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This is to certify that the
thesis entitled

ACCULTURATION AND ASSOCIATED FACTORS IN
RELATION TO GLYCEMIC CONTROL AND SELF-
MANAGEMENT OF DIABETES IN ASIAN INDIAN ADULTS
IN THE US.

presented by

SUMATHI VENKATESH

has been accepted towards fulfillment
of the requirements for the

MS. degree in Human Nutrition

 

 

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PLACE IN RETURN BOX to remove this checkout from your record.
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DATE DUE DATE DUE DATE DUE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5/08 ICIProj/AccG-Pres/CIRClDateDue.indd

 

 

ACCULTURATION AND ASSOCIATED FACTORS IN RELATION TO
GLYCEMIC CONTROL AND SELF-MANAGEMENT OF DIABETES IN ASIAN
INDIAN ADULTS IN THE US.

By

Sumathi Venkatesh

A THESIS

Submitted tO
Michigan State University
in partial fulfillment Of the requirements
for the degree of

MASTER OF SCIENCE
Human Nutrition

2010

ABSTRACT
ACCULTURATION AND ASSOCIATED FACTORS IN RELATION TO GLYCEMIC
CONTROL AND SELF -MANAGEMENT OF DIABETES IN ASIAN INDIAN
ADULTS IN THE US.
By
Sumathi Venkatesh

Type 2 diabetes, is disproportionately high among Asian Indians (AI), one Of the fastest
growing immigrant groups in the United States. If diabetes is not identified early or well
controlled as assessed by serum glycosylated hemoglobin (HbAlc), the propensity to
develop devastating complications is greatly enhanced, and may lead to increased
medical costs and premature death. Acculturation may be an important determinant of
disease management and hence control. Therefore, a mixed method (descriptive
quantitative and qualitative) study was conducted among 30 AI adults with physician
diagnosed type 2 diabetes in acceptable (AC) (HbAlc <7°/o) (n=15) or unacceptable
(UC) (HbAlc 37%) (n=15) glycemic control. Assessments of acculturation (SL-ASIA)
and diet (initial and follow-up 24-hr recalls) were followed by an audio-taped in-depth
interview that included socio-demographic, self-reported anthropometric, and open
ended diabetes self-care questions. Interactions of acculturation with income (interaction
b= 7.19; p= .01), duration of diabetes (interaction b= .30; p= .02), and body mass index
(interaction b= 1.11; p= .01) significantly predicted higher HbAlc levels. Diabetes
awareness, adherence to self-management behaviors, and support from physician
friends/ family members were more evident in the perceptions of the AC versus the UC

group. Cultural orientation and the patient’s social and health care networks might be

important for patient tailored interventions targeting A1 with diabetes.

Dedicated to myfitmily, friends. and teachers

iii

ACKNOWLEDGEMENTS

I am heartily thankful tO my major advisor Dr. Lorraine W eatherspoon for being an
excellent mentor throughout my thesis research work. She provided the guidance,
encouragement, and professional advice at the right times whilst allowing me the
freedom to be creative and function independently. 1 would like to express my sincerest
thanks to my guidance committee members Dr. Lorraine Weatherspoon, Dr. Won Song
and Dr. Stan Kaplowitz for their valuable inputs and encouragement right from the initial
stages of this research. With their knowledge and expertise, they made a significant
contribution to this thesis, which greatly enhanced the quality of this research. I want to
thank the Community Nutrition faculty members and graduate students in the Department
of Food Science and Human Nutrition for their support, and encouragement. I also want
to thank all my other friends outside the Department of Food Science and Human
Nutrition for their boundless love and friendship. Last but not the least, I want to thank
my family in India and the US. for their immense love and support, which greatly helped
me survive the academic stress. I especially thank my husband Venkatesh who was
always there to help me to balance my family, work, and school and my two adorable
daughters Supritha and Samyuktha for their unconditional and immeasurable love and
affection. Once again, I Offer my sincerest gratitude to all of you; I would not have

reached this stage without your love and support.

iv

TABLE OF CONTENTS

LIST OF TABLES ........................................................................................................... viii
LIST OF FIGURES ............................................................................................................ x
CHAPTER 1 ....................................................................................................................... 1
INTRODUCTION .............................................................................................................. 1
Research Objectives ........................................................................................................ 7
CHAPTER 2 ....................................................................................................................... 9
REVIEW OF LITERATURE ............................................................................................. 9
2.1 Diabetes Mellitus ...................................................................................................... 9
2.1.1 Classification, Risk Factors, and Pathology .................................................. 9

2.1.2 Metabolic Monitoring .................................................................................. 14

2.2 Diabetes among Asian Indians ................................................................................ 17
2.2.1 Characteristics of Asian Indian Immigrants in the US. .............................. 17

2.2.2 Prevalence of Diabetes in Asian Indians ..................................................... 18

2.2.3 Genetic Susceptibility of Asian Indians to Diabetes .................................... 21

2.2.4 Glycemic and Metabolic Control of Asian Indians with Diabetes .............. 24

2.3 Diabetes Self-management Behaviors .................................................................... 26
2.3.1 Healthy Dietary Practices ............................................................................ 27

2.3.2 Physical Activity .......................................................................................... 32

2.3.3 Weight Management .................................................................................... 34

2.3.4 Medication Adherence ................................................................................. 35

2.3.5 Self-monitoring of Blood Glucose ............................................................... 37

2.3.6 Foot Care ...................................................................................................... 38

2.3.7 Medical Monitoring ..................................................................................... 40

2.4 Theoretical Framework ........................................................................................... 41
2.5 Factors Influencing Diabetes Management ............................................................ 43
2.5.1 Personal/ Individual Factors ........................................................................ 44
2.5.1.1 Acculturation ................................................................................. 44

2.5.1.2 Educational Level ......................................................................... 49

2.5.1.3 Income Status ................................................................................ 51

2.5.1.4 Family History of Diabetes ........................................................... 52

2.5.1.5 Duration of Diabetes ..................................................................... 52

2.5.1.6 Diabetes Knowledge ..................................................................... 53

2.5.1.7 Values and Beliefs ........................................................................ 54

2.5.2 Environmental Factors .......................................................................................... 56
2.5.2.1 Health Care System ....................................................................... 56

2.5.2.2 Social Support ............................................................................... 58

2.5.2.3 Location Of Residence ................................................................... 59

CHAPTER 3 ..................................................................................................................... 61

METHODS ....................................................................................................................... 61
3.1 Design ..................................................................................................................... 61
3.2 Subjects and Recruitment ....................................................................................... 61
3.3 Eligibility Criteria ................................................................................................... 62
3.4 Procedures ............................................................................................................... 62

3.4.1 Theoretical Foundation ................................................................................ 62
3.4.2 Methods ........................................................................................................ 64
3.5 Instruments .............................................................................................................. 67
3.5.1 Suinn-Lew Asian Self-Identity Acculturation Scale (SL-ASIA) ................. 67
3.5.2 Twenty F our-Hour Dietary Recall ............................................................... 69
3.5.3 Interview Guide ........................................................................................... 74
3.6 Data Analysis .......................................................................................................... 76

CHAPTER 4 ..................................................................................................................... 81

RESULTS ......................................................................................................................... 81
4.1 Sample Characteristics ............................................................................................ 81
4.2 Dietary Quality and Meal Patterns Of participants .................................................. 86
4.3 Relation of Acculturation to Glycemic Control ...................................................... 89

4.3.1 Findings from the SociO-demographic and Self—care Survey (Quantitative
Findings) ............................................................................................................... 89
4.3.2 Perceptions about Lifestyle and Diabetes Management in the US.
(Qualitative Findings) ........................................................................................... 91
4.3.3 Triangulation of Data on Acculturation and Glycemic Control .................. 93
4.4 Diabetes Self-management Behaviors ..................................................................... 96
4.4.1 Adherence to Self-management Behaviors (Quantitative Findings) ........... 96
4.4.2 Perceptions about the Impact Of the Disease and Self-management
(Qualitative Findings) ......................................................................................... 100
4.4.3 Triangulation of Data on Diabetes Self-management ................................ 103
4.5 Factors Influencing Diabetes Self-management .................................................... 106
4.5.1 Individual Factors ...................................................................................... 106
4.5.1.1 Diabetes Knowledge ................................................................... 106
4.5.1.2 Values and Beliefs ...................................................................... 112
4.5.2 Environmental Factors ............................................................................... 115
4.5.2.1 Health Care System ..................................................................... 115
4.5.2.2 Support Network ......................................................................... 118
4.5.2.3 Location of Residence ................................................................. 121
4.5.3 Facilitators and Barriers to Self-management practices ............................ 123
4.5.3.1 Facilitators ................................................................................... 123
4.5.3.2 Barriers ........................................................................................ 124
4.5.4 Revisiting the Objectives of the Study ....................................................... 127

vi

CHAPTER 5 ................................................................................................................... 128

DISCUSSION ................................................................................................................. 128
5.1 Individual Factors ................................................................................................. 128
5.2 Environmental Factors .......................................................................................... 138
5.3 Implications for Future Research .......................................................................... 141
5.4 Strengths and Limitations ..................................................................................... 143
5.5 Recruitment Challenges ........................................................................................ 144
5.6 Summary and Conclusions ................................................................................... 144

APPENDICES ................................................................................................................ 148
Appendix A: Michigan State University Institutional Review Board Approval ........ 149
Appendix B: Recruitment Flyer .................................................................................. 150
Appendix C: Letters of Support .................................................................................. 151
Appendix D: Interview Guide ..................................................................................... 161
Appendix E: Preliminary Interview Guide ................................................................. 169
Appendix F: Participant Consent Form ...................................................................... 170
Appendix G: SL-ASIA Acculturation Instrument ...................................................... 173
Appendix H: 24-Hour Dietary Recall ......................................................................... 177
Appendix I: CodebOOk for Qualitative Analysis ....................................................... 179

BIBLIOGRAPHY ........................................................................................................... 184

vii

LIST OF TABLES

Table 2.1 Criteria for the diagnosis Of diabetes mellitus (ADA, 2009). ........................... l 1

Table 2.2 Risk factors for type 2 diabetes (ADA, 2009). ................................................. 12

Table 2.3 Biomedical management and recommendations by Centers for Disease Control
and Prevention (CDC, 2008) ............................................................................................. 16

Table 2.4 The recommendations of the American Diabetes Association for blood glucose
and lipid profiles for adults with diabetes (ADA, 2009). ................................................. 17

Table 2.5 Nutrition recommendations by The American Diabetes Association (ADA,
2009) ................................................................................................................................ 28

Table 2.6 Average values of various measures Of Obesity in Asian Indians (Misra et al.,
2004) ................................................................................................................................ 48

Table 3.1 Research Objectives, Research Questions, and Corresponding Interview
Questions ........................................................................................................................... 71

Table 4.1 Frequency distribution by glycemic control status and acculturation level of the
study sample (n=30) .......................................................................................................... 82

Table 4.2 Socio-demographic and medical characteristics Of the sample (n=30). ........... 83

Table 4.3 Mean differences in age, body mass index, HbA] c value, and SL-ASIA score
within groups (mean iSD, range) (n=30). ........................................................................ 85

Table 4.4 T-test comparisons of selected macro-nutrients based on two 24-hour diet
recalls, by glycemic control and acculturation level. (n=30). ........................................... 87

Table 4.5 Selected nutrient composition and meal patterns based on two 24-hour diet
recalls, by glycemic control and acculturation level. (n=30). ........................................... 88

viii

Table 4.6 Predictors of glycemic control among Asian Indians with physician diagnosed
diabetes (n=30). ................................................................................................................ 90

Table 4.7 Participant responses with regard to adherence to dietary and exercise
behaviors from the self-care survey (n=30). ..................................................................... 97

Table 4.8 Participant responses with regard to adherence to medication and weight
control behaviors from the self-care survey (n=30) .......................................................... 98

Table 4.9 Participant responses with regard to adherence to self-monitoring of blood
glucose, foot care, and physician consultation behaviors from the self-care survey
(n=30) ................................................................................................................................ 99

Table 4.10 T-test comparison of participants’ perceived difficulty to perform self-
management behaviors (n=30) ........................................................................................ 100

Table 1.1 Codebook for qualitative analysis ................................................................... 179

ix

LIST OF FIGURES

Figure 2.1 Social Ecological Theory: Correspondence Of Ecological Levels of Influence
with Resources and Supports for Self-management (Fisher et al., 2005) ......................... 42

Figure 2.2 Research Model for Diabetes Self-care Management (Adapted from the
Enhance-Behavior Performance Model) (Sousa et al., 2004) ........................................... 43

Figure.3.1 Integration Of the Social Ecological Model with the Enhance Behavior
Performance Model for Diabetes Self-Management (Fisher et al., 2005; Sousa et al.,
2004) ................................................................................................................................. 63

Figure 3.2 Data Collection Sequence for the Two Phases Of the Study ........................... 66

CHAPTER 1

INTRODUCTION
Diabetes is a globally prevalent, chronic, non-communicable disorder that has emerged as
a serious public health challenge in the 2lst century (Zimmet, 2000). About 2.8% (171
million) of the people in the world have diabetes, and the prevalence has been predicted
to double (4.4% or 366 million) by 2030 (Wild et al., 2004). Diabetes-related mortality
accounts for nearly 5% Of all deaths annually (about 3.2 million people worldwide),
which is projected to increase by more than 50% within the next decade (World Health

Organization (WHO), 2004).

With about 31.7 million people affected, India has the highest absolute prevalence of
diabetes among all countries, which is projected to grow to 80 million people by 2030
(Wild et al., 2004). Furthermore, the prevalence of diabetes has historically been much
higher among immigrant Asian Indians than among the host population Of the countries

to which they emigrate or among Asian Indians living in India (Ramaiya et al., 1991).

Within the United States (US), the prevalence of diagnosed type 2 diabetes in 2004 was
18.3% among Asian Indian adults in Atlanta, Georgia (Venkataraman et al., 2004). In a
more recent large randomized national study by Misra et a1 (2009), the prevalence of
diabetes and prediabetes was found to be 17.4% and 33%, respectively, among Asian
Indians residing in seven urban cities in the US, where the majority of Asian Indians in

the US. are located (US. Census Bureau, 2000). The rates documented by the above

studies are higher than that reported in the 2005-2006 National Health and Nutrition
Examination Survey (NHANES) for Hispanics (8.4%), Blacks (12.8%), and Whites

(6.6%) (Cowie et al., 2009)

The disproportionately high prevalence rates of diabetes among Asian Indians in the US.
warrants investigation Of disease management and hence control. Diabetes control is
usually assessed using the Hemoglobin Alc (HbAlc) laboratory test, which measures
glycemic control or the average concentration of glycated hemoglobin in the blood over a
period of three months (Nathan et al., 2008). The HbAlc value is the best long term
marker of glycemic control as it is not affected by the day to day variations in blood

glucose levels (Sacks et al., 2002; Saudek et al., 2006).

Ethnic disparities are evident in both the prevalence of diabetes and glycemic control
(Adams et al., 2008; Adams et al., 2005; Kirk et al., 2008; Kirk et al., 2006;
Mukhopadhyay et al., 2006). A few cross-cultural comparison studies conducted in
Singapore, the Netherlands, and Malaysia have shown Asian Indians to have poorer
glycemic control than the mainstream/other ethnic populations (Hong et al., 2004; Ismail
etal., 2000; Ray et al., 2007). In the US, despite the high prevalence of the disease
among Asian Indians, relatively little information is available about their diabetes

control.

It is estimated that 4.9% Of individuals in the US. have undiagnosed diabetes (Cowie et
al., 2009), and are not aware of their disease condition until the symptoms appear. If
diabetes is either undiagnosed or poorly managed/controlled, the propensity to develop
devastating complications is greatly enhanced and may result in premature death. For
example, people with diabetes are at higher risk of stroke (Lehto et al., 1996), and heart
disease (F ox et al., 2004) than those without the disease. Hypertension (Saydah et al.,
2004), neuropathy (Klein et al., 1996), retinopathy (Bunce et al., 2006), end-stage renal
disease (Foley et al., 2007; Perneger et al., 1994), and lower limb amputations are more
likely to occur among people with diabetes. Weakness and fatigue are additional
concerns among adults over 60 years (Centers for Disease Control and Prevention
(CDC), 2008). Complications Of diabetes can be reduced or prevented with a consistent

tight glycemic control.

Critical to glycemic control, is strict adherence to key self-management practices
recommended by the American Diabetes Association (ADA) as follows: healthy eating
and associated weight management, regular exercise, self-monitoring Of blood glucose,
foot care, regular consultation with a physician, and compliance with prescribed
medications. The ability and efficacy to perform self-management behaviors may be
related to ethnicity, which was documented by Thackeray et a1 (2004) in a cross-sectional
analysis of the Behavioral Risk Factor Surveillance System (BRFSS) survey. Based on
this study, ethnic disparities were evident in diabetes self-management practices such as

frequency of self-monitoring Of blood glucose, frequency Of HbAlc tests conducted

within the past year by a health professional, self—foot examination, type Of medication
prescriptions (insulin injections or oral medications), attending classes for diabetes
education, ever having blood cholesterol checked, and engaging in vigorous physical
activity after adjusting for sociodemographic factors and age at diagnosis of diabetes.
Therefore, due to the existence of ethnic disparities in self-management practices,
culturally sensitive and appropriate treatment programs are needed (Brown et al., 1995;

Middelkoop et al., 2001; Philis-Tsimikas et al., 2004).

The Asian population including the Asian Indian specifically, is among the fastest
growing immigrant groups in the US. (US. Census Bureau, 2000). A rapid rise in the
number of Asian Indian immigrants occurred within the last two decades (about a
fivefold increase from 387 thousand in 1980 to 1.9 million in 2000), constituting close to
1% of the total US. population and 16.2% of the Asian population (Frazier et al., 2006;
US. Census Bureau, 2000). The majority (65%) Of Asian Indians who reside in the US.
came between 1990 and 2000, accounting for a 133% increase (Frazier et al., 2006). The
enormous immigration to the US. warrants concomitant health status monitoring of this

population because of the potential for serious health-related cost implications.

Since the prevalence Of type 2 diabetes is high among Asian Indians in the US,
adaptation to the western culture could be a potential determinant of the rising prevalence
of the disease in this population. The extent to which immigrants adapt to the host culture

in comparison to retaining their ethnic culture is termed acculturation. Acculturation

could be a critical factor to be considered relative to Asian Indians and other immigrant

populations with regard to both diabetes prevalence and control.

An association between acculturation and increasing rates Of diabetes, Obesity, coronary
artery disease risk, and poor diet quality has been identified in various ethnic groups
(Aldrich et al., 2000; Dixon et al., 2000; Himmelgreen et al., 2004; Hubert et al., 2005;
Kaplan et al., 2002; Lands et al., 1990; Marmot et al., 1976). A few studies on Arab
immigrants and Mexican Americans, however, have documented the positive influences
of acculturation on immigrants’ health such as reduced risk for diabetes and lower rates
of Obesity than individuals with a lower degree of acculturation (Hazuda et al., 1991;
Jaber et al., 2003). Evidence from acculturation studies conducted thus far is therefore
inconsistent and reveals variations in health outcomes that may depend on the
characteristics Of the immigrant group. Therefore, the disease-acculturation link cannot

easily be generalized for all immigrant ethnic groups.

There are relatively few studies examining the impact of acculturation of Asian Indians
pertaining to their health outcomes. Mooteri et a1 (2004) found a significant association
between the duration of residence in the US. (> 20 years) and the increased risk of
coronary artery disease among first generation Asian Indian immigrants. Similarly,
lifestyle behaviors such as physical activity, alcohol consumption, and dietary practices
were also negatively affected. Although this study supports the notion that a longer

duration of stay in the US. may lead to behavioral and lifestyle changes in Asian Indians,

this study did not assess acculturation status of participants. Acculturation and associated
environmental (health care system, support network, location of residence and
neighborhood characteristics), and individual (values, beliefs and diabetes knowledge)
factors could be determinants Of diabetes self-management behaviors. However, the
relationship between diabetes self-management behaviors and acculturation has not been

studied among Asian Indians in the US.

The relationship of acculturation to health outcomes is complex and difficult to study in
populations with diverse religious, linguistic, and sociO-demographic characteristics such
as the Asian Indian. Quantitative data obtained from simple surveys may not adequately
describe the cultural complexities and the perceptions of patients living with diabetes.
Additionally, due to the racial/ethnic disparities in insulin resistance, diabetes prevalence,
and susceptibility to related complications, it is challenging to select appropriate
treatment methods and diabetes interventions targeting a particular ethnicity without

knowing their specific problems and cultural practices.

Therefore, the paucity Of data on acculturation in conjunction with other potentially
influential (individual and environmental) factors, justifies a qualitative study in Asian
Indians with type 2 diabetes. This information will provide rich in-depth data on the
cultural perceptions and experiences of diabetes management among Asian Indians in the
US. More specifically, barriers and facilitators to the management of diabetes in this

vulnerable population will be identified.

Hence, the present study will contribute to the efficacious planning and execution of
culture specific diabetes interventions targeting the Asian Indian population in the US.
Michigan was chosen as a suitable place to conduct this study because of its large Asian
Indian population. In 2000, with about 50,000 Asian Indians, the city of Detroit in
Michigan was reported to be among the top 10 cities with a large number of Asian
Indians (U .8. Census Bureau, 2000). Therefore, data from this study will provide a

“snapshot” Of a representative sample Of Asian Indians in the US.

Research Objectives

The objectives of this study on Asian Indian adults with physician diagnosed diabetes and
who were either in acceptable glycemic control (AC) (HbA1c< 7%) or unacceptable
glycemic control (UC) (HbAlcz 7%) were: (i) to determine if and how acculturation is
associated with diabetes control, and (ii) to describe and contrast self-management

behaviors and related factors Of subjects in the AC and UC groups.

Research Questions:
The research questions for this study as they pertain to Asian Indians with physician-
diagnosed diabetes are as follows:
(i) Is acculturation related to glycemic control, and if SO, how?
(ii) How do participants perceive the impact of the disease and the required self-

management behaviors?

(iii)

0V)
(V)

(Vi)
(vii)

(viii)

What do subjects perceive to be facilitators and barriers for better managing their
diabetes?

How does location Of residence influence self-management behaviors?

How does the subjects’ knowledge Of diabetes affect their self-management
behaviors?

How does the health care system influence self-management behaviors?

In what ways are support networks and self-management related?

How does an individual’s values and beliefs influence self-management

behaviors?

CHAPTER 2
REVIEW OF LITERATURE
The literature review consists of five sections: (i) overview of diabetes mellitus, (ii)
diabetes among Asian Indians, (iii) a review Of self-care behaviors as they relate to
diabetes control, (iv) theoretical framework for diabetes self—management, and (v) factors

that may influence self-management of diabetes.

2.1 Diabetes Mellitus

2.1.1 Classification, Risk Factors, and Pathology

Diabetes mellitus, the most common form of endocrine disorders worldwide, is a group
of metabolic disorders rather than just a single disease (ADA, 2008a). Diabetes is
characterized by high blood glucose concentration (hyperglycemia) due to defective

secretion of the hormone insulin by the beta cells of the pancreas and/or impaired

utilization of insulin by the cells of the body (WHO, 1999).

There are two primary forms Of the disease: type 1 and type 2 (WHO, 1999). Type 1
diabetes is characterized by a deficiency in the production of insulin due to an auto
immune disorder resulting in the destruction of the beta cells of the pancreas. Although
the cause for beta cell destruction in individuals with type 1 diabetes is not known, it is
believed to be due to genetic disposition and environmental factors such as viruses
(ADA, 2008a; WHO, 1999). The exact role of environmental factors in relation to the

development Of type 1 diabetes however, is still under investigation. About 5-10% Of

individuals with diabetes have type 1 diabetes (CDC, 2008), which requires an exogenous
source of insulin for survival, specifically for the prevention of ketoacidosis, coma, and
death (WHO, 1999). Although type 1 diabetes has predominantly been prevalent in

children and adolescents, it has also been increasing in adults (WHO, 1999).

Type 2 diabetes is the predominant form Of the disease present in about 90-95% of
individuals diagnosed with diabetes (CDC, 2008). Type 2 diabetes is a combination of
the body’s resistance to the available insulin and an inadequate insulin secretory response
(WHO, 1999). Type 2 diabetes typically begins with insulin resistance, which is a
decreased ability of body cells to utilize the available insulin resulting in compensatory
hyper-insulinemia and the pancreas gradually losing its ability to secrete adequate
amounts of insulin (WHO, 1999). However, many individuals with type 2 diabetes do not
necessarily need exogenous insulin for survival. This may change over time as beta cells

progressively degenerate.

Diabetes is diagnosed using one Of the three procedures listed in Table 2.1. For any Of
these methods, if the diagnosis of hyperglycemia was not clear or strong enough, a repeat
testing should be done for confirmation (ADA, 2009). Although the fasting plasma
glucose (FPG) is less sensitive than the Oral Glucose Tolerance Test (OGTT), it is the
preferred test for the diagnosis of diabetes because of its ease of application and
acceptability to patients (ADA, 2009). The OGTT is not recommended for routine

clinical use due to poor reproducibility (ADA, 2009).

10

Table 2.1 Criteria for the diagnosis of diabetes mellitus (ADA, 2009).

 

Symptoms Of hyperglycemia and a casual (random) plasma glucose _>_200mg/dl (11.1
mmol/l). Casual (random) is defined as any time of day without regard to time since last
meal. The classic symptoms of hyperglycemic include polyuria, polydypsia, and
unexplained weight loss.*

 

OI'

Fasting Plasma Glucose (FPG) 3 126 mg/dl (7.0 mmol/l). Fasting is defined as no caloric
intake for at least 8 hours.

 

OI'

2-hour plasma glucose 3200 mg/dl (11.1 mmol/l) during an Oral Glucose Tolerance Test
(OGTT). The test should be performed as described by the World Health Organization
using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in
water.*

 

*In the absence of unequivocal hyperglycemia, these criteria should be confirmed by repeat testing on a
different day

 

Screening for diabetes will help identify individuals with an existing condition and those
with pre-diabetes, who do not as yet exhibit adequate signs and symptoms to be classified
as diabetes. In general, a fasting plasma glucose level of < 100 mg/dl is considered as
normal (ADA, 2009). Pre-diabetes is a stage between normal glucose levels and that of
diabetes with an impaired fasting glucose of 3 100 mg/dl but <126 mg/dl (ADA, 2009).
In particular, screening is necessary every three years for individuals 245 years even in
the absence of risk factors. Screening at an even earlier age is advised for individuals who

are overweight and with an additional risk factor for diabetes (ADA, 2009).

ll

Individuals with a family history of diabetes, women who have experienced gestational
diabetes, Obesity, and of a specific ethnicity (African American, Hispanic-American,
Native American, Asian-American, and Pacific Islander) are at a higher risk Of being
affected with diabetes (Table 2.2) (ADA, 2009; WHO, 2004). Although type 2 diabetes
was initially believed to be an adult onset disease, more children (as young as 6 years)
and adolescents have been diagnosed with this disease in recent years (CDC, 2008),
particularly in populations with high rates of diabetes among adults (Pihoker et al., 1998;

Scott et al., 1997).

Table 2.2 Risk factors for type 2 diabetes (ADA, 2009).

 

Family history of diabetes (have a first degree relative with diabetes)

History of gestational diabetes or delivered a baby weighing 3 9 lbs

Impaired glucose tolerance or Impaired fasting glucose

Physical inactivity

Obesity

Race/ethnicity (e.g., African American, Hispanic/Latino American, American Indian,
Asian-American, Native Hawaiian, or Pacific Islander)

Hypertension (Z 140/90 mmHg in adults)

HDL cholesterol 5 35mg/dl (0.90 mmOl/L) and/or a triglyceride levels 2250 mg/dl (2.82
mmol/L)

Polycystic ovarian syndrome

History of vascular disease

Other clinical conditions associated with insulin resistance (e.g., acanthosis nigricans)

 

Early detection Of diabetes is imperative because if untreated or if poorly controlled, this
disease could result in serious complications and/or premature death (Groeneveld et al.,
2001). People with type 2 diabetes are at approximately two to four times higher risk of
stroke (Lehto et al., 1996) and death rates from heart disease (Fox et al., 2004) than those
without diabetes. Hypertension is a common problem among adults with diabetes

(Saydah et al., 2004). Individuals with severe hyperglycemia may experience mild to
12

severe neuropathy and may have neuropathy-related and impaired sensation in their feet
(Klein et al., 1996). They are also susceptible to diabetic foot ulcers (Ramsey et al., 1999)
and dental disease (Mealey et al., 2000; Tsai et al., 2002). Lower limb amputations are
more likely to occur among people with diabetes (Johannesson et al., 2009). Diabetes is
one of the leading causes of blindness (Bunce et al., 2006) and end-stage renal disease
(Foley et al., 2007; Perneger et al., 1994) Additional concerns in adults over 60 years
include weakness and lack of energy to do normal activities and household chores (CDC,

2008).

Due to high rates of morbidity associated with the disease, individuals with diabetes are
more likely to use medical care in the form of in-patient hospital care, outpatient
physician Office visits, emergency visits, and visits with multiple health professionals
(ADA, 2008b). In addition, purchase of diabetes medications, prescription drugs to
reduce associated complications, and medical supplies required for managing the disease
further increases the medical expenditures of people with diabetes compared to those

without the disease (ADA, 2008b).

The medical cost of people with diabetes is about thrice as that of those without diabetes
(Trogdon et al., 2008). In addition, the cost of management of diabetes in the US. in
2007 was estimated to be $174 billion, which includes direct ($116 billion) and indirect
($58 billion) medical costs. The direct costs include general medical costs and expenses

to directly treat diabetes and related complications. The indirect medical costs may

13

include disability, premature death, and limited employment or loss of work or work days
(ADA, 2008b). By 2034 diabetes related annual direct cost is expected to rise to 336
billion (Huang et al., 2009). These associated complications and exorbitant costs of
diabetes could be greatly minimized by maintaining or achieving blood glucose, lipid,
and blood pressure control, all achievable by adhering to self-management

recommendations of the American Diabetes Association.

2.1.2 Metabolic Monitoring

Glycemic control is assessed using the Hemoglobin Ale (HbAlc) laboratory test, which
measures the amount of average concentration of glycated hemoglobin in the blood over
a period of three months. Glycated hemoglobin formation is directly related to blood
glucose concentration since continuous glycosylation occurs during the 120 day lifespan
of erythrocytes (Saudek et al., 2006). Glycosylation occurs when blood sugar attaches to
hemoglobin A, which constitutes about 90% of adult total hemoglobin (Goldstein et al.,
2004). HbAlc, one of the minor components of HbA, results from posttranslational

modification of HbA due to condensation with glucose (Bunn et al., 1976).

HbAlc percent increases in poorly controlled diabetes (Rahbar et al., 1969) and has been
shown to be within normal limits when blood glucose is adequately controlled (Koenig et
al., 1976). In this respect, the HbAlc test value was found to be highly correlated with
mean plasma blood glucose levels on multiple testing over 2—3 months (Nathan et al.,

2008). The HbAlc value is widely accepted as the best long term marker of glycemic

l4

control since it is not affected by the day to day variations in blood glucose levels (Sacks
et al., 2002; Saudek et al., 2006). The HbAlc is used for follow up with patients who
have diabetes, to alter their medications and to foresee their risks for complications as

warranted (ADA, 2009; Berg et al., 2008; Saudek et al., 2006).

According to the American Diabetes Association, an HbAl e value between 4-6% is
considered normal; <7% is the target goal value for people with diabetes in general.
Additional action and modification Of medication is recommended for people with a
HbAlc 28%. Less stringent goals are recommended for individuals with severe
hypoglycemia, limited life expectancy, extensive co-morbidities, and advanced micro
and/or macro vascular complications (ADA, 2009). The HbAlc cut points for the
treatment goals were derived based on prospective randomized clinical trials such as the
Diabetes Control and Complications Trial (DCCT, 1993) and the United Kingdom
Prospective Diabetes Study (UKPDS, 1998) that showed the relationship between
glycemic control and the risks for the development and progression diabetes-related

complications.

The ADA recommends that the HbAlc test be conducted at least twice a year for people
who meet their treatment goals and every three months for individuals who do not meet
their goals or who have changed medications (ADA, 2009). Likewise, control Of blood
glucose and lipid profiles, and additional preventive care practices for micro and macro

Vascular diseases to avoid major complications in people with diabetes are also

15

recommended by the ADA (2009) and the CDC (2008) (Table 2.3 and 2.4). Therefore, in
addition to glycemic control, blood lipids and other clinical parameters are also regarded
as important adjuncts for metabolic disease monitoring. The primary goals Of these
biomedical recommendations are to help delay, prevent, or ameliorate complications of

the disease.

Table 2.3 Biomedical management and recommendations by Centers for Disease Control
and Prevention (CDC, 2008).

 

Glycemic control: GOOd glycemic control is essential for people with both type 1 or type
2 diabetes. There is a 40% decreased risk for micro and macro vascular complications if
the HbAlc drops by at least 1% for those with abnormally high levels.

 

Blood pressure control: Reduces risk of heart disease or stroke by 33% to 50%.
Reduces the risk Of micro vascular complications by 33%. Every 10 mm Hg reduction in
systolic blood pressure, if higher than normal, reduces the risk for any complication
related to diabetes by 12%.

 

Control of blood lipids: Improved control of LDL cholesterol can reduce cardiovascular
complications by 20% to 50%.

 

Preventive care practices for eyes, feet, and kidneys: Detecting and treating eye
disease in people with diabetes can reduce the development of severe vision loss by 50%
to 60%. Comprehensive foot care programs can reduce amputation rates by 45% to 85%.
Detecting and treating early diabetic kidney disease can reduce the decline in kidney
function by 30% to 70%.

 

16

Table 2.4 The recommendations Of the American Diabetes Association for blood glucose
and lipid profiles for adults with diabetes (ADA, 2009).

 

Glycemic Control

 

Ale <7.0%
Pre-prandial capillary plasma glucose 90 — 130 mg/dl (5.0 — 7.2 mmol/l)
Peak postprandial capillary plasma glucose <180 mg/dl (< 10.0 mmol/l)
Blood pressure <130/80 mmHg
Lipids
LDL <100 mg/dl (<2.6 mmol/l)
Triglycerides <150 mg/dl (<1.7 mmOI/l)
HDL >140 mg/dl (>1.1 mmOl/l)

 

2.2 Diabetes among Asian Indians

2.2.1 Characteristics of Asian Indian Immigrants in the U.S.

Asian Indians are among the fastest growing immigrant groups and constitute nearly 1%
(1.7 million) of the U.S. population (U.S. Census Bureau, 2000). Although Asian Indians
started migrating to the U.S. from 1907, the Immigration and Nationality Act of 1965 that
allowed 20,000 Asian Indians annually to the U.S. contributed to the significant growth
in Asian Indian population (Frazier et al., 2003). India is the fourth major source to the
U.S. in immigration; Frazier et al (2006) discussed how the growth of the Asian
population in the U.S. always exceeded projected values. Now, although 77% of Asian
Indians in the U.S. are foreign born about 30% Of these are naturalized citizens (U.S.
Census Bureau, 2000). However, based on the above evidence, it is likely that the actual

growth will surpass this estimation.

17

The Asian Indian group in the U.S. is a relatively young (median age: 30.3 years)
community with only about 4% in the 65 years or Older age group. Seventy seven percent
of Asian Indians in the U.S. are foreign born; however, about 30% Of the foreign born
Asian Indians are naturalized citizens (U.S. Census Bureau, 2000). In general, Asian
Indians in the U.S. are predominantly settled in the metropolitan areas. They have the
highest educational level and more likely to be in management, professional or related
occupations among all the Asian groups with a median income greater than the U.S.
general population (U.S. Census Bureau, 2000). Although the proportion of Asian Indian
females (46%) in the U.S. is almost equal to males, female participation in the labor force
is lower than males. Asian Indians are predominantly Hindus followed by Sikhs,
Buddhists, Jains, Christians, and Muslims. Since English is recognized as one of the
Official languages in India, urban Asian Indians who immigrate to the U.S. are well
versed in written and spoken forms of the respective language (Mehta et al., 1991). The
majority Of Asian Indians in the U.S. are good at Spoken English (80%) with about 20%

of them speaking exclusively English at home (U.S. Census Bureau, 2000).

2.2.2 Prevalence of Diabetes in Asian Indians

India has the highest absolute prevalence of diabetes among all countries. In 2000, 31.7
million people in India were affected with diabetes, which is more than China (20.8
million), and the U.S. (17.7 million) (Wild et al., 2004). Data from national
epidemiological studies that have been conducted within these countries shows a higher

prevalence of diagnosed diabetes of 12.1% in India (Ramachandran et al., 2001)
18

compared to 1.3% in China (Gu et al., 2002), or 7.7% in the U.S. (Cowie et al., 2009). It
has been projected that the diabetes prevalence among Asian Indians in India will

continue to grow with nearly 80 million affected by 2030 (Wild et al., 2004).

Within India, the prevalence of diabetes is rapidly escalating as evidenced by The
Chennai Urban Rural Epidemiology Study (CURES) (Mohan et al., 2006). The CURES
study documented the prevalence Of diabetes among adults _>_20 years in Chennai, a
metropolitan city in Southern India in 2000 to be 15.5%, which is a significant increase
by 72.3% from 1989 to 2004 (Mohan et al., 2006). Furthermore, studies that compared
the diabetes prevalence in rural vs. urban India documented a higher prevalence among
the urban (7.3 -8.2%) than the rural (2.4 — 3.1%) population (Mohan et al., 2008;
Ramachandran etal., 1992). It has been shown that lifestyle changes associated with
urbanization play a major role in the high prevalence Of diabetes in the urban regions Of

India (Ramachandran et al., 1999,).

Furthermore, studies have documented a higher diabetes prevalence among Asian
Indians/South Asians (individuals from Pakistan, Sri Lanka, Nepal, and Bangladesh)
residing in other countries than the host population of those countries. In countries with a
considerable Asian Indian population, such as the United Kingdom (UK) (10.0% in a
predominantly Asian Indian community vs. 3.5% in whites (Simmons et a1, 1989);
Canada (6.2% in South Asians vs. 2.2% in Caucasians (Anand et al., 2000), Singapore

(8.9% in Asian Indians vs. 7.6% in Malaysians (Thai et al., 1987), Mauritius (12.8% in

19

Asian Indians vs. 1 1.5 in Creoles (Dowse et al., 1990), Fiji (1 1.9% in Asian Indians vs.

5.3% in Melanesians (Zimmet et a1, 1983) , Trinidad (20.5% in Asian Indians vs. 12.5%
in Africans (Beckles et al., 1986), and South Africa (10.4% in Asian Indians vs. 3.6% in
Africans (Marine et al.,1969), the prevalence of diabetes was found to be higher among

Asian Indians compared to the host population.

Within the U.S., Venkataraman et al (2004) and Misra et al (2009) documented the
prevalence estimates Of diabetes among Asian Indians, which were much higher than the
percentage with diagnosed diabetes among non—Hispanic blacks (12.8%), non-Hispanic
whites (6.6%), and Hispanics (8.4%) in the NHANES 2005-2006 survey (Cowie et al.,
2009). A survey conducted by Venkataraman et al (2004) on 1,046 Guajarati Hindu
Asian Indian immigrants living in Georgia, was claimed to be the first study to determine
the prevalence Of diabetes among Asian Indians in the U.S. The study included a
questionnaire that consisted of sociO-demographic information, anthropometric profiles,
and questions about the presence of diabetes and related co-morbidities. According to this
study, the prevalence of diabetes among Asian Indians in 2004 was 18.3% (22.5 % in
men and 13.2 % in women). This study documented age, male gender, and family history

of diabetes to be independent predictors for diabetes (Venkataraman et al., 2004).

A more recent randomized national study was conducted by Misra and colleagues (2009)
in seven major urban cities where majority of Asian Indians in the U.S. are located (U.S.
Census Bureau, 2000). The study findings showed the prevalence of type 2 diabetes and

prediabetes among 1,038 Asian Indian adults 218 years to be 17.4% and 33%,
20

respectively. The study participants also exhibited abnormal lipid profiles, a major risk

factor for cardiovascular disease.

Mohanty et al (2005) conducted a cross sectional study Of the National Health Interview
Survey (NHIS) for 1997 - 2000 on 87,846 non-Hispanic whites and 555 Asian Indian
adults. Asian Indians, despite having a significantly lower Body Mass Index (BMI) than
non-Hispanic whites (24.0 vs. 26.2; p<.0001), had a greater likelihood of having diabetes
(OR: 2.7; 95%C1: 1.7 — 4.2) after adjusting for age and BMI than non-Hispanic whites
(Mohanty et al., 2005). Similarly, another cross-sectional study Of the National Health
Interview Survey (NHIS) for 1997 — 2005 documented that Asian Indians were more
likely to have diabetes (OR: 3.1; 95%CI: 2.4 — 4.0) than non-Hispanic whites, after

adjusting for age, sex, and BMI (Oza-Frank et al., 2009).

2.2.3 Genetic Susceptibility of Asian Indians to Diabetes

Certain genetic risk factors Of diabetes such as a high prevalence Of insulin resistance,
abdominal obesity, and abnormal lipid profiles have been shown to be common in the
Asian Indian population (Banerji et al., 1999; Chandalia et al., 1999; Enas, 2002; Misra et
al., 2004; Raji et al., 2001; Ramachandran et a1, 2004; Ramachandran, 1998). This cluster
of abnormalities is collectively termed as ‘Metabolic syndrome’ (The National
Cholesterol Education Program’s Adult Treatment Panel III (NCEP), 2001). Such a
cluster of metabolic disorders, characteristic Of Asian Indians, has been termed the

“Asian Indian Phenotype” (Joshi, 2003), which predisposes Asian Indians to a higher risk

21

of type 2 diabetes and increased risk Of metabolic complications even at a relatively
lower BMI (Banerji et al., 1999; Raji et al., 2001; Ramachandran et al, 2004). This “lean
phenotype” of type 2 diabetes among South Asians may be different from the
characteristic type 2 diabetes prevalent among Caucasians; however there is insufficient

evidence to support this assumption (WHO, 1999).

One explanation for the increased risk for type 2 diabetes among Asian Indians despite
the lower BMI could be related to the fact that Asian Indians have high percentage body
fat despite a lower waist circumference, when compared to Caucasians (Chandalia et al.,
1999). The International Diabetes Federation (IDF) recommends ethnic specific threshold
values for waist circumference for the diagnosis of metabolic syndrome. While the
criteria of waist circumference as a measure of central obesity is the same for South
Asian and Caucasian women (280 cm), it is however 4 cm lower for males of South
Asian (390 cm) than Caucasian (394 cm) origin (International Diabetes Federation (IDF),

2005)

In a study that compared 64 Europeans, 31 Pacific Islanders and 19 Asian Indians in New
Zealand, Asian Indians had a mean body fat % of 28.8 compared to the mean of 19.4 %
and 22.7 % for the Europeans and Pacific Islanders, respectively (Rush et al., 2004). In
this study, the appendicular skeletal muscle mass and bone mineral content were found to
be the least in Asian Indians; however, the abdominal fat was significantly higher than

Europeans and Pacific Islanders. Furthermore, due to a higher percentage of central body

22

fat in individuals of Asian origin overall, the BMI cut points for defining normal weight
(18.5 — 22.9) and overweight (223) have been lowered for Asians (Inoue et al., 2000).
According to the proposed classification of weight by BMI for Asians, overweight is
further classified as at risk for overweight (23 — 24.9), Obese I (25 — 29.9), and Obese II

(230) (Inoue et al., 2000).

Furthermore, using 123 healthy volunteers in India, Dudeja et al (2001) included body fat
percent to establish appropriate cut points to define overweight for Asian Indians. Based
on the calculated body fat percentage ( 21.3 for males and 35.4 for females), a lower BMI
cut point Of21.5 for males and 19.0 for females yielded the optimal sensitivity and
specificity in identifying subjects with high percentage of body fat (Dudeja et al., 2001).
Therefore, this study suggests a much lower BMI upper threshold in the classification of

weight status Of Asian Indians due to their high body fat percentage.

Based on the ‘Thrifty Genotype Hypothesis’ proposed by Neel (1962), the increased
predisposition to diabetes or Obesity of specific ethnic groups could be due to the
inherited hunter-gatherer genes. This theory purports that because hunter-gatherers were
exposed to famine situations often, physiological genetic adaptations for energy
conservation and or storage occurred. Prentice et a1 (2005) articulated the generalizability
of the ‘Thrifty Genotype Hypothesis’ to developing countries that had experienced a
history Of prolonged and mass starvation due to inadequate agricultural yields. Such

populations e. g. Asian Indian immigrants, when exposed to abundance or western

23

lifestyles, experience gene-environment interactions, which may lead to an increased

likelihood of developing metabolic disorders (Bajaj et al., 2004).

On the other hand, researchers argue that the ‘Thrifty phenotype Hypothesis’ could
possibly lead to the origin of disease in the fetal stage, based on the ‘Fetal Origin
Hypothesis’ theory. According tO the ‘Thrifty Phenotype Hypothesis’, maternal
malnutrition leads to poor fetal and infant nutrition thereby resulting in poor development
and functioning of pancreatic beta cells, other organ malfunctions, and insulin resistance
(Hales, 2001). In accordance with the ‘Fetal origin’ hypothesis, Yajnik et al (2002)
compared neonates of Asian Indian and Caucasian origin and showed that although Asian
Indian babies had lower birth weights, they had higher circulating insulin and adiposity
after adjusting for birth weight. Thus, diabetes in Asian Indians could be further
complicated by their genetic risk factors that predispose them to an increased risk of type
2 diabetes. For Asian Indians who have diabetes, early diagnosis as well as adequate

metabolic and glycemic control is therefore vital to prevent or delay complications.

2.2.4 Glycemic and Metabolic Control of Asian Indians with Diabetes

Examination of data from the UKPDS trial showed Asian Indian ethnicity to be
associated with diabetes related complications such as albuminuria and renal impairment
(Retnakaran et al., 2006). Inadequate control of diabetes would fiirther aggravate the
severity of the disease and susceptibility to related complications in this population. In a

few cross-cultural comparison studies that have been published, Asian Indians were

24

found to have higher HbAlc levels than the compared ethnic groups. In Singapore,
between Chinese (n = 792), Malay (n = 69), and Asian Indian (n = 106) patients with
diabetes, mean HbAlc levels were significantly higher for Asian Indians (8.36%)
compared to Chinese (7.65%) and Malays (8.18%). About 22% and 50% of Asian
Indians in this study had heart disease and a family history Of diabetes, respectively

(Hong et al., 2004).

In the Netherlands, between 48 Asian Indians and 48 Caucasians with diabetes, the mean
HbAlc level of the Asian Indians (7.85%) was significantly higher (p=.01) than that for
the Caucasians (7.20%) (Ray et al., 2007). In Malaysia, Ismail and colleagues (2000)
compared Chinese, Asian Indian and Malay people with diabetes and showed Asian
Indians to have higher HbAlc levels. In this study, for type 1 diabetes, the mean HbAlc
was the highest among Asian Indians (n = 92; HbAlc = 9.6%) compared to Chinese (n =
118; HbAlc = 8.1%) and Malays (n = 119; HbAlc = 8.9%). For patients with type 2
diabetes, the mean HbAlc was higher for Asian Indians (n = 161; HbAlc = 8.5%) than
Chinese (11 = 134; HbAlc = 8.0%), but similar to that for Malays (n = 302; HbAlc =
8.8%). Thus studies have shown poorer diabetes control among Asian Indians when
compared to other Asians or Caucasians. The HbAlc levels Of Asian Indians as
evidenced by the above studies are higher than the target glycemic control recommended
for diabetes patients (< 7%) by The American Diabetes Association (ADA, 2009), and

therefore warrants concern.

25

Within India, in an urban population in Chennai, the HbAlc was found to be 8.2%, 9.5%,
and 11.0% in Asian Indians with normoalbuminuria, microalbuminuria and
macroalbuminuria with retinopathy, respectively (Unnikrishnan et al., 2007). Adherence
to diabetes self-management practices is therefore critical because glycemic control is
directly related to the severity of the related complications as demonstrated by the

Chennai study.

2.3 Diabetes Self-management Behaviors

The most essential self-management practices as recommended by the American
Diabetes Association (ADA, 2009) that are complex and demanding, but critical to good
control of diabetes are: healthy dietary practices, an appropriate physical activity
regimen, compliance with prescribed medications, home blood glucose monitoring,
healthy weight management, foot care, and regular consultation with a physician (ADA,
2009). Lifestyle interventions that included healthy eating, weight management, and
physical activity have been shown to be associated with a reduction in the progression of
the disease in individuals who have and are at risk for diabetes (Lemon etal., 2004;
Tuomilehto et al., 2001; Williamson et al., 2009). Misra et a1 (2004) suggests early
initiation of diabetes preventive measures such as healthy dietary habits, an active
lifestyle and weight control for Asian Indians due to their high risk for the disease.
Patient self-management of diabetes is therefore undoubtedly important for attaining

diabetes control.

26

2.3.1 Healthy Dietary Practices

Dietary behavior plays a Significant role in the occurrence and control of metabolic
disorders, particularly type 2 diabetes. The major nutrition recommendations and
interventions suggested by ADA are summarized in Table 2.5. The ADA (2009)
recommends individualized medical nutrition therapy for people with diabetes to achieve
treatment goals. Consideration of the amount and type of carbohydrate consumed is
important for people with diabetes as it may influence blood glucose level. Although
people with diabetes should monitor their carbohydrate intake, low-carbohydrate diets by

restricting total carbohydrate to 5130 g/day are not recommended (ADA, 2009).

Some Of the ways by which carbohydrate intake could be monitored are carbohydrate
counting, exchanges, or experience based estimation (ADA, 2009). The use of glycemic
index (relative blood glucose response to carbohydrate containing foods) and glycemic
load (glycemic index times dietary carbohydrate content) may provide additional benefits
to monitor dietary carbohydrate intake (ADA, 2009). However, the total amount of
carbohydrates in foods consumed is more important than the type or source of
carbohydrates in diabetes patients (Franz et al., 2002). Furthermore, there is insufficient

evidence to support the long term effects of low glycemic index diets (Franz et al., 2002).

27

Table 2.5 Nutrition recommendations by The American Diabetes Association (ADA,

2009i

 

Amount and type of
carbohydrate

Fiber
Sweeteners

Dietary fat and
Cholesterol

Protein

Alcohol

Specific for type 2
diabetes

Recommendation

130g/day, low-carbohydrate diets, restricting total
carbohydrates to < 130g/day, are not recommended in the
management Of diabetes

2 5g fiber/serving, or ~50g fiber/day
Reduced calorie/non-nutritive sweeteners approved by FDA

< 7% total calories from saturated fats
< 200 mg/day dietary cholesterol

15-20% Of total energy

Two drinks per day or less for men, one drink per day or less
for women

Reduce intakes of:

Total energy

Saturated and trans fatty acids
Cholesterol

Sodium

Increase physical activity

 

Recommendations for protein, fiber, and alcohol for the general population and

individuals with diabetes appear to be the same (ADA, 2009). For those with normal

renal function usual protein intake should be 15-20% of total energy. A food containing

35 g of fiber per serving and a diet adequate in fiber rich foods such as fruits, vegetables,

whole grain products, fiber rich cereals and legumes is Often recommended. Alcohol

consumption should be limited to a moderate amount of 5 one drink per day for adult

women and 5 two drinks per day for adult men. While moderate alcohol consumption by

diabetes patients has been shown to be associated with reduced fasting blood glucose

(Shai et al., 2007) and HbAlc levels (Kroenke et al., 2003), and reduced risk for coronary

heart disease (Solomon et al., 2000; Tanasescu et al., 2001), the long term effects of

28

alcohol consumption on glycemic control and the impact of alcohol consumption on

diabetes self-management behaviors is still unclear (Howard et al., 2004).

Sugar alcohols (erythritol, isomalt, lactitol, maltitol, mannitol, sorbitol, xylitol, tagatose,
and hydrogenated starch hydrolysates) and non-nutritive sweeteners (acesulfame
potassium, aspartame, neotame, saccharin, and sucralose) approved for use in the U.S.
are safe when consumed within the acceptable daily intake levels established by the Food
and Drug Administration (FDA). However, the use Of sugar alcohols may sometimes
cause diarrhea and there is no concrete evidence to support the use of FDA approved
non-nutritive sweeteners for the long term improvement in glycemic control (Franz et al.,
2002). Lifestyle modifications by reducing total calorie intake, saturated fats (<7% of
total calories), trans fatty acids, cholesterol, and sodium, and performing at least 150
minutes/ week of moderate physical activity are encouraged in type 2 diabetes patients to

improve glycemic control, lipid control, and blood pressure (ADA, 2009).

Asian Indians in India consume excess refined carbohydrates such as dehulled white rice,
semolina, and white flour, which were shown to be associated with insulin resistance and
metabolic syndrome (Radhika et al., 2009). Asian Indians in southern India eat more rice
versus the larger quantities of wheat consumed in northern India (Malhotra, 1970;
Prashantharn, 2008). Classification of foods into vegetarian and non-vegetarian is quite
common in India, with varying degrees Of frequency and strictness in adhering to

vegetarianism (Prashantham, 2008). A variety of spices are often used in cooking and

29

eating habits of Asian Indians are to some extent determined by religion because Hindus

avoid beef and Muslims do not consume pork (Prashantham, 2008).

South Asians in the UK. with diabetes have been Shown to exhibit poor dietary practices.
In studies conducted on Asian Indians with diabetes, the majority did not follow a healthy
diet for diabetes despite physician recommendations (Baradaran et al., 2004; Naeem,
2003). In general, in the 1999 Health Survey for England, South Asians were found to
consume low amounts of fruits and vegetables, while the consumption of red meat and
total fat intake was lower among the Asian Indian sub-group (Stanner, 2001). Likewise,
Patel et a1 (2006) documented higher energy and fat intake among Guajarati Asian
Indians in Britain when compared to age, gender, and caste matched Asian Indians in

India. These patterns may be Similar for those with diabetes.

Within the U.S., Jonnalagadda et a1 (2002) conducted a telephone survey to study dietary
patterns of 237 Asian Indian adults (3 40 years) who had lived in the U.S. for at least five
years. Participants’ diets were assessed using a modified version of the Block Fat and
Fiber Screener. While fat intake was within the recommendations, participants’ diets
were deficient in dietary fiber content. The authors showed that almost half of the study
participants (43%) were overweight with a BMI 325, which was positively correlated

with total fat intake (1:027; p<.05).

30

The ADA recommends a minimal intake Of trans fat and restriction Of saturated fats to
less than 7% of total calories (ADA, 2009). An important dietary concern of particular
interest to the Asian Indian population is the consumption Of trans fat and saturated fat in
the form Of hydrogenated vegetable oil and clarified butter (ghee), respectively. While
many countries are advocating avoidance of trans fatty acids, there is a likelihood of an
increased intake of trans fats in India in the future due to increased consumption of
‘vanaspathi’, a form of hydrogenated fat that is used in Asian Indian cooking to replace

clarified butter (ghee) (Misra et al (2001).

Raj et al (1999) examined the changes in dietary habits after immigration tO the U.S.
among seventy three Asian Indians in relation to length Of residence in the U.S. Asian
Indians who have been in the U.S. for more than 10 years were shown to decrease the use
of clarified butter (ghee), butter, yogurt, and milk. In the study findings, Asian Indians, in
general had reduced the frequency of traditional mixed dishes made with legumes,
vegetables, and cereals because they require increased cooking time. Typical snacks that
were consumed during the week included apples, cookies, nuts, milk, crackers, and chips,
while energy dense Asian Indian sweet and salty foods were consumed at social
gatherings during the weekends. The consumption of carbonated drinks, fruit juice,
snacks, fruits, margarine, and alcoholic beverages however, increased regardless of the

length of stay in the U.S. (Raj et al., 1999).

31

Although the study by Raj et a1 (1999) showed decreased consumption of saturated fat by
Asian Indian immigrants who had stayed for a longer duration in the U.S., evidence from
another study in the UK. has shown increased consumption Of saturated fat in the form
of ‘ghee’ by Asian Indians (Naeem, 2003). ‘Ghee, which is commonly used in cooking
among Asian Indians, has been shown to have cholesterol oxides that might be the
potential cause of the high risk of atherosclerosis in this population (Jacobson, 1987).
Therefore health professionals should be aware of the concerns and trends in the Asian

Indian diet and provide individualized dietary advice to Asian Indians with diabetes.

2.3.2 Physical Activity

Physical inactivity is an important behavioral risk factor for type 2 diabetes as well as
other major metabolic disorders. A joint initiative of the International Diabetes
Federation (IDF) and the World Health Organization (WHO) mentions physical inactivity
to be a major global health risk which is prevalent in industrialized and developing
countries, especially in urban areas (WHO, 2004). Compared to the UK, fewer large
studies conducted in the U.S., have documented the physical activity level of Asian
Indians. Mohanty et a1 (2005) performed a cross-sectional analysis Of the National Health
Interview Survey (NHIS) survey for 1997-2000. Among 555 Asian Indians in the U.S.,
67% were found to be sedentary or never active and only 33% indulged in vigorous
physical activity. In a cross-cultural study conducted in Texas, Asian Indians were shown

to have significantly lower physical activity than Caucasians (Chandalia et al., 2003). In a

32

study by Misra et al (2005) in the San Francisco Bay Area, among 56 healthy Asian

Indians, 50% reported light or no leisure time activity.

In the UK, a low level of physical activity has been widely documented among Asian
Indian immigrants compared to the mainstream population (Fischbacher et al., 2004;
Hayes et al., 2002). Kolt et a1 (2007) conducted a study with Asian Indian immigrants in
New Zealand and based on the number of pedometer steps/ day; 48% and 33% of the
Asian Indians were classified as sedentary and “low active”, respectively. In a study in
Britain, about 85% of 106 Asian Indian men with diabetes, did not show any interest in
physical activity (Naeem, 2003). Therefore, promotion of physical activity might be a

major consideration of treatment for this population (Carroll et al., 2002).

A few studies, in which a qualitative approach was used, documented the barriers to
physical activity in this population (Lawton et al., 2006; Naeem, 2003). In the UK,
among thirty two Asian Indian and Pakistani individuals with diabetes, although all the
participants were aware Of the importance of physical activity, only seven practiced
regular exercise. In this group, perceived/ reported key barriers to physical activity were
lack of time and opportunity. More specifically, the pressure to work long hours and
family Obligations were mentioned as potential reasons for the lack of time (Lawton et
al., 2006). The other most prominent reported barriers for physical activity were language
for those who could not speak the language Of the host country, absence Of fellow Asian

Indians in the community, lack of culturally sensitive facilities, decreased confidence

33

due to diabetes, and climatic conditions (Lawton et al., 2006; Naeem, 2003). Asian
Indians also perceived that diabetes triggers an irreversible decline in their health that
weakens their bodies and makes it difficult to exercise (Lawton et al., 2006). These
barriers to physical activity should be taken into consideration when advising patients of

South Asian origin.

2.3.3 Weight Management

Overweight or obesity is a major risk factor for type 2 diabetes and indeed for control and
complications relative to the disease (Klein et al., 2004; Mokdad et al., 2003). Weight
loss decreases insulin requirements and increases insulin sensitivity thereby improving
glycemic control and overall health status (Wing, 1995). Even modest weight loss could
benefit individuals with type 2 diabetes (Klein et al., 2004; Wing et al., 1987). A
combination of behavior modification (increasing physical activity, monitoring caloric
intake, separating eating from other activities, removing food cues from the
environmemt, and eating slowly) has been shown to improve glycemic control in Obese

type 2 diabetes patients (Wing et al., 1991).

Compared to Caucasians and African Americans, Asian Indians have higher abdominal
and truncal adiposity despite their lower BMI (Misra et al., 2004). Studies have
documented an average BMI of 24 - 26 among immigrant Asian Indians in the U.S.
(Chandalia et al., 2003; Chandalia et al., 1999; Jonnalagadda et al., 2002; Misra et al.,

2009; Misra et al., 2005; Mohanty et al., 2005; Venkataraman et al., 2004), which is

34

classified as overweight (BMI :23 — 24.9) or Obese (BMI _>_25) according to the WHO
Asian Pacific guidelines (Inoue et al., 2000). Furthermore, based on the review of
literature on metabolic syndrome among Asian Indians by Misra and colleagues (2004),
the mean BMI is higher for Asian Indian immigrants (BMI 24.7) compared to Asian
Indians in urban (BMI 22.4) and rural (BMI 19.6) India (Misra et al., 2004). The authors
discussed urbanization/ emigration as influential factors for the increasing trend in BMI
from rural to immigrant Asian Indians (Misra et al., 2004). These higher BMI values for
immigrant Asian Indians, who are at risk for diabetes even at a relatively lower BMI,

may further aggravate the disease risk.

The importance of weight status and control, and especially if at risk for or diagnosed
with type 2 diabetes may sometimes not be perceived as a problem in Asian Indians. For
e.g. in a study by Naeem (2003) in the UK, 80% of Kashmiri immigrant men with
diabetes were informed by a health professional that they were overweight, but half
disagreed. This could be challenging for health care professionals, and necessitate

appropriate strategies for trying to address the problem.

2.3.4 Medication Adherence

Medication is usually an important adjunct to diabetes management (oral hypoglycemic
agents and/ or insulin injections). In addition, individuals with diabetes or other chronic
diseases may need to take diabetes medications in conjunction with medications for other

conditions such as high blood pressure, and coronary heart disease. The nature of the

35

treatment regimen, and a patient’s perceptions about potential side effects and benefits of
prescribed medications may influence compliance with prescribed medications (Rubin,
2005). In addition, patients’ understanding about the essential self-management practices
and provider communication about the treatment and medications have been shown to

influence medication compliance (Heisler et al., 2002).

In a study among 151 patients with type 2 diabetes in New York, poor adherence to
prescribed medications was evident in 30% of the participants (Mann et al., 2009).
Patients’ beliefs (“have diabetes only when blood sugar is high”, “do not have to take
medicine when the glucose is normal”, “worrying about side-effects of diabetes
medicines”, “lack Of self-confidence in controlling diabetes”, and “expressed difficulty in
taking medicines regularly”) were predictors of poor medication adherence. Thus,
patients’ perceptions about medications and the severity of the disease may play an

important role in compliance with prescribed medications.

Intensive insulin therapy for both type 1 and type 2 diabetes has been shown to delay the
progression of complications associated with poorly controlled diabetes (Hayward et al.,
1997; Ohkubo et al., 1995). Peyrot et a1 (2005), however, in a multi-national study
documented that about 50% of general practitioners and nurses compared to specialists
were more likely to delay insulin therapy for patients diagnosed with type 2 diabetes,
especially when the provider awareness of the efficacy of insulin was low (Peyrot et al.,

2005). Individuals with type 2 diabetes may also exhibit an aversion towards insulin

36

injection therapy, which is often associated with failure to adhere to other diabetes self-
management practices by patients (Hayes et al., 2006; Larkin et al., 2008; Polonsky et al.,
2005). On the other hand, some patients with type 2 diabetes, who are poorly controlled,
have been shown to perceive insulin therapy as beneficial (Peyrot et al., 2005). Hence,
patients’ positive perceptions and attitudes about insulin therapy could influence patient
satisfaction with insulin administration (Hayes et al., 2009). Therefore, health
professionals and the patients should recognize the importance of insulin therapy when it

is necessary and the therapeutic option should be clinically effective (Hayes et al., 2006).

2.3.5 Self-monitoring of Blood Glucose

Daily home blood glucose monitoring and quarterly HbAlc measures are two techniques
suggested by the American Diabetes Association for the assessment of glycemic control
(ADA, 2009). Self-monitoring blood glucose at home, which typically involves finger
pricking, facilitates patient understanding of day to day variations in blood glucose and
the evaluation of blood glucose response to diet and physical activity as well as to

treatment (ADA, 2009).

Self—monitoring Of blood glucose has been shown tO benefit patients and improve
glycemic control in patients with type 2 diabetes (Bode et al., 1999; Guerci et al., 2003;
Karter et al., 2001). In addition, studies have shown regular monitoring of blood glucose
to be associated with improved metabolic control and decreased diabetes-related

morbidity among people with diabetes (Guerci et al., 2003; Martin et al., 2006). On the
37

other hand, low socioeconomic status of the neighborhood, Old age, poor glycemic
control, fewer physician consultations, and obesity were associated with lower rates of
blood glucose monitoring in a cross-sectional study Of 4,565 patients with type 2 diabetes

in Massachusetts (Adams et al., 2003).

It is recommended by the ADA that individuals on insulin therapy should monitor their
daily blood glucose level three or more times a day (ADA, 2009). However, data from
the NHANES 111 Show that only 40% of individuals on insulin therapy actually
monitored their blood glucose at home (Harris, 2001). In addition, the NHANES 111 data
indicated that only a small proportion patients treated by diet or oral medications (5-6%)
self-monitored their blood glucose (Harris, 2001). Self—monitoring of blood glucose is a
useful guide for therapy for patients. Regular monitoring of blood glucose by patients
with type 2 diabetes who are treated with diet alone or diet plus oral medications has been
shown to improve metabolic control in the Auto-surveillance Intervention Active (ASIA)
study conducted in France (Guerci et al., 2003). Therefore, regardless of the type of
treatment, self-monitoring of blood glucose may be beneficial for all individuals with

diagnosed diabetes.

2.3.6 Foot Care

According to the North-West Diabetes Foot Care Study in England, each year about 2%
of patients with diabetes develop new foot ulcers (Abbott et al., 2002). Adherence to

proper foot care is essential for diabetes management given that 50% Of all non-traumatic

38

lower limb amputations occur in people with diabetes (Most et al., 1983). The risk for
lower extremity amputations is 15 times higher among individuals with diabetes than
those without the disease, especially for those in poor glycemic control (Most et al.,

1983).

Education about foot care and an annual comprehensive foot examination of foot pulses
and sensations to detect potential causes Of foot ulcers and amputations is recommended
for all individuals with diagnosed diabetes (ADA, 2009). Besides foot care, adequate
glycemic control is essential among diabetes patients with foot ulcers because poor
glycemic control is an independent predictor of lower extremity amputations among
people with diabetes (Davis et al., 2006). Moreover, the medical expenditures related to
diabetes increases in the presence of foot ulcers (Davis et al., 2006). In a study
conducted in India, the cost of management of the disease was shown to increase

threefold when patients had foot problems related to diabetes (Shobhana et al., 2000).

When diabetes is tightly controlled the incidence of new lower extremity ulcers and
amputations could be greatly reduced. In a longitudinal study of type 2 diabetes patients
in India, 82% who strictly adhered to treatment advice had fewer new foot ulcers along
with faster healing Of the existing ones when compared to 50% in the non-adherent group
(Viswanathan et al., 2005). Thus, patient adherence to recommended foot care practices

may prevent additional medical expenses and complications that may lead to disability.

39

2.3.7 Medical Monitoring

Diabetes patients should receive health care from a team Of health professionals that
include physicians, nurse practitioners, dietitians, nurses, physician assistants,
pharmacists, and mental health professionals with an expertise in diabetes (ADA, 2009).
Regular consultation with a physician to monitor disease progress and annual
consultations with specialists to screen for retinopathy and peripheral neuropathy is also
recommended to prevent complications such as blindness and amputations, or even death
(ADA, 2009). Four or more physician visits/ year have also been shown to improve the
odds of self-monitoring Of blood glucose by patients in a cross-sectional study Of diabetes

patients in Massachusetts (Adams et al., 2003).

In a study by Heisler et a1 (2002), patients receiving diabetes care evaluated their
satisfaction with their health care providers. Patient-provider communication (open
discussion about the disease, informing the test results on a timely manner, and
explaining treatment alternatives and medication side-effects) was shown to be
significantly associated with the overall self-management by patients (Heisler et al.,
2002). Difficulties in medication adherence and follow-up visits with the physician have
been shown to be evident among diabetes patients with low treatment satisfaction
(Biderman et al., 2009). Furthermore, the presence of diabetes—related complications such
as foot ulcers have been shown to be related to decreased satisfaction with the treatment
provided, which may affect the patients’ compliance with medical monitoring of the

disease (Biderman et al., 2009).

40

2.4 Theoretical Framework

This study was guided by two theories adapted for diabetes self-management: The Social
Ecological Theory (Fisher et al., 2005) and The Enhance Behavior Performance model Of
the Self Efficacy Theory (Sousa et al., 2004). According to Fisher et a1 (2005) “an
ecological approach to self-management integrates the skills and choices of individuals
with services and support they receive from (1) the social environment of family, friends,
worksites, organizations, and cultures; and (2) the physical and policy environments of

neighborhoods, communities, and governments” (see figure 2.1).

Based on the ecological approach, Fisher and colleagues (2005) identified the following
key resources and supports for self-management (RSSM) required by individuals: access
to resources in daily life, continuity of quality clinical care, follow-up and support,
enhancing skills, collaborative goal setting, and individualized assessment. The RSSM
depicts the influence of social and environmental factors on diabetes self—management

from the perspective of individual’s needs (Fisher et al., 2005).

41

Figure 2.1 Social Ecological Theory: Correspondence of Ecological Levels of Influence
with Resources and Supports for Self-management (Fisher et al., 2005).

  

Access to resources in
daily life

 
 
 

Community and policy

Continuity of quality
clinical care

 
 
 

System. group, culture
Follow-up and support

Enhancing skills

   

Family, Friends, small
groups

 
 
 

Collaborative goal setting
Individual, Individualized assessment
biological,
psychological

 
   
   
 

On the other hand, The Enhance Behavior Performance Model (E-BPM) was developed
from the Theory of Self-care and the Self-efficacy theory. A portion of the E-BPM was
used to design the model for diabetes self-management, which proposes that personal
(self-care agency (individuals’ capabilities), self-efficacy (beliefs in ability), diabetes
knowledge) and environmental factors (social support) influence an individual’s
performance of diabetes self-management behaviors (Fig 2.2). Based on this model for
diabetes management, it is postulated that an individual with greater diabetes knowledge
will have greater self-care agency and self-efficacy leading to improved diabetes self-
management behaviors (Sousa et al., 2004). Likewise, social support from family and

friends is believed to increase self-care agency thereby leading to improvement in

42

diabetes management behaviors, while self-care agency itself could lead to greater self-

efficacy and better diabetes management behaviors (Sousa et al., 2004)

Figure 2.2 Research Model for Diabetes Self-care Management (Adapted from the
Enhance-Behavior Performance Model) (Sousa et al., 2004).

 

 

 

 

 

 

 

 

 

 

 

Diabetes
Knowledge
Self-efficacy
I
Self-care Diabetes self-care
Agency management

 

 

 

 

 

 

 

 

{ ‘\‘\ . _
Demographic
variables

Social Support

 

 

 

 

 

 

 

 

2.5 Factors Influencing Diabetes Management

The present study employed the integrated model of ecological theory with the enhance
behavior performance model for diabetes self-management as a guide to identify the
factors that may influence self-management behaviors. Within the context of grounded
theory as described in section 2.4., there could be several personal/ individual and

environmental factors that may influence diabetes self-management behaviors. Asian

43

Indian immigrant relevant factors important for the present research study are

subsequently discussed in this thesis.

2.5.1 Personal/ Individual Factors

Individual factors such as acculturation to the mainstream culture, educational level,
income status, diabetes duration, knowledge about the disease, and individual values and
beliefs are relevant to self-management of diabetes because of the fact that they could all

influence behavior.

2.5.1.1 Acculturation

Culture is defined as “the collective programming of the mind which distinguishes the
members of one group or category of people from another” (Hofstede, 1991). According
to Berry (2005), when two or more cultures come into contact, psychological and cultural
changes occur at individual and group levels termed acculturation. The Social Sciences
Research Council (SSRC) in the U.S. defines acculturation as “culture change that is
initiated by the conjunction of two or more autonomous cultural systems. ItS dynamics
can be seen as the selective adaptation of value systems, the process Of integration and
differentiation, the developmental sequences, and the operation of role determinants and
personality factors” (SSRC, 1954). Immigrants to the U.S. may encounter challenges in
adjusting to the language, behavior, values, and characteristics Of the new culture and

hence experience acculturative stress due to difficulties in adaptation (Berry, 2005).

44

Berry et al (1987) categorized the areas of difficulties as follows: physical (climate,
shelter, population density, and pollution), biological (diet and diseases), social (friends
and relationships), cultural (political, economic, linguistic, and religious) and

psychological (attitudes, values and mental health).

Adaptation to a western dietary lifestyle especially with a decline in physical activity may
contribute to the high prevalence of diabetes among immigrants to western countries
(Abate et al., 2005; Zimmet et al., 2001). Studies conducted on various ethnic populations
have shown that acculturation to the mainstream culture could result in negative health
outcomes such as increasing rates of diabetes, Obesity, hypertension, coronary artery
disease risk, and poor dietary quality (Aldrich et al., 2000; Dixon et al., 2000;
Himmelgreen et al., 2004; Hubert et al., 2005; Kaplan et al., 2002; Lands et al., 1990;
Marmot et al., 1976). On the other hand as acculturation increased, the risk for obesity
decreased in Mexican American women in the San Antonio, Texas study (Hazuda et al.,
1991). Similarly, decreased acculturation was associated with increased risk for diabetes
in Arab immigrants in the U.S. (Jaber et al., 2003). Therefore, acculturation in relation to

disease management may not be the same across different ethnicity.

Due to their century Old immigration status, acculturation, and adaptation patterns of
Asian Indians is still being researched by social scientists. Information documented thus
far indicates that the tendency to acculturate and for bi-cultural functioning is quite

common for Asian Indians because of their prior experience with British colonialization

45

for several years (Ibrahim et al., 1997; Kurian et al., 1983; Saran, 1985; Wakil et al.,
1981; Williams, 1998). Their English fluency and prior exposure to western values
(Leonard-Sparks et al., 1980) may facilitate the acculturation process in this population.
However, religious and linguistic identity, family values, and close family ties are very
important in the Asian Indian culture (Williams, 1998) and therefore, Asian Indians also

have a tendency to retain their heritage values, beliefs, and traditions after immigration

(Patel etal., 1996; Wakil et al., 1981; Williams, 1998).

Typically, Asian Indians immigrants maintain the association with their heritage culture
by making frequent visits to the home country and by being a part Of various Asian
Indian social networks (Dasgupta, 1998). In such forms, Asian Indians in the U.S. exhibit
a pattern of psychological closeness to their heritage culture, which Dasgupta (1998)
describes as “reinventing Indian culture on a foreign soil.” Furthermore, Asian Indian
immigrants have shown to value their traditions and customs even more than their Indian
counterparts (Mehta et al., 1991). In other words, although Asian Indian immigrants
conform to the host culture and are integrated at the social level (clothing, language, and
housing), many appear to retain their Asian Indian culture within their family

environment (marriage and ethnic identity) (Mehta et al., 1991).

Socio-demographic characteristics are important determinants Of the degree of
acculturation. Higher educational level, employment status, and socioeconomic status

have been shown to facilitate the acculturation process (Cheung et al., 1995; Ghuman,

46

2000). The adaptation to a new culture could be different and faster for Asian Indian
males than females as Asian Indian males have been reported to enjoy more
independence and educational opportunities than females (Ghuman, 1997; Wakil, 1981).
Likewise, younger individuals tend to have a higher degree Of acculturation than Older
individuals (Cheung et al., 1995). Generational status (more recent vs. first generation)
(Varghese et al., 2007) and longer duration of stay in the host country (Cheung et al.,

1995) have also been Shown to favor the process Of acculturation.

While the degree Of acculturation may differ across different religious groups (Ghuman,
2000; Sonuga-Barke et al., 2000), immigrants with a strong ethnic identity have been
shown to have firm religious beliefs (Greeley et al., 1999). India is a multi-religious
country, with Hinduism the predominant religion followed by the majority (80%) of its
people. While urbanization in India has led to a decline in many of the original religious
practices (Mullatti, 1995), Asian Indians in the U.S., however, have tended to be more
religiously active after immigration (Williams, 1988). Religious groups give a group
identity and serve as a place for Asian Indians to feel “at home outside their home,” thus
allowing more freedom Of expression about cultural values within their group (Williams,

1988).

Misra et al (2004) reviewed articles related to obesity, metabolic disorders, and impaired
insulin mechanism among Asian Indians and summarized the differences in average

values of the common indicators of obesity between Asian Indians in India and Asian

47

Indian immigrants to other countries (see Table 2.6). Based on the study findings, it is
evident that Asian Indians who immigrate to other countries have higher BMI and body
fat than their counterparts in India, which could partly be due to adoption of the lifestyle
Of the host culture. Consistent with this review, Mooteri et al (2004) documented a
positive association between longer duration of residence in the U.S. and increased risk

for coronary artery disease among first generation Asian Indians.

Table 2.6 Average values of various measures Of Obesity in Asian Indians (Misra et al.,

 

 

2004)
Parameters Location of residence of Asian Indians

Rural India Urban Slums of Urban India Immigrants

India

Body Mass Index (Kg/m2) 19.6 (3674) 20.9 (674) 22.4 (11 1,722) 24.7 (7686)
Percentage of body fat 20.4 (149) 24.4 (674) 28.2 (273) 33.1 (107)
Waist circumference (cm) 79.4 (149) 83.7 (142) 85.2 (273) 83.7 (1837)
Waist-to-hip ratio .87 (3674) .92 (142) .87 (12,124) .92 (7686)

 

Despite the striking differences in the markers of chronic diseases as depicted in Table
2.6, there is no study of acculturation and diabetes control or management of Asian
Indians in the U.S. However, there are a few studies that focused on acculturation]
duration Of stay in the U.S. and dietary patterns of Asian Indians. The findings of these
studies showed that acculturation of Asian Indians was associated with frequent selection
of western foods and replacement of traditional foods with other ethnic or western foods
(ADA, 2000). Increased consumption of alcohol, whole grain foods, fish, poultry, meat,
salty snacks and desserts were noted (ADA, 2000). However, other studies have shown

the diet of Asian Indians in the U.S. to be deficient in dietary fiber (J onnalagadda et al.,
48

2002), but a longer duration of stay was associated with decreased consumption of
saturated fats (Raj et al., 1999). Therefore, acculturation may play a substantial role in
diabetes management by impacting the dietary behaviors of Asian Indians and perhaps
environmental and lifestyle changes after immigration may influence their level of

physical activity as well.

2.5.1.2 Educational Level

Lower educational level (<12 years of education) has been shown to be associated with
increased risk for type 2 diabetes (Maty et al., 2005). According to the data from the
National Health Interview Survey (NHIS) 1997 — 2002, individuals with lower
educational attainment (less than a high school diploma) were more likely (1.6 times) to

have diabetes than to those with at least a college degree (Borrell et al., 2006).

In addition, Miech et al (2009) calculated diabetes-related mortality rates using the U.S.
Vital Statistics and the U.S. Census data, and examined the trends in diabetes prevalence
and glycemic control across different educational levels using the NHANES data sets
1988-1994 and 1999-2004. The study documented an increasing trend in diabetes-related
mortality rates with decreasing educational level. Diabetes-related mortality was the least
among individuals with a college degree or more, at all the four time points included in
the study (1989, 1995, 2000, and 2005). There was also a decrease in the prevalence of

diabetes-related mortality from 1989 to 2005 for the group that had college degree, while

49

the prevalence increased for all other categories of educational levels (low education,

high school, and any college) (Miech et al., 2009).

Therefore, self-management and control and hence associated complications of the
disease may be associated with educational status. Additionally, Biderman et a1 (2009)
showed treatment satisfaction (assessed by the type of medical care, proximity to clinic,
routine diabetic nurse care, laboratory tests, and the type of treatment) be significantly
lower among patients who had _<_ 6 years of education than those with > 6 years. Chilton
et a] (2006) observed a significant association between education level and diabetes
knowledge of Hispanic adults. In this study, individuals with at least a high school
education had a better understanding of the disease and self-management behaviors than
those who did not (Chilton et al., 2006). Therefore, education may directly affect the
diabetes knowledge of patients and potentially indirectly impact their glycemic control.
Consistent with this finding, in The Los Angeles Latino Eye Study (LALES), type 2
diabetes patients with lower educational levels were more likely to be non-compliers of
ADA eye care recommendations (Paz et al., 2006). This was confirmed by Miech et al
(2009), who showed a decrease in the prevalence of diabetes and a relatively lower
HbAlc levels among those with a higher education in the NHANES data (Miech et al.,

2009)

50

2.5.1.3 Income Status

Diabetes has been shown to disproportionately affect populations of low income status
(Cuasay et al., 2001; Martinez et al., 2007; Rabi et al., 2006). Higher income status may
facilitate health promotion activities, quality of health care and facilities and health
outcomes among individuals with diabetes (Guimaraes et al., 2009; Kwan et al., 2008;

Levine et al., 2009).

Individuals with low socioeconomic status may not be eligible for health insurance
coverage and quality medical services, which will likely increase the burden of the
disease and related complications (Baker et al., 2000). According to data from the
National Access to Care Survey, individuals without health insurance coverage were less
likely to receive medical care when compared to insured individuals (p=.001) (Baker et
al., 2000). In a study among patients with type 2 diabetes in San Diego, absence of health
insurance significantly predicted poor glycemic control (Benoit et al., 2005), which was
evidenced by a higher mean HbAlc levels among participants who did not have health
insurance coverage (Benoit et al., 2005). In addition to glycemic control, low-income
status has been shown to affect diabetes self-management behaviors such as reduced self-
monitoring of blood glucose, medication adherence, and avoidance of healthy foods due
to the perceived high cost (Kwan et al., 2008). Therefore, income status is an important
consideration, which cannot be omitted in studies addressing diabetes self-management

and control.

51

2.5.1.4 Family History of Diabetes

A positive family history of diabetes is a significant predictor of the disease in Asian
Indians (Ramachandran et al., 2001; Venkataraman et al., 2004), with reported increased
risk especially when both parents have diabetes (Knowler et al., 1981). Individuals who
have a positive family history of diabetes overall are two to six times more prone to be
affected with the disease than those who do not (Harrison et al., 2003). In a study by
Venkataraman et a1 (2004), among Asian Indian immigrants to the U.S., 53% with
diagnosed diabetes had a family history of diabetes. In this study, family history was the
strongest predictor of diabetes (OR: 6.0; 95%CI: 4.2 — 8.4). Awareness about diabetes,
the inquisitiveness to learn about the disease, and engagement in health promotion
activities may increase if a family member is affected with the disease (Baptiste-Roberts
et al., 2007). Therefore, individuals with one or more family members with diabetes will
have prior exposure to the characteristics of the disease and the self-management

behaviors, which in turn may have an impact on self-management of the disease.

2.5.1.5 Duration of Diabetes

Studies that have analyzed the relationship of duration of diabetes with glycemic control
have shown a negative association between the two. In a cross-sectional analysis of the
1990 — 1991 Michigan Diabetes in Communities II study, a longer duration of diabetes
increased the likelihood of poorer control (Blaum et al., 1997). Similarly, in a

longitudinal study of type 2 diabetes patients in the Project Dulce program in San Diego,

52

the longer the duration of diabetes the poorer was the glycemic control of participants

(Benoit et al., 2005).

On the other hand, besides improving glycemic control, shorter duration of diabetes (< 2
vs. > 2 years) has been shown to be associated with better dietary and physical activity
behaviors of type 2 diabetes patients, who participated in a diabetes education program in
the Southwest (Parchman et al., 2003). Disease progression and complications could be
important factors that have contributed to duration of diabetes being an influencing factor
of diabetes management and control. Susceptibility to diabetes-related complications has
been shown to be significantly positively associated with disease duration (Roberts et al.,
2008). As repeatedly explained previously, the connection between appropriate self-

management and disease control cannot be overemphasized.

2.5.1.6 Diabetes Knowledge

Knowledge about diabetes has been shown to enhance understanding of the disease and
related complications and facilitate glycemic control among Asian Indians (Panja et al.,
2005; Iqbal et al., 2008). Awareness about the disease is especially important for high
risk populations like the Asian Indian to take preventive measures such as screening and
early detection of the disease. However, the awareness about diabetes self-management
behaviors was found to be poor among subjects with diabetes in India (Murugesan et al.,
2007). In the UK, Asian Indians were less aware of the long term complications of

diabetes (Macaden, 2007) and had significantly lower diabetes knowledge than the local

53

white population (Baradaran et al., 2004). Although there is no documented evidence in
the U.S., culture specific education may improve diabetes knowledge and glycemic

control as documented by Hawthome (2001) among Pakistani women living in Britain.

2.5.1.7 Values and Beliefs

Besides the other individual factors discussed, the beliefs of an individual and how he/
she values certain practices should not be ignored as they may impact ability to practice
self-management behaviors by the individual. Hjelm et al (1999) emphasized individual
care for diabetes patients with recognition of immigrant patients’ beliefs, experiences
pertaining to immigration, knowledge level, and health care staff expectations. In their
study of Yugoslavian and Swedish females with diabetes in Sweden, cultural differences
in beliefs about diabetes and self-management, which includes the use of complementary
and alternative medicines, were evident (Hjelm et al., 1999). India has a rich history of
complementary and alternative medicine usage. Therefore, it is not uncommon for Asian
Indians to follow traditional therapies. However, some of the non-prescription
medications such as folk medicines ingested by immigrant Asian Indians have been

shown to induce serious adverse side effects (Pontifex et al., 1985).

In addition, cultural differences may exist in beliefs of individuals about foods related to
diabetes management. Several traditional plant foods have been shown to be consumed
by Asian Indian immigrants due to their perceived medicinal properties, especially the

foods related to diabetes prevention and control (Pieroni et al., 2007). In a study

54

conducted by Baradaran and colleagues (2004) in Glasgow, several plant/ food remedies,
homeopathic medicines, and a few unknown medicines were used for diabetes
management by Asian Indians and Pakistanis. For example, plant derivatives such as
bitter melon (Momordica charamia), ivy gourd (Coccinia indica) and fenugreek seeds
(Trigonellafoenum graecum) were reported to be widely used as home remedies for type
2 diabetes in the Asian Indian population. These plant derivatives, believed to contain
antidiabetic properties, have been shown to induce a hypoglycemic effect and improve
glycemic control if used consistently for several weeks (Krawinkel et al., 2006; Kurpad et
al., 2008; Sharma et al., 1996). However, more research is needed before adjunctive use
of food remedies, as certain adverse effects such as headaches and hypoglycemic coma
and convulsions in children may occur due to their potential toxic components (Basch et

al., 2003; Krawinkel et al., 2006).

Religious beliefs are highly valued in the Asian Indian community, which affects their
dietary patterns because there are different dietary codes and laws for each religion
(Kulkarni, 2004). Previous studies have shown that South Asians in general perceived
diabetes to be a disease determined by God, which demonstrates the perceived
association between religion and health by people of this ethnicity (Lawton et al., 2006;
Naeem, 2003). Strict and prolonged fasting during religious occasions is performed by
many Asian Indians even when diagnosed with compromised health conditions such as

diabetes (N aeem, 2003). Diabetes is not considered by many as sufficiently serious to

55

exempt individuals from religious fasting (Tripp-Reimer et al., 2001 ). This might have

serious metabolic ramifications e.g. hypoglycemia.

2.5.2 Environmental Factors

The environmental factors that may potentially determine the diabetes self-management
behaviors of individuals are: health care system (facilities and providers); support from
social networks such as family, friends, and community; and location of residence and

neighborhood characteristics.

2.5.2.1 Health Care System

Patient and health care provider relationship is critical for open communication about the
disease, clinical recommendations, and challenges which a patient may face. Improved
glycemic outcomes have been documented in conditions where the patient and health
care provider share a good relationship (Aikens et al., 2005). In a study by Heisler et al
(2002), provider communication was also shown to be significantly associated with the
overall self-management by patients with type 2 diabetes. Participants of this study
perceived that the guidance provided by the physician (information about the disease,
medications, and treatment options) were more important than the patient’s participation
in making treatment decisions. Thus, patient-provider relationship is important for better
communication between the patient and the health care professional and possibly

adherence to treatment recommendations.

56

Culture is often perceived as a barrier to a more favorable patient-health care professional
communication, which could be addressed by using cultural assessment (Tripp-Reimer et
al., 2001). “A cultural assessment is a focused and systematic appraisal of beliefs, values,
and practices conducted to determine the context and substance of client needs, and then
to best adapt (or construct) and evaluate health interventions” (Tripp-Reimer et al., 2001).
For example, health care professionals should question patients about their dietary
practices and food preferences, before providing culturally appropriate dietary
recommendations for diabetes management (Kulkami, 2004). Involvement of the
patient’s family members and a dietitian would facilitate selection of appropriate foods

that are beneficial and acceptable to the patient (Kulkami, 2004).

Besides the physician, other health care professionals should work collaboratively with
the primary care physicians to facilitate tight glycemic control in people with diabetes. A
study by Aubert et al (1998) randomized people with diabetes into a “usual care” (regular
care) and a “nurse care” group keeping all other conditions such as medication type,
dosage, body weight, and blood pressure the same for both groups. The study
documented a 1.7% decrease in HbAlc value in the group that received the nurse care

versus 0.6% in the usual care.

In a study among patients of Kaiser Permanente’s Pleasanton, CA facility, subjects with
poorly controlled diabetes (HbA1c>8.5%) were randomly assigned into control and

intervention groups (Sadur et al., 1999). The intervention group received

57

multidisciplinary outpatient diabetes care, which included a psychologist, a diabetes
nurse educator, a nutritionist, and a pharmacist for six months. The HbAlc level of
participants in the intervention group significantly declined by 1.3% (p<.001) with
patients demonstrating improved self-management practices and self-efficacy (Sadur et
al., 1999). Thus, as suggested by the ADA (2009), a multidisciplinary approach in
treating diabetes patients by a team of health professionals with expertise in diabetes is

warranted.

2.5.2.2 Social Support

Social support from friends, family, and the community is critical for people living with
chronic diseases such as diabetes. Several studies conducted on different populations
have shown the beneficial effect of social support in relation to diabetes self-management
behaviors such as adherence to healthy diet, medications, and exercise (Lloyd et al.,
1993; Pham et al., 1996; Sousa et al., 2004). Furthermore, the risk for mortality has been
shown to be 55% lower among elderly diabetes patients with high social support, which

includes support from friends, neighbors, and relatives (Zhang et al., 2007).

In general, immigrants to the U.S. have been shown to have stronger social support from
friends and family (Frisbie et al., 2001). In this respect, Asian Indians in the U.S. were
shown to have good social support and strong interpersonal relationships in a study by
Misra et al (2000) that documented the health promotion activities of Guajarati Asian

Indians in Atlanta, GA. However, other than close family members, social support

58

received by Asian Indian immigrants may not be comparable to that received from

parents and extended family members in the home country (Kalra et al., 2004).

The role played by social support in diabetes management of Asian Indians is well
documented in the UK. In a study conducted in the UK, strong social networks were
perceived as resources by Asian Indians with diabetes for emotional support (sharing
diabetes experiences with peers) and empowerment through knowledge (relatives who
had the disease served as sources of knowledge about diabetes) (Stone et al., 2005).
Likewise, availability of support from trained diabetes support workers of the same
ethnicity may have a positive influence on patient disease management. In the UK,
South Asian community members were recruited and trained as diabetes support workers
to work with South Asian diabetes patients (Curtis et al., 2003). Consultation with South
Asian diabetes workers was perceived as helpful in the feedback provided by health care
professionals and diabetes patients (Curtis et al., 2003). Furthermore, being friendly and
encouraging two-way communication, by fluency in the native language of patients were
important aspects mentioned in the feedback. These could be important cultural barriers

for disease management at the health care provider/ community level (Curtis et al., 2003).

2.5.2.3 Location of Residence

Neighborhood characteristics have been shown to influence the health behaviors of
individuals living in the area (Cohen et al., 2003; Ross, 2000). Social structure and

economic disparities in a neighborhood have been shown to affect health behaviors

59

(Elliott, 2000; Stead et al., 2001). More specifically, in a study by Shaw et al (2006)
conducted in patients with diabetes, diet, physical activity and foot care were enhanced
with neighborhood resource support. On the other hand, Franzini et al (2005), who
studied low-income neighborhoods in Texas showed that neighborhoods that were

unsafe and disordered, exhibited poor social support and physical activity behaviors.

Low-income neighborhoods may not have sufficient access to supermarkets with a
variety of healthy food choices, but may offer options for promotion of unhealthy
behaviors such as alcoholic beverages (Morland et al., 2002). Likewise, fear and stress
associated with living in neighborhoods with high crime rates could aggravate the
situation via restricted outdoor activities (Gordon-Larsen et al., 2000; Ross et al., 2001),
while neighborhoods with sidewalks and scenic views have been shown to promote
physical activity (Brownson et al., 2001). Location of residence could therefore be a
critical factor relative to diabetes self-management especially from the availability of

resources perspective.

60

CHAPTER 3

METHODS
This section includes a description of the two phase study design and detailed explanation
of the procedures. Phase I is the validation of the interview guide using expert opinion
and a pilot study. Phase II is the actual study conducted in five steps using a validated

interview guide. The approval for this study was obtained from the Institutional Review

Board at Michigan State University (MSU IRB) (Appendix A).

3.1 Design

This was a cross sectional exploratory study that employed mixed methodology by
triangulating data obtained from qualitative and quantitative approaches with a
convenience sample of Asian Indian adults with physician diagnosed diabetes in the
acceptable (AC) (HbA1c<7%) and unacceptable (UC) (HbAlc37%) glycemic control
groups. An acculturation instrument and a socio-demographic and self-care survey were
used to collect quantitative data. A qualitative approach, using semi-structured in-depth
interviews, was used to document the effects of acculturation and lifestyle factors related

to self-management of diabetes.

3.2 Subjects and Recruitment
The study subjects were recruited from Indian organizations, stores and restaurants that
are frequently visited/ contacted by Asian Indians in Michigan. Five clinic physicians,

who treated a sizeable number of Asian Indians, also agreed to post the recruitment flyer

61

(Appendix B) of this study to attract the attention of potential participants. In addition,
participants were also recruited through a snowballing method i.e. participants contacted
potential study participants and informed them about the study. Participants were
recruited and interviews were conducted until qualitative data saturation. Half of the
participants were in the AC and half in the UC group. An attempt was made to have age

and gender matched equal numbers of subjects in the AC and UC groups.

3.3 Eligibility Criteria

Eligibility for participation included: (i) physician diagnosed diabetes, (ii) age _>_ 18 years,
(iii) Asian Indian descent, (iv) non-institutionalized, (v) ability to read and converse in
English, (vi) not Pregnant/ lactating, (vii) most recent hemoglobin AlC (HbAlc)
measured within the past twelve months, and (viii) resident in the U.S. for at least one

consecutive year.

3.4 Procedures

3.4.1 Theoretical Foundation

The pertinent variables as identified in the literature were included in an integration (Fig
3.1) of The Social Ecological Theory (Fisher et al., 2005) and The Enhance Behavior
Performance model of the Self Efficacy Theory (Sousa et al., 2004). Based on this model,
key individual (acculturation, educational level, duration of diabetes, diabetes knowledge,

income status, and personal values/ attitudes) and environmental (medical insurance,

62

health care, social support, location of residence) components that could potentially

influence diabetes self-management behaviors were assessed in this study.

Figure.3.1 Integration of the Social Ecological Model with the Enhance Behavior
Performance Model for Diabetes Self-Management (Fisher et al., 2005; Sousa et al.,
2004)

 
       
      
       
   
   
     
       
   
       
   
 
       
   

Environmental Factors
Medical insurance
Health care
Social support
Location of residence

[_ndividual Factors
Acculturation
Educational level
Duration of diabetes
Diabetes knowledge
Income status
Values/ Attitudes

 

Behavior/ Lifestyle Factors
Dietary intake
Physical activity
Medication adherence
Home blood glucose monitoring
Weight management
Foot care
Physician consultation

 

Health and Well Being
Glycemic Control

Acceptable HbAlc < 7 %
Unacceptable HbAlc 2 7 %

63

3.4.2 Methods

Prior to conducting this study, Indian organizations were contacted to determine interest
in co-operation and hence feasibility. Letters of support (Appendix C) were obtained
from the organizations to provide permission to post flyers at their facilities, use their
email listservs, and attend events for personal recruitment. An electronic version of the
same flyer was also circulated as an email attachment via listservs provided by the
organizations for members. The study was conducted in two phases described in

summary in Fig 3.2.

Phase I included validation of an interview guide. Three nutrition/endocrinology experts
of Asian Indian origin reviewed the interview guide (Appendix D) for face validity and a
pilot study of four initial interviews was conducted (described in detail in section 3.6.3).
The comprehensive five step procedures of the actual study (Phase II) were also followed
in this pilot study to determine respondent burden and feasibility. Since there were no
contextual changes made to the interview guide, and answers to the modified questions
were provided by the pilot subjects, the data collected in the pilot study was also included

in the final sample. Phase II was conducted in five steps:

(i) The investigator contacted interested participants and conducted a preliminary
interview (Appendix E) by phone to determine eligibility for participation.
(ii) Eligible participants were invited to participate in this study and the interview

site (own home or other mutually agreed upon location) was determined based

64

(iii)

(M

(V)

on the convenience of the participant. The participants signed a consent form
(Appendix F) and a copy of their HbAlc laboratory test value was requested and
obtained from the participant.

An acculturation instrument specific for Asians (SL-ASIA) and adapted for
Asian Indians (Appendix G) was administered by the investigator to assess the
acculturation level of the participants towards mainstream U.S. culture. An
initial 24-hour dietary recall (Appendix H) followed immediately, also
administered by the investigator. The two instruments took approximately 45
minutes to complete.

An in-depth interview, which lasted approximately one hour was then
conducted. The interview consisted of an audio-taped socio-demographic and
self-care survey followed by open-ended questions regarding diabetes self-
management.

Participants were subsequently contacted by phone on another day for an
additional 24-hour dietary recall. The second dietary recall was collected for a
week day or a weekend day depending on the day of the initial recall. This step

took about 20 to 30 minutes to complete.

Upon completion of the in-depth interview and the second 24—hour recall, the participants

received a $25 gift card to a local grocery store, as an incentive for participation.

65

Figure 3.2 Data Collection Sequence for the Two Phases of the Study.

Data Collection

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MSU IRB Approval
Phase I Phase II
Instrument Validation Actual Study
/ )4 7
Step 1 Step 2 ‘ Preliminary interview by
Expert Review Pilot Study phone
Interview site scheduled for
eligible participants

 

 

 

 

Informed consent

 

 

 

 

V

 

SL-ASIA Questionnaire
First 24-hr dietary recall

 

 

 

 

V

 

Socio demographic and
self-care survey
In-depth interview

 

 

 

 

 

Second 24-hr dietary recall

 

 

 

66

3.5 Instruments

3.5.1 Suinn-Lew Asian Self-Identity Acculturation Scale (SL-ASIA)

Acculturation was measured using the Suinn-Lew Asian Self-Identity Acculturation
instrument (SL-ASIA), which has been widely administered to Asians to describe their
level of acculturation (Suinn et al., 1987). The SL-ASIA, which measures acculturation in
a linear fashion, is based on the concept that increased adaptation to the host culture
decreases the likelihood of retaining the heritage culture (Suinn et al., 1987). The
Acculturation Rating Scale for Mexican Americans (ARSMA) was originally used as a

model to develop the SL-ASIA instrument (Ceullar et al., 1980; Suinn et al., 1987).

The initial SL-ASIA instrument, which was used in this study, is unidimensional and
consists of 21 items that include four items each on language, identity, and friendship
choice, five items on behaviors, three items on generational background, and one on
attitudes (Suinn et al., 1992). The instrument measures the degree of acculturation with
Asian culture at one end and the host culture at the other and takes approximately 15
minutes to complete. The responses to the 21 items are added and then divided by the
number of items. The scores are reflective of the acculturation level of the participants as
follows: 5.00 is the highest possible value and indicates high acculturation or more
westemization and a score of 1.00 is the lowest possible value indicating low
acculturation or high orientation towards their heritage culture. A score of 3.00 is the

midpoint of the scale and is typical of bicultural individuals.

67

The reliability and validity of the instrument were reported using the initial validation
study with 82 Asian students in the U.S., followed by a concurrent and factorial
validation using 324 Asian American university students (Suinn et al., 1992; Suinn et al.,
1987). The scale had an alpha coefficient of 0.88 on the 21 items in the initial study
(Suinn et al., 1987) and 0.91 in the follow-up (Suinn et al., 1992), which is indicative of a
good internal consistency among the items of the instrument. Other studies using this
instrument have reported consistent results, with coefficients of internal consistency of

the items ranging from 0.68 to 0.88 (Ponterotto et al., 1998).

The validation of the SL-ASIA instrument was based on two criteria, generational
differences and duration of stay in the host country. The lowest acculturation was
observed in the first generation and in those with a minimum duration of stay in the U.S.
The highest acculturation was found in the most recent generation and those with the
longest stay in the US (Suinn et a1, 1987). Exploratory factor analysis identified five
factors that were influential: (i) reading/ writing/ cultural preference, (ii) ethnic
interaction, (iii) affinity for ethnic identity and pride, (iv) generational identity, and (v)

food preference (Suinn et al, 1992).

A cross-cultural examination of acculturation in Asians was done using this instrument
between Asian Americans in the U.S. and Asian individuals in Singapore (Suinn et a1,
1995). The results further supported the instrument to be a valid measure, as Asian

Americans scored more on the acculturation scale than Singapore Asians, which is

68

indicative of higher acculturation (Suinn et al, 1995). Since the initial and concurrent
validation was done using an Asian student sample, Ownbey et al (1998) tested the
instrument for its reliability and validity using non-student Asian Americans. The study
yielded a Cronbach’s alpha value of 0.89, which suggests that the SL-ASIA was a good

measure of acculturation even in non-student Asian Americans (Ownbey et al., 1998).

For the purpose of this research, all the relevant wording on the instrument which
referred to “Asians” was modified to “Asian Indian” to be able to administer it to Asian
Indians with the approval of Dr. Suinn (Personal communication, 2007). The
modification was done independently by two researchers of Asian Indian descent and
compared for consistency. Furthermore, the SL-ASIA instrument was also compared to
the ARSMA by the two Asian Indian researchers. Each researcher completed the
ARSMA and SL-ASIA separately, and when the two scores were compared, the
acculturation levels measured by the two instruments were consistent. This provided
support for the appropriateness of the use of the instrument to describe the acculturation

level of Asian Indians.

3.5.2 Twenty Four-Hour Dietary Recall

Dietary data were obtained by two 24-hour dietary recalls to compare nutrient intake,
frequency of meals/snacks, and the intake of food supplements of participants between
the glycemic control and acculturation groups. The recalls were administered by the

interviewer; one at the time of interview and the second one by phone within a week. The

69

interviewer was the primary researcher who was trained to use the validated USDA
multiple pass method (Conway et al, 2003; Jonnalagadda et al, 2000). The procedure took
approximately 20-30 minutes to complete, and the participants were informed about what
the assessment would entail at the time of consent as well as prior to the recalls being

conducted.

A quick list of foods and beverages consumed within the prior 24-hour period was first
collected. The interviewer used probes for foods forgotten during the quick list with
open-ended questions and mention of frequently missed foods. Mealtime and eating
occasions for each food were collected and reviewed with the participant. Detailed
descriptions of the foods and their preparation and serving methods with portion sizes
were obtained. The participants were asked if the day recalled was a typical day
pertaining to eating habits. Any dietary supplements, vitamins/minerals or herbal/ home
remedies were recorded and the interviewer used a final probe for anything else that was
consumed and double checked for incomplete items. It is recommended that dietary
recalls not be consecutive and represent a week day and a weekend day to account for
variability. Therefore, the recalls were for one week day and the other was for a weekend
day. The second dietary recall was conducted based on the day of the initial recall by

phone within a week.

70

 

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3.5.3 Interview Guide

Questions for the in-depth interview guide were developed based on the grounded theory
from the “Integration of the Social Ecological Model with the Enhance Behavior
Performance Model for Diabetes Self-Management” (Fisher et al., 2005; Sousa et al.,
2004) (Fig 3.1), research questions and objectives of this study (Table 3.1). For
comprehensiveness and to facilitate triangulation of data, the interview guide was
designed such that it consisted of two sections: (i) a quantitative socio-demographic and
self-care survey and (ii) a qualitative questionnaire with open ended questions pertaining

to diabetes and factors influencing diabetes self-management behaviors.

The quantitative survey included questions related to socio-demographic characteristics
such as age, education level, country of education, religion, native language, state of
origin in home country, employment status, marital status, household income, household
size, type of housing, and use of tobacco and/or alcohol. In addition, information on
physician diagnosis of diabetes, diabetes education, co-morbidities, family history of
diabetes, medications, diabetes monitoring, and anthropometric values such as self-

reported height and weight of the participants were also obtained.

Self-management behaviors were assessed by questions on diet, physical activity, self-
monitoring of blood glucose, weight management, medication management, foot care,
and regular consultation with a physician. The self-care items in the survey were framed

such that they allowed the participants liberal expansion of their responses to qualitative

74

questions. Participants were asked to rank the order of their ability to perform the seven
recommended diabetes self—management behaviors. A value of one indicated ‘very easy’
and seven indicated ‘very difficult.’ Participant responses to the survey questions were
also audio-taped, which enabled inclusion of important qualitative information in the

analysis.

The qualitative questionnaire was designed with open-ended questions and prompt
sentences/ questions that facilitated probing for additional information when needed (see
table 3.1). The interview questions were designed to obtain comprehensive information to
answer the research questions of the study. The interview guide was validated (Phase I)
using a two-step approach. First, three nutrition/endocrinology experts of Asian Indian
origin revised the interview guide for comprehensiveness, and to check if all questions
were worded correctly, and less likely to be misinterpreted by subjects. The experts
identified relevancy of content and necessity for additional items to be added to the

interview guide.

The experts made several suggestions and added items to improve the readability and
usefulness of the data. Second, the interview guide revised by experts was pilot tested
using initial interviews with four Asian Indian adults with physician diagnosed diabetes
to assure the appropriateness of the language used in the questions. The pilot test
included the comprehensive five step procedures of the actual study to determine

respondent burden and feasibility of the study. The pilot test facilitated further revision of

75

the guide and identification of additional probes for some of the questions to be used as
needed. The F lesch-Kincaid Readability test to indicate the comprehensive difficulty was
performed using Microsoft Office Word 2007 Software. The F lesch-Kincaid grade level
of the interview guide was 5.5, which falls between ‘easy’ and ‘very easy’ to read based
on the principles of readability (DuBay, 2004). Michigan State University Institutional

review Board approved the revised version of the interview guide.

3.6 Data Analysis

Data from the survey (socio-demographic and self-care behavior assessment) and the SL-
ASIA acculturation instrument were analyzed for descriptive purposes using SPSS
(version 17.0, 2009, Chicago, Illinois, SPSS Inc.). Glycemic control, the outcome
variable of this study was dichotomized into AC (HbAlc <7%) and UC (HbAlc 27%).
Participants were also categorized based on their acculturation level as Asian oriented
(A0) (SL-ASIA score<2.15) or bicultural oriented (BO) (SL-ASIA score32.15) to
identify differences in the self-management practices. The cut point of 2. 1 5 was chosen
because it was close to the mean value and allowed for an equal distribution of
participants in the AC and the UC groups. Due to the fact that there were no participants
with an SL-ASIA score above 3.0, there was no category as western oriented for this

sample.

To assess weight status, Body Mass Index (BMI) was used. The BMI has been widely

accepted as a measure of obesity; and was calculated by dividing weight in kilograms by

76

height in meters squared. BMl criteria proposed by the WHO Asia Pacific guidelines for
Asians was used to categorize subjects as underweight (BMI 518.5), normal weight

(>185 — 22.9), overweight (BMI 323 — 24.9) or obese (BMIZ25) (Inoue et al., 2000).

Dietary analysis of the two 24-hour recalls was done using Nutritionist Pro software
(version 3.1.0, Stafford, TX, Axxya Systems, 2009) that has an exclusive Asian Indian
database in addition to the United States Department of Agriculture (USDA) and
Canadian Nutrient File (CNF). The database contains food coding based on standard sets
of nutrient goals for a variety of ages and genders including the Dietary Recommended
Intake (DRI) and Recommended Dietary Allowances (RDA). The mean macronutrient
intake was compared across groups using independent t tests. Macronutrient intake and
meal patterns of participants by glycemic control and acculturation level was compared
using chi square distributions. The criteria for categorizing percentage of calories from
macronutrients were based on the recommendations of the American Heart Association
(AHA) and the U.S. Department of Agriculture (USDA) (Macronutrient composition of
total Kcals: 55% carbohydrate, 15% protein, and 30% fat) (AHA, 1986; USDA, 1995;
USDA, 1992). These reference values were also used to calculate the amount of
carbohydrate, protein, and fat in grams based on a 1600 Kcal diet (mean and standard
deviation of total caloric intake of the overall sample was 1516.53 i 528.9). According to
this calculation, the amount of carbohydrates, protein, and fat based on a diet consisting

of 1600 kcal were 220g, 60g, and ~53 g, respectively.

77

Participant self-management ranking was compared between acculturation and glycemic
control groups using independent t tests. Bivariate relationships between glycemic
control groups and other variables were tested prior to a regression analysis being
performed. However, since statistically significant differences were not observed
between AC and UC groups, the variables were selected based on the conceptual model
of the study. Multiple linear regression analysis using a backward elimination procedure
was performed to examine predictors of glycemic control (as a continuous variable) using
SPSS (version 17.0, 2009, Chicago, Illinois, SPSS Inc.). The first model included the
effect of acculturation level and other independent predictors, which were body mass
index, age, gender, duration of stay in the U.S., duration of diabetes, employment status,
educational level, prior diabetes education, and annual household income. The interaction
effects of acculturation level with other independent predictors were subsequently
examined in model 2. Based on R2 change and model significance level, a decision about
whether or not to include the interaction terms was made. Only the main effect variables
(BMI, diabetes duration, and annual household income) and the interaction terms that

significantly predicted glycemic control were included in the final model.

Qualitative data from the audio-taped interviews were transcribed verbatim and the
transcripts were checked for accuracy by listening to the audio conversations several
times. The four initial interviews were coded by the primary investigator to identify
emergent analytical codes. These codes were categorized into the following broad

domains to address the research questions of the study: (i) acculturation of participants,

78

(ii) participants perceptions about the impact of the disease and diabetes self-management
behaviors, (iii) participant’s knowledge about diabetes and self-management behaviors,
(iv) participant’s values and beliefs, (v) influence of health care system, (vi) influence of
social support network, (vii) influence of location of residence, and (viii) barriers and

facilitators to diabetes self-management behaviors.

A codebook (Appendix I) was developed that included codes with their corresponding
tags, definitions, and rules for applications and illustrations. The four initial interviews
and the subsequent interviews were coded using the codebook by two researchers using
Nvivo 8 (QSR International, 2009) software for qualitative research. The codebook was
revised when data emerged in subsequent interviews and coding consistency was
established by reviewing coded data, discussing coding discrepancies, and achieving
coding consensus by the two researchers to ensure reliability. The data organized by

codes were summarized and themes were identified.

As stated by Perone (2003), “Triangulation provides confirmation and completeness.
Triangulation is not simply combining different types of data, but it attempts to relate the
two types of information so as to leave the validity of each type of information intact.
The use of triangulation allows researchers to capture a more complete, holistic, and
contextual portrayal and reveal the varied dimensions of a given phenomena, with each
source contributing an additional piece to the puzzle. In using triangulation, bias can be

minimized and validity enhanced. Neither the qualitative nor the quantitative method

79

alone could yield the results of the two combined. The sum of the whole is greater than
its parts.” Therefore, the comprehensive picture obtained from qualitative data was
triangulated with the self-management behaviors and acculturation score, which allowed

the researchers to check for congruence of information.

80

CHAPTER 4
RESULTS
The research findings are organized according to the research questions of this study.
Triangulation of qualitative and quantitative data is shown for research questions one and
two because the participant responses for these two research questions were assessed

using both the self-care survey and the qualitative questions.

4.1 Sample Characteristics

Thirty first generation Asian Indian immigrants in Michigan participated in this study.
Table 4.1 shows the distribution of the sample by glycemic control status, and
acculturation level. There was an equal number of participants in the AC and UC groups
when categorized using the HbAlc cut point of 7% as suggested by the ADA (2009). The
acculturation level of the overall sample was below the bicultural level of 3.0 ranging
from 1.71 — 2.8 with a mean and standard deviation of 2.2 i 0.2. Participants with an
acculturation score <2.15 were categorized as Asian Oriented (AO) those with a score

greater than or above 2.15 score were categorized as bicultural Oriented (BO).

81

Table 4.1 Frequency distribution by glycemic control status and acculturation level of the
study sample (n=30).

 

 

 

Acculturation 7 Oiycemic Control
Level AC < 7% UC Z 7% Total P
n (%) n (%)
AO (< 2.15) 8 (53.737)7 77 6 (40.0) 7 174 77 7 .376 H
BO (2 2.15) 7 (46.7) 9 (60.0) 16
7777170721177 7 7 7 {s " 7" 1757 77 7 7307 7 7 7 7
ofiralfaaiifififieéi ('mcéh': so) = 2.2 : 0.2 and(ra7n7ge) 271.71 :23; 77 7

AC - Acceptable control; UC — Unacceptable control ; AO — Asian oriented; BO — Bicultural oriented

The characteristics of participants, based on acculturation level and glycemic control are
shown in Table 4.2. About half of the participants had lived in the U.S. for over 30 years,
had diabetes for less than ten years, and were over 60 years of age. There were sixteen
males and fourteen females and an equal number of participants in the AC and UC
groups (n=15). Although not statistically significant, there were more males than females
in the B0 and the UC groups. The data also exhibited a trend that a larger proportion of
participants, who had stayed for a longer period of time in the U.S., were more likely to
be in the B0 and UC groups (Table 4.1). Half of the participants were obese (BMI 225),
regardless of their glycemic control status based on the Asia-Pacific guidelines for
defining obesity. All the participants had medical insurance, and the majority of
participants (86.7%) had a strong family history of diabetes. More than half of the
participants (60%) had prior diabetes education; regardless of whether they were in the

AC or UC groups (Table 4.2).

82

Table 4.2 Socio-demographic and medical characteristics of the sample (n=30).

 

 

 

Glycemic Control Acculturation Total

AC UC A0 BO (11 = 30)
42* , #7 ____ (n=15) (n=15) (n=l4) (n=16)

Age (yr) < 60 9 6 7 8 15
> 60 6 9 7 8 15
Gender Male 6 10 6 10 16
Female 9 5 8 6 14
BM] Normal wt (>18.5 - <23) 5 3 4 4 8
Over wt (:23 - <25) 2 4 2 4 6
Obese (> 25) 8 8 8 8 16
Annual Household Income <75,000 2 6 3 5 8
76.000 - $100,000 4 3 3 4 7
> 100,000 8 6 7 7 14
Education Level < BS 4 8 5 7 12
MS 6 6 4 8 12
PhD/ MD 5 1 5 1 6
Duration of stay in U.S. (yr) <10 1 3 2 2 4
10 - 3O 8 2 6 4 10
> 30 6 10 6 10 16
Duration of Diabetes (yr) < 10 7 8 6 9 15
10 - 20 4 6 7 3 10
> 30 4 1 1 4 5
Diabetes education Yes 9 9 8 10 18
No 6 6 6 6 12
Family history of diabetes Yes 15 1 1 1 1 15 26
No 0 4 3 l 4
Married 14 14 13 15 28
Employed 10 6 8 8 16
Medical Insurance (yes) 15 15 14 16 30

Smoker

o
' N
N

 

 

 

 

83

The mean differences in age, body mass index, acculturation level, and glycemic control
of participants between the AC and UC groups and A0 and BO groups are presented in
Table 4.3. There were no significant differences in age and BMI of the participants
between the AC and UC as well as the A0 and BO groups. The mean HbAlc value and
SL-ASIA score were significantly higher in the UC (P<.01) and the BO (P<.01) groups
respectively. However, the mean acculturation level was not significantly different

between the AC and UC groups.

84

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4.2 Dietary Quality and Meal Patterns of Participants

The independent t test comparison of mean energy and nutrient intake of participants’
(from the two 24-hr dietary recalls) within glycemic control and acculturation groups is
shown in Table 4.4. The mean energy, macronutrient, and fiber intake of participants was
not significantly different between the AC and UC or A0 and BO groups. However, the
fiber intake in all groups were <25 g/ day. Table 4.5 shows the percentage of
macronutrients, meal frequencies during weekday and weekend, and use of supplements
within groups. The percentage of calories from protein was significantly higher in the BO
than the AO group (p=.03). Participants in the AC (p=.03) and BO (p=.01) groups were
more likely to take dietary supplements such as multivitamins, calcium, Omega 3 Fatty
Acids, Whey protein, and Vitamin E [AC(13) vs. UC(6) and AO(5) vs. BO(13)]. The
proportion of alcohol consumers were significantly higher in the BO group (p=.01)
[AO(2) vs. BO(11)]. Interestingly, the types of foods consumed by participants did not
vary between the acculturation and the glycemic control groups. All the participants
included both western (e. g. waffles, cheese, Barbeque chicken, meat/vegetarian patties)
and Asian Indian foods (e. g. meat or vegetable pulao, sambar (lentil curry/ soup), kheer
(Asian Indian dessert equivalent to pudding), and curries) in their diet. The majority of
the participants consumed a western breakfast as opposed to traditional Asian Indian

foods, typically consumed for breakfast in India.

86

Table 4.4 T-test comparisons of selected macro-nutrients based on two 24-hour diet
recalls, by glycemic control and acculturation level. (n=30).

 

 

Calories & Glycemic Control P Acculturation Level P
Nutrients AC UC A0 B0
(n = 15) (n = 15) (n = 14) (n = 16)

Calories (Kcal) 1558 i 559 1475 i 512 .68 1515 i 497 1517 i 571 .99
CHO (g) 232.9 3: 87.2 217.6 1 71.6 .60 230.8 : 76.2 220.4 : 83.2 .73
Protein (g) 62.0 i 25.4 55.5 i 19.1 .43 53.4 i 17.3 63.4 i 25.6 .23
Fat (g) 46.1 i 18.7 43.3 i 18.4 .69 42.9 i 18.2 46.3 i 18.8 .63
Sat fat (g) 11.1 15.0 11.9:58 .66 11.7i5.9 11.4i4.9 .87
Fiber (g) 19.1 i 7.5 18.2 i 7.6 .77 17.5 i 7.6 19.8 j; 7.3 .40

 

87

Table 4.5 Selected nutrient composition and meal patterns based on two 24-hour diet
recalls, by glycemic control and acculturation level. (n=30).

 

 

AC UC P A0 B0 P
(n=15) (n=15) (n=l4) (n=l6)
n (%) n (%) n (%) n (%)
Energy (Kcals)
51600 6 (40.0) 9 (60.0) .23 6 (42.9) 9 (56.3) .36
>1600 9 (60.0) 6 (40.0) 8 (57.1) 7 (43.8)
Carbohydrates (g)
5220 6 (40.0) 7 (46.7) .50 4 (28.6) 9 (56.3) .12
>220 9 (60.0) 8 (53.3) 10 (71.4) 7 (43.8)
% of Calories from
Carbohydrates
555 4 (267) 4 (26.7) -66 3 (21.4) 5 (31.3) -43
>55 11 (73.3) 11 (73.3) 11 (78.6) 11 (68.8)
Protein (g)
560 8 (53.3) 9 (60.0) .50 9 (64.3) 8 (50.0) .34
>60 7 (46.7) 6 (40.0) 5 (35.7) 8 (50.0)
% of Calories from Protein
515 8 (53.3) 7 (46.7) .50 10 (71.4) 5 (31.3) .03
>15 7 (46.7) 8 (53.3) 4 (28.6) 11 (68.8)
Fat (g)
553 9 (60.0) 11 (73.3) .35 10 (71.4) 10 (62.5) .45
>53 6 (40.0) 4 (26.7) 4 (28.6) 6 (37.5)
% of Calories from Fat
530 10 (66.7) 11 (73.3) .50 10 (71.4) 11 (68.8) .60
>30 5 (33.3) 4 (26.7) 4 (28.6) 5 (31.3)
Fiber (g)
<25 12 (80.0) 13 (86.7) .50 13 (92.9) 12 (75.0) .21
225 3 (20.0) 2 (13.3) 1 (7.1) 4 (25.0)
Number of meals (weekday)
_<_4 meals 7 (46.7) 6 (40.0) .50 6 (42.9) 7 (43.8) .63
>4 meals 8 (53.3) 9 (60.0) 8 (57.1) 9 (56.7)
Number of meals (weekend)
34 meals 8 (53.3) 12 (80.0) .12 8 (57.1) 12 (75.0) .26
>4 meals 7 (46.7) 3 (20.0) 6 (42.9) 4 (25.0)
Alcohol consumers (yes) 7 (46.7) 7 (46.7) .64 2 (21.4) 11 (68.8) .01
Supplements (yes) 12 (80.0) 6 (40.0) .03 5 (35.7) 13 (81.3) .01

 

88

 

 

Research Question (i): Is acculturation related to glycemic control, and if so, how?

4.3 Relation of Acculturation to Glycemic Control

4.3.1 Findings from the Socio-demographic and Self-care Survey (Quantitative
Findings)

Table 4.7 displays the final multiple regression model with the variables that significantly
predicted glycemic control (acculturation, body mass index, diabetes duration, and annual
household income). BMI and diabetes duration were continuous variables while annual
household income was dichotomized as a categorical variable with income<100,000 as
the reference category. Mean correction was performed for predictors that were
continuous variables (acculturation, BMI, and diabetes duration) such that they were
assigned a mean value of zero. This is done in order to reduce the collinearity between
these variables and the interaction terms based on their products, thereby reducing the
standard error of the regression coefficients. Since age, gender, duration of stay in the
U.S., employment status, educational level, and prior diabetes education were not

significant, they were excluded from the model.

There was no significant association between acculturation level and glycemic control
when linear regression analysis was performed with only acculturation, BMI, diabetes
duration, and annual household income as predictors of glycemic control (R2 = .019; p
=.98) (see Table 4.7). However, when the interaction of acculturation and these predictors
were added, the main effect of acculturation (unstandardized b= -2.67; p= .03) and the

interaction of acculturation with annual household income (unstandardized b= 7.19; p=

89

.01), diabetes duration (unstandardized b= .30; p= .02), and BMI (unstandardized b=
1.11; p= .01) significantly predicted higher HbAlc values (R2 change = .368; F change =
4.208; p =.02). Annual household income, BMI, and diabetes duration did not
significantly predict glycemic control in the absence of an interaction with acculturation
(p>.05). Interactions of annual household income, diabetes duration, and BMI with
acculturation status were both statistically significant and positive, which indicates that
the relationship between acculturation and glycemic control is determined by the specific

values of these three predictors (annual household income, BMI, and diabetes duration).

Table 4.6 Predictors of glycemic control among Asian Indians with physician diagnosed
diabetes (n=30).
Model 1 Model 2
R2 = .02 (p.93) R2 change = .37;
F change = 4.20 (p=.02)

 

 

Unstd. SE p Unstd. SE p
B B
Intercept 7.321 .28 <.01 7.08 .25 <.01
aAcculturation .049 .82 .95 -2.67 1.14 .03
Income (>$100,000) -.259 .41 .53 .03 .35 .94
aDiabetes duration -.006 .02 .76 -.01 .02 .75
aBMI -.023 .08 .78 -.08 .08 .30
Acculturation*lncome 7.19 2.3 1 .01
Acculturation*BMl 1.1 l 0.40 .01
Acculturation*Diabetes duration 0.30 0.12 .02

 

Outcome variable -— Glycemic control assessed using llelc laboratory value

aMean corrected variables
Model 2 - Includes interaction terms of acculturation with covariates

90

4.3.2 Perceptions about Lifestyle and Diabetes Management in the U.S. (Qualitative
Findings)

The two themes that emerged relative to acculturation and achievement of glycemic
control by the participants were ‘changes in lifestyle after immigration’ and ‘ease of
management of diabetes in the U.S.’ These were perceived within the context of “new

country” influences.

Changes in lifestyle after immigration

The changes that participants reported after immigration were: health perceptions,
changes in physical activity, lack of extended family support, and dietary changes such as
increased meat and alcohol consumption. Regardless of acculturation status, six
participants in the AC group mentioned that health awareness increased after immigration
to the U.S., which was not mentioned by participants in the UC group. “Ifind that I ’ve
benefited more because there is more awareness here (U.S.) of the disease and you do
find more information in the books, also the classes as an adult you can take um....even if
you have to pay for it by yourself or your insurance covers it, there are a lot more
information available which could guide you manage your diabetes better. " — (female,

AC, A0).

Similarly, four participants in the AC group, who were also AO mentioned that physical

H

activity increased after immigration. it ’5 easy to gain weight because of the food

that’s available and the weather of course in Michigan, we’ve always been in Michigan

91

so, but then I started reading about stuff and exercising, so exercise I would say is the

most that has changed " — (female, AC, BO).

Likewise, a few participants in the AC group, who were BO, also specified healthy
modifications to Asian Indian recipes. “Basically I think the diet has changed, which I
said the uh think the Indian diet is the worst diet. That regular conventional diet is the
worst diet that people eat. I don’t know. There is lot of fat and oil and they eat too much,
so heavy and I think it ’5 just like putting diesel in your car, I don ’t know. I think Indian
cooking, conventional Indian diet is... is extremely injurious to your health, but my style
of Indian diet is the best diet in the world. If you just eat good curried vegetable with very
small amount of oil ...stirfry you might call and with some good spices and all that. The

Indian spices are just are the most healthiest things ” — (male, A0, BO).

On the other hand, participants in the UC group, who were BO, mentioned decreased
physical activity (n = 2) and increased meat consumption (n = 3) after coming to the U.S.
“In India I was totally vegetarian, I come fiom a vegetarian family, so after coming here
(U. S.) I became a non-vegetarian so that ’s a big change. I don’t know whether that has

anything to do with diabetes or not, but that was a big change — (male, UC, BO).

Ease of management of diabetes in the U.S.
For the second theme ‘ease of management of diabetes in the U.S.’, participants in both

the AC and UC groups consistently mentioned that diabetes was easier to manage in the

92

U.S. than in India (participants recollected their experiences from the days before
immigration to the U.S. or when they vacationed in India). The reasons given for easier
management in the U.S. as specified by the participants were: availability of exercise
facilities, absence of negative influences by social networks, good health care facilities,
quality of healthy food choices, availability of self-monitoring devices, medical
insurance, potentially better quality medications, greater health awareness, and
infrastructure. “N0 1 think it is easier here (U.S.) than in India, we have insurance. In
India there is not much of insurance system, the medicines are very expensive and I am
not sure If they are correct. If you can’t manage in this country, then you can ’t manage

anywhere in the world, yeah " - (male, AC, A0).

However, two participants in the UC group, who were AO, mentioned that it would have
been easier to manage diabetes if they were in India. The reasons mentioned were
favorable weather, opportunity to use complementary and alternative medicine, and a
greater demand for physical activity due to the types of occupation and greater use of
public transportation. “IfI am in India, generally my diabetes does good because little bit
automatically you walk so that helps. And somehow the weather, it is possible because of

the weather that also helps. ”- (male, UC, A0)

4.3.3 Triangulation of Data on Acculturation and Glycemic Control

A trend was observed in the survey data depicting a larger proportion of participants in

the UC (10 vs. 6) and BO (10 vs. 6) groups with a longer duration of stay in the U.S.
93

Multiple linear regression analysis showed the relationship between acculturation and

HbAlc levels to be dependent on annual household income, diabetes duration, and BMI.

Data from the qualitative interview suggested that health promoting behaviors were more
likely to be evident among AC participants after immigration. Participants in the AC and
A0 groups reported increased health awareness and increased physical activity after
immigration. On the other hand, UC and BO participants specified sedentary lifestyle and
increased meat and alcohol consumption. Nutrient analysis of the 24-hr dietary recalls
demonstrated a significantly higher percentage of calories from protein in the BO than
the AO group (P<.05). Similarly, data from the quantitative survey, although not
significant showed an increasing trend in the number of alcohol consumers in the B0
than the A0 (11 vs. 3) group. A larger proportion of participants in the UC (n=12) and
BO groups (n=12) reported consuming less than or equal to 4 meals (inclusive of snacks)

during weekends versus the AC (n=8) and A0 groups (n=8).

The majority of the participants regardless of acculturation or glycemic control levels
believed that exercise and health care facilities, healthy food choices, availability of self-
monitoring devices, and medical insurance were favorable for diabetes management in
the U.S. Two AO participants in the UC group believed that diabetes management was
facilitated by the Indian weather, opportunity to use complementary medicines, and the
necessity for employment and transportation physical activities. The qualitative findings

demonstrate a trend in the changing dietary (increasing westemization of the diet) and

94

physical activity behaviors (increasing sedentary lifestyle) of the participants who were in
the BO and UC groups. While in the quantitative data, interactions of acculturation with
BMI, diabetes duration, and annual household income were significantly associated with
higher HbAlc levels. Although a limited sample size may have influenced the findings
from the quantitative data, it is important to recognize the influence of individual
characteristics such as BMI, annual household income, and diabetes duration on the
relationship between acculturation and HbAlc levels based on the significant interactions

of these variables with acculturation in the multiple regression model.

The majority of the participants, regardless of the acculturation or glycemic control
status, specified several advantages of diabetes management in the U.S. These included
exercise facilities (easy availability, accessibility, and affordability), absence of a social
network, which may have a negative influence in diabetes management, excellent health
care system and facilities, availability of healthy food choices and self-monitoring
devices, medical insurance benefits, quality of medications, and improved health
awareness afier immigration. Due to adaptation to the host country’s systems, these
environmental factors perceived as beneficial to diabetes management by Asian Indians,
could have potentially played a role in the positive association between HbAlc levels and

the interactions between acculturation and income, BMI, and diabetes duration.

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Research Question (ii): How do participants perceive the impact of the disease and the
wired self-management behaviors?

4.4 Diabetes Self-management Behaviors

4.4.1 Adherence to Self-management Behaviors (Quantitative Findings)

The quantitative survey responses pertinent to participant self-management behaviors are
summarized in Tables 4.8, 4.9, and 4.10. Data demonstrated that there were more
participants in the AC group who adhered to rigid diabetes self-management behaviors
such as performing frequent exercises for a longer duration, following a special diet for
diabetes, consulting their physician on a regular basis, and checking their feet on a

regular basis.

The mean ranking of participants’ ability to perform self-management behaviors shown
in Table 4.11 indicated the self-perceived relative difficulty in performing the ADA
recommended self-care practices. A lower mean value for any self-management behavior
within a group indicated that more participants in that group had reported that particular
self-management behavior to be easier. Mean values for the perceived difficulty with
adherence to all the self-management behaviors were similar between the two groups;

' however, the mean values for physician consultation and medication adherence for UC
participants were slightly higher than those for the AC group (significant at p<.10).
Participants in both AC and UC groups perceived taking medications to be the easiest
among all self-management behaviors, while consultation with a physician in the AC

group and regular exercise in the UC group were perceived as the most difficult.

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Table 4.7 Participant responses with regard to adherence to dietary and exercise
behaviors from the self-care survey (n=30).

 

 

AC (n = 15) UC (n = 15) p
n (%) n (%)
Healthy Eating
Do you follow any I 1 (73.3) 7 (46.7)
special diet? (yes) .13
What do you do? More: veg (2), protein (1), More: veg (3), protein (1),
complex carbohydrates (3) complex carbohydrates (1)
Limit: carbohydrates (5) eggs (1), nuts (1), dairy
Avoid: added sugar & products (2)
sweets (8), specific fruits or Limit: carbohydrates (5)
veg (4), red meat (1) whole Avoid: sweets (2) fruit
milk products (I) juices (1)
Reduce: fat/ fried foods (4) Reduce: fat (1)
Others: Early dinner (1), Others: Use sugar free
eat in moderation (2) products (3 ), very low
calorie diet (1)
No changes at all (4)
How often do you All the time (12) except All the time (5) — except
follow this diet when socializing (4) when socializing (2)
Most of the time (4) Most of the time (5) —
difficult during weekends except when away from
(2) home (1)

No special diet (5)

Regular Exercise

Do you exercise? (yes) 13 (86.7) 10 (66.7) .20
What do you do? Yoga (3), Walking (12), Yoga (1), Walking (5),
Treadmill (2), Gym (5), Treadmill (3), Gym (2),
Swimming (1), Snow Swimming (3), Snow

shoveling (1), Running (1), shoveling (2), yard work
physical activity in daily (2), cycling (2), golf (1),
chores (4), no physical physical activity in daily
activity (3) chores (2), no physical
activity (4), Do not
exercise (5)
Exercise duration/ week

< 150 min 3 (20.0) 9 (60.0) .03
Z 150 min 12 (80.0) 6 (40.0)

Exercise frequency

None or < 5 times/week 4 (26.7) 9 (60.0) .07
Everyday or Z 5 times/week 1 1 (73,3) 6 (40.0)

 

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Table 4.8 Participant responses with regard to adherence to medication and weight
control behaviors from the self-care survey (n=30).

 

 

AC (n=15) UC (n=15)
n n
Medication Prescriptions/Adherence
Medication prescription
Tablets 8 1 l
Insulin w/ wo tablets 5 3
None 2 I
Medications for health conditions
Diabetes 13 14
High BP 8 5
Cholesterol 5 8
Heart 4 4
Acidity l 4
Thyroid 2 2
Others 2 4
Number of medications
5 3 10 6
3 4 5 9
Do you have problems taking
medications?
yes 3 2
No 10 12
Weight Control
Are you trying to lose or gain weight?
Lose 1 l 9
Maintain 3 5
Gain 1 1
Current weight relative to weight at diagnosis?
Lost 10 9
Maintained 0 3
Gained 5 3
Current weight relative to highest adult weight?
Lost 12 12
Same 3 3

 

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Table 4.9 Participant responses with regard to adherence to self-monitoring of blood
glucose, foot care, and physician consultation behaviors from the self-care survey (n=30).

AC (n=15) UC (n=15)
n I]

 

 

Self-monitoring blood glucose
Did your doctor ask you to check your blood sugar at home?

Yes 1 l 13
No 2 2
Don’t have a doctor 2 0

How many times did your doctor ask you to check your blood sugar at home?

Doctor did not ask to check 2 2
Once/ day 5 6

2-3 times/ day 3 5

2 - 3 times/ week 2 2

Don’t have a doctor 2 0

Don’t know 1 0

How many times are you able to check your blood sugar at home?

Doctor did not ask to check 1 1
Once/ day 2 1
2—3 times/ day 2 2
Once/ week 2 2
2-3 times/ week 5 5
Once/ month 2 0
Don’t check 1 4
Foot Care
Did your doctor ask you to check your feet at home?
Yes 8 7
No 5 6
Doctor checks 2 2
How often are you able to check your feet at home?
Every day 10 2
Don’t check 2 4
Few times/ month 1 4
Doctor did not ask to check 1 3
Don’t have a problem 1 2
Physician Consultation
How many times have you seen a doctor in the past year for your diabetes?
Don’t see 2* 1
<3 3 6
_>_3 10 8

 

*Two participants in the AC group reported that they did not have a doctor

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Table 4.10 T-test comparison of participants’ perceived difficulty to perform self-
management behaviors (n=30).

 

Survey Responses Ability to perform self-
management (ranking)*

 

 

AC UC AC UC P

n=15) (n=15) i : SD in i SD
Follow special diet 11 6 3.3 i 1.8 4.2 i 1.7 .15
Regular exercise 13 9 4.4 i 1.9 5.0 i 1.7 .37
aPhysician consultation '0 8 4-9 i l-8 3.7 i 2'1 -03
Medication adherence 10 12 2.7 i 2.0 1.7 i 1.0 .10
Foot care 10 6 3.5 i 2.4 4.3 i 1.2 .23
Weight control 14 14 4.7 i 1.6 4.7 _t 1.8 1.00
bSelf-monitoring blood glucose 4 6 _ 4-3 i 2-0 4-1 i 2-5 ~81

 

 

 

ISelf-managemen‘trfitkifing27177=Tea7sy. .—..7'i diffichlt "
check with a physician 2 3 times/ year
everyday

4.4.2 Perceptions about the Impact of the Disease and Self-management (Qualitative
Findings)
Two themes “lifestyle changes after diagnosis” and “ease of management of diabetes on a

daily basis” emerged in the qualitative analysis.

Lifestyle changes after diagnosis

The majority of participants in the AC group reported more positive lifestyle changes
(n=9) after diabetes diagnosis, while most in the UC group reported no major lifestyle
changes (n=9). The positive changes mentioned were exercising more; taking
medications as prescribed; regular self-monitoring of blood glucose; positive attitude
towards health and life; weight control; and making healthier food choices, specifically

greater awareness about food and health, including more salads and complex

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carbohydrates in the diet, avoiding added sugar, controlling portion sizes, and giving up
some favorite foods. “I 've been testing everyday so that is one thing and secondly my
eating has definitely changed, try to be more careful with my eating so that has definitely
affected and exercise. Exercise 1 have always done so that 's not something, trying to

make sure I do it, I usually have inertia sometimes, I try to avoid this inertia " - (male,

AC, BO)

Although the majority of participants in the UC group reported no lifestyle changes after
diagnosis, four mentioned a few dietary changes such as using diet soft drinks instead of
regular, reducing sweet food intake, avoiding excess alcohol and fried foods, and trying
to control portion sizes when eating at home. “I would eat a lot earlier, so that has
changed. Sometimes I get flustrated with time...I try to control myself...I need to get
more, again typically if there is like chicken or something cooked or if we go out to eat, I

tend to not follow the portions or whatever that I am supposed to " - (male, UC, A0)

A few participants in the AC group (n=5) mentioned negative physiological and
psychological changes such as hypoglycemia, immobility due to amputation, easy weight
gain, tiredness, and losing self-confidence after diagnosis with diabetes. On the other
hand, responses in the UC group for negative changes were depression, difficulty in
cooking special meals for diabetes, inability to consume alcohol and favorite foods, and
tiredness. “I am going through depression and not happy because I never ate so much,

but I could at least choose some food, which one I can’t do it now. I love meat and

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whenever I socialize 1 love to drink, don 't want to get drunk, but love to drink you know,

socially always” — (female, UC, BO).

Ease of management of diabetes on a daily basis

The majority of participants in the AC group perceived performance of self-management
behaviors to be easy because they learned how to manage diabetes over the course of
time and through practical experiences. Only three participants in the UC group
perceived self-management to be easy. When asked about daily management of diabetes,
eating healthy and exercising regularly were the most mentioned as being important for
diabetes management by participants in both groups; however, more challenges in

performing the self-management behaviors on a regular basis were expressed by the UC

group.

Participants in the AC group had a tendency to explain dietary changes in detail versus
the UC group who simply mentioned “eating healthy.” The dietary changes mentioned by
the AC group were: carbohydrate control, reducing sweets and added sugar, portion
control, more rigid diet after “treats” were consumed, and reliance on the spouse for
selecting foods to facilitate portion control when socializing. On the other hand, two
participants in the UC group perceived difficulty in avoiding food temptations even
though they tried to regulate their diet. “I am just trying to change my diet habits so that
is the one I am doing daily...av0iding the temptation is the challenge because when there
are everything available right in front of the eyes and it ’s hard to resist ” - (male. UC,
BO).

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Two participants in both groups expressed inconsistency in exercise routine due to a busy
schedule. Participants in the AC group were more likely to play sports, walk instead of
drive, perform yard work and house chores, and incorporate exercise into their daily
activities. Although a few participants in the UC group mentioned these activities, many
(n=4) expressed a lack of motivation as the main challenge to exercise. “I take all my
medicines very well, regularly. I know that’s in my hands so I take my medication very

regularly. diet is alright, but don ’t tell me to exercise " - (female. UC, BO).

Taking medications was perceived to be a part of daily routine as it did not require major
lifestyle changes in the UC more than the AC group. “I have my medicines in the
morning, I have my medicines in the night, I make sure I have my medicines that he
(physician) gives me. It ’s something that is there in the back of my mind, its not that it is
hampering the way I am living or my lifestyle ”- (male, UC, BO). Self-monitoring blood
glucose was mentioned as a part of daily routine by one and two participants in the AC
and UC groups, respectively as were foot care and consultation with physician by one

participant in each group.

4.4.3 Triangulation of Data on Diabetes Self-management

The key findings of triangulation of information from the quantitative and qualitative data
for self-management behaviors were as follows: participants in the AC group consistently
mentioned eating healthy in the survey and the in-depth interview. Data from the

qualitative interviews provided a detailed explanation of dietary and physical changes by

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the AC group, similar to survey details. “I look at the food and 1 think, should I or should
I not eat. I pick and choose. So, like yesterday at the party, there were some other
desserts, which I chose not to eat because I chose from three or four varieties, I gave
myself the choice which ones do I really want to taste and eat. So I pick and choose, I try
to add more complex carbs so I add more salads to food than having more refined carbs.
It 's a huge change. I don 'I add sugar to my tea, I can live with little things but at the
same time then I am thinking ”okay I can avoid this much sugar in the tea at the same
time may be in a few days down the road, I can yearn myself to eat a cookie ”- (female.

AC, A0)

A trend that was evident from the data obtained from quantitative and qualitative
methods was that participants in the AC group excluded items such as added sugar,
refined carbohydrates, and foods rich in fats contrary to changes made by participants in
the UC group which were in the form of inclusion of foods such as nuts, eggs, sugar free
products, and dairy products. “Nuts do help, I just take a little bit you know like 5
cashews or 4, just that much... you can all the foods over here without sugar, you can get
sugar—free chocolates. you can get sugar-free this and that so at least that has helped " —

(female, UC, BO)

The perceived difficulty in adherence to healthy eating during the weekends and when
socializing in both the AC and UC groups, which was evident in the survey results also
emerged in the qualitative findings. “...during the weekdays I know I can manage my diet

very well because I am at work to have the time of the day so I try to control the carbs

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intake during the weekdays. Weekends 1 know I am exposed to such yummy foods.
sometimes... its hard to resist and avoid ” — (female, AC, A0). Some examples of foods
which appeared on the weekend day 24 hour recalls included pizza, kheer (sweet
pudding), halwa (Asian Indian dessert), and deep fried foods/ snacks such as samosas,
puris, fried fish, papad, and spicy Asian Indian snack mixtures, all of which have a large

amount of added sugar and] or fat.

Likewise, UC participants described tiredness, lack of motivation, and physical
discomforts as challenges to a regular exercise regimen, which explains their expressed
difficulties in exercise adherence as evidenced by the lower frequency and duration of
exercise compared to AC observed in the survey data. “...well I could do the biking too
but I get very much leg cramps. Legs get tired very easily but the walking thing you know,
the treadmill if I have I think that burns lot of calories... I was doing the elliptical and
here the aches...I went to the doctor and the doctor says the bone is getting thinner” —

(female, UC, BO)

A few participants in the AC group expressed in the in-depth interview that they were not
impressed with their health care, which was consistent with the self-management ranking.
AC participants ranked consultation with a physician as the most difficult. However,
survey analysis showed that they were more likely than the UC group to consult a
physician three or more times a year despite the perceived difficulty. Consistency
between quantitative and qualitative findings was distinctly observed in medication

adherence of UC participants. Participants in the UC group perceived taking medications

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as easier than major lifestyle changes in the qualitative interview. In the quantitative data,
medication adherence was reported to be relatively easier in the UC versus the AC group
as evidenced by the lower mean value for medication adherence in the survey item for
participant ranking of perceived difficulty to perform diabetes self-management

behaviors (p<.10) (Table 4.9).

4.5 Factors Influencing Diabetes Self-management

The quantitative data for individual (acculturation, age, educational level, income status,
duration of stay in the U.S., duration of diabetes, prior diabetes education, and family
history of diabetes) and environmental (medical insurance) factors were shown in the
descriptive characteristics in Table 4.2. Since the role of acculturation was discussed
earlier, the other findings pertaining to the influence of individual and environmental

factors on diabetes management from the qualitative interview are presented below:

4.5.1 Individual Factors

Research Question (iii): How does the subjects’ knowledge of diabetes affect their self-

management behaviors?

4.5.1.1 Diabetes Knowledge

The themes that emerged for diabetes knowledge of participants from the qualitative
interviews were “understanding the disease and consequences”, “knowledge about the
outcomes of self-management”, and “awareness of the important self-management

behaviors”.

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Understanding the disease and consequences

Participants’ responses for the theme “Understanding the disease and consequences”
were mainly derived from the questions “Can you tell me what diabetes is?” and “what
do you think will happen if you do not take care of your diabetes?” All participants in the
AC group and the majority of participants in the UC group had in-depth knowledge about

the disease onset and progress.

Participants were for the most part astute in specifying that diabetes is the culmination of
a defective insulin response to high blood glucose concentrations in the body because the
body is either not producing or not able to use the available insulin. Four participants in
the UC group had a vague knowledge about the mechanism of diabetes. “1 know there
are two types, high sugar and one is low sugar. I’ve got high sugar, that’s all” - (male,

UC, BO)

However, all the participants in both the AC and UC groups were well aware of the
associated short and long-term consequences of inadequate management of diabetes.
Participants in both the AC and UC groups mentioned that insufficient care may lead to
serious complications such as heart and circulation defects, stroke, hypertension, eye
disorders, kidney problems, peripheral nerve problems/ amputations, coma, liver
problems, dental problems, weight gain, and perhaps even death. The other consequences
Specified were: unhealthy life, weakness and fatigue, increased medical costs, the

necessity for insulin therapy, and worsening of the disease.

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Knowledge about the benefits and types of self-management behaviors

The concepts that were discussed were the potential benefits of adequate self-
management. Participants predominantly mentioned that self-management would lead to
a normal and healthy life followed by prevention and delay of complications. “Just that
these uh, these other complications will not happen soon. It will happen perhaps they will

happen eventually, but at a later stage ” - (male, UC, A0).

All the participants in the AC and UC groups had some knowledge about some of the key
diabetes self-management behaviors for controlling the disease. When asked to identify
specific key self-management behaviors, a healthy diet [AC (14) vs. UC, (10)] and regular
exercise [AC (11) vs. UC (9)] were the two behaviors that were most frequently
mentioned followed by taking medications [AC (6) vs. UC (5)] and self-monitoring blood
glucose [AC (5) vs. UC (4)]. “Maintaining low blood glucose levels, healthy weight,
keeping your sugar levels low mainly by eating healthy, exercising regularly... ”- (female,

AC, A0).

Reducing stress level was also interestingly mentioned by one participant in both the AC
and UC group. In addition, weight management [AC (3)] was specified by participants in
the AC group and checking hemoglobin Alc [UC (2)] and regular follow-up visits with a
physician [UC (3)] by the UC group. “It is very essential that you don’t miss your
medication because it is a supplement to your insulin deficiency you should definitely
take the three month check up if the doctor says because I give him the authority on those

sort of things because he is much more knowledgeable than me ”- (male, UC, BO).

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Importance of Diet, Medications, and Physical Activity in Self-management
Participants were asked about the roles played by food, medicine, and exercise in

diabetes self-management. When the participants were asked if any of the three was more
important than the others, the majority of the participants in both groups mentioned that
the combined effect of the three or any two worked together to maintain diabetes control.
However, five participants in the AC versus two in the UC group referred to exercise
alone as the most important. “Exercise is probably the most important, but I really should
be doing more exercise. I don’t do that much, it ’s kind of difficult for me, but I have to do

it so I do it. But I think exercise is most important ”- (male, AC, A0).

Participants were also asked about the independent roles of food, medicine, and exercise

and how each functions in diabetes management.

Diet: Participants in both the AC and UC groups recognized the role played by food in
controlling blood sugar [AC (10) vs. UC (5)] and the need to monitor food intake [(AC
(8) vs. UC (5)]. In addition, participants in the AC group mentioned that food could
improve satiety [AC (2)] as well as the importance of small frequent meals [AC (2)], and
portion control [AC (2)]. “You have to restrict the calories and yet eat a larger volume,
which you can only do by reducing your fat intake because fat has more calories grams
for grams. So the aim is to reduce your calories and eat a larger volume to satisfii your

stomach ” — (-male, AC, BO).

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Three participants in the UC group, who recognized the importance of food in blood
glucose management, also mentioned some of the challenges they faced such as not being
able to eat the desired amount after diagnosis with diabetes, and the need for more
medications when sweet foods were consumed. One participant in the AC and two
participants in the UC group said that they did not know the role of food. One participant
in each group mentioned that food is important for diabetes management regardless of
whether the patient takes medications or not. “Even though you can take medicines, if
you don ’t manage your food intake, you are not going to be able to have regular sugar

levels in your body. So, it does play a key role ” — (female, AC, A0)

Exercise: The majority of participants in both the AC (n=15) and UC (n=13) groups
mentioned that exercise plays a critical role in diabetes management. Exercise was
perceived by several participants to be important even in the absence of diabetes [AC (4)
vs. UC (1)], for metabolism of carbohydrates [AC (3) vs. UC (3)], and as an adjunct to
medications [AC (1) vs. UC (1)]. “Its very important because exercise not only burns the
sugar, it gives you lot of other advantages you know, circulation, improves circulation,

improves your strength, muscle strength, you can be more mobile” — (male, AC, A0).

One participant in each group reported that they did not know the role of exercise in
controlling diabetes. Three participants in the UC group acknowledged that exercise was
beneficial, but difficult to accomplish. “They tell me it is very good and I would love to
do a little more exercise but I can’t, I just can ’t do exercise, I don’t know why...1 have
lots of time the whole day, I don ’t know why” — (female, UC, BO). The other roles for

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exercise mentioned by participants in the AC group were for weight control [AC (2)] and
a healthy life [AC (3)]. Participants in the UC group specified that exercise helps to burn

calories [UC (6)], produce insulin [UC (1)], and for fitness [UC (1)].

Medications: When asked about the role of medicine, the majority of participants in the
AC and UC groups mentioned the importance for blood sugar control. Four participants
in the UC group said that medications were not effective, and did not play a major role.
Four in the AC and two participants in the UC groups said that medicine would help in
the management of diabetes if diet and exercise did not work. ”I think the medicines are
doing a great job in controlling my diabetes regardless of not exercising or not following

strict sugar” — (male, UC, A0)

Two participants in the UC and one in the AC group said that medicines might not work
if dietary and exercise habits were not good. One participant in each group believed that
medicines would decrease the likelihood of complications. Two participants in the AC
group perceived that tablets did not work as efficiently as insulin and two other
participants in this group perceived that diabetes should not be managed just by oral
medications, but with insulin injections as well. “Pills are useless in my experience, more
people are dying because they depend on pills and they are afraid of taking insulin and
they may have some value in early cases but at the end of the day most people will, if they
didn’t have pills, more people will live healthier and will have less complications of

diabetes ” — (male, AC, BO)

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Research Qgestion (iv): How does an individual’s values and beliefs influence self-

management behaviors?

4.5.1.2 Values and Beliefs

The themes that emerged for participants’ values and beliefs were “beliefs about
complementary and alternative medicine”, “religious beliefs”, and “perceived diabetes

enhancement foods.”

Beliefs about complementary and alternative medicine

There were no differences in the perceptions of participants in the AC and UC groups
about alternative medicines, with the exception that four participants in the AC group
were either physicians or had come from a family of physicians, and therefore reported
that they firmly did not believe in alternate therapies. “(Alternative medicines) all kinds
of myths, eat this and eat jamuns and all silly stories. They kill themselves, you know. Its

insulin, its insulin, you think all these things can get, people are so stupid " — (male, AC,

BO)

Three and six participants in the AC and UC group respectively, reported that they either
did not believe in or had never tried any type of complementary or alternative
medications. Six participants in each group mentioned that they had the experience of
taking alternative medications for either diabetes or other health conditions. A few
participants were skeptical about the side effects of alternate medications. However,

Some [AC(I) vs. UC(3)] perceived it to be a natural way of treatment compared to

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pharamacotherapy. A few participants [(AC(1) vs. UC(4)] expressed that they had
experienced satisfactory results from prior use of alternative medications. Some
participants in both the AC and UC groups expressed concerns that they had purchased
alternate medications in India, but experienced limited accessibility to alternative
medicine in the U.S. “I sometimes bring some food, medicines from overseas for a short
while and consume It helps actually, yeah it helps in so many ways it helps. I think that
medicine helps more than English medicine, I believe but it is hard to consume you know,

get, on a daily basis. ”- (male, UC, BO)

Religious beliefs

The religious affiliation of the subjects predominantly included Hinduism (n=20),
followed by Islam (n=4), Christianity (n=1), and other religions (n=5) such as Jainism,
Zoroastrianism, and Sikhism. Although religious beliefs had a role in participants’ food
choices, the responses did not differ between AC and UC groups. The majority of the
participants reported that religion did not affect their diabetes management. A few
participants reported that they consumed vegetarian food because they practiced a
“vegetarian religion,” similar to their families, while others reported that their choices of
foods were based on their preferences and the nutrient composition of foods. “I don ’t
follow any of the religious beliefs in terms of uh to eat beef or not to eat beef It does not
have to do with religion; it does have to do with the fact that it has lot of fat "- (female,
UC, BO). A few others, although born in a family that practiced vegetarianism, had
started eating meat and other non-vegetarian foods later in life or after immigration. “1 ’m

supposed to be (vegetarian), but because I was here (U. S.) at very young age, sometimes

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circumstances put you through so I did eat some non-veg in the beginning years " —

(male, AC, BO)

Four participants mentioned that religion was very important to them while one
participant reported less involvement in religious affairs because it was not acquired by
choice, but inherited by birth. The benefits of adhering strictly to religious beliefs as
perceived by two participants were reduced stress and facilitating the avoidance of non-
vegetarian foods. “ Well in a way it does because you know it cuts you out from eating a
lot of these uh what they say eating more of fish or eating more of you know. ”- (male,

UC, BO)

When the role of religion in diabetes management was addressed, participants in the AC
and UC groups reported discontinuation of religious fasting after being diagnosed with
diabetes. A primary concern relative to fasting was being on “an empty stomach” for a
prolonged period, inability to consume excess carbohydrates after the fasting, and
discouragement by family members for health reasons. “No. Um, well we have that one
week where we don ’t eat any greens or anything or you fast, and I know that as a
diabetic 1 should not fast so I don’t. 1 still eat the greens during those eight days, only
like one day I give up which you know you can have, you can go without vegetables for a

day and that ’s not bad ” - (female, AC, BO)

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Perceived diabetes enhancement foods

When asked about foods believed to be helpful with diabetes management, some UC but
no AC participants specifically mentioned eggs, chicken, and fish. “Basicallyfish,
chicken but more than chicken actually fish helps me. And also whole wheat so usage of
whole wheat and even roti, even if I make roti I use the coarse flours, we use brown rice,
so trying to manage with that ” — (female, UC, BO). Participants in AC and UC groups
mentioned Indian spices (cloves, cinnamon, fennel seeds, turmeric, fenugreek seeds, and
neem), all vegetables especially bitter melon, fruits, whole wheat products, lentils, low fat
dairy products, sugar substitutes, and nuts to be helpful for diabetes management. Two
participants in the UC group and one in the AC group said that they did not believe that

any specific food was independently helpful for diabetes management.

4.5.2 Environmental Factors

Influence of health care professionals and facilities, social network, and location of

residence were the environmental factors that were addressed in the interviews.

Research Question (v): How does the health care system influence self-management

behaviors?

4.5.2.1 Health Care System

The two themes that emerged for the influence of health care professionals and facilities

were “physician expectations” and “acceptability of health care services.”

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Physician expectations

Regardless of glycemic control level, participants in the AC and UC groups expected the
physician to be supportive and provide education about diabetes and self-management
behaviors. Two participants in each group expressed that the physician should have open

communication with the patients about problems and challenges related to diabetes.

UC participants were more likely than the AC group to report that physicians should
follow up and guide patients [UC (1 1) vs. AC (2)]. In addition, a few participants in the
UC group wanted the physician to provide individual attention, spend more time with
them and refrain from forcing them to comply with self-management behaviors. “T hey
are short on time nowadays, you know. They hardly have few minutes, my doctor give me
extra time, but even that should be, is not enough you know. So probably that is the best
we can hope for because they are expected to see that many patients and all that ”-

(female, UC, A0).

On the other hand, the AC group expected the physician to provide knowledge, support,
and refinement of treatment. Participants in the AC group, who were either physicians or
researchers, noted that the physicians who are not well informed about diabetes should be
receptive to advanced education. “If the patient it not aware of the problems, if they are
not aware of the condition, I think the doctor should be very well informed and then tell
them what the problem is to begin with. But then if the patient is aware of the condition
and know what they are talking about you should at least be supportive and find out more

or learn more you know, and be ready to help them out” —— (female, AC, A O). A few

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others in the AC group perceived that physicians should use a multidisciplinary approach
for more efficacious treatment, by working collaboratively with dietitians and exercise

therapists.

Acceptability of health care services

With regard to acceptability of health care series, ten participants in the AC and thirteen
in the UC groups expressed satisfaction with the treatment provided by their physician
and health care facility. Participants in both groups were pleased when the following
occurred: the physician allowed the patient to manage the disease with diet and exercise
in lieu of prescribing medications, the health care facility or the physician called and
enquired about health outside of formal office visits, the doctor advised self-management
and regular HbAlc testing to evaluate control status or progress, prompt scheduled

appointment reminders were provided, and referrals were made to a dietitian.

Health care was perceived to be neutral by three and two participants in the AC and UC
group, respectively. “I can give them credit so, they give whatever we ask, they give
certain thing we ask...I don ’t have a dislikeness or I like, plus side ”- (male, UC, BO)
Two participants in the AC group specified that they were not satisfied with their health
care. Since they worked in a medical or related profession, they perceived that their
physicians were not as knowledgeable or experts in diabetes management. “They
(physicians) don’t understand diabetes and actually when 1 was in practice I also didn’t

know what diabetes was you know ” — (male, AC, BO).

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Research Question (Vin In what ways are support networks and self-management

related?

4.5.2.2 Support Network

Two themes emerged for social support: “reactions to diabetes diagnosis by family” and

“help from social network”.

Reactions to diabetes diagnosis by family

The reactions to diagnosis by the family were similar between the two groups. The
predominant reaction was expectation due to a strong family history of diabetes followed
by support and concern. “Yeah of course they were supportive and they actually warned
me from the beginning that I should be careful, careful, careful. So actually because of
that (diabetes) my parents both had heart problems and they even got by-pass surgery
also both of them. So, right fi‘om the beginning they have been warning me to be careful,
my food mainly (female, AC, A0). Three participants in the AC and five in the UC
mentioned that their family reaction to diagnosis of diabetes was minimal to none. “I
don ’t think they (family members) knew, It was borderline, they didn’t note at all it was

normal ” — (male, UC, BO)

Help from Social Network
Participants were asked about people who were helpful and supportive of diabetes
management at the time of diagnosis through the time of interview. Participants in the

AC group were more likely to receive support from their families at the time of diagnosis

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[AC (7) vs. UC (4)]. Knowledge of the spouse, preparation of healthy foods,
encouragement to eat healthy, provision of moral support for exercise, and advice from
family members who were physicians or who were affected with diabetes were the
primary reasons specified. Encouragement to exercise and to eat healthy foods and make
healthy diet changes for the whole family was specifically mentioned by two participants

in the AC group.

Two participants in the AC and four in the UC group mentioned that it was their
physician or dietitian who informed them about diabetes complications and explained
about diabetes self-management. One participant in the UC group mentioned that
American doctors were not aware of Indian foods. Two participants in the UC group,
indicated that they did not get any social support from their friends or family, especially
at the time of diagnosis. “None, just doctor gave me the medicine I took them. My
husband didn ’t say anything; he is never very supportive either. He is like that is your
problem; you got it now, that’s it. He never will say anything you know. So I didn ’t get

any help, I can ’t talk to my friends about that — Oemale, UC, BO -122)

When asked about the person to whom participants would seek help with diabetes
management when needed, the results were consistent. Participants in the AC group
relied on family members primarily for help because family members were perceived as
being knowledgeable, especially if they were physicians, or had diabetes. Participants in
the AC group were more likely to have a family member with a medical background.

Two participants in the AC group were researchers in the biomedical field, three were

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physicians (versus one in the UC group) and three had physicians in their immediate
family (versus one in the UC group). “A gain, like I .said you know, a lot of physicians in
the family so they are like friends or cousins whatever you want to call and everybody
had a nice input and we just have been blessed that there is different expertise in the
family all around"- (male, AC, BO-129). Seven participants in the AC group said they
would go to the physician if they required help; however, three said the physician would
be their second choice next to family. Five participants in the AC group were of the
opinion that they did not need any help because they had learned to manage the disease

by themselves.

With regard to the UC group, eight participants said that they would go to their physician
first so that the physician could check their medications and medical record, if the
physician was an Asian Indian. “Um, my doctor. I mean there is one Indian lady now, she
is pretty good... she gives me tips on what Indian food is bad and how much this and that
and that kind of stuff — (male, UC, BO -116). The response from two individuals who
mentioned that they would seek the physician’s help suggested that physician interaction
was routine medication prescription and/or adjustment as well as generalized non patient
centered advice such as to follow a healthy diet and /or exercise. It was not perceived as
being “supportive” per se. Friends and family were reported by two participants. Two
participants indicated that they did not need help from anybody because they believed
that their diabetes had not progressed to an advanced stage, which would then require

help from others.

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Research Qtlestion (vii): How does location of residence influence self-management

behaviors?

4.5.2.3 Location of Residence

The place where the participants resided was reported as calm, safe, and peaceful by all
the participants. Neighbors and friends were perceived as approachable and friendly with
the exception of one participant in the UC group. Two themes emerged for location of
residence: “accessibility to health care and exercise facilities and other influences” and

“influence of support network.”

Accessibility to health care and exercise facilities and other influences

Accessibility to health care and exercise facilities and weather were perceived to be both
helpfiil and hindering factors for diabetes management, respectively. Proximity to health
care and exercise facilities was mentioned by a few participants in both groups, as
facilitators of diabetes management. “Actually health care is very nearby so whenever I
want I can go... luckily I got a gym nearby so I can go by walk itself In my leasing office
itself we have a gym so now in this climate we cannot go out for walk” — (female, AC,

A 0).

Participants in the AC group were more likely to indicate Michigan weather as a major
limiting factor to regular exercise [AC (6) vs. UC (1)]. “No because you’re in Michigan
and you ’re tied down half the winter (laughing). Place of work may help but not place

where I live, I should say " — (female, AC, A0). In addition, a few participants in both the

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AC and UC groups, who owned a house, perceived that working in their backyard
provided physical activity, which helped their diabetes management. “We have a nice big
yard so it keeps me busy in taking care of the yard and uh...since there is a good area I

can walk in the area in summer " — (male. UC, A0).

Influence of support network

Participants reported that they often attended Asian Indian community gatherings in the
city and lived in a neighborhood where they had at least a few to many Asian Indians.
Institutions where participants worked, neighbors and friends in their locality and social
events appeared to be important influential factors. Four participants in the AC group
mentioned that they obtained diabetes awareness through the institution where they
worked, which helped them to manage their diabetes more than the location of residence
because they worked in medical or research field. “ Well I work in a medical field so most
of the time I get lots of help through the, my work place and my doctor and some family
doctors whom we know” —— (female, AC, BO — 12 7). A few participants in the AC group
said their friends who lived in the same neighborhood accompanied them while walking,
and one participant in each group reported that they would meet with their Indian friends

often and eat healthy foods.

A few participants in both groups expressed concerns about other Asian Indians in their
city/neighborhood. These included not taking care of their health unless there was a
serious problem, their ignorance about diet and medication for diabetes, a lack of open

communication about diabetes in this population, and a lack of healthy choices at Asian

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Indian celebrations/ festivals. “ they don 't even know I have it. That ’s one thing about
the Indian community nobody tells anybody anything about what they have...we don’t

talk much about it because most of us are kind of borderline ” — (male, UC, B0).

Research nyestion (viii): What do subiects perceive to be facilitators and barriers for

better managing their diabetes?

4.5.3 Facilitators and Barriers to Self-management practices

4.5.3.1 Facilitators

Facilitators to diabetes management were slightly different for the UC and AC groups.
Commonly expressed examples by participants in both the groups included carrying
breakfast bars, substituting Indian with western foods, practicing portion control, and
avoiding sweets or sweet foods. “I don ’t really like sugar. If my sugar goes down, I don’t
know what to do because I don ’t, I am not used to eating chocolate, candy and those
kinds of things. Plus there are these now uh breakfast bars and things which have quite
high percentage of protein and they are vegetarian and I carry them anywhere and that

has been of great help ” — (female, UC, BO).

In addition to the above, AC participants mentioned making changes as a family,
learning/comparing self-management practices from family members with diagnosed
diabetes, reading food labels, and purchasing healthy foods when shopping. “So for my
morning breakfast earlier I could eat Indian cookies...now I don ’t, because I know about

those things, what’s right and what’s wrong so I try to. The easiest thing I find is I know

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what food choices I can make. So certain things are very easy, 1 buy some cereals that
are good for me, very low in sugars, I read the labels. I eat oatmeal, I eat more fruits and

vegetables ”- (female, AC, A0)

4.5.3.2 Barriers

There were more barriers than facilitators to diabetes self-management perceived in this
sample of Asian Indians. Food and healthy eating was a primary factor of concern. The
majority of participants in both groups mentioned several barriers to eating healthy foods
[AC (8) vs. UC (10)]. Cooking special healthy meals for diabetes, avoiding food
temptations especially sweet foods and sweets, difficulties in making healthy food
choices/ practicing portion control when socializing were key barriers in both the AC and

UC groups.

A key cultural contributor to the challenges of eating as recommended was hospitality of
Asian Indian friends, during social visits. Additionally, participants in the UC group also
mentioned irregular mealtimes, busy lifestyles, availability of refined foods (e. g. refined
vs. whole wheat flour) at home, frustration when blood glucose remained unchanged
despite “healthy” food consumption, and difficulties in assessing carbohydrates in Indian
foods as limiting factors. “...sometimes you know we cannot eat our meal in time because
busy lifia, yes and you know we have to prepare food whatever time permits you know.

Like sometimes uh, we don’t have salad available every time in the house, you know. So

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but we always have some wheat flour, rice and everything in the house so it is easy to

prepare food like that you know like dal, and roti and so ” — (female, UC, AO — 117)

Physical activity barriers were more evident in the UC than the AC group [UC(7) vs.
AC(3]. Exercise inconsistency due to busy lifestyles and weather were mentioned by
participants in the AC versus lack of time, lack of motivation, bodily discomforts such as
fatigue and tiredness, and preference for sedentary hobbies by the UC group. “Exercising
is number one, I would say and then monitoring my blood sugar. I guess, exercising I am
just too busy or I don’t give it enough time and monitoring, 1 ’m just too lazy ” — (male,

AC, A0 —107)

Two participants in the UC group mentioned that medications were a problem because
they take multiple medications for diabetes as well as other conditions. In addition,
adjusting insulin doses when the carbohydrate content of Indian foods was not known
was also deemed challenging. “ if you take more carbohydrates then your supposed to
take more insulin, but problem that happens with Indian food is it is very difficult to
measure the carbohydrates, you know. All you are just guestimating most of the time like
the sugar should be like if you eat um paratas suppose you know, how many carbs does it
have? So, you make an error, I try to make an error on the high side...and that ’s
probably the reason why I’m having this difficulty in not going below 7(HbAIc), because

I must be not calculating properly ” — (male, UC, BO — 130)

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Three participants in the AC and one in the UC group mentioned barriers to self-
monitoring blood glucose. Pain, forgetfulness, and laziness followed by availability of a
glucometer, personal/business travel, and inconvenience of place of business were
predominant reasons for not self-monitoring blood glucose in both groups. “No, no,
normally I am out for the meeting, occasionally I forget. Meeting times, I don ’t carry
glucometer with me so unless I ’m at home I don ’t‘ do it ” — (male, UC, BO -128). Stable
blood sugar in the AC versus aversion to and frustration with the glucometer readings in
the UC group were perceived as additional reasons for not monitoring blood glucose.
“Um, its just stable so I’m not doing it, in fact I think it’s been a long time now because I
don ’t have the right uh, instrument, or the lancet was missing, there was a part missing

and I have to go and pick it up and of course I was busy” — (female, AC, A0)

Inadequate understanding of the laboratory tests performed, a busy schedule, and
insufficient communication with the physician were barriers to regular consultation with
a physician. One participant in the AC group did not like to go to the physician as often
because of the belief that unnecessary tests were recommended. On the other hand
participants in the UC group felt that they were not able to efficiently communicate with
their physicians due to limited time and help from the physicians. There was a more
generalized perceived lack of confidence in knowledge about Asian Indian foods by
American physicians as clearly expressed by one person from the UC group. “ ...they
(American doctor) didn ’t know what kind of food and all that we eat so that was one of

the problem and still is because our food has got enough calories ”- (male, UC, BO)

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One participant in the AC group and four in the UC mentioned other barriers to self-
management such as old age, a lack of motivation, reluctance to acknowledge seriousness
of the disease, and a false perception that lack of symptoms signified that all was well. “I
would say, the most diflicult part is I can ’t stay younger because I do believe the body
ages and all the organs, they age. So, my metabolism has changed now and so how to fix

that, that is the problem. How tofix, you know" — (male, AC, BO).

4.5.4 Revisiting the Objectives of the Study

The objectives of this study were to determine if and how acculturation is associated with
diabetes control, and to describe and contrast self-management behaviors and related
factors of Asian Indian adults with physician diagnosed diabetes and who were either in
acceptable glycemic control (AC) (HbA1c< 7%) or unacceptable glycemic control (UC)
(HbAlc: 7%). In our multiple linear regression analysis, the interaction between
acculturation and participants’ BMI, diabetes duration, and annual household income
were significant predictors of increased blood HbAlc levels, and hence glycemic control.
Participants in the AC group were more likely to follow a healthy diet for diabetes
management and indulge in regular physical activity for a longer duration. Through
exploratory qualitative questions, environmental (neighborhood, social and health care
support) and individual factors (lifestyle changes after immigration), which influenced
self-management behaviors and some of the barriers and facilitators specific to Asian

Indian immigrants were identified.

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CHAPTER 5

DISCUSSION
In this sample of Asian Indians with physician diagnosed type 2 diabetes, interactions of
annual household income, BMI, and diabetes duration with acculturation status were both
statistically significant and positive, which indicates that the relationship between
acculturation and glycemic control is determined by the specific values of these
predictors (annual household income, BMI, and diabetes duration). Other key findings
showed that participants in the UC group were more likely to experience difficulties in
performing the ADA recommended self-management behaviors. Data from qualitative
questions highlighted environmental and personal barriers, while social (family,
institution, and neighborhood) and health care support appeared to be facilitators to

recommended diabetes self-management behaviors.

5.1 Individual Factors

Personal factors (old age, busy lifestyles, lack of motivation to exercise, as well as pain
and laziness to self-monitor blood glucose), extent of acculturation, diabetes knowledge,
and perceived diabetes enhancement foods were the individual factors that emerged as

primary influences on diabetes self-management behaviors of participants.

Inability to resist food temptations and regulate portion sizes influenced dietary
compliance, especially among those in unacceptable glycemic control. Similarly, lack of

time and motivation and physical discomforts were predominant reasons for non-

I28

adherence to a regular exercise regimen. Laziness, inability to tolerate pain, and aversion
towards pricking fingers determined the frequency of self-monitoring blood glucose. In
addition, personal experiences of participants were determinants of compliance with
regard to self-monitoring of blood glucose e. g. participants assumed their blood glucose

to be at a certain level based on their food intake (both AC and UC groups) or had an

"we!

aversion to monitor blood glucose because of frustration and dissatisfaction due to high
blood glucose readings (UC group). Our findings are consistent with other qualitative
studies on individuals with diabetes, which have documented similar barriers to diabetes

self-management. These include helplessness and frustration due to a lack of glycemic

 

control despite perceived adherence to self-management behaviors (Nagelkerk et al.,
2006), lack of time or opportunities and physical discomforts which prevent
increased/regular physical activity (Lawton et al., 2006), occasionally succumbing to
food temptations (Gazmararian et al., 2009), and dislike towards pricking fingers and
frustration with negative results of self monitoring of blood/urine glucose (Lawton et al.,

2004)

In their systematic review of literature pertaining to healthy coping in diabetes
management, Fisher et al (2007) identified that diabetes and its treatment were linked to
various emotions such as stress, depression, anxiety, and motivational factors, which
appeared to influence metabolic control and diabetes self-management. In our study,
stress, depression, old age, and denial of the disease emerged as additional barriers to
self-management behaviors. Diabetes (medical and psychological aspects) may affect the
health-related quality of life, which in turn when impacted due to diabetes may have a

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negative impact on diabetes self-management, thus exhibiting a bidirectional effect

(Polonsky, 2002).

One of the important objectives of our study was to examine if and how acculturation
was related to glycemic control in Asian Indian adults with diabetes. The acculturation
level of participants with the use of the SL-ASIA instrument was not high, consistent
with the findings of Vatrapu (2006). who documented a mean acculturation value of 2.08
ranging from 1.80 — 2.47 (below the bicultural value of 3.0) on first generation (foreign-
bom immigrants) Asian Indians in the U.S. A larger proportion of males and
participants, who had resided in the U.S. for a longer period of time, were likely to be in
the B0 and UC groups, although these findings were not statistically significant,
probably due to the small sample size characteristic ofqualitative studies. This may be a
critical consideration pertaining to glycemic control of Asian Indians because Mooteri et
al (2004) documented male gender and a longer stay in the U.S. as predictors of coronary
artery disease among 527 first generation Asian Indians in the U.S. Given the strong link
between type 2 diabetes and cardiovascular disease, it would be important to investigate

diabetes control in this high risk subpopulation.

In our multiple linear regression analysis, interactions of diabetes duration, BMI, and
annual household income with acculturation status were both statistically significant and
positive. The relationship between acculturation and HbAlc is therefore dependent on
annual household income, BMI, and diabetes duration in this sample. The direction of the

association between acculturation and HbAlc is therefore determined by the specific

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values of the other three predictors. In other words, only when all of the other predictors
(annual household income, BMI and diabetes duration) have the value zero, greater

acculturation will lead to lower HbAlc values.

Interestingly, a study on first generation Arab immigrants from the Middle East who
moved to the state of Michigan, in the U.S. documented lack of acculturation to be a risk
factor for diabetes (J aber et al., 2003). In this study Arab immigrant men with diabetes
were less likely to be integrated to the U.S. compared to those without diabetes (J aber et
al., 2003). The San Antonio Heart study showed increased acculturation to be associated
with a decline in both obesity and diabetes in Mexican-Americans (Hazuda et al., 1988).
Similarly, Mainous et al (2006) showed low acculturation assessed by language (Spanish
vs. English speaking) to be significantly associated with increased likelihood of having
diagnosed diabetes and peripheral neuropathy. However, these studies assessed the
relationship between acculturation and the risk for diabetes, while our study focused on
glycemic control. There might be implications for glycemic control, which might be more

clearly depicted in a larger quantitative study.

Lack of modification of a traditional high carbohydrate and high fat diet to healthy
versions by Asian Indians could be cultural determinants of HbAlc levels (Raj et al.,
1999). This was suggested in the qualitative data where although majority of the
participants regardless of acculturation and glycemic control groups indicated that they
made a few dietary changes such as reducing rice consumption and including sugar free

foods in their diet, participants more typically in the B0 group alluded to the fact that

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they made healthy modifications to Asian Indian recipes, included dietary protein from
animal sources such as meat and eggs, and made use of the healthy non-Asian Indian

foods available in the U.S.

In our study, the relationship between acculturation and HbAlc levels was dependent on
the annual household income of the study participants. Diabetes prevalence has been
shown to be associated with low income status (Cuasay et al., 2001; Martinez et al.,
2007; Rabi et al., 2006). In general, lower income status may place individuals at a
disadvantage from health insurance and access to health care facility perspective
(Guimaraes et al., 2009; Kwan et al., 2008; Levine et al., 2009). Low-income status, as
specified in these studies conducted in the U.S., was categorized as income below
$35,000. Since our sample was relatively from a high income group for the most part
with only two people with an annual household income less than $50,000, all the
participants in our sample had health insurance coverage. Therefore the study sample

cannot be compared to low-income populations that are typically discussed in literature.

In our sample, about half of the participants had lived in the U.S. for over 30 years, had
diabetes for less than ten years, and were over 60 years of age. Therefore, the fact that the
interaction of diabetes duration with acculturation level was significantly associated with
HbAlc, could be due to individuals with a shorter duration of diabetes experiencing
greater challenges with diabetes self-management behaviors compared to those who have
a longer disease duration. Chang et a1 (2005) discussed that diabetes education could be

related to the discrepancy in coping. Therefore, diabetes duration when coupled with an

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increase in acculturation could potentially facilitate diabetes self-management and hence

improve HbAl c levels.

We observed an association between HbAlc and the interaction of acculturation with
BMI. Studies have shown that Asian Indians have a high percentage of body fat despite
their low BMI increasing their risk for diabetes (Banerji et al., 1999; Raji et al., 2001;
Ramachandran et al., 2004). One assumption is that dietary regimen compliance for
diabetes may be low among individuals with a lower BMI, especially those with low
acculturation. Therefore, lack of healthy modifications of the Asian Indian diet by A0
participants compared to those who were BO in our study could be a possible explanation
for this association. Furthermore, in our qualitative data, Asian Indians who were A0 and
in the UC group, were less likely to be physically active after immigration when
compared to the AO group. Both diet and physical activity are important considerations

relative to a healthy weight or acceptable BMI.

Our qualitative analysis showed that there were specific differences in dietary changes
after immigration perceived by the A0 and BO participants. BO participants were more
likely to report increased meat consumption after immigration that was not mentioned by
the AO group. Consistent with the qualitative data, in our dietary analysis, the percentage
of total calories from protein was significantly higher in the BO group than the AO
group. One reason Naeem (2003) pointed out for increased meat consumption by Asian
Indians in the UK. was the low cost of meat compared to many vegetables. Increased

meat consumption could be due to an inclination to western foods by first generation

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Asian Indian immigrants, who were more vegetarian oriented in India, but have moved
towards bicultural characteristics in a western society. In addition, foods that participants
believed to be helpful with diabetes management differed between the AC and UC
groups. Non-vegetarian foods such as chicken, fish, and eggs were perceived to be
helpful for diabetes management by participants in the B0 and UC groups, who also
increased their meat intake after immigration. Asian Indians continue to consume E1
traditional foods but consumption of carbonated drinks, alcoholic beverages, ice cream, 1
cheese, margarine, and salty snacks has also increased among the Asian Indian

community in the U.S. (Nguyen, 2006). Duration of stay in the U.S. could have

 

influenced these participants’ beliefs about healthy foods because there were more

participants in the BO and UC groups with a longer duration of stay in the U.S.

The majority of our study participants were aware of diabetes and related complications
and self-management behaviors, which could partly be due to a strong family history of
the disease in most subjects. In a qualitative study by Kalra et al (2004) on Asian Indians
with cardiovascular disease in northern California, a family history of the disease
contributed to the knowledge level of the participants about the cardiovascular disease
risk factors and the disease (Kalra et al., 2004). In a study that used the Michigan
Diabetes Knowledge Test on Kuwaiti adults with type 2 diabetes, a low educational level
of participants and limited household income were associated with low knowledge about
the disease (Al-Adsani et al., 2009). Our study included participants with a high income

and educational level, which might have facilitated diabetes knowledge acquisition

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through adequate comprehension of the diabetes education materials and affordability of

diabetes resources and education classes.

Unlike other studies conducted in the UK. on Asian Indians and South Asians,

knowledge about the consequences and benefits of diabetes management appeared to be
adequate in the AC and UC groups as the participants were all aware of either the short 1
and/or long term complications of uncontrolled diabetes and the potential benefits of l
keeping the disease under control (Baradaran et al., 2004; Macaden, 2007; Naeem, 2003). 7

However, there were differences in how the AC and UC groups understood the intricate

 

details relative to self-management when participants were probed further. Participants in
the AC group had an in-depth understanding about the etiology and pathophysiology of
the disease and recognition of the importance of key self-management behaviors such as
eating healthy, exercising regularly and medication adherence. On the other hand,
responses of participants in the UC group were superficial and lacked sufficient detail.
Therefore, qualitative detailed responses provided identification on how there may be

discrepancies in the level of understanding, when “knowledge” appears to be evident.

According to the California food guide report (Nguyen, 2006), there is an increase in
meat consumption after immigration across all Asian sub-groups, including the Asian
Indian group due to the increase in affordability of meat in the U.S. versus fresh fruits
and vegetables in their home country. The report documented a decline in the
consumption of traditional plant based foods by Asian Indians (Nguyen, 2006).
Consistent with this finding, a report by Kulkarni (2004) documented a decline in fiber

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content of foods and increased meat and convenience food consumption by Asian Indians
after immigration to the U.S. The fiber intake was not different between the groups in our
study, but the majority of participants (n=25) consumed less than the recommended <25

grams of fiber.

It was expected that religious beliefs would be influential in participant’s dietary
behaviors. Studies conducted on South Asians have shown religious beliefs such as
fasting during religious occasions to influence diabetes self-management practices
(Macaden, 2007; Naeem, 2003). Despite participants’ religious beliefs, adaptation to the
U.S. lifestyle was found to be more influential in the food choices of participants. Several
participants (regardless of acculturation and glycemic control groups) who came from a
family that practiced vegetarianism or limited certain types of meat as advocated by their
religion, reported that they changed these practices after immigration, specifically beef or
pork by Hindus and Muslims, respectively due to the new environment. This might be
due to the easy availability of meat products at an affordable price (Nguyen, 2006) and/or
an increased exposure to foods containing meat during Indian socializing events (evident
in our findings). In general, the majority of participants of this study either gradually
decreased their religious beliefs after immigration or placed more emphasis on health

than religion. This could be attributed to the high educational level of participants.

An Asian Indian specific practice of interest was the use of complementary/ alternative
medicine for diabetes. In India, the use of non-formal medical treatment for disease is

common such as naturopathy, ayurveda, homeopathy, and acupressure (Kumar et al.,

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2006). This could be exacerbated by the fact that there is also evidence about the toxic
contents in some traditional Asian medicines (Ernst, 2002). A case report of Arsenic
poisoning was reported by Ernst (2002) in a five year old Italian boy who experienced
symptoms of toxicity due to the consumption of a traditional Asian Indian unknown pills
and powders prescribed by an Asian Indian healer to cure congenital bilateral
retinoblastoma. It was reported that the boy was recovered completely from Arsenic

poisoning after the discontinuation of traditional Indian remedies (Ernst, 2002).

The majority of the participants reported that they had faith in natural/alternative
medicine and showed an interest in trying certain products because they were considered
natural ways of treating the disease. A national study on complementary and alternative
medication use among Asian Indians reported that 63% of Asian Indians in the U.S. had
used at least one type of complementary or alternate medication such as ayurvedic and/ or
homeopathic medications, as well as biologically based herbal and dietary supplements
(Misra et al., 2010). Unavailability of alternate medications in the U.S. was raised as a
concern in our study, and therefore potentially limited the use of these products by our

study participants.

Many of our study participants also questioned the composition of these medicines in
general. Even though they tried them if available, they did not want to entirely rely on
them. Non-prescription medications could interact with medications prescribed by the
physician and may result in potential toxic effects (Pontifex et al., 1985). It would be

important that the health care professional was informed of such practices. The majority

137

 

of our study participants did not mention that they discussed the use of any alternate
medications taken for diabetes or other medical conditions with their physicians.
Eisenberg et al (1998) did a follow up of a national survey to study the trends in alternate
therapy use in the U.S. and the extent to which physicians were informed. This study
showed that in the overall sample, many patients who consulted with a physician for a
medical condition also tried alternate therapies, but did not share this information with
their physicians. Health care professionals should hence inquire about alternate

medications especially in Asian Indian patients with diabetes.

5.2 Environmental Factors

One of the primary self-management behaviors that was impacted by environmental
factors as reported by subjects regardless of acculturation or glycemic control group, was
exercise. The cold climate in Michigan was touted as a deterrent to regular exercise.
These findings are consistent with the findings of Lawton et a1 (2006), who studied the
barriers to physical activity perceived by Asian Indian and Pakistani people with diabetes
in the UK. In their study, lack of time and opportunities to engage in physical activities,
lack of social support for outdoor activities, obligations to family, and physical

discomforts were perceived as barriers to physical activity (Lawton et al., 2006).

Presence of social support such as encouragement from friends/ relatives and
accompaniment by a friend or relatives to exercise has been shown to be associated with
the likelihood of increased physical activity in a cross-sectional study among U.S. adults

(Brownson et al., 2001). In our sample, support from friends, family, and health care

138

professionals favored physical activity and other self-management behaviors.
Accompaniment by friends during physical activity, and attainment of information about
diabetes and important self-management behaviors from physicians in the family was
evident in the AC group. Participants in the AC group specifically reported increased
physical activity when social support was provided from their friends while exercising.
This is consistent with the findings of a national study of minority women conducted by
Eyler et al (1999), which documented low social support among women with sedentary

behaviors.

While social support emerged as a major facilitator for acquiring knowledge about
diabetes self-management behaviors and physical activity, influence of Asian Indian
community gatherings and hospitality of Asian Indian friends were perceived as barriers
especially to healthy dietary adherence. Naeem (2003) in a qualitative study conducted
on men from Kashmir, India, found that frequent visits to the homes of friends was as an
obstacle to a low fat or low sugar diet. In our study, a few participants in both the AC and
UC groups perceived that Asian Indians in general were insufficiently aware of the health
consequences of excessive dietary carbohydrate and fat consumption. Hence, social
expectations and pressure to eat such foods was perceived as sometimes being

challenging.

Asian Indian foods are typically rich in carbohydrates and fats (Macaden, 2007). Similar
to Kulkarni’s (2004) modification of Asian Indian diet for diabetes, participants in the

AC group made healthy modifications in their Asian Indian diets by reducing fats, added

139

sugar, and carbohydrates. This pattern was also evident among participants in a study on
Asian Indians with cardiovascular disease in northern California (Kalra et al., 2004). A
few participants in the UC group were curious to learn, but were unaware of resources
that provided education about healthy adaptations of Asian Indian foods. Hence, it
appears that a lack of educational resources in this respect was more of a problem

potentially than willingness to learn per se.

Varghese et a1 (2002) studied dietary acculturation of 132 Asian Indian immigrants in
Newfoundland, and demonstrated the willingness of Asian Indians to learn about nutrient
relevant information of foods. Providing information about the nutrient content of foods
especially culture specific foods is therefore critical for this population. In addition a
critical need by patients, who were treated with insulin for diabetes management, is the
ability to adjust insulin dose based on carbohydrate content, typically high in Asian
Indian foods, as stated previously. A few participants in the UC group, who were on
insulin treatment, expressed concern about their ability to assess nutrient content of Asian
Indian foods, which warrants an important consideration for health professionals working

with this target group.

Despite the increased knowledge about diabetes and related complications, Asian Indians
in both the AC and UC groups required and expected guidance from physicians either
within their families or from their health care facilities. Although regular consultation
with a physician was perceived as the most difficult self-management behavior by a few

AC participants in our survey assessment, this perception did not affect the regular

140

 

quarterly consultations with the physician. The reduced need for physician consultation
was evident in the AC group due to the availability of information and advice from
physicians among their friends and family members. A few participants in the AC group,
who were employed in the medical/nutrition field, also perceived that the physician did

not have adequate diabetes knowledge.

A key factor relative to health professional oversight might be the food portion control. !

Naeem (2003) in his study on Asian Indians in the UK. found that health professionals

 

had failed to convince clients that dietary modifications and portion control were L
essential for disease management. In order to better understand the problem of inadequate

healthy dietary adherence, Sohal (2008) suggested that health professionals should

increase the awareness about diabetes and related complications among South Asians

since they exhibited poor compliance with lifestyle changes such as diet, weight control

and physical activity. Sohal (2008) also advocated culture and language specific

community-based multidisciplinary approaches because of the serious diabetes-related

and cardiovascular disease risk implications in this population.

5.3 Implications for Future Research

This study explored acculturation relative to glycemic control and the factors influencing
diabetes management among Asian Indians in the U.S. The findings demonstrated that
lifestyle changes such as dietary and physical activity behaviors are important factors to
consider in this target group. Therefore, lifestyle interventions should include nutrition

education of culture specific foods. More specifically, resources for Asian Indian patients

141

are needed such as information about nutrient content of Asian Indian foods specifically
carbohydrate content of Asian Indian foods to facilitate insulin dosage adjustment for

patients on insulin treatment (Davachi et al., 2005).

Findings of this study also heightened the need for health professional awareness of the
importance of social support when interacting with Asian Indian patients with diabetes.
F riends/neighbors, health professionals, and family members of participants appeared to
be trusted sources of help when needed as well as potential barriers to self-management
behaviors. Health care professionals should spend adequate time soliciting social support

information, guiding the patients as well as involve the family.

The high prevalence of diabetes in urban India (Mohan et al., 2008; Ramachandran et al.,
1992; Singh et al., 1998) makes one wonder if translocation from rural to urban regions
in India, could have similar effects as immigration to another country. A study by
Ramachandran et a1 (1999) had documented the association between increasing diabetes
prevalence and sedentary lifestyle among Asian Indians residing in a peri-urban region
(city outskirt with easy access to urban facilities) in Chennai, India. Residents’ dietary
habits were similar to that of urban compared to the rural population. Future studies
should explore how acculturation in other countries compares with urbanization, in order
to refine and tailor existing interventions for the improvement of glycemic control for

immigrants as well as urban migrants in India.

142

Asian Indians in our study tended to perceive that American physicians were not aware of
ethnic-specific foods. Increased awareness and open communication of the patient-health
care provider about cultural barriers to adherence to self-management is critical for
achievement of glycemic control. There is a need for healthcare professionals to address
culture-specific community-based multidisciplinary approaches to the optimal
management of diabetes in this population (Sohal, 2008). A previous study on Pakistani
women in Melbourne, Australia documented successful treatment of metabolic syndrome
via culturally relevant interventions (Kousar et al., 2008). Therefore, culturally relevant
strategies are essential for efficacy of intervention for the immigrant population (Kreps et

al., 2008; Nguyen et al., 2006).

5.4 Strengths and Limitations

This was the first study to explore via a mixed quantitative-qualitative approach, the
relation of acculturation and self-management of type 2 diabetes in Asian Indians in the
United States. Dietary intake and acculturation level of participants were assessed using
validated instruments, which added strength to the methodology. Both qualitative and
quantitative methods were used to assess self-management behaviors and acculturation
level of participants. Data obtained by the two approaches were triangulated, which
facilitated validation of assessment methods and checking for consistency. Qualitative
data was coded independently by two researchers and coding consensus was obtained to
minimize bias. Since the primary researcher belonged to the same ethnicity, participants
were comfortable and more willing to disclose dietary and survey information, which

facilitated rapport with the participants as recommended by Vatrapu (2006).

143

 

In keeping with qualitative methodology, interviews were conducted until data saturation.
Although findings from a qualitative approach provided rich information, careful
interpretation of quantitative analysis should be performed due to the limited sample size.
Therefore, the inferential analysis of quantitative data may not be as conclusive due to
insufficient power. This sample was relatively homogenous consisting of Asian Indians
with a high education status and household income. Therefore the findings of this study
may differ for a more heterogeneous sample. Since this was a convenience sample
confined to Michigan, findings of this study (e. g. climatic barrier to exercise) cannot be

generalized to all Asian Indians in the U.S. or other countries.

5.5 Recruitment Challenges

Recruitment of participants was a challenge although the study was advertised through
various Indian organizations. Participants were therefore also recruited through a
snowballing method i.e. through participant referrals of other potential participants.
Initially, the study was intended to be conducted in Lansing, Michigan. However, due to
a minimal response from interested participants in Lansing, participants who met
eligibility requirements were also recruited from other cities such as Detroit, Ann Arbor,

and Novi.

5.6 Summary and Conclusions

This study provided a snapshot of the relationship between acculturation and glycemic
control and the factors influencing diabetes self-management behaviors of Asian Indians
in the U.S. Although the socio—demographic characteristics of the participants in the AC

144

and UC groups did not differ, more rigid adherence to self-management behaviors,
especially lifestyle/behavior changes (e. g. performing frequent exercises for a longer
duration, following a special diet for diabetes, and consulting the physician on a regular
basis) was reported by participants in the AC group. The majority of participants in the
AC group perceived performance of self-management behaviors to be easy, while
perceived challenges (e. g. inability to control dietary portion sizes, lack of motivation to
exercise, pain and aversion to self-monitor blood glucose) in performing the self-

management behaviors on a regular basis was higher among participants in the UC group.

Participants in both the AC and UC groups were aware of diabetes and related
complications; however, the knowledge level of AC participants about the disease
mechanism was superior to that of UC participants. Besides these differences, a few
participants in both the groups perceived dietary and exercise management as safe and
were reluctant to manage diabetes with insulin or oral diabetes medications due to an
aversion to insulin therapy (psychological insulin resistance) and potential side effects of

oral diabetes medications.

Although participants in both the groups questioned the efficacy of complementary/
alternative medications, they exhibited a tendency to believe in and willingness to try
them for diabetes or other medical conditions. Support received from family members,
health care professionals within friends/ family, neighbors and friends, and the influence
of institutions where participants worked appeared to be important influencing factors

that facilitated awareness about the disease and self-management behaviors. In addition,

145

UC participants were more likely to expect physician time and attention while the AC
participants expected increased knowledge and refinement of treatment from the

physicians.

Culture specific barriers to dietary adherence were specified by the study participants
such as challenges in counting carbohydrate content of Asian Indian foods, difficulty in
adjusting medications based on Asian Indian foods, and inability to communicate with
the American physician about Asian Indian foods. Furthermore, a lack of healthy food
choices at Asian Indian celebrations/ festivals, ignorance of Asian Indians about healthy
foods and health, hospitality of Asian Indian friends during social visits, and a lack of
open communication about diabetes among Asian Indians were additional concerns
pertaining to other Asian Indians. Adherence to healthy eating during the weekends and

when socializing was also perceived as a challenge by our study participants.

An interaction between acculturation and individual factors (diabetes duration, BMI, and
income) was observed, which significantly influenced glycemic control. Our study
findings indicate that participants’ annual household income, diabetes duration, and BMI
determined the direction of association between acculturation and HbAlc levels among
Asian Indians in the U.S. Increased health awareness and decreased physical activity after
immigration to the U.S. by a few participants in the AC and UC groups, respectively,

were evident in the findings from the qualitative data.

146

Participants in both the groups perceived that improved exercise and health care facilities,
quality of healthy food choices, availability of self-monitoring devices, and medical
insurance were favorable for diabetes management in the U.S. These findings suggest
that the host environment coupled with increased health awareness and social support
might have facilitated health promoting behaviors of participants. Therefore, diabetes
interventions that target this group should address social support, culture specific lifestyle
barriers, and provide awareness about the importance of strictly adhering to self-

management behaviors.

147

APPENDICES

148

Appendix A: Michigan State University Institutional Review Board Approval

MICHIGAN STATE Revision
U N I V E R S I T Y Application

Approval

October 17, 2008

To: Lorraine WEATHERSPOON
334 Trout FSHN Bldg
MSU

Re: iRBl 08-593 Category EXPEDITED 5. 6. 7
Revision Approval Date: October 14. 2008
Project Expiration Date: July 18. 2009

Title: Acculturation and Associated Factors in Relation to Glycemic Control and Self-management of
Diabetes in Asian Indian Adults in the United States

The Institutional Review Board has completed their review of your project. I am pleased to advise you that the
revision has been approved.

This letter notes approval for the revised preliminary questionnaire 81 interview guide.

The review by the committee has found that your revision is consistent with the continued protection of the rights
and welfare of human subjects, and meets the requirements of MSU's Federal Wide Assurance and the Federal
Guidelines (45 CFR 46 and 21 CFR Part 50). The protection of human subjects in research is a partnership

between the IRB and the investigators. We look forward to working with you as we both fulfill our responsibilities.

Renewals: lRB approval is valid until the expiration date listed above. If you are continuing your project, you
mustsubmit anApplicationiorRenewelappIication atleastonemonth beforeexpiration. Iftheprojectis
oornpieted. please submit an Application for Permanent Closure.

Revisions: The IRB mustreviewanychanges intheproiect, priorto initiation ofthe change. Please submit an
Application for Revision to have your changes reviewed. if changes are made at the time of renewal, please
include an Application for Revision with the renewal application.

Probbms: If Issues should arise during the conduct of the research, such as unanticipamd problems, adverse
events. or any problem that may increase the risk to the human subjects, notify the IRB ofiice promptly. Forms
are available to report these issues.

Please use the IRB number fisted above on any forms submitted which relate to this project, or on any
correspondence with the IRB office. '

Good luck in your research. Ifwe can be offurther assistance, please contact us at 517-355-2180 or via email
at lRmmsgedu. Thank you for your cooperation.

Sincerely,

W52!-

Ashir Kurnar. MD.
BIRB Chair

149

Appendix B: Recruitment Flyer

 

O
....OO00........«COOOOOOOOOOOOOOOO

Are you a person of Indian origin?
Do you have sugar diabetes?

Do you know that diabetes affects as many
as 1 in 5 Indians in the US?

 

......OOOCOO.

  
 

Would you like to help us understand
how you manage your diabetes?

We invite you to participate in a research study to help
us better understand how Indians in the US manage
their diabetes. As a thank you for your participation,

you will receive a $25 gift card to Meijers.

If you are interested in participating in this important
project, please contact Sumathi Venkatesh at:

Phone: (517) 355-8474 ext. 164 M [CH I CAN STATE
Email: venkate6@msu.edu W

......OOOOOOOOOO...

    

150

Appendix C: Letters of Support
ICS India Cultural Society

To The 111s11111111'1n.11 1111111111 111.1111 .11 \111‘1115;.111 81.1111 1I11i1'111s111‘:

This 1111111115 1111111'1111111'1111 111.11 11111 lndin C ulIu 1.11 811111111 (105) gives p111111ission 111 Lorraine
l-i’11.11l1111spo1111 PhD, RD, and 51111111111 Venkatesh from \111‘11111,.11181.1111 [111111151113 7133611
T111111 F81 1X Building. E151 Lansing, .\Il 18823 111.

l. 61101111111111.1111111 regarding 1111111111.1111111.1s 1111111111111 11151111111 in 11111 1C5 11111151111111. 1C5
11111111511111111.1111 this 111111. 1111111111111s 11.1 11111111 511111.11 .1111' 1111111111111 1179 1110111111118 1.111
1'11111.11‘1511n1.11l1i 1111111111:

P1131 111-11151 .11 161111111111 (upon coordination 111111 the ICS 811.1111).

Attend 91111111111011 ICS events to display 1111.111 11191111111 11111111 11111111 ".1\171‘1111u1.111on 111111
.1ss‘111 i.111-d 1.1111115 in 11111111111 11161111111111?1111111111 111111 5111-111.111.1g11n111111 1.11'T1'1111 2
1111111115 in 1151.111 111111.111 adults in 11111 1511111111 81.11115".

T1111 ICS Board 11.151111 111111.111 11111i1111s11111111 911111111111 111111 11111 1111 u11.111111 to do so until 11111111111
B1 1.1111 111111111113. 1111111111111, 11111 11.7.9 11.1.1111 1'1111si1l111s 1111s 1111111111‘111111111111111'1‘.111s11.11111 151-11111118
to help them 1151.1 [CS 111111111115 1111‘111111u11 11111111111u1.111on.11 11151111111. 111111.11011111U11s11‘1d 11111111
to 11.11.1111 1111111 5111111111); 1111 11111115 111111u11,11 11111 ICS media. l’l11.1s111‘11111.11'1 Ann [11.191111111111- .11
517311191113 or 11111 .11 5173971511113, should you 11.11'1111111' iurthcrqucslioiis1111.111 11111111111 us 111111

.JJ !-.J

.1111 more i1111'11m.1ti1111.

Thanking 131111.
511111111111;

\\ Int ..1'1
4 '1/1' .H'.

4 ”/

\-'.1isl1.1li Rajput

President, KB

151

 

Appendix C: Letters of Support (cont)
Bharatiya Temple of Lansing, Inc.

To:

Michigan State University
Institutional Review Board
202 Olds Hall

East Lansing, Ml 48824

May 25,2008

Dear Institutional Review Board at Michigan State University:

This letter is to inform you that, on behalf of the Board of Trustees of Bharatiya
Temple of Lansing, I give permission to Lorraine Weatherspoon Ph.D., RD,
and Ms. Sumathi Venkatesh from Michigan State University, 332 GM Trout
FSHN Building, East Lansing, Ml 48824 to:

U Post flyers at retigious/ meeting places designated for the community
information

0 Attend scheduled major events at our Temple for awareness and
volunteer recruitment

for the research study titted “Acculturation and associated factors in relation to
Glycemic control and self-management of Type 2 diabetes in Asian Indian
adults in the United States.” 1 have read the research proposal and agree to
have Sumathi Venkatesh contact members of our organization by above means
ONLY for her research purpose. You can contact me directly at the Temple
address given above or call me at 517-862-9683 if you have any questions.

Sincerely,

(Rajiv R. Das)
Chair,
On behalf of Board of Trustees

152

Appendix C: Letters of Support (cont.)
Lansing Tamil Sangam

Michigan State 1.71111 ersit}
lnslitutional Re1'1e11 Board
3112 (1111s llall

Fast Lansing. Ml 48824

Sudarsan V'aithu 111:11111111 e111 Susecla

L.

Lansing Tamil Sangam

111.111 211. 211113

 

Dear institutional Rc11c11 Board at Michigan State L'niversity:

This letter is to infonn you that Lansing Tamil Sangam gives pemiission to Lorraine
Weatherspoon 1’h.l).. RD. and Sumathi Venkatesh from Michigan State. University, 332
(11111111111 1’81 1N Building. l€ast Lansing. Ml 48823 to:

(i) send information and electronic flyers to Lansing Tamil Sangam

board 111cn1hers 111 forward to their members

(11) post tlyers at religious" meeting places

(iii) attend scheduled major e1'er1ts 1111 personal recruitment
for the research study titled “.1'\ccu1turation and associated t‘actors 111 relation 111(111ce1111c
control and self—111ar1agen1entot‘Type 2 diabetes 111 Asian 1111111111 adults 111 the ltnited
States". I have read the research pr1‘1posal and agree to have Sumathi Venkatesh contact
members of our organization 111111 respond to our emails for her research purpose. You
can contact me directl 1' at the above address or call me at 51741113368751 7256-5945 11‘
you have any questions.

Sincerely. ...
/ <1 / .
1 ' Til/1,1. "'11,..1’L/Ut,
'l’hangavelu Susecla
Board MCllllk'l'
Lansing Tamil Sangam

/' "l

153

 

Appendix C: Letters of Support (cont.)
Michigan Asian Indian Family Services

Michigan State I'niycrsity
Institutional Rc1ie11 Board
:11: (1111s IIaII

I‘Zast Lansing. 311148824

Michigan Asian Indian Iamily SerViccs
Suburban Shared (‘entcr

324111 \1’.1€ig111.\lilel{d

Liyonia. MI 18152

September 13. 311113

Dear Institutional Re1‘1c11 Board at Michigan State 1.1111 crsity:

This letter is to 1111111111 you that I gitc permission to Lorraine \1'eathcrspoon 1’11.1)., RIL
and Sumathi Venkatesh from Michigan State 1.'1111'c1'sity'. 332 UM 'I rout 1581 l.\' Building.
Iiast I ansing. MI «18333 to:

(i) use our email listscrt

(ii) post llycrs at religious." 111ceting places

(iii) attend scheduled major et'cnts tor perstmal recruitment
lor the research study titled "Acculturation and associated factors in relation to (ilyccmie
control and selli-management of diabetes in Asian Indian adults in the 17111ch States". I
haye read the research proposal and agree to hate Sumathi Venkatesh contact 111cmltcrs
of our organizatit‘tn 1111' her research purpose. You can contact me directly at 348-477-
4‘185 11‘ you hate any questions.

Sincerely.

?R~pflr IA 1:—

Brii Mohta ((.‘11ai1'pc1‘sor1. MAI I’amily Scrt iccsl

154

 

Appendix C: Letters of Support (cont.)
Coalition of Indian Undergraduate Students

Michigan State University
Institutional Review Board
202 Olds Hall

East Lansing, MI 48824

1426 North llidden Creek Dr.
Saline, MI 48176

May 26. 2008

Dear Institutional Review Board at Michigan State University:

This letter is to inform you that I give permission to Lorraine W eatherspoon Ph.D., RD,
and Sumathi Venkatesh from Michigan State Uni tersity, 332 GM Trout FSHN Building,
East Lansing. MI 48823 to:

(i) use our email Iistserv

(ii) post flyers at religious/ meeting places

(iii) attend scheduled major events for personal recruitment
for the research study titled “Acculturation and associated factors in relation to Glycemic
control and self-management of Type 2 diabetes in Asian Indian adults in the United
States”. I have read the research proposal and agree to have Sumathi Venkatesh contact
members of our organization for her research purpose. You can contact me directly at
”1426 North Ilidden Creek Dr. SalineLNI 48 l 76_____ or call me at 734-657-
5190 if you have any questions.

Sincerely,

1111a lama.

Radhika Menawat -—- President of the Coalition of Indian Undergraduate Students

155

 

Appendix C: Letters of Support (cont.)
Michigan State University India Club

Michigan State University
Institutional Review Board
202 Olds Ilall

East Lansing. 1.1148824

MSL’ India Club (MSIIICI

June 10. 2008

Dear Institutional Re1'ie11' Board at Michigan State University:

This letter is to inform you that MSL'IC gives permission to Lorraine \\"eatherspoon
PhD, RD, and Smnathi Venkatesh from Michigan State l’niycrsity. 332 GM Trout
I‘SIIN Building. East Lansing, MI 48823 to:

(i) use our email Iistserv

(ii) post llyers at religious/ meeting places

(iii) attend scheduled major events for personal recruitment
for the research study titled “Acculturation and itSs‘tX‘lttIt‘tl factors in relation to (ilyccmic
control and self-management of Type 2 diabetes in Asian Indian adults in the L'nited
States". I haye read the research proposal and agree to have. Sttmathi Venkatesh contact
members of our organization for her research purpose. through the aboye 111cntioned
channels. You can contact me directly at rautmlchtrt'msuedu or call me at 517-230-3451)
if you have any questions.

1

Sincerely.

11W
flu!" I“

Nikhil Raut

President MSU India Club

156

 

Appendix C: Letters of Support (cont.)
Oriental mart, East Lansing, Michigan

Michigan State Ifnitcrsity'
Institutional Re1 ieu‘ Board
202 ()Ids llall

liast Lansing. 11148824

Oriental Mart

2801) E (irand Rirer Me
East Lansing. MI 48823

September 23. 21.11.18

Dear Institutional Review Board at Michigan State IFniyersity:

This letter is to inform you that I gite permission to Lorraine \1'eathcrspoon 1’11.I).. RD.
and Sumathi Venkatesh from Michigan State L'nit'crsity. 332 GM Trout 1’81 11\' Building.
East Lansing. MI 48823 to post their recruitment llyers in ()riental Mart for their research
study titled "Acculturation and associated factors in relation to Glycemic control and self-
managcmcnt ofdiabetes in Asian Indian adults in the l’nited States". You can contact me
directly at 28110 Ii Grand Ri1er Aye. liast Lansing. MI 48823 or call me at (517133 -
251‘) if you hate any questions.

/- t. / .

Proprietor Oriental Matt

Sincerely.

      

157

 

 

Appendix C: Letters of Support (cont.)
Swagath Foods, East Lansing, Michigan

Michigan State liniycrsity
Institutional Re1'ic11' Board
202 Olds Hall

East Lansing. MI 48824

Swagath foods
1(160 Troubridge Rd. Suite 1
East Lansing MI - 48823

September 23. 20118

Dear Institutional Rc1‘ie11' Board at h’lichiean State l'nitcrsity:
t‘ .

This letter is to inform you that I give permission to Lorraine \1’eatl1erspoon I’h.D., RD.
and Sumathi Venkatesh from Michigan State Liniycrsity. 332 GM Trout 181 1‘11 Building.
Fast Lansing. MI 48823 to post their recruitment llyers in Swagath I‘oods for their
research study titled "Acculturation and associated factors in relation to (ilyecmic control
and self-management ofdiabetes in Asian Indian adults in the United States". You can
contact me directly at 10110 Trowbridge Rd. Suite 1. East Lansing MI - 48823 or call me
at (517)333-6536 if you haye any questions.

Sincerely.

 
   

) rictor . 11agath Foods

158

Appendix C: Letters of Support (cont.)
Sindhu Indian Cuisine, E. Lansing, Michigan

Michigan State I'ttiycrsity
Institutional Reyiew Board
20201115111111

liast Lansing. MI 48824

Sindhu Indian ('uisinc
47911 S llagadorn Rd 3 132
East Lansing. MI 9110‘)

September 22. 211118

Dear Institutional Re1ie11 Board at Michigan State I'mt‘crsity:

This letter is to inform you that I giye permission to Lorraine \1'eatherspoon PhD. RD.
and Sumathi Venkatesh from Michigan State I'nit'ersity. 332 GM Trout I’SI IN Building.
lfast Lansing. MI 48823 to post their recruitment llyers in Sindhu Indian ('uisine for their
research study titled "Acculturation and associated factors in relation to ( ilyccmic control
and selllmanagemcnt ofdiabetes in Asian Indian adults in the I’nitcd States". You cart
contact me directly at 471.11) South llagadorn Rd :1: 132 or call me at (517) 351-31181) if you
hate any questions.

Sincerely.

(‘1

V

I
.

/'\ « ‘ -
. "i - ,i ,- ( -': - 7 . ,

Proprietor Sindlm Indian (‘uisinc

159

Appendix C: Letters of Support (cont.)
Asia Bazaar Indian Groceries

Michigan State I’niy‘crsity
Institutional Reyien Board
202 ()lds llall

liast Lansing. MI 48824

Asia Bazaar
1754 (1 ‘n'tral Park Dr
()Ixemos. Ml 488114

September 22. 2008

Dear Institutional Rey'ieyy Board at Michigan State I’niycrsity':

This letter is to inform you that I giye permission to I on'aine Weatherspoon Plr.l').. RD.
and Sumathi \Fenkatcsl1 from Michigan State I‘niycrsity. 332 (181 Trout 1581 l.\' Building.
liast Lansing. MI 48823 to post their recruitment lly'er's in Asia Bazaar Indian groceries
for their research study titled "Acculturation and associated factors in relation to
Glycemic control and self-management ofdiabetes in Asian Indian adults in the United
States". You can contact me directly at 1754 (‘entral Parlt I)1'(.)ke11111s. MI 48864 or call
me at (517) 347-3505 ifyou hay-e any questions.

Sincerely,

I“ 1111'

Proprietor Asia Ba/aar Indian (iroeerics

160

Appendix D: Interview Guide
Participant ID Recruitment site Date of Interview

 

 

SOCIO-DEMOGRAPHIC INFORMATION
1) Date of birth (mm/dd/yyyy)

 

2) Gender

0 Male

Cl Female
3) Religion

Cl Hindu
Christian
Muslim

Other (specify)

UUU

 

4) Educational level
CI Less than high school
Cl High School
D Bachelors
D Masters
Cl Ph. D or MD

5) In what country did you get each of the following levels of education?
Cl Less than high school
CI High School
D Bachelors

 

 

 

0 Masters
CI Ph. D or MD

 

 

6) Employment status
D Employed (full time)
Employed (part time)
Homemaker
Unemployed
Disabled/Unable to work
Retired
Student
Other (specify)

DUUUUUU

 

161

 

7) If you are employed, please specify:

D
D
C]

Type of job

 

No. of hours you work / day

 

Describe the activity level of your job L] Heavy

8) Marital status

D

D
D
13

Single

Married

Widowed
Separated/ Divorced

9) Approximate annual household income

C]

00000

<$20,000
20,000 to 50,000
51,000 to 75,000
76,000 to 100,000
>$lO0,000
Other (specify)

 

10) With whom do you live?

Cl

UCICIUUU

Alone

With Friends
With spouse
With spouse and children

With spouse and parents

With spouse, children and parents
Other (specify)

 

l 1) Type of housing

E]

[313130

12) No. of members in Household

Cl
CI

13) Which state of India are you from?

Own House
Rental house
University apartments
Other apartment
Other (specify)

 

 

Adults
Children (<18 years)

 

 

162

CE Moderate

l3 Light

14) What language do you speak at home?

 

15) How many years have you continuously lived in the US? (years)

16) Have you lived in a country other than US?
Cl Yes (specify country) for how many years?
D No

17) Do you have medical insurance?

CI Yes (specify)

 

 

 

 

 

C] No
18) Do you smoke?
Cl Yes (specify) for how many years? no. of cigarettes day / week
Cl No
19) Do you drink alcohol?
Cl Yes (specify) for how many years? no. of drinks day / week
C] No
20) Of the following, please mark all that you DO NOT drink/eat?
D Milk
CI Eggs
CI Chicken
C] Mutton / Lamb
D Beef
13 Pork
Cl Seafood
C] Other (Specify)

 

DIABETES INFORMATION
21) How long have you had diabetes? (Years)

22) When did the doctor first tell you that you had diabetes? (mm/yyyy)

 

23) In which country were you when you were first diagnosed with diabetes?

 

24) How did you choose the doctor you visit for diabetes care?

 

25) Have you ever received any education about your diabetes from a health professional?
CI Yes (specify)
Cl No

26) Do you know if diabetes education is available to you?
Cl Yes (specify)
Cl No

 

163

 

27) How many times have you seen a doctor in the past year for your diabetes?

28) How many times have you had to stay in the hospital in the past year for diabetes or other conditions?

Please mention all that apply:

Cl High Blood sugar
Low Blood sugar

Blood pressure

D

D

CI Heart disease
Cl Kidney problems
Cl

Other (Specify)

 

29) Do you have any of the following medical problems (Yes / No)
CI High Blood pressure
C] Heart disease
C] Kidney problems
Overweight
Eye Problems
Nerve Problems
Other (Specify)

DUDD

 

30) Is there anybody else in the family who has diabetes? (Yes / No)

13

Father

Mother

Grand Parent
Sibling
Husband/ Wife
Children

Other (specify)

DDDDUU

 

MEDICATION

31) Were you given any medication for diabetes when the doctor first told you that you have diabetes? (Yes
/No)

CI Insulin
0 Tablets
CI Both
32) What medication are you taking for your diabetes now?
D Insulin
Cl Tablets

164

. ...,

 

CI Both
CI None (diet only)
33) Do you have any problems taking diabetes tablets/ injections prescribed by the doctor?
Cl Yes
CI No
34) What do you do if you have problems taking your medication (insulin injections / tablets)?
CI Take it later
0 Wait until the next medicine time

D Other (specify)

 

35) Can you tell me all the medications that you take including those not prescribed by the doctor?

 

 

 

D For what conditions?

D How many other medications?

Cl Please specify the names
MONITORING

36) Did your doctor ask you to check your blood sugar at home? (Yes / No) How often?

 

 

37) How often are you able to check your blood sugar at home/ work? day / week

 

38) If you are not able to check often, what interferes with your blood sugar testing?

 

39) Do you check it yourself? (Yes / No) If no, who helps you check your blood sugar?

 

40) Did your doctor ask you to check your feet at home? (Yes/ No) How often?

 

41) How often are you able to check your feet at home? day / week

 

42) Do you check it yourself? (Yes / No) If no, who helps you check your feet?

 

43) Do you follow any special diet? (Yes / No) If yes, what do you do?

 

44) How ofien do you follow this diet?
CI All the time
Cl Sometimes
D Rarely
CI Never

45) Do you exercise? (Yes / No)

D What do you do?
CI How long do you do it?

 

 

CI How many times / week?
CI What other physical activities you do each day? How many hours?

165

 

46) Are you trying to lose/ gain weight?

CI Yes (specify number of pounds you want to lose/ gain)

 

CI No
47) What was your weight when you were first diagnosed with diabetes? (pounds / kg)
48) What is your current weight? (pounds / kg)
49) What was your highest (pounds / kg) and lowest adult weight? (pounds / kg)

50) On a scale of l to 7 (l= least difficult...7 = most difficult) please rank the order in which you are able
to do the following as recommended by the doctor:

Healthy eating

Weight control

Regular exercise

Foot care

Self monitoring blood glucose

Taking prescribed medicines

 

Regular check up with a doctor

PHYSICAL EXAMINATION

 

Date Height (feet and inches) Weight (pounds)

 

 

 

 

 

 

LABORATORY DATA: HbAlc

 

Date HbA 1c

 

 

 

 

 

166

HOW DOES THE PARTICIPANTS KNOWLEDGE OF DIABETES AFFECT THEIR SELF-
MANAGEMENT BEHAVIORS?
I) Can you tell me what diabetes is? Prompt: Tell me anything you know about diabetes?

2) What do you think will happen if you do not take care of your diabetes? Why?
3) What do you think are the benefits of managing your diabetes? Why?

4) What do you think is important to take care of your diabetes? Prompt: How did you learn this
information?

5) What do you think the role of medicine is in managing diabetes?
6) What do you think the role of food is in managing diabetes?
7) What do you think the role of exercise or physical activity is in managing diabetes?

8) You told me about the roles of food, medicine and exercise, do you think that one is more
important than the other? How?

HOW DO PARTICIPANTS PERCEIVE THE IMPACT OF THE DISEASE AND THE REQUIRED
SELF-MANAGEMENT BEHAVIORS?

9) Can you tell me how having diabetes has changed your life? What do you do differently now?
Prompt: After being diagnosed with diabetes how has your daily routine changed?

10) What do you do on a daily basis to take care of your diabetes? How do you feel about it?
Prompt: Exercise, medical care, diet, testing blood sugar, foot care?

IN WHAT WAYS ARE SUPPORT NETWORKS AND SELF-MANAGEMENT RELATED?

l 1) When you first found out you had diabetes, who was the most helpful and how? Prompt:
family, fiiends, doctor etc.

12) How did your family respond or react when you first told them that you had diabetes? Prompt:
Can you give me an example? Were they supportive of it? Did they help in your diabetes
management? If so, how?

13) When you need help with your diabetes, to whom do you go to and how do they respond?
Prompt: Friends, family, doctor etc.

14) If you have relatives or friends with diabetes, how do you think having diabetes is the same or

different for you compared to your family member or friend with diabetes? Prompt — can you
give me some examples?

167

WHAT DO PARTICIPANTS PERCEIVE TO BE FACILITATORS AND BARRIERS FOR SELF-

MANAGEMENT BEHAVIORS?

15) What are some of the difficulties in managing your diabetes? Prompt: What are some things
that you don 7 do well? What makes it diflicult for you to do these well?

16) What helps you in taking care of your diabetes? Prompt: What are some of the things you do
well with regard to managing your diabetes? What makes it easy to do?

HOW DOES LOCATION OF RESIDENCE INFLUENCE SELF-MANAGEMENT BEHAVIORS?
17) Can you tell me about the area/ neighborhood where you live? Are there many Indians nearby?
Prompt: What do you think about the Indian community? Are they friendly, helpful?

18) Can you tell me how the place where you live helps you to manage your diabetes?
Prompt: For e. g. access to health care, physical activity, diet, friends etc.

19) Can you tell me how the place where you live prevents you from managing your diabetes?
Prompt: For e. g. access to health care, physical activity, diet, fiiends etc.

HOW DOES THE HEALTH CARE SYSTEM INFLUENCE SELF-MANAGEMENT

BEHAVIORS?

20) What do you feel about the health care that you receive from your clinic or doctor? Prompt:
What do you like or dislike? Why?

21) What do you think the role of doctor should be in helping you with your diabetes?

HOW DOES AN INDIVIDUAL’S VALUES AND BELIEFS INFLUENCE SELF-MANEGEMENT
BEHAVIORS?

22) Can you tell me if you manage your diabetes with any other Indian treatment such as
Ayurveda, Unani, Siddha, Homoeopathy, and Yoga etc?

23) What are foods that you don’t eat based your religion? Prompt: Do youfast on some days for
religious purposes?

24) What are some of the foods or other things that you believe help you with your diabetes?
Prompt: What are they? Tell me how they/it help/s you?

IS ACCULTURATION RELATED TO GLYCEMIC CONTROL, AND IF IT IS HOW?

25) How do you think your food habits, physical activity and other daily routines have changed
after coming to the U.S.? Prompt: What are some things you did in India but are not doing
here and vice versa

26) Are there any special difficulties/ benefits in taking care of your diabetes in the US when
compared to India? Prompt: How different do you think it would be if you were to take care of

your diabetes in India?

27) Anything else you want to tell me about your management of diabetes?

168

Appendix E: Preliminary Interview Guide

 

 

 

Date of Interview Participant ID
Participant Name Age Male Female
Address

 

Phone number

 

 

I) How long have you lived in the US?

 

2) Were you diagnosed with diabetes by a doctor?

CI Yes (specify when)

 

CJNo

3) If yes, how was this diagnosis made from what you remember?

 

4) Do you know what is the HbAlc test?

0 Yes (can you explain?)

 

DNo

If the answer is no or is incorrect: The investigator will explain that it is a blood sugar test taken in the
doctor ’3 office or at a laboratory facility that will tell you how your blood sugar was maintained during the
past 3 months.

5) Did you have HbAlc blood sugar test taken within the past one year?
D Yes (specify when)

 

D No
6) Do you have the HbAlc report with you?
D Yes (specify value)

 

D No
7) Will you be able to provide us a copy of your HbAlc report?
0 Yes
D No
8) Will you be able to participate in an interview conducted in English?
D Yes
D No

For females
9) Are you pregnant/ breastfeeding?

Cl Yes
D No

169

Appendix F: Participant Consent Form
Research Participant Information and Con_sent F org

 

You are being asked to participate in a research project. Researchers are required to provide a consent
form to inform you about the study, to convey that participation is voluntary, to explain risks and
benefits of participation, and to empower you to make an informed decision. You should feel free to
ask the researchers any questions you may have.

Study title: Acculturation and Associated Factors in Relation to Glycemic Control and Self-
management of Diabetes in Asian Indian Adults in the United States

Researchers and Titles: Lorraine Weatherspoon PhD, RD
Associate Professor in Human Nutrition &
Director, Didactic Program in Dietetics

Sumathi Venkatesh
MS Graduate Student in Human Nutrition

Department and Institution: Food Science and Human Nutrition Department
Michigan State University

Address and 334 GM Trout Food Science Building
Contact Information Michigan State University, East Lansing Michigan 48824-l224
for L.Weatherspoon: Tel: 517-355-8474 ext 136

Email: weathe43@msu.edu

Sponsor: Lorraine Weatherspoon PhD, RD
Associate Professor in Human Nutrition &
Director, Didactic Program in Dietetics

PURPOSE OF RESEARCH:

You are being asked to participate in a research study that will help us understand Acculturation and
Associated Factors in Relation to Glycemic Control and Self-management of Diabetes in Asian Indian
Adults in the United State. You have been selected as a possible participant in this study because you
contacted the researcher showing interest in participation in this research project. From this study, the
investigators hope to learn how living in the United States of America and other factors are related to
how Asian Indian adults are able to manage their diabetes. Diabetes management practices include
testing blood sugar between doctor visits, exercising regularly, following dietary recommendations,
taking prescribed medicines, weight control, regular foot care and visiting with the doctor. In the entire
study, approximately 30 people are being asked to participate. Your participation in this entire study
will take about 2 to 2.5 hours.

WHAT YOU WILL DO:

This study consists of four parts after we ask you the preliminary questions to see if you are eligible to
participate in the study. First we will ask questions about how living in the United States of America
has influenced your habits. Secondly, we will ask about the foods you have eaten in the past 24 hours.
These two parts will take about 45 minutes. The third part will consist of an audio-recorded interview
lasting about an hour. This interview will include questions, which will help us to better understand

170

the things you experience related to diabetes as well as some additional general survey questions. We
will also need to call you at a later date agreed upon with you, if you do not mind giving us your phone
number, to ask you questions about how you eat over a different 24-hour period. This will take
another 20 — 30 minutes and give us a clearer idea about how you eat both during the week and
weekends.

POTENTIAL BENEFITS:

Your participation in this study may help you better understand how you are managing your diabetes.
It may also benefit you indirectly and Indians with diabetes in the United States of America, in that
health care professionals, may be able to better understand special considerations for helping Indians
who have Diabetes from the information we collect.

POTENTIAL RISKS:

There are no physical procedures to your body expected of this research. Therefore, you should
experience no physical risks or discomforts. However, you may feel embarrassed or shy about
answering some of the questions. You are not obligated to answer anything that you would prefer not
to. There will be no penalty, if this is the case.

PRIVACY AND CONFIDENTIALITY

The interview will be done in a convenient place for you with complete privacy. Information about you
will be kept confidential to the maximum extent allowable by law. Each subject will be given an
identification number that will be on a log sheet with their corresponding names and contact
information. This log sheet will be used only for assignment of identification numbers and contact
purposes if and when necessary. All data will only have identification numbers with no personal
identifiers. Log sheets and data will be kept in separate locked filing cabinets. Only the primary
investigators L.Weatherspoon and Sumathi Venkatesh will have access to participant’s personal
identification information. Data with identification numbers only and audio recordings will be
accessible by L.Weatherspoon, S.Venkatesh and a trained undergraduate research assistant for data
analysis purposes. The results of this study may be published or presented at professional meetings, but
the identities of all research participants will remain anonymous.

YOUR RIGHTS TO PARTICIPATE, SAY NO, OR WITHDRAW

Participation in this research project is completely voluntary. However, the audio taped interview
section is very important. So, if you do not want the interview to be audio taped, you will not be able
to participate in this study. You may choose not to answer specific questions or to stop participating at

any time. If you withdraw from this project without completing all the four steps listed above, you will
not be eligible for the $25 gift card.

COSTS AND COMPENSATION FOR BEING IN THE STUDY:

There are no costs associated with participation in this study. Upon completion of the second 24 hr
food recall, you will receive a $25 gift card to Meijers as a token of appreciation for your participation.

171

CONTACT INFORMATION FOR QUESTIONS AND CONCERNS

If you have concerns or questions about this study or to report an injury, please contact the primary
investigator:

Dr. Lorraine Weatherspoon PhD, RD

Associate Professor in Human Nutrition &

Director, Didactic Program in Dietetics

334 GM Trout Food Science Building

Michigan State University, East Lansing Michigan 48824-1224
Tel: 517-355-8474 ext 136

Email: weathe43@msu.edu

If you have questions or concerns about your role and rights as a research participant, or would like to
register a complaint about this study, you may contact, anonymously if you wish, the Michigan State
University’s Human Research Protection Program at 517-355-2180, Fax 517-432-4503, or e-mail
irb@msu.edu or regular mail at 202 Olds Hall, MSU, East Lansing, MI 48824.
DOCUMENTATION OF INFORMED CONSENT.

Your signature below means that you voluntarily agree to participate in this research study.

Printed name of the Participant:

 

 

 

Signature Date

You will be given a copy ofthis form to keep.

172

Appendix G: SL-ASIA Acculturation Instrument

INSTRUCTIONS: The questions, which follow are for the purpose of collecting information about your
historical background as well as more recent behaviors which may be related to your cultural identity.
Choose the one answer which best describes you.

I. What language can you speak?

1. Indian only (for example, Hindi, Tamil, Telugu, Malayalam, etc.)
2. Mostly Indian, some English

3. Indian and English about equally well (bilingual)

4. Mostly English, some Indian

5. Only English

2. What language do you prefer?

Indian only (for example, Hindi, Tamil, Telugu, Malayalam, etc.)
Mostly Indian, some English

Indian and English about equally well (bilingual)

Mostly English, some Indian

Only English

9:59.“.—

3. How do you identify yourself?
1. Indian
2. Asian
3. Asian-American
4. Indian-American.
5. American

4. Which identification does (did) your mother use?
Indian

Asian

Asian-American

Indian-American

American

919.9459.—

5. Which identification does (did) your father use?
Indian

Asian

Asian-American

Indian-American

American

99939:"

6. What was the ethnic origin of the friends and peers you had, as a child up to age 6?
1. Almost exclusively Indians, Indian-Americans
2. Mostly Indians, Indian-Americans
3. About equally Indian groups and Anglo groups
4. Mostly Anglos, Blacks, Hispanics, or other non-Indian ethnic groups
5. Almost exclusively Anglos, Blacks, Hispanics, or other non-Indian ethnic groups

7. What was the ethnic origin of the friends and peers you had, as a child from 6 to 18?
Almost exclusively Indians, Indian-Americans

Mostly Indians, Indian-Americans

About equally Indian groups and Anglo groups

Mostly Anglos, Blacks, Hispanics, or other non-Indian ethnic groups

Almost exclusively Anglos, Blacks, Hispanics, or other non-Indian ethnic groups

173

.V'PP’E"?

8. Whom do you now associate with in the community?

Almost exclusively Indians, Indian-Americans

Mostly Indians, Indian-Americans

About equally Indian groups and Anglo groups

Mostly Anglos, Blacks, Hispanics, or other non-Indian ethnic groups

Almost exclusively Anglos, Blacks, Hispanics, or other non-Indian ethnic groups

9995’:-

9. If you could pick, whom would you prefer to associate with in the community?
1. Almost exclusively Indians, Indian-Americans
2. Mostly Indians, Indian-Americans
3. About equally Indian groups and Anglo groups
4. Mostly Anglos, Blacks, Hispanics, or other non—Indian ethnic groups
5. Almost exclusively Anglos, Blacks, Hispanics, or other non-Indian ethnic groups

10. What is your music preference?
Only Indian music

Mostly Indian

Equally Indian and English
Mostly English

English only

999’s):-

1 1. What is your movie preference?
I. Indian-language movies only
2. Indian-language movies mostly
3. Equally Indian and English-language movies
4. Mostly English-language movies only
5. English-language movies only

12. What generation are you? (circle the generation that best applies to you: )

1. Ist Generation = I was born in India or country other than U.S.

2. 2nd Generation = I was born in U.S., either parent was born in India or country other than U.S.

3. 3rd Generation = I was born in U.S., both parents were born in US, and all grandparents born
in India or country other than U.S.

4. 4th Generation = I was born in U.S., both parents were born in US, and at least one
grandparent born in India or country other than U.S. and one grandparent born in U.S.

5. 5th Generation = I was born in U.S., both parents were born in U.S., and all grandparents also
born in U.S.

6. Don’t know what generation best fits since I lack some information

13. Where were you raised?
1. In India only
2. Mostly in India, some in U.S.
3. Equally in India and U.S.
4. Mostly in U.S., some in India
5. In U.S. only

14. What contact you have had with India?

Raised one year or more in India

Lived for less than one year in India

Occasional visits to India

Occasional communications (letters, phone calls, etc.) with people in India
No exposure or communications with people in India

174

99919:-

15. What is your food preference at home?
I. Exclusively Indian food
2. Mostly Indian food, some American
3. About equally Indian and American
4. Mostly American food
5. Exclusively American food

16. What is your food preference in restaurants?
Exclusively Indian food

Mostly Indian food, some American
About equally Indian and American
Mostly American food

Exclusively American food

MPWN~

17. Do you

read only an Indian language

read an Indian language better than English
read both Indian and English equally well
read English better than an Indian language
read only English

9‘.“ri

18. Do you

. write only an Indian language

. write an Indian language better than English
. write both Indian and English equally well

. write English better than an Indian language
. write only English

MAD-IN—

19. If you consider yourself a member of the Indian group (Indian, Indian-American, etc., whatever term
you prefer), how much pride do you have in this group?
1. Extremely proud
2. Moderately proud
3. Little pride
4. No pride but do not feel negative toward group
5. No pride but do feel negative toward group
20. How would you rate yourself?
1. Very Indian
2. Mostly Indian
3. Bicultural
4. Mostly Westemized
5. Very Westemized

21. Do you participate in Indian occasions, holidays, traditions, etc?
1. Nearly all
2. Most of them
3. Some of them
4. A few of them
5. None at all

175

23.

25.

26.

. Rate yourself on how much you believe in Indian values (e.g., about marriage, families, education,
work):
I 2 3 4 5
(do not believe) (Strongly believe in Indian values)
Rate yourself on how much you believe in American (western) values:
1 2 3 4 5
(do not believe) (Strongly believe in American values)
Rate yourself on how well you/it with other Indians:
1 2 3 4 5
(do not fit) (fit very well)
Rate yourself on how well you fit when with other Americans who are non-Indian (westerners):
l 2 3 4 5
(do not fit) (fit very well)
There are many different ways in which people think of themselves. Which ONE of the following most

closely describes how you view yourself?
I . I consider myself basically an Indian. Even though I live and work in America, I still view

myself basically as an Indian.

2. I consider myself basically as an American. Even though I have an Indian background and
characteristics, 1 still view myself basically as an American.

3. I consider myself as an Indian-American, although deep down I always know I am an Indian.

4. I consider myself as an Indian—American, although deep down, I view myself as an American

first.

5. I consider myself as an Indian-American. I have both Indian and American characteristics, and
I view myself as a blend of both.

176

Appendix H: 24-Hour Dietary Recall

Getting started

Break the ice
Explain why the assessment is being done
Reassure the subject this will be kept confidential

USDA 5-Step Approach

1.

IIINII.

IIIWI

4.

IMII

Quick List — Collect a list of foods and beverages consumed the previous day
What was the lst thing you ate afier you got up yesterday?
0 Avoid terms like breakfast or lunch
Record only food at this time; don’t worry about portion sizes until later
Allow extra space for adding things later
Do NOT interrupt
Forgotten Foods — Probe for foods forgotten during the Quick List
Your turn to talk
Probe with open ended questions (how. what, describe)
Don’t forget...
o Condiments
0 Beverages
0 Alcohol
0 “Little bites” of food
Frequently missed foods
Time & Occasion - Collect time and eating occasion for each food
Review the day to them
Ask the subject to tell you the time of day each food was eaten
Ask if there are additions or corrections
Detail Cycle — For each food, collect detailed description, amount, and additions. Review 24-hour day
Obtain 4 kinds of info about each food/beverage
Kind of food/Beverage
0 Fresh, frozen, canned
o Skim, 2%, whole
Preparation of food
0 Fried or baked
0 Ingredients added
Portion size of food
0 Participant may underestimate so use models or examples
0 Make sure EVERY item has some measuring unit
How served
0 Butter, gravy, or cream added?
If you are not sure about a food, ask the participant to describe it to you
0 For example, Joe tells you he has a Gatorade® every morning after breakfast
0 Find out what is a Gatorade®...
I Is it a drink?
- An energy bar?
Get details (color, ingredients, etc)
0 Your mom’s BBQ is not going to be the same as his/her mom’s
Record dietary supplements or vitamins/minerals
Record any herbal or home remedies

. Final Probe — Final probe for anything else consumed

Remember...
0 Double-check name on each dietary assessment form
0 Check for completeness

177

Date:

 

24—HOUR DIETARY RECALL SHEET

Day of the week

 

Time ofthe Day

Food Items

Amount/Portion

What were you
doing?

Where were you
eating?

 

 

 

 

 

 

 

“Was this a normal day?” yes or no If no, specify

“Do you take vitamin or mineral supplements “ yes or no If yes specify

 

178

 

 

 

 

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