Haitian Immigrants and Type 2 Diabetes: An Integrative Review

Abstract

Type 2 diabetes (T2D) is a complex, lifelong condition that is disproportionately prevalent among minority populations. Haitian immigrants (HIs) living in the US with T2D have unique factors that influence diagnosis, treatment, and self-management. The purpose of this integrative review was to provide a synthesis of the research on T2D in the HI population. In a systematic literature search, 14 studies met the inclusion criteria. Three themes were identified: risk factors for less self-management and/or worse metabolic control; protective factors for better self-management and/or metabolic control; and mixed results. HIs had higher HbA_1c, yet better self-management, different genetic profiles, and lower levels of vitamin D and hemoglobin concentration compared to other ethnic groups. HIs also reported better dietary quality, less healthcare utilization, and higher perceived emotional/psychological stress compared to other ethnic groups. This study has implications for practice for integrating the unique cultural factors when assessing and intervening with HIs.

Introduction

Type 2 diabetes (T2D) is a complex, lifelong condition that is disproportionately prevalent among minority populations. Globally, the number of people living with T2D has quadrupled, with over 425 million affected [1]. Of the reported 425 million people with T2D, 44 million reside in North America and the Caribbean region (NAC) [2]. The NAC is known to have the highest prevalence of T2D per capita when compared to the other International Diabetes Federation (IDF) regions. The United States (US) and Haiti are among the 24 countries listed in the NAC. In 2016, the prevalence of diabetes in Haiti was 6.9%, affecting females (7.1%) more than males (6.6%) [1, 3]. In the US, the prevalence of diabetes was 9.4% in 2017, and the seventh leading cause of death in the country [3]. In the non-Hispanic, Black population, the prevalence is 13.2% [3], which includes Haitian immigrants (HIs) living in the US [3–5].

HIs are among minority groups with an increased prevalence of T2D, with higher rates of diabetes-related complications and death [4, 5]. HIs, however, present with a unique cultural background with probable differences in genetic predisposition, and not well-defined disease risk factors that differ from others of African descent within the diaspora [4, 5]. Health beliefs are also known to have a major impact on individuals’ diabetes management [6–8]. In general, cultural backgrounds, traditions, beliefs, and social and environmental factors may influence health behaviors, self-management activities, and outcomes in chronic illness [4, 5, 7, 8]. People of African descent who live in urban areas consistently experience unique health-related vulnerabilities in contrast to other minority racial/groups and Whites [8, 9]. In addition, immigration poses unique challenges to different racial/ethnic groups in access to care, self-management capabilities, and barriers/facilitators to healthy behaviors [10, 11]. Traditionally, immigrants have tendencies to bring cultural health beliefs, practices, and traditions from their motherland [5, 7]. Studies have shown that acculturation resulted in a negative shift of dietary habits (i.e., higher fast food consumption, lower intake of fruits and vegetables) in immigrant populations [10–12].

Self-management has been recognized as important in the treatment of T2D. An individual’s ability to effectively self-manage their condition plays a key role in maintaining metabolic control and preventing diabetes-related complications. More than 95% of all adult T2D self-management is performed by individuals themselves rather than providers [6, 12, 13]. Self-management in relation to T2D has been defined as a group of daily diabetes behaviors individuals perform in managing their disease [14–17]. These daily behaviors include exercise, healthy eating, blood glucose testing, and medication administration [6, 9, 16]. In a concept analysis of self-management of T2D in adult HIs, self-management behaviors were found to be influenced by culture [5].

Differences in T2D risk and self-management are emerging in the HI population. For example, differences in genetic profiles and diagnostic glycosylated hemoglobin (HbA_1c) levels have been reported [19, 20]. While an earlier integrative review has published on adherence in Haitians with diabetes [18], the focus on this paper was on theories of adherence and cultural competence relevant to Haitians, with only one research study of HIs mentioned. Thus, synthesizing the research on factors that influence T2D risk, self-management, and T2D health outcomes in the HI population is needed to guide practice and research.

Purpose

The purpose of this integrative review was to provide a synthesis of the research on T2D in the HI population with a focus on the genetic predisposition, biological or clinical factors, self-management, and metabolic control.

Design

Whittemore and Knafl’s integrative review methodology guided the analysis [21]. The following steps were taken: (1) a well-defined literature search was conducted with assistance from a medical librarian, (2) relevant primary sources were reviewed and organized into subgroups, (3) quality of the studies was evaluated using well-known and validated quality appraisal instruments, (4) subclassified data were organized and displayed in data display matrices to enhance the visualization of patterns and relationships within and across primary data sources, (5) conclusions were drawn and verified for accuracy and confirmability concluding the review process. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed [22].

Search Methods

The electronic databases searched were CINAHL, Cochrane Library, Medline, EMBASE, and PubMed for full-text articles that were published in English between 2006 and June 2018. The search terms included “self-management of diabetes, T2D, Haitian immigrants, Haitian culture, diabetes self-care behaviors and Haitian immigrant, Haitian Americans’ diabetes self-management behaviors, and Afro-Caribbeans.” The primary search terms were consistently used with each search conducted. For example, the PubMed database was searched using these key terms: “Haiti, diabetes mellitus type 2, African Continental Ancestry Group, African American.” The search terms for Ovid EMBASE were “diabetes type 2 mp., diabetes.mp, exp non-insulin dependent diabetes mellitus/, Haitian/, exp. Haiti/, self-care or self care or self-management or self management).ti,ab.”

All retrieved articles were assessed utilizing the inclusion and exclusion criteria. Inclusion criteria were the following: primary research, adult HIs, HIs’ T2D self-management, and/or factors related to T2D, and self-management or HbA_1c control. Exclusion criteria were as follows: studies that did not report data on HIs, duplicates, study participants less than 18 years of age, case studies, studies written in a language other than English, and unpublished manuscripts (i.e., abstracts, dissertations, and presentations).

Review Process

The search strategy yielded a total of 1686 potentially relevant citations of which 20 were duplicates, leaving a remainder of 1666 studies. Initial screening using inclusion and exclusion criteria led to the removal of 1582 articles. The papers classified as ineligible were most often eliminated for not including the target population. Based on second exclusion criteria, 84 articles were subjected to full-text review, and an additional 70 papers were excluded. This process was completed by one author (CMN), with the second author consulting about questions on inclusion/exclusion of specific articles. The final sample included 14 articles published between 2006 and 2017 (Fig. 1). Full citations including keywords, abstract, bibliography, and Web addresses were imported into Endnote, an online bibliographic management program, and combined into Covidence.

Fig. 1.

PRISMA flow diagram

Data Abstraction

The articles were summarized and categorized systematically using a data extraction form. Data were extracted on author, study purpose, study design, study sample, measures, and key findings by the first author (Table 1). Additional tables were created to display relevant information to facilitate data comparison among studies. The process was followed by analyzing data within categories to compare study results and to synthesize similarities and differences across selected studies while focusing on the purpose of the review. After independent screening, the authors met to discuss inclusion criteria and quality appraisal and to come to consensus.

Table 1.

Summary of published studies on type 2 diabetes mellitus in Haitian immigrants

Author [reference number]	Study purpose	Study design	Study sample	Measures	Key findings
Cheema et al. [19]	Investigate genetic association of peroxisome proliferator activated receptor, gamma, coactivator 1 alpha (PPARGC1A) polymorphisms implicated in energy metabolism with phenotype in T2D between HIs and AAs in FL	Cross-sectional	226 HIs out of 472 total sample	Demographics, BMI, BP, WC, DNA samples	Two out of four SNPs [rs7656250 (OR = 0.22, p = 0.005), and rs4235308 (OR = 0.42, p = 0.026)] showed significant statistical protective association with T2D in HIs. After stratification with sex, both rs4235308 7 rs7656250 showed protective association with T2D in HI females
Degazon and Parker [32]	Identify and understand the relationship of coping and psychosocial adaptation to T2D in the Southern US-born older Blacks or the Caribbean (Haiti, Barbados, Jamaica, Trinidad and Tobago)	Cross-sectional	44 HIs out of 212 total sample	Demographics, Jalowiec Coping Scale, Psychosocial Adjustment to Illness Scale-Self Report	HIs and Jamaicans with increased use of coping strategies. Extended family relationship, HCU, and psychological distress were found in Haitians only
Désilets et al. [25]	Assess CVD risk markers among HIs and Whites in Quebec, Canada	Comparison study RCT	40 HIs out of 80 total sample	Demographics, Quebec Family Study, serum glucose and insulin, indirect calorimetry, CT	HIs had lower BMI and TGs, higher BP and HDL, more insulin resistant
Exebio et al. [20]	Evaluate validity and cutoff points of HbA1c as a diagnostic tool for T2D in HIs	Case–control	130 HIs with T2D, 129 w/o T2D	Venous plasma: glucose: HbA1c	Genetically, HIs require a lower HbA1c cutoff point of (≤ 6.26%) compared to the ADA’s (≥ 6.5) for T2D diagnosis
Huffman et al. [26]	Compare association between higher dietary intake of certain flavonoids on LDL and HDL in two ethnic groups; HIs and AAs with or w/o T2D	Cross-sectional	259 HIs, 249 AAs	Harvard semi-quantitative, 2007 USDA classifications of flavonoids	HIs consumed more flavonol (p < 0.001) and flavones (p = 0.029). When stratified by diabetes, HIs with T2D consumed more flavonoids (p = 0.015) and flavones (p = 0.028) than AAs, had lower LDL and no link with HDL (p = 0.001); and results were reverse in LDL in the w/o T2D group (p = 0.0018)
Huffman et al. [27]	Examine the relationship between dietary HEI, the AHEI among HIs and AAs with and w/o T2D	Cross-sectional	246 HIs, 225 AAs	Demographics, WC, MAQ, Beck Depression Inventory, the Harvard semiquantitative FFQ, HEI-05, AHEI	Subjects with T2D were less educated than those w/o diabetes (p = 0.008). HIs with T2D consumed fewer calories, had smaller WCs, scored > on HEI scores on 9 out of the 12 dietary components (β = 10.9, [8.67, 13.1], SE = 1.12, p = 0.001), higher on AHEI scores ([p = 0.006] 13.8%) of AAs were on antidepressants, compared to (5.3%) in HIs
Huffman et al. [31]	Assess insufficiencies of essential vitamins and minerals, dietary fiber, and fat intake across three ethnic groups HIs, AAs, and CAs with and w/o diabetes	Cross-sectional	HIs 258 out of 868 total sample	Fasted plasma glucose, WC, BMI, PA, dietary intake, micronutrient intake-MAQ, the semi-quantitative FFQ, dietary reference intakes	Overall, 40% of participants had insufficiencies in vitamins D and E; HIs are more likely to have iron, B-vitamins, and vitamins D and E insufficiencies; > 50% of AAs and CAs consumed > 10% of calories from saturated fat than HIs; HIs w/o T2D were > likely to be calcium insufficient
Huffman et al. [30]	Assess the effect of dietary medical advice on diabetes self-management and glycemic control while adjusting for socio-demographic factors, coping abilities for HIs and AAs with T2D in FL	Cross-sectional	HIs 129, AAs 125	Dietary medical advice (DSM), Michigan Diabetes Care Profile, HbA1c, perceived stress, self-rated health, Perceived Stress Scale; depressive symptoms, Beck Depression Inventory questionnaire, PA, MAQ	HIs complied with dietary guidelines, had better DSM (p = 0.001), lower BMI and rates of smoking. Suboptimal glycemic control (HbA1c > 7.2), lower HCU (45%) compared to AAs (20%)
Huffman et al. [28]	Examine the association between perceived stress, self-related health, and diabetes status among HIs and AAs with and w/o T2D in FL	Cross-sectional	HIs 258, AAs 249	Perceived stress, Perceived Stress Scale, WC, BMI, HbA1c, venous plasma	Controlling for T2D status, age and marital status, HIs were more likely to report “good health,” yet they experienced higher perceived stress. HIs were less likely to report fair-to-poor health, and the odds of having diabetes were associated with fair-to-poor health at (p = 0.001) in both HAs and AAs
Moise et al. [34]	Generate culturally framed insight about Haitian’s knowledge, management, and prevention about diabetes in Haitian immigrants in Philadelphia	Qualitative Focus Group interviews	HIs 10	Semi-structured interview guide	Three themes emerged: cultural identity (person, extended family, and neighborhood), relationships and expectations (perceptions, enablers, and nurturers), cultural empowerment (positive, existential, negative)
Rosen et al. [43]	Determine the prevalence of T2D in the Little Haiti, Miami, FL	Descriptive	HIs 51	WC, BP, fasting glucose, lipid profile, venous plasma	47% Had glucose levels ≤ 99, 20% between 100 and 126, and 33% with glucose levels of 126 and above. The prevalence of metabolic syndrome was similar to the prevalence of impaired fasting glucose (40% had neither T2D nor metabolic syndrome, and 33% had T2D)
Shaban et al. [29]	Investigate the association between vitamin D levels and diabetes status in three ethnic groups HIs, AAs, CAs in FL	Cross-sectional	HIs 253 out of 700 total sample	Demographics, BMI, dietary intake, vitamin D, HbA1c, semi-quantitative FFQ, venous plasma	Participants with T2D were significantly older, had > BMI, lower caloric intake, and lower serum 25(OH)D levels as compared to those w/o T2D. HIs had lower BMI, vitamin D intake and serum vitamin D, and < proportion of smokers. HIs w/o T2D were at > risk for vitamin D insufficiency (OR = 31.75, CI 14.17–71.14, p = 0.001) compared to CAs w/o T2D
Vaccaro et al. [33]	Investigated the interrelationship among perceived family/friend social support, health-related behaviors on DSM (behaviors and beliefs) as modified by ethnicity (HIs, AAs, CAs) and gender (male/female)	Cross-sectional	HIs 121 out of 405 total sample	Diabetes Care Profile questionnaire, Diabetes Care Profile, Family Friend Social Support questionnaire, serum plasma, yes/no to diabetes education health insurance	HI had better DSM score (64.7, 59.5 AAs, 59.1 CAs), had lower rate of smokers, yet had poorer glycemic control compared to CAs and AAs: HbA1c 7.7, 7.3; 6.95
Vimalananda et al. [35]	Compare diabetes care and control between HIs, AAs and non-Hispanic Whites who received primary care services at an urban healthcare institution	Observational.	HIs 715 out of 2653 total sample	Chart review	HIs had lower BMI, smoking, healthcare utilization, yet, had higher mean HbA1c (8.2 ± 1.9 vs. 7.7 ± 2.0%, p = < 0.0001) compared to AAs and CAs. HIs had higher risk of poor LDL cholesterol and BP controls than non-Hispanic Whites

AAs African Americans, ADA American Diabetes Association, AHEI alternative healthy eating index, BMI body mass index, BP blood pressure, CVD cardiovascular disease, CAs Cuban Americans, DNA deoxyribonucleic acid, FFQ Food Frequency Questionnaire, FL Florida, HDL high density lipoprotein, DSM diabetes self-management, HIs Haitian immigrants, HbA_1c glycosylated hemoglobin, HCU healthcare utilization, HEI healthy eating index, HOMA homeostasis model assessment, LDL low-density lipoprotein, MAQ modifiable activity questionnaire, PA physical activity, SNPs single-nucleotide polymorphism, TG triglycerides, T2D type 2 diabetes, WC waist circumference, w/o without

Quality Appraisal

Quality appraisal of experimental studies was determined by using the Cochrane Collaboration’s tool for assessing risk of bias. The National Institutes of Health (NIH) Quality Assessment Tool for Case–Control, Observational Cohort, and Cross-Sectional Studies was used to determine relative quality of non-experimental studies [23]. Conversely, the Consolidated Criteria for Reporting Qualitative Research (COREQ) was used to determine the quality of qualitative studies [24]. Overall, the studies were moderate or high quality based on the respective quality assessment tools that were used.

Compliance with Ethical Standards

This article does not contain any studies with human participants or animals performed by any of the authors. Therefore, no informed consent was necessary.

Results

Study Design/Samples/Settings/Instruments

A total of 14 studies met the inclusion criteria. The majority of the studies (n = 10) used quantitative, descriptive, correlational methods. Included were one randomized controlled trial, one qualitative study, and two case–control studies. The number of participants in the studies ranged from 10 to 2653, and ages ranged from > 30 to > 60. The majority of the studies were conducted in the US: nine were conducted in Florida, and eight of the nine were led by the research team at the Human Nutrition Laboratory at Florida International University. Only one study meeting inclusion criteria was conducted in Canada [25].

Clinical, nutritional, and psychosocial characteristics, and self-management were among the measures studied in most of the articles. Clinical variables included body mass index (BMI), blood pressure (BP), HbA_1c, low-density lipoprotein (LDL), waist circumference (WC), and serum insulin. Dietary variables were included in four studies (dietary intake, dietary quality). Dietary intake was measured using the semi-quantitative Food Frequency Questionnaire (FFQ) and the dietary reference intakes (DRIs). The FFQ is an 18-item scale which asks about how often a variety of foods was eaten in the past month or year, including culture-specific foods. The DRIs is a set of reference values that can be used to assess the adequacy of an individual’s nutrient intake based on dietary recall. Dietary quality was measured by the Healthy Eating Index-05 (HEI-05) and the Alternate Healthy Eating Index (AHEI) [26–29]. The HEI-05 is a measure for assessing diet quality that provides a composite score calculated from 12 components of food group consumption indexed to the Dietary Guidelines for Americans. The Alternative Healthy Eating Index (AHEI) is designed to assess adherence to the Dietary Guidelines for Americans and the Food Guide Pyramid. Three studies evaluated perceived stress, self-related health, depressive symptoms, coping and psychosocial adaptation using: the Perceived Stress Scale (PSS-10), the Beck Depression Inventory Scale, the Jalowiec Coping Scale (JSC), the Psychosocial Adjustment Scale-Self Report (PAIS-SR) [30–32]. Social support was measured by the Diabetes Care Profile subscale and the Family/Friend Social Support Scale in one study [32]. Physical activity was measured with the Modifiable Activity Questionnaire (MAQ) [31]. Only two studies explicitly investigated diabetes self-management using the Diabetes Care Profile questionnaire [30, 33].

Data Synthesis

Three synthesized themes were found: (1) risk factors for less self-management and/or worse metabolic control (n = 9), (2) protective factors for better self-management and/or metabolic control (n = 9), and (3) mixed results (n = 6). Within these themes, studies focused on (a) genetic/biological, (b) clinical, (c) nutritional, (d) self-management, and/or (e) psychosocial factors (Table 2).

Table 2.

Summary of risk and protective factors in published studies on type 2 diabetes mellitus in Haitian immigrants

Factor	Risk factors for ↓ self-management and/or ↑ A1C	Protective factors for ↑ self-management and/or ↓A1C	Mixed results
Genetic/biological	Increased risk at lower A1C [20]	Protective genetic profile compared to AA [19]
Clinical	Increased BP, increased insulin resistance compared to AA, non-Hispanics, and White [25, 35] Increased prevalence of impaired fasting glucose [29] Increased A1C [25, 26, 29–31, 33, 35]	Decreased waist circumference compared to AA [25, 27] Lower rates of smoking versus AA and CA [27, 29, 35]	Decreased BMI but higher A1C compared to AA and CA [29, 35] Decreased LDL but higher A1C compared to AA and White [20, 21]
Nutrition	Vitamin D deficiency associated with increased risk for T2D [29] Greater risk for vitamin deficiencies (iron, vitamins B, D, E) compared to AA and CA [28, 29]	Consume fewer calories compared to AA [27]	Consume more flavones than AA but higher A1C [26]
Self-management	Lower healthcare utilization compared to AA and CA [33, 34]	Better self-management compared to AA and CA [30, 33] More likely to follow dietary advice (decrease calories, increase healthy eating) [30] Better “healthy eating” compared to AA [27]	Better self-management as measured by composite score, but higher A1C compared to AA and CA [33] Better self-management as measured by likelihood to follow dietary advice, but higher A1C compared to AA and CA [30, 33]
Psychosocial	Increased perceived stress and higher A1C compared to AA [31]	Increased family/friend support associated with better self-management [33] Solid community and cultural values [34] HI’s reported higher family/friend support compared to CA and AA [33, 34] Increased confrontational coping = better psychosocial adaptation [32] Decreased antidepressant medication than AA and CA [27, 29]

AA African Americans, A1C glycosylated hemoglobin, BMI body mass index, BP blood pressure, CA Cuban Americans, HI Haitian immigrants, LDL low-density lipoprotein, T2D type 2 diabetes

Risk Factors for Self-Management and/or HbA_1c

Risk factors associated with less self-management and/or worse metabolic control were identified in nine studies. Genetic differences in hemoglobin concentration in HIs was reported in one study [20], with recommendations for a lower HbA_1c diagnostic cutoff point (≤ 6.26) in HIs compared to the American Diabetes Association (ADA) recommendation for all adults (≤ 6.5). Clinical and nutritional risk factors for T2D in HIs included elevated BP, increased insulin resistance, increased impaired fasting blood glucose, elevated HbA_1c, and deficiencies in essential vitamins when compared to African Americans, Cuban Americans, non-Hispanics, and Whites [25, 26, 28, 30, 31, 34].

In two studies, HIs had higher BP readings, with increased insulin resistance compared to African Americans, non-Hispanics, and Whites [25, 34]. Vitamin D deficiency was reported in one study of HIs and was associated with increased risk for developing T2D [28]. HIs with and without T2D were noted to be at even greater risk for essential vitamin insufficiencies (i.e., iron, B-vitamins, and D&E) [28, 29]. HIs also demonstrated increased perceived stress and higher HbA_1c compared to African Americans [31]. Lastly, HIs had lower health care utilization compared to African Americans [33, 34].

Protective Factors for Self-Management and/or HbA_1c

Protective factors for better self-management behaviors and/or lower HbA_1c were identified in nine studies, which assessed protective genetic profiles, clinical factors, the effects of dietary medical advice, and levels of social support on diabetes self-management behaviors and glycemic control. A protective association for T2D in HIs appeared on two of the four protein metabolism gene peroxisome proliferator activated receptors, gamma, coactivator 1 alpha, compared to African Americans [30]. These detected protective associations signify lower risks of T2D development in the HI population compared to African Americans. HIs also had decreased WC compared to African Americans [25, 27] and lower rates of smoking compared to African and Cuban Americans [27, 28, 34].

With respect to nutrition and self-management, HIs consumed fewer calories, were more likely to report following dietary advice, and had better healthy eating and self-management compared to African Americans [27, 30]. Lastly, higher levels of family/friend support were associated with better diabetes self-management, increased confrontational coping resulting in better psychosocial adaptation, and less use of antidepressants were reported in HIs when compared to African Americans and Cuban Americans [27, 28, 30, 32, 33]. In a qualitative study, knowledge, self-efficacy, family, healthcare professional, community, and strong cultural values were perceived to be valuable to HIs in the prevention and management of T2D [34].

Mixed Results

In several studies, discrepant findings between positive health behaviors and negative clinical outcomes were reported. For example, HIs had lower BMI, better self-management behaviors, and were more likely to report positive family/friend support than Cuban Americans and African Americans, yet, had worse HbA_1c [28, 30, 33, 35]. In addition, lower LDL and consumption of more flavones were reported in HIs, although, they had higher HbA_1c levels compared to Whites and African Americans [25, 26].

Discussion

The purpose of this review was to synthesize the research on HIs and T2D to provide direction for practice and future research. Strong evidence exists that the burden of T2D is significant for HIs, who have an increased risk for poor health outcomes. The findings in this review support results from other reviews on T2D in similar racial/ethnic immigrant groups, indicating that T2D is a complex medical condition associated with considerable health consequences [36, 37].

We found genetic and biological differences, nutritional, clinical risk and protective factors, knowledge, and family support to be among the elements associated with effective or ineffective diabetes self-management and metabolic control in HIs [30, 31, 33].

While there is evidence to support a lower genetic risk in HIs compared to African Americans, HIs have a distinct genetic variance in hemoglobin concentration, which indicates that HIs are at risk for T2D at a lower diagnostic threshold than current recommendations. This could result in a delay in diagnosing T2D in HIs and increase risk for worsening metabolic control and subsequent complications [20].

Elevated BP, greater insulin resistance, deficiencies in vitamin D and essential vitamins were reported in HIs compared to African Americans, Cuban Americans, and Whites, which increases their risk for T2D development and diabetes-related complications. Insulin secretion and insulin sensitivity are reduced when vitamin D levels are deficient, which increases risk for obesity and subsequently T2D [38]. Research also supports a positive association between acculturation and WCs [36, 37, 39]. For example, cross-sectional studies in Latinos have suggested a causal link between obesity and acculturation [12, 40, 41]. However, HIs were found to have decreased WCs compared to African Americans, yet they experienced worse metabolic control [25, 27].

Discrepancies between health behaviors and clinical outcomes were also demonstrated in HIs. Despite their better self-management behaviors such as better healthy eating habits and being more likely than other ethnic groups to follow dietary advice when recommended, HIs had higher HbA_1c levels compared to other groups. Findings from the literature suggest that the majority of immigrants tend to maintain their cultural customs, especially dietary practices and preferences [5, 10–12, 33]. However, in selected groups of immigrants such as those with a Mediterranean dietary pattern, the process of acculturation has little effect on health conditions that are closely related to lifestyle and metabolism [38]. Acculturation may trigger a negative health impact on HIs, resulting in increased prevalence of T2D, higher risk for poorer metabolic control and diabetes-related complications that is not directly related to dietary health behaviors.

Social support plays a positive role in the management of chronic conditions [14]. Family/friend support and strong Haitian cultural values were associated with improved self-management activities compared to African Americans and Cuban Americans [33, 34]. In a study of Korean immigrants with T2D, family/friend support was significantly correlated with good metabolic control [42]. However, the link between social support and positive metabolic control was not demonstrated in HIs. Although HIs were less likely to be on antidepressants and reported better psychosocial adaptation than other ethnic groups, HIs reported increased perceived stress [28], which may be a factor linked with higher HbA_1c.

Thus, HIs present with unique risk and protective factors for T2D diagnosis and prognosis. More research is needed to understand the risk factors in HIs that contribute to a lower diagnostic threshold and worse metabolic control despite healthier behaviors. Understanding the factors that contribute to hypertension, insulin resistance, and perceived stress is important. In addition, addressing vitamin deficiencies and healthcare utilization in this population is warranted. Conceivably, there are additional factors not yet delineated that may influence HIs’ ability to successfully manage their T2D. Areas for research include (a) the development of validated measurements that reflect the cultural components specific to T2D in the HI population, (b) more in-depth exploration of HIs’ health behaviors including diet, exercise, and sleep behaviors, (c) examining bio-behavioral factors that influence diabetes self-management, (d) development of a middle-ranged theory for HIs so that knowledge regarding this population can be systematically explored, and (e) design and evaluate culturally sensitive interventions that may improve metabolic control.

Limitations

The number of studies on HIs with T2D was limited. In addition to small sample sizes, most of the studies were cross-sectional and conducted by one research team in Florida. Only English language publications were analyzed. Restricting the review to one language may have omitted other relevant studies unique to this ethnic group with unique religious and cultural health beliefs that could influence self-management behaviors and metabolic control.

Conclusion

HIs present with unique risk and protective factors for T2D diagnosis and prognosis. The risk factors included an increased risk for T2D at a lower HbA_1c threshold, increased BP and insulin resistance, greater vitamin deficiencies, increased perceived stress, and lower healthcare utilization. Protective factors included a protective genetic profile, lower BMI, better self-management behaviors, more social support, and better psychosocial adaptation. Across all studies, HIs had worse glycemic control than other ethnic groups. Research is needed to expand our understanding of the risk factors contributing to increased HbA_1c in this population. For example, qualitative research to assess cultural factors and health behaviors of HIs in various regions is needed. In addition, cross-sectional studies to examine psychosocial and biological factors associated with self-management and glycemic control such as social support, acculturation, perceived stress, and biomarkers for stress and inflammation are needed. Immigrants’ health involves a complex interplay of pre-immigration factors, bio-behavioral factors, and their integration in the host country.