CASAT Podcast Network

Hello and welcome to season three of CASAT conversations.

I am your host, Heather Haslem.

This season we will explore the weighty topic of health equity.

Within each conversation we will discover insights from researchers, practitioners and experts on this complex and important topic.

We hope you enjoyed today’s conversation on today’s episode.

We have Lorena Drago.

Lorena is a registered dietitian nutritionist and certified diabetes care and education specialist.

She specializes in multicultural aspects of diabetes, self management education and she is an expert in developing culturally and ethnically oriented nutrition and diabetes education materials.

Welcome Lorena.

We’re so happy to have you here today.

Thank you Heather.

So as we get started, I’d love for you to share more about your story and how you got into this important work of health equity.

Well, it started when I came here to the United States from Colombia and I wanted to study um health, I wanted to study medicine.

That’s really how it started.

And I was watching Tv and it, there was a commercial about orange juice and I was bilingual.

I had gone to school in Colombia and I went to an American school all my life From the time that I started school, Kindergarten all throughout the 12th grade, I went to an American school with the Americans teachers.

So I was fully bilingual and when I was watching Tv in Spanish, the commercial was about orange juice and it said “jugo de china.” C-H-I-N-A.

Uh and I see the oranges but I never heard the word naranja, which in Spanish is the word or orange, it was always china C H I N A.

So I was thinking, hmm, there’s never the word naranja, there was nothing printed with the word naranja.

So in my 17 year old head I thought, well maybe the company is importing the oranges from china and this is what makes this particular product so special later on because I was living in New York and I always have been living in New York since I came from Colombia, I learned that Puerto Ricans and Dominicans call orange is china’s instead of neurons.

So clearly this was not a language barrier because I was watching tv in Spanish, this was a cultural value.

So now I start my college immediately and I did not become a doctor, a medical doctor, I became a nutrition so I realized that I needed to communicate better.

So even though I was still a hispanic woman and I was working with hispanic patients, if I was not communicating correctly, there was still a gap, then that meant that I was not going to be able to provide equal care if we were not communicate correct.

So in order to have health equity, that means that we have to remove all obstacles to help.

So that means that communication is by and if we treat every in my case as a hispanic health provider and knowing that Hispanics are the largest uh majority minority group.

If we assume that everyone who is hispanic is the same, that we are a monolith, then that means that there is going to be gaps in the way that week provide treat.

So that was I guess many years ago this happened when I was 17.

I had just arrived in this country.

That’s when even before I knew what cultural competency actually was, what health equity was.

I realized that there was a disconnect.

Um and I knew how important it was.

So that’s probably what inspired at that time to start looking into better ways to communicate early on.

Mm I love that.

What is it about nutrition?

Um that interested you like you wanted to go in the healthcare field and you became a registered dietitian.

How did you um get to this place of nutrition education.

Well I’d love to um I love food.

And uh and I was always fascinated with with what food uh food as nourishment and food as medicine.

Mhm.

And how food was something that connects us.

I just recently took a culinary um class and culinary in culture and I was fascinated how so many different cultures have a version of a dumpling.

Mm And it did not matter what culture.

I was taking that culinary class.

There was a version of a dumpling.

I took a class on Russian cooking and it was the chicken bell Many.

And my husband is polish and there is the middle.

So it there is always a version of a dumpling style regardless of what the dough is, regardless of what the feeling is.

But there is always a dump and in Latin America it could be an empanada but there’s always something and food unite us in health and it’s unite us in disease if united in celebration.

So that’s where the love of food was what really interest me.

And I took that first nutrition class and then I just became fascinated and I was also taking science courses because I was going to be a pre med major.

So it combined both, it combined the science um of nutrition and it combined.

I still had to take biochemistry and I still had to take biology and chemistry etcetera.

So that’s the way that I entered nutrition and it was a decision that I have never regretted.

Can you share with us how nutrition plays a role in health equity?

Um if it plays a role because many of the chronic conditions that we see nowadays are associated with Boots, either an over abundance of food or a scarcity.

It also has um a lot to do with health equity and I’m going to mention both the over abundance of food and also the scarcity awful.

During this past two years we have seen um food insecurity and it has come to the forefront more than ever and I want to encourage the listeners the health professionals that that are listening to this podcast to include when you are working with your clients with your patient to include a few questions.

Just a few questions and ask your clients or your patients about food insecurity because when we’re talking about equity and health equity, it’s really about having a fair and just opportunity to be healthy.

And that is part of the social determinants of health.

And part of it is to try and remove those obstacles to help.

And one of those obstacles.

It’s really everything in our environment that prevents us from being healthy and having adequate nutrition.

It’s one of those obstacles.

So going back to those questions and that would be food insecure.

So what are the questions that you can quickly shut down and ask your clients or patients about?

And that is one ST what would best describe the food that is eaten in your household In the past 12 months?

Did you have enough of the foods that you want to eat?

Enough?

But not always the kind of foods that you want?

Um sometimes you may not have enough of the foods that you that you want to eat or often you don’t have enough of the foods that you have?

And then the second question is, are you worried whether you would run out of the foods before you get your money and then have to buy more?

And, and I just want to say, I was having a conversation with my brother and he had mentioned to me that he was talking to someone at his job.

There had been a glitch and they were unable to receive their weekly paycheck.

And because of that I think there was two days before his friend’s company resolve the issue with a role and his friend had come to him asking him four months.

And this was someone that my brother knew very well and my brother commented to me that did not realize how many individuals literally live from paycheck to paycheck.

Two feed their families.

And this it’s something that we hear.

But until it happens to someone who is closed in this case, my brother’s friend who was very close to and he was not aware because he never confided in him four until the moment that he was in such need that mm hmm came to him and asked and he felt so embarrassed.

Ask.

So it was a very humbling moment for my brother to realize that we usually think of this that this is happening but it’s far removed.

And many times we don’t realize that it might not be far removed because we don’t think about because it’s not happening to us so many because many of us are very lucky that it is not occurring but it but it may be occurring much closer than what we think about.

So that’s why I wanted to, I had wrote it down because I wanted to share it today.

That um this is important to recognize and my brother’s story recently was a a wake up call to know that food insecurity uh is real and uh and this has happened because many individuals have lost their jobs and and they have had to deplete their savings and this is a man of cards.

So now I just want to also discuss the over abundance that sometimes there may be an over abundance of food, but it may not be the most nutritious or nutrient dense.

And I just want to probably underscore nutrients nutrient dense foods that people maybe a costume two and Heather.

I just wanted to say that many times for um some hispanic individuals, especially those that may have had in their countries, they may have grown their own foods and they may have had access to their own foods and now they have migrated to the United States, that may not be possible to grow their own foods.

So they don’t have access to the foods that they did, and if they don’t have access to it, they may have access to other foods, but they might not be as nutrient debts.

So if that is the they may have other foods, but they may be abundant, not as nutrient dense and that also may cause other nutrition problems.

Uh so trying to encourage gardens in which people and plant and grow their own food and share, that will also increase the nutrient density of the foods and also access to better and higher quality.

I’m really struck Loreena.

Um you know your example of someone who has lived on a farm and has grown their foods and then migrates to the United States may no longer have access to these nutrient dense foods.

The foods that they’ve grown, whole foods and just really how heartbreaking our food system has become in a lot of ways that we’ve gotten so disconnected from the source of our foods.

Yes.

Yes, absolutely.

Because it could be transportation, sometimes transportation issues, it could be lack of time if you are working long hours.

That might be a reason why you are now unable to grow the food.

Certain foods may be much more expensive uh to access.

So then you don’t have access to, they may be available but then now it may be much more expensive so you don’t have access to.

It.

That becomes problematic and it also depends on where you are living.

Again.

I live in the East Coast.

So because of that, I know that there are many families that are living and working in one household.

So trying to buy um the foods that they may be accustomed to when they were living in different regions, whether it’s in Mexico or in el Salvador Guatemala, some foods they may not find.

So they have to use substitutes which will happen you know often um and it might be a little bit more expensive or you have to go to different places to buy different foods and and all that requires time and time that you don’t have, don’t you start then buying foods that are more accessible and economical and, and that’s when, when you start to see that the diet starts two to change and when it starts to change, you start adding things that are not as um, nutrient debts.

And that’s when, when, when things start two deteriorate in this sense that it’s not as helpful, you know, within your experience.

I know that you’ve identified ways that culture can sometimes be miscommunicated.

Can you share with us some of the important insights from your experiences?

Um, yes, so, um, again from within the hispanic latino culture, it’s, it’s always important to ask.

So there’s just the ask.

I will underscore that.

Um, for example, when I first graduated with my nutrition degree, I started to work in the hospital in Manhattan and um, again, the largest hispanic subgroup in New York city is Puerto Rican.

And so many.

So I went to the kitchen and the cook was preparing this meat.

It’s nice meeting.

It was all brown and just came out of the oven.

It smelled delicious and I turned to him and I said, hmm, what is this cut of meat?

And he looked at me and he said, that’s your national food.

And I looked at him and I said really, what, what is this cut of meat?

And and then he looked at me again and he says that’s your national food.

So again we went back and forth and he thought that I was joking, I was not joking and I said can you please tell me the name of this cut of me.

So he said you mean to tell me you don’t know what this cut of meat is is your national food.

So it was pork shoulder.

I didn’t know in Spanish, it’s called pernilla E R N I L.

For those of you that want to know what it’s called.

Um And that is a beloved Puerto Rican cut of meat.

Ah Pernilla pork shoulder.

And he thought that I would recognize it because he thought that I was Puerto Rican.

I mean what else would this Spanish speaking?

Latina be part Puerto Rican after all, what else could I possibly be?

Um So I understand the confusion.

Um Well because most Hispanics in New York are from Puerto rico, I am Colombian.

And I guess if I were in California, I would be Mexico.

If I were in Miami I would be Cuban.

So I get it, I understand that but we are not a monolith and I it was not about being offended.

Um I was sharing this with Heather that uh I am too much of an adult to be offended by the confusion.

But it is just to say that We are over about 21 million Hispanics in the United States, about over 60 percent of Hispanics are from Mexico, the six largest hispanic subgroups in the United States come from Mexico, Puerto Rico, Cuba, El Salvador, um Guatemala and the Dominican republic.

Those six Hispanic subgroups make up 90% of the Hispanics.

The seventh will be Colombians.

So if you want to know the seven largest groups, I will throw Colombians in the mix.

Even among each of the groups that I mentioned, even within each group, it’s still not a monolith.

Mexico has nine different regions, nine different regions.

So even within Mexico um there is still not a monolith.

So you will have individuals from the northern part of Mexico and that will have a very rich culture.

So for example, someone from the northern part of Mexico will have a diet that is rich in lauer tortillas and more meat, more beef and more cheese in their diet compared to someone in Oaxaca which will have a preference for more corn tortillas and they will have more more or less in their diet.

So the the Mexican culture is very rich in itself.

So just to say Mexican food, it will be you would have to divide it into nine distinct regions and learn about the traditions of each of those regions, Not to be confused with tex Mex culture, which is a completely different ones.

So what are we to do when we encounter individuals from different countries, it will be impossible for us as clinicians to learn.

So what should we do?

What I suggest is ask just ask, ask questions.

one simple question that I always ask is tell me about yourself, Tell me about yourself.

Opens up um the door for that individual to share.

And then from there ask more questions.

Ask more questions about, tell me about the foods that you enjoy about your culture.

You see this way you don’t because no one is going to know every single food or every single health belief and practice about every single culture.

In my own country we have a different regions that I don’t know about.

My own country.

I am from the Caribbean coast, we have different musics in different parts of my own country, different words and expressions.

We have different um demographics in my own country.

So it will be impossible for me to know every.

But if I ask someone, can you share what are some of your favorite cultural foods.

Then I am opening the door for someone to share that.

And then once someone says to me, I love Machaca.

Then I can ask the follow up question.

Can you tell me, how do you prepare Machaca?

And someone can share that with?

And then I can then do a follow up question.

If someone says well I prepare this with lard let’s say if the then as a dietitian, if I am concerned with this person’s the preparation of this food, then I can say, well I may I offer a suggestion about how you can prepare this differently.

If the person says yes, then I can share is the reason I’m gonna offer this suggestion is because higher saturated fat in the diet has been associated with an increased in insulin resistance heart disease.

And what that means is that it can put you at higher risk with heart.

But if you substitute this with this type of oil, it can reduce your risk.

Now the person understands why I am making this suggestion.

Now it becomes a decision for that person.

Because many times when we just say, don’t eat this, do that.

It becomes my cultural foods are bad and we are health defined the foods or what becomes worse is when we are taking away someone’s foods and we don’t explain, then what happens is they replace it on their own with something else.

But if we explain the reason why we are making this suggestion, we are still saying this is your food, continue enjoying your food.

But I’m explaining why making this change in your food with this other oils will make some much more sense to you because it’s going to improve the risk, then that makes sense why this change has uh has to be made.

And now then most likely you’re going to make this change because what usually happens is this.

What usually happens is someone is tall, don’t eat tortillas or in the case of my East coast example, people are told because they are Caribbean Hispanics don’t eat rice, which is the equivalent of the tortillas in the Mexican counterpart.

So what happened was in my case a patient of mine was told stop eating rice.

The patients stopped eating right, comes back to me and says I stopped eating writes very happy, very proud 12 eating right?

So then now the patient says to me, I’m only eating plantings now and I’m eating green plantings.

And I just had to laugh and I said to the patient, do you know that plantains have carbohydrates just like your rice.

And the patient said, but I’m eating the green ones, not the yellow plantings.

And I said they still have carbohydrates.

And that’s what happened when you don’t give the entire explanation.

Asian will make the substitution on is or her own.

So that’s the reason why when when you’re giving the the counseling you have whatever that may be, you have to provide that explanation.

You have to tell the why I had another patient say to me um Lori, you know, she calls me this was a hispanic patient and she says Lori.

Police police don’t take away mike before.

Please don’t take it away because the assumption is the dietician takes away my things takes away my foods.

You know what you’ve highlighted for us is the importance of the integration of cultural competency with health education and honoring people’s culture really by asking questions and learning about the individual that you’re treating?

Um and then weaving in the health education as part of it rather than just coming and coming straight at him with some health education, which is sometimes how it’s done.

Yes.

And many times Heather it is done because I have lived it.

It is done often when we are pressed for time, sometimes when we don’t know and many times when um what I had shared with you during a previous conversation, the law of the instrument, which is if the only tool you have is a hammer, everything looks like a nail.

Many clinicians have already teaching materials that have been downloaded that have been copied and those materials our hand and they are useful.

But what happens is that those materials are one size fits all those materials say eat whole grains and the whole grains are whole wheat bread, brown, right, whole wheat pasta.

Um those do not account for different cultural groups.

And then what happens is that individuals that have a higher prevalence of diabetes are individuals that are hispanic, asian, african americans, um american indians.

So the foods are not represented in those handouts.

So what happens is going back to health equity when they are community fairs, when there are guru education classes.

These handouts are provided to them right?

And what happens is even when they’re translated into other languages.

What do they find?

They find the whole wheat bread and they have their brand rights and the whole way pasta.

And then what happens is that the person from Vietnam, the person from India, the person from Colombia looks, where’s my arepa?

Um where is my tamal?

Where is my chap party?

Those things are not represented there.

And and then that’s the gap you see that’s where the gap is and and sometimes I have heard but I think that there’s more awareness now is when someone doesn’t know, they may just say well don’t eat tortillas, just have whole wheat bread or sour dough or puff or pumpernickel and someone might have never tasted pumpernickel bread.

And I it really, I just cannot even fathom someone saying to someone Dhoni tortilla eat pumpernickel bread, I can’t fathom that.

But I have heard from other dietitians that this has happened mm hmm.

Um and that is just something that you know, we need we need to study a little bit more.

If I have a patient who comes from Burma, the onus is on me to learn a little bit more about the culture or to ask the questions from the patient.

And again, I will ask, I will share what would be some of the questions that I would ask.

I would say I would ask the patients, do you eat any food to stay healthy?

Do you eat any foods when you’re ill?

And by asking just asking those two questions I can get so much out of the patient?

I remember one time I asked the patient, do you?

Because I have that in my own questionnaire.

Do you eat, do you eat any foods now that you’re ill or have you, are there any foods that you don’t eat anymore?

Uh Now now that you are that you have diabetes?

And the answer was yes, I don’t eat lemons, limes and orange juice and tangerines.

And I was very curious because I have never heard lemons and limes and she came with her husband and she said, I don’t give my husband lemons and limes.

And I asked why.

And she said because he’s because he has gout.

And I kept thinking, what is the relationship?

And there she said, because it’s uric acid, it’s high.

And that’s when he clicked that she thought uric acid.

So lemons and limes and oranges and tangerines, all that is acidic.

So she thought your as it is high, therefore this are acidic fruits and it will increase the uric acid.

So that’s how she interpreted uric acid with acidic fruit.

Had I not had that question in my questionnaire, I would have not missed it.

So that was an opportunity for me to be able two explain to her what was uric acid and what was the relationship with?

So that’s the reason why it’s so important.

Two ask questions about health beliefs um how why do they think the other the other part that that I also like to ask is what do you think is the cause of your diabetes?

And that could be asked about any kind of condition.

Because that’s part of why do they think they have diabetes?

Is it something that is going to go away?

The same thing with it could be with hypertension or any other condition?

Um because that also can address medication and whether they are going to take their medication.

What do they think about their medication?

Many times, individuals may not want to take their medication because they may think that they’re medication may cause more harm then.

Good.

So asking questions is viable and sometimes even pre facing the questions that you’re going to ask is important.

Why you’re going to ask those questions.

So that individuals No, I am going to prescribed insulin and I want to know.

What are your feelings about insulin?

I want to understand.

How do you feel about uh insulin and let the individuals share?

What are their concerns?

What concerns do you have about insulin?

I’m curious what are some of the health disparities that you see within your own practice?

Uh Heather.

One of the things that that I see is um that individuals that are uninsured or under insured may not have access to certain medication or technology.

Certain use of technology.

Um let’s say continuous glucose monitoring, certain devices that may improved the management of diabetes and because they don’t have access.

Sometimes they are not taught about or they may not learn enough about the technology.

So I feel that they fall behind in the knowledge of it.

So perhaps even when they do you have insurance later on, Maybe they are employed, um they become employed and have better insurance.

They don’t have the knowledge.

So they do not, they are not able to advocate for themselves because now they don’t have the knowledge to say, oh, I know that there is this new technology that can help me monitor my blood glucose much better.

And and by doing so I am going to be able to to manage my condition.

And by doing so it may help me to decrease the risks associated with diabetes and improve my health.

So it’s almost as if you’re going to be left behind in technology and by staying behind it reduces your chances of optimal health.

Well, that saddens me, you know, when I see when I see that, yeah, it really isn’t a level playing field.

Exactly.

Exactly.

Yes.

Because um that’s that’s just something that I that I saw is, well, we are not going to teach this because why are we going to teach about it when we are not going to be able to prescribe so we can prescribe it.

We can’t teach it, yep.

So there’s access to education, no ability to advocate for something that you don’t need.

Right.

Right.

So then um so it it compounds compounds the problem, right compiled problems in the management of the condition um as well as really prevention of the condition.

Well as we wrap up here, is there anything else that you feel is important for our listeners to know about?

Um Yes, I want to share um the importance of health literacy because it’s very near and dear to my heart.

So health literacy is if if if I want to use the health resources and services.

Administration’s definition is the degree to which individuals have the capacity to obtain processes and understand basic health information um that it’s needed to make appropriate health decisions.

But my definition is when you take health information and you put it into action to make the decisions that you that you know, Over 90 million people have low or restricted health literacy.

And it is much more prevalent in older adults.

Minority group individuals that have low socioeconomic status and medically underserved individuals.

And then we have restricted numeracy skills.

So that is when individuals do not have the ability to use and interpret numbers.

And many individuals brag about not being good with math.

A lot of people may not brag about um restricted literacy, but a lot of people say I’m not good with math and they brag about, but we use math all the time and when it comes to nutrition and especially diabetes, it could really impact someone’s health because we use math to calculate calories.

When we use the nutrition label to calculate carbohydrates, fiber, sugar, insulin, insulin to carbs.

It could really be detrimental.

If someone does not calculate insulin correctly, insulin to carbohydrate correctly, it could really, if someone does not use the correct amount of insulin to carbs, it could lead to someone having a hypoglycemic event and end up in the hospital.

So when you tell someone to read the label, what you should be checking is how someone is interpreting the food.

Like.

And I will end up.

I started with a story.

So, I am going to end with a story.

I had a an endocrinologist, a pediatric endocrinologist, refer a patient to me because the patient, I was a child had elevated blood glucose levels.

The patient’s mother was writing everything that her daughter I was eating.

She came to me and she was eating cereal and she was writing the amount that she was eating, the amount of milk that she was eating.

She was weighing the banana everything.

My first question was, How tell me, how are you measuring your daughter stereo?

She had written on her notebook that she was given her daughter 2/3 of a cup of cereal.

That was the serving size that she on the on the cup.

I looked at it and it said 20 g of carbohydrates, 2/3 of a cup as a Typical Dietitian.

I had my four cups on my desk.

It was a one cup, half a cup, a third of a cup and a quarter of a cup.

When I asked her, show me How do you measure 2/3 of a cup?

What she did was she took the one cup, the one cup And then she took the 1/3 of a cop and she gave me the two cops in my hand.

And she says, this is what I use To measure the 2/3 of a cup.

So what she had done was she was using one and 1/3 of a cop.

And that’s what she thought was 2/3 of a cop.

Mhm.

For what she was doing was she was actually Given her daughter one cop plus one third of a cop.

She was not Using 2/3 of a cop.

So what I had to do was the rest of that session was really teach the mom arithmetic.

I did not teach her nutrition.

I told her was was That 2/3 she had to use the 1/3 cup twice.

And that’s what she was doing.

So that’s the reason why her daughter was having high blood glucose because she did not know arithmetic, she did not know how to add brack shit.

And that’s what having restricted numeracy skills can actually do.

So the next time when you tell someone read the food label, that’s not the correct way to do.

You need to ask someone to interpret the food label.

And what you need to do is to ask them if you’re having two servings of this.

What is the result?

And to ask someone to actually, If the serving is 1 3rd then what would be two servings?

What what would be the cops that you would have to utilize to use two servants?

Because believe me, believe me many times we if you have not ah added or subtracted for actions then you may be surprised how many people, I do not remember how to do it.

So that’s the key when it comes to the importance of literacy and numeracy.

Mhm.

Thank you for that wonderful example.

And it really highlights the theme today which is that we it’s critical to check our assumptions when it comes to um health literacy.

Um and the importance of asking questions and just you know, has been really highlighted for us today and I want to thank you for sharing the importance of nutrition and health equity.

Um as we explore this important topic this season.

So thank you so much for your time, Lorena.

It’s just a delight to be with you.

Mm hmm.

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