Author: Thevaki Kulendran, RD, CDE, MHSc
Posted: November 24, 2021
The Mediterranean diet has become increasingly popular over the last decade and is frequently recommended to patients as a means to effectively prevent and manage chronic diseases (6). The cultural practices of the Mediterranean countries and surrounding regions are diverse in terms of socio-cultural factors that are not widely acknowledged (10). In fact, the benefits of the Mediterranean diet may in part be attributable to lifestyle and not dietary factors alone (3) and it should be noted that there are many Mediterranean diets (1). Recently, an article which circulated among the Primary Care Dietitians’ Association member group email sparked conversation on the need for a cultural translation of the Mediterranean diet.
The prevalence and variation of chronic disease and related comorbidities across different ethnic groups is well documented in the literature (9). It would seem practical that dietitians make cultural adaptations based on the mediterranean diet to meet the needs of different cultural groups (4). For example, olive oil is a staple in the Muslim diet, however alcohol is considered as taboo (2). It is reasonable to remove the alcohol (wine) recommendation in order to make it acceptable, but it fails to recognize that the nutrients recommended in the Mediterranean diet are already consumed by Muslims, as well as other communities, but these similarities are not well represented in the literature. In a profession where evidence-based practice is the gold standard, the evidence fails to acknowledge the disparities in research that do not hold space for equal representation across different ethnicities.
Studies have shown poorer health outcomes may be related to a diversion away from cultural traditions (7). The absence of culturally specific data and research gives rise to the erosion of the identities of these communities. It is safe to say, by now, that we are not looking to repeat any part of our history that diminishes the value of any cultural group, and cultural competency is integral for patient centered models of care. Though widespread cross-cultural knowledge has yet to be attained, it is necessary for high-quality and equitable healthcare (11). In such cases taking a culturally respectful approach that is inclusive and responsive to the cultural needs of a patient serves as an important facet of both patient-centred care and reducing health inequities (8).
It should be noted that culture – as a variable in dietary choices – is often not accounted for in many studies (5); as such, health recommendations should be made with as much cultural respect as possible (4). The absence of knowledge of culturally appropriate dietary recommendations that accepts a broader definition of culture to include beliefs, values, attitudes that affect food choices, meal patterns and lifestyle (12) is further complicated by the complex definition of culture and its intersections with individual identity and variations within subcultures (12). However, homogenous recommendations prioritizing foods that are not culturally aligned gives rise to recommendations that are fundamentally contributing to racism.
The Mediterranean diet is more than just food; it is a lifestyle (3). It exemplifies how culturally appropriate recommendations can contribute to positive health outcomes for the variety of subcultures that identify within this population (1, 3, 10). It is worthy to consider that the benefits of this diet are the alignment of recommendations that consider both the lifestyle and food. In the absence of careful consideration and translation of the research findings and culturally appropriate recommendations, dietitians and other health care providers may be contributing to health inequities among racialized people and deepening the disparities in our healthcare system.
Dietitians’ need to reconsider recommending the Mediterranean diet. An alternative can be to understand that the foods identified in this diet that are already in other cultural diets (2). It is important to recognize these similarities and not to reference the use of these nutrients as the “Mediterranean diet” as this lifestyle is not applicable to diverse cultural groups. Dietitians and nutrition professionals need to do more research to clearly identify the beneficial nutrients from the Mediterranean diet in other ethnic dietary patterns and more efforts are required to identify parallel data to support clients from diverse cultural groups. In short, we need tools and resources that increase our knowledge of cultural diets to support our daily practice within our diverse populations that we serve in Primary Care.
References:
1 Ann N., Arthur S.T., (2001). There are many Mediterranean diets. Asia Pacific Journal of Clinical Nutrition. Vol. 10. 2-9. https://doi.org/10.1046/j.1440-6047.2001.00198
2. Attum B, Hafiz S, Malik A, Shamoon Z. Cultural Competence in the Care of Muslim Patients and Their Families. In: StatPearls. StatPearls Publishing, Treasure Island (FL); 2020. PMID: 29763108. https://europepmc.org/article/nbk/nbk499933#free-full-text
3. Cena, H., & Calder, P. C. (2020). Defining a Healthy Diet: Evidence for The Role of Contemporary Dietary Patterns in Health and Disease. Nutrients, 12(2), 334. https://doi.org/10.3390/nu12020334
4. College of Dietitians of Ontario (2021) College of Dietitians – Registered Dietitians
consider how culture and values can affect your nutrition. https://www.collegeofdietitians.org/resources/pages/registered-dietitians-consider-how-culture-and-val.aspx. Accessed on November 1st 2021.
5. Jingjing Y,, Degang, Y., Xinhuan Z., Yufang, Z., Tianyi, C., Yun, H., Shenghui, C., Yaning, C. (202) Diet Shift: Considering environment, health and food culture, science of the Total Environment. Vol 719. tps://doi.org/10.1016/j.scitotenv.2020.137484.
6. Minelli, P., & Montinari, M. R. (2019). The Mediterranean Diet and Cardioprotection: Historical Overview And Current Research. Journal of multidisciplinary healthcare, 12, 805–815. https://doi.org/10.2147/JMDH.S219875
7. Miyagi, S., Iwama, N., Kawabata, T., & Hasegawa, K. (2003). Longevity and Diet in Okinawa, Japan: The Past, Present and Future. Asia Pacific Journal of Public Health, 15(1_suppl), S3–S9. https://doi.org/10.1177/101053950301500S03
8. National Institutes of Health (NIH.gov). Cultural Respect.https://www.nih.gov/institutes-nih/nih-office-director/office-communications-public-liaison/clear-communication/cultural-respect. Updated July 7 2021. Accessed October 29 2021.
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11. Saha, Somnath et al. (2008). Patient centeredness, cultural competence and healthcare quality.” Journal of the National Medical Association vol. 100,11. doi:10.1016/s0027-9684(15)31505-4
12. Winham D. M. (2009). Culturally tailored foods and CVD prevention. American journal of lifestyle medicine, 3(1), 64S–68S. https://doi.org/10.1177/1559827609335552