Diet and Education in Ethnic Minorities (DEEM)

Developing tools and methods for patient education and support targeting ethnic minorities with type 2 diabetes.

Aim and purpose
Little is known about how to improve self-management behaviours in ethnic minority groups. Interventions aiming at improving factors such as weight status and metabolic profile of South-Asians with type 2 diabetes or at high risk have not shown promising results (4, 5). The studies often suffer from laborious recruitment, high drop-out and lack of effectiveness. 

Studies have shown that South Asian migrants increase their energy and fat intake and lower their fibre intake when immigrating to European countries (1). Studies have also shown a higher prevalence of obesity and type 2 diabetes in South Asians compared with the majority population in several European Countries (2). A Danish study has revealed that the type 2 diabetes prevalence among immigrants from Pakistan is about 14 % compared with 2 % among Danish-born people (3). In fact, Pakistanis represent one of the largest minority patient groups at the Steno Diabetes Center.

Objectives of the research project
In order to increase participation and effectiveness of dietary education targeted ethnic minorities with type 2 diabetes, the aim of this project is to develop and test methods and tools for dietary education targeting non-Danish speaking patients (Urdu, Arabic and Turkish speaking). 

Design, method and theory
The research project is carried out using a design-thinking framework (6). This approach consists of different phases including problem-finding, problem-solving and solution-testing.

Attitudes, challenges and needs are assessed in qualitative in-depth interviews. Interviews are supplemented by observations of dietary counselling at the Steno Diabetes Center. Ethnographic attention was directed to the home setting in order to capture the role of the social context in relation to diabetes diet. Cultural probes such as illustrations of food, beverages and social situations were used in order to promote engagement and draw opinions from the patients.
As a starting point, a grounded theory analysis of barriers and facilitators regarding diet in ethnic Pakistanis with type 2 diabetes guided the development of tools and methods for dietary counselling.

Problem-solving and solution-testing
This phase involved presenting and discussing findings from the qualitative analysis in workshops and in interviews with patients and health care professionals, and thereby including these groups in the development of methods/tools.

A variety of ideas was generated for dietary education, meeting the needs and preferences of ethnic minority patients. 
Later in the process, we visualised methods/tools and explored if healthcare professionals had necessary competences to use the methods. 
Finally, a feasibility test of the methods will be conducted comprising 10-second-event coding (measure of dialogue), observations and interviews with patients.

Target groups

The research project targets ethnic minority patients with type 2 diabetes (Urdu, Arabic and Turkish speaking) as well as health care professionals delivering the dietary education.

Expected outcomes
The research project will provide new knowledge about the needs and preferences of minority groups with respect to dietary education. Based on the identified needs, tools and methods have been developed and subsequently tested in the Steno Patient Care Clinic and/or other settings.

The methods/tools are developed in order to increase awareness and self-management behaviours with regards to food in ethnic minorities groups and to strengthen health care professionals’ competences applicable in dietary education.
The results of the study will be communicated to the scientific community and health care professionals working in practice.


Nana Hempler, Senior Researcher and Team Leader, Steno Health Promotion Research
Bettina Ewers, Head of Nutrition, Steno Clinic
Lotte Vinther, Dietician, Steno Clinic
Patients from Steno Clinic


1.  Holmboe-Ottesen et al.  Changes in dietary habits after migration and consequences for health: a focus on South Asians in Europe. Food Nutr Res 2012;56.

2. Gholap et al. Type 2 diabetes and cardiovascular disease in South Asians. Prim Care Diabetes 2011;5: 45–56 S1751-9918.

3. Etniske minoriteters sundhed, juni 2008, Center for Folkesundhed, Region Midtjylland. 

4.  Admiraal et al. Intensive Lifestyle Intervention in General Practice to Prevent Type 2 Diabetes among 18 to 60-Year-Old South Asians: 1-Year Effects on the Weight Status and Metabolic Profile of Participants in a Randomized Controlled Trial. PLoS One 2013 Jul 22;8(7).

5. Hawthorne et al. Culturally appropriate health education for type 2 diabetes mellitus in ethnic minority groups. Cochrane Database Syst Rev 2008 Jul 16;(3):CD006424.

6. Brown. Design thinking. Harvard Business Review. June 2008.

Sidst opdateret 16-11-2016

Nana Folmann Hempler
Teamleader, Senior Researcher
Diabetes Management Research