ETHNIC GROUP	BREAD AND CEREAL	EGGS, MEAT, FISH, POULTRY	DAIRY PRODUCTS	FRUITS AND VEGETABLES	SEASONINGS AND FATS
Italian	Northern Italy: Crusty white bread Cornmeal and rice Southern Italy: Pasta	Beef, chicken, eggs, fish, anchovies	Milk in coffee, cheese	Broccoli, zucchini, other squash, eggplant, artichokes, string beans, legumes,* tomatoes, peppers, asparagus, fresh fruit	Olives and olive oil, balsamic vinegar, salt, pepper, garlic, capers, basil
Puerto Rican	Rice, noodles, spaghetti, oatmeal, cornmeal	Dry salted codfish, meat, salt pork, sausage, chicken, beef	Hot milk in coffee	Beans,* starchy root vegetables, green bananas, plantains, legumes,* tomatoes, green pepper, onion, pineapple, papaya, citrus fruits	Lard, herbs, oil, vinegar
Near Eastern	Bulgur (wheat)	Lamb, mutton, chicken, fish, eggs	Fermented milk, sour cream, yogurt, cheese	Nuts, grape leaves	Sheep’s butter, olive oil
Greek	Plain wheat bread, phyllo dough	Lamb, pork, poultry, eggs, organ meats	Yogurt, cheese, butter	Onions, tomatoes, legumes,* fresh fruit	Olive oil, parsley, lemon, vinegar
Mexican	Lime-treated corn tortillas	Little meat (ground beef or pork), poultry, fish	Cheese, evaporated milk as beverage for infants	Pinto beans,* tomatoes, potatoes, onions, lettuce, black beans	Chili pepper, salt, garlic
Chinese	Rice, wheat, millet, corn, noodles	Little meat and no beef; fish (including raw fish); eggs of hen, duck, and pigeon; tofu and soybeans	Water buffalo milk occasionally, soybean milk, cheese	Soybeans,* soybean sprouts, bamboo sprouts, soy curd cooked in lime water, radish leaves, legumes,* vegetables, fruits	Sesame seeds, ginger, almonds, soy sauce, peanut oil
African American or Southern United States	Hot breads, pastries, cakes, cereals, white rice	Chicken, salt pork, ham, bacon, sausage	Milk and milk products (often lactose-free for African heritage)	Kale, mustard, turnip, collard greens; hominy; grits; sweet potatoes; watermelon; black-eyed peas	Molasses
Jewish	Noodles, crusty white seed rolls, rye bread, pumpernickel bread	Kosher meat (from forequarters and organs from beef, lamb, veal); fish (except shellfish)	Milk and milk products Milk not eaten at same meal as meat	Vegetables—usually cooked with meat; fruits

^*Beans and legumes are also counted as a meat substitute.

In the ideal scenario the infant is exposed to a variety of foods and is fed in a manner that promotes positive meal association. Then the infant is more likely to become a child who learns to like a variety of foods that are of high quality and dense in nutrients. When a child has been allowed to eat on the basis of his or her own hunger and satiety cues in a positive meal environment, eating takes place according to growth needs; thus an appropriate quantity of food intake is maintained. (See Chapter 12 for more detailed information on child development and nutritional needs.)

Many factors can change this ideal scenario. Children may have food allergies or food intolerances, and these foods become associated with physical discomfort. Learned food aversions fall into this classification. For example, a food that is eaten before the onset of an illness that is unrelated to the food (such as a viral illness) becomes mistakenly associated with the illness. If this food is avoided in the future, the phenomenon is appropriately termed a learned food aversion.

Improvement in food selection patterns for bettering health status frequently means changing established habits. This is a slow, step-by-step, almost never-ending process that requires a real desire to change, a deep conviction that change is important, and the willingness to substitute desirable food habits for undesirable ones. Health care professionals dealing with nutritional improvement, although primarily concerned with the metabolic (biochemical) role of food in health, must also have some understanding of the circumstances under which dietary habits are acquired and the various meanings that food may have for different individuals. This is especially true in dealing with persons who suffer from a disorder or disease that requires drastic, long-term changes in dietary habits.

WHAT ARE BIOPSYCHOSOCIAL CONCERNS IN HEALTH CARE?

Biopsychosocial concerns address the interplay between external environmental (psychologic and social factors) and internal forces (genetic or biochemical/physiologic requirements). For example, the diagnosis of diabetes is primarily a biochemical or internal problem, but for the person hearing this diagnosis it involves psychologic issues of acceptance versus denial and anger and social concerns of healthy living in an environment that may be stressful and that discourages adherence to a healthy diet (external problems or social forces). The biochemical problem of either very high or very low blood sugars can also affect emotions and the ability to think. Another relatively common physical condition adversely affecting food choices and nutritional status is lack of teeth. One study found that with the loss of 14 teeth or more there was significantly lower intake of salad vegetables. This was found to result in lower blood levels for vitamins A and C and the B vitamin folate (Nowjack-Raymer and Sheiham, 2007).

Religious impact on eating, such as giving up chocolate for Lent or following a kosher diet, occurs. Religious holiday dietary practices have long been observed, such as 24-hour fasting for the Jewish holiday Yom Kippur, or abstaining from meat on Fridays among Catholics (which has developed into the Friday fish fry), or fasting by Muslims during daylight hours during the month of Ramadan. Fasting for religious reasons can be detrimental, such as development of hypoglycemia for persons with diabetes. Individuals with medical conditions in which adverse health outcomes are expected are not obligated to adhere to religious fasts.

An individual’s eating habits can have strong emotional reasons that health educators need to consider before providing nutritional advice. Too many individuals worry excessively over what they eat. We all need a variety of foods and flavors for good emotional and physical health. Feeling embarrassed regarding food choices is not conducive to good mental well-being. Health care professionals can promote the idea that “all foods can fit.”

Cultural Considerations

In a semirural area in Louisiana, various biopsychosocial factors were found to influence food choices. Those families with incomes of $15,000 or less were more likely to eat burgers and sandwiches than those with income over $45,000, and those with income over $30,000 up to $45,000 had lower consumption of mixed dishes. Intake of grains, dairy, fruits, 100% fruit juice, and vegetables was higher in those having some college education. European American men had more dairy products and sweetened beverages than African American men. European American women had more dairy products, vegetables, and fats than African American women. African Americans in general consumed more fruits and 100% fruit juices than European Americans. Married individuals consumed more snacks and desserts, but less alcohol (Deshmukh-Taskar and colleagues, 2007).

HOW DO CULTURAL AND SOCIETAL FACTORS INFLUENCE NUTRITIONAL INTAKE?

Many barriers to adequate nutrient intake are external in nature and may stem from a variety of causes:

• Economic (inadequate money to purchase food, limited finances for transportation to grocery stores such lack of a car or limited funds for gasoline)

• Physical (lack of food storage and cooking facilities, physical impairments that inhibit consumption of a variety of foods or ability to travel to grocery stores)

• Cultural (lack of exposure to a variety of foods because of limited parental offerings or overemphasis on excess intake with large portions of food in restaurants or at home)

• Ecologic (droughts, floods, earthquakes, snow and ice storms)

• Emotional (television advertisements and other media depicting nonnutritious foods as appealing and healthy foods such as spinach as unappealing)

• Religious (adherence to restrictive food codes, religious food celebrations)

• Political (food boycotts, forced starvation for military purposes)

One factor influencing food choices is availability and food costs found in supermarkets. This can have significant impact on lower-income families. It was found among supermarkets in the Sacramento and Los Angeles areas of California that the cost of a market basket meeting the 2005 Dietary Guidelines was less than the food stamp allotment of the Thrifty Food Plan (see Chapter 14). However, it was estimated to require a low-income family to spend about half of their food budget on fruits and vegetables to meet the Dietary Guidelines (Cassady, Jetter, and Culp, 2007). The situation can be more problematic in nonurban areas. One study found in a rural setting that there are primarily convenience stores, rather than the larger supermarkets. Less than half of convenience stores carried low-fat milk and high-fiber bread, with prices significantly higher than less-healthy choices (Liese and colleagues, 2007).

Cultural Considerations

Data analyzed from the National Health and Nutrition Examination Survey (NHANES) for 2001-2002 showed that among Mexican Americans, those with low acculturation, as indicated by lack of speaking English, were found to have less obesity (body mass index [BMI] greater than 30) (see Chapter 6) than those who had assimilated into the U.S. culture. Of those who were overweight (BMI greater than 25), low-acculturated Mexican Americans were less likely to perceive themselves overweight with fewer attempts to lose weight (Ahluwalia and colleagues, 2007). Using data from the National Health Interview Survey, it was found that the typical immigrant entering the United States has had a lower BMI than native-born citizens. However, BMIs increase to virtually the same level for females within 10 years, and men close a third of the gap within 15 years (Antecol and Bedard, 2006). Health care professionals can help slow down this trend by encouraging maintenance of traditional food habits and lifestyles.

CHANGING FOOD HABITS

Many young Americans have never had exposure to a variety of vegetables, such as Swiss chard, lentils, or even basic vegetables such as Brussels sprouts and broccoli. There are generational differences in food exposure and acceptance. People born before World War II (before the process of hydrogenation was used extensively) remember stirring their peanut butter, because the oil rose to the top in the natural form. This natural form of peanut butter has no trans fats, regardless of portion (see section on food labels). Older generations commonly ate salt cod, sardines, and herring along with a variety of vegetables, including turnips and parsnips. The availability of soft drinks into the midtwentieth century was generally limited to vending machines at gas station lots. Meals were typically always in a home setting.

Food cultures have been transported across the United States. For example, traditional Southern foods included okra, collard greens, kale, pinto beans, and black-eyed peas, but as Americans have moved across the country, these foods have followed suit. Bagels, tacos, baked beans, pizza, and other regional and ethnic foods are now commonplace across the country. Unfortunately, some of these foods have become Americanized, with excess fats and sugars. Traditional pizza was made without mozzarella cheese, known as focaccia. When Chinese restaurants first appeared in the mainstream they served foods low in fat, and the foods had the reputation for inducing early hunger. Now these same restaurants increasingly serve food high in fat, with large portions not typical in China.

As restaurant eating has increased in frequency, there have been a variety of effects on this nation’s health. One issue is increased portion sizes. Gone are the days of 4-oz juice glasses, with the exception of old-time diner type of restaurants or those juice glasses found in antique stores. Consuming soft drinks (also referred to as soda pop, pop, and carbonated beverages) that have similar kcalories as fruit juice is now commonplace in restaurants and other food venues. A small soft drink can be 32 oz in some locations (Figure 1-1). Data from the nationally representative Nationwide Food Consumption Surveys and the NHANES found the percentage of calories from beverages virtually doubled between 1965 and 2002, equating to an increase of almost 250 kcal daily (Duffey and Popkin, 2007). This increased kcalories of beverages does not appear to be due to milk intake because, on average, preschool children were found to drink less than the 2 cups of milk recommended for children by the 2005 Dietary Guidelines for Americans. Some excess kcalories for children does come from the butterfat content of milk because less than 10% of older children were found to drink low-fat or skim milk as advised for children over 2 years of age (O’Connor, Yang, and Nicklas, 2006).

FIGURE 1-1 Fruit juice and soft drink serving size changes. A, The equivalent number of oranges per portion of juice (8/qt, 2/cup, 1/4 oz). B, The equivalent number of teaspoons of sugar per portion of soda (20 oz bottle original 6 oz bottle, 26 tsp/liter, original large “poppa” mug (now considered small), original medium “mamma” mug (no longer available), baby mug.

Family composition and changing roles can influence food choices. Increasing numbers of men are now shopping for and preparing food (Figure 1-2). Households composed of single persons are growing, with an increased demand for more ready-to-use foods, which are often high in fat and salt.

FIGURE 1-2 Men are becoming more involved in food shopping and meal preparation, which has increased their concern with the nutritional value of foods.

Unfortunately, our society tends to overvalue many foods with empty kcalories. School personnel may still reward academic achievement with candy, divorced parents may give their children extra treats in an attempt to lessen feelings of guilt, and television advertisements tell us, “Go ahead, you deserve it!” Often, due to this reward system and because people like the taste of sweets, many Americans have excess intake of low-nutrient foods that are high in fat and sugar. Food should never be used as a reward in order to promote healthy attitudes toward eating.

Changes in diets are occurring around the world. Some are for the good with various types of cross-cultural cuisine. On the other hand, the so-called Western diet, which is high in saturated fat and sugar and low in fiber, is having an adverse effect on the health of populations around the world. Rates of obesity are increasing at alarming rates worldwide as food habits are changing. The World Health Organization (WHO) estimates that at least 1 billion people worldwide are overweight and 300 million are obese. See Chapter 14 for more on international nutrition concerns and programs.

The pace of eating during mealtimes is historically slower throughout the Mediterranean region, and great pride is taken in food selection and method of preparation. However, modern society is affecting this traditional style of eating. What has been termed the slow food movement began in the 1980s in Italy in recognition that thousands of food varieties and flavors were being replaced by a few foods with standardized flavors. This movement has spread around the world, including the United States. Traditional ethnic foods and enjoyment of eating are being encouraged by the 80,000 members of this movement.

VEGETARIAN DIETS

Two religious groups that forgo consumption of meat and other animal products are Seventh-Day Adventists and Hindus. Many persons of the Jewish faith adopt a vegetarian eating plan to help them follow a kosher diet. Others follow vegetarian diets for health, political, cultural, or economic reasons or a combination of these. Some athletes adopting a vegetarian diet may be masking a disordered eating pattern (see Chapter 12). If a vegetarian diet results in excess weight loss, a referral to a psychologist or eating disorder clinic may be necessary.

There are generally two main forms of vegetarian diets. Lacto-ovo vegetarian diet is the primary one; it excludes meat but includes milk and milk products and eggs. Lacto comes from the Latin word for milk, and ovo comes from ovum (egg). Lacto-ovo vegetarians may also eat fish, but this is more correctly referred to as a pescetarian diet. The lacto-ovo vegetarian diet can easily provide all necessary nutrients needed for health.

The vegan diet is increasingly becoming popular. This form of vegetarian diet excludes all animal food sources, including no fish, eggs, or dairy products. For this reason it is far more difficult to meet nutritional needs with the diet. It was once thought in the 1970s, as written in the well-known book Diet for a Small Planet by Frances Moore Lappe, that protein combinations were required within the same meal. It is now known that if complementary protein sources are included within a 24-hour period that protein needs can be met (see Chapter 2). Common nutrient deficiencies with the vegan diet include iodine, vitamin B₁₂, iron, calcium, zinc, riboflavin, and vitamin D. Because meat provides protein, a variety of B vitamins, and minerals, alternative foods high in these nutrients need to be included in the vegetarian diet for health (see Table 1-2, Box 1-1, Chapters 2 and 3).

Box 1-1 Sample Menu Nutritious Menu for a Vegan Diet

Breakfast

Oatmeal with soy milk

Whole-wheat toast with peanut butter

Tofu stir-fry with snow peas and carrots

Fresh spinach salad with croutons and dressing

Table 1-2

Food Sources for Important Nutrients in the Vegetarian Diet

NUTRIENT	SOURCES
Calcium	Milk and milk products, particularly cheese and yogurt; fortified soy milk; dark green leafy vegetables such as parsley, kale, mustard, dandelion, and collard greens
Iron	Legumes, dark green leafy and other vegetables, whole-grain or enriched cereals or breads, some nuts, and dried fruits (many factors may affect absorption of this nutrient)
Riboflavin (vitamin B₂)	Milk, legumes, whole grains, and certain vegetables
Vitamin B₁₂	Milk and eggs, fortified soybean milk, fortified soy products, Marmite
Zinc	Nuts, beans, wheat germ, and cheese
Protein	Eggs, milk, nuts and seeds, legumes, especially soybeans and tofu

There are potential benefits of following a vegetarian diet. Reduced heart disease can occur with reduced saturated fat from the exclusion of red meat. However, low saturated-fat intake, such as with use of low-fat milk products, remains important. A social impact is reduced armpit body odor (Havlicek and Lenochova, 2006).

Cultural Considerations

One study of medical students found about 7% of students identified themselves as vegetarians, although this percentage declined by the later years of study. About two thirds followed vegetarian diets for health reasons, and these individuals included more fruits and vegetables in their diets than those who followed vegetarian diets for nonhealth reasons. Vegetarians were more likely than their counterparts to eat fruits and vegetables, be female, politically liberal, of ideal body weight, or Hindu, Buddhist, or Seventh-Day Adventist. The vegetarians were also more likely to perceive nutrition counseling as highly relevant to their intended practices (Spencer, Elon, and Frank, 2007).

COMMON ETHNIC EATING HABITS

Table 1-1 shows how the food groups of the MyPyramid Food Guidance System are incorporated into different types of eating patterns. A typical day’s diet for any ethnic, regional, or religious group may be evaluated nutritionally by checking it against an acceptable meal plan such as the MyPyramid Food Guidance System.

WHAT IS THE MEANING OF MODERATION, VARIETY, AND BALANCE?

Moderation means avoidance of too much or too little of any food or nutrient. This implies that any food can be worked into a healthy way of eating. There are no good foods or bad foods. Foods that are higher in fat and sugar should be eaten in smaller amounts or less frequently than foods that are nutrient dense. Variety refers to eating a number of different foods, not just the same two or three types of vegetables, for example. Balance refers to the amount of macronutrients and micronutrients in the diet in relation to individual needs. Selecting a variety of whole grains, vegetables, fruits, and protein-rich foods with dairy sources helps promote a positive nutritional status.

It is the position of the American Dietetic Association that the total diet or overall pattern of food eaten is the most important emphasis of a healthful eating style. The value of a food should be determined within the context of the total diet because classifying foods as “good” or “bad” may foster unhealthful eating behaviors (Nitzke and Freeland-Graves, 2007).

Snacking that is planned and emphasizes fruits, low-fat milk products, and whole grains can play a positive role in nutritional status. Snacking on processed foods, especially those high in fat, sugar, and salt, is appropriate in moderation. A common cause of excess snacking on high-fat and salty snacks is watching television at night. Snacking that promotes nutritional status is positive. Snacking that promotes excess intake of salt and kcalories from fat and sugar, especially when consumed as an activity, rather than hunger, needs to be limited for optimal health.

Persons of various cultures eat at fast-food restaurants (Figure 1-3). As long as an individual remembers the goals of balance, variety, and moderation, fast-food meals can safely be included in the diet (Box 1-2). Healthy meal choices can be found on fast-food menus. Fast foods can meet nutrient-density criteria and the Dietary Guidelines if chosen wisely. Serving sizes are important. See Appendix 1 on the Evolve website for websites of fast-food restaurants where kcalorie and nutrient analysis can be obtained.

Box 1-2 Sample Menu Nutritious Menu Including Fast Food