Cultural Competency in Nutrition and Diabetes: Food Choices, Physical Activity and Obesity among Ethnic and Cultural Groups in the United States

Karmeen Kulkarni, MS, RD,

BC-ADM, CDE

U. S. Population : Year 2000

• White : 75 %

• Hispanic or Latino : 12.5 %

• African American : 12.3%

• Asian American : 3.6%

• American Indian :0.9%

• Other : 5.5%

Population Projections

• In percentage terms , Asians are the most rapidly growing minority group. By 2020 , Asians will compose 6.5% of the U.S. population.

• In absolute numbers , Hispanics are the most rapidly growing group. By 2020 , Hispanics will compose 16 % of the U.S. population.

Disparities in Health Status

The demographic statistics are significant , because minority groups often suffer a disproportionate burden of disease and other health care problems

“It is much more important to know what sort of a patient has a disease , than what sort of disease a patient has .”

- William Osler

Dubos RJ. Mirage of Health Utopias, Progress and Biological Change. New Brunswick , NJ. Rutgers Univ Press: 1997

Culture

Implies patterns of human behavior including thoughts , actions, customs, values, and beliefs that can bind a racial, ethnic, religious, or social group within a society

Cultural Competence

• A complex integration of knowledge , attitudes, and skills that enhances cross –cultural communication and appropriate interactions with others. It includes at least 3 perspectives :– Knowledge of the effects of culture on others’ beliefs

and behavior– Awareness of one’s own cultural attributes and biases

and their impact on others and – Understanding the impact of the sociopolitical ,

environmental, and economic context on the specific situation

Cultural Differences

• Race and ethnicity

• Gender

• Religion

• Age

• Physical disability

• National origin

• Sexual orientation

Your Culture

• Where were you born

• Where were your parents born

• Where is your sense of belonging in terms of culture ?

• What positive and negative experiences have you had with other cultural groups ?

Stereotypes

• We are often influenced by our perception of a person’s cultural back ground , socioeconomic status, gender , or age. These perceptions are influenced by our stereotypes of certain groups or individuals.

• Examples :– Elderly people can’t hear well and talk too much– People who talk slowly are ignorant

Different Ways of Thinking

• Patients may be unwilling to share health beliefs until a safe environment has been created and a trusting relationship has been established

• Example : evidence that patients do not tell their physicians about their use of alternative therapies

Exploring Patients’ Health Beliefs

• Etiology : What or who caused this illness, and why ?

• Symptoms : What are your symptoms ? When did they occur ? Why do you think they began ?

• Pathophysiology : How has your body ( or mind ) been affected by this illness ?

• Diagnosis : What do you know about this illness ? What have people told you ? What do you believe about this diagnosis ?

Exploring Patients’ Health Beliefs

• Treatment: What should be done about this illness ? Who should do it? What have you tried already ? Did it work ? How do you feel about taking medications ?

• Prognosis : How long will you be ill ? Will anything that you do help to control or cure this illness ?

• Coping : What or whom do you need to help cope with this illness?

• Meaning : What does this illness mean to you ?

Quality of Healthcare

• Influenced by socioeconomic status

• Level of education

• Income

Current Healthy People 2010

Goals for Hispanics include :

_ Increase quality and years of healthy life (including life expectancy and quality of

life )

_ Eliminate racial and ethnic disparities in health ( U.S. Department of Health and Human Services, 2000 )

N D E P

• Diabetes education and prevention are objectives that have been set forth as ways to achieve the health goals

• NDEP , is designed to improve treatments and outcomes for people with diabetes , promote early diagnosis, and ultimately prevent the onset of diabetes

• The return is a reduced morbidity and mortality

Integrating Therapies:Physical Activity

• Improve fitness• Helps in weight

management• Increases insulin

sensitivity• Improves risk factors for • Cardiovascular disease:

– Blood pressure– Lipid profile

• Maintain bone health

• Increases:– Energy– Muscle strength– Endurance– Flexibility– Sense of well being

Benefits of regular physical activity

Integrating Therapies:Physical Activity

Type 1• Consider the timing of the exercise• Increase in food?• Decrease in insulin?• Both, an increase in food and decrease in insulin?• Check blood glucose; if >13.9mmol, check for

ketones• If ketones are present, do not exercise• Frequent monitoring

Integrating Therapies:Physical Activity

Type 2• Consider safety, obtain medical clearance• If over 35, consider EKG stress test• Determine best time to exercise• If BG > 16.7mmol, do not exercise• Monitor BG, if >13.9mmol, check for ketones• Additional food usually not necessary

Integrating Therapies:Physical Activity

Type 2 Diabetes in Minority Populations

• African Americans

• Hispanics

• Asian Americans

• Native Americans

• Disproportionate burden due to : genetic predisposition, family history, food choices, limited physical activity, and a complex interplay between these factors

Nutrition Counseling : Mexican Americans

• Assess level of acculturation to mainstream American dietary practices

• Determine the primary language at home

• Use food models, pictures, actual food during the session

• Influence of which foods are considered hot and cold

• Use of folk remedies

Nutrition Counseling : Mexican Americans

• Emphasize positive food practices, related to traditional health beliefs and dietary customs

• Traditional Mexican diet is low in total fat and high in fiber

• Encourage consumption of healthy foods that are familiar and culturally acceptable

• Dispel myths and misconceptions about dietary recommendations

• Involve family members in the counseling session

Meal Pattern for Mexican American Client with Type 2 Diabetes

• Breakfast : typical : ¾ cup refried beans with chorizo( Mexican sausage ), 2-3 corn tortillas, 8 oz coffee with 3 oz milk.

• Breakfast : modified : 1/3 cup boiled beans with chili sauce, 2 corn tortillas, 8 oz coffee with 3 oz low fat milk, 1 small banana

Meal pattern for Mexican American Client with Type 2 Diabetes

• Lunch : typical : 2 cups chicken soup with assorted vegetables and 3 oz of chicken, 2-4 tortillas, 1 cup Mexican rice or pasta, fried in 1 tbsp. of oil, 8 oz sweetened carbonated or uncarbonated drink.

• Lunch : items modified : 2 corn tortillas, 1/3 cup Mexican rice or pasta , fried in ½ tsp. oil; 8 oz of diet soda or non caloric beverage or water

African Americans

• A study at Grady Memorial Hospital in Atlanta found that clients primary reasons for not using meal patterns were , that the information was alien to their lifestyle and contained unaccustomed foods

• Positive aspects of the traditional food practices should be affirmed

• Emphasis on vegetables and complex carbohydrates from traditional recipes , is of benefit

Meal Pattern for African American Client

• Breakfast: typical : ½ cup grits, 2 fried eggs, 2 sausage patties, 2 buttermilk biscuits, coffee with sugar, 1 tbsp. margarine

• Breakfast : items modified: ¼ cup egg substitute, 1 homemade sausage, 2 slices whole wheat toast, 1 cup cubed cantaloupe, coffee with sugar substitute , 1 tsp. margarine

Meal Pattern for African American Clients

• Lunch : typical : 1 fried chicken leg quarter, ½ cup mashed potatoes, ½ cup green beans seasoned with ham, 1 medium tomato, 1 hot roll, 1 tbsp. margarine, ½ cup blackberry cobbler, iced tea with lemon and sugar

• Lunch : items modified : 1 skinless baked chicken quarter, green beans seasoned with fat free , low sodium broth , 1 tsp. margarine, 1 ¼ cup strawberries with sugar sub, iced tea with lemon and sugar sub

Navajo Current Food Practices

• Frying is a common method of food preparation

• 15-46 % of the macronutrients are derived from the following foods : Navajo tortillas, fry bread, home –fried potatoes, mutton, processed meats ( bacon, sausage, lunch meats, and canned meat products ), soft drinks, coffee , and tea

Navajo Traditional Foods

• Blue corn mush , Navajo cake , hominy , kneel down bread, blue corn bread, and roasted and steamed corn

• Watermelon, pinon nuts, and Navajo tea

• Sumac berries, and a pudding is made from it

Meal Pattern for Navajo Clients

• Breakfast : typical : 2 fried eggs, 3 slices bacon, 1 flour tortilla, 1 cup orange drink, 2 cups coffee with 4 tsp. sugar

• Breakfast : Items modified : 1 cup blue corn mush , ½ cup low fat milk , 1 slice bacon, ½ tortilla( part whole wheat) , ½ cup orange juice, 2 cups coffee, with sugar sub

Meal Pattern for Navajo Clients

• Lunch : typical : 2 slices white bread, 2 slices canned lunchmeat, ¼ inch thick, 1 oz American cheese , 1 tbsp. mayonnaise, 4 sandwich – type cookies,1cup non carbonated soft drink

• Lunch : modified: 2 slices whole wheat bread, 1 slice lunchmeat, lettuce, 1 tbsp. reduced calorie mayonnaise, 2 graham squares, 1 small banana , ¾ cup vegetable juice

Chinese Americans: Culturally Appropriate Counseling

• Dispel myths and misconceptions• Take advantage of the cultural concept

that certain foods are good for certain organs, to teach food groups by their functions , rather than their nutritional properties

• Example: instead of saying “ these foods are high in fat and cholesterol “, try ‘ these foods can hurt your heart and arteries’

Chinese Americans’ Con’t

• Encourage consumption of foods that are familiar and culturally acceptable, for example , in addition to recommending cheese and milk as food for the bones, suggest tofu and green leafy vegetables

• Point out mistakes in a way that will not cause the client to lose his or her self - respect

Meal Pattern for Chinese American Clients

• Lunch : typical : 1 bowl pork broth with Chinese herbs, stir fried beef with broccoli, 2tbsp; peanut oil, scrambled egg with barbecued pork, 2 bowls rice, 1large apple, and plain tea

• Lunch : modified: 1 bowl pork broth with Chinese herbs ( fat – skimmed ), stir fried beef with broccoli, steamed egg with minced pork, 1 cup spinach with oyster sauce, 1 bowl rice , 1 small apple , plain tea

Indian / Pakistani: Nutrition Implications of Contemporary Food

Habits

• From low fat and high fiber diets, have changed to high saturated fat, animal protein, and low in fiber

• Increased intake of convenience foods

• Reduced use of traditional foods and cease to be vegetarian

Meal Pattern for Indian and Pakistani Clients

• Lunch : typical : 2 parathas , 1 cup spinach curry, ½ cup potato curry, ½ cup raita, 1 banana, 3 tsp. oil used in cooking , 1tsp. Ghee

• Lunch : modified: 2 sookhi roti, 1 cup spinach curry, ½ cup tomato dhal, ½ cup low fat yogurt raita, ½ banana , 2 tsp. oil used in cooking

Margaret Mead

“I rather change a man’s religion

than his food habits.”