Maria is a 54-year-old Mexican immigrant with type 2 diabetes mellitus, hypertension, and obesity. Her visits to your clinic have been challenging because of her limited English proficiency, late arrivals, and nonadherence to several medications. She agrees to start taking medications, but does not refill her prescriptions or lose weight.

During Maria's next visit, you arrange for a telephone interpreter, which enables you to take a brief social history. She has three grown children: two still live in Mexico, and the third lives in a distant U.S. city. Her husband died in an industrial accident four years ago, and she is still grieving. She asks about your family, and hesitantly, through the interpreter, you share a bit about your own children. Her face lights up when you share this.

Using the LEARN model, you listen to her story about her poor control of diabetes and frustration with her diet. She says that she does not feel better when taking the medicine, and says the diet you prescribed does not include tortillas or any of the foods she likes. She says that since her husband died, she has lost interest in what might happen to her in the future. You explain why these interventions are necessary, but acknowledge her frustration and agree to revise her diet. You recommend a compromise treatment plan for her diabetes and grief. After some negotiation, she agrees to see a dietitian and a bilingual counselor, and agrees to take just two medications, metformin (Glucophage) and lisinopril (Zestril), although she understands that they will not make her feel better right away. You use “teach back” to ensure that Maria understands your directions, and you provide her with Spanish-language handouts about the benefits of controlling her diabetes and hypertension. You then schedule a return visit, during which an interpreter will be available.

You call the dietitian to alert him to this patient's cultural concerns. Maria needs to eat fruit; she should also consume more fiber to counteract her high-carbohydrate diet. One suggestion she readily agrees to is to include nopales (prickly pear cactus pads), a favorite from her childhood in Mexico. This traditional food is high in fiber and pectin and lowers lipid levels by binding bile acids; when eaten with other foods, it reduces the glycemic index of the meal by 50 percent.28 Because nopales may inhibit the absorption of drugs as well as glucose,29 Maria was told not to take her medications within a few hours of eating it. Other vegetables and fruits she likes are added to replace some other carbohydrates. The counselor helps her with her grief, and gets her involved in an exercise and weight loss group at her church.

Your efforts pay off at the next visit, when Maria expresses much more interest in controlling her diabetes and shows personal warmth that was missing from earlier encounters. She has lost 10 lb (4.5 kg), and for the first time has acceptable blood pressure and fasting glucose levels. It took extra time in relationship-building (personalismo), a team approach, an interpreter, negotiation, and a bit of research to make it all happen.