Tailor diabetes education to specific ethnic groups

Impact risk factors with same message in different forms of delivery

It is a well-known fact in the health care community that there are diabetes disparities among ethnic groups. Diabetes is a problem throughout the United States. An estimated 18 million people suffer from the chronic disease, and people of color are more likely to develop Type 2 diabetes. This includes Native Americans, Alaska Natives, African Americans, Hispanic/Latinos, Asian Americans, and Pacific Islanders, according to statistics gathered by the Atlanta-based Centers for Disease Control and Prevention (CDC).

Because of their increased risk, many individuals within these groups have a fatalistic attitude about developing the disease. However, an increased risk shouldn’t be viewed with fatalism but as a call to action, says Jane Kelly, MD, director of the CDC National Diabetes Education Program.

In the past, an attitude of fatalism was pervasive among American Indians and Alaska Native populations who believed that, no matter what they did, they would develop diabetes, says Carol Maller, MS, RN, CHES, diabetes project coordinator at Southwestern Indian Polytechnic Institute in Albuquerque, NM. "Today, we know the importance of prevention in overcoming lifestyle diseases and diabetes is no exception. Type 2 diabetes can be prevented or delayed by making healthy choices — that is the message," she says.

The core message is the same for everyone, agrees Kelly. Environment and socioeconomic constrains and implications are often far more important than genetics. Being overweight and having a sedentary lifestyle increase a person’s risk for developing diabetes.

While the message is the same for everyone, the way it is delivered is not. While developing educational materials specific to various ethnic groups for the National Diabetes Education Pro-gram, work groups had to consider many factors. For example, the perception of being overweight differs among ethnic groups. African American and Caucasian women have different perceptions of what constitutes being overweight. Therefore, many would not be aware that they are at increased risk for diabetes because of their weight. This information was uncovered in focus group research, says Kelly.

Studies have determined that Asians are at risk for diabetes at a lower body mass index (BMI) than Caucasians. For many, a BMI of greater than 25 increases a person’s risk for diabetes. However, for Asians, a BMI greater than 23 is the cutoff point, she explains.

Understanding that barriers to change of lifestyle differ from group to group is also important. For example, many older adults think they can’t be more physically active because of ailments such as arthritis. Therefore, it is important to help them understand that they don’t have to run a marathon to be physically active.

For Asians, the barrier to exercise is time. "Clearly, you hear that from anyone, but it came out very strongly in our Asian work group," says Kelly. When tailoring education on diabetes prevention to ethnic groups, it is important to consider their perception of risk factors, barriers to lifestyle change, and what motivates them, she explains.

Develop specific strategies

Maller oversees a program that was developed to prevent diabetes among Native Americans by introducing diabetes-based science education in tribal schools. "The goal is to integrate principles of diabetes prevention into the existing school curriculum at a very early age and reinforce the message throughout the formative years of schooling, K-12 grades. Taking patient education out of the clinical arena and bringing it into communities is the focus of this early intervention," she says.

To eliminate health disparities, minority community involvement is essential. "American Indian and Alaska Native cultural traditions and knowledge affect their health beliefs and behaviors, and each tribal community needed to be represented. Understanding the beliefs, values, traditions, and practices of a minority culture was necessary to develop working relationships for curriculum development and implementation," says Maller.

The diabetes curriculum for tribal schools is designed to engage teachers and students in activities that make a difference in preventing diabetes. For example, a Walking Unit using pedometers has been developed for middle school students to count steps to learn about the importance of increasing activity. Students take the message home and soon entire families are out walking in their tribal communities. Students are given water bottles with the amount of sugar in the same quantity of soda imprinted on them in an effort to encourage children to drink more water. The activity corresponds to a lesson plan on hidden sugar.

To determine what type of prevention education would work with local populations, Kelly advises patient education managers to assemble focus groups. "Focus group testing is not something that you need a sophisticated research grant for. It could be as simple as getting five to eight people from your clinic together and asking their opinions on materials," she says.

States have diabetes prevention programs that target ethnic populations that have settled there and are a good source for information, she notes. For example, many Haitians have immigrated to Florida; therefore, that state would have information on that particular ethnic group. In addition, the National Diabetes Education Program has developed pamphlets that target ethnic groups and are written in several languages.

Providing people with the proper tools to make changes is also important, says Kelly. In a game plan toolkit created by the National Diabetes Education Program, there is a fat and calorie counter and a food and activity tracker. These tools help people monitor the small lifestyle changes they are making and motivate them to continue their efforts to improve their health. Weight loss is often used to monitor progress, and it can take quite a while to see a difference. In the meantime, people can become discouraged and return to their unhealthful habits.

Tailoring the message of diabetes prevention to special populations in their native language with respect for their cultural heritage is critical, notes Maller. It also is important to identify influential community leaders to carry the message back to their communities. "We cannot afford to overlook cultural heritage as we work to restore a culture of health across the country," she says.


For more information about tailoring the message of diabetes prevention to ethnic groups to decrease disparities, contact:

Jane Kelly, MD, Director National Diabetes Education Program, Centers for Disease Control and Prevention, Division of Diabetes Translation, Mailstop K-10, 4770 Buford Highway, Atlanta, GA 30341. Telephone: 770-488-5196 Fax: 770-488-5195. E-mail: jkelly@cdc.gov

Carol Maller, MS, RN, CHES, Diabetes Project Coordinator, Southwestern Indian Polytechnic Institute, 9169 Coors Road, N.W./P.O. Box 10146, Albuquerque, NM 87184. Telephone: (505) 259-4729. Fax: (505) 346-7713. E-mail: cmaller@sipi.bia.edu

National Diabetes Education Program, web site: www.cdc.gov/diabetes/ndep/. Telephone: (800) 438-5383. All publications produced by this group are copyright-free and can be duplicated and distributed.