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Nutrition 411: The Nutritional Melting Pot: Understanding the Influence of Food, Culture, and Religion on Nutrition Interventions
Ostomy Wound Management presents this extended version of Nutrition 411 to help readers address transcultural nutrition concerns. We are grateful to the authors for their timely insights.
According to US Census Bureau data, as of July 2006 approximately one in three US residents (about 100 million people) was a minority. Hispanics are the largest minority group (44.3 million, 14.8% of the population), followed by black Americans (40.2 million or roughly 13.5% of the population) and Asians (14.9 million).1 Census statistics project that racial and ethnic diversity will continue to increase into the middle of the century. By 2050, the minority population is forecasted to reach approximately 235.7 million or 54% of the US population.2 The Hispanic population is expected to triple, and the Asian population is expected to more than double. The number of American Indians and Alaskan natives also is projected to increase from 4.9 million to 8.6 million (or from 1.6% to 2% of the total population), and the number of native Hawaiians and other Pacific Islanders is expected to more than double, from 1.1 million to 2.6 million.
Tremendous variations in language, culture, religious beliefs, education, food habits, and socioeconomic status exist within each minority group. Patients with different cultural and religious backgrounds often bring their own sets of beliefs and practices that can affect medical treatment, including wound healing. Healthcare professionals cannot assume that each group, neatly categorized by the US Census Bureau, is heterogeneous. However, a basic understanding of religious and cultural norms as they relate to food habits can help registered dietitians (RDs) and other members of the healthcare team. The nutrition care plan goal for patients with wounds is to meet nutrient needs within the context of customary food habits.
This article addresses the food habits of our nation’s largest ethnic, racial, and religious groups and discusses how these diets affect nutrient intake as it relates to wound healing. The general nutrient guidelines for wound healing are outlined in Table 1. Individual treatment plans, including decisions about vitamin and mineral supplementation, must adapt these guidelines to meet the needs and medical conditions of each specific patient. 
Hispanic Food Patterns
The US Census Bureau defines the Hispanic/Latino profile as Cubans, Mexicans, Puerto Ricans, and South and Central Americans. The Mexican-American population makes up the majority of the Hispanic population. The typical Mexican diet is rich in complex carbohydrates in the form of corn, corn products, beans, and rice. Enough protein to meet most needs is provided by eggs, fish, beans, and most types of meat and poultry.3 Mexican diets often are high in fat because many of the foods are deep-fried. The nutrients most likely lacking are calcium, iron, vitamin A, folacin, and vitamin C,3 many of which are essential to wound healing.
If nutrient needs are increased because of wounds, a diet with meat, poultry, beans, and low-fat cheese can provide additional protein. Liberal use of tomatoes and fruits, common ingredients in Mexican foods, can increase vitamin C intake. Clinicians also should encourage a diet that includes dark-green leafy and deep-yellow vegetables, even though some of the Hispanic population is not familiar with these foods.
Asian Food Patterns
The US Census Bureau classification of Asians includes persons from a wide variety of countries, including Vietnam, China, India, Pakistan, and Japan. Their corresponding cultures have diverse food habits. However, meal composition and cooking techniques are similar across Asian regions. Preparation includes stir-frying, barbecuing, boiling, and steaming. These quick-cooking techniques may prevent nutrient loss. Another common element is that dairy products are rarely used.4 Most Asian cultures obtain protein from fish, pork, and poultry, which can provide adequate amounts if food intake is sufficient. The major staple in all of the diets in this culture is rice, including products made with rice flour, which provides energy (calories) for wound healing. Vegetables and fruits also make up a large part of the diet for many Asians.
The traditional Chinese diet obtains more than 80% of its calories from grains, legumes, and vegetables and 20% from animal protein, fruits, and fats.5 Most Asians are lactose intolerant and obtain calcium from tofu or by consuming small fish with bones. Because this population typically does not drink milk, creamy medical nutritional supplements sometimes are not easily accepted. Most commercial dietary supplements recommended for wound healing are lactose-free. It is important to communicate to the lactose-intolerant individual that these supplements are appropriate and safe for their use.
Asian Indians and Pakistanis, classified as part of the Asian population by the US Census Bureau, use legumes more than other Asian cultures. A vegetarian or vegan diet is common for many from this region. A well-planned vegan diet can meet patients’ nutrient needs. However, vegans who do not consume a wide variety of protein sources may lack some essential amino acids, particularly if their protein needs are increased because of wounds. If it is not possible to meet protein needs with the customary diet or meal intake, a protein supplement may be necessary. Selection of protein supplements for vegans sometimes is complicated because many use animal products as their base.
The diet high in rice, vegetables, and fish common to the Chinese, Filipino, Asian Indian, Laotian, and Vietnamese population may result in iron or zinc deficiency, which can affect wound healing. Laboratory tests can confirm suspected iron-deficiency anemia, which can be corrected, if necessary, in an attempt to improve the wound healing process. Zinc supplementation in patients with wounds is controversial. However, when a deficiency is suspected or confirmed, a trial of a low-dose zinc supplement or multivitamin with zinc might enhance wound healing.6
African-American Food Patterns
Many African Americans are several generations removed from their original homeland. Evidence suggests that today’s typical African-American diet is influenced by the lifestyle of the grandparents or great-grandparents who lived in the southern US.7 The traditional African-American diet includes collard greens, legumes, beans, rice, potatoes, and other dark-green and yellow vegetables. This diet is high in vitamin A, iron, and fiber. Legumes, beans, lean meats, fish, and poultry usually provide adequate protein for wound healing.
In this culture, the food often is fried and/or includes the addition of rich sauces and gravies that might increase the fat and caloric content of meals. Many African Americans are lactose intolerant and, as a result, might not consume much milk or cheese. Like other lactose-intolerant populations, if supplemental protein or calories are needed, a lactose-free supplement or juice-based supplement sometimes is indicated.
Table 2 summarizes the general characteristics of these three main ethnic groups. 
Health Issues of Minority Populations That Affect Wound Healing
According to 2007 data from the Behavioral Risk Factor Surveillance System (BRFSS),8 the rate of obesity in the US was 25.6% in 2007. Obesity is a major risk factor for diabetes. Some ethnic groups, particularly Mexican-Americans and African Americans, have higher rates of obesity and diabetes than other population groups.9,10 Statistics indicate Hispanics are twice as likely to have diabetes than non-Hispanics.10 African American adults are 1.9 times more likely than non-Hispanic white adults to have diabetes.9
Both diabetes and obesity can have a detrimental effect on wound healing. Uncontrolled diabetes can result in cellular malnutrition and ultimately delayed wound healing. When a person is overweight, repositioning and turning to relieve pressure over the bony prominences is more difficult. A consequence of the extra weight is more pressure on the pressure points, possibly contributing to pressure ulcer development and/or making healing more difficult. Treatment of both diabetes and obesity probably is within the cultural norms of a patient. However, severe restriction of calories is not recommended when a patient has a healing wound.
Religious Dietary Practices
Religious beliefs influence a person’s value system, traditions, and dietary practices, which, in turn, can affect food selection. A person’s level of commitment to their religion may affect whether they adopt the dietary practices of that religion. An understanding of various religious beliefs as they pertain to diet can help practitioners make recommendations for wound healing.
Hinduism. Hinduism, the oldest continuing religion in the world, is common among persons of Indian descent. Hindus respect all life, both human and animal. In this religion, meat and eggs are not consumed because they represent life, nor are chicken and pigs, because these animals are considered scavengers.11 The majority of Hindus are vegetarians, but some eat fish and others may consume dairy foods. Because protein is a key component of wound healing, providing adequate protein sometimes is challenging. Iron-deficiency anemia and zinc deficiency also are possible issues.
Buddhism. Persons from Southeast Asia, including Vietnam, Cambodia, Laos, Tibet, China, Japan, and Thailand, commonly practice Buddhism. Some Buddhists abstain from eating meat and fish, but it is not forbidden.12 Rice is a staple for most Buddhists and moderate eating (not eating too much at meals) is a common practice. Meeting calorie and protein needs may be challenging for persons accustomed to eating moderately. Buddhist patients with wounds need encouragement to consume calorie-dense foods such as items fortified with calories and protein several times a day.
Judaism. Judaism traces its roots back to ancient Hebrews. Jewish dietary laws are biblical ordinances that include rules regarding food, chiefly about the selection, slaughter, and preparation of meat.5 Kosher food products, which are ritually prepared and approved for consumption, are designated with the appropriate mark such as K or U.13 Some protein and calorie supplements are kosher-approved and also are identified by the K or U symbols on the label. The most devout members of the Jewish faith do not combine milk and meat in the same meal; traditional orthodox Jewish homes keep two sets of dishes, silver, and utensils, one for milk and one for meat.5 Healthcare institutions with a large Orthodox clientele have Orthodox kitchens, where separate utensils and dishes for meat and dairy foods are used. Many Jewish people, even those not strictly kosher, adhere to the rule to foresake consumption of all animals that do not have cloven hooves and do not chew their cud. Hence, most Jewish people do not consume pork and pork products. Also, any seafood that does not have fins and scales is forbidden. This means shellfish, including lobsters, oysters, shrimp, clams, and crabs, are not appropriate choices for this group. A controversial issue within Judaism is the value of initiating enteral and parenteral feedings and then when to terminate the feedings. Orthodox individuals usually are insistent that feedings not terminate once they are initiated.14
Islam. Islam (Muslim) is the youngest of the major religions but is growing rapidly. Muslims are advised to stop eating when they are still hungry and to always share food.5 The dietary laws established by Muhammad prohibit eating swine and drinking alcohol. Saum, the ritual of fasting observed during the 30 days of Ramadan, requires abstaining from all food from sunrise until sunset.15 Sick individuals are excused from fasting. The sanctity of life is important to Muslims. However, maintaining a terminal patient on artificial life support for a prolonged period in a vegetative state is not encouraged; advanced directives are favored.16 Muslims believe illness is atonement for sin, but they are encouraged to seek medical assistance when needed.
Other Cultural Issues
Many cultures have beliefs that might affect food consumption. For example, Chinese medicine cites the need for a balance between yin and yang and among the five elements of water, fire, earth, metal, and wood. Yin foods are hot, higher in calories, and thought to improve circulation by raising the metabolism; yang foods are cool and eliminate toxins by lowering the metabolism.4 The ideal Chinese diet includes a blend of both types of food to keep the body balanced. Traditionally, the less active the person, the more yin food required.
Some Hispanics of various cultures believe in the “hot” and “cold” concept of foods, herbs, and illnesses. As part of this belief, a good meal provides a balance of hot and cold foods and those who eat foods with temperatures that are wrong for them can get sick.17 “Hot” foods include chili peppers, garlic, onions, most grains, expensive cuts of meat, oils, and alcohol. “Cold” foods are most vegetables, tropical fruits, dairy proucts, and inexpensive cuts of meat.
When evaluating individuals from the Chinese or Hispanic culture, the assessment process should include questions concerning their beliefs in this type of system. If possible, nutrition care should include a diet that includes the yin/yang or hot/cold principles, if this is important to the patient.
Nutrition Care for Wound Healing
All patients with wounds require a complete nutrition screening and assessment. The RD should review the medical record and form a treatment plan. The assessment must incorporate evaluation and review of anthropometric data — ie, height, weight history, and body mass index — as well as biochemical tests, particularly those indicating protein stores, iron stores, and hydration status. A thorough food and nutrition history, which includes questions about cultural and religious eating habits, rounds out the data collection. The practitioner may find it helpful to assess cultural influence on food habits using the pneumonic ABCDE18:
A: Attitudes of clients and families within their culture
B: Beliefs—religious beliefs and traditions
C: Content—personal history, including economics, emigration, and the role of food in the family
D: Decision-making style within the family and culture
E: Environment—interpreters of culture or language
Interview style. When interviewing patients and/or families, it is important to consider differences in communication styles between American/Western and non-Western cultures. For example, eye contact is valued by Caucasian Americans but is considered impolite for many Asian and Native Americans. Greeting on a first name basis denotes disrespect in some cultures. Table 3 describes some of the cultural parameters that can affect interaction with patients of different cultures.
After completing a nutrition assessment, the RD will compare the nutrient needs to the patient’s diet. Depending on nutrient needs and meal intake, additional food, vitamin supplements, or high-calorie, high-protein supplements are sometimes recommended to enhance wound healing. Monitoring and evaluating the wound healing process may result in changes in nutrition interventions over time. Whether a patient is living at home or in an institution, the clinician should make every effort to meet a patient’s needs within the context of his/her cultural and religious beliefs. If supplements are needed, provide products that do not violate a patient’s belief system.
Putting It in Practice
Cultural diversity in America is changing the healthcare and food service landscape. Assisted-living and long-term care facilities are required to provide an environment that is as homelike as possible. For patients in these facilities, clinicians should encourage family members to suggest culturally appropriate foods that the facility can provide. The facility also should encourage family members to provide familiar foods from home, especially if the patient’s meal intake at the facility is poor. Familiar foods serve two benefits — they make an institutional environment more homelike and also may encourage greater nutrition intake. The care facility and family members can work in tandem to maximize the meal intake of each patient at nutritional risk because of wounds, regardless of culture or religious beliefs. Different groups working together for the betterment of the elderly and sick exemplifies our forefathers’ melting pot ideal.
For more information vistit the USDA Food and Nutrition Information Center. Cultural and ethnic food and nutrition education materials: a resource list for educators, January 2008. Available at: www.nal.usda.gov/fnic/pubs/bibs/gen/ethnic.pdf. Accessed March 15, 2009.
Coming next: Understanding the Protein Digestibility Corrected Amino Acid Score (PDCAAS)
Nancy Collins, PhD, RD, LD/N, FAPWCA, is founder and executive director of RD411.com and Wounds411.com. For the past 20 years, she has served as a consultant to healthcare institutions and as a medico-legal expert to law firms involved in healthcare litigation. Liz Friedrich, MPH, RD, LDN, is a registered dietitian in Salisbury, NC, whose specialty is long-term care. She is associate director for RD411.com and an evidence analyst for the American Dietetic Association's Evidence Analysis Library. Mary Ellen Posthauer, RD, CD, LD, is a registered and licensed dietitian in Evansville, IN, whose specialty is long-term care. Correspondence may be sent to Dr. Collins at NCtheRD@aol.com.
This article was not subject to the Ostomy Wound Management peer-review process.
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