Improving Nutrition in Spanish-Speaking Communities, with Maria Aguero de Manunta

Maria Aguero de Manunta is a local dietitian from Paraguay who previously worked for Neighborhood Health Center in Buffalo, New York.  As a Spanish-speaking dietitian, she is making significant progress in reaching our predominantly Spanish-speaking population in Buffalo related to nutrition care, specifically diabetes, weight management and heart disease.  Maria is currently serving as the Clinical Director for University at Buffalo's Department of Exercise and Nutrition Sciences.  

Resources: Maria LifeStyle Nutrition

Credits: 
Host/Writer: Nicole Klem, MS, RD
Guest: Maria Aguero de Manunta, MS
Production Assistant: Sarah Robinson
Video/Audio Editor: Omar Brown
Theme Music: Sungmin Shin, DMA
Faculty Consultant: Nicole Klem, MS, RD

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Transcript

Intro  0:00 
Welcome to Buffalo HealthCast, the official podcast of the University at Buffalo's School of Public Health and Health Professions. We are your cohosts, Schuyler Lawson and Tia Palermo. In this podcast, we'll cover topics related to health equity in Buffalo, around the US, and globally. This season we'll be talking about nutrition from a health equity perspective. You'll hear from community members, practitioners, researchers, students, and faculty on topics related to nutrition, including food security, food access, social protection to improve nutrition outcomes, food apartheid, culturally tailored nutrition interventions, and more in this season of Buffalo HealthCast.

Nicole Klem  0:48  
Hello everyone, and welcome to another episode of Buffalo HealthCast, the University at Buffalo's premier public health podcast. I'm your host today, Nicole Klem, a registered dietician and Director of the Clinical Nutrition graduate program in the School of Public Health and Health Professions. It's National Diabetes Month in November and the CDC estimates there are 34 million American adults living with diabetes, and an estimated 88 million more may be at risk of developing the disease. Hispanic or Latino people make up a diverse group that includes people of Cuban, Mexican, Puerto Rican, South and Central American, and other Spanish cultures and all races. Each has its own history and traditions. But all are more likely to have type 2 diabetes - 17% more likely than non-Hispanic white people, who have an 8% chance of developing diabetes. But that 17% is just an average for Hispanic or Latino groups. The chance of having type 2 diabetes is closely tied to background. For example, if your heritage is Puerto Rican, you're about twice as likely to have type 2 diabetes as someone whose background is South American. With us today is Maria Aguero de Manunta, a registered dietitian and owner of a local private practice, and Clinical Director of the Clinical Nutrition graduate program. Thank you so much for taking the time to speak with us today. So I'll begin by asking you to tell me about yourself and why you started in nutrition and became a dietitian.

Maria Aguero de Manunta  2:19 
Hi. So I am originally from Paraguay, South America, and I moved to the United States with my husband and four children in 2001. We love Buffalo and now it is our home. I chose to become a dietitian because of my love for food. I grew up in a German town in my country, and one of the traditions in the town was baking wonderful German cakes and cookies. And after we finished with everything, we shared all these delicious pastries with friends and neighbors. And I can say that my love for food started when I was very young. I was always interested in working in the healthcare field to help others. And I thought that becoming a dietitian was a perfect career for me. I always wanted to learn more about foods and healthy eating. So I think when I started my nutrition career, this one, I learned a lot and I feel that I can help my patients and even friends and family who asked me about what is maybe the best food to eat if I have elevated cholesterol.

Nicole Klem  3:47 
That's really exciting. So this year's Diabetes Awareness Month is "It takes a team." Does the dietician work together with other health care providers?

Maria Aguero de Manunta  3:56 
Yes. The dietician work with other health care providers in the team, and we call this the interdisciplinary team.

Nicole Klem  4:07 
So what is the role of the dietician on that interdisciplinary team? And then what barriers do Hispanic and Latino communities face getting to that team or accessing that team?

Maria Aguero de Manunta  4:19 
The role of the dietitian in the interdisciplinary team is to work closely with other providers to manage and improve patients in the community health. As a member of a team, dieticians can help patients to meet their needs, not only about nutrition, but about any concerns that the patients can have. Because we are very closely working with providers and this interdisciplinary team, if our patient needs to make an appointment with the dentist, we can contact the patient and the patient can get that appointment faster because we are there, and sometimes we talk with our patients, and sometimes the patient says, "Okay, I really would like to see a counselor." So we have a counselor. If we don't have, in the place where we are working, we can refer to some counseling in the area, so that we can guide our patients not only if they have any nutrition concern, but about all their concerns. You mentioned, what barriers do Hispanic and Latino communities face accessing that team. When I did my Master's in Nutrition Science, I had to work on my thesis, and the topic of my thesis was assessing barriers that prevent treatment compliance in Hispanic adults with type 2 diabetes. And what I found was that the most significant barriers were lack of transportation in language and communication. My patients always said that they prefer to receive information in Spanish when they go to see their doctors or any providers. But sometimes they say that the doctors give them educational materials in English, and they cannot understand most of the information. Or I have a lot of patients that they cannot come to their appointments because they don't have transportation, and Medicaid offers cab or taxi. But sometimes they said, "I had an appointment with my doctor or with you, but they didn't show up, the driver didn't show up or the driver called and said, No, I cannot come", so they miss their appointments. So I believe that lack of transportation is a very important issue for them. The other barriers were access to health care and other providers, related to lack of health insurance, so they cannot pay out of pocket there. There's the consultation with the doctors, or if they have some oral health or oral problems, they cannot go to the dentist because they say that it's very expensive, they cannot afford it. So the limited budget is another barrier that I found. Other things that I found was family support and environment influence. So when they mentioned about this, they said that sometimes they want to follow maybe a healthy diet because the patient has diabetes, but because they have to buy the foods, and it's going to be very expensive, just buying for the patients who have diabetes. So they say that they have to buy - they have to cook the same food for the whole family. And sometimes they said they don't find that support in the family. So they if they have to follow a diet maybe very low in sugar, especially refined sugars, and they said, Oh my cousin brought for me some donuts or cookies and I cannot say no. So those are the most important barriers that I found when I did my thesis and the result those were. And this also demonstrated the need for qualified providers - dieticians who speak Spanish fluently, and understand that diverse Hispanic culture.

Nicole Klem  9:03 
All right, thank you. It must be a challenge really to overcome some of those barriers because of the limited numbers of providers that speak Spanish, particularly in areas like Western New York versus other, you know, more Hispanic- or Latino-dense communities. The CDC estimates that one in two people of Hispanic and Latino background may actually develop diabetes in their life, but it's due to so many reasons. Sociocultural factors like lower income, like you mentioned, decreased access to education and to healthcare, again, points that you made that are barriers, which may be due to a combination of language barriers, lower high school graduation, employment and lower wage jobs, some genetic susceptibility to obesity and higher insulin resistance. Racial inequity is also embedded in that health care system. So despite growing numbers of Hispanic and Latino communities, can you help us understand or explain why these communities are still underserved by dieticians, and how do you see things changing?

Maria Aguero de Manunta  10:03 
As I mentioned before, many Hispanics have a hard time accessing dietitian services because they do not have health insurance, or the health insurance that they have do not cover dietitian services. And they cannot pay out of pocket because I believe that dietitians charge maybe $80 to $120 an hour for their services. And they say that that is very expensive, because if they - some patients explain to me that if they go to see a dietitian, and they have to pay $80 for the dietician service, and then they are not going to have the money to buy the food. So it depends if the patient really doesn't have a limited budget, I think they have a very hard time to see a dietitian. I think that what needs to happen is that health insurance providers need to cover medical nutrition therapies in the same way that they cover all their medical specialties.

Nicole Klem  11:18 
How do you think that nutrition education and counseling could be made more accessible to the communities?

Maria Aguero de Manunta  11:24 
This is a complex social issue that needs are tackled from different front. The main one is education so that the community can understand what needs to be done. The professional community to raise awareness of the importance of these therapies, because I think dieticians, when they are doing their counseling, it's not just to help patients if the patient has diabetes, but it's to prevent disease. So we are here to counsel or to provide nutrition education to prevent maybe the patients can have diabetes in the future, can have cardiac events, can have hypertension. And also government agencies need to work with insurance provider to make nutritional services available to the larger population. And according to Healthy People 2030, the goal is to reduce the economic burden of diabetes along with the disease, and to improve the quality of life for people at risk, or who already have diabetes. And one of the objectives of Healthy People is to reduce the amount of new cases per year of diagnosed diabetes in the population and to reduce the diabetes death rate.

Nicole Klem  12:59 
Yeah, I hope we make some progress on those goals, unlike some other goals, and we see some reward for that effort. Would you tell me a little bit about your experience working at Neighborhood Health Center and with our Spanish-speaking Western New York community?

Maria Aguero de Manunta  13:14 
Yeah, Neighborhood Health Center has different locations. And one of their location is called Mattina, where I worked for six years, a little bit more, and the majority of their patients are Hispanic. They are really always looking for providers who speak Spanish. And they have a lot of representive staff who speak Spanish and these staff really help patients with all their needs. I was working as a Clinical Dietitian there, and 80% of the patients that I saw were Hispanic-speaking, so 80% of the patients that I saw every day, and they were really very happy because every time when I am with them, they said, "Oh, I am so happy because you speak Spanish and I can understand every single word that you say." Because once you speak Spanish, you can understand everyone in the world. If the person lives in Uruguay, I am from Paraguay, from Puerto Rico. So there are going to be maybe little words that are different, but that doesn't mean that we cannot understand someone who speaks Spanish. I can speak 100%, or maybe 99% with a person from Spain. So that's why the communication is very fluent, so we don't have any problems, and we also understand their culture. I learned a lot about Puerto Rican culture, Dominican culture here because when I was living in my country, we have our culture related to foods - it's a little different than food from Puerto Rico or from Dominican Republic. But I learned a lot with my patients. And I love their foods. And when I mentioned to them the food that we eat, they said, Oh my God, I want to try that food too. So there are very similar foods, but there are very different. Like when I was living in my country, I think I never tried tacos until I came to the United States. So I learned about Mexican food here in United States. So Neighborhood Health Center, they have one program that is called a sliding scale fee program. They provide some discounts for patients who qualify so they can offer their services to see dieticians, dentists, doctors, any providers there with a very low cost.

Nicole Klem  16:07 
Wow, what a great service and what a nice, sort of patient care model, you know, for our Spanish-speaking community in Western New York. In your experience, what kind of disparities do you see between the Hispanic and non-Hispanic communities in Buffalo related to diet and nutrition?

Maria Aguero de Manunta  16:25 
Based on my experience, I noticed that the Hispanic population has a higher tendency to acquire type two diabetes compared to the non-Hispanic population. Other things, too, is because they're low budget, they cannot go to the gyms or do physical activities, especially during the winter time. And so they start having more problems about elevated cholesterol, hypertension, and of course, then they can have any other health conditions.

Nicole Klem  17:04 
You do see it a little more often just because of some of those, maybe, you know, sociocultural barriers they've got, or different, you know, living conditions. In general, and I want to say even in education, we sometimes hear that Hispanic diets are unhealthy - high sugar, high fat from fried foods. But is that true? And would you tell me a little bit about the foods and recipes in the Hispanic diet and where maybe the bias or the assumption about their foods has come from?

Maria Aguero de Manunta  17:37 
The Hispanic diet is not one, but many, depending on from what country a specific community comes from, diets vary greatly. But in general, these diets are like most - they have good things and not good things like everywhere, I can say. On one hand, it is true that there is a high intake of sugars and fat, but on the other hand, Hispanic communities tend to avoid processed food and give preference to fresh home cooked meals. So most of my patients mentioned that they cook at home, but sometimes they, of course, they go to Burger King, McDonald's restaurants but they cannot even afford to go many days. Like maybe, I don't know, five times per week, but maybe sometimes they go one or two, but they really cook at home. When we go and review their eating habits, I know that some cultures - they eat more rice and beans than other cultures, or maybe less vegetables but one of my patients explained to me that in Puerto Rico they don't eat too much vegetables because they don't have a lot of vegetables over there or maybe in the area where this patient was living especially. And he said, So that's why they eat lettuce and tomato, but like in my country, we don't have, maybe broccoli, so we are not used to eating a lot of broccoli. If someone wants to eat broccoli, maybe, I don't know, they have to pay more than just buying lettuce and tomatoes. The same in Puerto Rico, but that doesn't mean that we don't eat vegetables. And there are some foods that are high in fat, such as the pork - it's called "pernil" in Spanish. It's so good, I love it. And these foods, it's very high in fat, but you can make a very lean pork too -a very lean pernil, and they have another meal or food that's rice and beans, or rice with ganulas, so the gandulas are very similar to beans. And they make some dessert, that one of their cakes is called torta de tres leches - it's very good, and I can say doughnuts, those are high in sugar but they don't eat like every day, so it's more like on special occasions. The other dessert is called flan. I love it. So, yeah, they have some foods that are high in sugar or fat. And some bananas, fried bananas, that I love it. But yes, but once they started learning about - they see the dietician, they they learned that they can still have those foods, but in moderation. It's not that they are not going to have them for the rest of their life, if they have diabetes, sometime they can have it. But they create a healthy routine, some patients who are - who really need to make some changes in their diet.

Nicole Klem  21:18 
Where do you think some of the assumptions that it is unhealthy have come from? Do you think it's just because we see brown rice, chicken and broccoli as healthy? And we don't see rice and beans and lean pork as healthy? Or? Yeah, where do you think some of the, I don't know, assumptions that that diet is unhealthy have come from? Because you're right, we have chicken wings, and doughnuts and pizza, plenty of unhealthy things in our diet, but we maybe aren't as critical or judgmental on, you know, the diet we eat here versus a different cultural diet.

Maria Aguero de Manunta  21:53 
Yeah, so I think it's because maybe the portion sizes than what they are eating because they love - Puerto Rican people love rice and beans. And when I mentioned that to my patients that they have - or what is the portion size that you are eating about your rice and beans, and they said, show me about the fists of your hands. So they start laughing when I show them that the recommendation is to have one fist of the hand, and they start laughing they say Oh my God, I maybe have two or three or four or full of my plate. But once they learn what is the recommendation about starchy vegetables and grains, they really start cutting down the portion sizes. And, of course, they have, as I mentioned, like fried bananas or other foods that are high in fat. But I believe that maybe that is more related to the portion sizes.

Nicole Klem  22:57 
You know, and I guess you kind of lead into my next question, because if there is some truth to that - maybe the portion sizes are a little bigger foods, are there specific recommendations that you give them to modify their diets, while still telling them they can include some of these favorite foods? So maybe reducing the portion size slightly? Are there other tips that you give them to enjoy the foods that they enjoy, but still, you know, move towards maybe a more, you know, healthier choice overall?

Maria Aguero de Manunta  23:26 
Yes. And as dietitians, we have to be very careful when we provide nutrition education to our patients, because we have to take into considerations their culture, their beliefs. So we cannot just walk with our patients, even not just, I would say not just Hispanic, any person in the world, we have to learn about their cultures, what their preferences, we cannot just go to a patient or a patient who is Asian patient who they love rice. And we cannot say, You cannot eat rice anymore. So we have to go and understand what they want and what they believe. And then of course, we can start with our nutrition education and recommendation. And because there are other factors, like I don't know, maybe the biggest factor is the one of the budget. So we cannot recommend a patient to eat salmon if the patient have elevated triglycerides, but there are options, so we can tell the patient you can eat tuna fish, which is cheaper or they can get from their food pantry. So we have to be very careful about that in any recommendations that we are giving to our patients and understand first what our patients want. And based on that, we can start and do the recommendations. I always recommend my patients to have the rice and beans or rice with gandulas in moderation. I recommend them to have half of their plate with a starchy vegetables. Or if they cannot go so fast to that portion size, I told them gradually, maybe you can start reducing that and adding more starchy vegetables. And we go over to how to prepare meals, maybe better bake or grill chicken or any meat, lean meats and you're not going to believe but at the next visit, they said, Oh, I buy the air fryer, so they want to make those changes, because they know that this is important for their health.

Nicole Klem  25:55 
Yeah, that sounds like small changes could really add up but also preserve some of their favorite flavors or foods or dishes. So where do you go to find reliable resources or tools for your patients or for Spanish speakers?

Maria Aguero de Manunta  26:13 
I go a lot to MyPlate.org because they provide a lot of recipes in Spanish and English, even they have now in so many different languages. So if I have a patient from Arabic or Africa, they have a lot of options now in those languages. And when I was working at Neighborhood Health Center, we develop our educational materials, I think now they have five different languages. So Arabic, I cannot remember very well, but they have a few educational materials in other languages. So MyPlate.org is a very good resource, very reliable. Centers for Disease Control and Prevention, the CDC, they have materials in Spanish and the American Diabetes Association.

Nicole Klem  27:16 
Yeah, really fantastic resources for us to build our toolboxes. Well, thank you this has been really wonderful. Is there anything else you'd like to share?

Maria Aguero de Manunta  27:26 
I believe that it is important of providing more bilingual services and qualified dieticians, who speak Spanish fluently and understand the diverse Hispanic culture, as well as funding for programs to reduce the financial burden of these segments of the country's population. Because low income and a relative lack of financial resources can severely impact a patient's ability to treat diabetes and other chronic conditions effectively.

Nicole Klem  28:05 
This has been another episode of Buffalo HealthCast. Thank you to our guest, Maria Aguero de Manunta, for taking time to speak with us today. I'm your faculty consultant, Nicole Klem, Sarah Robinson is our Production Assistant. Omar Brown is our Sound Editor. And our theme music was written and recorded by Sungmin Shin of the UB Music Department. Again, my name is Nicole Klem, your host and writer for this week's episode. And thank you for listening. Tune in next time to learn more about health equity in Buffalo, the US, and around the globe.