I worked with a wide variety of people in five cities in South Africa: Pretoria, Durban, Cape Town, Bloemfontein and Johannesburg. Each part of the country had different cultures and foods. For example:

English speaking

- For those who spoke English, their foods and manners were influenced by the British.

- A large Portuguese population was also present due to nearness of Mozambique. Their foods are deliciously spiced.

- I also had a large Jewish practice and consulted to a Jewish Hospital. Kosher rules would vary according to each individual and this had to be identified. In the hospital, the kitchen was Kosher, so there were certain areas I was not allowed to enter, as I am not Jewish.

Afrikaans speaking

My practice was bilingual with handouts in Afrikaans as well. You needed to know the foods they ate and respect their family values, as they were sensitive on many issues. There was Dutch, French, Indonesian and Malay influence in their foods. They ate foods such as “bobotie” (meatloaf with curry), vegetables prepared with butter and sugar, “koeksusters” (fried twirled dough dipped in syrup), and “biltong” (dried salted meat).

Among the population I worked with, there is a group with familial hypercholesterolemia (FH), an autosomal dominant disease caused by mutations in the LDL receptor gene. It is five times more frequent in the Afrikaner population of South Africa than it is in the population of the United States and Europe. (J Clin Invest 1989 Sep;84(3):954-61) They often die from sudden death between the ages 11 and 27 years. One teenager came to see me with a cholesterol level of 16 mmol/l (650 mg/dl). One married couple, both with FH, came to me. They had started their children on cholesterol lowering drugs from six years of age. I helped them with their diet but their eating habits were among the best I’d seen. You feel quite helpless in these situations.

Indians

A dietary history would determine their way of eating, mainly Hindu or Muslim. You would need to understand they ate with their right hand, loved their sauces and cooked with ghee, a clarified butter. Some ate only Indian foods at home, prepared by the women. Others were more westernized. However, they had the same problems as western societies do: obesity, diabetes and high blood pressure, and the same rules apply: less fat and smaller portions.

Black African people

Those who came to see me were very wealthy and referred by their doctor. They arrived in their chauffeur driven Rolls Royce's and an entourage. However, this did not matter to my receptionist. She was from the Zulu tribe. If the patient was from the Xhosa or Sotho tribe or any of the other 40 tribes, she would walk out of the reception area, and not return until the client had left. No matter how many times I explained to her the doctor had sent the patient, she felt I was being disloyal by seeing someone from another tribe. You cannot change their feelings. These patients were well educated and wanted their meal plans in English. Their diet would vary from English style foods to traditional foods. Actually, I LOVED the African traditional food. It is puthu pap, a stiff cornmeal porridge, served with a meat, tomato and onion sauce. Delicious. Even now I go to Brooklyn, NY, to a South African restaurant, to eat this dish. My American friends seem to play with it more than eat it. Elephant and Mopani worms - part of the African diet - are seldom served to tourists. Ostrich, wildebeest, crocodile, springbok and guinea fowl are popular for tourists in game reserves.

Study Subjects

With my first master’s degree, my subjects were 50 white and 50 black colostomates, comparing the difference in eating habits and concerns. The interesting differences were: whites had colostomies mainly due to cancer; young blacks had colostomies due to stab wounds; and older blacks had colostomies due to enemas by witchdoctors. The potions had destroyed the colon. Whites were more depressed and very aware of noisy bowel movements, gas, diarrhea, constipation, their appearance and their change in lifestyle. The blacks did not consider these problems serious, as they believed it was the workings of the body and they were fortunate to be alive. With some of the rural black subjects, I needed a translator. The nurses at the hospitals were very helpful.

Specific to developing countries

When it came to deficiency diseases such as kwashiorkor and marasmus, we would go to the wards to see these patients. You didn't see under nutrition in the cities or townships; they came from the rural areas. One of the main reasons was that men were fed first, then children; women had numerous children; once breastfeeding stopped, there was little food for that child and the mother would fall pregnant again. They lived far away and would take days to get the malnourished into the hospital. Unfortunately, once the child recovered, the mother would return to the rural areas and the cycle of more pregnancies and under nutrition would set in again.

Obesity

Hypertension is a big problem and getting women to lose weight is difficult. Women are considered attractive and wealthy if they are obese. I come from an overweight family. My mother was involved in fundraising with other Canadians where they sold clothes for charities. Black women would only buy from my Mom, as she was "wealthy and beautiful." Needless to say, the other Canadians were fashionably slim and "ugly" in their minds. I was considered wealthy too as I was overweight until I decided to practice what I preach before moving to North America. My cook felt sorry for me while I was losing weight. In her mind I couldn't enjoy large portions of her food and I was making myself unattractive.

Lactose intolerance

Lactose intolerance is high among the black race. My cook used to be happy when milk went sour, because she would use it to make sour puthu pap.

Giving talks and media work

For one organization, I would teach nurses from different cultures the basics of eating well on a low income with traditional foods. We used pictures. The nurses would then go into the rural areas by horseback, speaking the language of their people. As they were nurses, they could identify malnutrition and illnesses and send the people to the nearest hospitals.

I would give talks and be interviewed in English or Afrikaans. Although I also speak German, Dutch and French, I am not fluent enough to give talks or do media work in these languages, however I have been called on to translate at hospitals and universities.

I hope you don't feel it was all doom and gloom in the nutrition field in South Africa. People were cheerful with a great sense of humor. They had me laughing all the time.

You can find more information on Dining in South Africa on my website.

My tips for multi-cultural counseling

- Use the Internet and read whatever you can on the client’s culture.

- Expand your horizons with different cultural foods and food practices.

- Don’t apologize because you don’t understand their culture’s eating habits. Explain this is new to you and you will learn from them, and adapt their foods to a healthy meal plan. When new in Canada, I had a client threaten to walk out of a counseling session because she had binged on Oreos, and I didn’t know what an Oreo was. She felt I was ignorant.

- When moving to a new country, learn the spelling, metric blood values, and local foods quickly. Taking the country’s dietetic registration exams will get you started. Transcripts of your degrees and internships direct from the college to the new country’s registration department are needed.

- Don’t fear taking on a client from a different culture, you can learn a lot and help them as well. Often, they don’t have someone from their own culture who is available.

- Consulting across cultures: Learn whatever you can and ask questions when taking a dietary history. Ask questions if there are some things you don’t understand when taking a dietary history.

- With language barriers, people may come with an interpreter. Estimate twice the amount of time for counseling. Keep in mind when using interpreters that not everything can be interpreted exactly the same. You can also request an interpreter or use telephone interpreter services, such as AT&T’s Language Line to help with the counseling session.

- Multi-cultural materials are available in each country. Read and refer to them.

- In my experience, developing cultural sensitivity, i.e. getting information of how to approach and counsel someone from a different culture, didn’t seem to be a problem. They accepted that I was from a different culture, and were grateful I was willing to help them.

From the Nutrition Entrepreneur’s Ventures newsletter.