If the videos aren't working, please view it on drive; https://docs.google.com/presentation/d/1aUztu8fQL2FYmDo2gjuG-MbtTuKyNBRhmhKxmaroNNg/edit?usp=sharing

1. My interview with Dr. Douma
Cultural food and nutrition in
the mid michigan immigrant
population

2. My interview with Dr. Douma. Introduction
“I am Mari Douma. I am an associate
professor of pediatrics at MSU school of
osteopathic medicine. I teach medical
students in the classroom. I have been
involved in breastfeeding research, I spend
most of my time working clinically at the
ingham county health department pediatric
clinic where we provide to the underserved in
the greater lansing area. About half of our
population are refugees from many different
places in the world, generally wherever there
was armed conflict in the last 5 to 10 years.”
Dr. Douma is also a farmer, and this interview
took place on the farm during some garden
work.

3. Who are we seeing in the office? What is our population?
“Currently we are seeing a lot of
patients that originated in the Congo
and Burma (Myanmar).”
The second Congo war: 5.4 million
dead, 2 million displaced. Continued
violence, disease and malnutrition.
Rohingya people fleeing violence and
injustice: 128,000 internally displaced,
712,700 fled to bangladesh.

4. What are we talking about at the doctors office?
“The first time we interact with these families is during their intake,
which occurs within a month of their arrival. And this is a head to
toe examination to identify any medical issues as well as
developmental screens to identify any developmental issues. We
look at their growth as well as their development. Many of these
children are very small for their age when they arrive and we see
them at the regular intervals that we would see any other child
which is age dependent to monitor their growth. When they come
in for this initial intake we need to convey certain information to
them, that is a major part of any maintenance health visit. We talk
about safety and we need to make sure that they understand that
the children need to be in the appropriate type of restraint in the car
which is totally new information for them. We talk about safety in
the home. We talk about dental care which has generally been
nonexistent for them up until this point, although processed sugars
have not been a large part of diet in many cases up until this point
either. And we talk about diet, diet is a big one.”

5. What are people eating? Is it healthy?
“Most of the folks, when they’ve been living in the camps
have not had access to large quantities of food and they
prepare their traditional foods which focus a lot on whole
grains and non grain starches as well as a wide variety of
vegetables and some animal proteins. Generally they will
prepare things, as they describe it, “all cooked together”.
With different forms of starch on the side. One of the things
having recognized that this diet is actually pretty healthy
compared to what we call the standard american diet or the
westernized diet, which is high in processed foods, we try to
empower the parents to continue to prepare the traditional
healthy foods and not succumb to their children's wishes to
have the standard american processed foods which we all
know are not very healthy.”

6. Encourage and Empower: Nutrition
“So I developed a pictorial guide to facilitate these
discussions since we are working through an
interpreter. I hold the guide in front and point to the two
cups of fruit, three cups of vegetables, the whole grains
and the proteins and then on the flip side we show
pictures of the unhealthy food we prefer they not eat.
And that side always makes the children smile because
that’s the food they wish to eat. But the parents as soon
as I started to do this I noticed that they were nodding
with a certain sense of relief that these healthy foods
that I am encouraging them to eat are what they are
already eating. And they are in a fairly tenuous position,
they’ve arrived here with nothing but the clothes on
their back, they don’t know the language, they’re
significantly disadvantaged socially but they’re doing
something right. And it’s something we choose to build
on and encourage.”

7. Healthy foods: Pictorial guide
The World Health Organization
outlines what a healthy diet for
an adult should look like. Five
portions of fruit and vegetables
per day. Whole grains such as
rice, maize, and wheat are
encouraged. Unsaturated fats
are considered the healthiest
type of fat and should make up
as much of the recommended 30
percent as possible. Nuts and
fish are two of the main good
sources.

8. Unhealthy foods: Pictorial guide
Sugars should make up less that 10
percent of the total energy intake (ideally
this should be less than five percent). This
applies to sugar present in fruit juices as
well as any added or refined sugar present
in processed food, or sugar from cane,
honey, agave, or syrup added to a meal by
the cook. Salt intake should be limited to
about one teaspoon per day and the salt
should be ionized. Total energy intake from
fats should be less than 30 percent. This
takes both saturated, unsaturated, and
trans fats into consideration, however some
are preferable to others. Industrial trans fats
found in packaged and fried foods should
be avoided all together.

9. Healthy children are the goal
“One of the the sad things we often see is that because
of the harsh conditions that many of them came from
there’s a certain value place on a child that is perhaps
on the heavier side because they have more resilience
in the face of devastating circumstances, for example
they can lose a little weight without becoming
malnourished and so we’re working with that
perspective with parents that are happy to see their
children put on weight oftentimes their height growth
will jump percentiles the first few years as they are here
doing catch-up growth essentially. But we monitor that
carefully with a lot of continued education and
empowerment to eat healthy foods in the right amount
so they do not become obese.“

10. Encourage and Empower: Breastfeeding
“There’s a parallel situation with breastfeeding, in this country
we’ve struggled to get mothers comfortable with the process and
the idea of breastfeeding over the last 30 years or so, and we’ve
made a lot of headway, but the mothers have had a lot of struggles.
What I’ve seen with the folks that have come from places in the
world where breastfeeding is very common is that they just assume
they’ll do it, and they do, and they don’t really have the difficulties
that we were so commonly seeing in the US populations across
socioeconomic levels. These moms just expected they would
breastfeed for at least a year and many breastfeed well into the
second year. And again that’s something that in the past because
formula would be provided free through the WIC program, that
would be seen as something more american and more desirable
thing to do, we really emphasize that breastfeeding is really the
healthiest thing to do for the mother and the baby, and that formula
is really substandard to that. So again just to try and empower a
very healthy positive cultural practice they already have and to let
them know that we see that and that is a very valuable thing they
are doing.”

11. Differences of opinion: Children’s wants vs needs
“The children always seem to look very happy
when I show pictures of the unhealthy over
processed foods and they clearly like them and are
familiar with them. We don’t say that you can’t ever
have them, but we try and emphasize that they are
special occasion foods, they are for holidays or
feast days or something like that. They are not
often really keen on eating the healthy foods,
although some parents will relate that their kids
really do like their vegetables or their fruits or they
do well with such and such. Many of these people
are from parts of the world where dairy is not a
common source of food, however it is an easy way
to get calcium in an industrial country. It is hard to
get access to eating foods that have high calcium
content that is not dairy, and again we emphasize
not excessive amounts, two servings a day,
cheese, yogurt, or milk.”

12. Differences of opinion or lost in translation?
There was a recent situation where I was providing the information
to the family a mother and a young teenage daughter who was
translating. The teenage daughter told me they were poor and
could not afford those foods. The mother who did not speak english
but could understand enough about what was going on and she
made it a point to point out all of the vegetables she was indeed
serving her family and that her daughter was indeed spinning off a
bit into other areas. We talked and I asked her what they did eat
and she said they did have their cultural foods that were very
important to them and that they ate and we talked a little bit more
about those and it came down to it being a stew that the mother
would incorporate the vegetables in with the starch and the protein
and we talked about eating healthy foods eating the vegetables did
not mean you have to eat the vegetables separate which can often
be a misconception because traditionally people would just put
everything in a stew or a casserole type situation, and that is
perfectly fine. I do emphasize that throughout the year you can
always find some fruits or vegetables that are not super expensive
in the store and if a child is only eating two cups of fruit a day three
cups of vegetables a day for a child, between frozen vegetables
and inexpensive produce or applesauce it can be very affordable.

13. Barriers to healthy eating
“There’s also a big barrier of poverty, there are some local
markets where people are able to find their cultural foods,
their traditional foods, or at least close approximations of
those”
The story told previously does not mean that poverty is not a
major barrier to healthy eating. Dealing with the
misconceptions surrounding diet is one way to make this
barrier not seem so insurmountable. The exact barriers that
immigrants in Ingham county and mid michigan face is
something we hope to delve deeper into when interviews can
be done firsthand.

14. Barriers to healthy eating
“Well, they can range from transportation; just
getting to the places where the food is sold. And
most of the places in lansing are fairly close by
but you know if you have a bunch of kids and
it’s wintertime and you have to walk to the store
that can provide some barriers. Money is also
an issue, things can be costly. And for the
people who aren’t immigrants just lack of
familiarity with home cooked foods. The
immigrants actually have an advantage there in
that it’s their cultural practice to cook food from
scratch from inexpensive ingredients. And most
of their food is high in fiber which is really
crucial to maintaining a healthy microbiome.”

15. Barriers at the doctors office
“Sometimes time in the office can be a
barrier, sometimes there cannot be
enough time. Language barriers are huge,
pre-covid we would have an interpreter in
person in the office, now we have to rely
on phone interpreters or family members
which can be difficult. I do use pictorial
guides for a lot of things which has made
a tremendous amount of difference. And
we already discussed several of the
economic barriers people have to go
through.”

16. Barriers to health
“A problem that really arises for these
immigrants in staying healthy is lack of
physical activity and that is often due to a
perceived or perhaps real sense of lack
of safety to have the children outside
playing. They are not necessarily living in
the safest areas of the city and the
parents have a lot of reasons to have
concerns and the children really lack
appropriate outdoor time and appropriate
physical activity.”

17. Solutions at the doctor’s office
“Also in our clinic we have a nutritionist on staff and
when we do encounter issues of growth with a child
where they’re getting too much or too little we have
a nutritionist who’s also a certified lactation
consultant who can go in and do extensive
interviews to find out exactly what the child is eating
and how much and formulate a healthy eating plan.
And in fact with the kids that are identified as
overweight they’re routinely having the nutritionist
speak with the family. Help them set goals for some
changes and we see them back every month until
they and we feel they’re on the right track and
we’ve seen some remarkable success with this
program.”

18. Solutions in the community
“There are a lot of programs in ingham county
that are uniquely situated to provide some
excellent services to people, especially pre-
covid days. The building in which the office is
situated also has a women’s health office and a
WIC office which provides a lot of nutritional
counseling to people. The county extension
office is also in there and again, pre-covid days
they would provide free cooking classes where
the participants would get a free bag of
groceries after doing the cooking classes. They
created a cookbook with simple healthy
recipes.”

19. On a personal note...
“In the process of giving presentations to my
colleagues I’ve done a lot of nutritional things and
became interested in the gut microbiome a few
years ago and read many papers on that as to how
it relates to our diet and I've presented on that on a
few different occasions. What’s been really
interesting is how humans in the past probably ate
well over 100 grams of fiber a day, while we’re
encouraged to get 20 to 30 grams of fiber now as a
minimum and people only really get half of that.
Fiber comes from plant based foods and it’s really
important, and it’s interesting that eating a variety of
plant based foods helps support different
populations of gut microbes which are beneficial.”

20. Basil seeds from Thailand
“This is the plot that I will be growing
basil that came from seed that came
from thailand, one of my colleagues a
nurse practitioner came from thailand
then she was a young child she brought
the seed along and hid it in her pockets
because she wanted to make sure she
could grow that when she came to the
new land here. So it’s something I’ve
been really proud to propagate myself
and to continue.”

21. Seeds of thought from Thailand
“When I was in Thailand and when she came here
to visit us it was just so impressive the variety and
diversity of the vegetable products in their diet.
When she was looking at my garden and saw the
carrot tops she said you can eat these, we don’t eat
carrot tops here [in the US] we just eat the carrots,
and I never would’ve thought about that. When
you’re in the market [in thailand] you see all sorts, a
huge diversity of different seafood and different
types of plant materials that are eaten and that’s
why they have a healthier gut microbiome because
they eat a wider variety of foods, and that’s
something we should be doing too for a healthier
gut.”

22. What can we learn?
-Encourage and empower immigrants to continue their traditional diet and
practices.
-These traditional diets lead to a much healthier and more diverse microbiome
- There are obstacles and misconceptions which can hinder healthy diets.
-Health professionals are a big part of this process.

23. Bibliography
Who.int. 2021. Healthy diet. [online] Available at: <https://www.who.int/news-room/fact-
sheets/detail/healthy-diet> [Accessed 14 April 2021].
Global Conflict Tracker. 2021. Rohingya Crisis in Myanmar | Global Conflict Tracker. [online]
Available at: <https://www.cfr.org/global-conflict-tracker/conflict/rohingya-crisis-myanmar>
[Accessed 14 April 2021].
Bavier, J., 2021. Congo war-driven crisis kills 45,000 a month: study. [online] U.S. Available at:
<https://www.reuters.com/article/us-congo-democratic-death-idUSL2280201220080122>
[Accessed 14 April 2021].
Thank you Dr. Douma for being my most importance source!