Cultural Awareness of Eating Patterns in the Health Care Setting

Watch a video presentation of this article Culture influences what and when individuals eat. Awareness and understanding of cultural beliefs and practices as it relates to nutrition, such as eating patterns and sources of nutrition, is important for appropriately educating and building rapport with patients in the health care setting. More specifically, an understanding of frequently consumed protein sources among various cultures is essential because high-protein foods are a common component of nutrition education for various diseases and conditions, such as liver disease. To promote cultural awareness, clinicians, registered dietitians, and physicians must learn about patient-specific cultures and how they pertain to nutrition and eating to provide nutrition education specific to the patient’s culture in a culturally sensitive manner.1 Cultural awareness of commonly consumed protein sources is necessary for properly educating and treating patients from various cultures. This review will examine the cultural eating patterns, with a focus on protein foods, of the Mexican, Chinese, Japanese, Indian, and Middle Eastern cultures. Cooking and eating homemade traditional foods together as a family is important in the Hispanic culture. A few staples in Mexican cuisine include beans, rice, and corn. Commonly consumed protein sources include pozole (hominy pork stew), ceviche (marinated fish or shrimp), grilled steak, carnitas (roasted pork), and meats prepared with specialty sauces (Table 1). Ceviche, however, is contraindicated in the liver transplant population because the fish or shrimp is not cooked. These protein sources are incorporated into meals, such as tacos and enchiladas. Even though many of these foods are rich protein sources, they can be high in sodium and fat.2 In traditional Chinese medicine, foods are grouped as hot or cold, applying the yin/yang balance principle where yin foods are cold and yang foods are warm and often prioritized when one is feeling ill.3 The protein sources frequently seen in Chinese cuisine consist of beef, lamb, tofu, and roasted or stir-fried chicken, which are commonly incorporated into stews (Table 2). China is a large country; thus, food behaviors differ across the country. There are many staple foods in Chinese cuisine, with rice being a staple for people living in southern China and bread, steamed bread, and buns a staple among those living in northern China. The steamed buns and dumplings are often filled with meat, making these rich protein sources. Many dishes in Chinese cuisine contain soy sauce, which is high in sodium. Although Chinese cuisine contains a variety of high-protein foods, some of these staple foods, such as rice, buns, and dumplings, can also be high in carbohydrates, specifically refined carbohydrates.4-7 In the Japanese culture, Washoku is a social practice associated with food embodying the Japanese people’s spirit. Commonly consumed protein sources in Japanese cuisine are fish and seafood, which are typically served grilled or raw (Table 2). Surimi is a popular processed fish product in Japan that is commonly used to imitate the texture and color of lobster, crab, grilled eel, and other shellfish. Sashimi is thinly sliced raw fish, meat, or tofu skin that is often eaten with soy sauce. Rice, miso soup, and pickled vegetables are other commonly consumed foods in the Japanese culture. Miso soup, soy sauce, and tofu are common staples in Japanese cuisine that are made from soybeans. Although Japanese cuisine contains high-protein foods, such as fish and seafood, these foods are also rich sources of the polyunsaturated fatty acid, omega-3.8 In the Indian culture, a vegetarian diet, more specifically a lacto-vegetarian diet (allows dairy and excludes meat, eggs, and fish) is commonly followed by the Hindu population.9 Grains are a primary staple in India and are typically fermented as beans, and lentils are a major source of protein in the Indian diet. An example of a fermented grain is Idli, which is a product of rice and black gram batter by steam cooking (Table 3). Another commonly consumed grain is Hawaijar, which is an alkaline-fermented soybean product consumed in northeastern India and a rich source of protein. Hawaijar and Idli are also both rich sources of fiber. Dairy, fruits, and vegetables are also largely consumed in the Indian cuisine. Dahi, also known as yogurt or the middle eastern dish, Labneh, is a naturally fermented milk product from pasteurized cow and buffalo milk, fermented by using mixed lactic cultures, and is a good source of calcium.10 Although some of the foods consumed when following a lacto-vegetarian diet are high in protein, calcium, and fiber, they are also high in carbohydrates and lacking in vitamin B12, which is primarily found in meat and eggs. Even though a large sect of Indian culture avoids meat, there are some in India who do consume meat. The meat dishes are usually paired with a grain, such as rice and roti. Rice is eaten mostly in the southern part of India, and roti, a flat unleavened bread made with whole wheat flour, is mostly eaten in the northern part of India. The commonly consumed meat sources include chicken, mutton (lamb), and goat and are typically served in a curry seasoned with spices, such as coriander, cumin, turmeric, and ginger. The meat dishes are usually paired with a grain, such as rice.9 The Middle Eastern diet consists of a variety of both plant and animal protein sources. Popular animal protein sources include lamb, goat, fish, and chicken. Commonly consumed plant-based protein sources include fermented dairy products, such as labneh, chickpeas, lentils, and seeds and nuts (Table 4). Almonds, pine nuts, walnuts, pistachios, sesame, fennel, and caraway are among commonly consumed nuts and seeds. Although these foods are rich protein sources, they are also high in fiber, iron, and monounsaturated and polyunsaturated fats. The plant and animal protein sources in the Middle Eastern cuisine are commonly prepared with olive oil, rice, eggplant, dates, olives, figs, tomatoes, and various herbs and spices, such as cumin, coriander, cinnamon, ginger, dill, garlic, saffron, paprika, cayenne, and thyme.11 Food choices and eating patterns across differing culture groups result in varying protein sources consumed (Table 5). It is essential that medical providers understand cultural food practices. Once medical providers more fully understand their patient's respective diet patterns, they can refer patients to a registered dietitian to continue more thorough and individualized nutrition education. It is important that medical providers and registered dietitians collaborate and support each other's recommendations as research has shown that physician reinforcement improves patient adherence.12 Overall, the awareness and understanding of cultural beliefs and practices as it relates to nutrition is important for appropriately educating and building rapport with patients in the health care setting.