Cultural awareness in today’s society has become increasingly important for diabetes clinicians and educators. Demographics in the United States are changing rapidly, and the prevalence of type 2 diabetes among many racial and ethnic groups is extremely high. To be effective in encouraging clients among these groups to make healthier food choices, counselors require a specific knowledge of various food habits, preferences, and practices.

All people use food in culturally defined ways, and the meaning of food in our lives far exceeds that of simply providing sustenance. Cultural food patterns are defined by what foods are eaten, when they are eaten, how they are eaten, and with whom they are eaten. Ethnic groups differ in how they identify foods and how they prepare them, the condiments they use, and the timing and frequency of meals. Foods are also frequently used in symbolic ways, playing an integral role in religious ceremonies and social events. Although cultural food practices are dynamic and ever-changing, many of the traditions relating to them persist even with a high level of social acculturation.

Cultural competency is the ability to work effectively with clients of different cultural backgrounds. Counseling must be based on counselors’ awareness of their own cultural beliefs and worldview and of their own personal stereotypes and preconceived notions. This self-awareness is the starting point for developing sensitivity to cultural differences and for understanding the importance of family patterns, cultural values, and beliefs and behaviors that relate to food practices.1 

Knowledge of the culture of an ethnic group can be obtained from many sources: first from the current literature; then through working with community leaders and members, spiritual and religious leaders, and medical practitioners (particularly community health workers) who serve the group; and, if it is appropriate, from consultation with traditional healers. Counselors should also be familiar with other resources in the community, such as ethnic food markets, and informal places of socialization, such as restaurants, cafés, and barber and beauty shops. All of this knowledge can be extremely useful in adapting nutrition interventions and available materials to meet the needs of various clients.

General considerations

The following list outlines the basic skills required for an effective approach to diet counseling in any community.

  • Establish respect and trust. Maintain client dignity. Keep a nonjudgmental attitude, and accept cultural differences.

  • To increase credibility, have knowledge of clients’ food habits and health beliefs.

  • Be sensitive to verbal and nonverbal communications (e.g., know what is the appropriate degree of eye contact in a given culture).

  • Determine primary language, written and verbal, used in clients’ homes.

  • When necessary, use trained interpreters who understand medical terminology and the concepts being taught.

  • Determine clients’ preferred communication style: Does a given client prefer direct or indirect communication? Indirect communication may mean presenting information in the third person (e.g., “Someone who has been asked to eat less fat, might do this . . .”) or explaining the necessary nutrition concepts through the use of stories.

  • Provide information that is most pertinent to clients (i.e., what they need to know, rather than what is nice to know).

  • Focus on positive messages, such as prevention of complications, well-being, and balance.

  • Be consistent in the messages you communicate.

  • Work in partnership with community leaders and social institutions within the community.

  • Train and collaborate with community health workers who can play an essential role as a cultural link to the ethnic community.

  • Disseminate information through established channels (cultural leaders, ethnic radio and television stations, ethnic newspapers).

Assessment of cultural beliefs and food practices

Assess clients’ ethnicity, degree of affiliation with their ethnic group, and level of acculturation. Also, be aware of religious practices and patterns of decision-making within clients’ families. Discover clients’ reasons for seeking care, their beliefs about these problems, and their treatment choices and goals for care. Gather information about their previous or anticipated treatments. Discuss clients’ current and preferred diets and the meaning of food in their lives. Ask about their specific food preparation methods, the timing and frequency of their meals, and the size of their usual portions.2 

Adaptation of diabetes education approaches and materials

Assess any potential barriers clients may have to learning and to behavior change, such as socioeconomic status, education level, and literacy skills. Determine clients’ preferred learning styles, whether visual, auditory, or experiential, and consider appropriate teaching methods within the community, such as one-on-one, didactic, peer education, talking circles, storytelling, or spiritual and gospel songs. Also consider incorporating rituals into nutrition interventions, such as initiating a project with a prayer.

Questions for dietary recalls should be very specific and adapted to clients’ reading level. Adopt a single-concept approach to diet instruction, through which you focus on one important topic. To support nutrition counseling, choose appropriate brochures that are culturally sensitive and not unnecessarily complex, have a reasonable type size and reading level, and, if possible, include graphics. Eve Gehling, in her article “The Next Step: Stage-Matching Your Patient Education Materials,”3 outlines five steps to stage-match existing educational materials:

  1. Consider creating new culturally specific materials. Define the audience (race/ethnicity, gender, age, education, income).

  2. Identify the behavior that needs to be addressed. Pick one behavior to focus on, for example, “Eat less fat.”

  3. Identify factors that influence the health behavior (e.g., explore how eating less fat affects clients, their families, and their finances).

  4. Identify the stage of the reader’s readiness to change stage, and match the message to that stage.

  5. Include a call to action.

Other counseling considerations

Clients should be involved in problem solving and in developing strategies for behavior change. Ask clients what they have done so far to change their eating habits and what they think they can do. Include clients’ family members who are involved in food preparation.

Use familiar foods in meal planning as much as possible, and encourage incremental changes in food practices when medically feasible. Address myths and misconceptions about the role of foods in disease treatment and prevention, and explore clients’ uses of special food or beverages as folk remedies.

Be careful not to make clients feel that they have made mistakes when pointing out needed dietary modifications because this may cause them to lose self-respect. It is important for counselors to continually assess their cultural competency and to take action to address deficiencies.

A Practical Approach

Bearing in mind that clients’ willingness to make healthy food choices must be supportable at every meal, every day, we devote the remainder of this article to providing a sample study of the food practices, beliefs, and customs of a specific ethnic community. This and other studies that offer information about various ethnic and racial groups in the United States can be obtained from the American Dietetic Association.4 Working from this kind of cultural information, counselors will be able to give their clients ongoing support and to discuss with them the options available in most situations and social occasions.

Traditional food practices

  • Alaska Natives traditionally subsisted on a high-protein, high-fat, animal- and fish-based diet rather than a plant-based diet (carbohydrate foods made up only 10% of total calories).

  • Staple foods were fish, fish eggs, shellfish and crustaceans, sea mammals, wild game and birds, and some edible indigenous plants such as wild greens, seaweed, roots, and berries. (Specific foods varied by region.)

  • Fats consumed included whale blubber, seal and fish oils, and caribou fat.

  • Before coffee and tea were introduced, water, broth, and tundra tea were beverages traditionally consumed.

  • Hunting, fishing, and gathering were traditional methods of obtaining foods; food quantity and selection varied by season.

  • Boiling was used as a traditional food preparation method.

  • Raw, frozen meat and fish were eaten by the Inupiat Eskimos in Northern Alaska. This food practice was unique to this Alaska Native group.

  • Alaska Native people used a variety of traditional healing methods, such as herbal remedies, massage, and steam baths and were accustomed to seeking the assistance of healers or shamans.

Current food practices

  • Traditional foods and food practices are still common.

  • Fish consumption is still high. Consumption of shellfish and crustaceans, fish eggs, sea mammals, and wild game and birds is still common. These may be boiled, fried, baked, salted and dried, or eaten raw and frozen.

  • Many families still gather wild berries and other local edible plants (sour dock, willow greens, wild celery, beach asparagus, and fiddlehead fern) that are eaten fresh or frozen or dried for later use.

  • The use of beef, pork, and poultry and the increased use of sugary and starchy foods are two major changes from traditional food practices.

  • Today’s Alaska Natives rely more heavily on grocery stores for food in areas where there is a limited supply of fresh foods. Large quantities of sugar-sweetened drinks, convenience foods, and snack foods are purchased from village stores.

  • Federal food programs have encouraged the use of store-bought foods.

  • Commonly consumed carbohydrate foods include sugar, white bread, rice, pilot bread (unsalted, dense round crackers), sourdough pancakes, and cooked cereals.

  • Fruits and vegetables are eaten infrequently. Potatoes, lettuce, onions, and carrots are among the vegetables that are consumed most often. Canned fruits, juices, and vegetables are used more frequently than fresh produce.

  • Major types of fat used today include the traditional fats listed above, as well as butter, margarine, lard, shortening, and vegetable oils.

  • Imported foods are transported to village stores by plane or barge and are expensive.

  • Milk is consumed infrequently. Fresh milk is expensive, and lactose intolerance is common. Tea, coffee, and sugar-sweetened drinks are now the most commonly consumed beverages.

  • Alaska Natives do not commonly follow a three-meal-a-day eating pattern, although breakfast and evening meals tend to be consistent. Mid-afternoon and evening snacking is common.

Holidays, celebrations, and fasting

  • Traditional foods are eaten at potlatches, ceremonial feasts, memorial dinners, and holidays. Potlatches occur throughout the year, but especially in the winter, and are a part of the religious ceremonies and winter festivals.

  • Alaska Eskimo celebrations are held during whaling season. There may be feasts before or after whale hunting. Whale meat is shared among community members, and nothing is wasted.

  • Alaska Indian and Aleut potlatches and ceremonial feasts are held to honor the deceased and celebrate special occasions. These include dancing and the distribution of goods to guests.

  • According to information from the Alutiiq Museum in Kodiak, Alaska, the potlatch is actually a Tlinkit-Haida tradition that was adopted by the Aleuts. However, there is a big difference between the two groups’ practices. In the Tlinkit-Haida culture, the chief invited a neighboring village over and gave away blankets and other valuable items. The goal of the chief was to “become poor.” In the Alutiiq culture, other villages are invited to winter ceremonies for mask dancing, feasting, and gaming. However, the largest activity by far is gambling; people can lose valuable items, such as their skiffs. This version of the potlatch is less a practice to distribute goods than an invitation to share celebratory feasts.

  • In the Russian Orthodox religion observed by many Aleuts and Alutiiq, there are as many as three to four fasts per month throughout the year, mainly on Wednesdays or Fridays. Fasts may last from one to seven days depending on the occasion (the beheading of John the Baptist, elevation of the Cross, Ascension of the Lord, a Saint’s birthday, to name a few). The fast for Lent lasts 40 days, ending on Easter. In general, dairy products, eggs, red meat (except salmon), oil (including foods fried in oil), alcohol, and chewing gum are excluded from the diet during fasting. Liberal exceptions are made for the sick, the elderly, and pregnant women.

This type of information will help provide diabetes clinicians and educators with a foundation on which to build to understand their patients’ cultural practices and personal preferences. Assessment and learning will be ongoing and individualized with each patient.

Implications for nutrition counseling

  • Health professionals should encourage the consumption of traditional foods because of the rich nutrient content they offer and their strong association with cultural customs.

  • English is commonly a second language and there is a need for trained translators.

Tammy L. Brown, MPH, RD, BC-ADM, CDE, is a nutrition consultant at the Indian Health Service National Diabetes Program in Albuquerque, N.M.

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