How Does Diabetes Affect Special Populations? (Cont'd)

However, the underlying reasons for the health status of many groups at high-risk for diabetes involve the lack of conditions necessary to be healthy:

• Legal, economic, education and historical discrimination
  Due to segregation and other discriminatory laws, policies, and employment practices, certain groups have historically been forced to live in specific areas, limiting options for work, education, career preparation, and healthcare. While segregation no longer is legal, it persists in various forms, and actions to ensure equal economic access and equal access to healthcare services, health insurance, grocery stores, fresh produce, and safe parks and recreational facilities have not been uniform across the country. (Note: In one study of more than 3,700 women of color, participants who had a regular doctor were at least twice as likely as those who did not to receive preventive care for diabetes and other conditions.⁹¹)
   
• Interpersonal discrimination
  Healthcare providers, other professionals, and support staff sometimes make false assumptions about patients or clients, consciously or unconsciously. Sometimes, discriminatory healthcare practices sanctioned by local, state, and federal government agencies remain in the memory of elders from a particular group, such as the Tuskegee Syphilis study among African American men⁹² and the treatment of tuberculosis in Filipinos and Latinos in Los Angeles County and other parts of California.⁹³ Cultural competence training and use of healthcare providers representative of the community being served has been shown to help healthcare providers provide more sensitive care to their patients.⁹⁴
   
• Internalized discrimination
  With life experience and history lessons taught by parents and grandparents, many people of color learn to expect to be treated differently based on their appearance. This can result in depression, anger, and limiting one's options for job training or career pursuits. Researchers have found people of color also have higher stress levels (called allostatic load) not explained by income, education, or other characteristics.
   
• Cultural characteristics relating to food and physical activity
  Physical activity and eating customs vary widely from culture to culture, and within each race and ethnic group, people may be from different countries of origin, different tribes, and different parts of the country or state.⁹⁵ It is well-documented that:
  • Women generally are less active than men at all ages, people with lower incomes and less education are typically not as physically active as those with higher incomes and education
  • African Americans and Hispanics are generally less physically active than whites
  • Adults in northeastern and southern States tend to be less active than adults in North-Central and Western State.
  • People with disabilities are less physically active than people without disabilities
  • And, by age 75, one in three men and one in two women engage in no regular physical activity⁹⁶

  Nearly every group has healthful foods -- preferred vegetables, fruits, grains, and legumes -- rooted in its cultural traditions. Over time, many cultures have eschewed traditional healthful foods for more readily obtained high-calorie, high-fat, high-salt, or high-sugar foods. Recommendations to increase dairy consumption go against the cultural dietary habits (and the lactose intolerance) of most people of color -- 90 percent of the world's population, in fact.⁹⁷ According to an article published in the American Academy of Family Physicians, 60 to 80 percent of Blacks, 50 to 80 percent of Hispanics, 95 to 100 percent of Asians, and 80 to 100 percent of American Indians are lactose intolerant and may suffer stomach cramps, diarrhea, and other painful or distressing gastrointestinal symptoms. Lactose intolerance occurs in 6 to 22 percent of American whites.⁹⁸
   

• Low health literacy
  Older adults from all racial and ethnic groups are likely to become confused by medical information; elders of color even more so, especially if English is a second language. Hospital signage, directions for obtaining appointments or performing tests, instructions for taking medications, and explanations relating to the causes of a disease often are given using confusing terminology. Such confusion can lead to medication-related problems, missed appointments, poor follow-up care, and worse overall health. Studies have shown that low health literacy leads to worse health outcomes for people with diabetes in particular.^99,100
   
• Immigration status
  Research has shown that immigrants to the United States have better diets (higher in fruits and vegetables and lower in fat) than their children or grandchildren who are born in the United States. However, they have worse diets with respect to diabetes than the people in their countries of origin.
   
• Language
  In a study of the health of older Californians, while about 4 in 5 older non-Latino whites reported having private supplemental health insurance, only 37 percent of limited-English speakers reported having that insurance. In the same study, older Latinos and older Californians with limited-English were more likely than the total state average to report diabetes, fair/poor health, emotional difficulties, use of preventive services. (Note that in the population studied, about 40 percent of Latinos were limited-English, and about 45 percent of the older limited-English group is Latino).¹⁰¹ Elders who are not proficient in English may shy away from educational and health services not available in their language. Outreach, dissemination of health information, and advertising of services should be done via culturally appropriate, in-language media channels, such as Chinese language newspapers and Latin American telenovelas on local Spanish television.

⁹¹ Cornelius, L.J., et al. (2002) "What Factors Hinder Women of Color From Obtaining Preventive Health Care?" American Journal of Public Health 92(4):535-539.

⁹² University of Virginia, Health System. "Bad Blood: The Troubling Legacy of the Tuskegee Syphilis Study." Available on the World Wide Web: www.med.virginia.edu/hs-library/historical/apology/.

⁹³ Abel, E.K. (2004) "'Only the Best Class of Immigration': Public Health Policy Toward Mexicans and Filipinos in Los Angeles, 1910-1940." American Journal of Public Health 94: 932-939.

⁹⁴ Fortier, J.P. and Bishop D. (2004) Setting the Agenda for Research on Cultural Competence in Health Care: Final Report. Edited by C. Brach. Rockville, MD: U.S. Department of Health and Human Services Office of Minority Health and Agency for Healthcare Research and Quality.

⁹⁵ Cornelius, L.J., et al. (2002) "What factors hinder women of color from obtaining preventive health care?" American Journal of Public Health 92(4):535-539.

⁹⁶ U.S. Department of Health and Human Services. (2000) Healthy People 2010: Understanding and Improving Health, 2nd ed. Washington, DC: U.S. Government Printing Office

⁹⁷ Beyer, P.L. (2004) "Focus on Lactose Tolerance: An Uncommon Anomaly?" In Chapter 30: "Medical Nutrition Therapy for Lower Gastrointestinal Tract Disorders" (p. 720), Mahan, L.K., and Escott-Stump, S. (eds.), Krause's Food, Nutrition, and Diet Therapy. Philadelphia, PA: Saunders.

⁹⁸ Swagerty, D.L.,Walling, A.D., and Klein, R.M. (2002) "Lactose Intolerance." American Family Physician 65(9):1845-1850.

⁹⁹ Schillinger, D., et al. (2002) "Association of Health Literacy with Diabetes Outcomes." Journal of the American Medical Association 288(4):475-482.

¹⁰⁰ Rothman,R.L., Malone, R., Bryant, B., Shintani, A.K., et al. (March 2005) "A randomized trial of a primary care-based disease management program to improve cardiovascular risk factors and glycated hemoglobin levels in patients with diabetes." American Journal of Medicine 118(3):276-284.

¹⁰¹ Wallace, S.P., et al. (2003) Data from the 2001 California Health Interview Survey and 2000 U.S. Census: Health of Older Californians: County Data Book. The Regents of the University of California. p. 4.