Journal of Religion and Health

, Volume 52, Issue 4, pp 1319–1332

The Health Behavior of Sri Lankan Buddhist Nuns with Type 2 Diabetes: Duty, Devotion, and Detachment

Authors

  • Sunny Wijesinghe
    • College of NursingUniversity of New Mexico
    • College of NursingUniversity of New Mexico
Original Paper

DOI: 10.1007/s10943-012-9592-y

Cite this article as:
Wijesinghe, S. & Mendelson, C. J Relig Health (2013) 52: 1319. doi:10.1007/s10943-012-9592-y

Abstract

Sri Lanka has experienced an increase in the rate of type 2 diabetes. Selfmanagement of diabetes among Sri Lanka’s Buddhist nuns, who depend on food donations and limit physical activity in accord with the monastic code of conduct, presents unique challenges and has not been previously studied. The purpose of this focused ethnographic study of 10 Buddhist nuns was to understand how they managed their illness within the restrictions on diet and physical activity. Three themes—duty, devotion, and detachment—explained and described their health behavior regarding type 2 diabetes within the context of their daily routines and obligations.

Keywords

Diabetes mellitusType 2Self-managementBuddhismSri Lanka

Introduction

The burden of diabetes falls heavily on low- and middle-income countries, and this burden is expected to continue to rise in the future (International Diabetes Foundation 2011). The upsurge in cases of type 2 diabetes in the developing world can be attributed to rapid globalization, resulting in urbanization, cultural and dietary changes, and adoption of conveniences that lead to a sedentary life style (Sicree and Shaw 2007). In type 2 diabetes, the body fails to produce sufficient insulin, or muscle, liver, and fat cells do not use insulin properly; it differs from type 1 diabetes, in which the body fails to produce insulin.

Sri Lanka has not escaped this chain of events. A large study in four provinces in Sri Lanka showed that the average prevalence rate of diabetes was 14.2% for men and 13.5% for women (Wijewardene et al. 2005). The health care community in Sri Lanka responded quickly with a large-scale education campaign to emphasize the importance of physical activity and diet in the prevention and management of diabetes (Gunathilake et al. 2006). However, knowledge alone is insufficient to change health behaviors. Cultural values influence the perception of risk factors, illness experience, and its management (Macaden 2007; Meetoo and Meetoo 2005; Nichter 1985).

Faith and spirituality are thought to support diabetes behavior modification (Lujan and Campbell 2006; Naemiratch and Menderson 2006; Polzer and Miles 2007; Sowarranangoon et al. 2009). Sri Lanka is a predominantly Buddhist country, and monks and nuns serve as spiritual guides within Buddhism. Buddhist monks and nuns with diabetes, like all Buddhist monks and nuns, depend on members of their communities for meals and their general livelihood. In addition, they must modify their diets and physical activity in accordance with the Buddhist monastic code, which prescribes dietary rules and general etiquette for movement. The purpose of this study was to discover how Buddhist nuns with type 2 diabetes managed their illness within the restrictions on diet and physical activity imposed by the Buddhist monastic code. Thus far, no research has been conducted on diabetes management in the religious community in Sri Lanka. Understanding how Buddhist nuns manage their diabetes within the context of their daily life activities can provide insight into promoting better health strategies in this spiritual population that meets their food needs through the donations and can explicate the role of Buddhist spirituality in diabetes management.

An Introduction to Buddhism

To provide context for the research described in this article, a brief description of Buddhism, the definition of Sri Lankan Buddhist nuns and the Buddhist monastic code as it applies to Buddhist nuns follows. Buddhism is a religion based on the principle of cause and effect in the ethical realm, which is described in four universal truths: suffering, cause of suffering, cessation of suffering, and the eightfold path to annihilate suffering. According to Buddhism, all phenomena in the universe are impermanent, bound to be unsatisfactory, and deprived of a self. The idea of a self is an imaginary belief without a corresponding reality, which is the root of all evil. The eightfold path taught by the Buddha consists of a moral and responsible way of life, meditation, and insight; following this path will transform ignorance into wisdom and lead to total liberation, called Nirvana (Mahathera 1982; Rahula 1978; Varela et al. 1993).

Sri Lankan Buddhist Nun

A Sri Lankan Buddhist nun is a world renunciant who can be either ordained (Bhikkhuni) and observe 311 monastic rules and the 10 Buddhist precepts or nonordained (Dasa-silmata) and observe just the 10 Buddhist precepts.1 All ordained and nonordained nuns are dependent on the community for their livelihood. The Buddhist community members who frequently meet the nuns’ needs and often live in their vicinity are their devotees. Ordained and nonordained nuns coexist and, arguably, perform similar functions, but they do not usually share accommodations.

The Buddhist Monastic Code

The Buddhist monastic code contains 227 rules for Buddhist monks and 311 for Buddhist nuns (Kusuma 2003). The rules are categorized according to the penalty for breaching them, which ranges from confession in the presence of another monk/nun to permanent expulsion from the religious order. Some categories are not assigned a penalty; rather, they provide disciplinary direction, which is to be incorporated into their monastic lives (DeGraff 1994). Several rules that pertain to food and physical movement arise from the categories of paciyyiya and sekhiya.Paciyyiya rules govern food and include not eating after noon time, eating only food received and formally given, not storing food received today for tomorrow, not prompting a donor before offering or taking advantage of an extremely generous donor, not cooking food for oneself, and not cooking and storing food in the living quarters. Sekhiya includes rules of etiquette. According to the sekhiya rules, a Buddhist nun’s movements should portray her discipline in public places. She should walk with her eyes lowered and talk with a lowered voice and without laughing. She may not swing her body or arms when walking or put her hand on her hip (DeGraff 1994; Kusuma 2003).

Methods

We conducted a focused ethnography with a purposive sample of 10 Buddhist nuns recruited from four provinces in Sri Lanka. An exploratory approach was chosen because little is known about the health behaviors of this population, and an ethnographic approach situates the behaviors of the participants’ activities within the social and political contexts of their lives (Creswell 2003; Patton 2002). The study population was restricted to Buddhist nuns because it would be inappropriate for a female researcher to interview Buddhist monks, and the study goals could be met by studying nuns.

Recruitment

Sandelowski (1995) suggests that estimating sample size in qualitative research is a matter of judgment and experience. In qualitative research, sampling focuses on locating information-rich participants who are well versed in the topic under research. In this study, we set an initial sample size of 10 participants based on the second author’s experience with small focused studies, with a plan to conduct additional sampling if needed to ensure data saturation. To protect against regionalism, we sampled from all four provinces in Sri Lanka. After securing approval from the institutional review board of the sponsoring university, the first author contacted the Sangamitta Buddhist Society in Sri Lanka by phone, explained the study goals, and requested assistance with participant recruitment. The Sangamitta Buddhist Society provided its support and forwarded a list of Buddhist convents for nuns (aramayas) in the Northern and Eastern provinces of Sri Lanka. A form letter written in Sinhala, the predominant language in Sri Lanka, was sent to the 12 nuns on the list, requesting their participation in the study if they had been medically diagnosed with diabetes. The letter explained the study and the inclusion criteria, and included a translated copy of the institutional review board-approved consent form. All letters included a self-addressed stamped postcard. Of the 12 letters sent, 5 affirmative responses were received. We located telephone numbers for 2 of the nuns who did not initially respond to letter, and they reported that they did not have diabetes. We had no further contact with the remaining 5 nuns. Acquaintances of the first author facilitated meeting 3 additional Buddhist nuns with diabetes. Telephone directories in the Central and Uva provinces were consulted to locate Buddhist aramayas, which resulted in the recruitment of the last 2 participants. The process of in-depth interviews with the 10 participants combined with participant observation conducted during the first author’s time in the aramayas, resulted in data that was saturated, a state in which no new information was arising from the interviews, negating the need for additional sampling.

Participants

The sample consisted of 10 Buddhist nuns with type 2 diabetes, aged 52–89 years, with an average age of 65 years. The time since diagnosis ranged from 1 month to 15 years. The number of years since participants had entered the religious order ranged from 8 to 31; only 1 nun was ordained. The newest member was from a Catholic background and had chosen this path to find solace in the Buddha’s word following a personal tragedy. All others had been devoted to Buddhism since childhood. The participants came from eight districts in four provinces in Sri Lanka. Except for 1 nun who occupied a partially constructed house, the nuns lived in aramayas with one or two other nuns and a live-in female aide.

Data Collection

Data were gathered through the ethnographic research methods of semistructured, in-depth interviews and participant observation. Interviews were conducted in Sinhala at the nuns’ aramayas; observations were conducted by the first author, who spent 1–2 days in three of the aramayas to observe the nuns’ daily routines, which were documented in detailed field notes.

Prior to beginning each of the interviews, the consent form was reviewed with the participant, and any questions about the study were answered. All interviews were audiotaped with the nuns’ permission. Interviews began with the question: “please tell me what it is like to be a Buddhist nun with diabetes?” Follow-up questions were asked to learn about the diagnosis, progression of the illness, diabetes knowledge, and diabetes management. Questions were also asked about demographics, the nuns’ activities, meals, and the code of conduct. Participants were encouraged to fully share their thoughts and experiences. The interviews lasted between 40 and 60 min. Donations of food items, such as fruits, vegetables, grains, and skimmed powdered milk, were provided to all the nuns at the end of the visit.

Data Analysis

In qualitative research, data collection and data analysis occur at the same time. The first author listened to the audiotapes within hours of collecting the data to gain a gestalt of the interview and make notes of her initial interpretations in her field notes. The audiotapes were then transcribed verbatim by a Sri Lankan assistant and then translated into English by the first author, who is bilingual. Consistent with an ethnographic approach and the purpose of the study, we approached our analysis of the data from the perspective of the nuns and mindful of the context of their lives and their communities, taking care to not superimpose preconceived notions about diabetes management or Buddhism on the data. Data analysis was conducted using the iterative process of immersion and crystallization. Miller and Crabtree (1999) describe immersion and crystallization as the “analyst’s prolonged immersion into and experience of the text and then emergence, after concerned reflection, with an intuitive crystallization of the data” (p. 23). Immersion and crystallization require the researcher to read the data multiple times to gain a sense of how it fits together. Although immersion and crystallization are most closely associated with the heuristic research of Moustakas (1990), they are similar to methods used throughout the social and human sciences, including anthropological texts (Borkan 1999). At the conclusion of the crystallization process, a series of codes, thematic statements, and the essential components of the stories (subthemes) for each participant, were then compared, analyzed, and abstracted across all the participants in the study. Themes were identified through the analytic process, which is both active and dialectic (Charmaz 1990; DeSantis and Ugarriza 2000). DeSantis and Ugarriza (2000) define a theme as an “abstract entity that brings meaning and identity to a recurrent experience and its variant manifestations. As such, a theme captures and unifies the nature or basis of the experience into a meaningful whole” (p. 362). The development of the final analysis and thematic structure was iterative and was informed and refined by successive reviews of the data, the interpretation, and the conceptual links.

In qualitative research, the goal is usually not to generalize the findings but rather to perform a rigorous study and provide sufficient thick description that allows the reader to determine whether the findings can be transferable to other contexts. We took a variety of steps to enhance the rigor of our study. We selected our sample from across the country to protect against regionalism. The first author is bilingual and bicultural and is fully aware of local customs, which increased the participants’ comfort with the research process. We improved the trustworthiness of our study through the processes of prolonged association, data source triangulation, and member checks (Lincoln and Guba 1985). Prolonged association was a consequence of the first author’s time in the field, which included spending the night at three aramayas and traveling across Sri Lanka to collect data from the nuns in the four provinces, which provided her with ample opportunities to observe Buddhist nuns in their daily routines and casually discuss health issues. Triangulation of the data provides an opportunity to extend the range of each type or source of data being collected (Knafl and Breitmayer 1989). We were able to maximize and check our data by comparing the interview data with the observations made during interviews and overnight stays at the aramayas. Member checks were conducted with the nuns who participated in this research. Three of the nuns were visited in person to discuss the findings, and the rest were contacted by telephone to confirm the researchers’ interpretation and elicit feedback.

Findings

Three themes characterized diabetes management in the lives of Buddhist nuns in Sri Lanka: duty, devotion, and detachment. The theme of duty is predominant in relationship to others because it establishes the relationship to the community. Although the three themes are presented separately, there is considerable overlap among the patterns of behavior.

Duty

Duty consisted of a mutual responsibility between the nuns and the community, which encompassed neighbors as well as Buddhist devotees who associated with the nuns. The nuns’ sustenance depended heavily on a harmonious relationship between the nuns and the community. Nuns’ earnest sense of duty to fulfill their part of the relationship was very much congruent with their understanding of the role of the monastic code. Because 9 of 10 nuns were nonordained, the monastic code did not technically apply to them; however, most of the nuns had a pragmatic view of how these rules applied to their lives. Although they were not able to fully abide by all rules, such as not cooking for themselves or not touching money, they understood that Buddhist philosophy and discipline functioned to develop the mind and character of the Buddhist religious community. Thus, they regarded monastic discipline as essential to a peaceful life with fellow nuns and to prevent burdening the community that supported them.

The nuns’ sense of duty led them to serve the spiritual needs of the community. Nuns participated in community births and various other rites of passage. Some held Sunday school classes for community children. The nuns in the study were older women, and the demands of their schedule were trying, but they gave the Buddha as an example of “not thinking about physical exhaustion when preaching for the good for the people.” The nuns’ responsibility to the community discouraged them from giving into sickness. One said, “When we have a disease, we do not like to show it to others because there is no point in making that person sad. My aim is to give knowledge in all my interactions.” However, 2 nuns believed that their diabetes was triggered by the stress involved in large religious ceremonies on festival days.

Except for the hour during which they took their main meal of the day, the nuns’ doors were open to their community. Most nuns understood community in a global sense to encompass those who did and did not contribute to their livelihood. Despite their full dependence on others, the nuns attempted to attend to the material needs of others within their means. All visitors who crossed their doorstep were offered at least a glass of water to quench their thirst. Nuns even considered animals as part of the community. Many unwanted pets ended up in the village aramayas, and nuns fed these animals without complaint.

Nuns’ dependence on community food influenced their management of diabetes significantly, and the variety of food differed, depending on the location of the community, the community members’ knowledge of diabetes, and economic status. In more urban and populated areas, almost all the nuns’ meals were cooked and brought to them. The nuns were also often invited to almsgiving services at devotees’ homes or in other temples. On these occasions, food had more variety, and when devotees were knowledgeable about diabetes and put that knowledge into practice, the donations included food items with a low glycemic index appropriate for a diabetic diet. Some nuns appreciated their devotees’ perspicacity:

I eat things like kohila [a plant in the yam family] with fiber, red rice often, very rarely white rice, millet pittu [a roll made of flour and coconut] mostly without any oil; really, the devotees are very good. They know I have diabetes, and they bring foods recommended for the disease.

When the community placed importance on the taste rather than the nutritional value of food, only a self-assertive and diabetes-wise nun could communicate effectively to change the situation, for example, by requesting just the raw material for the food to be cooked at the aramaya:

When we accept an offering, we accept only the ingredients, and those devotees get together with the live-in aide to prepare it because if they prepare [the food] in their own homes using different flavorings, it will be a problem for us, not for just a diabetic person, but even for a healthy person. These flavorings are disease makers; when making food, it is not the side of taste you have to look at, but the nutritious aspect of it

However, consistent with the monastic rules not to prompt donors for offerings and not to keep taking from a generous donor, the majority of the nuns were reluctant to make any demands on their communities. Moreover, the low economic status of a community was a disadvantage to these dependent nuns. One nun who lived in a remote “sacred area” frequented by large numbers of Buddhist nuns was not willing to ask for special favors from her devotees:

Well, some may know I have diabetes because I am old, but we cannot tell devotees this and that. They give according to their possibility. We cannot disturb anybody. There are a lot of nuns all over here. There are temples all over … So whatever they give cooked food or raw material, we accept them.

The nuns’ self-imposed vegetarianism, however, helped them to improvise, even in a hardship area. For instance, 1 nun had learned through trial and error that wild plants were more fibrous and nutritious than food bought in grocery stores.

According to the participants, the communities never failed to reciprocate the goodwill. As 1 nun pointed out, “A truly devout nun will never be without a loyal community in a Buddhist society like Sri Lanka.” Community functioned like an adopted family to these women, who had left their own families. Devotees played a significant role in the nuns’ lives. Responsibility between nuns and devotees showed a strong reciprocity, and a subtle equilibrium between negotiation and compromise influenced the nuns’ diabetes-related health behavior regarding diabetes. The mutual responsibility was seen in the nuns’ food intake and how they enhanced the diabetes knowledge base, sought medical care, and inconvenienced themselves for the sake of devotees.

In some cases, the nun’s responsibility was toward the live-in aides, who were usually elderly women. If the devotees brought only raw foods, which were sometimes preferable for disease management, it added to the work load of the live-in aide. A nun explained:

[We] cannot always ask devotees to bring raw material because it is too much work for the live-in devotee; she has already a lot to do, such as wash robes when the head nun is ill, weed around flowering plants. She is also getting old.

In addition to nutrition, a knowledgeable community also contributed to enhancing the knowledge base of the nuns by exposing them to educational information and motivating them to keep medical appointments. The nuns knew their community well and conversed with diagnosed diabetics and their families. The nuns who had a radio or television listened only to programs related to Buddhism. It was the devotees who alerted the nuns whenever a diabetes education program was in progress on TV or radio. Also, devotees who came across newspaper or magazine articles on diabetes often passed the information on to the nuns.

Nuns’ descriptions of their health providers were often couched in terms of mutual respect and regard. Only 1 nun, however, reported making monthly medical visits. Medical visits often took place after great persuasion by devotees. At least 2 nuns had their diabetes diagnosed because of their devotees’ watchfulness and concern. One said, “My live-in devotee kept saying, ‘Why do you sleep like this? It is not normal. You were not like this before. Why don’t you go to the doctor and ask about this?’” Another nun reported:

I was drinking water, but I was not hungry. I was just thirsty. So one lady said, “Venerable mother, my daughter also had this problem.” She asked me to give her a sample of my urine so she would take it to the doctor. So this lady took my urine to the doctor.

Devotion

Devotion calls for strict discipline in mind and body. For example, the nuns emphasized that practicing both amisa puja, rituals of worship, and prathipatthi puja, meditational and reflective activities, was absolutely necessary and equated the connection to “what the bark is to a tree.” All nuns showed great discipline with timely offerings of flowers, food, and beverages to Buddha statues, chanting, worshipping, and clearing the altar for the next offering. Although many of the nuns mentioned meditating to clear their minds, they described their practice in general terms, such as “thinking of qualities of Buddha,” “compassion meditation,” “revulsion of the body meditation,” “walking meditation,” and “sitting meditation.”

All nuns believed that controlling the mind was important in diabetes management and painted a picture of an uncontrolled mind affecting one’s health. At times, the nuns experienced anger and stress associated with communal living. One said, “Anger brings commotion in the circulatory system and has an effect on illness.” Another commented, “When I am angry, my sugar level goes out of control.” Meditation was a way to calm the mind. One nun explained, “Meditation helps control one’s mind. It helps cultivate good thoughts, grow compassion, remove angry thoughts, and in that sense, it affects your health.” Another nun felt that meditation also improved the state of her diabetes:

If I continue meditating for a long time, I feel it helps to reduce diabetes. Now, it is not possible to do it for a long time because of the condition of my feet. If I can remain in one pose for 3–4 h concentrated, I can improve my conscience through meditation. If I do that, there is a change in diabetes.

Discipline in physical movement was also important. The nuns respected the monastic rule to maintain graceful behavior and limit vigorous movements or combine their movements with necessary activities, such as sweeping, cleaning flower beds, and walking to and from the bus stop. Sweeping inside and outside of the house was the most frequently mentioned physical activity. One nun explained, “We sweep the entire outdoors, we sweep slowly, and we do that as an exercise.” All the nuns had been advised by their health care providers that they should walk daily, and they understood the benefits of daily exercise in diabetes management. Although a few nuns indicated that they had been more active with chores inside and outside of their homes before becoming ill, current explanations as to why they could not follow their doctor’s advice ranged from being “out of breath” to having “numb legs.” However, seemingly purposeless exercise was problematic for these women. A nun with limited mobility due to a dislocated hip explained, “Even when I could put the leg down, I would only move in a manner appropriate for a nun.” Another nun placed the problem of exercise in context:

Vigorous exercise, the type others do, does not fit our virtuous practice. It is better to combine it with something that is useful to us; for example, when we sweep, we clean and sweat at the same time. We go back and forth and meditate and that way doing two things that are good for mind and the body.

However, 1 nun found a way to be more vigorous while still doing appropriate activities:

I do chores to sweat. It is not that I need these chores, but as an exercise. I do these because I think it helps me manage diabetes. I sweep, break cobwebs, climb up stairs, and get down, teach kids. I feel that does good in the body. We get enough food to satisfy us, but we do not use it up. So is it a wonder that we get sick?”

All nuns believed that food control was important in diabetes. One said, “If one says, you cannot control diabetes with food, I would think that person’s mental state is a bit weak.” A nun summarized the role of food in a Buddhist nun’s life:

We take food as a “kasaya” [bitter traditional herbal medicine], not for its taste, but aiming for health. We are not a group of people who live desiring food. We eat aiming to be healthy because in order to attain Nirvana, we need a good state of mind.

The nuns believed that dietary rules facilitated their diabetes management because they took only two meals/day and ate in moderation, consistent with traditional practices. They took breakfast around 7 am after their morning devotional activities, and lunch, the main meal of the day, around 11:30 am. This meal consisted of a large portion of carbohydrates, always rice, and a small amount of accompaniments, such as vegetables. Because dietary rules prevent food intake from 12 noon until dawn the following day, they took only a light beverage at 5 pm as their dinner.

Despite their highly disciplined lives, some nuns openly discussed their struggle with their diet, “I know what I should be taking for diabetes, but sometimes, I feel like taking a bit of what I am not supposed to take. It is not that every day we eat like that.” Another said:

Although we talk about managing, it is difficult to do. Do you know why? I need to have rice in the morning. They advise to eat rice only once, not to eat rice often … have to have rice; if not, I get hungry. I have reduced taking foods high in cholesterol, but every once in a while, I have to have kaludodol [very oily and sweet dessert]. Some days, I have to have sweet foods, and I rummage the cupboards, and other nuns hide sweet foods from me.

Detachment

The Buddhist phenomenon of impermanence shaped the nuns’ outlook in life. Detachment, denoting the point at which the nuns surrendered to the illness, is consistent with the Buddhist phenomenon of impermanence. All nuns accepted that, ultimately, the body disintegrates into original constituents, and karma decides how and when this occurs. Diabetes was just one manifestation of that process. Although impermanence in life was the backdrop against which all the nuns functioned, nuns deferentially surrendered to their illness. For example, nuns who had a strong sense of purpose to follow the path delineated by the Buddha and to encourage many others to do the same found it important to maintain good health as best as they could within the confines their lifestyle. Moreover, a woman’s reason for choosing to be a nun and the age at which she did so shaped her life-purpose. The nuns who were ordained later in life seemed less diligent regarding self-care and gave the transient nature of life as their reason for indifference. These nuns, having cared for parents, husbands, and children earlier in life, viewed their current sense of responsibility differently than the nuns without this past.

The nuns tried to manage their disease by picking and choosing the healthier alternatives from their donated food, such as brown rice, that had a lower glycemic index. They also tried to reduce the amount of white rice they ate, experimented with foods and home remedies, and gave up or reduced their intake of sweet foods. However, at a certain point, they detached themselves from being overly concerned about “the processes of life” and accepted disease as a natural phenomenon. The nuns used phrases such as “even the Buddha could not avoid his final illness,” “it is the nature of life to disintegrate into the original constituents,” “happiness and sorrow alternate in a cycle, and human body manifests that in various diseases,” and even “we have lived long enough.” Even the sole nun who understood her diabetes from a scientific perspective and discussed the genetic link to her diabetic mother pointed out that, ultimately, it was the “karma” that led her to this destiny.

Discussion

The purpose of this study was to understand how Buddhist nuns with diabetes managed their illness within the restrictions on diet and physical activity imposed by the Buddhist monastic code. The findings showed that the 10 nuns’ health behavior toward diabetes revolved around three main themes that were identified as devotion, duty, and detachment. Within these themes, the primary challenges in diabetes management were dietary management and exercise. The frequently mentioned practice of meditation seemed more focused on general discipline toward food control than on stress management, which could also influence diabetes outcome.

Dietary Restrictions

The monastic code influenced the nuns’ dietary restrictions in several ways: nuns ate only what was offered to them, ate fewer meals/day, resisted snacking from stored food, practiced moderation in their portions, and followed a self-imposed vegetarian diet. Because they depended on the community to supply their food, their diet was generally consistent with the dietary norms of Sri Lanka, which, for the most part, consisted of a diet high in carbohydrates, high in lipids mostly from saturated fat, and low in essential fatty acids, which contribute to high insulin resistance (Abeywardena 2003; American Heart Association 2001). However, the nuns’ vegetarianism and their limited diet under hardship conditions contributed to a more healthy fibrous, low-fat diet (Craig and Mangels 2009), which could be considered beneficial in light of the traditional Sri Lankan diet. The nuns’ dietary pattern of one large meal followed by fasting, which they believe provides them with an edge in managing their diabetes over the Sri Lankan general population, is inconsistent with dietary recommendations for optimal diabetes management, which calls for 5–6 small meals/day (University of Michigan Health System 2010). However, consistent with other South Asians, Sri Lankans take their evening meals 2–3 h later than Europeans (Simmons and Williams 1997) but do not expend that postprandial energy. Although the two-meal regimen is far from ideal, the nuns’ practice of eating their large meal earlier in the day allows them time to expend the energy.

Nuns’ usage of the term “moderation” also needs to be seen in the context of Sri Lankan culture. The nuns’ full plate of carbohydrate-laden food for lunch (usually rice) was not dissimilar to that of their lay counterparts. Rice is the main staple in Sri Lankan meals, without which “lunch would not be considered a lunch.” Most Sri Lankans fill the plate with rice before adding the accompaniments. Moderation of a meal is measured not so much by what is placed on the plate on the first serving but by the number of servings one allows oneself, especially on occasions when a host serves the food. In this context, the nuns’ concept of moderation may be supported more by the fact they take fewer meals/day.

In keeping with the restrictions imposed by the monastic code, there are limitations on what the nuns can and will modify. For example, it is unlikely that they will take an evening meal. However, opportunities exist to improve the nutritional content of the nuns’ diet and the diet of the community. Although many Sri Lankans can name food items with low glycemic indexes suitable for an individual with diabetes, combining foods to prepare a meal that would deliver a low glycemic load to illicit a favorable insulin response (Ekanayake et al. 2009) requires practice and support. Exploring innovative ways to conduct community dietary education would benefit not only the Buddhist nuns but the lay population as well, including those with and without diabetes, because a diet that is healthy for those with diabetes is generally health supportive.

Exercise

Rules of etiquette regarding movement dictate that the nuns’ behavior reflects their discipline. The nuns’ lack of enthusiasm for physical exercise, however, was not inconsistent with the cultural norm for middle-aged women in Sri Lanka. Research attests to the reluctance of South Asian (including Sri Lankan) women to participate in physical activity, even when they had assimilated into a Western culture and were well aware of their high-risk status for coronary heart disease (Sriskantharajah and Kai 2006). Limitation of physical activity on the grounds of social and religious norms and physical ailments has been reported among Bangladeshi, Indian, and Pakistani women (Grace et al. 2008; Lawton et al. 2006). South Asian alienation from physical activity unrelated to everyday chores may be traced back to their original agrarian roots. There is some evidence that male and female South Asians performed intense physical activity in their daily activities as rural agriculturists (Gupta et al. 2004). Similar and additional changes are evident in Sri Lanka, where physical activities such as pounding flour, drawing water from wells, and walking long distances have been replaced by the adoption of modern conveniences. Reverting to such physical activities is not likely to be an option in modernized Sri Lanka. However, in light of the most recent reiteration of healthy lifestyle changes to significantly lower elevated levels of triglycerides (Miller et al. 2011), it is incumbent on the health care community to explore creative ways to involve the religious and lay population in sustainable, culturally acceptable physical activity. Because walking is an acceptable physical activity to Buddhist nuns as well as other Sri Lankans, incorporating additional opportunities within the Sri Lankan cultural context, such as significant religious festivities, pilgrimages, rites of passage, and other cultural gatherings, would be a start. Popular media campaigns can promote walking as “fashionable” to the young and old in modern Sri Lanka, and the religious community’s involvement in promoting a concept such as “reclaiming Sri Lankan health and vigor” could be one part of a multipronged approach to fighting the diabetes epidemic in the country.

Meditation

Meditation has been shown to reduce stress and thus aid in diabetes management from a physiological and psychological standpoint (Bonadonna 2003); however, the role meditation played in terms of stress reduction in these nuns’ lives was difficult to ascertain. A few of the nuns indicated that they believed meditation helped to control the mind and that there was a link between and their diabetes and stress and anger, but their meditation practice was not at a level significantly advanced beyond that of the lay Buddhist population. According to Theravada Buddhism, the foundations of mindfulness in Vipassana (insight) meditation are fourfold: contemplation of the body, contemplation of feeling, contemplation of consciousness, and contemplation of mental objects. Meditation encompasses a complex exercise that is considered part and parcel of the world renunciant’s meditation repertoire (Thera 2000). Sri Lankan lay Buddhists usually practice only a small part of the first foundation, contemplation of the body, which is called “meditation on the revulsion of the body” (Obeysekere 1989) and compassion meditation, similar to most of the nuns in this group. Because only 1 nun in the study was ordained, and ordination required achieving a deeper level of knowledge in Buddhism (Bartholomeusz 1996), it is difficult to determine whether this group’s ritual and meditational activities provided the serenity that could benefit diabetes management.

Limitations

Because of time and budgetary limitations, we conducted a modest focused ethnography that provided valuable and previously unknown information about how Buddhist nuns incorporate diabetes into the rhythm of their lives. The study findings demonstrate the seamless link between Buddhist cosmology and practices and diabetes management, and in some cases, the lack of it. However, many questions remain. A larger multidisciplinary study that includes, primary care providers, ethnographers, and nutritionists could take a wider community approach and explore chronic illness management of both nuns and monks, incorporating clinical markers of disease, laboratory testing, and nutritional analysis, and explore the symbiotic relationship between the religious and lay communities. This type of wider study can include survey research that explores social support, medical follow-up, and questions that focus more on a scientific view of diabetes management within this community.

Conclusion

The most important factor that influenced nuns’ self-management of diabetes was their dependence on others for food. A well-informed community contributed actively to assisting the nuns with managing their diabetes by providing them with appropriate nutrition and educational information, and ensuring that they kept their medical appointments. When the nuns’ sense of purpose was strong, they were motivated to do their best to manage their diabetes within their confines. Finally, the Buddhist phenomenon of impermanence helped the nuns to cope with the chronic nature of diabetes.

Footnotes
1

The 10 precepts are vows to abstain from killing any living creatures; taking what is not given; unchaste conduct; false speech; taking intoxicants; eating after midday until the light of dawn; dancing, singing, and seeing entertainments; wearing garlands, perfumes, and cosmetics; using high and large beds; and abstaining from accepting money (Thera and Kassapa 2003).

 

Acknowledgements

We are grateful for the generosity of the nuns who participated in this study and the people of Sri Lanka who facilitated this work.

Copyright information

© Springer Science+Business Media, LLC 2012