Successful Diabetes Management in Diverse Populations
By Constance Brown-Riggs, MSEd, RD, CDE, CDN
As the United States becomes more ethnically diverse, so will the face of diabetes. The US Census Bureau projects that by 2050 the Asian, Hispanic, and black populations will increase 212.9%, 187.9%, and 71.3%, respectively, compared with 32.4% for the white population.
And according to the American Diabetes Association’s National Diabetes Statistics Report, 2014, diabetes prevalence is significant among these groups: 13.2% in blacks, 12.8% in Hispanics, and 9% in Asians, compared with 7.6% in whites. This changing diabetes demographic increases the likelihood that dietitians will encounter clients and patients from cultural backgrounds different from their own. Successful diabetes self-management education must address cultural differences to improve patient care. When cultural differences between the client and RD aren’t taken into consideration, diabetes self-management goals won’t be met.
This article discusses how culture plays a role in diabetes self-management, the challenges RDs may encounter when counseling patients from different backgrounds, and the importance of individualized diabetes care.
Why Cultural Competence?
The goal of diabetes self-management education is to help clients learn how to incorporate healthful behaviors in their lives to prevent diabetes complications and improve their quality of life.1 The key to achieving these goals is to provide culturally competent care, which is linked to client satisfaction, adherence to intervention strategies, and health outcomes.2
“As diabetes educators and registered dietitians, we need to learn to understand the population we serve and provide relevant, culturally sensitive education,” says Mariana Chaparro, MPH, RDN, CDE, LD, a spokesperson for the Academy of Nutrition and Dietetics. “Part of being a culturally competent educator is to understand how culture plays a role in your clients’ health care practices. When you understand the whys, hows, and whats of clients’ beliefs, practices, and values, you can truly be effective.”
Nutrition is the cornerstone of diabetes self-management, and individual dietary patterns are influenced by food availability, perception of healthfulness, culture, religion, health beliefs, and access to food.3 Therefore, these factors must all be considered when making individualized recommendations. “You must do your homework,” Chaparro says. “Find out about special holiday celebrations, key food groups, eating habits, customs, [and] beliefs, and learn about the community.”
Melissa Joy Dobbins, MS, RDN, CDE, a media spokesperson and speaker known as “The Guilt-Free RD,” agrees: “Each culture has its own traditions and meanings behind those traditions. If RDNs are both aware of and sensitive to this, they can have an open dialogue about what food, exercise, and health means to the patient and their family.”
A challenge for nutrition professionals is stereotyping and assigning one characteristic to an entire ethnic group. “For example, assuming that all Hispanics eat tortillas,” says New York-based dietitian Lorena Drago, MS, RD, CDN, CDE, owner of Hispanic Foodways and creator of the Nutriportion Measuring Cups. “It’s important to acknowledge that there are differences among people of the same culture.” Asking the right questions is important even when the client and RDN share the same cultural background. Dietitians can use the following questions to guide the cultural encounter and avoid stereotyping:
- Do you eat ethnic or traditional foods?
- What foods do you commonly eat?
- What are your favorite foods?
- How many times per week do you eat your favorite foods? and
- Which foods do you traditionally eat during holidays and special occasions?
RDs can use the American Association of Diabetes Educators’ (AADE’s) “Five Tips for Improving Self-Care” to ensure successful cultural encounters:1
- Encourage activity rather than exercise. Instead of urging patients to partake in traditional exercise, suggest they choose from a variety of activities they find enjoyable. For example, a black teenager who has diabetes and is overweight may be reluctant to go to a Pilates class, lift weights, or ride her bike, but she may enjoy dancing with her friends.
- Emphasize health, not weight loss. In some cultures, weight loss can have negative implications. Mexican Americans, for example, consider a full figure representative of good health and weight loss a sign of disease. Instead of telling your patients to lose weight, suggest they list their goals, such as playing with their grandchildren or avoiding diabetes complications they’ve seen in relatives or friends. Explain how eating healthfully and moving more will lower their blood glucose levels, which in turn will help them achieve their goals.
- Include familiar foods. Patients with diabetes are more likely to follow a healthful diet if it includes familiar foods they like. Adapt favorite foods to make them healthier, such as baking instead of frying chicken or using dry beans, which are lower in sodium than canned beans.
- Recruit the family. Many cultures are family-focused, and the support of family members can help patients with diabetes better manage their condition. Encourage family members to be supportive, not judgmental or scolding, by providing positive feedback such as, “You look great, Mom!” and agreeing to avoid sodas and unhealthful foods.
- Partner up. Work with people from the local community and church groups who can provide tips and help dietitians understand the culture.
Drago, author of Beyond Rice and Beans: The Caribbean Latino Guide to Eating Healthy With Diabetes, finds AADE’s suggestions particularly helpful for RDs working with Hispanic/Latino clients. “Behaviors have to change first and then weight follows,” she says. “It’s important to share with patients that modest weight loss can lead to significant improvements.” As in every culture, Hispanic families want to retain their traditional foods and flavors and yet learn to make them more healthful. “The selling point for patients is striking a balance between flavor, tradition, and health,” she says. Family involvement is also particularly important, as Hispanics are family-centric. “Decisions are made for the family. Therefore, the nutrition professional should encourage family participation and support.”
Chaparro, owner of Nutrichicos, a bilingual children’s nutrition center in Miami, says AADE’s tips highlight the need for individualization. “There’s no one right way of doing things, nor is there a cookie-cutter solution. Let’s meet our patients where they are, not expect them to meet us where we are,” she says.
More Ethnic Diversity
The diabetes population is becoming more racially and ethnically diverse. Clients and patients with diabetes will benefit from and appreciate recognition of their culture. Joining one of the Academy’s member interest groups representing the ethnic populations with whom you work is a great way to learn more about cultural competence. Understanding the perspective of the client, both culturally and as an individual with diabetes, can lead to more successful outcomes.
— Constance Brown-Riggs, MSEd, RD, CDE, CDN, is past national spokesperson for the Academy of Nutrition and Dietetics, specializing in African American nutrition, and author of The African American Guide to Living Well With Diabetes and Eating Soulfully and Healthfully With Diabetes.
- Successful diabetes management should address cultural differences: five tips for improving self-care. American Association of Diabetes Educators website. https://www.diabeteseducator.org/docs/default-source/legacy-docs/_resources/pdf/general/Five_Tips_for_Improving_Self-Care_v3.pdf. Accessed July 12, 2015.
- Betancourt JR, Green AR, Carrillo JE, Park ER. Cultural competence and health care disparities: key perspectives and trends. Health Aff (Millwood). 2005;24(2):499-505.
- Evert AB, Boucher JL, Cypress M, et al. Nutrition therapy recommendations for the management of adults with diabetes. Diabetes Care. 2014;37(Suppl 1):S120-S143.