Type 2 Diabetes among Asian Americans: Effectiveness of a Culturally Tailored Diabetes Education Program
PICOT question: In Asian Americans with type 2 diabetes (P), does a culturally tailored diabetes education program, including patient-specific dietary and lifestyle modifications, (I) reduce A1C levels (O) after 2 months (T) versus a control group of Asian Americans?
Literature Review
According to Nguyen, Fischer, Ha, and Tran (2015), type 2 diabetes mellitus (T2DM) is a growing epidemic in the United States. This is further collaborated by Wang, Wang, and Chan (2013) who observe that the condition is not only a concern in the United States but also across the world. This, according to the authors, is more so the case given that Type 2 diabetes has been associated with multiple complications and comorbidities. Some of the well-documented complications of type 2 diabetes include, but they are not limited to, nerve damage and heart disease.
To demonstrate just how serious the condition really is, Laakso (2010) points out that while it was estimated that a total of 151 million people had diabetes in the year 2000, this figure was projected to grow by almost 50% a decade later. If recent estimates are anything to go by, the number of persons with type 2 diabetes is projected to increase to 552 million by 2030 (Thomas and Ashcraft, 2013). It is for this reason that quite a number of research undertakings have been instituted on the nature, control, and management of type 2 diabetes so as to ensure that adequate strategies are put in place to rein in the condition. Various studies conducted in the past indicate that type 2 diabetes is more prevalent in some demographic groups that in others, with the said prevalence being specifically noted for Hispanic Americans, as well as non-Hispanic Blacks and native Americans (Nguyen, Fischer, Ha, and Tran, 2015). This could be attributed to a myriad of reasons. Laakso (2010) observes that changes in human environment, behavior, and lifestyle have resulted in a dramatic increase in the incidence and prevalence of diabetes in people with genetic susceptibility to diabetes. With regard to changes in environment, Thomas and Ashcraft (2013) observe that Asian Indians, a subgroup of Asian Americans, tend to be at a higher risk of developing the condition. This the authors attribute to the metabolic impact of a westernized diet or reasons based on tissue resistance to insulin (Thomas and Ashcraft, 2013). This, in essence, warrants focused attention to the entire demographic group. In recent times, Nguyen, Fischer, Ha, and Tran, (2015) point out that increasing attention has been drawn to the problem of T2DM among Asian Americans.
As a matter of fact, it should be noted that over time, quite a number of studies have been conducted in an attempt to investigate and examine the claim that Asian Americans have a high risk of type 2 diabetes. Most of the said studies compare the conditions prevalence in Asian Americans in relation to other ethnic formations. In their research piece titled Trends in the Prevalence of Type 2 Diabetes in Asian Versus Whites, Lee, Brancati, and Yeh (2011) come to the conclusion that compared with their white counterparts, Asian Americans have a significantly higher risk for type 2 diabetes, despite having substantially lower BMI. Thomas and Ashcraft are in agreement. In their own words, type 2 diabetes is the fifth leading cause of death in the Asian American population (Thomas and Ashcraft, 2013). However, amongst this general demographic group, the authors point out that Asian Indians are the most afflicted. Others who have reported a higher prevalence of type 2 diabetes among Asian Americans include Alpert and Thomason. The authors note that the prevalence of the condition in this demographic group is largely misunderstood. This is more so the case given the lower BMI levels of Asian Americans in comparison to other demographic groups. More specifically, the authors observe that Asian Americans are not frequently thought of as being obese or overweight yet some of the Asian American subgroups have a disproportionate risk for cardiovascular disease and type 2 diabetes mellitus (Alpert and Thomason, 2016). In essence, obesity, as Ganz, Wintfeld, Li, Alas, Langer, and Hammer (2014) point out, continues to be a significant type 2 diabetes risk factor. In a study seeking to assess and investigate how BMI is tied to the risk of type 2 diabetes, the authors came to the conclusion that not only is BMI strongly and independently associated with the risk of being diagnosed with T2D, but also that the magnitude of this positive association is larger for higher BMI values (Ganz, Wintfeld, Li, Alas, Langer, and Hammer, 2014). It is little wonder, therefore, that most would be concerned that the Asian American demographic group has higher diabetes type 2 prevalence rates despite reporting lower BMI values. It is for this reason that Alpert and Thomason (2016) come to the obvious conclusion, to the effect that: although the standardized body mass index (BMI) assessment is an adequate tool for reporting secular prevalence trends for overweight/obesity across populations, it falls short in accuracy when assessing Asian Americans (Alpert and Thomason, 2016).
According to Lee, Brancati, and Yeh (2011), one of the reasons that have been advanced in seeking to explain the high prevalence of type 2 diabetes amongst Asian Americans is genetic predisposition. In their own words, the authors point out that Asians appear to be more genetically predisposed to develop type 2 diabetes compared with their white counterparts. Other possible explanations include, but they are not limited to, immigration acculturation stress and high visceral fat levels. The authors further point out that both BMI and diabetes prevalence are rising in all Asian subgroups, especially Filipinos (Lee, Brancati, and Yeh, 2011). While the rising diabetes prevalence in this case is well documented and researched issue, there is need for additional research to be conducted on the rising BMI factor among Asian Americans. The rise in type 2 diabetes prevalence levels in recent times in the demographic category under consideration, as suggested by Lee, Brancati, and Yeh is an assertion supported by Nguyen, Nguyen, Fischer, Ha, and Tran (2015), who are also of the opinion that based on available data, type 2 diabetes has been on the increase amongst Asian Americans.
In the past, obesity rates have been reported to be lower amongst Asian Americans in comparison to their white counterparts (Lee, Brancati, and Yeh (2011). It is important to note that according to Wang, Wong, Dixit, Fortmann, Linde, and Palanippan (2011), NHANES data indicates that on average, Asian Americans have a lower average BMI in comparison to other demographic groups. Generally, persons having BMI above 25 are considered to be overweight, with those exceeding 30 deemed to be obese. The survey conducted by NHANES indicates that Asian Americans have an average BMI falling below 25. This, as has been pointed out by Alpert and Thomason (2016), leads to the mistaken belief that Asian Americans are at lower risk of type 2 diabetes than other demographic groups. According to Herman and Rothberg (2016), the greater prevalence of undiagnosed diabetes among Asian American individuals suggests that less screening and diagnostic testing is being performed among less obese Asian American individuals, despite the greater cardiometabolic risk that occurs at lower BMI levels.
As Sun, Tsoh, Saw, Chan, Cheng (2012) point out, very few studies have assessed how effective diabetes education programs that are culture sensitive really are, especially amongst Asian Americans. In a study assessing various populations (i.e. Asian American – AA, Native Hawaiian – NH, and Pacific Islander – PI) and the best strategies to put in place in an attempt to address the special needs of this populations with regard to the management of type 2 diabetes, King, McNeely, Thorpe, and Mau (2011) areof the opinion that the said demographic groups happen to be significantly diverse on the genetic, cultural, and geographic fronts. On this basis, the authors conclude that there is a great need to understand the prevalence and pathophysiology and discuss potential intervention strategies regarding diabetes in AANHPI populations given the unique characteristics of this population (King, McNeely, Thorpe, and Mau, 2011). Being a chronic condition, the need to emphasize self-management as far as type 2 diabetes is concerned cannot be overstated. In essence, self-management has got to do with the development as well as enhancement of skills and capabilities deemed critical towards the promotion of behaviors and habits key to the enhancement of the quality of life for those living with the condition (Sun, Tsoh, Saw, Chan, Cheng, 2012). For this reason, there is a need to take into consideration such factors as how diverse people learn or process information and how prior life experiences impact learning. In essence, this alludes to the need to take culture into consideration in diabetes education programs, including patient-specific dietary and lifestyle modifications, of diabetes type 2. In their study seeking to assess and examine how viable or effective self-management and education programs for diabetes were for Asian-Americans, and more specifically Chinese Americans, Sun, Tsoh, Saw, Chan, Cheng (2012) came to the conclusion that a culturally tailored support group utilizing a community-based participatory research approach is an effective format to improve diabetes self-management skills among Chinese Americans.
By definition, cultural tailoring is, in essence, the design of interventions using information available on the impact cultural characteristics have on health behaviors (Sun, Tsoh, Saw, Chan, Cheng, 2012). Others who have defined cultural tailoring include Wang, Wong, Dixit, Fortmann, Linde, and Palanippan (2011), who point out that the concept has got to do with the application of the native language, integrating cultural dietary preferences, encouraging family participation and support, and holding open discussions of cultural beliefs and treatment practices for diabetes (e.g. home remedies, oriental medicine). As it has been pointed out elsewhere in this text, type 2 diabetes prevalence rates have been on an upward trend amongst Asian Americans. Some of the studies that have been conducted in the past seem to be in agreement that a myriad of factors keep this demographic group from seeking and continuing diabetes interventions, and engaging in effective management practices. These factors are socioeconomic and cultural in nature (Sun, Tsoh, Saw, Chan, Cheng, 2012).
It is important to note that although many diabetes management programs are available in various health institutions, these programs fail to appreciate the special needs of ethnic minorities. Most of the diabetes management programs currently in place are not culturally adapted. As a matter of fact, as Lorig, Ritter, Turner, English, Laurent, and Greenberg (2016), point out, until recently, the need for cultural adaptations in the management of diabetes had not been fully appreciated. The reasons for this are varied, with inadequate research on the effectiveness of a culturally tailored diabetes education program being the main culprit. For this reason, the effectiveness of type 2 diabetes management and intervention measures currently in place could be put into question. According to Ivey et al. (2012), the problem is even more significant amongst Chinese Americans considered to be underserved medically. Apart from ineffective programming, other contributing factors include lack of healthcare insurance amongst members of the demographic group under consideration. This yet again highlights the need for health institutions and centers to incorporate cultural-tailored diabetes programs. It should, however, be noted that various cultural-related circumstances could complicate the treatment and management of diabetes amongst members of the Asian American demographic group. This is particularly the case when it comes to health care services utilization rates. Chinese Americans for instance, according to Wang, Wong, Dixit, Fortmann, Linde, and Palanippan (2011), have been shown to have a cultural reluctance to seek healthcare from individuals or organizations outside of their communities as a consequence of a wide range of factors including, but not limited to, lack of trust in Western doctors.
According to Nguyen, Fischer, Ha, and Tran (2015), there is evidence to the effect that interventions targeting diet and behavioral changes amongst pre-diabetes individuals are effective in reining in the development of type 2 diabetes. Data supporting this assertion comes from the Diabetes Prevention Program, which is in essence a multicenter randomized clinical control trial. More specifically, results from this intervention model indicates that the approach reduced the development of diabetes by 58%, and that the protective benefits persisted over ten years (Nguyen, Fischer, Ha, and Tran, 2015). The authors, however, point out that there is need for continued research in this particular area, particularly given the fact that Asian Americans have cultural norms as well as diets that do not match those of the general population. It would, therefore, be interesting to find out what impact culturally tailored diabetes education programs would have on A1C levels after 2 months amongst the demographic grouping under consideration. As far as control improvements is concerned, Sun, Tsoh, Saw, Chan, Cheng (2012) point out that in one study, a statistically significant reduction in A1C levels was experienced six months from the baseline.
Research studies conducted on the effectiveness of diabetes education programs in place further reinforce the assertion that there is need for interventions that are culturally adapted in seeking to bring down mortality and morbidity rates related to diabetes amongst Asian Americans. Prevention efforts, in the words of Nguyen, Fischer, Ha, and Tran (2015), need to be culturally tailored to meet the unique needs of the various Asian American ethnic groups. This is more so the case given that data presented by various studies over time indicates that this specific demographic group has a higher prevalence of the condition than whites. Ivey et al. (2012) are in agreement. According to the authors, very few interventions have been developed or adapted for Chinese Americans with diabetes. As the authors further point out, there are is need to develop interventions tailored specifically for Asian Americans, and more specifically Chinese Americans. There is sufficient evidence indicating that diabetes self-management education interventions designed specifically for underserved ethnic-specific groups (i.e., interventions that specifically incorporate sociocultural aspects) can significantly improve outcomes, including improvements in health behavior and knowledge, health status, and self-efficacy (Ivey et al., 2012).
According to Nguyen, Fischer, Ha, and Tran (2015), the Asian American health services have for many years been under the mistaken belief that this particular demographic group suffers lower disease burdens. This is a myth that was in the past promoted by the lack of reliable data that often lumped Asian Americans into one large category, when in fact they represented a heterogeneous group (Nguyen, Fischer, Ha, and Tran, 2015). A study of this nature is highly relevant as the population of Asian Americans in the U.S. has been growing exponentially within the last few decades (Lee, Brancati, and Yeh 2011). As a matter of fact, a decade ago, the Asian American population was, according to King, McNeely, Thorpe, and Mau (2011) considered to be the fastest growing population in the U.S., having expanded six times faster than the general population un the 1990s.
Lee, Brancati, and Yeh (2011) call for additional research on the higher prevalence of type 2 diabetesamongst Asian Americans, with the aim of tailoring optimal diabetes prevention strategies to Asian Americans. In their study, Ivey et al. (2012) conclude that it is feasible to implement a culturally tailored, linguistically appropriate teamed model of care for Chinese Americans with type 2 diabetes. This is an assertion supported by Sun, Tsoh, Saw, Chan, Cheng (2012), who in their study found out that cultural tailoring not only enhanced participation in diabetes self-management efforts, but it also increased knowledge, and resulted in better glycemic control for patients with diabetes, thereby mitigating their risks for microvascular problems. Others who are in agreement are Wang, Wong, Dixit, Fortmann, Linde, and Palanippan. In their own words, Wang, Wong, Dixit, Fortmann, Linde, and Palanippan (2011) point out that culturally sensitive lifestyle changes, including promotion of physical exercise and diet modification in a relevant context (e.g., recommendations on how to modify traditional recipes and portion sizes), have been shown to significantly decrease the progression of type 2 diabetes in Asian Indians and Filipinos. According to Ivey et al. (2012), an approach of this kind has also been shown to reduce the levels of A1C. This is more so the case considering trends in A1C improvement during 6-month pilot (Ivey et al., 2012).
In the final analysis, it is important to note that the number of studies focusing on diabetes amongst Asian Americans have increased in recent times as the prevalence of type 2 diabetes amongst this demographic group continues to be significantly high in comparison to other demographic categories. These populations need diabetes interventions that are culturally tailored to address their special needs. This is also an issue of great relevance at the policy level. In essence, an increase in the prevalence of diabetes in the United States would definitely burden the countrys healthcare system, with 12% of Americans already being affected by the condition (Konchak, Moran, OBrein, Kanduls, and Ackermann, 2016). At present, the healthcare system is feeling the weight of an increase in a variety of lifestyle diseases as a consequence of poor lifestyle decisions including, but not limited to, poor eating habits and lack of exercise (Bodenheimer, Chen, and Bennett, 2009). As Thomas and Ashcraft (2013) point out, based on the American Community Survey, between 2000 and 2010, the Asian Indian population in the USA grew by 67.60% (3.2 million) and represented the third largest Asian subgroup in the US. This is a point of view reinforced by Cobly and Ortmans assertion (as cited in Alpert and Thomason, 2016) to the effect that the reason for concern is because the Asian American population is one of the nations fastest growing ethnic/racial groups, growing at a rate four times that of the total U.S. population. As it has been pointed out elsewhere in this text, amongst the Asian American group, the Asian Indian subgroup happens to have the highest type 2 diabetes prevalence (Thomas and Ashcraft, 2013). For this reason, the results of this study would come in handy as far as the provision of the relevant information is concerned to aid in not only the formulation, but also the implementation of valid and viable diabetes management strategies and interventions.
References
Alpert, P.T. & Thomason, D. (2016). Metabolic Syndrome: Differences for Asian Americans is in their Body Fat Percentages. Asian/Pacific Island Nursing Journal, 1(3), 70-81.
Bodenheimer, T., Chen, E. & Bennett, H.D. (2009). Confronting the Growing Burden of Chronic Disease: Can The U.S. Health Care Workforce Do The Job? Health Affairs, 28(1), 64.
Ganz, M., Wintfeld, N., Li, Q., Alas, V., Langer, J. & Hammer, M. (2014). The Association Of Body Mass Index With The Risk Of Type 2 Diabetes: A CaseControl Study Nested In An Electronic Health Records System in the United States. Diabetology & Metabolic Syndrome, 25(2), 93-102.
Herman, W. & Rothberg, A.E. (2016). Prevalence of Diabetes in the United States: A Glimmer of Hope? JAMA, 314(10), 92-107.
Ivey, S., Tseng, W., Kurtovich, E., Lui, B., Weir, R.C., Liu, J., Song, H., Wang, M. & Hubbard, A. (2012). Evaluating a Culturally and Linguistically Competent Health Coach Intervention for Chinese-American Patients with Diabetes. Diabetes Spectrum, 25(2), 93-102.
King, G.L., McNeely, M.J., Thorpe, L.E. & Mau, M.L. (2011). Understanding and Addressing Unique Needs of Diabetes in Asian Americans, Native Hawaiians, and Pacific Islanders. Diabetes Care, 35(5), 1181-1188.
Konchak, J.N., Moran, M.R., OBrein, M.J., Kanduls, N.R. & Ackermann, R.T. (2016). The State of Diabetes Prevention Policy in the USA Following the Affordable Care Act. Curr. Diab. Rep, 16(1), 55.
Laakso, M. (2010). Cardiovascular Disease in Type 2 Diabetes from Population to Man to Mechanisms. Diabetes Care, 33(2), 442-449.
Lee, J.W., Brancati, F.L. & Yeh, H. (2011). Trends in the Prevalence of Type 2 Diabetes in Asians versus Whites. Diabetes Care, 34(2), 353-357.
Lorig, K., Ritter, P.L., Turner, R.M., English, K., Laurent, D.D. & Greenberg, J. (2016). JMIR, 18(12), 322-339.
Nguyen, T.H., Fischer, T., Ha, W. & Tran, T.V. (2015). Type 2 diabetes among Asian Americans: Prevalence and prevention. World J Diabetes, 6(4), 543-547.
Sun, A.C., Tsoh, J.Y., Saw, A., Chan, J.L. & Cheng, J.W. (2012). Effectiveness of a Culturally Tailored Diabetes Self-Management Program for Chinese Americans. Diabetes Educ., 38(5), 685 694.
Thomas, A. & Ashcraft, A. (2013). Type 2 Diabetes Risk among Asian Indians in the US: A Pilot Study. Nursing Research and Practice, 24(6), 324-341.
Wang, Z., Wang, J. & Chan, P. (2013). Treating Type 2 Diabetes Mellitus with Traditional Chinese and Indian Medicinal Herbs. Evidence-Based Complementary and Alternative Medicine, 93 (2), 118-136.
Wang, E.J., Wong, E.C., Dixit, A.A., Fortmann, S.P., Linde, R.B. & Palanippan, L.P. (2011). Type 2 Diabetes: Identifying High Risk Asian American Subgroups in a Clinical Population. Diabetes Res Clin Pract, 93(2), 248-254.
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