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The Hispanic/Latino Diet and CKD
Claudia M. Lora M.D., M.S. Assistant Professor
University of Illinois at Chicago Department of Medicine Division of Nephrology
Objectives
• Review kidney disease disparities in Hispanics/Latinos
• Understand the potential role of culture in health disparities
• Review nutritional content of the Traditional Hispanic/Latino Diet
• Discuss cross cultural nutritional counseling
Disclaimer
• Hispanics in the U.S. are culturally, socio-economically, and genetically diverse
• Avoid stereotypes
• Relationships described may have subtle differences among Hispanic groups
• Undocumented immigrants--growing and understudied segment in which these relationships may be amplified
Objectives
• Review kidney disease disparities in Hispanics/Latinos
• Understand the potential role of culture in health disparities
• Review nutritional content of the Traditional Hispanic/Latino Diet
• Discuss cross cultural nutritional counseling
ADJUSTED POINT PREVALENCE RATES* OF ESRD
Race 1996 2005 2011
Non-Hispanic Whites 875.1 1,226.7 1,395.5
Non-Hispanic Blacks 4,097.6 5,126.3 5,583.5
Hispanic/Latinos 1,722.8 2,475.3 2,817.5
*per 1 million population
USRDS 2011
PREVALENCE OF CKD IN NHANES
Race 1988-1994 1999-2004
Non-Hispanic Whites 10.3% 13.8%
Non-Hispanic Blacks 10.2% 11.7%
Hispanics/Latinos 6.3% 8.0%
Coresh. AJKD. 2003
PROGRESSION OF CKD HISPANIC VS. NON-HISPANIC WHITES IN KAISER PERMANENTE
Model Nested OR for ESRD
Unadjusted 1.99 (1.78-2.21)
+ Age, gender, income, education, and preferred language 1.83 (1.72-2.17)
+ Hypertension and medical history 1.74 (1.55-1.96)
+ Diabetes and use of insulin 1.50 (1.33-1.69)
+Baseline eGFR and time-updated proteinuria 1.29 (1.14-1.48)
+ Time-varying medication use 1.33 (1.17-1.52)
Peralta. J Am Soc Nephrol. 2006
ASSOCIATION OF RACE/ETHNICITY WITH CKD PROGRESSION
Models
Hispanics vs. Non-Hispanic White
50% eGFR loss or ESRD OR (95% CI)
p
Model 1: Unadjusted
4.91 (3.81 - 6.32) <0.001
Model 2: Age 4.49 (3.48 - 5.79) <0.001
Model 3: model 2 + BMI 4.56 (3.54 - 5.89) <0.001
Model 4: model 3 + baseline eGFR 3.03 (2.34 - 3.92) <0.001
Model 5: model 4 + diabetes 2.50 (1.93 - 3.24) <0.001
Model 6: model 5 + urine protein 1.23 (0.92 - 1.63) 0.157
Model 7: model 6 + systolic blood pressure 1.09 (0.82 - 1.45) 0.564
Objectives
• Review kidney disease disparities in Hispanics/Latinos
• Understand the potential role of culture in health disparities
• Review nutritional content of the Traditional Hispanic/Latino Diet
• Discuss cross cultural nutritional counseling
HEALTH CARE DISPARITIES Figure 2. Socio-ecological model of factors influencing chronic kidney disease outcomes.
Environment/System
Local/National Policies Sociopolitical Context Cultural Context
Neighborhood/Social Community
Social Stressors Exposures Resources Health Services
Inter-Personal
Social Networks Social Support Intra-Personal
Age, Gender, Race, Socioeconomic Status, Insurance, Health literacy, Acculturation, Language, Perceived Social Support
Lora et al AJKD, 2011
ACCULTURATION
• Definition: the process by which individuals adopt the attitudes, values, customs, beliefs, and behaviors of another culture
Original
Culture New Culture
HIGHER ACCULTURATION
PROS: • Higher Use of Preventive
Health Services • More Likely to Have Health
Insurance • Higher Access to Health Care • Increased Adherence to
Treatment • Higher Socioeconomic Status • Greater Exercise • Greater Leisure Time Activity
CONS:
• Increased Obesity
• Increased Fat Intake
• Increased Fast Food Consumption
• Decreased Intake of Fruits and Vegetables
• Increased risk of Smoking (particularly in women)
• Increased Alcohol Consumption
ACCULTURATION AND CARDIOVASCULAR RISK FACTORS
Study Findings
HCHS/SOL Daviglus et al 2012
• Higher acculturation associated with >3 cardiovascular risk factors compared to lower acculturation.
NHANES Kershaw et al 2012
• Foreign born Mexican-Americans were more likely to be low risk than non-Hispanic Whites.
• U.S. born Mexican-Americans were less likely to be low risk than non-Hispanic Whites.
ACCULTURATION AND MORTALITY
Study Findings
San Antonio Heart Study (Diabetic participants) Hunt et al 2002
• U.S.-born Mexican Americans had a greater risk of all cause and cardiovascular mortality compared to non-Hispanic Whites.
San Antonio Heart Study (Elderly participants) Colon-Lopez et al 2009
• Earlier migration age conferred a higher risk of cardiovascular mortality.
ACCULTURATION AND KIDNEY DISEASE
Day et al. Nephrol Dial Transplant. 2011
* p < 0.001
Speaking exclusively Spanish is the reference group *data from Model 1 (adjusted for age, sex, income, and education)
Objectives
• Review kidney disease disparities in Hispanics/Latinos
• Understand the potential role of culture in health disparities
• Review nutritional content of the Traditional Hispanic/Latino Diet
• Discuss cross cultural nutritional counseling
Hispanic/Latino Population in Chicago, IL
Hispanic Population Foreign Born
1,971,000 39.6%
% of Population % under 18
21.5% 30.3%
Top Three Hispanic Origin Groups Population % Among Hispanics
1 Mexican 1,561,000 79.2%
2 Puerto Rican 190,000 9.6%
3 Guatemalan 41,000 2.1%
2011 American Community Survey
The Hispanics Diet
• Food habits vary depending on: – Country of origin
– Acculturation • Length of time in the US
– Socio-economic status
– Education
– Age
– Gender
– Geographic location
– Level of contact with other ethnic groups
Traditional Food and Traditional Food Preparation
• Source of Comfort
• Mode of maintaining cultural identity
• Last customs to change
Commonalities
• Consume more fruits and vegetables
• Legumes and Tuberous Vegetables
• High in Potassium, phosphorus, and sodium
The Hispanic/Latino Diet
Mexico: Native Indians,
Spanish, French,
Indian, and Viennese
Caribbean Islands: Indigenous Indians,
Spanish, French, British, Dutch, Danish, African, Asian, Indian,
and Chinese
Central America: Native Indians,
Spanish, Caribbean Islanders, Southern Mexicans,
Europeans, Africans
Legumes High in Potassium
Mexico Caribbean Central America South America
Frijoles • Black • Pinto • Kidney
Habichuelas • Black • Kidney • Pink • Red • Lima • White
Frijoles • Black • Kidney • Red • White • Fava
Frijoles
Garbanzo Garbanzo
Alubia Gandules/Guandules (Pigeon peas)
Lentils (Lentejas) Lentils (Lentejas)
Fruits High in Potassium Mexico Caribbean Central America South America
Avocado Avocado Bananas (banananos)
Avocado
Banana (platano) Bananas (guineo) Coconut Bananas (banano)
Guayaba/guava Oranges Passion Fruit Coconut
Melon (Cantaloupe) Coconut Cantaloupe Guanabana
Guanabana (soursop)
Guayaba/guaba Oranges Higos (fig)
Orange Guanabana Papaya Passion Fruit
Papaya Plantains (sweet and green)
Plantain (sweet) Oranges
Tuna (cactus fruit) Papaya Zapote Raisins
Zapote Mango Plantains
Dried Fruits Raisins Zapote
Passion Fruit
Root Vegetables High in Potassium
Mexico Caribbean Central America South America
Beets Batata (white sweet potato)
Potatoes Ñame (Sweet Potato
Sweet potatoes Pana Ñame (Sweet Potato
Potato
Potatoes Ñame (Sweet Potato
Yuca Yautia
Yuca Potatoes Yuca/Mandioca
Beets
Yautia/malanga
Beets
Other Vegetables High in Potassium
Mexico Caribbean Central America South America
Squash Squash Squash Asparagus
Chayote Tomato Squall
Spinach Okra
Nopal (cactus) Artichokes
Acelga
Quelite
Verdolaga
Sources of Phosphorus Mexico Caribbean Central America South America
Rice pudding Batidos (Fruit shakes) Beans Beans
Atole (with milk) Café con Leche Garbanzo Cheese
Café con Leche Desserts with milk and coconut milk
Fava Dulce de leche
Cajeta Flan Rice pudding Milk
Flan Gandule Cheeses Hot chocolate
Alubia Beans Cream nuts
Alverjon Garbanzo Nuts
Garbanzo Lima Beans Yogurt
Lentils Lentis
Beans
Nuts
Cheese
Yogurt
Objectives
• Review kidney disease disparities in Hispanics/Latinos
• Understand the potential role of culture in health disparities
• Review nutritional content of the Traditional Hispanic/Latino Diet
• Discuss cross cultural nutritional counseling
Dietary Adherence in Hispanics Receiving Hemodialysis
Morales Lopez. Journal of renal nutrition. 2007
CULTURAL COMPETENCE
• Acknowledge the culture served – Posters, printed materials, audio-visual tools that
reflects the culture
– Translational Services
– Bilingual/Bicultural/Multicultural Staff
• Acquire cultural knowledge & skills – Diet
– Learning key words in Spanish/Colloquialisms
• View behavior within a cultural context – Beliefs
Objectives of Cross Cultural Nutrition Counseling
• Assess attitudes, beliefs, practices and rituals associated with food before discussing lifestyle changes
• Provide individualization for cultural patterns.
• Determine which dietary habits, if any, are detrimental to the patient.
• Correct diet deficits
• Offer suggestions for changes in food preparations
Burrowes, JD. Advances in Renal Replacement 2004.
Kittler And Sucher 4 Step Process
Step 1: Become familiar with your own cultural attitudes and knowledge. Examine your own comfort interacting with individuals from a different cultural background.
Burrowes, JD. Advances in Renal Replacement 2004.
Kittler And Sucher 4 Step Process
Step 2: Become acquainted with the cultural background, eating patterns, and cultural and ethnic influences on food consumption in the patient.
Burrowes, JD. Advances in Renal Replacement 2004.
• Research
• Shopping in neighborhood food stores
• Learning about where food is purchased; what food is available, how it is stored, prepared, served and consumed.
• Ask the patient and/or family member about specific foods and food practices.
– e.g. diary
• Ask other health care professionals
Burrowes, JD. Advances in Renal Replacement 2004.
Kittler And Sucher 4 Step Process
Step 3: Establish the patient’s food habits and personal preferences (include the person who does the food shopping and preparation).
Burrowes, JD. Advances in Renal Replacement 2004.
Kittler And Sucher 4 Step Process
Step 4: Modify the diet to incorporate the personal food preferences of the patient.
Burrowes, JD. Advances in Renal Replacement 2004.
Conclusion
• The Hispanic population is fast growing minority population.
• Hispanics are culturally, socioeconomically, and genetically different
• Acculturation level may vary by individual and may influence health outcomes
• This factor needs to be taken into account when counseling Hispanics patients.
Recommended Sources
Morales Lopez, C. Cultural Diversity and the Renal Diet: The Hispanic Population. Nephrology Nursing Journal. 35 (1): 69-72; 2008.
Burrowes, JD. Incorporating ethnic and cultural food preferences in the renal diet. Advances in Renal Replacement Therapy. 11 (1): 97-104; 2004.
Conclusion
• The Hispanic population is the fastest growing and largest minority population.
• Hispanics are culturally, socioeconomically, and genetically different
• Health literacy, acculturation, and social support may vary by individual and may influence health outcomes
• These factors need to be taken into account when counseling Hispanics patients.