Shireen: Dr. Enrique Caballero discusses type 2 diabetes in the Hispanic/Latino population and diabetes disparities among racial and ethnic minorities. He talks about diabetes education programs specifically for Hispanic and Latino communities and how diabetes management programs must be culturally adapted. Listen to this episode to learn how to best support nutrition in the Latino community. 

Podcasting from Dallas, Texas. I am Shireen and this is the Yumlish podcast. Yumlish is working to empower you, to take charge of your health through diet and exercise and reduce the risk of chronic conditions like type two diabetes and heart disease. We hope to share a unique perspective and a culturally relevant approach to managing these chronic conditions with you each week. 

Dr. Caballero is the Director of Latino Diabetes Health in the Division of Endocrinology, Diabetes and Hypertension at the Brigham and Women’s Hospital and Director of International Innovation Programs in the Office for External Education at Harvard Medical School.  He is also the Chair of the Health Care Disparities Committee for the American Diabetes Association.  Welcome Dr.Caballero! How are you? 

Dr.Caballero: I’m doing great. Thank you for inviting me to this interview.

Shireen: An absolute pleasure Dr.Caballero. Diving right in, what led you, how did you get involved in medicine and what drew you to work focused on diabetes specifically in underserved communities? 

Dr.Caballero:: I would say that I was very fortunate to grow up in an environment where, um, My parents, my family and people around us, taught me from a very early on about the importance of helping other individuals. And I found that medicine is one of those very special  areas of work where you can have a direct impact on people's lives. There's obviously many ways to do it, but I was somehow inclined to do that because you do that directly. You can help people in their health, Not just physically, but also emotionally, psychologically. And I have always believed that as human beings, you, we, we can improve all our areas of life. And, I thought that was a great opportunity. 

Now, unfortunately, there are people who struggle more than others in achieving a good health status. And I identified that early on. I was born and grew up in Mexico city. And, obviously that was part of my, In terms of being acquainted with many of the challenges that a lot of people have. And then I came here to the United States after my initial training, and I had that commitment of continuing to work with people that have more difficulties in improving their health.

And that is for example, the Latino, Hispanic community here in the United States, the black community, and many others. But unfortunately you do not have an equal opportunity to achieve good health status. And, from very early on, I identified that as a mission for myself, in being a doctor and having the opportunity to help everybody, of course, cause I have worked with all different types of patients over the years,, but I have a particular inclination to help those that need the most help. And that's how I came here and I have established that as a lifelong commitment in terms of improving the health of those with more significant difficulties. 

Shireen: So Dr.Caballero, better help us understand what diabetes disparities exist among racial and ethnic minorities.

Dr.Caballero: Yes. This is a very sensitive issue because it is really unfortunate that despite all the advances that we have seen in the field of diabetes,in terms of technology, medications, and knowledge we are not having the impact that we should in improving diabetes care. Most people are not achieving treatment targets that apply to everybody.

But when it comes to underserved communities, racial, ethnic minorities, the problem is worse. It is less likely for these populations to achieve good control of diabetes and related disorders. There's more disease and there's a lot of studies that show that there's more type two diabetes in particular. And when people have diabetes, the chance of developing complications is higher. There's a lower life expectancy and increased mortality rates in these populations. 

And you could argue, well, you know, this is because they just don't take good care of themselves. They don't follow the instructions. They don't follow their meal plans. They don't take their medications. It's their fault. But no, no, no. That's not actually the whole explanation. Some of the disparities, the inequities are based on the system that we have both in our society and in our healthcare system because the people don't get equal opportunity to access the healthcare system and even when they are in a healthcare system to get the best quality of care, there is a lot of data and studies that show that people don't get equal treatment opportunities. They're not evaluated in the same way. They're not screened properly sometimes. And that's really a shame.

That's really sad that we are not doing things in the same way for everybody. The healthcare system is not conducive to culturally oriented programs sometimes. There are not enough human resources and sometimes the emphasis is not there in order to develop what is needed in order to provide equal care to intervene. And we as healthcare providers also have an important role because sometimes we're not aware of what's happening. I don't want to say that there is intentional racism and discrimination in everybody. But I think that there are unconscious thoughts. So unconscious biases, implicit biases, as they have been described that make us believe that some people deserve better treatments than others, that some people are not going to do well in. Therefore why bother? And that's a problem. I think that's really, really sad. So I think that we should embrace the opportunity to fight inequities and disparities in healthcare. I think this is the best time actually in history because there's a little bit more awareness about this. Because of political reasons because of what's happening in our society. I think we do have the opportunity to really make a significant impact  at this point in time. So this is an important conversation to have disparities exist, but I think that there is a great opportunity to eliminate them. 

Shireen: Can you discuss a bit more about how these disparities exist specifically in the Hispanic population today and how diabetes affects this population? 

Dr.Caballero: The Latino Hispanic population has a higher risk of developing type two diabetes. And we have known that for a long time. It is based on genetic factors. There's a genetic predisposition in the community to develop diabetes that has to do with the fact that there is more insulin resistance. That means that the insulin that the body produces does not work very well more than in other populations. Also the cells in the pancreas called beta cells that produce insulin may get tired more rapidly. So those are things that we have known for a long time. but there's also the lifestyle factors.

The population tends to be less physically active, for example, Obviously the meal plans are not optimal as they're not in other populations either, but there is a high carbohydrate intake and saturated fat intake in many of the meals. So there's lifestyle factors that in combination with genetics increase the risk of type two diabetes.

But as I said earlier, I think it's also the fact that people are not receiving appropriate care. So we know for example, that people may go four years without really identifying diabetes, because at the beginning, diabetes is a silent disease. It doesn't cause any symptoms. So data show that someone may have diabetes for 10 or 15 years before they are identified with the disease, And  those are lost years because they are not receiving proper treatment in order to prevent complications, et cetera.

So there's the high risk for diabetes, late diagnosis, late interventions, and all that has led to the devastating consequences of diabetes in this community. As I said, their rates, for example, of end stage renal disease, cardiovascular disease, mutations, blindness, all the complications that are related to uncontrolled diabetes for a long time are much higher in this community. So it is definitely a problem that we are seeing. And again, this is not just with the Hispanic communities, with other communities as well, But the Latino and Hispanic community has been hit hard with diabetes. 

Shireen: As you work in underserved communities, what are you really seeing and understanding are some sort of deep rooted misconceptions in mainstream medicine surrounding the management of diabetes, again in the Latino and Hispanic communities? 

Dr.Caballero: That is a great point you are  sharing because, there's a concept among health care professionals that Latino, Hispanics, they just don't follow a good meal plan and everything that they eat is wrong. And we all have seen that, over the years. And first of all, I think it would be important to recognize that there's no good or bad meal plan for a particular culture.

It really depends on how the meals are prepared and what they do. In fact, there is some data that shows that traditional meals in different populations may be healthier than the sort of modern meal plans that people consume. For example, we know that fast food, ultra processed foods, the  beverages and most of the fast food that people have access to is highly detrimental.

Whether you call that America or any other type of meal plan, it's the same thing. I think it's the quality of food that really matters in the. One of the misconceptions is really to try to impose a meal plan to different groups based on what our current concept is in terms of what people should eat. For example, everybody should have a salad for breakfast, for lunch and eat fruit in the morning. Well, in some groups that may not be possible because it's not part of what they're used to. So one of the opportunities that we have is to work with communities, guiding them on how to prepare their own meals in a healthier way, without putting their culture on the side.

The other misconception is that, you know, the way in which Latinos eat is exactly the same throughout the whole continent and in different countries in Latin America. That's why, when people ask me, can you recommend a good Latino meal plan, when there's no such a thing as a single Latino plan or Hispanic meal plan because it's very different across different countries.

In fact, the way in which we refer to foods is quite different across Latin America. It's not exactly the same, whereas rice and beans could be very similar everywhere. There's so many other pieces that are so different. I think samples that I always give are that even the same foods receive different names. For example, I'm originally from Mexico, I would call a banana Platano. Whereas if someone is from Venezuela they would say Cambodia, someone would be, if someone is from Puerto Rico would say Grinnell or from Dominican Republic. And we're talking about very similar things, but they have very different names.

So one of the challenges in our healthcare system is that when someone goes and sees a dietician, for example, and that dietician is not familiar with the foods that that person eats based on his or her country of origin, then it's a problem that person may speak some Spanish, but may not be familiar with what that person really does at home.

So one of the main challenges and misconceptions is about how these could be improved in this population. And there's also a lot of myths in terms of the disease itself. You know, people don't think diabetes is that serious. That is just a touch of sugar, you know, a little bit of an elevation of the blood sugar and that's it. It's not detrimental. I always say when people hear the word cancer. No, everybody gets scared or equally it's a serious condition. They hear the word diabetes and it's not that bad. Well, the reality is that people don't know that diabetes kills a lot more people than all cancers combined. And so it's a serious condition.

People don't pay attention to it, but a lot of this has to do with education, of course, of the patients and the community. So I always say that it's important to get familiar with the culture and this is not just with the Latino community. All patients around us and for all of us in our society to go out of our comfort zone and, uh, talk to other people who have different cultures, different perspectives, learn from each other, embrace other points of view. And I think that if we do that better in the healthcare system, I think that, uh, the outcomes would be very different as well. 

Shireen: I like how you draw that sort of distinctiveness. To say that not all Hispanic Latinos are the same. It's different. So when you talked about the banana example, you know, how do you then approach patient patient education? And I'm sure it gets challenging then to understand from a provider's perspective, for instance. Right. So how do you approach patient education for Latino, Hispanic minorities? 

Shireen:: Again, just with that focus on diabetes. I think you have to consider that everybody is different and everybody's in the end an individual that is not because he or she belongs to a particular, Latino sub group, it means that not everything that we know about that sub group applies to that individual. It's about meeting the patient where he or she is. It's about getting to know preferences, background, and lifestyle. And based on that, suggest some changes that are feasible, that are attainable, that are measurable so that some of these changes can be implemented. I think that the wrong approach is to try to implement the same guidelines or same recommendation to every person.

And we know that that is not the way it works. Actually that's the reason why in the field of diabetes, uh, again, in the area of nutrition, we don't have a universal meal plan for all patients with diabetes. There's many different options. There's many ways to get to the goal and we need to decide based on each person's characteristics and background, et cetera.

So I think education needs to be really a way in which we get to the person first, what the person wants to do is able to do, what has happened before, what has worked and what has not worked. And then based on that, suggest and work together in identifying a plan that would work. Something important is that it should be a plan for a long time. Not something that is just for a few weeks, even though, you know, everybody's looking for miracle recommendations and ways to lose weight and diets and all that, that doesn't exist in diabetes. As a chronic disease, we want to implement changes that are durable, that are sustainable, and that people can really adhere to all these recommendations.

Not just for a few days or weeks, but for a long time, because in the end uncontrolled diabetes may lead to complications. If we don't implement all these changes. So we're working very closely considering cultural social factors because another element here, Shireen, in the social aspect, you know, the cost of all these, recommendations, not everybody has access to healthy foods, not everyone has access to a place where they can exercise. You know, this is part of the recommendations. So working with people about identifying their own possibilities and resources and offering options in their own community, their programs that can help them with identifying foods that they can afford about places where they can exercise about how to implement some of these changes is absolutely crucial.

That has not been part of our healthcare system. We don't usually do that. People come to us, we provide recommendations. And that's the end of this story. I'll see you again in three months. We don't know if they're actually able to implement those changes and that's where medicine needs to go. It needs to be based on what we call the management of chronic diseases, the chronic care model, which is not that episodic encounter with patients only, but really find ways to provide the resources and information that they need in order to make decisions every day of their lives. And that has to do with identifying who they can work with, where they can go, how they can get all these foods and, and all the recommendations that were approved. So I think we have a long way to go, but I think that's why this is needed in our healthcare system.

Shireen: And everything you're saying, Dr. Caballero is really music to my ears, The cultural competence with the work that we do at Yumlish with, even to what you mentioned with the quick fixes, like, you know, 30 days, 30 pounds, or, you know, whatever it may be. We have this sort of mentality for instant gratification. I just want to get it done, and I want to move on to the next thing. And the thing with diabetes really becomes it's it's every day. Every single decision every time, the three times a day that you're eating your meals, you're making a decision towards your diabetes and your A1C at the end of that three months, every single day.

Dr.Caballero: And what we have found is that people don't need to do things perfectly. I mean, no one is able to actually modify a meal plan and do everything perfectly every single day, but there are changes that can lead to significant improvements in their blood sugar control, their blood pressure, even their weight, um, data show, for example, in someone with diabetes, that if they lose five to 10% of their body weight, uh, their diabetes control significantly just by doing that. So we're not talking about a huge amount of weight loss. We're not talking about dramatic changes, but for example, in the Hispanic community, as it happens in others, just eliminating, uh, sugary drinks, eliminating juices, for example, that's another misconception that, you know, a lot of people say, Hey, I have a juice every morning and should be fine because It is fruit based, the juice, like orange juice or whatever it is, apple juice. And I always tell my patients, well, that's actually just sugar that you're putting in your system. So not as a prize, the blood sugars may go up after that, even though it comes from a fruit that is supposed to be natural and healthy, it's just sugar.

A lot of the education can really come with some of those small changes that can be implemented in those could really be very helpful. So again, people don't need to abandon their culture and their Meals at home. I think it's one of the strengths in the Latino, Hispanic community, more than going out and trying to go to restaurants and find healthy meals. That's really more difficult because it could be more expensive as well. But I think that teaching people how to bring home, you know, good foods, good quality foods, hopefully without spending more money and teaching them how to prepare them at home in a healthier way. I think that's the way to go. And I think that's what education should be all about in this area of nutrition. 

Shireen: Your work starting the Latino diabetes initiative and the diabetes program at Brigham and Women's hospital is quite remarkable. Can you discuss the structure of these programs and why community outreach and participation are crucial for diabetes management?

Dr.Caballero: I had the fortune of working at The Joslin Diabetes Center, a specialized center for diabetes for many years, where I founded and directed the Latino diabetes initiative, a comprehensive program to improve the lives of Latinos with diabetes or at risk for the disease. And I am also now at the Brigham and Women's Hospital where I have taken the huge challenge of doing this at a wider level, because there it is a bigger hospital and there's community health centers that are affiliated with the hospital. So I'm happily working now with primary care physicians, with people in the trenches, so to speak, that provide care to Latinos with diabetes and it's really gratifying to see how we all can make a significant impact in, in diabetes care.

But the community-based activities are something that I have embraced for a long time, because rather than again, just waiting for people to come to see us and providing recommendations. I think that in the management of chronic diseases, we need to find ways to connect with people when they are not in the clinic or in the office. Because if you think about it, if someone has diabetes every single day over their life, and we spend only a few minutes with them, two or three months at best, how can we truly impact their lives if we only provide recommendations, you know, for a total of one hour per year or so? it's, it's impossible. So what we need to do is to develop ways in which we can connect with individuals, with patients when they're not with us.

And then for everybody that is listening  about how to really take charge of their disease, how to make decisions on their own, feeling the confidence to implement changes. So that can only happen if there's constant communication with a healthcare system. Now that doesn't need to be with a doctor all the time, because the reality, and honestly, I think we are so busy that it is impossible for us to be talking to our patients everyday.

But there are other members in the health care team. There are, for example, diabetes educators. There may be people that can provide some counseling. Now there's community health workers, navigators, people that can guide patients on how to access the healthcare system that can reinforce some of the messages that are provided by the doctor.

So I think that an invitation is for everyone to identify in their healthcare system, all the resources that are available, human resources, people that can help. For example, with some of the challenges that I mentioned earlier, if people have issues with transportation, they may not be able to go to the doctor because they don't have any way to get there. Well, in some programs, there are opportunities to be helped with transportation issues if people are really trying or struggling with  buying the foods that the doctor is recommending or exercising. Well, there are sometimes programs in the community and there are people in the health care system, at least in some that could guide patients on how to do that.

So I think that this idea that it's only the patient and the doctor and that's it, it's wrong. I think that we should acknowledge that there are other members of a healthcare team that can have a particular influence and beneficial impact in the management of diabetes. So I think that's something that we all should consider, uh, as we move forward.

And I would say sharing what has happened with the pandemic right now, which is of course unfortunate, but there's always good lessons to learn. We have been forced to establish some sort of communication with patients when they're not in the clinic, because right now, because of the pandemic, people cannot come to the clinic or the hospital as they used to. And now we are establishing these communications via a phone or telemedicine or videos, et cetera. And what I am hoping actually is that once everything goes back to normal, hopefully soon. we don't do exactly the same thing that we were doing before. I think that this is an opportunity to capitalize on what we learned during this pandemic.

And instead of just going back to the clinic and waiting for patients to come is to communicate with them in the way we're doing now during the pandemic. Without having to go to the clinic all the time, and maybe again, it's not the doctor, but it's the healthcare team. How can I help you implement the changes that you need to do? Let me provide some education. 

There are programs now that are doing telemedicine. Providing support through video conferences, through, FaceTiming and using cell phones and all these different things. And I think that's the way we need to go. It is really to try to work with people when they're not in the clinic or in the hospital only, but try to provide some support throughout the whole year.

Now, what is the challenge? This is not part of the healthcare system. No one pays for these services at this point, but I think that as we move forward, If we identify that some of these interventions work, they could be part of the healthcare system. Maybe there are people that could be hired in health care teams to do this type of activity.At this point, it's usually sometimes because we have a program, we have a grant, we have something that can help us build on that, but it's not sustainable. So I think that's something that we all should try to consider as an opportunity to improve the way in which we provide care to patients with diabetes.

This is really about creating that ecosystem, a sustainable ecosystem that lasts them over their diabetes. 

Shireen: Okay. Okay. Interesting. So with that, Dr. Caveat, or unfortunately for toward the end of the episode, at this point, how can our listeners connect with you and learn more about you? 

Dr.Caballero: Yes. Well I have to say that I'm still a little bit old fashioned, so I don't have a Facebook page and Twitter and all that.  I do have, however, LinkedIn, and that's what I use to connect with other people. There's also the Harvard website where people can find me, but. I think it's also about trying to reach their health care providers. I think that we need to find ways for everybody to get closer to their healthcare teams  and get the right  information.

 I'm really concerned about the fact that diabetes is really creating a lot of problems for this community and others as well. So people need to be aware that diabetes is not something trivial, like. Inconsequential. It could be really a devastating disease. If it is not treated properly, now it is possible to control it, but people need to be proactive.

Even if people think that they don't have diabetes because they feel well. You know, we know that that's not the case. So for everybody that is listening, I would just encourage you all. To go with your doctor, have your blood sugar checked, to be sure that, you know, whether you have diabetes or not. Sometimes there is pre-diabetes, which is the prior stage to diabetes. And if that is there, well, it's not the end of the world because you can control it. And again, this may require of course, lifestyle modification, sometimes medications, et cetera, but that's better than dealing with the consequences of diabetes later on.

And again, I think that it's embraced. These changes with healthcare providers and, and following the best recommendations. I think that we can make a significant impact in diabetes, but that requires a collective effort. It’s all of us as healthcare providers, everyone who is listening to the episode. The community is patients, families, and it's the healthcare system in general. And I think our society, because unfortunately,, I think that we need to recognize that there are structural, uh, problems, structural discrimination, racism sometimes. And that's the world we live in, unfortunately, So hopefully all we can work together in also eliminating these problems so that everybody has equal opportunity for a healthy life.

Shireen: And on that note, Dr. Caballero, thank you so much for your time as an absolute pleasure having you. 

Dr.Caballero: Thank you very much for inviting me. And I hope that everybody listening enjoyed it and that we can work together on this. 

Shireen: Thank you very much.

Shireen: Thank you for listening to the Yumlish Podcast. Make sure to follow us on social media @Yumlish_ on Instagram and Twitter and @Yumlish on Facebook and LinkedIn. For tips about managing your diabetes and other chronic conditions and to chat and connect with us about your journey and perspectives. You can also visit our website Yumlish.com for more recipes advice and to get involved with all of the exciting opportunities Yumlish has to offer. If you like this week's show, make sure to subscribe so you can hear more from us every time we post. Thank you again, and we'll see you next time. Remember your health always comes first. Stay well.

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