Cultural Diversity and the Renal Diet: The Hispanic Population

Claudia Morales López

As chronic kidney disease (CKD) progresses, a series of lifelong changes in dietary habits are needed (Burrowes & Cockram, 2004). The dietary management is prone to fail for different reasons. One reason, and probably the most important, is the modification of the patient’s lifestyle, which involves the time needed for hemodialysis treatment spent alongside a machine, and the fact that the patient has to take multiple medications and follow a restrictive diet. The latter is probably the most difficult part of the whole medical treatment because it affects personal habits, alters lifestyle and generates considerable psychological stress (Hoover, 1989). A new challenge is faced when the patient comes from another country with a different culture, language, feeding practices and/or foods. This article discusses cultural feeding practices and lists traditional foods among people from the Hispanic population that may help healthcare providers guide, educate and give advice when caring for a patient on hemodialysis with this cultural background.

Hispanic Populations in the United States

Minority populations are growing in the United States (U.S.), especially the Hispanic population, which in 2002 became the most rapidly growing and is the largest minority group in this country. In 2005, Hispanics were 14.5% of the population in the U.S. Hispanics or Latinos include Mexicans (64%), Puerto Ricans (9%), Cubans (3.5%), Dominicans (3%), Central Americans (7.5%), South Americans (5%) and other groups with markedly different characteristics, such as Spaniards, Spanish, Spanish Americans, and others not elsewhere classified (8%) (U.S. Census Bureau, 2005).

The demand for health care among this population is growing as well. Hispanic individuals in the U.S. have a high prevalence of type 2 diabetes mellitus, which is a risk factor for the development of CKD (Lopes et al., 2003). This places the Hispanic population at high risk to develop CKD Stage 5 requiring maintenance dialysis. Therefore, health care providers, including physicians, nurses, social workers and dietitians, must be aware of the importance to recognize the needs of this growing population.

Culture, Acculturation, and Cultural Foods
“Culture is broadly defined as the values, beliefs, attitudes, and practices accepted by a community of individuals” (Kittler & Sucher, 2001, p. 4). Culture influences why and how people make decisions. Acculturation has been defined as the extent to which mainstream customs, beliefs and practices are adopted by immigrants (Neuhouser, Thompson, Coronado & Solomon, 2004).

It has been found that Hispanics consume more fruits and vegetables than the non-Hispanic population (Bermudez, Ribaya-Mercado, Talegawkar & Tucker, 2005; Neuhouser et al., 2004; Sharma et al., 2004), and that among Hispanics, those that are highly acculturated, eat less fruits and vegetables (Neuhouser et al., 2004). Further, Sharma et al. (2004) found that non-U.S. born Hispanics consume more servings of fruits and vegetables than U.S.-born Hispanics. These studies suggest that because of the tendency of Hispanics to eat more fruits and vegetables, it is probably harder for them to adhere to a low potassium, low phosphorus diet, which limits several types of fruits and vegetables. Furthermore, Burrowes (2004) noted that the diets of Mexican Americans, Puerto Ricans, Cuban Americans, Dominicans and Central Americans are comparable in that they are high in nutrients such as potassium, phosphorus and sodium, because the staples of their diets are beans, tomatoes, tuberous root vegetables, and tropical fruits, among others. Bermudez et al. (2005) found that Lycopeno intake was significantly higher among Hispanics and was mostly derived from cooked tomato sauce used when preparing different cultural dishes, which is also high in potassium.

There may be a tendency to generalize by ethnic group when assessing or educating patients, however, there is also great diversity within groups whereby practices among certain subgroups may not be similar to the practices of others. This is the case of the various groups within the Hispanic population, such that traditions and foods in North America (Mexico) differ from those in Central and South America, and the Caribbean. Some findings suggest that acculturation indicators appear to be strongly modified by Hispanic subethnicity and gender and that the relation between acculturation and specific diseases or behavioral risk factors is not consistently found across subgroups (Perez-Escamilla & Putnik, 2007).

Jones (1993) found that ethnicity plays a major role in food choices and patients on dialysis are eating cultural foods that negatively impact on the ideal renal diet. Therefore, it is very important for healthcare providers to be familiar with some of the foods that are culturally consumed among Hispanic individuals in order to address these food choices when assessing and educating the patient. Table 1 lists the foods that are commonly found in different Hispanic regions that are high in potassium and phosphorus. Examples of traditional dishes that need to be limited in the renal diet because of the possible high content of any of these nutrients are also listed. It is important to instruct the Hispanic patient that if a dish is made with one or more of the ingredients listed in this table it is most likely not suitable for the renal diet.

Not adding salt while cooking is an important measure that needs to be emphasized while educating a patient following a renal diet. However, among Hispanics individuals, condiments high in salt are also commonly used, especially adobo, sofrito, and sazón. Other foods and condiments that are high in salt commonly used in the Hispanic community are listed in Table 2.

Healthcare givers must also pay special attention when providing directions to take medications. For example, misinterpretation can occur frequently when the words “comida” and “comidas” are used. It is important to note that among some Hispanics “comida” may only mean food, but it can also be translated to signify lunch (a big meal that typically takes place in the afternoon); while “comidas” means meals (breakfast, lunch and dinner). The importance about knowing this vocabulary is that when the patient is advised to take some medications, it is usually in relation to meals, i.e., “with meals,” “before meals,” etc. This can be confusing when a Hispanic patient is instructed to take, for example, phosphate binders with meals. If the health care provider uses the word “comida” vs “comidas” the patient may take this medication only at lunch instead of with all meals.

Adherence to the Renal Diet and Education
The role of the healthcare team is to provide patients with knowledge and awareness so that they can make informed choices. Appropriate education and planning to achieve long-term adherence must be empowered.
 
Adherence can be achieved when the patient understands the disease and its implications and assumes more responsibility in the management of his or her medical condition (Burrowes & Cockram, 2004). Mayers (2000) found that when diet education is unrelated to the patient’s culture and lifestyles, dietary guidelines failed to serve its purpose and patients experience difficulties in food selection.

In a study developed with Hispanic patients undergoing hemodialysis, it was found that the patients were adherent to the diet. One of the factors that probably influenced this positive result was that educational materials were available in Spanish, which most likely facilitated the understanding of the restrictions of the renal diet (Morales López, Burrowes, Gizis, & Brommage, 2007). Since the Hispanic culture is very family oriented, education provided to family members may also increase adherence, not only to the diet but also to medications.

Conclusion
Dialysis staff members play a fundamental role in educating the patient to increase adherence to diet and medications. In order to provide better quality of care that will have a higher impact in the patient’s treatment, healthcare providers must take the cultural habits of patients into account.

References
Bermudez, O.I., Ribaya-Mercado, J.D., Talegawkar, S.A., & Tucker, K.L. (2005). Hispanic and non-Hispanic white elders from Massachusetts have different patterns of carotenoid intake and plasma concentrations. The Journal of Nutrition, 135, 1496-1502.

Burrowes, J.D. (2004). Incorporating ethnic and cultural food preferences in the renal diet. Advances in Renal Replacement Therapy, 11, 97-104.

Burrowes, J.D., & Cockram, D.B. (2004). Achieving patient adherence to diet therapy. In J.D. Kopple & S.G. Massry (Eds.) Nutritional management of renal disease (pp. 629-639). Philadelphia: Lippincott Williams & Wilkins.

Hoover, H. (1989). Compliance in hemodialysis patients: A review of the literature. Journal of the American Dietetic Association, 89, 957-959.

Jones, W.O. (1993). Effects of cultural preferences on nutrition. Transplantation Proceedings, 25, 2508-2510.

Kittler, P.G., & Sucher, K.P. (2001). Food and culture. Belmont, CA: Wadsworth/Thomson Learning.

Lopes, A.A., Bragg-Gresham, J.L., Satayathum, S., McCullough, K., Pifer, T., Goodkin, D.A., et al. (2003). Health-related quality of life and associated outcomes among hemodialysis patients of different ethnicities in the United States: The Dialysis Outcomes and Practice Patterns Study (DOPPS). American Journal of Kidney Disease, 41, 605-615.

Mayers, J.D. (2000). Dietary restrictions in maintenance hemodialysis: Experiences of English-speaking West Indian adults. Nephrology Nursing Journal, 27, 315-319.

Morales López, C., Burrowes, J.D., Gizis, F., & Brommage, D. (2007). Dietary adherence in Hispanic patients receiving hemodialysis. Journal of Renal Nutrition, 17, 138-147.

Neuhouser, M.L., Thompson, B., Coronado, G.D., & Solomon, C.C. (2004). Higher fat intake and lower fruit and vegetables intakes are associated with greater acculturation among Mexicans living in Washington State. Journal of the American Dietetic Association, 104, 51-57.

Perez-Escamilla, R., & Putnik, P. (2007). The role of acculturation in nutrition, lifestyle, and incident of type 2 diabetes among Latinos. The Journal of Nutrition, 137, 860-870.

Sharma, S., Murphy, S.P., Wilkens, L.R., Shen, L., Hankin, J.H., Monroe, K.R., et al. (2004). Adherence to the guide pyramid recommendations among African Americans and Latinos: Results from the Multiethnic Cohort. Journal of the American Dietetic Association, 104, 1873-1877.

U.S. Census Bureau. (2005). Race and ethnicity – American FactFinder. 2005 American Community Survey. Retrieved July 27, 2007, from http://www.census.gov�