Transcript Cultural Competency in Nutrition and Diabetes

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
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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
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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 )
NDEP
• 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
Benefits of regular physical activity
• Improve fitness
• Increases:
• Helps in weight
– Energy
management
– Muscle strength
• Increases insulin
– Endurance
sensitivity
– Flexibility
• Improves risk factors for
• Cardiovascular disease:
– Sense of well being
– Blood pressure
– Lipid profile
• Maintain bone health
Integrating Therapies:
Physical Activity
Type 1
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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
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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
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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.”