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Category: Type 2 Diabetes

Hispanic Heritage Month: Managing Type 2 Diabetes in Hispanic/Latino Patients

September 15th marks the beginning of Hispanic Heritage Month  – a national observance celebrating the vast historic and cultural contributions of Hispanic/Latino Americans. During this time, healthcare organizations spotlight some of the medical conditions affecting this community and emphasize the urgency of problems resulting from pervasive racial health disparities.

As part of a new campaign, the American Heart Association and American Diabetes Association introduced a Spanish-language effort to address the disproportionate rates of cardiometabolic conditions affecting this group and raise awareness among Hispanic/Latino individuals. By underscoring the link between type 2 diabetes (T2D) and detrimental cardiovascular complications, the organizations aim to inspire action among these at-risk patients to improve prevention and management.

Type 2 Diabetes in Hispanic/Latino Populations

Hispanic and Latino Americans – which include those of Cuban, Mexican, Puerto Rican, South and Central American, and other Spanish descent – experience a heightened risk for developing prediabetes and type 2 diabetes. The average risk for type 2 diabetes in patients of Hispanic heritage is 17% compared with 8% for non-Hispanic white patients. This risk is also closely tied to patient background; for example, Mexican and Puerto Rican patients are twice as likely to develop type 2 diabetes as South American individuals, per data from the CDC.

Overall, Hispanic/Latino American adults have a 50% chance of developing the type 2 diabetes, are more likely to develop it at a younger age and more likely to experience worse outcomes. At the same time, this population is 3 times more likely to be uninsured than non-Hispanic whites, a factor that consistently impedes access to necessary healthcare and contributes to racial health disparities.

Causes of the Disparities

Underlying the disproportions in type 2 diabetes prevalence are several, multifactorial and multilevel factors including environmental differences, which range from a limited access to healthy food to differential access and quality of medical care. A lack of awareness alongside health insurance disparities contribute to decreased rates of patients seeking medical care. Further complicating the issue are low socioeconomic status, poor health literacy, language barriers, and prominent cultural values and belief systems that influence diabetes perception, management, and outcomes in Hispanic/Latino patients.

Cultural and Genetic Risk Factors

Several important risk factors which can significantly impact the level of risk for type 2 diabetes and its complications in this group of patients need to be considered in the clinical setting. Both genetic and cultural variables found in patients of Hispanic origin exacerbate the likelihood of adverse health outcomes. In particular, cultural behaviors – such as a prevalence of high fat foods and food-centered celebrations – can have a profound impact of health status as this demographic. In addition, this demographic has higher rates of obesity, tending to be less physically active than non-Hispanic whites.

Management of T2D in Hispanic/Latino Patients

Managing type 2 diabetes in this group of patients requires careful consideration of the multilevel factors influencing the condition and requires the clinician’s cultural awareness. This does not have to mean speaking the same language as the patient, although interacting in the same language is helpful and strengthens the patient-provider relationship. Cultural awareness implies a deeper understanding of the patient’s health beliefs, attitudes, and habits that ultimately affect their willingness to undergo and adhere to treatment.

Diabetes management is challenging in all patients; however, Hispanic/Latino patients face additional barriers to successful treatment. Communication is essential to ensuring patient adherence to therapeutic strategies; in such cases it is important to consider language barriers when matching patients and providers. Patients who can communicate their concerns directly and be understood tend to exhibit greater adherence, improved diabetes self-care behaviors, and better clinical outcomes.

Targeting cultural factors, such as traditions and beliefs, is also important as Hispanic cultures tend to consume high-fat diets and some view being overweight as a sign of health. Improved educational efforts are needed to raise awareness of the detrimental effects of obesity, need for effective weight management, and the multifaceted benefits of a healthy diet and regular physical exercise among this population.

Improving outcomes requires tailoring diabetes education and treatment strategies to specific populations. Educational efforts aimed at Hispanic/Latino patients must consider racial, ethnic, social, cognitive, and cultural factors to improve health literacy and with it, health outcomes for this group.

Clinical Challenges

Clinicians face the challenging task of diminishing prevailing racial disparities in type 2 diabetes care among a culturally diverse patient population. While there may be many ways to address differences in health outcomes, community-driven strategies that engage community members and address socioeconomic and cultural factors have proven most successful at improving health outcomes. To optimize their efficacy, these programs needs to be based in cultural practices that influence the development and progression of type 2 diabetes in this population.

Targeted, community-driven interventions specific to Hispanic populations should place an emphasis on prevention tactics and highlight medication adherence, lifestyle changes, and educational programs to improve the standard of diabetes self-care. Research has found that live and technology-based interventions largely improve behavioral and clinical outcomes in T2D patients of Hispanic descent. Innovative, culturally aware interventions have the potential to improve quality of life and offer promising results while highlighting areas for future research.

In light of the COVID-19 public health crisis, improved type 2 diabetes management techniques are particularly important. The virus poses a significant threat to Hispanic and Latino patients with type 2 diabetes while also highlighting the overall need for an increased emphasis on cardiometabolic health in this subgroup to reduce type 2 diabetes incidence, morbidity, and mortality.

 

Intermittent Fasting in Patients with Type 2 Diabetes

Currently experiencing a surge in popularity, intermittent fasting has become an increasingly adopted dietary regimen due to its many purported health benefits. The concept of intermittent fasting refers to a spectrum of nutritional behaviors that aim to intentionally disrupt energy consumption for extended periods of time, for example, for between 16 and 24 hours on a regular intermittent schedule. In some intermittent regimens, individuals restrict food consumption to a 6- to 8-hour period, while in others they fast for a full 24 hours during several days of the week.

Some individuals may be inclined to adopt these dietary patterns as a means of weight loss or for their promised health benefits supported by anecdotal evidence, including the treatment of type 2 diabetes which remains unproven and untested entirely. While caloric restriction and weight loss are known to beneficially influence health outcomes in patients with type 2 diabetes – leading to improved glucose control, hypertension, and abnormal lipid levels – achieving them with intermittent fasting presents concerns.

Published on July 2, 2020 in JAMA, a new viewpoint underscores the limited body of evidence of the health benefits of intermittent fasting among type 2 diabetes patients and reveals the potential adverse complications that may result from this approach if patients are not carefully monitored.

Intermittent Fasting and T2D

To date, intermittent fasting in patients with T2D has only been studied in a few small, short-term trials yielding limited evidence of its benefit. Recently, a team of researchers examined the evidence for the health benefits and safety of intermittent fasting in this group of patients specifically. For the purposes of the study, intermittent fasting was defined as time-restricted feeding, or fasting on alternate days or during 1-4 days of the week, with only water, juice, or bone broth and no more than 700 calories consumed on fasting days.

In total, the study’s authors found seven published studies of fasting in T2D patients – only one trial had over 63 patients. Most studies were short in duration, occurring over 4 months or less, and evaluated five different fasting frequencies. All reported a connection between intermittent fasting and weight loss, while the majority also noted decreased A1c and improved glucose levels, quality of life, and blood pressure. Due to the lack of homogeneity in design, measures, and regimen styles, clinically meaningful conclusions could not be drawn.

In addition, only one study addressed the safety of two intermittent fasting regimens, finding that both increased the incidence of hypoglycemic events despite the use of a medication dose-change protocol.

Improved Glucose, Heightened Risks

The primary implication of the latest findings is that intermittent fasting may be less safe than caloric restriction, although it could be equivalently effective. Patients with existing diabetes who experienced weight loss saw a benefit of improved glucose, blood pressure, and lipid levels, according to the researchers.

While weight loss associated with intermittent fasting appears to be similar to that attained with caloric restriction, in the case of type 2 diabetes patients it can pose a risk of glycemic variability. Hypoglycemia can occur during fasting and hyperglycemia during feeding times, researchers note, and presents potentially dangerous clinical implications.

“Studies have raised concern that glycemic variability leads to both microvascular (eg, retinopathy) and macrovascular (eg, coronary disease) complications in patients with type 2 diabetes,” the authors cautioned. As such, the report highlights the need for continuous glucose monitoring aimed at detecting glycemic variability in susceptible patients as well as throughout studies of clinical interventions involving intermittent fasting in T2D patients.

Recommendations

Although further evidence is needed, the study’s lead author, Benjamin D. Horne, PhD, MStat, MPH, concluded that he would recommend intermittent fasting for patients with type 2 diabetes with caveats due to safety issues. These can include factors such as low blood pressure, weakness, headaches, dizziness – all of which are important considerations alongside the risk for hypoglycemia. Thus, caloric restriction may be a safer choice for certain patients.

Horne recommends giving patients intervention options to choose from as some may be better positioned to handle intermittent fasting. Until intermittent fasting is proven more effective at controlling diabetes, the currently available study data implicate that such regimens for patients with type 2 diabetes should be approached with caution, the risk of hypoglycemia closely monitored, and medications carefully adjusted to ensure both safety and efficacy of nutritional interventions.