Influence of national culture on diabetes education in Malta: A case example Cynthia Formosa, Kevin Lucas, Anne Mandy, Carmel Keller Article points Diabetes is a condition of particular importance to the 1. This study aimed to Maltese population. Currently, 10% of the Maltese population explore whether or has diabetes, compared with 2–5% of the population in not diabetes education the majority of Malta’s neighbouring European nations improved knowledge, HbA1c and cholesterol (Rocchiccioli et al, 2005). The high prevalence of diabetes levels in Maltese people results in nearly one out of every four deaths of Maltese people with type 2 diabetes. occurring before the age of 65 years (Cachia, 2003). In this 2. There was no difference article we explore the possible contributions of the unique between the intervention and control groups in Maltese culture to the epidemiology, we hope that some lessons any of the metabolic can be taken when attempting educational interventions in parameters. people of differing backgrounds. 3. Sophisticated programmes that take account of the unique nature of Maltese culture are necessary to he reasons why Malta has such a high living conditions started to improve for ordinary bring about behavioural incidence and prevalence of diabetes Maltese people (Savona-Ventura, 2001). and metabolic changes in are complex. The Maltese population Extensive social disruption was brought this group. T Key words is the result of the inter-marrying between about by lengthy blockades that occurred peoples of the various cultures and nations during the Second World War, resulting in - Education that have occupied the island through the ages. near starvation for many Maltese people. The - National culture - Metabolic parameters Eating habits are rooted in traditional culture. initial response to the blockade was an apparent The apparent gradual steady increase of type 2 increase in mortality from diabetes reaching a diabetes’ prevalence in Malta during the late peak of 86.6 per 100 000 population in 1942. nineteenth to early twentieth centuries has been This sudden surge in mortality was possibly a Cynthia Formosa is a Podiatry associated with drastic changes in dietary habits result of difficulties in maintaining adequate Co-ordinator at the University of Malta, Kevin Lucas is a and food availability. During the nineteenth clinical management of the more severe cases Senior Lecturer in Health century, the majority of the population existed of diabetes. The immediate post-war years Psychology, Anne Mandy is a on large quantities of barley bread and wine, witnessed an apparent fall in mortality of 23 Principal Research Fellow and supplemented by olives, oil, onions, garlic, per 100 000 population by 1948. This fall may a Research Student Division cheese and very little fish or meat. In season, have been partly a result of the previously high Leader and Carmel Keller is a Principal Lecturer at the melons, prickly pear and raw vegetables were selective mortality pattern. It may also have been Institute of Post-graduate abundant, but meat was rarely affordable. It was in response to the subsequent better control of Medicine. All are based at the not before the turn of the twentieth century that surviving people with diabetes following the University of Brighton. Diabetes & Primary Care Vol 10 No 2 2008 109 Influence of national culture on diabetes education in Malta: A case example Page points period of dietary restrictions during the war the Mediterranean region suggests a possible 1. In the 1950s, Maltese years (Savona-Ventura, 2001). Semitic and Middle Eastern contribution to the cooking had been The later post-war period saw an improvement genetic pool of countries such as Malta where described as ‘sub-Italian, in the social conditions for the Maltese diabetes is more frequent. In Cyprus, Israel, monotonous and drab’. population. In the 1950s, Maltese cooking had Italy, San Marino and Turkey, a positive history It included a high been described as ‘sub-Italian, monotonous and of diabetes in first-degree relatives was found in proportion of starch and fat that adversely affected drab’. It included a high proportion of starch 34–45 % of people with diabetes but only in the physical appearance and fat that adversely affected the physical 15–20 % of the general population (Schranz, of the majority of the appearance of the majority of the Maltese by 1997). The situation is complicated further by Maltese by their mid- their mid-twenties. The continuing presence the fact that the vast majority of Maltese people twenties. of the British resulted in the introduction of marry and have children with others from 2. It has been hypothesised foods such as fried eggs, bacon and chips into within the Maltese population. that type 2 diabetes the Maltese diet. Nutritional studies carried Despite the high prevalence of diabetes in is a particular risk in out in 1981 confirmed that the Maltese were Malta, no studies to date have explored the populations who have experienced cycles of consuming large quantities of food with an possible contributions of the unique Maltese feast and famine, as the average individual’s daily intake at 6.5–8.5 MJ. culture to these epidemiological findings. Maltese have repeatedly With the improvement of the financial status done. of the population after the post-war years, Methods 3. People eligible for this the specific mortality rate from diabetes rose This study was approved by the University of study were Maltese, markedly, reaching a peak of 129.2 per 100 000 Brighton Research Ethics Committee and by the aged between 45 and 65 population in 1975 (Savona-Ventura, 2001). University of Malta Ethics Board. Individuals years, living with type 2 There is sufficient evidence to attribute the were recruited from the diabetes outpatient diabetes according to the WHO criteria, and had late nineteenth to early twentieth century clinic, St Luke’s Hospital, Malta. This hospital never attended a diabetes increase in cause-specific mortality rates and is the only public hospital on the island and is education program in the presumed increased prevalence of diabetes to the sole provider of diabetes education in Malta. past. a change from a thrifty Mediterranean diet to It is estimated that an average of 1100 people 4. Group diabetes education a relatively abundant Anglo-Italian one (Neel from all over Malta visit the diabetes outpatient sessions were held in the et al 1998; Savona-Ventura, 2001). Prior to the clinic at St Luke’s Hospital every month, the diabetes clinic, St. Luke’s twentieth century, the Maltese had adapted to majority of whom present with type 2 diabetes Hospital, Malta. a physiology best suited for a diet based mainly (Azzopardi and Grixti, 2000). People eligible on unrefined carbohydrates. This adaptation of for this study were Maltese, aged between physiology in some individuals enabled those 45 and 65 years, living with type 2 diabetes with the adaptation to be more likely to survive (type 2 diabetes defined using World Health during periods of restricted diet, a phenomenon Organization [WHO] criteria), and had never that has been described as the ‘thrifty genotype’ attended a diabetes education program in the (Neel et al, 1998). Neel and colleagues suggest past. People at the top of the waiting list for the that the increase in fat and refined carbohydrate programme were invited to participate as the intake that occurred during the late twentieth intervention group while those lower down the century ‘overloaded’ such individuals, giving waiting list were used as the control group. Both rise to the observed increased incidence of groups provided consent to participate in the obesity, increased peripheral insulin resistance study. and consequent higher prevalence of type 2 Group diabetes education sessions were diabetes in the Maltese population. For similar held in the diabetes clinic, St. Luke’s Hospital, reasons, the anthropologist Robert Ferrell has Malta. Sessions were held on Saturdays for hypothesised that type 2 diabetes is a particular a period of four consecutive weeks. Sessions risk in populations who have experienced were 90 minutes in duration and usually run cycles of feast and famine, as the Maltese have continuously throughout the year, except repeatedly done (NMSU, 1998). Moreover, for the months of July and August when the the history of early population movements in weather was too hot. The content consisted of 110 Diabetes & Primary Care Vol 10 No 2 2008 Influence of national culture on diabetes education in Malta: A case example information about various aspects of diabetes people who have type 2 diabetes and it is a Page points management that were delivered variously by reliable and valid measure that is relatively 1. Participants were a consultant diabetologist, a diabetes specialist easy to administer (Garcia et al, 2001). The encouraged to ask nurse, a dietitian and a podiatrist. Sessions contents of this questionnaire were read to the questions and share their were delivered in a large lecture room that was participants in one-to-one interviews in their experiences in diabetes well aerated and had good light and a friendly language of preference (English or Maltese). self-management. Educational leaflets were atmosphere. Participants were encouraged to ask When translating the DKQ-24 into the Maltese also distributed after the questions and share their experiences in diabetes version, the ‘back translation’ method was sessions. self-management. Educational leaflets were also used. This method has been used extensively 2. In total, 50 people were distributed after the sessions. in translations of questionnaires across many recruited into each of countries in order to ensure reliability and two groups. Subjects Procedure validity and is described in detail elsewhere were matched for gender, Sample size was determined by the use of (Leung and Arthur, 2000; Frosch et al, 2001; educational level attained, a power calculation using fasting blood Halepota and Wasif, 2001; Nusbaum et al, current medication taken and marital status.