Table 1. Diabetes Self-Management Education.

Component	Cultural Considerations
Healthy eating	Nutrition strengths in the food culture: Steamed and grilled fish, chicken, seafood, seaweed. Targets for nutritional change in the food culture: Salt, a lot of rice, sweet breads, sugary drinks, fast food. Nutrition beliefs: Carbohydrates seen as filling them up/satiety. Introduce Western fruit and vegetables as snacks to increase fruit intake. Concept are viewed dichotomously—yes versus no, versus in gradations, thus present examples of health foods versus non-healthy foods instead of in variation of healthiness God has given us strength to eat healthy through making small changes and additions to the usual diet, and through consuming appropriate portions sizes.
Being active	Physical activity needs to have a purpose—Walking to a neighbor's house to visit versus walking around a track or just walking to walk. God has given us strength to be physically active. Younger generation (age <40 years) physical activity suggestions: Sports, organized events. Older generation (ages ≥40) physical activity suggestions: Gardening, cleaning, play with children and grandchildren.
Monitoring blood glucose levels	Collectivistic (vs. individualistic) orientation, for example, the whole family needs to be involved and work together to be healthier versus just the person with diabetes. Set family-oriented goals where each member of the family has a role. Grandchildren have the power to change their grandparents' behaviors. Use analogies from nature in the Marshall Islands to describe difficult or new concepts (sea tide), such as why blood glucose needs to be in a certain range.
Medicine	Value of ‘pacific natural’ medicine from plants, from nature so emphasize how Western medicine comes from plants (e.g., metformin is derived from the French Lilac). Acknowledge and respect traditional Pacific treatments for diabetes. Education on Western medicine is needed: Even if a pill looks different it is the same medication; expect mild side effects and communicate any side effects with the provider—feeling worse does not mean the medicine is not working; taking generic is not a problem; make sure to get refills before you run out of medicine. God has made us unique so being on insulin does not mean that one's diabetes is worse than someone who is not taking oral medication.
Problem solving	Tendency to want to hide symptoms from family members so not to worry them. Engage the entire family to problem solve for the individual with diabetes. Need counter narratives to some spiritual beliefs that it is God's will or punishment that one has diabetes.
Reduce complications	God has given us knowledge to be healthy and that knowledge includes practicing self-care to reduce complications. Set family-oriented goals where each member of the family has a role.
Coping with stress	God encourages us to support one another; power of prayer to cope with stress. There will likely be a limited expression of emotion, so encourage expression of emotion (fear, overwhelmed, anxiety) through trust-building activities.