February 2012 Issue

Improve Diabetes Care in the Latino Community — RDs Who Learn the Culture and Language Are Off to a Great Start
By Jill Weisenberger, MS, RD, CDE
Today’s Dietitian
Vol. 14 No. 2 P. 10

Rosa, a 45-year-old Latina woman, enters a diabetes clinic for a follow-up visit. She missed her appointment last month and the month before. When she arrives, she’s 30 minutes late, and her blood glucose is 280 mg/dL. She explains she hasn’t taken her glucose-lowering medications in weeks because she doesn’t have the money to renew her prescriptions.

Rosa lives with her husband, their four children, her mother, and her brother. During the day, she cleans guest rooms at a motel; at night, she waits tables at a neighborhood restaurant. She speaks little English, and she doesn’t drive.

Rosa’s home life and work life is typical of the Latino community, according to David Orozco, MS, RD, a private practice dietitian and consultant to the Emory University School of Medicine’s Latino Diabetes Education Program in Atlanta. What’s also typical among Latinos is a diabetes diagnosis.

Latinos are the largest minority group in the United States, and their prevalence of diabetes is twice that of non-Hispanic whites. Latinos tend to have higher hemoglobin A1c levels, greater rates of obesity, diabetes complications, and associated mortality. When working with Latinos, Orozco says, dietitians need to understand their culture and unique barriers to healthcare to engage and help them set and meet goals.

This article will provide strategies dietitians can use to help Latino patients with diabetes stabilize blood sugar, increase physical activity, and eat more healthfully despite the unique cultural and lifestyle challenges they face.

Road Blocks to Diabetes Care
Helping Rosa and others in her community control blood glucose and prevent diabetes complications poses several challenges. The first is getting Latinos to make and keep their appointments, Orozco explains. Latino families may have legal US citizens and illegal immigrants living together under one roof. And as a result, they won’t seek medical care for fear of someone in the family being discovered. Medical personnel who call to confirm appointments often have problems reaching Latino patients because their phone numbers change frequently; many use prepaid cell phones; or they change addresses to begin new jobs.

“Culture defines when to seek treatment for illnesses,” says Lorena Drago, MS, RD, CDE, owner of Hispanic Foodways in Forest Hills, New York. Many Latinos won’t use medical services until their symptoms are severe enough to interfere with daily activities, Drago adds.

Furthermore, many Latinos see no point in seeking medical care because they believe diabetes is out of their control. Many Mexicans, for example, link a single stressful event such as a car accident to the onset of diabetes, and some Puerto Ricans frequently blame diabetes on long-term stressors such as caring for an elderly parent, she explains. Still, others believe God is in control of their diabetes and, therefore, won’t visit a doctor, Orozco says.

Other barriers include lost wages from taking time off from work to go to the doctor in addition to the cost of medical services and medications. Many people receive paid sick leave, but low-income Latino workers often don’t. Like Rosa, many Latina patients with diabetes don’t drive, so they must rely on their husbands or brothers to take time off from work or pay for public transportation.

Then there’s the language barrier, which is a major hurdle for patients receiving and dietitians providing quality healthcare. Many Latino patients aren’t fluent readers of their own language, so diabetes education brochures written in Spanish must be presented simply. Poor health literacy further complicates matters, Drago says. It’s not just the issue of understanding the language but being able to apply health information to daily life. 

Where the Rubber Hits the Road
These challenges seem insurmountable, but the following strategies can help RDs and CDEs work around them and provide better diabetes care that will result in better health outcomes for Latino patients.

• Speak the language. Buy a book or take a Spanish-language class geared specifically for healthcare workers, Orozco urges. That way, you’ll be able to communicate more effectively by instructing patients and asking and answering basic healthcare questions.

• Use an interpreter. Hiring a certified interpreter or a trained Spanish-speaking patient may be the best way to bridge the language gap.

Amparo Gonzalez, RN, CDE, FAADE, director of the Emory Latino diabetes program, advises dietitians to teach interpreters about diabetes and make it clear to them that they’re not to change what you say when speaking to patients. If interpreters feel it‘s necessary to enhance a dietitian’s comments, the interpreter must run it by him or her first before relaying the message to the patient. And dietitians should always remember to speak directly to the patient, not to the interpreter, to show respect.

• Expect patients to come late and with family members. If sticking to a schedule is important, dietitians should ask patients to arrive 20 or 30 minutes early. Provide space for family and friends and crayons or other supplies to occupy children.

• Build confianza. “Confianza is the mutual respect, trust, and kindness between the health professional and the patient,” Orozco explains. Spending several minutes at the beginning of a counseling session getting to know patients on a personal level builds trust. Ask them about their family and friends and share details of your personal life as well.

• Offer a kind touch. “We touch, hug, and kiss,” Orozco says. Strong handshakes are out, but a touch on the arm or a friendly kiss on the cheek is welcomed.

• Know what foods Latinos like to eat. “Learn about your patients’ traditional foods and how they prepare them,” Drago says. “Even within the same country, there are regional differences in food selection and preparation,” she adds.

Collect food models, supermarket flyers, and pictures of various foods to help patients discuss their diets. Drago suggests asking patients to list the 20 foods they buy most often. Be aware that some patients may scoop their food with tortillas as edible utensils, thus consuming several tortillas per meal.

• Keep it simple. Instead of teaching complex concepts like carbohydrate counting and the exchange system, introduce them to MiPlato, the Spanish version of MyPlate. Teach patients that half their food intake should include fruits and vegetables.

And instead of having patients keep food records, ask for a quick diet history or a 24-hour recall, Orozco suggests. Dietitians can gauge whether patients understand the dietary instructions by asking them how they plan to use the new information, Drago says. For example, RDs can ask, “How will you modify your meals?”

• Ask about alternative treatments. The use of nopal (cactus), cinnamon, herbs, teas, and other supplements is common in the Latino community. “Latinos often visit natural healers and use herbal supplements to heal themselves,” Orozco says. “So it’s important to ask about this since many are taking prescription diabetes medications.” 

• Encourage personal responsibility. Because of the common belief that diabetes is out of their control, some patients will ignore their diabetes or expect to suffer complications. Remind them that they do have some control. To those who say their health is in God’s hands, express that they can assist God by making use of medications, information, good nutrition, etc.

• Make exercise fun. Tap into the Latino community’s passion for dance, walking, and soccer, and encourage patients to engage in these fun activities. In classes or group sessions, bring out the boom box and crank up the Latino music for an energizing dance break. Using elastic bands and chair exercises are additional ways to engage patients in physical activity.

• Engage their peers. To provide additional support, introduce clients to other Latino patients with diabetes who have been successful at eating healthfully and controlling their blood sugar. Peers can offer positive feedback, allay fears, lift spirits, and improve outcomes, Drago explains.

— Jill Weisenberger, MS, RD, CDE, is a freelance writer, nutrition consultant, and diabetes educator based in Virginia and is the author of the upcoming book Diabetes Weight Loss Week by Week: A Safe, Effective Method for Losing Weight and Improving Your Health.