Outlook: Newsletter of the Society of Behavorial Medicine

Dr. Linda Gallo and Dr. Addie Fortmann on Addressing Diabetes within the Latino Community

Maggie A. Crawford and Naomi S. Kane, Senior Student Co-Chairs, Diabetes Special Interest Group (SIG)

Linda Gallo, PhD
Linda Gallo, PhD
Addie Fortmann, PhD
Addie Fortmann, PhD

Diabetes is a growing epidemic that heavily impacts the Latino population--- diabetes prevalence for Latinos was 17%, compared to 8% in non-Hispanic whites in the National Health and Nutrition Examination Survey. The Diabetes SIG spoke with Dr. Linda Gallo to learn how she studies the diabetes-related health needs of the Latino population in Hispanic Community Health Study/Study of Latinos (HCHS/SOL), and how she translates these findings into intervention research aiming to successfully promote diabetes self-management in this population. Dr. Linda Gallo is a Professor of Psychology and Co-Director South Bay Latino Research Center at San Diego State University. We also interviewed Dr. Addie Fortmann, PhD Research Scientist at the Scripps Whittier Diabetes Institute (SWDI), to learn how she collaborates with Dr. Gallo to create and implement diabetes management interventions for the Latino population.

Diabetes SIG: What are the guiding research objectives of the HCHS/SOL? How has the design influenced its findings?

Dr. Gallo: The goal of HCHS/SOL is to establish prevalence, incidence, and risk and protective factors for major chronic diseases. This landmark study includes >16,000 adults of Latino descent, enrolled from four US cities (Bronx, NY; Chicago, IL; Miami, FL; San Diego, CA). The communities selected have high concentrations of specific heritage groups, allowing the study to examine variability in disease prevalence. For example, diabetes prevalence varied from 10.2% in South Americans to 13.4% in Cubans, to 17.7% in Central Americans, 18.0% in Dominicans and Puerto Ricans, and 18.3% in Mexicans. The cohort provides an opportunity to understand the health needs of the US Latino population, and guide interventions by identifying factors that may explain why some groups fare better than others.

Diabetes SIG: What key needs has the HCHS/SOL highlighted in the Latino population?

Dr. Gallo: 36.3% of HCHS/SOL participants have pre-diabetes, placing them at high risk for developing diabetes. Latinos with diabetes also show worse glycemic control, more complications, and higher mortality than non-Hispanic whites. Of the participants who have diabetes in HCHS/SOL, only 48% have adequate glycemic control. The high prevalence of diabetes and pre-diabetes highlights the need for accessible, culturally appropriate healthcare strategies to reduce diabetes disparities among Latinos. At the baseline assessment (2008-2011), only 52% of HCHS/SOL participants with diabetes had health insurance, so access is a major factor. However, there are additional practical, social, and cultural barriers that may interfere with optimal care and glycemic control even among those with insurance.

Diabetes SIG: In addition to SOL, you collaborate on a number of diabetes interventions with the SWDI. Can you talk about how SOL has influenced the objectives of these interventions?

Dr. Gallo: My recent research has focused on developing and testing culturally appropriate interventions to prevent diabetes and improve outcomes among Latinos. I have asked SWDI Co-Investigator Dr. Addie Fortmann to join me in discussing these efforts.

Dr. Gallo and Dr. Fortmann: Working with Neighborhood Health, a large federally qualified community health center that serves a largely Latino population, we are testing diabetes interventions that involve lower-cost personnel (e.g., medical assistants, community health workers) to improve adherence and provider-patient communication, and integrate approaches that address both behavioral and physical healthcare needs of underserved patients. We work closely with our community partners, providers, and patients to ensure that the intervention design and content is culturally appropriate, acceptable, and sustainable in today’s healthcare environment.

Diabetes SIG: How has the use of technology evolved in your diabetes interventions?

Dr. Gallo and Dr. Fortmann:  Culturally, members of the Latino population might prefer personal interactions to digital intervention modalities. In our Dulce Digital ME study, we are comparing a non-tailored text messaging intervention to a personally tailored version that sends participants personalized feedback in response to bluetooth transmitted glucose and medication adherence data. Feedback is either issued immediately via texts generated from computer generated algorithms, or delivered by specially trained medical assistants. We hope to guide how best to incorporate technology into a real world, low resource primary care environment to promote patient outcomes, and effective, cost-efficient care.

Diabetes SIG: How has the leverage of social support evolved in your diabetes interventions?

Dr. Gallo and Dr. Fortmann:  Our interventions often rely on specially trained laypersons, such as community health workers (otherwise known as promotoras) who can relate to patients culturally, understand barriers, provide support, and connect participants with community resources. In one current trial, we are testing how effective a team-care approach is for improving self-management and clinical outcomes--- this utilizes medical assistants who collaborate with primary care providers and provide health coaching to participants. In our text messaging intervention, we encourage participants to engage family and friends in their lifestyle goals, or as a resource to cope with stress. Given the research showing that social support is a critical predictor of many health outcomes, it makes sense that it is a critical “ingredient” in effective chronic disease management.

References:

Schneiderman N, Llabre M, Cowie C, et al. Prevalence of Diabetes among Hispanics/Latinos from Diverse Backgrounds: the Hispanic Community Health Study/Study of Latinos (HCHS/SOL). Diabetes Care. 2014;37(8):2081-2083.

Centers for Disease Control and Prevention. National Diabetes Statistics Report: Estimates of Diabetes and Its Burden in the United States, 2014. Atlanta, GA: Department of Health and Human Services.

Fortmann AL, Gallo LC, Garcia MI, et al. Dulce Digital: An mHealth SMS-based intervention improves glycemic control in Hispanics with type 2 diabetes. Diabetes Care. 2017;40:1-7.

For more information about the HCHS/SOL: https://sites.cscc.unc.edu/hchs/; https://www.nhlbi.nih.gov/research/resources/obesity/population/hchs.htm

Dulce Digital Me is funded by NIH/NIDDK (NIH/NIDDK 1 R01DK112322-01A1; Gallo & Philis-Tsimikas); The Medical Assistant Coaching Trial is funded by NIH/NIDDK (NIH/NIDDK 5 R18 DK104250-02; Gallo & Philis-Tsimikas)