Karmeen Kulkarni, MS, RD, BC-ADM, CDE

1. 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

2. 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%

3. 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.

4. Disparities in Health Status The demographic statistics are significant , because minority groups often suffer a disproportionate burden of disease and other health care problems

5. “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

6. 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

7. 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

8. Cultural Differences • Race and ethnicity • Gender • Religion • Age • Physical disability • National origin • Sexual orientation

9. 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 ?

10. 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

11. 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

12. 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 ?

13. 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 ?

14. Quality of Healthcare • Influenced by socioeconomic status • Level of education • Income

15. 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 )

16. 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

17. 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 Integrating Therapies:Physical Activity Benefits of regular physical activity

18. 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

19. 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

20. Integrating Therapies:Physical Activity

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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’

34. 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

35. 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

36. 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

37. 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

38. Margaret Mead “I rather change a man’s religion than his food habits.”