"دیابت همدم من است": شیوه زندگی و خودمدیریتی در میان بیماران مکزیکی مبتلا به دیابت کنترل خوب و بد

This paper identifies naturally occurring lifestyle and self-care practices in managing type 2 diabetes mellitus that are associated with good glycemic control. In-depth, qualitative interviews were conducted in Guadalajara, Mexico, with 31 matched pairs of good and poor control diabetic patients (n=62), who were matched on their duration of disease and use of medications. While many themes were listed by both groups, a comparison of the responses indicated that themes of daily exercise with a preference for walking, eating beef and milk rather than chicken and fish, economic issues, and emotional issues distinguished poor-control patients. Good-control patients were more likely to have a negative reaction to their initial diagnosis, take a more comprehensive approach to control, eat only two meals a day (plus snacks), use noncaloric beverages to satisfy desires for more food, and know what their blood sugar levels should be.

This paper identifies lifestyle and self-care practices related to successful glycemic control. Hyperglycemia is associated with poorer outcomes in type 2 diabetes (Turner, Cull, Frighi, & Holman, 1999; UKPDS 33, 1998; UKPDS 34, 1998), and although self-management activities can improve glycemic control, improvements can be small and short lasting (Deakin, McShane, Cade, & Williams, 2005). Quantitative epidemiological studies of correlates of glycemic control have been limited by a focus on demographic variables, such as age, educational level, and gender. Qualitative anthropological studies have been limited by using a single group of patients and not distinguishing good- and poor-control patients in their study design. In this study, a case-control design is combined with qualitative interviewing. In addition, good- and poor-control patients are matched on their duration of disease and use of anti-diabetic medications. These latter two factors are known to affect glycemia and could potentially bias findings if either of the two factors were unequally distributed across the good- and poor-control groups. Thus, our study design highlights lifestyle practices that differentiate the groups. Anthropological contributions to the study of disease have identified macro-level forces that create epidemics such as the current increase in type 2 diabetes (Chaufan, 2004) and have also demonstrated the importance of the micro-level emic perspective in developing successful interventions. While theoretical work has implicated creation of unhealthy social and physical environments in the overall increase in diabetes (Chaufan, 2004), a continuing problem is the associated increase in morbidity and mortality of affected individuals and the costs to them, their families, and society. Our goal in this study was to focus on individuals and identify strategies used by diabetic patients in good control, so that these might be emphasized in educational efforts for poor-control patients. In addition, we feel that an understanding of the strategies that actually work for control of diabetes may point to the direction that macro-level changes must take to deal with the current epidemic.

There is a clear pattern of differences in reported themes between GCPs and PCPs. GCPs tended to react to their diagnosis in a negative manner, showing feelings of loss and perhaps beginning to accept the diagnosis. PCPs appear to have more of a problem assimilating their diagnosis and are more likely to use popular/folk explanations for the cause of their diabetes. While both GCPs and PCPs are motivated to take care of themselves due to concern and self-esteem for themselves and the value they have for themselves, PCPs more often report being motivated by others. GCPs appear to have a clearer understanding of the need to comprehensively manage hunger, weight and stress, the need for exercise and a careful approach to diet. They may also have a strong concept of the importance of will in control. With regard to exercise, working class Mexicans have little physical space in which to exercise—both homes and yards are small. For this reason, walking is an inexpensive and appropriate approach to exercise for adults. PCPs were more likely to mention walking as their preferred exercise and said they exercised daily. GCPs were more specific about the actual exercise they did, but claimed to exercise only twice a week. Differences in dietary patterns included more fruits mentioned by GCPs, indicating that they may be familiar with more different types of fruit and can adjust consumption to seasonal availability. GCPs consume the nopal-cactus leaf (Opuntia) which may have hypoglycemic properties and could be useful in glycemic control ( Argaez-Lopez et al., 2003). Sources of protein also differ, with implications in terms of increased consumption of animal fat and cholesterol for PCPs. The difference in number of meals consumed is also important. PCPs mentioned three meals, while GCPs, in contrast, mentioned consuming two meals a day, with supplementary snacks of fruit. Dealing with hunger is an important problem for diabetic patients; GCPs use low-calorie beverages (coffee and tea) to satisfy hunger, as well as tortillas. Tortillas, and in particular corn tortillas are inexpensive, satisfy feelings of hunger, are a good source of energy and serve to extend other foods (as other foods are usually eaten by using tortillas to scoop them up). Further, they are among foods traditionally consumed in Mexico, particularly among the working class. GCPs may tend to be more concerned with problems in preparing a separate diet, as well as admitting to eating forbidden foods. However, PCPs may use more alcohol, be angrier about the need for a special diet, and have refused to accept such dietary restrictions. GCPs appear to have developed an improved version of Mexican popular culture. They maintain food traditions, such as eating tortillas, though in lesser quantities, have eliminated foods with a high degree of saturated fat from their diets, and have integrated effective exercise regimens into their lifestyles. They have found ways to control feelings of hunger with filling foods that are low in caloric content. GCPs mix traditional and modern approaches to life and lifestyle. In contrast, PCPs are aware of what they need to do but do not seem to have really internalized this. As one noted, “One thing is to know and one thing is to feel.” Emotional issues are another aspect of diabetes management. GCPs report fewer emotional problems, which may be related to the fewer economic problems they report. Work constraints are more important for PCPs, and they are more likely to report inadequate family support. The pattern of women seeking support from their (usually male) physicians may be related to Mexican patterns of male authority or machismo. Similarly, the pattern of women meeting the needs of male members of their households may be why males noted sufficient support available from their families. Finally, GCPs may have more faith in their prescribed medications, which may affect compliance; PCPs expressed more interest in using natural medications. And it is the GCPs who know the desirable level of blood sugar for which to aim. In contrast, the PCPs were unaware of or wrong about the meaning of biomedical glycemic control. Some aspects of our results confirm patterns cited in the literature, such as anger over one's diet and the problems of eating a diet different from that of the rest of the family (Eid & Kraemer, 1998). Women in our study also reported the lack of dietary and other support from family members as noted by other studies (Adams, 2003; Anderson et al., 1998; Mercado & Vargas, 1989; Savoca & Miller, 2001). Economic issues may also be a barrier to achieving good control. Hunt, Arar, and Larme (1998, p. 672) noted that financial resources of low income Mexican American diabetic patients “were already strained to the limit even before they tried to make special dietary arrangements.” A concern with economic problems was mentioned more often by PCPs, despite there being no significant differences in income level between the two groups. However, a large, representative US sample showed no association between economic status and glycemic control (Harris, Eastman, Cowie, Flegal, & Eberhardt, 1999). Similar to Daniulaityte (2004), who studied largely patients in poor control, these PCPs also tend toward folk explanations of diabetes. Nor do they seem to have accepted their diagnosis, a pattern also noted by Egede and Bonadonna (2002) in some African American diabetic patients. With regard to the issue of focus on self and personal responsibility, our results show some similarities to those of Ellison and Rayman who found that GCPs report “I’m the one that has to make it work. I can’t ask anybody else to do it for me, so any success I’ve had is mine, and my faults are mine too” (Ellison & Rayman, 1998, p. 327). However, our study suggests that this pattern is characteristic of GCPs and not of PCPs. But the pattern in our respondents may be less apparent due to the fact that these values and attitudes more alien to Mexican culture than to the Americans Ellison and Rayman studied. Those patients had a focus on self and control, the need to be personally responsible for their health needs, and learning to experiment for themselves, as did those studied by O’Connor et al. (1997). Yet it appears that Mexican GCPs may have been able to develop and incorporate these traditionally nonMexican approaches. Our study also contributes methodologically to work in this area; unlike most studies, we used a qualitative but case-control design of good and poor control diabetic patients. Furthermore, we also estimated the relative occurrence and importance of the themes respondents discussed, and noted differences between GCPs and PCPs. From this more systematic description, we find some themes mentioned by all patients, such as problems in exercising and following their diets. But these themes may not be the clue to better control. Our design made it possible to identify 10 major themes of specific differences not previously discussed in the literature; themes of daily exercise with walking preferred, eating beef and milk rather than chicken and fish, economic issues, and emotional issues distinguished PCPs. GCPs were more likely to have a negative reaction to their initial diagnosis, take a more comprehensive approach to control, eat only two meals a day (plus snacks), use noncaloric beverages to satisfy desires for more food, and know what their blood sugar levels should be. These patterns, as well as a number of other themes suggested by these data, should be explored further. We need to qualitatively investigate the process by which the self-focused identity of the good control diabetic develops in a cultural milieu which stresses the family over the individual. Also, while larger, systematic studies to date have not found an association between income and glycemic control (Garcia de Alba et al., 2006; Harris et al., 1999), our data do suggest that economic problems are a much greater concern for PCPs. In addition, due to the small size of the sample used in this study, the specific behavioral and lifestyle differences we found between GCPs and PCPs should be used as hypotheses and tested in a larger sample of both Mexican GCPs and PCPs. The GCPs in this study have evolved a number of successful strategies for dealing with their disease. If these are found in larger samples, they could be learned by health care personnel and become the basis of revised approaches to diabetes education and management. Such approaches would focus on what Mexican GCPs actually do, as opposed to more generalized biomedically based recommendations for diabetes management. In summary, this study has identified behavioral and lifestyle themes that may account for control differences between Mexican good and poor control diabetic patients. Diabetes is a health problem of sufficient magnitude that it behooves us to learn how control is achieved from those who actually live with this disease. We must learn from those for whom diabetes is the companion with whom they walk through their lives.