Diabetes Awareness on the Antilles
Tutor Suzanne Borst January 2015 Group I, VD-COM 3B Members: Susanne Drienhuizen, 12081353 Martina de Haan, 12099147 Evelien van der Heiden, 12076929 Anita Hellemons, 12020044 Floor Hendriks, 12089249 Maartje Hommeles, 12103276
Eleonore de Merode, 12105996 Suzanne Oomen, 12085316 Mabel Ouwerkerk, 08022275 Sabrina Pater, 12097527 Dirk van Stiphout, 12068691 Diaan Vroegh, 12101893
Index
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1. Introduction The ABC islands, also known as Aruba, Bonaire and Curacao have a shortage of registered dieticians. This can cause problems in the future, for example for the treatment of diabetes. According to the WHO, 9% of the people worldwide suffer from diabetes. On the Antilles prevalence is even higher. Diabetes is a disease in which the hormone insulin cannot be produced in sufficient quantities or cannot be made at all. Appropriate treatment is important because untreated diabetes can lead to serious complications, such as damage to the cardio-vascular system, kidneys, eyes or neuropathy (World Health organization, 2015). To be a successful dietician, one needs to be aware of the ins and outs of diabetes on the ABC islands. This report aims to provide guidelines for future dieticians and to paint a picture of the situation around diabetes on the ABC Islands, amongst which the following questions need to be answered: • Which elements in the communication between dietician/patient can ensure more compliance during treatment?; • How is disease perceived by the population?;
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What is the incidence and prevalence of diabetes on the islands?;
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Specific nutrition supplements for diabetes patients,
How is diabetes presently treated on the islands? The following factors should also be taken into account: • Local food and living habits, Local availability. Level of understanding and education of the population. Language.
Perception of Dutch citizens by the native population. In addition, recommendations on how the health care system could improve the way of treating diabetes will be made. Particular attention will be paid the way the dietician and other health care providers communicate and interact with the population. It also gives the dietician means and ideas to make the transition to the lesser Antilles as smooth as possible. 2. Method In order to find the answers for the questions above we used evidence based literature which is published after 2005. Besides this information we used other relevant documentation from websites and books. Questions that came to mind during our research were collected. One member of our group visited Curacao during this assignment. During an interview she submitted the list of questions to some students who are working as interns over there. She also tasted some local foods and visited supermarkets and local food stores in order to obtain a clearer picture of the situation around food and nutrition over there. The databases we used are: Google, Google Scholar, Cochrane, Cinahl, Library HHS, National Kompas, CBS The Netherlands, CBS Curacao, PubMed . Dutch and English keywords that were used are: diabetes, diabetes prevention, Curacao, Aruba, Bonaire, healthcare, Food habits, Fast food, Caribisch gebied, obesity, obesitas, nutrition, education, poverty, compliance, adherence, health providers; diabetes treatment,,treatment diabetes on the ABC islands, diabetes America, diabetes vereniging Aruba, Bonaire, Curacao, information programs diabetes on the ABC islands, Fietsen ABC eilanden, Bicycle ABC islands, physical activity ABC islands, Health promotion ABC Islands, perception Dutch citizens on Curacao. 3. Results 3.1 The demographics for diabetes type II With 328 million patients, Diabetes type II is a worldwide problem. (Diabetes in cijfers, 2014)
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In 2014 the International Diabetes Federation developed a scorecard to monitor the progress in reducing premature death by Diabetes type II worldwide. 104 Countries completed the scorecard survey, including Aruba and Curacao. 3.1.1 Aruba Aruba is the smallest island of the ABC group with 180 km2. The total population is 109,000 people, of which the age group of 20-79 years consists of 73,510 people. The number of people with diabetes type II is 12,630 (17%). In addition to which there are an estimated 3,500 inhabitants where diabetes type II is undiagnosed. Aruba is working on a plan to reduce the incidence of diabetes and is working towards a healthier lifestyle for its population with the aim of less overweight and more physical activity (International Diabetes Federation, 2014). The incidence of Diabetes type II on Aruba is unknown. The combination of overweight and aged over 60 years gives a higher risk of diabetes. 3.1.2 Bonaire Bonaire is in area smaller than Curacao but larger than Aruba. With only 15,700 residents Bonaire is sparsely populated and has the smallest population of all 3 islands. Recent figures about diabetes on Bonaire are lacking, but research from The Bonaire Health Study from 2002 showed that 6.7% of the population of Bonaire was diabetic. The real figure is likely to be much higher than that. The largest group of diabetics are aged over 65 (Antilliaans dagblad, 2014). Data on Bonaire is hard to find, but in the field of diabetes Bonaire is often mentioned together with Curacao and Aruba. Bonaire has not participated in the scorecard survey of the IDF. As the separate ABC islands are all independent of each other, there is not much collaboration in the field of diabetes prevention or treatment. On the ABC islands diabetes type II caused by obesity is a major problem. As two out of three people are overweight, this can lead to diabetes type II. Further interest in the prevention of type II Diabetes is important because it can result in a lower incidence of this disease in the future. Medical care and the government have long been unable to address the prevention of diabetes. This means that there is a high prevalence of diabetes II. The incidence of diabetes on the islands is unknown but the governments are becoming more and more aware of the severity of the problem. 3.1.3 Curacao Curacao, with an area of 444 km2 is the largest island of the three ABC-islands and with 150,000 inhabitants the largest population. In the age of 20-79 there are 112,140 inhabitants of which 20,920 people suffer from diabetes. According to the International Diabetes federation, the prevalence is 18.6%. This means the prevalence of diabetes cases in Curacao is in second place worldwide (following the United States as number one) (Verstraeten, Jansen, Pin, & Brouwer, 2013). Also see appendix 1. It is estimated that another 5,800 people on Curacao have not been diagnosed with diabetes. These people have diabetes and related symptoms, but are not (yet) being treated by a doctor or dietician (International Diabetes Federation, 2014). 3.2 How diseases are perceived on the Antilles 3.2.1 Population Curacao, Bonaire and Aruba differ in size, population, language and culture, and therefore also in healthcare development. Many different nationalities live on these small islands.
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The population of Aruba numbers 109,153 (2013), and consists of 80% Arubans, 10% Dutch and the remaining 10% consists of South Americans and other Europeans. Arubans are a mixture of original Indian inhabitants, Europeans (mainly Dutch), African slaves and to a lesser extent Sephardic Jews. (https://www.cia.gov/library/publications/the-world-factbook, 2014). The unemployment rate is 7.6% (Aruba, 2014). The population of Bonaire numbers 15,700 (2014). The majority of the inhabitants of Bonaire were born in the former Netherlands Antilles. One tenth of the population was born in the Netherlands. The rest of the residents are from South or Central America (http://www.cbs.nl/nl-NL/menu/themas/bevolking, sd). The unemployment rate is 10.3% (Statistics, 2009). The population of Curacao numbers 149,679 (2011). The inhabitants of Curacao come from diverse populations. In 2010, 107 different nationalities were represented. The majority is Creole; the native population. They are of African and European descent. Furthermore, there are minorities of Dutch, Chinese, Lebanese, Portuguese, Surinamese, Venezuelans, Indians, Dominicans, Haitians and Colombian descent (http://www.cbs.cw/, 2014). The unemployment rate is 6.3% (Statistics, 2009). 3.2.2 Health issues Research shows widespread poverty on the Antilles, low educational attainment, teenage mothers, drug and alcohol abuse and obesity. These conditions have a direct effect on health issues. Obesity is a major health issue on all the islands. As a consequence, there is a significant risk of eye disease, hypertension, kidney and heart failure. The underlying causes of these problems are unhealthy eating habits and lack of exercise. Healthy food is expensive as the islands depend on the import of fruit and vegetables. This explains why these are more expensive than other products. Food is important for the Antilleans and stands for hospitality. Moreover, the Antilleans lack a physically active culture (Astrid Westerbeek, 2013). Typical for health care on the Antilles is sending out patients for medical care and examinations to other islands or countries if appropriate medical care is not available on their own island. This means a lot of work for caregivers, such as communication and verification of data. This implies that patients may be confronted with a different language and culture and being far away from relatives (Astrid Westerbeek, 2013). Due to limited medical facilities on the islands, prevention of disease and its complications is very important. Here, the practitioner can play an important role in specialized care such as diabetes (Astrid Westerbeek, 2013). 3.2.3 Subjective health perception by gender and education Research by the Institute of Public Health Curacao shows that 73.4 % of adults rate their health as good or very good. The remaining adults evaluate their health condition as moderate (24.4 %) or as poor or very poor (2.2%). Men in the age from 18 to 24 and 45 years and older experience their health condition more positively than women in these age groups. Subjective health deteriorates with age. 52% of people 75 years or older consider themselves in good to very good health. With a higher level of education the percentage of people who rate their health as good/very good rises. Both men and women with low and secondary level of education are less likely to consider themselves as being in good health than men and women with high education (Verstraeten, Jansen, Pin, & Brouwer, 2013). 3.2.4 Causes of obesity The causes of obesity are multi-factorial:
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1. Bad food habits; there is lack of parental care. Many mothers take care of their family alone and
need to work many hours. Adolescent and younger children, especially after school, often eat snacks or cheap frozen food with poor nutritional value. Moreover, many overweight children are malnourished (Unicef, 2013). 8% of the adults eat fast food four times a week or more (Volksgezondheid instituut Curacao, 2013). 2. Lack of exercise; there is a lack of exercise, for example; about 77% of Aruban girls between six and eleven don't exercise regularly and take a walk less than ten minutes per day (Unicef, 2013). 3. Voluptuous beauty image; being overweight is not considered to be unattractive. Hence, the urgency to reduce weight is not present. In addition to this, little appreciation will be received from one’s social environment. 4. No relation between lifestyle and health; Individuals often doubt the relationship between eating more healthily and losing weight; as well as the link between obesity and health risks (Elvi van Wijk-Jansen, Leven om te eten, 2010). 3.2.5 Superstition Despite the fact that Antillean patients find their way to Western medicine easily, they tend to attribute mental illness to Brua, a folk religion with roots in the former slave culture. A Brua healer, called Kurioso is seen when Western medicine has no answer to a medical problem. 3.3 The way diabetes is treated on the ABC-islands Dieticians work in various places as independent practitioners. They have all been educated in the Netherlands. Patients usually visit a general practitioner or a medical specialist on referral; however a standard referral is not common. Dieticians give diabetes patients advice about a healthy diet and lifestyle. If needed they also help with losing weight. Exercise is important for diabetes patients, but the bad infrastructure and the warm and humid climate makes it difficult to exercise. Bureau Ziekte Verzekering (BZV) and the White Yellow Cross in Curacao organise programs for diabetes type II patients. These contain: a course about diabetes, budgeting (recipes for healthy and cheap meals), exercise, food education and social support (Pavert, 2009). In Aruba the White Yellow Cross organises information sessions about diabetes (Wit Gele Kruis Aruba, 2014). In Bonaire ‘healthy lifestyle and diabetes’ is the health theme for the years 2014–2016. The department Public Healthcare and the Care of the Public Body Bonaire promotes a healthy lifestyle to reduce the risk of diabetes. The program JOGG (Jongeren op Gezond Gewicht) is used (kikotapasando, 2014). On the ABC islands the same medication is available as in the Netherlands. However, American units for blood glucose levels are used. Blood glucose levels are converted to the same levels as in the Netherlands, but in Aruba, Bonaire and Curacao the notation of the blood glucose levels differ. In the Netherlands mmol/l is used and on the ABC-islands mg% (DVN, 2014), (American Diabetes Association, 2014). 3.3.1 Blood glucose level The ideal blood glucose level is: below 108 mg% with an empty stomach. When the level is higher than 108 mg% twice on different days the diagnosis is Diabetes Mellitus. When the level is above 198 mg% once, the diagnosis is Diabetes Mellitus (American Diabetes Association, 2014).
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3.3.2 Blood glucose testing There are different types of blood glucose measuring instruments. The diabetes nurse practitioner will offer a blood glucose measuring instrument that fits the patient’s needs (American Diabetes Association, 2014). 3.3.3 Types of Insulin Rapid-acting insulin: starts to work fifteen minutes after the injection, peaks in one hour, and works for two to four hours. There are different types: Insulin glulisine (Apidra), insulin lispro (Humalog), and insulin aspart (NovoLog). Regular or Short-acting insulin: starts to work within thirty minutes after the injection, peaks in two to three hours after injection, and is effective for approximately three to six hours. Different types: Humulin R, Novolin R. Intermediate-acting insulin: starts to work two to four hours after the injection, peaks in four to twelve hours and is effective for about twelve to eighteen hours. Different types: NPH (Humulin N, Novolin N). Long-acting insulin: reaches the bloodstream several hours after injection and works for twenty-four hours. Different types: Insulin detemir (Levemir) and insulin glargine (Lantus) (American Diabetes Association, 2014). 3.3.4 Diabetes Type I People diagnosed with type I diabetes usually start with two injections of a mixture of insulin per day and generally progress to three or four injections per day of insulin of different types. The types of insulin can be adjusted on the blood glucose levels (American Diabetes Association, 2014). 3.3.5 Diabetes Type II Most people with type II diabetes may need one injection per day without any diabetes pills. But some people only use diabetes pills. Sometimes diabetes pills stop working, and people with type II diabetes will need to start with two injections per day of two different types of insulin. This can progress to three or four injections of insulin per day (American Diabetes Association, 2014). 3.3.6 Insulin Pens There are different types of insulin pens: insulin pens that contain a cartridge of insulin and pre-filled pens with insulin which need to be discarded after all the insulin has been used. It only contains one type of insulin. The insulin dose can be chosen on the pen and the insulin is injected through a needle (American Diabetes Association, 2014). 3.3.7 Insulin pumps Insulin pumps contain rapid- or short-acting insulin. It delivers insulin 24 hours a day through a catheter placed under the skin. This catheter has to be replaced every two or three days. Insulin doses are separated into: - basal rates - bolus doses to cover carbohydrate in meals - correction or supplemental doses (American Diabetes Association, 2014). 3.3.8 Oral medication type II diabetes There are different types of oral medication for type II diabetes. These work in different ways to lower the blood glucose levels: Sulfonylureas, Biguanides, Meglitinides, Thiazolidinediones, DPP-4 inhibitors, SGLT2 Inhibitors, Alpha-glucosidase inhibitors, Bile Acid Sequestrants. These can be used together.
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The medication is available at the pharmacy (Botica’s). Including blood glucose measuring instruments, insulin pens, insulin pumps and all the requisites.
The health care team consists of: - An endocrinologist: this is the primary care provider. Visit two to four times a year. - A diabetes nurse practitioner: two to four times a year. - A registered dietician: two to four times a year. - A social worker/psychologist/psychiatrist/marriage and family therapist, if needed. - An eye doctor: once a year. - A podiatrist: once a year. - A pharmacist: needs an accurate and up-to-date profile of the medical history, allergies and medications (American Diabetes Association, 2014). 3.3.9 Local availability of specific nutrition supplements Plants or their extracts may have a potential therapeutic role in treatment for diabetes. Traditional health care systems, including herbal medicine, are widespread in developing countries. The care for diabetes has been influenced through alternative medicine (KURIYAN, 2008). Dieticians however, don’t prescribe specific nutrition supplements as a replacement or complement of medication. A general principle in advice for diabetics is a healthy and varied diet containing sufficient vitamins and minerals (Vitamine Informatie Bureau, 2014). All these supplements are available in the Antilles and in local shops. It is also possible to order supplements online. For an overview of herbal medicines and supplements see appendix 2. 3.4 Doctor-/nurse-patient communication/interaction in relation to compliance during treatment According to an evaluation of primary health care in Curacao carried out in 2012, patients view their general practitioners very positively. More than 90% of patients indicated that their GP is aware of their specific health problems and illnesses that have affected them in the past. Almost two thirds of the patients state that their GP is also aware of their personal situation and takes the time to help with personal problems and concerns. Patients are positive about the amount of time taken by their GP to talk with them and about the explanations received about their health concerns and the prescribed medication. Furthermore, 93% of patients believe that their GP listens to them well. This positive experience is reflected in the fact that 85% of patients believe that they can better manage their health concerns after a visit to their GP. Only 4% did not agree with this statement (Snoeijs, 2012). Statistics on patient satisfaction in Aruba and Bonaire are not available; neither are statistics relating specifically to the relationship of the patient with the dietician. When dealing with diabetes patients, it is important that doctors and dietician pay attention to the communication with the patient in order to ensure that there is more compliance to the prescribed treatment. Medical non-compliance is a major problem in health care, as it has a significant impact on the clinical outcome and is a source of frustration to doctors and health practitioners. A 2001 review by Vermeire has assessed the major issues in compliance to medical treatment and concludes that the quality of the communication between health practitioner and patient can be enhanced by the following factors: - friendly and approachable attitude of the practitioner;
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increase the patient’s understanding of the disease, its causes and the treatment by giving clear explanations; address and respect the patient’s unresolved concerns, i.e. side-effects of medication; gain a good understanding of patients’ health beliefs, experience of the illness and associated feelings and expectations; be based on the accurate recognition of the patient’s problem by the doctor demonstrate active listening and empathy; be respectful of the patient’s priorities and viewpoints even when they differ from the caregivers ideals and expectations. involve the participation of the patient in developing the treatment plan; check the patient’s attention to compliance; take into account spiritual and psychological dimensions which may be of primary importance to patients. Brua spiritual practices – in which a practitioner attempts to restore a patient’s health or heal disturbed social relationships (which are often considered to be at the root of disease) are widespread in the Antilles. Anyone working with the local population, especially the older generation, should seek to familiarise themselves with the main concepts. Speaking the same language as the patient (Papiamento in Curacao) is also a great asset.
Compliance with treatment can also be improved by: - Better patient educational strategies (both written and oral), aimed at improving patients' understanding of their treatment and its side-effects; - Simplifying treatment by prescribing fewer concurrent medications and longer-acting medicines, in cases where the complexity of the treatment is one of the patient's concerns. - Practical compliance aids include organisers and reminders such as blister packs, calendars, dosage counters, special containers, dosage forms, controlled delivery and microprocessors. - Adequate labelling and written information and oral information provided by pharmacists. - Presenting treatment instructions in a clear and simple manner, the use of concrete and specific advice, by repeating and stressing the importance of the critical components of the advice, by checking understanding and by providing feedback. - Involvement of the patient in the negotiation of treatment goals; - Tailoring the treatment to the patient's life-style; - Encouragement of family support. Health professionals need to shift the emphasis away from a paternalistic approach where they attempt to encourage patients to conform to their own expectations and take the medications they prescribe. They should instead consider the patients as the primary actors in making balanced decisions about treatments that best fit into their own beliefs and personal circumstance (Vermeire, 2001). 3.5. Means and ideas for a smooth transition of Dutch dieticians To make the transition as Dutch dietician to the Lesser Antilles as smooth as possible, the dietician will need to understand their clients. In order to treat clients successful they will have to delve into their way of thinking about good nutrition and a healthy lifestyle. 3.5.1 Health status A report of the Volksgezondheid Instituut Curacao provides key data on the health status of the Curacao population aged 18 years and older (Volksgezondheid instituut Curacao, 2013). As a dietician you should be aware of the following: - Most adults (73.4%) rate their health as good to very good.
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- Forty percent of the adult population suffers from one or more chronic diseases or long-term health problems, and less educated people are more likely to have one or more chronic diseases than highly educated. - The most frequently reported disease is high blood pressure in both men and women. Other commonly reported diseases include diabetes, high-cholesterol and allergies. - Eight in ten adults say they feel happy and full of life. - The average self-reported BMI value for the adult population is 27.8. This value is classified as overweight. This average is significantly higher in women than in men. - In percentage terms, the number of people who never exercise in Curacao is higher than in the Netherlands - Nearly half of the adults eat fruit every day - Nearly 70% of adults eat vegetables or salad daily. A number of habits, expectations and attitudes towards their lifestyle constitute barriers for Antillean women to eat more healthily and exercise more. From their social environment, the women expect little support for a healthier diet. A voluptuous beauty image is the basis and they expect little appreciation if they were to lose weight. In addition, they see little reason to exercise more, but they expect more support from their social environment to exercise more than for a healthier diet. They doubt the relationship between eating more healthily and losing weight; as well as between obesity and health risks (Elvi van Wijk-Jansen, Leven om te eten, 2010). In order to gain more insight into the beauty ideal that Antillean women have, the dietician can use drawings of female bodies well to find out how clients perceive their own and other peoples’ overweight (Figure Rating Scale). See appendix 3. 3.5.2 Working as a dietician on the Antilles The dietician on the ABC-islands works within a hospital, GGD or independently. The internist or physician refers the patient to a dietician. Standard referral is not yet happening. In the hospitals the dietician has insufficient resources to provide high quality care. There is hardly any software to calculate power values, there is less work space and an outdated registration system is used (Pavert, 2009). 3.5.3 Means and ideas To facilitate the transition, the Dutch dietician should be aware of the fact that clients have a different attitude towards healthy habits. It is important that the dietician’s first aim is to understand how he or she can help the client. Some tips: - Try to understand the beliefs and mentality of the client. - It is important to share knowledge. Explain that there is evidence that a healthy weight is linked to healthy food and that overweight and obesity entail health risks. - Ask how the client sees his or her own health status. Use the figure rating scale (Pulvers) to determine the self-image and the ideal of beauty of the client. - Discuss the importance of the social environment and the expectations regarding their reactions. - Build a good relationship with the client. - Give clients the confidence that they are able to adopt progressively healthy habits in their daily routine. - Try to think along with the client how healthy eating can be fun and enjoyable. For example, make ready-made recipes for healthier versions of traditional dishes. - Convince the client that exercise is important for a healthy lifestyle. Explain that this does not mean that the client should immediately go to the gym. Walking, cycling and dancing is also a way of exercise.
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3.6 Recommendations After completing the research, we came up with several recommendations for the ABC-islands. 3.6.1 Promotion of sport activities/ physical activity From research data it can be concluded that diabetes is a problem of proportion. The Dutch Diabetes Foundation recommends having an active lifestyle to reduce symptoms of diabetes. The advantages of sport are to reduce body weight and to reduce stress. Stress is the factor that deregulates the blood sugar levels in the body. Playing sports and being active give a person a fit feeling. An active lifestyle not only reduces the risk for diabetes, it also prevents the risk for other lifestyle diseases such as heart disease, stroke, high blood pressure and obesity. Campaigns to promote sports in primary and secondary schools are needed. These could also include after-school activities. 3.6.2 Promotion of cycling In 2010, Stichting ABC Advies did research into biking on the ABC-islands. The results showed that few people on the islands use bikes. Some reasons for that are: a lack of a ‘cycling mentality’, poor quality of cycle lanes, no bicycle racks and the costs of purchasing a bike. Biking amongst the Dutch is very common and they have a great ‘cycling mentality’. Cooperation at this level could be a huge success. The export of bikes, which are stored in the depots of the municipality, can serve the people of the ABC-islands. Bicycles are collected by the Dutch city council in big cities like Amsterdam and Rotterdam, when parked in the wrong place or abandoned in bicycle racks. As already mentioned in the assignment many Dutch students do internships on the ABC-islands. A programme could be initiated to teach biking to Antilleans by Dutch students. However, the government should also invest in safe cycle lanes and bike racks for the community. 3.6.3 More cooperation between the ABC-islands Cooperation between the islands can be cost effective and provides significant gains in practice. While working together, the islands can learn from each other’s mistakes, but most importantly their success. Exchange of ideas could be mediated by an official board that takes care of regular communication. Joint campaigns about food, physical activity and lifestyle diseases should be promoted on each island. This is cost reductive. Maybe it would even be possible to import healthy foods together, to lower the costs. This would make healthy foods cheaper for the inhabitants. This could result in more variation in diet and a healthier lifestyle. Local markets offer fruits and vegetables at a much lower cost than the big supermarkets do. These local markets depend on the import from fruits and vegetables from Venezuela. They cannot rely on continuous supply because of export embargos. Last September the Antilles suffered from such an export embargo. This resulted in empty fruit and vegetables-shelves in stores. Especially for poor people fruit and vegetables became unaffordable (Dias, 2014). 3.6.4 Broadening knowledge and understanding of a healthy lifestyle Obesity, type 2 diabetes, high blood pressure and high cholesterol occur mainly in women with lower education. As women still are the ones who primarily take care of the children, they are the ones to teach the children about a healthy lifestyle. These woman need to be taught and educated by people with knowledge. In 2011, the GGD The Hague did research about the need for health education and this seemed to be high. Community classes for woman and health care classes in primary and secondary schools are necessary. Children often come to school without eating breakfast and they don’t bring their own lunch. Fruit and vegetables are very expensive on the islands because of the import costs. Families simply can’t afford to buy these healthy products.
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3.6.5 Summary of different ways of communication and interaction with the population: - A board of health professionals from each island who discuss healthcare, health promotion and develops events and strategies to improve a healthy lifestyle. - Information to parents through the school of their children about healthy living and sports. Schools could also involve parents in after-school activities. - Yearly health promotion plus sport events on every island, on the same day, in the same format. - Promotion of cycling in cooperation with the Dutch government. - Import of vegetables and fruits in cooperation with all the islands. 3.7 Factors that have to be taken into account 3.7.1 Food habits Cultural background of the Antilles The merging of different people and cultures during the history of the Dutch Antilles has resulted in a great variety of cooking styles and food habits in Antillean cuisine. Indian, Spanish, African, Dutch, Jewish, South American and Asian cultures influenced the cooking of the Antilles. All these different food influences make the cooking on these islands very versatile (Wikipedia, 2014). Food Philosophy The people of the Antilles are known for their hospitality. Especially at public holidays or special occasions like weddings or communions everyone is welcome to join in. At special occasions food performs an important role. A proverb in Papiamento says: A stuffed stomach goes hand in hand with a happy heart. The people of the Antilles take this statement seriously (Römer, 1977). On the ABC islands food equals sociability. Because the refusal of food is seen as a rude gesture, people feel obliged to accept food offered to them. Daily diet Breakfast is normally very straightforward and similar to a European breakfast. Later on in the morning coffee is served, occasionally together with some pasty (empaná). For most families on the Antilles the main meal is served in the afternoon. On weekdays the main course will consist of meat, fish or chicken, which is braised or fried and served with ‘funchi’ or rice and stewed vegetables or fried banana. In general meat or fish will represent the largest part of the main course. Only a small part of the main course will consist of vegetables, and because fresh vegetables are regarded as a luxury product most of the vegetables eaten will be canned or frozen (Lugt, 2014). In the evening dinnertime varies in most families. Dinner will consist of bread, tea sometimes served with the leftovers of lunch. Low-fibre food products such as white rice and white bread are the most common sources of carbohydrates (Lugt, 2014). On Sundays and public holidays meals will be more extensive and luxurious. During the day soft drinks represent the main source of hydration. Sodas are preferred over water because of the general idea that the sugar in soft drinks helps with handling of the climatologically conditions (Lugt, 2014). Daily intake of fruit and vegetables for most adults on the Antilles is largely inadequate. Fruit and vegetables being too expensive is given as the main reason for the inadequate consumption of fruit and vegetables (Verstraeten, Jansen, Pin, & Brouwer, 2013). Fast-food Food knowledge among the population is limited and people therefore often choose flavour over health. As healthy foods are widely regarded as less tasty than foods rich in fat, sugar and salt, people often make unhealthy nutritional choices (Lugt, 2014). Fast-food is also an inexpensive source of food which
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is widely available and affordable for all economic classes on the Antilles. As the costs of fresh fruit and vegetables are high compared to the prices of fast-food, the less wealthy part of the population will easily resort to unhealthy food habits (Lugt, 2014). Many people on the Antilles eat fast food on a regular basis, at least 4 times week (Verstraeten, Jansen, Pin, & Brouwer, 2013). 3.7.2 Level of education Educational system The educational system on Curacao is similar to the system of the Netherlands. After primary education, pupils can go on to secondary education and then on to post-secondary education. In primary school the language of instruction is one of the official languages of the island, namely, English, Dutch and Papiamento (Kenniscentrum Beroepsonderwijs Bedrijfsleven, 2014). See appendix 4. The educational system in Aruba is also almost the same as in the Netherlands, with a few differences. Pupils in secondary school in Aruba make the same Central Examination (CE) as in the Netherlands (Wikipedia, 2014). In Bonaire the educational system is also similar to the Netherlands. As Bonaire is a small island, there is only one college and one university. Labour market and level of education In Curacao 45.3% (approximately 63,000 people) of the population participates in the labour market. Bonaire has a participation rate of 55% (CBS Labour & Social Security, 2013). The level of education of the working people in Curacao is improving. However, the majority of the employed people still has a low level of education. In 2011, 37% of the household heads had secondary education (HAVO/VWO/MBO) or higher (HBO/WO +). 63% of the household heads had a very low (none or only primary school) or low education (LBO/MAVO/VSBO). Male heads of households are better educated than female heads. 42% of them have secondary education or higher, while for women this is 30% (CBS Census Survey 2011, sd). Diabetes and level of education 27.4% of the total population reports having one or more chronic diseases and/or disorders. Diabetes is after high blood pressure, the second most reported disease. More women than men report having a disease or disorder. With increase in age, more people have a disease or disorder. When the education level is lower, more people report to have one or more diseases or disorders (very lowly educated 47.8%; highly educated 26.5%). People who are economically inactive more often report having a disease or disorder compared to those working or looking for a job (CBS Gezondheid en Beperkingen in Curacao, 2011). Poverty on Curacao The income differences between wealthy and poor households is significant. The so-called wealthpoverty indicator in Curacao is 9.5. That means that the group of wealthy households has 9.5 times as much income as the group of poor households. In comparison, the wealth poverty indicator in the Netherlands is 5.1 (1999). A quarter of the households lives below the poverty line (CBS Income & Spending, 2011). 3.7.3 The perception of Dutch citizens by the native population. The locals of the Antilles think more positive about the Dutch citizens than in the past. A few years ago one could speak of a slightly hostile environment. The language people speak, the cars that people drive
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and the colour of the skin were very important. The people that immigrate to the Antilles have adapted more than in the past. An interesting portrait of the makamba (white dutch immigrant) is sketched in a documentary ‘onder elkaar’ (Roethof & Bosman, 2013). It shows how the elite Dutch citizens think of the locals on Curacao and how they relate to them? The locals hate the people that come from this group. The lack of respect and not following the rules are an eyesore for the locals. After years of oppression of the black population there is some sort of reversed effect going on. Some of the coloured population of Curacao, sees the Netherlands and Dutch as oppressors and profiteers. This group doesn’t care much of the makamba's. A dietician must be aware that Dutch superiority is not well regarded. 4. Conclusion & discussion 4.1 Conclusion According to the International Diabetes Federation in 2014 17% of the adult population in Aruba suffers from diabetes type II; on Curacao prevalence is almost 19%. The figures about Bonaire are less recent, in 2002 7% of the population reported being diabetic. As on the islands there are also a large number of people with undiagnosed diabetes, this chronic disease is extremely widespread. Dieticians, educated in the Netherlands, who start working on the ABC islands will encounter an entirely different culture and other food habits. Important to know is that the three islands are all independent of each other and there is hardly any collaboration on health issues. However from this research it has emerged that in the way of living the people show many similarities, so the recommendations are equal for the three islands. Generally they have an unhealthy lifestyle with bad food habits and a lack of exercise. Traditionally the dishes they cook are rich in sugar, fat and salt and the regular consumption of fast food and soft drinks is no exception. Fast food is easy accessible; especially for the poor people that can’t afford more expensive vegetables and fruit, it is an easy way to feed themselves. Food has an important social role, the refusal of food is a rude gesture. As they are not aware of the negative health consequences and because they have a voluptuous beauty image the Caribbean people aren’t eager to change their habits. Despite the fact that diabetes, overweight, obesity and other food-related diseases are common, the majority of people rate their health as good or very good. It has emerged that lower educated women and economically inactive people have a higher risk at developing health problems than the working population and highly educated people. The main challenge on the ABC islands is to trigger the population to at least enter the contemplative stage of making lifestyle changes. As an information officer, the dietician needs to have excellent competencies for creating awareness and for supporting the people to reach this stage. As a practitioner, the dietician can recommend the same diabetes medications as in the Netherlands, as the medications are available at the pharmacy. However, the dietician should be aware that American units for blood glucose levels are used and the notation of blood glucose levels is in mg% instead of mmol/l. Despite the fact that it’s normal to use Western medication, the dietician must take in account that some people believe in the effect of alternative medicine. Since non-compliance to prescribed treatments is a major problem, the dietician should consider the patients as the primary actors in making balanced decisions about treatments that best fit into their own beliefs and personal circumstances. The perception of Dutch citizens by the locals has improved, nevertheless a dietician should be aware of not adopting an attitude of superiority. To gain confidence of the clients, the dietician should speak some basic words of the main spoken language Papiamento (see appendix 5).
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4.2 Discussion Although Curacao, Bonaire and Aruba are often mentioned in one name, they operate very independently from each other. One reason is the large distances between the islands - as many locals never visit the other islands, they are hardly aware of their existence. So, even though this report recommends to develop one single programme for the ABC islands, it is not sure if this will work. Therefore, it could be effective to start with different approaches for each island to improve health care and promote a healthy lifestyle, but more research for this is necessary. In the end it will be cost effective and efficient to collaborate closely between the three islands, aiming for a joint campaign to battle overweight and diabetes II. It would even be better to collaborate between other islands of the Antilles as well since the number of inhabitants on the various islands is low. Since most information was only available for Curacao, and not for Aruba and Bonaire, it was hard to get a clear picture for the latter islands. Therefore, information about Curacao is mentioned where data about the other islands was missing. It is very well possible that most of this information also counts for Aruba and Bonaire because the islands do have similarities. Nevertheless, lack of consistent data for all three islands is a limiting factor of this report. Moreover, differences in data between reports were noted. One reason for this is that reports are from different years, performed by different people. Another reason is that each island is doing its own research. Only Curacao has a CBS (Central office for statistics), they use different measurement standards from other research groups. Writing a report with 12 people is challenging. With everybody drafting a small piece of text it is hard to get the different chapters connected. This is also the reason why some overlap exists between different text parts and that there are omissions.
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Bibliography (2014, dec. 28). Retrieved from American Diabetes Association: www.diabetes.org American Diabetes Association. (n.d.). Retrieved from www.diabetes.org Antillaans dagblad (nov 15th 2014). Retrieved from http://www.bonaire.nu/2014/11/15/overgewicht-voornaamste-oorzaak-diabetes-bijjongeren/ Retrieved december 2014 from www.bonaire.nu Aruba, C. B. (2014). Anual Statistical Digest 2013. Aruba: Centrale Bank Van Aruba. Astrid Westerbeek, P. A. (2013). Trendrapport Caribisch Gebied 2013. Utrecht: FWG. CBS Census Survey 2011. (n.d.). Retrieved from CBS: http://www.cbs.cw/index.php? option=com_content&view=article&id=119&Itemid=83 CBS Gezondheid en Beperkingen in Curacao. (2011). Retrieved from CBS Curacao: http://www.cbs.cw/cbs/themes/Census%202001/Publications/Census%2020012014112473305.pdf CBS Income & Spending. (2011). Retrieved from CBS Curacao: http://www.cbs.cw/cbs/themes/Income%20and%20spending/Pressreleases/Income%20& %20Spending-2014061330139.pdf CBS Labour & Social Security. (2013, December 2). Retrieved from CBS: http://www.cbs.cw/cbs/themes/LabourandSocialSecurity/PublicationsLabour&SocialSecuri ty-20140511111148.pdf Diabetes Digital Media. (2012). Bitter melon and diabetes. Retrieved december 12, 2014, from Diabetes.co.uk - the global diabetes community: http://www.diabetes.co.uk/naturaltherapies/bitter-melon.html Diabetes in cijfers. (2014). Retrieved december 2014, from Diabetesfonds: http://www.diabetesfonds.nl/artikel/diabetes-cijfers Dias, J. M. (2014, september 4). Nieuwsberichten Cara誰bisch Netwerk NTR. Retrieved from Cara誰bisch Netwerk NTR: http://caribischnetwerk.ntr.nl/2014/09/05/schaarste-aan-groente-en-fruitdoor-exportverbod-venezuela/ DVN. (2014). Retrieved from Diabetes Vereniging Nederland : www.dvn.nl Elvi van Wijk-Jansen, L. J.-H. (2010). Leven om te eten. Den Haag: LEI Wageningen UR. http://www.cbs.cw/. (2014, december). Retrieved from http://www.cbs.cw/: http://www.cbs.cw/ http://www.cbs.nl/nl-NL/menu/themas/bevolking. (n.d.). Retrieved december 2014, from www.CBS.nl: http://www.cbs.nl/nlNL/menu/themas/bevolking/publicaties/artikelen/archief/2012/2012-3544-wm.htm https://www.cia.gov/library/publications/the-world-factbook. (2014, december). Retrieved from www.cia.gov: https://www.cia.gov/library/publications/the-worldfactbook/fields/2119.html http://www.idf.org/global-diabetes-scorecard/assets/downloads/Scorecard-29-07-14.pdf Retrieved december 2014, International Diabetes Federation, Global diabetes scorcard, tracking progress for action, (2014).
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Kenniscentrum Beroepsonderwijs Bedrijfsleven. (2014, December 7). Retrieved from Kenniscentrum Beroepsonderwijs Bedrijfsleven: http://www.kbbcuracao.com/index.php? topic=beroepsonderwijs_nl KHAN, K. (1980, april 12). Treatment of diabetes mellitus with. British medical journal, p. 1044. kikotapasando. (2014). Retrieved from Openbaar Lichaam Bonaire bezint over Wereld Diabetes Dag: http://kikotapasando.com/2014/11/14/gobiernu-di-boneiru-ta-reflekshona-riba-diainternashonal-di-diabetis-openbaar-lichaam-bonaire-bezint-over-wereld-diabetes-dag/ KURIYAN, R. (2008, februari 2). Effect of Supplementation of Coccinia. Diabetes Care, pp. 216-220. Lugt, M. v. (2014, december 17). Pavert, P. v. (2009). diabeteszorg op curacao: de eilandjescultuur op een eiland. Enschede: Universiteit Twente. Pulvers, e. a. (n.d.). Figure Rating Scale. R.S. Hariharan, S. V. (2005). Efficacy of vijayasar in the treatment of newly diagnosed patients with type 2 diabetes mellitus: a flexible dose double blind multicenter randomized controlled trial . Diabetologica Croatica, 13-20. Roethof, M., & Bosman, A. (Directors). (2013). Hollandse maatjes [Motion Picture]. Retrieved december 2015, from http://www.npo.nl/onder-elkaar/30-03-2013/NPS_1225070 Römer, R. (1977). Cultureel mozaïek van de Nederlandse Antillen. Zutphen: De Walburg pers. Retrieved November 20, 2014, from http://www.antilliaansekeuken.nl/historie-van-deantilliaanse-keuken/ Snoeijs, S. B. (2012). Evaluatie van de structuur en de zorgverlening van de eerstelijnsgezndheidszorg op Curação: een studie op basis van vragenlijsten, documenten en gesprekken met zorgverleners en andere betrokkenen in de gezondheidszorg. Utrecht: NIVEL. Statistics, C. B. (2009). Statistical Yearbook Of The Netherlands Antilles 2009. Wiilemstad: Central Bureau of Statistics. Unicef. (2013). De situatie van jongeren en kinderen op Aruba. Unicef Nederland. Vermeire, E. H. (2001). Patient adherence to treatment: three decades of research. A comprehensive review. Journal of Clinical Pharmacy and Therapeutics, 26 (5), 331-342. doi:PMID: 11679023 Verstraeten, S., Jansen, I., Pin, R., & Brouwer, W. (2013). De Nationale Gezondheidsenquete Curacao. Otobranda, Curacao: Volksgezondheids Instituut Curacao. Vitamine Informatie Bureau. (2014). Diabetes Mellitus. Retrieved december 12, 2014, from Vitamine informatie bureau- alles wat je wilt weten over vitamines en mineralen: http://www.vitamine-info.nl/vitamines-mineralen-en-mijn-gezondheid/diabetes-mellitus/ Volksgezondheid instituut Curacao. (2013). De Nationale Gezondheidsenquete Curacao. Curacao: VIC. Retrieved december 4, 2014, from file:///C:/Users/Susanne/Downloads/Rapport %20NGE2013%20Final.pdf Wikipedia. (2014, December 7). Retrieved from Wikipedia: http://nl.wikipedia.org/wiki/Aruba Wikipedia. (2014). Retrieved November 20, 2014, from Nederlands-Antilliaanse keuken: http://nl.wikipedia.org/wiki/Nederlands-Antilliaanse_keuken
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Wit Gele Kruis Aruba. (2014). Retrieved from http://www.witgelekruisaruba.org/Gezondheidswebsites/Diabetes,overgewichtenvoeding/t abid/2382/language/nl-NL/Default.aspx World Health organization. (2015, january). Retrieved january 2, 2015, from fact sheet Diabetes: http://www.who.int/mediacentre/factsheets/fs312/en Xue WL, L. X. (2007). Effect of triognelle foenum-graecum extract on blood glucose, blood lipid and hemorheological properties in streptozotocin-induced diabetic rats. Asia Pac J Clinical , 422426.
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Appendix 1 Prevalence of diabetes in adults by age, 2013
(International Diabetes Federation, Curacao, 2014)
Appendix 2 Local availability of specific nutrition supplements for diabetes patients Herbal medicine Plants or their extracts may also have a potential therapeutic role in treatment for diabetes. Traditional health care systems, including herbal medicine, are widespread in developing countries. The care for diabetes has been influenced through alternative medicine. (KURIYAN, 2008) Coccinia Indica is a climber that grows in Bengal. This plant has been used by Indians since ancient time for treating diabetes mellitus (KHAN, 1980). Studies have shown that the plant has an anti diabetic effect on alloxan-induced diabetic rabbits. The use of this plant leads according to R. Kuriyan (2008) to an significant decrease in the fasting postprandial blood glucose and A1C. However further studies are needed to elucidate the mechanisms of action (KURIYAN, 2008). Because it is necessary to do further research, Coccinia Indica isn’t advised to diabetes patients. Momordica charantia (bitter melon) is a vegetable that can be used as medicine for type 2 diabetes. The plant thrives in tropical en subtropical regions including the Caribbean. The plant has a blood glucoselowering effect and an insulin-like compound known as polypeptide-p. A four-week trial (2011) showed that a 2,000 mg daily dose reduced blood glucose levels among patients with type 2 diabetes (Diabetes Digital Media, 2012). Pterocarpus marsupium (vijayasar) is a traditional Indian plant which can be used for the treatment of diabetes. Vijayasar has an effective blood glucose lowering function. Its glycemic effect is being comparable to the effect of tolbutamide (R.S. Hariharan, 2005). Trigonella foenum greacum – the seeds of this plant have shown a hypoglycemic and hypo cholesterolemic effect on type 1 and type 2 diabetes mellitus patients (Xue WL, 2007). Vitamins
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A general principle in advice for diabetics is a healthy and varied diet containing sufficient vitamins and minerals (Vitamine Informatie Bureau, 2014). Supplements can be bought on Curacao at the Goisco. This is a shop where you can buy all sort of supplements. It is possible to order supplements online as well. Vitamin B12 absorption can be disturbed in patients taking the drug metformin. Metformin is a drug that is prescribed frequently to people with type 2 diabetes. It is possible that there is insufficient absorption of vitamin B12. In consultation with a physician it can be decided to start with the use of supplements. (Vitamine Informatie Bureau, 2014) Folic acid – Cardiovascular disease is a complication of diabetes. A predictor of cardiovascular disease and strokes is homocysteine. This is a substance that is produced during the metabolism of proteins. A high level of folate concentration in the body leads to a low level of homocysteine. It isn’t proven that a high level of folic reduces the risk of cardiovascular diseases. The folate dietary intake is on the tight side. A supplement is worth considering. (Vitamine Informatie Bureau, 2014) Magnesium – It occurs that people with diabetes more often have a magnesium deficiency than healthy people. Associated with magnesium deficiency are diabetes complications such as eye disease and cardiovascular complications. In consultation with a physician it can be decided to start with the use of supplements when a magnesium deficiency is detected. (Vitamine Informatie Bureau, 2014) Chrome – chrome improves insulin sensitivity; more studies suggest a beneficial effect of the use of chromium supplementation in diabetes. In consultation with a physician it can be decided to start with the use of supplements. (Vitamine Informatie Bureau, 2014)
Appendix 3 Figure Rating Scale
(Pulvers)
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Appendix 4 Educational system
FO VSBO SBO HAVO HBO VWO
: Funderend Onderwijs : Voorbereidend Secundair Beroepsonderwijs : Secundair Beroeps Onderwijs : Hoger Algemeen Vormend Onderwijs : Hoger Beroeps Onderwijs : Voortgezet Wetenschappelijk Onderwijs
Source: (Kenniscentrum Beroepsonderwijs Bedrijfsleven, 2014)
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Appendix 5 Crash course Papiamento for foreigners The local tourist newspaper of Curacao "Curacao what 2 do" says Papiamento is the language of Curaçao. Aruba has a different spelling of Papiamento, below the spelling of Curacao and Bonaire Glossary Dutch Goedemorgen Goedemiddag Goedenavond
Papiamento Bon dia Bon tardi Bon nochi
Hallo hoe gaat het Het gaat goed dank u Tot ziens Dank u wel Hoe heet je Ik heet... Waar is Wanneer
Kon ta bai Bon, danki Ayo / te despues Danki Kon ta bo nomber Ami yama... Unda ta Ki ora
Maandag Dinsdag Woensdag Donderdag Vrijdag Zaterdag Zondag Minuut Uur Week Dag Vandaag Morgen Aardig, lief, lekker, schatje Man Vrouw Kind Arts/dokter
Djaluna Djamars Djárason Djaweps Djabièrnè Djasabra Djadumingu Minut Ora Siman Dia Awe Mañan Dushi Homber Muher Muchanan Dokter
Ontbijt Lunch Diner Maaltijd Eten Drinken
Desayuno Lunch / almuerso Sena Kuminda Kome Bebe
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Tafel
Mesa
1 = Un 2 = Dos 3 = Tres 4 = Kuater 5 = Sinku 6 = Seis 7 = Shete 8 = Ocho 9 = Nuebe 10 = Dies Spreekt u Nederlands / Engels Ik spreek een beetje Papiaments Waar is ... Hoe kom ik bij/naar
Bo ta papia hulandes / Ingles Mi ta papia un poko papiamentu Unda....ta Kon mi ta yega....
For a stay in Curaรงao Papiamento words can be learned, for example, from theweb site: http://www.woordjesleren.nl/questions.php?chapter=107684 The online training site NHA, offers a Papiamento language course for about 230,00 Euros. There are many other suppliers to be found by internet.
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