February 2019 Issue

Ethnic Cuisine — A Bridge to Health Equity
By Constance Brown-Riggs, MSEd, RD, CDE, CDN
Today's Dietitian
Vol. 21, No. 2, P. 24

Revisiting African food traditions may empower African Americans to reclaim their health.

According to the Centers for Disease Control and Prevention (CDC), African Americans are living longer. The death rate for African Americans aged 65 and older declined about 25% between 1999 and 2015. However, that good news is tempered by the fact that younger African Americans aren't experiencing the same longevity.

A new analysis by the CDC shows that younger African Americans in their 20s, 30s, and 40s are living with or dying from conditions such as diabetes, high blood pressure, and stroke. When chronic diseases start early, they can lead to earlier death. African Americans aged 18–49 are twice as likely to die from heart disease than whites, and African Americans aged 35–64 are 50% more likely to have high blood pressure than whites.1

These disparities in preventable diseases such as diabetes often are due to economic and social conditions that are more common among African Americans than whites. For example, African American adults are more likely to report that they can't see a doctor because of cost or that they lack access to healthful food.1

Kelly Toups, MLA, RD, LDN, director of nutrition at Oldways, a nonprofit food and nutrition education organization in Boston, says, "Inadequate access to healthful, affordable foods and preventive health care may partially explain why African Americans are disproportionately affected by chronic disease. Studies show that diet also may play a role in the disproportionate rates of chronic disease in African Americans."

In a study of 6,897 adults published in the October 2018 issue of the Journal of the American Medical Association, researchers found that among all mediating factors the largest mediator was eating a typical "Southern diet" of fried food, processed meats, added fats, and sugar-sweetened beverages, accounting for 51.6% of the excess risk of high blood pressure in African American men and 29.2% of the excess risk among African American women.

"This 'Southern diet' is often seen as the traditional diet for many African Americans," Toups says. "However, a healthier, more solidly traditional model can be found by looking to the foods brought to the New World by Africans, along with those they adopted."

The traditional African American diet in the South was a combination of African food-ways, influenced by French and Spanish cuisines. The diet was filled with fresh garden vegetables such as cabbage, okra, tomatoes, peppers, and a variety of leafy greens including dandelion, mustard, collard, and turnip greens. Pickling was used to preserve many of these vegetables such as okra, beets, green tomatoes, radishes, cabbage, carrots, and cucumbers, making vegetables available all year long. Traditional cooking from South Carolina and Georgia's coast—also known as Low Country—featured oysters, crabs, shrimp, sweet potatoes, and Hoppin' John (black-eyed peas and rice). The result: a nutrient-dense diet rooted in wholesome plant foods with very little meat.2

The Great Migration
During the Great Migration in the early 20th century, African American migration patterns included relocation from Southern farms to Southern cities; from the South to the Northeast, Midwest, and West; and from the Caribbean to US cities as well as to migrant labor farms.3,4 This movement from rural communities in the South to large cities in the North and West changed the eating habits of African migrants. Prestige ingredients involving the use of processed flour and refined sugar, and celebratory foods such as fried chicken, fried fish, cakes, and sweet potato pies, once reserved for special events, now were eaten frequently during the week.5

"Movement from rural to urban areas resulted in increased availability and consumption of foods once reserved for special occasions," says California-based Cordialis Msora-Kasago, MA, RDN, a spokesperson for the Academy of Nutrition and Dietetics and founder of The African Pot Nutrition, a private practice focused on teaching people of African descent and others how to eat healthfully to prevent and manage chronic disease. "The impact of this on overall health cannot be understated as high-fat, high-sodium, sugary foods, often of inferior nutritional quality, became part of an overall daily diet, spurring chronic illnesses like diabetes and hypertension," Msora-Kasago says.

Scientific evidence shows that as people of Africa transition away from their traditional diet and adopt a more Western way of eating, chronic diseases that were either rare or unknown increase. A 2010 study in the Journal of Biomedical Science found that the prevalence of metabolic syndrome in young Tanzanian men increased as they ate more nontraditional foods such as donuts and ice cream and fewer traditional foods. The same trend can be found in Botswana. As younger populations shift from traditional to nontraditional lifestyles, signs of metabolic syndrome, such as increases in weight, blood pressure, and cholesterol, rise. The elderly, who are less inclined to change their eating habits, are healthier.

African American men and women have the highest rates of developing and dying from colorectal cancer than any other group in the United States. Moreover, a greater proportion of US African Americans die from colorectal cancer compared with rural Africans, suggesting that diet may play a role in disease prevention.

In a 2015 study published in Nature Communications, researchers performed two-week food exchanges including subjects from the same populations, where African Americans were fed a 55 g high-fiber, 16% fat, African-style diet and rural Africans a 12 g low-fiber, 52% fat, Western-style diet. At the end of the food exchange, the African Americans experienced a reduction in inflammation of their colons, improved markers for cancer, and an increase in the diversity of their healthy gut bacteria. On the other hand, rural Africans who ate a Western-style diet produced more bile acid—a risk factor for colon cancer—and experienced a decrease in the diversity of healthy gut bacteria.

The results of this study suggest that a high-fiber, low-fat, African-style diet can help promote a healthy digestive tract and potentially reduce the disproportionately high incidence of colon cancer in African Americans.

Closing the Culture Gap
A first step in reducing health disparities is to understand that health equity isn't the same as health equality. Health equity requires creating equal opportunities for people to live more healthful lives by removing obstacles and closing gaps in health outcomes.

"Health equality is represented by the dietitian who gives her group participants an equal opportunity to learn about healthful eating," Msora-Kasago says. "But to level the field and give everyone the same opportunity to achieve better health, the dietitian provides participants living in food deserts additional resources like access to a farmers' market—thus promoting health equity," she explains.

Nutrition plays a major role in advancing health equity. However, given health inequities such as food insecurity and different genotypes in communities of color, nutrition must go beyond a one-size-fits-all approach.

The 2015–2020 Dietary Guidelines for Americans (DGA) recommend three servings per day of low-fat and fat-free milk and milk products, such as yogurt and cheese, and fortified soymilk to help close the gap on calcium, vitamin D, and potassium deficiencies.6 This advice—although well intentioned—often is challenging for African Americans who avoid milk due to cultural food preferences or lactose maldigestion.

Recent research by Constance Hilliard, PhD, a professor of history at the University of North Texas who specializes in precolonial African history, suggests that, due to genetic adaptation, lactase nonpersistent African Americans with West African ancestry may retain more calcium in their bones, despite low calcium intake. Her research also shows that Africans of East African ancestry, despite higher calcium intake, have susceptibility to osteoporosis similar to persons of European ancestry.7

Hilliard supports the notion that one's nation and region of ancestral origin contributes to the risk of developing, or not developing, certain medical conditions. "The medical community should look at hereditary history and not put all races in a few categories," Hilliard said in a press release. There are approximately 40 million people of African descent living in the United States. Some have been in the United States for many generations; others are more recent immigrants from Africa, the Caribbean, or other parts of the world.

Although Hilliard's research suggests African Americans with West African ancestry may not need as much calcium for bone health, more research is needed in this area. Moreover, bone health isn't the only benefit of dairy. The 2015 Dietary Guidelines Advisory Committee report states that consumption of dairy foods is associated with a lower risk of diabetes, metabolic syndrome, CVD, and obesity—disease states that affect African Americans at disproportionate rates.8

Oldways—perhaps best known for creating the Mediterranean Diet Pyramid—developed the African Heritage Diet Pyramid to provide a more cultural model of healthful eating. "The African Heritage Diet Pyramid has brought to light a culinary legacy and often-unsung cultural ownership of healthful eating for people of African descent," Toups says.

With culturally inclusive messaging, the African Heritage Diet Pyramid recommends dairy "if tolerated" and suggests yogurt or lactose-free milk alternatives such as fortified soymilk, almond milk, or rice milk.2 Yogurt can help many African Americans with lactose intolerance meet their dairy requirements and obtain all the health benefits associated with dairy.

Consuming one 8-oz serving of nonfat or low-fat yogurt every day provides, in many cases, 30% DV for calcium and approximately 6% to 14% DV for potassium. Many yogurts also are fortified with vitamin D.9 Because of the presence of lactase-producing cultures, yogurt is a more easily digestible alternative to milk. On average, yogurt contains less lactose per serving than milk.

"The goal of the African Heritage Diet Pyramid is to illustrate the 'big picture' framework of African heritage diets, inspiring individuals and communities to reclaim their best health," Toups says. As illustrated in the pyramid, the African Heritage Diet is based on whole, fresh plant foods like colorful fruits and vegetables, especially leafy greens; tubers like yams and sweet potatoes; beans of all kinds; nuts and peanuts; rice, flatbreads, and other grain foods, especially whole grains; healthful oils; homemade sauces and marinades of herbs and spices; and fish, eggs, poultry, and dairy. It's naturally low in processed sugar, unhealthful types of fats, and sodium, and includes only small amounts of meats and sweets.2

Traditional Cultural Cuisines
The DGA identify three healthful eating patterns that illustrate their recommendations. These include the Healthy Mediterranean-Style Eating Pattern, the Healthy US-Style Eating Pattern—which reflects the principles of the DASH diet—and the Healthy Vegetarian Eating Pattern.10 These eating patterns have cultural influences and diverse nutrient-rich food choices that provide variety and culinary appeal in support of an overall healthful diet.

The Healthy Mediterranean-Style Eating Pattern is a plant-based cultural eating pattern based on the traditional ethnic cuisine of countries surrounding the Mediterranean. The Mediterranean eating pattern features fruit, vegetables, beans, nuts, whole grains, fish, and low-fat cheese and yogurt as well as other ingredients such as olive oil and wine.11 

The Healthy US-Style Eating Pattern is characterized by the DASH diet—adapted from the Dietary Approaches to Stop Hypertension research trials. This eating plan is low in saturated fat and rich in potassium, calcium, and magnesium, as well as fiber and protein. It's also lower in salt, added sugars, and red meats than the typical American diet.12 

The Healthy Vegetarian Eating Pattern can reflect traditional American foods but often may include other ethnic cuisines such as Asian, Ethiopian, Korean, and Indian. While these dietary patterns are of unique cultural origin, they exemplify the DGA Healthy Vegetarian Eating Pattern.

Reclaiming Traditional Cultural Cuisine
To help African Americans reclaim their traditional eating patterns of the past, dietitians can do the following during counseling sessions:

Be inquisitive and identify cultural barriers. In a thought-provoking 2018 Huffington Post article, author Kristen Aiken observed that some of the healthful foods RDs promote often are perceived as "white people's food" in communities of color, and that healthful eating must be addressed in the context of cultural barriers. Msora-Kasago agrees and says RDs should treat each client as an individual and be inquisitive. "Ask them how and where they get their food and how they include those foods on the plate. It's important to understand the unspoken injustices around food availability," Msora-Kasago says. Without any context of the individual's reality, it's easy to assume a mother who feeds her family what's available in her neighborhood simply needs someone to explain that fast food isn't the most healthful option.

Use ethnic food resources. Msora-Kasago developed an African food database (https://theafricanpotnutrition.com/african-food-database) to help her clients choose the most healthful foods and variety of ingredients from the African diaspora. "I wanted to provide a reliable resource and encourage the lay population to include heritage foods as part of an overall healthful diet," she says.

Use educational materials representative of the client's ethnicity. Toups suggests using the African Heritage Diet Pyramid. "When working with patients of African descent, using the African Heritage Diet Pyramid as a cultural model of healthful eating may be a successful strategy to positively influence eating behavior," she explains.

Take the African Heritage Diet CPE course. This course, developed by Oldways, offers an in-depth overview of the African Heritage Diet as an evidence-based, culturally meaningful nutrition intervention guide. To access the course, visit https://oldwayspt.org/programs/african-heritage-health/african-heritage-health-cpe-course.

Take an African Heritage cooking class. To bring the African Heritage Diet Pyramid to life, Oldways created A Taste of African Heritage, a six-week cooking and nutrition curriculum based on plant foods from the African diaspora. "Since its inception in 2012, it has been taught more than 300 times in communities across the nation, serving over 6,500 individuals," Toups says. Recently, A Taste of African Heritage was added to the online SNAP-Ed library, giving SNAP-Ed educators a more culturally relevant curriculum option. For more information, visit https://oldwayspt.org/programs/african-heritage-health/atoah-community-cooking-classes.

Final Thoughts
Studies have shown that when people adopt a more Westernized diet, their susceptibility to health problems increases. Reclaiming traditional, cultural cuisines and adopting a healthful eating pattern such as the African Heritage Diet and those highlighted in the DGA has both culinary and health appeal. These dietary patterns and the cultures and foods that support them can play a key role in bridging the health equity gap in African Americans.

— Constance Brown-Riggs, MSEd, RD, CDE, CDN, is a nutrition adviser for DanoneWave and author of the Diabetes Guide to Enjoying Foods of the World, a convenient guide to help people with diabetes enjoy all the flavors of the world while still following a healthful meal plan.

1. Centers for Disease Control and Prevention. Vital Signs: African American health: creating equal opportunities for health. https://www.cdc.gov/vitalsigns/pdf/2017-05-vitalsigns.pdf. Published May 2017. Accessed December 2, 2018.

2. African Heritage Diet. Oldways website. https://oldwayspt.org/traditional-diets/african-heritage-diet. Accessed December 2, 2018.

3. Great Migration. History website. https://www.history.com/topics/black-history/great-migration. Updated September 20, 2018. Accessed December 2, 2018.

4. ASALH announces 2019 black history theme, Black Migrations. Association for the Study of African American Life and History website. https://asalh.org/asalhs-2019-theme-black-migrations/. Accessed December 2, 2018.

5. Miller A. An illustrated history of soul food. First We Feast website. https://firstwefeast.com/eat/2015/08/an-illustrated-history-of-soul-food. Published August 25, 2015. Accessed December 2, 2018.

6. Nutrients and health benefits. ChooseMyPlate.gov website. https://www.choosemyplate.gov/dairy-nutrients-health. Updated June 26, 2015. Accessed December 2, 2018.

7. Hilliard CB. High osteoporosis risk among East Africans linked to lactase persistence genotype. Bonekey Rep. 2016;5:803.

8. US Department of Agriculture; US Department of Health and Human Services. Scientific report of the 2015 Dietary Guidelines Advisory Committee: advisory report to the Secretary of Health and Human Services and the Secretary of Agriculture. https://health.gov/dietaryguidelines/2015-scientific-report/PDFs/Scientific-Report-of-the-2015-Dietary-Guidelines-Advisory-Committee.pdf. Published February 2015. Accessed December 2, 2018.

9. United States Department of Agriculture. USDA Food Composition Databases. https://ndb.nal.usda.gov/ndb/. Updated April 2018. Accessed December 2, 2018.

10. US Department of Health & Human Services. Dietary Guidelines for Americans 2015–2020: Eighth Edition. http://health.gov/dietaryguidelines/2015/guidelines/. Published January 7, 2016. Accessed December 2, 2018.

11. Altomare R, Cacciabaudo F, Damiano G, et al. The Mediterranean diet: a history of health. Iran J Public Health. 2013;42(5):449-457.

12. DASH eating plan. National Heart, Lung, and Blood Institute website. https://www.nhlbi.nih.gov/health-topics/dash-eating-plan. Accessed December 2, 2018.