Keywords

Diabetes, a chronic illness that is “characterized by elevated levels of blood glucose, accompanied by disturbed metabolism of fats and proteins. Blood glucose rises because it cannot be metabolized in the cells, due to lack of insulin production by the pancreas or the inability of the cells to effectively use the insulin that is being produced” (Roglic, 2016, p. 4). Mainly, diabetes as chronic illness is divided into two categories: (1) Type-1 diabetes, where the pancreas does not produce insulin, and (2) Type-2 diabetes, where “the body cells are resistant to the action of insulin that is being produced and over time the production of insulin progressively decreases” (Roglic, 2016, p. 4). So, what are the causes of diabetes? What are the symptoms? And who it can be treated and managed? This chapter reviews the literature to find answers to those questions from a cross-cultural perspective.

2.1 Causes of Diabetes Across Cultures

The question “why me?”—as Kleinman (1988) discussed—is a process in which people try to make sense of or explain why they or people they know have illnesses based on their life experiences. This process of answering “why me?” (in general) and “why has diabetes happened to me?” (specific to this research) involves multiple explanations. After reviewing the literature, three overlapping themes were extracted across different cultures in terms of what causes diabetes from an emic point of view. The three themes are that diabetes is caused by (1) genetics; (2) behavior (diet, obesity, and lack of physical activity); and (3) mental states (susto/fright, stress, and depression).

2.1.1 Genetics as a Cause of Diabetes

Neel (1962) worked on the prevalence of diabetes among indigenous populations across the world. Everett (2011) noted that Neel “has pursued the genes presumed to be associated with particular ethnic groups and their potential role in the onset of the disease” (p. 1777). Neel’s (1962) thrifty genotype hypothesis “argued that diabetes mellitus involved a quick insulin trigger, which evolved in hunter-gatherer ancestors in response to periodic feast-famine conditions” (Everett, 2011, p. 1777). This hypothesis was revised later, when Neel (1999) admitted that his original hypothesis “presented an overly simplistic view of the physiological adjustments involved in the transition from the lifestyle of our ancestors to life in the high tech fast lane” (cited in (Everett, 2011, p. 1777). The knowledge that diabetes is caused not only by genetics but also by complex social and environmental factors has become well accepted in academics, but what about the emic point of view? Do people from different cultures believe that genetics can cause diabetes?

Skelly et al. (2006) worked among rural African Americans in North Carolina and showed that genes are thought to be a cause of diabetes and that, therefore, the illness cannot be prevented. A community member expressed that by saying, “It’s just in the genes. It’s nothing that you can prevent from happening. It’s something you are born with” (Skelly et al., 2006, p. 15). This cultural knowledge of the relationship between genes and diabetes is not necessarily fully understood by people, as Skelly et al. (2006) noted. This unclear relationship was expressed by a community member who said, “I think when you... you can inherit a lot of things, that’s why I think—mostly you can inherit diabetes I guess because you’re from the same blood and everything—same family. I don’t know. I can’t really explain it” (Skelly et al., 2006, p. 15). This unclear relationship was also expressed in Baglar (2013) study in the United Arab Emirates; a community member said that diabetes has “something to do with genes” (Baglar, 2013, p. 119).

Garro (1996) found that among Canadian Anishinaabe (Ojibway), there is a similar belief that diabetes is “all in the genes” (Garro, 1996, p. 399). Diabetes is not seen as different from any other illness that might be caused by genes shared among members of a family; a community member said that diabetes “runs in the family. And that’s just the same as a person with trouble with your heart. See, that runs in your family, all kinds of different diseases, you know, it runs in families” (Garro, 1996, p. 408). Through research at a public clinic in Oaxaca, Mexico, Everett (2011) also found the belief that diabetes happens because of genetic inheritance. A community member expressed this by saying, “I inherited it [diabetes] from my mother” (Everett, 2011, p. 1779). In a study of South Asians, Lawton et al. (2007) found that community members held a concept of diabetes as a hidden gene that people inherit and that is waiting to strike at any time; one person said that diabetes has “been there in the genes just waiting to happen.” Weller et al. (1999) showed that, across Latino populations, there is a consensus in the belief that heredity is a cause of diabetes, and people are thought to be born with diabetes.

Other studies showed that genes are believed to be only a minor cause of diabetes. In Choudhury et al.’s (2009) study of Bangladeshis in the UK, they found that the belief that genetics causes diabetes is not very common. Culhane-Pera et al. (2007) showed that genetics is not seen as a cause of diabetes by Hmong refugees in the United States; people from that population argued that diabetes is not caused by genetics. (Culhane-Pera et al., 2007).

Although people from different cultures mention genetics as a cause of diabetes, researchers have not examined how people think genetics can cause diabetes. How close must the genetic relationship be in order for a person to have diabetes? Can one inherit it only from immediate family, or can the source be far away in the family tree? Studies of people who say that diabetes is genetic and is just waiting to happen (Baglar, 2013; Lawton et al., 2007) do not explain what triggers diabetes. What makes the genes act up? This is a clear avenue of research.

2.1.2 Diet, Obesity, and Lack of Physical Activity as Causes of Diabetes

Studies among Latinos regarding cultural beliefs about diabetes show that being “chubby” (Everett, 2011) or overweight (Poss & Jezewski, 2002) are seen as causes of diabetes from the emic point of view. This belief is closely related to lack of physical activity and exercise (Jezewski & Poss, 2002). This belief is also shared by Canadian Anishinaabe (Ojibway). Garro (1996) presented a series of narratives that showed the relationship between diet, obesity, and diabetes; one community member said that people who overeat are “stuffing themselves” (p. 399) and “sometimes their faces get so round; they get so fat. I know a lot of people are going to get it [diabetes] because people are all out of shape” (p. 399).

In addition to the relationship between diet and obesity, Skelly et al. (2006) noted that among rural Africans Americans in North Carolina, there is a belief that age is closely related to lack of physical activity and obesity; one community member explained, “the older you get, the less active are your vital functions. And if you’re not exercising or stuff, you have a tendency to relax more. And your chemistry makeup slows down your organs—which slows down the process of intake and outtake of nourishment to your body” (Skelly et al., 2006, p. 17).

Emically, what types of food cause diabetes? Do the quality and type of food matter, or is the quantity the main cause? Both quality and quantity seem to matter in cultural explanations of diabetes. Consuming sugar and otherwise having a poor diet are the main causes of diabetes according to people from various cultures. Latino populations believe that poor diet (Poss & Jezewski, 2002) and “eating sugar or sweets: drinking sodas” (Weller et al., 1999, 2012) can lead to diabetes. Among African Americans, eating large quantity of sugar (Skelly et al., 2006) is seen as one of the main causes of diabetes. Sugar seems to be central in the discussion of the cause of diabetes; in fact, diabetes is known as “sugar in the blood” among Latinos (Luyas et al., 1991, p. 685) and “sweet blood” among the Hmong (Culhane-Pera et al., 2007, p. 181).

On the other hand, some African Americans are focused on eating well and maintaining body chemistry, as one community member explained: “If you’re not eating right, the chemistry in the body—the body chemistry gets off. And if you’re not eating right, then your sugar balance gets off. And if it gets off and stays off for a long period of time, then you’re prone to get diabetes” (Skelly et al., 2006, p. 16). Among the African Americans that Skelly et al. (2006) studied, eating well means not eating food that contain sugar and salt, and food that does not contain a lot of calories, or high levels of cholesterol and oil (Skelly et al., 2006); these restrictions are much broader than only avoiding consumption of sugar.

Studies have shown that people believe that in addition to the type and quantity of food, changes in food consumption behaviors and the availability of new types of food are closely related to increased consumption of sugar and other unhealthy foods, which in turn leads to diabetes. The Canadian Anishinaabe, whom Garro (1996) interviewed, attributed their high sugar consumption to changes in diet behaviors caused by increased availability of canned food, which is possibly contaminated with chemicals (Garro, 1996, p. 399). A member of the community said that changes in food consumption behaviors resulted in people possibly developing diabetes: “People from long ago didn’t have any kind of sweets or anything to get at, but when the white man came they brought all this different kind of foods, you know we start getting into it and not watching what we’re eating” (Garro, 1996, p. 403).

Baglar (2013) conducted a study in the United Arab Emirates on how changes in lifestyle and an economic boom led to changes not only in food habits but also in physical activity that led, according to informants, to diabetes. Reflecting on changes in her diet since the 1960s, one informant said that in the past, her diet depended on “home reared goat and chicken, fish and rice, vegetables and fruit, according to the season” (p. 113) and very “few boiled sweets” (p. 113). She also said that she and others “all ate together at the same time each day and there was no food between meals. Nobody bought the quantity they do now” (p. 113). Another female community member discussed how it was difficult to avoid being fat and to control eating habits while living a luxurious lifestyle: “They’re [people she knows] all so big, they never used to be like that” (p. 112); she explained that the people she knows got to this stage because “they don’t do anything, they just eat and sleep, they have maids to do everything” (p. 112).

Lawton et al. (2007) studied diabetes among Bangladeshi immigrants in the UK and discussed the process of migration from South Asia to the UK; this migration resulted in consuming more of what these immigrants consider bad food, which in turn caused them to have diabetes. A Hindu informant who was a vegetarian before moving to the UK said that he “blamed his diabetes on a high-sugar diet, which, for him, was necessitated by moving to a non-Hindu, meat-oriented culture” (Lawton et al., 2007, p. 896).

Culhane-Pera et al. (2007) studied diabetes among Hmong refugees in the United States and discussed how changes in diet and in physical activities are closely related to migrating from their countries of origin to the United States. The Hmong thought that the type of food available in the United States was not doing them any good; they believed that the food contains a lot of sugar, salt, fat, pesticides, and fertilizers, which have a negative effect of their health. A community member summed up their lives before migrating to the United States by saying how their day used to start with, as they worked all day long on rice fields, chopping trees, and climbing hills, which in his opinion helped in getting all the toxins out of their body compared to their lives in the United States, where their physical activates dramatically decreased, which led to the toxins staying in their body and therefore they become more likely to have diabetes (Culhane-Pera et al., 2007).

2.1.3 Susto/Fright, Stress, and Depression as Causes of Diabetes

Susto, or fright, is a widely recognized folk illness among Latinos. It was extensively examined by Rubel et al. (1984) in what is now a classic in medical Anthropology, Susto A Folk Illness. Since that book’s publication, the relationship between susto and diabetes among Latinos has been widely examined in two ways: susto as a perceived cause of diabetes (Everett, 2011; Mendenhall et al., 2010, 2012; Poss & Jezewski, 2002; Weller et al., 1999, 2012) and susto as a risk factor for diabetes (Baer et al., 2012).

Latinos, and particularly Mexicans and Mexican Americans, tend to consistently attribute their diabetes to susto, which is the result of a very stressful or emotional life event, such as being robbed (Everett, 2011; Mendenhall et al., 2010), having a bad car accident (Jezewski & Poss, 2002), or watching a child drown (Jezewski & Poss, 2002). In Oaxaca, Mexico, Everett (2011) found that susto, stress, and other emotions that were thought to cause diabetes were not necessarily linked to a single event. He found that “women in Atzompa were likely to attribute diabetes to a chronic excess of emotions (e.g. ‘soy muy enojona’) because they associate their failing bodies with the contradictions and disappointments of their lives” (Everett, 2011, p. 1781).

Nervios, another common ailment among Latino populations, like susto, is also an “expression of psychological distress” (Weller et al., 2008). Baer et al. (2012) designed an experiment to measure the relationship between susto, nervios, and diabetes among Mexican Americans. In this study, Baer et al. (2012) recruited two groups of people who had recently been diagnosed with diabetes and a control group of people who were not diagnosed with diabetes. The main goal of Baer et al. (2012) experiment was to empirically explore the folk belief—which was found in the abovementioned studies—that susto can cause diabetes. Baer et al. (2012) found that “the prevalence of susto among those with a recent diagnosis of diabetes (63%) was not higher than that among controls without a diagnosis of diabetes (69%)” (Baer et al., 2012, p. 344). Regarding nervios, the researchers did not find “a higher prevalence among those with recently diagnosed diabetes (52%) than among those without a diagnosis of diabetes (65%)” (Baer et al., 2012, p. 344).

Migration is a stressful life event and is believed to lead to susto/fright and thus to diabetes in some groups. Among Mexican American diabetes patients in Chicago, for example, Mendenhall et al. (2010) found that stress was highly related to susto. According to this population, high stress is caused by bad living conditions, crime, and social inequality. In addition, Mendenhall et al. (2010) showed that having stressful and traumatic experiences due to migration adds to stress levels. For example, one participant in the study said, “when one lives here illegally and one doesn’t have any documentation, immigration catches you, right and so after the first time that immigration catches you, you are traumatized. The trauma affects the diabetes a lot because you find yourself scared. One has the need to work to take care of the family” (Mendenhall et al., 2010, p. 228).

The perceived relationship between stress and diabetes is not limited to Latino populations. Choi and Reed (2013) studied Korean immigrants’ rates of depression and diabetes and found that people who had high levels of stress were more likely to suffer worse diabetes outcomes, have less family support, and have worse health in general.

Lawton et al. (2007) studied Bangladeshi immigrants in the UK; many participants in the study talked about having high stress due to migration and how this caused them to have diabetes. A community member expressed this by saying he had diabetes “because of stress... I had a lot of stress due to the family, like, if I was leaving them behind, how was I to move them forward. And when I did move forward [by migrating] then I thought of how to bring the family I had left behind forward... to the same place as I was. Because in our culture, even if you’re married you still have to think of your sister and their children, you have to think of your mother and father—I mean there’s no old people’s home in Pakistan, we have to do everything ourselves... So I thought like this a lot, so I think the mistake was made here” (Lawton et al., 2007, p. 899).

Culhane-Pera et al. (2007) studied the Hmong community in the United States and discussed how not fitting in and losing their homeland contributed to diabetes in this group. Culhane-Pera et al. (2007) discussed how the community felt out of balance emotionally, struggling with depression, stress, and anxiety. The researchers found that the community suffered from “difficulties of adjusting to this new country, including not knowing the language, not being able to support themselves, and raising children in a country with different cultural values” (Culhane-Pera et al., 2007, p. 183).

In addition to migration, other lifestyle changes are linked to stress and diabetes. Baglar (2013) studied diabetes in the United Arab Emirates and discussed the relationship between stress and diabetes there. Baglar (2013) showed that high stress levels among women in the community could be a result of changes in women’s roles because women now take on more responsibilities and participate in the economy by working outside of the home.

2.2 Symptoms of Diabetes Across Cultures

Symptoms of diabetes differ across cultures and are described as physical rather than emotional symptoms. While making sense of diabetes often includes a description of emotions and feelings, none of the studies reviewed in this chapter mentioned any emotional symptoms of the disease.

Weller et al. (1999) described the symptoms of diabetes, from the community’s point of view, among a representative sample of 131 respondents in the United States, Mexico, and Guatemala. The list contained 16 symptoms of diabetes: excessive thirst, lack of animation, changes in kidney function, frequent urination, burning sensation during urination, sugar in the blood, cravings for sweet things, dizziness, headaches, irritability, problems with blood circulation, elevated blood pressure, eye problems/vision loss, high susceptibility to other illnesses, slow wound healing, and no need to stay in bed. Another study, by Jezewski and Poss (2002), was less extensive but still listed eight symptoms of diabetes: “weight loss, visual problems, fatigue, weakness, headache, thirst, increased urination, dry mouth and skin” (Jezewski & Poss, 2002, p. 847).

Skelly et al. (2006) studied diabetes among rural African Americans in North Carolina, and the resulting list of symptoms shared many items with the lists from the studies by Weller et al. (1999) and Jezewski and Poss (2002). The participants in Skelly et al.'s (2006) study reported that the symptoms of diabetes are “increased thirst, dry mouth, weight loss, slow healing, and problems with vision” (p. 17), as well as “feeling weak, being easily tired, and having to decrease activities or symptoms of complications—fainting, shock, or coma, seizures, or swelling of the limbs” (p. 17). Masoudi Alavi et al. (2012) studied Iranian beliefs about diabetes and listed three symptoms: “fatigue, polyuria and mouth dryness” (p. 102). Culhane-Pera et al. (2007) studied the Hmong community in the United States, resulting in a list of four symptoms: “tired, weak, thirsty, with a dry mouth and frequent urination” (p. 184).

From the overall shared symptoms across the studies reviewed above, only nine symptoms were shared from among the 25 symptoms found: slow wound healing, eye/vision problems, thirst, fatigue, frequent urination, headaches, weight loss, weakness, and dry mouth.

In addition, very few participants in all cultures said that diabetes has no symptoms. Culhane-Pera et al. (2007) stated in his study of Hmong refugees in the United States that only one out of 44 male participants in his study said that diabetes has no symptoms. Skelly et al. (2006), in their study of African Americans in North Carolina, noted that people do not necessarily associate certain symptoms with diabetes until they are diagnosed by a doctor.

2.3 Treatment of Diabetes Across Cultures

Studies have shown that some populations do have the knowledge that diabetes is a chronic illness that cannot be cured but that needs to be treated (Weller et al., 1999, 2012). Treatment of diabetes varies across cultures and can include diet and exercise, traditional medicine, and prayer. These treatments are often combined.

Weller et al. (1999) found 18 treatments for diabetes in Latino populations in the United States, Mexico, and Guatemala. In general, Latinos in their study believed that diabetes has no cure and that it should be treated by doctors and not by pharmacists. The treatment process requires checking blood sugar on a regular basis, having a balanced diet, losing weight, taking pills that help “to process sugar,” not consuming sweets, not drinking alcohol, and not drinking lemon tea or the herbal drink known as yerba buena (Weller et al., 1999). In addition to these treatment options, Latinos recognize the danger of leaving diabetes untreated; kidney and heart problems, coma, and death are thought to result from lack of treatment (Weller et al., 1999).

Jezewski and Poss (2002) studied Mexican Americans with diabetes and listed four different treatments, which overlap with the list created by Weller et al. (1999): diet regulation, herbal remedies, prescribed medication, and regular exercise. In addition to the treatment list, this study indicated that people are afraid of having to take insulin in the future; a diabetic patient in the community said, “right now I am taking the medicine and checking the level of sugar, and I am doing more or less okay. I am doing this because, as I told you, I do not want to start taking insulin injections” (Jezewski & Poss, 2002, p. 851). Patients who are afraid of taking insulin believe that it can cause blindness, that it is addictive, or that it means they are in a very advanced stage of diabetes (Jezewski & Poss, 2002). In addition, the researchers listed several herbal treatments that are believed to treat diabetes, such as bricklebush, trumpet tree, tree of life, yellow bells, prickly pear, cactus, and creosote (Jezewski & Poss, 2002). Poss et al. (2003) studied home remedies used by Mexican Americans in El Paso, Texas, to treat diabetes and found that home remedies or herbal treatments are often used along with Western medication. Many diabetic participants in the study did not see any problems with combining the two types of treatments, but others noticed that taking some of the herbal medications could lower their blood sugar; one participant in the study said, “When I started taking Glucotrol, I stopped drinking the herbal tea. I used to drink it, but I don’t anymore because I am afraid that my blood sugar may go down too much” (Poss et al., 2003, p. 315).

Skelly et al. (2006) studied diabetes among rural African Americans in North Carolina; this community showed an interesting variation in diabetes knowledge based on age and gender. Younger participants believed that diabetes has no cure, on the other hand, older participants mentioned that diabetes can be treated and cured. In addition, the study found that both young and old males were not sure if diabetes can be cured compared to females (Skelly et al., 2006). In addition, the participants in the study showed very little knowledge of diabetes treatments; one of the participants mentioned “needles” without being able to recall the treatment name (Skelly et al., 2006).

Culhane-Pera et al. (2007) studied the Hmong community in the United States and found that the Hmong believe that treatments for diabetes are strictly related to diet and exercise. People in this community believe that in order to treat diabetes, they should limit consumption of salt, sugar, soda, alcohol, fruits, short-grained rice, sticky rice, spices, and fried foods (Culhane-Pera et al., 2007). When participating in exercise and physical activities, Hmong diabetics reported feeling “lighter, looser, and less tight” (Culhane-Pera et al., 2007, p. 185) and having better sleep. Although diabetics in the Hmong community recognize the importance of exercising, they reported barriers, such as fatigue, pain, and bad weather, which prevented them from exercising (Culhane-Pera et al., 2007). In addition to diet and exercise, the Hmong respondents added that feeling happy is important for getting better: “people have many ways to make themselves feel happier, and healthier. They travel to Southeast Asia or to other states, work in their garden, create harmony at home, get out of the house, visit family and friends, see a psychologist, and come to the group visits” (Culhane-Pera et al., 2007, p. 186), and “a few people described spiritual treatments for diabetes, both intercession through Christian prayer and assistance from shaman[s] and shamanic helping Spirits” (Culhane-Pera et al., 2007, p. 186). Hmong diabetics did not necessarily think that doctors should be the first treatment source; one participant in the study said, “I manage myself like I am my own personal doctor... because I know which medicines or things will make me feel better and which ones do not. So I treat myself all the time. Only when I cannot help myself, then I come in and let the doctors help me” (Culhane-Pera et al., 2007, p. 186).

2.4 Diabetes Management Across Cultures

Management of chronic illness, including diabetes, is a complex task that includes many players, parts, and situations. In order for diabetics to manage their illness well, there is a “wide range of life-long activities which must be carried out on a daily basis in different situations” (Masoudi Alavi et al., 2012, p. 101). Those daily tasks involve not only diabetic patients but also everyone with whom they live.

Accepting the illness is the first step in coping with and managing diabetes. In a study of 300 Turkish diabetes patients, Besen and Esen (2012) found that 46% had a low level of acceptance. A low level of acceptance of diabetes is associated with low levels of education, low income, having other chronic illnesses, a negative outlook on life, and less social support.

Masoudi Alavi et al. (2012) found that diabetic patients in Iran who received family support were more likely to cope with their new illness and accept it. For example, a 19-year-old participant in the study said, “I accepted my new situation very well, because of my mother, she helped me a lot and even now after 15 years, she comes to see whether I am all right at night” (p. 104).

Jezewski and Poss (2002) study of diabetes among Latinos showed a similar importance of one’s family in diabetes management. Participants in the study said that most of their lifestyle and care decisions were made with the help of their family members, such as help “from a spouse, parents, and/or children” (p. 852). In addition, the study showed that diabetic patients in this population had “changed their diets since the time of diagnosis, and most of them subsequently convinced their family members to join with them in following the new diet” (p. 852).

Baglar (2013) study of diabetes among Emiratis demonstrated the role of family when a patient with diabetes refused treatment. One man said that he initially refused to seek Western medicine and relied on traditional medicine, but because of the pressure his wife put on him, he started to go to the hospital. According to him, “I only go to keep her happy” (p. 118).

Henderson's (2010) study of American Indian elders presented the narrative of a diabetic family. A member of the family said, “we all diabetic, now, me and my brothers and sisters, and we all eat. My mom (also a diabetic), they feed her whatever she wants…makes her happy. One thing that’s hard to do is change in life. I guess I just Indian (laughs)” (p. 309). In addition, Henderson (2010) study showed that for elder Indians, “Non-adherence to medical recommendations was perceived as being socially desirable, because adherence placed the elder outside their peer group” (p. 303).

Edelstein and Linn (1985) found that patient family management and environment were associated with diabetes control for diabetic men in the United Kingdom; patients who lived in a family that was “low in conflict and organization and oriented toward achievement” (p. 541) were more likely to have better control over their illness. In addition, the study suggested that diabetes as a chronic illness was not any different from any other chronic illness when it came to the family’s role in management. Thus, a patient with hypertension who lives with a family with the above characteristics would also have better management of his or her illness.

Pinelli et al. (2011) studied family support and its association with success in losing weight among Arab American diabetic patients enrolled in a lifestyle intervention program. The goal of the program was to achieve 7% weight loss for each participant. This goal was accomplished by 44% of the participants in the program, and participants who achieved the goal were more likely to have a high level of family support, a high level of session attendance, and longer duration of physical activities. In addition, the amount of calories consumed by the participant was not significant in weight loss; this association was more significant among women than men. A similar result of women benefitting from intervention programs more than men was found by Chesla et al. (2014) in their study of first-generation Chinese Americans. Before enrolling in a behavioral intervention treatment program, women had a higher level of depression than men. After the program, women showed greater improvement than men. The study suggested that women are more likely to benefit from behavioral intervention treatment programs than men when it comes to managing diabetes.

Many studies have focused on couples’ relationships and diabetes management. Houston-Barrett and Wilson's (2014) study of diabetes management across various ethnic and racial groups (18 whites, 17 Hispanics, 6 blacks, and 2 Pacific Islanders) showed that couples who had positive behaviors and attitudes had the best management of diabetes, while couples who had accepted their diabetes but did not have a positive attitude had less successful management. Finally, the couples who had negative behaviors toward accepting their diabetes were likely to have the worst management outcomes.

In Iida et al.'s (2013) study in northeastern Ohio, diabetes symptoms were associated with lower levels of enjoyment and more tension between couples. Distress was not highly associated with a high level of tension between couples with non-diabetic spouses.

Seidel et al. (2012) studied spouses’ involvement in their diabetic partners’ disease management in the United States. Through 139 interviews conducted with participants above the age of 50, the researchers found that “Among male patients, when both partners shared an expectation for spouse involvement, greater diet-related spouse control was associated with better diet adherence of patients” (p. 698). On the other hand, when “expectations for spouse involvement were not shared, greater spouse control by wives was associated with poorer diet adherence” (p. 698).

Other factors, such as acculturation level, seem to have an effect on diabetes management among immigrants. In a study of 211 Chinese Americans with diabetes, Xu et al. (2011) found that those who were born outside the United States and those who were older had lower levels of acculturation, whereas people with a socioeconomic status and who had in the United States for longer had higher levels of acculturation. Moreover, those who were more acculturated were more likely to have better self-management of their diabetes than people who had lower levels of acculturation.

In addition, Weller et al. (2013) suggested a relationship between different illness models and diabetes management. In their study, the authors tested “whether differences between patient and provider explanatory models of diabetes affect self-management and glucose control in diabetes patients” (p. 1498) in Guadalajara, Mexico. The researchers found that different models of diabetes held between the patient and the provider may lead to negative diabetes outcomes and management behaviors. The study also suggested that the patient’s level of education might lead to problems in understanding the provider’s model of diabetes.

Other social and religious practices suggest interesting management challenges for diabetic Muslim patients. Salti et al. (2004) focused on measuring the effect of fasting during Ramadan among 1070 Muslims from 13 different countries. The researchers reported that people who have diabetes “fasted for at least 15 days” (Salti et al., 2004, p. 2306) out of the 28–31 fasting days. They also reported that only half of the participants with diabetes reported changes in their diabetes medication intake. Severe hypoglycemic episodes were reported to increase during fasting for participants with diabetes, especially among those who changed their diabetes medication dosage or physical activity patterns.

Pinelli and Jaber (2011) studied the practices of Arab Americans with diabetes during Ramadan. The authors interviewed 27 patients and found that most of the participants reported performing less exercise and physical activity during Ramadan. In addition, the researchers found that the majority of the participants in the study did not have knowledge of the risk of fasting while taking diabetes medication, when to break their fast, special diets that may be required, or how to exercise during Ramadan. Also, half of the patients reported changes in their insulin-taking patterns. Additionally, the respondents reported struggling with thirst the most. Only one participant reported breaking the fast during Ramadan. The study included no reports of participants going to the hospital.

Bravis et al. (2010) conducted a study among Muslims in the United Kingdom to “determine the impact of Ramadan-focused education on weight and hypoglycemia episodes during Ramadan in a diabetic Muslim population taking oral glucose-lowering agents” (Bravis et al., 2010, p. 327). When designing the study, Bravis et al. (2010) divided the participants into two groups: The first group attended educational programs about “physical activity, meal planning, glucose monitoring, hypoglycemia, dosage and timing of medications,” while the second group did not attend any such programs. The researchers found that, on average, the first group lost 0.7 kg after Ramadan, while the second group reported a weight gain of 0.6 kg. The researchers also found that there was a significant decrease in the number of hypoglycemic events in the first group compared to the second group. The researchers suggested that providing educational programs about fasting during Ramadan “minimizes the risk of hypoglycemic events and prevents weight gain during this festive period for Muslims, which potentially benefits metabolic control” (Bravis et al., 2010, p. 327).

Phumipamorn et al. (2008), in their study among diabetic Muslims in Thailand, tested “whether an extended pharmacy service would improve glycaemic control and cardiovascular risks in diabetic Muslims” (p. 31). To do so, they created two study groups: The first group (n = 63) received a diabetes education brochure and “met a pharmacist who educated and discussed with each patient regarding medication uses and diabetic treatment” (p. 31). The second group received regular pharmacist service. Average blood glucose levels, lipid parameters, medication adherence (number of pills taken), and diabetes knowledge score were collected from both groups. The researchers found that the first and second groups had similar average blood glucose levels, but the first group had lower levels of cholesterol and showed an increase in medication adherence and knowledge about diabetes. This means that pharmacy service similar to what the first group received has no effect on diabetes management but does have an effect on cardiovascular risks by lowering the levels of cholesterol among Muslim diabetes patients in Thailand.

Cultural models of diabetes across the world show some differences and some commonalities. The high prevalence of diabetes among ethnic groups in Western nations (the United States, the UK, Australia, and Germany) has led to a great amount of research focused on cultural models of diabetes. Building explanatory cultural models of diabetes has mainly followed the tradition suggested by Kleinman (1988) discussed in Chap. 1.

Causes of diabetes cross-culturally combine both physical causes—such as inherited genes and diet—and emotional causes, such as anger, susto, and depression. Symptoms of diabetes, on the other hand, mainly include physical symptoms such as thirst and fatigue. Those symptoms do not necessarily lead to one’s realization of having diabetes but rather generally act as a push to visit the doctor. The treatment of diabetes often combines traditional medicine, such as herbal treatment; Western medicine, such as visiting the doctor; spiritual treatment, such as praying; emotional treatment, such as joining support groups; and diet and physical activities that are practiced under doctors’ recommendations. Additionally, there are some cultural beliefs about what food or diet is good or bad in terms of causing or managing diabetes.

The behaviors for managing diabetes are complex; they require not only the self-effort of patients but also that of family members and spouses. The greater the family and spousal support are, the greater the management and control of diabetes will be. In addition to family and spousal support of the patient, intervention programs, such as managing emotional factors related to having diabetes and losing weight, combined with family support seem to have a positive impact on diabetes management. Other factors that contribute to the successful management of diabetes include the level of acculturation, diet, physical activity, and lifestyle strategies for diabetic people in various daily routines.