Written By: Grace Moore; SLU Dietetic Intern
I started the recording.
“Can you confirm your name and date of birth for me?” I asked my mom.
The assignment for my undergraduate nutrition counseling course was to choose a friend or family member who could stand in as a practice patient for basic nutrition counseling and education. My mom volunteered. She had some fun picking out a fake name so my recording could be HIPAA-compliant. We had a good laugh when she chose a date of birth that put her some years younger than she really was. Meanwhile, I brainstormed some topics and decided the DASH diet had some potential to be relevant.
My mother is of Japanese-Korean origin. American sodium intake is high, but East Asian sodium intake is even higher.1,2 This is due to the frequent consumption of soy sauce and other salted condiments, pastes which are a big part of the food preparation process 3 (think miso paste, gochujang) or used as sides. And did I mention the sides? The glorious array of banchan plates at restaurants, or the household staple that I have known some Korean mothers to have a separate mini fridge for: kimchi. So I figured, why not talk about sodium requirements using a DASH-diet handout.
Eating banchan in Jeonju, South Korea
At this point in my education, counseling still felt like new territory. It didn’t help that the most useful resource I had access to was the dry explanation of motivational interviewing techniques I found in my textbook. I felt like Monk, the protagonist from the eponymous comedy TV series, desperately reviewing his “swimming fundamentals” flashcards before being forced into the ocean.
But neck deep into trying to explain the DASH diet, I realized that I wasn’t just flailing about in a sea of counseling techniques. Really, the biggest mind-block was the realization that despite my mom’s patient responses and even genuine interest in developing achievable SMART goals, I could not imagine a future in which my mom did not cook with soy sauce.
****
A year later found me in a graduate course on human nutrition. In one session, a discussion arose on the Mediterranean diet. The Mediterranean diet is often hailed as the champion of diets, as the bestower of health benefits from decreased heart disease risk to improved mental health. “Are there any downsides to following a Mediterranean diet?” the instructor asked the class. Even as she asked, something tugged at my mind. I couldn’t put it into words but I felt the same feeling I had when going through the DASH handout sample menu with my mom a year earlier.
Someone raised their hand. “I think some people might feel like the Mediterranean diet is too different from their usual diet.” I nodded. Switching from meat to primarily fish, for example, might seem to some individuals to be a relatively dramatic change in their protein source.
Someone else argued that the Mediterranean diet can be broken into components like fruits, vegetable subgroups, legumes, and healthy fat sources that can be used as a guideline and applied to cultural diets. And I agreed with that too. But I can bet you right now: a quick Pinterest search or a rifle through hospital nutrition education handouts will show you no Asian-modified Mediterranean diet recipes.
In my rotations, I have observed that dietitians often have difficulty communicating across cultural lines. Many nutrition education resources do not include wording indicating that the Mediterranean diet pattern can be adapted for use by other cultures Although recommendations on handouts might have the potential to be adapted for cultural use, they read Western. Moreover, the health benefits of cultural eating patterns cannot be overlooked. Michelle Jaelin, RD, puts it well: “There is strong evidence that the Mediterranean diet helps with heart disease, depression and other forms of chronic disease…However, Japan has the highest number of people living past 100 years old; does that mean everyone should eat more tofu, purple yams, rice and seaweed? This is what it feels like when the Mediterranean diet is recommended all the time.”4
With the U.S. continuing to be a country of immigration and as biculturalism and its value are increasingly recognized, it is imperative that dietitians learn how to be culturally competent. Cultural competence is more than just being sensitive to cultures that are not one’s own. Cultural competence is the ability to manage cross-cultural situations sensitively and effectively.
In dietetics, cultural competence looks like interactions that clarify to individuals that healthy eating is not incompatible with eating according to their culture. Food enjoyment is a large part of the human experience, and our brain chemistry is wired to respond emotionally to food. In turn, the things we enjoy are largely determined by our culture. A previous SLU dietetic blog post focused on the comeback of the “comfort food” trend.5 Although comfort foods have the connotation of being unhealthy, it is important to remember that for some individuals, foods from their cultural backgrounds may be both comforting and healthful.6 Just as many dietitians warn the public to avoid restrictive diets, so should they refrain from discouraging people from eating their cultural foods.
On the other side of the same coin, people are entitled to information regarding the nutritional effects of their dietary patterns, and dietitians should keep the individual’s health and wellness at the forefront by providing accurate and evidence-based nutrition recommendations. For example, individuals with heart failure really should be informed of the relationship between sodium intake and fluid retention. Cultural competence can be a patient-centered approach to treatment that puts individual health first, in the prevention and management of health outcomes.
This can be a difficult balance. During my dietetic internship, I have learned some ways a dietitian can use their skills to help patients from other cultures walk through tricky changes.
Here are two of them.
1. Be curious.
Let’s think of “being curious” as “not assuming”. I will go into why.
At a 2022 FNCE* lecture on “Preserving Kidney Function with Cultural Plant-Based Foods: A Global Collaboration”, one speaker Dr. Varsha Tarvady joked, “I think the Tower of Babel must have been in India…I think every 500 meters we have a different dialect and we have a different cuisine.”
Although we should further our knowledge and appreciation of other cultures, our end goal is not simple knowledge-bearing. Memorization of a gazillion different cultural diets won’t make us more effective cultural communicators, much as rote memory of the DSM-V wouldn’t make anyone a psychiatrist.
The dietary patterns of individuals are influenced by their socioeconomic status, the resources available and accessible to them, and the social and cultural context of their daily lives. Moreover, when individuals migrate, they undergo a complex process of change called acculturation. Individuals pick up on some aspects of the host culture while holding onto aspects of their original culture. In other words, we do not know everything about a person by knowing facts about their culture. What, why, how, and where people eat is highly individualistic.
So, what’s the best way to know how to help your East Asian client lower their sodium intake?
Ask!
The best way to be culturally competent is to be curious, and the best way to be curious is to let go of assumptions. When Dr. Maria Romo-Palafox 7 spoke to the Dietetic Interns as a guest speaker about crossing cultural barriers to address Hispanic health outcomes, she advised the Interns to pretend that they were aliens and had never met a human before. As dietitians, we can use motivational interviewing techniques to allow our nutrition assessment to be highly individualized, whatever the culture of our clients.
Which leads me to point number two.
2. Help strategize.
Since my mock counseling session with my mom, I struggled to reconcile dietary recommendations for sodium limits with a diet that let my mom eat Asian foods within the
American Heart Association recommendation of 2300 mg a day – or even within the higher Japanese recommendations, which are 3,000 mg and 2,500 mg for men and women, respectively.2
Here’s what I mean. 1 tablespoon of soy sauce contains about 920 mg of sodium. Meaning, just 1 tablespoon of soy sauce in a portion of food they are eating, will hit 40% of their daily requirements– and don’t forget any other sources of sodium that might be going into the portion, like fish sauce, and other condiments. 1 tablespoon of gochujang (fermented chili paste) can contain 540 mg of sodium. If you’re eating a bowl of bibimbap and you have a decent spice tolerance, you might add around 2 tablespoons into the mix, hitting 47% percent of your daily intake with the paste alone. Again, not the only salted item in the meal, not the only salted item in the day.
Eating bibimbap at Jeonju, South Korea, a bibimbap pilgrimage site, with raw meat and an abundance of vegetables.
Dietitians generally guide people by using a helpful rule of thumb: using the food label, aim for <5% of the sodium daily value of sodium in every portion of food, or roughly 115 mg in every serving. Normally, this is very useful for giving people an easy way to make sure they are having low sodium portions throughout the day.
Helpful, but does this sound realistic for a Korean mother preparing food for her family?
And at risk of confusing you further, some studies suggest that fermented foods – like kimchi – may actually be cardioprotective.8
It might be time to get creative and put your thinking cap on (or maybe I should say, engage your clinical judgment). Again, it may be best to use motivational interviewing to allow your patient or client to inform you of what changes are reasonable for them and what their daily meal and snack patterns look like.
Dr. Romo-Palafox provided some good advice: ask your client what higher sodium foods are a can't-live-without. Then work from there in figuring out where sodium can be utilized more sparingly. Maybe snacks can be made lower sodium more easily than meals, or vice versa.
What western or “American” foods are they eating and can substitutions be made there more easily than with their cultural foods? Are there any cultural spices or flavoring items that would not have sodium? For example, gochugaru pepper flakes, shichimi, shisho (non-pickled perilla leaves). Let the patient lead you through spices that fit their preference and that they have access to.
Also, remember what your overall goal is. If you’re talking about salt, maybe it’s reducing blood pressure, the risk of a second cardiovascular incident, or fluid retention, or maybe the goal is the long-term prevention of cardiovascular disease.
Sodium intake itself is likely not the sole or chief end. Framing your discussion in terms of long-term goals will help you create holistic goals for your patient or client. Would they be willing to partake in moderate exercise? Are they eating whole grains or refined?
***
Photo from a kimchi-making class led by my mother.
I think back to the living room interview with my mom.
“I eat lots of fruits and vegetables,” she said. “I do a lot of these recommendations.”
And because I knew her, I knew this was true. Growing up, every meal she prepared for us had multiple servings of fruits and vegetables. She rarely drinks sugar-sweetened beverages. It was my mom who had taught me the trick of mixing her brown and her white rice so she can eat whole grains while still getting the nostalgic softness of the white rice.
So we brainstormed some achievable goals, and she told me that while she wouldn’t be able to stop using certain condiments, she felt she could exercise more and choose low-sodium snack options.
The opportunity to come to these goals might have been missed if someone assumed English language competency translated to health literacy, for example, or if no flexibility was given for my mom to tell you, as a human, what healthy living and healthy food meant to her.
Almost two years later, in the January of 2023, my mom ran her first 5K. She was proud of herself, and I was proud of her.
Footnotes:
*Food and Nutrition Conference and Expo
**Interestingly, leading Japanese food companies like Ajinomoto have invested in innovative efforts to reduce sodium while preserving everyday flavors, such as by using commercially produced glutamate umami.
REFERENCES
1. Lee YK, Hyun T, Ro H, Heo YR, Choi MK. Development and application of the sodium index to estimate and assess sodium intake for Korean adults. Nutr Res Pract. 2022;16(3):366. doi:10.4162/nrp.2022.16.3.366
2. Tsuchihashi T. Dietary salt intake in Japan - past, present, and future. Hypertens Res. 2022;45(5):748-757. doi:10.1038/s41440-022-00888-2
3. Firestone M, Beasley J, Kwon S, Ahn J, Trinh-Shevrin C, Yi S. Asian American Dietary Sources of Sodium and Salt Behaviors Compared with Other Racial/Ethnic Groups, NHANES, 2011-2012. Ethn Dis. 2017;27(3):241. doi:10.18865/ed.27.3.241
4. Food Insight. Diversifying MyPlate Series: Q&A on Culturally Sensitive Approaches in Nutrition. Food Insight: Your Nutrition and Food Safety Resource. Published September 29, 2021. https://foodinsight.org/diversifying-myplate-series-qanda/
5. Goumas O. Anticipated Food Trend of 2023: Comfort Foods. SLU Nutrition and Dietetics Internship Blog. Published January 23, 2023. https://slunutritiondi.blogspot.com/2023/01/anticipated-food-trend-of-2023-comfort.html
6. Azar KMJ, Chen E, Holland AT, Palaniappan LP. Festival Foods in the Immigrant Diet. J Immigrant Minority Health. 2013;15(5):953-960. doi:10.1007/s10903-012-9705-4
7. Saint Louis University. Maria, Romo-Palafox, Ph.D, RD. https://www.slu.edu/doisy/faculty/romopalafox-maria.php
8. Harvard Health Publishing. Fermented foods: Favorable for heart health? Heart Health. Published June 1, 2019. Accessed April 8, 2023. https://www.health.harvard.edu/heart-health/fermented-foods-favorable-for-heart-health#:~:text=Fermented%20products%20contain%20naturally%20occurring%20beneficial%20bacteria%20known,of%20the%20American%20College%20of%20Cardiology%20last%20yea
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