Acknowledgments Raymundo and his family would like to invite you to read this fotonovela and learn about how to control fat and cholesterol in your diet. This fotonovela can be used by many community health workers and Promotoras de Salud to help people control their cholesterol levels.
We would like to thank the Centers for Disease Control and Prevention project team of: J Nell Brownstein, PhD, Carma Ayala, RN, PhD, and Elena Kuklina, PhD, MD for their leadership and support.
lNational Center for Chronic Disease Prevention and Health Promotion.
l Elena Kuklina who made a major contribution to the script.
We would like to acknowledge the members of our UT SPH team and the promotoras de salud from AYUDA who helped in the development and focus groups activities.
Sincerely: Dr. Héctor Balcázar UT-SPH Principal Investigator Email: [email protected]
Content Introduction to the Ramirez Family...... 3 What you need to do to keep a heart healthy...... 4 What is the difference between good and bad cholesterol? ...... 6 Knowing your Food...... 12 Put it into practice ...... 23
Illustration and design by Salvador Sáenz
For more information about this fotonovela please contact Doctor Balcázar at [email protected] or 915 747-8507 Introduction to the Ramirez Family and to Olivia, the Promotora
Raymundo: 55 years of Doña Fela: age recently diagnosed Raymundo’s with hypertension in our mother, 75 years previous fotonovela. old.
Pedro: Laura and Luis’ son, Paulina: Olivia: Community Health 7 years old. Raymundo’s Worker, 45 years of age. wife, 55 years old
Luis: Laura’s husband, 40 years old.
Laura: Raymundo’s eldest daughter, 32 years old. Laura and her 7 year old son, Pedro thy are visiting Doctor Rosales’ office for Good morning Laura, Pedro’s yearly check up. AL I need to tell you something.
t he Hi doctor, I hope all AR is well. he A
P kee O t DO
O t D u nee O The doctor talks What is the Laura, I wanted to talk t y
A privately to Laura. matter? with you about your lab test results because Wh it shows that your cholesterol is high. That makes it hard for blood to move through your body.
High blood cholesterol can lead to heart disease, heart attacks, and stroke. You can do things that will help. Losing weight can help bring down cholesterol levels. Eating healthy and being more physically active This is what a healthy blood vessel with normal can help people cholesterol looks like. lose weight and is good for the whole family. Wh We were in a hurry,
Now let´s talk about Pedro, so he has not eaten A t y he is above the weight that anything yet. is healthy for his height. O u nee I would like to check his cholesterol today. D t O
If Pedro didn´t have DO
breakfast this morning t
I will be able to check O his cholesterol today. kee P
A he AR t he
Would you like to meet with the clinic’s community health later... AL I will need to see Pedro worker (promotora) Olivia? She has been helping adults thy again in a few days to talk and kids with high cholesterol and will be glad to help about his lab results. you.
That evening Thank you for The doctor tells me I have high Laura, it Laura coming over. cholesterol and extra weight. Olivia will is very invited Doña talk to me about ways to eat less food, fat, Fela and important and sodium which will help my heart and to follow Raymundo help me lose weight. over for a the doctor’s family talk. and Olivia´s advice. tO keeP A heARt heALthy Doctor Rosales cares a lot. With his Being more active, You are right, dad. We will DO support and yours, I have been able and losing weight. make the changes the doctor O to control my high blood pressure by and the promotora suggest. t
D eating healthy foods. This helps me to keep my heart healthy. u nee O t y A Wh
Luis, Laura and Pedro are back at the clinic to meet with On your last visit we checked Doctor Rosales and Olivia. Pedro’s cholesterol. Pedro’s lab ROL? Hello. It results are back. Pedro has high is good to cholesterol for his age. este see you all today. OL h C AD b D n A
OOD een g W
e bet Pedro’s lab results C show that his total His “bad” cholesterol is 148, but it should be less than en blood cholesterol is 110. His ”good” cholesterol is 54, which is fine. His R e 206, but it should be “good” cholesterol should not be less than 45. less than 170. DIFF s the I t A Wh
guidelines for total Cholesterol in Children and Wh A teenagers (ages 2-19) t I s the
LDL (bAD) hDL (gOOD)
ChOLesteROL: ChOLesteROL: DIFF Keep it low! The higher, the better!
Less than 110 Keep it 45 mg/dl e mg/dl is best. or higher. R en C e bet tOtAL ChOLesteROL: W
Less than 170 is good. een g Numbers 170-199 are on the borderline, 200 or more is high. OOD http://www.nhlbi.nih.gov/guidelines/cvd_ped/summary.htm#chap9
A
Doctor, can you explain the difference n total cholesterol is the amount of all types of D between “bad” and “good” cholesterol? b
And what is total cholesterol? cholesterol in the blood. AD C
FOR ADuLts tOtAL This includes both h OL ChOLesteROL: the good Less than 200 mg/dl este best. Good for you! and bad 200 to 239 mg/dl cholesterol. ROL? borderline. Be alert! 240 mg/dl or more high. Danger!
LDL or “bad” cholesterol builds up and clogs the blood vessels. The lower it is the better. HDL or “good” cholesterol helps keep the blood vessels Laura, your lab results show that your total cholesterol from getting clogged. The higher it is the better. is 245, but it should be less than 200. Your “bad” ROL? cholesterol is 168, but it should be less than 100. Your “good” cholesterol is 55, so I am not worried about it. este OL h C AD b D n A
OOD een g W
e bet Laura and Pedro can lower their cholesterol, but they Olivia, can help you to make your diet healthy and get C need to work together to eat healthy foods, be more enough physical activity also she has some cooking tips en active, and get to a healthier weight. It is good that and recipes that will help you and your family along the R Laura does not smoke because smoking also raises total e way. cholesterol levels. DIFF s the I t A Wh
Thank you for your help. We Great! I will see you in Hello, I have been working with will make the time and effort six months to check your kids and adults for the past 15 to drop our “bad” cholesterol. weight and cholesterol years. I’m sure that with your again. support, we will be able to help Pedro and you make healthy choices. Wh Olivia, can you tell us what
cholesterol is and why my family Cholesterol is a natural waxy, A fat-like matter that is in our t
should be worried about high I cholesterol? food, and it is also made by our s the liver. Your body makes all of the cholesterol it needs to do
important things, like breaking DIFF down fatty foods and making
hormones and vitamins. e R en C e bet W een g OOD
A
But too n D
much b
cholesterol AD from some C foods, like h fatty meat, OL
organ meats este like liver and kidney, cheese, ROL? and dairy desserts like ice cream may One egg yolk a day raise the amount of does not increase the cholesterol risk of heart attack in in the blood. healthy people.
My father, who Olivia, what causes Many things can cause died of a heart someone to have high LDL, or bad attack, had high cholesterol? cholesterol... diabetes, and his mother has high cholesterol. My father-in- ...does anyone in law, Raymundo, your family have has high blood high cholesterol? pressure and now Laura and Pedro have high cholesterol. Many things can cause high LDL, or bad cholesterol, but having a
ROL? family history of high cholesterol, diabetes, high blood pressure or heart problems, not being active, este eating an unhealthy diet, being at Relatives with history OL of high cholesterol, h an unhealthy weight, and being diabetes, high blood C of older age increases the risks and makes it especially hard for pressure or heart AD your family to have a healthy life problems. b
D style. n A
OOD een g W e bet C en R e DIFF s the I t A Wh
Luis, I suggest High cholesterol has no warning signs. Many times people have that you meet it without even knowing about it. It is important to have your with your family cholesterol tested because if it’s high you can talk to your family doctor and get doctor and control it by making changes in what you eat and your cholesterol how active you are. checked.
Luis, as a community health worker I will help you and your family to keep your heart healthy! Wh Healthy children should have their cholesterol checked between ages:
everyone A t
age 20 I years s the 9 and 11 17 and 20 and older
years years should DIFF have
their e R
cholesterol en checked C
at least e bet once every W
five een g years. OOD
A
Your doctor may advise checking your child’s cholesterol n
before age 9, between ages 12 and 16 years, or more D often if your child The first steps b already has high cholesterol to control high AD or other risk factors for cholesterol are heart diseases. to make changes C like eating healthy h foods... OL este ROL?
...getting more physical activity, and either losing weight if needed or Please come to one of my monthly maintaining a healthy weight. The doctor, nurse or I can help you find group classes to learn more about your healthy how to manage cholesterol and live weight. a healthy life. Everyone will welcome you. The following week... FOOD
R u O ng y OWI kn We are ready to start the session. Thanks everyone for coming. Let me introduce you to Luis, Laura, and their son Pedro. They will be taking part in our classes.
We will be talking about I have What foods have grains how to lower your questions and why do we need to cholesterol levels. A about eat more whole grain? healthy and balanced diet what What is saturated fat? is a very important step in makes up managing high cholesterol. a healthy diet.
Whole grains contain all parts of the entire grain seed. It is good to eat more whole grain food because it is less processed than refined grains in foods like flour tortillas, white bread and white rice and also helps reduce cholesterol. kn Examples of foods with whole grains include: brown rice, wild rice, oats, whole-wheat bread, OWI whole-wheat tortillas, whole-grain crackers, and whole wheat pasta. Look for the “whole grain”
label on food. ng y O u R
FOOD
Often, when people start to eat less cholesterol and increase their physical activity, their cholesterol level begins to drop within a few weeks.
They can be found in foods like whole fat milk and cheeses, butter, cream, ice Saturated cream, fatty meat, fatty poultry, lard, and pork fat. Tacos, sausages, bologna, hot fats and dogs, and beef burgers may contain a lot of saturated fat. cholesterol are found in foods that come from animals.
Activity sheet: Write in the white circle an ¨R¨ if it is a food FOOD
high in cholesterol or a ¨G¨if it is a food low in cholesterol. R u
O We need to learn to identify foods high and low in cholesterol, because the food we choose daily defines in a major way our health and the health of our ng y family. OWI kn
1 2 3 4
5 6 7 8
9 10 11 12
13 14 15 16 Answers: 1-R, 2-G, 3-R, 4-G, 5-R, 6-G, 7-R, 8-R, 9-G, 10-R, 11-R, 12-G, 13-G, 14-R, 15-R, 16-G 15-R, 14-R, 13-G, 12-G, 11-R, 10-R, 9-G, 8-R, 7-R, 6-G, 5-R, 4-G, 3-R, 2-G, 1-R, Answers: kn I thought foods from animals are high You can choose fish, lean cuts of meat and poultry and beans. In addition, in protein. If these foods are also high you can trim fat from meat and poultry and remove the skin from poultry OWI in cholesterol what kinds of foods with before you cook them. protein should we be eating? ng y O u R
FOOD
But, stay away from packaged food I replace animal fats such as lard and butter in my cooking with palm and coconut oils since with1 teaspoon of oils such as canola, olive, soybean, they are very high in saturated fats. safflower, corn, sunflower, or flaxseed. It is also very important to try to avoid foods with “trans fats.”
The amount for trans fat in a food is listed on the nutrition Facts label.
trans fats come from foods that contain partially hydrogenated oil and can sometimes be found in store- bought baked goods like cakes, cookies, and pies, and canned frosting. They are also in stick margarines, some fried foods, and may be in snack foods like chips and popcorn. Trans fats are also used
FOOD to cook in restaurants
R and fast food places. u O ng y OWI kn
trans fats can raise your bad cholesterol levels in your blood You said to use different There are many and damage your blood vessels, which can lead to heart attack kinds of cooking oils and things you can do. or stroke. You should try to eat foods with trans fats as little as whole grains. What other possible. changes can I make when I’m cooking?
Instead of frying meat, fish or potatoes, try baking, broiling, or grilling. Drain extra fat from cooked meats and poultry. Cooking and eating at home more often saves kn money, and it is better than the high-fat food at OWI fast food places. If you cook and eat at home, you ng y can control the
amount of fat in O u
your food. R
FOOD
You can also use non-stick or vegetable oil spray to grease your cooking pans. When cooking eggs or recipes with eggs, you can use egg whites. You can use 2 egg whites to replace one whole egg.
You can add flavor to foods with herbs Start a new tradition. When you go to big family dinners and spices. Use low-fat instead of bring healthy dishes. Don’t be surprised when family high-fat cheese. Also, serve smaller members and friends ask for your recipes. portions, especially when eating higher-fat dishes. Also, use smaller plates than you are using now. And eat more vegetables and fruits and limit the foods you eat with FOOD
added sugars. R u O ng y OWI kn
When eating out at restaurants, eat smaller amounts of You should: food, share a meal, or take part of your meal home. 1. Fill one half of your plate with fruits and vegetables 2. Make at least half of your grains whole grains
3. Pick a variety of high-protein foods that Today I want to finish Next week, I invite you all to attend are low in saturated fat and cholesterol the class by teaching my Low-Fat Cooking class. We will 4. Switch from full-fat (regular) to low-fat you to read a Nutrition be making a low fat chicken and (1%) or fat-free milk products Facts label. rice (arroz con pollo) recipe. I hope you will all be able to come. kn
Activity sheet: Fill in your plate, choosing healthy foods, write the numbers you OWI select in my Food Plate below ¨ChooseMyPlate.gov.¨ See page 18 for grouping foods with “ChooseMyPlate.gov.” ng y O u R
FOOD
On today’s class we´ll learn how to read a Nutrition Facts Today we’re focusing on items to eat less of as shown on the label. nutrition Facts label. The items to eat less of include: calories, FOOD total fat, saturated fat, trans fat, cholesterol, sodium and R Knowing how to read a u sugars. Nutrition Facts label is the O BEST tool for choosing healthy foods. ng y OWI kn
Check out our fotonovela “How to Control your Hypertension: Learning to Control Start by looking at the “serving size” printed right under “nutrition Your Sodium Intake,” which explains how Facts.” The Nutrition Facts label tells us the numbers of servings there we have used the are in the package or can. It tells us the amount of calories, saturated Nutrition Facts labels fats, trans fats, cholesterol, sodium and sugar for one serving. to teach people how to control sodium in their diet.
Many packages and cans have more than one serving. Check Remember to look at the serving the serving size and how many servings you are actually eating. size. A pint of ice cream is not If you eat double the serving size, you will also eat double a single serving; it’s FOUR the amount of calories, saturated fat, cholesterol, sodium and servings. If you eat an entire sugar. pint, you have to multiply by four the number of calories, grams of fat and milligrams of cholesterol listed on the label. kn
Activity sheet: Fill in the blank sheet comparing Nutrition Facts labels per serving. OWI ng y 1. Which label O
has the highest u R
cholesterol?______FOOD
How much?______
2. Which label has the least cholesterol?______
How much?______
3. Which food has the most saturated fat?______
How much?______
4. Which label has the highest amount of total fat? ______
How much?______
5. How much total fat is 1 serving of the food in label
# 1?______
(5.) 3.5 g. 3.5 (5.)
(4.)Label 4, 10 g; g; 10 4, (4.)Label
(3.)Label 5, 3.5 g; g; 3.5 5, (3.)Label
(2.)Label 3, 0 mg; mg; 0 3, (2.)Label
(1.)Label 5, 3 500 mg; mg; 500 3 5, (1.)Label Answers: Compare brands to Look for: Total Fat, Saturated Fat, Trans Fat and pick foods that have the FOOD
Cholesterol: Under Total Fat, you’ll find Saturated least saturated fat and R Fat and Trans Fat, then Cholesterol listed in bold. cholesterol and 0 grams u
O These all raise your cholesterol levels. trans fat, if you can. ng y OWI kn
Keep in mind And how can we You can go that fat-free become more to a nearby doesn’t mean active? park to play a food is games like calorie-free. soccer or Some lower- basketball, fat items have go for the same evening number of walks as a calories as family, jump the full-fat rope, ride item because a bicycle, they may roller blade have more or go added sugar. dancing. You also need to eat foods lower in sodium.
The community center has free Adults should be active at moderate The program Mi Corazón, Mi Comunidad in El Paso, intensity for at least 150 minutes per Texas is working in parks to bring health promotion Zumba and Salsa classes that week. Children and teenagers should be to our communities, are fun. active at least 60 minutes each day.
ask Dr. Balcázar about Mi Corazón Mi Comunidad program. kn I’ll be home from work earlier. If I can’t, I Luis and Laura: if you will go with you to a dancing class in the don´t have any other ...it was very OWI evening and to the park on the weekend. questions...
nice to see ng y you all. We’ll
see you in one O
month! u R
FOOD P Thank you Olivia…. Laura, how Doña Fela, ut everything You’ll see. We’re going everything is going? I is going t to do exactly what you I great! We’ve nt told us. You won’t be been eating O disappointed. healthier foods, PRAC eating smaller portions, and t
going to the IC
park several e days a week to walk laps or play soccer. And we are having fun at the Zumba classes at the community Center.
I have lost 10 pounds since That is We’ve gone back to see Dr. we started making all of these great news! Rosales and Olivia twice changes. since our first visit, and Pedro has already lost five pounds.
e “Now the entire family is enjoying a heart healthy lunch and laughing.” IC t PRAC
O nt I t I ut P
Six months later... We are doing everything you Well, Pedro is looking and Olivia advised. We feel good! He’s lost six better, have more energy, pounds in the past and we will continue with six months and his our healthy changes. cholesterol has gone down.
These fotonovelas were done through a CDC-ASPH grant program. We hope you and your family learn through the fotonovelas how to have a healthier lifestyle. Fall 2013