Type 2 Diabetes Podcast

Type 2 Diabetes Care Equity: What Can You Do?

Silvio Inzucchi, MD; A. Enrique Caballero, MD


June 15, 2022

This transcript has been edited for clarity.

Silvio Inzucchi, MD: Welcome to Medscape InDiscussion. I'm Dr Silvio Inzucchi, and today we'll be talking about treating type 2 diabetes in minority populations. This is a critical area for improvement in health outcomes across the United States. First, let me introduce one of the most qualified people I know of to speak on this topic. He is Dr Enrique Caballero, and he's been committed to working with underserved populations for many years. He founded and directed, for many years, the Latino Diabetes Initiative at the Joslin Diabetes Center in Boston and is now director of Latino Diabetes Health at the Brigham and Women's Hospital, also in Boston. Enrique is associate professor of medicine and director of diabetes education at Harvard Medical School and is also now the chair of the Health Care Disparities Committee at the American Diabetes Association. His steadfast work in this area and other areas as well has improved the lives of thousands of individuals with type 2 diabetes, and we're so fortunate to have Dr Caballero with us today. Welcome, Enrique.

A. Enrique Caballero, MD: Silvio, thank you very much for inviting me. I'm always excited to share this information. Hopefully that will be important for our audience today.

Inzucchi: Before we get into our main discussion, can you tell me a little bit about why you became interested in diabetes and specifically diabetes management in minority groups?

Caballero: Well, Silvio, as you know, I'm originally from Mexico. I was born and raised there. I belong to one of these racial/ethnic minorities in the United States and that allowed me to be a little bit more receptive and interested in understanding some of the challenges. But I also identified early on in my career, when I came here to the United States, that there are three facts that continue to be true. Number one is that racial/ethnic minorities continue to grow very rapidly in the country. It is predicted that in the year 2030, about 40% of the population will comprise racial, ethnic minorities. Point number two is that diabetes, particularly type 2 and its complications, are more common in these populations. Number three is that, unfortunately, the quality of care provided to this population is not the same. There's a lot of work to be done, and I think that's really one of the reasons I became so interested in that, seeing how we could identify the problems and, of course, try to identify some solutions.

Inzucchi: Let's talk about some of the compelling statistics regarding type 2 diabetes in minority populations, specifically in the United States — both the prevalence of complications and, as you've already opened the door on, the quality of care that we provide to these patients.

Caballero: Some of the most recent data show, based on the National Health and Nutrition Examination Survey (NHANES), that the prevalence of diabetes in the White population is about 12%. It's about 19% in Asians, 20% in Blacks, and about 22% in Hispanics. So this is consistent with that concept that we've had for a long time that is twice as common in minority populations when compared with the non-Hispanic White group.

Incidence rates have declined over time, as you well know, but this has not been seen in minority populations. That decline has been seen mostly in the White community. Now the prevalence of prediabetes, gestational diabetes, diabetes in youth is also higher when we look at all these statistics. It is less likely for patients in racial/ethnic minorities to achieve treatment targets. So for example, when we talk about A1c, blood pressure, cholesterol, and nonsmoking — some of the major goals we have with our patients with diabetes — statistics show, according to the NHANES data, that about 25% of people in the White community achieve these targets. When we look at racial/ethnic minorities it's about 1 in 7. That's almost a 50% lower chance of achieving targets in minority populations. So, obviously, the disease and complications and many different outcomes are very different in these populations.

Inzucchi: Let's get into a discussion of the underpinnings of some of these differences. Is this simply related to access to care? Are there pathophysiologic differences? Are there cultural differences.

Caballero: Over the years, what we have been able to identify is that certainly there may be some biological differences in some of these populations. But I would say that the more I work in this field, the more I am convinced that it's really not the biological elements that determine all this. But if we talk about biological differences, I think it is important to remember a few things that have been demonstrated over the years. For example, insulin resistance, which is of course important for the development of type 2 diabetes, has been demonstrated to be more common, more frequent in some of these populations in the Hispanic and Latino communities, in African Americans, in the Asian community, for sure. Asians are more likely to develop type 2 diabetes at lower body weight and BMI levels in comparison to the White community, for example. That has led to the concept that we all should screen for type 2 diabetes in Asians with a BMI above 23 and not 25 as recommended for other populations.

There are challenges that we see from the obesity perspective, the insulin resistance perspective. Now, no one would develop type 2 diabetes unless there is also beta-cell dysfunction, and there are some studies that show that in some of these populations, it is easier for the beta cells to get fatigued. That's perhaps the reason we also see younger individuals in these communities that develop type 2 diabetes. That applies to Asians, Latinos, Hispanics, and the African American community.

You may also remember, and the audience may also remember, this ketosis-prone diabetes that was described in New York some years ago; these are patients, mostly from the Black community, who may present to us with ketoacidosis and we may think they have type 1 diabetes. Well, they don't. They actually have type 2 diabetes, but they develop acute insulin deficiency that later on gets better. But it's interesting to see how some of these differences in biology may play a role.

So, yes, so there are some biological differences, but for the most part, I think it's all of the other aspects that play a role here. It's social determinants of health; these are the elements that lead to the development of type 2 diabetes and its complications in a direct way. Why do I say that? Because it's really the environment where people live that determines their lifestyle. If people don't have access to the right foods, if people don't have the ability to exercise as it is recommended for the general population, then that's a challenge. If people don't have access to good services in the same way that other people do, it will impact their lifestyle. There are elements that play a role here that I would say in general we don't pay too much attention to in clinical practice.

To sum up, I always think about the triad that explains basically all problems in healthcare. One is the healthcare system. The second is the patient, and third is the healthcare provider. But in the healthcare system, based on what I just said, I don't think that we are well prepared to provide care to minority patients because we don't have the structure for it. Our healthcare system, I have to say, is really more reactive than proactive. It is really illness-driven and not health-driven, so we solve acute problems in patients. We don't pay attention to what is needed in terms of the chronic care model, which may be more appropriate. There aren't enough culturally oriented programs, and I don't think that we have the teams sometimes that can work with us in providing appropriate care to our populations.

And then on the healthcare professional side, we are probably not used to assessing these other factors easily. So if we think about how to assess social determinants of health, I mean, that's not something that I will be able to modify. I prefer to be in my comfort zone of just doing what I was trained to do in medical school and in my area of work. And that's really to pay more attention to the pathophysiology and treatments.

Inzucchi: And the numbers, right? The insulin dose and things like that. So you're talking about the healthcare provider — how can we be more sensitive or, shall we say, culturally appropriate when we're dealing with patients from minority groups? What do we need to understand about these social determinants of health?

Caballero: I think the first thing is to abandon the status quo. We know that what we're doing now, based on everything that I said earlier, is not working. The reality is that these patients are not achieving targets. And the easiest answer would be, Okay, well, it's not my fault. I tell them what to do; they just don't do it. It's not something that I can modify. That's the wrong approach.

I think that we have an opportunity here to think outside the box and say, What is it that I am not doing that is impacting these outcomes? And that really takes courage and responsibility. It calls for addressing some of these aspects in more detail in clinical practice. I know what people may be thinking: Come on, I'm so busy and doing what I do already, and now you're asking me to do more than that. How am I going to do it? I don't have the time. I don't have the tools. I don't have the resources.

I think that there may be an opportunity to create teams to really do this more proactively in clinical practice. I take one of these aspects at a time and I try to address those with my patients — not in the same visit because that would be impossible. So maybe one day we talk only about food; for example, is there food insecurity? Can people really access the foods that we are recommending them? And if not, why not? Maybe I can refer them to a community-based program that can provide some of that help. Now, that's not something, again, that we routinely do, but I think that's one thing that we should address. Exercise: Are people able to follow the recommendations that I'm making? And if not, is there a way for me to help them with that? Medications, of course. Can they afford the medications? People try to save money in many different ways. And again, I don't want to create a stereotype here, because it's not just minority patients that are affected. It could be, honestly, anyone. So those are things that we need to pay attention to, and I don't think that we do that routinely. It's about integrating a more comprehensive approach to diabetes care by paying attention to all these different factors that I think would get us to a different level.

Inzucchi: So from your vast experience, particularly with the Latino community, are there any tips you might provide to us in terms of counseling patients about diet and lifestyle changes?

Caballero: A lot of people have asked me over the years, "Can you recommend to me a Latino diet that could work for my patient?" And what I say is, "Well, really, there's no Latino diet." I mean, as a Latino myself, I have to say that I learned almost every week about something different from different groups in Latin America and some of my patients. There's nothing that is uniform. People think, Okay, everybody eats rice and beans and that's the problem. I don't think that's the issue. I think it is about how people prepare foods; there are still a lot of fried foods and a lot of carbs in many of the meals. And it's obviously the amounts as well. The best way [to counsel] is to get closer to patients. And rather than imposing a diet, it's about understanding their preferences.

Work with them — preserving the culture, their culture — and then try to come up with some recommendations that make sense. Trying to ask people to abandon completely what they do is never going to work well. In terms of physical activity, it's the same thing. For example, I created a salsa dancing program with my patients because everybody likes to dance. That's getting closer to the culture also about identifying activities that people like to do. Don't impose guidelines and recommendations for everybody in the same way at the same time. I mean, you've been a champion about tailoring guidelines to patients, considering so many different things. Well, one of them should be cultural aspects, social aspects — you know, particular interests that people may have based on their background.

Inzucchi: Right after we're done, Enrique, I am going to search YouTube for Caballero salsa dancing and see what we can find.

Caballero: I have avoided showing myself intentionally.

Inzucchi: The pathophysiology of diabetes is fascinating as it is manifested across different ethnic and racial groups. We do know that Pima Indians — some of the seminal studies on insulin resistance and beta cell dysfunction occurred in Pima Indians, studies that were funded by the NIH many years ago — they are a very insulin-resistant group. As we talked about, Asians may have greater beta-cell decompensation, almost like the Asian beta cell can't tolerate the same degree of obesity that the European beta cell might. I think that is very, very interesting. And then we also know that in the African American community, there are differences in terms of a very commonly used metric for diabetes control quality, which is the hemoglobin A1c. What do we know about that?

Caballero: That's really very interesting, and thanks for bringing that up because that may have some practical implications. Even though there was some controversy at the beginning, I think that now we all agree that there may be different glycation processes when we compare different populations. It turns out that in the Black population, the African American population, the glycation process is different enough to basically increase A1c levels when people have the same degree of glycemia when compared with other populations. In general, A1c levels may be 0.3%, maybe 0.4%, higher in African Americans when compared with the White community, even though the degree of hyperglycemia may be the same. What we don't know is what the implication of this is. Is that glycation process also affecting the risk for complications? We don't know. People just need to be aware that if there's a mismatch — for example, if I'm looking at my patient's glucose levels and the A1c seems to be a little higher — if it is an African American patient, then maybe that's the reason.

Inzucchi: But it does raise the possibility that we could be overtreating certain individuals, correct? If we're targeting lower hemoglobin A1c and for the mean glycemia they have a higher hemoglobin A1c, that could be potentially risky.

Caballero: It could be. You may remember that in the ACCORD trial, for example, the risk for hypoglycemia was actually higher among African Americans. I still don't know why, to be honest, but this is something we need to take into consideration when establishing targets. Although at the same time, what we don't know, as I said earlier, is what the implications are for complications, which in the end is the reason why we try to control.

Inzucchi: With these thresholds we've set forth for prediabetes and then diabetes at 6.5%, a 0.3%, 0.4% difference is huge in terms of categorizing patients as having either normal glucose tolerance or prediabetes or diabetes.

Caballero: That's correct.

Inzucchi: Finally, let's talk about treatment of patients with type 2 diabetes across various ethnic and racial groups. Have you, in your experience, found any specific pearls that we can take from our discussion? You know, I've found that pioglitazone, which is a thiazolidinedione (TZD) that has become less commonly prescribed because of adverse effects, in my practice it's really effective in South Asians. My patients from India and Pakistan seem to do very, very well on it. They have enormous insulin resistance even though they don't have enormous obesity. They have a slight increase in BMI, as you alluded to before. But terrific insulin resistance demonstrated whether you measure insulin levels or whether you look at fatty liver disease and are predisposed to early coronary disease as well. I find that they do very well — admittedly anecdotal — but very well with TZDs, which are now very cost-effective because they're on generic formularies. Any stories like that that you can tell us from your practice?

Caballero: Unfortunately, there are not a lot of studies that can truly guide us on using one medication over another in particular populations. For example, metformin, which obviously is first-line therapy across the world, works very well in some of these populations. I've been very fortunate to be a co-investigator in the Diabetes Prevention Program (DPP). And in the DPP we found that metformin works very well, perhaps even a little better in some of these minority populations, although I would be careful because these are small groups and we can't make any robust conclusions about that. As you said, TZDs could work well because insulin resistance is a background problem in many of these groups. You remember the studies by Tom Buchanan with troglitazone, the first TZD, in the Hispanic community — that worked very well. So I think that there may still be a role for those. And by the way, nonalcoholic fatty liver disease is very common in this population. So that could be another reason why we should think about some of these therapies.

Inzucchi: It's a common cause of cirrhosis in that population as well.

Caballero: Correct. So that's a major issue.

But then about the newer medication, for example DPP4 inhibitors, there are studies that show they may work particularly well in the East Asian population. With SGLT2 inhibitors, I was reading a publication in Circulation by Alanna Morris, a cardiologist who performed a subgroup analysis of the EMPEROR-Reduced and DAPA-Heart-Failure study, showing that cardiovascular outcomes may be better in African Americans and Asians [on SGLT2 inhibitors] than in Whites.

Caballero: Now, again, I don't want anybody to think that that's what we need to do with everybody. These are subgroup analyses, but you're asking about data. Well, that's what we have. And then GLP-1 receptor agonists, because of obesity, may also work well. I think at this point, what I would say is that all medications seem to work [at least] equally well, perhaps better in some patients, but at least equally well, which I think is encouraging. We should follow guidelines as we try to tailor that.

Inzucchi: There's certainly a lot more to learn. Well, Enrique, it looks like we are out of time. I want to thank you so much for chatting with me today about diabetes in minority groups. Any last words you'd like to leave our listeners with?

Caballero: I would say that for us as healthcare professionals, again, thinking probably outside of our comfort zone and trying to think about some of these social determinants of health — everybody needs to discuss that with their teams and how to incorporate that routinely. But I want to finish with something at a much higher level. I think that there is institutional responsibility. I work at the Brigham and I'm very proud to say that the Brigham, as an example, is an institution that has taken this very seriously. And just if I may, in a couple of minutes, tell you what happened recently. A group of investigators at the Brigham identified that patients who come for heart failure to the hospital, if they're African American or Hispanic, they are less likely to go to the cardiology service for their treatment; they may go to the internal medicine or the general medicine department, whereas the White population is more likely to end up in the cardiology services. I mean, I think that's courage, that's brave, to publish that and to recognize that academic institutions as big as the Brigham — we have room for improvement and we have the responsibility of seeing what's happening.

Caballero: I would say for everybody that is listening, look at your practice, look at your institution. How are things happening? Are we providing equal opportunities to our patients? And if not, why is that happening? I'm sure we all can identify strategies that can help us do what we want to do, and it's to help everybody. But let's not forget that there are some people that need an extra hand, and I think that's the right thing to do.

Inzucchi: Absolutely. Thanks so much again for joining me today, Enrique.

Caballero: My pleasure. Thank you for inviting me.

Inzucchi: And thanks for listening. I'm Dr Silvio Inzucchi for Medscape InDiscussion.


National Health and Nutrition Examination Survey

Prevalence of Diabetes by Race and Ethnicity in the United States, 2011-2016

BMI Cut Points to Identify At-Risk Asian Americans for Type 2 Diabetes Screening

Diabetes Mellitus in the Pima Indians: Genetic and Evolutionary Considerations

HbA1c Performance in African Descent Populations in the United States With Normal Glucose Tolerance, Prediabetes, or Diabetes: A Scoping Review

ACCORD Trial: Effects of Intensive Glucose Lowering in Type 2 Diabetes

Diabetes Prevention Program Research Group: Reduction in the Incidence of Type 2 Diabetes With Lifestyle Intervention or Metformin

Effect of Thiazolidinedione Treatment on Progression of Subclinical Atherosclerosis in Premenopausal Women at High Risk for Type 2 Diabetes

Prevalence of High-risk Nonalcoholic Steatohepatitis (NASH) in the United States: Results From NHANES 2017-2018

Sodium-Glucose Cotransporter-2 Inhibitors in Heart Failure: Racial Differences and a Potential for Reducing Disparities

Identification of Racial Inequities in Access to Specialized Inpatient Heart Failure Care at an Academic Medical Center

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