Complete Nurse's Guide to Diabetes Care, 3rd Edition

Chapter 20:

Cultural Context of Diabetes Prevention and Self-Management Education

Kelley Newlin Lew, DNSc, C-ANP, CDE,1 and Gail D’Eramo Melkus, EDD, C-ANP, CDE, FAAN2

1Newlin Lew is an assistant professor at the University of Connecticut, School of Nursing in Storrs, CT. 2D’Eramo Melkus is associate dean of research at the New York University, College of Nursing in New York, NY.

Diabetes has emerged as a national epidemic with ethnic minority populations disproportionately burdened by the disease and many of its complications. Currently, 15.9% of Native Americans/Alaskan Natives, 14.7% of Native Hawaiian/Pacific Islanders, 13.2% of non-Hispanic blacks, 12.8% of Hispanics, and 9.0% of Asian Americans have diabetes relative to only 7.6% of non-Hispanic whites.1,2 Additionally, ethnic minority populations remain unequally affected by numerous diabetes-related complications:

•Eye disease or visual impairment secondary to diabetes is 1.2 times higher in non-Hispanic blacks relative to non-Hispanic whites.3

•End-stage renal failure secondary to diabetes is 3.8 times greater for non-Hispanic blacks, 3.5 times greater for Native Americans, 1.6 times greater for Hispanics, and 1.5 times greater for Asian Americans relative to non-Hispanic whites.3–5

•Lower-extremity amputations secondary to diabetes are highest among Native Americans and 2.7 times higher for non-Hispanic blacks relative to non-Hispanic whites.3,4

•Premature death secondary to diabetes is 2.2 times higher for non-Hispanic blacks, 2 times higher for Native Americans, 1.5 times higher for Hispanics, and 1 times higher for Asian Americans/Pacific Islanders relative to non-Hispanic whites.3–6

Diabetes health disparities persist although substantial, compelling evidence indicates diabetes may be prevented and controlled with significant reductions in risk for related complications. The Diabetes Prevention Program, a 16-week intervention emphasizing diabetes education, diet, physical activity, and behavior modification, prevented or delayed type 2 diabetes (T2D) onset with a 58% and 34% lower incidence for the intervention group, relative to control, at 3- and 10-year follow-up, respectively.7,Similarly, diabetes self-management education interventions, emphasizing diabetes knowledge, related skill acquisition, diet, and physical activity along with behavior modification, demonstrate efficacy in improving A1C (the gold standard indicator of glycemic control).9–11 Meta-analytic findings report diabetes self-management education reduces A1C levels by ~1%.12Clinically relevant, each 1% reduction in mean A1C level is related to a 37% decrease in the risk of kidney and eye disease and a 21% reduction in the risk of any diabetes-related complication or death.13

A gap exists, however, in what we know can prevent or control diabetes and its complications, and the care actually received by ethnic minority populations. Nurses now and in the future will play a vital role in addressing this gap as the largest segment of health-care professionals providing diabetes prevention and self-management education for patients and families. Addressing the gap will require that nurses address barriers to care for ethnic minority populations, which include medical distrust, poor communication, and lack of shared decision-making in care plan development with providers.14 Shared decision-making is a bidirectional relationship between patient and provider involving deliberation, negotiation, and agreement about the most suitable treatment plan.15

To overcome these barriers, it is essential that nurses, along with other providers, fully address the cultural context of diabetes for individual patients and families. This entails understanding and appreciating their explanatory models (i.e., how they construct meaning and approach concerns) of diabetes prevention and management. Influenced by culture, patient or family explanatory models inform causes for and experiences of living with prediabetes or diabetes as well as guide patients when seeking care and education.14 Without understanding patient explanatory models of diabetes, nurses, trained in the Western-dominant culture, unintentionally may marginalize or discount patient illness experiences and care preferences. A lack of effective communication in the health-care encounter thereby may ensue. Limited trust and satisfaction with the health-care provider may follow as well as missed opportunities for shared decision-making to address diabetes prevention or self-management.14,16

The American Diabetes Association (the Association) and American Association of Diabetes Educators (AADE) strongly recommend that diabetes prevention and self-management education address cultural factors. The Association’s clinical care guidelines and the AADE’s standards for diabetes education underscore the significant influence that cultural factors may have in adherence to prevention and self-management regimens, and thereby physiological outcomes. 17,18


Culture is a concept that is derived from anthropological and sociological concepts. Leininger, a nursing anthropologist, defines culture as the “learned and shared beliefs, values, and lifeways of a designated or particular group that are generally transmitted intergenerationally and influence one’s thinking and action modes.”18 Mechanic, a medical sociologist, proposes that great variation exists in behaviors among people within a particular cultural group; therefore, observed cultural patterns may be considered only rough approximations of how people act in specific contexts.19 Thus, among any ethnic or cultural group, there is a great degree of within-group variation in terms of socioeconomic status, traditions, concepts of health and illness, and personal identity.20 On the basis of both anthropological and sociological concepts, the Office of Minority Health, U.S. Department of Health and Human Services, defines culture as “integrated patterns of human behavior that include language, thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups.”21 Note, however, that membership within a given cultural group may or may not delineate a person’s ethnic affiliation.

Often, the term cultural competence is used interchangeably with cultural sensitivity, cultural awareness, cultural congruence, cultural relevance, and other related terms, suggesting that these terms are synonymous. They are in fact conceptually distinct. Cultural sensitivity or awareness refers to the examination of a person’s own assumptions regarding other cultural groups and becoming aware of how these notions might affect perceptions and prejudices of culturally different groups.22 Cultural congruence refers to a match between the delivery of care and the cultural values, beliefs, and patterned behavior of the care recipients.23 Cultural relevance involves the perception of the care recipient in terms of the cultural appropriateness of the delivery of health services. Cultural competence, as suggested by the Office of Minority Health,21 involves the actual integration of consistent behaviors, attitudes, and policies in the delivery of health care in cross-cultural situations. This involves blending congruent behaviors, attitudes, and policies in systems, in agencies, among professionals, and in therapeutic interventions to effectively work within cross-cultural contexts involving the beliefs, behaviors, communication patterns, and needs of health-care consumers and their communities.24

The research literature suggests that culturally competent or relevant health-care interventions may result in improved diabetes outcomes for ethnic minority patients. One systematic review, for example, examined the evidence on culturally competent interventions tailored to the needs of people with diabetes from diverse ethnic groups. Findings indicated that structured interventions tailored to ethnic minority groups by integrating elements of culture, language, religion, and health literacy skills produced a positive impact on a range of patient-important outcomes.25 Another systematic review, evaluating culturally component care interventions for Hispanics with diabetes, reported improved A1C values for program participants across a majority of studies.26

Closely related to the concept of cultural competence is cultural leverage. Cultural leverage refers to the application of cultural competence in health-care interventions. Cultural leverage is a focused approach for improving the health and well-being of racial or ethnic communities through behavior change with the application of their distinct cultural practices, products, philosophies, and environments. Cultural leverage has the potential to be operationalized across all levels of the health-care delivery process. Using the concept of cultural leverage and related strategies, a review of 38 interventions aimed at decreasing health disparities found similar results, with the majority of the outcomes being significantly improved.27

Patient-Centered Care, Cultural Competence, and Rules for Health-Care Delivery Redesign

To address national health inequities, the Institute of Medicine (IOM), in its seminal report, Crossing the Chasm, identified aims for health-care delivery improvement. This report emphasizes the critical importance of patient-centered care, and to facilitate operationalization of this concept, identifies rules for health-care delivery redesign. Patient-centered care refers to “care that is respectful and responsive to individual patient preferences, needs and values, and ensuring that patient values guide all decisions.”28 Inherent in this definition are cultural and religious preferences, and health-care provider acknowledgment that such preferences may shape health-care decisions based on value systems. Therefore, similar to cultural competence, patient-centered care should be operationalized at the patient, provider, and system levels in an attempt to provide quality health care from processes to outcomes.

Comparing and contrasting the concepts of patient centeredness and cultural competence, Saha et al.29 noted a great deal of overlap in the two concepts in terms of respective attributes and definitions such that the emphasis is on the individuality of each person and their unique orientation. The overlap in concepts and processes is depicted in Figure 20.1. It could be argued that cultural competence is a prerequisite for patient-centered care and that quality health-care outcomes are dependent upon it.

Figure 20.1—Overlap between patient-centered care and cultural competence at the interpersonal level

Figure 20.1—Overlap between patient-centered care and cultural competence at the interpersonal level.

Source: Saha et al.29

To facilitate operationalization of patient-centered care, among other health-care improvement aims, the IOM28 outlined rules for health-care delivery redesign. Key rules include: 1) care is customized according to patient needs and values; 2) the patient is the source of control; and 3) knowledge is shared and information flows freely. These rules for health-care delivery redesign will promote success when implementing patient-centered care and the closely related concept of culturally competent care. Customizing care according to patient needs and values requires systems resources to accommodate the cultural needs of diverse ethnic groups, such as religious or spiritual preferences in health-care settings, as well as more common health-care needs. To ensure that the patient is the source of control, patients should be given the necessary information to exercise control over health-care decisions while also encouraging shared decision-making between patients and providers. When knowledge is shared and information flows freely, effective communication (a critical component of patient-centered and culturally competent care) is fostered between patients and providers, as well as access to personal medical information and clinical knowledge. Collectively, successful achievement of the IOM28 aims for health-care delivery improvement, particularly patient-centered care, and related key rules for operationalizing this concept has the potential to effectively ameliorate the disparate burden of diabetes among diverse ethnic minority populations.


Ethnicity more specifically defines a person’s race, religion, national or geographic origin, or symbolic identification. Although there is no scientific or biological basis of race, the terms race and racism have meaning as social constructs and therefore have social connotations that differ from ethnicity.30 Although cultural competency is necessary for providing diabetes care and education to any given group, cultural assessment of each patient is necessary to prevent cultural stereotyping.

Cultural Health Beliefs and Practices

Beliefs of health and illness are derived from heritage and cultural phenomena that vary among cultural, religious, and ethnic groups. As stated, great within- and between-group diversity among any given group leads to a multicultural identity for many individuals. Thus, the domains of culture may vary based on the extent to which an individual has become acculturated to the dominant culture and the degree to which individuals have maintained their traditional heritage.31 Studies have shown that the more acculturated an individual is, the more likely he or she is to exhibit autonomy in the patient role and with patient–provider interactions,32,33 consistent with the U.S. or Western model of health-care delivery. Even when patient autonomy is present, however, individuals from different ethnic groups often rely on family involvement in the context of illness, regardless of their personal cultural identity. This is particularly true of Native Americans, whose family centeredness is often constant regardless of acculturation level, tribal affiliation, and family lifestyle (traditional or bicultural).34 Native Americans frequently value guidance and direction from the extended family above personal autonomy, in contrast to the dominant Western culture, and therefore may defer important health-care decisions until family preferences are considered.35

Spiritual and Religious Beliefs and Practices

Spirituality and religion are prominent cultural factors across U.S. ethnic groups, demonstrating constancy independent of other culturally related factors. In fact, most Americans (97%) consider themselves spiritual, religious, or both.36 Furthermore, many Americans indicate that spirituality and religion are important components of health, reporting the use of prayer in a medical context (67%) and the desire that physicians be “spiritually attuned to them” (70%).37 Spirituality and religion, although often used interchangeably, are conceptually different but related terms. Spirituality, as a broader term, often is defined by such attributes as transcendence, hope, strength, identification of meaning and purpose in life, and interconnectedness with others, God, or a higher power.38–41 Spirituality is further referred to as a source of peace, coping, and guidance.40 Religion may be conceived of as an organized system of beliefs and practices that provides intellectual, behavioral, and social forms to spiritual expression and thereby nurtures a relationship with God or a higher power.38,39,41

Religion and spirituality may contribute to diabetes prevention and self-management in terms of both psychosocial and physiological outcomes. Accumulating research indicates religion and spirituality are related to psychological well-being, coping styles or strategies, and glycemic control levels.42–47 The theoretical literature suggests psychosocial factors may mediate the significant associations observed between religion or spirituality and glycemic control, although beginning quantitative research in this area is inconclusive.47,48 The research literature suggests religious or church-based settings may be optimal venues for diabetes prevention and self-management education programs to maximize cultural leverage, particularly for Black and Hispanic Americans.49–56 According to the qualitative literature, religious or spiritual beliefs may limit or enhance confidence in the effectiveness of daily diabetes self-management.57–61 For some, religious or spiritual beliefs may foster deferring coping styles with relinquishment of diabetes self-management to God. For others, religious or spiritual beliefs may promote responsibility for diabetes self-management with increased psychological well-being and active or constructive coping styles and strategies.47,57–59,61–63

Hence, in clinical practice, increased awareness of specific spiritual and religious health beliefs and practices (see Table 20.1) is warranted because they may inform an individual’s approach to, preferences for, and behaviors in daily self-management of diabetes. Yet across and within ethnicities, religious or spiritual health beliefs and practices may be interfused with ethnically based values and traditions to varying degrees, further influencing a person’s orientation to health and illness.

Table 20.1—Religious Health Beliefs, Practices or Restrictions, and Dietary Habits Relevant to Diabetes Care

Table 20.1—Religious Health Beliefs, Practices, or Restrictions, and Dietary Habits Relevant to Diabetes Care

Table 20.1—Religious Health Beliefs, Practices, or Restrictions, and Dietary Habits Relevant to Diabetes Care, continued

Table 20.1—Religious Health Beliefs, Practices, or Restrictions, and Dietary Habits Relevant to Diabetes Care, continued

African Americans

Ethnically diverse, the population of Black Americans is among the most likely to report a formal religious affiliation (87%). Black Americans report formal affiliations most frequently with historically Black Protestant and Evangelical Protestant churches followed by Catholic, Jehovah’s Witness, and Islam, among other faiths.74

Most commonly affiliated with historically Black Protestant or Evangelical Protestant churches, Black Americans often share common religious beliefs or practices.74 For many Protestants, God or Jesus is believed to be the “supreme healer” or “divine physician.”67,75 His healing powers may be realized through faith and related religious or spiritual practices, such as prayer, scripture reading, and laying on of hands.67,76 Although often sharing common religious beliefs and practices, Protestant Black Americans, including those with African or Hispanic ethnic roots, may approach diabetes self-management differently based on conceptualization of God’s healing powers. For many Black Americans, their religious orientation guides them to assume responsibility for diabetes self-management, believing God’s healing powers are made manifest through application of medical knowledge with divine guidance. Following this orientation, Black Americans commonly feel obligation to care for their body, as the vessel of the Holy Spirit. Reports also suggest, however, that some Black Americans may prefer to surrender responsibility for diabetes self-management to God with demonstration of faith in His healing powers to cure disease.56–59,63

Haitian Americans most commonly subscribe to the Catholic faith.77,78 As with many Protestants, Catholics often believe illness may result from sin. According to Catholicism, forgiveness for sin with healing may occur through the sacraments (rituals manifesting Christ’s presence and grace) with less emphasis on personal relationship with God or Jesus.64,79 Catholic Haitians, however, may resist the sacrament of anointing the sick, fearing it is associated with death. Haitian Americans, including those with diabetes, may prefer to pray directly to God for healing and guidance with diabetes self-management.64,78 Others may take a more passive approach to diabetes prevention or self-management, believing outcomes may be determined by God’s will.77,78

Haitian Americans also may blend Catholicism with Voodoo. The Gods of Voodoo, the Loas, represent the spirits of African ancestors, Catholic Saints, and deceased family members. The Loas are perceived as guardian angels and protectors. Haitian families may have specific Loas that are passed down from generation to generation. In exchange for their protection, devotees must perform certain rituals to satisfy the Loas. Failure to do so may result in Loas’ retaliation in the form of illness, divorce, and other misfortunes. Hence, Haitian Americans may attribute the onset of diabetes and other illnesses to neglect of the Loas. Haitian Americans therefore may seek care from a Voodoo practitioner or participate in ceremonies honoring the Loas to be relieved of illness. Regardless of whether Haitian health beliefs are guided by Catholicism, a combination of Catholicism and Voodoo, or another religious framework, many Haitian Americans may be reluctant to engage in traditional Western diabetes care, preferring instead to seek out medical or nursing care once symptoms suggest care is undeniably warranted.77,78,80

Hispanic Americans

Following Blacks, Hispanics are the second most likely American population to report a religious affiliation. Almost 75% of American Hispanics report a religious affiliation, with most identifying themselves as Catholic (68%) or evangelical Protestant (15%).74 America’s Hispanic population consists of individuals of Mexican, Cuban, Puerto Rican, Central American, and South American descent, among others. Within this broadly defined ethnic population, spiritual or religious health beliefs and practices may be heterogeneous, despite the predominance of Catholicism. Mexican Americans, for example, may mix elements of Catholicism with Native American traditions, practicing curanderismo. Curanderismo is a folk medicine aimed at restoring balance among the spiritual, psychological, and physical through prayers, rituals, herbal remedies, and states of consciousness. Traditionally, curanderos are lay community members with expertise in treating folk and nonfolk illnesses, but increasingly, professional nurse-curanderos are emerging.81,82

Some Cuban Americans blend Catholicism with West African (Yoruba) tribal beliefs and practices into a religion called Santeria (also known as Regla de Ocha). Believers of this religion may view illness as caused by natural or spiritual intrusions into the body. Spiritual rebirth, protection, and cleansing may be sought with assistance from a santero, or spiritual healer, which may involve ritualistic spells, magic, and animal sacrifice.82–84Likewise, some Cuban and Puerto Rican Americans may integrate elements of Catholicism with both African and Indian beliefs, practicing espiritismo. According to this religious tradition, spirits may influence the health of individuals. Spiritual healers, or espiritistas, communicate with spirits to restore physical and emotional well-being.82 Related rituals may involve topical herbs, aromatic ointments or liquids, and prayers.85,86

Although some Hispanics may integrate elements of curanderismo, santeria, or espiritismo into their health practices, more traditional Christian beliefs and practices are reported as a source of guidance, support, and strength in self-managing diabetes.59,61,62,82 Regardless of religious tradition or related ethnic infusion, Hispanic Americans often report their religious faith and spiritual practices serve as an important source for coping with the daily demands of diabetes.

Native Americans

For Native Americans, as well as other ethnic minority populations, religious or spiritual beliefs and practices may be highly individualized. Yet, Native Americans, belonging to more than 300 individual tribal traditions, often view health and wellness as harmony with natural, social, and supernatural environments.65 Illness thus is viewed as disharmony or disruption in the delicate balance among these environments. Health maintenance or restoration may be achieved with traditional religious or spiritual practices, including cleansing sweats, prayer, and intervention of a medicine man or woman.65,68,70,87,88 Certain illnesses, however, such as diabetes, may be considered “non-Indian” diseases. In such cases, traditional Western medicine may be preferred and integrated with religious healing practices.70 Some Native Americans with diabetes, however, may rely on spiritual practices, such as those performed by a medicine man, especially when Western approaches have failed.88 Other Native Americans with diabetes may rely more on a personal relationship with God, the Creator, to cope with the emotional demands of diabetes. Some report drawing on their relationship with God for guidance and support in making positive diabetes-related behavioral changes, such as dietary changes.89

Irrespective of spiritual or religious approaches to diabetes, studies suggest ethnic minority populations may experience a lack of respect and communication in health-care encounters.90–92 In this setting, trust is not established and sharing of personal, sacred beliefs and practices is unlikely. African Americans with diabetes, for example, report that providers fail to take their religious beliefs seriously despite the centrality of God in their daily lives. In the absence of discussing religious beliefs and practices in health-care encounters, African Americans report agreeing to physician recommendations for diabetes management while intending to exclusively care for their diabetes with spiritual and folk remedies.93 Likewise, among Hispanics with diabetes, limited provider attention to their religious and spiritual beliefs may adversely affect the health-care encounter. Research indicates that, despite the salience of religious beliefs and practices among Hispanic patients, diabetes care providers do not routinely address these important cultural factors.94,95 Sometimes fearing ridicule, Native Americans report reluctance to share their religious experiences with health-care providers and may deliberately avoid adherence to prescribed diabetes self-management regimens.35,96

Overall, diverse religious and spiritual beliefs and practices play a salient role, to a greater or lesser degree, in diabetes prevention and self-management efforts for ethnic minority populations. Yet, research suggests religion and spirituality may not be addressed adequately in the provision of diabetes care.58,62,88 In the context of mistrust and poor communication, ethnic minorities may be reluctant to share their sacred beliefs and practices. Research suggests, however, that trust in providers may be fostered through respectful listening, authentic concern, and collaborative care planning.14,96 A comprehensive cultural assessment, conducted respectfully and authentically, as part of the diabetes education and collaborative care process may facilitate enhanced communication and the development of trust.


A cultural assessment addresses patient beliefs and practices in the context of the larger reference group, the family, and the individual. Culturally competent education and care requires skills of individualized cross-cultural communication, assessment, interpretation, and intervention.97,98 These skills are based on the cultural and linguistically competent care recommended by the Office of Minority Health, U.S. Department of Health and Human Services in the National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care, known as the enhanced National CLAS Standards. This document, Blueprint for Advancing and Sustaining CLAS Policy and Practice, is aimed at ensuring that health-care providers and health-care organizations implement and sustain culturally and linguistically appropriate services given the continued increased diversity in the U.S. (Table 20.2).98

Table 20.2—Standards for Culturally and Linguistically Appropriate Services Summarized by Themes

Standards 1–3: Culturally Competent Care

• Ensure diverse staff

• Ongoing training of staff

Standards 4–7: Language Access Services

• Bilingual staff

• Interpreter services

• Printed patient materials

Standards 8–14: Operational Support for Cultural Competence

• Community collaborations

• Demographic database

• Organizational assessment

Source: From Office of Minority Health, U.S. Department of Health and Human Services.98


The first step in cross-cultural communication and counseling is self-assessment. Health-care providers will have to identify cultural assumptions by reviewing their own social, religious, and personal beliefs and practices, particularly those related to health and illness. Diabetes education and care are focused on self-management of dietary intake, physical activity, medications, and screening and care practices for prevention of complications (e.g., eye examinations, foot care, and dental care). Therefore, nurses and other health-care providers who are involved in diabetes education and care must evaluate their own attitudes, beliefs, values, and norms that are related to having a chronic illness such as diabetes.

Religion and Spirituality

As a component of the cultural assessment, the patient’s individual religious or spiritual health beliefs and practices may be assessed. Several religious and spiritual clinical assessment frameworks have been advanced across health-related disciplines.99–104 When considered collectively, key components of a religious and spiritual assessment relevant to diabetes self-management emerge: 1) religious or spiritual identity and community; 2) religious or spiritual health beliefs and practices or rituals; and 3) integration of religion or spirituality into diabetes care (see Table 20.3). In new health-care relationships, some patients may perceive a religious or spiritual assessment as intrusive, whereas others may not. Those in an established health-care relationship may welcome and appreciate clinical acknowledgement of their religion or spirituality, engaging in discussion of associated health beliefs and practices. Certain patients may find it challenging to articulate their religious or spiritual health beliefs and practices as they pertain to diabetes. Pursuing verbal and nonverbal indicators may prove helpful in such instances.99 In any case, the religious or spiritual assessment process should be conducted in a nonthreatening, nonjudgmental manner to convey respect for and encourage open responses from the patient.105 The religious or spiritual assessment process may yield information suggestive of religious struggle or conflict. Clinicians without expertise in religious counseling may refer patients to professional religious or secular counselors as indicated.106

Table 20.3—Religious/Spiritual Assessment Relevant to Diabetes Self-Management: Key Components and Related Questions

Table 20.3—Religious/Spiritual Assessment

Source: Rivera,61 Carbone et al.,62 Samuel-Hodge et al.,63 Pew Research Center,74 and Glanville.75

Performing a religious or spiritual assessment may promote development or refinement of collaborative diabetes prevention and self-management plans congruent with the cultural orientation and preferences of care recipients. Research suggests addressing religion or spirituality in the context of diabetes care and education may foster greater motivation and responsibility for daily disease management while also fostering greater confidence and trust in the health-care provider.57,88

Nutrition and Meal Planning Dietary Practices

Diet and nutrition therapy is a core component of education and care for people with or at-risk for diabetes. For the majority of individuals with T2D, such care is focused on individualized meal planning modification for the purpose of weight loss and maintenance. Attitudes and beliefs about eating, body shape, and weight will influence the process and outcomes of nutrition therapy as well as physical activity recommendations. In conducting an assessment of personal attitudes toward patterns of food use, shape, and weight, health-care providers should acknowledge their own cultural assumptions and preferences, which may differ from those of other ethnic groups. In terms of weight and shape, white women often experience the greatest social pressure for thinness, whereas black women may not perceive weight as a problem when compared with a reference group of other black women.107,108 In some cultures, eating and overweight are equated with good health and thinness with illness. On the basis of such assumptions, suggestions to change dietary patterns and food preferences may be met with resistance.

Attitudes and practices related to types of food also differ among groups, and taking time to learn about a patient’s culture is another important aspect of cross-cultural counseling. For example, in certain European countries, corn is animal feed unfit for human consumption, whereas corn is a core food with spiritual connotations for some Native American groups (leading to the U.S. practice of using corn as both livestock feed and human food). Core foods and conventional methods of preparation are important factors for consideration in planning cross-cultural meal planning interventions. Japanese, Chinese, Korean, and other Asian groups, like many Hispanic groups, use rice as a core food, whereas Italians use pasta and Native Americans use cornmeal. Many African Americans, including those of Caribbean descent, enjoy fried foods, whereas West Africans use stews. Many African Americans, as well as various other groups living in or from the U.S. South, may be accustomed to conventional southern-style cooking, including fried foods. The cultural context of regional cooking needs to be considered in addition to ethnic and religious practices to avoid making generalized assumptions of food practices.

In many ethnic cultural groups, nutrition-based dietary practices and religious or spiritual beliefs are related. Chinese people with chronic illness, for example, use dietary manipulation based on the concepts of yin and yang to restore balance and health.109 Yin conditions (negative, dark, and cold) of yin organs, such as the heart, lung, liver, spleen, and kidney, are treated with yang (or hot) foods, such as ginger or beef. Yang conditions (positive, light, and warm) of the yang organs, such as the stomach, gallbladder, intestines, and bladder, are treated with yin (or cold) foods, such as coconut or pork. This association of hot and cold foods with health and illness is also found among Mexican and Filipino people. For instance, chest pain is considered a cold disease brought on by cold air or cold foods, such as tropical fruits, fresh vegetables, or dairy products, and is treated with hot foods, such as herbal teas, soups, and temperate-zone fruit. Some African Americans rely on folk medicine remedies, such as blueberry tea, peach tree leaves tea, lemon juice, vinegar, and aloe vera, to lower blood glucose or prevent diabetes-related complications.110,111

Practical Point

Four Steps to Cross-Cultural Counseling

1. Self-evaluation of own culture

• Review past and present social, religious, and personal beliefs and attitudes about health, illness, food, and food use

2. Learn patient culture

• Research written materials

• Talk with friends or colleagues of the same ethnic group as the patient

• Eat in a restaurant or visit a food store of the patient’s ethnic background

3. Interview patient

• Offer opportunities for family or other caregivers to participate as appropriate

4. Analyze information and plan intervention

• Identify cultural beliefs, practices, traditions, food preferences, meals, and patterns of eating

• Incorporate findings into management strategy

• Involve the patient in setting goals

Communication and Interaction Class Standards

Interactions between patients and health-care providers are heavily influenced by the personal beliefs and communication strategies of both parties. This communication consists of both verbal and nonverbal expression. Cultural differences in eye contact, touching behaviors, and personal space vary among cultures. For example, some Native Americans believe that avoidance of eye contact is a sign of respect and that a handshake is a sign of courtesy.34 The goals of communication between the patient and health-care provider are to 1) create a good interpersonal relationship; 2) exchange information, which consists of both giving and receiving information; and 3)make treatment decisions. These goals of communication are difficult to achieve when language and cultural barriers exist, underscoring the need for cultural literacy and linguistic competency.112 A recent study to identify barriers in the provision of diabetes care in 42 Midwestern community health centers found that providers frequently identified language or cultural barriers as elements that hinder the quality of patient education.113 Health-care providers can evaluate their cultural and linguistic competencies by using the Inventory for Assessing the Process of Cultural Competence Among Health Care Professionals.114 (see also the Additional Reading at the end of this chapter).


The goal of diabetes prevention and self-management education is to help the patient and family achieve optimal glycemic control and improved quality of life. In recognizing the increasing diversity of individuals affected by diabetes, patient-centered and culturally competent care must be incorporated into clinical practice and education programs. Patient-centered and culturally competent care are integral to the Patient Protection and Affordable Care Act of 2010 (ACA) to foster quality outcomes.

It has been written that “although the knowledge of differences between cultures may be useful, the knowledge of what is health and illness in different cultures does not reveal the how of being in the care experience as it is actually lived.”115 Cross-cultural counseling is an opening step in the long process of understanding and facilitating cultural diversity and specificity in the context of culturally competent diabetes education and care. Such may be facilitated through cultural leverage that involves individuals in the “lived experience” and employs strategies and processes of cultural competence. The goal of equitable health care for all people can be met only through a combination of approaches that minimizes the barriers for individuals from different cultural, ethnic, racial, and socioeconomic backgrounds and results in the delivery of patient-centered and culturally competent care.


1. Centers for Disease Control. Racial and ethnic differences in diagnosed diabetes among people aged 20 years or older, United States, 2010–2012. 2014. Available from Accessed 15 August 2014

2. U.S. Department of Health and Human Services, Office of Minority Health. Diabetes and Native Hawaiians/Pacific Islanders. 2014. Available from Accessed 15 August 2014

3. U.S. Department of Health and Human Services, Office of Minority Health. Diabetes and African Americans. 2014. Available from Accessed 15 August 2014

4. U.S. Department of Health and Human Services, Office of Minority Health. American Indians/Alaska Natives and Diabetes. 2014. Available from Accessed 15 August 2014

5. U.S. Department of Health and Human Services, Office of Minority Health. Diabetes and Hispanic Americans. 2014. Available from Accessed 15 August 2014

6. U.S. Department of Health and Human Services, Office of Minority Health. Diabetes and Asians and Pacific Islanders. 2014. Available from Accessed 15 August 2014

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9. Attridge M, Creamer J, Ramsden M, Cannings-John R, Hawthorne K. Culturally appropriate health education for people in ethnic minority groups with type 2 diabetes mellitus. Cochrane Database Syst Rev 2014;(9):CD006424

10. Padgett D, Mumford E, Hynes M, Carter R. Meta-analysis of the effects of educational and psychosocial interventions on management of diabetes mellitus. J Clin Epidemiol 1988;41:1007–1030

11. Gary TL, Genkinger JM, Guallar E, Peyrot M, Brancati FL. Meta-analysis of randomized educational and behavioral interventions in type 2 diabetes. Diabetes Educ 2003;29:488–501

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