Enrique Caballero MD

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Diabetes in the Latino/Hispanic Population The
Latino Diabetes Initiative

• Enrique Caballero MD
• Endocrinologist/Clinical Investigator
• Associate Director of Professional Education
• Director of the Latino Diabetes Initiative
• Joslin Diabetes Center
• Harvard Medical School
• Boston, MA

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Prevalence of Type 2 Diabetes
Previously undiagnosed diabetes
Physician-diagnosed diabetes
10 8 6 4 2 0
Age-adjusted prevalence ()
Non-Latino African Mexican Non-Latino
African Mexican White American
American White American American
Harris MI et al. Diabetes Care. 199821518-524.
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Pathophysiology of Type 2 Diabetes in the
Hispanic/Latino Population
Increased Abdominal Obesity
Increased Genetic Predisposition
Increased Genetic Predisposition ?


Skeletal Muscle
Increased Insulin Resistance
ß Cell Dysfunction
IGT
Liver
Type 2 DM
Substrates (FFA), cytokines (IL-1, IL-6,
TNF-?), hormones (decreased adiponectin,etc)
Adapted from Caballero AE. Current Diabetes
Reports. In press
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The Metabolic Syndrome
Genes
Obesity Hyperglycemia Dyslipidemia Hypertension
Type 2 DM
CVD
Insulin Resistance
Environment
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Age adjusted Prevalence of the NCEP Metabolic
Syndrome NHANES III by Race/Ethnicity
N 8814 gt 20 yrs
31.9
23.8
21.6
20.3

Differences persisted after controlling factors
such as BMI, smoking, drinking habits,
socio-economic status, physical activity and
menopausal status among women
Ford ES et al. JAMA 2002287356-359.
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Prevalence of the NCEP Metabolic Syndrome
NHANES III by Sex and Race/Ethnicity
36
28
25
26
23
21
20
16
Men
Women
Ford ES et al. JAMA 2002287356-359.
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Visceral AdiposityThe Critical Adipose Depot
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Visceral Fat, Insulin Resistance and Endothelial
Dysfunction
Increased Visceral Fat
IL1, IL6, TNF- ?, FFA,, PAI-1, RAS, leptin,
resistin Adiponectin
Cytokines, Substrates Hormones
Insulin Resistance
Endothelial Dysfunction
Hyperglycemia Hypertension Dyslipidemia
Modified from Caballero AE. Current Diabetes
Reports 2004 4 237-246
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To diabetes
Diabetes
Metabolic Syndrome ?
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Complications of type 2 diabetes in Minorities

• Disparate and Disproportionate prevalence of
  longterm complications of type 2 diabetes in
  minorities vs Whites
• lower leg amputations 2-4x
• retinopathy and blindness 2-4x
• stroke 2x
• ESRD 4-6x

Caballero AE. Diabetes in minority populations.
In Joslins Diabetes Mellitus. LW W 2005.
14th Ed. p 505-524.
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Cardiovascular Disease in Latinos with Diabetes

• Latinos have more insulin resistance and diabetes
  but no higher rates for CAD when compared to
  Whites
• A true Hispanic paradox?
• Data is some studies may be influenced by changes
  in the population due to migration factors and
  birth place
• Most likely, this paradox is not trueand
  therefore, aggressive management of
  cardiovascular risk factors in Latinos is
  warranted

Lerman Garber-I, Caballero AE. A true Hispanic
Paradox? Rev Invest Clinic. 2004 56 (3) 282-296
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Diabetes Incidence Rates by Ethnicity
N Engl J Med 346 393-403, 2002
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Cultural aspects influencing diabetes care
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MENTAL
SPIRITUAL
PHYSICAL
EMOTIONAL
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Cultural Aspects that influence Diabetes Care in
the Hispanic/Latino Population

• Patient issues
• Family Orientation
• Personalismo (Personal friendliness)
• Fatalismo
• Faith, Religion
• Body Image
• Lifestyle (Nutrition, Physical Activity)
• Acculturation
• Language
• Provider issues
• Cultural Competence
• Health Care System issues
• Cultural orientation

Adapted from Caballero AE. Current Diabetes
Reports. In press
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Percentage of Adults Reporting Communication
Problems
Collins, et al, Diverse Communities, Common
Concerns Assessing Health Care Quality for
Minority Americans, The Commonwealth Fund, March
2002.
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Language Barrier

• A true story
• 64 y/o Hispanic woman
• Patient does not speak English
• Treated for Hypertension
• Received a prescription for
• Lisinopril 10 mg.
• Once/d.
• Patient rushed to the ER due to severe
  hypotension

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What is Cultural Competence?

• The knowledge and interpersonal skills that allow
  providers to understand, appreciate, and work
  with individuals from cultures other than their
  own.  It involves an awareness and acceptance of
  cultural differences self-awareness knowledge
  of patients culture and adaptation of skills.
• American Medical Association

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Cultural Competence

• Purnells Model
• Person, Family, Community, Society
• Unconsciously incompetent
• Consciously incompetent
• Consciously competent
• Unconsciously competent

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Boston City Census 2000 Race/Ethnicity

• White/Caucasian 54.5
• Hispanic/Latino 14.4
• Black/African American 25.3
• Asian 7.5
• American Indian AlaskaNative 0.4
• Native Hawaiian Other Pacific Islander
  0.1
• Some Other Race 7.8
• Two or More Races 4.4

U.S. Census Bureau (2000) DP-1 Profile of
General Demographic Characteristics Boston City,
Massachusetts.
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The Latino Diabetes Initiative

• The overall goal of the Initiative is to improve
  
• the lives of Latinos affected by diabetes or
• at risk for the disease through culturally
  oriented patient care, education and research

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The Latino Diabetes Initiative
Patient Care and Education
Community Outreach
Research
Provider Education
Visit us at www.joslin.org/latino
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The Latino Diabetes Initiative
Patient Care and Education
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The Latino Program
Clinical Visits
Innovations

• MD Visits
• Educator Visits
• Pregnancy Clinic
• Ophthalmologist

Fully Bilingual/Bicultural Team Dedicated Latino
Care Ambassador Tailored Educational Program Low
Literacy Teaching Tools (Audiocassettes-CDs) Cultu
rally Oriented Nutritional Counseling Questionnair
es to Assess Barriers to Care
Education
Group Classes Individual Visits Support Groups
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Patient Education Materials
Coming soon
Rosas Story An Audio Novela
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The Latino Diabetes Initiative
Patient Care and Education
Community Outreach
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Community Outreach Programs - Latino and AA
population
Diabetes Clinic MD, RN, RD, EP, PA Classes in
English and Spanish Every Friday Provider
Education Massachusetts DPCP/BIDMC/ Joslin Clinic
Diabetes Clinic MD, RN, RD Classes in English and
Spanish 4 hrs a month Provider Education BIDMC
-Community Benefits Joslin Clinic
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The Latino Diabetes Initiative
Patient Care and Education
Community Outreach
Provider Education
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Provider/Professional Education

• Physician Education
• Certified Medical Education Programs hosted
  nationally and Internationally
• Joslin/Harvard Annual Course

• Student Training
• Clerkship for 3rd Year Harvard Medical Students
• Cultural Competence Instructor at Harvard Medical
  School

• National Collaboratives
• Designated thought leader for ADAs Latino
  Initiative
• National Hispanic Medical Association

• Clinical Education
• Allied Health Programs
• Community Health Training

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The Latino Diabetes Initiative
Patient Care and Education
Community Outreach
Research
Provider Education
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Research

• Ongoing studies
• Look Ahead Program
• Diabetes Education Study
• Endothelial function studies
• Specific studies for Latinos
• Adherence to treatment and its cultural and
  psychosocial determinants in Latinos with
  diabetes
• Endothelial function in overweight Hispanic
  children/adolescents
• Endothelial function in young Hispanic adults
  (18-40 y/o) at risk for type 2 diabetes
• Effect of metformin on markers of endothelial
  activation and inflammation in subjects with IGT

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THANK YOU