Chapter 11: Endocrine System and Diabetes

Social Determinant Considerations and Culturally Responsive Practice Points for Health Care Providers

Chronic conditions, like diabetes, are seen at much higher rates in Black and Indigenous populations on Turtle Island than in White populations. This has been very easily misconstrued as a genetic difference between racial populations (Chadha, Lim, Kane, & Rowland, 2020; Hogarth, 2017). However, there is growing evidence that these disparities in incidence are attributed to the social determinants of health and racism, not race. This conclusion is supported by the WHO. Race is a social construct, not a biological one, and there is more genetic variation within racial groups than there is between groups (Chadha et al., 2020; National Human Genome Research Institute, 2023). Reducing the explanation of health disparities to a genetic difference in race is “misleading, ignores structural factors that perpetuate disease and tends to perpetuate notions of racial inferiority and negative stereotyping” (Chadha et al., 2020, p. 12). This is a dangerous cyclical paradigm that has real effects on real people’s lives, and it must be interrupted.

Diabetes will present in people the same way, and the objective physical assessment will not change. However, it is present at disproportionate rates in Black and Indigenous populations, which also experience higher rates of complications of this chronic condition (Diabetes Canada, n.d.). A full and accurate assessment for diabetes includes the subjective assessment, which is where you will find the most important information. There is a stigma around this diagnosis, and people often feel like they did something to cause it or they didn’t do enough to prevent it (Diabetes Canada, n.d.). There is also a feeling of blame or shame when blood sugar levels cannot be controlled within a normal range (Diabetes Canada, n.d.; National Indigenous Diabetes Association [NIDA], n.d.). When this happens, people may not be open with their health care provider about what is affecting them (Diabetes Canada, n.d.; NIDA, n.d.). There are also many people who cannot afford their medications or insulin and who therefore start to ration the medications they have access to. This leads to higher blood glucose levels and higher rates of burden of disease (Dawson, 2018; Diabetes Canada, n.d.; NIDA, n.d.).

Food security, or access to healthy foods, can be another issue. There is also a huge misunderstanding of what “healthy food” consists of. Canada’s food guide has historically been depicted as a plate with sections of four food groups that show a typical North American diet. The most recent update of this guide does make room for cultural considerations. However, the uptake in application at the clinical level is lacking. As a result, there can be misinterpretations of what a diabetic diet can look like. For example, plain white rice is considered a food that should not be consumed because it has a high carbohydrate count and low nutrients. However, white rice is seldom eaten plain. It is usually combined with vegetables and meat or stewed in broth that has a lot of needed vitamins and minerals. Telling people to remove white rice from their diet completely does not incorporate cultural differences in consumption, nor does it empower people to make the changes that are right for their bodies and their health.

There are many food guides out there that can be used for educational purposes that incorporate a variety of different cultural dishes (see below). These resources are excellent guides to help health care professionals expand their ideas of what healthy food means. They can also help people living with diabetes feel empowered to make adjustments to food they normally eat and enjoy. Living with diabetes is a lifelong commitment and something people need to consider constantly. This can be exhausting on its own. To combine this with having to give up cultural foods that are normal to the person is to add an insult to an injury.

Continuing on with a subjective assessment, it is important to understand patients’ experience with the disease. Many First Nations communities in Canada report having many barriers to care, such as long wait lists, limited or no access to care, transportation costs, inconsistent health care providers, and limited explanations of the condition (First Nations Health and Social Secretariat of Manitoba [FNHSSM], 2018). In the 2018 First Nations Regional Health Survey Report, a significant number of people noted that care was culturally inappropriate or that the overall care that was provided was inadequate. If care is not provided adequately or appropriately, or if a patient feels like their concerns will be dismissed without being heard, they will not feel empowered to seek the care they are entitled to (FNHSSM, 2018). Screening done in First Nation communities found that they had double the rates of chronic kidney disease compared to the general population (FNHSSM, 2018). There were particularly high rates of undiagnosed chronic kidney disease in First Nations communities that are only accessible by air compared to those in communities that are accessible by roads (FNHHSSM, 2018). This shows how accessibility to care directly affects health and well being. A study done in First Nations communities in Alberta by Oster et al. (2014) showed the impact that culture, and specifically language, can have. Oster et al. (2014) found that there is a protective factor against diabetes in First Nations communities that have been able to preserve their culture.

Food Guides

The Institute for Family Health, Healthy Plates from Around the World: https://institute.org/health-care/services/diabetes-care/healthyplates/

Gifts from our Relations, Indigenous Original Food Guide: https://nada.ca/wp-content/uploads/NIDA_TRADITIONAL_FOODS_GUIDE-2019-English.pdf

Nourish, Food Is Our Medicine: https://www.nourishleadership.ca/fiom-overview. Food Is Our Medicine is an action learning series designed to introduce health care professionals and leaders to new and different ways of understanding the complex relationships between Indigenous foodways, reconciliation, healing, and health care.

Diabetes Resources

National Indigenous Diabetes Association: https://nada.ca/

The Institute for Family Health, diabetes care information: https://institute.org/health-care/services/diabetes-care/diabetes-information-for-you/

Diabetes Canada, Food Security and Diabetes: A Position Statement: https://www.diabetes.ca/DiabetesCanadaWebsite/media/Advocacy-and-Policy/Diabetes-Canada_Food-Security-Diabetes_Position-Statement_March-2020.pdf

References

Chadha, N., Lim, B., Kane, M., & Rowland, B. (2020). Toward the abolition of biological race in medicine: Transforming clinical education, research, and practice. Othering & Belonging Institute, University of California, Berkeley. https://belonging.berkeley.edu/sites/default/files/race_in_medicine.pdf?

Diabetes Canada (2020). Food security and diabetes: A position statement. https://www.diabetes.ca/DiabetesCanadaWebsite/media/Advocacy-and-Policy/Diabetes-Canada_Food-Security-Diabetes_Position-Statement_March-2020.pdf

Hogarth, R. (2017). Medicalizing blackness. University of North Carolina Press. https://www.perlego.com/book/539340/medicalizing-blackness-pdf

First Nations Health and Social Secretariat of Manitoba (2020). Annual report 2019–2020. https://www.fnhssm.com/_files/ugd/38252a_833d274892bb446ca53085e2f0e403e4.pdf?index=true

Oster, R.T., Grier, A., Lightning, R., Mayan, M., & Toth, E.L. (2014). Cultural continuity, traditional Indigenous language, and diabetes in Alberta First Nations: a mixed methods study. International Journal for Equity in Health, 13. https://doi.org/10.1186/s12939-014-0092-4

National Indigenous Diabetes Association (2020). Gifts from our relations: Indigenous original foods guide. https://nada.ca/wp-content/uploads/NIDA_TRADITIONAL_FOODS_GUIDE-2019-English.pdf