Building Cultural Competency for Improved Diabetes Care: Asian Americans and Diabetes

Assistant Professor of Medicine, Harvard Medical School Director, Asian Clinic, Joslin Diabetes Center, Boston, Massachusetts

Assistant Program Director, Family Medicine Stamford Hospital/Columbia University, Program in Family Medicine, Clinical Instructor, Family Medicine, University of Connecticut School of Medicine Stamford, Connecticut

Type 2 diabetes mellitus (T2DM) is an ever-increasing cause of significant morbidity and mortality worldwide. As one of the most common chronic diseases our nation is facing today, it is also a major contributor to rising health care costs. Complications from uncontrolled T2DM result in significantly higher per-patient health care costs for patients with diabetes compared to health care costs for nondiabetic patients.¹

Genetic factors play an important role in the development of T2DM, with prevalence among some ethnic groups—including certain Asian American groups—considerably higher than among white Americans.¹ Studies have shown that glucose control is also significantly poorer in this subgroup of patients.²

The need to address these ethnic disparities has led to the growing interest in cultural competency in medical care. While patient-centered care has tended to focus on the patient as a unique person, cultural competency recognizes that the individual is a product of his or her culture.³ The degree of disparity also varies, depending on how long the individuals have been living in the United States and how Americanized these individuals are. Patients whose health care providers may need a higher level of cultural competency include those who have recently emigrated from their home countries and those who have been residing in the United States for a long time but have not acculturated to the mainstream society, a scenario highlighted in the following case study.

 

CASE STUDY

Mrs Hu is a 54-year-old Chinese American woman who immigrated to the United States with her husband several decades ago. Her husband had worked for many years in the dry cleaning business, and they enjoyed a modest but comfortable lifestyle. Mrs Hu has associated mainly with other families who immigrated from nearby regions of her homeland.

Mrs Hu was recently widowed, and she has moved in with her son and his family. Her son is concerned that his mother did not take care of herself while caring for her dying husband. He brings her to Dr Smith for a checkup. He reports to Dr Smith that it has been several years since his mother has seen a Western health care provider, preferring instead to visit the neighborhood Chinese healer.

 

Asian American Demographics

Asian Americans are a very diverse and rapidly growing segment of the American population. Between 1990 and 2000, the Asian American population grew by 48%, far above the national growth rate of 13%.⁴ By 2000, Asian Americans made up 4.2% of the US population, and it has been projected that this figure will increase to 10.7% by the year 2050.⁵

To address the cultural issues in this ever-growing group, it is important to understand the diversity within the Asian American population. Included in this group are Chinese, East Indians, Filipinos, Vietnamese, Koreans, Japanese, and Pacific Islanders, among others. There are at least 49 ethnic groups speaking more than 100 languages and dialects.⁶

Despite the considerable diversity within the Asian American population, certain factors are common to many groups. A 1985 survey found that Asian Americans were more likely than white Americans to be without health insurance,² which limits their access to health care. Although the median family income is higher for Asian Americans as a group compared with the general population, socioeconomic status tends to be lower in certain groups,⁷ which is an independent risk factor for poor health.² Although the degree of language barriers as well as the immigration experiences among the different Asian American ethnic groups and individuals vary, the overall pattern contributes to the disparities in care received by various ethnic populations in the US health care system.

It is important to recognize that some of these issues can only be addressed on a system-wide level. However, others can be improved by the efforts of individual health care providers. It is through the careful study of the cultural beliefs, family relationships, views of illness, and styles of communication of Asian Americans that a provider can develop the appropriate approaches and skills to provide cross-cultural care.

 

CASE STUDY

During her visit with Dr Smith, Mrs Hu prefers to sit in the chair in the examination room rather than on the examination table. She tends to be quiet and brief with her responses and does not elaborate much in response to open-ended questions. Her son helps with translation, as she speaks limited English.

Dr Smith learns that Mrs Hu has been relatively healthy and has had no major health issues in the past. Her son does note, however, that over the last 6 months his mother has mentioned being very thirsty, and he has noticed that she needs to urinate quite often, which has disturbed her sleep. Mrs Hu has lost some weight despite having a good appetite, and her son reports that she has had several urinary tract infections that she has treated with herbal remedies. She fatigues easily and recently has been unable to perform her usual household activities.

During the physical examination, Mrs Hu appears fatigued but not in acute distress. Mrs Hu is 5 feet 3 inches tall and weighs 126 pounds. Her body mass index (BMI) is 22.3 kg/m². Vital signs show a pulse rate of 74, blood pressure levels of 134/88 mm Hg, respiratory rate of 14, and body temperature of 97.8°F. Her physical examination is unremarkable. A routine in-office urinalysis reveals the presence of both glucose and protein. A finger stick blood glucose test reveals a glucose level of 212 mg/dL. Her son reports that they last ate several hours ago and planned to have dinner upon their return home from today’s visit.

Dr Smith orders blood work, including a CBC, a chemistry panel with liver function, glycosylated hemoglobin (A1C), lipid profile, and microalbumin tests. He instructs Mrs Hu and her son that she cannot eat or drink anything after midnight that night. Mrs Hu’s son will bring his mother to the laboratory the following morning. Dr Smith asks that Mrs Hu return with her son at the end of the week to review the results and determine any appropriate follow-up care that may be needed.

When Mrs Hu and her son return to the office, Dr Smith reviews Mrs Hu’s laboratory results. Although the CBC and liver function tests are normal, Mrs Hu’s fasting plasma glucose (FPG) is 202 mg/dL and her A1C level is 9.3%. Her total cholesterol level is 238 mg/dL. The high-density lipoprotein (HDL) level is 46 mg/dL, the low-density lipoprotein (LDL) level is 165 mg/dL, and the triglyceride level is 345 mg/dL. Mrs Hu’s creatinine is normal at 0.8 mg/dL. Her urinary albumin to creatinine ratio is 89 mcg/mg. On recheck, Mrs Hu’s blood pressure is 134/82 mm Hg.

Dr Smith explains to Mrs Hu and her son that Mrs Hu has type 2 diabetes and recommends initiating oral therapy with metformin and glipizide. Dr Smith also provides a referral to a certified diabetes educator (CDE) for a review of dietary choices and for Mrs Hu to learn glucose self-monitoring. Mrs Hu’s son agrees to accompany his mother to the visit with the CDE.

Dr Smith recommends that Mrs Hu begin taking an angiotensin-converting enzyme (ACE) inhibitor to lower her blood pressure and as a renal protective measure, as well as a statin to help lower her cholesterol level. He also prescribes a daily aspirin.

Before Mrs Hu leaves with her prescriptions, Dr Smith inquires about any alternative therapies Mrs Hu is taking on a regular or intermittent basis. She acknowledges that she is taking an herbal tea daily that is believed to balance glucose levels and help with digestion. Dr Smith does some research and finds that, although there is no proven benefit, there are also no known adverse effects or interactions with the medications he has prescribed.

Mrs Hu accepts the prescriptions for the medications without question, listening closely as her son explains the plans. They agree to return in 1 month for a follow-up visit.

 

Discussion Points

The interview with Mrs Hu brings out several aspects of certain traditional Asian cultural values. For example, patients may not proactively ask questions and may not openly disagree with the health care provider about medical regimens. These behaviors stem from the belief system that such actions are disrespectful and are to be avoided. Health care providers can put their patients at ease by encouraging them to ask questions and eliciting their opinions on the prescribed medical regimen.

In addition, Asian culture is generally considered to be a “low-touch” society.⁸ Therefore, an explanation of what the health care provider will be doing during the examination can often diffuse a patient’s discomfort. Health care providers may find that the interview process tends to be unidirectional, with the provider led to ask more closed-ended questions. Much of the issue has to do with lack of linguistic proficiency. Techniques that may be helpful include using shorter and more simple sentences and speaking more slowly. The approach of asking more closed-ended questions is in contrast with what physicians are typically taught during training, which is to focus on more open-ended questions. This traditional open-ended questioning approach, although still valuable and appropriate in many patient encounters, may not always be the best for those patients who have limited English proficiency. Care must also be taken to extend the invitation for questions multiple times during the interview. This may facilitate greater information exchange during the visit.

Whenever a family member is acting as an interpreter, it is important to consider the capability of the family member to accurately convey the medical information being communicated. Studies show that the use of trained interpreters leads to higher-quality communication than translation by family members or untrained staff.⁹

Family obligations in Asian American culture generally are given higher priority than personal needs and wants.⁴ This is illustrated both in Mrs Hu’s dedication to her husband’s needs despite her own health issues and in her son’s concern for providing care for her after the death of his father. Indeed, Mrs Hu agreed to see Dr Smith only because she is concerned that her health is affecting her ability to perform her household duties.

 

Asian Americans and Diabetes

Several important aspects of the risk of diabetes in the Asian American population have become more apparent in recent years. For example, although first-generation Asian Americans tend to have lower body weight and BMI measurements, they have a greater prevalence of T2DM than the general population. Therefore, in this population, providers must be more aware of the need to screen patients even at a weight or BMI lower than one that would usually trigger suspicion.² In contrast, second- and later-generation Asian Americans tend to have higher body weight and are prone to developing T2DM at younger ages. Finally, Asian Americans have higher rates of certain complications such as end-stage renal disease.¹⁰

Some studies have shown that Asian Americans can tend to have lower levels of physical activity,¹¹ which increases their T2DM risk. In addition, as Asian Americans adapt to the American culture, dietary changes that occur (otherwise referred to as the Americanization of the typical Asian diet) likely have a dramatic impact on their risk of developing T2DM and cardiovascular disease, among other conditions.

Perspectives on factors influencing health and resulting in disease are quite different in the Asian American culture than in the American culture. There is a strong belief in the role of environmental factors, food choices, mental balance, and family harmony in the development of disease. One of the key aspects of the Asian American view on health is that of balance. Commonly known as yin and yang, Asian Americans typically seek balance in all aspects of their lives. The concept of balance includes viewing foods, illness, and treatments as being hot or cold.¹² These beliefs affect food choices, the willingness to take medicines, and the use of alternative therapies, including herbal remedies, acupuncture, and other traditional Asian physical therapies—a distinction that is often more true for Oriental than for East Indian cultures.

To achieve compliance with recommended therapies, health care providers must understand how medical recommendations interact with their patients’ beliefs. Only in this way can they provide care that is harmonious with the belief system of Asian American patients and facilitate improved health outcomes.

 

CASE STUDY

Mrs Hu returns in 1 month. Her physical examination is unchanged. Her FPG is now 208 mg/dL. Urinalysis continues to show protein and glucose, and her A1C level is only slightly decreased to 9.1%. Mrs Hu’s son reports that she has been feeling better and sometimes skips some of her medication as a result.

Dr Smith reviews Mrs Hu’s glucose diary, as well as the food diary that the CDE has asked her to keep. Dr Smith notes that there is significant carbohydrate intake. Her meals tend to consist of rice or noodles, with several side dishes made from fresh vegetables, meat, or poultry. Fruit is often consumed as a dessert dish.

Dr Smith asks Mrs Hu about her eating patterns. She explains that she prepares the meals with her daughter-in-law for the whole family to enjoy. She believes that her selections provide balance among the various types of foods, and she does not feel that she should deprive the family of any part of the meal because she is supposed to restrict her food choices.

Dr Smith, aware of the importance of food to Mrs Hu’s cultural and family values, decides that insulin will be the most effective way to provide adequate control of her glucose levels, while allowing her the flexibility to continue participating in family meals. Dr Smith decides to continue the metformin but discontinue the glipizide and initiate neutral protamine Hagedorn (NPH) insulin because Mrs Hu cannot reach an A1C level of less than 7% with other medications. She is instructed to begin with a twice-daily injection of 10 units, with dosing to be adjusted weekly as needed.

Mrs Hu expresses concern that the insulin will be too strong for her. In addition, she is concerned that having to take shots and the accompanying risk of hypoglycemia will be too disturbing to her family.

Dr Smith acknowledges her concerns, explaining that the insulin will restore the balance in her body. He further explains that the insulin is a replacement for the substance her body is no longer making. Dr Smith also enlists Mrs Hu’s son to address his mother’s concerns about her family. Her son explains how important it is to the family that she take care of herself so she can be healthy and continue to help care for them.

Mrs Hu agrees to start the insulin therapy that Dr Smith has recommended. She seems quite pleased with the permission to continue family meals in her usual tradition while reducing her own carbohydrate intake and increasing her intake of fruits and vegetables. Dr Smith advises Mrs Hu and her son on the use of insulin and the importance of regularly monitoring her blood glucose levels. Mrs Hu and her son agree to return in 1 week with her glucose diary.

One week later, Mrs Hu and her son return and Dr Smith reviews Mrs Hu’s glucose diary. Although the FPG is 123 mg/dL, the postprandial values—especially after dinner—remain high. This prompts Dr Smith to initiate bolus therapy with a rapid-acting insulin analog (4 units of insulin aspart) with the main meal, in addition to increasing the dose of NPH insulin by 2 units. Another follow-up visit is arranged for 1 week later, at which time Mrs Hu’s glucose levels seem stable. There have been no episodes of hypoglycemia. Mrs Hu and her son agree to return in 2 months.

 

Discussion Points

This conversation illustrates a key aspect of the culture of many Asian Americans. Food is essential to harmony and family relationships. The focus is on balancing yin and yang foods, texture, color, and aroma in addition to the nutritional quality of the food.¹³ Having meals together is an important means of relating within the family and, for Chinese Americans, protecting the quality and taste of meals for the family is often more important than managing personal health issues.⁴

In addition, providing food is often a means of expressing care for an individual. Family members often provide food aimed at restoring balance. For example, special teas or soups prepared with herbal supplements may be given to restore health and vitality.¹³ This arises from the belief that a lack of balance can be the cause of illness and that restoring that balance is essential to treating it.^4,13

Many Asian Americans are often reluctant to take medications, believing that dietary changes can restore balance and that Western medications will be too strong.^12,13 Dr Smith skillfully allayed this fear by relating the need to take insulin to Mrs Hu’s view of disease and treatment. However, in the case of T2DM, the provider must be sure to explain that the medications, including insulin, must be continued to maintain balance, as Asian Americans often believe that medications can be discontinued once balance is restored.¹²

Involving family members in encouraging patients to participate in treatment recommendations and reminding patients of their social or family responsibilities can be essential to good management of diabetes in the Asian American population. In fact, the need to maintain social and family responsibilities can be a major motivator for complying with recommended care.⁴ However, providers must be cognizant of relationships within families. In Asian American families, age, gender, and the family member’s relationship to the patient may determine who can participate or even have knowledge of medical issues.⁴

In this case, Dr Smith takes care to explain to Mrs Hu that her body is out of balance and that this is affecting her ability to do the things she cares about. Dr Smith also explains that this imbalance could cause more health problems and affect her abilities even further in the future if it is not treated properly.

 

CASE STUDY

At the 2-month checkup, Mrs Hu’s A1C level is down to 7.0%. Dr Smith performs a thorough foot examination and educates both Mrs Hu and her son on the importance of regular foot care and self-examination. Mrs Hu also receives pneumococcal and influenza vaccinations, and an ophthalmology appointment is arranged. Mrs Hu and her son agree to return in 3 months for a follow-up visit.

 

Principles of Diabetes Management

Effective management of T2DM has clearly been shown to delay or prevent the development of complications.¹⁴ National guidelines recommend a team approach to the management of diabetes in order to focus on all aspects of care.¹⁵ Important aspects to address with the diabetic patient include nutrition and dietary counseling, physical activity, treatment selection, glucose self-monitoring, psychosocial aspects of the disease, managing concurrent illnesses, and immunization needs.¹⁵

Decisions about medication selection are vital and are growing more complicated with the development of new treatment options. Vast amounts of literature have been published to help guide the provider through the various choices, with the focus being on achieving targeted glycemic control.

Recommended management also includes regular screening for complications, which includes monitoring lipid profiles, renal function, and blood pressure, as well as routine dilated eye examination, foot examination, and assessment for neuropathy.¹⁵

 

CASE STUDY

Mrs Hu returns in 3 months. Her physical examination is still unremarkable. Her blood pressure is now 120/72 mm Hg. She no longer has protein or glucose on urinalysis. Her FPG is 112 mg/dL, and her A1C level is 6.9%. She states that she is feeling much better and has significantly more energy. She has had a few episodes of hypoglycemia, but she is aware of the signs and was able to take some food to counteract them. Because of these bouts of hypoglycemia, Dr Smith decides to change Mrs Hu’s NPH insulin to insulin glargine, 16 units once daily, to be injected at bedtime.

Mrs Hu’s son informs Dr Smith that his wife has started walking daily with his mother as a way to increase Mrs Hu’s activity level. By doing this together, Mrs Hu feels she is also helping her daughter-in-law to increase her activity level and optimize her health as well.

Dr Smith provides some resources for the family so they can become involved with other Asian Americans in the area who are dealing with diabetes. The community leaders have started a support group, and Mrs Hu seems interested in participating and sharing her experiences with others.

 

Discussion Points

Mrs Hu has had great improvement in her T2DM through the use of insulin analogs. The enhanced control of a basal-bolus regimen enabled her to reach her A1C goal of less than 7% with a minimum of side effects. By presenting the need for insulin in the correct manner, Dr Smith was able to achieve compliance and enhance patient satisfaction. And by enlisting her family in providing direct and indirect encouragement, Dr Smith was able to help Mrs Hu overcome her fears of the medications and improve her physical activity status.

The use of complementary and alternative therapies is very common among Asian Americans.⁵ It is imperative, therefore, that the health care provider specifically inquire about the use of such treatments, as some of these remedies may interact with standard medications or result in adverse effects.

The use of community resources is very helpful in providing comprehensive and relevant care to Asian Americans with diabetes.^16,17 From the provision of translators, to the education of clinicians, to the sense of community support provided for the patient, these resources can help to erase the disparities in health care for Asian Americans with T2DM.

 

Summary

The United States has long been known as a melting pot of cultures. The current growth of various ethnic groups within the population ensures that this tradition will continue. Although all ethnic groups tend to assume some characteristics typical of the American culture, most also retain very distinct aspects of their native culture. Effective delivery of medical care requires that health care providers be educated about and respectful of these beliefs and traditions. Health care providers’ continued focus on attaining cultural competency will enable all ethnic groups to obtain equal access to quality medical care.

References

1. Lipsky MS, Zimmerman BR. Diagnosis and Management of Type 2 Diabetes. An American Family Physician Monograph. Kansas City, MO:AAFP; 1999.
2.  Asian American Health: Myths and Facts. Newton, MA: CEO Services; February 1999.
3. Beach MC, Saha S, Cooper LA. The role and relationship of cultural competency and patient-centeredness in health care quality. 2006. US Department of Health and Human Services. http://www.thinkculturalhealth.org. Accessed March 31, 2007.
4. Chesla CA, Chun KA. Accommodating type 2 diabetes in the Chinese American family. Qual Health Res. 2005;15:240–255.
5.  Complementary and alternative medical therapy use among Chinese and Vietnamese Americans. http://www.cmwf.org/publication/publications_show.htm?doc_id=365994. Accessed March 31, 2007.
6.  Diabetes education fact sheet. Background on Asian Americans and Pacific Islanders. http://www.aapcho.org/altruesite/files/aapcho/Publications_FactSheets/diabetes%20education %20fact%20sheet.pdf. Accessed March 31, 2007.
7. Reeves TJ, Bennett CE. We the People: Asians in the United States. Census 2000 Special Reports. December 2004.
8. Juckett G. Cross-cultural medicine. Am Fam Physician. 2005;72:2267–2274.
9. Betancourt JR, Green AR, Carrillo JE, et al. Defining cultural competence: a practical framework for addressing racial/ethnic disparities in health and health care. Public Health Rep. 2003;118:293–302.
10. Karter A, Ferrara A, Liu J, et al. Ethnic disparities in diabetic complications in an insured population. JAMA. 2002;287:2519–2527.
11. Kandula NR, Lauderdale DS. Leisure time, non-leisure time, and occupational activity in Asian Americans. Ann Epidemiol. 2005;15:257–265.
12.  Using focus groups to gain an understanding of living with diabetes in various communities. http://www.cdc.gov/diabetes/pubs/focus/lessons.htm. Accessed March 31, 2007.
13. Lin K. Chinese food cultural profile. Food and nutrition. http://www.ethnomed.org/ethnomed/cultures/chinese/chinese_food.html. Accessed March 31, 2007.
14.  American Academy of Family Physicians and American Diabetes Association. The benefits and risks of controlling blood glucose levels in patients with type 2 diabetes mellitus. A review of the evidence and recommendations. http://www.aafp.org. Accessed March 31, 2007.
15.  American Diabetes Association. Standards of medical care in diabetes. V. Diabetes care. Diabetes Care. 2006;29(suppl 1):S8–S17.
16.  Association of Asian Pacific Community Health Organizations. BALANCE program for diabetes. http://www.aapcho.org/site/aapcho/section. php?id=10937. Accessed March 31, 2007.
17. Hsu W, Cheung S, Ong E, et al. Identification of linguistic barriers to diabetes knowledge and glycemic control in Chinese Americans with diabetes. Diabetes Care. 2006;29:415–416.