Providing cultural awareness training for healthcare workers in diabetes

DRWF Research Manager Dr Eleanor Kennedy blog reports from Day Eight of the Diabetes UK Professional Conference.

Day Eight of this marathon virtual conference dawns but there are still plenty of healthcare professional delegates logged on to hear sessions ranging from the now ubiquitous Covid-19 pandemic to circadian control of systemic metabolism in type 2 diabetes and the impact of exercise training.

I decide to start my day by checking in for talks on cultural adaptations in the diabetes care of different ethnic communities.

There are pronounced ethnic differences in the scope and reach of care in diabetes. According to the first speaker, this is particularly so in black British adults who find it difficult to access first-line primary care services for diabetes. They are more likely to report that they have not had the opportunity to attend a diabetes education course.

In addition, healthcare professionals may lack cultural understanding and their subsequent advice may lack cultural relevance or be poorly adapted to the patient’s culture and needs. A meta-analysis published just a few years ago looking at self-management education in black populations found no effect on HbA1c.

Against the backdrop of type 2 diabetes being three times more common in these populations than in white Europeans, being diagnosed on average 10 years earlier and with poorer control.

What can be done to address this?

Introducing the HEAL-D (Healthy Eating and Active Lifestyles for Diabetes) study, we were given an idea of what can be done to deliver more culturally aware training for healthcare professionals.

This is a group-based delivery programme, fostering social connectedness but in non-medical settings to overcome distrust and to increase convenience. Using specialist dietitians and lay educators ensures credibility of advice whilst conveying cultural understanding. There are also flexible attendance patterns to overcome issues of conflicting priorities like work or carer responsibilities. In addition, the programme offers physical activity classes to allow for social cohesion and to demonstrate appropriate and culturally acceptable physical activity as well as practical Cook and Taste sessions with black British cooks to overcome the barriers to changing cooking practices.

The feedback is convincing with many of the participants commenting on learning about portion size, walking instead of taking buses everywhere and a lot around feeling supported as a result of meeting others from their communities.

This segued into a talk about using a dietary resource for ethnic communities.

Traditional diets of black and south Asian communities tend to have to 60% carbohydrate content but, of course, are not homogenous as there are many regional, religious and cultural variations. They are also subject to acculturation i.e., the assimilation of habits of the host country.

In a pilot study in Brent, north west London which is a majority ethnic, multilingual society with a high prevalence of type 2 diabetes, this intervention was picture based and culturally relevant with a booklet depicting foods commonly eaten by the Gujarati, Caribbean and Pakistani communities.

The results demonstrated that the booklet produced a better understanding of which foods and drinks contain carbohydrates or starches. Moreover, it facilitated an improved engagement between the healthcare professional and people from these communities as the cultural relevance of the booklet was greatly appreciated by the participants in the study.

By including a visual representation, the booklet could include values for carbohydrates, calories and fat along with a small icon that demonstrated the effect on blood glucose.

This presentation ended with a series of impactful feedback quotes from participants about now being able to make informed choices, help with meal planning and how to avoid or at least cut down on foods that will affect blood glucose levels more than others.

Diabetes and pregnancy

From here, I decide to dip into some talks on diabetes and pregnancy. One talk really catches my eye – Metformin and pregnancy and beyond: The pros and cons. It is not the first time metformin has been talked about at this conference and I am intrigued to see how this drug is used in pregnancy

Around one in every six pregnancies are affected by diabetes - 84% of this is gestational diabetes with the remaining 16% in women with pre-existing type 1 or type 2 diabetes.

The speaker, Professor Fidelma Dunne, a very well-known expert in this area, said that “diabetes begets diabetes,” because of the high number of women with gestational diabetes who go on to have type 2 diabetes post-pregnancy, in addition to the high number of babies born to mothers with gestational diabetes who go on to have type 2 diabetes themselves.

Why metformin? Why is this drug useful in pregnancy?

Metformin has been available for more than 60 years, so we have significant knowledge of its use and its safety data. It is simple to use as an oral medication, it is cheap and affordable with no complex storage issues. There is generally good compliance, and it has a global reach. In the mother, it reduces hepatic glucose output, increases insulin sensitivity without increasing the risk of hypoglycaemia (low blood glucose levels), is associated with less excessive weight gain during pregnancy and, in some trials, may reduce pregnancy induced hypertension.

In the foetus, because it crosses the placenta, it may reduce foetal insulin resistance and lead to less macrosomia and less neonatal hypoglycaemia.

Is metformin safe in terms of congenital malformations?

In an elegant and extensive database study, it has been shown that there is no evidence of any increased risk of congenital anomalies after first trimester metformin exposure.

In pregnant women with polycystic ovary syndrome, metformin treatment for the late first trimester until delivery might reduce the risk of late miscarriage and preterm birth but it does not prevent gestational diabetes. It also leads to less maternal weight gain which of course has future health benefits for the mother.

Despite all of this, there are still gaps in our knowledge of metformin and pregnancy. There has been no double-blind placebo-controlled trial of metformin in women with gestational diabetes. Women with a body mass index of less that 30 are generally not included in studies so we have no data on this cohort. In gestational diabetes, enrolment into trials is generally at 24-28 week and benefits of earlier enrolment needs to be explored and metformin use in women with gestational diabetes as diagnosed by the criteria laid out by International Association of Diabetes and Pregnancy Study Groups has also not been explored.

As I log off after this session, I realise that there is still so much that we don’t know – even for drugs like metformin – but, thanks to the efforts of thousands of people around the globe, we are making progress.

It is only through research that we will find the answer to “staying well until a cure is found…”

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