diabetes, faith community nursing, lifestyle modification, liturgical anthropology, patient education, self-care



  1. Ammerman, Cathy Eden
  2. Harden, Kelly
  3. Mitchell, C. Ben


ABSTRACT: Millions worldwide live with diabetes and are challenged to make lifestyle changes. Nurses help patients learn strategies necessary for successful diabetes management. However, patients frequently view long-term behavior change as unachievable. This article offers educational strategies based on liturgical anthropology that can be incorporated into any diabetic self-care education program, but particularly in faith communities. Lifestyle habits are tightly interwoven with cultural, social, and spiritual beliefs. Liturgical anthropology explores how cultural and spiritual customs mold us and influence our behavior choices. (Supplemental Digital Content: Video Abstract


Article Content

In 2013, 382 million people worldwide had diabetes, including 26 million Americans. Diabetes is the leading cause of nontraumatic limb amputations, blindness in working adults, and end-stage renal disease (Beckles & Chou, 2013; Guariguata, Whiting, Hambleton, Beagley, Linnenkamp, & Shaw, 2014). However, the risk of developing these complications can be reduced through modification of diet, weight control, and increased physical activity, all of which improve glycemic control (Beyazit & Mollaoglu, 2011).

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Patient education in self-care has long been an important component of diabetes management. Lifestyle modification requires significant changes that often are difficult to achieve (Scain, Friedman, & Gross, 2009). In addition, people with diabetes often do not make behavioral changes as advised, citing a lack of knowledge, feelings of helplessness, and lack of confidence in their efforts (Kluding et al., 2010). O'Hea et al. (2009) explained that although diabetic patients they surveyed believed recommended changes would benefit them, the patients did not believe they were capable of following those recommendations. Participants in a study by Ho, Berggren, and Dahlborg-Lyckhage (2010) indicated that many diabetic patients viewed the advice given as an impossible ideal.


With a basis of promoting, maintaining, and restoring health for the whole person, nurses in multiple roles are ideal professionals to assist patients in making lifestyle changes. Faith community nurses (FCNs) who specialize in health promotion and disease prevention, with an emphasis on spiritual care (American Nurses Association & Health Ministries Association, 2012), are in an excellent position to support lifestyle modification. FCNs can personally teach and offer spiritual support to those with diabetes, as well as bring into the faith community, or make referrals to, diabetic support groups, dieticians and cooking classes, organizations aimed at providing safe physical activity, and primary healthcare providers and diabetes specialists.


Given that making lifestyle changes is difficult, are there tools nurses can use to support those with a chronic disease that requires a lifetime commitment to improve health? What can healthcare providers do, in addition to simply giving people information?



Habits are behaviors repeated consistently in response to a given situation. The more often the behavior is chosen, the stronger the neural connections become within the brain, until the response comes so quickly after the situation is encountered it seems automatic and uncontrollable (Lally, Van Jaarsveld, Potts, & Wardle, 2010). Responses can be developed intentionally, as with practicing piano scales, or unintentionally, such as between-meal snacking or being sedentary.


Behavior choices reflect a person's perception. Choices are made to balance the way things are perceived with the way things ought to be (Smith, 2013a). Our view of the world is influenced by what we are taught, observe, and experience. Social and cultural norms, peer and gender expectations, family and community role responsibilities, and things that bring meaning and purpose to our lives all factor into our choices.


Changing habits requires a belief that we are capable of changing, and that our efforts to change will be worthwhile (Duhigg, 2012). Lifetime behavior change requires significant motivation and determination to achieve and maintain. If patients think they are capable of making a change, they will try. If they do not think themselves capable of making changes, they may not try, or will give up quickly when opposition is encountered (Stuart & Lieberman, 2002).


Failure in efforts to change can potentially lead to self-blame and feelings of frustration (O'Hea et al., 2009). Failure to change likely reflects the powerful draw of past responses, rather than a lack of knowledge or willpower (Neal, Wood, & Quinn, 2006). To identify diabetic patients impacted by despair, hopelessness, and powerlessness to change, Egede and Ellis (2010) developed the Diabetes Fatalism Scale. In Scripture, the apostle Paul understood this sense of fatalism. He lamented that he had the desire to do what was right, but not the ability to carry it out. It seemed as if his body automatically did the thing he had determined not to do (Romans 7:10-15).


Spirituality influences diabetic self-care choices. Polzer and Miles (2007) studied the association between self-management behaviors and spiritual beliefs held by African Americans with diabetes. They found that the person's perception of God's involvement in his health directly influenced healthcare choices and self-management efforts. Those who believed that God expected or approved of their self-management efforts were more likely to participate in those behaviors than those who believed God would heal them if they achieved a certain level of spiritual maturity and faith. Watkins, Quinn, Ruggiero, Quinn, and Choi (2013) also surveyed African American diabetics, and their research conclusions agreed that religious beliefs and participation in religious activities may improve self-management by providing support and hope, or may hinder efforts, if patients choose to rely on prayer or healing rather than participate in self-care.


Other ethnicities share similar beliefs. Dehning, Nelson, Stewart, and Stewart (2013) evaluated diabetics from many ethnic groups who identified themselves as Christian, or spiritual, without a particular religious tradition. Those who indicated a belief that God was concerned about their health were more likely to participate actively in self-management activities. The researchers also found that those who participated in worship attendance, Scripture study, and prayer were more likely to have confidence in their healthcare provider's motivation to help them.


Other researchers have observed that patients whose religions included worship attendance were more likely to have better glycemic control (How, Ming, & Chin, 2011), and that social support gained from religious participation improved diabetic self-care activities (Watkins et al., 2013). However, qualitative researchers who explored behaviors that influence the "perceptions of health, healthcare behavior, and adherence to treatment" found that although families and religion offered support for self-management behaviors, aspects of each hindered attempts to change (Ritholz, Beverly, & Weinger, 2011, p. 494).


Spiritual beliefs should be assessed in order to understand how beliefs influence healthcare and behavior choices (Sridhar, 2013). Harris and Pokorny (2012) suggested spirituality be added to existing standard medical practice in the treatment of diabetes. Current national standards for diabetic education include individualization of the program to include the "health beliefs and attitudes" of the patient (Haas et al., 2013, p. S103). Individual health beliefs and attitudes influence lifestyle choices, but cultural norms play a significant role in the selection of acceptable actions.



Cultural practices powerfully influence our behavior choices. Philosopher and theologian James K. A. Smith (2013b) suggests that as human beings, "We are what we love...We are creatures defined by our loves, but those loves are shaped by formative practices; [and] those love-shaping practices we call liturgies." This approach to understanding ourselves is known as liturgical anthropology. Liturgical anthropology explores how cultural and religious customs influence behavior and how spiritual rituals mold behavior choices (Smith, 2009).


Smith explains that liturgies are not just organized religious practices but include the "secular liturgies" constantly going on all around us. Liturgy shapes what we love because "we love what we worship" (2013b). By making certain liturgies intentional, we can reframe what we love, who we are, and what choices we make. For example, Westerners are lured through media advertisements and entertainments that picture behavior choices "in concrete, alluring ways that attract us at a non-cognitive level" (Smith, 2009, p. 58). To counter these effects, faith-based liturgies are a "hearts and minds strategy...that trains us by putting our bodies through a regimen of repeated practices that get hold of our hearts and 'aim' our love toward the kingdom of God" (Smith, 2009, pp. 33-34).


Four educational strategies were designed with the aim of offering a different liturgical anthropology perspective on lifestyle modification. Rather than describing an education program that teaches healthy eating, exercise, and details of lifestyle modification, the strategies incorporate faith-based practices into a diabetes self-care curriculum. The purpose of the strategies is to empower patients in making lifestyle modifications. The ultimate goal is for those with diabetes to retrain their perspective from doing healthier things, to being persons who love and seek God's best for their health.


Educational Strategy 1: Compare Nehemiah's task of rebuilding the wall of Jerusalem to lifestyle modifications (Nehemiah 1-6). Stories capture the emotion and imagination in ways that allow learners to incorporate a lesson into their desires and expectations (Smith, 2013a). The Old Testament account of Nehemiah's rebuilding the wall of Jerusalem is an example of success when faced with an impossible task. Nehemiah's belief that he was doing God's work sustained him through hard labor and challenges. The story of Nehemiah is relayed in the sidebar Impossible Task.


An analogy can be made of rebuilding the wall of Jerusalem to the diagnosis of diabetes, learning self-care techniques, and living with lifestyle modifications, a seemingly impossible task to many diabetics. The diagnosis of diabetes affects a person physically, emotionally, and spiritually. Physiologically, every cell is dependent on glucose for energy. Patients must learn self-management skills, make changes in their dietary habits, lose weight, increase physical activity, and take daily medication. Emotionally, they grieve the loss of their prediabetes self, address risks of depression, and may deal with moodiness related to fluctuating blood sugar levels. Their relationship with food changes; no longer are they able to eat without considering how it will affect their health. Spiritually, questions occur such as: Why me? What is the purpose of this in my life? Does this affect my relationship with God?


During the initial shock of the diabetics diagnosis, persons of faith can look to Nehemiah's example. They can cry out to God and ask for his help. As they begin to face the seemingly impossible task of lifestyle modification, they can assess their current level of knowledge, skills, and abilities as it relates to self-care; identify available resources; and begin to develop a health plan. They can realize with Nehemiah that the plan they are embracing is God's will for them.


Just as Nehemiah surveyed the damage to the wall and identified those who were willing and able to help the rebuilding efforts, the diabetic can identify areas of personal strength and weakness. Building on other life strengths may help with self-care. By first focusing on areas of strength and experiencing success, they will then be able to identify areas of weakness and recruit help as needed.


In Nehemiah's story, although many people were willing to help, others were not supportive, as they realized Nehemiah's success would affect their lives. Friends and family members are affected by an individual's lifestyle changes. Some may be asked to learn a different way to prepare food or celebrations. Family dynamics are complicated and do not always assure support of the patient's desire to change. Following Nehemiah's example, determination and perseverance can be realized. Although the Jerusalem wall was built in 52 days, Nehemiah and the workers had to systematically build step-by-step, day-by-day. Once lifestyle goals are met, it will take a lifelong commitment to maintain new behaviors.


Educational Strategy 2: Examine the process of habit formation and habit change. Duhigg (2012) describes habit formation as a three-step loop involving a cue, a routine, and a reward. The cue is a sensory input that triggers a response from the brain. The routine is the action selected by the brain in response to the cue to achieve a specific effect. The reward is the achievement of the desired effect. An example of this loop is:


* Cue: itch.


* Behavior: scratch.


* Reward: itch relieved.



Cravings are a variation of the habit loop, in which the brain anticipates reward without external sensory input, such as anticipation of grandma's Thanksgiving dinner, long before we see or smell the foods. The "Golden Rule of Change" asserts that a bad habit cannot be completely extinguished, but a habit can be changed by keeping the cue and reward the same, while changing the routine behavior (Duhigg, p. 63). This type of change requires significant effort and self-awareness of our cues, behavioral choices, and desires. Many factors affect these choices, a number of which are selected without conscious thought. Smith (2013a) suggests that habits are formed out of the liturgies in our lives, unconscious and conscious, secular and religious, and by intentionally engaging in spiritual practices, we can reorient and reform our habits toward God and his presence in our lives. Teaching these processes of habit formation and habit change can help those with diabetes identify their cues, behaviors, and rewards for healthy and unhealthy behaviors.


Educational Strategy 3: Illuminate how our worldview affects our choices. Choices are not made as independently as we like to think. Rather, choices are influenced by social and cultural norms, peer pressure, gender expectations, family roles and dynamics, and our personal worldview-that is, how we perceive the world and our place in it. When a person's worldview includes a belief in something that transcends one's self, it is described as being spiritual (Koenig, 2011).


Our behavioral choices are selected in an effort to balance the way things are with the way we think things oughtto be, based upon our observations, experiences, and what we have been taught (Smith, 2009). With time and repetition, choices become habits that seem automatic and instinctive, even uncontrollable. Making significant change requires altering our perception of who we are and what we are capable of changing. This requires a proper motivation to change, a reward worth the effort, a belief that we are capable of making the changes, and belief that support is available (Dunigg, 2012).


Educational Strategy 4: Explain how Christian faith-practices shape worldview. The motivation and determination to achieve and maintain the depth of commitment needed to make lifestyle modifications requires a new perspective. In a culture that encourages one to indulge and relax, it is difficult to commit to healthy behavioral choices. The apostle Paul instructed, "Do not be conformed to this world, but be transformed by the renewal of your mind, that by testing you may discern what is the will of God, what is good and acceptable, and perfect" (Romans 12:2, ESV).


To be conformed means to be molded or shaped. Our habits have been molded and shaped by peer pressure, cultural norms, family expectations, and personal desires. Being transformed requires change. Renewing our minds means gaining a new perspective of the triggers and meanings behind our behaviors. To renew our minds as Christians, we seek God's perspective and compare our choices to God's good, acceptable, and perfect choices. Healthcare providers and ethicists, Shuman and Meador (2003) rightly explain that Christians do not practice their faith to earn favor from God but to learn by faith to want the right things, at the right time, with the right attitude. Smith agrees that "being a disciple of Jesus is not primarily a matter of getting the right ideas, doctrines, and beliefs in your head in order to guarantee proper behavior; rather, it's a matter of being the kind of person who loves rightly-who loves God and neighbor" (2009, pp. 32-33).


Many persons with diabetes have incorporated faith-based practices that have helped empower them to successfully cope with managing their health. Worship attendance, Bible study, meditation, and prayer are practices that have been identified as useful to diabetics in their efforts to honor God via their lifestyle modification (Bell et al., 2013).


Worship calls us out of our daily routines to set aside time for God and fellow believers (Smith, 2009). Participating in the rituals of worship refocuses our perspective on things that are eternal and provides meaning and purpose. A renewed motivation is gained through what is taught, observed, and experienced during worship gatherings. It is through worship that God changes the heart and what we love (Smith, 2013a). The interaction with other believers reminds us that we are not alone in our struggles but find strength and support in community.


Bible study is both a part of corporate worship and an individual discipline. The book of Psalms opens with an encouragement to meditate on God's Word. "Blessed is the man... [whose] delight is in the law of the LORD, and on his law he meditates day and night" (Psalm 1:1-2, ESV). Unlike an Eastern view of meditation where one empties the mind, biblical meditation allows the learner to reflect about what was read or taught and how it applies to life. The psalmist declared, "I will meditate on your precepts and fix my eyes on your ways" (Psalm 119:15, ESV). The Hebrew word Selah is used to encourage the reader of the psalms to pause and ponder what was just read (Strong, n.d.).

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For individual or small group Bible study, leaders may select prepared sermons or devotionals for those facing challenges (such as living with diabetes). Others may pursue self-directed word or topical studies. Gaining power to accomplish God's will (Philippians 4:13), care of the body (1 Corinthians 6:19-20, 9:27; Romans 12:1), and the concept of daily bread (Matthew 6:11) and daily manna (Exodus 16:4) are examples of Scripture that can help learners understand what it means to honor God with healthy lifestyle choices. Stories of faithfulness despite adversities recorded about Abraham, Joseph, Job, and Moses provide inspiration and guidance to generate new behavior choices.


Prayer is the faith practice cited as most used and useful by diabetics (Bell et al., 2013). Prayer can be offered in solitude or with others; silent, recited, or sung; or be personal or corporate. Prayers can be invocation, supplication, confession, or intercessory in nature. In their meta-analysis on prayer and health, Masters and Spielmans (2007) explain that research on the positive health benefits of prayer is limited because the studies are designed with the assumption that "God is the mechanism of change working through prayer, but God's actions are not amenable to scientific study" (p. 332). Types of prayers, frequency of praying, and the content of prayer differ significantly between individuals and circumstances.


Two studies have evaluated the use of specific prayers in the management of diabetes. Sacco, Quinn Griffin, McNulty, and Fitzpatrick (2011) used the Serenity Prayer, whereas another author reported on the use of a prayer wheel (Deatcher, n.d.). Those who used the Serenity Prayer reported improved feelings of coping, despite no visible signs of improvement in outcomes during the study time period. Those using the prayer wheel were able to demonstrate better glycemic control from October to January, a holiday time when many struggle.


Bergland, Heuer, and Lausch (2007) assert that prayer is a common component of the religious Hispanic culture they surveyed. Study participants welcomed the opportunity to discuss with their healthcare providers the importance of their faith beliefs and the use of prayer in their diabetic self-management efforts. Bell et al. (2012) studied the use of prayer among older adults with diabetes, who lived in rural settings in the southeastern United States, and found that 80% of the study population used prayer to cope with or manage their diabetes. Participants encouraged healthcare professionals to be sensitive to and aware of how religious beliefs influence their disease management.


Brain mapping researcher and psychiatrist Daniel Amen (2002) explains that daily prayer and meditation help to focus and strengthen the brain's ability to form and solidify neural pathways. He asserts that certain prayers and meditations, such as the Lord's Prayer (Matthew 6:9-13) and the Prayer of St. Francis (Catholic Online, n.d.), offer clear moral guidelines. Wirzba (2011) explains that saying a prayer over a meal demonstrates our humble attitude and gratitude for God's provision and sustenance, thereby helping to align our desires with God's will.



Living with diabetes requires lifestyle modifications and prompts a reevaluation of a person's belief system and worldview. Before lifestyle modifications are made, patients must believe they are capable of making the changes, that resources are available to aid in their efforts, and that they will be able to overcome obstacles. Habit change requires self-awareness of the cues, cravings, behaviors, and rewards that drive choices. Belief in the ability to change is influenced by a lifetime of experience, observations, and instructions that have molded a sense of who we are, what we are about, and our place in the world. Immersion in the practices of faith provides a renewed perspective and set of stories from which to draw examples of right desires and behaviors. Christian faith-practices such as worship attendance, prayer, Bible study, and meditation provide a source of hope and a sense that change, though difficult, is possible.


Research findings indicate that faith-based activities provide diabetics with the sense of hope and help that can empower them to attempt the difficult changes that are necessary. Nurses need not be experts in theology to assess and understand the patients' perception of how their beliefs influence their healthcare choices. While all nurses involved with diabetic patient care can incorporate faith information to encourage their patients, diabetic educators and FCNs are in an ideal position to incorporate the educational strategies described in this article as tools the patient can employ for self-care.


It is important that faith be supported in a way that does not add one more expectation on diabetic patients. As clinicians, we should not use faith as another prescription the patient needs to follow. Rather, explore how patients feel their beliefs help or hinder their diabetic self-management. Remind them that God's love and approval are unconditional and do not depend on HbA1c levels or ability to count carbohydrates, weight, or blood sugar readings, or on how many minutes are spent in exercise, prayer, or Bible study. God's love is not dependent on whether or not we change. His love can, however, empower us to make choices to change. As healthcare providers, we can encourage the incorporation of faith in making healthy lifestyle choices.


Impossible Task

In the 5th century BCE, after 70 years of exile in Babylon (Jeremiah 25:11), the Israelites began returning to Jerusalem-an insecure city without a protective wall. The people faced insurmountable physical, spiritual, social, and political odds.


Nehemiah, a Jew, was cupbearer to King Artaxerxes I of Persia in the capital city of Susa (located in modern-day Iran). When Nehemiah learned of the condition of the wall and the plight of the inhabitants of Jerusalem, he prayed intently to God (Nehemiah 1:4-11). He felt called to take action and requested permission from the king to go to Jerusalem and rebuild the wall. The king granted permission and appointed Nehemiah Provincial Governor of Jerusalem. Nehemiah embarked on the estimated 1,000-mile journey to Jerusalem, a trip of around 50 days.


Upon arrival, Nehemiah took time to survey the damaged wall, about 4.5 miles in circumference, and assess what resources were available for rebuilding. One side of the wall was so crumbled his donkey could not traverse the path; most of the gates had been burned (Nehemiah 2:13-14). After his assessment, Nehemiah shared his vision of rebuilding the wall, identified all those able to help, and developed an action plan with specific steps. Groups of volunteers and families began rebuilding one small section at a time. When threats and resistance appeared, Nehemiah took measures to meet the opposition while working toward his goal.


The repairs, along with building new segments, were completed in just 52 days (Nehemiah 6:15), a remarkable feat! Nehemiah devoted his life to ensuring the walls, the people, and the city were maintained and protected. Archeological findings support that the historical book of Nehemiah is true (Biblical Archeology Truth, n.d.).


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For more than 40 additional continuing education articles related to diabetic care and treatment, go to and search "diabetes."


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