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Cultural Sensitivity in Diabetes Care and Education

Diabetes affects people of all cultures, races, and ethnicities. However, it impacts Hispanics, Blacks, Asian Americans, and American Indians/Alaskan Natives at higher rates. The good news is that diabetes can be prevented, treated, and managed. Aliya Haq, RDN, CD, is here to talk about how cultural awareness and sensitivity affect patient care.
Cultural Sensitivity in Diabetes Care and Education
Featured Speaker:
Aliya Haq, MS, RDN, CD
Aliya Haq has more than 20 years of experience in the management and delivery of nutrition services, and advocacy improving health outcomes for minority and immigrant people, especially women and children. In particular, Haq has taken a leading role as a national spokesperson advocating against the proposed changes to the “public charge” rule targeting immigrants who legally use government assistance programs. She has effectively articulated the harmful impact as WIC program participants have withdrawn out of fear of reprisal. For this Haq received the NWA’s National Leadership award in 2018.

Currently, Haq serves as the ICHS nutrition services manager, a position she has held since 2009. In addition to managing the Women Infants and Children (WIC) nutrition program and the Maternity Support Services (MSS) program, she also collaborates with the health center medical team to lead the delivery of culturally and linguistically appropriate medical nutrition counseling/ therapy for chronic disease management. Aliya is also the manager/coordinator of the diabetes self-management and education (DSME) program for which ICHS was recently accredited under her leadership.

She is the founder and organizer of Women's Heart Health Day, aimed at reducing the frequency of heart disease among South Asian women in the U.S. In 2001, Haq was awarded the Martha Tapia Award from the Washington State Department of Health WIC Nutrition Program.
Cultural Sensitivity in Diabetes Care and Education

Scott Webb: Though diabetes is common, treating patients with cultural and religious sensitivity is probably not as common. And I'm joined today by Aliya Haq. She's the nutrition services manager at International Community Health Services. And she's here today to discuss the importance of cultural sensitivity in treating diabetes patients and offer some suggestions for other providers.

Welcome to the Together We Rise Wellness Podcast from International Community Health Services. I'm Scott Webb.

So Aliya, thanks so much for joining me for this first ICHS podcast. You know, there are millions of people at risk of diabetes and millions living with diabetes. In your diabetes education work, what's the most important message that you share?

Aliya Haq: As a registered dietician and a diabetes educator, the first thing I would tell my patients is to not to be afraid of food, that there are many food options and choices that they can, you know, choose from to manage their blood sugars. The reason I do that is because I try my best to lessen the emotional burden of diabetes that a patient is facing. This is not only because of the news or the diagnosis that they have diabetes, but also the fact that it actually affects their daily routines, especially their food intake and their daily activities.

I see patients and my colleague dieticians also see patients afraid of choosing so many foods, you know, for the fear that the food would raise their blood sugar. And most often, these are the foods that they like to eat almost every day. And since food is so personal and satisfying, lots of control over it can be very, very depressing. And they're already overwhelmed with the diagnosis of diabetes and wish medication could just help cure the problem. And some patients think that if they simply restrict or limit the amount of food that they're eating, then they can, you know, manage their blood sugars and they go to such extremes as to limiting their food intake so much that they end up harming themselves. Let me give you an example, a pregnant woman diagnosed with diabetes or what we call as gestational diabetes, and we have seen so many of them do this, that they simply start restricting their food so much that they end up losing weight instead of gaining weight. And they not only, you know, risk harming themselves, but the unborn baby. And the woman, she's thinking that she's controlling her blood sugars, but on the other hand, she's actually hurting herself.

So, diabetes self-management and education training designed by the Association of Diabetes Care and Education Specialists actually emphasizes the independent effect of the emotional burden of diabetes on metabolic and quality of life outcomes. So they emphasize that healthy coping should begin before any learning can occur.

Scott Webb: Yeah, and it's such an important message there, just, you know, not to be afraid of food. Because there's just so many options out there and everyone living with diabetes is so worried about their blood sugar, you could see how folks would begin to become maybe a little afraid of their food. So, great messaging. And I know you serve diverse communities at ICHS, so what does cultural sensitivity mean when relating to patients with diabetes care and education?

Aliya Haq: Good question. Cultural sensitivity to me is reaching the patients where they are, which means their understanding of the disease, their cultural treatment options and methods, their food habits or cultural values relating to food or their lifestyle, including their work hours, their access to care. There is so much out there that a person is overwhelmed with. So understanding and reaching a patient is really, really important.

And just to give you an example of understanding chronic disease, for example, whether it's high blood sugars or high blood pressure or high blood cholesterol, since you don't see these problems and they're silently damaging your body, it's really hard for one to understand what this high blood sugar is doing to their body. So if you're culturally sensitive and aware of all these things, you would approach this subject with respect and understanding, and really strive to reach the patient where they are.

And at ICHS, the International Community Health Services, diabetes educators are very, very sensitive to this subject and try their best to understand all of these things that the patient is facing. And as I mentioned earlier, food is very personal to people. In a cultural setting, people, you know, eat different cuisines, and they have, you know, an attachment to food that they eat. So it's very challenging that we address their cultural foods as well.

Scott Webb: Yeah, I'm sure it is. And you use the word challenging there and it kind of leads to my next question. What are some of the challenges and what advice do you have for other providers?

Aliya Haq: Again, I would put connecting with the patient as the first and the most important one in diabetes education. An educator have to develop that rapport with the patient. And actually, the reason I call it challenging is because there are two components to this whole process of connecting with the patient. One is first, of course, the diabetes educator's education and advice. And the second very important part of it is the patient's acceptance and personal satisfaction. And if you do not connect with the patient or the patient doesn't connect with you and the patient doesn't connect with their own body, then the education is not going to be effective. So one has to help a patient understand diabetes and the role of diet, medication, physical activity and help them take control of their body. So that part is really, really challenging. And that's the first thing that happens in an education process.

And the second important thing, this is quite recent, is the technology advancement and technology. While it's making it easier for patients to manage their blood sugars and go on with their daily life, it is equally important for them to understand technology and then use it. And this is where again cultural sensitivity comes into play because there is not only a fear of this technology, but there are language barriers, affordability, and access to these devices.

So to address the second part of your question regarding advice to providers, I would say that, you know, be very patient, be a good listener and be respectful to their environment and the choices they make, and empower patients and help them make their personal goals and also help them understand the use of modern blood sugar control devices. And not just that, but also work towards making access to care, access to affordable care access to these devices possible for them. And finally, and very importantly, you have to set up follow-up appointments based again on their readiness.

Scott Webb: Yeah. And you've touched on the devices here and how amazing the new blood sugar devices are, whether they're smartwatches and phones, it's really amazing. I've hosted some other podcasts on these things. And maybe you can describe an example of how being culturally aware really helped to break ground with a new patient.

Aliya Haq: The one that comes to my mind of a very recent case that I handled is that if a patient who desired to fast for religious reasons, and this was supposed to be a fast in which the patient wouldn't eat certain foods and most of them were foods that she could eat or were sources of simple carbohydrates, and these are the ones that we want them to control, right? So in this case, it is very important for me to understand all the other cultural foods and understanding of those foods and treatment options that this person was considering. And I had to balance all that and work with the patient to choose the right combinations that would give them a better control of blood sugars. Just to be more specific, I had helped her identify good sources of fiber and plant protein because she was also a very plant foods person. And this understanding was so much appreciated by the patient that she desired to work with me and eventually succeeded in controlling her blood sugars.

Scott Webb: Yeah. And I'm sure this is such great messaging for other providers. I was just thinking along with you here and thinking, you know, most of us think of food in terms of its caloric count or the nutritional value of food, but really thinking of food through this sort of cultural lens or religious lens even, you can see how valuable that would be for providers and patients really ultimately.

Aliya Haq: Yes. It's not always the calories that they're counting. In fact, it's hard for them to understand what are calories. So it's food that they eat and how can you help them balance the amount they eat, when they eat, and how can they actually enjoyed that and be with their family and friends, because, you know, we make food choices based on social, cultural, religious, and so many reasons. And if diabetes is going to affect their daily food intake, I imagine the level of stress. And if you can't reach or address that, then again it leads to that emotional burden, which again affects their learning and self-management.

Scott Webb: Yeah, you mentioned the difficulty in sort of getting your minds around some of this stuff. And I know I took a nutrition class in college and I struggled with it, so great that we have experts like yourself who actually understand all of this and are culturally sensitive and aware. So, good stuff.

You know, the American Heart Association recently recognized ICHS with a gold award for its efforts to help patients manage type 2 diabetes. So this recognition means 25% or fewer of ICHS diabetes patients show poor control over their blood sugar levels and that 70% or more of ICHS diabetes patients have the disease under control. That's a great number, 70%. Love that. So how has ICHS achieved this goal, if you will?

Aliya Haq: We have a multidisciplinary approach to diabetes care and education at ICHS. We have a team of registered nurses, registered dieticians, pharmacists, and of course providers who do the diagnosis, timely diagnosis. And so we have RN case managers and a core team of RNs or registered nurses who begin the care coordination right after the diagnosis of diabetes. And we have registered dieticians who also take it on when these patients are referred to them.

And the topics addressed in the beginning itself are the basic pathophysiology, as I mentioned, to explain the whole process to them and prevention and treatment of acute complications. And referrals to specialists like, you know, endocrinologist or podiatrist or dieticians or behavioral health specialists, depending on the situation like, you know, what the person is going through, again, based on that, we make the referral. And also, teach them on checking blood sugars at home, injection technique as needed for injectable medications and insulin, lifestyle modifications, which include both diet and exercise. So we have both our nursing, pharmacy, and RD teams, registered dietician teams, who do the care coordination, including blood sugar monitoring and medicine titrations.

We also have a program called rapid cycle case management, which involves a provider, a pharmacist, a nurse, a dietician, and a behavioral health specialist. And we meet weekly for a close followup on patients identified by their primary care provider. And, of course, the weekly followup is done with patient consent, again, depending on if they are okay with that followup.

And I'm also happy to share with you that we are now accredited with the Association of Diabetes Care and Education Specialists. And now we can provide diabetes care and self-management and education in a more systematic and trackable fashion. And we have a group of trained instructors, including registered nurses and dieticians to provide what we call as DSME or diabetes self-management and education.

We have recently started support groups at two of our medical centers and planned to expand them to all of four medical centers. And, actually in 2021, one of our sites, the Holly Park site, took part in the NACHC, which is the National Association of Community Health Centers' Leading Change Program. And the Leading Change Program was basically like transforming at-home care pilot project. And the goals were to test the impact of self-care tools, like a patient care kit offered to patients in connection with the care team support to monitor and follow up in a virtual care setting, and then to develop workflows and protocols for virtual care management and monitoring offered by the health center. And of course, documented best practices for patient care kits in the virtual setting as the last implementation experience to benefit health centers nationally.

So, all these programs together, I think a combination of these approaches enabled us to achieve that success. And we definitely hope to continue to be even better as we move forward.

Scott Webb: Well, you've definitely set the bar pretty high for yourselves, and it's been great today to learn more about ICHS and especially learn more about this culturally sensitive approach to diabetes care and management. So thank you so much for your time. You stay well.

Aliya Haq: You're welcome. Thank you so much.

Scott Webb: And for more information, visit our website at And thanks for listening to the Together We Rise Wellness Podcast from International Community Health Services. I'm Scott Webb. Stay well.