Cultural Competence Is Essential in Diabetes Care

Cultural Competence Is Essential in Diabetes Care

As rates of diabetes continue to rise, endocrine nursing is a specialty that will continue to have a pressing need.

Diabetes care is only one aspect of an endocrine nurse’s specialty—thyroid disorders and adrenal gland disorders also are endocrine system problems—but November’s designation as American Diabetes Month highlights this particular condition.

An endocrine nurse can choose to work with adult or pediatric patients, and they will see different presentations of the same disease across all populations. Because diabetes can present in varying ways for each individual and treatment plans can differ widely, an endocrine nurse must have a broad expertise in how diabetes impacts many body systems.

Cultural competence is especially important in this nursing specialty as traditions around food alone—eating, feasting, or fasting—will have an immediate and potentially dangerous impact on someone with diabetes.

Diabetes is so prevalent today that most people know of someone who has Type 1, Type 2, or gestational diabetes. The different types of diabetes stem from separate issues, but result in the same inability to use insulin.

According to, these are the more common forms of diabetes:

  • Type 1 is a chronic autoimmune disorder that seems to have genetic and environmental causes and is something that cannot be prevented.
  • Type 2 is when the body is unable to use insulin (also called insulin resistance). This type has several causal factors including lifestyle factors like obesity, inactivity, or smoking, but there’s some research that notes a genetic cause for some minority populations with Type 2.
  • Gestational diabetes happens during pregnancy when hormones can interfere with the body’s normal use of insulin.

Like many chronic conditions, diabetes has a direct and significant impact on a person’s daily life and activities. Blood sugar rises and falls throughout a normal day, but other factors like an illness, stress, or travel can pose particular challenges for people with diabetes. They need to be vigilant and prepared for any red flags in their insulin numbers.

As an endocrine nurse, you’ll need to help your patient put the pieces of their personal diabetes puzzle together and then take it apart to examine all the factors that could change their typical treatment. Understanding your patient’s cultural norms will go a long way to developing a diabetes plan that will work and that the patient can and will follow.

Diabetes management will look different for each person, but it’s helpful to ask questions that might reveal religious or lifestyle preferences and choices that could play a part in how they can manage their condition. Children and teenagers can be particularly challenged by social pressures to keep on track. And many patients, young and old, go through a period of denial when they think they don’t need to worry too much about their disease. If you’re a nurse with diabetes, you know the challenges first-hand.

Educating patients about the severe complications that can arise from mismanaging this condition, no matter what type it is, is essential. But it’s also important to let people know how the diagnosis of a chronic condition like diabetes can cause changes in mental health and that help is available. You can share resources about the diabetes communities—both online and local—so that patients can learn from others and know they aren’t alone.

Endocrine nurses have the responsibility of helping patients follow their treatment plans and of having the compassion to understand why it is so hard to do. Nurses who understand their patient populations have an advantage, so learning as much as you can about the cultural norms will help.

What is A1C?

What is A1C?

A1C, or Hemoglobin A1C (HbA1c), is considered the gold standard for managing diabetes. But what is it?

The cell wall of the erythrocyte is permeable to glucose. Exposed to this glucose, the Hemoglobin molecule becomes “glycated.” The naming convention for HbA1c derives from Hemoglobin type A being separated using cation exchange chromatography. The first fraction, considered the pure Hemoglobin A is designated HbA0. After that comes HbA1a, HbA1b, and then HbA1c respective of their elution. Hemoglobin exposed to a normal level of glucose has an average glycation. As the glucose level rises, so does the fraction of glycated Hemoglobin, in a predictable way.

The average lifespan of a red blood cell is about 120 days before the cell membrane starts showing signs of wear and tear and they get shuttled off to the spleen, liver, and bone marrow for breakdown and recycling. The A1C therefore is a picture of the AVERAGE blood sugar over the previous 2-3 months. As an average, it cannot tell the difference between someone with tightly controlled blood sugar and a person with wildly fluctuating highs and lows. Neither does it identify episodes of hypoglycemia or periods of critically high blood sugar values. It’s great for population management but too crude a tool to manage an individual patient.

In the chart, we see a day in the blood sugar levels of three patients. All three have the same average blood sugar, but patient number 1 and patient number 2 have wildly fluctuating levels throughout the day. Patient 1 spends more time outside of range than inside, but her A1C would be normal.

The A1C coupled with the patient’s daily blood sugar record gives a more complete picture for individual patient management. Other shortcomings in the A1C happen with patients with high or low blood cell turnover.  Patients with kidney disease undergoing dialysis have especially high turnover of red blood cells due to the process of filtering the blood. Their A1C would be abnormally low. Cirrhosis of the liver decreases blood cell turnover leading to higher A1C levels. Certain types of anemia and blood disorders as well as some vitamins and medications can affect the accuracy of the A1C. If you hang your hat on the A1C for all your treatment decisions, you will be misled.

So, what is the A1C good for? The American Diabetes Association has the following guidelines to be used in the diagnosis of diabetes:


A1c Level What It Means
Less than 5.7% Normal (minimal risk for type 2 diabetes)
5.7% to 6.4% “Prediabetes,” meaning at risk for developing type 2 diabetes
6.5% or greater Diagnosed diabetes


Following it over time allows for risk evaluation for complications arising from diabetes. There’s a strong positive correlation between high A1C numbers and diabetic neuropathy, kidney disease, and eye disease. Diabetic specialists use the daily blood sugar levels to formulate an individual plan for each patient to drive the A1C numbers lower over time.

Understanding the A1C and what it does and does not tell you is important. It’s a great starting point, but not an accurate tool for individualized diabetes care.