Epidemiology/Observations
Note: This article focuses mainly on type 2 diabetes and Cambodian Americans, however the authors have provided some information about diabetes in Cambodia, directly below.
In Cambodia
Two field surveys were undertaken in Cambodia (one rural: Siemreap; and one semi-urban: Kampong Cham) in 2004 with 2246 randomly selected adults aged 25 years and older. The study found that prevalence of diabetes was 5% in Siemreap and 11% in Kampong Cham. Prevalence of impaired glucose tolerance was 10% in Siemreap and 15% in Kampong Cham. About two-thirds of all cases of diabetes were undiagnosed before the survey. Prevalence of hypertension was 12% at Siemreap and 25% at Kampong Cham. People in Kampong Cham had higher estimates of central obesity than those in Siemreap.
The authors’ interpretation of these findings is that diabetes and hypertension are not uncommon in Cambodia. A quarter of all adults in the chosen suburban community had some degree of glucose intolerance. Since Cambodian society is relatively poor, and lifestyle is fairly traditional by international standards, these findings were not expected by the authors. They suggest other explanations be sought for the high prevalence of glucose intolerance in Cambodia, identifying two possible theories as deserving further investigation. The first considers that because Cambodians may have been exposed to cultural and genetic effects from India in their early history (in A History of Cambodia, David Chandler writes about Indianization in Cambodia), and the population of India is known to be very susceptible to diabetes, Cambodia could have inherited a greater susceptibility to glucose intolerance than other countries in Indochina. The second considers that a possible association between diabetes in later life and nutritional deprivation in fetal life and infancy could have impacted the Cambodian people during the second half of the 20th century, particularly under the rule of the Khmer Rouge (1975 – 79).
In the U.S.
There is limited published data in the literature concerning the incidence of diabetes in Cambodian Americans. One Journal of Pediatrics article reports of at least one Cambodian American child with type 2 diabetes.
The following 2 paragraphs were excerpted from Cambodian Shop Around Program which describes a pilot project to promote healthy eating and dietary management of diabetes in Seattle’s Cambodian community.
While the total prevalence of diabetes (both diagnosed and undiagnosed) is not available for Asian Americans, the National Institute of Health estimates that Asians, Native Hawaiians, and other Pacific Islanders aged 20 years or older are more than two times as likely to have diagnosed diabetes compared to Caucasians after adjusting for population age differences (National Institute of Health, 2005).
It is suspected that Cambodian Americans are significantly more likely to die from diabetes than the general population. Data for Asian Americans/Pacific Islanders is collected as aggregate and there is no national data on subgroups (National Diabetes Education Program, 2003). However, in Lowell, Massachusetts, Cambodians aged > 45 years have higher death rates from diabetes (13.4%) compared with all Massachusetts adults in this age group (2.5%) (CDC, 2007).
The National Cambodian American Health Initiative (NCAHI) in November 2005 declared a health emergency in the Cambodian community in the United States, based on evidence of overwhelming life-threatening chronic illness and diminishing health resources available to survivors of the Khmer Rouge living in the United States. Mental health issues (depression, PTSD), diabetes, stroke, liver disease and cancers of the nasopharynx, liver and stomach were identified as causing suffering and early death in Cambodian American communities.
The NCAHI (2007) reports that “Cambodians have rates of these conditions many times that of the general population. The burden of disabilities caused by these co-morbid conditions contributes to a poverty rate of 29% and a disability rate of 30% for Cambodian adults” (p.1). In 2006, the National Diabetes Education Program (a program of the CDC, NIH and hundreds of partners) published a paper describing the link between trauma, mental health problems and diabetes (NCAHI, 2007).
Lifestyle issues
In the United States, incidence of gambling, alcohol abuse and domestic violence are issues that affect some Cambodian patients. Both males and females may smoke cigarettes, especially those patients who used to work in the fields and countryside in Cambodia. Many Cambodian patients work long hours and may report that they do not have time for exercise.
Translations and English Equivalents
Diabetes: The Cambodian/Khmer term for diabetes translates as “sweet urine” or “sweet water urine”.
Blood Sugar: There is no Cambodian/Khmer term or concept for blood sugar, at least among villagers, probably because there is no treatment (insulin) available, and no machine is used to monitor blood sugar control. An medical interpreter in the U.S. may translate blood sugar to mean “sugar is in the blood” or “sweet blood” which sounds like “chim im” im = sweet; chim = blood).
Hypertension: The Cambodian/Khmer term for hypertension sounds like “le chim” and translates as “blood over limit” (le=over; chim=blood). It has been observed that Cambodian patients in a Seattle hospital sometimes refer to high blood pressure as relating to their diabetes and it may be that a distinction between blood pressure and blood sugar is not clearly made across languages.
Methods and Background
The following account is taken mostly from notes of a focus group facilitated at a hospital in Seattle by nutritionist Doris Piccinin and pharmacist Katie Lai with five Cambodian immigrants: 2 women and 3 men, all seniors with diabetes, who came to the U.S. between 1979 and 1985, and eventually settled in Seattle. Three of the five group members came originally from rural areas of Cambodia, one very far from any city, one close to the Vietnam border. One participant was originally from a city in the province of Battambang in the northwest part of Cambodia near the Thai border. Jeniffer Huong, caseworker-cultural mediator for Cambodian patients at the hospital in Seattle, helped coordinate the meeting and interpreted the dialogue. The objective was to ask questions of the five seniors for the purpose of learning information for improving the diabetic patient care and education for these and other Cambodian immigrants. In addition to notes gathered during the focus group, information included here comes from notes taken during a nutrition class attended by 8 Cambodian American diabetes patients and 2 caregivers, and from a field test review of patient education materials with 47 Cambodian Americans, mostly seniors.
Cultural Knowledge and Traditional Treatment
Patients may believe there is a cure for diabetes if they take herbal medicine, and they may also have a difficult time understanding hypertension, believing it is due to too much blood in the body.
One member of the group asked why diabetes came to them in the first place, and the other four seniors nodded in agreement with the question. They all wanted to know why they have diabetes. The nutritionist told the group that doctors aren’t completely sure where the diabetes comes from, that family genetics, the change in diet due to migration, or a sedentary lifestyle are possible causes. The group nodded and spoke words of agreement and understanding that these are the likely factors that cause diabetes, maybe even their own diabetes.
One of the unmarried men in the group remarked that his family back in Cambodia had no history of diabetes. The married man across the table from him said the same is true for him. One of the women commented that no one in her family ever had diabetes either. She said that in the place she grew up people worked very hard and described a typical rural Cambodian as someone who sweats daily in the fields, walks a lot and does not use a car – or, in other words, is very active. Additional comments by the group suggested that they had previous experience in Cambodia relating the disease to heredity and lack of physical activity. When asked if they had heard of diabetes while in Cambodia, at least three of the five seniors responded that they had heard of royal families, rich people and also Chinese people getting the disease.
Some of the seniors spoke of “sweet pee”, urine to which ants are attracted, as a sign that a person has diabetes.
The group didn’t recall farm workers and villagers having diabetes. High blood pressure, however, was a condition known among rural Cambodians. One of the men heard that among some people back home, tired shoulders and neck are understood as symptoms of high blood pressure. The group explained that city dwellers buy their food and that rural folks grow and pick their food and raise chickens. It was stated that people living in the rural areas have less illness. One of the women mentioned that chai tao, a long white root, sometimes pickled or dried, can help bring blood pressure down for a short period of time, like a day or two. The chai tao root is known commonly in America as daikon.
Group discussion about foods or herbs traditionally used for diabetes management in Cambodia mostly yielded examples of what foods have not worked to manage diabetes. One woman spoke of a remedy she heard about from other people: cutting and boiling pineapple and drinking the juice to lower blood sugar. She said it didn’t work. She said that too much of the juice made her stomach hot and gave heartburn. Another recipe, involving the chopped and boiled leaf of a milky fruit, was a treatment familiar to several people in the group, but one that decidedly doesn’t work either. The same boiled, milky leaf, combined with a dried lung of an elephant, was also known by one member of the group to be a tried, but not necessarily true, treatment for diabetes. One man spoke of a star-shaped fruit called spoeu, likely a star fruit, and said he heard it was useful for diabetes management when cut up and boiled. The nutritionist asked about bitter melon. Members of the group replied that they had heard of the vegetable and that it works for diabetes control.
Diagnosis and Behavior Modifications in the U.S.
The five focus group participants learned they had diabetes when their doctors told them. Three of them said they don’t know where the disease came from. One woman experienced problems with her eyes, went to the doctor and was diagnosed with diabetes, high blood sugar and high blood pressure. One man was hospitalized for diabetes-related complications at the time he learned he had the disease. Feelings about being diagnosed with diabetes differed among the participants. One man was worried because he heard that high blood pressure could be dangerous; one man was not scared or worried about dying, but felt fine because of his knowledge that everyone will die one day or another. One woman worried that she will die in her sleep when she is sick, and feels lucky that she doesn’t die.
The group talked about making the changes suggested by their doctors: cutting down on fat and sugar and taking medicine regularly. All five participants explained the steps they are taking to control their diabetes. At the times when his blood sugar gets high, one man eats less sugar and desserts. Reducing intake of salt and sugar and following their doctor’s instructions for taking medication were mentioned by all as useful ways to control their diabetes. Only one of the seniors said she will do exercise (walking), although one man did say he has a stationary bike in his home.
In a separate diabetes management and nutrition class, 8 diabetic patients and 2 caregivers learned that using artificial sweetener does not increase blood sugar while providing a good sugar-taste. The patients expressed that substituting artificial sweetener for sugar was a diet change they could make.
Food Preparation and Diet
Influence of Living Arrangements on Diet
The group talked about who cooks the food in their households. Three of the seniors have caregivers who prepare their food, while two cook for themselves. All five said that they eat different foods than the rest of their families. However, no one saw this as a burden, saying that food cooked with less salt and sugar can be seasoned after it’s cooked by individual family members who want more of the restricted ingredients. Two of the seniors said they live with children, one lives with grandchildren, another lives with friends, and another person lives alone. When asked how these living arrangements affect the way they eat, members of the group replied that what others eat isn’t a big factor in their own diet.
Commonly Consumed Foods
Cambodians in Seattle prefer to eat fish, but this is fairly expensive. Since many of the Cambodian patients are low income they alternate between fish, pork and chicken. The elderly who have poor teeth may consume fish more often. Condiments such as fish sauce, fish paste, soy sauce and coconut milk are used in cooking. Certain holiday foods are full of carbohydrates and fat, like curried rice or noodle dishes made with coconut milk. Brown rice is not eaten, reportedly since brown rice is fed to pigs in Cambodia.
Meat, Oil
One of the women said sometimes she craves meat, eats it and then doesn’t feel well. The other woman agreed that meat makes the blood sugar and blood pressure increase and isn’t good for people with diabetes. Everyone in the group agreed that they mostly do not use butter for cooking, preferring to use vegetable oil, corn oil or nothing at all. The discussion revealed that not a lot of stir-frying happens with Cambodian food, except for Cambodians influenced by Chinese-cooking traditions. Though there are many foods that are fried, vegetables are either cooked into soups or steamed. One stir-fry recipe was offered: a little oil, green onions, cucumber and black pepper.
Salt
The group was split among the practices of using fish sauce, soy sauce or pickled fish to give salty flavor to cooking, possibly due to regional differences in their shared Cambodian origin. For example, one man said that shrimp paste, rather than pickled fish, is used close to the Thai border. At least one senior said that diabetics should use these salty ingredients only once in a while.
Sweeteners
In the nutrition class attended by 8 Cambodian American diabetes patients and 2 caregivers, the patients were asked to guess which of 3 desserts were made with real coconut versus coconut flavored extracts, and which of the desserts contained “Splenda” artificial sweetener. All patients ultimately verbalized that artificial sweetener provides a good sugar taste without increasing blood sugar.
Portion Sizes
A discussion of portion sizes had all the seniors demonstrating the amount of food they would take as roughly a small to medium-sized handful for each food group. One woman described a complete meal as being a small bowl of rice, soup and a little meat. When asked if they measure food, none of them said that they did. Instead, one woman said a person knows how much to use: not too much and not too little.
Feasting/Fasting
The group acknowledged that there are no traditional Cambodian holidays or festivities requiring fasting, unless a person is a nun or a monk. When taking part in festive occasions where lots of food is available to eat, two of the seniors said they would be careful and selective of the types and amounts of food they eat.
American Food, Restaurants and Shopping Places
Eating American food is a rare occurrence with these seniors, although one of the men said he cooked and ate American food for a whole year once and then stopped. It was even more rare for the group to eat out at restaurants. “Once in a while”, “Once every five to six months”, “Three to five times in twenty-one years” are phrases describing the frequency of this group eating out at restaurants. The restaurants that are chosen for occasional meals are mostly Chinese, Vietnamese and Cambodian. The Cambodian American youth eat more American food, according to this group.
These five seniors shop either at Safeway, a Cambodian grocery store, an Asian grocery store or a combination of these. (In Seattle, most Cambodian groceries are located in White Center in West Seattle. Several Cambodian groceries are located on Martin Luther King Jr. Way South, and one can be found in Chinatown.)
Preferred Education about Diabetes Control
After diagnosis, the seniors received more education about diabetes through nutrition and citizenship classes and through their doctors. When asked if they would attend classes about diabetes and nutrition if the classes were offered at the hospital, the group mostly said no. They expressed concern about the length of time required. The barriers to attending classes had to do with transportation to the hospital and the length and frequency of the classes. One person said that having classes every week is too much. On the other hand, the group agreed that classes arranged in easily accessible locations, like a community area in their own apartment building, would be better attended. Two-hour classes were preferred over four-hour classes.
One woman said she cannot sit very long before she gets tired. One participant said that she had attended a class about diabetes, but forgot much of the information. She only memorized the part about food. One person said that he relies on monthly visits with his doctor to learn about diabetes and doesn’t feel that a class would offer much of anything new. When the group was asked if they would come to classes if transportation were provided, they said yes, they would come. The group agreed that instructional videos with Cambodian-language (Khmer) information, made available for home use, would be the most convenient and useful means of patient education. All five seniors have VCRs in their homes. One senior expressed interest in learning to use the computer for accessing health education, if it were available in his community.
Most of the 8 patients attending the diabetes management and nutrition class preferred English-language educational materials. Many older patients are illiterate and rely on their children to help them read.
The project team conducted a field test that focused on reviewing translated patient education materials with a group of 47 mostly-senior Cambodian Americans. Very few of the patients were able to read the translated materials.
Recommendations for Providers:
- Determine patient’s mathematical skills for insulin dosing regimens and blood glucose monitoring.
- Provide easy to follow instructions and limited calculations for insulin and medication adjustments.
- Emphasize patient’s control over diet and exercise in controlling diabetes.
- Encourage the use of portion control of carbohydrate-containing foods, such as rice and noodles, as a means to controlling blood sugars.
- Provide practical, easy tips, such as walking or stretching exercises, to promote activity.
- Have available sample packets of artificial sweeteners for patients to take with them to the grocery store.
- Realize that hypertension, hyperlipidemia and coronary artery disease may accompany diabetes and so special attention should be paid to dietary factors that contribute to these conditions such as fat and salt intake.
References and Further Reading
- Fagot-Campagna A, Pettitt DJ, Engelgau MM, Burrows NR, Geiss LS, Valdez R, Beckles GL, Saaddine J, Gregg EW, Williamson DF, Narayan KM.
- Type 2 diabetes among North American children and adolescents: an epidemiologic review and a public health perspective. J Pediatr. 2000 May;136(5):664-72. Review.
- PMID: 10802501 [PubMed – indexed for MEDLINE] Table II footnote. (Journal of Pediatrics, 2000:136(5)
- King H, Keuky L, Seng S, Khun T, Roglic G, and Pinget M
Diabetes and associated disorders in Cambodia: two epidemiological surveys - Lancet. 2005 Nov 5;366(9497):1633-9. PMID: 16271644 [PubMed – indexed for MEDLINE]
- Cookbook: The Elephant Walk Cookbook by Longteine De Monteiro and Katherine Neustadt, Houghton Mifflin Co., Boston, NY, USA.
- Centers for Disease Control and Prevention (CDC). (2007). The Power to Reduce Health Disparities: Voices from REACH Communities. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Available at URL: http://www.cdc.gov/reach/community_profiles/index.htm Accessed February 17, 2009.
- Health Emergency in the Cambodian Community in the United States. Executive Summary. National Cambodian American Health Initiative. September 2007.
- National Institute of Health, National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), Diabetes Information Clearinghouse. National Diabetes Statistics. NIH Publication No. 06-3892. Nov 2005. Available at URL: http://diabetes.niddk.nih.gov/dm/pubs/statistics/ Accessed May 28, 2008.
- Khmer Health Advocates, Inc. Cambodian Diabetes Telemedicine Project. National Diabetes Education Program Partnership Networking Meeting. Atlanta, Georgia. December 2004. For more information visit: www.cambodianhealth.org
- Silent Trauma: Diabetes, Health Status, and the Refugee. Southeast Asians in the United States. Developed by the Southeast Asian Subcommittee of the Asian American/Pacific Islander Work Group National Diabetes Education Program. Available at URL:
http://www.ndep.nih.gov/resources/SilentTrauma.htm#DemographicInformation Accessed September 9, 2008.