The Failure of the Dietary Guidelines to Promote the Health of a Culturally Diverse America: An Abandonment of Social Science Principles-Rebecca Bokat
The Dietary Guidelines for Americans were first published in 1980 following the Senate Select Committee on Nutrition and Human Needs Dietary Goals, in order to combat the increased incidence of overweight, obesity, and chronic diseases that were the result of a poor diet and sedentary lifestyle (1). Despite the establishment and periodic revision of the Dietary Guidelines for Americans, the prevalence of obesity has doubled over the past three decades and continues to increase in the United States (2). Obesity is costly to society because it is associated with chronic diseases including cardiovascular disease, type II diabetes, hypertension, stroke, dyslipidemia, osteoarthritis, selected cancers, gallbladder disease, sleep-breathing disorders, musculoskeletal disorders, and all-cause mortality (3). The rate of obesity in the United States follows a socioeconomic gradient, such that the burden of disease falls disproportionately on people with limited resources, racial and ethnic minorities, and the poor (3). The goals of the Dietary Guidelines to promote the health of Americans and to reduce their risk for major chronic diseases has not been realized because the Guidelines rely solely on scientific evidence and fail to take into account basic behavioral and social science principals. In order to design an effective strategy to combat the obesity epidemic and meet the needs of a multicultural and dynamic population, the cultural, economic, and social differences among Americans must be taken into account.
The homogenous approach to nutrition recommendations reflected by the Dietary Guidelines for Americans fails to take into account the increasingly heterogeneous US population. Census data demonstrate an increase in diverse racial and ethnic groups in the United States from approximately one-fourth to one-third of the population, and this trend is expected to continue, such that by the year 2030, minority groups will account for forty percent of the total population (3). Given that African Americans are the second largest ethnic minority group in the country and that this population has a higher prevalence of obesity and weight-related diseases than the general US population, extensive research has been conducted on the eating practices of African Americans. Research has indicated that the dietary habits, food choices, and cooking methods unique to African Americans evolved from a long history of slavery, persecution, and segregation (5). The slaves who were brought to the US combined their West African cooking methods with those of the British, Spanish, and Native American techniques to produce a distinctive African American cuisine known as ‘soul food’ (5). Soul food emphasizes fried, roasted, and boiled food dishes using primarily chicken with the skin left intact, pork, pork fat, organ meats, sweet potatoes, corn, and green leafy vegetables (4). As a result of the high intake of deep fried foods, eating chicken with the skin, not trimming fats from meat, seasoning vegetables with fat and meat, and reusing oils, fats and grease to flavor foods, the traditional African American diet tends to be low in fiber, high in sodium, nitrates, sugar, fat and/or cholesterol (5). These dietary practices continue to persist despite their health implications because long-term beliefs, attitudes, and behaviors among the African American community have been handed down across generations. Subsequently, healthful eating is viewed as an abandonment of tradition and culture and is perceived as conforming to the dominant culture. Mexican Americans are a second minority group that is becoming a fast growing segment of the American population, and like African Americans, dietary practices and nutrition related behaviors are culturally defined and established early in life. A collaborative research study conducted by the CDC’s Division of Nutrition and Physical Activity found that the dietary practices typical of Mexican American families included eating traditional Mexican food that is high in fat and starch and low in vegetables (6). This study also discovered that young African Americans and Mexican Americans have different perceptions about healthy and unhealthy weight compared with whites (6). Specifically, a person who is overweight is considered to be well-nourished or “full figured” in the African American and Mexican American cultures. The Dietary Guidelines for Americans are not culturally relevant or sensitive to the dietary practices and food-related behaviors of the diversity of ethnic and racial minorities that represent large segments of the American population. The Dietary Guidelines, which are based on the medical model and view food as being therapeutically valuable, isolate food from the cultural context of eating and therefore has limited effectiveness with many minority groups.
The Dietary Guidelines for Americans 2005 recommends nine servings per day of a variety fruits and vegetables and three cups of reduced fat or fat-free milk or other dairy products for the reference 2,000 calorie level (7). However, the Guidelines do not take into account the limited availability and high cost of fruits, vegetables, and reduced fat dairy products and the greater availability and lower costs of high-fat foods in impoverished urban neighborhoods. These low income neighborhoods have a disproportionately higher number of racial and ethnic minority populations, particularly Hispanic and non-Hispanic blacks (8). The limited access and higher cost of healthier foods in poorer urban neighborhoods is a direct result of the migration of supermarkets to the suburbs, leaving low-income shoppers who do not have access to private transportation at the mercy of high priced convenience stores and local grocery stores (5). Convenience stores, also known as bodegas, and local grocery stores that serve poorer inner city neighborhoods have limited inventories and usually do not stock large amounts of perishable foods (5). In the Bedford-Stuyvesant neighborhood of Brooklyn, only 21 percent of the bodegas offered apples, oranges and bananas; leafy green vegetables were found in only 6 percent of the bodegas; and only one in three bodegas sold reduced-fat milk (9). A study that tracked the availability of diet soda, low-fat or fat-free milk, high-fiber bread, fresh fruit and fresh vegetables in food stores in East Harlem and the Upper East Side found that stores on the Upper East Side were more than three times as likely than the stores in East Harlem to stock all five of the aforementioned items, despite the fact that East Harlem had more than twice as many food stores per capita as the Upper East Side (10). East Harlem is around 90 percent Hispanic and black (10). Even if healthy food is available in these types of neighborhoods, local convenience and grocery stores often charge more for it than supermarkets (9). In the Bedford-Stuyvesant neighborhood of Brooklyn, the average cost of a gallon of milk was 79 cents higher in the Bodega than in a supermarket (9). Although there is limited access to healthier food options in most of these low-income neighborhoods, there is a greater availability of inexpensive, high-fat foods. A recent geographical analysis determined that predominantly black neighborhoods have 2.4 fast-food restaurants per square mile, compared to 1.5 such restaurants in predominantly white neighborhoods (3). On Third Avenue in East Harlem, a banner outside McDonald’s advertises a $1 menu, while down the street a KFC sign boasts that you can “Feed Your Family for Under $4 each (10)”. Foods that are energy-dense and highly palatable, like fast-food and potato chips, sodas, and doughnuts available at bodegas, are associated with diminished feelings of satiety and the over consumption of fats and sweets, leading to increased energy intakes (3). Research focusing on the availability and cost of foods in impoverished urban neighborhoods has concluded that neighborhood differences may account in part for health disparities that have a dietary component (5).
The Dietary Guidelines for Americans blindly assumes that provided with nutrition information, consumers will make the appropriate changes in their eating habits and lifestyles. The DGAs view individual level behavior change separate from the social context of eating, which research has shown influences all aspects of eating patterns. Social connections satisfy one of the fundamental human needs of belonging identified by psychologist Abraham Maslow in his Hierarchy of Needs (11). Humans need to feel belonging and acceptance whether it comes from large social groups or small social connections (11). Individuals have a need to belong to a social group and eating certain foods from one’s cultural group is a way of staying connected to that group. Research through focus group interviews has shown that minority groups, particularly African-American and Hispanic populations, report that eating healthfully is perceived as giving up part of their cultural heritage and trying to conform to the dominant culture (5). Individuals may consciously or unconsciously participate in culturally defined eating patterns in order to maintain group identity (5). A resident of Spanish Harlem was quoted as saying that people in his neighborhood “associate diet as unhealthy. If you’re dieting, then you’re sick. You look at people on the streets, they’re heavy. That’s the way we grow up here (10)”. Despite the resident’s family history of diabetes, he added that people in his community “love eating trash…we grew up eating McDonald’s and I still find myself eating candy and chocolate cake (10).” He also added that the members of his community have “cultural differences…for a guy to eat a salad, he’s a wimp. The women can’t be chumps either. A woman can eat a salad but has to eat it on the low. She has to do it quiet. They make fun of you: What are you, a rabbit (10)?”
It is evident from the obesity epidemic that is currently plaguing the nation that the Dietary Guidelines for Americans are an ineffective public health intervention. Not only are the Guidelines not reaching large segments of the American population, particularly low income ethnic minorities, but the Guidelines are not applicable and practical in the real-life setting of these people’s lives. The biomedical orientation of the Guidelines limit their effectiveness with lower-income minority groups because they isolate eating behaviors from the cultural, economic, and social context in which eating patterns are developed, maintained, and passed down. The individual-level nutrition recommendations made by the Guidelines developed for the general population are not culturally relevant or specific to many minority groups residing in poor inner city neighborhoods. The Guidelines expect these population groups to practice dietary patterns that are contrary to the foods available and the dietary practices followed in their environment. An effective public health intervention to reduce obesity and the risk of chronic diseases must take these cultural, economic, and social differences into consideration; otherwise the impact of the obesity epidemic will continue to disproportionately affect people with limited resources, racial and ethnic minorities, and the poor.
References
1. Mahan, L.K., & Escott-Stump, S. (2004). Krause’s Food, Nutrition, & Diet Therapy (11th ed.). Philadelphia: Saunders.
2. Zhang, Q. & Wang, Y. (2004). Trends in the Association between Obesity and Socioeconomic Status in U.S. Adults: 1971 to 2000. Obesity Research, 12(10), 1622-1632.
3. Boyle, M.A., & Holben, D.H. (2006). Community Nutrition in Action (4th ed.) Belmont: Thomson Wadsworth.
4. Airhihenbuwa, C.O., & Kumanyika, S. (1996). Cultural Aspects of African American Eating Patterns. Ethnicity & Health, 1(3), 245-263.
5. James, D. (2004). Factors Influencing Food Choices, Dietary Intake, and Nutrition-Related Attitudes among African Americans: Application of a Culturally Sensitive Model. Ethnicity & Health, 9(4), 349-367.
6. Centers for Disease Control (2000). Executive Summary: Healthy Weight, Physical Activity, and Nutrition: Focus Group Research with African American, Mexican American, and White Youth. DNPA Physical Activity and Nutrition Adolescent Initiative.
7. U.S. Department of Health and Human Services and U.S. Department of Agriculture. Dietary Guidelines for Americans, 2005. 6th Edition, Washington, DC: U.S. Government Printing Office, January 2005.
8. Townsend, M.S. (2006). Obesity in Low-Income Communities: Prevalence, Effects, a Place to Begin. Journal of the American Dietetic Association, 106(1), 34-36.
9. Santora, M. (2006, January 20). New York Pushing Better Diet in Poorer Neighborhoods. New York Times.
10. Kleinfield, NR (2006, January 10). Living at the Epicenter of Diabetes, Defiance, and Despair. New York Times.
11. Maslow’s Hierarchy of Needs. Wikipedia: The Free Encyclopedia. Retrieved November 11, 2006, from http://en.wikipedia.org/wiki/maslow’s_hierarchy_of_needs
The homogenous approach to nutrition recommendations reflected by the Dietary Guidelines for Americans fails to take into account the increasingly heterogeneous US population. Census data demonstrate an increase in diverse racial and ethnic groups in the United States from approximately one-fourth to one-third of the population, and this trend is expected to continue, such that by the year 2030, minority groups will account for forty percent of the total population (3). Given that African Americans are the second largest ethnic minority group in the country and that this population has a higher prevalence of obesity and weight-related diseases than the general US population, extensive research has been conducted on the eating practices of African Americans. Research has indicated that the dietary habits, food choices, and cooking methods unique to African Americans evolved from a long history of slavery, persecution, and segregation (5). The slaves who were brought to the US combined their West African cooking methods with those of the British, Spanish, and Native American techniques to produce a distinctive African American cuisine known as ‘soul food’ (5). Soul food emphasizes fried, roasted, and boiled food dishes using primarily chicken with the skin left intact, pork, pork fat, organ meats, sweet potatoes, corn, and green leafy vegetables (4). As a result of the high intake of deep fried foods, eating chicken with the skin, not trimming fats from meat, seasoning vegetables with fat and meat, and reusing oils, fats and grease to flavor foods, the traditional African American diet tends to be low in fiber, high in sodium, nitrates, sugar, fat and/or cholesterol (5). These dietary practices continue to persist despite their health implications because long-term beliefs, attitudes, and behaviors among the African American community have been handed down across generations. Subsequently, healthful eating is viewed as an abandonment of tradition and culture and is perceived as conforming to the dominant culture. Mexican Americans are a second minority group that is becoming a fast growing segment of the American population, and like African Americans, dietary practices and nutrition related behaviors are culturally defined and established early in life. A collaborative research study conducted by the CDC’s Division of Nutrition and Physical Activity found that the dietary practices typical of Mexican American families included eating traditional Mexican food that is high in fat and starch and low in vegetables (6). This study also discovered that young African Americans and Mexican Americans have different perceptions about healthy and unhealthy weight compared with whites (6). Specifically, a person who is overweight is considered to be well-nourished or “full figured” in the African American and Mexican American cultures. The Dietary Guidelines for Americans are not culturally relevant or sensitive to the dietary practices and food-related behaviors of the diversity of ethnic and racial minorities that represent large segments of the American population. The Dietary Guidelines, which are based on the medical model and view food as being therapeutically valuable, isolate food from the cultural context of eating and therefore has limited effectiveness with many minority groups.
The Dietary Guidelines for Americans 2005 recommends nine servings per day of a variety fruits and vegetables and three cups of reduced fat or fat-free milk or other dairy products for the reference 2,000 calorie level (7). However, the Guidelines do not take into account the limited availability and high cost of fruits, vegetables, and reduced fat dairy products and the greater availability and lower costs of high-fat foods in impoverished urban neighborhoods. These low income neighborhoods have a disproportionately higher number of racial and ethnic minority populations, particularly Hispanic and non-Hispanic blacks (8). The limited access and higher cost of healthier foods in poorer urban neighborhoods is a direct result of the migration of supermarkets to the suburbs, leaving low-income shoppers who do not have access to private transportation at the mercy of high priced convenience stores and local grocery stores (5). Convenience stores, also known as bodegas, and local grocery stores that serve poorer inner city neighborhoods have limited inventories and usually do not stock large amounts of perishable foods (5). In the Bedford-Stuyvesant neighborhood of Brooklyn, only 21 percent of the bodegas offered apples, oranges and bananas; leafy green vegetables were found in only 6 percent of the bodegas; and only one in three bodegas sold reduced-fat milk (9). A study that tracked the availability of diet soda, low-fat or fat-free milk, high-fiber bread, fresh fruit and fresh vegetables in food stores in East Harlem and the Upper East Side found that stores on the Upper East Side were more than three times as likely than the stores in East Harlem to stock all five of the aforementioned items, despite the fact that East Harlem had more than twice as many food stores per capita as the Upper East Side (10). East Harlem is around 90 percent Hispanic and black (10). Even if healthy food is available in these types of neighborhoods, local convenience and grocery stores often charge more for it than supermarkets (9). In the Bedford-Stuyvesant neighborhood of Brooklyn, the average cost of a gallon of milk was 79 cents higher in the Bodega than in a supermarket (9). Although there is limited access to healthier food options in most of these low-income neighborhoods, there is a greater availability of inexpensive, high-fat foods. A recent geographical analysis determined that predominantly black neighborhoods have 2.4 fast-food restaurants per square mile, compared to 1.5 such restaurants in predominantly white neighborhoods (3). On Third Avenue in East Harlem, a banner outside McDonald’s advertises a $1 menu, while down the street a KFC sign boasts that you can “Feed Your Family for Under $4 each (10)”. Foods that are energy-dense and highly palatable, like fast-food and potato chips, sodas, and doughnuts available at bodegas, are associated with diminished feelings of satiety and the over consumption of fats and sweets, leading to increased energy intakes (3). Research focusing on the availability and cost of foods in impoverished urban neighborhoods has concluded that neighborhood differences may account in part for health disparities that have a dietary component (5).
The Dietary Guidelines for Americans blindly assumes that provided with nutrition information, consumers will make the appropriate changes in their eating habits and lifestyles. The DGAs view individual level behavior change separate from the social context of eating, which research has shown influences all aspects of eating patterns. Social connections satisfy one of the fundamental human needs of belonging identified by psychologist Abraham Maslow in his Hierarchy of Needs (11). Humans need to feel belonging and acceptance whether it comes from large social groups or small social connections (11). Individuals have a need to belong to a social group and eating certain foods from one’s cultural group is a way of staying connected to that group. Research through focus group interviews has shown that minority groups, particularly African-American and Hispanic populations, report that eating healthfully is perceived as giving up part of their cultural heritage and trying to conform to the dominant culture (5). Individuals may consciously or unconsciously participate in culturally defined eating patterns in order to maintain group identity (5). A resident of Spanish Harlem was quoted as saying that people in his neighborhood “associate diet as unhealthy. If you’re dieting, then you’re sick. You look at people on the streets, they’re heavy. That’s the way we grow up here (10)”. Despite the resident’s family history of diabetes, he added that people in his community “love eating trash…we grew up eating McDonald’s and I still find myself eating candy and chocolate cake (10).” He also added that the members of his community have “cultural differences…for a guy to eat a salad, he’s a wimp. The women can’t be chumps either. A woman can eat a salad but has to eat it on the low. She has to do it quiet. They make fun of you: What are you, a rabbit (10)?”
It is evident from the obesity epidemic that is currently plaguing the nation that the Dietary Guidelines for Americans are an ineffective public health intervention. Not only are the Guidelines not reaching large segments of the American population, particularly low income ethnic minorities, but the Guidelines are not applicable and practical in the real-life setting of these people’s lives. The biomedical orientation of the Guidelines limit their effectiveness with lower-income minority groups because they isolate eating behaviors from the cultural, economic, and social context in which eating patterns are developed, maintained, and passed down. The individual-level nutrition recommendations made by the Guidelines developed for the general population are not culturally relevant or specific to many minority groups residing in poor inner city neighborhoods. The Guidelines expect these population groups to practice dietary patterns that are contrary to the foods available and the dietary practices followed in their environment. An effective public health intervention to reduce obesity and the risk of chronic diseases must take these cultural, economic, and social differences into consideration; otherwise the impact of the obesity epidemic will continue to disproportionately affect people with limited resources, racial and ethnic minorities, and the poor.
References
1. Mahan, L.K., & Escott-Stump, S. (2004). Krause’s Food, Nutrition, & Diet Therapy (11th ed.). Philadelphia: Saunders.
2. Zhang, Q. & Wang, Y. (2004). Trends in the Association between Obesity and Socioeconomic Status in U.S. Adults: 1971 to 2000. Obesity Research, 12(10), 1622-1632.
3. Boyle, M.A., & Holben, D.H. (2006). Community Nutrition in Action (4th ed.) Belmont: Thomson Wadsworth.
4. Airhihenbuwa, C.O., & Kumanyika, S. (1996). Cultural Aspects of African American Eating Patterns. Ethnicity & Health, 1(3), 245-263.
5. James, D. (2004). Factors Influencing Food Choices, Dietary Intake, and Nutrition-Related Attitudes among African Americans: Application of a Culturally Sensitive Model. Ethnicity & Health, 9(4), 349-367.
6. Centers for Disease Control (2000). Executive Summary: Healthy Weight, Physical Activity, and Nutrition: Focus Group Research with African American, Mexican American, and White Youth. DNPA Physical Activity and Nutrition Adolescent Initiative.
7. U.S. Department of Health and Human Services and U.S. Department of Agriculture. Dietary Guidelines for Americans, 2005. 6th Edition, Washington, DC: U.S. Government Printing Office, January 2005.
8. Townsend, M.S. (2006). Obesity in Low-Income Communities: Prevalence, Effects, a Place to Begin. Journal of the American Dietetic Association, 106(1), 34-36.
9. Santora, M. (2006, January 20). New York Pushing Better Diet in Poorer Neighborhoods. New York Times.
10. Kleinfield, NR (2006, January 10). Living at the Epicenter of Diabetes, Defiance, and Despair. New York Times.
11. Maslow’s Hierarchy of Needs. Wikipedia: The Free Encyclopedia. Retrieved November 11, 2006, from http://en.wikipedia.org/wiki/maslow’s_hierarchy_of_needs
posted by Elana at 9:52 AM
24 Comments:
This is a fabulous critique of the existing dietary guidelines, and a beautiful demonstration of the need to contextualize risk factors. By failing to consider the social, economic, environmental, and cultural context in which poor eating habits take place, the current approach is largely doomed to failure, and as you show, it is little surprise that we've made no progress towards improving nutrition and diet, especially in certain population groups.
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The Dietary Guidelines for Americans 2005 recommends nine servings per day of a variety fruits and vegetables:
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