Supplementary Data Part One: Please circle your answers, or write the information requested in the space provided.

1. My academic major is nutrition/dietetics: Yes No If you answered No, please return this questionnaire to the survey administrator without answering any more questions. If you answered Yes, please complete the rest of this questionnaire. 2. 3. 4. My gender is: Male Female

My age is ___________ years My racial/ethnic identity is: Non-Hispanic White Non-Hispanic Black Hispanic Asian or Pacific Islander American Indian, Alaskan Native, Hawaiian Native My year in school is: Freshman Sophomore

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I have taken a college level course that taught information about the foods, communication styles, and health beliefs of people from other cultures: Yes No I believe that the dietetics curriculum at my university should teach more information about the foods, communication styles, and health beliefs of people from other cultures. Strongly disagree Disagree No opinion Agree Strongly agree Which of the following potential barriers have prevented you personally from learning more about the foods, communication styles, and health beliefs of people from other cultural/ethnic groups? Circle all that apply. A. Monetary restraints keep me from learning more about other cultural/ethnic groups B. Not enough time to learn about other cultural/ethnic groups C. I have little interest in learning about other cultural/ethnic groups D. Family discouraged interaction with people from other cultural/ethnic groups E. Not enough information about other cultural/ethnic groups taught in my college level nutrition courses F. Dont know where to find information about other cultural/ethnic groups G. Little exposure to people from other cultural/ethnic groups in the community where I was raised H. Inadequate language skills I. Feelings of anxiety when interacting with people from other cultural/ethnic groups J. Other barrier: (Please identify) __________________________________________________

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Would you be interested in learning more about the foods, communication styles, and health beliefs of people from other cultural/ethnic groups? Yes No

10. Are you interested in counseling clients as part of your future job responsibilities? Yes No Part Two: Below are four case studies of ethnically diverse patients with type 2 diabetes mellitus (T2DM). Please read each case study carefully and answer all of the questions that follow each case. Case I: An African American client with type 2 diabetes mellitus (T2DM) Sylvester Malone is a 45 year old married African American high school graduate and father of two children. He was referred to a registered dietitian (RD) by his physician for nutrition counseling for T2DM. Sylvester grew up in a small town in the Southeastern United States and moved to a large Midwestern city where he is employed as an electrician at a local manufacturing plant. The RD calls him Sylvester and greets him with a smile, a handshake, direct eye contact, and invites him to sit in a chair at a table across the room from her desk. The RD discovers that he was seen by another RD six months ago and was scheduled for a one-month follow-up appointment that he did not keep. While reading the notes, the RD asks him why he did not keep the appointment. Sylvester looks down at some pamphlets on the table and says I had to take one of the older deacons in my church out of town to visit one of his sick friends. The RD informs Sylvester that by missing the follow-up appointment, he was endangering his health, and asks him if doing a favor for a church member is more important than taking care of his own health. Sylvester replies Yes, doing a favor for an old man who does not have any children in the city to do things for him is the right thing to do. What would God think of me if I did not help an old man? I already have sugar diabetes. After reviewing notes from the last visit, the RD moves to a chair next to him where she hands Sylvester a preprinted set of instructions and begins to explain the diet. The RD looks up from the instructional materials occasionally to ask Sylvester if he understands the diet. Rather than answering her directly, Sylvester occasionally utters I see. After 30 minutes of this type of interaction, the RD asks if he has any questions, and Sylvester replies that he does not. The RD schedules a follow up appointment with Sylvester. As the RD walks Sylvester to the door, he says I am not sure that my wife can cook the way you talked about. Even if she did, I am not sure we would really eat it. What did I do to deserve this curse? Id better ask Pastor Jones to lay hands on me real soon. The RD replies I will see you in three months. Good luck! 1. In view of his African American heritage, which beverage would be least acceptable to Sylvester? A. Coffee C. Milk B. Sweet Tea D. Fruit flavored drink

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Which is most likely Sylvesters preferred method for cooking fish? A. Fried C. Baked B. Broiled D. Poached Which is most likely the primary protein source for Sylvester and his family? A. Veal C. Pork B. Beef D. Lamb Which vegetable is most likely prepared by Sylvesters family by adding a ham hock? A. Carrots C. Potatoes B. Beets D. Turnip greens In view of Sylvesters African American heritage, which would have been the most culturally appropriate way for the RD to instruct this client? A. Giving him action oriented instructions such as advising him to eat chicken oven fried instead of pan fried B. Instructing him to keep a full record of his intake each day C. Instructing him to weigh out each portion of his meals D. Explaining that many soul foods will not be acceptable for his diet By not looking directly at the RD, what was Sylvester most likely communicating to her? A. Boredom with the diet instruction B. Disinterest in learning about the necessary dietary changes he would need to make C. Interest in listening intently to the instructions D. Embarrassment about his lack of knowledge of diabetes During the counseling session, Sylvester occasionally said, I see. What was he most likely communicating by using this expression? A. Agreement C. Apathy B. Rudeness D. Confusion Which would have been the most culturally appropriate response from the RD when Sylvester said, I am not sure that my wife can cook this way, or if we would really eat it.? A. Placing a hand on Sylvesters shoulder and saying, I am here to help you with the diet, please call me anytime. B. Saying to Sylvester, You may have to help your wife and family adjust to your dietary needs by helping her prepare meals. C. Extending open arms to Sylvester and saying, I see. D. Shaking Sylvesters hand and saying, It would be all right if you brought your wife to the next visit.

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9. Given Sylvesters African American heritage, why did he ask, What did I do to deserve this curse? A. Because he wanted the RD to feel sorry for him B. Because he wanted the RD to give him a more personal cause for his diabetes rather than the medical cause she provided during the counseling session C. Because he feared his wife would feel unappreciated when he returned home and told her about the prescribed dietary changes he would need D. Because he was feeling embarrassed after being scolded by the RD] 10. What do many African Americans believe to be the primary cause type 2 of diabetes ? A. A virus C. Worrying B. Inadequate sleep D. Frequent exposure to cold temperatures

Case II: A Navajo client with type 2 diabetes mellitus (T2DM) Will Whitefeather, a 48 year old Navajo, lives with his wife in a rural settlement 10 miles from the Navajo reservation in Arizona. He completed the eighth grade at a government school on the reservation and worked for various sheep ranchers in the area. Will was diagnosed with T2DM five years ago and has taken oral medications sporadically as money permits. He was instructed on a diet for diabetes at that time but has not followed the diet. During times of unemployment he eats small amounts, primarily fry bread, coffee and supplemental food from the family garden. He and his wife also get commodity foods. When employed as a ranch hand he eats large amounts of mutton. He has a strong family history of diabetes, with several relatives having had severe complications from the disease. During the past three months he has been experiencing increased thirst, urination, and excessive fatigue. Will went to the medical facility on the reservation where the physician explained that his diabetes was poorly controlled and referred him to an RD. However, on the day of Wills appointment with the RD, his mother was feeling poorly and he visited with her, missing his appointment. He rescheduled and was accompanied by his wife. The RD scolds him mildly for missing the first appointment and explains that he would need to stay at least an hour-and-a-half so that she can instruct him. The RD takes a thorough diet history. When he replies I dont know to a question, the RD redirects the question to his wife. His wife averts her eyes and gives a slight head shake to the redirected questions. The RD gives Will a diabetes exchange booklet with a dietary pattern, and plans a typical days menu using the pattern she has calculated. At the end of the session, the RD instructs Will to record his entire food intake for the next two weeks and to return for a talking circle at the end of that time with other Navajo clients with T2DM. 1. Given his Navajo heritage, which food would be LEAST acceptable to Will? A. Sugared cereal C. Soda pop B. Asparagus D. Peanut butter Which is a part of Wills traditional Navajo food habits? A. Scones C. Corn bread B. Fry bread D. Biscuits

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Which would be a staple food in Wills diet if he adheres to traditional Navajo food habits? A. Bread C. Wheat B. Corn D. Potatoes Which type of fruit would be most acceptable to Will, given his Navajo heritage? A. Pears C. Tangerines B. Plums D. Berries What is the most likely reason Wills wife did not respond to the questions that were redirected to her by the RD? A. Females are subservient to males in traditional Navajo culture B. It is considered inappropriate to answer for another in traditional Navajo culture C. She did not understand the questions D. She did not know the answers In view of his traditional Navajo culture, which counseling strategy would Will have responded to most positively? A. Detailed diet history C. Inviting Will to a talking circle B. Providing the exchange booklet D. Reviewing his lab values in detail What would have been the most culturally appropriate way for the RD to begin the counseling session, given Wills Navajo heritage? A. Ask Will yes/ no questions until he was comfortable B. Begin with a story about the counselors own family C. Skip the diet history and go directly to the diet instruction D. Ask Will to explain what he remembered from previous instructions Assuming that Will adheres to the traditional Navajo communication style, why did he answer I dont know to some of the RDs questions? A. He really did not know the answers B. He did not want to identify those foods he ate that he thought were unhealthy C. He felt the questions were too intrusive D. He was embarrassed because he had been scolded for missing his first appointment What is the traditional Navajo belief about how to achieve and maintain good health? A. By adopting healthful practices such as eating a nutritious diet and engaging in regular exercise B. By performing certain rituals and ceremonies C. By achieving harmony with family, community and environment D. By having reverence for nature

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10. Given his Navajo heritage, which behavior did Will most likely engage in prior to seeing the physician and the RD? A. Prayed for healing from God B. Visited a shaman or healer C. Returned to more traditional foods rather than convenience foods D. Drank tea steeped in white willow bark

Case III: A Latino client with type 2 diabetes mellitus (T2DM) Mrs. Maria Gonzalez, age 30, is a stay-at-home mother who completed six years of education at a rural village in Mexico. She immigrated to Texas ten years ago with her husband Jose, a construction worker whose employer provides no health benefits. Mrs. Gonzalez was raised according to traditional Mexican food habits, health beliefs, and family values. However, over the years her diet has undergone profound changes, brought about largely by the food demands of her children, i.e., many traditional Mexican foods and snacks have been replaced by those the children eat at school or at the homes of American friends, or by those advertised on television. These dietary changes and little physical activity have caused Mrs. Gonzalez to experience weight gain. Additionally, she complains of fatigue and difficulty reading the print in her novelas (novels) and revistas (magazines). Despite her reluctance to do so, Mrs. Gonzalez made an appointment with a physician, was diagnosed with T2DM, and was referred to an RD for dietary instruction. Mrs. Gonzalez arrives 40 minutes late for her appointment with the RD, accompanied by her husband, ten-year-old daughter, and mother who traveled from Mexico to be with her daughter at this critical time. The RD, annoyed by the late arrival of her client and confused by the presence of other family members, asks Mrs. Gonzalezs family to remain in the waiting room so she can counsel Mrs. Gonzalez in private, despite Mrs. Gonzalezs request that her daughter be permitted to remain in the room to act as her translator because My English not so good. At the beginning of the counseling session the RD hands Mrs. Gonzalez a booklet in English containing exchange lists, and apologizes for not having this booklet in Spanish. She then directs Mrs. Gonzalez to take a seat at a conference table in one corner of the room, and seats herself behind her desk across the room. Since her next scheduled appointment is in 35 minutes, the RD covers the information about the causes and complications of diabetes, as well as meal planning and exercise in 30 minutes. When asked if she has understood all that was explained to her, Mrs. Gonzalez lowers her head and quietly replies Yes. When asked if she has any questions, Mrs. Gonzalez raises her head slightly and again replies Yes, but says nothing more. The RD then walks over to Mrs. Gonzalez, bends over her, makes direct eye contact, and says in a very firm tone Maria, if you do not follow these instructions very closely, there is a good chance that you will go blind or lose a leg. The RD makes a follow-up appointment for Mrs. Gonzalez in two weeks to check her compliance with the care plan, but Mrs. Gonzalez does not return. 1. Which beverage is not a part of Mrs. Gonzalezs traditional Mexican food habits? A. Milk C. Fresh orange juice B. Hot cocoa D. Coffee

2. Which food would most likely be acceptable to Mrs. Gonzalez for breakfast, lunch, or dinner, given her Mexican heritage? A. Potatoes C. Beans B. Fish D. Olives 3. Which dish would Mrs. Gonzalez find most acceptable as a lunch or dinner entre? A. Lamb stew C. Lasagna B. Tamales D. Curried rice

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Which use of vegetables would Mrs. Gonzalez find most acceptable? A. As separate side dishes C. As stuffing for other foods such as poultry B. As ingredients in cold juices D. As part of mixed dishes such as stews Which would have been the most culturally appropriate way for the RD to address this client, according to the traditional Mexican communication style? A. Maria C. Mamacita B. Mrs. Gonzalez D. Mrs. Jose Which type of eye contact and seating arrangement should the RD use during the counseling session to show respect for Mrs. Gonzalez? A. Direct eye contact and a distant seating arrangement B. Indirect eye contact and a close seating arrangement C. Direct eye contact and a close seating arrangement D. Indirect eye contact and a distant seating arrangement Which individual would likely be the most effective translator during the counseling session with Mrs. Gonzales? A. Mrs. Gonzalezs ten-year-old daughter B. Mrs. Gonzalezs husband Jose C. A professional translator working for the clinic D. The curandero (folk healer) who has been treating the Gonzalez family for years How could the RD show the greatest respect for Mrs. Gonzalezs Latino family values? A. By politely asking her family to remain in the waiting room so that Mrs. Gonzalez could learn about T2DM without distractions from family members B. By including her family in the counseling session since decisions concerning health matters are made by the family rather than by the individual client C. By initially meeting with Mrs. Gonzalez in private and scheduling a later appointment to meet with the rest of the family D. By meeting with Mrs. Gonzalez in private and asking her to inform the rest of the family about what she has learned when they get home Since Mrs. Gonzalez adheres to traditional Latino health beliefs, which would she regard as the most likely cause of her T2DM? A. Eating too many sweets B. Going through a very frightening experience C. Not drinking enough water D. Getting too much sun

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10. Which traditional Mexican health practice did Mrs. Gonzalez most likely try before her visit to the physician and to the RD? A. Drinking herbal teas B. Eliminating sugar from her diet C. Undertaking more physical activity D. Eating less at mealtime

Case IV: A Chinese client with type 2 diabetes mellitus (T2DM) Li Chu Chang is a 65 year old Chinese woman who immigrated to the United States from Southern China ten years ago with her husband to live with their son. She speaks little English and depends on her son and daughter-in-law to translate. She assists her daughter-in-law tending to two children, housekeeping and preparing meals. She has recently been experiencing some blurred vision. Her son made an appointment for his mother with his family physician who ordered laboratory work to be completed before the office call. The doctor told his patient that she had T2 DM and referred her to an RD for special diet instruction. The daughter-in-law translated this information for Li and her husband. Changs daughter-in-law and husband accompany her to the RD. The RD greets each family member with a handshake and asks them to be seated. She begins by saying I need to know about your usual food intake. She asks questions about Changs diet and the daughter in law translates and relays the answers. The RD prepares a diabetic diet and begins the instruction. After explaining the diet, the RD asks Chang through her daughter-in-law if she will follow the diet. Chang looks at her husband but does not reply. The RD makes direct eye contact with Chang and asks again. When Chang does not reply the RD tells the daughter-in-law to have Chang follow the diet and call if she has questions. 1. Which is the traditional Chinese beverage that Chang most likely drinks with meals? A. Coffee C. Water B. Milk D. Tea Which traditional Chinese food would Chang likely have with two or possibly three meals every day? A. Rye bread C. Rice B. Fish D. Sushi Which aspect of the traditional Chinese diet should the RD consider when planning the meal pattern for Chang? A. The fact that kimchi (pickled vegetables) is served at every meal B. The proper balance of fan (grain) and tsai (meal and vegetable) foods C. The fact that fruits and vegetables are seldom eaten by Chinese D. The traditional Chinese diet is high in fat Chang uses soybeans extensively in her cooking. Which is a product made from soybeans? A. Bok choy C. Tofu B. Congee D. Gohan Which would be the most culturally appropriate way for the RD to greet her client and her clients family? A. A handshake and smile for each family member B. A nod or slight bow C. A simple smile with direct eye contact D. A handshake with only the females

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When the RD asked Chang if she could follow the special diet, why did Chang look at her husband? A. She did not understand the diet B. She wanted to show respect for the RDs questions C. Decisions are made by the eldest male in Chinese culture D. She wanted to refuse to follow the instructions but was being courteous Which aspect of the traditional Chinese communication style should the RD be familiar with when instructing Chang on the special diet? A. Pauses usually mean the question should be repeated B. Asking questions could be considered disrespectful to the RD C. An informal style of communication is preferred D. Completing the instruction within the time limit is of primary importance When the RD looked directly at Chang, how might this form of eye contact have been interpreted by Chang, in view of her Chinese heritage? A. Disrespectful C. Confrontational B. Respectful D. Insensitive Which would Chang regard as the best strategy for improving her symptoms, given her traditional Chinese heritage? A. Restoring her harmony B. Obtaining an over the counter medication from a pharmacy C. Avoiding fried foods D. Working fewer hours in the household and getting more sleep

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10. Given her Chinese heritage, which is the most compelling reason for Chang to follow her special diet? A. To achieve the desired old age of wisdom B. To alleviate her symptoms and feel better C. To be able to engage in more physical activity D. To one day be able to resume eating the foods she enjoys Part Three: Please circle the response that BEST reflects how much you agree or disagree with each statement. There are no right or wrong answers, so please give your honest opinions. 1. I generally feel comfortable when interacting with people from cultural/ethnic groups other than my own. Strongly disagree Disagree No opinion Agree Strongly agree People from cultural/ethnic groups other than my own should have the same access to high quality nutrition counseling services as people from my own cultural/ethnic group. Strongly disagree Disagree No opinion Agree Strongly agree Institutions offering nutrition services (e.g. hospitals, clinics, schools, wellness centers, etc.) should budget resources (e.g. money, time, energy) for developing nutrition programs to help culturally/ethnically diverse clients prevent or manage their diet-related chronic diseases. Strongly disagree Disagree No opinion Agree Strongly agree

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Nutrition professionals should include the cultural/ethnic health beliefs of their clients into the care plan if these beliefs do not interfere with desired treatment outcomes. Strongly disagree Disagree No opinion Agree Strongly agree Nutrition professionals should have an awareness of the core values, i.e. importance of family, spirituality, etc. of clients from cultural/ethnic groups other than their own. Strongly disagree Disagree No opinion Agree Strongly agree Nutrition professionals should make dietary recommendations based on the income level of their clients, regardless of their clients cultural/ethnic heritage. Strongly disagree Disagree No opinion Agree Strongly agree Nutrition professionals should take into account the language, vocabulary, and reading skills of their culturally/ethnically diverse clients when making dietary recommendations. Strongly disagree Disagree No opinion Agree Strongly agree Nutrition professionals should include the cultural/ethnic foods of their clients into the care plan if these foods do not interfere with desired treatment outcomes. Strongly disagree Disagree No opinion Agree Strongly agree Nutrition counseling for culturally/ethnically diverse clients should preferably be undertaken by nutrition professionals from their own cultural/ethnic groups. Strongly disagree Disagree No opinion Agree Strongly agree

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10. If given the choice, I would prefer to counsel clients from my own cultural/ethnic group. Strongly disagree Disagree No opinion Agree Strongly agree Part Four: Below is a list of 22 possible cultural experiences. Please circle Yes or No to indicate whether you have or have not ever participated in any of these experiences. Experience 1. 2. 3. 4. 5. Participated in a study abroad program Held a job in another country Completed an internship in another country Traveled to a foreign country as a visitor Born and raised in a country other than the United States Fluent (writing and speaking with ease and facility ) in a language other than English Had a friend/roommate from another cultural/ethnic group Have you ever? Yes Yes Yes Yes No No No No

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Eaten food from another cultural/ethnic group Attended lectures or taken a college course about the history, art, music, theater, food, etc of another cultural/ethnic group

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10. Watched a film or documentary about another cultural/ethnic group 11. Studied with a student from another cultural/ethnic group 12. Talked with a person from another cultural/ethnic group about nutrition/health 13. Worked with a supervisor or co-worker from another cultural/ethnic group 14. Attended a social event or festival important to another cultural/ethnic group 15. Participated in an athletic event with teammates from another cultural/ethnic group 16. Attended a concert featuring the music from another cultural/ethnic group 17. Taken a college course from a teacher from another cultural/ethnic group 18. Read a book written by an author from another cultural/ethnic group 19. Shared a meal with a friend from another cultural/ethnic group in his/her home 20. Received treatment from a healthcare provider from another cultural/ethnic group (e.g. nurse, physician, dentist, athletic trainer) 21. Participated in a group project with a classmate from another cultural/ethnic group 22. Attended a craft show/market featuring items from various cultural/ethnic group

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Thank you for your participation! Before turning in your questionnaire, please place it in the envelope provided, and seal it.