Minorities and Nutritional Status

By Sharon Ann Meyer, AS, AA, DTR,

Minorities are African Americans, Hispanics (Cubans, Mexicans, Puerto Ricans, and South Americans), Haitians, Latinos, Asians, Pacific Americans, Alaska Natives and Native Americans and more.

The HIV/AIDS epidemic disproportionately affects racial and ethnic minority communities.¹ We know there are many cultural differences among ethnic groups,² but many people don't know that some of these differences affect nutritional status. Also, the stigma of HIV often adds a terrible burden to people carrying the virus, so many HIV-positive minorities prefer not to seek help for fear of disclosing their infection. Learning about issues that lead to poor nutritional status and increased illness is integral to good nutritional health. A review of the various issues affecting the nutritional status of ethnic groups will help the reader to understand why this population is at increased nutritional risk.

Factors Affecting Nutritional Status

Problems such as poverty, ignorance, isolation, lack of education, and poor nutrition can adversely affect nutritional status. The first concern among many minority groups is overcoming the language barrier because without communication it is extremely difficult to access services. Although language deficiency can be a major barrier to obtaining services in multilingual environments, numerous organizations attempt to overcome this issue by using interpreters and translators to increase the flow of communication and to increase access to services. (An interpreter converts the spoken word from one language to another, while a translator converts the written word into another language.² The two conversion methods require different skills, but for both, subtle differences in dialects need to be recognized.) Culturally appropriate education is possible with the use of a bilingual and biculturally trained individual who speaks both languages and understands their subtle meanings. However, most studies show that individuals prefer counselors of the same race and ethnicity as themselves,² and providing therapy with the use of translators may be difficult and time-consuming, and always runs the risk of miscommunication.³

No matter what our cultural background, a number of factors affect our food intake. These include economics, food availability and access to transportation, cultural and family eating traditions, exposure to new foods and methods of food preparation, living arrangements, convenience of preparing food, and food- preparation skills.⁴

Economics and Nutrition

People who are living in environments that are dangerous, stressful, or isolated (either isolated in location or with respect to human interaction) are at increased risk for poor nutritional health. It's no surprise that those with annual family incomes of less than $10,000 are more than three times as likely to die in any given year as those with incomes of more than $30,000.⁵ Many African Americans and other ethnic minorities live in poverty and poor health. Access to preventive medical services is poor for these individuals; they may seek advice from family or friends in choosing a healer instead of turning to conventional health care.² Healers and providers of unconventional health care often provide unregulated herbs and other dietary substances to patients. Unmonitored interactions between herbal remedies, nontraditional diets, and common medications used to treat HIV/AIDS is also a concern. For instance, the Food and Drug Administration recently warned consumers that St. John's Wort decreases Indinavir concentrations. They noted that St John's Wort may also significantly decrease blood concentrations of all HIV protease inhibitors and possibly nonnucleoside reverse transcriptase inhibitors as well. This may result in decreased antiretroviral drug level, leading to loss of virologic response and development of resistance or class cross-resistance (to obtain more information, visit http://www.fda.gov/cder/drug/ advisory/stjwort.htm).

Since low-income patients are frequently dealing with overwhelming problems, HIV and nutritional status can be low priorities for them. As a result, low incomes are associated with less nutritious diets. Although the link between diet and chronic disease is considered a well-established medical fact,⁶ a regular meal pattern such as three meals a day is uncommon among low-income groups.⁷ For those taking medications with or without food, irregular eating patterns increase the chance that nutrition needs will not be met. Low intakes of fiber and excessive intakes of fat, saturated fat, cholesterol, salt, and alcohol, contribute to five of the ten leading causes of death in the United States: coronary heart disease, cancer, stroke, diabetes, and liver cirrhosis.⁶ African Americans are at greater risk of mortality from cancer and heart disease than any other age group in the 45 to 64 age range.⁸ The biggest killer of African Americans is severe high blood pressure.⁵ This condition leads to an increased risk of stroke, heart attack, and kidney failure, a risk that could be lessened by using the services of a nutrition professional. Heart disease is the leading cause of death in American women, and many women, particularly African American and Hispanic women, are at increased risk for heart disease (visit http://www.cdc.gov/nccdphp/cvd/womensatlas/). Minority women also suffer from a higher incidence of chronic diseases such as diabetes, have a shorter life expectancy, and have a higher incidence of death in childbirth and infant mortality.⁹ Hispanics and Native Americans are two to three times more likely than Caucasians to have diabetes.⁵ All of these conditions have nutrition components.

Access to Nutritional Services

Food availability and lack of transportation are more urgent issues among minorities than among the general population. This is often related to income status.¹⁰ Access to food and other nutritional services means more than just having a method of transportation. Even if the benefits of good nutrition are known, people living in poverty often can't afford to buy wholesome nutritious foods or to seek nutritional services. Thankfully, there are many food banks in the US that offer food programs to low-income, HIV-positive people (visit www.hivresources.com/Food.htm). Other considerations may also affect access to food services. Diana Peabody, RDN, from the Oak Tree Clinic in Vancouver, Canada, for example, reports that women of color in her area do not access free food services because they fear harassment from peers.¹¹ Moreover, besides dealing with issues of confidentiality, shame, and embarrassment, these women are often victims of family violence. Peabody notes that African American and Asian women often have little control over their lives. They may be shunned by their community if word gets out about their HIV infection. Peabody has learned that it is necessary to deal with social issues in order to address nutrition and clinical issues.

Not making one's nutritional status a priority increases the risk of adverse health consequences. Compromised nutritional status affects overall general health and makes it more difficult to avoid secondary illness. Malnutrition is a major factor in disease progression, especially among low-income minority groups with limited access to food and medications.¹² Iris House in New York serves low-income minority women living with HIV and has a program to improve the nutritional status of clients. The program appreciates the cultural preferences of the population served, and careful attention is focused on the early stages of HIV disease.¹² As in many such programs, emphasis is placed on empowering clients to make better food choices so that they can improve the quality of their diet and address needs such as weight loss, nausea, diarrhea, foodmedication interaction, and nutrient deficiencies. Eating habits and quality of life can be greatly improved in this population group with the right tools. Learning basic survival skills concerning buying, storing, and preparing foods can do much to improve the nutritional status of clients. Also, activities that enhance communication between culturesÑfor example, tasting parties where foods of different cultures are served so that people can learn about new foods and nutritionÑcan help overcome differences and conflicts among groups.²

Sadly, access to quality health care, which includes access to nutritional services, is limited at best (visit http://www.hivresources.com/CAForum.html). President Clinton's proposal to spend $400 million over five years for minorities in the areas of infant mortality, cancer, heart disease, diabetes, HIV, and immunization is a sign of hope that something will be done to help this special population.⁵ Funds that are provided by the Congressional Black Caucus (CBC) also help to combat racial and ethnic disparities in prevention, treatment, and management of HIV/AIDS.¹ Also, for the year 2000, Congress has mandated changes that will allow all 51 Title Ieligible metropolitan areas to receive supplemental minority-initiative funds. This will help to make increasing access to nutritional services for minorities cost-effective.

Food Selection and Preparation

Culturally based attitudes about food affect nutritional intake.⁴ It's important to know that the classification of foods, beverages, and medicines varies with each cultural group. Some cultures use food as medicine or to promote health.^2,4 For instance, numerous groups believe and that foods have symbolic temperatures and that a person must eat a balance of both hot and cold foods. Many clients from these groups believe they can get sick by eating foods with the wrong temperatures.² Other cultures believe in Yin and Yang forces and their influences on health; these groups believe that when such forces are out of balance, disease results. Also, pica, the consumption of non-food items such as clay, ice, and laundry starch for medicinal reasons, is more frequently reported in ethnic groups. This practice can lead not only to decreased nutritional status but also to obstruction of the gastrointestinal tract.

Europeans believe thinness is a desirable health goal, while others, such as Haitians, believe that having a certain amount of excess fat is good for health.^2,4 Many people connect thoughts of food with family, celebration, and caring; without the benefit of these healthy associations, nutrient intake can change. Also, recent studies have shown that minorities may be at higher risk for inadequate micronutrient intake.¹³ Most traditional eating patterns are healthful, but core foods and traditional food combinations often change when groups relocate.⁴ As people move from one area to another, they tend to adopt the behaviors, attitudes, and beliefs of the dominant culture. This contributes to changes in nutrient intake that may not be good for optimal nutritional status. For instance, faced suddenly with the large variety of junk foods that are aggressively marketed in the US, groups coming to this country may overindulge themselves, displacing healthier food choices. Chinese immigrants who adopt the typical American diet that contains larger amounts of animal fats than are used in traditional Chinese cooking may increase their risk of heart disease and stroke (visit http://naturalhealthline.com/news letter/991115/chinese.htm).

The family values and practices of extended families also play a role in decisions about food intake. Foods such as rice and beans made with large amounts of fat are considered important in the Haitian and Dominican cultures and have high status.⁴ But following cooking traditions of this type can increase the risk of heart disease and other conditions related to poor dietary habits. People with elevated lipids may need to modify this type of diet. Rachel Stern, MS, RD, a nutritionist at North Jersey Community Research Initiative, notes that some low-income groups often consume very large amounts of sugary drinks such as Kool-Aid and soda.⁷ Yoo-Hoo, a popular, sugary, chocolate beverage is preferred by many, and Snapple products are perceived as health drinks. Cooking methods strongly affect the nutrient content of foods. And methods of food preparation play a large role in influencing both food choices and dietary habits. Although preparing food in a healthful manner may be harder during family celebrations and holidays, learning how to prepare healthy food can help to decrease the risk of disease. Similarly, leaning to avoid high-fat, high-sugar American foods will decrease the risk of heart disease and diabetes, a bigger concern for minorities with lipodystrophy. A propensity for diabetes in Native Americans, Hispanics, Latinos, and African Americans complicates this picture.

Improper food storage is common among those with unstable housing situations.⁷ Some Latinos commonly add a raw egg to Malta (a sweet, thick, fermented beverage) or some other drink, and spoiled eggs can be a potential problem. The danger of food-borne illness can be minimized by learning about safe food preparation and storage. Saint Cyr and Donohue report that even organizations with limited resources can improve nutritional status and quality of life in HIV-positive people by using comprehensive food-oriented, hands-on experience and nutrition interventions that are sensitive to the cultural diversity of the population served.¹² Nutrition programs for low-income groups that address the selection, preparation, and consumption of appropriate and nutrient-dense foods help HIV-positive people to reach and maintain good nutritional health.

An estimated 60 to 95 percent of African Americans, Native Americans, Jews, Mexicans, and Asians are lactose intolerant.^2,4 For them, eating foods that contain lactose, such as milk products, can cause gas, stomach cramps, and diarrhea. Learning about other food sources of calcium can help clients from these groups to avoid deficiencies of this mineral (see sidebar).^14,15

Substance abuse is another factor that affects health in low-income groups. Weight loss in clients from these groups may be the result of substance abuse, not AIDS wasting,⁷ and many people who abuse intravenous drugs have liver disease due to hepatitis C. Use of recreational drugs can compromise nutrition and lead to nutrient deficiency and frequent secondary infections. Excessive alcohol intake can also cause nutrient deficiencies and can affect the action of some medications. And a large number of people who drink excessively have liver disease. Compared with other people living with HIV, substance abusers with HIV as a group include more women and ethnic minorities.¹⁶ They may experience conditions such as cerebrovascular accidents, hepatitis B and C, alcohol-induced hepatitis and cirrhosis, and alcohol-induced gastritis. As many as 70% of those with hepatitis C will develop liver disease.¹⁷ All these complications have a nutrition component.

Education Is the Key

Although most traditional eating patterns are healthful, some food practices may need modification. For example, certain Native Americans and Alaska Natives should be warned not to continue their practice of eating raw meat.² Asian Americans and Pacific Americans may benefit from decreasing the amount of salt used in cooking. Positive cultural food habits should always be encouraged. Food guide pyramids are available for various minorities (visit http://www.fcs.uga.edu/~selbon/ apple/guides/choose.html). These educational tools can help people of all cultures to practice healthful eating habits with familiar foods.

Waiting until nutritional services are desperately needed instead of seeking preventive health care ultimately does not make health or economic sense. Education is the key to good nutritional status and increased use of nutritional services. Learning how to build positive cultural food habits is much easier with the help of a trained nutrition professional. Registered Dietitians and Registered Dietetic Technicians are familiar with the nutrient content of foods and can help HIV-positive people plan a healthful diet.

Some organizations have made special efforts to address the unique nutritional needs of the minority populations they serve. Differences in language and culture are addressed in publications offered by God's Love We Deliver in New York (212/) and by MANNA (215/) in Philadelphia. Although it may be a struggle to increase nutrition awareness, educating people about the valuable benefits of nutritional services is vital for maintaining overall good health. Understanding what affects nutritional health helps people to make educated food choices and lifestyle changes that ultimately will improve overall well-being.

Sharon Ann Meyer, AS, AA, DTR, Certified HIV Counselor is the President of HIV ReSources, Inc. and Editor-in-Chief of the HIV ReSource Review. Contact her at .

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