Diabetes Prevalence in the Somali Community
According to the American Diabetes Association, as of 2015, approximately 30 million Americans were living with diabetes and nearly 1.5 million new cases were being diagnosed annually (American Diabetes Association, 2018). While these figures represent the sum of all genders, ages, and races of patients affected by the disease, there remains some disparity in the number of affected patients in each category. When compared to the makeup of the general population, one such category in which we see a correlation between diabetes disease prevalence and patient demographic is that of patient race.
In this paper, we will hone in on the issue of diabetes prevalence in African Americans, specifically in the Somali immigrant community. We will look at the issues contributing to the disparity in occurrence rates in the Somali population vs. other non-Somali populations, the impact that the prevalence of diabetes in this community has on the healthcare system, and also at ways in which our healthcare system can work with Somali patients to combat the disease through both prevention and effective treatment.
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Of the Somali population in the U.S., (many of whom reside in Minnesota), many have come to America as immigrants or refugees. When compared to U.S.-born patients afflicted with diabetes, diabetic patients with immigrant or refugee status are less likely to adhere to a prescribed diabetic care plan (Wieland, Morrison, Cha, Rahman, & Chaudhry, 2011). This lack of adherence is a compound problem, often consisting of a combination of non-compliance with medication dosing and administration schedules, failure to complete routine follow up physician visits and ongoing monitoring/testing, and a lack of adherence to a diet consistent with proper diabetes management.
Contributing, in part, to the lack of diabetic care plan adherence in Somali communities are problems inherent to many immigrant and refugee populations, such as language barriers, lack of financial resources, and cultural differences that hinder patients’ willingness or desire to seek medical care. When examining cultural background and education, many Somalis arrive to this country with a gross misunderstanding of the etiology of the disease. In 2002, when surveyed to assess the community’s knowledge and understanding of diabetes, responses of Somali individuals varied greatly amongst those surveyed. One man believed his work environment in a cold meat processing plant caused his diabetes, while another believed that the camel meat and milk he consumed in Somalia protected him from the disease and that, without access to such foods in the U.S., he is no longer protected. Many Somali women expressed a belief that it was a higher power who determines the occurrence of the disease in each person. Contrary to widely accepted medical opinion, the majority of the Somali population do not believe diabetes to be a disease related to or impacted by genetics or lifestyle choices (Wilson-Owens, Piccinin, & Lai, 2002).
In addition to contributing factors like cultural and language barriers, another factor of the prevalence of diabetes in Somali immigrants lies within the drastic changes to diet and lifestyle upon their arrival in the U.S. Dr. Mehmood Khan, a consultant in the Mayo Clinic’s Division of Endocrinology, states that an increasing number of Somali immigrants are developing Type 2 diabetes within five years of immigrating to the U.S., while others develop the disease within as few as 6 months. Dr. Khan attributes this phenomenon to a shift in diet with a dramatic increase in fat and calories consumed, accompanied by a decrease in the amount of regular exercise received (Wilson-Owens, Piccinin, & Lai, 2002).
Healthcare System Impact
While diabetes in itself is a disease with significant health impact, the disease often is not the sole affliction of those in whom it is diagnosed. Rather, a diagnosis of diabetes places patients at risk for other conditions such as diabetic neuropathy, hypertension, obesity, and kidney disease (American Diabetes Association, n.d.). In the case of the Somali population, Somali women are especially at risk for obesity, with studies showing they are likely to develop the disease at an even lower weight than the average American female (Mador, 2008).
With the risks associated with secondary health complications, those in the Somali community diagnosed with diabetes are faced with compounding health issues exacerbated by preexisting barriers to the receipt of care, such as a lack of English proficiency, transportation, and cultural and religious norms not well aligned with healthcare practices commonplace in Western medicine, (e.g. drawing blood). The healthcare system is therefore challenged to appropriately coordinate care for these patients who now require additional attention from and interaction with the medical community, yet whose exposure to Western medicine can often be met with resistance. Successful chronic disease management often involves a significant amount of self-care and patient participation in the care plan. Self-administration of medication, (sometimes in the form of an injection), regular clinic visits, (possibly to multiple specialties), self-testing and monitoring of blood sugars, and a specialized diet are a few of the aspects of a comprehensive care plan to which patients must adhere to maximize their level of control over their diabetic condition. Achieving cooperation with and adherence to such a plan can prove challenging to providers caring for diabetic patients in the Somali community. The provider must help these patients fully understand not only what is being asked of them, but why, and to also help them understand that such tasks are necessary and that failure to incorporate them into daily life may lead to severe and long-term consequences for their health. Overall, a highly tailored approach to disease management and patient education is required of the healthcare provider to address the cultural and religious components of treating diabetes in the Somali population (Sunni, 2015).
Given the challenges that diabetes presents to both Somali patients affected by the disease and the healthcare system tasked with treating them, one of the best tools in our arsenal for combatting the disease in this population is that of prevention.
In Minnesota, the Department of Health has developed the Diabetes Prevention Program (DPP) a cost-effective program lead by the CDC that helps participants achieve diabetes prevention and control over their health through lifestyle changes such as healthy eating, increased physical activity, and developing better problem-solving and coping skills (Minnesota, n.d.). In cooperation with their Health and Nutrition Extension program, the DOH has collaborated with the University of the Minnesota to make adaptations to the DPP’s curriculum that meet the needs of the Somali population. Given that cultural and religious beliefs, customs, and daily habits must be considered when developing a prevention and healthy living plan, this partnership customizes its approach for the Somali population. The program has changed the way in which it delivers diabetes education to the Somali population to help ensure that the information is easily interpreted, understood, and ultimately that the patients targeted by the program adopt the lifestyle changes it encourages.
In a similar program to the DPP, the University of Minnesota has partnered with Children’s Hospitals and Clinics of Minnesota to create educational materials especially for Somali children diagnosed with and at risk for diabetes. These materials help break down the barriers presented by language and/or literacy barriers by using picture-based dietary resources to help educate families on carbohydrate content in foods they consume regularly. The program has also developed a type of group therapy program which enables families of patients with or at risk for diabetes to come together to share advice and talk about their experiences with others within their community from the same ethnic background (University, n.d.).
As we know, the Somali community is at increased risk for diabetes due to a multitude of factors relating to language barriers, cultural and religious beliefs, and skepticism and fear of western medicine that contributes to an avoidance of receipt of care. Given these barriers, the healthcare system is challenged to provide the type of education and care to this population that produces the desired result of patients with controlled, well-managed diabetes. However, there is hope for improved outcomes. Through a variety of programs made available through entities like the Minnesota Department of Health, University of Minnesota, and Children’s Hospitals and Clinics of Minnesota, diabetes education and care can be tailored to meet the unique needs of the Somali population to aid in understanding, cooperation, self-care and ultimately prevention of the disease in our at-risk communities.