Cultural Considerations in Diabetes Management

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Diabetes affects people of all cultures, races, and ethnicities; however, it continues to impact non-Hispanic Blacks, Hispanics, Asian Americans, and American Indians/Alaskan Natives at higher rates. The good news is that diabetes is a disease that can prevented, treated, and managed.

One of the most important aspects of diabetes management is education. In fact, the cornerstone of exceptional diabetes care is diabetes self-management education (DSME) that focuses on individualization and takes into consideration a persons’ lifestyle, culture, and daily needs

Studies have shown that DSME can be cost effective, reducing hospitalizations, and help to reduce hemoglobin A1c (three-month average of blood sugar) by as much as 1% in people with type 2 diabetes.

DSME has also been shown to improve quality of life, reduce the onset and advancement of diabetes complications, and help people to engage in more healthy behaviors, such as exercise and eating a well-balanced meal plan.

But, not all diabetes education looks the same because no two people with diabetes are exactly the same. Culture and ethnicity are very important determinants of care. Therefore, it is vital for educators to understand that customization of care plans is especially important and that there is no one size fits all for daily living, medication management, or meal planning.

Cultural sensitivity, acknowledgement, and understanding can help practitioners, such as diabetes care and education specialists, understand the influence of culture on health. Taking into consideration all that encompasses a person’s health, such as their cultural beliefs can help break barriers and improve quality of life for those people living with diabetes.

Diabetes Statistics

The prevalence of diabetes diagnoses by detailed race and ethnicity according to the American Diabetes Association is as follows:

  • 7.5% of non-Hispanic Whites
  • 9.2% of Asian Americans
  • 12.5% of Hispanics
  • 11.7% of non-Hispanic Blacks
  • 14.7% of American Indians/Alaskan Natives

The breakdown among Asian Americans:

  • 5.6% of Chinese
  • 10.4% of Filipinos
  • 12.6% of Asian Indians
  • 9.9% of other Asian Americans

The breakdown among Hispanic adults:

  • 8.3% of Central and South Americans
  • 6.5% of Cubans
  • 14.4% of Mexican Americans
  • 12.4% of Puerto Ricans

The Center for Disease Control lists diabetes as the seventh leading cause of death in the United States. It is estimated that by the year 2050, roughly 1 in 3 people will have diabetes.

Establishing a Good Rapport

To help someone is to know and understand them. When caring for people with diabetes who are often responsible for multiple daily self-care activities daily, it is important to understand their lifestyle, beliefs, and customs. Culture encompasses a mixture of human behaviors, such as beliefs, values, customs, language, and family influences.

Maria Elena Fraga, MS, RD, CDCES diabetes and nutrition manager at Mount Sinai Health System tells Verywell, “Working as dietitian and diabetes educator in culturally diverse communities has provided me with a better understanding of the influence of culture on health care practices.”

She recommends being extra savvy with understanding a person’s specific food habits, cuisine of choice, and beliefs about diabetes and what is involved in managing it.

Food: Know the Menu

Eating is a daily task. We eat every day, multiple times a day, which means we are constantly making decisions about food. What should we eat, how much, what do we need to buy at the store? When it comes to managing diabetes, food is one of the most influential variables that contribute to blood sugar control.

Carbohydrates are the macronutrient that that impact blood sugar the most. Therefore, people with diabetes need to understand what carbohydrates are, where they are found, how they impact their blood sugar, which types of carbohydrates they should aim to eat most often, and how many carbohydrates they can eat to maintain good blood sugar control.

It is extremely difficult to connect with someone or help them adhere to dietary goals, create a meal plan, or communicate with them effectively without knowing their food practices, beliefs, and what food means to them.

To help better manage diabetes, it is important for practitioners to have an understanding about types of foods people eat daily, how they eat (do they eat on the go, family-style, etc.), who they eat with (extended family), who is cooking, and more.

Fraga recommends, “Have education materials readily available on all types of foods in multiple languages to help educate and increase adherence and motivation. Additionally, asking questions, and requesting pictures of food can help you understand what types of food are being eaten and how to modify them, if needed.”

Some cultures have a carbohydrate dominant meal plan, which can often make diabetes hard to control. But this doesn’t mean you should aim to “take away” the staples of a persons’ meal plan. Modifying a diet, rather than changing it altogether is really important in helping people manage their diabetes.

For example, if you are accustomed to consuming several servings of homemade juice daily, it is not realistic for you to stop drinking juice altogether. Instead, finding a realistic goal that will improve quality of life without being too overwhelming is more likely to facilitate long-lasting change. Instead, aim to reduce juice by half to start or swap out one serving of juice with whole fruit instead.

Fraga recommends, “If you are counseling a person with diabetes, you need to know what’s on the menu and what the person you are counseling is used to eating daily. If you are not familiar with those types of foods, ask them to share pictures with you and serving sizes.”

Visual learning, such as using pictures and photos is a great way to receive information as well as provide education. When teaching people about serving sizes and food choices, it is always a good idea to be able to show serving sizes by using real models, labels, and food samples.

In addition to visuals, it’s a wonderful asset to know what ingredients and recipes are used in cuisines around the globe. Nutrition professionals are taking action to help educate colleagues.

Dietitians, Kristy DelCoro, and Jackie Topol will be launching a web series titled A Taste of Culinary Nutrition from Around the Globe, Each session will be lead by a chef/RD presenter who will cover key ingredients and food traditions of their heritage, as well as concrete recommendations for healthy recipe modifications without compromising the cultural significance of the dish.

As part of each session, presenters will demonstrate several recipes in an interactive cook-along style for participants. They are offering 17 continuing professional education units (CPE), pending approval.

Del Coro states “Understanding the significance of certain ingredients and meals across cultures—and across various regions within each culture—is an essential piece to being an effective practitioner to a diverse population.”

Topol, who also specializes in prediabetes, adds “Providing culturally sensitive recommendations to patients and clients can be the difference between a person following a health practitioner’s advice or not.”

Understand Beliefs About Medication

Another component to diabetes care is medication. There are several different types of medications used to treat diabetes, including oral diabetes medication, non-insulin injectable medications, such as GLP-1 agonists, and insulin therapy.

The type of medication a person needs will depend on the type of diabetes they have, how long they have had diabetes, lifestyle, and their diabetes control. Other factors that come into play include insurance, doctor’s knowledge regarding medication, etc.

But another thing to consider when recommending a specific type of medication is cultural beliefs. Perceptions of a persons’ beliefs should be understood before recommending a treatment regimen.

Certain cultures, for example, have a negative perception of insulin. They may believe that once a person starts insulin, they are going to get sicker, have adverse reactions, be a burden to their families, it may interfere with religious obligations, or they have failed their diabetes.

While these are beliefs and not truths, it is important to validate and respect the persons’ beliefs. Listen to them and learn about why they feel this way and if there are any barriers in place that you can help them overcome. Educate them with the facts. And if they are still reluctant, respect their wishes and find an alternative method.

If you are a diabetes educator, doctor, nurse, or other health care worker working with people with diabetes, you are likely to be working with people of different cultures who have different meal patterns, food beliefs, and self-care routines or practices.

Being an active listener, getting educated in different cuisines and beliefs, and having access to resources can help you provide better care which will yield better outcomes for the people living with diabetes.

Be an Effective Communicator

If you are working with someone who has diabetes and you do not share the same first language, it’s important to be able to communicate effectively so that you can retrieve more accurate information which will help you to formulate a health care plan.

If you are working at a large institution, such as a hospital, you should have access to a language interpreter. If you work somewhere else, you may be able to use other tools for interpretation.

Frega tells us, “Using simple, clear language, pictures, and asking questions, is a great way to deliver and retrieve information.” It’s also important to, “Be respectful of accents, listen intently, and use simple language so people can understand more clearly.”

The American Association of Diabetes Educators emphasizes the need for effective communication in treating people with diabetes. “When teaching patients with low literacy and limited English proficiency, educational materials should be tailored accordingly with illustrated graphics, along with use of teach back methods to confirm patient understanding.”

The teach back method is an effective tool to assess a person’s knowledge and understanding of material. For example, if you are teaching a person with diabetes how to use an insulin pen, when you are finished have them demonstrate their knowledge by teaching back to you what you just taught them.

Family

Certain cultures live with extended family and their family plays a role in managing their diabetes. In this situation, it is important to have consent from the person you are counseling to share education points with other members of the family.

For example, a person living with diabetes may have their meals prepared by another member of the family. In this case, the cook will need to understand the role of food in diabetes management. Family acceptance and familial approval is often an important part of people’s lives.

Learning the role that family plays in a person with diabetes life can improve outcomes by increasing adherence to medical plans and follow up. Alternatively, lack of understanding can result in poor follow-up and negative outcomes.

Social Factors

How does diabetes management affect the person you are treating socially? This is an important topic to address because if a person feels like their diabetes is isolating, they may be less likely to pay attention to it or address it properly.

For example, a person with diabetes may find it socially unacceptable to take their medication in public and as a result may omit it or try to hide it from family, friends, or coworkers. Certain cultures may find that taking care of themselves takes time away from their family and this may not be socially acceptable.

Understanding social norms within cultures is an important part of overcoming barriers and providing optimal care.

Resources for Education Materials

Health care providers should have access to education materials in multiple languages. Having access to culturally sensitive education materials can assist in education, effective communication, and adherence to a diabetes care plan.

Organizations such as the Center for Disease Control, U.S. Department of Agriculture, National Institute of Health U.S. National Library of Medicine, American Academy of Nutrition and Dietetics, The National Diabetes and Digestive and Kidney Disorders, National Network of Libraries of Medicine have diabetes and nutrition education materials in a variety of languages.

A Word From Verywell

All different kinds of people from all different kinds of backgrounds can and will develop diabetes. Therefore, if you are a diabetes care provider, it’s extremely important to understand a person’s culture, including the role of family, medication beliefs, social norms, dietary habits, and more.

Valuing culture can help yield positive outcomes by establishing rapport and ensuring people with diabetes receive adequate care, while maintaining their quality of life.

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