Diabetes in the Eritrean and Ethiopian Community: Cultural Information and Recommendations for Diabetes Educators
Diabetes prevalence is increasing in many immigrant communities that have little to no experience with chronic disease management. Diabetes educators at Harborview Medical Center in Seattle, WA have been working to meet the needs of the rising population of immigrants with diabetes, both newly diagnosed as well as those living with pre-existing diabetes, by customizing education programs to provide culturally appropriate information and resources. The goal of this article is to address the unique cultural factors in the Eritrean and Ethiopian immigrant communities of Seattle that impact diabetes self-management (excluding gestational diabetes). This document does not focus on the many other variables beyond cultural factors that play a role in the health and care of immigrants, including health care access, health literacy, financial constraints, level of education, employment, and housing.
A convenience sampling method was used to identify eight key informants from Harborview Medical Center involved in the care of these communities for semi-structured interviews, including health care providers from the International Medicine Clinic (medical director/physician, clinical pharmacist, pharmacist, and a dietician), a nurse, a medical assistant, a diabetic patient, and a caseworker / cultural mediator for Amharic-speaking Ethiopian patients and their health care providers. Five interviewees were from the Ethiopian or Eritrean community including two who identified themselves as Ethiopian, two as Oromo, and one as Eritrean. Informal interviews were conducted with ten Ethiopian or Eritrean Harborview/University of Washington employees (housekeepers, patient transporters, medical assistants, and nurses). A short anonymous survey was conducted including 40 cross-generational members of the Eritrean community at an Eritrean health fair held in April 2010 in Seattle. The content from the interviews and questionnaire was analyzed and triangulated with existing content from the EthnoMed website and published literature for the development of this profile. While it is important to understand cultural influences when approaching health care issues, one must be careful not to simply generalize. Providers are encouraged to be aware of some of the overall cultural values of the community and then explore the pertinent themes as they relate to providing care for individual Eritrean and Ethiopian patients. There is great diversity within these communities.
The Ethiopian and Eritrean People
In the Horn of Africa, diversity of religion, language, politics, and culture mix to form the centuries-old history and rich tradition of the Ethiopian and Eritrean people that continues on among the immigrants who have resettled in the U.S. According to the Ethiopian Census of 2007 there are over ten major ethnic groups in Ethiopia, with Oromo (34.5%) and Amara (26%) comprising the largest groups (Federal Democratic Republic of Ethiopia Populations Census Commission, 2008). In Eritrea, there are nine major ethnic groups. The Tigrinya people make up 50% of the population (CIA World Factbook: Eritrea, 2010).
Emigration from the Horn of Africa
During the thirty-year civil war between Ethiopia and Eritrea, ending with Eritrea’s independence in 1991, daily life was disrupted and many people were displaced to refugee camps in neighboring countries such as Sudan, Somalia, Kenya, and Tanzania. Others emigrated to Europe (Germany, Sweden, Italy), North America (United States, Canada) and Israel. The largest wave of Ethiopians and Eritreans arriving in the U.S. was from 1989-1993, most seeking refuge from political turmoil, famine and economic instability. Eritreans fleeing to neighboring countries has sharply increased in the past few years due to repression, human rights violations, and forced conscription. According to the Sudan Tribune (Tekle, 2010) 1,458 Eritrean refugees were resettled to the U.S. Over the years, many Eritreans have arrived voluntarily in North America to further their education and seek opportunities difficult to attain back home.
The Communities in Seattle
In Seattle, the Ethiopian and Eritrean communities are diverse in economic, educational, and religious backgrounds as well as phases of acculturation from new arrivals to second and third generation youth immersed in American culture. It’s difficult to obtain accurate population numbers by country of origin, but East African community leaders estimate the Puget Sound population of East Africans, including Ethiopians, Eritreans and Somalis, to be 30,000-40,000 (Ho, 2006). Many Ethiopians and Eritreans maintain strong family and community relationships. People gather for support, education, and celebration in Oromo, Ethiopian, and Eritrean community centers and for spirituality in mosques and churches, including Orthodox Christian, Protestant and Catholic. The family unit is multigenerational, often living together in one home. This network strengthens the family and community, as those who are more acculturated help others navigate the new environment.
The major languages spoken by Ethiopians and Eritreans in Seattle include Oromo, Amharic and Tigrinya. Amharic is the national language of Ethiopia and Tigrinya and Arabic are the national languages of Eritrea. Oromo is a major language spoken by millions of people throughout Ethiopia and parts of other East African countries.
Accurate literacy data is hard to find. In 1996, soon after the arrival of the largest wave of immigrants to the U.S., it was estimated that 81% of Ethiopians and Eritreans had some English language proficiency, ranging from basic skills to fluent, while 19% had no English skills at all. Many elderly Ethiopians and Eritreans have had minimal or no formal education prior to arrival (Beyene, 1996).
Epidemiology & Observations
In sub-Saharan Africa the health care systems are often severely resource-limited. Without adequate financial, structural, and human resources, the management of acute care issues takes precedence over prevention-based interventions and chronic disease management (Whiting, Hayes, & Unwin, 2003). The prevalence of many non-communicable diseases is largely unknown because screening for and management of chronic disease are luxuries that most health care systems in developing countries cannot afford.
Reports on diabetes have been published in Ethiopian medical journals since the 1960s, most notably on atypical types of diabetes related to malnutrition. The World Health Organization (WHO) included malnutrition related diabetes on its list of major classes of diabetes in the 1980s but it has since been removed as the evidence for a distinct phenotype is not clear (WHO, 1999). The WHO classification describes these less well-understood types of diabetes as idiopathic and recognizes that there is a subtype of diabetes more common among individuals of African and Asian origin. This subtype presents with insulinopenia and a predisposition to ketoacidosis but no evidence of autoimmunity (WHO, 1999). In some literature this has been termed lean type 2 diabetes. Many of these persons can be managed on oral medications for many years but end up requiring insulin. Complications seen more commonly in these persons include neuropathy, infection, and nephropathy (Tripathy & Samal, 1997). With African migration to countries of Europe and North America, these atypical diabetic subgroups may become more common (Gill, Mbanya, Ramaiya, & Tesfaye, 2009).
Urbanization throughout the African continent has led to an increasing prevalence of typical obesity-related type 2 diabetes, associated with urban lifestyle changes including increased food quantity, reduced food quality, and low levels of activity compared to more traditional, rural lifestyles (Gill et al., 2009). Like the South East Asian population, metabolic risk for type 2 diabetes can occur at a body mass index (BMI) that would be considered normal or overweight in the Caucasian population.
While epidemiological data is difficult to collect in resource-limited settings, diabetes prevalence in Ethiopia and Eritrea has been estimated to be 1.9% (Gill et al., 2009). Recently published data from Eritrea report a prevalence rate of 2.2% based on patient information obtained through a National Diabetes Registry in 2004 (Seyum, Mebrahtu, Usman, Mufunda, Tewolde, Haile et al., 2010).
Thousands of Ethiopian Jews emigrated to Israel in the 1980s. Data collected among this population by the Endocrine and Diabetes Unit of Hillel-Yaffe Medical Center showed a rise in diabetes prevalence to 17%, twice as high as the average rate among Israelis (Jaffe, 2002). Another report from the Hebrew University of Jerusalem recorded a prevalence increase from 0.4% rising to 5-8% among young Ethiopians within five years of arrival. Obesity was not always correlated with diabetes in this sample where the average BMI was 20-22, but a waist-to-hip ratio of 0.9 suggested abdominal body fat accumulation (Trostler, 1997).
While documented prevalence of diabetes specific to Ethiopians and Eritreans in the U.S. cannot be found, there is observational evidence that diabetes is a growing problem in the East African community of Seattle. A provider at the International Medicine Clinic at Seattle’s Harborview Medical Center estimated that 60% of the East African patients he sees have diabetes. One Ethiopian interviewee living in Seattle stressed that the major question in his community is “Why do we have so many new cases of diabetes?”
Management of Diabetes in Ethiopia and Eritrea
Both Ethiopian and Eritrean health professionals have been affiliated with the International Diabetes Federation through national diabetic associations since the 1990s (Seyoum, 2007). Many people emigrating from Addis Ababa, Ethiopia; Asmara, Eritrea; or other large cities have heard of diabetes due to easier access to health care and rising prevalence of diabetes in urban settings. Outside of the urban centers, however, access to health care is far more limited and awareness of diabetes is far less. Oral medications currently available for diabetes in Eritrea, Ethiopia, and much of Africa include glibenclamide (a sulfonylurea medication used commonly in Europe, but not in the U.S) and metformin. Insulin remains very expensive and in limited supply (Whiting, 2003). Glucose testing strips are also generally not available for patients’ self monitoring and may even be in limited supply for health care providers. Patients in the U.S. are often very surprised to learn that they are expected to use a machine to monitor their blood glucose at home.
Management of Diabetes in the U.S.
Immigrants are more aware of diabetes in the U.S. than they were back home, making diabetes seem like an American phenomenon. Interviews and a literature review conducted for this project did not reveal any common folk explanations or treatments for diabetes; however, holy water and prayers remain a powerful healing force for many general health conditions in these communities. According to a survey done with Ethiopian immigrants in Israel, “Traditional healers are highly respected, but for diabetes people would use Western medicine.” (Guttman, 2002). A similar sentiment was gleaned from information gathered in Seattle.
Cultural Barriers & Support in Chronic Disease Management
The following were common themes that emerged through interviews and informal discussions, which impact acceptance of a diabetes diagnosis and self-management of this chronic disease.
Health Care Culture
Health care in resource-limited health systems is often difficult to access and episodic focused. As one Ethiopian interviewee explained, “Health care is a luxury back home. You go to the clinic when you are sick and expect a short course of medication that ‘cures’ the problem.” Coming from this type of health care culture, prevention of disease and chronic disease management are foreign concepts. It may be difficult for many persons in these communities to understand a disease that doesn’t make you acutely ill and must be managed over a lifetime without cure.
With longer duration of time spent in the U.S. comes more knowledge and experience of chronic disease, Western medicine, and the U.S. health care system. Many people do become accustomed to the concept of prevention and chronic disease over time. An informal, cross-generational survey of 40 participants at an Eritrean health fair in Seattle who had resided in the U.S. for 5 years or more revealed that two-thirds of those questioned knew someone with diabetes and 3 out of 40 participants had diabetes. Most middle-aged and older adult respondents named lifestyle factors such as poor diet, lack of exercise, and stress as contributing factors to diabetes. Many mentioned diet and exercise as primary treatments for diabetes, while only a few participants mentioned medications.
It can be difficult to address prevention when fate is determined outside the realm of the patient’s control. Dr. J. Carey Jackson, medical director and physician at the International Medicine Clinic at Harborview Medical Center explains, “There is a beautiful tradition in both Orthodox Christianity and Islam of ‘God’s Will,’ meaning when it’s time to go, it’s time to go. People don’t fear their mortality. What many don’t know is that diabetes takes you chip by chip by chip over the years. With the patient, I’ll break down the effects of chronic disease into terms that speak to a person’s day-to-day functioning, over which one may have more control. For example, I’ll say to the patient whose family situation I know well, ‘I know you’re not afraid to die, but do you know that your teenage grandson is going to have to take you to the bathroom and toilet you because you may have had a stroke and won’t be able to use your arm?’”
Death may not be feared, but most people don’t want to lose their independence or become a burden to their family. The “chip by chip by chip” approach can be used to illustrate the functional deficits that may occur from macrovascular damage (heart disease and stroke) or microvascular damage (renal damage, retinopathy, neuropathy, and erectile dysfunction) over time.
Medication adherence was a topic that came up frequently in interviews and discussions with providers and Ethiopian and Eritrean community members. Consensus was that most people do not want to take medication long-term. Back home, medication was used on a short-term basis to “cure” something and then it was stopped. Taking medication over a long period of time as a means to prevent damage from chronic disease may be unfamiliar and difficult to understand. In interviews, there were several recurring reasons people did not want to take medication including a generalized fear of side effects, a feeling that Western medicine is too strong, and a fear that once started, one may never be able to stop, perceiving long-term medication adherence as addiction or dependency rather than chronic disease management. Patients often stop taking medications without informing their health care provider.
Refills can be confusing for multiple reasons. Some people feel that once the bottle is empty, the treatment is done. Others may wait for their next visit, which may be weeks or months out, before they get another refill. There are many logistical reasons for having trouble refilling medications such as inadequate finances, lack of insurance, language barriers, and difficulty navigating automated systems.
An Ethiopian caseworker / cultural mediator pointed out that her clients are able to learn how to test their blood sugar but many have trouble determining how to interpret the results and integrate them into daily self-management. Several older, Tigrinya-only speaking women with diabetes at the Eritrean health fair sought clarification on what to do with their medication according to blood sugar levels asking, “Do I take my morning dose if my blood sugar is low?” Taking the time to ensure understanding of such concerns is paramount to effective diabetes self-care.
Being diagnosed with a chronic disease can be a shock to anyone, regardless of cultural background. For a community less familiar with diabetes, ensuring acceptance of the disease and an understanding of the disease process will be the key first step. Without acceptance of the disease, teaching the important aspects of diabetes self-management will be ineffective.
Denial of disease is common and spans generations. Examples of comments made to a pharmacist at Harborview’s International Medicine Clinic include a younger patient who expressed, “Diabetes is for older people and the obese. I am young and very active. How could I be diabetic?” and an older patient who remarked, “I’ve been living healthy for 60 years. How could I be diabetic? I don’t feel sick.”
Ethiopian and Eritrean interviewees stressed the importance of intensive counseling and education, especially when building the foundation of disease knowledge with patients. Taking the time to ensure understanding of this complicated disease can greatly enhance the patient-provider partnership and improve chronic disease outcomes in this vulnerable population.
When explaining treatment for diabetes, it is sometimes helpful to use analogies. For example, using the concept of 1. replacement therapy: “When the body does not make enough insulin, it can be added via injections.” and/or 2. correction versus cure: “Glasses do not cure vision but corrects it so that you can see more clearly, just as diabetes medications do not cure diabetes but correct high blood sugar so that the body remains healthy.”
There are many approaches to health education. The approach used should be tailored to the individual. For some, the consequences of poorly managed disease were effectively conveyed through graphic examples of potential outcomes including blindness, amputation, heart attack, stroke, and erectile dysfunction. This message becomes clearer as people experience real-life examples of disease progression themselves or within their family and community. Many interviewees encouraged reinforcing the connection between the impact of treatment interventions (diet, exercise, and medication) as prevention efforts that can avert debilitating, often irreversible outcomes.
Since many Ethiopians and Eritreans are averse to using medications, a motivational approach may be more appropriate focusing on how improving diet and exercise may decrease the need for medication, emphasizing the benefits to overall health and quality of life. Be cautious not to give false hope, as diabetes is a progressive disease usually requiring more medication over time, even in those with excellent control for years.
Family & Community
Extended family units in the Ethiopian and Eritrean communities of Seattle remain very strong and supportive across the generations. It has been observed at Harborview’s International Medicine Clinic, serving non-English speaking patients, that many older Ethiopian and Eritrean patients are accompanied by younger family members who help them navigate the health care system. Many Ethiopians and Eritreans in Seattle are employed in the local health care system from ancillary staff to medical professionals, who use their knowledge and expertise of the American health care system to educate their communities through individual support and community outreach projects. Eritrean and Ethiopian community groups have organized annual health fairs to raise awareness within their communities on topics such as diabetes, hypertension, heart disease, HIV/AIDS, domestic violence, and other health concerns.
The biggest barrier to exercise in Seattle was unanimously reported to be the weather. This barrier is not unique to Ethiopian and Eritrean immigrants but may be a greater challenge for those coming from a warmer climate. Other reported barriers include fear of getting lost, being outside the home with limited English language skills, fear of walking alone, having no one to walk with, and busy work schedules. People report they do far less walking than they did back home because of the availability of cars and public transportation. The most practical and familiar suggestion for older adults is to encourage more walking. Remind people of the walking they did back home and help them find ways to build it into their lifestyle here. One caseworker / cultural mediator recommends suggesting that people bundle up and find a walking buddy or walk in the mall when the weather is bad. Men often played soccer back home and many continue to get together weekly to play. People have mentioned joining athletic clubs and using exercise equipment available in their community. There are certainly many more exercise options that can be discussed on an individual basis. (See 2011 calendar dates for exercise classes held at the Ethiopian Community Mutual Association in Seattle)
Eating Habits in the U.S.
Many Ethiopians and Eritreans continue to adhere to traditional eating habits, finding ingredients from back home in specialty East African stores or substitutes in American grocery stores. Arriving in the U.S., however, brings dramatic change in available food with an abundance of high calorie, low nutritional value food at low prices (Venters & Gany, 2009). The economic pressures, fast pace of life, and availability of cheap, convenient foods are major contributing factors to rising rates of obesity with longer residence in the U.S. among many immigrant groups (Goel, McCarthy, Phillips, & Wee, 2004). Acculturation of younger generations brings more American influence into traditional homes.
Many immigrants continue to eat traditional foods prepared at home and served on and eaten by hand from communal platters, though some have adopted the use of individual plates and utensils. It is customary to offer generous amounts of food and is generally considered rude to decline even if one is no longer hungry. These are mealtime challenges for diabetics trying to address portion control. Generally, men eat outside the home more often than women. Women continue to do most of the cooking at home.
Food of Ethiopia and Eritrea
Ethiopian and Eritrean immigrants continue to celebrate and share their culture through the many Ethiopian and Eritrean owned restaurants serving traditional foods throughout the U.S. In interviews, Ethiopians and Eritreans concur that the traditional foods of their two countries are basically the same with some regional variations in recipes. Below are some of the more common ingredients and dishes.
Injera: This flat, sour bread is the traditional staple food of Ethiopia and Eritrea. It plays an essential role in the Ethiopian and Eritrean meal comprising both the serving platter and the utensil for consuming it. A piece of injera measures about 12-16 inches in diameter. Every meal is served with extra injera that is broken off into smaller pieces to pick up sauces in bite-sized portions. Traditionally, injera can be made with a variety of different flours including teff (three varieties: white, brown, and mixed white and brown), barley, wheat, millet, sorghum and corn depending on regional recipes. Brown teff is generally referred to in Ethiopia and Eritrea as “red teff.” Teff is the most popular ingredient and has unrivaled nutritional value. It provides more essential amino acids, iron, calcium, and potassium than any other grain. Due to its small size, teff cannot be refined like other flours so it is much higher in fiber and complex carbohydrates, which are important in blood sugar control (The Center for Innovative Food Technology). In the U.S., teff is expensive and not widely available so other, less nutritious flours are used as substitutes. Some people continue to make their own injera at home while others rely on store-bought injera. In Ethiopian grocery stores in Seattle, one can buy fresh injera made with a mixture of teff and self-rising wheat flour. A 25-pound bag of teff flour grown in Caldwell, Idaho can be purchased for around $40.
Genfo: This porridge made from barley or wheat flour is a comfort food often served for breakfast, especially during the Orthodox fasting periods. Butter or oil and berbere spice fills the middle of this porridge.
Other carbohydrate staples include pasta, rice, and breads.
Most traditional dishes are comprised of meats, legumes, and vegetables cooked into stew called wot (Amharic), tsebhi (Tigrinya) or itto (Oromo). The base of all stews is a mix of spices and oil. Some stews have spiced butter added, as well.
The mainstay of Ethiopian and Eritrean flavor is berbere. This is a traditional mix of spices used in many recipes that may include chili peppers, ginger, cloves, coriander, allspice, fenugreek, paprika, cumin, cardamom, nutmeg, cloves, cinnamon, anise seed, curry powder, onion powder, garlic powder and other spices grown in Ethiopia and Eritrea. Mitmita is a powdered seasoning made from hot peppers, cardamom and salt that is usually served with kitfo. Salt use is not as significant in the diet as these other spices.
Eating pork is forbidden for Muslims and most Orthodox Christians. Tibs is the name for cooked meat dishes made of beef, lamb, goat, or chicken. Small cubes of meat are often sautéed or fried and served with wot. Doro wot (Amharic) or tsebhi dorho (Tigrinya) is a chicken dish with boiled eggs commonly served on special occasions. Kitfo is a very popular specialty dish made of raw, ground beef mixed with spiced butter. Fish is eaten, as well, and allowed during the Orthodox vegan fasting periods.
Lentils, broad/fava beans, peas, and chickpeas are all staples, especially during the fasting periods. Shiro wot is a dish prepared with roasted and powdered beans (peas, broad/fava beans, chickpeas) mixed with oil and berbere sauce. Chickpeas are made into dumplings and sautéed in oil and berbere spices in a dish called shimbra asa.
Green pepper, mustard greens, collard greens, kale, spinach, carrots, tomatoes, cauliflower, green beans, and cabbage are used in a variety of traditional dishes. Vegetables are often cooked into an atkilt (Amharic) or atikilti (Tigrinya), which is a mild, vegetable stew. Gomen is a sauce made of collard greens with oil, onions, and herbs. Many meals are served with a small, fresh salad of iceberg lettuce and tomato with vinaigrette; otherwise most vegetables are commonly consumed cooked.
Tropical fruits including bananas, mangoes, oranges, and papaya are familiar.
Cheese plays a small role in the traditional diet. Aib is a soft cheese like cottage cheese consumed with meals. Yogurt and milk are also consumed.
Oil is an important part of traditional cooking. Homemade, spiced butter called niter kebbeh or kibe (Amharic, Tigrinya) or dhadha baksa (Oromo) is used in many meals.
The southwestern (Oromia) region of Ethiopia is the birthplace of coffee. The traditional coffee ceremony continues to be a daily tradition in the lives of many Ethiopians and Eritreans. Coffee and tea are often served sweetened with sugar or honey or served with salt. Traditional homemade alcohols include a honey wine, tej (Amharic), miyes (Tigrinya), or dadhi (Oromo); and homemade beer, tella (Amharic) or suwa (Tigrinya), or farso (Oromo).
Sugar and honey are commonly used in beverages. Sugary foods and soft drinks may be more available and affordable in the U.S. than they were back home.
Religious Observances and Fasting
Religion continues to play an important role in the lives of Ethiopians and Eritreans coming from a corner of the world where Christianity, Islam, and Judaism have coexisted in relative harmony for centuries. In Seattle, there are mosques and churches where many gather to worship, including Ethiopian Orthodox, Eritrean Orthodox (including Coptic Orthodox), Protestant, and Catholic churches. This section aims to address the Islamic and Orthodox Christian practices of fasting as they relate to diabetes self-management and by no means attempts to cover the rich and complex history of these religious traditions.
Islam was first introduced in Ethiopia in the 7th century A.D. via persecuted followers who arrived from Mecca. Today, about 34% of the population of Ethiopia and 50% of the population of Eritrea practice Islam (Federal Democratic Republic of Ethiopia Populations Census Commission, 2007; U.S. Department of State, 2008). The majority of Oromo people in Seattle are Muslim.
Fasting is one of the five pillars of Islam that all followers must observe during the holy month of Ramadan. Children who have not reached the age of puberty, sick persons, and pregnant or breastfeeding women are exempt from fasting (EthnoMed, 2010). The Islamic calendar follows a lunar cycle. The period of Ramadan is observed during the ninth month of the lunar calendar and lasts one lunar cycle, changing from year to year. Fasting consists of daily abstention from food and drink from sunrise until sunset.
Christianity was adopted as the state religion by an Ethiopian emperor during the 4th century A.D. (Sellassie & Tamerat, 1970). Today the Ethiopian Orthodox Tewahedo Church and Eritrean Orthodox Tewahedo Church (including the Coptic Orthodox Church) all follow traditions of the umbrella Oriental Orthodox Church. Approximately 44% of the population of Ethiopia and 30% of the population of Eritrea are Orthodox Christians (Federal Democratic Republic of Ethiopia Populations Census Commission, 2008; U.S. Department of State, 2007).
Since the earliest days of the religion, fasting has been practiced as a way to bring the body in line with the spirit (Sellassie & Mikael, 2003). There are over 250 fasting days in the year practiced by the most devout. Many faithful practice less than this, however. Unlike the structured fasting of Muslims during the holy month of Ramadan, Christian Orthodox fasting practices vary widely among individuals. While all fast with a vegan diet, the fasting periods of the year and times of the day one fasts are more individualized.
Orthodox Fasting Periods
In general, fasting implies abstention from food and drink until noon at the earliest, after which a meal is consumed. A modified (fish is permitted) vegan diet is followed during the entire fasting period with abstention from all animal products including meat, cheese, milk, eggs, and butter. Pregnant women, children under seven, and the seriously ill are exempt from fasting (Sellassie et al., 2003).
There are seven official fasting periods including (Sellassie et al., 2003; Aymero & Joachim, 1970):
- Abiy Tsom, the Great Lent (March/April). Abiy Tsom (Amharic) or Tso Arbaa (Tigrinya) is the most important and rigorous fasting period. It lasts a total of 56 days ending with Easter Sunday. The most devout abstain from all food and drink from the eve of Good Friday until Easter Sunday, remaining at church praying during these final fasting days. Many are less strict during the final days and eat an evening meal after prayers.
- Fast of the Assumption in honor the Virgin Mary’s assent into heaven (August). Fasting takes place for the 15 days prior to the Feast of Assumption on August 15.
- Gene (Amharic) or Tsome Tahsas (Tigrinya), the fast preceding Christmas (December/January). By the Ethiopian calendar, Christmas is celebrated on January 7th. This fast is during the 40 days prior to Christmas, ending on Christmas Eve.
- The Gahad of Christmas (Christmas Eve)
- The Fast of the Prophets of 43 days. This fasting period is compulsory for clergy only.
- The Fast of the Apostles. Yesene Tsome (Amharic) or Tsome Sene (Tigrinya), begins after Pentecost (50 days after Easter) and lasts10-40 days. This fasting period is compulsory for clergy only.
- All Wednesdays and Fridays throughout the year, except for the 50 days after Easter.
More Diabetes Education Tips for Providers/Educators
- Always ask a patient about his/her particular fasting practices. Discuss the effects of fasting on the management of diabetes, addressing diet changes, blood sugar monitoring, and medication management. Often patients have experimented with and developed their own regimens for fasting periods. Explore this with the individual to devise an appropriate, patient-centered plan for self-care during these times.
- Encourage patients to check blood sugars more often while fasting. Keeping a consistent fasting pattern and knowing how blood sugars change during fasting periods can help establish an individualized routine for medication modifications during these times.
- While both Islam and Christianity allow the sick to be exempt from fasting, many with chronic disease do not consider themselves sick enough to abstain from this important spiritual tradition.
- Ask about the foods the patient is eating so you can talk in a meaningful way about disease intervention through diet modification.
- Find out who is doing the shopping and cooking at home and try to get him/her involved in diabetes education and nutrition classes.
- Monitoring portions is an important intervention in diabetes self-management but may be difficult when eating from a shared platter with others. The “plate method” can help with understanding the concept of recommended portions of vegetables (1/2 plate), protein (1/4 plate), and carbohydrate (1/4 plate) even if eating from a shared plate. Encourage patients to cut their injera consumption to 1/2 or 3/4 of an injera per meal.
- Precise measuring of food is not common in traditional Ethiopian and Eritrean cooking. Dietary advice on portions is better-received using measures such as the palm of the hand or a ladle in lieu of measuring spoons, cups and other metrics.
- The concept of nutritional content of food is complicated. Counting carbohydrates is an unfamiliar concept in this community. In interviews, no one endorsed using carbohydrate counting to manage dietary intake.
- Stews (wot, atkilt, etc.) are made with varying quantities of oil. Try to get an idea of how much oil is being used by asking questions such as “How often do you go through a bottle of oil?” or “Is the oil visible atop the stew?” or other questions that can help quantify how much oil is being used per person or serving and what may be a major contributor to weight gain that predisposes to diabetes.
Disease Management Education
- Most interviewees felt education was best received when done directly and one-on-one with a provider. Many felt that getting messages out to the community about diabetes through outreach in community gathering places is a good approach and would be well received. Handouts were perceived as less useful educational tools. Classes may be hard to attend due to demanding schedules.
- Assess baseline diabetes knowledge and get a sense of the individual’s general understanding of chronic disease. An Ethiopian caseworker / cultural mediator has found that many of her diabetic clients have difficulty understanding how exercise, diet, and medication all work together to prevent the microvascular and macrovascular sequelae of diabetes. Allow ample time for education.
- People learn how to take their blood sugars but may not know how to interpret them in light of the disease process and self-management. A dietician at the International Medicine Clinic gives her patients homework assignments to help elucidate the link between diet and blood sugar. She has her client eat a typical quantity of food for lunch then check a blood sugar two hours later. The next day, the client is to cut the carbohydrate portion of lunch in half, check a blood sugar in two hours, and compare the change from pre- to post-meal from these 2 different meals.
- Assess whether the patient can work with numbers and do basic arithmetic before prescribing corrections to insulin regimens.
- Provide local community information about how patients can safely dispose of sharps and importance of not putting them in the household trash.
- Many older Oromos never went to school so may not speak, read or write Amharic, the national language taught in Ethiopian schools. Younger Oromos may not read or write Oromo but some speak Amharic because of time spent in public schools in Ethiopia. Many Oromos may prefer classes in Oromo or English if English language skills are proficient.
- At the Eritrean health fair, most middle aged and older adults surveyed stated they prefer health education in Tigrinya. The health fair posters, handouts, and lectures were all in Tigrinya.
- With over 80 languages spoken in Ethiopia and Eritrea, most people are functional communicators in several languages. Dialects may differ, however, which makes translation of written materials and interpretation complicated. Oromo translations of written material may be especially problematic because in 1991 the Oromo language was standardized to facilitate communication by individuals from different regions and aid communication in government, schools, and the media. Because many expatriate Oromo-language translators emigrated to the U.S. prior to 1991, translations may not be understandable by more recent Oromo-speaking émigrés. Spoken language is less problematic.
- If the client is not fluent in English, always use a trained medical interpreter for interactions, especially when explaining a new diagnosis, describing the disease process, and teaching disease self-management skills.
Other Related EthnoMed Links:
- Process and Practice of Cross Cultural Diabetes Education Teaching Vietnamese and Ethiopian Patients
- Guidelines for Interpreted Visits
- Multicultural Diabetes Materials from Harborview
References and Further Reading
- Alemu, S., Dessie, A., Seid, E., Bard, E., Lee, P.T., Trimble, E.R., et al. (2009). Insulin-requiring diabetes in rural Ethiopia: should we reopen the case for malnutrition-related diabetes? Diabetologia, 52, 1842-1845. doi: 10.1007/s00125-009-1433-5.
- Aymero,W. & Joachim, M. (1970). Religious holidays and calendar. Retrieved April 2, 2010 from http://www.ethiopianorthodox.org/english/calendar.html
- Beyene, Y. (1996). Ethiopians & Eritreans. In J.G. Lipson, S.L. Dibble, & P.A. Minarik (Eds.), Culture & Nursing Care: A Pocket Guide (pp101-114). San Francisco, CA: UCSF Nursing Press.
- Brown, D. The Center for Innovative Food Technology. Teff study. Retrieved April 2, 2010 from http://www.eisc.org/attach/teff.pdf
- CIA World Factbook:Eritrea. Retrieved April 26, 2010 from https://www.cia.gov/library/publications/the-world-factbook/geos/er.html
- Federal Democratic Republic of Ethiopia Populations Census Commission. (2008). Summary and Statistical Report of the 2007 Population and Housing Census. Retrieved March 15, 2010 from http://www.csa.gov.et/
- Gill, G.V., Mbanya, J.C., Ramaiya, K.L., & Tesfaye, S. (2009). A sub-Saharan African perspective of diabetes. Diabetologia, 52, 8-10. doi: 10.1007/s00125-008-1167-9
- Goel, M.S., McCarthy, E.P., Phillips, R.S., & Wee, C.C. (2004). Obesity among U.S. immigrant subgroups by duration of residence. JAMA, 292, 2860-2867. doi:10.1001/jama.292.23.2860
- Guttman, N. (2002). “We didn’t have it in Ethiopia”: Attitudes and belief of Ethiopian immigrants to Israel regarding diabetes. 130th Annual Meeting of the American Public Health Association. Retrieved November 15, 2009 from http://apha.confex.com/apha/130am/techprogram/paper_40695.htm
- Ho, V. (2006, April 12). Kids’ troubles shake Seattle’s East Africans. The Seattle PI. Retrieved from http://www.seattlepi.com/local/266361_eastafrican12.html
- Jaffe, A. (2002). A Challenge of Acculturation: The Ethiopian Community in Israel. Diabetes Voice, 47, 13-15. Retrieved November 15, 2009, from www.diabetesvoice.org/files/attachments/article_181_en.pdf
- Mbanya, J.C., Motala, A. A., Sobngwi, E., Assah, F.K., & Enoru, S. T. Diabetes in sub-Saharan Africa. Lancet, 375(9733), 2254-2266.
- Sellassie, S.H. & Mikael, B. (2003). Worship in the Ethiopian Orthodox Church. Retrieved April 2, 2010 from http://www.ethiopianorthodox.org/english/ethiopian/worship.html.
- Sellassie, S.H. & Tamerat, T. (1970). The establishment of the Ethiopian Church. Retrieved April 2, 2010 from http://www.ethiopianorthodox.org/english/ethiopian/prechristian.html
- Seyum, B., Mebrahtu, G., Usman, A., Mufunda, J., Tewolde, B., Haile, S., Kosia, A., & Negassi, E. (2010). Profile of patients with diabetes in Eritrea: results of first phase registry analyses. Acta Diabetology, 47(1), 23-27. Retrieved April 2, 2010 from Global Health Library.
- Seyoum, S. (2007). Interview with diabetes specialist Dr. Berhane Seyoum. Retrieved April 2, 2010 from
- Shimodate, T. (2001). Oromo. Retrieved April 2, 2010 from
- Tekle, T. (2010, September 7). Ethiopia: Over 1000 Eritrean refugees resettled to a third country. Sudan Tribune. Retrieved from http://www.sudantribune.com/Ethiopia-Over-1000-Eritrean,36200
- Tripathy, B.B & Samal, K.C. (1997). Overview and consensus statement on diabetes in tropical areas. Diabetes/Metabolism Reviews, 13(1), 63-76. Retrieved November 15, 2009 from http://www.ncbi.nlm.nih.gov/pubmed/9134349
- Trostler, N. (1997). Health risks of immigration: the Yemenite and Ethiopian cases in Israel. Biomedical Pharmacotherapy, 51(8), 352-359. Retrieved November 15, 2009 from http://www.ncbi.nlm.nih.gov/pubmed/9436530
- U.S. Department of State. (2007). Eritrea: International religious freedom report. Retrieved May 1, 2010 from http://www.state.gov/g/drl/rls/irf/2007/90096.htm
- Whiting, D.R., Hayes, L., & Unwin, N.C. (2003). Challenges to health care for diabetes in Africa. Journal of Cardiovascular Risk, 10, 103-110. doi: 10.1097/01.hjr.0000060846.48106.6d
- World Health Organization. (1999). Definition, diagnosis and classification of diabetes mellitus and its complications. Retrieved March 15, 2010 from http://www.who.int/diabetes/currentpublications/en/