In this issue, Susan Weiner, MS, RDN, CDE, CDN, talks with Carol Brunzell, RDN, LD, CDE,
about developing a picture-based carbohydrate-counting resource for
people with type 1 diabetes in a Somali community in the United States.
Brunzell is an expert on providing specialized medical nutrition therapy
to adult and pediatric patients with type 1 and type 2 diabetes, cystic
fibrosis- related diabetes, diabetes in pregnancy and diabetes with
celiac disease and other comorbidities. She has traveled with her
pediatric diabetes endocrine team to East Africa for the past several
years teaching diabetes management to health care professionals and
working with children with type 1 diabetes in clinics.
How did this project get started?
Brunzell: I work with both children and adults with type 1
diabetes as a dietitian and diabetes educator. In the pediatric side of
my job, I work with a team of endocrinologists and nurse diabetes
educators. Over the years, we have seen increasing numbers of Somali
pediatric patients with type 1 diabetes as the immigrant population has
grown. Minnesota has approximately 38,500 Somali residents and is home
to the largest Somali population in the United States. In one study,
type 1 diabetes prevalence was estimated at about 1 in 400 Somali
children and adolescents. Similarly, in Finland, which is also home to a
large Somali immigrant population, investigators found that the
incidence of type 1 diabetes in Somali children is similar to that of
the general pediatric population in Finland. Control of diabetes has
been noted to be poorer in Somali youths compared to non-Somali youths
with type 1 diabetes attending the same clinics.
Our University of Minnesota Health pediatric diabetes team embarked
on this project to develop culturally relevant education materials to
assist families and children in managing their diabetes. The team was
led by pediatric endocrinologist Muna Sunni, MBBCh, MS.
The goal was to develop a tool, which would be widely available online
free of charge, to assist patients in our own clinics as well as in
other immigrant communities around the world and for patients with
diabetes in Somalia.
What were some obstacles that led to the development of these materials?
Susan WeinerBrunzell:Managing type 1 diabetes is especially challenging
for immigrant families coming from countries with few resources.
Language barriers and variable education levels of parents, with low
literacy rates particularly among women who are typically the primary
caregivers, in addition to social barriers and stressors make management
more challenging. Somali families identified carbohydrate counting for
traditional Somali foods especially difficult due to lack of resources
available affecting their ability to manage their child’s diabetes
effectively.
What foods comprise the typical Somali diet?
Brunzell: The traditional diet includes a variety of foods that
vary slightly from region to region in Somalia. Typical carbohydrates
consumed include rice, spaghetti, soor (Italian polenta) and a variety
of breads: canjeero/lahoh (thin unsweetened pancake), malawah (thin
sweet pancake), muufo (similar to cornbread) roti (flatbread) and
sabaayad (chapati). Other grains consumed alone or in breads are
oatmeal, barley, teff and sorghum. The breads may be served with added
oil, butter, sugar, honey, sweet tea, or spiced meat and vegetable stews
(suqaar). Proteins consist of beef, goat, lamb, camel, goat liver and
kidney, chicken, fish and eggs. Vegetables are commonly eaten in stews
or soups, in addition to salads. A banana is traditionally served with
lunch. A wide variety of fruits are consumed. Beverages consist of very
sweet teas (chai), juice with added sugar, and milk. Oil is used
liberally in cooking and is added to many foods. Dinner is served late,
around 9 p.m., and may consist of beans or beans mixed with various
grains called cambuulo and/or roti. American foods may be more commonly
consumed at the later meal along with traditional Somali food. A variety
of special sweets and other fried snack foods are served during
Ramadan. Carol Brunzell
What process did you use to develop these materials?
Brunzell: Traditional Somali foods were selected for this
project after gathering information from hundreds of food recall
questionnaires from Somali adults and children, discussions with a local
Somali dietitian, home visits with Somali volunteers who prepared
traditional meals with project staff, attendance at lectures on Somali
food and culture given by members of the Somali community, and visits to
local Somali grocery stores and restaurants. We also searched the
internet for Somali diet information and recipes. I prepared the most
common foods from a traditional Somali cookbook.
I made carbohydrate
calculations using the USDA National Nutrient Database for Standard
Reference and Nutrition Facts labels on food packages. Calculations of
the carbohydrate content of traditional foods were made by preparing
individual food items, measuring total yield and total carbohydrates of
all ingredients and dividing by the number of servings and the serving
size to be consumed. All prepared foods were measured using standard
measuring cups or weighed on a digital scale for carbohydrate
estimation. For prepared foods purchased without a nutrition facts
label, carbohydrate content was estimated using similar foods with known
carbohydrate and weighed on a digital scale.
What has been the reaction from the Somali community?
Brunzell: It has been heartwarming to see the reaction of
patients and parents to this guide. They are so happy to see a
carbohydrate-counting guide with their traditional foods. I continuously
ask for their feedback and if I have missed any foods. So far, everyone
is very pleased and tells me I have included all the typical foods. We
have also recorded nine diabetes education videos spoken or dubbed in
Somali, which will be freely available at a later date.
I made one video
on nutrition, carbohydrate counting, and how to calculate insulin doses
based on an insulin-to-carbohydrate ratio for sample meals and snacks.
It was a great pleasure to be a part of this project and to learn so
much about Somali foods and the community, and people are genuinely
appreciative. The link to the carbohydrate guide and article is listed
below.
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