1. Cultural Competence in Treating A Chronic Disease: DIABETES Lorena Drago MS RD CDN CDE www.hispanicfoodways.com

2. Diabetes Scenario: A supermarket chain with a large Hispanic customer base is promoting a diabetes program titled “Shop for your Heart” The events will be held in Hempstead, L.I. and the Bronx. The event coordinator has asked you to provide: Heart healthy shopping tips Food demonstration suggestions Physical activity tips

3. ASPECTS OF HISPANIC CULTURE

4. COUNTRY OF ORIGIN U.S Population Hispanic Origin by Type, 2006 Decennial Census Counts of Major Hispanic Subgroups New York City and Boroughs, 2000

5. Preferred Foods Based on Country/Area of Origin Corn, beans, chiles, hearty stews, moles, chocolate Rice, beans, corn, chiles, chocolate Potato, corn, rice, Annato, coriander, onions, Beef in Brazil/Argentina Rice, beans, starchy root Vegetables, coconut, adobo sofrito Central America Mexico South America Caribbean

6. Latin American Breakfasts Eggs (with green, red, pasilla sauce) Green salsa Refried beans Chilaquiles Eggs with tomato sauce Fried green plantain Casamiento (fried beans and rice) with cheese/cream TortillasCoffee Mangú (mashed boiled green plantains) Fried cheese EggsSalami Orange juice/milk shake Colombia Mexico Dominican Republic El Salvador MEXICO EL SALVADOR DOMINICAN REPUBLIC

7. The Language of Food Caribbean South America Mexico Central America Beans: Frijoles Squash: Calabaza Beans: Habichuelas Judias Squash: Calabaza, Ahuyama Beans: Frijoles Habas Squash: Ahuyama, Zapallo

8. HEALTH LITERACY Low health literacy affects patient safety Less knowledge about disease and self-care In a 1995 JAMA study, what percentage of individuals could not understand the instruction "take medication on an empty stomach?" 29% 39% 49%

9. If you ate the entire bag of chips, how many total grams of carbohydrate would you eat?

10. In a recent study, 25% of patients could not determine what glucose meter readings were within normal range of 80-120mg/dl 56% could not calculate the total carbohydrate content in a container of snack chips 59% could not accurately calculate an insulin dose

11. Conveying Health Messages Successfully ½ cup of potatoes count as 1 CHO choice. How many choices does 2 cups of potato count as? Your target blood glucose level is 60- 120mg/dl. Circle the values that are in the target range –55 –88 –116 –145

12. CONCEPT WORDS “Balanced” “Healthy” Diet “Normal Range” CATEGORY WORDS “ Fats and Oils” “Whole Grains” VALUE/JUDGEMENT WORDS “Excessive” bleeding, drink in “moderation” Exercise “regularly”

13. FOUR CULTURAL VALUES FAMILYFRIEND S FAITHFATALISM

14. ADDRESSING FATALISM Appeal to the well-being of the family Use Risk Communication 1.Explain what is “at risk” 2.How high is the risk (compare high to normal) 3.Show patient his/her risk factor 4.Provide treatment strategies 5.Include testimonials (group specific)

15. How to Develop Cultural Competency Interventions Country of Origin –Language –Food Tastes and Predilections Health Literacy Health Beliefs and Attitudes –Family –Friends –Faith –Fatalism Culture is fluid – Culture guides but does not define the individual

16. Questions How does acculturation impact dietary behavior among Hispanics? How can we ensure that patient education materials are suitable for different Hispanic subgroups? What education tools have proven successful when working with Hispanics? What is the best way to determine and address health beliefs among different cultural groups?

17. Lorena Drago, MS, RD, CND, CDE Lorena Drago, MS, RD, CDN, CDE, is a registered dietitian, consultant and certified diabetes educator. She is Senior Associate Director of Ambulatory Care Nutrition Programs at Lincoln Hospital including: Director of the Diabetes Education Program and the Women, Infants and Children Supplemental Nutrition Program and maintains her own private practice. Lorena specializes in the multicultural aspects of diabetes self-management education and is an expert in developing culturally and ethnically-oriented nutrition and diabetes education materials. She founded, Hispanic Foodways, and most recently she developed teaching tools and patient education materials such as the Nutriportion™ Measuring Cups that has the calorie and carbohydrate amounts of common foods embossed on each cup and the Nutriportion™ Hispanic Food Cards that have pictures and nutrition composition of common Hispanic foods. Lorena serves on the American Association of Diabetes Educators board of directors; Nominating Committee Chair of the Member Interest Group Latinos and Hispanics in Dietetics and Nutrition; and is the Chair-elect of the American Diabetes Association Latino Committee. She also served as Past President of the Metropolitan New York Association of Diabetes Educators in 2004. She is the author of Beyond Rice and Beans: The Caribbean Guide to Eating Well with Diabetes, published by the American Diabetes Association in October of 2006 and a contributing editor of Newsflash, a publication of the Diabetes Care and Education Specialty Practice Group of the American Dietetic Association. She is a contributing author and co-editor of the book Cultural Food Practices and Diabetes, soon to be published by the American Dietetic Association. Lorena has appeared on several national TV shows speaking about diabetes management, including The Early Show and CNBC's dLife TV. She has also appeared on New York’s “Diálogo con Glenis” a live Spanish community cable show, where she discusses nutrition and diabetes, topics especially relevant to the Latin community of the Bronx, which has the highest diabetes rate in New York City. Lorena speaks on nutrition education, cultural competent diabetes care and health literacy. She has been an invited guest speaker and/or faculty member at the following annual meetings: Mexican Association of Diabetes Educators, Colombian Diabetes Association, American Diabetes Association and American Association of Diabetes Educators. Lorena graduated cum laude from Hunter College of the City University of New York with a Masters of Science degree in Food and Nutrition, and received her BA in Home Economics, Food and Nutrition from Queens College.