Diabetes care and education focuses on knowledge and self-management behaviors related to physical activity, healthy eating, taking medication, monitoring, reducing risk, and problem-solving.1-3 Certified Diabetes Care and Education Specialists provide individualized nutrition counseling and other behavior change strategies.4 Although nutrition counseling may be straightforward, such as recommending consistent carbohydrate intake at each meal, cultural foods and beliefs influence dietary choices and should be a consideration when counseling individuals of ethnically diverse backgrounds.
In the United States, ethnically diverse populations are disproportionately affected by type 2 diabetes (T2DM). Among Mexican Americans, the rates of T2DM are much higher (24.6%) than the overall US population (14.6%).5 Mexican Americans comprise 11.2% of the US population, and from 2010 to 2020, the Hispanic population grew by 23%, accounting for more than 50% of the population growth.6,7 The rate of T2DM prevalence is tied to age, family history, sedentary lifestyle, history of gestational diabetes or prediabetes, and overweight status, which are factors strongly linked to diet quality.8
Studies with Mexican Americans and Puerto Ricans suggest that including ethnic and cultural preferences can improve glycemic status and reduce the incidence of complications.9-13
Some examples of ethnic and cultural adaptations include the use of traditional foods, such as tortillas, rice, beans, and different forms of chili peppers; providing health information in the preferred language; and including a paraprofessional with a high degree of cultural and community knowledge as part of the health care team. However, it is still unclear which and how cultural adaptations influence self-management behaviors relative to diet, a cornerstone for ameliorating T2DM complications.
Resnicow and colleagues14 describe a cultural sensitivity model for public health interventions that provides a comprehensive approach to understanding how cultural influences may impact behavioral interventions for disease prevention.14 This approach distinguishes the types of cultural influences as either surface or deep structure. Surface-structure influences are those observable or “superficial” characteristics of a target population, such as using people, places, language, music, food, locations, and clothing familiar and preferred by the target population in audiovisual material. It also includes having ethnically matched staff who recruit participants and deliver and evaluate programs.14 Deepstructure influences require an understanding of cultural, social, historical, environmental, and psychological forces influencing the health of a target population. This includes examining how perceptions of religion, family, society, economics, and the US government influence health behaviors.14 Deep-structure influences in the literature are more prevalent in qualitative studies because the findings report stories, quotes, explanations, and examples to describe the phenomena being studied.
Due to increasing evidence of enhanced outcomes when accounting for culture in health interventions,15-17 the purpose of this article is to review qualitative studies to identify cultural factors important for health care professionals delivering nutrition education and counseling to Mexican Americans with T2DM. More specifically, this seeks to identify deep-structure cultural influences using a qualitative synthesis approach.18-20 Syntheses of qualitative studies can amplify the barriers and facilitators of diabetes self-management voiced by study participants, thereby providing an opportunity to build evidence-based recommendations.18
Studies with Mexican Americans and Puerto Ricans suggest that including ethnic and cultural preferences can improve glycemic status and reduce the incidence of complications.
Content analysis methodology guided this systematic, exploratory review of qualitative peer-reviewed studies.21-23 This approach allowed for the development of definitions that were applicable across studies from different disciplines (nursing, medicine, anthropology, health promotion, and diabetes).
Review by the Institutional Review Board was not required for this study because human subjects were not involved, per the US Department of Health and Human Services guidelines.24
Criteria for selecting articles for inclusion were developed based on content analysis methodology for a consistent, systematic approach to sampling studies (Figure 1).21 The criteria included:
Studies were located using Web of Science (indexes social science journals), PubMed (indexes health and biomedical journals), ProQuest (indexes social science journals), and Cumulative Index to Nursing and Allied Health Literature (indexes nursing and allied health journals). All articles were available in English and were published in peer-reviewed journals.
From the initial search, 244 abstracts were examined by the primary author. Duplicate abstracts were excluded, and an ancestry search (a search of the bibliography) was conducted to find missed studies. When the ethnicity of study participants was unclear, the corresponding authors were contacted for confirmation. Finally, the studies were included if the primary author and a trained research assistant reached consensus that the study’s abstract reported on a concept(s) culturally relevant to diet for T2DM self-management. A total of 18 studies were included.
The content analysis approach facilitated the “cultural influences” coding guide.21,25 The primary author developed the coding guide by reviewing the 18 studies that met the inclusion criteria. The coding guide was created using an inductive approach to identify and develop the initial list of definitions and descriptions of the cultural influences relative to diet for T2DM self-management from the selected studies. Next, the primary author (and the primary coder) trained a secondary coder on material and concepts relative to nutrition recommendations for T2DM self-management,26 cultural influences on T2DM self-management for Mexican Americans,26-28 and using the coding guide. The coders met weekly for 10 weeks to discuss and clarify concepts and establish consensus on subcategories and definitions.
A number was assigned for the level of evidence of cultural influences identified in the results section of the studies: 0 indicated that the cultural influence was not present in the study, 1 indicated that the cultural influence was stated or paraphrased by the authors, and 2 indicated that a direct participant quote that represented the cultural influence from the original data was provided in the study. Interrater reliability was evaluated with Cohen’s kappa using STATA/IC 14.1.
The adapted Critical Appraisal Skills Programme (CASP) qualitative checklist, which consists of 36 scored questions, was used to describe the quality of the article used in this study.23 The items on the CASP qualitative checklist had a percentage agreement between 68.42% and 100% and an overall average agreement of 85.26% among the 2 coders. Each of the deep-structure cultural influences identified was grouped into categories of influences.
The 18 qualitative studies examined for this analysis revealed a variety of deep-structure cultural influences that play a role in diet-related behaviors of Mexican Americans in their efforts toward achieving glycemic targets (Table 1). Among the 18 studies, 7 were focus groups, 7 were in-depth interviews, 2 used both focus groups and in-depth interviews, and 1 was a secondary data analysis of qualitative data.29-46 The average CASP score for all the articles was 17.16, ranging from 12.5 to 23 out of a score of 30; therefore, no studies were excluded from the analysis. At least one deep-structure cultural influence was coded in each study. The average percentage agreement for cultural influences in the analysis was 89%, and the average Cohen’s kappa was 0.79.21 Table 2 lists the food-related cultural influences related to the categories of family influences and beliefs about foods.
The 18 qualitative studies examined for this analysis revealed a variety of deep-structure cultural influences that play a role in diet-related behaviors of Mexican Americans in their efforts toward achieving glycemic targets.
The cultural influences related to family were the influences of familismo (7 studies), family involvement (11 studies), and family turmoil (7 studies).
Familismo was expressed as the importance of taking care of the family over oneself, and many of the quotes reflected on food or the needs of the youth in the family. Because family is an important value for many Hispanic/Latino ethnic groups, understanding familismo is central to making diet and health-related choices and can enhance the dietitian’s ability to help patients incorporate better choices toward achieving glycemic targets.47,48 Several studies support the value of familismo as a motivating factor for self-management.49-54 Understanding this cultural value may help health care providers build rapport and engage the family members by sharing knowledge and engaging them in a supportive role in the attainment of the patient’s goals.47,55
Family members also got involved in their T2DM care by communicating their opinions on food preferences or social support. Inclusion of family in nutrition counseling sessions may also increase collective knowledge regarding the severity of the disease and aid in facilitating T2DM self-management behaviors.56,57 Evidence supports family members’ role in supporting lifestyle behavior changes, including diet, physical activity, and simple daily tasks such as reminders to take diabetes medicine.49-51,53,54
The cultural influences related to beliefs about foods were beliefs or attitudes about foods in general (15 studies), beliefs or attitudes about Mexican/cultural foods (7 studies), beliefs or attitudes about nopal/cactus (5 studies), and beliefs or attitudes about tea (5 studies).
Family turmoil is an influence that harms mental or physical health—a type of disturbance, confusion, or uncertainty attributed to a family member or caused by a family member. Examples of family turmoil included teasing by family members regarding diet31,35 and feeling social pressure to eat foods not congruent with diabetes care.43,44 Diabetes educators and nutrition professionals can help patients overcome the challenge of eating different foods from their families. Nutrition professionals can also use their diet expertise to encourage a patient to include more cultural foods that the family enjoys, such as nopales, and set goals so that the family can explore and enjoy food together.
The cultural influences related to beliefs about foods were beliefs or attitudes about foods in general (15 studies), beliefs or attitudes about Mexican/cultural foods (7 studies), beliefs or attitudes about nopal/cactus (5 studies), and beliefs or attitudes about tea (5 studies). For the category of beliefs or attitudes about Mexican/cultural foods, participants reported reflections that associated Hispanic/ethnic cuisine as being detrimental to T2DM. Other studies show similar sentiments, specifically that tortillas and rice were “bad” for diabetes.9,51,55 These beliefs or attitudes about Mexican/cultural foods may be due to a Eurocentric view on health. In focus groups with 21 Mexican American participants, participants reported that food preparation at home is healthier than dining out at a restaurant, especially for preventing T2DM.58 To address the misconception that Mexican/cultural foods are detrimental to T2DM, nutrition counseling should be tailored to promote healthful food preparation methods rather than excluding cultural foods.9,58-60
The current study provides examples of cultural foods that may benefit the diet: nopales because they are high in fiber and herbal teas to displace the consumption of sugar-sweetened beverages. Individuals with T2DM perceived nopal/cactus to have positive glycemic benefits, while those participants describing tea as a treatment were mixed. A cup of cooked nopales with no added fat contains 24 calories, 2 grams of protein, and 3 grams of fiber. Nopales are a good source of calcium, with 246 mg, or 24% of the daily reference intake for adults ages 19 to 50.61,62 Regarding tea, the participants reported its use as either beneficial or ineffective but not detrimental. Chamomile tea or hibiscus flower (agua de jamaica) are popular beverage choices among Mexican Americans.63 Studies with Mexican Americans report examples of how nopales50,52 and tea64 are traditional cultural foods integrated into the diet. Knowledge and inclusive counseling of healthful traditional cultural food choices show attentiveness and respect for someone’s culture.
Dietary behavior and patterns play an integral role in disease management for diabetes and should not be generalized. Cultural mores, beliefs, and values, especially as they relate to food choice behaviors, are unquestionably important for providing culturally sensitive, tailored, appropriate patient care for all patients.
This study elucidates some key cultural considerations for practitioners involved in diabetes care with Mexican Americans.
Family influences and beliefs about food were key aspects identified in this study that need to be explored to facilitate efficacious interventions in this target population. Therefore, health care professionals specifically working with Mexican American patients who have diabetes should leverage such knowledge to identify if and how they can utilize it to better understand and appropriately advise their patients to maximize cultural acceptance and efficacy of interventions. The lack of knowledge about how cultural beliefs and values impact diabetes self-management is a barrier that must be integrated into care to enhance the likelihood of success. It is, hence, important for practitioners to practice cultural humility and acknowledge when unfamiliar with a cultural belief, value, or food. This creates an opportunity to collaborate with patients and engage them in their care.
Regarding family influences, practitioners can explore factors associated with family and home dynamics that positively and potentially negatively influence food choices. They can further identify and explore how these factors can be ameliorated or expanded to facilitate diabetes self-management. A more in-depth exploration and understanding of diet beliefs and practices (specifically foods consumed or avoided and why) will allow practitioners to adjust nutrition guidance to be more inclusive of diet-related culture and traditions.
It should be noted that the inclusion criteria in the current study focused on a Hispanic subgroup, Mexican Americans, and this limits the broad application of findings to other Hispanic subgroups.65 Another limitation is that studies published after 2015 were not included because the initial analysis was completed by the research team in 2015 and adding new studies would compromise the integrity of the content analysis methodology. Future studies should examine the clinical impact cultural influences have on diabetes outcomes.
Cultural mores, beliefs, and values, especially as they relate to food choice behaviors, are unquestionably important for providing culturally sensitive, tailored, appropriate patient care for all patients.
The study findings help diabetes health professionals differentiate diet and culture-specific influences shared by Mexican Americans with T2DM. This work offers a way to circumspect the work that is done in disciplinary silos by showing that several disciplines share a common interest and need for studying phenomena such as cultural beliefs in diabetes self-management. The concepts of family influences and beliefs about foods are important considerations and serve as a tool for researchers and practitioners to develop stronger interventions for building evidence on culturally appropriate lifestyle interventions.
Julie Plasencia, PhD, RDN, is with the University of Kentucky in Lexington, KY. Sharon Hoerr, PhD, RD, is with Michigan State University in East Lansing, MI. Hector Balcazar, PhD, is with Charles R. Drew University of Medicine and Science in Los Angeles, CA. Maria Lapinski, PhD, and Lorraine Weatherspoon, PhD, RD, are with Michigan State University in East Lansing, MI.
The authors would like to acknowledge Melissa Roberts, RDN, research assistant at Michigan State University, for her contributions to the development of the coding procedure. This study was completed as partial fulfillment of the requirements for the degree of doctor of philosophy in human nutrition at Michigan State University of the primary author.
The authors declare having no professional or financial association or interest in an entity, product, or service related to the content or development of this article.
The authors declare having received no specific grant from a funding agency in the public, commercial, or not-for-profit sectors related to the content or development of this article.
Julie Plasencia https://orcid.org/0000-0003-2143-3844
