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Mental Health Aspects of Diabetes in Elders from Diverse Ethnic Backgrounds
Mexican American Elders
Prepared by Dolores Gallagher-Thompson, PhD; John Di Mario
Based on work by: Dolores Gallagher-Thompson, PhD; Esperanza Garcia-Walters, MPH; Caroline Fee, MA; Gwen Yeo, PhD
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Background
Todays cohort of older Americans from Mexican ancestry is extremely heterogeneous Since much of the Western US was originally part of Mexico, some families have resided in the area longer than those from European and other ancestries Immigration has continued both formally and informally since the annexation of the Western territories to the US in the mid 1800s Periods of massive immigration, especially during crises in Mexico such as the Mexican Revolution in the early 1900s, have alternated with periods of forced repatriation such as that during the great depression, leaving families divided Not only Western agriculture, but increasingly agricultural and industrial areas in other parts of the US, have become dependent on Mexican labor
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Background cont
The large majority of the current Mexican American population, however, lives in urban areas,
and there is a growing middle class of professional and technical employees and business owners Strong family ties and values tend to keep Mexican American elders living close to their adult children, many times in heavily Spanishspeaking communities Although they and their children may be comfortable in English and acculturated to the larger community, they may prefer to communicate in Spanish and maintain some of their traditional culture
[1] Information in this section is excerpted from the chapter on Mexican Americans from Yeo, G, Hikoyeda, N, McBride, M, Chin, S-Y, Edmonds, Hendrix, L 1998 Cohort Analysis as a Tool in Ethnogeriatrics: Historical Profiles of Elders from Eight Ethnic Populations in the United States SGEC Working Paper 12 Stanford, CA: Stanford Geriatric Education Center Stanford GEC Copyright 2005

Experiences
Common Experiences of Mexican-American Elders
As children, working with their families in the fields as migrant laborers, staying in crowded labor camps with little running water and no electricity, and with little or no access to school; Having attended schools in which they were punished for speaking Spanish, even on the playground; Bracero programs,
and large numbers of Mexican American in the military in World War II; The Chicano Movement of the 1970s, increasing civil rights, and Cesar Chavezs United Farm Worker movement; Various periods of anti-immigrant movements, welfare reform, and immigration reform sentiment; Family reunification legislation after 1965 which allowed elders to immigrate as followers of children to join their adult children
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Health Care
Issues that may affect health care of Mexican American elders include: A large portion may have had access to minimal or no education Preference and comfort with the Spanish language Traditional Catholic participation, although there are growing Protestant and Evangelical Spanish speaking congregations Traditional expectations for family care and services rather than formal services, especially in relation to long term care
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Diabetes and Latinos/Hispanics
Diabetes is a serious health problem among Latinos in the United States Two million Hispanic Americans 102 had a diagnosed case of diabetes in 2000 National Institute of Health, 2000, NIDDK, 2002 Statistics on diagnosed cases of diabetes likely do not provide a
complete picture of diabetes in Latinos It is estimated that approximately one third of diabetes cases in Hispanic Americans are undiagnosed Harris et al, 1998
Note: In this curriculum the term Latino and Hispanic are used interchangeably
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Prevalence of Diagnosed Diabetes
Population Age 45-64 2522 1851 45-64 1363 1166 45-64 2502 2581 45-64 1811 1647 960 1640 756 Rate 1231

Table: Age-Specific Prevalence of Diagnosed Diabetes per 100 Population, by Hispanic Ethnicity and Sex, United States, 2002

Hispanic Females 65-74 75 White Females 65-74 75

Source Centers for Disease Control and Prevention, National Center for Health Statistics, Division of Health Interview Statistics, data from the National Health Interview Survey US Bureau of the Census, census of the population and population estimates Data computed by the CDCs Division of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion

Hispanic Males 65-74 75 White Males 65-74 75

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Prevalence of Diabetes
Diabetes is considerably more prevalent among Latinos than Anglos Mexican Americans, the largest ethnic subgroup in the Latino category,
and Puerto Ricans have 19 times the risk of developing diabetes as European Americans of a comparable age NIDDK, 2002 The prevalence among Cubans is only slightly higher than that of Anglos Harris, 1991; Stern Haffner, 1990

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Diabetes Risk Factors
Hispanic Americans have higher rates of genetic, medical, and lifestyle risk factors for diabetes than European Americans NIDDK, 2002 Mexican Americans are twice as likely to have a first-degree relative with diabetes than to have no family members with diabetes Stern et al, 1983 Mexican Americans have higher rates of pre-diabetes blood glucose levels above normal but subthreshold for diabetes Harris et al, 1998, higher rates of hyper-insulinemia Stern and Mitchell, 1995, and higher rates of obesity Kuzmarski et al, 1994 65 and 74 of Mexican American men and women respectively report engaging in minimal or no leisure-time physical activity Crespo et al, 1996 Prevalence of diabetes appears to decline with increasing levels of acculturation among Mexican Americans Hazuda, Haffner, Stern, Eifler, 1988
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Diabetes and Disease Risk
Mexican Americans with diabetes have been found to have
higher rates of disease than their Anglo counterparts with diabetes: More severe hyperglycemia Increased prevalence of retinopathy, increased proteinuria, and six times Higher incidence of end-stage renal disease Haffner, Mitchell, Pugh, et al, 1989; Pugh, Stern Haffner, et al, 1988

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Culturally Appropriate Assessment and Management
Culturally appropriate assessment and treatment for diabetes includes not only the standard laboratory tests and history taking available in Spanish, but also attention to the traditional cultural values of Mexican Americans which may influence elders expectation of the health care encounter, especially among those who are less acculturated Personalismo, or personal rather than impersonal relations, especially showing respeto, or respect, to elders, who are traditionally valued in Mexican society; Familismo, or emphasis on the value of, and reliance on the family This can be used as a motivation to encourage elders to be screened for diabetes, so that they can be treated if necessary to lessen the chance they will be a burden to their family Villa, et al, 1993
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Tradition and Culture
Eliciting
elders explanatory models of diabetes can help providers understand their patients view of the origin and process of their condition Questions such as What do you call this condition? What do you think caused it? can be used Some traditional perspectives and treatment in the Mexican culture are found in the following table which can guide the provider in exploring the practices of elders, some of which could be incorporated into a management plan if the patient and provider feel it is helpful eg, continuing the use of the common food nopales It would be helpful to know if the elder practices balancing foods that are considered hot and those considered cold in guiding the nutrition education
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Health Education Level
In addition to considerations of medication for diabetes, culturally appropriate treatment includes health education on lifestyle changes that is appropriate for the elders language and literacy level The population-based SALSA study showed that: 13 of the 1,789 older Latino elders from the Sacramento area had no formal education 48 had eight years or less 58 preferred to be interviewed in Spanish Haan, et al, 2003
American Diabetes
Association Information on diabetes in Spanish: http://wwwdiabetesorg/enespanol
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Nutrition Education: Traditional Foods
The traditional diet of Mexican American elders reflects the diverse cultural influences of their Mexican ancestry, especially indigenous Indian and Spanish Traditional diets also reflect the geographic regions of Mexico and the availability of local fruits, vegetables, grains, dairy products, and protein sources
Certain foods are considered staples of a traditional Mexican diet which includes corn tortillas and beans: Fruits: bananas, guava, mango, papaya, pineapple, and aguas natualales fresh fruit blended with sugar and water Vegetables: avocados, squash, cactus, ie,nopales or nopalitos, chile peppers, tomatoes, onions, and salsas

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Nutrition Education: Traditional Foods cont
Grains: corn and corn products tortillas and masa, long grain rice usually prepared with vegetables, ie, tomatoes, onions, and chile peppers, European-style breads and rolls, and pan dulce Mexican sweet bread Dairy products: atole a traditional hot milk beverage, cheese, and crema, ie, Mexican cream used for topping; and protein
sources: meats prepared with chile peppers, tomatoes, and other vegetables, carne asada grilled beef, chorizo spicy pork or beef sausage, eggs prepared with vegetables Lard is often used for cooking
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Acculturation Issues
Acculturation to mainstream American diets is influenced by numerous factors, including length of residence in the US, age, education level, income level, and ability to speak English In general, consumption of many traditional dishes decreases, while, with acculturation, many new foods are added: ready-to-eat breakfast cereals, flour tortillas, plain cooked rice, white bread, ice cream, cookies, salad dressing, mayonnaise, margarine, fruit flavored high sugar drinks, and sodas These dietary changes are postulated as risk factors for a number of diseases, including type 2 diabetes

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Culturally Appropriate Dietary Interventions
Make Healthy Food Choices: Low in total fat, especially saturated fat, cholesterol, and trans fats Increase intake of complex carbohydrates, fresh vegetables and fruits, and low fat sources of protein, for example, beans, lean meats, fish, and poultry Focus on a return to healthy
traditional foods Control Food Portions: Teach serving sizes and portion control use food replica s Use the Mexican food guide pyramid to discuss adequate servings and recommended choices from each food Modify Recipes: Recommend recipes that reformulate traditional dishes Low fat cooking methods grilling, roasting, stewing, and baking Use a small amount of cooking oil instead of lard when frying Group cooking classes
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Resources for Dietary Interventions
In-depth information on Mexican American cultural perspective, traditional and contemporary food habits in the US: Kittler, P G, Sucher, KP 2004 Food and culture 4th ed Belmont, CA: Wadsworth/Thomson Learning Romero-Gwynn, E et al1993 Dietary acculturation among Latinos of Mexican descent, Nutrition Today, 28: 6-12 Internet resources to locate Registered Dieticians or Certified Dietetic Educators include: wwweatrightorg wwwdiabeteseducatororg

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Resources for Dietary Interventions cont
Implementation of strategies listed above: Algert, SJ, Brzezinski, E, Ellison, TE 1998 Mexican Americans: Food practices, customs, and holidays: Available from American Dietetic Association,
216 West Jackson Blvd, Suite 800, Chicago, Illinois 60606-6995, 312 899-0040 Martinez, M 1995 101 great lowfat Mexican dishes Rocklin, CA: Prima Publishing Nasco Food Replicas: Mexican American Ethnic Food Set: Available from Nasco Nutrition Teaching Aids wwweNASCOcom Southeastern Michigan Dietetic Association SEMDA Mexican food pyramid
http://wwwsemdaorg/info/pyramidasp?ID27
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Risk of Depression and Latinos with Diabetes
Studies have documented the higher risk of depression and dysphoria among older Mexican Americans versus their Anglo counterparts Villa, Cuellar, Gamel, Yeo, 1993 Latino patients with diabetes have also been found to be more likely than non-minority diabetics to have depression Black Markides, 1999 Fisher and colleagues found that 316 of the Latinos with diabetes had CES-D scores that indicate likely depression, compared with 172 of Anglos Fisher, Chesla, Mullan, Skaff, Kanter 2001 In a study of Hispanic and European Americans, individuals with both major depressive disorder and diabetes were more likely than those without both disorders to be Latino Egede Zheng, 2003

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Diagnosis of Mental Health
Problems
Another study by Fisher and colleagues found no significant difference in rates of depression between Latino and Anglo partners of diabetics Fisher, Chesla, Skaff, Mullan, Kanter, 2002 Underestimation of the differences between Latinos and Anglos is possible due to the finding that Hispanic Americans are more likely than European Americans to have mental health problems, including depression, that go undiagnosed in primary care Borowsky et al, 2000

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Risk Factors for Depression
Latinos with diabetes have similar risk factors for depression as do their Anglo counterparts: Being older than 50 Having less education A low economic status Being unemployed Having greater functional burden of diabetes Greater levels of financial stress
Egede and Zheng ,2003; Fisher et al 2001

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Gallagher-Thompson Study
Dr Gallagher-Thompson and colleagues completed two studies examining the relationship between prevalence of diabetes and depression in middle aged and older Latino and Caucasian women caring for an elderly relative with dementia In the first study of 110 Latinas and 154 Caucasian caregivers, the prevalence of diabetes was
145 in Latinas compared to 4 in Caucasians p002 It is noteworthy that the mean age of Latina diabetics were significantly younger 55 than their Caucasian counterparts 70, suggesting that they would be living with their disability longer In this study there was no significant relationship between diabetic status and level of depression; however it should be noted that depressive symptoms were high in both ethnic groups, with or without diabetes This is consistent with the overall caregiving literature that generally reports rates of depressive symptoms at 30 - 50 among women caregivers Stanford GEC Copyright 2005

Gallagher-Thompson Study cont
In the second study of 30 Latinas and 76 Caucasian women caregivers of dementia patients, the prevalence of diabetes, again, was significantly higher among Latinas 23, compared to 6 of the Caucasians In this study, the presence of diabetes was significantly associated with depression, in two important ways First, using a structured psychiatric interview, 25 of those with diabetes across the two ethnic groups met criteria for Major Depressive Disorder, whereas only 5 of those without diabetes met the criteria In addition, higher self-reported
depression on the Beck Depression Inventory was found in the diabetics in both ethnic groups Taken together, results of these studies underscore the relationship between ethnicity, diabetic status and both depressive disorder and depressive symptoms in women caregivers
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Culturally Appropriate Diagnosis and Assessment
There are many self-report scales of depression that have been translated into Spanish For example, the CES-D and Geriatric Depression Scale GDS have been used with Mexican Americans with good results The GDS is available on the following website to download, including a version used in Mexico and others used in other Spanish speaking countries: http://wwwstanfordedu/yesavage/GDShtml Psychiatrically-based interviews translated into Spanish are also available
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Risk of Cognitive Impairment in Diabetic Latinos
The Sacramento Area Latino Study on Aging SALSA examined 1,789 Latinos aged 60 and over, 45 of whom were born in Mexico Overall prevalence of dementia was 48 not dissimilar to findings with non-Hispanic populations of the same age Dementia risk was nearly eight times higher in those with both type 2 diabetes
and stroke The authors estimate 43 of dementia was attributable to diabetes, stroke, or a combination Haan, Mungas, Gonzalez, et al, 2003
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Table: SALSA Study Findings
Percent of SALSA Study Subjects with Dementia Who Had Diabetes and/or Stroke by Type of Dementia
Alzeimers AD Vascular VaD Mixed AD VaD
n15 n13 n6

Diabetes Stroke Both Diabetes and Stroke

260 59 118

63 125 625

167 333 500

Note that those diagnosed with vascular dementia or mixed Alzheimers and vascular dementia were much more likely to have had both diabetes and stroke

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Culturally Appropriate Treatment
Psychotherapy for Latinos with diabetes and depression should include an emphasis on life stressors unrelated to diabetes, in addition to stressors associated with the disease Fisher et al, 2001 CBT combined with diabetes education was more effective than a control condition in helping to relieve depression based on a 10-week individual cognitive behavioral therapy, CBT, with depressed Latinos with diabetes by Lustman and colleagues Lustman, Griffith, Freedland, Kissel, Clouse, 1998
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Culturally Appropriate Assessment
A number
of measures of cognitive functioning have been successfully translated into Spanish and used in studies on cognitive impairment in Latinos Examples Haan et al 2003 used translated versions of the Modified Mini-Mental State Examination 3MSE Spanish and English Verbal Learning Test SEVLT for cognitive screening Spanish English Neuropsychological Assessment Scales SENAS, Informant Questionnaire on Cognitive Decline in the Elderly IQCODE for those who were referred for neuropsychological testing All have been validated with older Latino populations The CASI has also been translated into Spanish
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Information from Interviews with Three Mexican American Key Informants
In the Mexican American community diabetes is very common and accompanied by many losses Since so many people have it, people are unfazed by it, even though it is a very bad disease People dont have a lot of information about it, and many dont understand it Some commonly associated causes of diabetes: un susto a fright or a sudden negative incident in their lives or eating sweet foods Some think it can be passed from husband to wife, but few relate it to parents having diabetes

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Copyright 2005

Information from Interviews with Three Mexican American Key Informants
A simple and positive approach in talking about it is recommended, especially what can be done about it Words such as: Problema con azucar en la sangre,problem with sugar in the blood or azucar en el urina sugar in the urine can be used Nopales cactus and other herbs are frequently used to treat diabetes, and many use prayer and other religious practices hoping for a cure Some fall prey to scams such as a mattress or a bracelet Self management is difficult, especially for women who are less likely to modify their diet since they cook for the family
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Key Informants: Depression
Depression is seen as being sad, but the term depression is seldom used Some Symptoms: Tired [No tengo animo I dont have energy] or sad [Me siento triste I feel sad] They might also talk about being on the edge, being irritable, being de mal humor bad mood, todo le molesta everything bothers them or /estit sola No one comes to see me Diagnosis: To elicit symptoms of depression, one can ask if they feel triste sad or sola alone or if hay problemas con depremido o depressión there are problems
with depression

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Key Informants: Causes of Depression
Possible causes of depression: Lack of understanding of the changes that are happening along with the complications and costs of those changes Lack of power or options to change circumstances, or fear of negative things that can happen in the future They may be just getting tired of not feeling good Unless the symptoms of depression are extreme, Mexican American elders would probably not seek help for it They are more likely to look to religion and prayers and seek support from their family A small percentage might consider seeing a healer, such as a curandero or sobador A primary care physician reported one patient whose demeanor or reported symptoms never hinted at depression, then she was hospitalized in crisis
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Key Informants: Memory Loss
Memory loss is even less likely to be reported, and the term dementia is not a term people recognize In the extreme, it might be called, loco crazy In talking about memory loss, someone might say Ya se me olvida Now, I forget things Ya no conosco gente Now, I dont know people Ya no se acuerda Now, she doesnt remember One provider
commented that the individuals with dementia often had a history of alcohol abuse

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Source:clevelandclinic.org