Shireen: Candice Jones, originally from Maryland, presides as the dietetic technician program chair at Cincinnati State Technical and Community College overseeing the dietetic technician and pre-nutrition science degrees and dietary management certificate. For the past 13 years, Candace has also continued to work as a certified Diabetes Care and Education Specialist at the Christ hospital diabetes and Endocrine Center. Welcome, Candice. 

Candice: Thank you for having me 

Shireen: An absolute pleasure. So Candace diving right in, I want to start out by asking you what sparked your interest in nutrition and led you to eventually become a registered dietitian? 

Candice:  Well, I was always very active in sports at a young age. I specifically played tennis, softball and basketball, but also battled with asthma. And so when trying to figure out how to manage my asthma and then also physically recover after, let's say, three hour tennis matches.

Shireen: So that is that is great. Thank you for sharing that. I want to dive in and tell you about the National Diabetes statistics recorded 2020. It suggests that the black and Hispanic Latino populations are disproportionately affected by diabetes. I want to get your take to see why you think that is. 

Candice: So based on the research that's been conducted to the most significant indicators, when assessing diabetes risks or statistics that themselves, are low socio economic status, and then level of education. They tend to go hand in hand. So typically, what we see is those that have a higher socioeconomic status more often have a higher level of education, and therefore an increased awareness of where to find resources about diabetes, and have more access to healthcare resources. So on the flip side of that those with lower socio economic status are more likely to have lower education level. So we're looking at high school or even less than high school, and then more likely to have limited access to healthcare resources. And personally, I've seen this in Cincinnati over my 13 years as being a diabetes educator, which is why it's so important to get out into communities to start to be visible resources. 

Shireen: So important, how have the traditional cultural foods associated with these populations really changed?

Candice:  So a couple of things when it comes to our cultural or traditional foods, one how much we consume, our portions have greatly increased ever since the 1970s, specifically, but then also how often we consume these, these foods. As an African American, I remember growing up with fried chicken, and it was typically only served at special occasions. So maybe someone's birthday, or Christmas, but specifically celebrations and now we can go to gas stations and see five fried chicken being provided. But again, our portions, we went from a six inch plate to no a 10. In some places, 12 inch plates. I mean, that's it, these traditional foods get a bad rap often, but it's about how much we consume and how often we're consuming them. But it's also paired with the fact that there's a lot more of access to processed foods, and we have a significant decrease in physical activity. So for traveling back in time to the say, days of slavery, slaves could burn over 5000 calories, working in the fields. So those calories from these, these meals that maybe can contain the high fat were necessary, but we're not nearly as active and our portions have grown and we're eating some of these foods more often. So it's not necessarily the foods are negative. It's, what are we doing with those foods? 

Shireen: And then what are the barriers to specifically diabetes care related to cultural food pair practices? 

Candice: I love this question. So it's kind of multi layered, if we're specifically talking about patients or clients lack of culturally relevant resources, can I get resources or handouts or materials that are in different languages? And if I can, are they easy to, for the clients to read? And what's their education level? What's their health literacy? Are they able to understand what these handouts say? I also think that the method in which we provide nutrition information or diabetes information, I think the old school method is lecturing and passing out handouts that are typically black and white versus using pictures or colors or other types of visuals or demonstration, some type of hands on and involvement with clients to help stimulate and engage clients to better understand how to manage diabetes. I think there are also a lot of misunderstandings or misperceptions or exceptions about the expense of healthy foods. And I think there are mis messages sent about the notion that we always have to eat organic or quote unquote, clean foods. But we also have to look at food availability, food deserts. And lastly, I really want to focus on the family support system. Often there's this concern about diabetes being disgraceful or somehow shaming the family and a family were to find out about diabetes or someone having diabetes, the, the type of support becomes more of the food police. And therefore there's that sense of guilt. There's an old saying that I grew up with in my household, my family, you don't air your dirty laundry on the clothesline for everyone to see. And unfortunately, diabetes often can be viewed as that and it shouldn't be. And that's what we're working on changing. And then there's also this population, specifically, I'm thinking about Latino population, that there could be that fear of being deported or there are some legal issues, which hopefully, we're in the process of changing that. But then when it comes to the educator, side, educator side, sometimes there are barriers to actually finding materials that are culturally competent, but I'll be addressing some solutions so that some available resources here shortly. But there's also the issue of whether or not we're providing diabetes education as an inpatient versus outpatient slash community. And time is very limited. As an inpatient dietitian or educator versus outpatient. We may not always, but we may have a little bit more time, such as an hour session, a two hour session to work with clients. And I think that's where inpatient and outpatient slash community, diabetes educators and specialists need to work together, we need to have more referrals or referral process in order to treat the community, help the community. Lastly, I think that sometimes there are barriers or as I like to call them resistance to change among individuals. And I think that we need to take this as just a period or moment for growth, for personal growth, to think about why we got into healthcare, we want to help others, which means helping others involves me learning how to teach others, not the way that I would want to be taught, but maybe the way that could engage someone else. So it involves thinking outside the box, which takes more time, if we're unfamiliar with it. So with that, I want to talk about the cultural considerations, specifically diabetes is education. And the charter is a path for that. Yes. So the first component is I think it's important that we all acknowledge the fact that there are cultural perceptions of health that are very unique and different for each individual. Everyone views health differently and so having that as the initial notion of going in a meeting with a client or patient greatly can help starting the, the process of opening one's mind. And being an active listener. What is your client stating that they learn best from? So when we're considering the context of learning experiences, which is different for everyone? How can we best assist someone so for example, in diabetes, old school methods, or the exchange system carb counting? For many of my clients, I actually don't do a lot of carb counting, especially when working with type two diabetes, I may be working more on portion control or using my plate methods. And that helps also with that health literacy component. Because within health literacy, there's also numeracy. So we're dealing with numbers, can we understand and identify what numbers mean, in relation to our health, our health, but then also, someone's willingness to carb count, if someone does not feel comfortable with carb counting, that's not a great place to start. diabetes can be managed in other ways. It's not a one size fits all. I also like to try to address any limitations to diabetes care needs. So I always have conversations about food access, or availability, I look at: “Can someone afford transportation or do they have transportation to appointments? What type of health care coverage do they have?” Because financial barriers are also very prevalent within different communities. But again, also assessing what kind of environment is a patient or client trying to learn in, so as I mentioned, inpatient is very different than outpatient. And even both of those are different from community setting. So such as a church setting, or someone may feel a lot more comfortable with their peers talking about diabetes, I try to be as sensitive, culturally sensitive as possible. And remember my own cultural humility, that how I grew up is very different from how others have grown up and their morals and values or how they, their relationship to food is and so I try to meet patients or clients with where they are at. That is where we start and then I try to provide information in any type of manner that is very relatable to the learner or the patient or client. And I try to be as person centered as possible when helping someone create their goals around their nutrition management or diabetes management, I should say. So again, really looking at our any resources that I use culture, age, literacy level and learning readiness appropriate. 

Shireen: You mentioned my plate and I'm curious to see if you can share an example with us of what that plate looks like and how you sort of adapt that for, for various cultures. 

Candice: Absolutely one of my resources that I love to use is out of the Bronx, New York and it is called the Institute of Family Health. The Institute of Family Health has done a great job of basically creating materials or resources that are patient centered, that are directly targeting the needs of medically underserved communities. So the communities were basically talking about, and they actually created these wonderful, colorful MyPlate. So again, half the plate is filled with non starchy vegetables from a specific cultural background, a quarter of it has some type of protein, and then the other quarter has some type of starch or carbohydrate. And so they have what they call the American plate has like spaghetti and or pasta with a salad and meatballs. But they also have plates from African American culture, which then has macaroni and cheese, it has greens, it has roasted chicken instead of fried chicken, they have a creole yo plate that kind of focuses more on the Caribbean, and they have a Mexican plate, which is very different than the Caribbean plate. And so I strongly recommend looking up the family Institute of Health in order to take or the Institute of field of Family Health, I should say, to take a look at these my plates, and they will allow you to use these as resources, all you have to do is email them that you're interested in using these as diabetes resources and they will send them as PDFs for free. Now, with that said, actually on the Indian native plate is available more my native plate is available, which focuses on different indigenous tribes or Native Americans as to how to structure their my plate to and this is a government website. So again, it is free to use it is www.Ihs.gov diabetes. And so they have a great plate that also follows the structure. When we had the as I like to call them the universal cultural Food Guide pyramids, they were tools more for I would say the educators or specialists more than the community and when they went away and we just had this MyPlate structure through the USDA. There wasn't as much of an initiative to create those, that same effort of creating culturally competent MyPlate structures or templates. And that's exactly what the Institute of Family Health did.

Shireen: Candice, thank you for sharing those resources, I am going to ask you for other recommendations that you may have for culturally competent dietary, you know, any other resources that you may have to that.

Candice: Absolutely. Old Ways. Old Ways is a wonderful website that focuses on African, Asian, Mediterranean, vegetarian, vegan, and of course African practices, dietary practices, but then there's also a really good paperback resource specifically focusing on diabetes called cultural food practices, cultural food practices. It's actually written by the Diabetes Care and Education dietetic practice group and the authors are Cynthia goody, and Lorena Drago. This is a great resource that can be found on the eat right.org website for the Academy of Nutrition and Dietetics. It is a very detailed row pertaining to different cultures. What are their considerations? What are the health risks that are often seen, and how to address them through cultural sensitivity competence? Wonderful resource if you're working in diabetes, or even heart disease, I strongly recommend that purchase. 

Shireen: Thank you for that. So with that we're toward the end of the episode, Candace. This episode just flew by how can our listeners connect with you and learn more about your work 

Candice: This way to connect with me is through LinkedIn and I believe my URL will be provided. I can also be reached by going to the Cincinnati State Technical and Community College website. I am the Program Chair of the dietetic Student Program and my email address is candice.jones@cincinnatistate.edu. 

Shireen: Lovely, thank you so much for sharing and thank you so much for coming on this episode and talking to us today. 

Candice: I had a lot of fun. Thank you for having me. 

Shireen: And so to all our listeners out there, head over to our Instagram and we have a poll set up for you and tell us how you feel the healthcare that you have previously been provided, if it has been culturally relevant to you. So how do you feel about that? Let us know your thoughts again, head over to our Instagram at Yumlish underscore and find them.

Connect with Candice!

Email: candice.jones@cincinnatistate.edu

LinkedIn

Resources mentioned: 

The Indian Health Service

Institute of Family Health 

Old ways

Cultural Food Practices: eatright store

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