Introducing physiology of diabetes to American Asian middle school and high school students

Introducing physiology of diabetes to American Asian middle school and high school students. Adv Physiol a chronic condition that impacts millions, is a complex disease. Understanding the disease can contribute to increasing awareness about this debilitating condition and preventing occurrences. Further- more, inculcation of physiology knowledge may lead to an increased likelihood of career goals that align with this area of study. In pursuit of these goals, we set out to educate middle and high school students about diabetes. Thirty (16 high school; 14 middle school) students from a Sunday school program at an urban religious center completed a 10-question pretest as a way to measure initial knowledge about diabetes. Following completion of the survey, a 1-h education session was presented by a local physician who also brought a glucometer and insulin syringes for students to have a hands-on experience with some disease-speciﬁc tools. A posttest was administered following the presentation. The posttest consisted of 11 questions, where all but 2 questions were the same as for the pretest, measuring improvement of prior knowledge and engagement in the presentation. The overall posttest average score increased by approximately two correct re- sponses, which was a signiﬁcant improvement ( P (cid:2) 0.0001), suggest-ing that the students were motivated to and did learn diabetes con- cepts. This study also suggests that exposing students to educational activities related to physiology is beneﬁcial and may lead to an increase in interest in physiology, an awareness of diabetes, and perhaps the development of healthy habits.


INTRODUCTION
Diabetes mellitus, commonly referred to as diabetes, is a metabolic disorder that is characterized by high blood glucose levels over a prolonged period. There are two main forms of diabetes mellitus, type 1 and type 2. Diabetes is often associated with the dysfunction of insulin production and secretion, as well as the target cells' responsiveness to insulin. The latest estimate of people with diabetes in the United States as per the Diabetes Statistics Report for 2020, is 34.2 million (10.5% of the U.S. population of all ages) (7). It is estimated that~7.3 million people have the condition but have not been diagnosed (7). In addition,~79 million people in the United States are estimated to have prediabetes, a condition in which blood glucose levels are abnormally high, but not high enough to be classified as diabetes.
Diabetes often progresses undiagnosed for years. Over time, persistently high levels of glucose in the blood injure tissues throughout the body, especially those of the blood vessels and nerves. Complications of this disease make diabetes the seventh leading cause of death in the United States (10). Early detection and subsequent treatment decrease the chance of developing the more serious complications of diabetes.
Learning about the disease can contribute to both increasing awareness about this debilitating condition and may lead to preventing occurrences. A key component to prevention is education about risk factors for developing the disease, including being overweight or obese, a family history of diabetes, high blood pressure, low high-density lipoprotein (HDL) cholesterol or high levels of triglycerides, lack of physical activity, and being of African American, Alaska Native, American Indian, Asian American, Hispanic/Latino, Pacific Island, or Native Hawaiian descent (18). Particularly, among non-Hispanic Asians, Asian Indians are at the highest prevalence of diabetes (7). Creating opportunities for primary prevention activities may prove to be particularly fruitful for long-term health among Asian Indian youth.
While educating adults is important, educating youth about the disease and its risk factors may lead to greater prevention through the possibility of longer term adherence to positive health behaviors. Many of these opportunities occur outside of the formal school setting, partially due to curricula changes in public and many private schools that have increased the emphasis on language arts and math, and limited time for science (15). Providing educational opportunities in extracurricular environments, such as youth organizations, typically require parental support for participation and the enthusiasm of the volunteer scientist (4). As recognized by Wang and Staver (24), parental support for learning science is strongly associated with career aspiration. In addition to learning more about the disease itself, providing youth with learning opportunities that allow them to explore topics related to the health sciences can increase the likelihood that these youth will become interested in and pursue careers in this area. Furthermore, a better understanding of one's career aspiration may lead to better planning when it comes to determining coursework in high school and beyond (1). These factors combined may encourage students to follow careers in health and science.
Specifically, this experience took place during Physiology Understanding (PhUn) Week. PhUn Week was an annual outreach program sponsored by the American Physiological Society (APS), partnering physiologists, and grades K-12 students, introducing students to physiological concepts. Since 2005, physiology professionals, researchers, and teachers have been providing focused efforts to educate youth in kindergarten through 12th grade about a variety of topics related to physiology during one specific week in November each year (23). Through the introduction of concepts related to physiology and health, youth become more aware of, and are potentially more likely to learn about and pursue careers related to, physiology and health.
In pursuit of these goals, we set out to educate a group of Asian Indian middle school and high school students about diabetes, the impact of this disease on health in the short and long term, and the possibilities of pursuing a career in an area of physiology, such as diabetes.

METHODS
This project was approved by the Institutional Review Board at Southern Illinois University Edwardsville. Students attending a Sunday school program at an urban religious center were recruited to participate in an educational session on diabetes. Before the session, students completed a 10-question pretest (APPENDIX A). The first question asked if students had heard of diabetes previously. The remaining questions measured initial knowledge about the disease. A physician expert provided a 1-h educational session, discussing diabetes mechanisms, causes, symptoms, and treatments. Students also had the opportunity to learn about the purpose of a glucometer and its use as well as to manipulate it. They were also introduced to insulin syringes. A posttest was administered following the presentation, measuring improvement of prior knowledge and engagement in the presentation. The posttest consisted of 11 questions, 9 of which matched the pretest (APPENDIX B). The first question was an opinion question, asking students if they learned anything new about diabetes through the presentation. The final question asked students to name one thing new that they learned about diabetes during the session. A paired Student t test was used to analyze the data from both the pretest and the posttest using Graphpad Prism. Responses to the final question were summarized for reporting.

RESULTS
A total of 30 students (16 high school; 14 middle school) from the Sunday school program, and all of Asian Indian descent, participated in the event (Fig. 1). The pretest began by asking students if they had heard of diabetes before this event; 90% of students stated that they had heard of diabetes before. The next nine questions were used to assess knowledge. The overall posttest average score increased by approximately two correct responses, which was a significant improvement (P Ͻ 0.0001) (Fig. 2). Evaluated separately, posttest scores for both middle school and high school students reflected a significant improvement (Figs. 3 and 4). The topics mentioned most frequently as additional points that students learned about diabetes were diet ("carbs have a large impact on diabetes"), the organs involved or impacted ("the pancreas is the organ that creates the insulin"), and impacts of the disease ("polyuria-excess urination").

DISCUSSION
A special session was organized to provide an educational opportunity to youth as a means of exposing them to physiology, a science that receives little emphasis in the schools. This one-time, short-duration session provided the opportunity for youth to learn about a disease relevant to their ethnic group (20). Furthermore, it allowed students to be exposed to concepts that they may want to learn more about and use in a future career.
As shown from the pre-and postsurveys, this one, short presentation about diabetes, provided by a trusted source, led to a significant improvement in knowledge on the topic. While there is certainly more knowledge and depth for students to learn on the topic, this does provide evidence that a one-time, short educational session can prove impactful for such an audience. Similarly, short-duration interventions with adolescents on topics such as breastfeeding (19) and organ donation (6)   by literature in the area of experiential learning, wherein the addition of such opportunities yields significant gains in student understanding (13). As stated previously, individuals of Asian Indian descent are at increased risk for developing diabetes. At a minimum, the short-term gains in knowledge and understanding of the disease meet the goal of primary prevention programs (11). In the long term, this knowledge could serve a twofold purpose related to prevention: 1) to increase the knowledge base related to this disease among youth who may one day develop the disease; and 2) the opportunity for youth to bring such knowledge home to the adults in their family, thereby helping to lower risk among a larger portion of an ethnicity already at increased risk for disease development.
Students in both middle and high school participated in this event. While the middle schoolers still have plenty of time before making career and college major decisions, the earlier students are reached, and the larger the number of career exposures, the greater the likelihood that they will be able to make an informed decision about their major and future career (9). For older students, exposure can lead to career decisions, and repeated exposures can help to solidify previously made decisions (8). There are several strengths to this study. First, the youth who participated in this project meet together regularly, providing an audience for intervention. Because these youth regularly meet together, the level of comfort with the situation was quite likely high. Additionally, utilizing pre-/ posttests that are essentially the same allowed us to effectively assess change in knowledge related to listening to the presentation.
Furthermore, opportunities such as this, even as a one-time short-duration session, may instill interest in students to pursue health careers due to the new knowledge they were able to receive from the PhUn activity. Providing learning opportunities in venues that are familiar and comfortable to attendees allows them to focus on the topic and presentation, rather than their potential discomfort in the situation itself. Even among students already on a career path, such as medicine, shortduration interventions providing exposure to a specific topic (such as surgery) were effective in generating interest toward career pursuits (22). As found by Blotnicky et al. (5), middle school students have little exposure and, therefore, little knowledge about what a career in STEM (Science, Technology, Engineering, Mathematics) involves, let alone about the STEM careers themselves. Exposing children to a variety of careers affords them more opportunities for self-evaluation of abilities and interests and, therefore, allows for greater fit of career expectations (21).
A limitation of this work is the small sample size. While it would have been desirable to reach more youth for this project, we were still able to observe a significant improvement in knowledge about diabetes among both middle and high school students. Furthermore, a point that we were not able to measure directly, or even measure at this point in time, is the residual influence of this event on students' behavior, as well as their career trajectory. Learning about diabetes is important for everyone, but particularly for those who are at increased risk for development of the disease. Asian Indian Americans are at increased risk for developing diabetes compared with white Americans (16).
While any number of subtopics under the heading of physiology could have been selected to present to these students, diabetes was specifically chosen, given the increased risk among individuals of Asian Indian descent. As stated previously, in the United States, Asian Indians are among the highest risk populations for developing this disease (16). Asian Indians in the U.S. and other Western countries are at a particularly increased risk due to adoption of a Westernized diet, as well as increased risk for insulin resistance (12,14). Even within India, due to this increased risk for insulin resistance compared with white people, risk for developing diabetes as well as other diseases, such as cardiovascular disease, are increased, even without the increase in weight seen in Western countries and other types of risk factors (2,3,17).
In conclusion, the positive impact shown through this study suggests that the students were motivated to and did learn diabetes concepts. This study also suggests that exposing students to educational activities related to physiology is beneficial and may lead to an increase in interest in the topic. Additional opportunities should be created to increase awareness of common chronic diseases early in life as a preventative measure, as well as a means of exposing youth to potential career paths and opportunities.

AUTHOR CONTRIBUTIONS
J.Z. and C.G. conceived and designed research; J.Z. and C.G. performed experiments; J.Z. and C.G. analyzed data; J.Z. and C.G. interpreted results of experiments; C.G. prepared figures; J.Z. drafted manuscript; J.Z. and C.G. edited and revised manuscript; J.Z. and C.G. approved final version of manuscript.