Heterogeneous Hispanics: Tailor Care for Latino Diabetes

Marcia Frellick

November 13, 2017

Lumping all "Hispanics" together is not an effective approach to the diagnosis and treatment of type 2 diabetes, as there are a myriad of risk and lifestyle factors that vary among individuals from different Hispanic heritage groups, say the authors of a new review.

Yet finding effective approaches is critical as Hispanics form the largest minority group in the United States and are twice as likely to have diabetes compared with non-Hispanic whites, say Larissa Avilés-Santa, MD, MPH, division of cardiovascular sciences at the National Heart, Lung and Blood Institute in Bethesda, Maryland, and colleagues.

Studies show that 40% of US Hispanics with diabetes have not been formally diagnosed, for example. And diabetes has also become a major cause of death in Latin America, they explain in their expert review published online in Frontiers in Endocrinology ahead of World Diabetes Day on November 14.

Despite these striking facts, the representation of Hispanics/Latinos in pharmacological and nonpharmacological clinical trials has been suboptimal, and they have not fully benefited from substantial advances in prevention and treatment in the past 2 decades while the prevalence of diabetes in these populations continues to rise, they stress.

Dissecting Out the Differences: Research Has Been "Mexican"-Heavy

In the review, Dr Avilés-Santa and colleagues note that the US Census Bureau defines Hispanic or Latino as "a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture regardless of race," although this definition is currently being debated, they note.

Despite originating from many different countries, people sometimes assume such individuals have broadly similar backgrounds.  

Work coming from the United States has often focused primarily on Mexican populations, for example. Yet there is little evidence to show that these findings would be generalizable to all Hispanics, Dr Avilés-Santa said, noting, for example, that type 2 diabetes prevalence varies widely.

For instance, it is higher among those from Central America, affecting 18.3% of Mexicans and almost as many Puerto Ricans and Dominicans (18.1% each), but the prevalence is much lower in South Americans (10.2%), the report indicates.

And so it will be necessary to dissect out differences between these populations in order to tailor the best approaches to the specific ethnic groups, with their many genetic, biologic, environmental, socioeconomic, lifestyle, and cultural variations, the researchers stress.

Doctors should therefore ask numerous questions when taking personal and family histories of Hispanic/Latino patients, Dr Avilès-Santa told Medscape Medical News.

"There could be some intrinsic cultural differences or personal beliefs that are playing very important roles in how that participant views health or disease or physical activity," she explained.

She also emphasized that physicians "may want to carefully approach prevention at a much younger age" in some of these patient groups, particularly if there is a family history of diabetes, if the patient is overweight or obese, or there are signs of insulin resistance or lipid abnormalities.

The American Diabetes Association recommends annual screening in patients 45 years and older or in patients younger than 45 years with major risk factors.

"In Hispanics, a significant number at a younger age already have some glucose abnormalities or other factors that increase their risk for developing diabetes," depending on their exact ethnic origin, she explained.

More Tailored Research Needed in Diverse Hispanic Populations

Another important point is that investigators of studies included in the review, which also looks at gestational diabetes, often based their findings on theories of behavior gleaned from other population groups such as nonHispanic whites or African Americans, Dr Avilés-Santa said.

Applying them to Hispanic populations may not have the same effect.

Observing Hispanic cohorts and generating theories from those observations may be more effective, she added.

"We need to start designing more effective lifestyle intervention studies for Hispanics/Latinos that incorporate sound understanding of their diverse cultural norms and...daily life."

A recent analysis cited in the review found only 12 published studies on behavioral interventions aimed at reducing type 2 diabetes specifically designed for Hispanic/Latino adults (Am J Prev Med. 2017;52:519-529).

Dr Avilés-Santa and colleagues also found lack of agreement among prior studies about which tests should be used to diagnose prediabetes and diabetes. Some used both fasting glucose and HbA1c to detect prediabetes and diabetes.

"In Latin America there is a tendency to use fasting glucose only, but that is just part of the story," Dr Avilés-Santa said.

Collaboration among researchers in many countries on which tests to use to diagnose diabetes and better alignment of study methodologies could help make for better comparisons, she stressed. For example, the researchers found lack of consistency in selection of study populations, failure to distinguish between type 1 and type 2 diabetes, and the time period of analysis.

And Dr Avilés-Santa added that, in some lifestyle intervention studies, while the interventions were long enough to show that risk factors had improved — such as weight loss and lower HbA1c — they were not long enough to show any overall effect on diabetes.

Yet despite the numerous challenges the report highlights, it should not be seen as painting a "doomsday" scenario, she stressed. "We did [this] with a strong hope that these needs could be turned into opportunities to expand research and work collaboratively."

One example of progress is the fact that within the past decade countries throughout Latin America and the Caribbean have started to raise awareness about chronic disease, including prevention and treatment of type 2 diabetes.

The Latin American Association for Diabetes has published guidelines about the treatment and management of type 2 diabetes through the collaboration between medical associations in 17 countries (Rev Panam Salud Publica. 2010;28:463-471).

The authors have reported no relevant financial relationships.

Front Endocrinol. Published online November 13, 2017.  Article

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