Jay H. Shubrook, DO: Hi. This is Jay Shubrook, DO, professor and diabetologist at Truro University, California. Today, we’re going to continue our series on practical use of insulin in primary care. Our program is here at the American Diabetes Association’s 77th Scientific Session in San Diego, California. I’m happy today to have Carlos Campos, MD, a primary care diabetologist from south-central Texas, with us to talk about cultural issues and cultural barriers for the Hispanic population and diabetes. Welcome aboard.
Carlos Campos, MD, MPH, CDE: Thank you, Jay.
Dr Shubrook: Maybe to start, can you just tell us a little bit about your practice.
Dr Campos: I’ve been in practice in New Braunfels, Texas, which is right between San Antonio and Austin, for the past 34 years. The first 15 years, I did everything from deliver babies to see people in nursing homes. I did the whole what I call ” womb-to-tomb practice.” For the past 15 years, I have morphed into a diabetologist; I really enjoyed and became really interested in diabetes.
Dr Shubrook: You certainly have lots of expertise, then. What is the ethnic and racial makeup of your practice?
Dr Campos: I grew up in an old German town, and that’s where I practice. Right now it’s about 40% Hispanic [and] about 60% non-Hispanic white.
Dr Shubrook: One of the things I have a question about is related to semantics. When do I use “Hispanic,” [and] when do I use “Latino,” both in terms of care and in practice?
Dr Campos: If you look at the cultural competency literature that discuss Hispanic and Latino patients, those terms are always brought together. “Hispanic” refers to that population that shares the same language, which happens to be Spanish. “Latino” refers to the geographic area where the population’s from. For example, Spaniards would be considered Hispanic, but not Latinos. People from Brazil would be considered Latinos but not Hispanic, because they speak Portuguese in Brazil. However, in the literature you will typically see the terms coupled together and written as “Hispanic/Latino.”
Dr Shubrook: I moved from Ohio to California, and the demographic of my practice changed a lot. What advice would you give me if I want to engage my Hispanic/Latino population?
Dr Campos: There are three things that I really focus on when I give talks on cultural competency. One of them is the importance of language. Certainly, if you’re a provider who sees a large number of Hispanic/Latino patients, and if you don’t speak the language, get people in your practice that do to help facilitate that.
The second big issue is the issue with family and the family values in this culture. We need to make it easier for patients to bring their families in. As we do that, we can develop a trust and a relationship with the patient, and they’re more apt to do the strategies that we have to better control their diabetes. Families are really important. We need to make room in our exam rooms, have more than just one or two chairs, and do those things that facilitate families to come in together. We should not see them as a barrier, but really see them as a plus for us.
Dr Shubrook: That to me is a game changer.
Dr Campos: We often can use those families to help us build care for that patient. I tell them that we need their help with their family member’s nutrition, which is the third thing that I focus on when discussing cultural competency. I ask family members to make sure that individual takes their medicines, and, if we have to use insulin, to help them be able to use it.
Dr Shubrook: So, I have a patient. I ask them to bring their family in, and the family does come. At what point am I talking to the patient? At what point am I talking to the family? How do I do that in a way that’s meaningful to them and not disrespectful?
Dr Campos: That’s a very good question. Remember, certainly the patient will always be first. If you don’t speak Spanish, you’re going to use an interpreter to help you with that. What I often will do when a patient comes in and has a family member there is recognize that, when one person in a family has diabetes, chances are the family members are going to have diabetes. So I incorporate the family members into all of my discussions. I ask if they’ve ever been diagnosed or even been checked for diabetes. I’ll often say to that family member that if you have a parent that has diabetes, your risk of having diabetes is about 40%. If both your parents have diabetes, it’s a little more, 75%, so we really need to check you. We try to catch those patients early.
Dr Shubrook: How about involving the children? One of the things I found to be a very useful tool is to say [that] this is important not only for you, but your children. How do you do that?
Dr Campos: Again, part of that is knowing the risk of developing diabetes as children grow. And I emphasize the importance of this risk by talking about diet. That’s the other component that we talk about: the whole issue of nutrition in that culture. Often, when I talk to other providers about cultural competency and nutrition, they really are surprised to know, for example, that one 10-inch flour tortilla will have the equivalency of about 10 teaspoons of sugar. [This] blows peoples’ minds sometimes. If you’re talking about slamming down two breakfast tacos, we’re not even talking about what’s inside the taco, we’re talking about just the tortilla itself—that’s 10 teaspoons of sugar, [and] 20 teaspoons of sugar if you’re doing two.
Even though we want our patients to enjoy their culture, we need to make some modification. We don’t tell them that they can’t eat tortillas; we tell them to modify. Maybe instead of eating flour tortillas all the time, maybe they do some corn tortillas, which have about two or three teaspoons of sugar. Steps such as this can really decrease the glucose burden and is still culturally competent while making some adjustments. Don’t say to a patient and family that they can never eat a food that is an important part of their culture, but instead, tell them those things that they can do to modify.
The other big issue is refried beans. Suggest that families go from refried beans to boiled beans. We tell them to add that hot sauce in there, because all those ingredients are great stuff, but not using refried beans really cuts down on the amount of fat that they eat.
Especially for children, another important things to discuss is the whole issue of the licuados [smoothies] that our patients drink. Patients will drink mango or coconut juice and they think it’s healthy, but it’s loaded full of sugar, and often just referred to as “liquid candy.” We talk about maybe doing other substitutes for that.
Dr Shubrook: That is so important, because people drink juice because they think it’s healthier than soda, but there’s still a lot of sugar in that. Addressing that juice is important in a culture. So, suggest corn tortillas instead of flour. You can still have still beans, but there’s ways to adjust it. Those are important things.
Dr Campos: I often tell providers, if you walk into a room and the room is flooded, what do you do? Do you grab a bucket or a mop? No; you go to see where the leak is and turn the leak off. Most of the time in our patients, the leak is that they’re overwhelming themselves with carbohydrate-heavy foods. If you can make that adjustment, it really helps to control their blood sugar.
Dr Shubrook: That’s great. You talked about three things. First, certainly engage in the language of the patient. If you don’t know the language, make sure you have a team of people that can help you with that. Two, engage the family and let the family be part of that care. Three, look at ways to engage nutrition as not only a way to treat diabetes but to prevent diabetes, and make it something the family can engage in.
Dr Campos: Exactly. The other thing about language is to recognize the importance of language that we as providers use. We often use insulin as a punishment for the patient. We’ll say, “If you don’t do what we tell you to do, we’ll eventually have to put you on insulin.” When it’s time to put the patient on insulin, they often see that as a punishment. When I talk about insulin to patients, I often will say that “we’re hoping that you live long enough to need insulin; all we’re doing when we give you insulin is giving you back that natural hormone that your body should be making. Diabetes is a state of insulin deficiency.” We have to be careful how we use our language when we use medications such as insulin, to make it more palatable for patients in this culture.
Dr Shubrook: You find your patients are willing to consider insulin?
Dr Campos: If we talk about it early on, then patients know that there is going to come a time where they might need insulin, and they should not be afraid of that. It’s just a natural hormone that your body’s deficient in and we might need to use it down the road. If we do that early on and walk patients through that, they’re more apt to be able to take it.
Dr Shubrook: These are important things you shared with me and you shared with the Medscape community. We thank you so much for being here.
Dr Campos: Thank you.