Jeniffer Huong, a caseworker / cultural mediator for the Community House Calls Program at Harborview Medical Center, has worked in Seattle for the past fifteen years. Jeniffer has observed an increase in the prevalence of diabetes among the Cambodian refugee patients she has encountered. She also observed a high rate in the complications associated with diabetes. This led Jeniffer to seek funding to initiate a “Shop Around” program to educate Cambodian community members about the management and prevention of diabetes through diet, including instruction about basic nutrition principles.
The following article presents information about the prevalence of diabetes and other health conditions affecting Cambodian Americans, along with considerations of some historical and environmental factors that may influence Cambodian American diet. The shop around program is then described.
While the total prevalence of diabetes (both diagnosed and undiagnosed) is not available for Asian Americans, the National Institute of Health estimates that Asians, Native Hawaiians, and other Pacific Islanders aged 20 years or older are more than two times as likely to have diagnosed diabetes compared to Caucasians after adjusting for population age differences (National Institute of Health, 2005). It is suspected that Cambodian Americans are significantly more likely to die from diabetes than the general population. Data for Asian Americans/Pacific Islanders is collected as aggregate and there is no national data on subgroups (National Diabetes Education Program, 2003). However, in Lowell, Massachusetts, Cambodians aged > 45 years have higher death rates from diabetes (13.4%) compared with all Massachusetts adults in this age group (2.5%) (CDC, 2007).
The National Cambodian American Health Initiative (NCAHI) in November 2005 declared a health emergency in the Cambodian community in the United States, based on evidence of overwhelming life-threatening chronic illness and diminishing health resources available to survivors of the Khmer Rouge living in the United States. Mental health issues (depression, PTSD), diabetes, stroke, liver disease and cancers of the nasopharynx, liver and stomach were identified as causing suffering and early death in Cambodian American communities.
The NCAHI (2007) reports that “Cambodians have rates of these conditions many times that of the general population. The burden of disabilities caused by these co-morbid conditions contributes to a poverty rate of 29% and a disability rate of 30% for Cambodian adults” (p.1). In 2006, the National Diabetes Education Program (a program of the CDC, NIH and hundreds of partners) published a paper describing the link between trauma, mental health problems and diabetes (NCAHI, 2007).
Factors Influencing Nutrient/Dietary Intake
Experience in Cambodia
Prior to living in America, many Cambodians were subject to intense physical activity as a part of everyday living. During the Khmer Rouge regime Cambodians were required to perform exhausting labor under restricted dietary-intake conditions. Over 2 million people died from starvation in Cambodia from 1975 to 1979 (Khmer Health Advocates, 2004). Many Cambodians survived on less than 600 calories per day. Nutrient intake did not improve much at all while the Cambodians were living in refugee camps in Thailand. The Thai government received money and food aid from the United Nations and then decided what food would be rationed. People would sometimes receive food that had gone rotten, and often the refugees had to scavenge for food outside the camp. By all accounts, this food situation in the camps was not very different or improved than the experience during the time of war.
Experience in U.S.
Cambodian Americans now live in a culture with easy access to unhealthy foods. The American culture of a sedentary lifestyle and a surplus of convenient high fat, high calorie, low-cost foods may contribute to weight gain and disease. In 2002, a report by the Lowell Community Center (Lowell, Massachusetts) suggested that an estimated 26% of approximately 10,000 Cambodians in Lowell ate American meals at least once a day (Cambodian Community Health 2010, 2002). Adjusting to a Western lifestyle may result in increased risk for diabetes and adverse health outcomes for many Cambodian Americans.
Many of the issues that Cambodian Americans face when trying to eat healthily in the U.S. are similar to those faced by many other Americans but with higher incidence. Rising food costs, unfamiliar foods, busy schedules and lack of nutrition education are some of the challenges Cambodians face when trying to improve dietary habits.
Vegetables that are familiar to Cambodians because of their common use and availability in Cambodia may be unavailable in the U.S. When they are imported, they may not be fresh or affordable. There is lack of knowledge about how to prepare vegetables that are available in the U.S. but which were not eaten in Cambodia. Consequently, people consume a reduced number of vegetables.
Busy schedules constrain the time people can spend on food preparation and meal planning. Many people choose less healthy alternatives that are ready to eat or quicker to prepare, such as Vietnamese sandwiches and Ramen noodles. Traditionally, at least one meal a day would be prepared to be eaten as a family meal. Nowadays this may not occur as regularly.
Recently, the increased cost and shortage of rice on the world market may have an impact on Cambodian families for whom rice is a staple food.
The Pilot Project: “Shop Around”
Conducted in spring 2008, the Shop Around Program consisted of a series of five classes focusing on nutrition education as a strategy to treat and prevent diabetes. Jeniffer Huong, Cambodian caseworker / cultural mediator, recruited five leaders in the Cambodian community who each agreed to attend the classes and then teach what they learned to at least five other people in their community. Jeniffer organized and led each class discussion, also serving as interpreter. The instruction included information about the dangers of consuming excess fat, saturated fat, sodium, and refined sugars. Students participated in a tour of a Cambodian grocery store to help them identify healthy food choices. The series culminated with a cooking demonstration that incorporated food preparation methods that reduce fat while cooking traditional meals. This program was funded by the Healthy and Active Rainier Valley Coalition for $1350, which covered the costs of honoraria for community participants, grocery gift certificates, kitchen rental and food for cooking class demonstrations, and transportation expenses.
- Cambodian community leaders will be recruited to attend the series of five classes. (For the purposes of this project, a “leader” is defined as a person who interacts with at least ten other Cambodian persons in the community on a regular basis.)
- Class members will learn how to read nutrition labels and demonstrate this by participating in a “Shop Around” at a local Cambodian grocery store.
- Class members will demonstrate knowledge of nutrition principles and skills gained in this course through participation in a meal preparation/cooking demonstration.
- 100% of the class members will agree to teach others by committing to take at least five other people on a “Shop Around.”
- At least 80% of members will indicate that this class was useful (on the feedback forms).
Curriculum, Recipes, Class Photos
Class 1: Learn to Read Food Labels; Basic Nutrition
One of Harborview’s outpatient dietitians volunteered to teach basic nutrition principles. She emphasized grocery shopping as a part of healthy eating, providing suggestions on what to look for at the grocery store. A portion of the class was devoted to teaching class members how to read nutrition labels – particularly fat, sodium, and sugar.
Class 2: Basic Diabetes
This course provided basic information for Cambodian leaders about diabetes, how nutrition affects the management of diabetes, and complications of diabetes. The format of the class was an informal question and answer session. Emphasis was placed on management and prevention of diabetes through diet.
Class 3: Shop Around
After some nutrition counseling, the class members were ready to venture on a shopping trip together. Kris Timme, a public health nutrition graduate student at the University of Washington, attended the shop around to answer basic nutrition questions. The purpose of the shop around was to apply principles learned in previous classes. Class members read food labels to identify foods that are high in sodium, trans fat, saturated fat, and added sugars. They also generally learned which foods are high in whole grains and fiber.
Class 4: Cooking Demonstration: Cambodian Baked Lemongrass Chicken and Chinese Broccoli with Oyster Sauce
Class members convened to practice cooking a healthy meal together. A typical Cambodian dish was selected and slightly altered to improve its nutrient quality. (See recipes below.) Members participated in meal preparation, cooking, and clean up. The members stated that it was very helpful for them to learn the importance of measuring the ingredients. This was an effective way for them to monitor their sodium, fat, and carbohydrate intake.
|Cambodian Baked Lemongrass Chicken|
|6 medium skinless, boneless chicken breasts|
3 tablespoons reduced sodium soy sauce
1 ½ teaspoons sugar
½ tablespoon canola oil
4 cloves of garlic/chopped
10 lime leaves/chopped
2 long lemongrass/chopped
|Combine soy sauce, sugar, garlic, lemongrass, lime leaves, and oil. Marinate the chicken for at least 1- 2 hours. Preheat the oven to 400 ° F for 10 minutes then cook chicken for 30 to 40 minutes or until done, occasionally flipping it over to cook both sides. Serves 6.|
|Chinese Broccoli with Oyster Sauce|
|4 cups water|
1 tablespoon canola oil
3 pounds of Asian broccoli (7 cups raw)
3 ½ tablespoons vegetarian oyster sauce
|Combine water and oil in a medium sized pot. Bring to a boil. Add pre-washed broccoli into the pot and stir. Cook 1-2 minutes, then drain. Place broccoli on a large plate and add the vegetarian oyster sauce.Serve with 1 cup brown rice on the side.Yields 3 servings, 1 ½ cup each.|
Nutritional changes made to make the recipes healthier included using reduced sodium soy sauce to lower sodium content of the meal. Using small amounts of soy sauce and oil created a good flavor without a lot of fat. Skinless chicken breasts were selected to lower saturated fat and cholesterol content. The meal was served with brown rice instead of white to increase the whole grain and fiber content of the meal. While the class members commented that brown rice is not widely accepted in the community, they also stated that some members (especially those who have been directly impacted by diabetes) are willing to try substituting it for white rice on a regular basis.
The cooking demonstration, in particular, may be a successful way to improve the health of immigrant and refugee populations. A cooking demonstration is organized by a skilled leader and involves gathering members from the targeted community together to learn to cook healthier meals that are native to their culture. Participants can choose where and how often to hold these demonstrations depending on the availability of those who want to participate. Cooking demonstrations are a great way to promote social interaction, which can combat the depression and isolation that many refugees experience. Some health care professionals have found that treating depression among refugees can improve patient compliance and overall health outcomes.
Class 5: Wrap Up Session/ Evaluations
The purpose of the final class was for the class participants to provide feedback on the classes. Everyone gathered for an informal lunch and “graduation” ceremony. Participants received a certificate of completion. This fostered a sense of fun, celebration and accomplishment. It instilled confidence in the students, preparing them to teach other members of their community. Evaluation forms were distributed to give students the opportunity to provide feedback on the usefulness of the course. These forms also will serve as a guideline for setting goals for class improvement. On the forms, students indicated the course was effective and they learned many new principles. They also stated that they strongly desired that this class be repeated to refresh them on the information learned.
Outcomes, Challenges and Lessons Learned
Each objective was achieved and members had a positive experience. In summary, five leaders were selected to take part in the classes. Class members were willing and eager to learn. The Shop Around was successful because it was very educational and fun at the same time. The cooking demonstration was a great opportunity to reinforce principles taught during classes. By the end of the classes, students were not only prepared but were also motivated to teach others what they had learned. There was such a strong energy and enthusiasm among the class participants that they did not want the classes to end. One unexpected outcome was the idea of forming a Cambodian Community Coalition. While this coalition is still in the making, class members anticipate they will meet once a month or once every other month to discuss ways to improve the health of the Cambodian population.
The greatest project challenges included money, space, and time. Initially, it was a challenge to obtain funding. Finding a location to meet and to cook was tough. Time was a challenge because there was so much information to teach in a short amount of time. On occasion, students felt a little overwhelmed with all of the information provided.
The Shop Around Program provided insight into some of the nutrition issues faced by Cambodian Americans and ways to address them. Touring the local Cambodian grocery market provided education about the sodium, fat, sugar, and carbohydrate content of Cambodian food choices. Participants needed and received information about American fruits and vegetables that can be substituted for expensive, imported varieties. The program increased awareness of how to purchase and cook low fat, low calorie, and nutrient-rich foods.
The project organizers were guided by some key ideas summarized by a motto—“Keep it simple.”
First, less is more. It was very important to keep the nutrition classes very basic, with minimal content. Class lessons focused on a few important principles and avoided superfluous details. Even with simple lessons, many of the students felt overwhelmed with the new terms they were learning. Repetition and simplicity of the lessons was a great way to facilitate learning of basic principles.
Second, time is a barrier. Like most people in the United States, many of the Cambodian participants explained that one barrier to healthy eating is a lack of time to shop, prepare, and cook meals. This class group valued access to quick, healthy recipes and the skills to use those recipes. They encouraged efforts in the community to create, distribute, and practice cooking quick, healthy, inexpensive recipes in order to have a lasting impact on health.
Third, small changes make a big difference. Many of the principles taught in these classes could lead to significant changes in the health of the population if widely implemented. While many people have difficulty changing habits, the class participants warmly embraced instructors’ ideas, suggestions, and recommendations to make small changes. During the shop around and the cooking demonstration, participants identified at least one way they could change their current eating habits. For example, one woman said she would substitute canola oil for corn oil when cooking. Because of its high content of monounsaturated fatty acids, the use of canola oil may help reduce risk of cardiovascular disease, especially among susceptible individuals (including those with diabetes). Another woman committed to using egg substitutes (such as EggBeaters) because they are fat free and cholesterol free. Such changes will make a difference over time and have the potential to impact future generations. While diet is only one of the many factors influencing the health of the Cambodian American population, attention and efforts to increase healthy eating in the community may have lasting results.
Centers for Disease Control and Prevention (CDC). (2007). The Power to Reduce Health Disparities: Voices from REACH Communities. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Available at URL: http://www.cdc.gov/reach/community_profiles/index.htm Accessed February 17, 2009.
Health Emergency in the Cambodian Community in the United States. Executive Summary. National Cambodian American Health Initiative. September 2007.
Khmer Health Advocates, Inc. Cambodian Diabetes Telemedicine Project. National Diabetes Education Program Partnership Networking Meeting. Atlanta, Georgia. December 2004. For more information visit: www.cambodianhealth.org
Lowell Community Health Center. Cambodian Community Health 2010. Community Behavioral Risk Factor Survey Results, 2002. (Note Feb 2009: This information is no longer available).
National Institute of Health, National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), Diabetes Information Clearinghouse. National Diabetes Statistics. NIH Publication No. 06-3892. Nov 2005. Available at URL: http://diabetes.niddk.nih.gov/dm/pubs/statistics/ Accessed May 28, 2008.
Silent Trauma: Diabetes, Health Status, and the Refugee. Southeast Asians in the United States. Developed by the Southeast Asian Subcommittee of the Asian American/Pacific Islander Work Group National Diabetes Education Program. http://www.ndep.nih.gov/resources/SilentTrauma.htm#DemographicInformation Accessed September 9, 2008.