Culturally relevant tools needed to improve diabetes care in immigrant communities
In this issue, Susan Weiner, MS, RDN, CDE, CDN, talks with Carol Brunzell, RDN, LD, CDE, about developing a picture-based carbohydrate-counting resource for people with type 1 diabetes in a Somali community in the United States. Brunzell is an expert on providing specialized medical nutrition therapy to adult and pediatric patients with type 1 and type 2 diabetes, cystic fibrosis- related diabetes, diabetes in pregnancy and diabetes with celiac disease and other comorbidities. She has traveled with her pediatric diabetes endocrine team to East Africa for the past several years teaching diabetes management to health care professionals and working with children with type 1 diabetes in clinics.
How did this project get started?
Brunzell: I work with both children and adults with type 1 diabetes as a dietitian and diabetes educator. In the pediatric side of my job, I work with a team of endocrinologists and nurse diabetes educators. Over the years, we have seen increasing numbers of Somali pediatric patients with type 1 diabetes as the immigrant population has grown. Minnesota has approximately 38,500 Somali residents and is home to the largest Somali population in the United States. In one study, type 1 diabetes prevalence was estimated at about 1 in 400 Somali children and adolescents. Similarly, in Finland, which is also home to a large Somali immigrant population, investigators found that the incidence of type 1 diabetes in Somali children is similar to that of the general pediatric population in Finland. Control of diabetes has been noted to be poorer in Somali youths compared to non-Somali youths with type 1 diabetes attending the same clinics.
Our University of Minnesota Health pediatric diabetes team embarked on this project to develop culturally relevant education materials to assist families and children in managing their diabetes. The team was led by pediatric endocrinologist Muna Sunni, MBBCh, MS. The goal was to develop a tool, which would be widely available online free of charge, to assist patients in our own clinics as well as in other immigrant communities around the world and for patients with diabetes in Somalia.
What were some obstacles that led to the development of these materials?
Brunzell: Managing type 1 diabetes is especially challenging for immigrant families coming from countries with few resources. Language barriers and variable education levels of parents, with low literacy rates particularly among women who are typically the primary caregivers, in addition to social barriers and stressors make management more challenging. Somali families identified carbohydrate counting for traditional Somali foods especially difficult due to lack of resources available affecting their ability to manage their child’s diabetes effectively.
What foods comprise the typical Somali diet?
Brunzell: The traditional diet includes a variety of foods that vary slightly from region to region in Somalia. Typical carbohydrates consumed include rice, spaghetti, soor (Italian polenta) and a variety of breads: canjeero/lahoh (thin unsweetened pancake), malawah (thin sweet pancake), muufo (similar to cornbread) roti (flatbread) and sabaayad (chapati). Other grains consumed alone or in breads are oatmeal, barley, teff and sorghum. The breads may be served with added oil, butter, sugar, honey, sweet tea, or spiced meat and vegetable stews (suqaar). Proteins consist of beef, goat, lamb, camel, goat liver and kidney, chicken, fish and eggs. Vegetables are commonly eaten in stews or soups, in addition to salads. A banana is traditionally served with lunch. A wide variety of fruits are consumed. Beverages consist of very sweet teas (chai), juice with added sugar, and milk. Oil is used liberally in cooking and is added to many foods. Dinner is served late, around 9 p.m., and may consist of beans or beans mixed with various grains called cambuulo and/or roti. American foods may be more commonly consumed at the later meal along with traditional Somali food. A variety of special sweets and other fried snack foods are served during Ramadan.
What process did you use to develop these materials?
Brunzell: Traditional Somali foods were selected for this project after gathering information from hundreds of food recall questionnaires from Somali adults and children, discussions with a local Somali dietitian, home visits with Somali volunteers who prepared traditional meals with project staff, attendance at lectures on Somali food and culture given by members of the Somali community, and visits to local Somali grocery stores and restaurants. We also searched the internet for Somali diet information and recipes. I prepared the most common foods from a traditional Somali cookbook. I made carbohydrate calculations using the USDA National Nutrient Database for Standard Reference and Nutrition Facts labels on food packages. Calculations of the carbohydrate content of traditional foods were made by preparing individual food items, measuring total yield and total carbohydrates of all ingredients and dividing by the number of servings and the serving size to be consumed. All prepared foods were measured using standard measuring cups or weighed on a digital scale for carbohydrate estimation. For prepared foods purchased without a nutrition facts label, carbohydrate content was estimated using similar foods with known carbohydrate and weighed on a digital scale.
What has been the reaction from the Somali community?
Brunzell: It has been heartwarming to see the reaction of patients and parents to this guide. They are so happy to see a carbohydrate-counting guide with their traditional foods. I continuously ask for their feedback and if I have missed any foods. So far, everyone is very pleased and tells me I have included all the typical foods. We have also recorded nine diabetes education videos spoken or dubbed in Somali, which will be freely available at a later date. I made one video on nutrition, carbohydrate counting, and how to calculate insulin doses based on an insulin-to-carbohydrate ratio for sample meals and snacks. It was a great pleasure to be a part of this project and to learn so much about Somali foods and the community, and people are genuinely appreciative. The link to the carbohydrate guide and article is listed below.
- Oilinki T, et al. Pediatr Diabetes. 2012;doi:10.1111/j.1399-5448.2011.00783.x.
- Sunni M, et al. J Community Health. 2015;doi:10.1007/s10900-015-0006-4.
- Sunni M, et al. Pediatr Diabetes. 2017;doi:10.1111/pedi.12369.
- Sunni M, et al. J Int Med Res. 2018;doi:10.1177/0300060517718732.
- For more information:
- The picture-based carbohydrate-counting resource is available at: http://journals.sagepub.com/doi/suppl/10.1177/0300060517718732/suppl_file/Supplementary_material.pdf. Accessed Feb. 20, 2018.
- Carol Brunzell, RDN, LD, CDE, is a certified diabetes educator at the University of Minnesota Health in Minneapolis. She can be reached at email@example.com.
- Susan Weiner, MS, RDN, CDE, CDN, is the 2015 AADE Diabetes Educator of the Year and author of The Complete Diabetes Organizer and Diabetes: 365 Tips for Living Well. She is the owner of Susan Weiner Nutrition, PLLC, and is the Endocrine Today Diabetes in Real Life column editor. She can be reached at susan@ susanweinernutrition.com.
Disclosures: Brunzell reports no relevant financial disclosures. Weiner reports she is a clinical adviser to Livongo Health.