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One nurse, two dietitians help give diabetes care in the Marshall Islands
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When Linda DeLand, RN, BSN, MA, Betty Krauss, RD, CDE, and Sandra Parker, RD, CDE, signed on to a trip to the Marshall Islands, they had one goal in mind: to help improve diabetes care among the high-risk population there.
The threesome traveled to the group of islands in the Pacific Ocean as part of a month-long task to help assess and improve diabetes care and self-management on Mejatto, one of the four outer atolls in the Marshall Islands.
Diabetes is a health concern in the Marshall Islands. It is estimated that the incidence of type 2 diabetes among adults living in the Marshall Islands is 30% to 40%, Parker told Endocrine Today. They believe the high rate of type 2 diabetes in the Marshall Islands may be attributed to overweight, underactivity and large portions of food. Of note, children had a low incidence of diabetes and obesity, which was surprising, they told Endocrine Today.
From Michigan to Mejatto
The mission was organized by Trinity Health International, a nonprofit organization based in Michigan, which administers the 177 Health Care Plan, a U.S. relief program for Marshallese exposed to nuclear radiation.
For DeLand, this was her second trip to Marshall Islands — from 1985 to 1987 she helped to implement the New Majuro Hospital in the capital of the Marshall Islands.
The goal of the team was to assess local medical care, educate the people and help the on-site physician and health assistant pilot a standardized diabetes plan established by the 177 Health Care Plan.
“We were really happy to have the chance to participate in a project needing diabetes expertise and experience, and the combination of dietitians and diabetes educators was a rare opportunity,” said Parker, who is a self-employed diabetes consultant in Grand Rapids, Mich.
DeLand, Krauss and Parker first visited the capital, Majuro, where they learned about local culture and customs and met with 177 Health Care Plan staff, Ministry of Health leaders, politicians, community organizations, physicians and nurses. Two 177 Health Care Plan physicians and a translator accompanied the team to Mejatto.
On Mejatto, they worked in the clinic. During their assessment they identified several areas of concern, including lack of medical records and proper diabetic foot care, according to the team. Using fasting, random and HbA1c tests, the team found two residents with significantly elevated blood glucose levels.
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“When they came to the clinic, they didn’t even know they had diabetes,” said Krauss, who is a dietitian with the Mary Free Bed Rehabilitation Hospital, Grand Rapids, Mich.
The average HbA1c was >11%, according to Krauss, although these are rough data. Monofilament tests were used to assess neuropathy — 18 residents reported loss of sensation in their feet, ranging from some sensation to a total lack of sensation.
During their week on Mejatto, the team established a diabetes treatment plan that included tracking standards of care on a diabetes care flow sheet, comprehensive history and physical exam, routine HbA1c and blood glucose testing and microfilament testing. They left the on-site physician with several recommendations to help achieve results during the clinic visit and to make adjustments in the care plan.
The team also stressed the importance of daily physical activity, although men and young children regularly engage in activities such as biking, swimming, running and model outrigger racing.
“I felt we had collaboratively, with the local staff, produced a realistic, scientifically based plan to improve the diabetes care of many of the people of the Marshall Islands,” said DeLand, who retired from the State of Michigan Department of Community Health and is currently a part-time, self-employed diabetes consultant.
Evaluating nutrition was a big component of the care plan. The women were particularly interested in the eating habits of the Marshallese and saw them first-hand when the local women organized a cook-out to demonstrate their food preparation and sample local cuisine.
The team observed a dependence on canned foods delivered by the U.S. Department of Agriculture, such as canned meat and vegetables. After the cook-out, Krauss and Parker held group diabetes nutrition classes to demonstrate proper portion control and encourage use of locally grown foods and gardening techniques.
According to their final report, “Our observations led to ideas to help educate, encourage and reward participation in the self-management of diabetes and primary prevention of diabetes. Because of what was learned on Mejatto, the 177 Health Care Plan should look at implementing diabetes care and education activities on all four of the islands and the Majuro dispensary.”
Challenges, accomplishments
Krauss has diabetes herself and had several concerns on the trip, including the temperature affecting the insulin, possible malfunction of her insulin pump, unexpected hypoglycemia and dehydration.
“The biggest challenge was not knowing how to cover anything until after I ate. But, I am very proud because I know that in years past no diabetic would have been able to take this on. It was challenging, but achievable,” she said.
All three women said the Marshallese were wonderful to work with, welcoming and willing to learn.
Their work in the Republic of the Marshall Islands earned Krauss, DeLand and Parker the 2007 State Outstanding Achievement Award from the Michigan Organization of Diabetes Educators. – by Katie Kalvaitis