Not scared of sugar™: the Australian-first culturally tailored diabetes education program for the Chinese community

Dietitians are trained to respect cultural diversity and adapt practice to ensure cultural competence and enhance clinical effectiveness.

Dr Tammie Choi from the Monash University Department of Nutrition, Dietetics and Food specialises in closing the cultural gap in patient education, particularly amongst the Chinese-Australian community. Tammie explained that “migration to Australia is often accompanied by a pronounced Westernisation of peoples’ lifestyle”. Chinese migrants transition from traditional lifestyle behaviours towards a more sedentary lifestyle which includes a diet high in energy-dense food, which in turn predisposes them to obesity and type 2 diabetes [1]. Diabetes also progresses at a faster rate in the Chinese population [2]. Tammie highlighted that the increased risk of type 2 diabetes, combined with the growing Chinese Australian population, means that health professionals need to consider how to provide culturally appropriate care for Chinese Australians with diabetes. Despite the fact that type 2 diabetes disproportionately affects the Chinese community, the current literature and national guidelines on facilitating diabetes self-management have been largely based on Western literature.

Tammie’s previous research identified that the diabetes participatory self-management education model used in Western countries does not align with the preferred learning style of many Chinese people who in turn, stop attending diabetes care services and instead negotiate this complex condition without information and support. Unfortunately, many Chinese Australians with diabetes reported fear of diabetic complications and often imposed extreme dietary restrictions to manage their blood sugar levels such as cutting out all carbohydrate and meat from their diet. In response to this lack of culturally appropriate education in Australia, Tammie designed and implemented a culturally tailored diabetes group education program that aligned with Chinese people’s expectations. The program was named ‘Not Scared of Sugar™’ (不再慌糖™); in Chinese this translates to stop being ridiculous (in restricting your diet)! 

Tammie and her team developed and piloted an Australian-first culturally tailored group education program (Not Scared of Sugar™) with Melbourne-based Cantonese-speaking people with type 2 diabetes. The Not Scared of Sugar™ program teaching styles were aligned with the Confucian cultural process of learning and incorporated culturally tailored strategies to promote healthy behaviour change. Specifically, the diabetes self-management information was delivered in a top-down approach to the participants and family collectively, with in-between-session activities to promote the individual application of a healthy lifestyle. Thirty-four individuals (35% male) attended five education sessions over ten weeks, delivered by Tammie and a multidisciplinary team of health professionals, in Cantonese. The Chinese preference for information-packed, teacher-oriented lectures was the focus of the program, rather than the experiential learning and problem-solving encouraged in Western classrooms. The Not Scared of Sugar™ clinicians were trained to adopt an authoritative role as educators in providing detailed teaching materials with prescriptive instructional self-care recommendations and minimal audience participation.

We were beyond pleased with the results, Tammie explained. “The program resulted in reductions in waist-to-height ratio and waist circumference in participants, increased their frequency of diabetes self-management behaviours and reduced diabetes distress”. Tammie pointed out that while the reduction in HbA1c observed in this study was too small to be statistically significant in their sample size of 34 participants, the mean HbA1c at baseline (HbA1c 51 ± 7.9 mmol/mol (Ideal ≤53 mmol/mol)) was already within the ideal range before the commencement of the program. This demonstrated the clinical effectiveness of this culturally tailored program. More importantly, the attrition rate of this diabetes education program was the lowest in the world. Participants were very committed to attending the sessions, presenting with a desire for self-management information. One participant even discharged himself from the hospital to avoid missing a class (a practice we don’t advocate our program participants undertake, despite their commitment to the program. The participant was sent back to the hospital). 

Dr Tammie Choi and graduates of the Not Scared of Sugar™ program.

Reflecting on the program, Tammie said that “the success of this program highlights a need to incorporate cultural learning orientations and community expectations into the design of future diabetes education interventions”.  One participant in the program commented that “after attending [the] class, I learnt how to control my diet, balance my intake, and am more confident in managing my diabetes”, with another stating “why didn’t we attend an education like this 10 years ago, it could have saved us all the sufferings!”. When reflecting on the participant experience, Tammie told us she felt extremely humbled by the feedback, with another participant commenting that “it is such a great program with a great name, I feel empowered and truly not scared of sugar anymore!” - exactly the kind of outcome Tammie and her team were after. 

Tammie and her team aren’t finished just yet, “our passion in Chinese Australian research continues and we are currently looking into developing capacity building modules for clinicians to adopt the cultural tailoring strategies. We also want to test this program with Chinese patients with not so well controlled diabetes, and see if it works well too”. 

More information

This work was supported by the Australian Diabetes Educators Association (ADEA) Research Foundation, Australia. The funding body had no involvement in the study design or collection, analysis and interpretation of data. This work was conducted in collaboration with Carrington Health.

The authors wish to acknowledge Carrington Health for their in-kind support in donating clinician time to the intervention and thank Janine Scott and Carina Martin, senior managers of Carrington Health for their support. The authors are also grateful for the financial support from the Australian Diabetes Research Foundation. 

Publication information:

Kellow, N. J., Palermo, C., & Choi, T. S. (2020). Not Scared of Sugar™: Outcomes of a structured type 2 diabetes group education program for Chinese Australians. Health & social care in the community, 10.1111/hsc.13046. Advance online publication. https://doi.org/10.1111/hsc.13046

Dr Tammie Choi is an Accredited Practising Dietitian, lecturer and researcher with the Monash University Department of Nutrition, Dietetics and Food. Her research focuses on closing the cultural gap in patient education and higher education. Access Tammie’s research profile here. You can follow Tammie on Twitter via @tammie_choi. 

Dr Nicole Kellow is an Accredited Practising Dietitian, Credentialled Diabetes Educator and Senior Research Fellow  within the Department of Nutrition, Dietetics and Food at Monash University. The focus of her research is dietary and lifestyle interventions to improve metabolic health and fertility. Access Nicoles’s research profile here. 

Associate Professor Claire Palermo is a lecturer and researcher within the Department of Nutrition, Dietetics and Food at Monash University. The focus of her research is education research. Access Claire’s research profile here. You can follow Claire on Twitter via @ClairePalermo.

Stay connected with Monash Nutrition on Twitter (@MonashNutrition) and Facebook (@MonashNutrition). 

References

[1] Weng J, Bi Y. Diabetes in China: The challenge now. J Diabetes Investig. 2010;1(5):170-1.

[2] Park YW, Allison DB, Heymsfield SB, Gallagher D. Larger amounts of visceral adipose tissue in Asian Americans. Obes Res. 2001;9(7):381-7.

For more information about the unique diabetes education paradigm used in this intervention:

Choi TS, Walker KZ, Ralston RA, Palermo C. Diabetes education needs of Chinese Australians: A qualitative study. Health Education Journal. 2015 Mar;74(2):197-208.

Choi TS, Davidson ZE, Walker KZ, Lee JH, Palermo C. Diabetes education for Chinese adults with type 2 diabetes: A systematic review and meta-analysis of the effect on glycemic control. diabetes research and clinical practice. 2016 Jun 1;116:218-29.

Choi TS, Walker KZ, Palermo C. Culturally tailored diabetes education for Chinese patients: A qualitative case study. Journal of Transcultural Nursing. 2017 May;28(3):315-23.

Choi TS, Walker KZ, Lombard CB, Palermo C. Optimising the effectiveness of diabetes education in an East Asian population. Nutrition & dietetics. 2017 Jul;74(3):253-60.

Choi TS, Walker KZ, Palermo C. Diabetes management in a foreign land: A case study on Chinese Australians. Health & social care in the community. 2018 Mar;26(2):e225-32.

Choi, T. S. T., & Kellow, N.. Adding cultural dimensions to person-centered diabetes care for the Chinese community. Australian Diabetes Educator, 2018 Dec;21(4), 1-4.