Evaluation of research methodologies and outcomes

Type 2 diabetes (T2D) is a major chronic illness in the U.S., with 84 million adults being pre-diabetic (Centres for Disease Control and Prevention, 2017). Whereas risk factors are numerous, minority groups are at a particularly greater risk for T2D compared to the rest of the population. The high risk stems in large part from acculturation challenges – difficulties associated with adapting to the host country’s social and cultural norms (Deng, Zhang & Chan, 2013). This is especially true for Asian Americans (King, 2014), with prevalence for T2D being estimated at 9% (Nguyen et al., 2015). Appropriate intervention strategies are important for preventing type T2D in this group. Literature demonstrates that education can be useful for preventing the condition (Kerr et al., 2011; Deng, Zhang & Chan, 2013). This paper provides an evaluation of literature relating to T2D prevention through education. The evaluation is premised on the following PICOT question: Population (Asian Americans newly diagnosed for type 2 diabetes), Intervention (health education to implement patient-specific dietary and lifestyle modifications), Comparison (patients who receive culturally tailored diabetes education with those patients who just receive standard education), Outcome (reduction of A1C levels), and Timeframe (3 months after initial diagnosis).
Education is a powerful intervention for preventing diabetes among Asian Americans. According Dr. George L. King, a board member of the American Diabetes Association and a practitioner at the Joslin Diabetes Centre, diabetes awareness among Asian Americans remains a major problem (King, 2014). Asian Americans and even healthcare providers have little or no knowledge of the risk. This is particularly because body mass index (BMI) is not a significant threat for the community like other ethnic communities. It is imperative for healthcare providers to understand what works for the Asian American community, and provide guidelines that resonate with the unique needs of the community and individuals.
Diabetes treatment and prevention interventions generally advocate for diet and lifestyle modifications (Theobald, 2014). For Asian Americans, adhering to a traditional Asian diet with high fibre and low fat and maintaining a physically active lifestyle can be helpful in preventing and managing T2D (King, 2014). Accordingly, educational interventions should focus on familiarising Asian Americans with diets and lifestyles that would help reduce the risk of T2D. Though King (2014) offers valuable insights on T2D risk among Asian Americans and prevention measures, his insights are not preceded by empirical data. Even so, King boasts a strong reputation in diabetes research and practice, making his insights credible. The usefulness of education in T2D prevention has also been supported by Kerr et al. (2011). Nonetheless, though with a large sample (n = 3,871), Kerr et al.’s (2011) study did not specifically focus on T2D education – the main focus of the study was to investigate five-year mortality rates for patients diagnosed with T2D and attending a community-based education program.
T2D education is more effective if it reflects the individual needs of the patient (Nguyen et al., 2015). In other words, it is important to handle T2D patients on a case by case basis. This is because different individuals may have different risk factors, especially in terms of medical history, age, and BMI. Moreover, different individuals may have different preferences for diet and exercise. This means that diets or exercises that may be likable for some individuals may not necessarily be likable for others.
Whereas education is important for T2D prevention, it may be of little use if it is not culturally-appropriate. The importance of culturally-appropriate T2D education is demonstrated in a review of literature by Deng, Zhang & Chan (2013). Cultural values, beliefs, and practices tend to differ from one racial or ethnic group to another. Accordingly, educational interventions that may work for Caucasians or Latino Americans may not necessarily be appropriate for Asian Americans. As demonstrated in a similar literature by Nguyen et al. (2015), the importance of considering cultural factors especially emanates from the strong connection between culture and dietary habits. Since nutritional therapy constitutes an important aspect of T2D prevention, considering the dietary choices or habits of the group in question is essential. For instance, recommending pork consumption to patients of an Islamic background would be inappropriate since Muslims do not eat pork. Equally, Indians may feel offended if beef is included in the dietary guidelines as they view cows as sacred animals.
Culturally-appropriate nutritional education means that the prescribed dietary and physical exercise guidelines ought to be acceptable to the target audience with respect to food preferences, liking, pleasantness, and palatability (Deng, Zhang & Chan, 2013). For instance, the Chinese generally prefer traditional foods (e.g. starchy vegetables, ethnic breads, rice, and noodles), meaning that adherence to dietary guidelines is likely to be higher if the recommended diets include more traditional foods and less or no Western diets. Research has shown that these diets can lower the incidence of diabetes (King, 2014). However, most Asian Americans shift to Western diets once in the host country, consequently increasing the risk for diabetes. The risk is especially compounded by the greater amount of abdominal fat in Asian Americans compared to other ethnic groups (King, 2014).
A systematic review of nine articles published since 2000 also demonstrates the usefulness of culturally-appropriate education for preventing T2D among Asian Americans (Sun et al., 2012). The review, which specifically focused on studies describing interventions for Asian Americans with T2D, shows that Asian cultures are unique, hence the need for culturally-responsive interventions. A major strength of the review is that all the studies included used either a randomised controlled trial (RCT) or quasi-experimental design. Experimental studies are the gold standard of research as they demonstrate cause-and-effect relationships. Nonetheless, the number of studies (9) included is quite small.
Cultural sensitivity also encompasses considering common values and language capabilities (Deng, Zhang & Chan, 2013). For instance, Asian Americans value family harmony immensely. This means that dietary guidelines that are not culturally acceptable may result in conflict between family members as well as between the patient’s family and healthcare providers. Considering language barriers is even more important. Most Asian Americans have little or no English proficiency. This may affect adherence to dietary guidelines (Sun et al., 2012). Therefore, providing guidelines in a manner that is understandable is crucial for effective T2D prevention amongst Asian Americans. On the whole, culturally-appropriate education is vital for ensuring adherence to dietary guidelines. Whereas the three reviews (Sun et al., 2012; Deng, Zhang & Chan, 2013; Nguyen et al., 2015) provide valuable insights on culturally-appropriate education, they fail to consider other factors that may elevate the risk for T2D such as age, genetic history, and economic status.
On the whole, if effectively adhered to, educational interventions for T2D could lead to lower A1C levels, eventually delaying or avoiding the onset of the condition (Nguyen et al., 2015). Also, educational interventions can contribute to positive psychobehavioural outcomes (Sun et al., 2012). Achieving these outcomes, however, requires robust commitment from the patient (Theobald, 2014) – it is a long term commitment, not a one-time undertaking.
The evaluated literature will be useful for the author’s DPI project. The literature provides valuable information on the usefulness of personalised and culturally-appropriate education in preventing and managing T2D among Asian Americans. The information will be useful in formulating, implementing, and evaluating an educational program for the target population.


References
Centers for Disease Control and Prevention. (2017, June 01). About Diabetes. Retrieved from https://www.cdc.gov/diabetes/basics/diabetes.html
Deng, F., Zhang, A., & Chan, C.B. (2013). Acculturation, Dietary Acceptability, and Diabetes Management among Chinese in North America. Front Endocrinol (Lausanne), 4: 108.
Kerr, D., Partridge, H., Knott, J., & Thomas, P. W. (2011). HbA1c 3 months after diagnosis predicts premature mortality in patients with new onset type 2 diabetes. Diabetic Medicine, 28(12), 1520-1524.
King, G. L., Dr. (2014, May 05). Stopping Diabetes in the Asian American Community. Retrieved from http://diabetesstopshere.org/2014/05/01/stopping-diabetes-in-the- asian-american-community/
Nguyen, T. H., Nguyen, T.-N., Fischer, T., Ha, W., & Tran, T. V. (2015). Type 2 diabetes among Asian Americans: Prevalence and prevention. World Journal of Diabetes, 6(4), 543–547. http://doi.org/10.4239/wjd.v6.i4.543
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. The Diabetes Educator, 38(5), 685–694. http://doi.org/10.1177/0145721712450922
Theobald, M. (2014, September 16). 5 Ways to Lower Your A1C. Retrieved from https://www.everydayhealth.com/hs/type-2-diabetes-live-better-guide/lower-your-a1c/