Methods and Background
The content of this article has been developed from three main sources:
- Notes gathered by members of the Multicultural Diabetes Project team including nutritionists, pharmacists, interpreters and a medical librarian in their work with a total of 17 Somali women who were diabetes patients at Harborview Medical Center in Seattle during March 2002. Providers, caseworker / cultural mediators and patients participated in a focus group, cooking demonstration, food shopping field test, review of patient education materials, and nutrition class.
- Notes gathered from diabetes classes held for Somali male patients at Harborview Medical Center in April 2005. Up to 12 patients attended the sessions without their wives. Presenters included diabetes educators, pharmacists and dietitians. Pre- and post-assessment questions were administered to evaluate the level of knowledge patients had before and after the classes.
- Various cited articles and personal accounts from Somali individuals in the Seattle community.
- Literature review conducted August 2009.
Diabetes Etiology & Prevalence among Immigrant Somalis
There has been little research conducted and published about the prevalence rates of diabetes occurrence or development of the disease among Somali immigrants to the United States.
In May 2002 the Associated Press reported on a statement made by Dr. Mehmood Khan, a consultant in the Mayo Clinic’s Division of Endocrinology that “a growing number of Somali immigrants are developing [Type 2 diabetes] within five years, and some as quickly as six months, after their arrival in this country.” Dr. Khan attributed the phenomenon to a lack of exercise and a dramatic increase in fat and calories experienced by Somali immigrants (Associated Press, 2002).
In Seattle, a medical librarian reported that some of the young Somali men who came to the library expressed concern about diabetes. They had observed that many young men like themselves have been diagnosed and reported that some think it is just American medicine making up diseases and so they don’t take the diagnosis seriously. Similarly, men in the diabetes project thought that people with diabetes are not “really sick.”
During a discussion among a half dozen Somali women participating in a review of education materials about diabetes, one woman stated that problems such as asthma, diabetes, and sleeping disorders were not common (in Somalia), and that she had never heard of diabetes occurring in anyone except old people in Somalia. In addition, the women in this project believed that diabetes happens more in the U.S. because in Somalia farmers sweat and are very active. They define the disease as one which causes tiredness, sleepiness, frequent urination and for which there is no cure. They did not believe that diabetes is a genetic disease for it is God who determines its occurrence. The women understood that the diabetes medicine comes from the doctors, but that God dictates whether or not the medicine will help. Most of the women knew what type of diabetes they had.
According to the group of Somali men in the project, none expected having diabetes and all were shocked to learn of their initial diagnosis once in the U.S. The men had other explanations for diabetes. One felt that coming to the U.S. made him sick. Another reported that working in a very cold beef processing plant predisposed him to diabetes. Another felt he developed the condition in the U.S. because in Somalia he ate camel meat and milk and this protected him. Most of the men did not know which type of diabetes they had.
Traditional Treatment for Diabetes
No traditional treatments for diabetes were known to the Somalis participating in this project. Honey is known by some patients to be used as medicine for asthma, anemia and flu, but honey was not said to be used for diabetes treatment. Garlic is known by some patients to be used for hypertension, but not known to treat diabetes.
According to Anab Abdullahi, a Somali physician who was trained in Rome and Somalia and now works as a medical interpreter at Harborview in Seattle, there is no routine screening for diabetes in Somalia. Diabetics are not diagnosed until they are very sick or unable to walk. Rather, in Somalia, there is more emphasis on screening for infectious disease like malaria. Further, many patients may be in denial of a diabetes diagnosis as they feel they were screened by INS and were given a clean bill of health upon immigrating.
Management of Diabetes in the U.S.
Generally, diabetes is managed through four key interventions: nutrition management, physical activity, oral medicine and insulin, and alternative therapies. Monitoring of blood glucose levels, including Hemoglobin A1C, is an important aspect of diabetes management as it guides health care providers in how to utilize these interventions.
Somali patients may resist having their blood drawn, thinking there is not enough blood to spare. Some may wonder if blood is being sold for profit. Providers should explain why blood is being taken. For those with high blood pressure, the translation of the word “hypertension” takes on the meaning of “blood boiling” and can lead some to believe that high blood pressure means blood loss, promoting further resistance to blood draws.
Most Somalis have had some experience with Western-style medicine in Somalia. The concept of using the medical system to keep people healthy, such as with routine prenatal care, well child care or other similar care may not be familiar, depending on whether a person comes from a rural or urban area. Regardless, there is a general desire to receive treatment in the form of medications or other tangible goods like injections or vitamins; however, one Somali interpreter reports that, in general, members of her community in the Seattle area so dislike the idea of taking insulin shots that they may be motivated to adopt lifestyle changes to avoid them.
Cultural Health Beliefs about Food
Somalis come from a context where nutrition is key to survival and caloric or fat restriction is a new concept (Renzaho, 2004). Obesity or having “rounded bodies” is a sign of wealth, prosperity and health, and many believe that “fat is beautiful.”
Over 99% of Somalis are Muslim and are accustomed to following religious dietary proscriptions. Halal foods are those which are allowed and haram are those which are forbidden such as eating pork and other meats not prepared properly under Islamic Law, drinking alcohol, and smoking cigarettes.
Camel milk has been described as low in fat and high in calcium, and is thought to have medicinal properties among nomads. Somali patients who were interviewed say that they substitute whole-homogenized milk for camel milk since camel milk is not available in the U.S., feeling that low-fat versions are inferior and only for poor people.
Consuming salty or vinegary foods is thought to assist with sweating due to hot climates.
Vimto (a carbonated strawberry-flavored beverage) is found in Somali stores and is thought to help with low hemoglobin or to replace blood loss.
Eating chicken injected with hormones is believed to be bad for health and that it will contribute to obesity. Somalis are used to fresh food from the markets back home, so there is a preference for organic meats and a dislike of processed foods.
See Food and fasting in Somali Culture and Report on Somali Diet.
Regional influences in Somalia
Traditionally, food differences are related to different areas of the country. In Mogadishu, the capital city of Somalia, almost all foods are available.
In the northern region and more extreme climate conditions where there are more nomadic persons, there is a heavier reliance on camel and goat meat and camel milk as staple foods. In northern Somalia, papaya and oranges are the primary fruits consumed. Rice is also a large component of the diet.
Southern Somalia has greater Italian influences with more emphasis on pasta dishes.
In the south, or “highline” area, grapes, guavas, papayas, mangoes, bananas, corn, fish, millet, sorghum, and a variety of vegetables are grown and consumed.
Coastal areas of Somalia rely more on fish dishes cooked with coconut milk or semolina.
According to one interpreter, a common Somali breakfast includes the breads injera or muufa; mushari (a porridge made of corn similar to polenta); milk (whole is preferred); and tea cooked with spices with milk and sugar added (similar to chai). This is very similar to the breakfasts reported by Somalis who have immigrated to Minneapolis, Minnesota where they number over 30,000 and represent the largest population of Somali immigrants in the U.S. (Gaard, 2008). In native Somalia, breakfast would also likely include sheep or goat liver or kidney.
Pasta. Image by Tammy Amina Gale
Typically, lunch is the largest meal of the day. Some common lunch items include rice or pasta; muufa or chapati; meats mixed with vegetables such as carrots, potatoes and tomatoes; cooked spinach; banana; red beans and rice; salad; and spaghetti sauce made with ground beef or chunks of goat or beef, mixed vegetables and olive oil. Less sauce is used on pasta than is typical in America, possibly due to Italian influence and likely because food is eaten by hand without utensils (too much sauce makes it difficult to eat by hand). Somalis generally like their food spicy, so hot peppers are commonly used in cooking.
At dinner, smaller portions are eaten than at lunch. Some people eat bread or cereal, milk and tea, and juices of fruits like papaya, mango and grapefruit. Cooked azuki beans may be eaten.
Cooking and Shopping
Somali culture traditionally maintains separations between men and women in daily activities like cooking, eating and socializing. Somali women tend to be in charge of food preparation and will cook food for themselves and their families. Men rarely cook, except in restaurants where the customers are mainly men.
In general, frying is the most common method of cooking. As observed in a cooking demonstration, Somali food preparation involves a combination of stove-top boiling, simmering, frying (pieces of meat) and oven-baking. A little salt and cumin were added as flavoring to a simmering sauce, along with vegetable oil which was also added to boiling pasta and brushed over bread before baking. Somalis add oil to a lot of what is cooked, even hot cereal. Butter, olive oil, and sesame oil are commonly used, in addition to regular vegetable oil.
In Somalia, women do the food shopping. In the U.S. both men and women shop.
Most food is purchased at Somali grocery stores to ensure it is halal. Factors affecting healthy eating for Somali immigrants in the U.S. include:
- a general view that overweight and obesity are signs of success, good health, and happiness
- difficulty giving up traditional food
- language barriers
- lack of understanding about how food choices affect chronic disease
- concern about unfamiliar Western food not being halal
- higher cost for healthier food items
See Hyperlipidemia: Diet, Education & Health Promotion for Somali Refugees.
Eating at Home
Somali rice image by Tammy Amina Gale
Somali men and women typically do not eat together and at home; men will often eat first followed by the women. Women and children eat together, often sitting on the floor and sharing meals from one large plate in the center of the table. Due to this, it may be difficult and not practical for families to follow the “plate method” of dividing recommended serving sizes on individual plates. Because this method for maintaining appropriate portion sizes is useful, creative ways to incorporate it in a culturally sensitive manner may be worthwhile. Limiting food consumption is also contrary to Somali custom in which all available food is eaten at the time it is prepared. Wasting food is not accepted, but most Somalis do not prefer to save and eat leftovers.
In general, the Somali patients seen at Harborview rarely eat out due to limited finances. Somali restaurants are reserved mainly as a social gathering place for men. Women have their own gatherings, taking turns having potlucks at each other’s homes. The men report that they receive large portions of food at the restaurants and that they can’t eat just a little bit.
Fast food/ Acculturated diets
A common concern of most Somali parents is that their children are moving more towards a diet of fast foods. French fries and the like are readily becoming popular in Somali homes in the U.S., as is the consumption of soda pop and high-fat snacks. Younger Somalis and children reportedly like to eat at McDonald’s and Burger King, which can result in conflict when the children and youth refuse or resist eating traditional foods. For some, however, the concept of “healthy” food versus “junk” food does not carry much weight, and as long as the food is halal, it is acceptable.
Other changes are being observed as a result of acculturation and are noted under each food group below.
Beverages and Hydration
Black and brown teas (largely imported from China) and a coffee drink made from the covering of the coffee beans versus the beans themselves are common types of drinks. Typically, tea is consumed with large amounts of honey or sugar and milk, up to 2-4 cups a day.
Alcohol or foods that produce even minor amounts of alcohol (like balsamic vinegar and natural vanilla extract) are not allowed in the Somali diet (Gaard, 2008).
According to one interpreter for the project, the climate change to colder weather may mean Somali immigrants are less thirsty and may generally be drinking less fluid than they did in Somalia.
The everyday Somali diet is typically heavily based on carbohydrate foods (Gaard, 2008).
Rice: According to one Somali interpreter interviewed, brown rice and basmati rice may be an acceptable substitution for white rice.Rice is usually cooked with lots of ghee (clarified butter) or oil, and may have cardamom, raisins, and nuts added. Rice may also be steamed or fried with onions and spices.
- Biryani, a dish made with rice and meat, is commonly eaten if people have Kenyan ancestry.
- Iskudahkaris is the Somali word referring to a method of cooking rice and is a combination of onions, vegetables, and meat that are fried in oil to which rice and water are then added.
- Pilau, a yellow rice of Middle Eastern and Asian origins is served at celebrations and weddings.
Breads: One influence of westernization is that injera (also spelled anjera) bread is sometimes made from self-rising pancake mix or all-purpose flour. Traditionally, injera is made with corn flour or teff, a grain grown in Somalia. Compared nutritionally, teff has 30% more protein, twice the iron, three times the fiber, and three times the potassium than pancake mix or white flour. (See: More About Ethiopian Food: Teff.) Injera made the traditional way, therefore, has a greater source of many nutrients along with probiotics that support healthy intestinal micro flora. It is not yet known what impact this decrease in use may have on the diet of Somali immigrants. (Gaard, 2008)
- Somali anjera photo by Tammy Amina GaleSomali injera (also spelled anjera) is about 6-8 inches in diameter and is much smaller than Ethiopian-style injera that is large enough for an entire family to share during a meal. Somali injera is of a pancake-like consistency often made of flour or corn. The injera may be eaten with butter and sugar, or with tea that has milk and sugar added which is then poured over the injera
- Muufa is bread made with corn flour, salt and sugar and is baked like a cake.
- Roti is pan-cooked bread without oil.
- Chapati is a pan-fried bread using oil or butter like the East Asian style bread of the same name.
- Malawa looks like a pancake and is made with flour, sugar, oil and eggs. It may or may not be served with honey.
- Burkaki is fried bread
- Maqhumri is sweetened fried bread.
- Sambusa (samosa) are curry puffs stuffed with meat and vegetables and then deep fried. This is often used traditionally for celebrations and to break a fast.
Fruit and Vegetables
Bananas, dates, apples, oranges, pears and grapes are among some of the more popular fruits eaten by Somali immigrants to the U.S. Back home, mangoes and guava were also eaten and used for making juice. Somali stores, therefore, carry among the widest selection of fruit juices that include Kern’s and imports from India and Canada. Instant juice is available frozen or as a powder.
Commonly consumed vegetables are carrots, tomatoes, potatoes, green peppers, spinach and lettuce. Usually, broccoli is not eaten. The Somalis interviewed say they eat fewer vegetables in the U.S. because they fear pesticides and because they are unfamiliar with many of the vegetables grown here. Because of the language barrier, some Somalis are unable to ask how to prepare these vegetables.
Meats and Proteins
Pork or pork products (including gelatin) are not allowed (Gaard, 2008). Otherwise, Somali meals are generally meat driven and vegetarianism is relatively rare. Commonly eaten meats in order of preference are camel, goat, beef, and chicken. Camel meat is not yet found in U.S. groceries but may soon be shipped from Australia and be made available. Lamb and sheep are usually bought frozen as an Australian import. Most often meats are purchased at Somali grocery stores rather than at American groceries. Other types of protein eaten include beans, eggs, and fish.
Milk is commonly consumed. Camel milk is preferred — though not available in the U.S. — along with goat and whole cow’s milk. Some people eat yogurt, buttermilk, and ice cream, and cheese has been added among the foods regularly eaten.
Oils and Fats
There are huge variations in the quantity of oil consumed by Somalis, depending on family, taste preferences, and level of understanding of associated risks and education provided by doctors, dietitians and community. Large amounts of oil are known to be used in cooking for a large family. Somali cooks do not measure ingredients, as many U.S. cooks do. So, it is easy to be liberal when pouring oil. The type of oil most used is vegetable; however, immigrants from Southern Somalia may use olive oil in some dishes due to the influence of Italian colonization.
Honey, jam, chocolate and Vimto are commonly consumed sweets. Sugar added to milk, tea, coffee and some foods tends to be in large quantities. Halwa is a candy made of sugar, a little flour, and ghee.
Most of the men attending the diabetes classes reported that honey tastes better than sugar, and they did not believe it affects blood glucose levels in the same way as sugar. They also thought that Somali honey has less sugar than American honey.
Using artificial sweeteners with tea rather than sugar was also acceptable among most of the women in the nutrition class and in fact more desirable as it produced a sweeter tea resembling their native Somali tea.
Soups, called maraq, are also important in a Somali diet. These hearty, stew-like soups are used as an appetizer, with meats, potatoes, vegetables like onion and tomato, Italian spices and vinegar. This type of soup is not light fare.
Exercise, especially walking, is a normal part of everyday life in Somalia. In Seattle, many Somalis do not like to walk outdoors due to rain and cold weather, and for fear of getting lost and being unable to communicate due to language barriers. Some men have accepted the use of exercise gyms and machines offered by physical therapists. Many Somalis report that their activity levels have decreased since arriving in the U.S.
One interpreter suggests that the reasons for reduced physical activity are the Western lifestyle which encourages driving rather than walking, coupled with unwillingness among Somalis to exercise in public. A Somali caseworker / cultural mediator reports that in the U.S., some Somalis feel like they are under house arrest because the weather is so cold.
In the nutrition class, the younger women said dancing was an acceptable form of exercise and they participated in a short dancing activity, while most of the older women did not participate and expressed feelings that dancing was inappropriate to include in the class time. Women and men do not dance or engage in exercise together. Women are typically limited to exercising in female-only facilities (like Curves), because religious requirements prohibit Muslim women from showing parts of their body besides their ankles, feet, face, and hands. This may reduce their ability to engage in certain physical activities. See Responding to a Request: Gender Exclusive Swims in a Somali Community for information about a creative intervention to improve physical activity among Somali immigrants in Seattle, Washington from 2006-2008.
Somali women living in Seattle who have received massage therapy have reported positive effects of this intervention on general aches and pains commonly experienced by these women. Additional research on its use with this population may prove a worthwhile pursuit.
Related Health Issues
In the Somali language, the English word constipation is equivalent to a word that sounds like “sahara.” It is a common condition both in native Somalia and among Somali immigrant patients at Harborview. Fiber, which is used to treat this condition, is a word not easily understood when translated into Somali. Providers have helped patients understand the concept by referring to fiber as “foods to help with constipation” or “foods that cause the bowels to move.” Examples of beans, prune juice, salad, apple, and orange juice were used in the nutrition class to illustrate fiber-containing foods. The Somali caseworker / cultural mediator and interpreter suggest that constipation may be of concern due to decreased levels of exercise, increased consumption of fatty foods, and decreased consumption of fluids and vegetables, all of which are influenced by a Western lifestyle.
Common addictive substance use
Khat also spelled chat, qat, or kat is a sypathomimotic compound that is used to decrease depression, fatigue, obesity, gastric ulcers and male infertility. It is typically used during social gatherings by Muslim men and youth from the Horn of Africa region, including Somalia, and occasionally by women. Some taxi drivers use khat to increase energy during long work shifts. Users may experience increased energy, euphoria, and reduced appetite. The leaves and stems of khat are usually chewed and the practice is associated with drinking many cups of very sweet tea. The leaf itself is not physically addicting but is associated with psychological dependence. Khat is illegal in the U.S., but is available imported from London or Canada where it is legal. Side effects can include cardiac arrhythmia, high blood pressure, hyperactivity, and anxiety.
It is important to note that khat suppresses appetite and can cause people to skip meals which put them at risk for hypoglycemia, and it can also decrease adherence to dietary advice or increase consumption of sweetened beverages, potentially aggravating hyperglycemia.
None of the patients in this project admitted to using khat in the U.S. though some report using it in Somalia. The men were surprised that providers were aware of this substance. One believed that khat could lower blood glucose levels. Khat will lower blood sugar but not reliably. It can therefore cause hypoglycemia in diabetics receiving treatment. It cannot be used to treat diabetes.
Religious Observances and Fasting
Somalis are predominantly Sunni Muslims who practice Islam, the religion of more than a billion Muslims throughout the world. The Islamic faith necessitates strict observance of the injunctions of its holy book, the Koran, and the sayings and actions of the Prophet Mohammed (Sunnah). Muslims must fulfill a number of religious obligations, the essence of which is known as the five pillars of Islam. (Sansal, 2008):
- stating one’s faith
- praying five times a day
- giving to the poor
- fasting during Ramadan
- making the pilgrimage to Mecca, the holy city of Islam in Saudi Arabia.
A Somali caseworker / cultural mediator commented that many patients will consult with a sheik or imam in the U.S. about their fasting practices when a Western doctor advises against fasting. A sheik holds the equivalent of a high school degree in the study of Islam, while an imam holds the equivalent of a college education in Islamic studies.
The implications of Ramadan fasting for diabetics and those with other chronic illnesses must be considered because this fast requires abstention from all food, fluids, oral medications, and IV fluids during daylight hours, which during the summer months may have duration of over 18 hours.
For more information about managing diabetes during Ramadan see Muslim Religious Observances and Diabetes.
Recommendations For Diabetes Educators & Providers
- For recommendations on Ramadan fasting, see the article cited directly above.
- Emphasize understanding of hypoglycemic and hyperglycemic signs and symptoms, focusing on the former just before Ramadan.
- Ask a sheik to help teach patients about the side effects of fasting for uncontrolled diabetics.
- Avoid holding classes during Ramadan.
- Emphasize how patients are able to control how they eat during Ramadan and how this same skill can be used to control diet and exercise in managing diabetes everyday. For women who cook their own food at home, emphasize control of what goes into their food.
- Encourage and educate about the use of portion control of carbohydrate-containing foods as a means to controlling blood sugars, especially for those who have other people prepare their food for them.
- Speak in terms of one’s ability to function independently and maintain responsibilities instead of the threat of dying when trying to motivate behavior change. Somalis are often not fearful of death, as God dictates when this will happen, but they generally do not want to be a burden to one’s family.
- 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 for those with limited math skills.
- Be aware of the requirement for Muslim patients to pray throughout the day and how this might impact medical appointments and diabetes education sessions.
- Be aware of gender variations in the experience of diabetes and how this might affect content of the education provided. Educators may consider different options for holding class: a separate class for women and men; a combined class for both women and men; or a combined class, but using some form of divider between the men and women so they do not visually see each other. Depending on the group served, one method may offer greater reassurance for women to have more open discussions.
- Since oils are used a lot in the Somali diet, education should be provided about different types of oils and which are healthier to use. One strategy for teaching about oils and fats is to provide a large cooking pot and one container of oil, and give women a cooking scenario. For example, they can be told what they are cooking and for how many people, and then asked to pour out the amount of oil they would typically use. This often elicits a more true account of how much oil is actually used for cooking. (See section on Oil and Fats above)
- Have sample packets of artificial sweeteners available for patients to take with them to the grocery store. Dispel any myths around sugar, honey, and artificial sweeteners.
- Educate patients about how low-fat milk is made so that they understand it is halal and may be substituted for whole milk. Encourage smaller portions of whole milk or blending together whole and 2% milk to address patients’ taste preferences.
- Allow patients the opportunity to discuss issues around barriers to self-management adherence such as the lack of freedom from strict everyday management of blood glucose levels and factors that affect healthy eating. (See Cooking and Shopping above)
- Be aware that khat use is often associated with drinking large quantities of sweetened tea and therefore may need to be addressed in reference to blood sugar control for men.
- Provide practical, easy tips, such as walking or stretching exercises to promote activity, including ways to overcome barriers like weather and not having access to indoor fitness facilities.
- Although real opportunities for group exercise and massage therapy are limited, some effort should be made to make these possible for the Somali women — especially massage therapy — which has been reported to be helpful in alleviating the aches and pains often described by these women.
- When choosing exercise tapes and DVDs, be aware of clothing that is worn by the exercisers. Avoid those showing individuals in tight or skimpy clothing as these are considered offensive. Listed below are a few of the more appropriate tapes/DVDs in which the exercisers expose only their arms, neck and head, and the movements are basic and low impact. Most include both male and female exercisers:
60 second clips of these and others can be viewed at Exercise, Workout and Fitness DVD.
Patient Education Materials
How Foods Affect Blood Sugar: A Guide for Somali Patients with Diabetes
EthnoMed diabetes handouts are available in Somali for the following topics (some are available in audio format):
- Sick Days and Diabetes
- Exercise and Diabetes
- Meal Plan Basics
- Meal Portions
- Foot Care & Daily Foot Check
Recommendations for Management of Diabetes during Ramadan
This article, written by 14 Muslim physicians from around the world, is an excellent resource for clinicians. It was published in 2005 in the American Diabetes Association’s journal Diabetes Care.
Davila, Florangela. Food and Fasting In Somali Culture, 2001, EthnoMed website: https://ethnomed.org/ethnomed/cultures/somali/som_food.html
Gaard, Pamela, RD. MidWest Clinicians’ Network News: From Mogadishu to Minneapolis – African Cuisine in Minnesota. Cedar Riverside People’s Center, Minneapolis, Minnesota. Pages 2-3, October 2008. http://www.midwestclinicians.org/files/news/October%202008_final.pdf
Haq, Aliya. Report on Somali Diet, 2003, EthnoMed website: https://ethnomed.org/ethnomed/pearls/p_haq.html
Lewis, Toby (MD). Somali Cultural Profile, 1996, EthnoMed website: https://ethnomed.org/ehtnomed/cultures/somali/somali_cp.html.
Renzaho, Andre MN. Fat, rich and beautiful: changing socio-cultural paradigms associated with obesity risk, nutritional status and refugee children from sub-Saharan Africa, Health and Place. 10(1), 105-113, 2004.
Sansal, Burak. The Five Pillars of Islam, http://www.allaboutturkey.com/5pillar.htm, accessed August 2008 by Multicultural Diabetes Team, Harborview Medical Center.
Schwartz, Keri. Hyperlipidemia: Diet, Education and Health Promotion for the Somali Refugee Population, 2008, EthnoMed website: https://ethnomed.org/ethnomed/clin_topics/hyperlipidemia_somali.htm.
Somali Immigrants Suffering a Peril of Plenty: Diabetes. Associate Press, May 2002.
Unpublished data: Notes from diabetes classes for Somali women (2002) and men (2005) held at Harborview Medical Center by diabetes educators, pharmacists, dieticians and cultural mediators.