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Strategies for Lowering Rates of Diabetes Within the Filipino Community

Abstract

Diabetes is a disease that disproportionately affects Filipinos, as they have one of the highest rates of diabetes diagnoses compared to other ethnicities. Current established strategies to lessen diabetes symptoms today are underutilized by Filipinos because of cost and inaccessibility. Recently developed strategies utilize new ways to decrease the rates of diabetes diagnosis among Filipinos while minimizing cost and improving accessibility. One strategy that is being researched is finding better diets that implement Filipino dishes yet are still healthy for a Filipino with diabetes, such as incorporating rice with healthy alternatives such as fish to minimize blood glucose levels. Another strategy is to implement informative educational programs and trust among Filipinos, giving them the resources necessary to assist them with mitigating diabetes symptoms. Current research shows that these strategies are as effective as previously established strategies. Patient education and trust of caregivers show some significant effects but should be analyzed further to understand if these effects are still relevant years after they received the education. Further research should investigate physiological studies and increase the sample size for stronger significance.

Introduction

Diabetes mellitus, commonly known as diabetes, is a metabolic complication that arises when a person has exceedingly high blood glucose levels. Physiologically, a person is considered diabetic if their blood glucose level is above 200 mg/dL at any point in time. This is due to insulin ineffectively signaling glucose transporters to intake glucose from the blood to the liver, causing glucose to stay in the bloodstream. This disease affects people of certain ethnicities disproportionately. Specifically, the Filipino community has one of the highest rates of diabetes among all ethnicities [1]. As of 2020, Filipinos have the second-highest diabetes prevalence among all ethnicities with a prevalence rate of about 31%, with the highest being Native Hawaiian/Pacific Islanders with a rate of about 35% [1]. This prevalence is significantly higher than the average rate of about 12% in the United States [1]. Studies find a positive correlation between obesity and diabetes rates, where Filipinos had the strongest correlation compared to other Asian subgroups for obesity [1].  There are many risk factors involved with diabetes, including lack of exercise and healthcare inaccessibility. However, one risk factor that is strongly positively correlated with diabetes in Filipinos is an unhealthy diet [1]. Specifically, Filipino foods, like sisig, puto bumbong, and lechon are very high in saturated fat. Most of these foods are also accompanied by rice, a food with a high glycemic index. The glycemic index is a rating system that is based on how much one’s blood glucose levels rise when consuming the food. A higher glycemic index for a food means that consuming that food increases one’s blood glucose levels higher than other foods. For example, glucose has a glycemic index of 100, which is the highest that can be assigned to a food. Rice has a glycemic index that ranges from 64 to 93, with the range depending on the type of rice [2]. In comparison, ice cream only has a glycemic index of 51. Thus, a diet containing a large amount of rice can rapidly increase blood glucose levels, leading to diabetes. Current strategies that have shown to be effective such as limiting sugar intake or increasing exercise are widely known and established by healthcare workers, butstill are not enough to combat the high rate of diabetes among Filipinos. 

Many currently researched strategies take different approaches to this problem. Some researchers are refining current strategies used today. For example, researchers are developing more accessible ways for people to self-assess their blood glucose levels through at-home glucometers. Glucometers today are more portable and require less time to determine a person’s blood glucose level. This makes the strategy more cost-effective, giving more Filipinos access to this strategy. Some researchers are creating new strategies that minimize expenses while effectively lowering the symptoms of diabetes. Instead of using modern technology such as diabetes test strips and finger-stick glucose monitoring, researchers use socialization and education to inform Filipinos of their diabetes and how to combat the symptoms, focusing on the mental aspect rather than the physical. This review focuses on what the current literature reveals about new strategies that are being developed to lower rates of diabetes in the Filipino community. Furthermore, it explores the effectiveness of each new strategy and how they compare to previously established ones.

Discussion

Dietary Changes

One major strategy that is used to lower rates of diabetes is decreasing blood glucose levels by changing food intake. When diabetes was determined to be due to a lack of insulin in the 1900s, scientists suggested that people with diabetes should change what they eat to manage diabetes symptoms: specifically, decreasing the amount of sugar intake in their meals [3]. Recent studies suggest that people with more control over their diet have better control over their health, allowing them to effectively handle health conditions, including diabetes [3, 4]. Those who are aware of their diet can alter it accordingly, resulting in lessened symptoms of diabetes [3, 5]. This includes lowering the amount of protein one consumes and introducing more fruits and vegetables to their diet because of correlations between certain proteins and diabetes [5]. Furthermore, fruits have lower glucose levels than carbohydrates but still provide essential nutrients and vitamins. Thus, diets that make Filipinos more cautious of what they eat and allow them to implement dietary changes can help with diabetes symptoms.

The Filipino Plate Method, also known as Pinggang Pinoy, is a system that provides recommendations on how Filipinos should portion their plate with certain foods, including fruits, vegetables, protein, and carbohydrates [3]. The Filipino Plate method is unique compared to other plate methods because it incorporates signature Filipino dishes such as fried tinola, bangus, and pinakbet. These proportions help Filipinos adopt a healthy diet, preventing Filipinos from increasing their risk for diabetes. However, the study analyzing the Filipino Plate method only indicated significantly lower blood glucose levels two hours after testing [3]. Furthermore, they did not test blood glucose levels beyond two hours following testing. No other study has researched the effects of the Filipino Plate method. Future studies should explore dietary changes that investigate long-term effectiveness. 

Furthermore, compared to strategies widely established to be effective by the American Diabetes Association (ADA) such as changing diet or increasing exercise, the methods established by recent studies such as the Filipino Plate Method are not significantly more effective than those strategies [3, 6]. In comparison to the American Diabetes Association’s (ADA) standard nutrition education, the Filipino Plate method showed similar results in lowering blood glucose levels even when using less educational time [3]. On top of this, the Filipino Plate method is considered to be easier to understand, requiring less comprehension than the ADA’s standard nutrition education [3]. In the Filipino plate method, proportions are specific, recommending how much of each type of food such as protein, fats, and carbohydrates should be consumed at each meal. The Filipino Plate method is even further specified, creating a “plate” for specific population groups, from children to pregnant women. For example, kids are recommended to eat only half a cup of carbohydrates such as rice or pandesal (Filipino bread), while pregnant women should eat one-and-a-half cups of carbohydrates. The ADA’s education only explains what foods should be eaten as an alternative and gives vague serving sizes, such as “one-quarter of a plate” [7]. Nevertheless, these comparisons show that although these developing strategies are effective, they are not more effective than widely known strategies such as … [3]. This raises questions about whether there is a better diet than one already established for diabetics to follow. However, developing new diets that are accessible to everyone can significantly decrease rates of diabetes within the Filipino community. 

Education on Diabetes

Another strategy that has been shown to lower rates of diabetes effectively is patient education. Extensive studies show that people who understand the causes, symptoms, and complications of diabetes are less prone to being diagnosed with diabetes [3, 8, 9, 10, 11].  One particular study shows a negative association between routine check-ups and the risk of cardiovascular disease, a major symptom of diabetes [11]. Current rates of routine check-ups by Filipinos are minimal due to the stigma around diabetes and mistrust of Western medicine [9]. Filipino culture and values find diabetes a highly sensitive topic, to the point where a study had to separate men and women to prevent shame [12]. Although separation is common in most studies, participants requested this separation to ensure that their self-esteem was preserved [11]. Participants gave a variety of reasons for requesting separation but the main request was due to the sensitivity of the topic [12]. Both groups expressed fear of embarrassment if they shared their perspective of diabetes with the opposite sex [12]. Furthermore, in the early 2000s, Filipinos and other Asian ethnicities reported receiving improper treatment and discrimination in healthcare settings [9]. Because of this, Filipinos have less trust in the healthcare system, decreasing their frequency of routine check-ups. 

However, routine check-ups can be increased by using Tiwala, a technique used to gain the trust of Filipino-American families by integrating cultural storytelling [9]. Tiwala is a word in Tagalog that is defined as the amount of trust one has with someone. Tiwala, as a practice, consists of adding a layer of Filipino culture with check-ups. This includes personal stories told by Filipino caregivers to increase trust between caregivers and patients. Stories from Filipino caregivers provide Filipino patients with a reason to trust caregivers since they are giving them the necessary healthcare. With more caregivers giving education to Filipino-Americans, they can be more willing to get check-ups on their health, lowering their risk of cardiovascular disease.

These studies can be extended to lower-class Filipinos, as lower-class Filipinos have less access to education, so they have insufficient knowledge about diseases such as diabetes [13]. Education significantly increased the understanding of the risk factors of diabetes among lower-class Filipinos [11]. On top of educating Filipinos on the risk factors of diabetes, educating them on their diet using the Filipino Plate Method has shown to be effective [4]. Recent studies show that providing Filipinos with the necessary education about diabetes can prevent them from being diagnosed with diabetes [10, 11]. Although this strategy does not directly decrease rates of diabetes, it prevents the rates from increasing [10, 11]. 

However, the current literature does not extensively analyze if patient education is being applied and utilized by patients. In other words, patients with diabetes learn about the disease but there is no explanation on whether they use what they learned.  Many studies that implemented patient education do not show a significant decrease in blood glucose levels; rather, the education only informs them on how to prevent diabetes [3, 10, 14]. This suggests that these strategies are an indirect way to lower rates of diabetes by preventing people from becoming diagnosed with diabetes. Compared to changing diet as a strategy, educating patients shows little effectiveness for blood glucose levels in the short term. Nevertheless, there is an opportunity to determine its effectiveness in the long term because current studies have yet to test its effectiveness over a long period of time.

Patient education shows no significance for those who are already well-informed about diabetes. This creates conflicts with research articles because it opens up a new group for researchers to analyze: diabetics who are well-informed about diabetes. Researchers can investigate these unexplored groups to determine if patient education is an effective strategy or not. Previous studies do show a more significant understanding of diabetes only if they were previously unaware [10, 11, 12, 15]. Furthermore, blood glucose levels were not tested before and after receiving the education. This large gap in the literature is crucial to look into because it helps determine the causality between patient education and lowering blood glucose levels. This problem can also be a large limitation to understanding patient education on diabetes due to subjective reports about education.

Patient Trust

A strategy that has been proven to create a foundation to combat diabetes effectively is gaining the patient’s trust. Recent studies show that patients who are more willing to comply with family members and caregivers can better cope with symptoms of diabetes [8, 9, 14, 15]. Compliance includes cooperation between patients and caregivers, increases in check-up frequency, and more consistent routine medication for patients. Using Tiwala to gain a patient’s trust can increase Patient Activation scores, a measurement of a patient’s willingness to accept a caregiver’s decisions and processes [8, 9]. Patient Activation scores are determined by a self-questionnaire about their health [8]. Each question has an answer range from 0 to 4, 0 being non-applicable to the responder and 4 being strongly applicable. A higher Patient Activation score indicates that a patient feels like they have control over their disease [8]. In comparison, a lower Patient Activation score is indicative of a patient feeling helpless about their disease [8]. This is very significant because higher Patient Activation scores show a negative correlation with blood glucose levels, a major risk in diabetes if levels get too high [8]. Furthermore, patients are more willing to comply if their family members and friends are there to support the patient with their decision [14]. This was especially prominent during COVID-19, as diabetics were able to cope with both physical and mental stressors using the support of friends and family [15].

Literature also suggests that implementing Filipino culture in caregiving is an effective way to gain the trust of Filipino patients [4, 9, 14, 15]. Thus, Filipino patients will listen to their caregiver’s decision and comply instead of ignoring the caregiver’s decision [8]. With their trust, studies indicate that patients feel better suited to combat diabetes [15]. These research studies agree that trust is a foundational way of helping diabetics work with their caregivers to develop diabetes care strategies [8, 9, 15].  Furthermore, it provides diabetics with a sense of control over their health [3]. This intervention demonstrates the connection between patient education and patient trust: when diabetics understand the complications of diabetes through education and the support of those around them, they can generate personalized strategies to help them overcome diabetes. This idea is highly overlooked in the literature due to the longevity required for this research [2, 3, 9, 14, 15]. Nevertheless, these strategies do show that enhancing trust between patient and caregiver is a unique and effective strategy for alleviating the psychological symptoms of diabetes among Filipinos.

Gaining the trust of Filipino patients can help them cope with the symptoms of diabetes, and some of these strategies can indirectly influence the physical symptoms of diabetes. Analysis of Patient Activation scores and blood glucose levels show a significant positive correlation [8]. The mental aspect of diabetes is often overlooked in the literature, and recent studies have shown that addressing the mental health of diabetics is a way to help them physically [3, 12, 15]. For example, patients who are more involved in their local communities report having a sense of trust around them [12]. With this trust, they were found to have lower blood pressure than diabetics, showing the effectiveness of trust for physical symptoms of diabetes [12]. This idea can give interested researchers a new perspective when developing new strategies to combat diabetes in the Filipino community.

Conclusion

Based on current research, dietary changes, patient education, and increased trust between patients and caregivers show some effectiveness in lowering diabetes symptoms. Furthermore, recent studies of these methods have yet to explore their longitudinal effectiveness. However, research should look into the intertwining effects of these variables. There is a strong possibility that educating a patient can help them trust their caregivers more, which can help patients with both physical and psychological symptoms.

Author's Note

One significant aspect of my social identity is my ethnicity. As a Filipino, my research is primarily based on health equity issues the Filipino community deals with. Furthermore, I look for significant disparities in certain diseases that impact Filipinos. Understanding the disparities, finding underlying causes, and determining effective methods for the Filipino community is the fundamental basis of most of my research. As I further my academic career and pursue to become a healthcare professional, I plan on deepening my understanding of certain diseases that are disproportionately prevalent in the Filipino community.

References

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