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Language Barriers and LDL-C/SBP Control Among Latinos With Diabetes
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Language Barriers and LDL-C/SBP Control Among Latinos With Diabetes

Alicia Fernandez, MD; E. Margaret Warton, MPH; Dean Schillinger, MD; Howard H. Moffet, MPH; Jenna Kruger, MPH; Nancy Adler, PhD; and Andrew J. Karter, PhD
Among Latino patients with diabetes, ethnicity and language barriers were not associated with lipid and blood pressure control despite their associations with glycemic control in prior research.
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In a study of language barriers and lipid and blood pressure control among insured patients with diabetes receiving uniform access to care in an integrated health plan, we found no substantive differences in the prevalence of poor lipid control or poor blood pressure control among LEP Latino patients by the language ability of their physician. This contrasts markedly with the prior finding of large differences in poor glycemic control by ethnicity, language status, and language concordance in the same patient population.4 However, it is in line with the findings of a recent study reporting no improvement in lipid or blood pressure control when Latino patients with limited English proficiency switched from a language-discordant to a language-concordant PCP.7

We can only speculate as to why language barriers did not lead to differences in lipid or blood pressure control. First, about one-third of the patients in each group had poor lipid control despite high rates of dispensing of lipid-lowering medications, suggesting that difficulties in achieving patient adherence to lipid-lowering therapy may apply to patients regardless of their primary language.19-21 English-speaking Latinos had a somewhat higher prevalence of poor lipid control than LEP Latinos, even though LEP Latinos were less likely to have been dispensed medications for hyperlipidemia, suggesting a lower prevalence of high lipid levels among the LEP patients at baseline. In this context, limited English proficiency may function not only as a marker for language barriers, but also as a proxy for acculturation, which is known to adversely impact diet and lifestyle. Second, LDL-C and SBP control may be less sensitive to patient–physician communication than glycemic control. Lipid and blood pressure control are primarily functions of adherence to the appropriate medications; glycemic control often requires both medication and lifestyle changes. In another study from the DISTANCE cohort, Ratanawongsa et al reported better adherence for cardiometabolic therapies among patients who felt their doctors listened to them, involved them in decisions, and gained their trust; however, the communication–adherence association was stronger for glycemic control medications than for lipid and blood pressure medications.22 Clinicians in interpreted encounters often have difficulty eliciting patient viewpoints and values.23 Common misconceptions about insulin among LEP Latinos (eg, that insulin causes blindness or death)10,24 and discussions about patient lifestyle modification involved in glycemic control may be more easily addressed in language-concordant relationships than in interpreter-mediated clinical encounters, which tend to stay narrowly focused on symptoms and therapy.25,26 In short, counseling patients on lifestyle changes is likely easier and more effective in a language-concordant encounter than in one mediated through an interpreter.


Our study has several limitations. First, prior work has established that Kaiser Permanente patients with limited English proficiency are less likely to report problems with access to care or care quality than LEP patients in other major health plans,27 so our results may not generalize to other insured LEP Latino patients, particularly if their services are less robust. Robust language access services, such that clinicians and patients have easy access to interpreters, can greatly mitigate the impact of language barriers. Second, although it is possible that survey participants differ from nonrespondents, we found no substantive differences based on clinical data and Census-based socioeconomic data, which were available for all members of the cohort.16 Third, most Latinos in the DISTANCE cohort are of Mexican ancestry, so our results may not be generalizable across Latinos of other nationalities.28,29 Fourth, sample size limitations, particularly among LEP Latinos, could mean that we missed a small language-associated difference in outcomes, although this is unlikely to be of clinical significance. Fifth, we used exclusion criteria similar to those of an earlier study on glycemic control in order to create comparable populations; results might vary in other patient samples. In particular, we should note that patients who underwent no LDL-C or SBP testing were excluded from the study. These patients may be particularly vulnerable to language barriers, and their exclusion may bias our study toward the null.


We found no evidence that language barriers for LEP Latino patients with diabetes resulted in worse lipid or blood pressure control relative to English-speaking Latino patients or English-speaking white patients in a health system with access to interpreter services and low financial barriers to medications and clinical care. This contrasts with other research showing a strong association between language barriers and glycemic control and suggests that more research is needed to further our understanding of how patient–physician communication impacts healthcare outcomes. There is room for improvement in clinical outcomes among all patients with diabetes, including the growing Latino population. Effective strategies to improve lipid and blood pressure control for both English- and Spanish-speaking populations need to be developed, tested, and deployed.

Author Affiliations: Department of Medicine (AF, DS, JK), and Department of Psychiatry (NA), University of California, San Francisco, San Francisco, CA; Division of Research, Kaiser Permanente (EMW, HHM, AJK), Oakland, CA.

Source of Funding: Funding for this study was provided by R01 DK090272 from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). This study was an ancillary study of DISTANCE, which was supported by R01 DK090272, DK65664, DK081796, DK080726, P30DK092924 from NIDDK and R01 HD046113 from the National Institute of Child Health and Human Development. Dr Fernandez was partly supported by NIDDK K24DK102057.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (AF, DS, HHM, AJK); acquisition of data (AF, EMW, HHM, NA, AJK); analysis and interpretation of data (AF, EMW, HHM, JK, AJK); drafting of the manuscript (AF, DS, JK, NA); critical revision of the manuscript for important intellectual content (AF, EMW, DS, HHM, NA, AJK); statistical analysis (AF, EMW); provision of patients or study materials (AJK); obtaining funding (AF, HHM, AJK); administrative, technical, or logistic support (HHM, JK); and supervision (AF, AJK).

Address Correspondence to: Alicia Fernandez, MD, UCSF Box 1364, DGIM Zuckerberg San Francisco General Hospital, San Francisco, CA 94143. Email:

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