Editor’s note: This article was adapted from the address Dr. Marrero delivered as the recipient of the American Diabetes Association’s Richard R. Rubin Award for 2021. This award recognizes a behavioral researcher who has made outstanding, innovative contributions to the study and understanding of the behavioral aspects of diabetes in diverse populations. Dr. Marrero delivered the address in June 2021 at the Association’s virtual 81st Scientific Sessions. A webcast of this speech is available for viewing at https://bit.ly/3HIkOpz.

I was greatly honored and quite humbled to be the recipient of the Richard Rubin Award for 2021. In many respects, Richard Rubin embodies the field of behavioral diabetes. He was one of the first to bring the importance of psychosocial issues into focus in the clinical management of diabetes. These efforts shaped the field and influenced many, including myself. Indeed, that is why this award was named in honor of him.

For me, he was more than just a colleague; he was also a close friend. On many occasions during the meetings that we would both attend, we would go out to dinner together. Many recipients of this award have used this opportunity to discuss their personal, celebrated research, which often is based on the foundational work of Dr. Rubin. I have chosen to take a different approach. So, this article is organized into two parts. The first is about Richard, or Dick, as his friends called him, and the issues we talked about over dinner. The second is about my current research: what we can do to reduce health disparities in diabetes care.

One of the first things Dick taught me, when we first met over 30 years ago, is that people with diabetes are more than twice as likely to face depression and are at varying degrees of higher risk for other mental health issues than their brethren without diabetes (15). That was a surprise to me and helped to focus much of my research through the years.

The World Health Organization (WHO) has reported that mental illness is a leading cause of disability-adjusted life years (a measure of overall disease burden, expressed as the number of years lost due to ill health, disability, or early death) worldwide, accounting for 37% of healthy years lost from noncommunicable diseases (6). Depression alone accounts for one-third of this disability (7). The WHO also estimated that the global direct and indirect costs of mental illness totaled nearly $2.5 trillion in 2010, with a projected increase to more than$6 trillion by 2030 (8). Additionally, the WHO provided comparisons across noncommunicable diseases to give some sense of the main drivers of this global economic burden. Mental health costs were reported to be the largest single source of economic burden—larger than cardiovascular disease, chronic respiratory disease, cancer, or diabetes (9). Indeed, mental illnesses alone will account for more than half of the projected total economic burden from noncommunicable diseases over the next two decades and 35% of global lost output (10).

These statistics reflect things that Dick and I talked about during our dinners. As a clinical psychologist who had many patients, Dick was very aware of these numbers, and we would often discuss his concerns about such alarming trends.

So, where are we now? Despite the clear role behavioral factors and mental health play in diabetes self-management and treatment, they have not received adequate attention in terms of research and research funding. This was a belief that Dick held dearly and that I share. Dick felt that the next frontier of research in diabetes needed to focus more on behavior and mental health. I could not have agreed with him more. He felt that significant increases in funding needed to be established to identify the best strategies for integrating chronic illness services with care for a broad range of mental health conditions. He argued that we needed to better understand not only which behavioral interventions are most effective, but also how they can be scaled up. To have them is one thing, but to make them available is quite another.

Dick also thought we needed to work to increase the number of highly trained professionals who can effectively address the mental health issues associated with adapting to and coping with diabetes treatment. I am happy to say that one initiative I helped to launch was a collaboration between the American Psychological Association and the American Diabetes Association to build training programs for psychologists to learn how to more effectively treat people with diabetes.

We still need more research into the behavioral aspects of diabetes care to guide health care providers in addressing and supporting the emotional needs of their patients as part of routine care. We also need to contribute guidance to the policymakers who control health care spending to ensure that all individuals with diabetes have unfettered access to the quality care, medications, and management tools they need to effectively control their diabetes.

I will shift gears soon, in the second half of this article, to focus more on how we can improve access to underserved populations. Before I do, though, I want to say that I am sorry Dick Rubin is not with us anymore. He taught me many things, and he contributed to all of our understanding of the behavioral aspects of diabetes. He was a tireless advocate for mental health support in diabetes and was always ready to contribute to the cause. I am glad I was able to spend so much time with him while he was still with us. As they say, you never know the value of a moment until it becomes a memory.

In the remainder of this article, I will address the need for improved access to quality diabetes care, using the Hispanic populations I work with in Arizona as an example.

What does diabetes look like in Hispanics? Many people treat Hispanics as a homogeneous group of people; if you speak Spanish, you are all the same. But that is not really the case, and it is particularly not the case when we look at statistics on diabetes. For example, the prevalence of diabetes is 10.2% in South Americans, 13.4% in Cubans, 17.7% in Central Americans, 18.0% in Dominicans and Puerto Ricans, and 18.3% in Mexicans. It is apparent that Mexicans have the dominant position among Hispanic people when it comes to prevalence of the disease.

Why are these statistics important? Collectively, Hispanics are a rapidly growing group of ethnicities and cultures within the United States. There were 58 million Hispanics in this country in 2016, which was 17% of the population (11). That proportion is expected to increase to almost 30% by 2060 (12). This increase in the Hispanic population is the principal driver of U.S. demographic growth, accounting for more than half of the growth in the nation’s population since 2000 (13). Hispanics will comprise the largest minority group in the United States within the next 10–15 years.

According to the WHO, as of 2016, diabetes was the leading cause of death in Mexico, accounting for 14% of all deaths in the country (14). The percentage of Mexican deaths attributable to diabetes has tripled since 1990 (15), and one study predicted that, by 2050, up to half of all Mexicans could develop diabetes in their lifetime (16).

Why is this issue important to me, personally? It has a lot to do with where I live, which is Tucson, AZ. Arizona’s population is 31.7% Hispanic (17), the vast majority of whom are of Mexican origin. This is the fourth largest statewide Hispanic population in the country (18). Tucson’s population is about 44% of Mexican origin, and for Phoenix, that percentage is 41%. In 2021, Phoenix was the fifth most populous city in the United States, and the U.S. Census Bureau has projected that its population will reach 2.2 million, with a metropolitan area population of 6.3 million, by 2030 (19). Such a large population has a unique impact on our health care system.

When you look at all Hispanics in Arizona, 85% are of Mexican origin. So, it is important to understand why diabetes is increasing so rapidly in Mexico and among Mexicans in the United States.

### Health Disparities: A Multifactorial Problem

Obesity is one major factor contributing to the high rates of diabetes among people of Mexican origin and other Hispanic populations. We all know there is a direct link between obesity and diabetes (20). Mexico ranks as the most obese country in the world among adults (21); one estimate suggests that 24% of Mexicans >15 years of age are obese (22). The percentage of Mexicans >20 years of age who are overweight rose from 71.2% in 2012 to 72.5% by 2020 (23). Among Mexican adults, 74% of women and 70% of men are overweight or obese (21). Clearly, obesity drives a lot of the rapidly escalating rate of diabetes among Mexicans.

Complex interactions among biological, genetic, environmental, and psychosocial factors contribute to diabetes disparities among Hispanics. These factors include not only obesity, but also food insecurity, which is another major issue among Mexicans living in Arizona. Nearly one in four Latino households are considered to be food insecure, compared with ∼11% of White households (24). In 2019, 22% of Latino families in Tucson lived below the poverty line (25). Low-income Latino families spend one-third of their income on food (26), and much of the food they purchase is calorie-dense, low in fiber, and high in fat, sodium, and carbohydrates (27). Fast food is a viable option for people who are economically depressed. Furthermore, Latino neighborhoods have one-third the number of supermarkets as non-Latino neighborhoods (28). Thus, getting quality food that can help you regulate your caloric intake is much more challenging for people of Mexican origin and other Hispanic populations. Partially as a result of food insecurity, and also for cultural reasons, we know that people of Mexican origin tend to consume higher amounts of total and saturated fat, refined carbohydrates, and sugar-sweetened beverages and to eat fewer vegetables per day than non-Hispanic Whites (29,30). They are also less likely to meet physical activity guidelines than non-Hispanic White and non-Hispanic Black adults (31).

Language discordance and undocumented immigration status are also relevant issues. Many people come to the United States who do not speak English, which makes it much more difficult to negotiate social systems and the health care system here. In border states such as Arizona, undocumented immigrants may find it extremely difficult to access optimal or even adequate health care.

We also know that it is difficult to engage people of Mexican origin, and particularly Mexican men, in lifestyle interventions. When you look at big national studies, they tend to have very low representation of this population (32).

### Reducing Disparities: A Multifaceted Solution

How can we reduce these serious health disparities for Hispanic populations? First, we need health care that is accessible to everybody regardless of their ethnicity, country of origin, economic circumstances, or immigration status. We need to put this health care into communities versus providing it only at central medical centers. In Arizona, for example, it is difficult for many people of Mexican origin to get to medical centers for care. First, there are not many such centers available. I am based in the only medical school in the state, in Tucson. This region features huge geographical expanses to traverse, and our environment is not pleasant in summertime. Thus, many people, including our Hispanic patients, have difficulty getting where they have to go for care.

We also need to consider the appropriateness of where and how we try to deliver health care. We will not succeed by assuming that people will go to a place that may be difficult to get to, where they may not have language congruence, and where there may be an uneasy history with their community. The relationships between Hispanic communities and major medical centers have not always been positive. Many major medical centers have not been welcoming or accommodating to people of different cultures, ethnicities, and racial backgrounds. We need to think more aggressively about that very real obstacle and how to overcome it.

In addition to addressing where we deliver our services, we also need to vary the forms of our health care delivery. We cannot use traditional models to reach people in cultures that have different views of health, health care, and how health care interactions should take place. Additionally, we need to consider payment structures and how we can better serve people with limited financial resources. Transportation issues must also be addressed. Many of the people who I work with only have one car that is shared by multiple family members, who use it to get to different jobs at different times. Public transportation in my city is sorely lacking as well. We need to think about these issues very carefully when we decide where to put services and how people will get to them. Rural settings present related barriers. In Arizona, much of the state’s population is centered in Phoenix and Tucson. Everything else is largely rural, out on the edges, and quite remote. Often, we fail to consider this problem when we think about the placement of clinics.

We also need to focus more on providing culturally tailored education. This effort must go beyond simply translating materials we have used with English-speaking people into Spanish. We need to consider cultural concepts specific to our target population when trying to engage them in health interventions. Three concepts that are very common in the Mexican culture can be used to appeal to Mexican origin individuals about why they should take certain behavioral decisions seriously or why they should engage in lifestyle changes. These include:

• Machismo: Adherence to a Hispanic ideal of hypermasculinity, which encompasses behaviors and characteristics such as power-seeking, aggressiveness, dominance, competition, and emotional disconnectedness

• Familismo: Perceived obligation to family members, including beliefs about reliance on support from family members and the use of family as behavioral and attitudinal referents

• Caballerismo: Behaviors that incorporate displays of honor, respect, dignity, social responsibility, care for family, and emotional connectedness

All of these concepts incorporate different attitudes and beliefs that are cultural norms in the Mexican community but are not always represented in non-Hispanic cultures.

Finally, we need to rethink how we provide education, and by whom. Incorporating health care delivery via smartphone is one promising approach. In Tucson, there is a very high penetration of smartphones in the Mexican community; in fact, more people of Mexican origin use cellphones as a primary source for education and linking to personal health services than any other racial or ethnic group in our area. For many individuals, the internet is already their primary source of health information.

There is increasing focus on people using media to do some of the things we have traditionally done in person. I applaud these efforts and believe we need to step them up further. Internet-based programs allow people to access interventions at a time that is convenient for them. Many people of Mexican origin in Tucson are unable to carve out part of a work day to go to a medical center and attend an education session or support program. They need to be able to access an intervention in a way that does not require them to change their usual life pattern for a day or a week or a year to benefit from it. Thus, providing education and interventions through the internet and through smartphones is a smart idea in my opinion and the opinion of others (33). Phone-based interventions can be highly personalized, rather than being limited to a one-size-fits-all design. They can be engaging and designed to appeal culturally to the populations we are trying to reach. They can incorporate interactivity and graphically rich content. Importantly, they can be disseminated rapidly for a low cost.

I also want to mention promotores, or community health workers. These are neighbors, moms, dads, children, youth, and others who believe in helping and being part of the solution to create healthier lives for all members of their community. In our programs in Tucson, promotores are not simply people who are trained to go out and deliver whatever we think they should deliver. Rather, they embody a spirit of community that is very rich in Mexican culture. They do not “target” the community. Instead, they join with their neighbors to create relationships built on trust. As a result, participants in the programs they lead learn about far more than the basics of managing their diabetes. Promotores understand the problems, concerns, and barriers that exist within their community, and they help people circumvent them. I encourage everyone to think about integrating such community health workers into all of our models of care delivery, education, and social support for underserved communities with diabetes.

Diabetes remains a major public health crisis not only in the United States, but worldwide. Many populations experience significant health disparities that can influence both their likelihood of developing diabetes and their ability to adequately manage it when they do. Many of these factors extend beyond physical characteristics; they encompass social determinants as well. As a community of researchers who follow in the steps of Dr. Rubin and the notable previous recipients of the award named in his honor, we need to continue our efforts to address these issues and explore strategies to mitigate their impact.

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