Counseling Hispanic Clients - Today's Dietitian Magazine

February 2022 Issue

Counseling Hispanic Clients
By Jamie Santa Cruz
Today’s Dietitian
Vol. 24, No. 2, P. 34

Learn about the wide variety of different cultures across Latin America and strategies to better counsel patients for improved outcomes.

Just over 60 million people in the United States identify as Hispanic or Latino—that’s 18.7% of the total US population.1 Mexico is their most common country of origin, representing about 61% of all US Hispanics.2 But millions of others living in the United States trace their ancestry to other parts of Latin America. These Hispanic populations have unique dietary patterns and specific health risks depending on their country of origin.

Dietitians unfamiliar with the Hispanic population and the cultural differences within Latin America may tend to take a similar approach to nutrition counseling. The fact is, Hispanics comprise six large subgroups from six different Latin American countries that have distinct histories, cultures, food preferences, and cuisines. Attempting to learn and understand the many differences of the Hispanic population to provide optimal patient care may seem daunting. But the good news is that RDs can build their cultural understanding and practice cultural humility regarding the Hispanic population and improve health care for patients.

In this article, Today’s Dietitian gives an overview of the different health risks Hispanics and Latinos face outside and inside the United States and discusses the historical, cultural, and dietary distinctions that span across the six largest subgroups within Latin America.

Health Risks in the Hispanic Population
Hispanics in the United States are less likely to die from cancer and heart disease, but they’re more vulnerable to certain other chronic conditions than are non-Hispanic whites. For example, Hispanics have a 66% higher risk of developing diabetes.3 Hispanics also are at greater risk of cervical cancer and experience a higher prevalence of obesity, chronic kidney disease, and liver disease compared with non-Hispanic whites.4,5

Importantly, the risk of these conditions varies across Hispanic groups. For example, among males of South American origin, the obesity rate is only 26.8%, whereas among Puerto Rican females it’s 51.4%.5 The risks also vary depending on whether an individual was born outside the United States (a first-generation immigrant) vs inside the United States: Only 36.7% of Hispanic individuals born outside the United States have obesity compared with 47% of US-born Hispanics. Diabetes and heart disease also are more common for US-born Hispanics than for those born outside the United States.6-8

Differences in Subcultures
Although there’s a tendency to view Hispanic populations as monolithic, this is problematic, says Diana Mesa, RDN, LDN, CDCES, owner of En La Mesa Nutrition in Miami, where she counsels mostly clients of Hispanic and Caribbean descent. “The foundation may be the same, but there are so many differences [in cuisine] from East to West Cuba, for example, or the different regions of Colombia, or the expansive area that Mexico covers—there are so many nuances.”

Not only does diet vary across Hispanic populations but so do cultural experiences. This can lead to significantly different behaviors in the United States, particularly in terms of how Hispanic immigrants interact with the health care system, says Lorena Drago, MS, RD, CDN, CDCES, owner of Hispanic Foodways, LLC, specializing in multicultural nutrition education. For example, undocumented immigrants or immigrants who come from an impoverished background may not seek health care in the way immigrants from other backgrounds might. “It’s important to understand not just what happens here, but what happened before they got here.”

The Six Largest Subgroups
With that in mind, here’s an introduction to the six largest subgroups of Hispanics in the United States as well as strategies for providing more effective nutrition counseling.

1. Mexico
A major event in the history of Mexico that substantially affected Mexican eating patterns was the passage of the North American Free Trade Agreement in 1993. This trade agreement was a boon to the United States because Americans suddenly had access to plenty of avocados and other Mexican exports. But “what happened was that people in Mexico started exporting all the avocados [and other crops], and that depleted Mexicans from a lot of the foods that they were growing,” Drago says. At the same time, processed foods became substantially cheaper, so the average Mexican diet shifted toward significantly higher quantities of industrialized foods. Sugar-sweetened beverages also became more popular, such that Mexicans now have one of the highest rates of sugar-sweetened beverage consumption in the world. As a result, “there was a huge increase in chronic diseases in Mexico,” Drago says.

As for the traditional Mexican diet, it’s based on corn and beans, but there are significant regional differences. “The north usually eats wheat tortillas. Most of the south eats corn tortillas,” Drago says. “Salsas can vary from house to house even in the same neighborhood. [It’s] the same thing with moles, which are thick, traditional sauces with layers of flavor derived from dried chiles, spices, and fruits. You could have very different ingredients, not just from region to region but from one neighborhood to another.”

One factor that can greatly impact a Mexican immigrant’s diet—and the health quotient of that diet—is whether the individual came from a rural area or an urban area. Thus, Drago says, dietitians should ask Mexican clients where they learned to cook. “If the person came from a rural area in Mexico, they might have come from a place in which they grew their own food and they learned how to cook from scratch,” Drago says. “They know how to make their own tortillas from scratch, their own mole from scratch.”

Alternatively, “that person may say, ‘I learned how to cook,’ but maybe they were from a large city where they had large supermarket chains, and they bought their mole in a container, and they bought their salsa frozen, and they pretty much just learned how to assemble food, but they never really grew anything.” The difference matters, Drago says, because supermarket products usually contain more sodium and fat than scratchmade versions.

2. El Salvador
The first large surge of immigration from El Salvador to the United States was prompted by El Salvador’s civil war, which took place in the 1980s. “Most people were moving from rural countryside areas, and they were also coming with little or no formal education—they were not literate. They were coming from a poverty situation,” says Kennia de Salazar, ND, CDE, a clinical dietitian and former professor of nutrition at the Evangelical University of El Salvador. Today, immigration from El Salvador continues, but instead of fleeing war, many are escaping crime, poverty, and political corruption.

The most popular traditional dish eaten daily among Salvadorans (regardless of whether they immigrated from the Salvadoran countryside or from an urban area) is pupusas, which are filled tortillas. To make pupusas, white corn dough is filled with cheese, fried red beans, and pork. Then the mixture is cooked all together in the tortilla dough. Though corn tortillas are a staple in Salvadoran diets, Salvadoran tortillas are much thicker than Mexican versions. The diameter of a Salvadoran tortilla is similar to that of a Mexican taco tortilla, but due to the thickness, one Salvadoran tortilla can contain anywhere from 15 to 30 g carbohydrate. Salazar says it’s important for dietitians to help Salvadoran clients understand the impact of these carbohydrates and make sure they’re eating tortillas in moderation.

An important flavor in Salvadoran cuisine, according to Salazar, is loroco. Loroco is a bud flower rich in vitamins and fiber that has a strong flavor similar to bell pepper. It’s often mixed with eggs or cheese.

Fresh produce, such as coconut, tamarind, guanava, guava, carao, and paterna, is plentiful in El Salvador year-round. However, fruits and vegetables aren’t necessarily a central focus of Salvadoran diets, Salazar says. “They’re always there, but not understood to be a key part of well-being.” The good news is that the taste of fruits and vegetables typically isn’t foreign; it just needs to be cultivated. “Fruits and vegetables are not a dislike, but we just need to eat them more frequently,” Salazar says.

When counseling Salvadorans, dietitians should be aware that the Salvadoran culture is very yielding, meaning that Salvadorans may agree to a recommendation from a health care professional but have no intention to follow through. “Sometimes they say yes out of stress. They may say yes bu without knowing how to commit to that action,” Salazar says. Thus, when making recommendations to clients from El Salvador, dietitians should ask what they think they can realistically implement and discuss strategies on how to do it within the context of their cultural and food preferences.

Also, make sure to smile. “Smiling is a really important part of our culture,” Salazar says. “A serious face might be interpreted as distant.”

3. Cuba
Up until the 1990s, Cuba’s main trading partner was the Soviet Union, and Cuba was dependent on Soviet economic subsidies. When the Soviet Union collapsed and subsidies ended in the early 1990s, Cuba plunged into a serious economic crisis, prompting large-scale emigration to the United States. Although living standards improved significantly in Cuba in the 2000s, the country remains diplomatically isolated, and chronic shortages of food and medicine continue to persist.

Cuba’s isolationism and economic inefficiency greatly have impacted the diets of the Cuban people, Mesa says. “There isn’t a lot of variety. You get what you get in Cuba, and it’s not like in other countries where they might have open trade with other countries and they might have resources to grow crops that aren’t indigenous to the country.”

Although there’s little variety, there are three major cultural influences on Cuban cuisine, Mesa says. The Indigenous peoples made the first impact, cultivating several key crops, such as pumpkin, yuca, beans, and corn, all of which remain foundational today. Then, Spanish colonizers came and introduced olive oil, an array of spices, and various food preparation techniques, such as drizzling seafood dishes, including octopus and shrimp, with olive oil and sprinkling them with smoked paprika. Similarly, Cuba adopted the Spanish dish paella, made with seafood, but made it with chicken instead, calling it arroz con pollo. Finally, Africans who were brought to Cuba during the Transatlantic Slave Trade also had an influence. People who were enslaved “brought their own ways of preparing foods, their own crops, and their own adaptations of African dishes [using the] native ingredients of Cuba,” Mesa says. For example, the breakfast dish fufú, made of mashed boiled green plantains cooked with pork chunks and garlic and onions, is one such African adaptation, with plantains substituting for the cassava that would have been used in Africa. Other African-inspired dishes include rabo encendido, an oxtail stew, and ajiaco, a stew made with corn, meat, and root vegetables, including cassava and yautia. Ajiaco is so important in Cuban cuisine that it’s considered by some to be the country’s national dish. Other essential dishes of Cuba include lechon asado, roasted pork marinated in a garlicky citrus sauce, and ropa vieja (literally, “old clothes”), a dish of stewed beef cooked in a tomato sauce with onion and bell peppers.

What’s important to note when counseling Cubans in the United States is that they typically consume plenty of starchy vegetables, such as sweet potatoes, yams, and yuca, but hardly any nonstarchy vegetables, especially leafy greens. When Cubans emigrate to the United States, “they bring the customs of the island with them, so they may be [turned off by] green, nonstarchy vegetables they’ve never tried before.”

Dietitians shouldn’t discourage Cuban clients from consuming starchy vegetables, Mesa says. But nonstarchy vegetables are important, too. Dietitians can encourage their consumption by helping Cubans identify which nonstarchy vegetables they already enjoy—such as tomato, cabbage, bell pepper, cucumber, avocados, and olives, all of which are nonstarchy but nonetheless popular. In other words, build on foods clients already like and expand from there, Mesa says.

4. Dominican Republic
Immigration from the Dominican Republic to the United States increased substantially after the 1960s due to political and economic upheaval in the wake of the 1961 assassination of the country’s longtime dictator, Rafael Trujillo. Today, immigration continues, with the vast majority of Dominican immigrants coming to the United States on the basis of family connections.

The Dominican Republic has many of the same cultural and dietary influences as Cuba—namely, Indigenous, Spanish, and African influences. “A lot of our dishes overlap, although they may have different names,” Mesa says. The difference is that Dominicans “may have more access to things and may have a broader availability of nonstarchy vegetables.”

One example of a recipe that’s common in Cuba and the Dominican Republic is the rice and bean dish known as congri in Cuba and as arroz moro in the Dominican Republic. Another dish shared between the two countries is the Cuban breakfast dish fufú, mentioned earlier, which is the same dish Dominicans call mangú. There’s also the Dominican soup sancocho—made with corn, meat, and root vegetables—which is essentially the same soup Cubans refer to as ajiaco.

5. Guatemala
Between 1960 and 1996, Guatemala was engulfed in civil war, caused in part by land disputes. Guatemala has a history of highly unequal and highly concentrated land distribution, and exclusion from the land remains a major cause of poverty in Indigenous and peasant populations, even after the war.9 All of these problems have contributed to high levels of emigration out of the country.

Most Guatemalan immigrants in the United States come from farming backgrounds and have a very low socioeconomic status, says Lucy Herrarte, ND, DCES, a dietitian in Guatemala City, Guatemala. “Research shows that what makes people from Guatemala migrate to another country is [the lack of] economic access to buy food.” And many of these immigrants come from a background of poor health care, according to Herrarte. The prevalence of type 2 diabetes and hypertension is high, but not all patients can buy the essential medication to treat diabetes or hypertension.

The traditional Guatemalan diet includes a wide range of foods. “The agriculture of Guatemala is varied from coffee, vegetables, legumes, corn, bananas, to sugar cane; therefore, the diet is varied,” Herrarte says. In general, the diet in Guatemala is similar to that of other Central American countries, though Guatemalans consume more beans and corn than their neighbors.

Guatemala has a strong Mayan influence that has impacted its cuisine, including many of its national dishes, according to Herrarte. One national dish with Indigenous influence is pepian, a spicy stew made with tomatoes, garlic, and local chiles combined with chunks of meat and vegetables; this dish reflects the fusion of Spanish and Mayan cultures. Another example is kak’ik, a traditional Mayan turkey soup packed with spices. Other common dishes with Indigenous influence include jocon, a nonspicy chicken stew, and mole de plátano, a dessert made with cooked plantains and chocolate.

One important point dietitians should note when counseling Guatemalan clients, according to Herrarte, is that Guatemala has a high prevalence of chronic malnutrition in children younger than 5, and malnutrition remains a significant concern in Guatemalan children once they arrive in the United States.

6. Puerto Rico
Puerto Ricans who move to the mainland United States differ from other Hispanic immigrant groups in that they come from a US territory, not a different country. This provides some advantages for Puerto Ricans. “We as a group don’t have the same challenges with immigration and status in this country,” says Christina McGeough, MPH, RDN, CDCES, LCCE, CLC, a dietitian in Queens, New York. On the other hand, many Americans still think of the island as foreign. “When you go to middle America, they don’t really know that Puerto Rico is part of the United States.”

The typical Puerto Rican diet includes plenty of white rice with either pigeon peas or beans, McGeough says. Plantains also are common—either green plantains (eaten boiled or fried) or sweet plantains (eaten mostly fried). Plantains usually are mixed with rice or eaten with chicken, beef, or pork. The vegetables Puerto Ricans typically eat are boiled root vegetables, such as cassava, malanga, and yautia. Salads also are popular and include iceberg or romaine lettuce, tomato, cucumber, corn, and a sliver of avocado. Common fruits in Puerto Rico include passion fruit, ciruela, acerola, and mangoes, although bananas and oranges also are eaten regularly. Passion fruit usually is consumed in the form of concentrated juice or nectar.

Despite regular consumption of legumes, fruits, and vegetables in Puerto Rico, there are high rates of diabetes and other health disparities due to the large influx of fast food chains and the increase in poverty in recent years. “When non-Hispanic dietitians start working with” Puerto Ricans, they “might not understand the social determinants of health,” McGeough says. “The assumption is, you drink soda, you eat french fries, you’re lazy—that’s why you have diabetes.” The reality, however, is that Puerto Ricans are influenced by a range of factors including environment, access to health care, housing, poverty, and economics. “We have a model that often places blame on the individual,” McGeough says. “If we really want to support people, we have to be kinder in our messaging and willing to actively listen and learn from the individual.”

Counseling Strategies
Once dietitians educate themselves about the countries from which their Hispanic clients are from and the foods and dishes they may eat regularly, they’ll be in a better position to use the following strategies to improve overall patient care:

• Be inquisitive. When Hispanic clients refer to specific dishes or foods, ask them for details about those dishes. What are the ingredients, and how do they prepare them? “That curiosity not only informs the dietitian more but it creates a better bond,” Mesa says. Asking questions also can clear up confusion in cases where a single dish may go by different names, depending on their country of origin.

• Get familiar with their food. Try the traditional foods of the Hispanic population you’re counseling. Seek out, say, a Dominican or Cuban restaurant to taste the local dishes, Mesa says. Then take it a step further by following the Instagram accounts of Hispanic RDs, reading books and watching TV shows about the Hispanic culture—all of which will increase your understanding of your clients and the foods they eat.

• Show respect. Respect Hispanic clients’ culture and cultural food preferences by finding ways to make their recipes more healthful and nutritious. It’s best to work with the foods they’re accustomed to eating and not against them. Often, Hispanic clients are told, “stop eating rice, stop eating tostones. Those things are bad for you, and they’re making your diabetes worse,” McGeough says. But this can hinder a client’s motivation. “When you tell someone to do something that [goes] outside of their cultural norms, that [steers them away from their] cultural foods, you likely won’t see change.” McGeough says.

In addition, instead of labeling foods as good or bad, dietitians should focus on portion size. Ask clients how they can balance their intake of traditional foods rather than eliminating them entirely. “Wellness is not one-size-fits-all. Not everybody wants to eat quinoa and barley. Those are not superior to our cultural foods,” McGeough says.

Final Thoughts
What’s essential for dietitians to know is that Hispanics comprise a significant demographic group in the United States. Therefore, it’s vital to become familiar with their unique health risks and nutritional needs. While various Hispanic groups may have many things in common, from a shared language to shared cultural influences, and even some shared dishes, dietitians must recognize that Hispanic people from different countries are dissimilar to each other regarding dietary patterns and taste preferences. Learning the nuances of the major Hispanic groups in the United States is critical to serving these unique populations.

— Jamie Santa Cruz is a health and medical writer based in Parker, Colorado.

References
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2. Hispanic population groups in the United States, by country of origin 2019. Statista website. https://www.statista.com/statistics/234852/us-hispanic-population/. Published September 20, 2021. Accessed November 24, 2021.

3. Fortmann AL, Savin KL, Clark TL, Philis-Tsimikas A, Gallo LC. Innovative diabetes interventions in the U.S. Hispanic population. Diabetes Spectr. 2019;32(4):295-301.

4. Hostetter M, Klein S. In focus: identifying and addressing health disparities among Hispanics. The Commonwealth Fund website. https://www.commonwealthfund.org/publications/2018/dec/focus-identifying-and-addressing-health-disparities-among-hispanics. Published December 27, 2018. Retrieved November 24, 2021.

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6. Afable-Munsuz A, Mayeda ER, Pérez-Stable EJ, Haan MN. Immigrant generation and diabetes risk among Mexican Americans: the Sacramento Area Latino Study on Aging. Am J Public Health. 2013;103(5):e45-e52.

7. Ahmed AT, Quinn VP, Caan B, Sternfeld B, Haque R, Van Den Eeden SK. Generational status and duration of residence predict diabetes prevalence among Latinos: the California Men's Health Study. BMC Public Health. 2009;9:392.

8. Gill C, Lee M, Vatcheva KP, et al. Association of visceral adipose tissue and subclinical atherosclerosis in US-born Mexican Americans but not first generation immigrants. J Am Heart Assoc. 2020;9(20):e017373.

9. Guatemala. LandLinks website. https://www.land-links.org/country-profile/guatemala/. Published August 2010. Accessed November 24, 2021.