The Hispanic/Latino Diet and CKD - National Kidney ... Diet •Discuss cross cultural nutritional counseling Disclaimer •Hispanics in the U.S. are culturally, socio-economically,

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





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

WHY THE DISCREPANCY?

• Accuracy of Estimating Equations

• More Rapid Progression?

• Sampling Bias

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





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

Lora et al AJKD, 2011

ROLE OF HEALTH LITERACY AND ACCULTURATION IN CKD PROGRESSION

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





HISPANICS/LATINOS IN THE UNITED STATES

52.9 million in 2012

Hispanic/Latino Origin

Mexican Puerto Rican

Cuban Salvadoran

Dominican Other

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

QUIZ TIME

Gandules/Guandules: Pigeon Peas

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


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


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

Sources of Sodium

Morales Lopez. Nephrology Nursing Journal. 2008

Objectives





Dietary Adherence in Hispanics Receiving Hemodialysis

Morales Lopez. Journal of renal nutrition. 2007

Adherence


Attitudes Toward Adherence


Behaviors Related to Adherence


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.



Step 2: Become acquainted with the cultural background, eating patterns, and cultural and ethnic influences on food consumption in the patient.


Dominican Christmas Food

Mexican Christmas

• 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



Step 3: Establish the patient’s food habits and personal preferences (include the person who does the food shopping and preparation).



Step 4: Modify the diet to incorporate the personal food preferences of the patient.


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.

The Hispanic/Latino Diet and CKD - National Kidney ... Diet •Discuss cross cultural nutritional counseling Disclaimer •Hispanics in the U.S. are culturally, socio-economically,

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