The Hispanic/Latino Diet and CKD

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1 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

2 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

3 Disclaimer Hispanics in the U.S. are culturally, socioeconomically, 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

4 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 ADJUSTED POINT PREVALENCE RATES* OF ESRD Race Non-Hispanic Whites , ,395.5 Non-Hispanic Blacks 4, , ,583.5 Hispanic/Latinos 1, , ,817.5 *per 1 million population USRDS 2011

6 PREVALENCE OF CKD IN NHANES Race Non-Hispanic Whites 10.3% 13.8% Non-Hispanic Blacks 10.2% 11.7% Hispanics/Latinos 6.3% 8.0% Coresh. AJKD. 2003

7 WHY THE DISCREPANCY? Accuracy of Estimating Equations More Rapid Progression? Sampling Bias

8 PROGRESSION OF CKD HISPANIC VS. NON- HISPANIC WHITES IN KAISER PERMANENTE Model Nested OR for ESRD Unadjusted 1.99 ( ) + Age, gender, income, education, and preferred language 1.83 ( ) + Hypertension and medical history 1.74 ( ) + Diabetes and use of insulin 1.50 ( ) +Baseline egfr and time-updated proteinuria 1.29 ( ) + Time-varying medication use 1.33 ( ) Peralta. J Am Soc Nephrol. 2006

ASSOCIATION OF RACE/ETHNICITY WITH CKD PROGRESSION Model 1: Unadjusted Models Hispanics vs. Non- Hispanic White 50% egfr loss or ESRD OR (95% CI) 4.91 (3.81-6.32) <0.001 p Model 2: Age 4.49 (3.48-5.

9 ASSOCIATION OF RACE/ETHNICITY WITH CKD PROGRESSION Model 1: Unadjusted Models Hispanics vs. Non- Hispanic White 50% egfr loss or ESRD OR (95% CI) 4.91 ( ) <0.001 p Model 2: Age 4.49 ( ) <0.001 Model 3: model 2 + BMI 4.56 ( ) <0.001 Model 4: model 3 + baseline egfr 3.03 ( ) <0.001 Model 5: model 4 + diabetes 2.50 ( ) <0.001 Model 6: model 5 + urine protein 1.23 ( ) Model 7: model 6 + systolic blood pressure 1.09 ( ) 0.564

10 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

11 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

12 ROLE OF HEALTH LITERACY AND ACCULTURATION IN CKD PROGRESSION Lora et al AJKD, 2011

13 ACCULTURATION Definition: the process by which individuals adopt the attitudes, values, customs, beliefs, and behaviors of another culture Original Culture New Culture

14 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

15 ACCULTURATION AND CARDIOVASCULAR RISK FACTORS Study HCHS/SOL Daviglus et al 2012 NHANES Kershaw et al 2012 Findings Higher acculturation associated with >3 cardiovascular risk factors compared to lower acculturation. 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.

16 ACCULTURATION AND MORTALITY Study San Antonio Heart Study (Diabetic participants) Hunt et al 2002 San Antonio Heart Study (Elderly participants) Colon-Lopez et al 2009 Findings U.S.-born Mexican Americans had a greater risk of all cause and cardiovascular mortality compared to non-hispanic Whites. Earlier migration age conferred a higher risk of cardiovascular mortality.

ACCULTURATION AND KIDNEY DISEASE * p < 0.

17 ACCULTURATION AND KIDNEY DISEASE * p < Speaking exclusively Spanish is the reference group *data from Model 1 (adjusted for age, sex, income, and education) Day et al. Nephrol Dial Transplant. 2011

18 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

19 HISPANICS/LATINOS IN THE UNITED 52.9 million in 2012 STATES

20 Hispanic/Latino Origin Mexican Cuban Dominican Puerto Rican Salvadoran Other

21 Hispanic/Latino Population in Chicago, IL Hispanic Population Foreign Born 1,971, % % of Population % under % 30.3% Top Three Hispanic Origin Groups Population % Among Hispanics 1 Mexican 1,561, % 2 Puerto Rican 190, % 3 Guatemalan 41, % 2011 American Community Survey

22 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

23 Traditional Food and Traditional Food Preparation Source of Comfort Mode of maintaining cultural identity Last customs to change

24 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,

25 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

27 QUIZ TIME

29 Gandules/Guandules: Pigeon Peas

30 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 Alubia Lentils (Lentejas) Garbanzo Gandules/Guandules (Pigeon peas) Lentils (Lentejas)

34 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

36 Root Vegetables High in Potassium Mexico Caribbean Central America South America Beets Batata (white sweet potato) Potatoes Sweet potatoes Pana Ñame (Sweet Potato Potatoes Ñame (Sweet Potato Yuca Ñame (Sweet Potato Potato Yautia Yuca Potatoes Yuca/Mandioca Beets Yautia/malanga Beets

37 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

39 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 Cajeta Flan Rice pudding Milk Dulce de leche Flan Gandule Cheeses Hot chocolate Alubia Beans Cream nuts Alverjon Garbanzo Nuts Garbanzo Lima Beans Yogurt Lentils Beans Nuts Cheese Yogurt Lentis

41 Sources of Sodium Morales Lopez. Nephrology Nursing Journal. 2008

42 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

43 Dietary Adherence in Hispanics Receiving Hemodialysis Morales Lopez. Journal of renal nutrition. 2007

44 Adherence Morales Lopez. Journal of renal nutrition. 2007

45 Attitudes Toward Adherence Morales Lopez. Journal of renal nutrition. 2007

46 Behaviors Related to Adherence Morales Lopez. Journal of renal nutrition. 2007

47 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

48 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.

49 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.

50 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.

51 Dominican Christmas Food

52 Mexican Christmas

53 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.

54 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.

55 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.

56 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.

57 Recommended Sources Morales Lopez, C. Cultural Diversity and the Renal Diet: The Hispanic Population. Nephrology Nursing Journal. 35 (1): 69-72; Burrowes, JD. Incorporating ethnic and cultural food preferences in the renal diet. Advances in Renal Replacement Therapy. 11 (1): ; 2004.

58 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.

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