February 7th-9th, 2013 EthnicEthnic FoodsFoods andand PDPD Patients:Patients: whatwhat toto bebe awareaware of?of?
JiakJiak ChinChin KohKoh RD,RD, MScMSc.. [email protected]@providencehealth.bc.ca FebFeb 9,9, 20132013 Background:Background:
Personal background: - Grew up in Malaysia (early exposure to 3 different cultures) - Traveled to over 50 countries - Renal dietitian in Vancouver for 10 yrs
Presentation background: - Focus will be on: * Understanding the role of culture in food preferences * Recognizing challenges integrating some ethnic foods in the PD diet * Learning practical strategies to support consumption of healthy foods that are culturally acceptable to our patients. - Unique feature of this talk: interviewed RDs from various cultural backgrounds LearningLearning toto cookcook whilewhile travelingtraveling
“Berber Omelete” at the edge of Sahara Desert in Morocco
“Cactus” in Oaxaca, Mexico “Pizza” on lava bed in Hawaii ““GroceryGrocery shoppingshopping”” whilewhile travelingtraveling
Fresh Dates orchard in Tunisia Bargaining for Red Bananas in Tanzania
Fresh fruit on the street in Barbados StatisticsStatistics CanadaCanada 20062006 CensusCensus DataData
200200 differentdifferent ethnicethnic originsorigins reportedreported
~16.2%~16.2% totaltotal populationpopulation isis ofof visiblevisible minorityminority
ProjectsProjects byby 2031,2031, 28%28% ofof CanadianCanadian populationpopulation willwill bebe foreignforeign--bornborn
SubstantialSubstantial increaseincrease inin Chinese,Chinese, FilipinoFilipino andand SouthSouth AsianAsian immigrationimmigration DemographicsDemographics inin BCBC && YukonYukon PDPD andand AllAll DialysisDialysis PD Patients All Dialysis Patients
2002 2007 2012 2002 2007 2012
# Patients 591 704 841 2050 2578 3071 (28.8%) (27.3%) (27.4 %) (100%) (100%) (100%)
Age Mean ± SD 57 ± 16 61 ± 16 63 ± 15 61 ± 16 64 ± 16 66 ± 15 Median [IQR] 58 [47-70] 64 [50-74] 65 [54-75] 63 [50-74] 66 [54-76] 68 [56-77]
Male 56% 56% 61% 59% 59% 60%
Source: BC Patient Records & Outcome Management Information System (PROMIS) database EthnicEthnic groupsgroups ofof PDPD patientspatients inin BCBC (%(% consistentconsistent withwith ““AllAll DialysisDialysis””))
70 62% (2012) 60 50 40 2002 30 2007 16% 2012 20 8% 5% 3% 3% 3% 10
0 Caucasian Asian East Indian Filipino First Nation Others Unknow n Orie ntal Source: BC PROMIS database Ethnicity,Ethnicity, Culture,Culture, andand RelationshipRelationship ofof CultureCulture withwith FoodFood andand DiseaseDisease
EthnicityEthnicity oftenoften refersrefers toto ““asas aa commoncommon ancestry,ancestry, nationality,nationality, socialsocial customscustoms andand religionreligion””.. OneOne ofof thethe waysways ethnicethnic groupsgroups maintainmaintain theirtheir culturalcultural identitiesidentities isis throughthrough foodfood practices,practices, valuesvalues andand beliefs.beliefs.
CultureCulture determinesdetermines howhow aa personperson definesdefines health,health, recognizesrecognizes illness,illness, andand seeksseeks treatment.treatment. CultureCulture andand FoodFood
FoodFood andand languagelanguage areare thethe culturalcultural habitshabits humanhuman learnlearn firstfirst –– thereforetherefore greatestgreatest reluctancereluctance toto change.change. EvenEven wherewhere socialsocial attitudesattitudes becomebecome homogenized,homogenized, culturalcultural foodfood practicespractices tendtend toto maintainmaintain theirtheir ethnicethnic features.features.
AreAre traditionaltraditional culturalcultural foodsfoods healthful,healthful, oror atat leastleast compatiblecompatible withwith modernmodern dietarydietary goals?goals? GoalGoal isis toto supportsupport patientspatients inin maintainingmaintaining theirtheir culturalcultural foodfood practicespractices asas muchmuch asas possible.possible. CulturalCultural CompetenceCompetence
Means recognizing and forming one’s attitudes, beliefs, skills, values, and level of awareness to provide culturally
appropriate, respectful, and relevant care and education (Campinha-Bocate Model)
Complex integration of: - Attitudes (open-minded, value diversity), - Knowledge (understanding the language, culture, behaviours) and - Skills to enhance cross-cultural interactions, to work effectively with and to make appropriate recommendations for individuals from different backgrounds. CulturalCultural CompetenceCompetence
Cultural competence exists on a continuum from incompetence to proficiency
- Developing awareness - Acquiring knowledge and - Developing and maintaining cross-cultural skills (Requires long-term commitment of active learning and practicing).
Culturally competent health care fosters: - favourable clinical outcomes results - positive and rewarding interpersonal experiences, - promotes patient/client satisfaction PDPD DietDiet Requirements:Requirements:
Nutrient Amount Protein Emphasize High Biological Value (HBV) Protein Stable state: 1.2-1.3 g/kg (e.g.: 70 kg: 7-8 oz + 1 glass dairy) Peritonitis: 1.5 g/kg Sodium (Na+) < 2300 mg/d
Potassium (K+) Typically 3000-4000 mg/d
2- Phosphorus (PO4 ) 800-1200 mg/d
Fluid Typically 6-8 glasses/d ChineseChinese (Protein)(Protein) LessLess Often:Often: BetterBetter Choices:Choices: Organ meats, bone marrow, Lean meats, poultry, sardines, dried shrimps fish, eggs ChineseChinese (Vegetarian(Vegetarian Protein)Protein) SoyaSoya BeanBean ProductsProducts (High(High Phosphorus):Phosphorus): Tofu,Tofu, BeanBean curds,curds, BeanBean CurdCurd Sheets,Sheets, TofuTofu dessertsdesserts ChineseChinese (Noodles)(Noodles) LessLess Often:Often: BetterBetter Choices:Choices: InstantInstant NoodlesNoodles –– RiceRice noodles,noodles, vermicellivermicelli -- 800800--2000mg2000mg NaNa+/packet!/packet! butbut checkcheck NaNa+ contentcontent too.too. ChineseChinese (Soups)(Soups) SoupSoup basebase –– AvoidAvoid usingusing bonesbones (phosphorus(phosphorus leachingleaching intointo soups).soups). UseUse meatmeat oror vegetablesvegetables instead.instead.
Bone-based soups (Higher phosphorus)
Vegetable / meat-based soup (Lower phosphorus) ChineseChinese (Sauces(Sauces && Spices)Spices) LessLess Often:Often: BetterBetter Choices:Choices: Oyster, Hoisin, Plum, Ginger, garlic, onion, chives, Char-Siu sauces green onion, sesame oil, Chinese five spice ChineseChinese (Beverages)(Beverages) LessLess Often:Often: BetterBetter Choices:Choices: Milo,Milo, OvaltineOvaltine,, HorlickHorlick,, GreenGreen tea,tea, LemonLemon tea,tea, SoyaSoya milkmilk WaterWater withwith lemon/lime,lemon/lime, RiceRice beveragebeverage ChineseChinese (Beliefs)(Beliefs) Yin/YangYin/Yang (Cold/Hot)(Cold/Hot) FoodsFoods ““YinYin ”” (Cold)(Cold) foodsfoods (e.g.:(e.g.: manymany fruits)fruits) avoidedavoided whenwhen sicksick –– maymay bebe challengingchallenging toto raiseraise KK level.level. MayMay needneed toto considerconsider KK--supplement.supplement.
PostPost surgerysurgery –– avoidingavoiding ““toxictoxic”” foodsfoods suchsuch asas somesome proteinprotein foods.foods.
ComfortComfort foodfood –– CongeeCongee (rice(rice porridge).porridge).
ChineseChinese YangYang // HotHot vsvs YinYin // ColdCold Lunar/ChineseLunar/Chinese NewNew YearYear CelebratedCelebrated forfor 1515 daysdays JapaneseJapanese (( SeasonalSeasonal Eating)Eating)
JapanJapan’’ss traditionaltraditional cultureculture oftenoften describeddescribed asas thethe seasonalseasonal culture.culture. TheThe sensesense ofof seasonseason isis highlyhighly valued.valued.
PremiumPremium placedplaced uponupon freshnessfreshness andand naturalnatural flavourflavour .. EatingEating foodfood atat theirtheir ““ShunShun”” oror ““NowNow--inin SeasonSeason”” –– believedbelieved toto bebe goodgood forfor health.health.
Spring: Bamboo shoots, tuna, herring
Early summer: Bonito (fish)
Autumn: Matsutake (a type of mushroom), chestnuts
JapaneseJapanese ((““JapanJapan--izedized”” andand TrendyTrendy Foods)Foods)
JapaneseJapanese cuisinecuisine hashas alsoalso takentaken upup manymany otherother cultureculture ’’ss foodsfoods e.g.:e.g.: JapaneseJapanese currycurry (block(block currycurry roux)roux) JapandogJapandog (Japanese(Japanese stylestyle hothot dogs)dogs)
TrendyTrendy foodsfoods promotedpromoted onon TV/MediaTV/Media (e.g.(e.g. mucousymucousy seaweed)seaweed) JapaneseJapanese (Condiments)(Condiments)
WasabiWasabi PickledPickled GingerGinger (Japanese(Japanese horseradishhorseradish fromfrom wasabiwasabi root)root) Pickled in salt, sugar & vinegar – usually don’t eat much 30g = 275 mg Na+
Tube, paste form – Salt may be added
Powder form (need to add water) – No salt JapaneseJapanese (Soup(Soup && RiceRice Accompaniments)Accompaniments)
Miso Soup • Dark brown miso paste ~2000mg/tbsp • Light brown miso paste tends to be lower in Na ~1000mg/tbsp
Tsukemono (Pickled vegetables -salty) JapaneseJapanese (Rice(Rice Accompaniments)Accompaniments)
Furikake (Salty sprinkles on rice)- Iriko/Chirimen-jako (Salt preserved/dried many contain Nori (seaweed) anchovies
Fish roes - Tobiko, Kazunoko (herring roe), Mentaiko (cod roe) – all salt cured JapaneseJapanese (Cooking)(Cooking)
UsesUses quitequite aa bitbit ofof sugarsugar –– e.g.:e.g.: teriyakiteriyaki && sukiyakisukiyaki sauces,sauces, basicallybasically sugarsugar && soyasoya saucesauce (Watch(Watch ifif havehave diabetes).diabetes).
SushiSushi ricerice –– hashas salt,salt, sugarsugar andand vinegar.vinegar. ThereforeTherefore alreadyalready quitequite saltysalty eveneven withoutwithout soyasoya sauce.sauce. JapaneseJapanese (Sauces)(Sauces)
LessLess Often:Often: (Na mg/Tbsp) BetterBetter Choices:Choices: (Na mg/Tbsp) Soya sauce (1029mg), Teriyaki (690mg), Low Sodium Soya Sauce (600mg), Sukiyaki (460mg), Ketchup (140 mg), Ponzu (Mixture of lemon/lime and Japanese Mayonnaise (~14mg but may soy) (400 mg), Sesame oil contain MSG) Homemade sauces: Ponzu: 1:1 soy sauce & lemon or lime juice/ rice vineagar Soy & Balsamic: 1:1 or even 1:2
JapaneseJapanese (Vegetables)(Vegetables) (mg(mg KK // halfhalf cupcup 125125 mLmL)) HigherHigher potassiumpotassium
Burdock (Gobo) (225 mg K)
Fiddleheads Chrysanthemum (416 mg K raw) leaves (144 mg K) – must be – medium K cooked! JapaneseJapanese ((OtsumamiOtsumami ““SnackSnack””)) LikeLike ““tapastapas”” -- multiplemultiple dishesdishes aroundaround dinnerdinner time.time. MayMay thenthen havehave rice/noodlesrice/noodles atat thethe endend ofof night.night.
OtsumamiOtsumami isis usuallyusually accompaniedaccompanied byby alcoholalcohol –– beerbeer mostly,mostly, butbut winewine isis gaininggaining popularity.popularity.
Note: May need to consider phosphate binders for Otsumami! KoreanKorean RiceRice atat everyevery mealmeal (including(including breakfast).breakfast).
BreakfastBreakfast andand lunchlunch –– littlelittle oror nono proteinprotein usually.usually. Therefore,Therefore, proteinprotein intakeintake potentiallypotentially low.low.
Typical Korean meal : Rice, Panchan (pickled vegetables), meat / fish / seafood KoreanKorean ((PanchanPanchan))
PickledPickled sideside dishesdishes –– highhigh inin salt.salt. e.g.:e.g.: radish,radish, lotuslotus root,root, daikondaikon,, beans,beans, fish,fish, kimchikimchi
Kimchi (Fermented cabbage) Even if homemade, still has salt KoreanKorean
FriedFried fishfish withwith soyasoya saucesauce
Tip: Cut soya sauce with water, sugar and vinegar
InstantInstant CoffeeCoffee –– veryvery popularpopular 3 in 1: Coffee, sugar and coffee whitener EastEast IndianIndian
DependsDepends onon regionsregions
VegetariansVegetarians andand nonnon-- vegetariansvegetarians
Celebrations:Celebrations: -- Dewali (Festival of Lights) - Birthdays of Gurus (Can be multi-day celebrations involving eating) EastEast IndianIndian
Typical meal Rice, roti/chapati, curry (meat, fish, dahl, vegetables) EastEast IndianIndian (Dairy)(Dairy)
HeavyHeavy onon dairydairy –– phosphorusphosphorus && fatfat potentiallypotentially highhigh
Paneer (Cottage Cheese) – 100g contains: 18 g protein, 20 g fat, 138 mg phosphorus
Lassi (Sour Yogurt Drink) EastEast IndianIndian (Fried(Fried foodsfoods /Fats)/Fats)
Samosas Pakoras
Prashad Ghee (religious (Clarified offering) – butter) may contain flour, sugar and ghee EastEast IndianIndian (Vegetarians:(Vegetarians: addingadding protein)protein)
ForFor vegetarians,vegetarians, ifif lowlow inin proteinprotein intake,intake, considerconsider addingadding ProteinProtein PowderPowder into:into: -- DoughDough forfor rotiroti,, chapatichapati,, naannaan (Indian(Indian flatbreads)flatbreads) -- DahlDahl (lentil(lentil curry),curry), ChanaChana masalamasala (chickpea(chickpea curry)curry)
Roti & Chapati Dahl and Chana masala FilipinoFilipino
MalayMalay influenceinfluence
Coconut milk (High K & Fat) In 100g: K+ 220 mg; Fat 21 g
Kare-Kare (High phosphorus & fat) (Oxtail in peanut butter sauce) FilipinoFilipino ChineseChinese influenceinfluence
Pancit (Noodle dishes with meat, shrimp, vegetables)
Lumpia Sinigang (Ground meat, (Tamarind usually pork, soup / stew) filled spring rolls) FilipinoFilipino SpanishSpanish Influence:Influence: 80%80% ofof dishesdishes IntroducedIntroduced tomatoes,tomatoes, garlic,garlic, sauteeingsauteeing onionsonions inin oil.oil. BakedBaked goodsgoods && dessertsdesserts –– PanPan dede salsal (rolls),(rolls), lecheleche flanflan (egg(egg custard)custard)
Menudo Pan de sal Leche flan (Stew of pork, sausages, (Rolls) (Egg custard) potatoes, carrots in tomato sauce) FilipinoFilipino (Sauces/Condiments/Spices)(Sauces/Condiments/Spices) Less Often: Better Choices: Fish sauce, shrimp paste, Vinegar & chilli, garlic, soya sauce, spaghetti sauce, onion, ginger, bay leaves, pritong tuyo (salted herring) oregano, basil, calamansi
Calamansi FilipinoFilipino (Snacks)(Snacks)
Taho (Sweet tofu pudding): phosphorus & Halo-Halo “Mix mix” sugar Shaved ice with red beans, yam, corn, jackfruit, etc with Cornicks evaporated milk / ice (Corn chips) cream With garlic/onion & salt FilipinoFilipino (Fruits(Fruits RichRich inin Potassium)Potassium) (mg(mg KK+// halfhalf cupcup 125125 mLmL)) Banana,Banana, mango,mango, papaya,papaya, guava,guava, jackfruit,jackfruit, durian,durian, coconut,coconut, tamarind.tamarind.
Papaya Jackfruit Durian Tamarind (390 mg) (250mg) (530mg) (377mg)
Big NO – Belimbing (Starfruit) FilipinoFilipino (Vegetables(Vegetables richrich inin Potassium)Potassium) (mg(mg KK+// halfhalf cupcup ofof 125125 mLmL)) Spinach,Spinach, kangkang--kongkong (water(water spinach),spinach), yam,yam, sweetsweet potato,potato, cassava,cassava, bamboobamboo shoots,shoots, okra,okra, bitterbitter melonmelon
Kang-Kong Cassava (Water spinach) (279 mg)
Bamboo shoots Okra Bitter melon (320 mg) (187 mg) (198 mg) Caution:Caution:
PitfallPitfall ofof ““culturalcultural sensitivitysensitivity””–– stereotyping.stereotyping.
DoDo notnot assumeassume ““culturalcultural foodfood practicespractices””..
SeekingSeeking newnew foodfood experiences:experiences: thethe moremore choiceschoices thatthat wewe have,have, thethe moremore separatedseparated wewe areare fromfrom ourour culturalcultural roots.roots.
TheThe riserise ofof thethe newnew foodfood culture.culture.
MeltingMelting potpot vsvs SaladSalad bowl?bowl?
In the U.S.: “Melting Pot” vs “Salad Bowl”
- Current U.S. population is more like a salad bowl than a melting pot. - Salad bowl contains many ingredients, blend together but each ingredient retains its unique taste and texture. - More politically correct than Melting pot – which suggests ethnic groups may be unable to preserve their cultures due to assimilation.
In Canada: “Cultural Mosaic”; in Europe: “Multiculturism (multikulti).
ChineseChinese RenalRenal NutritionNutrition PatientPatient EducationEducation MaterialsMaterials PartnershipPartnership betweenbetween ProvidenceProvidence HealthHealth CareCare RenalRenal DietitiansDietitians andand thethe BCBC ProvincialProvincial RenalRenal AgencyAgency
DevelopedDeveloped 1515 nutritionnutrition handoutshandouts inin ChineseChinese andand EnglishEnglish FeaturedFeatured inin 22 articlesarticles inin JJ RenalRenal NutritionNutrition
SharedShared withwith 5555 healthhealth carecare teamsteams aroundaround thethe worldworld uponupon requestsrequests IfIf interested,interested, contact:contact: JiakJiak ChinChin KohKoh [email protected]@providencehealth.bc.ca SamplesSamples ofof ChineseChinese RenalRenal NutritionNutrition HandoutsHandouts (PHC/BCPRA)(PHC/BCPRA) Recipes/Recipes/ ResourcesResources
NKF: List of http://www.kidney.org/professionals/crn/ cookbooks for cookbooks.cfm kidney patients Davita www.davita.com
Renal Support http://www.rsnhope.org/recipes/ Network Acknowledgements:Acknowledgements:
Dr.Dr. PaulPaul Taylor,Taylor, TeresaTeresa MaMa && WCPDWCPD OrganizingOrganizing CommitteeCommittee
PROMISPROMIS SupportSupport TeamTeam
DietitianDietitian colleagues:colleagues: LindaLinda Lim,Lim, MichMich Upton,Upton, ClaraClara Sohn,Sohn, MarisaMarisa Bhatti,Bhatti, EileenEileen Cabrera,Cabrera, MeherMeher Shergill,Shergill, MaudeMaude HenriHenri--Bhargava,Bhargava, VickyVicky Ngo,Ngo, DaniDani RenoufRenouf