Hyperlipidemia: Diet, Education & Health Promotion for Somali Refugees

Background/Methods

Somalia is a long, narrow country that wraps around the Horn of Africa. Many Somalis are nomadic or semi-nomadic herders, fishermen, farmers, and merchants. Many here are business people, merchants, civil servants, and teachers from Mogadishu. These various lifestyles, as well as the climate and geography of the regions of Somalia, influence the dietary patterns and practices of the people. Migration to the U.S. has additional influence on their dietary practices. Interpreters, community leaders, dietitians, and healthcare providers who work with Somali patients were consulted about the dietary patterns of the Somali community in Seattle as well as their knowledge about promoting healthy diet with this population. The underlying goal was to better understand the use of oils and fats in food preparation for patient education related to lowering cholesterol levels. Additionally, these interviews were intended to gain insight about Somali people’s health beliefs to help guide providers towards culturally appropriate health education and promotion, and the prevention of hyperlipidemia for this population.

Epidemiology/Observations

There is limited published data in the literature concerning the prevalence of high cholesterol among the Somali population. Conversations with providers in Seattle revealed a high incidence of elevated cholesterol among their Somali patients. Providers also noted the high frequency of obesity, diabetes and metabolic syndrome in their Somali patients, all of which are associated with hyperlipidemia. All participants discussed the need to expand providers’ knowledge regarding Somali dietary patterns and cultural views in order to better reach this population as cultural interpretations of health play a role in epidemiology of these diseases. In fact, for Somalis overweight and obesity has not been seen as a disease but rather has been considered to be a sign of success, wealth, good health, and happiness. Culinary practices and eating habits often become tools for displaying wealth and power, with oil, fat, and meat as primary components of a meal. (Renzaho, 2004) Clinical impressions by clinicians in Seattle suggest among older Somalis, obesity is becoming epidemic.

Clinical Features

High cholesterol is a risk factor for conditions such as heart disease, stroke, and peripheral vascular disease. Prior to the onset of these complications, symptoms are relatively absent. Because of this, it is sometimes referred to as a “silent illness.” This can be a difficult concept for Somali people. In their culture no disease is perceived as a problem unless it is associated with a symptom such as pain, diarrhea, cough, fever, rash, etc. It is the symptoms that drive one to seek health care and warrant treatment. In Somalia, chronic conditions such as hyperlipidemia, diabetes, and cardiovascular disease are often not tested for and consequently are not well documented and may have gone undetected and/or untreated. Thus, the terms cholesterol and hyperlipidemia may be new to many Somalis. In addition, the concept of preventative medicine is new to many Somalis and testing for asymptomatic illness may be misconstrued as “fortunetelling.” The patient may challenge that only God can say what the future may bring.

Treatment and Prevention

The lack of symptoms associated with high cholesterol can be a challenging aspect of patient education and participation in treatment plans. It requires time and explanation to ensure patient understanding about: (1) cholesterol’s role in the body, (2) long term consequences associated with high cholesterol levels, and (3) goals of therapy.

Approaches for Lowering Cholesterol Levels

1. Food and Nutrition (less fat and oil; more vegetables, whole grains and fiber)
2. Exercise/Activity
3. Medication
4. Combination of all of the above

Therapeutic lifestyle changes (TLC) in diet and exercise are part of the NHBI ATP III Clinical Practice Guidelines for prevention and management of high cholesterol.

Translation or Language Equivalents

Cholesterol: The Somali language does not have a term for cholesterol. The phonetic spelling is kolestarool . A definition of cholesterol and its effects on the body serve as the best translation. Analogies, such as a “clogged hose,” work well.

Somali Dietary Practices

Foods Commonly Consumed

Commonly eaten Somali foods mainly consist of rice, pasta, and meat (goat, camel or beef). Vegetables are included in the meal as a side dish or as an ingredient in stews. The traditional breads and snacks, such as sambosas (fried pastry filled with meat, peas and onions) are considered to be high in fat and carbohydrates while the meats and beans consumed are high in protein and fiber. Sugar is also consumed in high quantities in tea and other sweet snacks. (MIHV, 2005)

In the U.S. the family meal is still the norm. Frying is the most common method of cooking. Lamb or goat meat is considered the best meat to eat. Tea is the most common drink with lots of sugar. Drinking 2-4 cups of sweet tea a day is common. Homemade cakes are often eaten as snacks.

Some Common Somali Dishes

• Malawa, Chapathi, Roti Shanai, and Halwa are high carbohydrate/high fat foods.
• Sambosa, Burkaki, and Maqhumri are high fat foods.
• Ambola, Fool, Iskudahkaris, and Soor are high fiber foods.
• Meat sauce/curry, Sukhar, and Kabaab are high protein foods. (EthnoMed, 2003)

Portion Size

• Somalis traditionally eat family style from one large plate in the center of table. Therefore the divided plate reference for recommended serving sizes may be impractical to adopt. Also, limiting food consumption is contrary to Somali custom in which all available food is eaten at the time it is prepared. In Somalia, most do not have refrigerators to store food.

For more information see Report on Somali Diet.

Food Preparation

Methods of Cooking

Frying food is the most common method of cooking. Women traditionally do most of the cooking. Some people may hire “chore workers” to do their cooking for them.

Oils/Fats Used in Cooking

• Ghee (clarified butter)
• Butter
• Coconut oil
• Palm oil
• Olive oil
• Vegetable oil
• Canola oil
• Animal fats (the fat of a sheep’s rump or a camel’s hump are considered to have healing/medicinal properties)

Quantity of Oils and Fats

Many Somalis use large quantities of fat and oil when cooking. A visible layer of oil on pasta and salad is common and considered healthy.

Precise measurement of quantities is not common cooking practice. It is more common to use a little of this or a pinch of that. For oil, one might gesture with several snaps of the finger to indicate the duration that oil is being poured while cooking.

Suggested Cooking Alternatives

Food	Cooking Alternative
Rice	Steamed instead of fried. Brown instead of white.
Meat	Baked or grill instead of fried. Remove the skin.
Oil	Use olive or vegetable oil instead of butter or ghee.
Quantity	Use less oil instead of more oil.
Spices	Use traditional spices instead of salt or butter flavor products.

Cultural Knowledge

Prevention

 For many Somalis, their focus has been on immediate survival rather than long-term and future-oriented regarding health matters. However, vaccines and immunizations are a familiar form of preventative medicine in their homeland. In fact many equate prevention with immunizations. (Carroll, Epstein, and Fiscella , 2007)

Chronic Illness/Follow-up Vsits

The long term management of chronic illness with multiple visits and long-term therapy is contrary to the episodic care and treatment associated with acute conditions.

Dietary Guidelines

Somalis come from a context where nutrition is key to survival. Caloric or fat restriction is a new concept for Somalis. (Renzaho, 2004) However, the majority of Somalis are Muslim. Somali Muslims are accustomed to following religious dietary proscriptions. Halal foods are those which are allowed and haram are those which are forbidden. For details, see Report on Somali Diet.

Food labels/Packaged Food

Somalis may not be familiar with looking at food labels so it may be necessary to explain how to read and interpret labels with regards to fat content. Many Somalis are Sunni Muslims and may check labels to ensure that pork is not listed in the ingredients, which is prohibited by their religion.

Obesity

Rounded bodies are a sign of wealth, prosperity, and health in the Somali culture. “Fat is beautiful.”

Exercise/ Physical Activity

In Somalia, activity and walking are part of daily life and Somalis are not accustomed to putting time aside to walk or going to a gym. Cultural aspects such as women’s concern about skin exposure and co-ed facilities may hinder participation. (Guerin, Diiriye, Corrigan, and Guerin, 2003)

Death and Dying

Death is considered to be an act of God or God’s Will. It is not something that is feared, but rather viewed as a natural course of passing on. For many Somali patients it may seem arrogant to hear a provider talk about preventing or delaying death, for death is in the hands of God (not their health care provider). Death will come at “one’s time.”

Health Care in Somalia

The effects of the prolonged fighting, combined with years of drought and famine, have had devastating consequences for the health and well being of the Somali people. According to the World Bank 2006 data, life expectancy in Somalia is only 47 years. Social and health infrastructure in many parts of the country are non-existent or poorly organized and regulated. International agencies and the private sector have struggled to fill some of the widening gaps affecting public health services. However, inequality in access to basic health services remains. The scarcity of health care clinics means that people may walk miles for even the most basic of health services.

Common illnesses in Somalia include TB, malaria, infection, parasites, dehydration, and malnutrition. Acute symptoms such as diarrhea, cough, fever, rash, pain, or weight loss are what drive people to seek health care. Pharmacies outnumber clinics and sell drugs of all types and to everybody . Therefore medications are common and often desired. (WHO: Eastern Mediterranean Regional Health System Observatory, 2006)

Also see our Somali cultural profile.

Factors Contributing to Chronic Illness

Lifestyle and Change in Diet

Lifestyle and change in diet may be contributing factors to chronic conditions such as hyperlipidemia.

Somalia

The majority of the Somali people live a nomadic lifestyle. Therefore, Somalis were much more active in their home country. They walked most places and carried what they needed. Being active was a part of their everyday routine.

Markets in Somalia sell whole foods, grains, fresh fruit, fresh milk, and vegetables.

United States

In contrast to the whole foods of Somalia, much of the food in the United States is processed and packaged. Fast food is prevalent, affordable, and convenient. The urban way of life relies on cars and public transportation and therefore, results in less walking.

Stress among Somali refugees is high and related to:

• The loss of loved ones and the loss of home and the likelihood of no return
• Pressures of being in a foreign land with a different language, laws, climate, food, and culture
• The fact that their children adopt customs foreign to them
• Difficulty finding work: language barriers, technical skills
• Lack of money and support systems

“In my country when you buy meat you buy the fattest meat, but later you walk and sweat so all the fat dissolves but here I don’t sweat even with the hottest summer.”

“[In Africa] there was no car, I had to walk or run everywhere. There was no fridge in the house, so I had to go shopping everyday, walking.”

Somali Informants (Guerin et al., 2003)

Barriers to Healthy Eating

• Language
• Packaged foods
• Non halal or kosher (there are some halal stores in Seattle that take coupons)
• Cost
• Convenience
• Lack of disease understanding and benefit to health
• Trust

Also see our Somali cultural profile.

Quotes from Somalis

“In our country, people (who) look big look nice. The culture is basically different. When you look at the nomadic society, which we are from, they exercise from dawn to dusk. Very labor intensive. And health care is very different. Most of the facilities we are from don’t even measure it, cholesterol and all that. So having come here, it is a new concept and it will take a lot of time for it to be realized that heart disease is a priority. They have to see one or two people diagnosed with heart conditions” .

“My husband is health conscious. He goes out and buys skim milk for us. My mother-in-law goes after him and gets normal milk. Sometimes she prepares the food for us, which is full of oil. My husband doesn’t allow us to eat fried food or he doesn’t like us to eat any red meat but my mother-in-law thinks all my kids are wearing glasses because they [don’t eat meat]. It is always a confrontation for me… It is difficult right now. I don’t want to hurt my mother-in-law because she is cooking for me. Something that she fixes, I cannot say no. I know it is unhealthy” .

“We eat meat in the morning, lunch, at night. Three times a day. The concept of healthy food is totally different. The more you eat meat and whole milk and food with oil you look healthy because you are fat .”

“Somali men like a fat woman .”

“The culture we are from is that food is wealth. It is a kind of supplication to God. Eating and feasting together is a socially acceptable culture. The essence to measuring food where you have to have this in this quantity and quality at this time and this time and not at this time (referring to low-fat, 5 fruits and vegetables). It is not in our culture .”

Source:  Minnesota Department of Health: Preventing Heart Disease and Stroke

Tools & Suggestions for Providers

I. Table: Traditionally Consumed Foods, Common Substitutes, and Healthier Options

	Traditional Food in Somalia	Common Substitutes Found in Seattle	Healthier Options
Fruits	Mango, guava, banana, orange, avocado	Banana, orange, avocado	½ of banana available fruits
Vegetables	Cabbage, carrot, tomatoes, legumes	Carrots, tomatoes, lettuce, cabbage, lentils	Limit quantity of salad dressing and oil.
Meats	Goat, lamb, Camel (fish only if right on the coast)	Goat, lamb, chicken, beef	Fish, chicken, Turkey, Goat
Staples	Sorghum porridge, millet, beans, potatoes, maize,	Noodles/Pasta, white rice, potatoes, beans	Whole wheat products, promote ethnic bean foods, such as fooul Cook with less oil
Oils/Butter	Lard, Ghee, Palm oil	Butter, ghee, olive oil	Olive oil, vegetable oil, Canola oil
Dairy	Camel/cow/goat milk	Whole milk, cheese	1-2% milk
Beverage	Tea with honey	Soda, sugary juice	water, decaffeinated tea with less sugar
Seasoning	Cardamom, cloves, cinnamon, lemon, garlic	Dried lemon, salt, sugar	Cardamom, cloves, cinnamon, garlic, fresh lemon (dried powders may have additional salt)

II. Cooking Alternatives:

Food	Cooking Alternative
Rice	Steamed instead of fried. Brown instead of white.
Meat	Baked or grill instead of fried. Remove the skin.
Oil	Use olive or vegetable oil instead of butter or ghee.
Quantity	Use less oil instead of more oil.
Spices	Use traditional spices instead of salt or butter flavor products.

III. Table: Traditional Foods High in Carbohydrates, Fat, Fiber and Protein

High carbohydrate/ high fat foods	High fat foods	High fiber foods	High protein foods
Malawah Chapathi Roti Shanai Halwa	Sambosa Burkaki Maqhumri	Ambola Fool Iskudahkaris Soor	Meatsauce/curry Sukhar Kabaab

Source: EthnoMed, 2003

Prevention

• Help people understand the concept of prevention.
• Years of eating ghee or high fat does not mean that there is no benefit to lowering fat in diet now.
• When discussing long-term effect on health, speak in terms of one’s ability to function independently and maintain responsibilities, rather than the threat of dying. No one wants to be a burden to one’s family and speaking from this premise may help motivate a patient toward healthy behavior change.
• Link high cholesterol to heart disease or stroke to give it a context. Knowledge of these illnesses may help to conceptualize the potential risks and detriment to one’s lifestyle.

Lifestyle

• Acknowledge the differences in lifestyle between the U.S. and Somalia.

Traditional Food

• Emphasize the strengths in their diet such as tomatoes, bananas, spices, red beans, and enjera made the traditional way. Avoid words that convey blame or judgment towards their traditional food and cooking style.

Food Preparation/Oil Quantity

• Suggest decreased quantity of oil by putting oil in a spray bottle and spraying the oil on the food instead of pouring. Offer alternative cooking methods and substitutions for fried foods.
• Ask about how something is made. For example, pasta: “How do you boil the noodles? What do you add to the noodles?”
• Determine how much oil one uses. It may be helpful to ask how many bottles of oil a household goes through in a day or week. Or, ask patient to show how long he/she pours oil onto pan when cooking. Explore ways they can cut down.
• Ask who does the cooking and involve this person in the discussion about food preparation. Most people will eat whatever is offered regardless of whether it is known to be prepared healthfully or not.

Weight

• Older Somali patients are likely aware of the health benefits of weight loss. It is important to keep in mind that in Somalia, body fat is generally viewed as a sign of wealth, success, and beauty. Also, weight loss is often associated with illnesses such as TB.

Goal Setting/Patient Involvement

• se charts and graphs to draw out goals and timelines to help engage the patient in his/her care and the treatment plan. Many people like measurable indicators to show that something is working and it helps to instill trust in the treatment plan. Remember, patients historically may be used to acute conditions that resolved with medication or time, providing concrete proof of efficacy
• Discuss the aspect of long-term management vs. treatment.

Medications

• Discuss potential side effects so that the patient is prepared. Acknowledge that it might seem counter-intuitive to give a medication that might make the patient feel worse for a short while. This instills trust.

Coordination or Care/Referrals

• Involve community centers as well as outreach and resource programs, if possible.
• Coordinate information with the dietitian, social worker, and whoever else may be involved in the patient’s care. Conflicting information is often a reason for a patient not to follow given advice. (Renzaho, 2004)

Suggestions for Community Outreach:

• Involve the whole family in dietary education. Many women are now working and men are at home.
• Provide education about what foods are healthier than others.
• Provide education about cholesterol: what it does in the body and what happens if not treated.
• Group education classes
• Cooking groups/classes
• Use community outreach workers.
• Mosques and sheikhs could be used to share health messages and promote healthy behaviors.
• Somalis listen to religious leaders, health professionals, and people who have experienced a particular illness. Word of mouth works well as the Somali community is tight knit.

Patient Education in the Somali Language

Health Information Translations
Translated information about cholesterol

Health Information Translations: Somali Language
Several health topics including cholesterol

Further Reading

Somali Cuisine - Recipes Wiki

References

1. Burns C. (2004). Effect of Migration on Food Habits of Somali Women Living as Refugees in Australia. Ecology of Food and Nutrition. Vol 43(3) 213-229
2. Carroll, J., Epstein R., Fiscella K. (2007) Knowledge and Beliefs about Health Promotion and Preventitive Health Care Among Somali Women in the United States. Health Care for Women International 28:360-380
3. Guerin P., Diiriye R O., Corrigan C., Guerin B. (2003). Physical Activity Programs for Refugee Somali Women: Working Out in a New Country. Women & Health. Vol 38(1)
4. Haq, A. (2003). Report on Somali Diet; Seattle: Ethnomed Web Site
5. Laverentz M L., Cox, C. (1999) The Nuer Nutrition Education Program: Breaking Down Cultural Barriers. Health Care for Women International 20: 593-601
6. Lewis, T. (1996). Somali Cultural Profile. Seattle: Ethnomed Web Site
7. Preventing Heart Disease and Stroke:  Minnesota Department of Health
8. Diet and Physical Activity in the Somali Community:   WellShare International (formerly Minnesota International Health Volunteers)
9. Renzaho, Andre M.N. (2004). Fat, rich and beautiful: changing socio-cultural paradigms associated with obesity risk, nutritional status and refugee children from sub-Saharan Africa. Health and Place. 10(1) 105-113
10. World Bank Coutry Brief. (June 2008)  The World Bank.
11. Health Systems Profile- Somalia; Regional Health System Observatory:  WHO: Eastern Mediterranean Regional Health System Observatory, Health System Profile, Somalia.  (2006).