Social Inequality and Type 2 Diabetes Management among Older Latinx Immigrants

Being an immigrant in the contemporary U.S. is stressful. During the pandemic of 2020, these stressors are amplified for all populations. At the same time, Latinx immigrants are also disproportionately affected by the pandemic. They are more vulnerable, face greater economic challenges, and are more likely to die from the virus. In addition to these difficult realities, regardless of status, Latinx immigrants are often perceived as illegal and subjected to discriminatory treatment [1]. Type 2 diabetes is also an illness that disproportionately affects minorities and immigrant populations. In 2018, there were almost 60 million Latinos-18% of the U.S. population (more than one in six)-living in the United States [2]. In addition to the myriad of stressors that immigrants, particularly older immigrants experience, the stigma and vulnerability associated with the pandemic of 2020 are likely to have serious negative consequences on their health and well-being. This paper addresses some of the challenges Latinx immigrants face as they struggle to manage Type 2 diabetes during a pandemic. © 2020 Jasmin Tahmaseb McConatha. Hosting by Science Repository. All rights reserved


Introduction
This paper addresses some of the challenges Latinx immigrants face as they struggle to manage Type 2 diabetes during a pandemic. Type 2 diabetes is an illness that disproportionately affects minorities and immigrant populations. In 2018, there were more than 44.7 million immigrants (13.7% of the total population) in the United States. Nearly one in seven U.S. residents is foreign-born [3]. While immigrants come to the U.S. from around the globe, many come from Latin American countries. In 2018, there were almost 60 million Latinos-18% of the U.S. population (more than one in six)-living in the United States [2]. Of all foreign-born U.S. residents, those of Latino origin make up 44.3% [3]. Recent data indicate that Latino populations are not only at a greater risk for developing COVID-19, they also have higher mortality rates from the virus. In addition to the myriad of stressors that immigrants, particularly older immigrants experience, the stigma and vulnerability associated with the pandemic of 2020 are likely to have serious negative consequences on their health and well-being. For those who struggle with Type 2 diabetes, these consequences can be devastating.
Since 1990, the population of older immigrants in the U.S. has increased significantly with older Latinos accounting for one of the largest increases [3,4]. In the next 10 years, older Latinos are expected to make up 22 percent of all older adults in the U.S. [4,5].

The Healthy Immigrant Effect
Historically, U.S. immigrants live longer and tend to be healthier than native-born Americans [6,7]. This trend, however, is changing, as the "healthy immigrant effect" appears to be dissipating. Years of poor labor conditions, lack of medical care, stress associated with discrimination can result in the development of multiple health challenges, often at an earlier age [7]. Being an immigrant in the contemporary U.S. is stressful. Regardless of status, Latinx immigrants are often perceived as illegal [1]. All too often, such perceptions lead to discrimination [1,8]. A lifetime of discriminatory treatment has cumulative negative health consequences.
As people live longer lives, there is an increase in the percentage of women and men who struggle to manage one or more chronic conditions. The most common chronic illnesses in the United States are heart disease, stroke, cancer, Type 2 diabetes (and prediabetes), obesity and arthritis [9]. Approximately 80% of adults over the age of 65 suffer from at least one of these conditions [10].

The Prevalence of Type 2 Diabetes
Globally, about 422 million people were affected by diabetes in 2016, up from 108 million people in 1980 [11]. At least 26.8% (14.3 million) of American older adults over the age of 65 have Type 2 diabetes; these rates are even higher for minority and immigrant populations [9]. In 2018, diabetes was the 7th leading cause of death in the U.S [9]. However, the actual number of diabetes-related deaths may be even greater since diabetes is likely underreported as a cause of death. Studies have found that of people who died who had diabetes, only 35% to 40% had diabetes listed anywhere on the death certificate. Of those, diabetes was only listed as the underlying cause of death for about 10% to 15% [12]. Chronic illnesses such as diabetes have a significant selfmanagement component including medication adherence, physical and social activity, dietary and weight management, and other illness-related behaviours. Self-management of chronic illness refers to daily activities that keep an illness under control and minimize its impact on overall physical and psychological health and well-being.
Successful management is related to better overall well-being and health outcomes. Illness self-management does not occur in a vacuum. Personal factors such as beliefs and cognitions about one's illness and one's ability to manage, as well as community, cultural, and environmental factors interact to influence the outcome of an illness. Age, gender, ethnicity, and income appear to moderate the relationship between social and cultural factors and illness efficacy. Women, for example, are often responsible for meal organization and preparation, making personal dietary factors difficult to maintain. As such, the nature of family relationships, cultural expectations, gender roles, family responsibilities intersect to influence women's illness management success [13].

The Importance of Food in Immigrant Populations
Food consumption is often the central ingredient of social gatherings. For immigrants, social gatherings serve to reinforce connections with people of their own culture of origin. Social gatherings that feature an array of traditional foods contribute positively to a sense of cultural connection and continuity. Holidays and traditions are shaped by specific foods. A diabetes diagnosis can pose a challenge to maintaining cultural connections because diet restrictions can result in disengagement from social gatherings, leading to isolation and feelings of loneliness.
For Latino populations, many of the traditional foods are laden with carbohydrates and not on the recommended diet for Type 2 diabetes management. Missing large family and community gatherings during the pandemic and attempting to manage dietary needs can be overwhelming and lead to feelings of helplessness and loneliness. Social isolation and loneliness are also common among older adults, especially those who have been diagnosed with a chronic illness [14,15]. For Latino and other immigrants, social gatherings that involve traditional food, not only reinforce cultural identity, provide comfort but they also combat loneliness. Forty percent of older adults over age 65 have reported experiencing feelings of loneliness at least some of the time [16]. Loneliness is a feeling of distress in which individuals feel that personal relationships do not meet their social needs.
For older adults, especially those with a chronic illness such as Type 2 diabetes, it is likely that attempts to manage their illness can result in increased feelings of isolation and loneliness [17]. In Latino immigrants and other immigrant communities, loneliness and isolation may be determining factors in the success or failure of chronic illness management. These feelings are likely to be increased during pandemic associated isolation. Those who do not have access to regular contact with family or adequate social support may experience greater rates of morbidity and mortality [18]. In general, the health risks that occur with social isolation tend to increase with age, particularly if aging is accompanied by stressful life events and difficult transitions such as the immigration process [18].
Older diabetes patients, especially those who are lonely or socially isolated, are also more likely to spend considerable time ruminating about their illness and the potentially dire consequences associated with it [17,19]. Those who are connected to satisfying networks of relationships, by contrast, are less likely to ruminate and more likely to get the necessary encouragement to maintain lifestyle changes necessary for illness management. Older immigrants, who are more likely to be socially isolated and culturally alienated, are also more likely to ruminate about chronic diseases such as diabetes [20]. Having to cope with a serious health concern reduces a person's ability to control her or his interaction with the environment at the best of times, during a pandemic, feelings of helplessness are likely to increase. Managing a serious illness also means that one must confront the medical establishment and submit to unpleasant, painful, and anxiety-producing treatments, something not necessarily possible during a pandemic [20,21]. Comorbid conditions also make coping with diabetes more difficult, especially during a pandemic.
The ways that older immigrants are able to cope with a serious illness such as Type 2 diabetes during a pandemic is partially dependent on lifelong coping strategies [22]. The motivation to successfully adjust to a diagnosis of a chronic illness like diabetes is a struggle, particularly given that diabetes is the type of illness that must be, to a large extent, managed through radical lifestyle changes. A person's prognosis largely depends upon them making significant dietary and exercise adjustments, which is not an easy task for older immigrants who may also be struggling with issues of loneliness, stigmatization, and poverty. The incidence of Type 2 diabetes has reached epidemic proportions, especially among older immigrants. In more collectivistic cultures like Latinx culture, families encourage interdependence and social support is a given; however, pandemic isolation can significantly threaten illness management leading to increased loneliness, isolation, and depression [23]. Successful coping depends on the intersecting influences of illness severity, comorbid conditions and satisfying family, social, and spiritual support. Researchers have addressed the prevention and management of this debilitating illness; however, few studies address the struggles that older immigrants face in the management of diabetes.