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Unmet Needs in Hispanic/Latino Patients with Type 2
Diabetes Mellitus
Kenneth Cusi, MD,a and Gloria L. Ocampo, MDb
a
The University of Florida at Gainesville, Gainesville, Florida, USA, and bUniversity of Texas Health Science Center, San Antonio,
Texas, USA
ABSTRACT
In the United States, the prevalence of adults who are overweight or obese is higher in Hispanics/Latinos
compared with non-Hispanic whites. In addition, data from the National Health and Nutrition Examination
Survey (NHANES) indicate that the prevalence of type 2 diabetes mellitus is consistently greater in
racial/ethnic minority groups, such as Hispanics/Latinos, compared with non-Hispanic whites. In fact, data
from the Centers for Disease Control and Prevention (CDC) from 2007 to 2009 suggest that the prevalence
of type 2 diabetes is almost twice as high in Hispanics/Latinos compared with non-Hispanic whites (11.8%
vs. 7.1%, respectively). Although genetics plays a role in the increased prevalence of type 2 diabetes in
Hispanics/Latinos, cultural and environmental factors also contribute. In addition to the increased prevalence of type 2 diabetes in Hispanics/Latinos, evidence suggests that the patients in this population are
often undertreated and, therefore, less likely to achieve control of their glucose, blood pressure, and lipid
levels. Because individuals with type 2 diabetes have a 2- to 4-fold increased risk of cardiovascular disease
compared with individuals with normal glucose levels, there is consensus that targeting environmental factors,
particularly the development of obesity at an early age, is the most cost-effective approach to prevent the
development of type 2 diabetes and its broad spectrum of complications, including cardiovascular disease.
Cultural and socioeconomic barriers, such as language, cost, and access to goods and services, must be
overcome to improve management of type 2 diabetes in this high-risk population. By increasing healthcare
provider awareness and the availability of programs tailored to Hispanic/Latino individuals, the current
treatment gap among ethnic minorities in the United States will progressively narrow, and eventually, disappear.
© 2011 Elsevier Inc. All rights reserved. • The American Journal of Medicine (2011) 124, S2–S9
KEYWORDS: Culture; Hispanic; Latino; Type 2 diabetes mellitus; Unmet needs
The metabolic syndrome is frequently used to define a
cluster of risk factors (central obesity, high triglyceride/low
high-density lipoprotein cholesterol levels, hypertension,
and elevated plasma glucose levels) that increase the risk of
developing cardiovascular disease.1 Evidence suggests that
its presence increases healthcare utilization and costs compared with patients without this condition, with average
annual costs increased 1.6 times for patients with the metabolic syndrome compared with those without it (mean cost
in 2005 US dollars, $5,732 vs. $3,581).2 In the United
States, healthcare expenditures for obesity-related condiStatement of author disclosure: Please see the Author Disclosures
section at the end of this article.
Requests for reprints should be addressed to Kenneth Cusi, MD, Chief,
Endocrinology and Diabetes Division, The University of Florida at Gainesville, 1600 SW Archer Rd., Room H-2, Gainesville, Florida 32610-0226.
E-mail address: [email protected].
0002-9343/$ -see front matter © 2011 Elsevier Inc. All rights reserved.
doi:10.1016/j.amjmed.2011.07.017
tions were estimated to be approximately $168 billion, or
approximately 17% of total healthcare costs based on data
collected from 2000 to 2005.3 In the United States in 2007
to 2008, almost one third of children aged 2 to 19 years
(31.7%)4 and approximately two thirds of adults (68.0%)5
were overweight or obese. Obesity is increasing at alarming
rates in the United States, particularly in Hispanics/Latinos
and African American women as well as socially disadvantaged groups.6 Similarly, diabetes mellitus is a substantial
healthcare burden in the United States; in 2007, costs associated with diabetes were estimated at $174 billion.7 By
2030, it is estimated that approximately 30 million Americans will have diabetes.8
There is a strong ethnic component to both the metabolic
syndrome and type 2 diabetes mellitus, with non-Caucasian
(non-white) populations having an increased prevalence.9,10
The prevalence of the metabolic syndrome is 1.5 times
Cusi and Ocampo
Unmet Needs in Hispanic/Latino Patients with Type 2 Diabetes
Figure 1 Age-adjusted prevalence of metabolic syndrome
(defined as a collection of risk factors that increase a person’s risk of
developing cardiovascular disease)1 by sex and ethnicity among
adults aged ⱖ20 years in the National Health and Nutrition Examination Survey (NHANES): United States, 2003–2006.11
higher in Mexican American females living in the United
States compared with non-Hispanic white females (odds
ratio, 1.55; 95% confidence interval [CI], 1.06 to 2.29);
however, the prevalence of the metabolic syndrome is not
significantly different between Mexican American and nonHispanic white males (Figure 1).11 In addition, the prevalence of adults who are overweight or obese is higher
among Hispanics/Latinos compared with non-Hispanic
whites,5 as is the prevalence of type 2 diabetes9,12 and
prediabetes.12 The American Diabetes Association (ADA)
has estimated that 79 million adults in the United States
have prediabetes, including one third of adults aged ⬎60
years, which puts them at high risk for developing type 2
diabetes.13 Prediabetes is defined as impaired fasting glucose (based on a fasting plasma glucose [FPG] level of
100-125 mg/dL [1 mg/dL ⫽ 0.05551 mmol/L]) and/or impaired glucose tolerance (IGT; based on a 2-hour postprandial glucose level of 140-199 mg/dL as measured during an
oral glucose tolerance test [OGTT]).14 Recently, a hemoglobin A1c (HbA1c) level of 5.7% to 6.4% has been included
in the definition of prediabetes.14 It is important to realize
that Hispanics/Latinos are much more predisposed to develop prediabetes compared with non-Hispanic whites, and
that individuals with prediabetes have a 1.5-fold increased
risk of cardiovascular disease compared with people with
normal glucose levels. Furthermore, individuals with type 2
diabetes have a 2- to 4-fold increased risk of cardiovascular
disease.
THE METABOLIC SYNDROME IN
HISPANIC/LATINO PATIENTS
The hallmarks of the metabolic syndrome are obesity, dyslipidemia, hypertension, and hyperglycemia, against a back-
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ground of insulin resistance. The prevalence of the metabolic syndrome by sex and race/ethnicity, according to
data from the National Health and Nutrition Examination
Survey (NHANES) from 2003 to 2006, is summarized in
Figure 1.11 The prevalence of individual metabolic abnormalities in Mexican Americans according to sex is
presented in Figure 2.
Generally, NHANES data showed that Mexican Americans had an increased prevalence of dyslipidemia compared
with non-Hispanic whites and non-Hispanic blacks; however, increases in abdominal obesity in Mexican Americans
varied according to sex. In males, all of these abnormalities
(high FPG, increased triglycerides, low high-density lipoprotein cholesterol levels) were shown to have a higher
prevalence in Mexican Americans compared with non-Hispanic whites or non-Hispanic blacks, with the exception of
abdominal obesity, which was higher in non-Hispanic
whites, and hypertension/use of antihypertensive agents,
which showed a trend to be higher in non-Hispanic whites
and was significantly higher in non-Hispanic blacks
(P ⬍0.05 vs. Mexican Americans; Figure 2).11 In contrast,
in females the prevalence rate of abdominal obesity was similar in Mexican Americans compared with non-Hispanic
blacks and the prevalence rate of hypertension/use of antihypertensive agents was similar compared with non-Hispanic
whites; however, all other parameters were higher in Mexican
American females compared with their non-Hispanic white
counterparts (Figure 2).11
When general obesity (as measured by body mass
index [BMI] rather than abdominal obesity) is considered, Hispanics/Latinos have a higher prevalence of obesity
compared with non-Hispanic whites. Based on NHANES
data from 2007 to 2008, there was a higher prevalence of
obesity in Hispanic/Latino men and women (34.3% and
43.0%, respectively) compared with non-Hispanic white
men and women (31.9% and 33.0%).5 Similarly, the prevalence of obesity in Hispanic/Latino adolescents (12 to 19
years of age) was higher than in non-Hispanic whites (BMI
ⱖ95th percentile: 21.7% vs. 15.6%, respectively).4
TYPE 2 DIABETES MELLITUS IN
HISPANIC/LATINO PATIENTS
Comparison of NHANES data from 1988 to 2006 show that
the prevalence of diagnosed type 2 diabetes increased significantly over time, and that minority groups had a consistently higher prevalence of both diagnosed and undiagnosed
type 2 diabetes compared with non-Hispanic whites.12,15 According to Centers for Disease Control and Prevention (CDC)
data from 2007 to 2009, the prevalence of type 2 diabetes in
persons aged ⱖ20 years was almost twice as high in Hispanics/
Latinos compared with non-Hispanic whites (11.8% vs. 7.1%,
respectively).13
As mentioned earlier, the presence of prediabetes increases
the risk of developing type 2 diabetes. NHANES data from
1984 to 2000 show that the lifetime risk of developing type 2
diabetes for Hispanics/Latinos born in the United States in
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The American Journal of Medicine, Vol 124, No 10S, October 2011
Figure 2 Prevalence of metabolic abnormalities in adults aged ⱖ20 years according to sex and
ethnicity. BP ⫽ blood pressure; FPG ⫽ fasting plasma glucose; HDL-C ⫽ high-density lipoprotein cholesterol; TGs ⫽ triglycerides.11
2000 is 45.4% (men)/52.5% (women); overall, this analysis
indicates that Hispanics/Latinos have the highest lifetime risk
for type 2 diabetes compared with other racial/ethnic groups.16
A recent analysis from the CDC found that the percentage of
adults in the United States aged ⱖ20 years with prediabetes
(using either FPG or HbA1c for diagnosis) in 2005 to 2008 was
similar for non-Hispanic whites (35%), non-Hispanic blacks
(35%), and Mexican Americans (36%) after adjusting for population age differences.13 However, it should be noted that an
OGTT, the “gold standard” for diagnosing type 2 diabetes, was
not used for this analysis, which could explain why Hispanics/
Latinos and other ethnic minorities had a higher prevalence
of type 2 diabetes despite apparently similar rates of prediabetes. Based on the latter observation, recent treatment
guidelines have acknowledged the increased risk among
ethnic minorities. Guidelines from both the American Association of Clinical Endocrinologists (AACE) and the
ADA include Hispanic/Latino ethnicity as a risk factor for
prediabetes and type 2 diabetes and support priority screening for these populations.14,17
Cusi and Ocampo
Unmet Needs in Hispanic/Latino Patients with Type 2 Diabetes
Figure 3
S5
Genetic and acquired factors that can cause metabolic abnormalities.
METABOLIC ABNORMALITIES IN HISPANIC/
LATINO PATIENTS WITH TYPE 2 DIABETES
MELLITUS
The “thrifty gene” hypothesis proposes that insulin resistance was a mutation that became imprinted on the genome
because it conferred a survival advantage during periods of
famine, allowing individuals to store adipose tissue and
thereby survive longer than those without the mutation.
However, now that food supplies are more abundant, certain
populations that carry this mutation are predisposed to conditions such as type 2 diabetes.18,19 The resultant insulin
resistance and obesity-related metabolic complications create a constellation of cardiovascular risk factors, as observed in the metabolic syndrome and type 2 diabetes, that
are more frequently found in Hispanic/Latino populations.
The metabolic abnormalities of type 2 diabetes are believed
to be caused by both genetics and environmental factors
(Figure 3).20 While the genetics of type 2 diabetes in
Hispanics/Latinos are poorly understood,21 there is consensus that targeting environmental factors, particularly the
development of obesity at early stages, is the most costeffective approach to prevent the development of the disease and its broad spectrum of micro- and macrovascular
complications. The development of obesity and type 2 diabetes in Hispanics/Latinos, as well as in other ethnic minorities, is not only related to genetically determined ethnic
susceptibility but also linked to the impact of migration and
the effects of urbanization, mechanization, nutrition transi-
tion, physical inactivity, stress, and other poorly defined
factors.22
Insulin resistance is a well-known precursor to type 2
diabetes. Although insulin resistance can be caused by obesity,23 studies suggest that insulin resistance in Hispanics/
Latinos is caused by a combination of environmental and
genetic factors.18,21,24 In general, Hispanics/Latinos have a
higher level of insulin resistance compared with non-Hispanic whites, and ethnicity has been shown to be an independent correlate of insulin resistance after adjustment for
BMI, age, and presence of type 2 diabetes.25 The Insulin
Resistance Atherosclerosis Study (IRAS) demonstrated that
both insulin resistance and ␤-cell dysfunction predicted conversion to type 2 diabetes in all ethnic/racial groups evaluated—Hispanics/Latinos, African Americans, and non-Hispanic
whites.26 However, Hispanics/Latinos have a higher rate of
conversion from prediabetes to type 2 diabetes than nonHispanic whites; in the general population of the United
States, about 5% to 10% of patients with prediabetes are
believed to convert to type 2 diabetes annually, but this
figure may be as high as 15% in Hispanics/Latinos.27 In the
Diabetes Prevention Program (DPP), the overall conversion
rate was 11%, similar to that reported for Hispanics/Latinos
(11.7%).28 In a 10-year follow-up of the DPP, event rates
ranged from approximately 5% to 7%.29 In the Diabetes
Reduction Assessment with Ramipril and Rosiglitazone
Medication (DREAM) study, the progression from IGT to
type 2 diabetes was 6.5% in patients with a BMI ⬍28 kg/m2
but as high as 10.2% in patients with a BMI ⱖ33 kg/m2.30
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Notably, a proportional hazards analysis of these patients
found no significant increase in the progression to type 2
diabetes or death for the Hispanic/Latino population compared with the European population for either the unadjusted risk (hazard ratio [HR], 1.25; 95% CI, 0.95 to 1.65)
or the risk adjusted for baseline differences in age, sex,
waist– hip ratio, BMI, geographic region, and average annual weight change (HR, 1.26, 95% CI, 0.89 to 1.80).31
Hispanic/Latino individuals also have a tendency to develop abdominal obesity, which, as well as being linked to
insulin resistance, is associated with endothelial dysfunction
and vascular inflammation.32-34 In the San Antonio Heart
Study, predictors of type 2 diabetes included both waist
circumference and BMI, suggesting that the increased risk
of type 2 diabetes in Hispanics/Latinos may be related to a
greater amount of visceral fat and overall obesity.35 Endothelial dysfunction and subclinical inflammation contribute
to the development of both type 2 diabetes and cardiovascular disease, with evidence suggesting links between a proinflammatory environment and altered glucose homeostasis
and atherogenesis (reviewed by Sjöholm and Nyström36). A
study of Hispanic/Latino children and adolescents that compared lean and obese individuals without type 2 diabetes
found that those who were overweight had elevated levels
of markers associated with endothelial dysfunction and inflammation, such as tumor necrosis factor–␣, tissue plasminogen activator, and C-reactive protein, compared with
lean individuals; the increase in these markers was closely
related to body fat and insulin resistance, suggesting that
obese children may be at higher risk of developing type 2
diabetes and cardiovascular disease compared with lean
children.37 Overweight Hispanic/Latino youth with the metabolic syndrome are significantly more insulin resistant,
compared with those without the syndrome. The adipocytederived hormone adiponectin may be an important predictive marker for the metabolic syndrome. Hispanic/Latino
children with type 2 diabetes have significantly lower adiponectin levels compared with children without the disease
(P ⬍0.05).38 Adiponectin has also been independently reported to predict the metabolic syndrome in overweight
Hispanic/Latino youth.38
Hispanic/Latino persons generally appear to have higher
triglyceride levels than non-Hispanic whites, and there is
some evidence suggesting a genetic basis.39 In a study of
173 Hispanic/Latino and African American youth, Hispanics/Latinos had a significantly higher triglyceride level compared with African Americans (113 mg/dL vs. 72 mg/dL
[1 mg/dL ⫽ 0.01129 mmol/L], respectively; P ⬍0.001).40
Similarly, triglyceride levels were highest in Hispanics/
Latinos compared with non-Hispanic whites and African
Americans in IRAS (n ⫽ 1,625; 148 mg/dL, 134 mg/dL,
and 102 mg/dL, respectively; P ⬍0.001)41 and in NHANES
data from 1999 to 2002 (n ⫽ 2,804; 144 mg/dL, 140 mg/dL,
and 99 mg/dL, respectively).42 In contrast, a retrospective
chart review of 6,450 patients from a single center showed
that Hispanic/Latino patients had a 42% lower risk of having abnormal triglyceride levels compared with white pa-
tients.43 It may be that these differing results are owing to
differences in study populations.
Evidence indicates that Hispanic/Latino patients with type 2
diabetes are at greater risk for microvascular complications
associated with this disease (reviewed in Umpierrez et al44).
For example, NHANES data from 1988 to 1994 for patients
with type 2 diabetes who were ⱖ40 years of age found that
the prevalence of diabetic retinopathy was 84% greater in
Mexican Americans compared with non-Hispanic whites.45
Furthermore, after adjustment for duration of type 2 diabetes, HbA1c level, and antidiabetes treatment (insulin
versus oral agents), the risk of retinopathy in Mexican
Americans remained twice that of non-Hispanic whites.45
Renal complications also appear to be increased in Hispanic/Latino patients with type 2 diabetes compared with nonHispanic white patients. A large, longitudinal observational
study (n ⫽ 62,432) reported that the incidence of end-stage
renal disease was approximately 40% greater in Hispanic/
Latino patients with type 2 diabetes compared with nonHispanic white patients.46 Although the incidence of microvascular complications is higher in Hispanics/Latinos
compared with non-Hispanic whites, evidence from the San
Luis Valley Diabetes study suggests that cardiovascular
disease mortality was equal or lower in Hispanic/Latino
patients compared with non-Hispanic white patients (8.8/
1,000 vs. 12.9/1,000 person-years, respectively).47
ACHIEVEMENT OF TREATMENT TARGETS IN
HISPANIC/LATINO PATIENTS
In general, data suggest that Mexican Americans with metabolic risk factors are undertreated and less likely to achieve
control. In NHANES (1999 to 2002), the percentage of
Mexican Americans being treated (42% vs. 61%; P ⱕ0.001)
and achieving control (blood pressure ⬍140/90 mm Hg;
49% vs. 58%; P ⱕ0.05) was significantly lower compared
with non-Hispanic whites.48 NHANES data from 1999 to
2002 also demonstrated that, although the prevalence of
dyslipidemia was slightly lower in Mexican Americans
compared with non-Hispanic whites (31% vs. 35%, respectively; P ⱕ0.05), Mexican Americans received less
treatment for dyslipidemia (14% vs. 30%; P ⱕ0.001).48
Consistent with these findings, the Multi-Ethnic Study of Atherosclerosis (MESA) reported the prevalence of dyslipidemia
to be slightly lower and to be undertreated when comparing
Hispanics/Latinos with non-Hispanic whites.49 In MESA, 32%
of Hispanic/Latino men and 27% of Hispanic/Latino women
had dyslipidemia compared with 37% and 24% of non-Hispanic white men and women, respectively, and Hispanic/Latino patients were approximately 20% less likely to receive
pharmacologic treatment for dyslipidemia. As a result, control
rates were lower in Hispanic/Latino men (69%) and women
(75%) compared with non-Hispanic men (76%) and women
(86%).49
Similarly for blood pressure and dyslipidemia, Hispanic/
Latino patients are less likely than non-Hispanic white patients to achieve recommended HbA1C treatment targets.
Cusi and Ocampo
Unmet Needs in Hispanic/Latino Patients with Type 2 Diabetes
Historically, Hispanics/Latinos in the United States are considered to be a genetic mix of Native American, black, and
Spanish ancestry, and their risk of developing type 2 diabetes is dependent on the specific mix of genes inherited; for
example, those who have a higher proportion of Native
American genes have a higher risk of developing type 2
diabetes.50,51 Kirk and colleagues52 examined differences in
the treatment of minority patients with type 2 diabetes by
comparing data from African American, Hispanic/Latino,
American Indian, and Asian/Pacific Islander populations
with that from non-Hispanic white populations (data from 78
studies were included in this analysis). Overall, Hispanics/
Latinos had poorer outcomes for control of hyperglycemia,
as well as hyperlipidemia (defined as elevated low-density
lipoprotein cholesterol) and hypertension. In all 8 studies
that evaluated glycemic control specifically in Hispanic/
Latino patients with type 2 diabetes, mean HbA1c was
higher in the Hispanic/Latino population compared with the
white population. Although the disparities between Hispanics/
Latinos and non-Hispanic whites were most pronounced
with regard to glycemic control, low-density lipoprotein
cholesterol levels and blood pressure were also less controlled.52 Based on NHANES data from 1999 to 2006, an
HbA1c level of ⬍7.0% was achieved by only 37.8% of
Hispanic/Latino patients with type 2 diabetes born in the
United States compared with 58.1% of non-Hispanic white
patients (P ⬍0.001).53 Furthermore, the disparity between
the percentage of Hispanic/Latino and non-Hispanic patients achieving an HbA1c level of ⬍7.0% continued to
increase from 1999 to 2006. Similar to trends observed for
glycemic control, blood pressure control rates (⬍140/90
mm Hg) were also significantly lower for Hispanics/Latinos
than for non-Hispanic whites (42.5% vs. 52.8%, respectively; P ⫽ 0.005).53 A recent study54 reported similar
trends to the McWilliams et al53 study in terms of glycemic
control, with Mexican Americans less likely than whites to
achieve an HbA1c level of ⬍7.0%.
Barriers to the achievement of treatment goals include
cultural and socioeconomic factors such as language, cost,
and access to goods and services.55 For instance, a study in
18,510 non-Hispanic white patients and 2,078 Hispanic/
Latino patients found that the latter were less likely to
receive appropriate type 2 diabetes quality of care and to
self-monitor their disease, including measurement of
HbA1c, foot check by healthcare provider, dilated eye exam,
influenza and pneumococcal immunizations, type 2 diabetes
education, and self-monitoring of feet and blood glucose.56
Ethnic/racial disparities for HbA1c testing and foot exams
persisted even after controlling for access to care, socioeconomic status, and demographics.
Evidence suggests that the use of culturally sensitive
education programs can improve type 2 diabetes outcomes
in the Hispanic/Latino patient population.55,57,58 Liebman
and associates57 implemented self-management activities in
Hispanics/Latinos over a course of 3 years using bilingual
(Spanish/English) multisession activities, including formal
type 2 diabetes education classes, exercise, and chronic
S7
disease self-management classes. Nearly half of the participants achieved an HbA1c level of ⬍7.0%, and fewer had
markedly elevated HbA1c levels.57 More recently, Castillo
and colleagues58 reported that the use of community health
workers in Hispanic/Latino communities is helpful in teaching basic type 2 diabetes management skills, delivered in
short 2-hour classes over 10-week programs, that have a
positive impact on glucose and blood pressure control.
SUMMARY
The Hispanic/Latino population in the United States has a
greater prevalence of metabolic abnormalities and type 2
diabetes compared with non-Hispanic whites. Compared
with non-Hispanic whites, Hispanics/Latinos tend to be
generally more obese, and are less likely to achieve control
of parameters such as HbA1c, blood pressure, and lipid
levels. Overall, the magnitude of the problem of type 2
diabetes in Hispanics/Latinos is large, worrisome, and getting worse. Some of the ethnic differences in prevalence
between Hispanics/Latinos and whites have a genetic basis,
but socioeconomic and cultural factors have a greater influence. To achieve treatment goals, healthcare providers must
understand the spectrum of socioeconomic and cultural factors affecting Hispanics/Latinos. Recent studies in a variety
of settings clearly demonstrate that type 2 diabetes education programs specifically tailored to the Hispanic/Latino
patient frequently yield significant success. We envision
that with greater healthcare provider awareness and wider
availability of programs tailored to Hispanic/Latino individuals, the current treatment gap among ethnic/racial minorities in the United States will progressively narrow, and
eventually, disappear.
ACKNOWLEDGMENTS
Medical writing services and editorial assistance provided
by Sheridan Henness, PhD, Karen Stauffer, PhD, and Lucy
Whitehouse, of inScience Communications, a Wolters Kluwer business, were funded by Daiichi Sankyo, Inc.
AUTHOR DISCLOSURES
The authors who contributed to this article have disclosed
the following industry relationships:
Kenneth Cusi, MD, has served as a consultant to Daiichi
Sankyo, Inc., Merck & Co., Inc., and Schering-Plough Corporation (now Merck).
Gloria L. Ocampo, MD, has served as a consultant to
Daiichi Sankyo, Inc.
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