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

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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

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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

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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.

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Disparities in Health Status

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

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• 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

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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

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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 ones 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

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Cultural Differences

• Race and ethnicity
• Gender
• Religion
• Age
• Physical disability
• National origin
• Sexual orientation

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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 ?

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Stereotypes

• We are often influenced by our perception of a
  persons cultural back ground , socioeconomic
  status, gender , or age. These perceptions are
  influenced by our stereotypes of certain groups
  or individuals.
• Examples
• Elderly people cant hear well and talk too much
• People who talk slowly are ignorant

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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

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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 ?

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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 ?

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Quality of Healthcare

• Influenced by socioeconomic status
• Level of education
• Income

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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 )

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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

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Integrating TherapiesPhysical Activity
Benefits of regular 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

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Integrating TherapiesPhysical 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 gt13.9mmol, check for
  ketones
• If ketones are present, do not exercise
• Frequent monitoring

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Integrating TherapiesPhysical Activity

• Type 2
• Consider safety, obtain medical clearance
• If over 35, consider EKG stress test
• Determine best time to exercise
• If BG gt 16.7mmol, do not exercise
• Monitor BG, if gt13.9mmol, check for ketones
• Additional food usually not necessary

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Integrating TherapiesPhysical Activity
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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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Chinese Americans Cont

• 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

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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

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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

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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

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Margaret Mead

• I rather change a mans religion
• than his food habits.