In Tonga, a small island kingdom in the South Pacific with a population of about 100,000 people, girth is a sign of success. Western-style medical care tends to be utilized only for illnesses related to the West, and hospitals are viewed as places for people with life threatening illnesses; as many as 70% of the patients go there to die. These insights gained by Ruth Breitenbach, a nurse and diabetes educator at Redwood City Kaiser in California, and her colleague Donna Wright, MA, RN, have helped them pioneer a successful, culturally sensitive diabetes education program aimed at the Tongan population in Redwood City. Tongan-Americans comprise a large percentage of the patients treated for diabetes there.
Shortly after Ruth Breitenbach began working as the metabolic services coordinator at Kaiser Permanente in Redwood City, she noticed that the Tongan patients had a low level of compliance regarding their diabetes regimens, particularly in terms of diet. Based on this, she suggested Tongan-Americans with diabetes as a thesis topic to Donna Wright, who was commencing her master’s thesis in international health at Stanford. Ultimately, the two RNs received an invitation from Tongan Crown Princess Salote Pilolevu Tuita and grants from two drug manufacturers which allowed them to travel to Tonga, where they visited hospitals and clinics, met with nurses and physicians, and gave a personal lesson in blood glucose monitoring to Tongan King Taufa’ahau Tupou IV.
The grant money was also used to publish a bilingual, English/Tongan brochure on diabetes and diet. The brochure is unique in its recognition of Tongan values, using illustrations of typical Tongan foods and people in native Tongan dress.
Since her trip, Breitenbach has also decorated her clinic with photographs of King Taufa’ahau and Tonga, and is now able to greet Tongan patients in their own language. In addition, through her willingness to learn about Tongan culture, Breitenbach is far more sensitive to, and therefore able to appropriately address, the specific needs of Tongan-Americans.
For example, the Tongan diet is very high in carbohydrates, particularly potatoes, yams, and taro root; there are no green leafy vegetables in Tonga, and many dishes are cooked in rich coconut cream or mayonnaise. Portion size, which is critical to diabetic dietary management, is also problematic for Tongans who are accustomed to eating sweet potatoes the size of large cantaloupes. And finally, as most Tongans grow older and stop working, they stop getting any form of exercise.
So Breitenbach has used Tongan foods to design meal plans, and has even devised an alternative coconut cream recipe, using corn starch, low-fat milk and artificial sweetener. She has also been able to draw inspiration for her patients from the example of King Taufa’ahau who, at age 75, now exercises every day, and has dropped from 440 to 300 pounds.
At Kaiser in Redwood City, Breitenbach reports that as Tongan-Americans have begun to make changes in their dietary habits, their average blood glucose levels have begun to drop. The fact that they feel better and have more energy helps encourage them to continue. Based on her work with Tongan-American people with diabetes, Breitenbach fully recognizes the importance of developing culturally sensitive programs, and hopes that her program will serve as a model for other similar programs. “You cannot develop a successful program for another culture based on books and translators,” she insists. “You need to really understand the culture, and to be willing to learn from its people if you want them to be able to learn from you.”