April McMurray and Dr. Brown, Lora Beth; Department of Nutrition, Dietetics, and Food Science

Introduction

DMT2 is a lifestyle-related disease where the body does not produce enough insulin or the cells are unreceptive to it, and it is now the most common form of diabetes1. DMT2 has several risk factors: obesity, poor nutrition, a lack of exercise, and genetics1. The diabetic population is growing throughout the world. Individuals who do not control the disease can suffer serious complications such as limb amputation and damage to the eyes, kidneys, nerves, and heart; treatment can also be very costly1.

The Tongan people are particularly at risk, because many have genetic dispositions for both obesity and diabetes2. Tongans generally consume larger meals, more meat, and less fruits and vegetables than other ethnic groups3. The rate of DMT2 in Tonga doubled in just 25 years. The prevalence of diabetes in Tonga is 15.1%, with more than 80% of cases undiagnosed4. This is almost double the rate of prevalence of DMT2 (8.3%) in the United States1. While living in Tonga, I observed that many people did not realize the seriousness or prevalence of the disease, or how it was negatively affecting their health. Those who were interested in taking the appropriate lifestyle changes and health measures often lacked the fiscal means to do so. My research project was a descriptive study of cultural, nutrition-related educational, and economic factors in diabetes in Tongans. Living in Tonga before, I observed that the level of nutrition related education was low; the people did not seem to know or care much about diabetes or how to maintain a healthy lifestyle. Even if they had known, the cultural practices and attitudes would have created barriers to making the necessary changes. In addition to the cultural barriers, Tonga did not have access to the resources required for treating diabetic patients. Due to my prior observations, I chose to focus my research on those three factors and examine the influence that each one has on DMT2 in Tongans.

Methodology

With the help of Lora Beth Brown, EdD, RDN I developed two surveys to be used in Tonga: one for diabetic patients and one for medical staff. We created a list of questions pertaining to each of the three factors, examining patient attitudes towards DMT2 and disease management practices. For the medical staff we chose questions that focused on their perceptions of the patients’ disease management and their recommendations for patients. The questionnaires were translated and pretested with Tongans living in Provo, Utah, then revised further and printed with the implied consent. In May 2013 I traveled to Tonga with the BYU nursing students. The surveys were administered during the time that we spent in the hospital on the main island. I also took daily field notes based on my personal observations. Because the sample population groups were too small for advanced statistical analysis, I analyzed the data with frequency distributions.

Results and Discussion

Due to the small sample size it is difficult to draw firm conclusions about the data gathered from the surveys; I was able to gain greater insights through my personal observations. Some of the most significant findings from this study are:

• About half of the DMT2 patients feel worried about the implications of their disease
• Most DMT2 patients take oral medication, but do not have the resources to do much else
• Medical staff members feel that many DMT2 patients are not compliant
• DMT2 patients have follow-up appointments every three to four months, and only get to visit with the doctor or dietitian for a few minutes. There are insufficient resources to educate and treat patients more thoroughly
• DMT2 patients often rely too heavily on the health care system itself, with the attitude that it is the doctor’s job to “fix” their disease
• Traditional foods are more nutritious, but younger Tongans are moving away from the traditional diet and consuming more convenience foods
• With modern developments, Tongans tend to consume the same sized portions as before, but make less nutritious food choices and get less exercise
• Tongans cannot afford more nutritious foods because they are so expensive, so they frequently fill up with cheap, processed foods such as Raman noodles and cookies
• There is an increased awareness and concern about health, particularly about DMT2, but there continues to be a wide range of attitudes

Conclusion

Although the limitations of this research project made it difficult to draw firm conclusions, the information I gathered from both the research and my informal observations suggested that there are cultural, educational, and economic factors that contribute to certain behaviors that may affect the prevalence for DMT2 in Tongans. Although there were many other aspects I would have liked to investigate, and the limitations of my project affected the ability to draw stronger conclusions, I was pleased with how much I found during the trip that supported me principle research claim. Amidst the roadblocks and frustration at each step in the process came some of my greatest professional development. Because of this experience, barriers included, I am prepared to be a more competent dietitian in the future.

References

1. American Diabetes Association. Available at: www.diabetes.org. 1995-2012. Accessed October 31, 2012.
2. Duarte NL, Colaguiru S, Palu T, Wang XL, Wilcken DEL. Obesity, type II diabetes and the ß2 adrenoceptor gene Gln27Glu polymorphism in the Tongan population. Clin Sci. 2003;104:211-215.
3. Bell AC, Swinburn BA, Simmons D, Wang W, Amosa H, Gatland B. Heart disease and diabetes risk factors in Pacific Islands communities and associations with measures of body fat. New Zeal Med J. 2001;114(1131): 208-214.
4. Colagiuri S, Colagiuri R, Na’ati S, Muimuiheata S, Hussain Z, PaluT. The prevalence of diabetes in the Kingdom of Tonga. Diabetes Care. 2002;25(8):1378-1383.