owen LJ, Suggs LS. Culture counts: why current treatment models fail Hispanic women with type 2 diabetes. Diabetes Educ 1999;25:220–225.
28. Flores G. Culture and the patient-physician relationship: achieving cultural competency in health care. J Pediatr 2000;136:14–23.
29. Caballero AE. Building cultural bridges: understanding ethnicity to improve acceptance of insulin therapy in patients with type 2 diabetes. Ethn Dis 2006;16:559–568.
30. Caballero E, Montagnani V, Ward MA, et al. The assessment of diabetes knowledge, socio-economic and cultural factors for the development of an appropriate education program for Latinos with diabetes. Diabetes 2004;53(Suppl 2):A514.
31. von Goeler DS, Rosal MC, Ockene JK, et al. Self-management of type 2 diabetes: a survey of low-income urban Puerto Ricans. Diabetes Educ 2003;29:663–672.
32. Groman R, Ginsburg J. Racial and ethnic disparities in health care: a position paper of the American College of Physicians. Ann Intern Med 2004;141:226–232.
33. American Diabetes Association. Por tu familia: la diabetes y los latinos. Available at: http://www.portufamilia.org. Accessed August 25, 2006.
34. Fernandez A, Schillinger D, Grumbach K, et al. Physician language ability and cultural competence: an exploratory study of communication with Spanish-speaking patients. J Gen Intern Med 2004;19:167–174.
35. Berlin EA, Fowkes WC A teaching framework for cross-cultural health care. application in family practice. West J Med 1983;139:934–938.
36. Philis-Tsimikas A, Walker C. Improved care for diabetes in underserved populations. J Ambul Care Manage 2001;24:39–43.
37. Brown SA, Garcia AA, Kouzekanani K, et al. Culturally competent diabetes self-management education for Mexican Americans: the Starr County border health initiative. Diabetes Care 2002;25:259–268.
38. Ingram M, Gallegos G, Elenes J. Diabetes is a community issue: the critical elements of a successful outreach and education model on the U.S.-Mexico border. Prev Chronic Dis 2005;2:1–9.
39. Two Feathers J, Kieffer EC, Palmisano G, et al. Racial and ethnic approaches to community health (REACH) Detroit partnership: improving diabetes-related outcomes among African American and Latino adults. Am J Public Health 2005;95:1552–1560.
40. Rosenstock J. Insulin therapy: optimizing control in type 1 and type 2 diabetes. Diabetes 2001;4:50–64.
41. Hirsch IB. Insulin analogues. N Engl J Med 2005;352:174–183.
42. Standl E, Maxeiner S, Raptis S, the HOE90/4009 Study Group. Once-daily insulin glargine administration in the morning compared to bedtime in combination with morning glimepiride in patients with type 2 diabetes: an assessment of treatment flexibility. Horm Metab Res 2006;38:172–177.
43. Rosenstock J, Sugimoto D, Strange P, et al. Triple therapy in type 2 diabetes: insulin glargine or rosiglitazone added to combination therapy of sulfonylurea plus metformin in insulin-naive patients. Diabetes Care 2006;29:554–559.
44. Riddle MC, Rosenstock J, Gerich J, et al, on behalf of the Insulin Glargine 4002 Study Investigators. The Treat-to-Target trial: randomized addition of glargine or human NPH insulin to oral therapy of type 2 diabetic patients. Diabetes Care 2003;26:3080–3086.
45. Hermansen K, Davies M, Derezinski T, et al, on behalf of the Levemir Treat-to-Target Study Group. A 26-week, randomized, parallel, treat-to-target trial comparing insulin detemir with NPH insulin as add-on therapy to oral glucose-lowering drugs in insulin-naive people with type 2 diabetes. Diabetes Care2006;29:1269–1274.
46. Kennedy L, Herman WH, Strange P, et al, for the GOAL A1c Team. Impact of active versus usual algorithmic titration of basal insulin and point-of-care versus laboratory measurement of HbA1C on glycemic control in patients with type 2 diabetes: the Glycemic Optimization with Algorithms and Labs at Point of Care (GOAL A1c) trial. Diabetes Care 2006;29:1–8.
47. Davies M, Storms F, Shutler S, et al, for the AT.LANTUS Study Group. Improvement of glycemic control in subjects with poorly controlled type 2 diabetes: comparison of two treatment algorithms using insulin glargine. Diabetes Care 2005;28:1282–1288.
48. Philis-Tsimikas A, Zhang Q, Walker C. Glycemic control with insulin glargine as part of an ethnically diverse, community-based diabetes management program. Am J Ther 2006;13:466–472.
49. Pettitt DJ, Knowler WC, Lisse JR, et al. Development of retinopathy and proteinuria in relation to plasma-glucose concentrations in Pima Indians. Lancet 1980;316:1050–1052.
50. Gerich JE. Clinical significance, pathogenesis, and management of postprandial hyperglycemia. Arch Intern Med 2003;163:1306–1316.
51. Rašlová K, Bogoev M, Raz I, et al. Insulin detemir and insulin aspart: a promising basal-bolus regimen for type 2 diabetes. Diabetes Res Clin Pract 2004;66:193–201.
52. Bergenstal RM, Johnson ML Powers MA, et al. Using a simple algorithm (ALG) to adjust mealtime glulisine (GLU) based on pre-prandial glucose patterns is a safe and effective alternative to carbohydrate counting (carb count). Presented at the 66th Scientific Sessions of the American Diabetes Association, June 9–13, 2006, Washington, DC. Abstract 441-P.
53. Rosenblum MS, Kane MP. Analysis of cost and utilization of health care services before and after initiation of insulin therapy in patients with type 2 diabetes mellitus. J Manag Care Pharm 2003;9:309–316.
54. Schwartz S, Sievers R, Strange P, et al. Insulin 70/30 mix plus metformin versus triple oral therapy in the treatment of type 2 diabetes after failure of two oral drugs: efficacy, safety, and cost analysis. Diabetes Care 2003;26:2238–2243.
55. Rhoads GG, Orsini LS, Crown W, et al. Contribution of hypoglycemia to medical care expenditures and short-term disability in employees with diabetes. J Occup Environ Med 2005;47:447–452.
56. Heaton A, Martin S, Brelje T. The economic effect of hypoglycemia in a health plan. Manag Care Interface 2003;16:23–27.
57. Bullano MF, Al-Zakwani IS, Fisher MD, et al. Differences in hypoglycemia event rates and associated cost-consequence in patients initiated on long-acting and intermediate-acting insulin products. Curr Med Res Opin 2005;21:291–298.
58. Zhang Q, Menditto L. Incremental cost savings 6 months following initiation of insulin glargine in a Medicaid fee-for-service sample. Am J Ther 2005;12:337–343.
59. Heine RJ, Van Gaal LF, Johns D, et al, for the GWAA Study Group. Exenatide versus insulin glargine in patients with suboptimally controlled type 2 diabetes: a randomized trial. Ann Intern Med 2005;143:559–569.
60. Ryan GJ, Jobe LJ, Martin R. Pramlintide in the treatment of type 1 and type 2 diabetes mellitus. Clin Ther 2005;27:1500–1512.
61. Edwards KL, Irons BK, Xu T. Cost-effectiveness of intermediate or long-acting insulin versus Execatide in type 2 diabetes mellitus patients not optimally controlled on dual oral diabetes medications. Pharmacy Practice 2006;4:129–133.
62. Buse JB, Henry RR, Han J, et al. Effects of exenatide (exendin-4) on glycemic control over 30 weeks in sulfonylurea-treated patients with type 2 diabetes. Diabetes Care 2004;27:2628–2635.
