Aside from a litany of cultural and clinical barriers many Hispanics face in getting proper healthcare, supply and demand has proven difficult with certain medications, most recently tirzepatide. Rodolfo Galindo, MD, discusses these issues as well as why clinicians must often go “beyond the guidelines” when treating specific patient populations.

In 2023, Hispanics represent the largest minority group in the United States – more than 60 million people, or about 19%. It’s well known that Hispanics have a high incidence of diabetes, obesity, and cardiovascular disease, due to various factors, yet this population remains underrepresented in clinical trials.

In August, a paper appeared in The Journal of Clinical Endocrinology & Metabolism, titled, “Tirzepatide in Hispanic/Latino Patients with Type 2 Diabetes: A Subgroup Analysis of the SURPASS Program,” that further drives the above point home. The authors write: “The risk of diabetes and excess weight in people of Hispanic/Latino ethnicity increases with age, likely due to a combination of genetic, socioeconomic, and cultural factors. Optimal glycemic and weight control after diabetes onset also remain a challenge for Hispanic/Latino patients with T2D. Hispanic/Latino patients with T2D are, therefore, more likely to be hospitalized and to die of T2D-related complications than non-Hispanic/Latino patients. Despite these differences, clinical trial data from Hispanic/Latino patients with T2D are limited.”

As the title of the paper suggests, the SURPASS Program wanted to look at how this drug affects people, especially as tirzepatide keeps making headlines, not just for treating diabetes, but for weight loss as well. Rodolfo Galindo, MD, associate professor of medicine and director of the Comprehensive Diabetes Center at the University of Miami Miller School of Medicine and co-author of this JCEM paper, tells Endocrine News that when new drugs are developed and approved, there is always a question if the effect found on the validating studies can be generalized to other sub-groups with different risks or exposures, particularly minority populations. “Notably, the SURPASS program probably had the largest representation of Latinos in any prior validating clinical program in diabetes so far,” he says. “Hence, we examined the efficacy and safety of the novel dual-agonist GIP-GLP1 agonist in Latinos.”

And while Galindo and his co-authors found that tirzepatide worked wonders for the Hispanic/Latino population (“In the SURPASS-1 to -4 trials, treatment with tirzepatide resulted in similar robust improvements in glycemic and body weight control, shown consistently both in Hispanic/Latino and non-Hispanic/Latino patients with T2D,” the authors conclude), disparities and barriers remain in treating patients with obesity and diabetes in this community, culturally and clinically.

Culturally Sensitive Strategies

Diabetes rates continue to climb worldwide, due in part to genetics and age, but Galindo says that the latest guidelines recommend addressing excess body weight as one of the key underlying pathophysiological factors for type 2 diabetes. Of course, the first and best way to lose weight is to eat less, but for some in the Hispanic community, that can be something of a non-starter. Galindo explains that in the Hispanic culture, the matriarchs play a key role in diet and lifestyle, and a big part of that diet can be unhealthy foods.

But for Galindo, it’s not about giving up favorite foods, it’s about adjusting quantities, portions, and timing. “Hispanic/Latinos love to eat from generations, like arroz con pollo, seasoned food with a high sodium content, fried foods, high carbohydrates — tasty food. It’s not that you cannot eat those, it’s just to eat healthier,” he says. “It’s part of our culture to eat around family and what our matriarchs have prepared for us. Hence, dietary modification will not translate into action unless family is involved.”

“Focus on providing culturally appropriate advice more than strictly following the guidelines. As a member of the guidelines myself, I see it as the initial step but not as the only approach. A personalized approach, focusing on culture, background, and disease specifics is a winning formula.”

Rodolfo J. Galindo, MD, associate professor of medicine, University of Miami Miller School of Medicine; director, Comprehensive Diabetes Center, Lennar Medical Center, University of Miami Health System; director, Diabetes Management, Jackson Memorial Health System, Miami, Fla.

It’s also important to remember that the Hispanic community is highly heterogenous, so endocrinologists treating these patients with obesity will have to individualize care plans. Galindo points to a paper he co-authored that was published in January in the journal Obesity. “Key to successful management of obesity in the Latinx population is the development of culturally sensitive intervention strategies, ideally including bilingual and bicultural staff, adjusting interventions to suit Latinx diets, and encouraging the participation of key family members,” the authors of that paper write.

The authors of the Obesity paper give several examples of the challenges of managing obesity in Hispanic people, from genetics and environmental factors like food insecurity, to cultural disparities such as curvier bodies being more desirable in the Hispanic community. The authors go on to note that only 4.4% of U.S. physicians identify as Hispanic or Latinx. “The shortage of Latinx healthcare providers can lead to language barriers between Latinx people and their healthcare providers, which can negatively impact the management of obesity and related comorbidities,” the authors write. “Limited English proficiency among Latinx patients is associated with lower receipt of advice about diet and exercise.”

Galindo says that over his years of practice in New York City, Atlanta, and now Miami, treating Hispanics with diabetes and obesity, he has learned from his patients, and he feels lucky to understand their varying cultures and traditions. “Focus on providing culturally appropriate advice more than strictly following the guidelines. As a member of the guidelines myself, I see it as the initial step but not as the only approach. A personalized approach, focusing on culture, background, and disease specifics is a winning formula.”

Overcoming Supply Issues

And while diet and lifestyle modification is a great first step that has its challenges in the Hispanic community, tirzepatide looks like another excellent tool in the treatment of diabetes and obesity — if those who need it can get it.

Tirzepatide’s efficacy has almost made it a victim of its own success, which has put up another barrier, especially in the Hispanic community. “While clinicians, journalists, and even politicians were amazed with the great results, many of our patients are not able to access it,” Galindo says. “One issue is lack of coverage by insurance and high cost, particularly for Hispanics, who tend to have more ‘underinsured or uninsured status.’ We expect this to improve or change, as usually happens with new drugs.”

“We all educate our patients for potential side effects or intolerances and have had not bad outcomes so far. The only negative issue has been that some patients sometimes cannot get it due to supply issues. The supply deal improved, then got worse again – which I think is related to local/regional market needs.”

Rodolfo J. Galindo, MD, associate professor of medicine, University of Miami Miller School of Medicine; director, Comprehensive Diabetes Center, Lennar Medical Center, University of Miami Health System; director, Diabetes Management, Jackson Memorial Health System, Miami, Fla.

“But the more commonly seen issue is when patients start using it and then they cannot continue it due to ‘supply issues,’” Galindo continues. “These drugs were developed for type 2 diabetes, but their incredible weight loss results also triggered approval for obesity for some agents. Hence, many people without diabetes or even obesity, including celebrities, started using it — and paying cash without insurance approval for weight loss, while our patients who truly needed the drug had issues with supply.” 

Still, the drug appears to work wonders for people who can actually obtain it. Galindo says that the SURPASS Program’s results showed that tirzepatide reduced HbA1c up to 2.58% and body weight up to 14%, the highest ever reported for any diabetes medication. “The results in clinical practice are similar to the validation trials,” he says. “We all educate our patients for potential side effects or intolerances and have had not bad outcomes so far. The only negative issue has been that some patients sometimes cannot get it due to supply issues. The supply deal improved, then got worse again, which I think is related to local/regional market needs.”

But the hope remains these are temporary setbacks and patients who need tirzepatide will finally be able to start affordably taking it, especially as study results have been so positive and physicians and patients become more optimistic. “We demonstrated that the results in HbA1c and body weight reductions were comparable between subgroups and with the overall trial population,” Galindo says. “We have another tool to modify the disease of diabetes, not just lowering the glucose in Hispanics.”

Bagely, who has been with the Endocrine Society since 2013, is the senior editor of Endocrine News. In the September issue he wrote about the concerning link between obesity, diabetes, and liver disease in the article, “Guilt By Association.”