Immigrant women's health: nutritional assessment and dietary intervention

This article is the third in a series of 5 articles exploring immigrant women's health. The first and second articles appeared in the May and June 2001 issues, respectively. See this article on the wjm web site (www.ewjm.com) for links to the previous articles. These articles are adapted from the book Immigrant Women's Health, published by Jossey-Bass, San Francisco; 1999.

A thorough assessment and understanding of immigrant women's dietary intake permits more complete delivery of health care. In all cultures, food is more than a nutrient. It may signify prosperity, good health and strength, or love; it may be a distraction, the centerpiece of family gatherings, or a stress release.¹ Which foods are consumed and preferred is based on physical and cultural availability.² Therefore, an understanding of the needs, preferences, and beliefs of certain immigrant groups in food allows health care providers to target dietary intervention plans that will improve the health of immigrant women.

ACCULTURATION, DISEASE, AND NUTRITION

A relationship exists among diet, nutrition, health, and disease.^3,4 Disease patterns of immigrants to the United States, whose food consumption remains consistent with their traditional culture, more closely resemble those of the home country. As immigrant Japanese become acculturated, they are more likely to suffer similar kinds of illness as North Americans.⁵ A typical Asian diet consists primarily of rice, vegetables, and noodles; the major ingredients of the North American diet are animal protein, fats, and sugar. This shift in diet results in increased body weight and prevalence of coronary heart disease, stroke, and certain types of cancer.

In the United States, dietary intake and nutritional factors have been associated with 6 of the 10 leading causes of death: hypertension, coronary heart disease, cancer, cardiovascular disease, chronic liver disease, and type 2 diabetes mellitus.³ Diets high in saturated fat and cholesterol contribute to atherosclerotic disease. High fat consumption also has been associated with an increased incidence of breast, colon, and prostate cancers.⁶

Using general characteristics to define immigrant populations can be dangerous because of the numerous differences that exist. Diseases and customs that apply to 1 immigrant group may not hold true for another group within this general category. An increased mortality from heart disease is seen in Japanese Americans, and hypertension is particularly prevalent among Filipinos.⁷ Hypercholesterolemia is prevalent among Japanese Americans, Filipino Americans, and Native Hawaiians.^7,8 Differences exist in Hispanic populations. Within Hispanic subcultural groups, culture and ethnicity play an important role in patterning food behavior.^1,9 Therefore, health care professionals need to integrate knowledge of differing dietary beliefs and practices to implement appropriate therapy.

The problem of obesity in the Hispanic population is multifactorial because it reflects genetic, environmental, cultural, and socioeconomic factors. Romero-Gwynn, who studied obesity in Mexican Americans living in California, found that these immigrants have become acculturated and given up much of their traditional diet in exchange for one higher in fats and sugars.¹⁰ The changes include an increased consumption of flour tortillas, which are higher in fat than traditional corn tortillas; a decreased use of lard but increased consumption of margarine, butter, vegetable oil, mayonnaise, salad dressing, and sour cream; an increased consumption of sliced white bread; an increased consumption of sugar-rich drinks and condiments; an increased consumption of ready-to-eat breakfast cereals; and a decreased consumption of chilis and many traditional dishes with vegetables. The resulting diet is lower in fiber, β-carotene, and specific nutrients provided by vegetables.

Dietary intervention and behavior intervention programs can be useful adjuncts to teaching. A weight loss manual with information on nutrition, exercise, food lists, and recipes; bilingual videotapes; food records; and cooking demonstrations may assist in addressing obesity and associated health-related problems in immigrants.^2,10

Kunstadter analyzed the epidemiologic consequences of migration and rapid cultural change among Hmong refugees in Fresno, California.¹¹ Compared with nonmigrating Hmong in Thailand, an increase was seen in the rates of upper respiratory tract infections, gastrointestinal complaints, hypertension, stroke, diabetes, depression, neoplasms, and allergies in the immigrant group. Dietary changes among the Hmong immigrants reflected an increase in fat and salt intake. A possible explanation for these changes may be that in Thailand, the cost of meats was greater than the cost of vegetables, whereas in California, the prices were more comparable. The increase in meat intake among the immigrant Hmong may contribute to the increased rates of hypertension, diabetes, and cancer that are reported in the study.

Table 1.

Questions for a dietary history

How often does the patient eat? Is food available regularly? Who buys the food? Who prepares the food? What cooking and storage facilities are available? Is food eaten mainly at home or away from home? Is food eaten alone or with others? Does the patient use any special diet? Does the patient take any dietary supplements? If so, which ones? Does the patient drink alcohol? If so, how much? Does the patient take medications or use any drugs (prescription and nonprescription)? Does the patient have any allergies? What foods are eaten daily? What are the patient's favorite foods? Does the patient have excessive cravings for sweets, bread and butter, salt, coffee, fried foods, or junk foods? Are there particular foods that make the patient feel better or worse? Does the patient snack between meals or at bedtime? If so, how often? Does the patient ever binge?

In a study comparing dietary habits, physical activity, and body mass index between Chinese in North America and those in China, differences in the nutrient intake of the 2 populations suggest possible explanations for observed differences in their rates of chronic disease.^12,13 North American Chinese eat more meat and dairy products and consume about 35% of total calories from fat. Chinese immigrants to North America often go through a gradual and continuous process of assimilating a Western lifestyle, although not entirely abandoning their native habits.

DIETARY ASSESSMENT

A clinical assessment of nutritional status involves a combination of methods. An initial clinical evaluation that consists of a medical history, dietary intake, and physical examination is followed by and augmented with anthropometric measurements and laboratory test results.^14,15

Initially, a comprehensive interview to elicit health, social, and family history should be done to better understand lifestyle, psychological, and eating patterns that may influence the nutritional status of the patient. Social conditions involving food should be emphasized and analyzed. The questions to be asked in eliciting the history are shown in the box. These questions can be used to identify high-risk patients who may require further evaluation by the primary care physician or referral to a dietitian or nutritionist for further assessment.

A comprehensive analysis includes a physical examination in addition to a clinical history. The examiner should pay particular attention to the skin, eyes, lips, mouth, gums, tongue, hair, and nails because these areas of the body often will display signs of malnutrition.^15,16 In addition, the patient's height, weight, blood pressure, glands, subcutaneous tissue, musculoskeletal system, gastrointestinal system, nervous system, and cardiovascular system must all be examined carefully to assess for physical abnormalities that may be related to poor or inadequate nutritional intake. Many signs may be mild or nonspecific, and they may be attributable to non-nutritional factors.

The patient's dietary intake can be further evaluated by various techniques, including food frequency questionaires, 24-hour diet recalls, and a 3-, 5-, or 7-day food diary.⁴ Several screening tools that focus on a particular nutrient, such as fat, fiber, or calcium, have been developed for the general population as a quick means of evaluating eating patterns.¹⁷

Twenty-four-hour diet recalls provide quick and rough estimates of nutrient intakes.⁴ Patients are asked to recall all foods, beverages, and additives consumed at meals and snacks in a specific 24-hour period. Information about preparation methods and eating habits should be obtained. Problems with this method include errors in recall, poor estimations of serving size, and poor generalizability from a specific day to overall dietary habits. The patient may keep a food diary to record all foods, beverages, and additives consumed within a specific period. Although this method provides more accurate quantitative information, the same problems of omissions, poor estimations of serving sizes, and so forth may arise. Before employing these methods, the examiner should ascertain whether the patient can read and write and is able to keep records accurately.

Information about dietary intake can be analyzed using food consumption tables, food groups, or computer analysis. Food consumption tables provided by the US Department of Agriculture¹⁸ and manufacturers' nutrition labels offer nutrient values for various foods and beverages. After the nutritional composition of each recorded food item is obtained, the nutrient composition of the overall diet can be calculated by a computer program.¹⁷ This can be compared with the recommended dietary allowance, the standard for the evaluation of dietary intake.¹⁹

Food intake also may be evaluated through the use of food groups and by ascertaining how many servings were consumed from each basic group. The Food Guide Pyramid (figure) is available in many languages and cultural adaptations, including Spanish, Chinese, and Arabic.²⁰ The use of food groups provides a general guideline of nutrient adequacy of the overall diet and serves as a basis for patient education. However, it does not reveal whether the patient's food intake is deficient in any particular nutrient.

Anthropometric and body measurements are sensitive to dietary intake and may be useful in the assessment of nutritional status.^14,21 Height and weight, triceps skinfold, and midarm muscle circumference are the most commonly measured. Weight measurements allow for the calculation of relative weight ([current actual weight/desirable weight] × 100). Relative weight greater than 120% is defined as obesity. A body mass index above 27 (25 for Chinese) is considered overweight, and 30 or above is defined as obesity.^* The triceps skin-fold and midarm muscle circumference measurements serve as estimates of fat stores and skeletal protein. Perhaps more important, waist and hip circumferences should be measured. For women, a waist-to-hip ratio greater than 0.8 indicates abdominal obesity, a risk factor for coronary heart disease, stroke, type 2 diabetes, and some cancers (including breast).

Laboratory tests such as serum albumin and serum transferrin levels and total lymphocyte counts may be used to ascertain the nutritional state^14,22; confounding factors, however, such as the number of hours since the patient last consumed food, may make the test results unreliable.

All patients should be counseled if they have obesity, hypertension, diabetes, or high cholesterol levels. Specific diets are used for common chronic diseases—for example, weight loss for obesity, low-sodium diet and weight loss for hypertension, low-calorie diet and weight loss for diabetes, and low fat and low cholesterol intake for high cholesterol levels.

Primary care physicians must be able to assess a patient's motivation before specific diets and behavioral changes are implemented. Only motivated patients should be started on formal dietary therapy. When dietary therapy is begun, regular follow-up visits should be scheduled. Serial measurements of body weight and regular clinical assessments should be performed. Meetings with dietitians and peer support groups should be suggested to improve adherence. The patient should be given direct feedback with support and reinforcements. Patients who do not show any improvement in 3 months should be switched to a more quantitative approach with the assistance of a dietitian.

Primary care providers may help patients establish an environment that offers a range of healthy foods and reinforces good nutrition. Patient empowerment must be stressed. Small and sustained changes in weight must be accepted and should elicit satisfaction. Both patients and providers must keep in mind that change comes gradually.

The key components of successful dietary intervention involve the development of awareness and sensitivity in working with patients. Cultural differences in behaviors, feelings, and preferences must be respected, and socioeconomic and environmental issues relevant to particular ethnic groups must be understood. Rosenstock et al's health belief model stresses the importance of individual perceptions and of demographic, personal, situational, and social factors that affect a person's ability to adhere to treatment.²³ A primary care provider or dietitian must explain the diet rationale in a language or in terms that the client can grasp easily and explain the need to modify harmful behaviors in a way that will increase the likelihood of action. To increase recent women immigrants' adherence to dietary intervention, the provider must keep in mind the following precepts:

• Understand the woman's past

• Address her fears and anxieties and increase her perception of control over the outcome of events

• Encourage the patient to maintain a traditional diet. Knowledge about price differences is important to understanding the reasoning behind the dietary choices of immigrant populations and may assist the health care provider in addressing dietary issues

• To increase adherence, set up support networks by involving family members, relatives, neighbors, and friends

• Be a partner with the woman by thoroughly describing benefits and risks and offering trade-offs and compromises

Healthy People 2000 stresses the importance of understanding the needs of different immigrant populations to target health programs and dietary interventions.⁸ The report emphasizes the challenge in developing an understanding and refining knowledge of different cultural and ethnic groups for health policies to be translated into effective community prevention programs and clinical preventive services.

Summary points

• Because dietary factors are associated with many leading causes of death, including cancer and heart disease, a thorough assessment of immigrant women's diets is a part of complete health care

• Physicians may need to intervene in the diets of immigrant women

• Food intake can be assessed using the Food Guide Pyramid, which is available in many languages and cultural adaptations

• Intervention will be effective only if providers are sensitive to women's cultural behaviors, feelings, and preferences

Figure 1.

The Food Guide Pyramid: a general guide to choosing a low-fat diet that is balanced and nutritious. From the US Department of Agriculture²⁰

Figure 2.

Food consumption by immigrant women usually remains consistent with their traditional culture

Jeremy Horner/Panos Pictures