Reducing Diabetes Disparities With Lifestyle Medicine

Diabetes hits minorities harder. Americans from racial and ethnic minority communities are more likely to develop type 2 diabetes, and have higher rates of diabetes complications and early mortality. Experts believe that these disparities are chiefly caused by the disparities in the social determinants of health — the unequal distribution of wealth, healthcare, and other resources. These problems, caused by socioeconomic inequities that have been in place for generations, can seem “intractable.”

Until society changes, Hugo Ortega, MD, has a solution for patients with meager access to healthcare resources: Take matters into your own hands.

“The best way to prevent all these health inequities is by not having to deal with the hospital system as often. And the best way to do that is to take care of yourself better.”

Dr. Ortega, an internist at Northwell Health, wants patients to know “that they have a lot more control over their diabetes than they think.”

Ortega is based in Glen Oaks, New York, just outside of New York City. He treats a diverse population, all of whom are on Medicare, Medicaid, or have no insurance. He’s spearheaded a new initiative named Eliminating Barriers, aimed at empowering patients with type 2 diabetes.

“It’s helping patients take control of their own health. It’s the ‘I can do this’ attitude. The higher the self-efficacy, the more likely someone is able to achieve healthy lifestyle change. You want to give patients the motivation and confidence to take care of themselves.”

This story starts with a personal journey. Looking to improve his own chronic disease risk factors, Ortega enrolled in a local plant-based diet program for healthcare providers. He lost weight, felt great, and came away convinced of the power of lifestyle medicine: “The more I saw how effective lifestyle medicine could be, the more I knew I had to teach this to my patients.”

Now he’s on the board of directors at the American College of Lifestyle Medicine (ACLM), an organization devoted to the idea that chronic diseases can be treated through proper nutrition and other healthy habits. The ACLM promotes six pillars of lifestyle medicine: in Ortega’s words, “a whole foods and plant-predominant diet, restorative sleep, regular physical activity, positive social connections, stress management, and avoiding risky substances.”

“When patients focus on these six pillars, they have the ability to prevent, treat, and to even reverse chronic disease. Type 2 diabetes is one of our main focuses.”

It’s no secret that diabetes can be substantially treated through diet and exercise, but many doctors are doubtful that patients have the willingness or ability to make lasting lifestyle changes. The problem is especially acute in low-income and minority communities, where studies have shown that limited access to healthy foods and socioeconomic stress make it even harder to adopt a healthy diet. I asked Ortega how he was able to get his patients on board with the changes that so many struggle with.

“The first thing I ask my patients is, ‘Do you know that diabetes can be reversed?’ And most of them don’t know that. To be fair, most doctors don’t know that either.”

“What I tell my patients is, ‘My goal with you is to make it so that eventually, you don’t need me as much.’

“Usually that gets buy-in.”

From there, Ortega tries to focus on whichever lifestyle medicine pillars his patients are most interested in. Nutrition improvements usually get the best results.

Much has been written about the challenge of advocating healthy eating to patients with closely held food traditions, some of which may seem to conflict with diabetes diet recommendations. Ortega tries to meet his patients halfway:

“Every culture has healthy food and healthy meals. We can almost always work together to find changes that will make it healthier. The problem isn’t the culture; the problem is the culture getting Westernized and adding these fats, added sugars, salt, and oils. Those are the things that make the food unhealthy. The more traditional food — from places like rural South America or China — is super healthy!”

There are resources out there for this approach. The Association of Diabetes Care & Education Specialists, for example, has created an African heritage food pyramid (PDF) to help highlight healthful foods that are already a part of the “food traditions of Africa, the Caribbean, and the American South.” And a quick search will find many websites devoted to diabetes-friendly Latino cuisine, such as “Fiesta of Flavors,” an online cookbook from the University of Illinois.

Dr. Hugo Ortega

Ortega generally doesn’t tell his patients to restrict anything, and he doesn’t ask them to count calories: “I focus on adding stuff to your diet that’s healthy, rather than removing stuff that’s unhealthy. If you’re adding fruits, vegetables, whole grains, beans, nuts, and seeds to your diet, naturally you will eat less processed foods, refined grains, and saturated fats. And usually, you’ll be getting enough of what your body needs without having to track anything.”

Cost, however, is a barrier that’s not so easily eliminated. One reason that diabetes is so prevalent among disadvantaged Americans is that maintaining a healthy lifestyle can require a bit of disposable income. Among other money-saving “tips and tricks,” Ortega recommends trying bodyweight exercises and calisthenics (no gym membership necessary), using frozen fruits and veggies, and taking full advantage of social services like WIC and SNAP. Many people don’t realize that SNAP benefits count for double at many farmers markets.

Two of Ortega’s patients recently achieved diabetes remission — having lowered their A1Cs below the diabetic range without the use of medication. “Seeing them get rid of something they thought they were going to have forever, it’s super rewarding.”

“I hope patients start to take charge of their health, to make us doctors a little more obsolete.”

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